What’s the real chance of having a C-section if you give birth in a hospital? A lot lower than you’ve been told.

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If I had a nickel for every time a homebirth advocate claimed that a “risk” of hospital birth is a 1 in 3 chance of having a C-section, I’d be a very rich woman indeed.

What’s the real risk of having a C-section? A lot lower than you’ve been told.

I’ve written in the past that homebirth midwives have a one size fits all approach to childbirth. It makes no difference who you are, what your past medical history, what your test results in this pregnancy show, or what complications you’ve experience in this and previous pregnancies, all women are treated as if they are identical, and homebirth is nearly always prescribed as the correct course of action. That refusal to personalize care (the exact opposite of obstetric care) is used to scare women into believing that because the C-section rate is 32%, the average woman’s chance of having a C-section is 32%.

To understand why that is foolish, it helps to consider other examples, like lung cancer.

The lifetime risk of developing lung cancer is slightly less than 7%. Does that mean that YOUR chance of developing lung cancer is nearly 7%. No it does not. The lifetime risk of a specific individual developing lung cancer depends greatly on whether or not you have ever smoked or still do. The risk of developing lung cancer is more than 20 times higher for smokers as for non-smokers. So if you are a smoker, your lifetime risk of developing lung cancer is much higher than 7% and if you are a non-smoker, your lifetime risk of developing lung cancer is much less than 7%.

The same principle applies to C-sections. The personal risk of ending up with a C-section in any given pregnancy is dependent on your personal situation. For example, if complete placenta previa is diagnosed at term in your current pregnancy, you chance of having a C-section if you go to the hospital is not 32%, it is 100%. A C-section is always performed because attempted vaginal delivery through a complete placenta previa invariably leads to the death of the baby and mother.

As I discussed recently, the chance of having a C-section after a previous C-section is dependent on your personal situation. For the average woman with one previous C-section, the chance of a woman attempting a VBAC ending up with another is 39%. However, the chance of ending up with a C-section falls to only 10% if you’ve had a vaginal delivery since you’ve had the C-section.

So what is the real risk that someone contemplating homebirth would actually end up having a C-section if she went to the hospital instead.

No one should be having a homebirth after a previous C-section. The risk of a severe complication is simply too high. Therefore, any one who meets the low risk criteria for homebirth has never had a C-section in the past. For them, the risk of having a C-section in the current pregnancy is NOT the same as the total C-section rate. To determine that risk, we must look at the primary C-section rate.

According to the paper Primary Cesarean Delivery in the United States, the chance of having a primary C-section is 21.9%. Does that mean that a specific individual’s chance of having a C-section is 1 in 5? No, it does not, because the risk of a primary C-section is dependent in large part on whether you have given birth in the past. The primary C-section rate for women who have never given birth in the past is 30.8%, but the primary C-section rate for women who had given birth to at least one child was only 11.5%.

The typical woman who chooses homebirth has had at least one child in the past, so her actual risk of having a C-section if she has a hospital birth is NOT 1 in 3, but slightly higher than 1 in 10. That’s a very big difference.

How does that compare with the primary C-section rate at homebirth. According to the MANA study, the overall C-section rate was 5.2% and the primary C-section rate was 4.3%. Unfortunately, MANA did not break down the primary C-section rate by parity. Of the overall group of women attempting homebirth, we do know that 77.7% had given birth to at least one child. The primary C-section rate among parous women is likely to be lower than 4.3%. Nonetheless, for women who have given birth before, the risk of having a C-section after attempted homebirth is around 4%, while the risk of having a C-section in the hospital is 11.5%. At the same time, the risk of having a baby die at homebirth is dramatically higher than the risk of perinatal death in the hospital.

Most women who choose homebirth have had a baby in the past. Therefore, they are trading a small risk of having a C-section in the hospital (11.5%) for a dramatically increased risk of having a dead baby. Is that really worth it?

  • Storm

    I’m really glad I found this site before I get pregnant. I watched my mother’s best friend give birth at home twice. My mother was all for it but did drum into my head that her friend’s husband was a surgeon. When she had to give birth to a third child in the hospital, I was afraid that something horrible happened because you don’t go to the hospital unless you are sick but my mother told me it was normal for some babies to be born at home and some in the hospital and that mom and baby were fine. I hate the hospital because I have been chronically ill my whole life and I really do still feel like you only go there when sick. I’m rapidly approaching 40 so I am starting to let go of my dreams of a home birth and face the reality that due to my age and medical conditions if I have a baby soon I will need to be under medical supervision. I refuse to feel weak because of this and I still plan on going as naturally as I can, but the safety of my future child far outweighs my discomfort with hospitals. Hopefully, if I do get pregnant, I’ll be able to use the new birthing center attached to the hospital and it won’t feel so much like I am a sick patient. My Biological mother had me in twilight and researching that didn’t help me much with my fears. This site calms me quite a bit.

  • Jen

    So 30% of first time mothers have c-sections? That is higher than what I thought it was.

  • Hush

    I live in an area where primary cesarean rates are about average, at some hospitals a little less at some a little more. Thing is, at all of them they have VBAC bans. So, you have a 3 hour radius of area with no hospital VBAC. Women here who really want VBAC are planning home VBACs or traveling 4 hours away to the nearest hospital VBAC provider. More home VBAC in my usual circle than hospital….. I don’t understand the “VBAC ban” thing. It seems unethical.

  • batmom

    My healthy son is almost a year old. Delivery was a circus — lost heart tones for about five minutes (probably a pinched cord when I changed position), but then they came back as they were prepping me for a C-section, and labor proceeded for another seven hours until the OB helped him turn with forceps. We’re all fine. But as his birth date approaches, I’m having nightmares and flashbacks.

    We’re starting to think of having another baby, and while I want another baby, there’s a lot that worries me:
    a) Do I count as a previous vaginal delivery for estimating C-section likelihood, given that the first needed forceps?
    b) How can I get past my fear of labor? I feel so stupid given that everything was ultimately fine but I seriously get anxiety attacks just thinking about it.
    c) Would it be possible just to schedule a C-section at 39 weeks to avoid the whole labor nightmare? Is this the kind of thing that I can discuss or would get me laughed out of the office?

    • wookie130

      I really don’t see what would be wrong with just requesting a c-section, and I can nearly guarantee that your OB would be understanding, in light of your previous experience. There is no harm whatsoever in discussing this, nor do I think you’ll be a laughing stock or anything like that.

    • anion

      Absolutely talk to your OB. No one should laugh at you, and if they do, find another OB immediately (but they won’t anyway).

    • moto_librarian

      Talk with your doctor about your concerns. It took me two years to get to a place where I could contemplate getting pregnant again, mainly because I was still terrified of giving birth again. When I went in for my first prenatal appointment, I had a very frank conversation with my primary midwife (she had also been my primary during my first pregnancy, but didn’t get to catch either of my sons). As I rotated through the other midwives, I made sure that all of then were aware of what had happened during my first delivery, and made sure that they all understood that an epidural was a priority for me. They were incredibly supportive and committed to making sure that my son and I were both kept safe. When I went into labor, as soon as I was admitted, the on-call midwife put in my order for the epidural. When the catheter came out during transition, the midwife got the anesthesiologist up as soon as possible. I was complete by the time that she got there, but since the baby looked good on the monitor, I was redosed before I had to push. No recurrence of my prior complications occurred, and I was up and walking around within 2 hours of delivery (and I was completely numb from my waist to my toes during the delivery – ZERO PAIN – it was awesome).

  • Lion

    Wish this post had been available a few weeks ago when a friend was considering a HBAC. Thankfully every midwife she approached said no and the one who was willing was too expensive. She tried VBAC in hospital and labour was very long and a case was done. Everyone feels very sorry for her. I feel relief. Our midwives are all nurses, we don’t have CPMs here.

    • Lion

      Oh my auto correct. C-section not case.

  • Felicitasz

    Once again, these are the pieces I come to this blog for. Wow, and THANK YOU.

  • KarenJJ

    So MANA have a 1 in 20 chance of a c-section and similar profile hospital births it is 1 in 10.

    So you have twice the chance of having a c-section in a hospital, but 3 times the chance of having a dead baby and 18 times the chance of having a baby that needs cooling therapy due to brain injury.

    Homebirth benefits vs relative risks doesn’t come out for the win, does it?

    • The Bofa on the Sofa

      But the c-section rate is too high, m’kay?

  • Arwen

    Ah…it’s not just homebirth midwives who claim you’ve got a 1 in 3 chance of a c-section, and they’re not the only ones acting like that’s a bad thing. For my first child, when I asked about the possibility of a c-section (since my own birth was an emergency section), they said I had a 1 in 3 chance of a section, but if I took care of myself that risk was a bit lowered. For my second, I wanted no part of a TOL after my weird series of pregnancy complications, including preeclampsia. They denied me a MRCS on the grounds that I might have another kid. They also refused to induce before 39 weeks, despite the fact that my PIH was getting worse and I had fluctuating levels of protein, claiming the March of Dimes did not allow that sort of thing anymore.
    It’s not just homebirth midwives who are steeped in woo, here. I was just too scared to switch providers mid-pregnancy, or I think I would have seen through the woo sooner.

    • Certified Hamster Midwife

      I didn’t know that the March of Dimes was a regulating body for hospitals.

      • Arwen

        My jaw dropped when I heard that one. I could not believe a supposedly educated doctor was trying to tell me this. I told them I had protein in my urine, my hypertension was getting worse, what were they waiting for? An emergency c-section? I wanted a controlled landing, not an emergency one. Turns out I have auto-immune disease. Why on earth would a bunch of OBs who see a woman in her childbearing years with a bunch of wacky symptoms NOT refer her to a rheumatologist? Ohyes, because they believed that everything was a variation of normal, and I was a whackjob for not sharing in that belief.

        • Young CC Prof

          In defense of their not diagnosing your autoimmune disease, a lot of weird things go on during pregnancy and most of the time they clear up afterward. (If they continued to blow you off afterward, that’s not cool.)

          Not delivering a woman past 37 weeks with worsening signs of preeclampsia, however, is indefensible. Remind me NEVER to go to that hospital.

          • Arwen

            They continued to blow me off afterward. Who does that to a woman of childbearing years? Who tells a woman “gee, I don’t know why you’re having this mixed bag of symptoms, including rampant uncontrollable inflammation 6 months post-partum?” Idiots who are steeped in ideology, not medicine, that’s who. How hard is it to write out the name and phone number of a rheumatologist? It even gets you off the doctor’s back!

    • Young CC Prof

      That is the big problem with the NCB movement. It’s not just the tiny fringe who do home birth, parts of the NCB ideology have crept into the public conventional wisdom and the actual medical establishment, despite strong evidence that they are false.

    • moto_librarian

      The March of Dimes needs to back off on this 39-week rule bullshit and start looking at root causes of prematurity. Why can’t they start a campaign to figure out what causes pre-eclampsia?

      • Karen in SC

        There’s an honorary plaque somewhere waiting for the person who figures out the cause and a cure of pre-e.

        • Young CC Prof

          This company claims that they may be able to prevent or slow the progression of pre-e by filtering a certain substance out of the bloodstream. No idea whether it’s even plausible, but I look forward to finding out. http://www.advancedprenatal.com/technology.htm

          • Ash

            It seems their apheresis product isn’t anywhere close to proving efficacy&safety at this moment in time.

          • Young CC Prof

            No, they haven’t even started any trials yet. I’m just wondering whether it has basic plausibility.

      • Young CC Prof

        You know, the March of Dimes isn’t really driving that 39-week bus, they’re just part of the parade. And they’re one of the very few organizations that are actually trying to do something about perinatal death. They’re drinking too much of the NCB kool-aid, but they are trying. Their little pregnancy book is in favor of dating scans, anatomy scans and flu shots, and says flat-out that home birth increases the risk of neonatal death.

        No, they don’t really get that waiting too long can be as dangerous to babies as being born too soon, and they condone waiting up to 42 weeks to induce, but that may change if ACOG’s statement in favor of induction by 41 ever gets any actual press.

        I don’t agree with everything they do, but I’d rather work with them than against them at this point, since they are NOT birth-worshipping kooks.

        • moto_librarian

          I have seen billboards by the March of Dimes all over my city urging mothers to wait to deliver until 39 weeks. They are the primary organization pushing for this in a public way.

      • Arwen

        Absolutely. I will never give a thin dime to the March of Dimes. As far as I’m concerned, they either have blood on their hands, or they will soon.

    • Jessica S.

      That’s awful! I’m sorry you had to go through that.

  • Tara

    http://www.babycenter.com.au/a538711/how-age-affects-pregnancy#section1

    “Women of 35 and over are more likely to have induced labour, diagnosis of fetal distress, epidural anaesthesia, or forceps or ventouse delivery, and virtually all studies agree that the rate of caesareans rises with maternal age, though again this rises with private care, regardless of age (Roberts C, Tracy S, Peat B, 2000, BMJ). However, this increase does not appear to be connected with any specific problem. There is a question mark over how much of this intervention is necessary, and how much is caused by a general perception that ‘older’ mothers are ‘high risk’. Once the course of nature is interrupted by one intervention, others frequently follow in what is known as a ‘cascade of intervention’, so as in pregnancy, if you want to give the physiological processes of birth a chance, be well informed, prepared to ask questions and seek a second opinion if you are not satisfied with the first.”

    And then, in the VERY NEXT PARAGRAPH-

    “There is however, one small but serious risk to the babies of more mature mothers. Inexplicably more babies die, in utero, right at the end of pregnancy in this group of mothers – 1 in 440 pregnancies of women aged 35 or more, as opposed to 1 in 1000 for younger women.”

    Talk about not being able to see the forest for the trees…

    • Tara

      So that “cascade of interventions” “does not appear to be connected with any specific problem.” Perhaps, they do not consider your baby being more than twice as likely to “inexplicably die, in utero, right at the end of pregnancy” to be “specific” enough.

    • Young CC Prof

      Let’s make an analogy.

      SIDS: We don’t really know why it happens, or what’s going on physiologically. Often, there are no advanced warning signs. We do know risk factors, and some are modifiable. We encourage parents to modify their risk factors, especially if multiple risk factors are present.

      Term stillbirth: Often, there are no warning signs. Sometimes it involves cord accident or placental failure, but sometimes we don’t really know why it happens or what’s going on physiologically. We do know risk factors, and some, like going past your due date, are modifiable. We encourage women to avoid the “cascade of interventions”, even if multiple risk factors are present.

      Say WHAT?

    • The Bofa on the Sofa

      Women of 35 and over are more likely to have … diagnosis of fetal distress,

      I quit reading right there.

      Who wouldn’t want to prevent fetal distress?

    • Jessica S.

      Which is why no one is going to tell me this baby isn’t arriving at 40 wks. (I’m 37) Sure, it could be mostly paranoia but I’d like to get this kid out safely so I can be done with childbirthing. :)

  • The Computer Ate My Nym

    IMHO, if we want to lower the c-section rate safely, here’s what we should do: First, make sure that the ONLY reason any woman doesn’t get prenatal care is that she actively refuses, knowing the risks. No lack of prenatal care because of no insurance or no lack of prenatal care because they can’t find an OB or medwife CNM with an opening in her/his schedule, no lack of prenatal care because of stigma and fear. That means spending more money to make sure everyone is fully insured (sorry, Obama, but you’re not nearly there yet), increasing spending on medical education and making sure that medicine is a viable field* that people want to go into, stop blaming “teen pregnancy” for every social ill from obesity to crime, and make birth control readily available. That will take care of some of the currently preventable c-sections (gestational diabetes, etc).

    But that won’t be enough. That will reduce the number of c-sections perhaps a bit, but it won’t get them down to the mythical 15% or any other goal one would care to mention. That will require something else: Medical research. We don’t know which c-sections are unnecessary. If we want to know that, we’ll have to do clinical trials. And pre-clinical studies. In short, the NIH and similar organizations in the rest of the world need to have a MASSIVE funding increase. Doubling would not be too little. Doubling for several decades in a row would be better. Take the funds out of the 1%’s taxes and the Pentagon’s budget. The CDC is doing more to protect the population of the US, including from “foreign invasion” (i.e. Aedes mosquitoes and their pathogens) than the Pentagon anyway.

    In short, lecturing women won’t do it. We need a paradigm shift. We need to start taking biology seriously. Shall we?

    *There’s a whole separate comment to be made about why medicine is becoming less attractive over time. The short version is that if we want people to continue to be willing to be doctors we’ve got to stop demanding that they make money at all costs. Or simply make the reimbursement for non-surgical specialties higher. Or something.

    • AmyP

      I had gestational diabetes my last pregnancy, and I can see that there would be a lot of issues with compliance at home, even if the patient were seeing the doctor for all appointments.

      I was kept faithfully to the diet necessary to keep my blood sugar within bounds, and I was half-starved about half the time and finished up with a 12 pound net weight gain for the entire pregnancy, 9 pounds of which was baby (beautiful, healthy baby). It was TERRIBLE.

      • The Computer Ate My Nym

        I’m convinced that only pregnancy induced nausea kept me from getting GD: you can’t have an elevated blood sugar if you can’t actually eat anything…10 pound weight gain, 7.5 pound baby.

        And, yes, the GD diet is awful! Another area where more research is needed: what can we do to help women who are diabetic and pregnant besides starving them?

        • http://kumquatwriter.wordpress.com/ Kumquatwriter

          They’re not mutually exclusive. I had severe hyperemeses (puked for 8 months) and also GD. My net gain was also about 13lbs – but part of that is I lost about 13 in the first trimester.

          • Wren

            Oh, that’s just unfair Kumquatwriter. I puked at least once a day from before 6 weeks until I went into labour, even with meds, but at least I avoided GD.

          • The Computer Ate My Nym

            Biology stinks sometimes. That’s why I’d much rather trust technology than birth. (Not that I’d advocate blindly trusting technology either, of course…)

      • atheist mommy/Oma

        My GD was all around horrible too. Even complying with the starvation diet, I still ended up with a 10lb 3oz baby and gaining 60lbs. I thinks the majority of my weight gain was water though since I lost 50lbs of it within a week of giving birth.

  • Ellen Mary

    So the group I went to had a primary rate of 9% on all mothers (overall rate of 22%) and a lower rate on mothers who had given birth before (unknown). So according to MANA’s stats, did I actually have a similar risk of Cesarean in either setting, with a lowered risk of a bad outcome in the hospital?

    And I am in OR where the Midwifery regulations allow for a higher intrapartum death rate.

    There were still things I felt could have been done much better in my hospital birth. However this analysis makes it seem like my decision to go to the hospital was just smart, rather than the trade off I have framed it as.

    • Young CC Prof

      I think most mothers have a similar risk of Cesarean in either setting! (Slightly lower out of hospital, but the difference is much smaller than most people realize.) And of course the section rate of your particular hospital or provider is a poor measure of your probability of winding up with one.

      • Ellen Mary

        Can you explain why you think the Cesarean rate at your hospital or provider does not impact your chances of winding up with one? I feel like it has been shown to be a determinant to some extent. Of course your personal health plays in, but given equal risk levels, some providers will skew toward or away from Cesarean (for example some offer instrumental vaginal delivery, some do not . . .)

        • moto_librarian

          I think that a provider’s comfort level with various situations likely plays a role in the rate, but probably not in a huge way. Personally, I don’t see the gradual phase out of instrumental deliveries as a bad thing (I have mild pelvic floor damage, and I cannot even imagine what it must be like for women who have had 3rd and 4th degree lacerations). I also think it depends on what type of hospital you deliver in. I gave birth at a university medical center, a tertiary care center. The c-section rate is higher than at many hospital, but that is because there are lots of sick babies being delivered there due to the presence of the level IIIB NICU. The overall rate is higher, but the rate for my CNM practice was right around 10%.

          • Ellen Mary

            Yes I was just discussing with my SIL how large regional trauma centers can actually give some mothers a better chance at vaginal delivery because they can afford to take more risks, as they have the ability to respond to emergencies. (For example CMC Main in CLT has one of the highest area VBAC rates).

            Suburban hospitals often have some of the highest section rates (for example Newton W in Boston. It seems to be a combination of just enough staff to keep high risk mother’s in house but not enough to take the same chances that a large urban hospital can . . .

            I lived near a rural hospital that lacked even a NICU & transferred out most high risk patients early in pregnancy. They had the next to highest section rate in the entire state & an L&D nurse there seemed to think that they could not take risks at all, and that explained their rate.

        • Young CC Prof

          It’s not totally irrelevant, but your medical history is a better predictor. The Cesarean rate of a hospital is, as moto pointed out, more closely linked to the risk profile of the typical patient at that hospital than to the hospital’s specific policies on when to operate.

          Of course, there are some instances when policies matter. Some doctors will happily do a maternal request c-section with no medical indications whatsoever once informed consent is provided, some will absolutely not. And with VBAC, local variations DO become much more important. Some doctors or facilities just plain don’t allow it. Other places strongly encourage trial of labor unless there’s a good reason not to. If you want VBAC, you do have to choose a hospital that offers it.

          • anne

            I was thinking of my friend’s who had c-sections yesterday and only two of them were a surprise during labor. For my other friend’s the babies were breech, preemie with problems, multiples, mom was obese with GD and over 40, etc. It’s anecdata but the vast majority of my friend’s who had c-sections had about 100% chance of them and scheduled in advance.

        • batmom

          Here’s an example: the hospital at which I delivered has a level 3 NICU, so its rate is a bit higher than some of the other hospitals. But not because they’re madly rushing women into surgery, but because if you’re high risk, that’s where you go. And because they had a dedicated OB anaesthesiologist and an OR right across the hall, they were willing to watch and wait — so a higher section rate probably meant for me a better chance of vaginal delivery.

          The CNM who cared for me during pregnancy has a low C-section rate, because obviously she can’t do them, and risks out women who are high risk. The OB she works with in her practice has a higher rate, because he cares not just for his patients that need C-sections, but for hers should they become necessary.

  • Jocelyn

    OT: I’m looking for a blog someone linked to on here once. It’s written by a dad whose son died at a homebirth. The blog extends back before the birth and then afterwards. Does anyone know which blog I might be talking about?

    • Dr Kitty

      Maybe Wren Jones’ dad?

      • Jocelyn

        Thank you, but no; the baby died from a shoulder dystocia or something, not GBS.

        • Medwife

          Sounds like Elm City Dad. I stumbled across that blog about a year ago. Heartbreaking

          • Tara

            I’m reading the birth story on this blog and the mother claims that the outcome of shoulder dystocia is the same whether in hospital or at home. And of course when I google it, it’s a bunch of articles trying to state that home birth is SAFER for shoulder dystocia. Any references for actual numbers on this?

          • Medwife

            Did you read the disclaimer at the very end of the birth story? She didn’t edit what she originally posted but said basically that they are not on the homebirth bandwagon anymore. Like so many loss parents their views of what happened evolved over time to hold their midwives and homebirth responsible for the death.

            Shoulder dystocia outcomes at hospital vs home? Not aware of any publications comparing the two. For obvious reasons I very, very much doubt hb outcomes are anywhere near as good as in hospital.

          • Jocelyn

            Yes, that’s the one. Thank you. It is heartbreaking.

          • Medwife

            Did you note that it was a CNM attended birth? There was, and still is, only one CNM homebirth practice in Connecticut. Hm.

  • KarenJJ

    Are there any real variables that women can control to try to avoid a c-section? Anything really effective that is not currently done in a hospital?

    The ones I can think of are:

    1. Controlling gestational diabetes well.

    2. Not catching herpes.

    3. Waiting for as long as it takes for a baby to come out vaginally (seems ot be the preferred method of homebirth midwives but obviously with potentially bad consequences to baby and mother).

    4. Procreating with men that have small heads.

    • Young CC Prof

      I am highly amused by #4.

      But I would add, contrary to NCB propaganda, consenting to labor augmentation (if the doctor recommends it) can sometimes prevent a c-section by getting the baby out before an emergency situation develops. There is no cascade of interventions.

    • Jessica S.

      As theadequatemother pointed out down thread, have your kids before 25.

    • yugaya

      “4. Procreating with men that have small heads.” Dang. Big headed men dominate the gene pool on offer over here. :)

    • T.

      Try not to be overweight?

    • Aussiedoc

      4. I can tell you that don’t work out if you have a big head yourself. Fortunately I ended up with a pelvis to match apparently but I’m still irritated about it,

    • Trixie

      Actually, I procreated with a man with a huge, giant melon head, and both of my newborns had average to slightly below average head circumference at birth. My son’s head got rapidly larger in his first year until it was (and remains) in the 99% like my husband’s. My daughter’s stayed average.

      • MLE

        Similar story here. My son was head down from 28 weeks and stayed that way, so I am wondering if his head didn’t have the room to grow. He was born in the 50th percentile and by 6 months was in the 95th. Glad it turned out that way.

    • fiftyfifty1

      “Anything really effective that is not currently done in a hospital?”

      1. Find yourself an OB who is skilled in forceps and willing to do them and make it clear that you want to avoid c-section at all costs and are willing to accept the higher risk of injury to your baby and yourself.

      • The Bofa on the Sofa

        You can try, but why would the doctor go for it? You cannot sign away your right to sue, so you can be as adamant as you want, the doctor is still liable for the outcome, and is ill-advised to do something that goes against their better judgement.

        If the dr thinks that something is a bad idea, tells the patient that they advise against it, then they really are stuck, because if something goes wrong, the patient can say (and would be correct to say) you KNEW it was a bad idea, why did you let me go through with it?

        Get on the stand and tell the jury, “Because that’s what the patient wanted”? Nope, doesn’t fly. You lost.

        • fiftyfifty1

          And yet there are still some OBs out there that do forceps, including mid forceps. They won’t do them in situations that they think are truly ill advised, but if you and your baby are decent candidates, they will. Even if you are a good candidate, the risks to you and baby are still there, but they are small and there are some old time docs willing and skilled enough to do it.

          • The Bofa on the Sofa

            They won’t do them in situations that they think are truly ill advised,

            And this is the key difference.

          • fiftyfifty1

            Sure, but the question was how a woman can reduce her chance of having a c-section. Being willing to have a forceps delivery + finding an OB who has forceps skills = one way of reducing your chances of a c-section. Of course there are situations where forceps would be truly ill advised, but I’m not talking about those. I’m talking about all the situations where forceps are not unreasonable in skilled hands and the alternative is a c-section.

          • The Bofa on the Sofa

            are willing to accept the higher risk of injury to your baby and yourself.

            But here you acknowledge that it is a higher risk of injury. This is the problem with your scenario.

            If the doctor has adequate forceps skills, it would not be occurring with a higher risk of injury.

            This is the statement that prompted my reply.

            I am perfectly fine with the idea of finding a provider with forceps skills that can do it as safely. But in your setup, you are indicating that they don’t.

          • fiftyfifty1

            “If the doctor has adequate forceps skills, it would not be occurring with a higher risk of injury.”

            Wrong. The increased risks of forceps (3rd and 4th deg tears for mom, risk of damage to baby) can’t be completely eliminated, even in the most skilled hands. That’s why they have fallen largely out of favor. But there are some (usually older) OBs out there still willing and able to do them. An example I’ve mentioned previously on a different post is one woman in my system who is a grandmultip with an odd shaped pelvis who has required mid-forceps rotation and delivery for all of her infants. The docs here have been willing to accommodate her.It helps that she has a good reason for wanting to avoid CS (planning a large family for ethnic/cultural reasons).

          • Ash

            I read an admission note for planned instrumental delivery. I was quite surprised.

    • Mtbakergirl

      Take up smoking? :)

      • Young CC Prof

        50 years ago, that was a serious recommendation.

        • Karen in SC

          My mother smoked, drank coffee and highballs, and wore a maternity girdle. All five of her children were a little over 5 pounds, born from 1958 – 1969.

          She considered my 8-9 pounds boys quite large!

    • theadequatemother

      I’m going to repeat this: have your children in your 20s.

      • Box of Salt

        That’s only possible if you meet someone who you recognize will be good partner for raising children while you are still in your 20s.

        And that is not necessarily something a woman can control.

        • theadequatemother

          Oh I know. I had my kids in my 30s but I recognized that there was an increased risk of complications throughout pregnancy and a higher chance of needing an urgent section. Clearly modifying this risk factor isn’t possible for everyone that wants kids. But from a public health perspective if we wanted to improve maternity outcomes (decreasing intralabour urgent cs) the creation of structures to support earlier childbearing might be an option worth considering – removing some of the systemic penalties women face wrt higher education and career building that come wih childbearing for example.

          • Young CC Prof

            Believe it or not, if you look at neonatal death rates by maternal age group, 20-24 is above average risk. 25-29, 30-34 and even 35-39 are all below average risk. Obviously this is sociological and economic rather than obstetric, and may correlate with things like access to care and intended vs unintended pregnancies, but yes, there are MAJOR systemic obstacles and disadvantages to young childbearing.

            Clearly, the solution is to produce children in your twenties and give them to adoptive parents in their mid-thirties, then adopt someone else’s baby when you are old enough to care for it. (I’m mostly joking. Mostly.) Or, cryogenic suspension of newborns! That would work perfectly!

          • fiftyfifty1

            Neonatal death rates may not be better for those 20-24, but c-section rates sure are lower.

    • Kory Oransky

      Sorry, but sometimes #1 just is close to impossible, even with sticking to the diet and using medication (yes, the dreaded insulin shots, too.)

      I never managed to get mine controlled well. I remember crying in my OB’s office, and she told me that the baby’s needs can throw everything off in spite of every effort by the mother to regulate her blood sugar. Some days I was able to hit the targets, but on other days, I was nowhere close even if I ate the same meals as on my “good” days.

  • Deena Chamlee

    So many variables. Informed choice and informed consent remain central to the topic. And correct data. It seems to be an issue for OOH birth more than in hospital birth with midwives. Am I assuming correctly?

    • Young CC Prof

      You mean bad data and inadequately informed patients are more common out of hospital? I totally agree.

  • disqus_FeN6LaMBls

    Has this story been posted here before? With the recent discussion of Ms. Nirvana and doulas practicing outside their scope, I was happy/sad to stumble across it

    http://greatminuseight.wordpress.com/2014/04/14/21-doulas-and-donts-my-cautionary-tale/

    • Gene

      “If I am ever blessed with another pregnancy, I will hire another doula, and attempt another natural birth, because I really believe our bodies were made to birth babies without *unnecessary* intervention.”

      It’s being discussed with some interest on a doctors’ board. The sad thing is that after all the crazy woo she fell for, she STILL trots out the party line of “made to birth” and “unecessary interventions”.

      • Kira

        Would any doctor let her attempt a natural birth? How do y’all deal with someone who almost lost her baby due to her devotion to natural birth and fully intends to try it again? Would insurance even allow that? If I were an OB, I’d classify her as too high-risk for my practice and refer her to a perinatologist.

        I wonder if OBs will start screening their patients on social media in the near future? I would.

        • Anj Fabian

          I don’t see why she couldn’t try. She’d be high risk due to history and is at risk of developing the same conditions that led to the complications – GD and GBS+.

          • Kira

            I don’t think this woman, specifically, should try. The only intention she stated is that she’ll do the same thing over again with another doula. She didn’t state any intention to prevent or control GDM, manage the symptoms of her PCOS, etc. or any understanding of how high risk she is now.

            I think I’d feel differently if she would indicate that she is 100% willing to be compliant with her OB.

          • AmyP

            I think there was actually a lot more trust and friendliness toward doctors toward the end of her post.

            Where she’s still on the woo train is this “meant to birth” stuff. She’s 80% converted to common sense, though, as I read her.

        • ngozi

          You can have a low intervention, no pain meds labor and delivery at a hospital, if your health condition allows for it. I having a natural childbirth means different things to different people. I am sorry to be offensive, but more than a perinatologist she probably needs counseling (not that it would help if she doesn’t realize she has issues).

          • Kira

            I was thinking about the liability for the OB. Would the insurance company who covers the OB let him/her accept the poster as a patient? With malpractice insurance rates so high and OBs already so busy, I wouldn’t blame them for refusing non-compliant patients.

          • 3loveme

            Your professional liability carrier really has nothing to do with who you choose to take on as patients. It’s up to the physician to handle non-compliant patients correctly. Give written notice and provide obstetric care until a new physician takes over. All while CLEARLY charting everything.

          • 3loveme

            I should also say – if a physician is concerned about a non-compliant patient, a professional liability carrier will guide them through the correct steps to keep them protected.

    • Anj Fabian

      What the fuckity fuck? [apologies for language]

      “My doula loaned me one. She made a mixture to help the inflammation from my episiotomy. I asked if we could have done anything differently, and she said that “If you’d had a homebirth, she’d be fine. We would have hung you up by your toes to get that baby out.”

      My nerves were shot. I felt fully responsible. She suggested I sue
      the delivering doctor for malpractice, though now I can’t remember what she suggested as the reason.”

      This is a doula who advised the woman to stay home for 48 hours after SROM who was GBS+. (Also PCOS and GDS, but who is keeping track?)

      • Anj Fabian

        One of the comments that is not like the other comments…

        “I’m sorry you had such a traumatic birth. I hope that writing out your
        story helps you to process the experience. Shoulder dystocia can be an
        extremely hard thing to deal with, especially in light of providers who
        panic at the time of the event. I’m glad your daughter is doing well.”

        “panic” Yeah….right.

        • Young CC Prof

          “Heart attacks can be an extremely hard thing to deal with, especially in light of providers who panic when you show up in the ER.”

      • Ash

        What the hell does it mean they would have strung her by her toes?

        • ngozi

          Doesn’t sound very helpful…

        • Siri

          It means stupid hyperbole with no basis in reality. Empty boasting after the fact, designed to make mum feel bad about her choices. It’s despicable.

    • Kira

      I cannot process what I just read. This doula “coached” a laboring woman who had GDM and was GBS+ (has PCOS and possibly obese) to lie about when her water broke? And had counseled her over and over again to lie to her doctors? And then argued with a neonatologist?!? I’m fixing to ask my husband if there is any way she can be brought up on *criminal* charges.

      I don’t understand how someone who has undergone fertility treatments can then think that “our bodies were made to birth babies without *unnecessary* intervention.”

      • Wren

        Actually, I can understand that thought process. Infertility can be hard, especially when it is the “fault” of just one of you. It took us 5 years and plenty of intervention to get pregnant and I did not want to think my body was any more “broken” than that. I absolutely did not want any interventions and was going to breastfeed for at least 2 years, etc. My body was going to work right. Well, my body worked but my son had other ideas and c-section it was and he quit nursing at 9 months. At the time, both seemed devastating and somehow proof I was broken. Now, both are just events in the past and don’t really matter except that he is here and healthy.

        • Kira

          YMMV. My girls are all from fertility – IUI and injections. I was so pleased that medical technology had gotten me pregnant that I was more than happy to keep going in that direction.

          The NCB woo never appealed to me in the first place, so I never had any desire for a natural birth. I had seen my mother and grandmother suffer from their natural births and I’ve seen cows and goats being born. I had had a very realistic view of birth and just wanted the babies and myself to come out of it alive.

          In general, I’m a big fan of better living through science and that has greatly informed my worldview.

          At some point, you have to accept the limitations of your body. I will not be able to push my daughter (she’s an assisted athlete) in any race longer than a 10K this year because of a knee injury. Instead of running the local half marathon with my daughter, I like I had planned, I will be running it alone. I am bummed out, but I’m not going to ignore my orthopedist and risk damaging my knee to the point of needing surgery.

      • AmyP

        And coached the dad, too.

    • Jessica S.

      I’m speechless. What a horrifying tale and yet she still thinks there are “unnecessary interventions?” She acknowledges that her daughter is alive and well today b/c of medical advances and scientific technology but still thinks women’s bodies were “made to birth”? In the literal sense that we have all the required parts, yes. But just b/c you have vagina does not necessarily mean that babies will fall from it like raindrops.

  • EM

    As women we are supposedly given the right to control over our bodies. But apparently, when it comes to childbirth we don’t have the right to choose a cs… It’s bizarre. So here, make a choice…as long as you choose vb, unless WE determine that YOU “need” a cs.
    I had a cs, at 35 weeks for pre-e with bp so high it led to organ failure and my son suffered IUGR. We were separated for around a week in our respective ICUs. I will be forever grateful for this lifesaving intervention. If I had to do it all over again I would choose the cs, even under different circumstances. And I definitely choose it for my next child.

    • Sue

      It’s the same ”false choice” that the anti-vaxers claim – ”we are not anti-vax, we are pro-choice, but, if you really understood, there is only one choice you could possibly make”.

      • Poogles

        “if you really understood, there is only one choice you could possibly make”

        I once had an anti-vaxxer accuse me of lying because I told her I had once been an anti-vaxxer and so I have seen most of the “research” against vaccines and am still now pro-vax. She refused to believe I could possibly be pro-vax if I’d seen the “research” that convinced her to be anti-vax, so obviously I was just lying…

  • Certified Hamster Midwife

    OT: http://www.longestshortesttime.com/2014/04/16/podcast-28-the-missing-chapter-to-ina-mays-guide/

    “And then I actually gave birth. And it was nothing like what Ina May said it would be. I felt like I had failed. But I also felt mad at Ina May. And the whole natural birth industry, actually. For making me believe that natural birth was not only possible, but that it had the potential to be an ecstatic experience. And for not telling me what you were supposed to think if you didn’t get to have it.”

    • C T

      I’m really appreciating the comments to that post as well. Thanks for sharing it.

      • Certified Hamster Midwife

        I hope everyone clicks through and listens to the interview. Including Dr. Amy.

    • T.

      I notice how there is no words about the little girl that Ina Gasking let die. Fancy that!

  • almostfearless

    Here’s what I wonder… if it’s 4% c-section rate for homebirths and 10% rate for hospital birth then it’s only 6% chance of an “avoidable c-section” by having a homebirth. But we also know that homebirth has an increase in HIE or other birth injuries to the baby that lead to death or permanent brain damage. So ALL the homebirths increase their risk of anoxic brain injury by 18%… women who would not have had a c-section in either environment, plus that small number of women who avoid a c-section by birthing at home– are all taking on an 18% increased risk that their child will have brain damage– right? Here’s Dr.Amy’s post on that study http://www.skepticalob.com/2014/01/risk-of-anoxic-brain-injury-is-more-than-18-times-higher-at-homebirth.html

    • Young CC Prof

      Not 18% chance. Infants born at home were 18 times more likely to need brain cooling to treat HIE, but it wasn’t 18% of them.

      Your point remains, though. You’re trading a few less c-sections for a significant increase in the risk of disaster.

      • almostfearless

        Typo… fixed it. I don’t know what the risk is for brain cooling in general, so what’s 18X higher… maybe 1 in 1000?

        • Young CC Prof

          The article cited in that post did NOT attempt to find the overall odds of brain cooling, so I’m not sure.

          • 3loveme

            Also keep in mind, not all hospitals are equipped to do brain/ full body cooling for infants unfortunately.

          • ngozi

            An excellent point. Many hospitals that deliver babies aren’t equipped to do anything near that.

          • Mac Sherbert

            No, but they can do the most appropriate interventions available to them and transfer care efficiently to a hospital that does cooling. That would be remarkably better than to have a disastrous home birth, call 911, be taken to nearest hospital, then transferred to another hospital.

            Not to mention that in most cases the hospital will know the baby is going to need help before it comes out limp.

          • 3loveme

            Yes Mac, NICU’s do use all appropriate interventions at their disposal, especially when they know the baby is going to come out “limp”, as you say. Nobody has said otherwise.

      • The Bofa on the Sofa

        And I think the most important lesson is that, in the end, you really AREN’T trading all that many c-sections. As you show below, the crowd that is suited for HB is not the ones getting c-sections.

        • T.

          Yes. You are trading probably not that many c-s for baby’s brains. Litterally.
          It would be interesting to make a study of this kind: seeing how the percentage of cs in hospitals vs percentage of bad outcomes (death, disabilities) on homebirth.

          • Amazed

            Who is willing to bet that if such a study is produced (Hi, Dr Grunebaum, my name is Amazed and I might have a project for you), they’ll start scrambling for each tiny factor that could not have been taken into account and so was not taken into account to explain why the findings aren’t actually true?

          • Young CC Prof

            It’s an interesting idea, but I don’t have any idea how to find the data on disabilities. Maybe pediatric neurologists in some homebirth-heavy counties in the Pacific Northwest area? But it’s tough to link birth records to health records for older children. And home birth mothers may be more likely to homeschool, which may lead to a lower rate of diagnosis for milder injuries…

            Neonatal death is solid and unmistakeable, and it’s very well tracked. Birth records undercount the disasters, because they don’t account for transfers or intrapartum stillbirth, but they still count enough to make the differences clear, as one of the Gruenbaum papers shows. I don’t have any idea how to do the same thing for injuries.

            Actually, which large health insurers pay for home birth? State of Vermont, right? How about Kaiser? They might have enough data to pull it off–and then stop covering it.

          • Amazed

            I am not sure how legal and ethical it would be to collect data on injured children. Parents might be able just to refuse to participate while birth records are something that is out of their control.

          • Young CC Prof

            I just looked it up. HIPPA does have a research exemption, although of course the details are complicated, identifying information has to be stripped out, and you need specific IRB approvals to do it.

            So, it’s probably possible to do something like that, but I’m not entirely sure how.

          • T.

            It would be very interesting, though. Just catastrophic emergency (like the need for brain cooling) would do. That and neonatal deaths. It would tell us a lot about CS and how many bad outcomes are avoided.

            Say, for every 3 CS there is 1 brain damage. For every 6 there is a dead baby. Wanna take your chance in the russian roulet?

  • MLE

    That’s all well and good, but what of the tummy tucks?

    • http://whatifsandfears.blogspot.com/2012/12/the-business-of-being-misled.html Doula Dani

      LOL LOL LOL LOL :) :) :) :)

    • Young CC Prof

      Absolutely there are too many tummy tucks! And it is entirely the fault of those greedy grasping plastic surgeons!

      • MLE

        And then you have the HB OBs who are literally grasping you *cough* Biter *cough*

    • Amy

      Your chance of getting a tummy tuck during a birth is 0% at home.

      • Amy Tuteur, MD

        Your chance of getting a tummy tuck during a C-section is also 0%. Plastic surgery is always elective surgery and elective surgery should not be performed at the same time are required surgery.

        • theadequatemother

          both the OBs and plastic surgeons I work with say its very well known that tummy tucks at the time of CS have a very poor result compared with those done later. so they don’t recommend it at all.

          • Haelmoon

            We do tubal ligations at the time of c-section. However, I don`t encourage women to do so unless they mention it early in the consult. Unless you start out early knowing that you are done, there is a relatively high risk of regret when tubal is done with a c-section. Plus, things like the IUD offer other benefits and are as effective. If you have an unplanned tubal, unless it was documented before labour, I refuse to preform a tubal because you are not in the best state of mind to be making such a big decision. I know that opens a whole other bag of worms about consent in labour, but more than I really want to think about today.

          • Susan

            I thought it was illegal to do a tubal without the 72 hour consent. Is that just a California thing?

            http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/pm284(eng-sp).pdf

          • atheist mommy/Oma

            I don’t know about CA but in MI medicaid won’t pay for a tubal unless you sign a consent at least 30 days before. It was the same for my SO to have his vasectomy at the VA.

          • KarenJJ

            I was 6 weeks pregnant and it was the second thing out of my mouth at my obgyn’s office at my first appointment for my last pregnancy (the first thing was to ask for an elective c-section). Knowing my medical history he was fine with both.

        • MLE

          On a more serious note, does that include tubal ligation (or whatever the current procedure is), or is that not considered elective?

        • Certified Hamster Midwife

          Isn’t tubal ligation elective surgery and sometimes performed during a c-section?

      • MLE

        What? Just press the folds flat and adhere with a paste composed of puréed kale and vernix.

        • Bombshellrisa

          Seaweed, don’t forget the seaweed!

      • LMS1953

        Heck, your chance of having a third degree obstetric/perineal laceration recognized and repaired at a home birth ain’t much better.

        • Trixie

          Don’t be silly, just strap a slice of placenta to that tear and you’ll be better in no time*.
          *According to this month’s edition of Midwifery Today.

          • Young CC Prof

            A slice of placenta after 30 hours of ruptured membranes! Excellent idea! (Shudder.)

  • Kira

    I would imagine that advanced maternal age, obesity, and herpes more than account for any rise in C-Section rates. All of these are very taboo to talk about, both in and outside of medical settings.

    I have had 3 C-Sections and I *loved* them. My first was a life-saving emergency at 26 weeks, after a month in the perinatal ICU. My second was 37-week twins, very much planned. My OB would have let me try a VBAC, but I laughed in her face when she offered (she laughed back – we have a wonderful relationship). It was a fantastic experience and it helped us to get over the last bit of trauma from the first birth. I was on my feet that same day and had the girls at Mommy & Me four days later. My last baby was a whopping 9 pounds and every time I look at his giant melon head and broad football shoulders, I am *so happy* I didn’t have to push him through my lady business. I’m also very happy that I can run, laugh, and sneeze without peeing. Both my mother and grandmother (who only had 1 and 2 children, respectively) had lifelong complications from their natural childbirths. I’m a petite woman who is married to a 6.6-foot man, so those kids would have wrecked me.

    I always think of my great-grandmother, who had 10 babies naturally. Six of the babies survived and four died during or shortly after the birth (records indicate that they died on the days they were born). I’m sure that my great-grandmother would have preferred to have 4 C-Sections, rather than to bury 2/5 of her babies.

    • Deena Chamlee

      Not arguing that either. I am saying there are just as many women, believe me I have cared for them, that do not want to be placed in any situation that would increase their odds for a cesarean birth. This has nothing to do with me or my belief, it is their wishes.
      Thus, inducing a 40 yo primipara at 39weeks or 40 weeks with a bishop score of 2 is not her wish. Her wish is to perform biweekly fetal surveillance and wait for the onset of labor.
      Is this being a crazy midwife? No because it has nothing to do with me, it has to do with informed choice.

      • Trixie

        But was she also informed of the vastly increased risk of stillbirth at her age?

        • Deena Chamlee

          YES!

      • The Bofa on the Sofa

        I am saying there are just as many women, believe me I have cared for them, that do not want to be placed in any situation that would increase their odds for a cesarean birth. This has nothing to do with me or my belief, it is their wishes.

        It does TOO have to do with you and your belief, because you are among those running around demonizing c-sections in the first place.

        How many of those women who don’t want a c-section do so because they have been taught that a c-section is undesirable? Not based on anything real, but c-sections are bad.

        That’s the attitude you are promoting, and it affects others.

        • Deena Chamlee

          C-sections are not bad, for Pete sake. What I am saying is I would love to see research on fetal surveillance for those women who are at increased risk for poor outcomes if not delivered via induction with an unripe cervix. For example AMA.
          Many women do not want to be induced, as crazy as it seems many don’t. Particularly the ones who seek midwifery care.

          And inducing someone with an unripe cervix increases the odd for a LTCS at what percentage?

          • The Bofa on the Sofa

            C-sections are not bad, for Pete sake.

            So why are you complaining about how often they occur?

          • Deena Chamlee

            Bofa I am seeking options for women who do not want to be placed in any situation that may increase their risk for a caesarean.
            Maybe “high” is the wrong descriptive terminology. How does often sound?
            How many interventions because of “what if” places women at an increase risk for caesarean? Just a thought.

          • The Bofa on the Sofa

            Bofa I am seeking options for women who do not want to be placed in any situation that may increase their risk for a caesarean.

            BUT you are ignoring that much of the source of their desire to not want to have a c-section is the negative connotation put upon c-sections by people like you, who think they are something to be avoided.

          • Deena Chamlee

            Avoided, that is a word for me to honestly ponder. To avoid unnecessary risk that could yield to a C-section that might not have occurred if labor ensued yes, avoid a necessary c-section no.

          • The Bofa on the Sofa

            But the risk exists. The example you gave, induction due to AMA, is due to risk that is present. OK, the induction creates a risk for c-section, but what’s the alternative? Don’t induce and increase the risk of problems due to AMA?

            Why accept that risk just to avoid a c-section? It only makes sense if you start with the presumption is something bad that needs to be avoided.

          • Mariana Baca

            To be fair, for women who want more than 2-3 kids, the cumulative risk might be higher to have c-sections with all than to gamble with the risks in one pregnancy if they arent high and have them all be vaginal. Of course, with AMA, how many future pregnancies are likely is also something to consider, and whether the risks present in one pregnancy will present in all.

          • almostfearless

            Maybe 30% is just perfect. Maybe it’s too low. The focus should be on perfectly healthy and unharmed babies and mothers. Things no one would be okay hearing: “Sorry your baby is in the NICU having his brain cooled, but YAY we avoided a c-section!” or “Hey, it’s fine, you’re going to have pelvic floor damage because of a prolonged pushing stage, and it’s going to affect your sex life, forever, but dude, I avoided giving you a c-section, so You. Are. Welcome.”

          • Somewhereinthemiddle

            And there are women who want to avoid CS for other, not insignificant, reasons. Most of the women I know that seek to avoid a CS are doing so because they desire larger families. I have a friend who has a large family and one of her middle pregnancies necessitated a CS for previa after several uneventful vaginal births. She knew she wanted to have many more children and opted to VBAC for that reason. She didn’t want to undergo multiple surgeries that brought on additional risks both for her as well as for future pregnancies. As the number of cesareans a woman undergoes increases, so does her risk of rupture, previa, accreta, percreta, etc. It isn’t just ideology that drives women to want to avoid surgery and to characterize it only as such is untrue.

            Cesareans aren’t bad, but they don’t come without risks. I had a CS to save my child and recognize it a necessary. But I also respect surgery, much like I respect birth for the potential complications and harm that can result.

          • The Bofa on the Sofa

            And there are women who want to avoid CS for other, not insignificant, reasons.

            Of course, no one said otherwise.

            It isn’t just ideology that drives women to want to avoid surgery and to characterize it only as such is untrue.

            Good thing that no one has done that, then.

          • Somewhereinthemiddle

            I have read very few responses here that would indicate an indepth understanding about why someone would want to avoid a cesarean.

            This is your statement that prompted my response about ideology.

            “BUT you are ignoring that much of the source of their desire to not want to have a c-section is the negative connotation put upon c-sections by people like you, who think they are something to be avoided.”

            This sort of statement seems to imply that most women who want to avoid surgery during birth if possible are doing so because they have been told that cesareans are “something to be avoided” when that, in many cases, is false.

          • The Bofa on the Sofa

            This sort of statement seems to imply that most women who want to avoid surgery during birth if possible are doing so because they have been told that cesareans are “something to be avoided” when that, in many cases, is false.

            Even given what you said, it’s not inconsistent with my statement.

            That’s even assuming that your assertion is correct (seriously, how many women wanting to avoid c-sections are doing it because they want a large family? Apparently, you are basing it on a sampling of people you know, but have you done an actual survey? Moreover, how does that account for AMA women who want to avoid a c-section with their first? Does a 36 yo first time mom really want to avoid a c-section because she is planning a large family? Second, how much of the “I need to avoid a c-section because I want a large family” is based on misinformation about c-sections as it is? In that case, even for them it is based on anti-c-section attitudes)

          • Jessica S.

            There may not be a good representation in this specific comment thread, but I know that several other posts where we’ve discussed the legitimate concerns of CS and why a specific woman would want to plan ahead, particularly in cases with wanting large families. It just may not be apparent in this post.

          • Stacy21629

            “This sort of statement seems to imply that most women who want to avoid surgery during birth if possible are doing so because they have been told that cesareans are “something to be avoided” when that, in many cases, is false.”
            That was EXACTLY my view when I was planning a home birth for my first child. C-sections were bad. Why? Because they are bad. Period. I had NO idea about the dangers of vaginal birth and the ways that C-sections save lives. But I KNEW that C-sections were bad and all OBs were just itching to cut me open. Maybe my ignorance was unusual…but I don’t think so.

          • Young CC Prof

            I never thought of home birth, but I did consider birthing center. My younger brother was born in a (licensed, insured) birthing center with (real) midwives. The main reason I went with a hospital OB was that there were no midwives or birthing centers nearby that took my insurance!

            I knew enough history and classic literature to be well aware that birth could kill women without medical care, but I had no idea that death or serious injury to the child was even more common in nature. I was aware that c-sections were sometimes necessary, but I did believe doctors did “too many” out of impatience or overcaution. I did overestimate the risks of cesarean delivery to the mother. (Partly because a friend DID have a serious complication, although I have since learned that there was a lot more to that story.)

            So I was about halfway in NCB. Meanwhile, I had a graduate degree, grew up in a secular household in a large city, thought vaccine rejection was for the birds, and adhered strictly to science in many many other areas.

            I would NOT say your prior beliefs were unusual!

          • Young CC Prof

            Many women do want to avoid a c-section if possible. Some of their reasons are good, some may be coming from NCB misinformation. Trouble is, the most important risk factors for primary cesarian are unmodifiable.

          • The Bofa on the Sofa

            Many women do want to avoid a c-section if possible.

            Of course, that is because the things that indicate c-sections indicate that there are risks to the pregnancy. Who wouldn’t want to avoid that?

            However, what are you going to do about it? As you note, the risk factors are unmodifiable. That’s why they do c-sections.

            So how are you going to reduce c-sections? By reducing interventions that are done to deal with risk? You can do that, but the risk is still there.

          • Young CC Prof

            Exactly. That’s why I don’t see a way to significantly lower the c-section rate without increasing adverse outcomes.

            Actually, I’ve thought of a few risk factors that are modifiable, at least a little bit:

            1) Limit weight gain during pregnancy to what your doctor or midwife recommends. Get tested for GD, and if you have it, keep it under control.

            2) Go along with recommended interventions. Inducing before a risky situation becomes an emergency, or dealing with labor issues promptly, may actually help make a safe vaginal birth possible.

            3) If undergoing fertility treatment, try to avoid multiple pregnancy. (Single-embryo transfer, etc.)

          • theadequatemother

            have all your children before the age of 25…

          • Jessica S.

            Ha! Great point. And yet another very valid – and unavoidable – potential reason c-sections may be more common and necessary. Inevitable, if you will.

          • ngozi

            And limit weight gain BEFORE pregnancy…

          • Amy

            Who CARES how many cesareans are due to “what if” interventions? I’d rather have a numb area on my abdomen and a scar than a dead or brain-damaged child, or a uterine rupture.

            Ditto for interventions for other issues that increase the “risk” for a cesarean. Induction because your membranes have ruptured or your post-dates or your blood pressure is spiking may increase the “risk,” but not inducing increases the risk of death. The idea that having a c-section is as bad as death is ludicrous.

            If the worst thing that’s happened to a woman is that she “lost” the chance for “her” natural birth, then she leads a charmed life.

          • http://kumquatwriter.wordpress.com/ Kumquatwriter

            What. About. Women. Who. Do. Want. Them. But. Are. Refused. Because. Of. This. Mindset? Vaginal birth has plenty of activists, what about US??

          • Deena Chamlee

            Any patient that desires a LTCS or needs one, and is at risk for one for any reason is:
            1. Counseled by MDs
            2. Receiving care by MDs not me

          • Jessica S.

            I don’t know what to make of this mindset that interventions necessarily lead to CS. Case in point, one woman I’m close with has had three babies, all vaginal, with minimal to no delivery complications. Her third was even a “failed” induction, in that she ended up going back home after spending part of the day in L&D, only to come back 15 hours later and went on to deliver an almost 10 lb baby. (I don’t know the particulars of what they used to attempt to jump start labor, but I assume it was safe enough to let her go home. And it didn’t lead to a CS!) My point is that she, at one point or another across those births, had all the same “interventions” (Pitocin, cervical ripener, fetal monitoring, epidural, all the standard hospital stuff) as myself yet I ended up with a CS. So, obviously, it’s not the interventions that lead to CS, it’s the unique cases of each individual woman to whom the interventions are applied that indicate CS.

            I know it may seem like I’m oversimplifying the issue of interventions, but I’m really not. I think the idea that too many interventions (which is the same as saying “unnecessary”) lead to CS is an NCB trope that needs to retire. Along with the notion that doctors apply “what if” interventions willy-nilly. Thus, it seems misguided to look for a way to accommodate the belief that interventions can be “bad” and work on educating people to the reality of what interventions are for.*

            Edited to acknowledge that I relied on anecdotes, but it was on purpose.)

            (* I really hate ending sentences with “for” but I have little brain power as it is!)

          • Young CC Prof

            There is a statistical association between certain interventions in labor, and c-section. However, it is NOT causative. Most of the time, what happens is that labor isn’t progressing well, so the doctor attempts Pitocin or this or that to try to get things going. Sometimes it works, sometimes it doesn’t. But the interventions don’t cause the c-section, they are a marker for abnormal labor.

          • The Bofa on the Sofa

            Moreover, there was a reason why they were doing the intervention in the first place. Even if it DOES cause an increased chance of c-section, do you avoid an intervention to circumvent a risk just to avoid the increased chance of a c-section?

          • Jessica S.

            Exactly. The fact that my friend is several years younger than myself, having had all her kids under 35, is but one factor as to why her deliveries were different. She also went into labor spontaneously with the first two (and arguably the third; I don’t know how much whatever it was they tried actually helped start her labor) and that right there is a huge plus in the vaginal column. (That sounds odd. Ha!) When they induced me, it was on an unfavorable cervix, but I was leaning towards pre-e territory so it was needed. From all the research I’ve done, spontaneous labor is a significant “get”, if you’re hoping for a vaginal delivery.

          • Elaine

            Can we tattoo that on every NCBer’s forehead?

          • Jennifer966

            You know what increases their odds of having a c-section? Getting pregnant. If they are not willing to “put themselves in a situation” where they may get one they shouldnt be pregnant. C-sections depend on the situation not the location.

          • FormerPhysicist

            I love this!

          • ngozi

            How you take care of your health before you get pregnant affects your chance of having a c-section.

        • http://kumquatwriter.wordpress.com/ Kumquatwriter

          THIS THIS THIS

      • Mac Sherbert

        The problem isn’t with you. The problem is that these women have a fear of c-section. Surgery is often scary and I get that! However, the NCP propaganda war on c-sections is the real reason women do crazy things to avoid them.

        The problem is WHY women are so against c-sections. They have been fed a steady diet of how horrible they are! The NCB community has put a stigma on them.

        • The Bofa on the Sofa

          And not only that they are “horrible” but the whole message that they are undesirable and should be avoided, which is implicit in the message that there are too many.

          Sure, we’d all pretty much hope that the circumstances of pregnancy are such that a c-section isn’t indicated (although even in those situations, some would opt for a c-section). That would be great. However, in those circumstances where there is risk, THANK GOODNESS we have c-sections as an alternative!

          Notice that almost all the developments in terms of improving maternity care involves finding new ways to identify risky situations, so we know better when to do c-sections and when not to.

          • Jessica S.

            I could be wrong, but I assume from the baby’s vantage point, a c-section is MUCH more desirable than a cramped canal of who-the-hell-knows what might go wrong – much more likely in a home setting, a hospital would have the best window either way. Luckily, they can’t form memories or analyze the experience yet, so in reality, they have no desire. Except perhaps the desire and will to live.

          • Ob in OZ

            you get it! Since it is well known that a c-section is safer for the baby in the long term under almost every circumstance, if we were able to ask the fetus what they would prefer based on risk benefit, they would pick c-section.

        • Jessica S.

          The most horrible thing about my CS was throwing up due to the anesthesia – but I’ve been told by many helpful folks here that the docs should be able to help with the next time around. Oh, I guess there are two most horrible things: I hated feeling them tugging and pressing and whatever else was going on. It wasn’t painful at all, it was just CREEPY. But at least now I know. :)

          • ngozi

            And I don’t think there would be as much pain afterward for some women if steps were taken to make sure that the woman doesn’t have to recover with a full bowel. Simply making sure they pass gas isn’t enough.

      • Jessica S.

        I would hope you – being the well-informed midwife I know you are! – could eventually encourage her to be induced sometime before 41 wks, if she hasn’t spontaneously started labor already. She should be shown that current research supports the idea that induction at that point could actually lower her risk of CS than if she were to wait until time ran out, which would mean almost certainly a CS, pray God not for a crisis. In addition, she should be shown that the risk of stillbirth increases after 41 wks (or is it slightly at 40 wks and then more sharply at 41 wks?) and, correct me if I’m wrong, AMA increases the overall risk of stillbirth. But again, and seriously, I know you are informed so I assume that’s the information she would receive from you. :)

        Personally, I just turned 37 last Saturday, and I’m due in July. I haven’t met with the OBs at my hospital to determine if a repeat CS is the plan for me, but I have already decided that unless I go into labor on my own by 40 wks, they’re cut this wee babe out. I’m hoping they’ll agree! (I only want two kids – best laid plans, I know! – so for me, it’s an easy decision to have another CS. I know other women, and women younger than myself, have other considerations.)

        • Deena Chamlee

          Yes I want to induce them and many refuse. So I am left with documenting furiously and testing biweekly and knowing she was properly informed. I pull studies for them, and some will continue to have a desire to wait. Everyone is different in their response to counseling.

          • Kira

            Why not try what Dr. Amy used to do when she was practicing and give them a letter that makes them confront their dangerous choice? Hers read like so:

            “Dr. Tuteur has explained to me that she believes my baby is in imminent danger of dying and needs to be delivered by C-section immediately. I understand that my baby might die without an immediate C-section, but I refuse and I take full responsibility for my baby’s death.”

            Yours could read something like:

            “Midwife (Nurse Midwife?) Chamlee has explained to me that she believes that [induction/C-section/other necessary intervention] is the best and safest choice for me and my baby. I understand that I am risking my life and my baby’s life by refusing her advice and I take full responsibility in the event of my baby’s death.”

          • Jessica S.

            I know you care a lot, Deena. :) And I really do understand that some women will just choose not to be induced, etc., even after being given accurate information. I really appreciate that you push for the monitoring and testing, so at least they have some sort of view as to what’s going on with baby. Many midwives actively work against that, but I know you don’t. :)

      • Bombshellrisa

        “, that do not want to be placed in any situation that would increase their odds for a cesarean birth” Then these women should not be getting pregnant. I think there needs to be more of a discussion about C-sections early on in prenatal care. Knowing the facts early and before the decision ever has to be made might make more women comfortable and less determine to avoid a c-section,

      • theadequatemother

        okay but what are they basing that desire on? Are they being presented with balanced information or are they just hearing about how cs are MAJOR surgery and BAD for mom and baby? CS aren’t even covered in many prenatal classes, esp the non-hospital ones and very rarely are women presented with the pros and cons of planned cs vs planned TOL during their pregnancies.

        My position is that a desire for one kind of birth is fine…but when it is based on ignorance and bias there is a problem.

        and there IS a problem in maternity care wrt to this right now.

        • Deena Chamlee

          I send clients for counseling to MDs. Therefore, they are receiving the counseling from my backup MD. Thus, we are all on the same page.

          • Bombshellrisa

            But if they were able to hear it from you, speaking calmly and matter of factly about a C-section then it would really be everybody on the same page. I respect the work that you do, but I wish there wasn’t this attitude that the MD is the only one who can mention sections and talk about them the way that they are: not as this huge thing to be avoided, simply a way to give birth.

          • Deena Chamlee

            I discuss c-sections and risk ect. when appropriate. But maybe I should discuss them with every woman after listening to you all share. I send them to MDs for formal counseling that everyone must have in their chart due to legal boundaries. I have practiced in an environment that dimmed the lights in the OR after the baby was out. Not over the surgical area of course but in the room itself for bonding after I placed the baby on the mom’s chest.
            Ok Bomb I can do this in the future.

          • Wren

            Does dimming the lights actually contribute to bonding at all?

          • Haelmoon

            I recently did a c-section with dimmed light. The operating lights were bright of course, but the other lights were dimmed. No impact on surgery at all, but I think it actually helped the patient (homebirth transfer).

          • Mishimoo

            I hope that everything turned out okay for mum and bub. It was awesome of you and your team to try and make them as comfortable as possible.

          • Haelmoon

            All were healthy and fine. I work with a really good group of midwifes, most of the transfers are very uneventful. The patient stays under the midwife’s care, I am just a consultant. It actually works well for the patients, there is no real barrier to transfer, except the crazy ideas some patients have.

          • Ob in OZ

            Doubtful. I do it becasue sometimes the baby will open its eyes a little wider, which is nice.

          • Wren

            That does make some sense, as does the idea that it might be more comfortable for the patient. I think there is a lot of false information floating around, especially in the NCB group and it’s become so ubiquitous that we just let it slide. Bonding is used as the excuse for so many practices by NCB, and the arguments against hospital birth, c-sections and basically anything home midwives cannot do frequently seem to come down to “bonding”. C-sections are bad because they are “major abdominal surgery” and they will interfere with bonding. Not breastfeeding hurts bonding. Pretty much everything that isn’t NCB approved will prevent or harm bonding.

            Funny how many people think they are bonded to their child or parent without following these rules. Fake bonding must be a huge problem.

          • ngozi

            My son came out not breathing after my c-section. I had to ask if he was alive while I was being stitched up. My newborn and I were separated for 4 days because he was transferred to a NICU and I remained in the hospital. When my husband and I visited him in the NICU, it was WONDERFUL when he heard our voices and turned and looked at us. He was so alert. There has been absolutely NO PROBLEMS with bonding, even though it was a c-section and separation for several days.

          • jenny

            I got a little teary thinking about your son turning his head toward you when he heard you. That’s so beautiful. Is he well now?

          • ngozi

            I think my comment got eaten…

            From all the test he has received so far, he is doing just fine. There are no bonding issues. He has made our large family very happy. His many siblings fight over him constantly and would neglect homework and household chores if I didn’t shoo them away from the baby sometimes.

          • Bombshellrisa

            Yes-you are in a good position to be able to have a positive discussion about c-sections with those who have strong feelings about avoiding them. Since these women are seeking the midwifery model of care, I assume they are wanting a low intervention labor and birth. You could be straight forward about the fact that despite having a birth wish list, many women will need interventions and c-sections, So just give them the facts early and tell them why. Tell them you don’t want them to feel blindsided if after a long labor they need a c-section. Tell them they need to know that if they intend to give birth and not have the baby beamed out, c-section will always be a possibility. Don’t make it some dreaded discussion just put it out there.

      • OldTimeRN

        But don’t your patients want to be placed in a situation where their baby has the best chance to live? I thought the whole goal of pregnancy was to deliver a live bouncing baby? Who knew it was all for the experience?

      • http://www.canadianliving.com/ Jennifer Gruden

        Reading your comment I feel kind of angry actually. This mother did not suddenly arrive at 40 weeks with this belief about c-sections out of nowhere.

        I too wanted to avoid a c-section. That’s because every birthing class I went to, and even discussions with my first OB, all centered around pain management (or the lack of need thereof) and breastfeeding. No joke. They never discussed risk profiles. They never brought up that out of every 100 babies born in my province about 98 go home okay. A c-section was presented as The Very Last Resort And The Worst Thing That Might Happen.

        The truth is, worse things do happen. No one wants to scare a pregnant woman, but it is not informed consent if you have never sat down with your client and said “dear client, did you know that a c-section is not the worst thing that can happen? The worst things that can happen are death, including stillbirth, brain damage, and permanent disability.”

        • http://www.canadianliving.com/ Jennifer Gruden

          P.S. just to be clear – yes, in fact, my first baby died (cord accident).

          • Trixie

            I’m so very sorry.

          • Deena Chamlee

            Jennifer I am sorry. And I am listening to what you are sharing. I do not talk poor regarding C-sections. If I have a VBAC candidate I send her for counseling regarding risk at 28 weeks, unless something necessitates an earlier visit with the MD.
            If a patient wants a C-section I am a midwife who truly believes in informed choice. I send them for counseling also with my back-up.
            I am asking for further fetal surveillance because many patients do not want to be induced after appropriate counseling. I do not know why, except maybe because we look at the rate. And that influences the public. And of course NCB press.
            I do not know the answers except to continue dialogue like this so many can be heard.
            Again I am so sorry for your loss.

          • Kira

            Do you have any kind of parent-to-parent volunteer program where you work? One of my duties as a volunteer in the hospital is to talk to the women in the Perinatal ICU and to parents in the NICU. As a “graduate parent,” I do my best to support them and I give my perspective as someone who loved her 3 C-Sections. If you have access to anyone like me, that might be helpful.

            I did undergo extensive training, btw.

          • Young CC Prof

            I’m active on a board for other IUGR mommies, and I run into a lot of women who are pretty freaked out by the possibility of needing a c-section. (Growth restricted babies CAN be born vaginally if they carry reasonably close to full-term, but c-sections are a lot more common.)

            So I get it. They thought pregnancy would be all yoga and kale, followed by a beautiful natural birth. I thought so, too. I’m glad I can explain to them that a c-section at the end of a high-risk pregnancy can be a beautiful moment, too. Hearing that cry that filled the whole room, as if he was saying, “Here I am, mama! And I’m as strong as you dared to hope I’d be.”

          • anion

            That cry is awesome. I remember it very well with both my babies, particularly the second because the room was so quiet (Hubs and I were having A Moment while the doctor worked; he actually had to say, “Hey, [husband], if you want to see the baby being born you need to look over here now,” because we weren’t paying attention).

            I remember the sudden *whoosh* feeling of pressure-release, and a silence where the room itself held its breath, and then that cry. And every person in there–doc, me, hubs, anesthesiologist, one or two nurses–gave this triumphant cheer, and hubs and I started to cry, and then it became just a regular happy chatter; my doc confirmed we had a girl, and told me how beautiful she was and how much she weighed, and within a minute or two tops she was swaddled and in my husband’s arms, brought to me so I could see her and kiss her and smell her lovely baby smell.

            I honestly can’t see how any other “method” of birth could have been any more amazing or joyful, or what I could possibly have missed out on by not giving birth vaginally.

          • http://kumquatwriter.wordpress.com/ Kumquatwriter

            I wish I had heard my son – he didn’t cry immediately (good – they told me due to the mec in the water they wanted to suction him first) but I couldn’t make out the sound once he was crying – they all kept saying “can’t you hear him?” And I was sobbing that I couldn’t. The only thing that calmed me was my grinning husband giving me a thumbs up from across the room.

          • http://www.canadianliving.com/ Jennifer Gruden

            I’m glad to hear that Deena. I think mostly it’s that women do not really understand that it is interventions which have created an environment where most of us aren’t aware of babies who have been lost (although once you join the club, the stories start coming out). I know I look to my care providers to be clear on the value of interventions as well as the risks.

          • http://kumquatwriter.wordpress.com/ Kumquatwriter

            Well said and seconded. And Deena – once again I want to express my admiration for your passionate journey out of the Woo. We’ve all still been butting heads about c-section rate and demonization, but what you have to say is valuable.

          • Jessica S.

            I’m so sorry, Jennifer. My brother lost their first to a cord accident, a week before the due date.

    • Jessica S.

      My great-grandmother had a 13lb baby! Just think what our great-grandmothers would have thought if we told them today’s women were rejecting medical advancements, in favor of what our GGs had no choice in. They’d think us nuts, I’m sure.

    • Ainsley Nicholson

      I’m so sorry to hear that your C-sections deprived you of the full post-birth experience. REAL mothers pee their pants.
      /sarcasm

    • Kira

      Of my 4 CS babies, I was only unable to nurse my micropreemie. She had apnea episodes every time we tried in the NICU, so I pumped for 6 months and switched to formula. I easily tandem nursed my twins until they self-weaned at age 2 and I nursed my last baby until he started biting me at 17 months, which I consider a form of self-weaning. NCBers and similarly crunchy ladies don’t know what to make of me because I am the opposite of what they “know” is true.

      I am anecdotal evidence of the opposite of what women are taught about C-Sections. I had fast, easy recoveries and zero problems bonding. I nursed my term babies with no problems. All of my children are freakishly healthy, to the point where my nerdy husband refers to them as mutants (none of them has ever had strep, no RSV, no flu, about 25% of the usual colds/bugs of their peers, and only my son has ever had an ear infection). I have some numbness in my lower abdomen, but that hasn’t impacted me at all.

      And it’s been *awesome* having my lady business in its factory original condition.

      • Certified Hamster Midwife

        I’ve heard from childless menopausal friends that not pushing a baby through one’s ladybusiness doesn’t necessarily protect you from pelvic floor issues in your later years: normal wear, tear, and aging will do that. It’s just not as bad as it could have been if they had pushed a few people out of that area of their bodies.

        • T.

          As a childfree person I know several CF women in menopause, and they tell me that yes, there are problems but not as heavy ones as the people who had children (vaginally is worse).
          Which is more or less logical :)
          Now, what about hamsters? Do they get pelvic floor problems? :P

          • araikwao

            No, they trust birth ;)

        • theadequatemother

          That argument is used all the time to suggest that CS don’t protect the pelvic floor. Well, leaking a bit of pee in your 50s and 60s and onwards is one thing, and can often be fixed with some topical estrogen and exercises. But incontinence in your 20s and 30s when you are likely to want to be active is limiting in an entirely different way. And that should be the conversation. What is your risk of not being able to chase your kids around the back yard without excusing yourself to go to the bathroom to put a pad on first?

          • Certified Hamster Midwife

            Well, the risk is zero if you don’t have kids, but that’s not the question. Ads for Poise pads on TV don’t have 25-year-old moms.

          • Poogles

            “But incontinence in your 20s and 30s when you are likely to want to be active is limiting in an entirely different way. And that should be the conversation. What is your risk of not being able to chase your kids around the back yard without excusing yourself to go to the bathroom to put a pad on first?”

            Unfortunately, the risk is 100% for me…I’ve had incontinence issues since childhood (I’m 30 now) :( One reasons I want a MRCS – I’ll do whatever I can to keep it from getting any worse than it’s going to get just from age.

      • ngozi

        I understand your point, but my husband still likes my “lady business”

  • Deena Chamlee

    Yes I am a midwife and just because I cannot perform surgery does not mean it’s the rationale for questioning a first time mom’s odds of primary LTCS being 1 in 3.
    I have stood by mothers who chose a primary LTCS, nulliparous, because of sexual abuse issues. Those issues are very real and requesting such is absolutely appropriate regardless of the C-section rate. In fact I do not practice according to the overall rate or make any decisions based on such.
    ACOG has recently supported vaginal breech births, in appropriate women, and vaginal birth for second twin that is breech, in appropriate women. This is a very wonderful thing to witness.

    19 and 3 percent respectively, primiparas and multiparas in labor and vertex, as is noted in Canada seems more realistic from an informed consent standpoint.
    Midwives along with all healthcare providers will always need to self evaluate and rates of C-sections are part of self evaluations.

    • Young CC Prof

      Yes, the 1 in 3 includes c-sections that are scheduled in advance of labor as well as those performed for medical emergencies on a woman who isn’t in labor yet.

    • fiftyfifty1

      “Midwives along with all healthcare providers will always need to self evaluate and rates of C-sections are part of self evaluations.”
      I agree completely. As health care providers we need to be able to scrutinize our c-section rates. Simultaneously, we need to be looking at our rates of other outcomes: stillbirths, brain damage, pelvic floor outcomes etc. An unnecessary c-section in a woman who doesn’t desire one is indeed a bad outcome. But it’s not the only bad outcome and it is far from the worst outcome.

      • Deena Chamlee

        For instance someone with a previous 4th degree. Should she have an option for an elective LTCS with her subsequent pregnancy?
        In the first case she is an Apostolic Lutheran who plans on having 10 children and this is her 4th pregnancy, the 3rd resulted in a 4th degree.
        In the second case the patient only wants two children, and this is her second, and she desires a tubal ligation.
        In the third case the patient has no idea how many children they plan to have, it is up to God, and this is her second pregnancy the first resulting in 4th degree.

        • Amy Tuteur, MD

          Each woman needs to be counseled about her specific risk factors for various outcomes. In other words, her care needs to be personalized. That’s the opposite of care that presumes that a vaginal delivery is always better than C-section.

          • Deena Chamlee

            I concur. All CNM patients get counseled by MDs who are performing the surgery. And I would hope any client who is questioning a vaginal birth for whatever reason is counseled regarding risk by a MD. That is my practice.
            Which means any patient desiring a homebirth should be counseled on the risk by a MD. Including, previous C-sections, breech, A1DMs, twins and primaparas ect.
            Because their risk increases with each risk factor.

          • Noh

            But why just OBs? If they’re considering homebirth/believe in natural birth/etc, it’s rather likely that they at least a little bit buy into that whole ‘OBs are bad!!!1111!’ mindset and believe that a OB might push a C-section just to get back to their golf game/vacation/whatever instead of actually believing that they’re being counselled with what is appropriate for their risk level.

      • Deena Chamlee

        Or should anyone who wants a csection have a csection? I believe yes they should if they know all the risk and have been appropriately counseled.

        But many colleagues would absolutely disagree. So yes there are many variables. Counseling, bias patient and provider, location of facilities (are VBACS allowed, I hate that word allowed), and risk factors maternal and fetal.

        Women want choices that is all I am saying. They want choices that decrease their odds of a LTCS and some want a choice to choose a LTCS.

        • yugaya

          “Or should anyone who wants a csection have a csection?”

          Yes if we believe all mothers should have the right to chose how they want to give birth. But, in the Animal Farm that is the NCB world, some births are more equal than others.

  • attitude devant

    My personal primip c/s rate hovers around 17%, even though I’m notoriously liberal about CDMR. And I don’t take stupid chances to reduce it further because my assumption is the primary goal is and always will be healthy moms and babies.

    • http://Www.awaitingjuno.blogspot.com/ Mrs. W

      A. Devant – I love you for your stance on cdmr.

  • anne

    At the hospital education class I attended they told us that their c-section rate was 10% for first time moms. However all the really high risk moms went to a different hospital to give birth because it had more comprehensive NICU facilities.

  • Zornorph

    Hey, even Caesar himself was not born via Caesarean birth.

    • http://kumquatwriter.wordpress.com/ Kumquatwriter

      Et tu, Brute.

  • 3loveMe

    A c-section saved my sons life. There was a lot that went wrong with my delivery, poor choices were made by medical professionals, but that is all bedsides the point. If I had chosen a home birth he wouldn’t be here with us today. Wise up people, get over having your “ideal” birth. The only important thing is the health and life of the mother and child. Live one day as a parent of a severely brain damaged child and you will agree, trust me.

  • http://Www.awaitingjuno.blogspot.com/ Mrs. W

    This is a great post and illustrates how the issue is not very black and white. I think there’s so much damage done to the health and well-being of women as a result of the hyperbole around cesarean and the lack of awareness of the risks of vaginal birth. Further – there’s a big difference between a planned cesarean and an unplanned cesarean. Women deserve to have an honest discussion about the risks and benefits of their birth plans that takes into account their own personal circumstances and they deserve to be supported in making medical decisions for themselves after they have been appropriately counselled by someone who is qualified to do so.

  • Deena Chamlee

    The primary C-section rate for women who have never given birth in the past is 30.8%, but the primary C-section rate for women who had given birth to at least one child was only 11.5%.
    Really, 30.8%. You guys that is high.

    • http://Www.awaitingjuno.blogspot.com/ Mrs. W

      High in what context? We really don’t have enough information to say if it is high, low or otherwise. How many first time moms are over 35? How many are obese? How many are presenting with other chronic health conditions including heart disease? Further, we need to know how many are planned cesareans, and how many are emergent – and we need to respect that there are some women who for a variety of reasons, choose cesareans.

      • Deena Chamlee

        Well since it wasn’t given, I can not extrapolate. And you all know I am all about change in midwifery.
        30.8% for first time mothers is 1 in 3, regardless of the reason. And we can do better than that, I am sure.

        • http://Www.awaitingjuno.blogspot.com/ Mrs. W

          We can do better by focussing on the things that matter, and by quitting the obsession with cesarean birth rates. Things that matter: avoidance of death and disability over the entire life course, respect for women and their bodies, avoiding trauma.

          • C T

            Avoiding trauma? Oh, like abdominal surgery? There’s room for debate on the issue of whether C-section rates might be too high sometimes. Maybe they are too low in some circumstances and too high in others. Resources, cultures, etc. vary. We do no favors to women by pretending that either increased risks of prolapse or uterine ruptures are not worth discussing.

          • http://Www.awaitingjuno.blogspot.com/ Mrs. W

            Abdominal surgery isn’t trauma for every woman and it certainly isn’t worse trauma than vaginal delivery for every woman either. What’s traumatic – near death is pretty damn traumatic. Not being able to make a reasonable medical decision for oneself is pretty traumatic. Quit pretending that c-section in and of itself is traumatic – it might be, it might not be, and it might be less traumatic than the alternative in many circumstances.

          • C T

            I am not pretending that. One can simultaneously be grateful for C-sections and think they are usually a good thing and still recognize that they frequently cause other problems that women would understandably wish to avoid when possible.

          • Young CC Prof

            For me the prospect of a c-section wasn’t scary, partly thanks to all of you, but perhaps even more because I’d had surgery four times before, including one abdominal surgery. Most first-time mothers can’t say that!

            For weeks before my first surgery back in ’08, I could barely sleep. I was horribly anxious about what could happen. By the time my planned c-section rolled around, I was stressed about the baby’s health and about impending motherhood, and slightly stressed about the fact that I didn’t get a date until like 2 hours in advance, but the surgery itself was no big deal.

            I can definitely understand, however, why someone facing surgery for the first time would be freaked. And women SHOULD know and understand that if a woman has had a relatively normal pregnancy and goes into spontaneous labor at term with a vertex fetus, her probability of needing a c-section is lower than 1 in 3, much lower if she’s had a previous vaginal delivery.

          • anne

            Or the general unfriendliness of the workplace towards families. I have a friend that might have been able to have a successful VBAC in a hospital but chose to schedule a repeat c-section instead. She was able to have her mother come out of state to help, arrange childcare for her oldest child, work up until the last day to extend the amount of maternity leave she would have with her new baby, and have her husband’s schedule adjusted so he could spend more time at home.

          • Jessica S.

            Very, very valid point.

          • Siri

            But avoiding a section matters just as much to many women as the opposite mattered to you..it is an important issue, that doesn’t make it an obsession.

          • Amy

            But WHY is avoiding a section SO important to SO many women?

            In my case, it was entirely, 100% because of NCB propaganda. I was gung-ho about breastfeeding, and was already living pretty “naturally” in my pre-pregnancy life, so I gravitated toward the more pro-natural pregnancy, birth, and parenting books, and all of them went on at length about how horrible c-sections were and listed all the ways I could prevent the need for one. Even the mainstream books gave tips for avoiding c-sections and listed all the bad side effects.

            Yes, c-sections have risks, just like any other procedure. But I can’t think of a single other procedure where we place the onus on the patient to avoid needing one, or talking about the crisis-level rate.

        • DaisyGrrl

          But what is “better”? Since we don’t know why these sections are being done, we can’t say that they’re unnecessary or that we can reduce the rate. How does the increasing age and obesity rate play into the increase in sections? I’m interested to see what happens with the new guidelines on when to section for failure to progress. Will the c-section rate drop significantly? Will there be increased mortality or morbidity?

          • Amy M

            Yeah, instead of focusing on the rate of Csections themselves, maybe look at why they are done, and see if any changes could be made there. Could women’s health/care be improved before and/or during pregnancy to the point that maybe they don’t need a section for a heart condition because it’s under control? Or maybe someone figures out exactly what starts birth and learns to prevent pre-term labor and finds a better way to induce post-dates that is more effective. I don’t suppose much could be done about breech….but maybe better screening/controlling of GD. Better information about pre-e/hypertensive disorders could lead to fewer sections for those reasons. All of this takes time and research, but it could happen.

          • Young CC Prof

            Actually external cephalic version fixes about half of breech babies. An awful lot of women don’t want a version, though, because they are uncomfortable with the small but very real risk of messing up the cord or placenta.

      • anne

        I’m also curious what turning down interventions does to the c-section rate – are moms who go without epidurals, pitocin, etc. more likely to get a c-section?

    • http://kumquatwriter.wordpress.com/ Kumquatwriter

      So. What? C-sections are NOT BAD OUTCOMES.

      • Deena Chamlee

        no but it is major surgery. I am not saying it is not a life saving procedure. No debate there, the debate is 1 in 3 for first time moms is high.

        • http://Www.awaitingjuno.blogspot.com/ Mrs. W

          And surgery for pelvic organ prolapse later in life is a walk in the park?

          • Deena Chamlee

            Still not an appropriate response for a debate, in my opinion.

          • http://Www.awaitingjuno.blogspot.com/ Mrs. W

            What’s not appropriate is the obsession with birth mode, all the while ignoring things like pelvic organ prolapse, brachial plexus injuries, hypoxic ischemic encelapathy, urinary and fecal incontinance, instrumental deliveries, 3rd and 4th degree tears, birth trauma, low APGARS, etc.

          • anne

            After a year of specialized PT for my prolapse and other pelvic floor dysfunction I wondered a lot if it could have been avoided by a c-section. I have a friend who had two homebirths but needed surgery to repair all the damage. Having babies is hard on the body.

          • Karma Kidney Stone

            I agree. I should have been given a c-section during my second delivery because of a malpositioned baby. My midwives (CNM’s, in the hospital, but no pain meds) lied to me about the position and did not offer me a c-section. My baby was a brow presentation, but they only told me that he was face up. After the vaginal birth, they told me the truth, and patted themselves on the back for the vaginal delivery. Meanwhile, I damaged my pelvis, broke my tailbone, and have permanent nerve damage in one of my feet. I will be numb for the rest of my life and deal with pubic symphasis pain. My son also has severe developmental delays, but who knows if it was related to the birth, or if he was positioned that way because he already had neurological problems. We’ll never know, but I do wonder.

          • http://Www.awaitingjuno.blogspot.com/ Mrs. W

            I’m so sorry you have to live with that. You should have been provided informed consent of your options and respected in your decision.

          • anne

            I’m so sorry.

          • Deena Chamlee

            I am sorry also.

          • DaisyGrrl

            Why not? I think it’s perfectly appropriate for a woman to weigh her odds of various outcomes and choose accordingly.

          • Siri

            That’s a bit of a strawman; doctors do not normally decide to perform c-sections in order to prevent future risk of prolapse, even in cases of prolonged second stage of labour. And childless women sometimes need surgery for prolapse, as do women whose children were born by c/s.

            I could have had five sections to lower my risk of needing prolapse surgery in the future, but I can’t see UK obstetricians regarding that as a sensible plan.

          • http://Www.awaitingjuno.blogspot.com/ Mrs. W

            That’s a plan for a large family – that’s very different than the woman who is wanting not more than 3 children.

          • theadequatemother

            The NNT to prevent treatment for pelvic floor issues is 5-7 cs. That’s better than baby aspirin for heart disease. So it’s not a strawman.

          • Siri

            That’s interesting, thanks for that! And the strawman bit was accusing anyone querying a high section rate of being somehow ‘pro’ pelvic prolapse surgery in women, which clearly is not true.

          • theadequatemother

            btw the powers that be tend to think that hysterectomies are overused and we should all just be on OCP or whatever for our dysfunctional bleeding or mennorhagia. What they fail to think about is that pretty much > 50% of the hysterectomy procedures I am involved with include ANTERIOR AND POSTERIOR repairs for cysto and rectoceles.

            Are the gynes doing that just because they are there or because the pt has symptoms? Because the fee code for them doesn’t change (ie they don’t get paid more).

          • Young CC Prof

            OCP is terrible! No sex drive, constant infections, so many I’m now allergic to most of the treatments. I would SO rather have the hysterectomy and get it over with, if I was in that situation!

          • Mishimoo

            I was lucky enough to dodge the infections, but ended up with constant spotting regardless of which one I tried (even with the Deprovera shot). I’m so glad that having kids changed my period for the better, otherwise I’d be begging for a hysterectomy.

        • http://Www.awaitingjuno.blogspot.com/ Mrs. W

          And I’ll be very honest with you – there are some first time moms for whom the risk of cesarean should be as close to 100% as possible – specifically those who are aware of the risks and benefits of planned cesarean and planned vaginal delivery and have CHOSEN planned cesarean. Sadly, there are far too many vaginal deliveries among that group of women.

        • ngozi

          How many of them are gestational diabetic? How many of them have an active herpes infection? How many of them have a health condition that makes a c-section really necessary?

      • C T

        They are if they were based on poor medical decisions. Surely you can accept that sometimes medical professionals just make mistakes. I have a friend who was told to have an induction based on a likely wrongly-recalculated (to be much earlier based on size, apparently, and she’s a big woman) EDD. The induction didn’t work, and she ended up with a section (and, yes, her OB had a vacation to get to which she says contributed to the C-section decision…golf games might be a myth, but as the child of a self-centered physician myself, it’s foolish to pretend that there aren’t decisions being made by some OBs for their own convenience). She’s planning her 2nd hospital VBAC now and is still very annoyed at the initial bad call that put her in the VBAC boat.

        • anion

          But her OB’s scheduled vacation “contributed” to her decision, which means she could have said no and had whichever OB was on call deliver her baby. So it wasn’t necessarily the OB’s “self-centered decision,” because the mother also had a choice, correct? Just because your OB says, “Hey, I’m going on vacation in a week, so if you want me to be the one attending your delivery we ought to think about induction,” doesn’t mean you have to do it. They’re making the offer out of a desire to help you feel comfortable, not because they want you out of their hair asap.

          OBs do have a right to vacations just like the rest of us. Some women want that specific doctor to deliver their babies, and some are happy to wait and see who they get. For every one of the latter, there is one of the former, who would be very angry and upset if her doctor didn’t offer her an induction so she could have *that doc* at her birth.

          I’m not saying doctors are never egotistical/self-centered/whatever, just that I don’t think this is a great example of that.

          • C T

            I have no idea what the dynamic was between her and her OB. I do know that she lived in an area where there were few options (just one hospital, etc.) and she was a young woman having her first child. It’s important to remember in these discussions that most who comment here are far more knowledgeable about medical options, and depending on where they live, often have more health care options than many an average primipara.

          • anion

            Being knowledgeable really isn’t the point, though, and there being only one hospital in town doesn’t matter either, unless there is also only one OB in the area and if he’s away no one can have babies.

            My point is that if the OB suggested induction to the mother because he was going on vacation, it was just as likely to be out of a desire to make her happy and comfortable as it would have been out of a desire to not inconvenience himself–to be honest, I fail to see how he would be inconvenienced if a patient delivers while he’s out of town or what the specific benefit to him would be of inducing her before he does. You mean he didn’t have to go to work after all, just like he wouldn’t have been going to work anyway since he’s on vacation?

            Unless he outright said, “I’m going on vacation, so I’m sending you to be induced now, so don’t ask me questions just get in the car and head for the hospital,” she did have a choice. It may not have been the one she would have preferred and I’m not saying she should have been armed with data sheets or whatever, but I think pretty much any woman, when their OB says, “I’m going on vacation next week, so I can induce you now,” can ask what her other options might be if she wants to avoid induction. She knows the vacation was a factor, so it’s not like the OB lied to her about the reasoning behind the induction.

            Again, I’m not saying doctors never do things for their own convenience and I’m not pulling out the “She should have educated herself!” thing that so many NCBers use to shame women whose births go badly. I’m just saying in this case and many similar cases, the OB may well have thought s/he was doing a good thing in offering that induction, and it is an option many mothers would jump at with pleasure–and there are quite a few mothers who would have been very upset *not* to be offered that induction.

        • 3loveme

          I’d rather have a physician poorly choose a CS than allow a vaginal birth to go wrong.

          • C T

            Of course. I’m not arguing that. But blanket statements like “C-sections aren’t bad outcomes” are simply not true for the woman who really doesn’t want to live with the results of a C-section and most likely didn’t need the C-section. Pretending that isn’t the case is more of the one-size-fits-all problem.

          • http://Www.awaitingjuno.blogspot.com/ Mrs. W

            Doctors do not do cesareans without cause – so unless the risk of proceeding with a vaginal delivery was greater than the risk of proceeding to a cesarean, it is unlikely a doctor would advise that route. She might have had a vaginal delivery – but it is very likely that living with the outcome of that, might not have been as easy as you are assuming. She deserved informed consent for the options available.

          • C T

            But the initial early induction does not appear to have been based on correct dates. Mistakes happen

          • http://kumquatwriter.wordpress.com/ Kumquatwriter

            I’m not pretending that. However, the pressure to VB and the demonization of CS is completely out of control at this point.

          • ngozi

            Well said.

          • 3loveme

            I’m happy to live with the results of my CS, I have my child in my arms with me right now. I have a jaded view though, it’s all relative.

          • ngozi

            Could you elaborate on the “results of a c-section.” I am not arguing, just asking.

          • C T

            Well, just from what I’ve observed with friends and picked up from this blog: uterine rupture probability increases, family size often ends up limited (admittedly not a concern for many), some women have much harder recoveries than others (like literally not being able to stand up straight for 6 weeks or more). I’m sure there are more. For instance, a quick search just now confirmed my suspicion that the placenta accreta risk goes up. Mayo Clinic and WebMD have some good information on C-section risks.

          • Guesteleh

            CT: all credit to you for standing your ground. I agree with you and I know it’s tough to voice unpopular opinions here.

            Another risk of CS: Hospital acquired infection

            Puerperal infection remains a major cause of maternal morbidity and
            mortality. The primary risk factor is cesarean delivery, which increases
            the risk 5- to 20-fold.

          • theadequatemother

            Some questions for you to ponder: is that risk still there if you take out emergency cs? For example those for prolonged unproductive labours? Prolonged rupture of membranes? Is the cs the culprit or the long TOL that preceded it?

            Here’s the thing, most of what is quoted about the risk of cs lumps all cs (elective and those after failed TOL) against all the vaginal deliveries. It all looks different if you analyze outcomes by planned cs vs planned TOL. Analyzing it the second way is arguably more useful for women making the decision of delivery mode.

          • Guesteleh

            Here is a table that lays out risk factors. But to answer your question, yes, CS itself is a risk factor even without the addition of emergency CS, prolonged ROM, etc.

            http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3410505/table/T1/?report=objectonly

            I’m not anti-CS at all. But the tone of the comments is that wanting to avoid a CS is wholly irrational, which: No. Plenty of good reasons not to want one. Doesn’t mean you shouldn’t get it if needed. But not wanting abdominal surgery doesn’t make you crazy.

          • theadequatemother

            I think sometimes the lengths women go to in order to avoid the cs are crazy and that can get conflated in these discussions to mean avoiding cs is crazy. That is not so. But additionally it is assumed in maternity care that women prefer vaginal births or attempts across the board and that is accompanied by inflating the risks of cs and deflating the risks of vaginal attempts. And often the discussion just includes the cs rate and the risks of cs. In his discussion there has been a lot of backlash against attempts to discuss the downstream affects of vaginal births. I think that is upsetting to me and other women here who have sustained pelvic floor damage or scary or mismanaged vaginal births.

          • Jessica S.

            This is excellent and deserves consideration.

          • Eddie Sparks

            “I think that is upsetting to me and other women here who have sustained pelvic floor damage OR scary or mismanaged vaginal births.”

            Quoted here again just to emphasis the “OR” in this sentence. Permanent pelvic floor damage can arise form the setting of a completely natural, uneventful, unmedicated vaginal birth. Doesn’t need to be scary or mismanaged or even prolonged.

          • C T

            Tough, but possible. :)

          • Siri

            Wouldn’t that depend on the actual outcome, though? What if the poorly chosen section led to hysterectomy?

          • 3loveme

            No, it would not depend on the outcome. The only outcome that is ideal is a healthy alive baby and mother. The “what ifs” are much easier to handle while you are cuddling your baby, not visiting your baby in a NICU.

    • fiftyfifty1

      But the nullip primary c-section rate does not mean “your chance of having a c-section if you walk into the hospital at term in labor with a vertex baby”. It means the *overall* c-section rate for first time moms. It includes all the pre-planned c-sections (for breech, twins, maternal request, preemies, pre-eclampsia, herpes etc).
      What women really want to know is this:
      If I am a first time mom and I present to the hospital in labor with a term vertex baby planning a vaginal birth, what are my chances of ending up with a c-section instead?
      and
      If I am a mom who has already had one successful vaginal birth, and I come to the hospital in labor, at term with a vertex baby planning a vaginal birth, what are my chances of having a c-section instead?
      Do we have good answers to these questions? My guess would be 20% for the first and 5% for the second. Anybody else?

      • theadequatemother

        Perinatal bc collects cs data based on the robson criteria. It’s 19% for vertex term in labour nullips and less than 3% for multiple same criteria.

        http://www.perinatalservicesbc.ca/NR/rdonlyres/64B57FCD-9A7F-4E51-8B07-99779082B406/0/BC_RobsonGroups_2014.pdf

        • Young CC Prof

          Thank you! I’ve actually been wondering about these exact questions for some time, but had no idea where to find the data!

        • Young CC Prof

          Wow! That document says that if you are a decent candidate for home birth: “Parous women, no uterine scar, with a single vertex pregnancy at 37+ weeks in spontaneous labour” your chance of c-section if you go to the hospital in British Columbia is around 2.5% based on data from the last several years.

          That is far lower than your chance of intrapartum transfer in attempted home birth. It’s far lower than your chances of a PPH that could have been easily prevented in the hospital. And next to a 2.5% “risk” of c-section, a 0.1% risk of preventable baby death looks pretty outrageous.

          That right there is the number that could blast the home birth myth wide open. Does anyone know how to find similar figures for the USA?

          • Deena Chamlee

            But homebirth in the United States includes:
            Previous LTCS up to two without a vaginal birth
            Breech, this includes footlings
            Twins
            Diabetics on oral meds for control
            Hypertension on meds for control
            Obese women BMI greater than 30
            AMA and postdates
            And the list goes on and on.
            So one cannot quote their C-section rate would be 2.5% in the United States.
            If the United States implemented national guidelines/standards for homebirth one could use the 2.5%. But as it stands to date, it doesn’t relate the American homebirth.

          • Young CC Prof

            I said the c-section rate of reasonable candidates.

            Most US women who home birth are multips, at least, but you’re right, all kinds of stupid things go on, and the probability of a c-section for many of those women is much higher. For some women, including breech, it’s approximately 100%. But for those groups, the probability of a home birth ending in disaster is also much higher.

            I now want to build a calculator. Put in your risk factors, it tells you the probability of:

            1) c-section, if you do hospital care.

            2) Serious morbidity or mortality in the hospital

            3) Serious morbidity or mortality at home birth.

            4) Probability of home birth ending in transfer.

            5) Probability of home birth ending in c-section.

            I wonder if I can find enough data to create such a thing. Certainly, I can find enough data to get across the basic idea:

            If you are very likely to have a c-section in the hospital, attempted home birth is very likely to end in disaster. If you are “low risk” at home birth, you’ll probably be able to deliver naturally even if you do go to the dreaded hospital.

          • C T

            “If you are “low risk” at home birth, you’ll probably be able to deliver naturally even if you do go to the dreaded hospital.”
            So true.

          • Manabanana

            I would like to add to your list:
            HBA3C
            HBA4C
            HBAC with “special scars”
            Planned home delivery prior to 37 weeks
            Rh sensitization
            Poorly estimated due dates (related to conceiving while lactating, refusal of early ultrasounds, unknown LMP)

            These types of planned home births are occurring with CPMS and licensed midwives. Your list, Deena, was not inclusive enough.

          • Young CC Prof

            CDC WONDER shows 2,397 babies born out of hospital with a midwife at 34-36 weeks gestation. Astonishingly, only 20 died.

          • manabanana

            So it must be safe, then!

      • Deena Chamlee

        That is what I wanted to hear, thanks Fifty.

      • Elaine

        This is what I want to know as well. And, I suspect, a lot of moms. I hear that “30% of c-sections in first time moms” stat thrown around as a reason to HB, so I didn’t find Dr Amy’s post very convincing, as it assumes that HBers aren’t going to be first-timers.

        Also, I would amend this to “If I am a [first-time mom/mom with a successful past vaginal birth] with an uneventful pregnancy and no risk factors and I present to the hospital in labor with a term vertex baby planning a vaginal birth, what are my chances of ending up with a c-section instead?”

        Because that 30% includes pure maternal-request c/s (say, for a history of sexual assault) as well as those done for complications and/or in high risk pregnancies.

    • guesting

      Isn’t that like saying that it’s terrible that there are so many surgeries on burn victims? If there’s a medical necessity shouldn’t the best and fastest treatment be available regardless of how often it happens? And there are cases when C-sections are unnecessary but how in the world would that be known beforehand unless we can see everything going on in the uterus and how the baby is interacting with the birth process in detail? Wouldn’t it be best to err on the side of caution instead of hesitate and have a worse outcome when it only takes a few moments for life to slip away?
      What *should* the rate be and how do we know that?
      How can we tell when a C-section is unnecessary until after the fact?

      • http://Www.awaitingjuno.blogspot.com/ Mrs. W

        And there’s a group of women that are traumatized by having to have a trial of labour and vaginal delivery because some a$$hole has decided that their personal reasons for wanting a c-section aren’t good enough. A potential vaginal delivery is reason enough for some people to violate a woman’s right to make a medical decision for herself.

    • Karen in SC

      Do you have a crystal ball you’re hiding from the world?

    • Montserrat Blanco

      25% of adults living in BC is obese. That might have something to do with the c-section rate. The average mother’s age at first child was 30.2 years in 2010. c-sections are more frequent in older women. Not all primiparous women are healthy and young. I have made myself the choice of delaying childbearing after 35 years old. I am happy with that choice even if it increases my odds of getting a c-section and it means I would have to get genetic testing for the baby. But I would not be surprised if my chances of getting a C-section are over 50%.

    • The Computer Ate My Nym

      30% is high. But that’s not enough. Is it too high? Maybe that’s how many are needed to get the best possible outcomes right now. Or maybe it is too high, in which case we need to ask questions about which ones can be avoided. Questions which can probably only be answered with appropriate clinical trials. Ready for a tax increase to pump more money into medical research*?

      *I am.

    • The Bofa on the Sofa

      Which of those 30.8% should not have had a c-section, and how did you determine that?

      • Deena Chamlee

        Can’t determine but what I can determine is:
        Instead of inducing women with an unfavorable cervix for AMA (or other reasons that do not include maternal diagnosis that would warrant ending the pregnancy before the onset of labor) and with excellent fetal surveillance, if they so desire, continue to implement biweekly fetal surveillance and wait for labor onset.
        Instead of mechanical cervical ripening with a foley, then attempting to induce when there has been zero contractions.
        Sometimes we muck with nature and make an environment ripe for the “domino affect”.

        • Karen in SC

          But AMA is a risk in itself. And depending on the age, there may not be a “do over.” Is biweekly fetal surveillance enough?

          • Jessica S.

            My thoughts exactly. I won’t take the risk, at 37.

        • The Bofa on the Sofa

          Instead of inducing women with an unfavorable cervix for AMA (or other reasons that do not include maternal diagnosis that would warrant ending the pregnancy before the onset of labor) and with excellent fetal surveillance, if they so desire, continue to implement biweekly fetal surveillance and wait for labor onset.

          Why?

          There is a reason they are inducing in the first place, right? You think that they are just inducing willy-nilly?

          • Deena Chamlee

            No I am asking for options for women regarding counseling.

          • The Bofa on the Sofa

            But if that provides less than optimal outcomes (in real things, not “c-sections = bad”), wouldn’t that be the proper counseling?

            And if the doctor knows that it is a less favorable outcome, going with it puts them at risk professionally, so they have to recommend the best option.

          • Deena Chamlee

            I understand, I really do. So that brings us back to:
            Is the number attached to C-section rate important? And if it is not then why look?

          • Young CC Prof

            Actually, I think that the overall c-section rate (of a nation or a hospital) is NOT very important. I think it’s talked about, published and analyzed far too much, to the detriment of actual outcome measures.

            I just did a quick Google check. 444 MILLION hits for “US c-section rate.” Only 370,000 for “US perinatal mortality rate”. Yes, one is a more scholarly phrasing than the other, but still, does anyone else have a problem with the priorities these numbers suggest? Are c-sections 1000 times more important than perinatal deaths?

          • OldTimeRN

            Alive baby vs potentially? What option counsel do they need?

        • Young CC Prof

          Early induction, yes. (Of course, most early inductions are done for specific medical reasons.) But ACOG’s “Safe prevention of the primary caesarian” bulletin states that (as long as the due date is known with reasonable precision) inducing at 41 weeks not only results in better fetal outcomes than waiting for 42, it actually results in fewer c-sections!

          After all post-dates babies are at risk of macrosomia or placental degradation. The first increases the risk of arrested labor, the second increases the risk of fetal distress.

          • Deena Chamlee

            Is macrosomia rationale for induction? And I do offer induction at 41 weeks but there again, many midwifery clients decline.
            Ultrasound is not an exact science.

          • The Bofa on the Sofa

            Ultrasound is not an exact science.

            Yeah, but if it is likely to be off in either direction, it is a mistake to not do it “because the US could be wrong.” It could just as likely be wrong in OTHER direction, meaning that the baby is bigger than estimated. If that is the case, opting out is a big (pun intended) mistake.

          • Young CC Prof

            Nowadays, most ultrasound estimates of fetal weight are accurate to within about a pound, which is good enough for decision-making purposes.

            But I’m not even talking about pre-labor c-section for suspected macrosomia, I’m talking about arrested labor, a woman who goes into spontaneous labor well past her due date and simply cannot squeeze the baby out, because he’s too big.

          • Deena Chamlee

            Attempting an induction for macrosomia after 40 weeks with no other risk factors is not unreasonable. If it is not successful she can always go home or opt for a LTCS if the MD thinks it is reasonable.
            Many of these situations I am consulting on the case, I am not out there alone. And that is why back-up is a necessity for any midwife. And that is why if you all only recommend CNM/CMs, ACNM, MANA and NACPM must acknowledge this. No midwife should be practicing without a back-up.

          • OldTimeRN

            IMO, induction at 42 weeks is crazy as 37 week inductions. The only thing you swap is potential under-developed lungs leading to TTN with MSAF leading to potentially over-stressed babies with mrs aspiration.

          • Jessica S.

            Yes, this is the bulletin I was thinking about when I mentioned the window of time where an induction can actually decrease the likelihood of a CS.

        • FormerPhysicist

          I was induced, unfavorably, for my first. I’d MUCH rather have gone straight to ‘elective’ c-section, but I didn’t even know to ask.

          Why was I induced? High blood pressure, leading towards pre-E.

          With my second, elective c/s at 39 weeks, no labor. Easy peasy, wonderful.

          With my third, full-blown pre-E, so close to eclampsia, c/s moved up due to labor having started to get this thing OUT of my body, and what an AWFUL recovery. My OB sent me to the hospital at 11 pm when my last blood and urine tests pointed to pre-E. Moved the scheduled c/s up two days to 7 am the next morning. At 4 am, I was in labor, at 5 am the nurses finally believed me and called in my OB who did the c/s immediately. I think she would have rather done the c/s at 11 pm the night before instead of monitoring overnight, and I REALLY wish she had been able to.

        • theadequatemother

          the data is there for term stillbirth in AMA. Even with the recommended fetal surveillance. I am getting the sense that you are a bit cavalier about AMA and the risks it entails. Are you? Is that attitude affecting how you frame the discussion around induction with your clients? How could it not?

          I’ve put enough epis into women being induced after IUFD to have a different opinion. for some reason those women get epidurals as soon as they feel the slightest bit uncomfortable whereas the rest of us have to wait until the LDR RN is comfortable that we won’t end up with a cascade of interventions (snark). Wonder why that is? Because there is no cascade of interventions (shouldn’t we be trying to “prevent” the cs after a IUFD?) and people still hold a “feeling” that drugs = epidurals are somewhat nebulously bad for the baby.

          • Deena Chamlee

            NO I send them for counseling. I never and I mean never allow a patient to not I am called a medwife.

          • moto_librarian

            Deena, sending them counseling with an OB is indeed important, but it also suggests that you and your midwife colleagues dislike c-sections. You should be having these conversations with patients as well! If you are the primary caregiver, your attitude about c-sections is extremely powerful. It concerns me that you are issuing a blanket statement that a 30% c-section rate is too high – give me some real evidence that explains WHY this is the case!

          • Deena Chamlee

            I discuss c-section rates in my practice, 11-13%, I discuss morbidity, I discuss risk associated with not intervening such as stillbirth in AMA clients who refuse induction even pull studies for patients and families to read.
            I do not discuss overall c-section rate in the country because it doesn’t affect the overall decision making process for the patient, that is unless I am asked.
            If one honestly stops and thinks about the overall rate being 1 in 3 for first time moms, regardless of outcome measures (we know that is what drives C-section rates is a good outcome) it is pretty disturbing. At least it is to me.
            30.8% of first time moms, overall rate, in the United States are receiving a caesarean, 30.8%. While many bloggers in this forum are MDs and harmed family members I can understand why it probably doesn’t seem very high at all. Because bad outcomes are a known reality.
            And of course, the risk must always be weighed by the family regarding choice. I guess I ponder how we all have gotten here at times. Obstetrics and Midwifery, because from where I sit we are very much broken and screaming and fusing over C-section rates, homebirth morbidity and mortality leaves me with a very deep sadness for all concerned.
            I have not lost my compassion yet for all of us because the way we view the world is based upon our life experiences, each experience is not the same. But fixing our broken system will take each of us to understand shortcomings are abundant on all sides. And each will have to look at themselves honestly, painfully at times, for change to occur.
            So why do I say the C-section rate is “high” for first time moms, it is because through my lens it seems to be.

          • moto_librarian

            But don’t you see an increasing number of women who are AMA, overweight/obese, with preexisting health conditions, etc., than in the past? My Mom had her last child (3rd) at 32; I didn’t have my first until I was 31. I am now 36, and I have tons of people asking if we’re having anymore kids. My answer is that I am uncomfortable with the increased risks of pregnancy past 35, and that we have our hands full with two boys as it is. The immediate reply is something like “oh, you’re still really young!” I have plenty of friends having children in their late 30s and 40s, and it is becoming the norm, but it also carries its own risks. I firmly believe that this has a lot more to do with the c-section rate than scalpel happy doctors who want to make their tee time.

          • ngozi

            OMG it is like you are reading my mind, only you said it better!!

          • Deena Chamlee

            It is up to the patient and what risks they are willing to accept after appropriate counseling. That is called autonomy. So some look at the increased rate for stillbirth, particularly if it is their first child, as an acceptable risk. Thus, I encourage kick counts daily and biweekly testing, BPPs at a minimum and I have never had anyone decline this.
            Some women maybe 35 but plan on having more than one child. So they want to attempt to avoid induction with the chance it may not be successful and the inevitable LTCS or it may be successful. Once again every situation is different, many cofactors play into one’s decision. But the bottom line is it will always remain informed choice and just because one may choose not to induce does not make them stupid. It makes them autonomous and a well informed consumer who is playing the odds and those odds they accept.

          • The Bofa on the Sofa

            I discuss c-section rates in my practice, 11-13%

            Why?

            What relevance do the c-section rates of the population that comes to your practice have to do with the person sitting in front of you?

            If one honestly stops and thinks about the overall rate being 1 in 3 for first time moms, regardless of outcome measures (we know that is what drives C-section rates is a good outcome) it is pretty disturbing.

            Why?

            You told me yesterday that “C-sections are not bad.” If that is the case, why should 30% be disturbing?

          • Deena Chamlee

            Do you think it is disturbing? If it isn’t then we should not look Bofa. If it won’t change practices there really isn’t any point, is there?
            Because what it does do is cause further debate such as this and it causes public concern because of those who think it is disturbing.
            If it is a measure that doesn’t drive practice standards why look?

          • The Bofa on the Sofa

            If it is a measure that doesn’t drive practice standards why look?

            See my response above: the overall rate does NOT drive practice standards, or at least, it should not.

            What would drive practice standards depends on the specifics of the patient. What is the c-section for a breech presentation? How do we compare that to the risk of a vaginal breech delivery? If that rate is only 30%, then I would agree it is very disturbing. But I don’t think that is what you are suggesting.

            The overall c-section rate is going to reflect how we handle individual situations, and how often those situations occur. As others have discussed above, there are some ways to control the situations that lead to risks that warrant c-sections (weight issues that translate into diabetes, age, kale (oh wait)), but our main control is in how we deal with those situations that are presented to us.

            You can look at the tradeoffs of induction due to AMA, for example. You’ve asserted that they occur too often, but provided no basis for that. But that’s what happens when you work within a premise that c-sections are bad and should be avoided.

            The problem I have with your “30% is too high” attitude is that I still have not heard a single example of someone who had a c-section where you can say that it was not necessary. Therefore, in order to make that rate lower, you are going to have to not do c-sections on people for whom it may be necessary. Isn’t that bad?

  • Renee Martin

    Now, how do we get all the idiots that hate Dr Amy to read this?
    I loathe how they refuse to check stuff out on this site, even when its just factual. This is a great example. All of the NCBers need to read this. Few will.

    Maybe Dr Amy could change the title to something more catchy and infuriating, as it seems the only time they are willing to visit is when they are mad about something she has done. Which is why her persona is successful.

    Great post by the way.

    • ngozi

      They will just call her Dr. Satan and cover their ears…

      • Karma Kidney Stone

        You mean “Dr.” Satan.

    • Amy Tuteur, MD

      Don’t be fooled by their protestations. They read the blog. They may not admit it, but they read it and they learn from it.

      • CognitiveDissonaceHurts

        I’m here reading and I’m passing along the info wherever I can.

    • 3loveMe

      They read it. I don’t know if they pull the placenta completely out of their eyes enough to clearly take it all in, but they read it.

      • Trixie

        “Pull the placenta out of their eyes.” Lol

    • manabanana

      How do we get all the idiots to read this?
      I don’t know. Maybe stop calling them “idiots”?

      Just a suggestion.

      • C T

        That was my reaction, too. I have friends who I would desperately love to see getting this information. But name-calling like this turns them completely off. No matter how right and righteous the arguments, coupling them with ad hominem attacks makes people defensive and completely unwilling to entertain thoughts that would already cause them much pain from cognitive dissonance.

        • manabanana

          I don’t agree with everything written here. But the praise I will heap on Dr Amy is that she has yet to delete any of my comments. Can’t say the same of Evidence-Based Birth, Midwives Alliance of North America, Midwifery Today, etc. Here we can actually have real discussion. THAT I do appreciate.

          If MANA ever stopped deleting/censoring comments, I wouldn’t have to come here to have a thoughtful discussion.

          I liked the point of today’s post. That it is not true that walking into a hospital gives one a 1/3 chance of having a c-section, like it’s some random occurrence. That’s a load of crap.

          I also agree with many of the points that you brought up, C T, about C-sections not always being done for all-the-right-reasons.

          There is a false dichotomy of RISKY VAGINAL BIRTH versus PERFECTLY SAFE C-SECTION.

          It’s just not that cut and dried. I have no idea what the optimal c-section rate is. I don’t even know if we can say there is such a thing.

          I will say that physicians have different c-section rates – why is this? Is the physician the variable? Or do they see higher risk patients? There was a study out a few years ago that showed a correlation between the labor nurse and c-section rates. Hospitals have different c-section rates – can this be attributed to the patients or the providers?

          There are many variables that go into the rate of c-section deliveries. Some of these variables are 1) convenience, 2) fear of lawsuit, 3) maternal request, 4) nursing staff perception of labor, 5) length of time since interventions started. The c-section rate is not solely determined by physiology. It’s not. There are a lot of things that factor into that decision.

          I’m glad that women are happy with their c-sections. That really is the optimal outcome. A good birth. A good recovery. A satisfied patient.

          Not all women who’ve had c-sections have had that experience. Women want to know that they had a c-section because the risks continuing labor outweighed the risks of c-section. Sometimes that is hard to determine.

          (Oh yeah, and this place gets to be quite an echo chamber, so you’re welcome.)

          • Young CC Prof

            “It’s just not that cut and dried. I have no idea what the optimal c-section rate is. I don’t even know if we can say there is such a thing.”

            I absolutely agree. The optimal c-section rate of a population (the one that results in the lowest rate of serious maternal or child complications) is a function of many things, from preexisting health status of the average mother to the level of available surgical technology to typical family size. I don’t have any idea what the optimal rate for the US population is! I suspect it’s not radically different from our current rate, but there’s no way to be sure short of highly unethical things like artificially changing it.

          • The Bofa on the Sofa

            It’s just not that cut and dried. I have no idea what the optimal c-section rate is. I don’t even know if we can say there is such a thing.

            Here’s the question:
            Who’s c-section was unnecessary? How do you determine that a c-section is unnecessary? Because the baby was born without a problem? But that is the whole objective of c-sections, to prevent a problem.

            Now, if a VB takes place successfully, we can know that a c-section was not necessary. However, we cannot determine whether a VB would have been successful when a c-section has occurred.

  • ngozi

    I just wish I hadn’t spent so many years so afraid of a c-section that I would literally vomit while pregnant. It seems as though the Internet is full of horror stories about c-sections, instead of informative information about them. My c-section was absolutely necessary, and the pain afterward would not have been so bad if I hadn’t had a full bowel (I wish the.nurses had of known that).
    The people who are focusing on scaring women about c-sections, especially people in the healthcare profession aren’t doing the women they swear they are trying to help any good at all.

    • guesting

      I agree. My two csections weren’t fun, but neither was my all-natural third degree tear. Childbirth is HARD on the body no matter what, there’s really not an easy way to do it.
      I do feel that the negative aspects of csections were completely exaggerated and led to a ton of worry and angst that was unnecessary. I especially worried about bonding and breastfeeding, which were total non-issues. Who was the guy in Business of Being Born who insinuated that we would see long-term mental issues with C-section babies and mothers because csections interfere with bonding? Odent? What a terrible thing to say, and a slap to all of the loving mothers and their beloved kids – adoptive and C-section birthers.

      • http://Www.awaitingjuno.blogspot.com/ Mrs. W

        I hope karma exists – because that guy deserves some kind of karmic retribution.

        • Siri

          How about a karmic kidney stone? Not fatal or even very dangerous, just incredibly painful. He should be made to endure it without pain relief; just dim the lights, offer warm baths, and provide such comfort as is given to labouring women in his clinic. Then, when it’s born, he should be made to breastfeed it.

      • ngozi

        The only thing I liked about Odent was his accent.

    • Karma Kidney Stone

      I had major surgery recently, and I was like you. Petrified. Absolutely petrified. It was like all my worst fears come true. I’m not exaggerating at all. I cannot describe the complete and utter terror I was feeling. But you know what? It wasn’t bad at all! The staff were wonderful, I had good pain control, and recovered quickly. And felt like an ass for being such a big baby about the whole thing. It was not a big deal at all. I’ve had outpatient procedures that were worse. Who knew? All the horror stories I read about c-sections really clouded my view of “major abdominal surgery” and fed in to my fears. And it was all hooey.

  • http://www.antigonos.blogspot.com/ Antigonos CNM

    This is why the C/S “rate” is such a loaded–and misleading subject. Thanks for writing about it. But for all the xplanation, one problem remains: how to distill the facts presented into a 30 second (or less) soundbite. It is just SO easy to say “the chance of C/S is X”; end of discussion even if someone then says “Not really……”because the listeners aren’t listening any more.

  • Mel

    I wish I could show people who are so obsessed with avoiding C-sections the real problems that occur when you trust birth rather than doctors.

    You should visit a local dairy farm. We’ve always got cows giving birth. First-calf heifers often lose the calf during delivery because the heifer’s pelvis and soft tissues just can’t expand fast enough to deliver the calf before the umbilical cord breaks. I hate, absolutely hate, watching those deliveries because we often see the calf die during the delivery. It’s not pretty or peaceful.

    Humans, though, have a plethora of options for avoiding baby dying during birth. It’s so much better to have a CS and cuddle your healthy baby afterward than have a ‘peaceful’ homebirth (and IMO home birth stories rarely sound peaceful or pleasant) and bury your baby afterward.