Should We Care How Beyoncé Gave Birth?

Update: after posting this, Beyoncé released a statement saying that she had a “natural” birth.

Right now, the blogosphere, facebook, and apparently the entire internet, are all on fire about how Beyoncé gave birth to her baby. Does it matter? Should we care? My answer is, yes… and no.

Celebrity is a two-edged sword. The same people that want tons of attention when it comes time to sell an album, star in a movie, or play a game, can’t just suddenly plead the interests of privacy, and desire inattention, when it comes to their personal lives. That sort of sucks, but there you are. I wouldn’t want to be stalked by paparazzi, either, and have every bad photo of me and my cellulite plastered over every tabloid, but for the most part, that is unfortunately the price to pay for celebrity. We can argue over whether it should or shouldn’t be, but the reality is, for the moment, that is what is.

I remember a reply by John Lennon, in an interview in which he and the rest of the Beatles were asked if they would like to be able to walk down the street without anyone recognizing them or without anyone causing an uproar; his response demonstrates that he understood the reality that he couldn’t have it both ways; he said: “We used to do that all the time, without any money in our pockets. Why would we want to go back to that?”

Beyoncé, and certainly every other celebrity, justly or unjustly are put under the microscope, and fortunately or unfortunately thousands of people will follow the example of one famous person. In that aspect, those of us who care about issues of birth and pregnancy, and especially those of us who support and promote vaginal birth, unmedicated birth, and/or home birth — “natural child birth” folks — are frequently (and rightly, I believe) dismayed at the high rate of C-sections, and what we perceive as almost the promotion of it in celebrity births.

So, thinking about how that many people (particularly today’s generation of teenage and young girls) may look up to Beyoncé, and possibly may be influenced by reports of her C-section, to plan on having their babies by C-section, it is possible that every celebrity C-section today may result in an increased percentage of C-sections in the future, and therefore, it does matter, and we should care about how others, particularly celebrities, give birth, because of that influence; and while Beyoncé’s C-section may have been the best choice for her (either for medical benefit/necessity or personal preference), and she may have no negative repercussions from it, almost everybody who takes an interest in birth realizes that C-sections as individual choices may be better, but C-sections as an aggregate tend to have worse outcomes for both mother and baby, particularly repeat pregnancies and C-sections.

Unfortunately, births don’t happen in aggregate — they happen to individuals. So, in dissecting birth as a whole, we end up trampling on individual births. This is one reason it’s so difficult to talk about many birth topics, such as C-section vs. vaginal birth, because no matter what you say, there will always be at least one person who said, “I did that, and it turned out horrible!” or “I did that, and it was the best decision I ever made!” Many women report that their C-sections were horrible, with nightmarish recoveries; and many other women report that their C-sections were a breeze; and some women who have had both C-section and vaginal births will say diametrically opposite things — that some found their C-sections to be easier recoveries, and others that their vaginal births were easier to recover from. Unfortunately, there is no 100% certainty in any decision made, no matter what, so women just have to choose what they believe to be best for them (and I hope that they will be given accurate information, and not pressured or coerced in any way).

I don’t know why Beyoncé made the choice she did, though there may have been some medical reason (I haven’t read any of the reports because, quite frankly, I don’t care; I’m not “into” pop culture, and she’s basically just a name to me, though I *think* she was in the Pink Panther movie with Steve Martin some years ago, and I did watch that). I did read this and this commentary on the blowback she has received, which, along with a few headlines, is the sum total of what I’ve read, and several people threw out in her defense that there may have been unreported medical reasons, such as pre-eclampsia or breech baby. I must admit that when I saw that she had had the baby already, I was a tad worried that the baby might be early [it seems just a month or two ago, I saw some headline about her being pregnant, so I thought at first it might be **really** early], and if she had an elective induction/section at or before 37 weeks, I was concerned on her baby’s account, because I know in aggregate, these early births are worse for the baby, though in particular, it may not be horrible for any individual baby. Also, someone suggested that they intentionally gave the wrong due date, to avoid increased press scrutiny at the time of the correct due date, and the baby may have been 40 weeks, or possibly even over 42 weeks, instead of the reported 37 weeks.

Whatever. I don’t care. I really don’t.

I don’t care why she chose it, whether there was a true medical need, too posh to push, desire for being able to schedule the birth, the belief that it was safer, the desire for privacy, or whatever her reason(s) were. [Although I must admit, that if there was a real medical reason, I hope it will be told, because I think the last thing our society needs is another high-profile celebrity having a medically unnecessary C-section, and making it look like it’s the smarter, better, easier choice.] For Beyoncé as a person, it makes no difference; for her as a celebrity with influence, it does make a difference to the thousands she may influence.

Her desire for privacy could be the sole reason for choosing a C-section, and I would understand that. I’m not a celebrity, so I can’t pretend to have the same knowledge base or experiences a celebrity has, but I have a pretty good imagination, coupled with sufficient knowledge of the paparazzi and how they work. What wouldn’t one of these people do, to get a picture of Beyoncé in labor, giving birth, having a C-section, holding her baby, or anything else related to this time? It would be pretty hard to impersonate a labor nurse or otherwise infiltrate the L&D floor, but it could be done, by someone with the knowledge and desire to do it. However, it could be easier to pay off an employee to break regulations and get such a picture. Also, put yourself into a celebrity’s place, and imagine trying to relax through the contractions, or push your baby out, with the fear that somebody somewhere had planted a hidden camera and/or microphone, and would be selling it for thousands upon thousands of dollars to some tabloid magazine somewhere. Yeah, that would make renting out a hospital floor and scheduling a C-section more appealing to me, too.

I also don’t have a problem with her renting out the entire floor — it’s her money, she can spend it as she wishes. I’d spend it differently, but that’s me; this is her choice — she can do with it whatever she wants, as long as it isn’t harming anybody else and is not illegal.

Ah, but there’s the rub, isn’t it? Her choice to take over the hospital floor *did* harm others — apparently there were many stories from parents who were not allowed to visit their babies in the NICU, because of this. She went to such lengths to choose what she felt was best for herself and her baby, but in so doing, the rights of other parents to even see their fragile newborns (most of them probably preemies, many of them with serious, even potentially lethal, conditions) was trampled on. It is my hope that she didn’t know what was happening, and when she chose to rent the entire floor so that she could have privacy, that she did not intend for other parents to be separated from their precious babies.

One of the articles I linked to above was sarcastically “Beyoncé Must Be a Terrible Mother” [it was a collection of various comments from people on facebook, reacting to the news that she had had a C-section, though no reason was stated, and that she had rented out an entire hospital floor to do so], and I agree with the blogger’s point of view — that having a C-section, even a medically unnecessary one, does not make one a bad mother. However, I would say, that keeping parents from their children does make you at best an unthoughtful human. I don’t say that’s Beyoncé’s fault; I think that was the hospital’s fault, plain and simple. Even if Beyoncé knew that many parents would be separated from their NICU babies and didn’t care (which would be pretty heartless, if true), it is still the hospital’s ultimate responsibility, so I lay most if not all of the blame at their feet, because the hospital folks should have known what the result would be, and they chose to put money and fame (having Beyoncé pick *them* to have her baby in), over principles, and also over the benefit of the many parents, who likewise entrusted their births and their babies to this hospital, and deserved more consideration.

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Cesarean Scar Website

Barb from Navelgazing Midwife has launched a new website dedicated to the “story” your Cesarean scar tells. From the “About” page on the website:

Something told me the cesarean scar needed a place to speak.

As this site was being born, I asked three things:

-1. Take a picture of your scar.

-2. What does your scar say when you look at it?

-3. What does your scar say when you touch it?

What followed was a steady trickle of photos and stories… tender, painful, wonderful, awful stories.

Here, I humbly offer space for the stories to find their way to light.

I’ve read a few of the stories, and already there is a wide range of emotions: “I hate my scar,” “My scar mocks me,” “I’m now at peace with my scar,” “I love my scar because that means my child(ren) are alive,” etc. Everyone has a story to tell…

Culture, shmulture

Recently, “Courtroom Mama” wrote a new post [The Most Important Thing] in response to a comment thread from a previous post [VBAC Doesn’t Make it All Better, by Emjaybee], which are both at The Unnecesarean. If you haven’t read the posts you should, to at least give more context; however, briefly, the VBAC post discusses the grief a woman might feel after having a C-section, and the responses she may get from people may exacerbate her grief and/or pain; and The Most Important Thing takes on the question, “How, exactly, does a C-section ruin your life?” Courtroom Mama says, in part,

This is something that may be difficult for a person who had a necessary surgery, or who is okay with having had an unnecessary surgery, to understand. I’ve tried to explain the fact that the outcome doesn’t erase the pain of the journey, but there really is no metaphor. The closest I have come is this:

Imagine you get in a car to drive and see the person you love most in life. You get into a car accident on the way there, are rushed to the hospital, and the doctors save your life. When you open your eyes, your loved one is there to greet you. Now imagine instead that you get into the car, and on your way there, you’re pulled over for driving too slowly, and then taken to the hospital, where your healthy appendix is removed. When you open your eyes, your loved on is there to greet you.*

Notwithstanding your happiness to eventually get to your goal, you might have some questions—or even anger, sadness, or grief—about what happened to you on the way there. Why were you interrupted just for getting where you were going too slowly? How did that justify unnecessary surgery? Even in the first circumstance, might you not still feel trauma from the terror of fear of dying or never seeing your loved one? Getting to see that loved one might be the most important thing, but it doesn’t diminish the importance of your own physical and mental health. This is something that mothers don’t often get to hear: you are important too!

Dr. Amy left a comment which said something along the lines of, “A C-section isn’t inherently traumatic — it’s only a cultural construct.” [Those aren’t the exact words — her comment came up in Google Reader, and I didn’t respond immediately because I wanted to take some time to think about what, precisely, I might say about that. Not having had a C-section, I don’t know by experience how I might react emotionally, but I thought about being a bit of a smart aleck and point out that surgery — cutting into the body — by definition is a trauma, hence the scars that invariably form — such as the one I have decorating the entire length of my sternum — very necessary, but undoubtedly traumatic. However, by the time I clicked over to respond, a moderator had removed the comment and replaced it with something humorous, so I didn’t respond — nor can I look back to see what exactly what was said.] She left a second comment, which was likewise removed (this time before I saw it, so can only guess at the contents); a third comment from her asked Jill (the moderator and blog owner) to “grow up”; and finally a in a fourth comment, she presented her evidence for her original comment. Citing a 24-year-old study, she says in part,

NCB and all that it implies is restricted by race and class. This is not my idea. It was noted as far back as 1986. Cesarean Birth Outside the Natural Childbirth Culture was published in Research in Nursing and Health in 1986. It highlights the fact that “natural” childbirth is a philosophy that is not universal, but rather the product of a particular subculture. It points out that “natural” childbirth emphasizes process over outcome, and it concludes that C-section itself is not particularly emotionally traumatic, but has the power to be traumatic among women schooled in the rhetoric of “natural” childbirth….

A notable feature of the literature describing the negative psychosocial consequences of cesarean birth is its emphasis on a particular group of women. Specifically, this literature emphasizes the values, expectations, and experiences of women who belong to what can loosely be termed the “natural childbirth culture”. For women interested in natural childbirth, typically from the middle classes, the experience of birth is an end in itself, and cesarean birth is a devastating interference with nature.”

In other words, “natural” childbirth philosophy does not represent universal truths; it is merely a reflection of the cultural pre-occupations of subset of Western, white, middle class women.

The authors are concerned that the values, expectations and reactions of women outside the charmed circle of NCB advocates are simply being ignored. The basis of this study is open ended interviews with 50 women who were medically indigent. In contrast to NCB advocates, the interviewees were predominantly African-American, of limited economic means, and of limited educational achievement….

The full comment was much longer (it’s currently on page 2 of the comments, if you want to easily go there and read the entire comment). Some follow-up comments derided her for choosing a 24 year-old study, while others provided counter-balancing arguments, citing their own or others’ experiences, as women who were not “Western, white, middle class,” yet still found C-sections to be traumatic. They were all interesting and had valid points, but I want to take a different tact. Accepting that this study is valid and still pertinent for today, there are many observations I would have.

First, not every woman who wants and plans a natural childbirth but ends up with a C-section (necessary or not) finds them traumatic. My sister-in-law whom I’ve mentioned before was such — she planned a home birth, took Bradley childbirth classes, the whole nine yards; but ended up with a C-section when not even forceps could help bring the baby down and out. While she found it physically traumatic, and had a lengthy and difficult recovery (compared to vaginal births with or without forceps), I don’t know that she was emotionally traumatized by it — in fact, she was waffling between trying for a VBAC and going in for an elective repeat Cesarean during her second pregnancy, when labor started. She became afraid of a repeat long and hard labor with another C-section, and decided just to “pull the trigger” and go for a C-section to start with. Although I never discussed it with her (and she has since passed away due to colon cancer at a very young age — know the symptoms!), I know that she was in charge of her labor and birth the whole time and ultimately chose the C-section herself, without the doctor giving undue pressure.

Second, while all surgery is physically traumatic, any surgery can be emotionally traumatic, no matter how necessary it might be. Part of that depends on the person undergoing the surgery; and some of it may depend on the type of surgery. There are probably thousands of people today who will be taking Valium or some other similar drug tonight to calm them down so that they can sleep well before their planned surgery tomorrow. That’s just the nature of things! It can be very scary to think about somebody cutting your body open and rummaging around inside; and although the risk of death for most surgeries is fairly low, it is always a possibility, and for some people even that slight possibility can be extremely nerve-wracking.

Third, so what if it is a cultural construct?!? What does that mean — we shouldn’t hope for the best and try for the best, in case the worst happens? Should we just keep our mind on the dirt, focusing on our toes, never looking up to the heavens and imagine that we can fly? I have an analogy (don’t I always? ;-)):

Not everyone wants to be a doctor; some are pretty grossed out by the whole idea of dealing with people’s bodies and bodily functions, or couldn’t make it through med school with cutting up cadavers and all that. A few might like the idea for the money, but other than that would gladly pass on anything to do with medicine. Does the fact that most people wouldn’t want to be doctors if they could, mean that those people who want to be doctors but for some reason can’t (whether they can’t get funding for med school, can’t pass certain courses, etc.) shouldn’t feel badly that they can’t fulfill their lifelong dream of becoming doctors? Is it just a “social construct” or “cultural construct” that some people have the dream of learning how to heal people?

Something about this topic also made me think about those pictures you might see of the orphaned children in Africa — you know the picture — the child with flies all over his face, and he doesn’t even bother to brush them away. Wouldn’t that just drive you nuts, to have flies walking around on your face? Is that just a “social/cultural construct”? In a way, yes — for children like that, there is no real reason to brush away the flies, because they’ll just settle right back down again — there are too many flies to fight. You and I probably can’t imagine that, because we’ve never been in a situation like that, so our social/cultural upbringing leads us to shoo away the flies, not expecting them to land again, while this child’s upbringing leads him to just live with flies on his face. But does that mean that the child is not bothered by flies on his face? — that given the opportunity, he’d as soon choose to have flies as no flies on his face? — that there is no inherent difference between having flies on one’s face and not? Surely no one would say that. Yet he is probably not “traumatized” by the flies — doesn’t have the same reaction that we would have, because he’s become inured to it. I don’t know about you, but it would drive me nuts to have flies on my face all the time. Eventually, I’d probably get used to it, but I wouldn’t like it. I may stop complaining, but that doesn’t mean it’s not bothersome. I may have more pressing needs (such as trying to find food to eat) that would render flies on my face as insignificant, and might even become inured to them myself to a certain extent, but I can’t imagine ever saying that it doesn’t matter whether there are flies on my face or not. Nor do I think that this child would say that, even with his social/cultural construct.

So, yes, I think we can be culturally influenced to expect certain things and to react in certain ways — examples too numerous to be told could be brought up in just a few minutes to support that point. People living in areas with high infant mortality may view their pregnancies and/or infants in a different way from how those of us living in areas of low infant mortality would view it. I remember reading something years ago, in which American infant mortality back in the 1800s or early 1900s was so high (particularly in big cities, which were notoriously filthy and nasty — horse manure in the streets, little or no indoor plumbing, etc.), that mothers were cautioned not to become too attached to their children in the first year of life, not to count the child as really alive until they lived past their first birthday. Surely a similar attitude must exist in other cultures that still have high infant mortality. Yes, it’s a social/cultural construct — a survival mechanism, if you will. But would anyone argue that it’s no big deal whether a mother is attached to her children or not? Sure, in countries where mothers have a pretty good chance of losing an infant, it may be preferable (in one way) for her to remain detached — but wouldn’t it be a better thing to try to reduce infant mortality, than to reduce a mother’s attachment?

Finally, I will close with a comment made on that thread by Patrice, which may shed additional light onto the topic:

I can say that I’ve been deeply affected by the comments on blog post. So affected that I decided to blog about my own first birth experiences. http://mamachildbirtheducator.blogspot.com/2010/04/battle-of-birth.html One thing I remember clearly about it, is my need to forget. My need to not complain. It wasn’t something that was forced upon me. It’s very much culturally ingrained in black women not to talk about trauma’s, not to complain about pain both physical and emotional and in cases not to even recognize it. Culturally we’ve learned to swallow our misery, deny shame, break our backs emotionally. The subject of birth and traditions of birth with black women over the last 50 years only shows how even more marginalized we are, not only by others outside our cultural, but within. We have pain, we have birth trauma. We just need to learn it’s okay to talk about it. We too, have to make our voices heard. We have to realize it’s not just, the way it is. Like everything else this system throws at us.I defy you, Dr. Amy, to try an tell this Black woman, this Black mother, otherwise.

And now, Dr. Amy, since I know you read my blog, feel free to respond — after you’ve read the entire post, of course. I won’t delete your comments unless they get way off track. If any of my readers who have had cesareans think that they may be upset by remarks along the lines previously quoted in this post, please don’t read the comments, just in case.

“Safety net” or trampoline?

What if there were no C-sections? What if that simply wasn’t an option? Do you think doctors would practice differently? I do.

No one discounts that C-sections can be beneficial, saving the lives of mothers and/or babies. However, our country is currently experiencing its highest C-section rate, with maternal mortality increasing right alongside the C-section rate (not saying necessarily that it’s causative; however, if these C-sections were life-saving to the mother, one would expect the maternal mortality rate to be decreasing or at least staying the same), and perinatal mortality not doing that much better either. [If you want some state-by-state breakdowns, Jill at the Unnecesarean has compiled several, with the most recent one being California.] Most people agree that the C-section rate is too high, and could safely be brought down. There are many factors going into the increase incidence — some of which may be valid and beneficial reasons, but others that are not.

Carla Hartley recently wrote a note in which she cleared up some misconceptions that have apparently been told about her and “what she believes.” Among other things, it appears that some have said that she thinks midwives ought not take Pitocin with them to home births (for postpartum hemorrhage). She said (paraphrasing), “But what if you as a midwife had no Pitocin in your bag? Would that change your practice style? Knowing that you didn’t have that as a backup, would you be less tempted to act in a way that might cause a postpartum hemorrhage?” That’s food for thought.

Taking this out of the birth realm, we see that when there is a safety net, it changes people’s behavior — how many of you would walk across a tightrope without a safety net below? Some do; but far fewer people would risk crossing if they knew that there was a real risk of death, as opposed to a slight risk of death and a real likelihood of safely bouncing on a net if they fell. There are always adventurous people, daredevils, pushing the envelope — doing things that are dangerous or downright deadly, just because they can. But most people only do something if they think or know that there is a reasonable chance for them to succeed and come back alive.

In another, much more mundane vein, we see banks and other companies loaning people money for various reasons, including education, buying a house, buying a car, etc. The more collateral you put up, the more they’ll lend you; the more you earn, the more they’ll give you; or if the government guarantees that they’ll pay the loan should you default or die, they’ll gladly loan you the money you ask. Why? There really isn’t that much risk involved, if the government is the guarantor; and the risk to the lender is dramatically lowered if you have something valuable that they can take if you can’t pay your bills. It’s a safety net for them.

Back to birth — I wonder how it would affect doctors’ practice style if they knew that there was no “safety net” of a quick, easy, safe Cesarean. I’m reminded of something one of my email doula friends said — she’s attended hundreds of births, many of which became necessary C-sections, but none of which were necessary at the outset of labor. This is not to say that the only time C-sections become necessary during labor is if they were interfered with — sometimes the most natural labors end up requiring C-sections, and sometimes interventions can help preserve a vaginal birth when otherwise a C-section might be necessary; but frequently, it is the interventions which lead to a C-section then becoming necessary. We all have heard of “Pit to Distress” — the practice of increasing the dosage of Pitocin until the baby is born, or becomes so distressed by the unnatural labor that the doctor then has a reason to call for a “necessary” C-section. What if doctors didn’t have easy access to surgery, in the event the baby was distressed? Do you think they’d be so quick to give Pitocin to a baby that is tolerating labor, just to speed things up? I don’t. It’s relatively easy to say that it’s no big deal if the baby becomes distressed due to X, Y, or Z, because “she can always be given a C-section.” But what if she can’t? Then, if the baby becomes distressed because of something the doctor did, it’s all on him if the baby is injured or dies.

If there were no C-sections, doctors would still be taught how to best manage vaginal breech births and vaginal twin births. I think of one snippet of media coverage I saw in the aftermath of the Haiti earthquake. An American woman (probably an OB, maybe not), was attending births in the street “hospital,” and a Haitian woman was in labor. Probably the baby began “crowning,” except that it wasn’t the head, but the rump that was presenting. The American wailed, “It’s breech! I don’t know what to do!!” She had probably never seen a vaginal breech birth before — even assuming she was a trained and practicing obstetrician, she likely was trained in100% C-section for breech, rather than how to safely assist a vaginal breech birth. All well and good for America, with plenty of hospitals and operating rooms, technology and antibiotics — but when the OB is removed from all of that, what skills does she really have to help make birth safe?

If there were no fetal monitors, doctors would not feel safe with administering Pitocin, particularly in high doses, because they would have no way of knowing how the baby was tolerating it. If there were no C-sections available should the baby become distressed, doctors would be more cautious to keep the baby from distress, don’t you think?

I’m afraid that our safety net of technology and interventions has become more of a “trampoline” — rather than being used only to save someone’s life or health in rare events, it is being used on a regular basis, as if it’s meant to be bounced on. And, no, I’m not calling for a complete ban on the use of Pitocin, C-sections, or any other intervention — they have their place. However, if they were reduced only to what was necessary (which we as fallible humans cannot know with 100% certainty which are truly necessary and which are not, so we could not truly reduce the rate of unnecessary intervention to zero; but looking at some things like mortality and morbidity with and without C-sections, and retrospective studies showing that most inductions were not medically necessary [and failed inductions certainly increase the rate of C-sections], we can see that it certainly can be reduced), we would see a very different (and, I think, better) picture in labor and birth, compared to what it is now.

One time my sister was talking to a police friend of ours, and sort of complaining about getting pulled over for speeding tickets. [At the time, she did have a “cop magnet” — a sweet little black T-top Thunderbird.] And our friend said, “Always drive like there’s a cop behind you.” That’s good advice, isn’t it? We often don’t — relying on radar detectors just to keep from getting caught; but if we drove safely and cautiously, within the speed limit, and obeying all laws, we’d likely never get a traffic ticket, and we’d reduce the likelihood that we’d end up in an accident. Maybe if doctors, midwives, and nurses would “practice like there are no C-sections,” we’d be able to safely reduce the C-section rate much closer to the minimum necessary.

Prevent C-sections — learn about cervical scar tissue

This was an interesting post, and I thought I’d pass it along. If you’ve ever had a procedure done on your cervix (including, surgery to remove pre-cancerous cells, and, rarely, a D&C), you may have scarring, which can cause slow or no dilation, despite adequate contractions. One to save in the files…

Iatrogenic Prematurity

This month is Prematurity Awareness Month, and although I missed the “calling all bloggers” Prematurity Awareness Campaign for Nov. 17 [I just didn’t feel like writing about it — sorry — nothing “sparked” in me at the time], since that time, I’ve gotten “sparked” about iatrogenic prematurity. If you’re unfamiliar with the term, it just means “doctor-caused” prematurity.

The March of Dimes is the main organization leading the Prematurity Awareness campaign, but I have to admit to being a little perturbed that they didn’t speak more strongly about the one cause of prematurity that could be most easily changed — iatrogenic prematurity, caused by elective inductions and C-sections.

It’s possible that “iatrogenic prematurity” might include necessary or beneficial cases of babies born by induction or C-section too soon — for instance, a baby who suddenly stops moving at 34 weeks and is obviously compromised. But for my purposes, I’m restricting it to medically unnecessary inductions and C-sections.

Here is one link: Why do women deliver early? Did you catch the discussion on elective inductions and C-sections? No? Not surprising — it receives only the briefest of mentions. However, this March of Dimes article, “Why the last weeks of pregnancy count” does dwell on the topic a bit more. Elective C-sections and inductions are (thankfully!) not one of the four main causes of prematurity, but iatrogenic prematurity could be stopped tomorrow. And I think that’s important to note.

Some doctors have a laissez-faire attitude about inductions and C-sections, and have no problem with either as soon as the mom hits 37 weeks. Perhaps that attitude is changing a bit, since research has demonstrated that infant outcomes are much worse in several different areas if the baby is born unnaturally at 37 weeks, compared to 38 and especially compared to 39 weeks. [And when I say “unnaturally,” I’m meaning, by induction or C-section — babies born to women who go into labor naturally at 37 weeks do as well as those born at 38 and 39 weeks, naturally — it’s the unnaturally early births that are the problem. When the woman goes into labor, that is an evidence that her baby is actually ready, as opposed to having reached some arbitrary date on the calendar.] Some doctors may even do an elective induction or C-section at 36 weeks. I read a story some time ago about a woman who had a late-term fetal demise in her first pregnancy, so opted for an elective induction at 36 and a half weeks. She thought he was ready “enough” — that it was “close enough” to term for him to be born. Her baby was in the NICU for 6 weeks, and had long-term health problems (mostly related to his lungs and breathing), because he was not ready.

A woman’s dates can be off, which could really cause problems with her baby, if she electively induces or has a C-section at 37 weeks (or even later). What if her little one would have been born naturally at 41-42 weeks? That’s 5 weeks early. And if her dates are off, it may be even earlier. There’s a lot of brain, lung, and body development that happens in those last few weeks, that ought not be circumvented without an awfully good reason. Although rare, “superfetation” — conceiving a second baby many days or even a month after the first baby was conceived — is also a possibility, as Abby Epstein found out. What if she had gone by “I thought I was pregnant a month ago,” even though that baby died, and her later-conceived baby lived? Perhaps they were conceived at the same time, and this was just “vanishing twin,” but perhaps some of these super-long gestation times one occasionally reads about were actually due to undiagnosed superfetation with a hidden/missed miscarriage. Could happen. I remember in reading through some of the causes of death listed on the CDC linked birth-death certificates, that one hospital-born baby born at 42 weeks died due to “extreme prematurity.” It could be a typo — perhaps it should have been “24 weeks”; or maybe the code was entered wrong. Or maybe the mother’s dates were miscalculated. Or maybe she happened to skip a period prior to conception, so she thought she was at 42 weeks, when she was 6-8 weeks earlier. I wonder, though, if she was induced because she was “42 weeks” and her baby was nowhere near ready. Unlikely, but possible.

Then there’s this little gem of an article: Many Women Miscalculate Time to Full-Term Birth. One paragraph reads,

“About one-quarter of new mothers surveyed in the study considered a baby born at 34 to 36 weeks of gestation to be full term, while slightly more than half of women considered 37 to 38 weeks full term.”

Only problem is, that’s not what the question was. Here’s the actual question (also from the article):

“What is the earliest point in pregnancy that it is safe to deliver the baby, should there not be other medical complications requiring early delivery?”

It didn’t say “when is full term?” It asked “when is it safe?” Ok, so define “safe”. Most babies will do fine born electively at 34 weeks. Obviously, not all will — some will die that would have lived; of those who live, some will have long-term negative effects related to their prematurity. If safe is some sort of “beating the odds” — well, 90% of babies born at 30 weeks survive, and the odds go up every week. Many (perhaps even most) of these babies will not suffer long-term negative effects (like cerebral palsy, blindness, etc.) which used to be so common at this age, but now are more common with preemies born at earlier gestational ages; and the risk goes down with age. Even fewer babies born at 37 weeks will have problems, than those born at 36, 35, or 34 weeks. Does it mean it’s “safe” for them to be electively induced or sectioned then? Well, sure, compared to preterm babies; but not compared to 38-weekers, or 39-weekers. But again, babies are naturally born at 37 weeks all the time and have no long-term problems compared to babies naturally born at 38, 39, 40, 41, etc. weeks And if a woman goes into labor at 36 weeks, doctors will not try to stop the labor. I daresay that many people would say, “If the doctor won’t stop labor at 36 weeks, then it must be safe for the baby to be born then.” Is that a wrong supposition? Yes, if you’re talking about elective inductions; perhaps no if you’re talking about natural labor.

I will also note that the question was not, “When is the earliest point in pregnancy that an elective induction or C-section should be used?” Had this been the question, I would have answered “never” if that was a possibility 🙂 or else “39-40 weeks,” if that were the latest time frame given. However, in the question that actually was used, I probably would have answered 37-38 weeks, because that’s “term”; or possibly at 36 weeks — if the woman goes into labor at that point, the doctor won’t stop it, after all. Not because it is best for the baby to be born at that point, but because I don’t know if it totally meets the threshold of “unsafe” for the baby to be born early. Not optimum, but perhaps “safe.” Is it “safe” to drive a car? Almost everybody would unhesitatingly say “yes!” but people are injured and killed in car wrecks every day. And some people are injured or killed as pedestrians, who would have lived had they been in a car. “Safe” does not necessarily mean “absolutely no risk,” because as probably everybody over 12 understands, there is almost nothing in life that is completely risk-free.

Although there were several good parts of it, this article was irritating on a few points, including the following:

Misconceptions about what constitutes full gestation and how soon it’s safe to schedule an elective induction or cesarean delivery are contributing to increasing numbers of premature births in the United States, said lead study author Dr. Robert L. Goldenberg, professor of obstetrics and director of research at Drexel University College of Medicine in Philadelphia.

Ah, yes — blame the mother! I feel so sorry for these poor spineless doctors who just can’t stand up to the strong woman who demands an early end to her pregnancy, regardless of how much damage it does to her baby. You know how thoughtless and uncaring women are! They don’t give a rip about the baby they’ve just spent the last 8-9 months of their lives growing! Odds are, they’ll leave the baby at the hospital and just walk away!

Ok, so maybe the sarcasm was a little heavy in that last paragraph, but seriously, folks!! It makes me want to scream! Sure, some women are selfish and truly don’t care about their babies — after all, some women abuse alcohol and use illicit drugs while pregnant. But I daresay that if doctors tell most women that their baby will be twice as likely to die (or whatever the actual rate is), if born electively prior to 37 weeks, or even in the early term period, and will be 3-4x more likely to have serious morbidity, that would put a curb on elective inductions. Some women may have legitimate or quasi-legitimate non-medical reasons for induction — husband home from Iraq for two weeks, previous stillbirth in the term period, severe pregnancy discomfort, and maybe others. [The  McCaughey septuplets just celebrated their 12th birthday (I remember because they were “due” the same day my sister was due with her first child), and they were born two full months early. In an interview soon after the birth, their mother, Bobbi, said that she just couldn’t stand the nausea and other side effects of the pregnancy itself and the drugs she was on to maintain the pregnancy. She held on as long as she could, knowing that every day they were inside her, it would be better for her babies; but finally she just couldn’t take it any more. That doesn’t apply to most women.]

So, yeah, educating women about prematurity and the problems babies have when born too early (by the babies’ clocks, even if not by the doctor’s calendar!) will help, because it will likely reduce the number of women wanting an early end to their pregnancy, and those who look at their due date as an expiration date. But women could not induce if doctors did not allow it! Inductions and C-sections don’t schedule themselves. Last time I checked, women can’t call the hospital and set up an induction or C-section without their doctor’s approval. They also don’t perform themselves — doctors (and nurses) have to perform an induction or a C-section. So, why does this article have such a strong tone of “it’s all the women’s fault!”?

I’ll say it again — iatrogenic prematurity could be stopped tomorrow, if doctors wanted to.

That’s a lot of C-sections!

I recently found this article on a women’s website a friend recommended to me, and just had to share it. Wow. A woman had all of her children by Cesarean — seven total surgeries! And it mentions another doctor who performed thirteen C-sections on one woman back in the 1970s. Incredible!

However, I will point out, that statistically, the risk of adverse complications (both during the C-section and in a subsequent pregnancy) do increase with every C-section, sometimes exponentially. So, if you can avoid a C-section in the first place, or have a vaginal birth after Cesarean, that’s going to be better for you and any future babies. I don’t know if these grand multip C-section moms have been studied to see what the rate of adverse events (like hysterectomy, hemorrhage, hemorrhage requiring hysterectomy, future placenta previa/percreta/acreta, etc.) are. There probably aren’t enough of them to do anything but case studies.

Still, that was incredible to me. I honestly would have assumed that the rate of complications would have been so high that most women would have ended up with a hysterectomy or chosen to have their tubes tied (or been coerced into it, as was attempted for this mother, or even sterilizing her without her consent) , or in some other way just stopped having babies. I was wrong. I’m not sure if these women are “beating the odds” necessarily. As long as the rate of X is below 50%, then odds are that they will not have X problem. But, the odds of a hysterectomy or hemorrhage or any of these other bad things with a VBAC is much lower than with a repeat C-section — especially when you get into higher numbers of C-section.

I would assume that the mother from the 1970s would have had a classical or vertical incision, which is contraindicated for VBAC attempt (although I know a woman by email who did have a VBAC after a classical C-section, and the labor was induced or augmented with Pitocin, which adds another layer of contraindication; but her uterus did just fine), so she may have been a poor VBAC candidate (especially at a time when “once a C-section, always a C-section” was the rule of the day). But there is no indication why the other mother had any of her C-sections, either the first, or any of her repeats.

Interesting. Very interesting.

~*~

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