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msjones
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Reading another thread I saw some sky-high stats about c-sections -- some hospital mentioned in the thread had a 48% c-section rate. That is hard to understand.

 

I'd like to have a discussion about c-sections based on the assumption that the doctor is NOT performing the procedure for his/her own personal benefit. I've read plenty of those threads, and would like to discuss other reasons that so many women are having surgical births.

 

I've heard about elective c-sections and know two women who've had them. I've heard about women scheduling their births merely for their own convenience, but have never spoken to a woman who has done so. I hear about more high-risk births, but 48% is a LOT of high risk that doesn't seem to exist elsewhere. Is this mostly malpractice concern? Unhealthy women? Multiple births?

 

What are your thoughts? (Again, other than the-doctor-wants-to-go-golfing or the-doctor-doesn't-like-vaginal-births discussion. I know those are legitimate discussions, but that's not what I'm interested in here.)

 

What's going on?

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Guest inoubliable

Edited.

 

Neither of mine was scheduled for convenience. They were scheduled taking into account the best information we had at the time including my medical history.

I do know some women who have scheduled c-sections for their convenience. I judge not.

I know my SIL had to have all three by c-section. Her first was an emergency and her OB wouldn't let her try a VBAC with the later two babies because of the higher chance of uterine rupture after an emergency c-section. I don't profess to know how an emergency c-section differs from a scheduled c-section other than hastily done incising. Some women have SIL that she should have insisted on a VBAC. Or at least trying to, with an understanding with the OB that a c-section can be performed if something isn't going well. I judge not.

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To answer your question, I vote for risk concerns as the basic reason (risk-averse doc view being something along the lines of "in the current situation I can more easily ensure a live baby").

 

I only know one person who had a section for no medical reason, and that was a (wealthy) ex-pat living in the UK at the time.

 

Personally, I had a section for breech, followed by four VBACs, including premie twins (so five kids by vbac), in both private and teaching hospitals in two different states between 2001 and 2009. I can't say that the births I hear about anecdotally line up with the high statistics on sections. Of the babies I can think of that have been born in the last several years, I can't even think of one that was born by section (not that I know how every one was born, but of the ones that I do know about - wait, I take that back, I remember one).

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More later when I am not typing on a phone. You are so unfortunately right about the abuse of C-sections. In my case, however, both my baby and I would have died without the appropriate choice to discontinue the labour and deliver via surgery. There ARE good, careful, cautious doctors who make this choice when appropriate.

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C-sections are done for many reasons. Many women have them for breech babies and multiples. The pendulum swings back and forth on VBAC, so many women have repeat c-sections instead. If the induction doesn't work/doesn't work quickly enough, c-section. There is often a timetable for how long labor should last. If it takes too long, c-section for failure to progress. Placenta previa, placental abruption, concerns about the baby's condition or the mother that preclude labor or get worse during labor, fear of uterine rupture. I could go on all day. C-sections reasons range from life saving operations to mother or doctor convenience.

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BIL is a physician, the hospital where he did his residency had a 45%+ c-section rate, he ascribed the high rate primarily to liability concerns; apparently it is easier for a doctor to defend the decision to perform a c-section than the decision not to if something goes wrong.

 

He and his wife chose a midwife practice to deliver their own children.

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The issue of course is not whether or not c-sections are sometimes necessary (they absolutely save lives) but what accounts for the difference between a reasonable rate for necessary c-sections and almost half of all births being performed via c-section.

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I think the heavy use of pitocin has done a lot to increase the number of cesareans. Many women are being induced near their due dates when their body/baby may not be ready for another week or so. The pitocin makes the contractions so intense that doing it without an epidural is immensely difficult. The epidural can make pushing less effective and make it impossible to walk, sway, or move into better positions. If the woman's body wasn't ready to go into labor, she may very well not progress with a mild amount of pitocin, so they up it. The woman can't really feel the contractions anymore anyway, but the unnatural intensity of them can certainly still impact the baby. So...

 

1) Woman isn't ready and doesn't progress even with the pit? Csection

 

2) Pitocin contractions are so intense they start causing problems for the baby? Csection

 

3) Woman gets to the pushing stage, but isn't able to to get the baby to descend because of physical limitations caused by the epidural? Csection

 

 

My homebirth turned into a transfer for a cesarean, and I'm very grateful for my surgery. They definitely save lives when they are necessary.

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WIth the overall uptick in c/s, then it is more likely that subsequent births will be *planned* c/s due to vbac bans or defacto bans or discouragement from vbac. I'd say that's a significant driver. Essentially a non medically necessary primary c/s is likely to impact a woman's choices down the road with subsequent deliveries. She may want to vbac and be a good candidate but hospital or physician policy may make it essentially impossible for her to vbac.

 

The use of electronic fetal monitoring is another big one. Studies have shown that routine use doesn't really improve overall outcomes for mom or baby in most cases, but it does increase the c/s rate. Now that monitors are here, they've become a CYA thing. If there's a concern based on monitoring, docs may jump to the c/s. This has been discussed for years but this recent piece was interesting: http://www.medpageto...t&mu_id=5345887

 

You probably need a login to read that, so I'll quote from it:

About a third of women have a first cesarean section based on "nonreassuring" fetal heart patterns seen with the electronic monitors despite almost no evidence for benefit, Alison G. Cahill, MD, of Washington University in St. Louis, explained during a symposium.

The goal of intrapartum monitoring is to catch signs of fetal distress before hypoxia leads to brain damage and, ultimately, death. Yet none of the 11 randomized controlled trials of electronic fetal monitoring showed fewer neonatal deaths or any other advantage over standard care, except for fewer seizures in one of the trials that didn't translate into a difference in long-term outcome.

 

 

Also

 

Yet, of the 32% of primary cesareans done with fetal heart tracings as an indication, only a tiny portion reach the category III level at which the National Institute of Child Health and Human Development recommends cesarean delivery or operative delivery.

Most are taken to surgery over an indeterminate category II pattern, Cahill noted.

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I know my SIL had to have all three by c-section. Her first was an emergency and her OB wouldn't let her try a VBAC with the later two babies because of the higher chance of uterine rupture after an emergency c-section. I don't profess to know how an emergency c-section differs from a scheduled c-section other than hastily done incising. Some women have SIL that she should have insisted on a VBAC. Or at least trying to, with an understanding with the OB that a c-section can be performed if something isn't going well. I judge not.

 

If the uterine incision (not the same as the incision on the skin) was vertical - which is more common with a time-sensitive emergency - the chance of rupture goes up a LOT. A vbac is *totally* contraindicated by a vertical incision.

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The issue of course is not whether or not c-sections are sometimes necessary (they absolutely save lives) but what accounts for the difference between a reasonable rate for necessary c-sections and almost half of all births being performed via c-section.

Exactly. No one's intent is to question an individual's situation, but rather the overall pattern of overuse. And pretty much all of the major medical bodies acknowledge the c/s rate here is excessively high and unwarranted.

 

Some people will say all that matters is a healthy baby. No doubt a healthy baby is the desired outcome. But I think it is important to acknowledge that an unneeded primary c/s sets a woman up to have an increased risk of rupture and other complications for her future pregnancies. In many places, there is no option to vbac, even if a woman is a good candidate. So those unnecessary primary cesareans do have an effect on the health of mother and child in subsequent births.

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Guest inoubliable

If the uterine incision (not the same as the incision on the skin) was vertical - which is more common with a time-sensitive emergency - the chance of rupture goes up a LOT. A vbac is *totally* contraindicated by a vertical incision.

 

That makes sense. I hadn't heard that. Thank you for sharing that.

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I hear about more high-risk births, but 48% is a LOT of high risk that doesn't seem to exist elsewhere. Is this mostly malpractice concern? Unhealthy women? Multiple births?

Well, part of the reason the high risk doesn't exist elsewhere is that the high-risk births are filtered to particular hospitals if at all possible.

 

The hospital where I had DD1 has a very low c-section rate. Part of that is because they have great policies and aren't c-section happy. Part is that if mother and/or baby are expected to need a higher level of care and are stable enough for a twenty minute transport, they aren't birthing there. So their section rate is correspondingly lower, and the rate at the hospital they transfer to correspondingly higher.

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I think there are valid medical reasons for a c-section in some cases. I also think more c-sections are perfomed not because the doc wants to go golfing, but because it is easier for him/her. I have a friend who wanted to try a VBAC. Doc said absolutely not. She asked why. He said he did not want to be responsible, "Just in case."

 

SIL had a miscarriage when she was a teen. Ten years later, she was pregnant again with no complications. Doc says c-section. I asked her why. She said, "Because he said so."

 

Some people think is it easier to have a c-section than give birth. Never having personally had one, I cannot say, but I do have a number of friends that say the recovery is longer and you have to be much more careful about doing things. My SIL's incision became infected and she had to deal with that, plus they took the baby earlier than he was due so he ended up in NICU.

 

I have given birth to all of my dc vaginally. Only had an epidural with one, all others were drug-free except 7yo dd, where I had pitocin (but nothing else). Dh was in the midst of a deployment at the time, was on leave for R&R, and we had 15 days to have the baby before he had to go back. Her due date was March 24, we induced on March 22 after trying other methods to induce naturally.

 

I have had babies stateside and overseas, in birth centers and hospitals, with midwives and doctors. I much prefer the birth center/midwife setting and plan to do that again with the new one coming.

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One important thing to keep in mind is that hospitals with cesarean rates in those upper numbers are usually high-risk hospitals. Moms who have gone into labor at an early stage of labor, need to be on bedrest in the hospital, high risk birth defects, etc. are housed there. Many of these are automatically going to be c-sected.

 

For me- my mom labored for over 50 hours with my oldest sibling, pushed for 5-6 and then it ended in an emergent cesarean with a horrible, painful and long recovery. With me, she had a scheduled cesarean, easy recovery. I had seen it in my own patients as a pediatric nurse- the moms who had emergent cesareans after laboring naturally had a much, much more difficult recovery than those with scheduled (for a reason) c-sections.

 

My son was measuring very large at 8 months. They suspected he would be over 10 pounds at 40 weeks, his head was at that point 97% for a full-term baby AND his shoulders measuring closer to that of a one month old. Serious concern, especially with a family history of insufficient pelvic inlet/outlet and it wasn't something I was willing to risk.

 

I got a lot of judgement from friends and family who thought I should just have a "trail of labor first," which is understandable, but I was not favorable at all for labor and was going to be induced at 39 weeks. It would have likely turned into a semi-emergent cesarean, even in the best of circumstances after many hours of labor.

 

My OB is a family friend. I have known him since I was about 12 years of age, and greatly trust his opinion. And he trusted my judgement. We chose together that the best decision for my birth was a schedule cesarean. When my son was born, his cord was tightly wrapped around his neck THREE times and he had a tight true knot. At that point, I was very thankful for my "elective" (as some considered, but medically, it was deemed a necessity) cesarean. I would have ended up in a VERY emergent birth when/if my son started moving down in the birth canal and the true knot continued to tighten, cutting off his oxygen supply.

 

I had an extremely easy recovery, easy breastfeeding experience and a very supportive hospital staff (Especially lactation and nurses- in recovery, the post-op nurse helped me to nurse within 30 minutes of his birth- it led to a very successful nursing "career" of 13 months, a month past my goal). I was off of pain medication altogether before I left the hospital, and we went shopping at Target on the way home to get some needed baby items for the house.

 

Even though I am very supportive of necessary cesareans (as deemed by physician and patient), I was surprised to hear that we are not the highest c-section rate in the world, not even close. Brazil has a c-section rate of 93%! 93!!! Many (most) physicians there do not feel like vaginal birth is safe. I was very shocked to hear that there was ANY country with a c-section rate that high.

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I think the reasons are complex. A few thoughts ...

 

  • Poor science reporting. The science journalists have very little science literacy and publish stuff that makes headlines without looking deeper into the issue. This helps skew public perception about relative risk.
  • Society (doctors, media, the general public) has portrayed the risk of c-sections to make them appear so benign. We have been sold the idea that they are no big deal, so why not have the baby when you want? We as a society have become comfortable with them so why not make things more convenient?
  • Doctors are often more comfortable with things they can control. Labor is a process outside of their control so they work to put inside their realm ... inductions, keeping mom in bed, turning up the pit, c-sections on demand. Doctors are afraid of what goes wrong, but are often not the experts in normal labor. They are experts in surgery as a solution to what goes what looks abnormal to them.
  • The skyrocketing induction rate ... inductions don't work well on women who are not ready so they often lead to c-sections. Conditions that used to be treated with watchful waiting are now reasons to induce (but no improvement in outcome has been seen from this shift in treatment protocol.) Also, many situations that would have called for closer monitoring in labor are not treated as c-section issues.
  • Women have been told that c-sections preserve the pelvic floor. There was lots of media attention on a couple of poorly done studies. Many doctors pushed this idea without having the evidence behind them (namely one of the Berman sisters of that sex show.) Physiological pushing (gravity positive or neutral positions, pushing only according to maternal urge, etc do much more to preserve pelvic floor functioning than c-sections.

 

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I think there are valid medical reasons for a c-section in some cases. I also think more c-sections are perfomed not because the doc wants to go golfing, but because it is easier for him/her. I have a friend who wanted to try a VBAC. Doc said absolutely not. She asked why. He said he did not want to be responsible, "Just in case."

 

SIL had a miscarriage when she was a teen. Ten years later, she was pregnant again with no complications. Doc says c-section. I asked her why. She said, "Because he said so."

 

Some people think is it easier to have a c-section than give birth. Never having personally had one, I cannot say, but I do have a number of friends that say the recovery is longer and you have to be much more careful about doing things. My SIL's incision became infected and she had to deal with that, plus they took the baby earlier than he was due so he ended up in NICU.

 

I have given birth to all of my dc vaginally. Only had an epidural with one, all others were drug-free except 7yo dd, where I had pitocin (but nothing else). Dh was in the midst of a deployment at the time, was on leave for R&R, and we had 15 days to have the baby before he had to go back. Her due date was March 24, we induced on March 22 after trying other methods to induce naturally.

 

I have had babies stateside and overseas, in birth centers and hospitals, with midwives and doctors. I much prefer the birth center/midwife setting and plan to do that again with the new one coming.

 

 

In response to the bolded- a doctor has a right to refuse something that he deems dangerous. His license and malpractice are on the line- and if he doesn't feel it is safe, of course he should refuse. It is up to the patient to find a provider who is willing and able to perform whatever it is that they desire. It can be difficult, because we are in a very sue-happy time, and doctors can lose everything they have worked for at the drop of a hat.

 

The second bolded, regarding your SILs miscarriage- that is ridiculous, IMO that a doc would even say such a thing. I have never, ever heard of that (unless it were a late term demise, and baby had to be born by cesarean the first time, which doesn't sound like the case), and I would be finding a new doctor stat.

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I agree with the post about the cascading events of interventions such as inductions, pitocin, epidurals and sometimes those leading to c-sections. I think it's especially common for first-time mothers whose bodies take longer to give birth to go down that route to a c-section. And then once a woman has had a c-section doctors are scared to do a VBAC. So if a woman has three or four children and her first one was a C-section it is very likely she will end up having three or four c-sections in her life. I was lucky in that although with my first I was induced with pitocin and had an epidural, when my baby's heart rate started going down my doctor just told me that I was close to pushing and if I pushed hard enough I could avoid a c-section, which luckily I did.

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I already posted that my first c-section was absolutely necessary. After labour with our second baby, with identical problems, the same doctors as before reluctantly decided to perform surgery. With the third baby, these doctors told me that my history predicted very likely another c-section. It was not scheduled; they told me just to call them when I went into labour and they would meet us at the hospital. Fast-forward to our fourth baby, in another city. Nasty doctors and staff who seized every opportunity to push sterilization on me, and who insisted on scheduling a c-section when it was convenient to them. They were horrible, as was the birth itself -- three epidurals because the first two were botched, then the third one wore off almost immediately. If curious as to why I stayed with such a rotten OB/gyn practice, I had trouble finding a doctor because forty-three was considered too old to have a baby. [insert my loud snort of derision]

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My first section was because her head was stuck, stuck, stuck. 3 hours of pushing insured that! I feel that with this c section, if I had had a midwife it would have gone better and I may have been able to deliver. The nurses were useless. My second section was planned, but I never made it - the day before, my uterus burst. I didn't feel a thing, just a lot of blood, and it was many hours before a doctor or nurse would take me seriously. My dd and I are both fine, but it's God's hand alone that kept us alive. My third section was done early, with little weight gain, due to the previous rupture.

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The near-complete rejection of VBACs is a driving factor. I think unnecessary inductions are also a huge factor. I have one friend who was induced at 38 weeks with her first baby for no medical reason and then had a c-section for "failure to progress."

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I think it is a combination of doctors being concerned about malpractice and things going bad and fewer doctors having experience with complicated vaginal births. I also think it may have to do with case load. If a doctor has many laboring women at once, he or she cannot monitor them all personally and closely, and so perhaps the doctor will act more conservatively. I wish more doctors did have experience and did receive more training and supervised practice with complicated births.

 

My first OB was so wonderful. He was older, delivered most of the local Amish and Mennonite families with house calls, and had a ton of experience. He preferred to avoid c-sections, was comfortable with some breech deliveries, was happy to deliver multiples vaginally, was happy to let labor progress slowly and watch carefully, he was in the room with me more than most midwives, and I felt so comfortable and safe with him. He let me deliver my DS vaginally when most doctors would have done a c-section and even I was doubting myself. If someone had suggested a c-section and told me that it was taking too long, I would not have resisted and I would have gone through life thinking it was necessary and probably would have had all my children via c-section.

 

My twins were delivered in a high risk hospital preterm. I was life flighted to a different city from where my OB was. This was a c-section happy place. They said they had never had a vaginal unmedicated multiples before me. The nurse told me almost all of their multiples were scheduled c-sections. I was so lucky that my girls were both head down or they would not have given me a choice. They flat out would not deliver a breech baby b. My old OB would have delivered baby b in any position. The whole environment was different. They told me I could not do it and were very discouraging. I had to sign papers AMA to avoid a c-section and epidural. The doctors were also very rushed. They came in to see me before delivery only a few times and just popped in and out to fuss at me. Then, when I was ready to deliver- they weren't there! I had to wait on them and try to hold the preterm babies in! No wonder they wanted to schedule me- it is not safe to deliver preterm twins on your own. I'm glad I didn't have the c-section, but I know they would have been nicer to me if I had. The doctors, residents, nurses, and pretty much everyone, were not used to delivering someone with a little complication that an experienced doctor would have been comfortable with. My old OB had told me that what I was doing was safe which was why I resisted the pressure.

 

I think doctors feel in the case of risk, a bad vaginal delivery will result in a dead baby or mom and a bad c-section usually doesn't. My OB nurse friends have seen things go bad and it is traumatizing. They don't see unnecessary c-sections as unnecessary, but as a potential fatality averted. Maybe only 1% of those c-sections would have ended up as a fatality, but they don't know which ones. My nurse friends have been sued, have seen what they thought was a minor complication turn serious, and I don't blame them for being more risk adverse. I wish there was more of the country doctors like I had who are willing and able to take on young doctors as apprentices or something like that. And, I think malpractice reform would help.

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My first was an emergency c-section. After many many hours of attempting a natural birth, he was stuck. Super duper stuck and both of our health was beginning to be in jeopardy. He was "sunny side up" and it just wasn't going to happen. I am grateful that I live in a time with these modern, relatively safe options or our outcome was not likely to have been a happy one.

 

My second child was a scheduled c-section. My doctor was a good one, though, and we waited to make the decision VBAC vs. repeat c-section until fairly late in the pregnancy when it became obvious that the second baby was much larger than the first--almost 9 lbs as opposed to the first's 6.5. Given my record with the first labor/delivery and my anatomy (I'm only 4' 11" with shoes on) it seemed unlikely that I'd be unable to deliver vaginally this time either, so the c-section choice seemed prudent. I realize some might have tried a trial by labor in that situation, but IMO it is situations like mine for which c-sections were invented. I have no regrets.

 

I think that for some hospitals, those numbers appear abnormally high, because those are the hospitals for which more high-risk pregnancies are delivered, which would naturally result in more c-sections. In those areas, the lower risk pregnancies are doing homebirths and birth center deliveries. That's an overgeneralization, of course, but I do think that's part of it. I guess I don't really understand what the "optimal" c-section rate would be, or why a high c-section rate is necessarily considered a bad thing.

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I think there are a lot of factors. Fear of lawsuits, fear of birth for some women, etc. I think a lot comes down to fear and control. Doctor's feel more in control if they can "do" something whether that is induction or a c-section. My SIL wanted a planned c-section so she could pick her babies due date and she was scared of labor. She ended up going into labor early. She was progressing well, but insisted on an unnecessary c-section and her doctor obliged. My sister OTOH wanted a VBAC after her first was born and the hospital she delivered at refused to allow VBACs.

 

My first birth was an induction, cascade of events, and finally a c-section after almost 3 days of induced labor. After DD was born they figured out that she had been trying to come down the wrong way (side of her head). I never wanted another c-section so I did my homework and then found a doctor that was pro-VBAC. I had to drive an hour away, but i found the right birth center and everything. Then I never went into labor except prodomal which never helped me to dilate much. After almost 3 weeks of this and being 2 week past my due date they scheduled a c-section because induction was too risky with a previous c-section. I was disappointed but I had done everything in my power to prevent it. I knew going into another pregnancy would mean a c-section. There were very few doctors that would even consider a VBA2C. I did talk to my doctor about it. In the end even if I had found a doctor that would have helped with a trial of labor, my last birth was a true emergency where my internal organs were shutting down due to severe per-eclampsia.

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I consider my situation with my first to have been a needless c/s due to catering to my OB's schedule. I was naive & agree to be induced on my due date b/c a late US showed a large baby (late US are proven to be inaccurate in predicting baby size, my doctor didn't know that?). I believed what they told me - that if I went post-dates my baby would be huge & I'd need a c/s. Well, baby was posterior & got stuck. After 36 hours of horrific labor I had an emergency c/s. DS came out with a huge bruise on his forehead. He weighed 8 lbs exactly. Roughly average.

 

OB went on extended leave a few days later. I didn't know she was planning on leaving & I felt duped.

 

I have since had 3 easy VBACs - after searching high & low for doctors willing to 'allow' me to try. All of my babies have been post-dates - my last one coming 13 days late. It isn't an exact science.

 

Overall, my c/s experience, alone, was a good one. But I never should have had one. I was a c/s walking in the door that day & my doctor should never have put me in that position. Yes, for me it all turned out overall. BUT. There have been suggestions to me by other docs that the c/s COULD BE a factor in why my oldest has asthma. I am somewhat limited as to how many children I could have. Pregnancy & delivery are higher-risk for me. All because of a c/s that never should have happened.

 

I'm glad there are c/s available. They should not be treated as minor. They are major surgery that should be avoided/prevented if possible.

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That high rate is the rate for all pregnancies. It is lower for first pregnancies. Most c-sections are elective repeat c-sections after an initial one for whatever reason. The reason for the high number of repeats is the general anti-VBAC climate that is in existence now, for which there are many reasons.

 

I think a higher than optimal initial c-s rate is affected by the way women give birth in hospitals with many interventions. If more women were allowed to labor and give birth in their own time, with good support, in positions of their choosing, I think the rates would be lower. But the reason it had gone up so high in the past thirty years has to do with doctors being more reluctant to use forceps, vacuum extraction, and other manual interventions to get babies or, due to injuries with those methods as well as liability. I don't think hospital births practices were much different when the c-section rates were lower, in fact in some ways I think they were worse as far as mother-baby separation and breastfeeding support goes. However, back then doctors were willing to manually extract babies with assistance when their interventions used women's labs to slow and stagnate. Nowadays, these same women go to surgery. This includes breech births which used to be often attempted vaginally but now are not.

 

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Also many of the doctors being trained have never been trained in how to vaginal birth a feet first breech baby or multiples with baby b breech ect. They just don't know how to do it but they do know how to do a c-section which probably makes it safer to do the c-section. I think one of the things that needs to happen is training these doctors in these more common complications.

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My first was an emergency c-section. I got to the hospital, the nurses are all chatty and laid back, they got me hooked up to the monitors and the mood in the room changed dramatically. The nurse started yelling for other people and nurses/doctors poured into my room. They told me his heart rate was dangerously low and that it was getting lower with each contraction. I was in the operating room less than 30 min after getting to the hospital. There was no time to explain anything. The doc told me I needed one and I took her at her word.

For my second I wanted a vbac, but they wouldn't let me go more than a week past my due date because of the previous c-section. So it was a "planned" c-section, but not an optional one. Afterwards, the doc told me my uterine wall was very thin and that it was good that we'd done the c-section. She had been supportive of my wanting a vbac until we'd gone past my due date.

If there is a third (fingers crossed!) this doc has told me the best course of action is a c-section one week before my due date. So that's what I'll do.

 

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I found this article interesting.

 

 

But the new study, published in the journal Health Affairs this week, showed a much bigger increase among women who were low-risk patients. Because they did not have the factors that might increase their odds of having a C-section -- preterm birth, a breech baby, multiples or a history of C-section -- the investigators expected to see less variation from hospital to hospital in their Cesarean rates. Instead, hospital C-section rates in that group varied from 2.4 to 36.5 percent.

"The variations we uncovered were striking in their magnitude, and were not explained by hospital size, geographic location or teaching status,†said lead author Katy Kozhimannil, an assistant professor in the University of Minnesota School of Public Health in a statement. “The scale of this variation signals potential quality issues that should be quite alarming to women, clinicians, hospitals and policymakers.â€

 

 

So in some hospitals even low-risk women are facing a c-section rate of 36.5%. These are the people without a prior c-section, without a multiple pregnancy, without a breech baby. So if NONE of those factors is coming into play, what could possibly explain more than 1/3rd of these deliveries being done via c-section except for inappropriate medical management and decision making, whether that is linked to liability concerns, physician convenience, or some other factor?

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(Haven't read any other replies yet)

 

Once you have a c-section, for whatever reason, you are more likely to have a c-section with your following pregnancies due to the risk of uterine tearing along the first incision site. There are probably more people who opt for a (considered) safer 2nd c-section rather than a (considered) more risky vbac. This could be uping the stats. My first two were emergency c-sections and even if I don't have an emergency with this one (please, Lord) I will still have a scheduled c-section because I am unwilling to risk a vba2c.

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I found this article interesting.

 

 

 

 

So in some hospitals even low-risk women are facing a c-section rate of 36.5%. These are the people without a prior c-section, without a multiple pregnancy, without a breech baby. So if NONE of those factors is coming into play, what could possibly explain more than 1/3rd of these deliveries being done via c-section except for inappropriate medical management and decision making, whether that is linked to liability concerns, physician convenience, or some other factor?

 

Thanks for posting this. The tertiary hospital (high-risk) argument for high c-section rates just doesn't hold water. I remember reading a WHO document that asserted that a tertiary hospital shouldn't have c-section rates over 25% (or was it 20%.) Around here, the higher c-section rates are in the areas with the wealthiest populations. Areas where you would expect higher risk due to lack of access to health care have rates that are much more in line with recommendations. I read a WHO report recently that talked about how inappropriately high c-section rates are creating a barrier to health care access. $$ used to pay for inappropriate c-sections could be used to help low-income women get access to care. Our system is so screwed up. Due to our unique history, we turned the birthing practices upside down when the majority of maternity care was yanked away from midwives, the experts in normal birth, and put in the hands of physicians. In countries where midwives see most patients and OBs only see the higher risk patients, maternal and neonatal outcomes are much better. The spend less money and get better care. A good source of information about evidence-based maternal care is Childbirth Connection.

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I think you'll also see a higher rate at hospitals with highly rated NICU's. Those that service preemies are going to have a higher rate because many preemies cannot handle a vaginal birthing process. Once it's determined they can't stay in another day, they generally need to be delivered quickly and that's especially true 32 weeks and earlier. So, in my friend's case, she had preemie twins. One born at 26 weeks and one at 28 both by C-section. That really doesn't help her particular hospital's c-section statistics, but her sons are alive and home and thriving.

 

It seems like in Michigan, the more advanced the NICU, the higher the c-section rate for that hospital and for some particular OB's. In our area, it's not uncommon for women on bed rest in danger of premature labor more than six weeks early, to be turfed to U of M and other hospitals. Getting turfed there increases that hospital's section rate while probably lowering the local hospital's percentage since they tend to turf an awful lot of high risk patients down to the U or Beaumont.

 

My Ob's office had a 22% section rate for the doctors, and 7% for the midwives - they had three midwives that handled a LOT of the low risk pregnancies. These were hospital births, but just about zero interventions...very comfy LDR rooms, showers, tubs, choice of birthing positions, etc....kind of a nice compromise between the low key affair of a home birth and yet having emergency care at your fingertips. But, women in danger of delivering little babies definitely got sent on and so that helped keep the OB rates lower. I'd say the OB's in my office did what I would call, mid-risk care which caused the difference between their rate and the midwives. Only one did what I would call truly higher risk care and due to the limitations of the NICU, he sometimes still sent his patients to a colleague at the U.

 

Faith

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I found this article interesting.

 

 

 

 

So in some hospitals even low-risk women are facing a c-section rate of 36.5%. These are the people without a prior c-section, without a multiple pregnancy, without a breech baby. So if NONE of those factors is coming into play, what could possibly explain more than 1/3rd of these deliveries being done via c-section except for inappropriate medical management and decision making, whether that is linked to liability concerns, physician convenience, or some other factor?

 

Thanks for posting this. The tertiary hospital (high-risk) argument for high c-section rates just doesn't hold water. I remember reading a WHO document that asserted that a tertiary hospital shouldn't have c-section rates over 25% (or was it 20%.) Around here, the higher c-section rates are in the areas with the wealthiest populations. Areas where you would expect higher risk due to lack of access to health care have rates that are much more in line with recommendations. I read a WHO report recently that talked about how inappropriately high c-section rates are creating a barrier to health care access. $$ used to pay for inappropriate c-sections could be used to help low-income women get access to care. Our system is so screwed up. Due to our unique history, we turned the birthing practices upside down when the majority of maternity care was yanked away from midwives, the experts in normal birth, and put in the hands of physicians. In countries where midwives see most patients and OBs only see the higher risk patients, maternal and neonatal outcomes are much better. The spend less money and get better care. A good source of information about evidence-based maternal care is Childbirth Connection.

 

I wonder if they compared type of insurance to the rate of c-section. I know in my state, where about 70% of births are paid for by medicaid, medicaid pays 4x as much for a c-section than a vaginal birth just for the OB - not counting in all the extra to the hospital, etc. And just because a hospital is in a wealthier area doesn't mean it's patients are, especially for L&D. I delivered at a hospital way across town from where I live, even though there were closer ones as that is where my OB practice was from.

 

I don't know the rate at the local hospitals here, but I would not be surprised to find it over 50%. I know with dd they started trying to pressure me into a c-section at my FIRST prenatal appointment, simply because I was overweight & they were sure the baby would be huge. They also tested me 5 times for gestational diabetes using the 3 hour test, each time emphasizing that a diagnosis of GD meant an automatic c-section. I never developed GD, only gained 15 lbs total, and dd was born a perfectly healthy & slim 7lbs 8oz & 19 inches long.

 

I think OB's today are quick to run to c-section, where in the past they would have delivered vaginally. Almost anything can deem you high-risk now, where maybe 10-15 years ago that wasn't the case. It's almost like you are high risk until proven not to be, when really it should be the other way around.

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I think that the number of first time moms having c-sections is growing. That increases the rate of c-sections as VBACs are often not attempted or allowed. All subsequent births are more likely than not to be surgical if my has had a c-section.

 

Loss of skill. The doctors most skilled with less than perfectly positioned births (breech, twins for example) are old. The younger doctors are not learning how to deliver in these cases- their training is all in a paradigm that accepts a very high c-section rate and uses that as the default even when not necessary.

 

Also, I think it is the prevailing opinion that c-sections somehow lower doctors' liability because if a suit ever goes to court the insurance company lawyers can argue that the doctor did everything that could have been done. While that may not be forefront in the OBs mind, it is a consideration and becomes a pattern. Parents are no longer able to accept less than perfect outcomes. Not every birth gone wrong is someone's fault, despite it beong a heartbreaking tragedy. Childbirth is an inherently uncertain thing.

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Have you ever had a c/s? Because I've done it both ways and a c/s is soooooo much easier. My first was an emergency c/s due to preeclampsia and DS being transverse. No question it was necessary. Despite being on bedrest for the three months prior to delivery, I was up and running within days. (Okay, not literally running, but walking).

 

I opted for a VBAC with #2. OMG! It was horrible! The labor itself wasn't so bad. I labored drug free for about 12 hours before opting for the epideral. But the recovery...horrible. It took almost a YEAR before it didn't hurt to have tEa. It took a lot longer for even the basic recovery after that delivery. Blah.

 

So when it came time to decide about what to do with #3, I opted for the c/s right off the bat. So much easier. I scheduled it around Hubby's work schedule (I had DD on a Saturday), I could line up childcare, etc. I was fully back to normal by the time I left the hospital. No lingering pain. No painful tEa.

 

Now you can say you have officially met someone who would purposely choose a c/s despite having successfully had a VBAC. When my dr offered me the choice, it was a no brainer.

 

My own personal opinion on why so many c/s's? I bet it's in direct proportion to the number of inductions. The majority of women I know IRL who have been induced from a cold start (meaning they weren't dilated at all) ended up laboring and pushing and ending up with a c/s after hours of labor. They are exhausted after being awake for over 24 hours, sometimes 2 days. They are hungry because they haven't eaten in that entire time. By the time it's time to push, they just don't have the energy. I can name over 10 women off the top of my head where this was the case.

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My very local hospital doesn't keep an anesthesiologist on staff 24/7, so once you're a cesarean, you're always a cesarean there. I disagree with their policy on VBAC-ing, but it's common in my midwest area.

 

The more distant hospital, where I deliver, is very pro-vbac. Their cesarean rate is well below the national average for uncomplicated vbacs, but hovers around 25% because they are also the high risk NICU hospital. My last delivery was a cesarean there (I had had 3 VBACs previously) because baby was having 10 minute long bradycardias and my water had ruptured at 33w. Baby needed out ASAP.

 

Other reasons for increased number of cesareans besides lack of anesthesiology care and more high risk deliveries:

1. lack of skill/experience in doing breech births among obs

2. decision making of mother (it's easier to choose a repeat cesarean and plan for the experience rather than VBAC)

3. health concerns of mother or baby (babies are being born with defects that are being caught through monitoring and they have cesarean to relieve stress on baby)

4. docs who push unnecessary interventions like inductions, pitocin, etc.

 

I think the pendulum is swinging back against intervention...protections are in place for VBACing women, the ACOG has changed its policy on VBAC-ing, and inductions are no longer happening unless medically necessary until after 39w. I still think inductions should be required to be medically necessary. I think the evidence coming out about issues in babies born 35-38weeks will help keep swinging that pendulum back towards encouraging non-intervention vag births.

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Here's the medically researched and documented explanation for what's going on:

 

http://www.amazon.co...trical myth vs.

 

 

Also, keep in mind that people don't sue for over intervention-they sue for under intervention. So hospital obstetrical care is not a self-correcting system. Compare it to a self-correcting system like homebirth midwifery: If you transfer to the hospital for unecessary c-sections, those wanting a homebirth won't hire you. If you don't transfer for a c-section when it is needed, you go to jail. Self-correcting systems are essential to keeping a balanced approach. My mid-wife's c-section rate (I was one of them for my second delivery with her) is 1 in 80. Her hospital transfer rate is 1 in 40. The current trend in my part of the country runs about 1 in 3 at a hospital with a few hospitals at 1 in 2 and others at 1 in 4.

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My first child was an emergency c-section at 32 weeks for a placental abrupt ion. It saved our lives. My second was a VBAC, but due to complications after an extremely long labor, I have had C-sections ever since. I've been told that if a mother has had 2 c-sections, most OBGYNs won't risk attending a VBAC for liability purposes.

 

I wish I could deliver naturally, there are soapy risks associated with major surgery such as a c-section, and several of my c-section recoveries have been much more difficult than my complicated VBAC (I've had 5 c-sections and will have number 6 this summer).

 

My sister has had 3 natural home or the attended by a midwife. They have been quick and relatively easy, no complications. She is so lucky!

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My first was an unplanned csection.

Diva was induced, VBAC.

Tazzie was VBAC

Princess, another induction, VBAC

Boo, induction, VBAc

 

This one, hopefully another VBAC. The recovery diff btwn the csection vs VBAC makes it no contest, imo. I *do* get frustrated when I'm pushed towards a csection. Happened w/Tazzie..for no good reason, at appts. I swtiched to a VBAC friendly OB for the last 2, and this one, she's VBAC friendly too. I've been *very* clear that if there's a life at risk, I don't care if they use a rusty soup spoon, get baby out. Otherwise, no. I'm not opting for it.

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For another point of view, talk with a doctor who's been involved in a malpractice case.

 

I'll never forget what an ER doc once told me, about a horrendous case he was involved with where the hospital personnel had done everything possible, but there was still a bad outcome... he was sitting in the umpteenth meeting with lawyers, insurance people, and the victim's family hammering out settlement details, a settlement decided on by the insurance carrier not because they admitted any fault, but because it was cheaper than going to court. He realized at one point that he was the only person in the room NOT getting paid for being there.

 

As a few people have mentioned, people won't sue over a (possibly) unnecessary c/s with a healthy baby at the end. Lawyers will be beating down the door if there's a dead or injured baby because the doc didn't make the surgery call.

 

Is it any wonder OBs are risk-averse?

 

(FWIW, my OB will do VBACs (and is truly wonderful in every way you would never imagine a male M.D. being), but told me that 90+ % of women who come in wanting one change their minds by delivery time or want to be induced, and since he won't do an induced VBAC it's another c/s for them)

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My twins (9 days late!!) were to be natural delivery - ended up emergency c-section (they both wanted to come out at once. Ouch.). Next kid was to be VBAC - but she was almost ten pounds, placenta partially tore off, and emergency c-section. So doctor, since I had been sliced open a few times already (earlier a different doctor did a big incision to remove a fibroid) decided to do a c-section for the last kid - and we thought we had picked a good day, planning to get it done with time for me to recover before the twin boys got out of preschool for the summer. So, yes, we scheduled the last section for convenience.

 

Added - I have been watching Call the Midwife on PBS to get the "natural" experience :-)

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That high rate is the rate for all pregnancies. It is lower for first pregnancies. Most c-sections are elective repeat c-sections after an initial one for whatever reason. The reason for the high number of repeats is the general anti-VBAC climate that is in existence now, for which there are many reasons.

 

 

There are many hospitals with PRIMARY (so first time mothers) c-section rates 30-40%. Unless it is a hospital that primarily does only high risk births, I would steer clear of a hospital where 1 in 3 or more of first time moms are ending up with c-sections.

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I'm a vbac. with my last child - my doctor was willing to do a vbac *even though the hospital had all but aboslished the procedure* due to *their* insurance costs. I did not know beforehand that my doctor had to cancel his afternoon clinic for me to deliver vbac because he had to stay on the hospital campus. (down the street at his office was too far.).

 

It was a hospital that probably had more interventions than average - the only nurses I've ever had attend me that I hated, were at that hospital. I delivered three at a different hospital - and while some of the nurses were flaky pastry, I didn't *hate* them. (but I liked my doctor and didn't want to drive as far.) If I had more children, I would have switched back, or even gotten a midwife. (though as a vbac, I dont' think that was an option.)

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Also, obesity plays a role. Maternal obesity is on the rise in a serious way. It increases risk of certain health conditions like gestational diabetes which increase the overall risk level of the birth. Also birth is a physical thing. It is harder on a body that is not in good shape/health. And I am not saying this as a thin person. I was overweight (though fairly fit) when I had #2 by repeat c-section that we choose to do because I developed pre-e out of nowhere. Many women are overweight or obese before they become pregnant.

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I think also CS rates are higher is because they scare you to death that you are going to burst open if you have had a previous c-section!!! I was also reading on one sight that more emergency c-sections are done between the hours of 8am-5pm and drops during the docs off hours :). My 1st baby was c-section because I didn't progress fast enough then my doc told me that my pelvis was very small and I probably wouldn't of been able to push my 6 lb baby out. My 2nd was a VBAC and I had no problem pushing my 8 lb baby out ;) (used the same doc too). We moved states for #3 and she was ok with me doing a VBAC even though she had never done one before. She admitted to me it would be malpractice if she didn't allow it but when time came the ultrasound showed my baby was big so we had to immediately do a c-section (ok she was a whopping 9lb 11 oz baby). Our last one was done with midwife at Vanderbilt Hospital and they let me do a VBA2C. It was an amazing experience. I was given the option of having a c-section as soon as I got there but really didn't want to do that if not totally necessary. Anyway, most people around here who have known that I had a VBAC seem to be totally shocked that I survived the experience and didn't pop open so my thoughts are fear of the unknown and lack of knowing that they are just as many different risks for having more c-sections :)

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