Thursday, September 8, 2011

I Had A C-Section And I Loved It

Guest blogger Barrie Hardymon, an editor for NPR's Talk of the Nation, sent us a note arguing that the Baby Project has placed too much emphasis on birth stories that are natural, or planned to be natural. "Birth has become so politicized," she wrote, "that it's not OK to even intimate that you had a scheduled C-section." She wanted the NPR project to reflect a variety of experiences, and so offered us hers — the guilt-free C-section.

There are women who love being pregnant. They feel voluptuous, earthy, secure. I was not one of them. I was nauseated, cranky and terrified.

I first knew that I was failing at pregnancy when I attended a highly recommended prenatal yoga class at a local studio. The room was filled with glowing, curvy ladies, calmly resting hands on stomachs. I sat on the mat and tried to look pleasantly confident. Before the class began, we went around the room and introduced ourselves. (This was not a good start. I had never had to do this in my spin class.) Several of the women were planning home births. I leaned over to one of them and whispered, "But how will you get an epidural?" She looked appalled and scooted a little farther away from me. When, at the end of the TWO-HOUR class, we began dancing in a circle and singing, "beautiful, bountiful me," I lumbered sulking out the door, and wondered if the bar next door would feel funny serving a visibly pregnant woman a beer.

When I got home that night, I thought about all the women in the yoga studio who were planning the delivery of Ricki Lake's dreams — drug-free, ancestors whispering softly in attendance, gentle music playing, a delicate whoosh in the birthing pool.

Many of my friends, my dear friends, have made similar choices. I love and respect them — but reader, this was not my dream. Being pregnant exposes you to a layer of the world you had no idea existed — those whispering, wise women who have done it before. All of them, bless their hearts, have got some advice for you.*

They offer you nausea remedies, pillow recommendations and favorite Tums flavors. But much of their advice has to do with — brace yourself — your vagina. It is impossible to get away from it — any conversation about birth has to do with that enormous trial your nether regions must go through.

For the most part, when I entered these conversations with the wonderful women who offered me advice and support, I felt gratitude. But rarely did I identify with the birthing choices that were the norm for some of my dearest friends. How, I thought as I tucked my yoga mat in the back of the closet where it still sits, was I going to get this baby out of me? At a party, a woman I'd just met asked me what my "dream delivery" was. I mentioned Mad Men's much maligned "twilight sleep." It seemed perfect to me (minus, maybe, the enema): Go to sleep, wake up not pregnant, baby in arms. I received the same appalled look from her that I'd gotten at the yoga studio.

"Don't you care about your birth experience?"

"Well, no," I said. "I guess not. I care about the baby experience."

She sniffed and told me that both her children were born without intervention. Intervention! I was dying to have someone intervene — as soon as possible — and get this child into the world with a minimum of fuss. I was clearly destined for at least an epidural, and if there was any way I could get Betty Draper's drugs, I'd be thrilled.

Hank was breech, so Barrie scheduled a C-section — and she says she was happy about it.

And then, at 33 weeks, my doctor had news for me. The baby was breech. Although I was obviously worried about any risks this might create for him, I had to admit that for me it was occasion for enormous relief. I scheduled my C-section right away.

On my BabyCenter "mommy boards," other women reassured me that the baby might turn, and that there were things I could do to help the process along. "That's OK," I wrote. "I'm OK with cesarean." Others told me to try to have the baby vaginally anyway — women had been doing this for thousands of years without medical intervention. Hmm. You know what I bet those women would have liked, as they clutched at twisted bedsheets and screamed for hour upon hour, only to, in some tragic cases, have a baby get stuck in the birth canal? A C-section.

One woman went so far as to say that I was selfish not to even try to turn the baby. "Some babies are breech because they feel their mother's ambivalence. Motherhood," she wrote, "isn't supposed to be easy." Her signature read, "hippie, feminist, home birthing, working mom!" This was really confusing. You mean, we're supposed to start martyring ourselves even before the baby is born? We're still mad at Eve for eating that apple?

Worse, I thought, we're mad at each other. For every woman that whispered a recipe for ginger tea, there was one ready to tell me I was already failing at motherhood — before the baby was even born. I couldn't even get him into the world properly. How would I ever get him to college?

Women who choose C-section, especially those who do it for no medical reason, have more in common than they think with women who choose home birth. At opposite ends of the spectrum, both are accused of being selfish or ignorant, of putting their babies at risk. The two groups would be natural allies for women's choices, if they could only stop griping at each other.

My son Hank was born at 8:44 a.m. on March 1. It took 35 minutes, a lot of tugging, and some mild nausea. I had a good night's sleep and a pedicure before the birth. (Unfortunately, I heaved a little from the nausea when I first saw him, but I don't think he took it personally.)

Bright-eyed and healthy, he nursed well and gained his birth weight back in record time. I weathered the ups and downs of the postpartum hormone drop, and found myself up on my feet within a day and a half. When I got home, I forgot to take my Percocet. The pain didn't feel much worse than the time I took a really hard abs class. (In which, I might add, I did not have to introduce myself at the beginning.)

When people give me a pitying look when I tell them about my C-section, and ask if I had trouble bonding with the baby, I've learned to smile sweetly, and tell them I had the perfect birth experience. After all, Hank and I were clearly bonded even before birth — his breech turn was the first gift he ever gave me. Motherhood, in all its wonderful terror, is hard enough. Better to remember what all we parents have in common — however our babies arrive, the moment afterward, equal parts relief and desire, wriggling, warm and contented upon our chests.

*Pregnant women, please see me for advice.

Barrie Hardymon is an editor for NPR's Talk of the Nation.



Pelvic Muscle Strength Greater Following C-Sections

Jody A. Charnow

August 29, 2011 

GLASGOW—Pregnant women who deliver their babies by C-section have higher pelvic floor muscle (PFM) strength, higher vaginal resting pressure, and higher PFM endurance than women who deliver vaginally, researchers reported here at the International Continence Society annual meeting.

Investigators in Norway studied 135 pregnant women, of whom 114 (84.4%) had a vaginal delivery and 21 (15.5%) had a C-section. Among those who delivered vaginally, 13.3% had an instrumental delivery. The researchers, led by Kari Bø, PhD, of the Norwegian School of Sports Sciences in Oslo, measured (in cm H2O) vaginal resting pressure, PFM strength, and PFM endurance at gestational week 22 and six weeks post-partum. Overall, vaginal resting pressure was reduced by 10.6, PFM strength by 15, and PFM endurance by 95.8.

At six weeks post-partum, the vaginal resting pressure was 37.4 among women who delivered by C-section versus 29.2 for those who delivered vaginally. PFM strength was 31.4 in the C-section group compared with 15 in the vaginal delivery group. PFM endurance was 207.1 compared with 101.4. All of these differences were statistically significant. Additionally, among women who delivered vaginally, those who delivered without the aid of instrumentation had significantly higher PFM strength than those who had an instrumental delivery (16.2 vs. 9.4).

The investigators explained that the pelvic floor muscles play a significant role in pelvic organ support. During vaginal delivery, the pubococcygeous part of the levator ani muscle undergoes a stretch estimated to be three times its own length. When striated muscles are forcibly stretched, they noted, general muscle weakness and injury may occur, resulting in reduced ability to contract.


Clinical Practice Guideline Watch

ACOG Updates Guidelines for Thromboembolism During Pregnancy

New recommendations provide some flexibility in prevention and management.

Although pregnancy-related venous thromboembolism (VTE) is relatively uncommon, it is a leading cause of maternal death in the U.S. Physiological changes during pregnancy and the puerperium raise risk for deep vein thrombosis (DVT) and pulmonary embolism (PE); this risk is compounded in women with inherited or acquired propensities for thrombosis. Prevalence of risk factors such as maternal obesity and cesarean delivery continues to rise. The American College of Obstetricians and Gynecologists (ACOG) has updated its guidelines for managing women at risk for VTE during pregnancy.

Evaluation of suspected VTE during pregnancy

  • If DVT is suspected, compression ultrasound is recommended; if PE is suspected, ventilation-perfusion scanning and computed tomography of the chest involve acceptable levels of fetal exposure to ionizing radiation.
  • Women with VTE histories should be tested for antiphospholipid antibodies and inherited thrombophilias to determine risk for recurrent VTE.

Anticoagulation during pregnancy and the puerperium

  • Low molecular weight heparins (LMWHs) and unfractionated heparin (UFH) are generally considered safe during pregnancy; LMWH may be stopped during the last month to permit regional anesthesia at delivery.
  • As a teratogen, warfarin is usually avoided during pregnancy (except for rare clinical situations that warrant its use after the first trimester).
  • Women at high risk for VTE (e.g., those with high-risk thrombophilias) should receive anticoagulation therapy during pregnancy and postpartum.
  • Women at lower risk for VTE (e.g., those with low-risk thrombophilias but no more than 1 prior episode of VTE) may be observed without anticoagulation during pregnancy; alternatively, prophylaxis may be considered.
  • VTE prophylaxis should be equally or more intense during the puerperium than during the antepartum period.
  • Acute VTE should be treated with therapeutic doses of UFH or LMWH as guided by activated partial thromboplastin times or antifactor Xa levels.
  • Women who undergo cesarean delivery are at excess risk for VTE; pneumatic compression devices should be used intraoperatively in patients who are not receiving anticoagulation.
  • Resumption of anticoagulation 6 to 12 hours after uncomplicated delivery is reasonable; resumption 12 hours after epidural catheter removal is acceptable.

Comment: To some extent, morbidity and mortality associated with venous thromboembolism during pregnancy and postpartum are preventable. These updated guidelines rely on good-quality evidence to allow clinicians some latitude in safely caring for women at risk for VTE. Obstetric practices would do well to develop VTE protocols and use adherence to them as a metric for quality of care.

Allison Bryant, MD, MPH

Published in Journal Watch Women's Health September 22, 2011


ACOG Committee on Practice Bulletins–Obstetrics. Practice Bulletin No. 123: Thromboembolism in Pregnancy. Obstet Gynecol 2011 Sep; 118:718.



Summary and Comment

The Volume–Quality Relation in Obstetrics

Providers with lower annual delivery rates had higher maternal obstetric complication rates.

Critical assessment of quality of care in obstetrics has been relatively slow compared with that in many medical fields. In other surgical specialties, low hospital and provider volume has been associated with poor health outcomes. Now, investigators analyzed data from a nationwide sample of 380,000 deliveries in 2007 to determine whether similar associations exist in obstetrics. Hospitals and providers were stratified into quartiles based on delivery volume; among providers, rates ranged from <7 (lowest volume) to Description: ≥90 (highest volume) deliveries annually. Obstetric complications included severe perineal lacerations, postpartum hemorrhage, infections, and thromboses.

After adjustment for medical and pregnancy-related risk factors, complication rates were 50% higher in women delivered by lowest-volume providers than in those delivered by highest-volume providers (17.8% vs. 12.7%; P<0.001). The only significant relation between hospital volume and obstetric complications was higher risk for infection in higher-volume hospitals.

Comment: Consistent with findings in some other surgical specialties, an inverse relation characterizes provider volume and rates of maternal obstetric complications. This study was limited in that providers were not characterized beyond annual volume, even though factors such as medical specialty and total years of clinical experience would be interesting to know. Although the results might be viewed as lending support to expanding the ranks of obstetric hospitalists or to public reporting of outcomes to improve quality, I agree with the authors that the best use of data such as these is to identify practitioners who need supplemental training and support.

Allison Bryant, MD, MPH

Published in September 29, 2011Journal Watch Women's Health


Janakiraman V et al. Hospital volume, provider volume, and complications after childbirth in U.S. hospitals. Obstet Gynecol 2011 Sep; 118:521.


 “obstetric violence” was recently introduced as a new legal term in Venezuela,

According to an editorial [link requires subscription] published last month in the International Journal of Gynecology and Obstetrics, the law defines obstetric violence as “…the appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, an abuse of medication, and to convert the natural processes into pathological ones, bringing with it loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women.”


The Biggest Change in Women's Rights since they got to Vote


One of the many supportive doctors I've worked with over the years sent me an email today that got me thinking.

He (yes - a male doctor) had written, "it's a major breakthrough. The biggest change in women's rights since they got to vote" (in response to the NICE Guideline news).

I realized that just because we take the vote for granted as a good thing now, this doesn't mean that the women who campaigned had much support at the time - and least of all from other women.

Which is precisely what I've been finding over the past few days.

Many women (and particularly those who've already had their babies) are blogging, tweeting and phoning into radio shows to voice their disapproval of maternal request cesareans.

Education is Key

And perhaps this is not so shocking, especially when you consider what a massive change in public knowledge, understanding and awareness of the facts now needs to occur in order for some people to better understand why NICE has revised its recommendation.

It has been accepted for so long that vaginal delivery is the norm, and that when it comes to childbirth, natural is next to Godliness, some see women who choose a cesarean as being rather closer to the devil incarnate (e.g. selfish, posh, wasting NHS resources).

Women - Their Own Worst Enemies

This view is of course disconcerting at times, but I am comforted by the fact that at the time of the Suffragettes' campaign to ensure women were given the right to vote, not only was there strong opposition from men, but moreover, some of the most vehement condemnation of their ideas came from women.

For example, some said that they didn't even want the right to vote and would never choose to use it if they had it; others felt that it might upset the established balance of things - a woman's natural place was in the home.

And then there was the argument that I think matches particularly well with the view that pregnant women shouldn't be involved in cesarean decision-making at all - this should be the sole charge of medical professionals:

"The vast mass of women are too ignorant of politics to be able to use their vote properly."(*)

Sovereign Criticism

Even Queen Victoria herself was not at all enamored by the campaign.

According to Lytton Strachey's biography 'Queen Victoria' (cited here), "In 1870, her eye having fallen upon the report of a meeting in favour of Women's Suffrage, she wrote to Mr. Martin in royal rage--

"The Queen is most anxious to enlist everyone who can speak or write to join in checking this mad, wicked folly of 'Woman's Rights,' with all its attendant horrors, on which her poor feeble sex is bent, forgetting every sense of womanly feeling and propriety.

"Lady--ought to get a GOOD WHIPPING. It is a subject which makes the Queen so furious that she cannot contain herself. God created men and women different--then let them remain each in their own position.

"Tennyson has some beautiful lines on the difference of men and women in 'The Princess.' Woman would become the most hateful, heartless, and disgusting of human beings were she allowed to unsex herself; and where would be the protection which man was intended to give the weaker sex? The Queen is sure that Mrs. Martin agrees with her.""

Social Change

Also, as I've written about before, there are many, many people who fear the consequences of NICE's draft recommendation - what will the world do if more women decide to choose surgery?

What will happen if we empower women, provide them with all the facts and allow them to make an informed choice about how they want to give birth (at least those who want to make a choice - remember that many women are content with a more paternalistic approach in maternity care)?

The Future

No one can know for sure, and only in the future will we be able to look back and make a judgment call on whether NICE has done the right thing this week.

But personally, having communicated with the women that I have, I'm convinced that there is no other ethical way forward than to support maternal request, and I commend NICE for taking this historical step forward.