Reply turned post, three way mirror style

This was a reply to Jill from the Unnecesarean’s thoughtful comment on my already-a-reply-turned-post about requests for cesareans for moms who were tired of pushing. (See why I called it “three way mirror style”? It is a post of replies reflecting upon replies…)

That is a really good point. I have discussed this with my faculty adviser at school. He thinks elective cesarean section is a valid choice in the patient choice spectrum, and is an integral part of reproductive rights and patient autonomy. I sometimes wonder if I am rigid in my ignorance of what the “real world” is like in practice, and if I would consider doing some elective cesareans in the future.

Even when I was writing this post, I paused at the last paragraph and thought a lot about my language. I will tell people that I don’t think cesareans are medically justified in many situations, and that I would advise against them in situations that are medically normal (like a not-even-prolonged 2nd stage) when the risks outweigh the benefits.

The only person I know well who opted for a true maternal request elective cesarean had a family history of complications in labor and delivery. From what I have heard, none of these would indicate that she would have similar issues (I think one was a severe shoulder dystocia with a poor outcome), but I can clearly see her fear of vaginal delivery. I have strong faith in genetic issues with labor and delivery. Women deliver like their mothers and sisters, and I take do not take these concerns lightly.

I think this is a fine line that needs a lot of cooperation between patient and doctor, and an acknowledgment that this is a gray area. (OK, I have a feeling this is turning into a reply-turned-post). I know many people want a strong balance of maternal rights with practitioner or government legislation. Limiting women’s choices for elective cesarean might also limit her access to homebirth. Or VBAC. Or selective reduction. Or abortion.

I think this is a topic that needs to be discussed with a lot of nuance (der) and there is room for a balance between evidence based medicine, patient autonomy, informed consent, and yes, sigh, provider conscience. I am strongly in favor of all of these thing with a passion that sometimes makes ethical hypotheticals (as of now, who knows what I will be facing in the next few years?) very challenging.

I strongly support the right of refusal of care. I am not as fervent about the right to interventions that are not evidence based. That is one of the ways I base my ethical decision making. I am much more willing to listen to an argument against intervening rather than for intervening, for the most part. This consideration seems more likely to prevent an overzealous practitioner from pressuring someone into an unwarranted procedure or medication. Or, an uneducated or emotional patient or guardian insisting on an invasive procedure that is either elective or not indicated, that has inherent risks over any potential health benefits. Or, less likely to favor patients who insist on the latest advertised medication for PMDD or the latest compounded hormone recommended on Oprah. Most favorable health outcomes based on available literature is also a large factor for me. Luckily, for obstetrics, these two things tend to go hand in hand.

As of right now, this is how I think I will handle maternal request for elective cesarean. I will inform them of the risks versus the benefits of all of their options. If they seem to understand that cesarean section on a healthy mother and fetus with no medical indications for surgery has more risk than benefit to the mother and fetus (according to current literature), and still want a cesarean, I think I will politely refer them to one of my peers who I think is an excellent surgeon and wish them the best.


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27 responses to “Reply turned post, three way mirror style

  1. I think your approach to maternal-request cesareans is a good one: give them sound information and refer them elsewhere if they still wish to have an elective CS. I don’t think refusing to do elective CS with no medical indication is the same as restricting access to VBAC or homebirth, etc. A VBAC or birth at home are something that will happen inevitably; in other words, they aren’t medical procedures. A restriction on VBACs, then, isn’t simply *not* doing a medical procedure because it will happen on its own. So that’s the big difference I see between VBAC and ECS: one will happen spontaneously, while the other is a surgical procedure. Thus I think it’s ethically justified as a health care provider to refuse to do an ECS, while I don’t feel it’s ethically/morally right to mandate that women *have* to have a repeat CS. Make sense?

    • Based on the fallacious argument that c/s and vaginal birth are simply two equal ends to pregnancy that both result in a live baby (usually) and live mother (usually), then it would seem to me to be ethical to offer or recommend either. However, as you stated and as I stated in my original comment, they are not apples for apples. If an end to pregnancy can occur in the car on the way to a c/s appt, they are not in the same category even if they both result in a separated mother and baby.

      I do believe it is ethically justifiable to refuse to perform elective procedures, especially major abdominal surgery, in the absence of evidence. So does ACOG.

      ACOG’s stance on the ethics of maternal request c-section is the following:

      In the case of an elective cesarean delivery, if the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than does vaginal birth, then he or she is ethically justified in performing a cesarean delivery. Similarly, if the physician believes that performing a cesarean would be detrimental to the overall health and welfare of the woman and her fetus, he or she is ethically obliged to refrain from performing the surgery. In this case, a referral to another health care provider would be appropriate if physician and patient cannot agree on a method of delivery.

      So as long as you BELIEVE that what you are doing has some benefit to the woman and fetus, you’re behaving ethically. So what if you BELIEVE that c/s is not a negative outcome but simply an equal or superior alternative? Then it’s ethical (according to ACOG’s opinion). It seems then that if you DO NOT BELIEVE that VBAC is safe or that vaginal birth of a suspected macrosomic fetus is safe, then you can refuse to participate in the birth. A doctor could refuse to catch the baby, which will exit vaginally and spontaneously within 43 weeks whether a c/s is on the calendar or not. The total absence of medical intervention does not, of course, guarantee perfect outcomes for everyone. Then again, neither does a c-section. There are no guarantees.

      Whether it’s ethical to perpetuate VBAC bans, gross overuse of inductions and gratuitous cesareans is, in my opinion, subject to the provider’s core beliefs about birth in general. If enough physicians feel that a c/s is the safer, more controlled and more humane alternative to vaginal birth, the ethics of banning vaginal birth in hospitals will probably never be challenged on a systemic level.

  2. I completely agree with Rixa here. And I see the point that if we as providers refuse access to maternal requested c-sections, does that also lead to providers refusing access to other women’s health options? Your approach is very realistic and honest. I wish I could say that of all providers (doc’s and mid-levels) who “don’t do________” (fill in the blank for whatever medical procedure) and then don’t refer the women to another provider who can do what they are requesting or need.

    • MomTFH

      No kidding. I had an ob/gyn refuse to insert an IUD in me, saying I was a bad candidate because I was divorced (huh?) even though I was in a monogamous relationship, was not then or ever positive for GC or chlamydia, could not take hormonal birth control, had a child already, and wanted long term birth control. She not only told me I was a poor candidate, she told me if I went to another clinic to get one they were just greedy for my money and that it was a poor medical decision. She told me that they did not protect against STDs, and then proposed that I use the NuvaRing.

      Umm, what part of no hormones and still doesn’t protect against STDs makes the NuvaRing a more appropriate choice for me?

      Then, when I showed back up pregnant less than a year later (you didn’t see that coming, did you?), and I told her I wanted to use a midwife for my delivery, she literally yelled at me and stormed out of the room and slammed the door.

      Yeah, there are ways to explain your decision making to patients without sounding like a judgmental fool that doesn’t really care about your patient’s needs and desires.

  3. As you will read from my blog and the links to my main website and online petition on this subject, I wholly support a healthy woman’s decision to choose the risks and benefits of one birth plan (i.e. cesarean delivery) over another (i.e. vaginal delivery).

    I think you strike a very positive and understanding tone in your post, and I just wanted to highlight one of the statements you make as something you may actually want to investigate further. You write that ‘cesarean section on a healthy mother and fetus with no medical indications for surgery has more risk than benefit to the mother and fetus (according to current literature)’ but in fact both ACOG and the NIH have reviewed the current literature and concluded that it doesn’t have ‘more risk’, just different risks, and that therefore this birth plan is a legitimate decision.

    The biggest problem in comparative studies is that they look at spontaneous vaginal delivery (SVD) OUTCOMES and then compare these to various cesarean delivery types when in reality, SVD is entirely unpredictable and cannot be guaranteed for any woman. A more appropriate and accurate comparison would compare ALL the outcomes of a planned vaginal delivery (incl. instrumental and emergency cesarean delivery) with the outcomes of a planned cesarean delivery.

    The majority of ‘current literature’ fails to do this and is therefore often biased favorably towards vaginal delivery. As a trainee medical professional with an evidently open mind, I hope that you will look into this further.

    • MomTFH

      The current literature I have read does indicate that cesarean section, in general, is higher risk for the fetus / baby and the mother than cesarean section, but that primary section without labor is better than emergency section after trial of labor. However, just as we have to take into consideration the complications that can happen from a spontaneous vaginal delivery, we also have to consider the risks not only of a primary cesarean delivery, but of repeat cesarean deliveries, which are almost mandated in the current medicolegal environment.

      Not only is each subsequent cesarean delivery inarguably riskier, but the state maternal mortality reports in Florida list cesarean section as an INDEPENDENT risk factor for maternal mortality.

      I also disagree that ACOG’s position statement on elective cesarean states that it is not more risky than spontaneous vaginal delivery. And, I heard a keynote speech at an ACOG convention delivered by Ralph Hale, MD, VP of ACOG, just last year lamenting the non-evidence based increase in primary cesareans without medical indication, and he quite specifically said he was personally shocked and disappointed that so many of their members agreed to do them. Their position statement advises that the physician evaluate the risks and benefits to the specific patient, it does not say that each choice is equally risky to a mother with no medical indications for surgery.

      The current literature is not biased towards vaginal delivery,it is a collection of evidence that points to higher risks of unwarranted surgical interventions. And, your statement was frankly biased against vaginal delivery. Every decent study takes into account trial of labor with intended vaginal delivery with operative outcome if that ends up being the outcome. A trial of labor is unpredictable, but so is spinal anesthesia and major abdominal surgery, especially if it is repeat cesarean surgery, but with extra risks included.

      • I completely agree that the literature shows increased risks with repeat cesarean deliveries, and I’d like to just state for the record that I don’t view primary planned cesareans as being free of risk either – rather, that they are no more risky than a primary planned vaginal delivery. Each birth plan carries DIFFERENT risks, and women will have different tolerance levels for these different types of risks. ACOG and NIH both warn that CDMR should only be considered by women planning small families, and I would add that with fertility rates being lower than 2 in large parts of the developed world, this is entirely possible.

        Regarding maternal mortality, you might be interested in these studies that show the LOWEST rates with planned cesarean delivery:
        *UK study of more than 2 million women >24 weeks EGA. Fewer maternal deaths with elective CD (n7; 0.31 per 10,000) than any other delivery type (Treadwell M, BTA, 2008)
        *U.S. study in Massachusetts 1995-2003; risk of maternal death with primary elective CD is less than that associated with VD; also, death directly due to surgery itself is extremely rare (Berger M and Sachs BP, 2006)
        *U.S. study in Massachusetts 1954-85; CS-related deaths per 100,000 live births did not significantly change despite quadrupling of CS rate; In fact, mortality rate for CS = 5.8 per 100,000 and VD = 10.8 per 100,000 (Sachs et al, 1988)

        I met with and interviewed Ralph Hale, MD, VP of ACOG in 2005, and you can read the full transcript of this interview on my site. He told me that he is supportive of CDMR. Also, I didn’t say that ACOG says ‘each choice is equally risky to a mother with no medical indications for surgery’ – please review my previous post.

        I stand by my point that much of the current literature is biased towards spontaneous vaginal delivery (SVD) – simply by virtue of the fact that the evaluation and even categorization of SVD as a stand-alone OUTCOME of a PVD is irrelevant in any true comparison at the birth PLANNING stage. You say that ‘every decent study takes into account trial of labor with intended vaginal delivery with operative outcome if that ends up being the outcome’, but I challenge you to identify a body of research that includes emergency cesarean outcomes at the end of PVD (in terms of physical, psychological and/or financial outcomes) when making comparisons with a planned CD. For many years, emergency cesarean outcomes have actually been taken and merged with planned CD outcomes – and then compared with SVD! If this is not biased towards SVD outcomes, then I don’t know what is.

        Again, I agree that spinal anesthesia and major abdominal surgery are unpredictable, and I would add that there is the risk of human error too. Please understand that it is not my aim to argue that planned CD is ‘safer’ than PVD; it is my view that ALL birth plans are inherently risky. I just don’t believe that women planning a small family who want to avoid a trial of labor should be denied the legitimate option of a planned CD at 39 weeks EGA.

  4. MomTFH

    I just reread the ACOG statement. Here is a link(pdf), not sure if non ACOG members can access it through this path, but there are other options available if you let me know.

    We are definitely reading the information from different viewpoints. However, I think we can agree that the outcomes discussed in this paper definitely compare elective cesarean without labor to the combined outcomes of spontaneous vaginal delivery, operative vaginal delivery and emergency cesarean after trial of labor. This ACOG position paper in particular quotes about a dozen studies. That seems to be the standard of the admittedly small amount of literature on the subject they chose to review.

    After reading the review, I think the evidence is pretty strongly stacked against primary elective cesarean delivery, even giving it the best case scenario of a patient who only wants one child, and waits until 39 weeks. The increased risks goes up with the second child, and as this position statement clearly warns, half of pregnancies in the United States a re unplanned. Just as spontaneous vaginal delivery does not occur in the most ideal circumstances all the time, neither does cesarean section. I am sure you acknowledge that not all, maybe not even most elective cesareans happen at 39 weeks or later with a solid EDD, a test for lung maturity and a first time mother.

    I understand that you have an objective to promote elective cesarean birth. This and other ACOG statements do not, in my mind, support it as a justified intervention. Interventions, especially major surgery with significant anesthesia that modifies future birth modes of delivery, do not simply have to be possibly as risky as the alternative. They have to be medically justified. You do not give a patient a drug or perform a procedure and say, “If we’re lucky and the circumstances are ideal, we MAY break even.”

  5. This is what ACOG wrote in 2003:

    “In the case of an elective cesarean delivery, if the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than does vaginal birth, then he or she is ethically justified in performing a cesarean delivery… ACOG cautions that “both sides to this debate” must recognize that evidence to support the benefit of elective cesarean is still incomplete and that there are not yet extensive morbidity and mortality data to compare elective cesarean delivery with vaginal birth in healthy women. With better data, there may be a shift in clinical practice.”

    I would also recommend that you read the NIH statement following its 2006 state-of-Science conference on CDMR, during which members of the panel looked at far more than a dozen studies.

    You’re correct that there is a small amount of literature on this subject specifically, but there is actually a great deal of literature on the risks of vaginal delivery – the avoidance of which is one of the main benefits of a planned cesarean delivery (hence the term ‘elective prophylactic cesarean delivery’).

    You’re also correct that neither SVD nor CD ‘occur in the most ideal circumstances all the time’, but just because there are planned CDs carried out at less than 39 weeks (for various reasons – the vast majority being medical), this should not be a reason to deny cesarean surgery to a woman who is completely willing to wait until 39 weeks EGA. It is also important to understand that while all births are unpredictable to a certain extent, a planned CD has a far greater likelihood of resulting in a PCD than does a planned SVD have of resulting in a SVD.

    Finally, you actually misunderstand what I am saying if you think my ‘objective [is] to promote elective cesarean birth.’ On the contrary, as I explained at this weekend’s Controversies in Childbirth conference, my goal is to promote true childbirth autonomy for all women (see the group I co-founded last year – and to campaign for greater clarity in the collation of birth data. The reason I highlight the risks of vaginal delivery is not because I want other women to avoid it, but rather to illustrate the legitimacy of a woman choosing planned cesarean delivery in order to avoid it. I have many friends who have had vaginal deliveries, and if that is the birth plan a woman chooses, she has my total support.

    As for your last point about ‘breaking even’, I think you will never find the evidence you are seeking if you expect to discover a straightforward answer on which birth is ‘safer’. Vaginal and cesarean delivery have different risks and benefits, and there are different percentage likelihoods of these risks for different pregnancies. But most importantly, you need to appreciate that women’s personal tolerance of each set of risks is an important factor too.

    For example, the Declercq et al study in 2007 found that postpartum difficulty was “most frequently cited by mothers who’d had a cesarean delivery” – 79% in the first two months and 18% by the sixth month. By comparison, between 43% and 68% of mothers experienced a painful perineum in the first two months following vaginal delivery, and this number reduced to 2% by six months.

    Well some women may have a personal preference with regards to the location of their postpartum pain, and so even if the incidence of pain is lower following VD, a 43- 68% chance of perineal pain is still an unacceptable risk, whereas pain in the abdomen area (even for a longer period) is not. This is just one example of where looking at the numbers alone will not provide the most effective measure of informing women of which delivery is ‘safest’ in a woman’s mind.

    • Benjamin Sachs (co-author of two of those studies) called the c-section rate too high at 22% and argued that reducing it could harm women and babies. I wonder what he feels about it now that it’s 10% higher.

      Traveling the web arguing that surgical birth is as safe as vaginal birth seems to be getting some interesting results. Your link pops up in Google Alerts from time to time and it’s usually prefaced with something like, “OMG, can you believe this?” In the recent NY Magazine home birth article comments, someone wrote, “I’m sorry, but: Electivecesarean is nuts.” I don’t think you’re nuts.

      Health-wise, your argument’s ground seems shaky. Maybe that’s why no one shows up on your debate site to debate you? If there were myriads of women requesting c-sections, I think people might view maternal request c-sections differently. How many women are actually requesting c-sections that are not at their doctor’s behest?

      Respectfully, I’ll never view surgery as safer than something that could happen with no one around in the hospital parking lot. “ALL birth plans are inherently risky”? Nah. They’re just not. Maybe from your vantage point as someone that’s not interested in vaginal birth.

      You know what I could get into? Emotions. I don’t buy the “too posh to push” crap. I would be interested to hear to struggles of all of the women who are terrified of birth or disgusted by birth or just don’t want to give birth. I would love for more women to be able to break their silence and let go of feeling bad about not wanting to give birth vaginally. Isn’t that part of the effort to trying to convince people that CDMR is a legitimate decision? It’s not all quoting the research du jour, is it? Maybe if people rethought their biases on women’s duties, roles and responsibilities when it comes to reproduction, the decision would be viewed a legitimate. In the meantime, vaginal birth remains a safe physiological function.

      Openly discussing how some women don’t want a baby coming out through their vagina would probably go over like a lead balloon at first in the fashion of Hanna Rosin’s anti-breastfeeding article in The Atlantic. People would go crazy wondering what this world has come to when MOTHERS don’t want to just be MOTHERS and do motherly things like give birth, whatever, etc., etc. [Insert mad discussion about evolution, pelvises, Nazis, Aldous Huxley, derogatory terms for vaginas and more]. When all of those crazies leave, I could see true maternal request c-sections garnering some understanding.

      Maybe some birth stories if women are comfortable sharing their experiences? What is tokophobia like? How often does it get diagnosed? What kind of discrimination do women who simply don’t want to give birth for personal reasons experience? Since maternal request c-sections are so rare, I think most people (like me) are ignorant to the issue because we don’t really know anyone that requests one. Help us out!

  6. MomTFH

    I don’t think the hypothetical chance of being the 2% that 6 months out may have continuing perineal pain (which is repairable with minor surgery in many cases) is enough for me, as a practitioner, to consider major surgery a viable intervention.

    There is a certain amount that I value patient autonomy and input, but many patients in many situations have unreasonable expectations. I do not think maternal cesareans should be illegal. However, I will choose to advise against them and any other intervention that arguably has higher risks than avoiding the intervention. Vaginal birth and cesarean delivery are not equal interventions. One is an intervention: cesarean birth. For me as a practitioner to subject a patient to a procedure with the extensive list of maternal risks in the ACOG position statement, I would need evidence of benefit.

    I believe in a woman’s right to choose that mode of delivery, I just think it is not advisable and would refer out. I don’t have time for a point by point rebuttal now.

  7. MomTFH:
    I appreciate your point about the difficulty in terms of finding time for a point by point rebuttal, and I must of course accept that it is your prerogative to refer women to other doctors. I also respect the fact that you are not seeking to deny women their choice of mode of delivery; only that you would rather not personally provide this particular choice.

    I hope you don’t mind me adding one other comment, but I just wanted to address your concern re: ‘I don’t think the hypothetical chance of being the 2% that 6 months out may have continuing perineal pain (which is repairable with minor surgery in many cases) is enough for me, as a practitioner, to consider major surgery a viable intervention’

    In my blog post of March 28th – ‘Caesarean beliefs ‘misguided’ – says misinformed article’, I give a number of examples of research papers that cite the long-term damage associated with planned vaginal delivery (e.g. pelvic organ prolapse (POP), urinary incontinence and fecal incontinence), of which these are just three examples:

    *Swedish study of a total 1.4million women found the ‘strong and statistically significant association’ that CD ‘is associated with a lower risk of POP than VD.’ (Larsson et al, 2009)
    *Norwegian population-based study of 2,001 randomly selected women found that 118 (6%) women reported symptomatic prolapse. In multivariable analysis, the risk of prolapse was significantly increased in women with one, two, and three or more VDs compared with nulliparous women. (Rortveit et al, 2007)
    *Australian study of 801 women with a mean age of 55.3 years (range 17–90) found 79% complained of SUI and 28% of symptoms of prolapse. The risk of levator trauma increased for every year of delay in child-bearing and operative VD was associated with a near-doubling of the odds of trauma. ‘The global trend towards delayed child-bearing may result in an increased prevalence of pelvic floor disorders in coming decades.’ (Dietz et al, 2007)

    Again, I am only trying to stress that there are women for whom these risks outweigh the risks associated with planned surgery, while others will agree with you entirely – that the risk is still relatively small and if it happens, they are comfortable with having minor surgery to repair the damage.

    Best wishes with your studies, and thank you for taking the time to discuss this with me.

  8. Dear Jill: I don’t believe that there are necessarily ‘myriads of women requesting c-sections’, but the data that does exist regarding numbers suggests that there are more women requesting cesareans than there are women choosing to deliver their babies at home.

    Your response to my comment that ‘ALL birth plans are inherently risky’ is of particular interest to me, as I recently had this very discussion with vaginal birth advocates. We knew we had opposite points of view, but we sat down and talked through all of our arguments for and against different birth plans in an open and supportive way, and it turned out that this issue could be the fundamental point that distinguishes us from one another. You see, they, like you, feel that birth is ‘inherently safe’ while I feel that birth is ‘inherently risky.’ This may sound too simple a way to define our different perspectives, but it really seemed to make sense as we talked.

    Your other comments about ’emotions’ are also interesting, and indeed intuitive; I have some data that addresses this precise area in fact. When women who have chosen cesarean delivery are asked for their reasons, many DO say that they have a fear of or are terrified by vaginal delivery, and yes, some even say that they find it disgusting.

    That said, I receive emails from women with many reasons – yes, that they are too frightened to go through a trial of labor, but also that they feel cesarean delivery is safer for their baby and they are more tolerant of its maternal risks than those associated with vaginal delivery. I agree that the issue of fear of birth is definitely part of convincing people that CDMR is a legitimate decision, but demonstrating that CDMR has been shown to have fewer risks in some studies is also important – as many OBGYNs (my own included) agree with. Unfortunately, it has been my experience that tokophobia is often dismissed as a psychological reason to be treated with antenatal counseling or alternatively, simply offering these women access to an epidural during labor to relieve their pain. In other words, they are denied access to cesarean surgery.

    This is why I work so hard to quote research. I feel that the word ‘safe’ in the context of childbirth is very subjective, and besides that, there are also some women who simply don’t want or have no desire for a vaginal delivery experience. Like you say, ‘openly discussing how some women don’t want a baby coming out through their vagina’ can be tricky, but I can honestly say that I have put this point of view across too. Indeed on Friday of last week at the CIC conference, I said, ‘I have two options for how my baby comes out of my body, through my vagina or through my abdomen, and I have chosen the latter’.

    You sound like an open-minded person that is willing to listen to both sides of this debate, and I appreciate that you show an interest in the plight of women who experience tokophobia and the discrimination faced by some women who choose CDMR. I can only say that I am working as hard as I can to get this information into the spotlight, together with my wonderful partners at the Coalition for Childbirth Autonomy, and while we do so in the face of much criticism, the women we receive emails from are our main concern.

  9. MomTFH

    Although I am not going to completely refute both new comments, I did want to point out that the two meta-analyses (ACOG and NIH) that YOU link to both state that vaginal birth has a weak or no association with a higher risk of lasting sexual dysfunction or fecal or urinary incontinence. The NIH meta-analysis says there is NO evidence of increased organ prolapse with vaginal delivery.

    Make sure you are not quoting studies that include operative vaginal delivery. You seem to want to quote the vague, analyzed meta analysis when it comes to the risks of cesarean, but your standards aren’t as high when it comes to the risks of vaginal delivery.

    If I cherry picked through the articles in the NIH meta-analysis, I could post up risks to the mother and baby that sound much more significant than non statistical increases in temporary stress incontinence. Respiratory distress, placenta accreta, NICA admissions, etc.

    As a practitioner I will not recommend any intervention: drugs, medical devices or surgery, without evidence that there are health advantages.

    The option for delivering a baby is vaginal. A surgical delivery is a major medical intervention if there are complications with this natural status quo. If one of my boys is afraid of defecating (withholding of stool – there have been news specials on how to deal with it in your kids, it is not uncommon) I am not going to have his stool surgically removed and put in an ostomy bag. Of course, unless he has a medical condition indicating that this is the correct course of action.

    It’s my son’s birthday. Let’s retreat to our respective corners on this one, OK?

  10. MomTFH: I am happy to retreat to our respective corners as I too have many other things that need to be done today. However, as I’m sure you can appreciate, I’d like to defend myself against your new personal accusations. First of all, I do not cherry-pick; if you look at the dates of the studies, you’ll see that the very reason I’ve quoted the 3 studies that I have on POP is because they have been published SINCE the ACOG and NIH statements we have been referring to. Therefore I believe they are relevant.

    Secondly, your request that I do not quote ‘studies that include operative vaginal delivery’ highlights perfectly our different perspectives on how comparative analysis should work. Why shouldn’t every possible outcome of a PLANNED vaginal delivery be used in order to assess the risks and benefits of a vaginal delivery PLAN – both short- and long-term outcomes? And I do not shy away from highlighting planned cesarean risks either; I have whole sections on the risks of placenta complications, adhesions, respiratory illness (to name a few), as I believe a woman should be fully informed of ALL the potential risks of surgery.

    As for your comparison of women choosing cesarean delivery being akin to the surgical removal of a child’s stool, I feel that (as so often happens in these discussions) we have ventured into fairly insulting territory, which is very disappointing.

    • Nobody is calling anyone’s baby “feces.” I’ve heard people horrified of hearing how bearing down in childbirth can feel like defecating. I do think it probably comes down to that polar opposition in beliefs that you mentioned. Birth is safe versus birth is dangerous. Bodily functions are normal versus bodily functions can be bypassed by choice. No moral right or wrong—just different.

      I’m glad that MomTFH hosted a discussion on her fab blog. It has been hard for me to form any opinions on maternal request c-section since I only know one person who’s requested one. I’ve never wanted to totally dismiss the issue as a non-issue or a straw man because I know for the handful of women who really, really don’t want to go through vaginal birth, it is important. I am listening. I could hear a lot better if the “issue” were humanized. The point-by-point debate tactics kind of take away from the big picture for me.

      See y’all on the internetz.

  11. MomTFH

    I do not believe it is insulting. A phobia of vaginal birth is not an indication for surgery. Just as a phobia of defecation is not an indication for surgical removal of impacted stool. A bowel obstruction would be.

    Every outcome of birth, planned or not, is a consideration. Emergency cesarean outcomes are as relevant when discussing planned cesarean birth just as much as operative vaginal delivery is relevant when discussing planned vaginal birth.

  12. “Why shouldn’t every possible outcome of a PLANNED vaginal delivery be used in order to assess the risks and benefits of a vaginal delivery PLAN – both short- and long-term outcomes?”

    Why? I’ll tell you why – because vacuums and forceps are not a normal part of birth. They are an intervention, decided by a doctor, with increasingly less evidence to support their use. If we want women to understand SAFER birth, we need to explain that there is a difference between a completely natural, supported birth with a trained, experienced birth professional (i.e. midwife) VS a birth smothered in convenience-based procedures performed by doctors for no evidence-based reason.

    The argument is not between “Vaginal” vs “Cesarean.” The argument should be between “Natural” vs “Unnatural.”

    Natural birth has consistently better outcome than does a birth with forceps, vacuums, Pitocin, or scalpels. If you try to tell women that all vaginal birth is the same, interventions or not, they aren’t getting the truth. There must be a distinction.

    I hate to say it, but women need tough love in this department. Our society is too brain-washed for many women to make this “cesarean” decision on some gut fear of childbirth. Many of us (self included) didn’t have a clue how important natural birth was until it was taken away/cut out of us. Trust me, if you’ve never had a cesarean, you are NOT missing anything – oh, except a life-changing uterine scar and serious emotional trauma.

  13. The Birth Trauma Association supports women who have had traumatic experiences in childbirth. Many traumatic deliveries arise from planned vaginal deliveries that either go wrong and end in instrumental deliveries/emergency caesarean or start with induction. It is true that these are not ‘normal’ dleiveries but it is also true that in countries where there is no access to intervention, many women and babies die unnecessarily during childbirth. It is ALSO true that some women are traumatised because they dreamed of a natural birth but were traumatised because it became meidcalised.

    What is needed is respect for the values, attitudes and beliefs that individual women have about childbirth. A good experience of childbirth can be a natural birth or a caesarean depending on the woman’s point of view. So what is the difficulty about recognising that women have different perspectives?

    Beliefs about birth are hard to shift so why do women try? We accept that people can hold different religious beliefs so why is it so challenging that women have different beliefs about birth? Why is it impossible to see that a woman who wants a caesarean can be as informed and passionate about what she wants as a woman who wants a home birth? Should we not respect the wishes of all women?

    • MomTFH

      I do respect patient autonomy. However, I also would not write a prescription for a drug unless there was a medical indication, even if the patient wanted it. I will refer that patient to someone with no judgment or hassle. I will just simply say it is not in my scope of practice. Same thing if someone asks me for an antibiotic when they have the flu.

      Even the ACOG position on elective cesarean says that a woman who is simply afraid of the pain of a vaginal birth should be counseled and offered adequate pain relief.

      We do try to shift women who have a dysphoric view of other issues. We try to convince anorexics to change their behavior. We would try to modify the behavior of someone who is drug seeking. If a patient wanted unnecessary liposuction or repeat plastic surgery, many doctors would turn it down if they deemed the procedure more harmful than helpful.

      If a woman who was low risk came to me and wanted amniocentesis, chorionic villi sampling and an induction, I would also turn her down and explain why, and encourage her to look for a practitioner who would. If the community supports elective cesarean as acceptable standard of care, which it seems to right now, it is fine to me that some physicians choose to perfrom them and some mothers choose them. That does not mean I have to agree that it is sound.

    • Is “fear of childbirth” really an “informed” decision? No, it is not. We fear what we do not know or understand. If a woman is asking for a cesearan because she has researched every statistic and understands every possible alternative, THEN she is informed. But asking for a life-altering procedure based solely on fear makes as much sense as cutting off your nose for fear you’ll break it one day.

  14. Anon

    “The Birth Trauma Association supports women who have had traumatic experiences in childbirth. Many traumatic deliveries arise from planned vaginal deliveries that either go wrong and end in instrumental deliveries/emergency caesarean or start with induction…..It is ALSO true that some women are traumatised because they dreamed of a natural birth but were traumatised because it became meidcalised.”

    Many normal births go wrong simply because woman are sexually assaulted during birth in the name of the debunked Friedman’s Curve, prolonged labor due to invasive examinations and medications, and operative birth which includes everything from episiotomy to cesarean. Providers are not giving women the opportunity to give legal valid consent because it requires too much time and would cause women to refuse interventions. Instead, women are coerced and criminally assaulted without necessity in the name of defensive medicine, protocols, and provider preference. Then, if the assault results in a c/s, the provider has illegally provided repeat trade for the industry which is currently banning VBAC, and through some women being too traumatized to even consider trying to go though VB “after what happened last time.”

    The fact is, that the pitfalls of drugged labors and operative birth have been researched and recorded and have been available for over 20 years, and the change in practice has been to INCREASE their use. Seeing these tactics defended sickens me.

    Natural, unfettered birth is a human right. In hospital it is a “dream” only because the trade organizations are holding on to drugged operative birth as a proliferation of trade. Are women allowed to position themselves comfortably? NO. Are they supported by staff during birth? NO. Are they encouraged to go with out drugs? NO. Are they told the truth about drugs, prolonged labor, and operative birth? NO. Are medicos hiding behind a standard of practice, which, if amended, would render half their numbers out of work? YES.

    So, please, no more of this bullshit that women are choosing c/s for their own reasons. We are talking about women whose doctors are encouraging and manipulating their fear for their own ends, and who know that they are practicing without consent. These people do not deserve to hold their degrees, and I see that the profession itself is responding to this obvious abuse of power by beginning to speak out publicly. I believe a class action lawsuit against ACOG and the AMA for organized crime and trafficking in women in children would balance out the scales of justice and return money stolen from insurance companies and the taxpayers quite neatly, and provide for the many emotionally and physically scarred customers who were relying on their doctors to be, well, doctors, and not deviants.

  15. Anon

    B.M. Morgan et al., ‘Epidural analgesia for uneventful labour’, Anaesthesia, 35 (1980), 57-60

    E. Tronick et al., ‘Regional obstetric anesthesia and newborn behavior: effect over the first ten days of life’, Pediatrics, 58 (1976), 94-100

    J.F. Pearson and P. Davies, ‘The effect of continuous lumbar analgesia the acid-base status of maternal arterial blood during the first stage of labour’, Journal of Obstetrics and Gynaecology of the British Commonwealth, 80 (1973), 218-24

    J.F. Pearson and P. Davies, ‘The effect of continuous lumbar analgesia upon fetal acid-base status during the first stage of labour’, Journal of Obstetrics and Gynaecology of the British Commonwealth 81 (1974), 971-4

    J.W.W. Studd et al., ‘The effect of lumbar epidural analgesia on the rate of cervical dilation and the outcome of labour of spontaneous onset’, British Journal of Obstetrics and Gynaecology, 87 (1980), 1015-21

    I.J. Hoult et al., ‘Lumbar epidural analgesia in labour: relation to fetal mal-position and instrumental delivery’, British Medical Journal, I (1977), 14-16

    Roberto Caldeyro Barcia, ‘Some consequences of obstetrical interference’, Birth and the Family Journal, 2:2 (1975), 34-7

    G. Tutera and R.O. Newman, ‘Fetal Monitoring: its effect on the perinatal mortality and Cesarean section rates and its complications’, American Journal of Obstetrics and Gynecology, 122 (1975), 750-54

    T.J. McManus and A.A. Calder, ‘Upright posture and the efficiency of labour’, Lancet, I (1978), 72-4

    etc., etc., etc.

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