Monthly Archives: April 2010

Fantasizing about residency sites

I have been doing more research on residency sites. I have been searching the far corners of the intertubes, from sites as divergent as the dreaded SDN to the dreaded MDC, with a little help from FREIDA and APGO.

I have three top sites identified right now. One is an old favorite, one is an old favorite that fell out of favor, but further research has given it a renewed shine. And, a new up and coming favorite.

The old stalwart: OHSU in Portland, OR.

The old favorite that is back in favor: MAHEC in Asheville, NC.

And, my new love: St. Luke’s / Roosevelt in New York City.

New York City. Ulp!

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Reply turned post, Mothers in Medicine specialty style

There is a new post up at Mothers in Medicine. It’s a letter from the mailbag, from an ambitious high school junior named Taj, who knows that zie wants to go to medical school, and will be starting an accelerated BS/MD program soon.

Taj writes:

I am really interested in anesthesiology and cardiology so my question is really for MommyDoctor and JC. I wanted to know how and when did you ladies juggle and decide when to have kids and also what do you both love about your careers?

Taj goes on to say that zie is also interested in ob/gyn and thoracic surgery. I was surprised to see such a wide range of specialties that I see as really, really different from each other.

I wrote a reply that I wanted to reproduce here, since it’s about how I ended up where I am. But, please go check out the original post, especially to see if the contributors that Taj asked talk about their choices and paths, too.

Here is my reply:

I know I wasn’t specifically addressed, but I just wanted to jump in and say something. Hope that’s OK.

I have a different perspective than the contributors you asked, and I hope they weigh in from the point of view as someone who is living with their career choices. I am sure they all have really good things to say about the specialties you are interested in. I am halfway there, and you sparked some thoughts.

Congrats on knowing that you want to do something in the medical field, and good for you for planning and thinking in advance. I am a big advocate for dreaming and planning ahead, because the shlep to the light at the end of the tunnel in medicine is a long one.

I noticed that the three areas you are interested in are quite different types of medicine. Anesthesiology is a completely different life, not just lifestyle, than ob/gyn, with a completely different type of interaction with patients (asleep vs. awake, acute vs. long term).

A thoracic surgeon (9 years of training, general surgery (6)–>thoracic surgery (3) ) is much different that going into internal medicine (3 years) then a cardiology fellowship (another 2 t0 3).

I think you will see which specialty and training requirements suits your temperament and interests the best. I was convinced during my premed that I wanted to be an endocrinologist. But, after spending just a little bit of time with pregnant women, I was sold on ob/gyn and have never looked back. That was after swearing I would never be interested in ob/gyn. But, I haven’t done my clinical rotations yet.

I think I could never do anesthesiology, because I love patient interaction and continuity of care (and, frankly, I wouldn’t have the grades to go gas if I wanted to). I couldn’t do orthopedics because it seems like bicycle repair to me, and I would be miserable. I couldn’t do pediatrics, because I would cry all the time. I can barely make it through a lecture about a sick toddler without tearing up.

I am thrilled there are people who are attracted to these other specialties, and hope they love their careers. I would hate for anyone who is ill-suited for ob/gyn to end up there, also. It is a unique area in which you interact with people who are on a wide spectrum of well to sick in a lot of important and highly emotional times in their lives. It is a great balance between surgery and medicine.

I tell people to sign up for email table of contents of the main journals in each field, and glance over them once a month. If the titles excite you, and you want to click through and read the abstracts of at least a few of the articles, then that may be a good field for you. If all else fails, you can try out Fizzy’s handy guide to choosing a specialty.

Good luck!

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Hellooooooooo?

I am in a childless house. S is with his dad, and Z is spending the night at a friend’s.

I am not sure what to do with myself! Should I read? I have quite a few books to read, including Pollan’s In Defense of Food and Atwood’s The Flood. I could read some of the 1572 posts in my Bloglines Reader. I could do some yoga. I could cook.

I think I am going to put on this podcast on “Listening Generously” that was recommended to me by a friend. I may listen to it in bed. And if I fall asleep, so be it.

I live in the fast lane.

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Things to read

I have a new post up at Mothers in Medicine, my first official post as a contributor, not a guest. Exciting! Please check it out.

There is also some interesting discussion going on in the comments of this post about breastfeeding and shame. I am not as involved in discussions online about breastfeeding as I was when I was breastfeeding. It is still a difficult topic, and I only want to delve into it occasionally, for reasons that are pretty obvious in the comments.

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Reply turned post, same old song about breastfeeding shame

On my Facebook page, I linked to this article asking the president of Facebook to change its policies on breastfeeding. In case you don’t know, Facebook considers photographs of breastfeeding to be obscene, and deletes them as pornography. Yet, they put underwear advertisements from American Apparel on my homepage.

The letter uses statistics from this recently publicized article from Pediatrics that enumerates the risks of our low breastfeeding rates in the United States in numbers of money spent and lives lost. This is a common way to discuss large scale public health issues. But, as usual, someone wants to hold breastfeeding to a different standard than other health issues.

A former friend of mine, who I thought I had blocked on Facebook, but I guess I hadn’t, replied with this comment:

i’m all for facebook changing its policies, but i don’t think that we need to demonize women who choose not to (or cannot) breastfeed.

*facepalm*

OK, I know the post took the mortality numbers and ran with them. I have to admit, they are startling numbers, and there is something about putting a mortality number on something to really drive home how policies can really affect public health. It’s all theory on the internet when we’re bloviating about whether breastfeeding in public is obscene, or whether being “pro-life” really can be reconciled with being against legal and safe abortion, but numbers of actual deaths per year are a powerful, powerful argument. There is nothing inherently different about breastfeeding that makes it somehow sacrosant, however, and therefore we cannot use our most powerful tools to promote it. There was not ONE word in this article that I thought demonized women who choose not to breastfeed. It acknowledged how breastfeeding successfully, even getting out of the hospital breastfeeding, needs a lot of support and education. It needs all the help it can get, and treating photos of breastfeeding like pornography on the most popular, incredibly pervasive social media outlet in the world may be a factor in the public perception of breastfeeding. Period. It wasn’t this post that linked breastfeeding to preventing almost 1000 deaths a year. It was the researchers who were published in Pediatrics, and then the article was publicized by outlets like CNN.

Here was my reply:

I don’t think that this post does that. It is a letter to the president of Facebook about its policy on breastfeeding photos being obscene, and draws attention to the fact that breastfeeding is important by using real epidemiological statistics on the public health effects of the low breastfeeding rates in the country.

I know that discussing breastfeeding’s very real health benefits may make women who don’t or can’t breastfeed feel bad, and that’s a shame. It’s hardly the most important point, however, as the statistics in the article clearly explain, and isn’t a reason to suppress real public health statistics on its benefits. It’s hard to discuss breastfeeding without talking about the true risks of low breastfeeding rates, and how these low rates may be related to how it is treated by various media sources, including social media.

One journal article on why women choose not to even initiate breastfeeding showed that the most prevalent reason was fear of what others, especially their partners, will think of them. The public shaming of breastfeeding is an important topic, even when discussing why some women choose not to breastfeed.

I didn’t see one line in this piece that said women who don’t or can’t breastfeed are wrong in any way. It’s an important health decision with important health consequences, and when I talk about it as a public health issue, I am not commenting on individual women’s health choices, which, when regarding many aspects of pregnancy, birth and parenting, are complicated and multi factorial. I don’t think this piece was, either.

In fact, in the comment section, I think the author answers this point rather well. Mothers, especially first time mothers, cannot make an informed health decision about breastfeeding when the behavior is shamed socially by prominent, pervasive outlets like Facebook. When mothers who don’t breastfeed have their bottle feeding pictures banned from Facebook for being pornographic, then we are talking about a similar issue. Otherwise, I don’t this article has anything to do with demonizing women who don’t breastfeed, but is rather about shaming women who do.

********************

I want to add, since this is my blog and not Facebook, that this is a major pet peeve of mine, and this person knows it. I hate that almost any internet discussion of breastfeeding is derailed by “Don’t hurt mothers’ FEELINGS!!!” and accuses me of being unsupportive.

I have a very good friend who had an awful struggle with breastfeeding who eventually had to give up and use formula, another who had to stop due to allergies that led to constant GI bleeding and anemia in her child, and a few cousin Susans who didn’t breastfeed after the first feeding or two in the hospital. I was a doula to a mother with MS that couldn’t breastfeed because she wanted to go back on her medications. I find it really insulting to be told that I am not supportive of mothers, since it is something I take very seriously. I have wiped tears off of a mother’s breast while helping her tape tubing of an supplemental lactation system to her breast, and I doubt any of these people who have accused me of that have ever been that supportive of mothers trying to breastfeed without judging them. And, I think crying “FOUL!” any time the subject comes up allows people to have an excuse to not consider the true risks to not breastfeeding, and casts it as a lifestyle decision rather than a health decision. And, I think this recasting of breastfeeding is a major reason why women choose not to do it.

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Michel Martin rocks the mic

I have been a Michel Martin fan ever since I got satellite radio, and I was able to listen to her NPR show Tell Me More. She is a great interviewer, and I love the Barbershop segment.

But, it’s her “Can I Just Tell You?” commentaries that really impress me. She is thoughtful, analytical, intelligent, and not afraid to draw conclusions and make judgment calls. So much of journalism is pure regurgitation of talking points, it is refreshing to hear someone, especially a woman of color, not just break news, but put it back together, to paraphrase an NPR advert.

Well, her most recent “Can I Just Tell You” segment, No, We’re Not Going to Sit Down and Shut Up made it on my Newsfeed on Facebook, since I am a fan of NPR. Good for them for trying to increase exposure to this commentary.

She not only crosses ideological lines to defend Sarah Palin from some pretty atrocious sexism, but takes the unfortunately predictable blame-throwing response and uses it to paint a really insightful big picture. I recommend you read or listen to the whole segment at the link above, but here is a particularly great part:

“I cannot help but think that what the fury is really about is the loss of entitlement. It used to be that men with a shred of power could say whatever they wanted about women and women had to put up with it, or get a man to duel for them or something. Well now women get to rock the mike too.

It used to be, and often still is, that one set of values or perspectives dominates the way we look at issues and talk about them. You can see where the people who share that particular perspective begin to feel they are entitled to shape the conversation for all time. But things change — new voices rise, different people win elections, or dare we say it, get on the radio. Maybe some people have a problem with that. Tough. Because we’re not going anywhere.”

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Reply turned post, patient safety and midwife witchhunt style

This is a reply to Amy’s fantastic post about patient safety and the marginalization of midwives. While physicians have flocked to defend and rationalize an induction and cesarean on a non-pregnant woman with pseudocyesis, she points out that the same community often villainizes midwives for less.

She wrote:

The consensus on Facebook and around the web was that if midwives had been involved in an incident of this magnitude, they would have had their licenses revoked post-haste. Why? Because all kinds of disciplinary actions are made against midwives, whether they are practicing safely or not. Very often, the complaint is issued by a physician rather than a patient.

Dr. Amy swooped in to criticize direct entry midwives (pretty much proving the point) and a midwife named Margie wrote a gorgeous comment defending direct entry midwives that is as worth reading as the original post. For example:

And, if you think that CMN’s are the answer then you need to open your eyes and look around you. You would see communities such as mine where there is a population of nearly 2 million people without a single hospital that allows CNM’s to handle childbirth; a community that doesn’t have a single freestanding or hospital connected birthing center; a community with a cesarean section rate nearly 40%. In our state as in the majority of states, a CNM is regulated by the state nursing board and hey[sic] are pretty much treated like any other nurse in that state, unable to do anything without a doctor taking full responsibility. If, as you stated, these CNM’s are so educated and capable, then why are they still treated as underlings of the birthing community? Why are they not allowed to practice midwifery as they see fit? Why are they not allowed to make serious pregnancy and delivery decisions and only call in physicians when they feel it’s appropriate? Why are they not allowed to do procedures that they feel skilled in, such as vaginal breech deliveries, even though the doctors they work with are not skilled with or comfortable doing? Why are they NURSES first and then midwives?

Once you go and read Amy Romano’s full post and Margie’s full comment, you can come back and read my reply:

***********

Margie, that was wonderful! *clap clap clap*

Amy, thanks for this post. I wish I had made a comment last night when I read it for the first time, but I needed some time to process it. I still don’t know if I can articulate a good thought, but I’ll try.

This is why I left midwifery and went to medical school. I was training with a direct entry midwife. She was being investigated for delivering an IUFD. It was a known IUFD. The father of the pregnant patient was a practicing ob/gyn in another state. He sat in on an ultrasound, and talked with his daughter about inducing at a hospital or waiting to go into labor and going ahead with a delivery at the birth center. She wanted to deliver naturally at the birth center, and did with his support, blessing, and presence.

The problem came when the midwife needed someone to sign the death certificate. She called around to physicians and the medical examiner, and one of them called in a complaint to the health department.

Apparently, state law requires that a midwife in Florida only participate in the delivery of what should be a healthy, uncomplicated labor and delivery of a healthy, normal baby. Although there was no question as to whether the prenatal care was adequate or if the IUFD could have been avoided, she is still being investigated four years later.

Yes, their constant probing has uncovered disgruntled former employees with dirt to dish, irregularities of paperwork, and the like. But, as my medical jurisprudence professor taught us, anyone can be busted for paperwork or charting errors. Anyone. They will find a technical error. It doesn’t matter what the complaint is about, they will pull years worth of charts (like they did with her – 5 years worth) and pore over them to find any charting error.

She has had to continue to try to run a birth center with all of her charts missing, various inspections and raids, and scrutiny of her past patients and anyone who has ever worked with her. All for delivering a known IUFD with compassion the way the patient wanted it to be, with no complications.

There are a lot of reasons why I decided to go to medical school. I had planned on it before midwifery school, actually. But, this was the event that led me to leave midwifery, especially direct entry midwifery, and go to medical school. I did not want the scrutiny, the bizarre overregulation, (at least in Florida – mandatory transfer of any postpartum patient with total blood loss of more than 500cc, for example), the lack of respect, or the hostility from the mainstream obstetrical community. I didn’t want to sit there with an impending investigation for what I would consider good care, going over five years of charts, terrified that I made a mistake, tempted to go back and “fix” items here and there on charts of uncomplicated, healthy, successful deliveries, to make sure that there were no holes or oversights that would cause me to lose my license.

I figured I could go into medicine and get away with a helluva lot more. I am not going to jump on a physician bashing bandwagon or anything – I respect many, many obstetricians and other physicians, and think that it is a wonderful field, or I wouldn’t be joining it. That being said, after being to a lot of hospital births, either as transfers from our center or as a doula or friend of the patient, I saw just how unsupervised and unscrutinized a private obstetrician with hospital attending rights can be. As long as you are not violating a major policy, like allowing trial of labor for VBAC *eye roll*, or letting patients and fetuses die, or majorly abusing the staff, there is an awful lot of pure, unadulterated autonomy. For all of the malpractice complaints, obstetricians should be happy that their practice patterns and standards of care just have to meet a bare minimum (baby comes out) to not get investigated by the licensing board. If every doctor I know who didn’t give informed consent before an episiotomy, (much less did one as a routine practice!) or had more than 500cc of blood loss without calling in a specialist had to worry about losing their license, it would be a very different atmosphere. Not that I think that is the answer. I just didn’t want to live with that spectre looming over me. I took the malpractice boogeyman instead. (which midwives still have to deal with, too.)

I completely agree with Amy. Punitive measures aren’t the answer. I am not asking to have these obstetricians run out of town, tarred and feathered. I think the whole system needs to be examined, focusing on the needs of the pregnant women, first.

That means recognizing and treating mental illness without doing an unnecessary induction and surgery, and then blaming and ridiculing her afterward. No sane woman goes through a two day induction and cesarean without being pregnant. Sane women who are pregnant want to avoid that! That means not investigating their practitioner for delivering their IUFD in an environment that was safe and good enough for a live fetus. That means allowing near miss reviews and apologies from physicians without placing them in legal jeopardy. That means not pitting obstetricians and midwives on opposing sides of a battle, where it seems women and babies are the ones caught in the crossfire.

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Reply turned post, advice on VBAC in rural New Mexico?

I replied to a post on Shakesville in which a community member who is pregnant after a prior cesarean asks for advice in seeking a VBAC in rural New Mexico, when the nearby hospitals have a no VBAC policy.

This is my reply:

You can contact me at hilseb at gmail dot com, if you’d like. I know a bit about this. I am in medical school, and am planning to be an ob/gyn. I am doing a research fellowship on obstetrics right now. I am a big proponent of evidence based medicine, which means I am a big proponent of VBAC.

Here is a link to all the blog entries at my blog I have written on VBAC. That’s just the first page. Click on older entries, and the list goes on. Just to give myself some cred, if my alleged bio doesn’t.

Here (pdf) is the incredibly recent, like published last month, and very thorough NIH evidence report on VBACs, which concludes “This report adds stronger evidence that VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans.”

Here is an excellent academic article on risk and pregnancy written by the American College of Obstetrics and Gynecology risk task force that has some very supportive language on offering VBAC and how to present risk to obstetric patients. According to this article, “Although rates of delivery-related perinatal death are indistinguishable between VBAC and primary vaginal delivery, there is a genuine differential in the rate of uterine rupture–related hypoxicischemic encephalopathy. Such perinatal morbidity is indeed devastating. It is also extremely rare. In a recent large prospective study, the probability of this outcome was 0.00046 in infants whose mothers underwent a VBAC trial at term compared with no cases in infants whose mothers underwent repeat cesarean delivery.” (emphasis mine)

Here is the website for ICAN, the International Cesarean Awareness Network. Here is their page on VBAC. Here is their VBAC reading list. Here is their database on hospital policies on VBAC. Here is their FAQ on how to face a VBAC ban. Unfortunately, there is no New Mexico chapter listed on their site, but there is a national group, an AZ group, and lots of resources available.

Here is a link to my buddy Jill’s incredible blog, the Unnecessarean.

I have been to many, many beautiful VBACs, most of which were successful, safe vaginal deliveries, which goes with the 75% to 80% “success” rate numbers abundant in the literature. Even the ones that ended in a cesarean were happy, healthy births that fit the informed consent of the pregnant person.

Please, please, don’t hesitate to contact me, if this post hasn’t overwhelmed you.

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If anyone else has any advice, please comment at the original post at Shakesville.

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Second stage, take center stage

When Amy announced the Fifth Healthy Birth Blog Carnival Get Up, Stand Up, which is based on the Lamaze Healthy Birth Practice “Avoid giving birth on your back and follow your body’s urges to push,” I knew exactly what I was going to write about. I have been planning a post on the second stage of labor, which is the pushing stage, for a while.

To me, this is the neglected part of birth, which is surprising, because it is, well, the actual birth part of the birth. Many women, even if they are the birth advocate types, focus more on the pregnancy, then some thought to the first stage of labor – the dilation and effacement process. OK, let’s not talk about what I think most women do. Let’s talk about my first birth.

I chose my provider and my place of delivery. I chose a midwife who delivered at the hospital near my house. I thought choosing a midwife meant I would have a “natural” birth, and having the baby in the hospital meant I would have a “safe” birth, and didn’t give it much more thought than that. Not that I didn’t give pregnancy, birth and parenting much thought. I was a pre-medical student and a voracious reader who worked in the health food industry. Trust me, there was thought. I read Mothering Magazine, Parenting Magazine, Healthy Pregnancy. I read What to Expect When You’re Expecting. This was 1999. The internet was decade younger, and so were my friends. I didn’t consider myself to be a particularly young mother at 25, but I was the first out of my group of friends to have a baby.

Since a recent newspaper article I had read (in the real paper, they didn’t have archives on the internet at the time, much less cesarean rates by hospital by state, thanks to the wonderful birth advocacy bloggers we have today!) said that my hospital of choice had a 50% primary cesarean rate the year before, I thought using a midwife and not electing to have an epidural would lessen my chances of a surgical delivery, since I was low risk in every other conceivable way. I was also terrified of the epidural, since my brother had just had a spinal tap, and said it was the worst experience of his life. Unlike many pregnant moms, I was told horror stories about spinal punctures, not labor pain. Ha! Imagine if it was the other way around. Anyhoo, back on track…second stage, right.

I ended up flat on my back (with pitocin and external fetal monitoring) pushing against a cervical lip for three hours, while being barked at and blamed by my CNM. I don’t look back on my first stage of labor as painful, even with pitocin, no epidural, and being placed on continuous monitoring. I remember that midwife trying to rub out my inflamed cervical lip with horror, however. I remember begging her to stop, and feeling defeated while I was forced to push, and push, and push, as my mother, husband, and even the labor nurse looked on with dread. I was unprepared for pushing the first time around, and terrified of it the second.

I was not allowed to labor down. I never felt the urge to push. I wasn’t encouraged to stand up. The bed wasn’t raised, I wasn’t told to get in the Captain Morgan position (*wink wink nudge nudge* Amy). I wasn’t allowed to be in any position but flat on my back. I was told by my midwife that my fetus showed signs of distress on the strip and this was the only safe say to be. Know that I know a heck of a lot more about pregnancy, birth, and cardiovascular physiology, I find this laughable and despicable on her part.

Finally, I peed (hey, it’s a medical and birthy blog – get used to the TMI!) all over the midwife (ha! karma!) and then the baby came out soon after. Maybe if I was allowed to walk around freely (like, to the bathroom to empty my bladder after my IV infusion…) I would have been able to deliver my son a little more easily.

It’s not just the attitude of the midwife that I found troubling. Looking back armed with a lot more knowledge, it was her bluster with an absolute LACK of evidence to back her up that I find truly appalling. I was at another birth recently, of my cousin Susan, and it was an affront to evidence based medicine from beginning til end. At one point in the fiasco of a second stage, the NICU doctor rushed in. The obstetrician was so horrified at the possibility of a shoulder dystocia that she called in every available practitioner on the labor floor. (The fetus was not predicted to be macrosomic, the mother was not a gestational diabetic, and there were no other predictors of dystocia, but the obstetrician mentioned it so many times during the pushing stage that the mother to be actually told her to “shut up about it already, I get it” and then the doctor said she had to mention it repeatedly for legal reasons….huh?) I was at the mother to be’s head, supporting her, talking to her softly, and supporting the back of her neck and head when she was pushing.

The NICU doctor placed herself right next to me, and when the pushing started up again, the NICU physician turned to me and started chastising me loudly, saying I was “doing it wrong”. She ordered me to painfully shove the mother’s head into her chest so that her chin was hurting her. She kept saying “harder!” to me, not the mom, and finally said “No, like THIS” and shoved her head so her chin hit her sternum.

I was furious. What was worse, the husband started watching me with every push, and would tell me if he thought I wasn’t pushing her head into her chest hard enough.

If my cousin wasn’t about to push out her son, and I wouldn’t have been completely out of line with a physician at an institution where I would most likely be doing clinical rotations, I would have LOVED to step out of the room with the NICU doctor and ask where the literature was on chin and neck positioning during the pushing stage, and what measurements had been done of the force of shoving the mother’s head into her sternum to determine the proper crushing force. Like the existing evidence on upright positioning, which the mother to be had to insist on after some time on her back. The NICU doctor didn’t tell anyone to stop directing her to do Valsalva (holding your breath and pushing against a closed throat instead of unrestricted breathing) pushing, and didn’t ask if anyone allowed her to labor down and wait for an urge to push before ordering her to push. That didn’t seem to bother the NICU doctor.

But I didn’t. I stayed with my friend, who asked to be repositioned even more favorably in an even more upright position. The obstetrician acquiesced (yay!) and the baby was born soon after.

This is the first post in a two part series. Being at a primip delivery can be hard,

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Cesarean Awareness Month

I’m not that great when it comes to participating in scheduled bloggy things, such as Wordless Wednesday or NaBloWriMo or whatever it is. Not that I begrudge anyone who does it – they have their blogging acts together better than I do. I promise I will do a submission for the Fifth Lamaze Healthy Birth Blog Carnival. Soon. Promise.

But, in the meantime, I would like to at least acknowledge Cesarean Awareness Month, sponsored by ICAN.

In case you haven’t heard about the latest cesarean rate numbers, please read this article at ICAN’s blog about the 53% increase in cesarean section delivery in one decade.

What is most surprising (and disconcerting) to me is this quote: “The most significant increase is among women under 25, up 57% since 2000.” So, the largest increase has been in the group that are LEAST likely to have comorbidities, especially the advanced maternal age (AMA) patient blaming I have heard as an excuse. This does not bode well, considering these under 25 year old mothers will most likely have no other choice but to get a repeat cesarean section with any subsequent pregnancies, since VBAC is getting vanishingly rare.

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