The Flawed Assumption of Cost-effective Natural Birth

I'm an economist by training - but more than that, I am a health economist by profession. I understand (probably better than most) the concepts of scarcity, risk, cost, expected cost and cost effectiveness. I also understand the challenges that are facing our health care system - both today and going into the future.

Perhaps that is why I am particularly perturbed when time and time again I hear that reducing the number of cesareans would save the health system money and in particular how reducing the number of maternal request cesareans would save the health system money. On it's face it seems to be such a no-brainer, after all how could an expensive surgery (cesarean birth) compete with the free birthing procedure that nature gave us (unmedicated vaginal birth)?

Of course not using health system resources is cheaper (on its face) than using the health system.

Have a heart attack and die where you stand: $0 health expenditures, alternatively have a heart attack and go to the hospital, get a coronary artery bypass and go on to live another decade or two: A whole lot more than $0 health expenditures. Develop cancer and let the disease progress as nature intended: $0 health expenditures, alternatively going to your doctor, get diagnosed (likely via some screening program), get chemotherapy/radiation therapy, and either cure the cancer or buy some additional time: A whole lot more than $0 health expenditures.

Yet there is no widespread calls for natural heart attack therapy or natural cancer care. Anyone who stood on the corner saying that people should put the needs of the health care system ahead of their own needs - would be told to apply their 'natural therapies' to themselves and to stuff it.

The natural childbirth movement is standing on the corner and shouting (rather loudly) that women should forego medical care during birth because it will save the system money. What's worse is that government seems to be encouraging them to shout even louder.

The assumption that is behind this is that intervening in birth does not buy better health outcomes. Either that or, because the better health outcomes accrue to women and their children, they simply aren't "worth it". I would hope that it is the former rather than the latter driving the "save the health system money by avoiding cesareans" mantra.

Unfortunately this assumption is flawed and very likely, very wrong.

Intervening in birth by providing pain relief or access to surgical delivery for those who want or need it does buy better health outcomes and may even save the health system money over the longer term.

Those who choose cesarean are doing so for a wide variety of reasons. They are doing it so that they may avoid the risk of an emergent cesarean. They are doing it to avoid the risk of a perineal tears. They are doing it to avoid a pelvic floor injury. They are doing it to reduce the risk of developing urinary or fecal incontinence. They are doing it to reduce the risk of severe disability or death to their unborn child. They are doing it to better arrange the support resources they need during and after the birth. They are doing it to avoid the risk of having a traumatic experience. They are doing it to reduce the risk of developing PTSD or PDD. They are doing it to protect their sex lives. They are doing it to avoid the risk of severe, uncontrolled pain.

Chances are they are doing it for several reasons and in all circumstances they are doing it because the benefits of choosing to intervene exceed the costs and/or risks of not intervening at an individual level.

I would even be so bold as to argue - that the government would do well to spend MORE on maternity than it does now as the expenditures on maternity are likely to buy more than expenditures in other areas of care. Those served by maternity services tend to be young and as such any gains in health outcomes are likely to accrue over many years. A single case of cerebral palsy that is averted could save the health care system millions of dollars in costs of future care. Avoiding a pelvic floor injury that requires subsequent repair, would likely save thousands. Avoiding a case of PTSD or PDD, again would result in significant savings.

Further, it is unclear whether or not maternal request cesarean is even significantly more expensive than planned vaginal delivery to begin with. A study entitled "Cesarean delivery on demand: What will it cost?" in the American Journal of Obstetrics and Gynaecology Volume 188, Issue 6, pp. 1418-1423 found that the average cost difference between women who attempted a vaginal delivery and those who had an elective cesarean was just 0.2% in favour of vaginal delivery. Hardly a cost savings to deprive women of their treatment of choice - which is perhaps why many US health insurers (arguably even more keen to save money to boost profits than Canadian medicare) now cover elective cesarean section.

So why don't we start with the assumption that healthcare providers and mothers who choose cesareans are doing so in their own best interests and that they are no more "milking the system" than those with cancer or cardiac problems are "milking the system"? And maybe, just maybe we ought to look at the real economics of birth choice - the answers might be very surprising indeed.

Is CDMR a societal and professional failure?

In this month's edition of Lamaze's journal Birth - Dr. Michael C. Klein will publish an article entitled "Cesarean Section on Maternal Request: A Societal and Professional Failure and Symptom of a Much Larger Problem".

I wish that this article would focus on the professional and societal failure associated with maternal request cesarean and the much larger problem. However, knowing Dr. Klein as a staunch natural childbirth advocate who is ideological in his belief that medical intervention should play a minimal role in birth; I know that this article will disparage the choice that some women make to deliver by way of cesarean as being driven by misinformation and fear and will completely fail to address the much larger problem.

I would argue that the rates of maternal request cesarean are indeed driven by misinformation and fear. In short, I believe the risks and negative impacts of vaginal delivery are understated and the risks and negative impacts of an elective cesarean delivery are overstated. Further, I believe that the advantages of vaginal delivery are systematically inflated, while those of cesarean delivery are systematically discounted. I believe that the fear of surgery drives many women to avoid it - even when a surgical delivery would have resulted in a better outcome for either mother or child than a vaginal delivery. I also believe fear and misinformation drive a lot of women to forego epidural pain relief. Yes, fear and misinformation are a big problem when it comes to birth - and likely result in lower rates of maternal request cesarean and use of epidural pain relief than would be 'ideal' as many women who would have a much better birth experience by having an elective cesarean or using epidural pain relief forego doing so based on misinformation and fear.

I also believe that the situation around maternal request cesarean is a symptom of a much larger problem. That problem is that not all women are supported when it comes to the choices that they need to make during pregnancy, labour and delivery. That the information given to women regarding pregnancy, labour and delivery is heavily biased. That many women have difficulty finding a provider and a care facility that will be supportive and respectful of a mother's requests for cesarean delivery and in many cases even access to epidural pain relief. That many other women seem to think that it is okay to criticize the informed choices some women make to deliver by way of cesarean or use epidural pain relief.

I will also agree with Dr. Klein that the system of maternity care, particularly in British Columbia, is in dire need of reform - all pregnant women need to be supported and empowered to meet their own needs with unbiased information and access to medical care including access to surgical delivery and epidural anesthesia on request. All pregnant women need to know what their choices are, the risks and benefits of those choices and to have the right to informed consent. Further, all pregnant women need to know that their choices will be respected and confident that just because they are pregnant does not mean that they lose the right to decide what is done with their body.

Mum's the Word on Maternal Choice Cesarean

I never had any desire to have a vaginal birth. In another time or place, I may have considered foregoing motherhood or adopting rather than subjecting myself to the conventional whims of nature. However, knowing that cesarean was an option, I knew that foregoing biological motherhood would be an unnecessary toll for wanting to avoid a vaginal birth. I knew that cesarean birth was a feasible (safe and effective) way to have a baby - I lived in a first world country and could find nothing that indicated that women in Canada weren't allowed to have cesareans on demand or that such a choice would be inaccessible in my own community. For myself, it was clearly preferable over conventional birth. It seemed to me that the biggest challenge would be finding a doctor to accede to the request-but given the controversy around maternal choice cesarean, I knew that while many doctors would not accede to a request, that many other doctors would. I felt confident that I could secure a maternal choice cesarean before I even got pregnant - even if it would have meant travelling to access care.

That being said, I also knew that rejecting a conventional birth (a trial of labour in a hospital) would not be a socially acceptable choice. None the less, I was open about my plans during the pregnancy with my daughter. Not because I wanted the stamp of approval from others, but because I felt that it was important for others to know that it was an informed choice that I had made freely. A choice I felt best met my needs and those of my child. That I was happy with choosing cesarean, and that any concern about my birth plan was misplaced.

By the time I was admitted to hospital for the birth of my daughter, there was nothing that had been said to me that had changed my mind about vaginal birth or cesarean birth - not for the lack of trying by others and a hefty dose of misinformation about cesareans. Others regaled me with the horrors of cesarean birth - It's major abdominal surgery! The recovery is horrid! What about the scar! Adhesions! Infection! They further regaled me with the virtues of vaginal birth - it's the way nature intended! With an epidural, it's not painful! The recovery is easy! Thanks, but no thanks. Conveniently absent in the vaginal birth love-in was any acknowledgement of the virtues of cesarean (indeed it does have advantages) or the genital warts of conventional birth (indeed conventional birth is not completely a thorn-free bed of roses).

I was even open about my choice with hospital staff when I was in hospital awaiting for the cesarean that did not happen for the birth of my daughter.

My experience of vaginal birth proved to me why I had wanted to avoid it in the first place, even in the absence of the worst consequences of vaginal birth. I pooped in front of people. I experienced the worst pain of my life. I was terrified. I tore. My daughter needed narcan and resuscitation. I was left feeling violated and abandoned. I developed a vaginal infection. For more than a year afterwards, I had mild urinary incontinence. My enjoyment of intimate relations with my husband was adversely impacted. Memories of my daughter's birth continued to haunt me, and rather than looking at photos of that day with a sense of joy or accomplishment, they are a reminder of the worst experience of my life. I felt socially isolated among other mothers, particularly those with strongly held beliefs about conventional birth.

After my daughter's birth I understood why so many women who prefer birth by cesarean are mum about their preferred path to motherhood. I understood why some mothers make up a medical reason for their cesarean - it is far more socially acceptable to say you had no choice in the matter and in some cases making up a medical excuse might be the only way to access care. In some cases, where cesarean is seen as being inaccessible, some women are choosing to forego motherhood - choosing to prevent pregnancy, adopting or aborting. Other mothers are paying a hefty financial price for their preferred method of birth.

Indeed, during my pregnancy with my son, I found myself being a lot more mum about my choice.

However, being mum doesn't help other moms who share the same view on birth. Being mum does not make it easier for the next mom to make and exercise her choice. It does nothing to ameliorate the undeserved stigma or shame associated with being a woman who would prefer to avoid a conventional birth and choose cesarean. It does little to address the misinformation or myths about mothers who choose cesarean (the vast majority of whom are not "too posh to push"). It does little to address the misinformation or myths about elective cesareans as medical procedures - or even the misinformation or myths about other birth related medical procedures (such as epidurals). It does little to address the problem of those who would seek to deny moms like me their chosen path to motherhood and it does little to help women make truly informed decisions about the birth choices available to them (have I ever blogged about how little data is out there on maternal request c-sections and how they are not formally tracked in administrative databases???). Maternal choice cesarean needs to be an accessible, accepted, and respected choice - and as such moms like me can remain mum no longer.

Is encouraging homebirth in British Columbia to save healthcare dollars going to come at the expense of women and babies?

This morning I woke up to an article in my local paper with the headline Health Minister encourages home births in low-risk cases.

While I support the option of home birth as an informed choice that should be supported with access to qualified and regulated care providers in low-risk situations, encouraging it is another matter, and encouraging it to save money strikes me as being unethical and short-sighted.

I am tremendously thankful that home birth in British Columbia is highly regulated with care providers who are well trained - as it reduces the harm that may be incurred by those who would choose this option anyways. Further, I will begrudge nobody a natural childbirth - if that is what the woman giving birth desires. However, knowing that home birth in the Netherlands has led to low-risk women undergoing home birth to have worse outcomes than high risk women undergoing hospital birth with an OB, gives me pause for thought. The idea that in the vast majority of studies on home birth perinatal and maternal mortality and morbidity is significantly higher than that experienced with hospital birth (with the exception of the one study cited in the article), again gives me pause for thought. Knowing that a low risk woman can go from being low-risk to high-risk in a matter of minutes, further gives me pause for thought. Knowing that some of the consequences of birth gone wrong can be life long and devastating, further gives me pause for thought. Lastly, knowing there's a lot that "low-risk" women, particularly first-time mothers may not be told about birth and its attendant risks, makes me think that encouraging home birth is irresponsible. It also worries me that such a statement coming from the head of the ministry, a former doctor, may make women think that Homebirth is safer than it really is.

Further, such a stance worries me that the Ministry of Health in British Columbia thinks that it is okay to restrict access to medical care for women during labour and delivery for low risk women. After all if low risk women outside of the hospital do not need medical care (epidurals, cesareans) - then why should low-risk women in the hospital need access to these services?

I would further hope that rather than encouraging a risky birth option such as home birth (note this is ALL about saving money) that the Ministry would strive to make safe birth options (in the hospital) more accessible, available, attractive and more cost-effective. Doing otherwise is just saving money at the expense of women and babies - and there's something very wrong with that.

Cesarean by Choice Awareness Network - now on Facebook

A group has been established on Facebook for cesarean by choice moms, those who support cesarean by choice, those planning on becoming cesarean by choice and care providers who facilitate cesarean by choice. It is called "Cesarean by Choice Awareness Network", and can be found here. It's a closed group, meaning that only members can see what is posted in the group.

I'm hoping it'll be a place where moms and care providers can connect, share information, and work to improve awareness and respect for cesarean by choice.

A Shameful Culture

Shortly before the delivery of my son, my mother was recounting to me a conversation she had with a co-worker (while they were having a smoke break no-less) about the impending arrival of my son - the impending planned cesarean. My mother's coworker asked why a cesarean was planned, and when my mother told her co-worker that it was because it was what I wanted, her co-worker proceeded on a tirade of derogatory commentary about my birth choice. That I was a burden on the health system (that's rich coming from a woman who is on a smoke break). That women had been giving birth the way nature intended for thousands of years. That it was a real shame that I did not have confidence in my body and its ability to birth a baby. That vaginal birth was best for both mother and child and cesareans should be reserved only for those who "need" them. My mother found herself defending me, defending my choice - but more than that, defending my right to make such a choice in the first place, my right to determine what was done with my body.

I love my mom for standing up for me - as her co-worker is not some rarity. I have become far too familiar and tired with such sentiments. I spent my first pregnancy defending my choice only to have my right to choose violated, and my second pregnancy in dread that my right to choose would be violated again.

There is something that is deeply wrong about the culture surrounding birth in Canada today. It is a culture that says that it is okay to criticize the legitimate choices of others. It is a culture of fear. It is a culture of competition. It is a culture that shames women for choosing cesarean. It is a culture that shames women for choosing pain relief. It is a culture that preaches empowerment from a bodily function. It is a culture that legitimizes the denial of choice and access to modern medical technology and the most qualified care providers.

It is a culture that tells women to be proud of vaginally delivering their children and to be proud of rejecting pain relief in the process of doing doing so - it is also a culture that tells women who deliver by cesarean or with the use of epidurals that they are somehow failures or lesser women.

It is perverse and filled with misplaced pride.

I have no shame about the cesarean birth of my son. It was an informed choice. It was a safe choice. It was the choice that best met my needs and those of my baby. I am no less a woman for having had a cesarean. I am proud that I was enabled to make an informed choice about the healthcare I received - one which enabled the healthy and safe arrival of my son. I am proud of my health care providers for giving me excellent care, and for respecting, supporting and enabling my choice with regards to the delivery of my son.

Women who choose cesarean have nothing to be ashamed about, and its time we quit thinking that they do.

Avoiding Birth Trauma: A Laudable Goal

Those that regularly read this blog, know that I do not think much about using rates of cesarean as a measure of quality for maternity care. Yet many health administrators and policy analysts seem to think that lowering the rate of cesareans is a laudable goal. In the more than two years since my daughter was born, I have come to know just how misguided this goal really is - and believe that it is time that quality in maternity care was measured differently.

Birth trauma is a negative outcome of the birth process - one that could and should be avoided in many cases.

Having read the accounts of women who have been traumatized by birth, in addition to my own experience, it is clear that birth trauma is not caused by the mode of delivery. There are women who have vaginal deliveries and are traumatized. There are women who have cesareans and are traumatized. There are women who have vaginal deliveries and are not traumatized. There are women who have cesareans and are not traumatized.

Birth trauma is also not caused by the location of delivery. There are women who are traumatized by home birth. There are women who are traumatized by hospital birth. There are women who are not traumatized by home birth. There are women who are not traumatized by hospital birth.

Further, birth trauma is not caused by the choice of care provider. There are women who have midwives and experience birth trauma. There are women who have doctors or obstetricians and experience birth trauma. Further there are women who have midwives or doctors or obstetricians who do not experience birth trauma.

Also having read the accounts of women traumatized by birth, in addition to my own experience - the impacts are lasting and wide ranging. There are women who would like more children, who choose to forego additional pregnancies. There are women who having had a negative experience in one pregnancy, make risky choices in subsequent pregnancies in the hopes of avoiding a repeat experience. There are women who experience excessive anxiety in their subsequent pregnancies. There are women who suffer from post-partum depression and post-natal post traumatic stress disorder - many of whom suffer in silence. Some women who experience traumatic births are left with lasting physical repercussions for either themselves or their children.

Despite the significance of traumatic birth experiences, for women, their children and their families - it largely goes unmeasured. As a result it remains poorly understood and stigmatized.

Would it not be better to measure things that actually gauge quality care than to monitor a measure because it is easy and pretending that it has anything to do with quality?

Is the patient perspective lacking?

This morning while the boy napped and my daughter burned off some toddler energy (which if it could be harnessed would solve all of the world's energy problems) by bouncing on her Rody while watching cartoons - I read a story in the Times Colonist bemoaning the rates of mastectomy versus lumpectomy it reminded me a lot of the bemoaning that goes on with respect to cesarean sections. Many of the surgeries are labelled as 'unneccessary' - however in both the case of cesareans and mastectomies patients are making decisions prospectively and outcomes are only known retrospectively.

In both cases I wonder if a better understanding of the patient perspective is needed to better assess why a more aggressive treatment is preferred over what is considered a more conservative treatment with equal or better outcomes?

Further, if patients are freely choosing these more aggressive treatments, what are they gaining over the more conservative options? Lastly, if these surgeries are a result of patient choice, should they be bemoaned as unneccessary?

The challenge is that the information in the system is limited to what was actually done and lacks information from the patient and provider perspective on why what was done was done. This leads armchair policy analysts and some health system administrators to conclude that there is waste in the system caused by 'unneccessary procedures' (there is waste in the system, but I for one am not convinced that it is caused by people undergoing 'unneccessary' procedures).

Being a patient who would have undergone what some would consider an unneccessary cesarean for the birth of my daughter and did undergo a cesarean for the recent birth of my son, I feel very strongly that care decisions should be 'patient centered and patient driven' and not 'guideline driven'. I worry that the labeling of some procedures as 'unneccessary' without complete information - in particular without either patient or provider information on why the procedure was undertaken and their satisfaction with the outcome - may result in some patients being forced into treatments that are different from that which they would freely choose for themselves (in consultation with their care providers) - and may result in less patient satisfaction and poorer outcomes than could otherwise be achieved.

We owe it to the healthcare system and the patients it serves to refrain from jumping to the conclusion that certain procedures are unneccessary and to improve upon the information available to better understand why certain treatment decisions are made in the first place. To do otherwise is to risk creating a 'health system centered' model of care.

Are women, babies on Vancouver Island still facing inadequate access?

I've been under a bit of a proverbial rock over the last couple of months - first preparing for the arrival of baby W and then in the sleep deprived after-glow of the first few weeks of life with a newborn.

This past week I have gotten around to reading the defenses that have been filed with regards to the litigation I have decided to pursue with respect to my daughter's 2010 birth. The health authority claims access was available but not exercised by my physicians (a deprivation of patient autonomy). My physicians claim that access to the needed resources was not available, and that use of the back-up anaesthesiologist was limited to "life and limb" emergencies (a deprivation of access to medical services). There's also a sprinkling of blame the victim and inconsistencies of facts. Next stop examinations for discovery.

I also came across this news article which indicates that reports of dedicated obstetric anaesthesiology (DOBA) may have been premature. It would appear that women giving birth at Victoria General are still facing challenges accessing the services of anesthesiologists when they need them as those resources are frequently called upon to provide care to other emergent patients.

Timely access to anesthesiologists should Be a given, and an adequately resourced system should be able to provide for the needs of pregnant women AND other patients. It is deeply concerning that it appears that the problem persists.

The W Family Needs a New Family Doctor

My family doctor shares a practice with the doctor who provided my prenatal care during my last pregnancy. This is not an ideal situation for either my family doctor or for myself. It is uncomfortable to access care there - and in truth, it has caused me to avoid accessing care there while I was pregnant. When there was a minor case of bleeding due to a small sub-chorionic hemmorhage during my first trimester, I went to a walk-in clinic instead of seeing my family doctor. Earlier this summer when my daughter managed to get a case of jock itch diaper rash - again I took her to a walk in clinic instead of my family doctor.

So this past week when I took my son for his one week check-up - it was the first time I had seen my family doctor since getting a referral to my OB for this pregnancy.

I have been with my family doctor for nearly 16 years - she's seen me since I was a university freshman. She had nothing to do with what happened during the last pregnancy and, while foreseeable, it is an unfortunate price that must be paid for what happened last time. She has indicated that she will not leave us before a replacement is found - however, it is clear that a replacement is needed.

So the W family is in need of a new family doctor...which in Victoria is a bit of a daunting prospect given that according to the College of Physicians and Surgeons and the Victoria Medical Society say that no family practices in Victoria are currently accepting new patients.

The search begins - hopefully, my family will get lucky and we'll find a family physician that will guide us through the next chapter of our lives as we raise our children and navigate through "middle age". Hopefully, we will be blessed with the same calibre of professional that I had during my pregnancy and birth of my son.

Winning the Birth Lottery

In the afterglow of my son's birth - I have nothing but gratitude and thankfulness about the care I received and I am very happy that I didn't have to leave the country or take out the equivalent of a car loan to get it. My son's birth, far exceeded every expectation that I had, on every account. It was everything and more than I had hoped for when I planned my daughter's birth. In short, I feel a little like a lottery winner on so many accounts - or at least on any account that really matters.

I got the healthy baby - APGARS of 9 and 9.5. There was nothing sweeter to my ears than to hear him cry within moments of being born. My son has 10 fingers and 10 toes. He has good hearing. His blue eyes checked out. He is perfect from pin-pricked heal, to the top of his fair head.

I did not experience labour this time around. There were some Braxton Hicks contractions, there was a softening of the cervix, there was some dilation - but labour held at bay. Thank god labour held at bay.

Pain management exceeded my expectations - I'll be frank, I expected there to be some pain involved - in truth I always kind of thought that instead of the pain of labour that there was the pain of recovery, and that in the grand scheme of things that the two methods (vaginal birth versus caesarean) were kind of 'on par' in this regard. From the time the spinal was placed until now - 4 days post partum, I haven't experienced any pain that has been worse than a bad period cramp. The pain I experienced during my daughter's delivery was unimaginable. The anaesthesiologist worked magic - and I am extremely grateful for his skills. Further - not once did I feel 'out of it' or high, and there is a lot to be said for being able to remain 'sober' during a time like the birth of your child.

I felt involved in my care, every step of the way. I was given plenty of opportunity to ask questions and was told what was going on and what to expect at each step.

I got continuity of care - the OBGYN who provided my prenatal care was the same person who delivered my son. I knew the person who would be delivering my son had delivered hundreds (and likely thousands) of babies before mine. My Dr. Visited me both days I was in hospital after the surgery.

I got a room full of trained experts - a pediatrician, an OBGyn, an anaesthesiologist, residents and nurses - as a result, I knew that if anything were to go wrong, the right person would be there at the right time. I felt safe.

My mood this time around is dramatically improved - I am not in shock over what happened. Reflecting on the experience generates overwhelmingly positive feelings. For the first time since my experience with my daughter's birth, I feel myself again. It would seem in part (at least right now) that the surgical birth of my son might have helped to alleviate some of my psychological issues.

I had no idea just how much my daughter's birth had really impacted me - but perhaps it's a little like having a bad relationship, in that it's hard to understand how bad it really was until you have had a good relationship to compare it to - after all I got a healthy baby out of that deal, an AMAZINGLY wonderful little girl. However, I now understand just how much more was possible from that experience and how many of the negative consequences could have been avoided.

I feel like I've hit the jackpot with my son, I got the healthy baby and I got so much more than I could have hoped for - I am so thankful for my family, friends, readers, therapist, and healthcare providers who supported me through my pregnancy and the birth of my son as without them, it would not have been possible. I got what every woman giving birth deserves, regardless of the mode of delivery chosen.

Everything, According to Plan - One Happy Mother

Just a quick post today...

The csection was yesterday and went exceptionally well - I could not have asked for a better experience, it was truly pleasant to be able to focus on the arrival of my son in the absence of pain.  All of my Dr.s and nurses have done a very good job and so far, the pain of recovery has been managed very well.  Now knowing how pleasant the experience could have been, it would be wonderful if every woman in BC could have access to the same kind of experience if she desired it or at the very least that such access would not be unreasonably withheld.

I am so very thankful to have gotten everything I wanted this time around, I have a healthy baby, I have had exceptional pain management, I have had respectful care, and I had an uneventful delivery and seem to be having an uneventful recovery. I am counting my blessings, knowing how differently things could have gone and tremendously relieved that this time, it was different.

Vancouver - Home away from home until we take the little Mr. home

The newest little W-to-be managed to stay put over the weekend, for which I am most grateful. I'm asking him to stay put just a little while longer (until the elective c-section date), and am trying my best to help him in that regard by staying off of my feet as much as possible. I'm now in Vancouver - so feel as though even if I were to go into labour my chances are good that a csection, or at a minimum an epidural could be secured and I am relieved that the risk of a delivery at Vic General is now eliminated. I relocated myself yesterday (a thousand and one thank-yous to my brother-in-law for use of his North Vancouver condo)

Mr.W and the girl will be joining me later today. I am quite pleased that they are coming sooner than planned as the original plan was for Mr.W to stay in Victoria with the girl until Tuesday (the day before the c-section) and then for the girl to stay with her aunt and uncle in Victoria until we returned home from Vancouver with the newest little W. However, that meant that I would be in Vancouver solo, and should I go into labour - Mr. W might miss out on the arrival of little W, a prospect I wasn't overly happy with, but given the need to care for the toddler, and my desire to avoid a delivery at Victoria General, seemed a neccessary trade-off. It is a trade-off that I am quite happy to be unlikely have to made.

I'm hopeful that little W will wait until Wednesday - surgery has risks and those risks are minimized when it is undertaken in a planned manner (there's a reason why they ask you to fast beforehand).

Now if only I could donate points from my Bishop's score (I calculate that mine is at a 10-11) to some other woman who could really use them as I have no desire to actually go into labour or have a vaginal birth.

Tokolytic Thoughts at Term

The boy to be is now term - and my only hope is that he stays put until the elective c-section date and time. Since my last OB appointment I've adopted a much more slothful lifestyle - the letter of the final weeks is "R" for rest and relaxation. There will be no more heavy duty gardening (it can wait). Late nights are not going to happen, the dog can do without any long walks, the girl does not need to be carried anywhere, and if it takes me a little longer to get from point a to point b then so be it. While I've learned that sex does not induce labour (that is an old wives' tale) - there will be no nookie. Same goes for spicy foods and pineapples. Further - as soon as its logistically feasible to go to Vancouver, I likely will. That looks like it'll be this upcoming Wednesday.

The logistics would be better if this were my first pregnancy, but it's not and that being the case there's limits to when I can go there, and there will be some trade-offs to doing so. Our lives are in Victoria, and so are all the resources that may be called upon in the event of an "unplanned" labour. It being a second pregnancy, and given the relatively short duration of my first labour - time is unlikely to be a luxury that I will have should the unplanned happen. The time off work that can be taken by my husband is limited...and so as much as I'd like to not be here, now, it really isn't an option until Wednesday.

So until then I'll be thinking tokolytic thoughts and hoping that the labour day long weekend is not taken literally by either the womb dweller or my body.

Sporadic Blogging Likely

I've been somewhat absent from blogging lately - I've tried to compose posts but, there have been more than a few times when doing so in recent days has proven too overwhelming. I've been checking in on the comments - and must thank those who have taken the time to make them - particularly the words of support and encouragement.

The new edition is looming on the horizon, and I find the reality of that when I try to blog to often be a bit much - so I've been trying to do things that allow me to think about that on my own terms. I'm finding that I am preferring to avoid social situations, as invariably someone comments on my burgeoning belly and the imminence of the arrival (please baby boy - just stay put until the csection date and time, please). I'm finding naming hard, actually baby preparations in general are proving somewhat challenging this time. It's not that I'm not looking forward to having a son, but rather the deep desire to be on the otherside of his arrival. The deep desire to know that everything is okay and that this time is not last time. Part of me thinks if I'm just not ready for his arrival, maybe it just won't happen until I am ready for it - logically I know babies don't work that way. Logically, I know that I can be as ready as possible and things can still go sideways - for reasons completely beyond my control. Logically I know that things going well are a result of the actions of other people and I must trust that this time it will be different.

I am very thankful that I have a supportive and watchful OB who has scheduled a date and time that is as soon as is feasible - I appreciate that he seems to appreciate my desire to avoid a vaginally birth and my desire to avoid giving birth at Victoria General Hospital.

I am also thankful for my husband who also is supportive and seems willing to do what is neccessary to put my mind at ease - if the OB thinks labour might be imminent, he seems willing to go to Vancouver to help me avoid Victoria General Hospital...he also seems to be fairly cautious about what I do in the interim.

Further, I am thankful for my therapist - who has her work cut out for her in terms of helping me remain rational - and coaching me as to the what ifs...I'd prefer just not to think about them but, I know that if the what ifs materialize that having not thought of them could be harmful.

So I'm doing what I can to minimize the risk of going into labour prematurely by trying not to let the anxiety get the better of me, reminding myself that my OB is watching me, not overdoing things, reminding myself that this time is not last time.

And what if?

Then I'll do what is neccessary and what I can- I will go to Vic General (even though that is the last place I want to be - because, the alternative is even more scary - at least at Vic General, there is a chance at getting a csection or an epidural), I will let them know that I was planning on giving birth by csection in Vancouver - the name and number of my OB and psychologist. I will let them know that I'd like to avoid a vaginal delivery. I will let them know that I'd like an epidural as soon as possible. I will let them know that I do not want the lights low or to be told that "my body was made to do this", that I do not want the same people who provided care to me last time to provide care to me this time - if at all possible. That I want the best pain relief available to be used. Then I'll try to keep it together as best I can for the sake of my son. But if I have no choice - I will do what must be done, as I did last time - however, I will not waste a year trusting that what happened was with good reason and beyond the control of the hospital or doctors - I will investigate the reasons, and if good reasons for a lack of access to adequate care that respect what I would have liked to have happen with my body are not found - I will again hold the hospital and my care providers to account. And if there are good reasons, well then the circumstance is entirely different and I will just have to deal with that as best I can - I will be thankful for a healthy son, I will relish mothering him, and I will know that my care providers did as best they could and that sometimes bad things happen despite having done everything to ensure that they wouldn't ...

But I am truly hoping the what if doesn't happen...because if it does, I know it will be among the most painful experiences I will have in my life - and that no amount of wishing myself elsewheres will change that, that no breathing exercises hold a candle to an epidural and that my vagina won't be the same again...and the idea that the what if could happen again without good reason - unnecessarily - well that would demonstrate a deep seated misogyny that should be fought with every shred of my being.

It is reasonable to expect that what happened last time, won't happen this time (although I find myself having to often remind myself that I should not expect what happened last time to happen this time) - but if it does (again and without good reason) - I will do what is neccessary.