Thursday, June 27, 2013

Sweet and Sour

Recently, a friend pointed me in the direction of a blogpost - one where the author was excited about having a date for her elective cesarean. Of course, such a post will draw some criticism, typically from a Natural Child Birth True Believer - the following is just such a comment on the original post.

Anonymous - June 26, 2013 at 9:20 AM

Every mother has the choice to schedule a C- section. I understand that it may be right for you but I also very much believe that women need to be informed about the ways to have an empowering birth. Women need to trust in their bodies and research midwifery and the benefits of having natural birth. The birthing process begins the bond betweek mother and child. If both are on drugs and unable to have that immediate bond, it starts a life and a relationship out with stress and disconnect. With thousands of readers, I find that you have an amazing platform to discuss empowering birth options and educate women and pregnant mothers everywhere. I find that the rate of C-sections IS an issue, an important one to talk about. While you may not want to appear apologetic, I still feel that talking about it would continue a conversation that needs to be brought up again and again. I am a long time reader of your blog and I really do respect all mother's decisions. I just feel strongly about the casual nature of this post and the casual nature of all the women commenting about planned C- sections.

It's these kinds of comments that continue to astound me - how can women be so ignorant and judgemental of other women's choices? I found myself responding with the following comment.

Mrs. W. June 26, 2013 at 10:58 PM

Danielle - you are so much more gracious than I would be.

Anonymous - Danielle or anyone else does not need to justify their choice to have a cesarean to you - you are not their doctor, you are not their spouse and you are not their child. Please start with the assumption that women who choose cesarean are doing so from a position of choosing the birth that is best for themselves in their own particular circumstance. After all, most mothers who choose cesarean are capable of assuming that your choice to pursue a natural birth is an informed choice that you have made after having determined that it is best for you and your family in your particular situation.

I understand you are concerned about the rate of cesareans - however, I would argue that such concern is woefully misplaced and the focus on a specific procedure or process (normal birth), results in a complete blindness to what really matters. What really matters is getting through birth healthy and happy - what really matters is avoiding trauma and life long disability or death. Having a normal birth is not and should not be the goal - it forgets all the days that follow. If it can be achieved (and the mother wants it) safely, then great - but if the mother doesn't want it or it puts her life or the life of her child at risk, then is it worth being able to say that you pushed a baby through your vagina? Isn't being a woman about more than what you can do with your body, isn't it time that biological essentialism be laid to rest? Further, it's a rather cheap shot to declare that cesarean mothers don't or can't bond with their children as well as mothers who gave birth naturally - as a mother who ADORES her 3 year old, I can say that bonding with her was far more difficult than bonding with my 9 month old - I love them both but the PTSD her unwanted normal birth resulted presented specific challenges.

We don't measure the rates of women denied informed consent during birth. We don't measure the rates of women unable to access adequately trained and qualified care providers for prenatal care and birth. We don't measure the rates of births that result in post-natal PTSD. All of these things matter far more than whether or not the birth was a result of a cesarean.

I challenge you to become more informed on the issue of Cesarean by Choice. A good place to start might be Pauline Hull and Magnus Murphy's book "Choosing Cesarean: A Natural Birth Plan". Also look at the blogs Cesarean Debate and Awaiting Juno. And though you may hate me for it - browse through Dr. Tuteur's blog (the Skeptical OB) for a look at the seedier and far less respectable side of natural birth.

Friday, June 21, 2013

A Cesarean by any other name

There seems to be some confusion when cesareans are discussed, with elective cesareans often being confused as all being maternal request or patient choice cesareans. While the vast majority of maternal request or patient choice cesarean are elective, not all elective cesareans are patient choice or maternal request cesareans and the vast majority of elective cesareans have clear medical indications for being performed. The term "elective" simply means that the procedure was scheduled in advance - and given that maternal choice cesareans account for maybe 2 percent of all deliveries - it is very likely that the elective cesarean in question had a medical indication for being performed (breech, big baby (macrocosmic), etc.).

Maternal request or patient choice cesareans are those that are performed because the mother has decided that she prefers cesarean delivery over an attempt to deliver vaginally. And for some reason, many people get all hot and bothered when a woman who potentially could deliver vaginally chooses not to. It is almost as though they see a woman making a choice that is different from the one that they would make as being some kind of criticism of the choice they would make. It is very similar to those who are up in arms about a man or a woman's right to marry a partner of the same sex - even though giving a person the right to marry who they want to has absolutely no impact on their own ability to marry who they want to.

To be fair the terminology in discussing maternal request and patient choice cesareans does leave a little to be desired. I find request to be a really weak word - it paints the woman as almost having to "beg" for the treatment of choice. Similarly I find the word demand - as in "patient demanded cesarean delivery" to be really aggressive. I have come to prefer "patient choice cesarean delivery", but even that seems to negate the very real need for a cesarean delivery to occur once a patient has decided that it is her preferred mode of delivery. After all, we do not call patient chosen cancer treatment, patient choice chemo or patient choice radiotherapy. That being said, I am not sure what better terminology could be used.

Regardless, patient choice cesareans are not worthy of the disdain they seem to attract - particularly from those with absolutely no medical training.

Saturday, June 15, 2013

Congratulations Kanye and Kim - Wishing You the Best of Luck

Kim Kardashian gave birth today - and invariably there was reports it was an elective cesarean. And then a while later it was reported that she delivered "naturally".

The comments section on the elective cesarean story is like NCB (Natural Child Birth) activists greatest hits. With such tried and true statements like, "a cesarean is major surgery", "recovery from a vaginal delivery is so much easier", "our bodies were designed to do this", "how selfish", "cesareans should be reserved for those who need them", "cesareans are more dangerous for the baby", etc.. It seems as though almost everyone is an armchair OB, and if they could have a natural delivery - why couldn't Kim suck it up and have a natural delivery too?

I'm a little tired of the armchair OB's in this world and would like to put out the following:

1. Yes, cesarean is surgery it has risks, but vaginal delivery is a major medical event that also has risks. Discuss both options and their associated risks and benefits with your care provider - ideally someone with a real qualification for childbirth that was earned at an accredited post-secondary institution and not Google U or Anecdote High.

2. Recovery from a vaginal delivery is not always easier than recovery from a cesarean delivery.

3. Our bodies weren't designed. They evolved - somewhat awkwardly with tradeoffs made between head size and pelvic girth. Birth is not an easy process for many women. Many women historically died. Many babies historically died. Some were disabled. Birth is incredibly painful for many women. If this is something we're "designed" to do - would someone please fire the designer, or at least start a class action for negligent design.

4. Cesareans have some serious risk avoidance benefits for the baby and for the mother and may in many cases be safer for the baby and comparably safe for the mother - again discuss this with a qualified care provider.

5. Choosing a cesarean is often the anti-thesis of "selfish", mothers who choose cesarean often knowingly increase some of their risks in order to reduce the risks of delivery to their child. That seems pretty unselfish to me. Or at the very least not more selfish than mothers who choose vaginal deliveries for the sake of "easier recoveries".

I do not really care whether or not Kim had a natural delivery (maybe she did) or elected to have a cesarean (maybe she did) for the birth of her child. I care that she was able to have an open and honest discussion with her care providers about the options available to her, that she was empowered to make a decision and have that decision respected, and that she and new baby are happy and healthy at the end of the day. It's what I hope every pregnant women is able to do - have access to appropriately trained care providers who can advise accordingly, retain the right to make medical decisions, have access to timely care and go home at the end of the day with a healthy baby in her arms being mentally and physically ready to start parenthood.

I partly wonder if reporting one mode of delivery and then the other mode of delivery is strategic - a way of keeping the actual mode of delivery between the mother and her care providers confidential. If so - that is not such a bad thing, but wouldn't it be even better if they were straight up with it and take a few notes from a commenter here a few days ago who offered something along the lines of the following "We'd like to maintain the confidentiality of the medical care received, but we assure you that the baby and the mother will be receiving the best care possible."

It is rather sad though, that such a personal decision can spark such derision. But given the derision that is associated with other personal mothering choices right now (formula versus breast-feeding, cry-it-out versus never cry, stay at home versus work out of the home, cloth versus disposables) that it is not really overly surprising.

I guess we're still a ways off from a world where the majority of comments following a celebrity birth announcement manage to ignore the mode of delivery and focus on what really matters - a healthy and happy mother and baby!

In closing, "Congratulations Kanye and Kim and Little Baby Girl K - wishing you a long, healthy and happy life together as a family!"

Monday, June 10, 2013

Why do women choose cesarean?

I still get annoyed when those who just don't get it attempt to speculate why women choose a cesarean delivery for their child, particularly in the absence of a medical indication for one. They continue to speculate that it is because some celebrities have chosen it. Or because they need to choose a particular day for their child to be born. Or because they need to schedule the rest of their lives to accommodate the arrival of their child. Or that women who choose cesarean are just uneducated and ignorant of the wonders of vaginal birth. The paradoxical bemoaning of cesarean being "major surgery that is much harder to recover from", while at the same time being "the easy way out" continues to boggle my mind.

The reality is that the women who choose cesarean are among the most informed women I have ever encountered - not only on the specifics of delivery by planned cesarean, but also the realities of planned vaginal deliveries. They have seriously considered both options and have decided that they prefer the risks and benefits of cesarean delivery over the risks and benefits of vaginal delivery for themselves in their own circumstances. Most of them have encountered significant resistance and challenge to their choice from family, friends and their own care providers. Few women who choose cesarean (particularly among primiparous women), simply choose an elective cesarean delivery and then have that choice respected and facilitated without challenge throughout their pregnancy. Women who choose cesarean, particularly without a medical indication for one, have to be strong advocates for themselves in order to survive the inevitable criticism of their choice and to overcome barriers to realizing that choice.

The reality is that women who choose cesarean, are not doing it to emulate some celebrity idol.

The reality is that women who choose cesarean, are not generally doing it to achieve some favourable birth day for their child as most women who choose cesarean also choose a delivery that is at 39 weeks gestation unless there is a medical indication for an earlier delivery.

Some women who choose cesarean are doing it out of an unreasoning dread of vaginal delivery. Sometimes this can be addressed with counselling, sometimes it cannot. For these women, a planned cesarean provides a tremendous amount of psychological relief and enables them to enjoy their pregnancies.

Some women who choose cesarean are doing it to avoid the vagaries of vaginal delivery. It's generally accepted that an uncomplicated vaginal delivery is easier to recover from and considered better for both mother and baby - but knowing that an uncomplicated vaginal delivery will actually materialize is something that can only be known retrospectively. Many women who choose cesarean are knowingly sacrificing a chance at the ideal outcome, in the hopes of maximizing the chance of a good outcome.

Some women who choose cesarean are doing so to protect the integrity of their pelvic floors and to reduce the risk of urinary and/or fecal incontinence later in life. It is true that pregnancy on it's own poses a significant challenge to the pelvic floor - but a vaginal delivery further increases the risk of damage. Often the solution to pelvic floor problems is surgery but unfortunately surgery often fails - incontinence products and pessaries are also an option to manage the symptoms. To some women, a cesarean is a fair price to pay to minimize the risk.

Some women choose cesarean because of serious doubts about the availability of effective epidural pain relief at their planned facility of delivery. For facilities that do not have dedicated obstetric anaesthesiology - there might be delays or complete lack of availability of epidural pain relief. Sometimes this can be addressed with a planned induction, sometimes it cannot.

Some women choose cesarean because of prior birth experiences that were traumatic. Birth experiences that resulted in extensive tearing. Birth experiences that had unmanaged and intolerable amounts of pain. Birth experiences that might have lead to urinary or fecal incontinance. Birth experiences that might have resulted in long term or permanent injury to their children (HIE, brachial plexus injuries). Birth experiences that might have resulted in PTSD.

Saying that women who choose cesarean do so because celebrities choose cesarean, or to fit a child into their busy schedules, trivializes what is a very serious choice for many women. It discounts the real reasons women choose cesareans and it makes life that much more challenging for those who are wanting to choose cesarean for the delivery of their child.

We don't say women choose vaginal delivery just because "they want an easier recovery" and go on to decry the choice of planned vaginal delivery as being selfish - so why do we trivialize and disparage moms who choose cesarean, after all for many moms who are choosing cesarean, their reasons for doing so are just as valid as the moms who are choosing a vaginal delivery?