More wailing and gnashing of teeth over the C-section rate

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The sky is falling! The sky is falling!

That’s the impression you might get from an article in today’s Guardian, ‘A third of people get major surgery to be born’: why are C-sections routine in the US?

Caesareans have transformed from life-saving intervention into risky procedure performed for one in three births – and often geography is the deciding factor.

Yet the scientific evidence shows that the demonization of C-sections is based on ideology and contradicted by data.

Ideology oozes from nearly every quote in the piece.

“We are quite worried when the C-section rate goes above 30%, as it is in the United States,” said Dr Flavia Bustreo, the assistant director general for family, women’s and children’s health at the World Health Organization…

A C-section rate of 10% to 15% is “natural”, she said. “Above 15%, you don’t have additional benefits, and you have the risks, and you have the unnecessary health costs.”

There is no such thing as a natural C-section rate. Perhaps Dr. Bustreo means that a C-section rate of 10-15% is “optimal,” but that’s not what the scientific evidence shows.

In fact, some experts believe this rise in caesareans is one of the many intertwining factors contributing to crisis rates of maternal mortality, or death, and morbidity – defined as significant injury related to a pregnancy – which are increasing in the US even as they fall in other first-world countries.

“It’s certainly one of the downstream consequences” of performing avoidable C-sections, said Jill Arnold, who runs a website, The Unnecesarean, that tracks individual hospitals’ C-section rates …

Jill Arnold is not an expert. She’s a lay person and an ideologue. And she has no data that shows that C-section increase maternal mortality because there isn’t any.

“A third of people get major surgery to be born,” said Dr Neel Shah, a research physician at Beth Israel Deaconess Medical Center who works on ways to reduce avoidable C-sections.

As someone who had a 16% C-section rate when I practiced, I find myself mystified by a C-section rate of over 30%, but that, in itself, is not a reason to demonize C-sections. A third of the people in the US need glasses for nearsightedness yet we don’t conclude that glasses are over prescribed.

“It is very, very clear to me the connection between the number of C-sections and mortality and morbidity,” said Dr Shah.

I don’t know how it could be clear to him that C-sections increase maternal mortality since his OWN data show precisely the opposite.

Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality was published in JAMA in 2015. The authors, including Dr. Shah, concluded:

The optimal cesarean delivery rate in relation to maternal and neonatal mortality was approximately 19 cesarean deliveries per 100 live births.

They graphed their data:

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These graphs show that C-section rate below 19% lead to preventable maternal and neonatal deaths. In other words, they show that the WHO “optimal” rate, far from being optimal, is actually deadly.

They also show that C-section rates above 19% are NOT harmful. There appears to be NO increased risk of either maternal or neonatal mortality for rates as high as 55%.

US maternal mortality statistics show that most of the leading causes of maternal death have nothing to do with C-sections.

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The most important message in this graph is that fully 41% of US maternal deaths are caused by cardiovascular (including cardiomyopathy) and non cardiovascular diseases. And that reflects the fact that pregnant women are now older, more obese and suffering from more chronic diseases than ever before. There’s no evidence that a high C-section rate contributes to maternal mortality.

Indeed, Gene DeClercq, a professor at the BU School of Health echoes my view:

… Declercq, who notes he is “no fan of unnecessary C-sections”, says the bigger drivers of maternal mortality probably include factors like the opioid crisis and the fact that many new mothers are dropped from Medicaid, the government-run health program, shortly after they give birth.

Just addressing the C-section rate alone won’t reduce the maternal mortality rate. Other developed countries have C-section rates that are as high as the United States’. A 2012 international comparison found that the C-section rate was 21.8% in Norway and 24.4% in the UK but 31.7% in Germany and 38.8% in Canada.

Despite the claims of C-section alarmists, the sky is not falling.

But even if it were, wailing and gnashing of teeth, the preferred response of those who demonize C-sections, would not accomplish anything. That’s because the driver of C-section rates is uncertainty. We know that lack of oxygen during labor, either from placental insufficiency, trapped head during a breech birth or severe shoulder dystocia can lead to permanent brain damage and death of babies. Unfortunately, we don’t have an accurate way of determining IN ADVANCE which babies will be injured during birth.

We are forced to resort to crude methods like measuring the baby’s heart rate to determine if it is at risk, and therefore are forced to perform C-sections that turn out to be unnecessary in retrospect. We know that some babies will die during breech birth because their heads will get trapped but we have no way of predicting in advance which babies will get stuck and therefore we recommend routine C-section for breech even though we know that nearly all of those C-sections are unnecessary. We know that some babies, particularly large babies, will suffer serious complications from shoulder dystocia, up to and including death, but we don’t know how to determine which babies will suffer shoulder dystocia so we are forced to recommend C-section in many cases where it is unnecessary.

Natural childbirth advocates like to pretend that the solution to imperfect technology is no technology. Since electronic fetal heart rate monitoring has a high false positive rate, we should just stop using it. Since most breech babies will fit, we should just stop doing C-sections for breech. Since most big babies won’t be harmed by shoulder dystocia, we should simply stop worrying about it.

But the solution to imperfect technology is not forgoing technology; it is improving technology. We need to spend tens of millions of dollars (or more) perfecting a way to determine fetal oxygen levels during labor. We need to spend tens of millions of dollars (or more) perfecting a way to determine whether a specific baby in a specific position will fit through a specific pelvis. When we create such technologies, the C-section rate will drop precipitously because we learn in advance which C-sections are unnecessary and stop doing them.

Wailing about the C-section rate accomplishes absolutely nothing. Crying “the sky is falling” does not prevent the sky from falling; it’s even more irresponsible when the sky is not falling at all.

  • Cynthia

    There is a real benefit, as a patient, to knowing that you have options within the circumstances that exist, and that your provider respects your decisions.

    I chose to plan c-sections with my first 2 deliveries when I found out that they were breech. I am grateful that I was given the option of trying to turn the babies or trial of vag birth, and considered those options, but in the end felt that planned c-section was a better option for me personally. The OB wanted to document my reasons, but didn’t argue.

    There are risks and benefits either way, and evaluating those can be really personal. If I had wanted a lot of kids, I may have tried harder to avoid the c-sections. OTOH, I knew that my anxiety was extreme going into my first birth since I had lost a previous pregnancy, and I didn’t want to deal with the possibility of an emergency c-section if something went wrong with the turning or a vag breech delivery.

  • oscar

    This story is quite apposite to this post: it is about a prehistoric, relatively undisturbed, grave in northeastern Asia that contained the remains of a young woman who may have died giving birth to twins. The bones suggest that the first twin was a breech birth and could not be delivered. The second twin was still in the abdomen. It’s a little reminder of how dangerous childbirth can be without current technology…

    (I also learned from the article the ghastly term “coffin birth”, also known as postmorten fetal extrusion i.e. when the gas from a decomposing woman pushes out her fetus)….

    https://www.livescience.com/49680-siberia-grave-mother-twins.html

    • MaineJen

      Holy crap, that’s terrifying 😮

  • Thiel

    Hey, this isn’t in any way related to the article, but I wanted to introduce myself. I’ve been lurking for a while and I finally got a disqus account so I could join in the conversation.

    • Hi and welcome.

    • momofone

      Welcome!

    • Casual Verbosity

      I recently made the transition from lurking to contributing. You won’t regret it!

      • Thiel

        I’m actually a bit surprised at myself; I’m not an active commentor (commenter?) on any other blogs and this isn’t even one that’s particularly relevant to me personally (I’m childless and hope to remain so), but the commentariat here really makes me want to participate.

        • Casual Verbosity

          Same for me. I have a lot of passionate opinions about a lot of subjects, but I’m usually pretty good at refraining from entering the fray. However, this topic and this particular community really encouraged me to participate. I’m looking forward to hearing your thoughts.

          • Thiel

            And the same to you 🙂

  • Mac Sherbert

    The c-section rate is above 30% because we can. We can prevent bad things from happening, so we do. I don’t know how many of these people who think babies need to be close to death before a c-section has ever spent time around children with disabilities. I have! It’s not worth it to risk it! Let’s just called it a privilege of living in a first world nation. Maybe that’s really the problem they see it as unfair.

    • Nina Yazvenko

      But what if preventing one bad thing causes another bad thing?
      I am not saying that there are easy answers except perhaps – there are more C-sections and inductions performed certain times of the day and certain times of the week. Perhaps if there was constant shift staffing and doctors weren’t trying to get home, at night, this might improve things.

      • swbarnes2

        Are you suggesting that a woman with a breech baby should schedule her C-section at 2 in the morning on Saturday?

        Do you think that hip surgeries should be equally spread out across times and days? Wisdom teeth extractions?

        • Nina Yazvenko

          I’m not talking about C-sections that are scheduled for necessity – maternal or fetal such as fetal position, or health problem. I’m talking about inductions that are scheduled for convenience that then lead to C-sections, for example.
          http://www.kansascity.com/news/local/article1208178.html

          And C-sections that are a result of false positive from Continuous fetal heart beat monitoring.
          I have a personal experience with it – continuous fetal monitoring is made for immobile laboring mothers, not mobile ones. The problem with it that the belt that is affixed around your belly shifts with every movement (it did for me), then the following happens:

          Nurse: (during a contraction) OMG your baby’s heartbeat is 89 it is in distress!!!
          Me: (takes my own pulse) That’s my pulse…
          Nurse: How do you know?! OMG OMG
          Me: err… because I can take my own pulse and it is synchronous to the one I hear from the monitor….
          Nurse: (Shifts belt to re-capture fetal pulse) oh baby’s pulse is 140, its normal.
          *next contraction*
          Nurse: OMG fetal pulse is 89!!!
          Me: *sigh* … the belt shifted again, that’s my pulse again.
          *repeats every 5-10min until I finally get epidural and stop moving*

          • Azuran

            Look, even in your case where the nurse got the pulse wrong. Do you really think that your OB would have wheeled you in for a c-section without checking out your baby himself?

          • Nina Yazvenko

            Nurse freaking out during labor freaked me out, even though I knew she was wrong. What if I didn’t know she was wrong? I could have freaked out and demanded C-section for my baby’s sake. She could have told the doctor that the baby was in distress for last so long, thats a reasonable grounds for a c-section. Nobody wants their baby to be injured during birth. I am just saying that now I know exactly how those continuous fetal monitoring false positives happen, and how they can quickly scare everyone in the room. Now if you combine that with a tired doctor who just wants to go home to their family, they can make questionable calls without even realizing it.

          • Chi

            Better a high false positive rate than a high false negative rate.

          • Nina Yazvenko

            That’s not always the case though. High false positive rate in PSA testing has been found to be harmful.

          • Azuran

            I do agree that the nurse freaking out like that in front of you is massively unprofessional. I’d tear a new one to any of my tech who pulled out something like that.
            But the fact remain that even if you didn’t know your baby was fine, the OB wouldn’t have rushed into a c-section without checking and confirming himself that your baby was indeed in distress. Even IF the nurse had told the doctor that the baby was in distress, he would still have taken the time to check it, not doing it himself would have been malpractice.

            As for ‘doctor wanting to go home’ and doing unnecessary c-section. Even IF OB’s were doing that, you really think that the hospital and other staff would just accept it and not make it stop? A C-section doesn’t require only an OB. An OB calling a c-section for his own convenience would mean making an anesthesiologist stay longer or have him come to the hospital.
            You think the anesthesiologist (who would want to stay at home just as much as the OB) wouldn’t complain about an OB making him come repeatedly to the hospital, or stay late longer, because he wanted to leave earlier?

          • MaineJen

            “A tired doctor who just wants to go home to their family” You really don’t think much of doctors, do you?

          • Roadstergal

            ” low-risk births”

            The referenced PDF didn’t say low-risk births. Did you read it?

          • The Bofa on the Sofa

            I’m talking about inductions that are scheduled for convenience that then lead to C-sections, for example.

            Since you are the one who talks about “population statistics” I will just point out that, at the population level, inductions don’t lead to c-sections. In fact, they actually prevent c-sections.

      • Empress of the Iguana People

        Planned c-sections are indeed planned for usual business hours. What’s wrong with that?

        • Nina Yazvenko

          There is nothing wrong with those, I’m talking about unplanned C-sections and inductions during business hours, rather than when they are actually warranted. I know that in other countries shift systems that remove “going home” incentives for doctors (as they are not going home regardless of how the labor goes), intervention rates are lower and maternal and fetal outcomes are better.

          • Empress of the Iguana People

            I was induced in the middle of the night. In 2 different hospitals

          • Nina Yazvenko

            Again, great for you. Maybe you chose the hospital right.
            And I had a really good experience with a CNM, and being induced, and super easy vaginal birth. That is anecdotal. We are talking about regional and population level statistics, not personal anecdotes.

          • The Bofa on the Sofa

            We are talking about regional and population level statistics, not personal anecdotes.

            As I noted above, it’s ALL anecdotes. Each case is determined on the individual level, as they must be.

            Or do you think that doctors should base their decision on how to handle a case based on population statistics? “Well, Mrs. Brown, there are some concerning indications in your delivery. Normally I would recommend a c-section in this situation, but given the prevalence of c-sections in the US, I’m not going to do it and we’ll just take the risk.”

          • Azuran

            Practising with population statistics: Don’t worry about doing surgery on your 17 years old, septic, extremely dehydrated half dead dog. Statistically, pyometra surgery has a >92% survival rate, it’s going to be fine.

          • The Bofa on the Sofa

            My wife has a personal joke from vet school about whenever we hear pyometra:

            “Die, pyometra dog! Die!”

            (it was an A&I case from their first semester of grad school)

          • Azuran

            See, in my hospital, the OB was actually going home no matter how the labour went. Because someone else was coming it to replace them. Yet we still have pretty average c-section rate.
            I also ended up in the hospital a 1am with ruptured membrane. The OB had to check on me. And then, since I was perfectly stable, they offered me to start the induction right away (it was 3am by that point) or wait until morning.

          • Nina Yazvenko

            Good for you. I also had ruptured membranes without labor starting, and based on latest data my CNM checked on me, then told me to go home and come back in 24h, when infection risk starts ticking up. That was the hospital policy/guideline. If I was induced right when my membranes had ruptured, that would have raised my risk of c-section. But since it was started slowly 24h later, my labor started right away with lowest dose of pitocin and progressed incredibly quick and I didn’t need c-section.

          • Azuran

            Wait, you mean the hospital didn’t force you to have an induction for their own convenience?

          • Nina Yazvenko

            No, I chose a round the clock practice and low c-section hospital for that reason :).

          • Azuran

            So where is the problem? You wanted something and got it. Has it occurred to you that maybe other women just don’t have your baseless aversion for induction? (seeing as inductions actually reduces the risks of c-section) And that most women are totally fine with being induced and totally fine with a c-section at the first sign of a problem?
            Basically every single pregnant woman I’ve met was doing everything she could to start her labour. They all bemoaned that they couldn’t get induced before 42 weeks. Every time they showed up at work they showed disappointment that their labour hadn’t started, and hope that their third stripping would do the trick. They all would have jumped on any reason to have an induction. I’ve seen 2 women in their 41th week in the hospital crying and begging to be induced because they just couldn’t endure being pregnant anymore.
            Maybe most women don’t want you to protect them against the ‘mean’ induction.

          • Daleth

            If I was induced right when my membranes had ruptured, that would have raised my risk of c-section

            So, I hear that you believe that, but for the life of me I cannot figure out why. Induction LOWERS the risk of needing a c-section. This metastudy (link below) looked at one hundred and fifty-seven randomized studies of induction to see what they all said, and here’s what they said:

            “Overall, the risk of cesarean delivery was 12% lower with labour induction than with expectant management [i.e. letting labor progress naturally]…. initial cervical score, indication for induction and method of induction did not alter the main result. There was a reduced risk of fetal death (RR 0.50, 95% CI 0.25–0.99; I2 = 0%) and admission to a neonatal intensive care unit (RR 0.86, 95% CI 0.79–0.94), and no impact on maternal death (RR 1.00, 95% CI 0.10–9.57; I2 = 0%) with labour induction.”

            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4049989/

            Look at how much induction reduced the risks:
            – Lowered the risk of c-section by 12%
            – Lowered the risk of the baby dying by 50%
            – Lowered the risk of the baby being admitted to the NICU by 14%

            Interesting, no?

          • Nina Yazvenko

            You are right, my info was out of date. That article was published about 6m after I delivered. If my membranes break without labor on the next one, I’ll probably get induced right away then.

          • Daleth

            unplanned C-sections and inductions during business hours, rather than when they are actually warranted

            Large hospitals don’t have business hours. There are always OB-gyns, nurses, and anesthesiologists available. When their shifts end, new OB-gyns, nurses and anesthesiologists replace them, 24/7.

            So no, that is not a thing. If you’re talking about people who gave birth at a large hospital, the fact their emergency c-section or their induction started in daylight hours has absolutely nothing to do with “business hours.” That just happened to be when the patient needed or wanted the procedure.

            And small hospitals may NOT have appropriate staff on hand in the middle of the night. They may just have an anesthesiologist on call who can’t get there until 20-30 minutes after she’s called. That is not fast enough if there’s a life-threatening labor emergency. So of course they’re going to move to a c-section or try induction before night falls. They want to make sure they have the right staff on hand in case that particular woman’s labor degenerates into a serious emergency.

          • Nina Yazvenko

            Which is why small hospitals should be subsidized to be able to afford those things, to improve overall health care.

          • The Bofa on the Sofa

            But they aren’t. So until they are, what do you do?

          • Roadstergal

            Why? If a small hospital has a very light workload, why hire people who aren’t needed and just sit around the vast majority of the time?

            That takes away money and resources from larger hospitals that serve large communities and struggle to have enough staffing for the actual workload they have.

            You have to go places for care. The US is big. L&D isn’t different from any other medical care in that way. Some people have to drive hours to see a specialist, or to get a certain drug with a long infusion time. Some women have to travel to go to a hospital that’s equipped for VBAC. Having every little care center be equipped for VBAC makes as much sense as having an lab that does crossmatches at every little care center.

          • Daleth

            If you do the math, you will realize why that is not possible. The average salary for an anesthesiologist in the US is $350,000/year. To have 24/7 anesthesiologists, you would need three on staff, at an annual cost of $1.5 million in salary plus about another $500k in salary taxes and benefits–so, $2 million/year. Who is going to pay for that?

            There are a little more than 1600 small hospitals in the US, defined as hospitals with fewer than 4000 admissions per year (this is total admissions–OB-gyn admissions are only about 15%-20% of that).* On average, it’s around 2000 admissions/year. The average cost per hospital admission in the US in 2010 was $9700;** presumably it’s a bit higher now–let’s say it’s $11,000.

            Multiply $11k x 2000 and you find that the average small hospital is taking in about $22 million a year FOR EVERYTHING, FOR EVERYONE… except that you also have to account for patients who don’t pay their bills; so let’s say instead of $22M, they’re taking in $20M. On average only about 5% of that, so $1 million, is for pregnancy and childbirth.

            They’re bringing in on average $1 million/year. The one additional service you think they should offer would require them to SPEND another $1 million/year just in case a few local women wanted to attempt to VBAC there rather than traveling to a larger hospital. Where are they supposed to find that money? How could it possibly make sense for a small hospital that has maybe 200 to 400 births/year to spend $2 million a year to have 24/7 anesthesiologists, for the few dozen women who want to attempt a VBAC? Those anesthesiologists would spend most of their time not working because in a small hospital, there’s simply not enough demand for anesthesiologists to keep them busy 24/7.

            And what is special about VBAC that makes it something all hospitals should provide? Why shouldn’t small hospitals also be required to provide NICU care, open heart surgery, brain surgery and a transplant program? Oh right — because we can’t afford it.

            * Number and definition of “small hospitals”: http://www.aha.org/about/membership/constituency/smallrural/index.shtml

            ** Average cost of hospital stay: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb146.pdf

          • Daleth

            in other countries shift systems that remove “going home” incentives for doctors (as they are not going home regardless of how the labor goes), intervention rates are lower

            Do you really want a completely exhausted medical team that hasn’t slept in 24 hours? Why? That’s not an incentive–it’s abusive and it dramatically increases the risk of accidental malpractice. Sleep deprivation is not good for decision-making or fine motor skills.

            I know I prefer a fresh team. When I developed pre-e and was heading quickly towards HELLP syndrome, my hospital still waited until shift change to do my c-section, so that my team would be completely fresh and well rested. I far prefer that approach.

          • Nina Yazvenko

            Shift system means that they come to work night fresh after having slept at home, not working night after having worked the day.

          • Roadstergal

            Please name one of these ‘other countries’ and a: what maternal and fetal outcomes are better, and b: evidence that these outcomes are due to a reluctance to perform C-sections.

          • Nina Yazvenko

            I was thinking about countries that have similar obesity rate to US: like UK and Canada, that have lower c-section rates, and much better maternal outcomes. But it is complicated by the fact that every single other developed nation has universal healthcare, and US does not. There is correlation, which does not equal causation.

          • Roadstergal

            And yet you have repeatedly implied in various posts in this thread that C/S is a hefty driver of maternal mortality, despite the difference in health coverage.

            I’ll repeat what I asked above – what are the drivers of maternal mortality in the US? Since you are so certain that reducing C/S can help them, you must be very familiar with what they are.

      • Mac Sherbert

        That’s an old argument and one that most commenters here will destroy quit easily. My doctor came in at a really inconvenient time for her to perform my c-section. She even offered to let me VBAC, if I had wanted. Most OBs are not single practice they rotate shifts. Probably, does depend on the hospital and resources though. Inductions are obviously done at a certain time of day because they are generally planned ahead of time. There has also been much discussion here about inductions and how they are actually associated with better outcomes. So what? Please, tell me what’s worse than a dead or injured baby.

        • Nina Yazvenko

          I’m very happy that your doctor put your health above their convenience, but that’s not the overwhelming culture, which determines outcomes on population level. An anecdote does not an evidence make.
          https://opinionator.blogs.nytimes.com/2016/01/19/arsdarian-cutting-the-number-of-c-section-births/
          “What’s likely to be the biggest influence on whether you will have a C-section?

          (A) Your personal wishes.
          (B) Your choice of hospital.
          (C) Your baby’s weight.
          (D) Your baby’s heart rate in labor.
          (E) The progress of your labor.

          The answer is B. In California, for example, hospitals’ rates for cesarean sections performed in low-risk births range from 11.2 per cent to 68.8 per cent. (pdf) The rest of the factors do influence the decision. But the hospital determines how these factors are treated.”
          ” “’She’s going to have a C-section in a couple of hours anyway, so let’s get it over with. The patient won’t suffer more, and I can go home and I won’t get replaced by someone else.’ Or, you can say, ‘Let’s wait another hour or two.’””

          • Poogles

            “The answer is B.”

            That is an opinion piece, not any type of proof that the choice of hospital is actually the biggest factor in any individual woman’s case. There are multiple reasons why rates of CS vary wildly from hospital to hospital and it’s almost never the reasons that NCB advocates like to believe (Doctor convenience, money, etc.).

          • Chi

            Exactly. I think one of the biggest factors that anti-cesarean proponents DELIBERATELY ignore is that a hospital might have a higher c-section rate because they’re a level IV NICU and the majority of their patients are mothers who are in premature labour/have pre-eclampsia/HELLP syndrome etc etc etc.

            A lot of babies in those hospitals are likely born via c-section because either the mother or the baby are struggling and it’s less risky to birth the baby, than it is to try and hold off labour any longer. And it’s done via c-section because TOL presents a bigger risk to either mother or baby than a c-section.

            But hey, it’s all about the money and convenience right? Risk analysis has absolutely nothing to do with it /sarcasm.

          • Nina Yazvenko

            Which is why they only compared low risk nulliparous women with singletons. Premature labour, pre-eclampsia, and HELLP syndrome automatically disqualify you from that category.

          • Chi

            That’s my biggest problem with these comparisons. What EXACTLY constitutes ‘low-risk’?? Because the simple fact of the matter is this. A LOT of women are low-risk…until they’re not.

            You can be a textbook pregnancy…but still wind up with pre-eclampsia.

            You can be a textbook pregnancy and still wind up with a baby who is lying breech.

            You can be considered ‘low-risk’ until you’re in the middle of labour and suddenly the baby’s heart rate plummets.

            I really hate people like you who go on and on about excessive c-section rates and ‘unneccesarians’ when, at the end of the day, you simply CANNOT say, with 100% accuracy that a woman’s c-section was totally unnecessary in her case. Because you weren’t there. You weren’t privy to the same information the doctors/nurses/midwives/registrars had. You don’t know WHY they made the decision to go to c-section.

            Let me clue you in. It is NEVER for ‘convenience’ or ‘to make money’ as you claim. It is because they have detected distress from either mother or baby and have decided that it is better to be safe than sorry and gotten the baby out and mother patched up.

            Because at the end of the day, their goal is NOT making money (because most OB’s are salaried and don’t get bonuses for surgery), it’s to ensure that both mother and baby survive and are as healthy as possible.

          • The Bofa on the Sofa

            you simply CANNOT say, with 100% accuracy that a woman’s c-section was totally unnecessary. Because you weren’t there.

            Actually, the fact that you cannot say with 100% accuracy that a c-section was not necessary is not just because you aren’t there, it’s because it’s logically impossible. When a baby is born healthy by c-section, you cannot say for sure that it would not have had a problem had it been born vaginally.

            If the baby is born successfully vaginally, you can say that a c-section was not necessary. When a baby has a problem being born vaginally, you cannot say for sure that it would have been better with a c-section, but you can argue that there was a chance for a better outcome (hence the basis for lots of lawsuits). If a baby is born by c-section has a problem, you cannot know that it would have been ok born vaginally, but you don’t see too many claiming it would have been (hence the doctor line, “I’ve never been sued for doing a c-section too soon”). But when a baby is born successfully by c-section? Tells you nothing about what would have happened in a vaginal birth.

            You don’t know that the baby wouldn’t have gotten stuck, for example. Or that a rupture would have occurred. Can happen, and you can’t say it wouldn’t have.

          • Nina Yazvenko

            You cannot say anything for sure, I agree with that. That’s why you look at group outcomes and try to determine what’s actually produces better outcome. It has been determined that for breach birth and twin birth C-section produce better outcome on average. You cannot say that it produces better outcome for any particular case, just average.
            http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)02840-3/fulltext?_eventId=login
            So it would be reasonable to recommend c-section for every breach and twin birth. It might harm a particular individual who may die from C-section complications, but overall it will save lives.
            Same thing with antibiotics for GB+ pregnant women. Intervention may harm a few, but overall saves lives.

            When there aren’t clear indications, that’s when you run into trouble on trying to judge whether an intervention is beneficial, detrimental, or neutral. That’s why clinical trials, and studies are so important to give statistical view of the outcome. Rather than trying to see whether a rupture would have occurred, you can say “these were the chance that a rupture would have occurred” just like they do with VBAC. They have statistics on the chances of the uterine rupture, and subsequent outcome.

          • Azuran

            All of this doesn’t matter if you don’t have the tools to accurately predict who will have complications.
            True, we could have a lower rate of c-section and have the same outcome, but we have no way of knowing which one would have turned out fine.

            To use your own exemple, the risk of vaginal breech birth is what, somewhere around 5%? So you agree with 100% of breech birth being done by c-section because of that 5% (even though 95% where technically unnecessary) But you are against a c-section rate of 30%, because somewhere between 10-15% of those might have been ‘unnecessary’.

            Population statistics don’t matter when you have the patient in front of you. You shouldn’t aim for a specific rate of anything, you give every patient what you think they need.
            If you want to know what happens when one tries to lower intervention for the sake of lower intervention, you might want to check what happened at morecambe bay.

          • Nina Yazvenko

            I believe that overall morbidity and mortality should be minimized. So for breach presentation planned c-section should be OFFERED 100%.
            Newer articles show data that WHO’s 15% is too low, as Amy has been claiming for years now. New recommendations should be closer to 20%.

          • Azuran

            given an average c-section rate around 30-35%, I find an error margin of 10-15% to be extremely acceptable, considering we are talking about babies.

          • The Bofa on the Sofa

            That’s why you look at group outcomes and try to determine what’s actually produces better outcome.

            But in order to do that, you have to actually address the problem at the individual level.

            Show me a c-section that was done that should not have been. And none of this “it was done in the afternoon at a convenient time, they should have waited until it was an emergency in the middle of the night” stuff, that doesn’t fly.

            Yes, it is based on probability. And despite the fact that 95% of breech births could be delivered safely vaginally (that’s population statistics), it is better to do all them c-sections. Why? Because regardless of the population level, what matters is the individual.

          • Casual Verbosity

            Okay, right now I should be writing my thesis about this very topic, but I felt the need to chime in.

            When making decisions in a real-world scenario (i.e. one in which you cannot magically project forward in time to determine the outcomes of each possible decision) you cannot make every decision the correct one. As per signal detection theory there are four possible scenarios for every decision:
            1. Hit – Mother/baby needed a CS and one was given
            2. Correct rejection – Mother/baby did not need a CS and was not given one
            3. False alarm – Mother/baby did not need a CS but was given one
            4. Miss – Mother/baby needed a CS and was not given one

            The first two scenarios are your possible positive outcomes and the second two are your possible negative outcomes. When making decisions, we have to decide which of these outcomes we value the most, because increasing one positive type will necessarily increase a given negative type and decrease the other positive type.

            If you wish to increase your Hits, you will necessarily increase False Alarms and decrease Correct Rejections. But you will also decrease Misses.
            If you wish to increase your Correct rejections, you will necessarily decrease your False Alarms and your Hits. But you will also increase Misses.

            Because we cannot perfectly calibrate our threshold to get all the Hits and Correct Rejections and avoid all Misses and False Alarms, we have to decide which outcomes we value most and accept that maximising our most valued outcomes will also increase less desirable outcomes.

            In this context, most people would argue that it’s most important to increase Hits and decrease Misses, because Misses have the most negative effects e.g. dead or disabled baby, dead or disabled mother. However this will necessarily increase False Alarms and decrease Correct Rejections. The consequences of a False Alarm (longer recovery time, missing out on magical vagina bugs) are negligible by comparison to the consequences of a Miss.

            Hence, we set our threshold for caesarians reasonably low because we have decided that it’s our priority to avoid death and serious injury to mothers and babies. Does this mean the system is perfect? Far from it. We should be trying to develop more sensitive tools to improve our ability to predict the necessary cases. However, unless we can develop a tool that perfectly predicts the future, we will always perform some unnecessary caesarians. Of the other possibilities, that’s actually a pretty good outcome. Of course there’s the philosophical argument about what constitutes a ‘necessary’ vs an ‘unnecessary’ CS, of which people will have vastly different opinions, but that’s a discussion for another post. And I really need to finish my thesis.

          • Azuran

            My mom had a VB… after 6 hours of pushing, multiple forceps attempts, multiple vacuum attempts and the OB breaking both of my brother’s clavicle. (yay for VB?)

            I had a c-section after 2 hours of pushing and 1 forceps attempt. It’s probable that if they had me go through what my mom went through, I eventually would have been able to squeeze my baby out. Does that mean I had an unnecessarian?

          • Nina Yazvenko

            I know someone who had some complications, then was still so set on having a VB, pushed for 3 hours, and came out of it with significant injuries. So I do think that c-section to prevent maternal injuries is warranted. I would do it.

          • Azuran

            Then why do you have a problem with the c-section or induction rate? In every single of those case (except in very extreme cases), the woman gave her consent. She decided that she.d rather face the risks of a c-section than VB.

          • MaineJen

            She would do it to prevent injury or death for *herself* or *her baby.* She just thinks other people are having too many c sections.

          • Nina Yazvenko

            That’s why associations like ACOG define low-risk for everybody. And that’s why scientific articles cite their sources and disclose their methods, then you can follow above mentioned citations to dissect their exact methodology and criteria.
            Pre-eclampsia is associated with significant expected risks for both patient and fetus, so will disqualify you from being low-risk.

          • swbarnes2

            Did you notice that your paper doesn’t actually say “low-risk”? It says lower risk. So sure, they knew what the definition of “low-risk” was. And they knew they did not meet it. You read the paper, you knew that too, so you just lied when you described the study as looking at “low-risk” women.

          • Nina Yazvenko

            Here is the quote from citation they used to define low-risk
            http://images.ibsys.com/2005/0504/4450560.pdf
            “Accordingly, it would seem appropriate to focus on
            low-risk nulliparous patients with term singleton fetuses with vertex presentations
            when evaluating strategies for lowering the primary cesarean delivery
            rate”
            so I went with the terminology of the source. My apologies.

          • swbarnes2

            Sigh. But that’s not YOUR PAPER. Why didn’t you know what YOUR PAPER said?

            Oh, and when are you going to explain how the clinical details on the reasons for C-sections were taken into account in your paper? An honest person could cite the appropriate part in 5 seconds. My guess is, you won’t answer. You just can’t. You read the part where that is addressed, but you won’t answer.

          • Roadstergal

            In NCB-land, ‘low-risk’ means ‘no-risk.’

            It’s funny that Nina can ‘get’ that heart rate monitoring is an imprecise diagnostic that can have a false positive rate.

            But she doesn’t ‘get’ that ‘low-risk’ is also a diagnostic, based on a constellation of measurements, and that it can be wrong, as well. And when it is, it’s wrong in the bad direction. :p

          • swbarnes2

            Show us in the paper where it says that. Because everyone can read

            “We identified this subset by excluding pregnancies with any of the following characteristics: preterm delivery (prior to thirty-seven weeks gestation, ICD-9 644.2, 644.20, 644.21), multiple gestation (ICD-9 651, 651.0X, 651.1X, 651.2X, 651.3X, 651.4X, 651.5X, 651.6X, 651.8X, 651.9X), fetal malpresentation (ICD-9 652.X, 660.0X), and prior cesarean delivery (ICD-9 654.20, 654.21, 654.23). ”

            So show us in the paper where it says the filtered out women with other health conditions.

            Do it immediately, or you are a liar.

          • Nina Yazvenko

            Wow, name calling. I am disappointed. I read Skeptical OB and the forums because I have found crunchy “natural birth” and “breastfeed at all costs” crowds un-hinged in reality.

            But since you don’t seem to be able to follow citations here you go:
            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3615450/
            “To determine which pregnancies were lower risk, we followed the recommendations of the American College of Obstetrician-Gynecologists as closely as our data allowed.(13)”
            http://images.ibsys.com/2005/0504/4450560.pdf
            p. 6 “low-risk women with uncomplicated singleton term pregnancies with a vertex presentation who are expected to have an uncomplicated birth”

            That document is actually a fascinating read.

            “In hospitals and practitioner groups with high
            cesarean delivery rates, the provision of dedicated
            24-hour, in-house obstetric coverage has
            been beneficial in reducing cesarean deliveries
            in some of these groups”
            “There appears to be a pattern of clinical behavior
            associated with practice style (55, 56). Cesarean
            delivery rates are higher for male obstetricians ”
            “Studies report that cesarean delivery rates often are
            related to the source of payment. Rather, women who
            have private medical insurance are more likely to
            have a cesarean delivery than those insured by a
            health maintenance organization or by public insurance
            (49, 50, 62–71).”
            “■ Induction of labor for suspected macrosomia
            does not improve outcome, expends considerable
            resources, and may increase the cesarean
            delivery rate.”

          • swbarnes2

            Show is IN YOUR PAPER where it ways that women with pre-eclamsia were omitted. The paper is perfectly explicit about the ICD codes they excluded by, just show us IN YOUR PAPER when they excluded women with risks other than the ones I already noted.

            (Hint, that “as our data allowed” line probably means they didn’t have data on other complications, so they had to leave them all in)

          • Roadstergal

            “As closely as our data allowed.”

            How closely did their data allow?

            Can you identify risk factors that they did not consider that influence your chance of a successful uncomplicated vaginal delivery?

          • Nina Yazvenko

            No research is perfect.
            However, I can also say “Identify factors that will influence your chance of not having successful vaginal delivery.” and we don’t know those yet. We also don’t know risk factors for having complications after c-section vs not having them, or having complications from VB vs not having them.

          • Roadstergal

            “Identify factors that will influence your chance of not having successful vaginal delivery.”

            Obesity.

            Diabetes.

            Advanced maternal age.

            Just to start.

            Were those controlled for in Your Favorite Paper?

          • The Bofa on the Sofa

            Wow, name calling. I am disappointed.

            I have reread swbarnes2 comment a couple of times and I fail to see where she called you any “name”

            The only insult she included was to say that an honest person could show where it says they filtered out women with other health conditions, which is what you have implied, with the implication of her statement being that a dishonest person could not do it.

            Now, in order to be an insult toward you, it would only apply if you can’t show where the paper says they filtered out those other conditions. Are you admitting that is the case, then, that you can’t show that part in the paper?

          • MaineJen

            Those naughty doctors, wanting to do inductions and c sections when they actually have the staff on hand (i.e. during working hours).

          • Nina Yazvenko

            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3615450/

            Here is published article that opinion piece was based on.

            And that’s why they are comparing low risk nulliparous women. While I agree that some difference due to hospital facility etc. is possible, I wouldn’t expect it to be between 15% and 70%. That is too much.

          • Roadstergal

            I can think of at least four risk factors for C-sections that were not accounted for in this paper and whose rates can vary dramatically between populations (and therefore between hospitals).

          • Azuran

            The absolute vast majority of doctors put their patient’s well-being above their own ‘convenience’.
            The whole ‘convenience’ thing is just so ridiculous.

          • Nina Yazvenko

            There is mounting evidence that many decisions that we think are made conciously are in fact made unconciously and in advance:
            http://www.nature.com/news/2008/080411/full/news.2008.751.html

            So while I don’t doubt that most doctors try to put their patient’s well being above their own convenience, that doesn’t mean that that’s what they are actually doing. Which is why policies and guidelines that are written out are so important.

          • Azuran

            You are citing a nature.com that has absolutely nothing to do with medical decision and expect to be taken seriously?

          • AnnaPDE

            My mother’s OB said, when at 3pm her labour with me wasn’t really going anywhere: “I don’t think this baby will come out by herself. You can keep trying if you want to, but I’m pretty sure that’s only going to end up with me rushing in for an emergency CS at 3am, when the hospital is half staffed and everyone is sleepy, and you’ve been hurting yourself and maybe your baby for 12 hours longer. Please let’s get this over with now, when I’m still fresh and alert, Dr X is here to do your anaesthesia, Dr Y is here to handle the baby, and we’ve got a lot of nurses on duty.”
            You can try and interpret this as a case when the doctor was prioritising his own convenience above my mum’s and my health. Or you can see it as the rational decision to do things when they’re easier for everyone and thus safer.
            Turns out the doctor was right, btw — I was a bit stuck and also had the cord nicely looped around my neck. Lucky he found out at 4pm.

          • Nina Yazvenko

            You are talking about an individual case. I’m talking about health policy and population level statistics. I know cases, when they should have done C-section earlier, but pushed for vaginal birth for some reason, induction didn’t take that well, they rushed placenta removal and the mother almost died. I know case when the mother wanted VB so bad that she labored for way too long and sustained severe pelvic floor injuries. My mother labored for over 24, no issues, delivered me with no issues, had episiotomy that healed with no issues, then was bored out of her mind for the rest of the week in the hospital. I know a case when a woman died 1wk after c-section due to an infection. It all happens, and you need more than a couple of anecdotes to access policies and make improvements to the system.
            Otherwise you get the situation where US is right now – with the only developed country with rising maternal mortality, and maternal mortality that’s higher than the rest of developed countries.

          • AnnaPDE

            Nope, you’re not talking “population level statistics” when you’re speculating about the thought processes of doctors making clinical decisions and weighing risks. In particular your accusation about doctors’ insufficient experience and convenience driving their judgement of how to best handle a birth have nothing to do with statistics, instead you’re just ascribing motivations to them without a single piece of factual evidence, citing a made-up conversation. “’She’s going to have a C-section in a couple of hours anyway, so let’s get it over with. The patient won’t suffer more, and I can go home and I won’t get replaced by someone else.’ Or, you can say, ‘Let’s wait another hour or two.’”
            This is why I have shown you what the decision process actually looked like in one of those cases — that’s only a single data point, but at least it is what really happened, as opposed to some fantasy in your head.

          • The Bofa on the Sofa

            You are talking about an individual case.

            But this is the problem. EVERY C-section is an “individual case.”

            Here’s the question I always ask: if you think there are too many c-sections, please identify a c-section that was done that should not have been?

            My wife has had two c-sections. For the first, the baby was breech. For the second, it was a repeat c-section and the local hospital was not equipped to safely do a VBACS, and to do a VBACS we would have had to go to a different hospital with a different doctor.

            Do you think that either of those should not have been c-sections? I’ll give you a hint: NO. They were both perfectly appropriate.

            Oh, but you say, these are just individual cases. But everyone’s c-section is an individual case, and that is what matters. We are not going to risk our babies or go out of our way to have a VBACS just to make the population look better. We are going to do what is best for us given the circumstances. And you have no business second-guessing that.

          • Roadstergal

            What happens if there’s a false positive that means a woman has a C-section when her baby could have been delivered vaginally successfully? The baby is born via C-section.

            What happens if there’s a false negative that means a baby that couldn’t be delivered vaginally isn’t born by C-section? The baby is harmed or dies.

            I don’t know why this is so often elided over when it comes to the ‘unneccesarean’ discussions.

          • Roadstergal

            What are the drivers of maternal mortality in the US?

            How is avoiding C-sections going to help with those drivers?

          • Heidi

            Where’s your evidence that C-sections are to blame for the increase in maternal mortality?

          • swbarnes2

            Her own links say that “there is no evidence that maternal and fetal morbidity and mortality are affected by a cesarean section for which there is no medical indication,”

            It would be rather bizarre to hold that, and to hold that C-sections with some medical cause that happen to co-incide with the end of an OB’s shift are so frequent and so dire that they are dragging down the populations statistics.

          • Azuran

            To be fair, if a Doctor’s professional opinion is that a labouring woman will not be able to have a vaginal birth no matter how long she tries, than yes, it is absolutely his job to inform the woman that he doesn’t think this is going to work and recommend a c-section.
            They can, of course, ALSO give the woman the option to keep trying if she wants to, but not offering the c-section at all is wrong.

          • FormerPhysicist

            My OB did this for me. He informed me I wasn’t progressing, opined that I wouldn’t, and asked if I wanted to try labor an hour longer before c/s (if no progress) or go directly to c/s. I tossed the question back in his lap, telling him I hired him because *he* was the expert and I was on my first kid, couldn’t tell, and hadn’t studied medicine anyhow. We went directly to c/s.

          • Nina Yazvenko

            Absolutely, but doctors rely on culture/guidelines/experience/what they know other doctors to do in order to make those assertions/recommendations, rightfully so. (I scour those guidelines put out by various associations and hospitals for management of my own chronic conditions to study up for my doctor’s visits, and so that I don’t have to go to the doctor each time I need to change the dosage.) Many cases are not as clear cut as “you will never birth this 15lb baby”, which makes them subjective. And if the doctor hasn’t seen many successful vaginal births after 12h labor (for example) in his practice because the culture/guidelines in that hospital are to suggest C-section after 12h, he will be less likely to even consider that. Even if in the hospital next door there are many successful VB’s after 12h labor. This is exactly what is happening with VBACs. For the longest time most hospitals’ policy was to not allow them, and as such they didn’t happen. Now they are allowed, and starting to happen again. But still some doctors “grew up” in the “VBAC will kill you 100%” culture, and when they express those not entirely statistically correct fears to their patients, that influences patients’ decisions. I don’t want to get into argument about VBACs since that’s a giant can of worms too, but that’s just an example.

          • There was never the idea that VBAC would always kill you. There was the idea that it was a very risky thing to do. We figured out that for some people, it wasn’t as risky as we feared, but it’s still scary enough that an OR for a crash C-section (so surgeon and anesthesiologist) must be available. And, of course, not all women are good candidates for VBAC; for a lot of people who want to VBAC it’s just not a good idea. Doctors aren’t perfect, of course, but for this specific situation there’s been a lot of coverage about it and updated studies and guidelines. That doesn’t mean 100% of women who want to VBAC should. It means some of them can.

            VBAC is riskier than repeat C-section. Some of those risks are terrifying and deadly. Doctors are not scare-mongering to tell women about those risks, and it would be malpractice if they didn’t.

          • Nina Yazvenko

            I cringe at 1/100 VBAC uterine rupture rate myself. I was under the impression that every hospital that has ER has and OR where crash c-section can be performed…
            However I still cringe reading articles like this:
            http://www.elle.com/life-love/a41109/vbac-vaginal-birth-after-c-section/
            “More telling is a 2015 paper in the journal Obstetrics and Gynecology that found that 42 percent of 171 Florida physicians surveyed stated litigation as the primary reason they did not do VBAC, whereas lack of experience handling uterine ruptures was the primary concern for only 11 percent of these doctors.”

            This is where american litigiousness hurts people….

          • Poogles

            “42 percent of 171 Florida physicians surveyed stated litigation as the primary reason they did not do VBAC”

            Right, almost half felt the risks were too high, that a bad outcome (the only kind that result in litigation) was too likely to take the risk. I see nothing wrong with this.

          • Cynthia

            I understand the need for any OB to protect themselves.

            At the same time, I can recognize that this has an impact on patient choice. At some point, like Dr. Tuteur points out, choices need to be made based on risks and benefits, when we don’t have a perfect crystal ball. One woman may have a good reason to want a c-section, another may have a good reason to want to avoid one if at all possible. At some point, fear of litigation means that it is the OB making the decision, as opposed to the patient making the decision based upon the advice of the OB and her own tolerance for the risks and benefits involved either way.

            I may be an oddball here, but while I chose to go straight to planned c-sections for my 1st 2 births due to breech presentation, I wasn’t happy to be told by (different) OB that I had to have a planned c-section with baby #3, no matter what. Yes, I understand that there is an increased risk of uterine rupture. I would have preferred to have had the opportunity to take that information into account and make the final decision myself. As it happened, that c-section, unlike my previous ones, had more issues. Nothing that I could sue over, but the price of my OB being risk-averse was that I was struggling to breathe after the spinal paralyzed my diaphragm during the surgery, and I had a nurse screaming when she saw my incision still bleeding after the surgery. I also realized that my odds of being able to safely have more children had gone down. Later, I developed adenomyosis which caused anemia.

          • Wren

            If an ob is unwilling to undertake the risk then it is the choice of the patient to either accept that and continue with that ob or go looking for one who will. The ob should have the choice to avoid what she or he feels is an unacceptable risk too.

          • Cynthia

            I understand, and I’m in a profession where I sometimes have to decline service to clients who won’t follow my advice for liability reasons.

            I’m just saying that the result is less patient choice and therefore reduced opportunity for them to have full bodily autonomy.

          • Not every hospital with an ER has an OB and anesthesiologist standing by for hours and hours and hours just in case something goes wrong. Only larger hospitals might have that. I don’t think you understand that a VBAC means they have to reserve an OR and keep it open just in case the VBAC goes wrong.

          • The Bofa on the Sofa

            Exactly. The reason our ob would not due a vbacs is because the hospital could not guarantee anesthesiology within 12 minutes, which would be required for the proper standard of care. Therefore, if she were to do a vbacs, she would be liable for any outcome due to malpractice.

            I have a hard time understanding why that is considered a bad thing?

            You can go bitch and moan all you want about how hospitals should be spending money on such things, but that does not change the situation we are in.

          • Who?

            Insurers may choose to not cover doctors for VBAC. That’s smart, because insurers have a primary obligation to make money for their shareholders. Rupture is not that rare, and really expensive.

            Just who do you think should be the crash test dummies for all these VBACs? Will you line up?

      • Heidi

        That’s just it…what if? Or what if it doesn’t? We don’t have any conclusive evidence that c -sections cause “bad things.” And the “bad things” some people accuse them of are relatively minor compared to a brain- damaged or dead baby or dead mother that we actually know could result if a C-section is avoided and was needed. But a lot of the time, we have no way of knowing which was *absolutely* necessary. Most doctors and mothers don’t want to play roulette with babies’ lives.

        • Nina Yazvenko

          There is conclusive evidence that C-sections are riskier than vaginal deliveries.
          https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4555060/
          https://www.ncbi.nlm.nih.gov/pubmed/18307481

          Sometimes those risks are absolutely warranted, as you are facing much greater risks of breach position, or other complications.

          • Amy Tuteur, MD

            This is basically an opinion piece. The authors personally think the complications of C-section are “worse” than the complications of vaginal birth. Each women is entitle to be counseled about risks and benefits and make the decision for herself.

          • Nina Yazvenko

            Thank you for clarification.
            I agree that patients need to be given info on both and make their own decisions. However, child birth is a scary and very stressful time for the patient, making it very difficult to make any decision. As such the decision often ends up being made by doctors, in reality. This is where hospital guidelines/policy becomes important over time and over large numbers of patients. It wasn’t my mom’s decision to labor for 24h, doctor looked at her at night said “you look fine, it’ll happen when it happens” – it was maternity ward’s policy. And from personal experience it is hard to stay calm and rational, telling the nurse that the fetus is fine because the heartbeat she is picking up is actually mine – when she is going “OMG OMG the baby is in distress!!!”. I managed only because I can take my own pulse, and I have read about high false positives of continuous fetal monitoring. So now I know how it happens. But not everyone can take their own pulse (they really should), and not everyone reads scientific literature for fun.

          • Poogles

            “I agree that patients need to be given info on both and make their own decisions. However, child birth is a scary and very stressful time for the patient, making it very difficult to make any decision.”

            Which is why the risks and benefits of vaginal vs. CS need to be addressed in prenatal visits before the woman actually goes into labor – none of it should be new information by the time the woman is at the hospital for birth.

          • Nina Yazvenko

            In ideal situation, yes. In reality, people go “yeah, yeah yeah” during discussion, since people really don’t want to hear too much about complications, then in the end most people will follow their doctor’s suggestions, rightfully so. Which is why we are back to hospital culture/policy/guidelines being important.

          • Roadstergal

            So you think that instead of addressing the issues with bringing informed consent to a level that most women can comprehend and give input on, doctors should just decide for their patients.

            And that the doctor should decide that based on _your_ values. (Vaginal birth except for breech (would it kill you to spell it right?) or twins.)

            Because…?

            (BTW, I’m calling bullshit on most women being all “yeah yeah yeah” when it comes to the life of their baby and/or their ability to control their bladder and/or stool when they’re middle-aged.)

          • Heidi

            I’m curious if in all those links she’s pasted, she’s noticed things like 4% of women have fecal incontinence after vaginal birth, and 36% experience urinary incontinence after VB? That to me is a serious, very much not rare risk.

          • The Bofa on the Sofa

            I’ve said it before: my wife was happy to have an excuse to have a c-section. She had no interest in going through a vaginal birth.

            She should have been forced to, right?

          • Nina Yazvenko

            I actually work in Clinical Research, and informed consent forms are already written to be understood with 6 grade reading skills. IRBs actually actively check for that. But most patients still don’t read them, don’t comprehend them, or don’t remember them, and rather heavily rely on their doctor’s opinion, rightfully so, because they are the professionals.

            https://www.ncbi.nlm.nih.gov/books/NBK133402/
            “Interviews 3 hours after consent in 100 patients scheduled for transurethral prostatectomy revealed that less than 50% of the patients could accurately recall the risks of potential complications.28 Sixty five percent of 104 patients consented for neurosurgery could remember no more than two of six major risks associated with their surgery 2 hours after informed consent was obtained.29 Among 633 patients who were offered coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI), there was very low concordance between what physicians reported telling the patients about expected symptom benefits and what the patients reported as their expectations, and there was no correlation between what physicians and patients expected regarding potential mortality benefit (with patients believing there would be a survival benefit even when physicians reported telling them there was not). 30”

          • Roadstergal

            What do you do in clinical research? Or Clinical Research, if that’s different?

            So, you’re saying that the solution to informed consent issues is medical paternalism, correct?

          • Azuran

            And what does that have to do with anything?
            If anything, we don’t talk enough about the risk of vaginal birth.
            I’ve seen many different OBs during my pregnancy. Not once was any risk of VB explained to me. I was never asked if I wanted an elective c-section either.

            I’m pretty sure that the requests for elective c-section would skyrocket if women where told about the risks of fetal/urinary incontinence, pain during sex, need for pelvic floor surgery etc.

          • Amy Tuteur, MD

            The MacDorman paper was amended because the authors dramatically exaggerated their findings.

          • swbarnes2

            So you read : “there is no evidence that maternal and fetal morbidity and mortality are affected by a cesarean section for which there is no medical indication,” And conclude that C-sections are more dangerous?

            For your purposes, box 4 is most relevant, but when you actually follow the citation back to the origin, it’s a guideline. A guideline is evidence of what the guideline is, it’s not clinical evidence of anything.

          • Nina Yazvenko

            I read the conclusion, not just the part for elective C-section.
            “Conclusion
            A cesarean section is a surgical procedure which can lead to numerous complications in both mother and child. A WHO study of adverse maternal and fetal outcomes between 2004 and 2008 in 24 countries showed that cesarean sections are associated with increased risks for mother and child, and that therefore a cesarean section should only be performed when clear advantages are to be gained”

          • swbarnes2

            If the conclusion is not supported by the body of the paper, it’s worthless. The body of the paper says “there is no evidence that maternal and fetal morbidity and mortality are affected by a cesarean section for which there is no medical indication”.

          • Nina Yazvenko

            In Box 4 they are specifically talking about elective C-secitons, In conclusion they are including C-sections that were non-elective and were done out of abundance or caution that may or may not have been necessary.

          • Heidi

            See, you don’t get to decide which risks warrant a C-section or not. In my opinion, wanting to avoid vaginal tearing and pelvic floor damage is a warranted reason to choose a C-section. I don’t take kindly to statements that suggest women should be robbed of that decision.

          • Heidi_storage

            Mm-hmm. The first paper is a non-systematic review (i.e. selective, i.e. biased review) whose primary focus is on why cesareans are performed. Although the abstract conclusion says that cesareans are riskier, the only evidence for this actually IN THE ARTICLE appears to be in Box 4, which says “The [comparison of cesarean vs. vaginal birth] data are based on the NICE guideline, in which the few prospective studies that exist were evaluated according to the criteria of evidence-based medicine (EBM). However, as the guideline remarks, the quality of the evidence is low to very low.” Hardly “conclusive evidence.”

          • The Bofa on the Sofa

            There is conclusive evidence that C-sections are riskier than vaginal deliveries.

            So just to make sure, ClinicalResearcher, you consider a “guideline” that is based on “low to very low” quality research (according to the guideline itself) an example of “conclusive evidence”?

            You were the one who claimed there was “conclusive evidence,” but you admit these are just ACOG guidelines. How does that become evidence, much less “conclusive”?

      • Azuran

        Of course there are different rates of procedure at certain times of the day. You don’t do elective c-section or elective induction during the night or during the weekend.
        I’ve never seen anyone complain that most brain surgery is done during business hours.
        The fact that you think this is somehow a problems shows how little you know about health care.

      • The Bofa on the Sofa

        there are more C-sections and inductions performed certain times of the day and certain times of the week

        And there are more breast cancer mastectomies performed at certain times of the day and certain times of the week.

        So?

        Our OB scheduled our C-section for Monday of the week we were due (39+2, I think). She did that because that was her hospital day, where she didn’t have scheduled appointments. It was scheduled for the am, because her goal was to start in the morning and then go through the day until she was done.

        So what’s wrong with any of that? It was a scheduled c-section, of course it was scheduled for a time that was convenient for everyone. Why shouldn’t it be?

        • Azuran

          Even purely from a safety perspective, it makes sense to decide to speed things up if you are in a small hospital with a smaller night shift staff and it’s the end of the day.

          If someone calls me at 7pm with a possible dystocia, of course I’m going to recommend that she comes in right away instead of waiting until 2am to see if it turns out alright. At 7pm I have 2 other vets with me and around 10 techs to help with the c-section and puppy resuscitation.
          At two am, it’s only me, one tech and the owner. If there’s anything wrong with the puppies, I can only give instruction, because I have to finish the surgery. If things aren’t going well in surgery, the tech is going to need to stay with me and the owner will be left alone to resuscitate the puppies.
          Needless to say a night c-section has a higher rate of death for puppies.

          Nina might want to blame it on ‘convenience’, but any medical intervention will be safer if you have more staff to help. And if you don’t have to wait 30 minutes for the anesthesiologist/surgical staff to make their way to the hospital.

          • Casual Verbosity

            Not to mention the role of human error when people are tired.

        • momofone

          When I had my mastectomies, I told my surgeon I preferred Tuesday or Wednesday, and wanted to be his second or third case. He laughed and said that he had never had anyone be so specific, but he did it. Convenience matters.

      • anh

        I’m having a csection Monday at noon. It’s easier for literally everyone and safer for my baby. Wtf is wrong with that?

        • Roadstergal

          If you scheduled it for 2am, it might improve things. #NinaLogic

      • MaineJen

        Preventing one bad thing = death/injury of mother or infant

        Causes another bad thing = ?……..gut microbiome? IDK

        I had both my kids on Saturday nights, at a hospital that was fully staffed 24/7 and the doctors and nurses actually did work in shifts. If I had needed a c section or induction, I probably would not have scheduled it for a Saturday night.

  • rox123

    Related question: my dr says that – leaving aside complications at vaginal birth – the risk for the damage of the pelvic floor is not the birth but the pregnancy, and this is revealed by latest studies. Is this true? He said I should read Michael Odent’s ‘C section’ book on the topic of the real risks of cesarean section.

    • Daleth

      Your doctor is wrong. Pregnancy itself does place strain on the pelvic floor, but only vaginal birth can cause severe injuries, and proceeding far into labor (second stage, especially a prolonged second stage) before switching to a c-section is also associated with much higher risks than a prelabor or early-labor c-section.

      A few links:

      Parity, mode of delivery, and pelvic floor disorders
      https://www.ncbi.nlm.nih.gov/pubmed/16738149
      “There were no significant differences in the prevalence of disorders between the cesarean delivery and nulliparous groups. The adjusted
      odds of each disorder increased with vaginal parity compared with cesarean delivery: prolapse = 1.82 (95% CI 1.04-3.19), stress urinary incontinence = 1.81 (95% CI 1.25-2.61), overactive bladder = 1.53 (95% CI 1.02-2.29), anal incontinence = 1.72 (95% CI 1.27-2.35), and any one or more pelvic floor disorders = 1.85 (95% CI 1.42-2.41). Number-needed-to-treat analysis revealed that 7 women would have to deliver only by cesarean delivery to prevent one woman from having a pelvic floor disorder.

      CONCLUSION: The risk of pelvic floor disorders is independently associated with vaginal delivery but not with parity alone. Cesarean delivery has a protective effect, similar to nulliparity, on the development of pelvic floor disorders when compared with vaginal
      delivery.”

      Effects of prolonged second stage, method of birth, timing of caesarean section and other obstetric risk factors on postnatal urinary incontinence: an Australian nulliparous cohort study
      https://www.ncbi.nlm.nih.gov/pubmed/21489125

      “Compared with women who had a spontaneous vaginal birth,
      women who had a caesarean section before labour (adjusted odds ratio [OR] 0.2, 95% CI 0.1-0.5) or in the first stage of labour (adjusted OR 0.2, 95% CI 0.1-0.4) were less likely to be incontinent 3 months postpartum. Adjusted OR for incontinence after caesarean section in the second stage of labour compared with spontaneous vaginal birth
      was 0.5 (95% CI 0.2-1.0). Prolonged second stage labour was associated with increased likelihood of postpartum incontinence in women who had a spontaneous vaginal birth (adjusted OR 1.9, 95% CI 1.1-3.4) or operative vaginal birth (adjusted OR 1.7, 95% CI 1.0-2.8).”

      • rox123

        Thank you for the elaborate answer! It sounded like it can’t be true to me as well. The NCBI is a reliable source of information, correct?

        • Daleth

          Yes. That’s PubMed, which is put out by the NCBI, which is part of the National Institute of Health. AFAIK PubMed is the country’s largest, and perhaps the world’s largest, publicly accessible database of medical-journal publications.

          • Heidi_storage

            Yes, but bear in mind that an awful lot of worthless junk gets published and indexed in PubMed too (not the link you provided); just because it’s on PubMed doesn’t mean it’s beyond question.

          • Daleth

            Sure, but when you have multiple studies going the same way, or even just one or two large, well-designed studies, it says something.

          • Heidi_storage

            Oh, yes; it’s just that I wanted to point out that you can’t point to something on PubMed as Authoritative Fact, necessarily. That’s all.

    • EmbraceYourInnerCrone

      Dr Michael Odent also thinks fathers should not be allowed at the births of their children and that pain in childbirth is necessary to bonding with your child. He’s also against C-sections and inductions because they supposedly interfere with proper bonding (apparently adoptive and other non-birth parents couldn’t possibly properly bond with there kids!). He’s a quack. He is also a general surgeon NOT an OB.

      Having actually HAD a vaginal birth of a 8lb 15 oz baby (I am 5 foot nothing) that resulted in 2 tears and needed am episiotomy to get my in-distress baby out, I think I would be more of an expert on pelvic floor damage. In retrospect I would have LOVED a scheduled C-section for macrosomia.

    • MaineJen

      Hahahahaha yeah, Dr. Odent. Carrying a baby is going to do *just as much damage* to your pelvic floor as squeezing something the size of a watermelon out of an opening the size of a lemon. That’s ridiculous on its face.

      • rox123

        Sounds ridiculous to me as well.

    • AnnaPDE

      Yeah nah. On a reasonably toned pelvic floor, carrying the extra weight of a baby is not such a big deal — we’re talking 10-15 kg here.
      Whereas having said baby, pass through a more or less elastic opening between those muscles is a potentially very destructive act. Not just on the connective tissue that can get overstretched, but by literally tearing the muscles off the bones they connect to.
      Whoever (especially male) doesn’t realise this should try and poo out a rockmelon in one piece. And I’m very happy to assist in shoving it up far enough to make the passage through their pelvic floor happen.

      ETA: This is a serious red flag for that doctor. You may want to find one who actually understands your anatomy.

      • rox123

        I am considering changing the doctors, right now I am actually seeing another OB as well and she is waaay more understanding about my preference, having herself had elective c sections. I was hoping to give birth by c section with this OB -the guy – because of the hospital (it’s a better hospital).

        • Roadstergal

          “she is waaay more understanding about my preference, having herself had elective c sections”

          Option B! Take option B!! 😮

      • Daleth

        Not just on the connective tissue that can get overstretched, but by literally tearing the muscles off the bones they connect to.

        Yes. Google “levator ani avulsion.” It’s horrifying, AND completely unfixable. There is no surgery or other treatment that can repair it, ever.

        And that’s another risk no one warned me about–I discovered it myself, while googling the risks of vaginal birth. So glad I insisted on a c-section.

        • AnnaPDE

          Yup. My #1 specific concern too, right after baby getting stuck and taking damage.

        • rox123

          It sounds terrific. I know that there are risks associated to the C section as well – adhesions, nicking adjacent organs, infections and endometriosis, but I think I should get to choose which risks I want to take.

          • Daleth

            I think I should get to choose which risks I want to take.

            EXACTLY. That is such a fundamental right. It’s your damn body, you get to choose what risks to subject it to! I can’t believe how many people don’t get that.

          • KeeperOfTheBooks

            Precisely. And insofar as at least the nicking-adjacent-organs thing, that is much less likely in an calm, elective, pre-labor C-section than in a “holy crap, put mom under and get that baby out NOW!” c-section.

          • rox123

            I read the same, emergency c section = worse outcome compared to planned c section. And the adhesions thing and nicking become considerable risks at the subsequent births/pregnancies which won’t be my case, husband & I agreed on only one child, whatever the outcome.

        • Heidi

          Oh, wow. It happens to 36% of women who give vaginal birth. And here people are worried about a C-section rate above 30%.

          • Daleth

            Oh, wow. It happens to 36% of women who give vaginal birth. And here people are worried about a C-section rate above 30%

            I know, seriously! I would rather have ten “unnecessareans” than one levator ani avulsion.

    • Who?

      The devil is in the parentheses ‘…leaving aside complications at vaginal birth…’.

      That’s a lot to just sweep to one side and dismiss.

      If this doctor promises you a complication-free vaginal birth, run for your and your baby’s life.

      The singing sounds nice though.

      • Sarah

        Yes, what he’s basically saying is, leaving aside the risk factors specific to this mode of delivery, there are no risk factors specific to this mode of delivery. Mmmkay.

    • Allie

      No expert, but I don’t buy it for a second. If that’s the case, why wasn’t I having incontinence during the late stages of pregnancy. The incontinence only started after having her head wedged in my cooter for 5 hours of pushing. I’m pretty sure my ongoing incontinence (almost 5 years later) is due to the scar tissue from my tear. I still experience numbness with some things (so I can’t feel when I’m peeing), and sharp pain at times with intercourse.

      • rox123

        Exactly what I was thinking. I googled for forums where women complain about the state of their pelvic floor, and guess what, the ones that had problems always had them after birth! Not in the last months of pregnancy when the load on the pelvic floor is at its heaviest.
        The good part is this OB actually said – he won’t force me into a vaginal birth, but this was 3 minutes after saying he can’t give me an elective C section. Now I am wary of him. I hope I won’t find myself in a situation where he says I can get my C section and when I go to the hospital I get a ‘bait and switch’.

        • AnnaPDE

          BIG BIG BIG red flag. Someone who says they can’t give you an elective CS probably won’t. And honestly, insisting on a trial of labour when you don’t want a vaginal birth is just pointlessly giving trouble a chance to happen.

          Counterexample: When my German OB removed my specialised not-available-in-Australia IUD, she asked about my preferred birth option, and when I said that I’m hoping for an elective CS, she asked me whether doctors/health system where I live agreed to those willy-nilly: for example in Germany, health insurance wants a medical reason. One of the reasons they accept is a narrow pelvis as certified by an obstetrician after ultrasound measurement. And funnily enough, she pointed out, all her patients up to this point who were hoping for an elective CS turned out to have pelvises that a mouse would be happy to fit through, and she doesn’t think I’d be an exception… *wink wink nudge nudge*

          Oh and last point about incontinence: What the 40wks of kid sitting on my pelvic floor and bladder did to me was to totally recalibrate my baseline for feeling the urge to pee. I basically didn’t feel like I had to go unless I was almost bursting (and then it was a “you’ll pee in 20 seconds, regardless of circumstances” thing). It got better about 4-6 weeks postpartum, and until then I set myself alarms on my phone to make sure things didn’t get embarrassing.

        • Azuran

          I had light incontinence during my third trimester. It went away instantly once my baby was born by C-section.
          If
          pregnancy was the cause of most pelvic damages, at the very least I
          should have stayed incontinent for a few days while my pelvic floor healed from the ‘damage’ of the pregnancy itself.

          • The Bofa on the Sofa

            Can’t avoid making a serious mistake without a red flag!

            https://youtu.be/x5EmpGOKB4A
            (watch the whole video, he also sells Danger Signs)

        • Daleth

          I hope I won’t find myself in a situation where he says I can get my C section and when I go to the hospital I get a ‘bait and switch’.

          You know why you won’t find yourself in a bait-and-switch situation? Because he already said no elective CS. There’s no bait here, no suggestion that he might respect your wish for a CS. You have no reason to believe he will respect your wish for a CS, because he straight out told you he won’t.

          A doctor who says he won’t do an elective CS, won’t do an elective CS. And will probably try to talk you out of a CS if you request one in labor. And might even underplay the risks when he sees slight complications developing, and let labor go on longer than other doctors would… with potentially awful results.

          You need a new doctor.

    • Daleth

      Holy crap, an actual doctor with a real MD is suggesting you read Michael Odent? Omg. Odent wrote a flattering preface to a book about how beautiful UNASSISTED CHILDBIRTH is: https://www.amazon.com/Unassisted-Childbirth-Laura-Kaplan-Shanley

      Odent also wrote the forward to Grantly Dick-Read’s “Childbirth Without Fear”: https://www.amazon.com/Childbirth-without-Fear-Principles-Practice

      Odent is one of those folks who believe “if only women gave birth in dimly lit caves while their relatives sang and beat drums, there would be no birth injuries and no mental illness because everyone would feel so loved and supported all the time.” He started practicing like 50 years ago and did some cool stuff way back then, making maternity clinics really peaceful pleasant places and listening to what women said they wanted, etc. etc., but at some point he turned into a total back-to-nature hippy.

    • Daleth

      Oh, and PS, here is a book by Michel Odent: “Water and Sexuality.” In that book, which I once owned (I used to be very woo) so I’m telling you this first-hand, Odent literally argues that people are probably descended from dolphins, NOT from apes, as “proven” by his misunderstanding of genetics and his observation that women often dream of giving birth in water. Therefore, he concludes, we should give birth in water.

      Um. This is the LAST doctor you want remotely associated with your own childbirth. And your OB-gyn who recommended Odent is the second-to-last one!

      https://www.amazon.com/Water-Sexuality-Arkana-Michel-Odent/dp/0140191941

      • AnnaPDE

        OMG. It’s that lunatic? Run, rox123, run. A doctor who cites someone like that as a source on the risks of CS is more than a bit unhinged.

    • Dr Kitty

      Strongly suggest an alternative reading list.
      Choosing Caesarean: A Natural Birth Plan
      By Magnus Murphy and Pauline McDonagh Hull.

      You might even want to gift your copy to your OB once you’ve read it.

      Regardless- if it’s not a risk you wish to take, ask your OB to explain, in writing, why they believe you should be denied an elective CS and forced to have a trial of labour against your expressed wishes.

      Of course, if you have it in writing- find a different doctor.

      If they won’t put it in wiring, have them put in writing that after discussing risks and benefits you prefer CS and that your request is to be honoured.

      Then there is no risk of a “bait and switch”.

      If they won’t put *that* in writing- find a different doctor.

      • rox123

        Oh, I love Pauline Hull’s blog! I will definitely read the book.

    • Platos_Redhaired_Stepchild

      Odent is quack. He pushes the Aquatic Ape birthing “theory”. He’s the one that made water births mainstream.

      http://www.southwarkbelle.com/2017/10/michael-odent-wants-me-dead.html?spref=tw

      https://theconversation.com/sorry-david-attenborough-we-didnt-evolve-from-aquatic-apes-heres-why-65570

      You may want to find a new doctor.

    • KeeperOfTheBooks

      Strict anecdata here. I have no doubt at all that vaginal birth can and does cause pelvic floor issues. However, I will say as a 30-year-old woman who’s had two babies but never labored with either, my pelvic floor ain’t what it was pre-kid. I have NOTHING like the kind of issues that some women have post-vaginal-birth, mind you! Still, I do have to go more often, am much more sensitive to it than I used to be, and am unable to do, say, running or similar vigorous exercise without discomfort unless I pee immediately beforehand, even if I’d gone 15-20 minutes prior.
      Basically, it wouldn’t shock me if pregnancy can indeed contribute to pelvic floor issues, but if you’re pregnant anyhow and therefore assuming that risk, why increase risk of pelvic floor damage still further if that’s higher on your priority to-avoid list than certain C-section risks?

  • Squillo

    Why is it that for most other medical conditions (and sorry, pregnancy is a medical condition), when both conservative or aggressive management are available and have acceptable outcomes, we tell patients the risks and benefits and let them decide which they prefer?

    • Daleth

      Exactly. Doctors never mention the risks of vaginal birth unless there’s a glaringly obvious risk factor (e.g. gestational diabetes, giant baby, small mom). Even with a breech baby in my experience they downplay the risks. One of my twins was breech, or sometimes transverse, at almost every ultrasound and they were still trying to convince me to try vaginal labor because the breech one was Baby B, who would come out second. WTF? No!

  • The Bofa on the Sofa

    Dr Neel Shah, a research physician at Beth Israel Deaconess Medical Center who works on ways to reduce avoidable C-sections.

    I am all about trying to find ways to reduce avoidable C-sections.

    The problem, of course, is to figure out which C-sections are avoidable and which ones aren’t. And anyone who can help us do a better job of figuring that out is helping.

    However, saying “Over 30% is too high” is not actually addressing the question.

    There is no question that many c-sections are unnecessary, in that the baby could be born successfully without one. But unless you know ahead of time which ones those are, it is meaningless. I mean, most people who drive drunk do it successfully, too. Therefore laws preventing drunk driving are usually not needed. You only need to stop the drunk drivers who are going to cause an accident. If you only knew ahead of time who they were….

    • AnnaPDE

      I think they also count these unnatural women who just WANT a CS even if they don’t need one. And I don’t want those reduced, being one of them.
      I mean, in hindsight my CS was probably necessary (our Plan A of the “gentle” procedure with baby poking his head out first, taking a breath and then getting “pushed” out turned into a “baby’s out with forceps because his head’s a bit wedged” exercise), but it’s not like I knew that when my decision happened not to even try for labour years before my son’s conception.
      And to add to the non-legitimate reasons, it was great to have a proper, almost-guaranteed due date that could be planned around: I knew when I was going to hospital for 5 days, so that’s when we scheduled the “house is uninhabitable for 3 days” final step of the renovation/extension. At least it wasn’t a round of golf, right?

      • Christy

        Yeah, I was one of those that got reduced. I wanted an elective CS but allowed myself to be talked out of it by my OB. Everything turned out ok, but it was scary and stressful and I think an elective CS would have been much easier on my mental health. Which is coming dangerously close to valuing process over outcome I suppose, other than the main reason I wanted an elective CS was to feel more confident about getting a positive outcome. Anyway, my baby and I are in the “good” statistic, whoopee.

  • Andrew Broselow, MD

    I’m so glad you pointed this out Dr. Tuteur. I did not have as low a rate as you did, but then again so what? I remember sitting for my oral boards – which as you recall you do after a couple years in practice. You have to submit all of your surgical cases. One of the questions I got was “Dr. Broselow, I see that you have done X number (I don’t remember the exact number) of C-sections for “fetal intolerance of labor”, yet you don’t have one baby delivered with an Apgar score under 5, how do you explain that?”. Of course the answer was in the question – the point was to proceed with C-section BEFORE the baby was in imminent danger.

    • attitude devant

      Did we have the same board examiner? I told him it was my job to get the baby out BEFORE it was injured. I’m sick of being told by lay people that this or that c/s wasn’t needed because the Apgars were good. Seriously, people?

      • Roadstergal

        I didn’t need to wear my seatbelt, because I walked away from the accident uninjured.

        • Merrie

          I didn’t need to wear my seatbelt, because I swerved to avoid the accident.

        • Amazed

          Sad thing is, this oral examiner would have been very welcome here. The healthcare system won’t let me any preventable treatment for my hands because the blood tests don’t show anything disturbing. It’s all mechanic, not bad enough to show on the analysis. It doesn’t matter that the mechanical symptoms are evident, that I have risk factors – computer-based work, kind of fragile bones, wearing of the knuckles that is freaking obvious. I am not sick enough for them, so no prevention for me but oh, they will treat me when things get bad enough. Really people?

          I can see lay people thinking this way about high Apgar baby. Or me, for that matter. For medical professionals, this is simply unconscionable. But… saving money for the system, what can I say.

    • Lilly de Lure

      I wish you had been present when my son was born! I was more or less told by the doctor monitoring my induction that the monitoring that clearly showed decels wasn’t that bad and that she’d pronounce the induction a failure and proceed to an emergency c-section when and only when the monitor started to show evidence of tachicardia.

      • Andrew Broselow, MD

        Thank you for the kind sentiment. Of course I can’t comment on the particulars of your care but C-sections that are done on an emergency basis are not only not often safe for the baby but for you as well – things move faster, so more chance of surgical injury to you and your baby, infection, etc.

    • kilda

      seems to me that no babies with an apgar score under 5 means you did a great job getting them out in time!

      Were they seriously saying that if you didn’t have any babies with a suboptimal outcome it meant you were being overly cautious?

      How does this sentence: “you have done X number (I don’t remember the exact number) of C-sections for “fetal intolerance of labor”, yet you don’t have one baby delivered with an Apgar score under 5,” end with “how do you explain that” instead of with “well done!”

      • Andrew Broselow, MD

        I wish they had said “well done”!!! But it is their job to ask the questions and not give any feedback. They may have just been interested in how I responded to them- they want to make sure you are practicing medicine with good judgment and have a logical thought process. I have never in my life felt as stupid as I did when I was through with that day – I walked around my hotel in Dallas, where every ObGyn goes to take their oral board exams, bought a six-pack, and went back to my hotel room and watched “Pearl Harbor” on demand (that dates me I’m sure). But after a tense month I received the letter that I passed my oral boards and was thereafter “board certified”.

  • mike

    Neel Shah. A fairly inexperienced ob, who does minimal clinical work. He believes that more births occur during full moon. He is “with the woo”.

    • attitude devant

      There’s one man (and it’s always a man) like that in every department

  • BeatriceC

    Totally OT: I’d like to introduce Betty, our newest addition. Betty is a temporary resident. Her human got into an accident and had to move in with her parents while she recovers. Her parents don’t like her bird and wanted her to get rid of her, but I offered a long term foster instead. Betty is a red lored amazon, and is about 35-40 years old. She’s ridiculously cute.

    https://i.imgur.com/3ESxTD6.jpg

    • MaineJen

      Adorable!!

    • StephanieJR

      Aww! Give her some scritchies from me!

    • Roadstergal

      Pretty girl!!

    • Christy

      Hello Betty! What a sweet face!

  • Zornorph

    Macduff is in favor of C-sections whereas Macbeth is very much opposed.

  • AnnaPDE

    As someone who was born by C-section and gave birth by C-section, a big YES to this. Both dispelling the myths of CS being “unnecessary”, and highlighting the potential harm to babies that is prevented is important.

    But can we also have a quick look at the mothers? Because I do think that a lot of the time, C-sections also help them avoid long-term complications. I for one went for a CS right away, because I saw the long-term outcomes of vaginal births vs C-sections for the women in my family, and decided that with the narrow pelvises and massive heads that run in our family, a scar-free vagina and perineum, and intact pelvic floor were more than worth the price of a slower recovery and belly scar.
    Women’s vaginal birth injuries are no walk in the park, and as we see in the current lawsuit over transvaginal mesh implants, the women suffering them are pretty much out of luck for the rest of their lives.

    • maidmarian555

      This!! It drives me mad that maternal request c-sections are pretty much always dismissed as ‘unnecessary’. As far as I’m concerned, mine absolutely wasn’t and the thought of facing the trauma of a failed induction/EMCS again was unbearable. My mental wellbeing was suffering and would have only got worse in the final weeks of pregnancy. Wanting your baby to be safe, wanting to avoid trauma, wanting to have a better chance of retaining a satisfying sex life or wanting to avoid incontinence are NOT unnecessary reasons for choosing a c-section. It’s my damn body and it should be me who gets to determine what constitutes ‘necessary’ surgery. I’m the one who gets to live with the consequences for the rest of my life and, as you point out thanks to the vaginal mesh scandal, those consequences of ‘successful’ vaginal birth can be life-long and devastating.

      • AnnaPDE

        Exactly. I can go to the doctor anytime and get my boobs enlarged or reduced, my nose reshaped, fat from my stomach removed, along with other completely elective and unnecessary surgeries for the sole purpose of me wanting it so. No one bats an eyelid, there are no campaigns to reduce these procedures to a “natural” rate or ban them, harping on endlessly about the terrible horrible risks that posh/slutty/cowardly women are taking there.

        But opt for surgery that actually reduces some major risks of childbirth, and it’s all “NOOOOOO you can’t do that for no good reason, do it naturally, a bit of incontinence later on is normal, why do you even want pain relief, don’t involve one of those scary doctors, a midwife is fine and really why even go to hospital when you can get it done on some old towels at home, like our grandmothers did, now stop acting like a spoiled slutty wuss and do your duty as an empowered woman!”

        • StephanieJR

          I regret that I have but one upvote to give.

      • Merrie

        I have gotten the impression that getting an RCS is less of an issue in the US than in the UK. (Maybe related to our “unbearably high” c/s rate! Lol.)

        Either way, both VBAC attempt (in suitable candidates) and RCS should be supported. Each individual needs to do what works for them!

        • KeeperOfTheBooks

          I suspect that’s at least a little due to our system of malpractice insurance coupled with having a lot of very rural hospitals. No hospital without 24/7 anesthesia coverage is going to be okay with VBAC (and I agree entirely with their reasoning), and an OB who has something go wrong at a VBAC, as will happen, however rarely, will have to explain to lawyers and her insurance company why she didn’t do a C-section instead (something I’m less thrilled with, provided the risks of both options are clearly explained to a patient).
          When my father was alive and in bad health, he lived near a tiny village that had a medical clinic staffed during the day, but not at night, and when he had a heart attack or diabetic crisis, it would take the paramedics, once they got there, 45-60 minutes to get him to a hospital that could handle that sort of thing. There were a few closer, but if he needed emergency surgery, they simply didn’t have the resources. Such are the realities of very rural life in the US; we’re just a very, very big country.

    • Heidi

      What is the recovery time of a C-section? My vaginal birth recovery was more than 6 weeks. This was recovering from second degree tears and my baby was not big. He was 6 lb 5 oz with a normal sized head and I no problem pushing him out. I think I had a lot going for me compared to many women so I am skeptical that vaginal birth recovery is as quick as they say for most women. I’ve mentioned it before, but I was very worried I’d been seriously damaged because at 6 weeks I was still having pain but I think I’m okay now.

      • AnnaPDE

        I guess it depends what you call recovered, and even with that fixed YMMV massively.
        Some people can walk around no worries as soon as their spinal/epidural wears off. Others (such as me) can’t stand for longer than half a minute without having horrible “it’s all ripping apart inside” sensations for the first few days even with painkillers galore, and really only start walking longer distances than to the toilet after over a week. And there’s everything in between. According to my obstetrician, walking around (on meds) after 3 days is typical.
        Same with how the scar looks; mine you can hardly spot since month 6 and the line where the undies’ elastic digs in is more pronounced; my cousin’s still looks angry and red 18mo later.

      • Sarah

        It isn’t just about pain either. I didn’t find the EMCS recovery especially painful, but I did feel completely physically wiped for a while. That was more of an issue than it hurting, really. I actually stopped having the pain relief early on because I didn’t like the side effects.

      • Young CC Prof

        My first, at about three and a half weeks, I was saying, “Hey, I want to go back to the gym now.” My second was harder, and it took about 2 months before I felt like myself.

        Why the difference? Maybe because my first was prelabor and my second was after a few hours of labor. Maybe because I was older, maybe because of internal scarring from the first one, maybe because I had salpingectomy also, or maybe all of the above.

      • Mac Sherbert

        I think it depends on a lot of factors!! Like how long they labored before the c-section, health before the c-section, complications, etc. I had a very easy recovery from my second c-section and I basically felt normal by the time I left the hospital and didn’t stay on pain meds much longer than that. I basically walked out to my car and installed the car seat when we left the hospital because Hubby couldn’t remember how it worked! Sorry, you’ve had such a hard time! I had a friend that a very bad tear and after hearing about her recovery I was very thankful for my c-section, which she couldn’t understand.

        • Heidi

          It wasn’t even that bad, but I thought 6 weeks and I should be back to sexual intercourse, pain when sitting on the toilet would be non-existent (that really seemed to pull and hurt for the longest time. I tried those sitz baths and my, it was not relief.), and the birth injuries would be but a distant memory. I had some dark moments where I really thought it would not be okay and I might be looking at surgery, which I’ve read sometimes doesn’t even improve the situation. I felt so overwhelmed with a new crying baby that I couldn’t bring myself to make a postpartum appointment where I’d probably been reassured that everything was healing okay and six weeks is more like a minimum. I suspect other women have had similar experiences to me. We find that our rather common vaginal births may take a longer recovery than some C-sections. I don’t regret my vaginal birth, and I would not opt for C-section in retrospect but I wish I knew what to possibly expect! I’d have felt better for sure.

          • maidmarian555

            I think one of the main differences, having experienced an attempted vaginal birth and planned CS, is that when you have a planned CS you’re thoroughly warned about many of the things that could potentially go wrong. When I had my son, I didn’t have to attend appointments to discuss the risks of vaginal birth. When I went into hospital, nobody even really went through exactly what was going to happen as far as the induction was concerned (I even had one midwife outright lie to me at one point, so that the next shift had to break the news that the 12hr pessary thing they gave me was actually a 24hr pessary thing). Even when my labour wasn’t progressing, people just kept saying things like ‘well this never happens’ rather than explain that failure to progress is actually a thing and it does happen and that there might be a reason for that. I think this lack of information contributes to the shock that occurs when things do go awry or recovery is slow- it’s (from what I can gather) pretty likely that at least one thing won’t go as expected and unless you’re really lucky, some recovery time will be necessary. If they approached vaginal birth with the same caution and insistence on explaining risk and recovery like they do with a CS, I think women would at least feel better prepared and less shocked if they aren’t up and about immediately afterwards.

          • Mac Sherbert

            I think that’s just it. Women need real information and real stories. I hope I didn’t imply that you would have been better off with a c-section as that wasn’t my intent. As it certainly varies from woman to woman what their best choice is. For me it was the best choice and I don’t regret my maternal request c-section for a baby that turned out to 9.6 lbs with broad shoulders!

          • Heidi

            No, I didn’t think you were saying I needed a C-section.

      • momofone

        I was pretty much recovered (from my c-section) after a couple of weeks, doing my usual things. I was tired, but I don’t think I was more tired than any other parent of a newborn. I had heard horror stories about how my whole maternity leave would be spent recovering, and that was not the case for me. I was interested and ready to resume sex after about 4 weeks but waited until 6 weeks postpartum just to be safe (sorry if that’s TMI, it was something I’d wondered about before my son was born). I also was fortunate in that my husband was very involved in caring for our son, and for me, so I’m certain that that affected my recovery time as well.

      • Allie

        You’ll have to define “recovered”. The bowel incontinence (yeah, yuck!) went away by six weeks post vaginal birth, but after almost five years, I don’t think my girl parts will ever be the same. The scar tissue, paradoxically, causes both numbness and searing pain, depending on the circumstances, and the incontinence is no doubt permanent.

      • guest

        2 vaginal births with minimal tearing for both (OB said they could put in a stitch or leave to heal on it own) and both recoveries took much longer than I expected. The second required physical therapy for internal bruising when I still couldn’t stand more than 5-10 minutes without significant pain at 8 weeks after delivery. And with both deliveries, I was left with permanent issues regarding sex (permanent scarring from the 1st and nerve pain from the 2nd). Everyone around me had C-sections and were back to full activity by 2 weeks. I definitely think people minimize the recovery involved with a vaginal delivery. Any pregnant women I meet who seems on the fence about C-section vs vaginal, I tell my ongoing issues to and that I would go back and have pre-labor C-sections for both if I could.

      • Heidi_storage

        I’m sure it varies, but I wonder if it varies as much as vaginal birth recovery? I’ve been lucky in my recoveries from three vaginal births–teeny tiny baby heads vs. largish birth canal. But there was no way to know ahead of time that this would be the case, though my mom’s history gave me hope.

      • KeeperOfTheBooks

        It does seem to vary wildly, and for different reasons. Some TMI below.
        First kid, I was (with one exception I’ll explain in a minute) physically just about recovered at 2-3 weeks. The first few days were really hard in terms of moving around. I was not in good shape going into pregnancy, and basically ate whatever I wanted for nine months, which I’m sure didn’t help.
        Second kid, I was in much better physical shape going in, and felt it afterwards immediately. I had no trouble getting in/out of bed once the spinal had worn off. With both kids, it took my bladder a little while to figure out how to pee again due to having the catheter in, but that resolved with patience and a day or so. Sex was resumed at the 6 week mark with first kid, and more like 2-3 months with the second, though that was more because of how our method of birth control (NFP) works than issues on my part.
        Really, the biggest issue with both was the two weeks of horrendously itchy rash from my torso through my thighs that erupted within about 12 hours of both sections. The working theory seems to be that it’s a massive yeast infection thanks to shaving (they do have to shave a fair bit of pubic hair for a CS, something I never do because it always causes a yeast infection for me) that then spreads due to all the antibiotics. It’s…less than fun. I can’t use an ab binder, for example, because it’s too rough, and the roughness and heat will make the rash worse. Have to take cold showers for two weeks, because ditto on the heat. Have to wear soft camis or t-shirts only. Regular bras make it worse, same with sweating, or having the kids brush up against me. Etc. And I live in a sub-tropic climate! Honestly, I would consider a VBA2C with the next kid if it weren’t so contraindicated in my case just to try to avoid that damn rash! :p
        (I do realize this is a minor issue compared to those that so many women have post-birth, but it does make life pretty miserable for a couple of weeks there.)

  • KeeperOfTheBooks

    Going to bore the usual audience here by making you hear this again, but for the lurkers:
    That Unnecessarian site is utter, total BS, and a hospital’s C-section numbers make no sense out of context.
    One hospital near me has a 50% C-section rate, which sounds absolutely insane until you put it into context: it’s THE major regional center for very, very sick moms and babies. If Sally Smith, having had three vaginal births, walks in in a nice, established labor at 39 weeks, that doesn’t mean she has a 50% chance of a C-section. Her chance of a C-section is going to be far, far lower than that. If Mary Jones, primipara, seriously nasty case of pre-eclampsia, 27 weeks along with a baby who has been diagnosed with spina bifida, gets wheeled in, her chance of a C-section is, yes, going to be higher than that, and there are a lot more Mary Jones there than there are Sally Smiths because many hospitals in a multi-hour radius will transfer them there rather than try to handle all that in a more poorly-equipped, lower-level-NICU hospital. (And were I either Mary or Sally, I’d find that damn comforting, thankyouverymuch.) Yet to hear the local NCB types talk, so much as walking past this place while trying to conceive is enough to get you listed for a C-section. Never mind that Sally, should she want it, would be an excellent candidate for their Jacuzzi labor tubbed/low-lit birthing suites. Sigh.

    • Heidi

      Yes! The hospital I gave birth had our city’s major high risk OBs on their campus. I think they have the best NICU in the area, too. Of course, they are going to be doing quite a few C-sections. If I knew I was going to require a C-section, I’d want to be there. But did I receive a C-section? Nope, I labored for 5 or 6 hours, and besides being induced, my delivery was unremarkable. I mean, it didn’t seem unremarkable to me. Tearing suuuucks but to be expected.

    • demodocus

      Sounds like the hospital I delivered my first in. Not quite Philly’s Childrens, but Rainbow Babies is pretty damned good. Granted, I wasn’t going to be able to labor in the tub because of my pre-e, but i did deliver vaginally in a hospital with a really high c-section rate.

    • The Kids Aren’t AltRight

      It is a shame that the whole child-birth rights movements seems innumerate. I think there really is a need for a movement to insure that new mothers are given the best information and treated fairly and to insure that poor and rich alike have access to maternal care, but the existing movement seems like innumerate middle class white ladies looking for meaning in their lives, facts and other mothers be damned.

  • Gæst

    Okay, first of all, the fetus being born isn’t the one who “gets” the surgery, so a third of all people are NOT “get[ting] major surgery to be born.”

    And second, there is no “natural” c-section rate. The human body does not spontaneously part at the abdomen in a difficult birth and allow the fetus an emergency exit. There’s one way out – or you die. What IS natural is the human instinct to preserve our lives, to the point where we have developed amazing advanced medical care. “Natural” would be ensuring that all people, worldwide, can have access to it.

  • Young CC Prof

    Can people in developed countries PLEASE stop thinking that the WHO can deliver a single optimum c-section rate for all countries and environments? Because there’s no such thing.

    Countries with a high birth rate and limited access to medical technology will see optimum outcomes at a fairly low c-section rate, perhaps even that 10% number.

    Countries where most families are small, and where birth control, surgical technology and even care for very premature babies are routinely available, will see optimum outcomes at a much higher rate.

    In the USA, it is incredibly rare for a mother to die of complications of cesarean delivery when no seriously dangerous condition (other than maybe stalled labor) existed before the surgery. In many parts of the world, mothers do die of surgical complications, because hospitals lack the facilities to adequately manage those complications.

    • Heidi_storage

      Yeah, why does the WHO like to pretend that there’s no difference between, say, Finland and Swaziland? This makes no kind of sense.

      • Sarah

        I initially read that as Switzerland and was thinking, well, they’re fairly similar as countries go.

    • EmbraceYourInnerCrone

      Yup the Csection rate at the only hospital in my hometown population 55,000 is zero as they stopped delivering babies two years ago. The Csection rate at the local university hospital is probably really high. But it is a university hospital that’s about 300 years old so….

    • The Kids Aren’t AltRight

      Did they really just take the raw numbers for infant/maternal mortality compared to the c-section rate without any controls? Like it doesn’t look at maternal age, or physical fitness, or anything? That seems a really shoddy basis for a health recommendation.

  • Mel

    I like the idea of modeling the factors that determine if a woman will be able to deliver a given baby vaginally – but I have serious reservations about if clinically significant markers can be measured.

    We could probably measure things like maximum head diameters of the baby using an MRI and most of the pelvic diameters prior to labor but all of those values change during labor to greater or lesser degrees. Yeah, at least one brave woman was loaded into an MRI during labor – but I can’t imagine that would be terrible effective from a cost or comfort standpoint.

    Then we run into the problem with modeling itself – the most significant factors for a population of women-infant dyads may not be the most significant factor for a given woman-infant dyad.

    I find the idea intriguing from an academic sense – but the clinical applications may not be workable.

  • crazy mama, PhD

    I know the WHO has backed off that 10–15% number in recent years, but they really need to come out and formally retract it.

    • Heidi_storage

      Especially since you so often see people pointing at that “optimal” rate, without any acknowledgment that it was never evidence based or that the WHO hasn’t promoted it for years.

      • EmbraceYourInnerCrone

        Not just not evidence based, they apparently just pulled a number out of their butt

  • Sheven

    What are the criteria for a surgery to be “major” rather than “minor” or just “surgery”?

    • Roadstergal

      I healed my collarbone due to major surgery instead of letting it hall naturally!

      And I preferred it that way. :p

    • Gæst

      I would assume it’s related to expected recovery time, but I don’t know where the dividing line is.

    • fiftyfifty1

      Yeah, it’s a silly distinction. Technically if you have to cut through the peritoneum or pleural cavity etc. it is major surgery instead of minor surgery. But that distinction was coined years ago during a time when surgical technique and anesthesia were very different. C-section is a straightforward, simple surgery that a first year OB resident can perform without help.

      • Sheven

        Thanks! I always wondered if it had a definition or was just a turn of phrase. It looks like it has a definition but not one that’s particularly useful if you’re a patient trying to judge risk.

      • FormerPhysicist

        My first was done by a resident. No issues. Watch out for OBs that ski. Hard to perform surgery with a broken arm.

      • Karen in SC

        Yep. In the words of Dr. Cristina Yang to Dr. Meredith Grey, upon being told her baby was in a face presentation. “It’s just a C, Meredith. Any moron can do a C.” She adds to the OB, “No offense.”

  • Mel

    My annoyance with that article is the statement that 1/3 people undergo major surgery to be born.

    That’s badly misleading; the mother is undergoing major surgery. The baby – while an important factor in the surgery – is generally not undergoing surgery during their delivery unless the kidlet is having a form of CS with fetal repair which is a tiny, tiny fraction of CS anywhere.

    • mdstudentwithkids

      That was my first thought. No, 1/3 of people are NOT getting surgery to be born, their mothers are. I couldn’t tell if the statement was intentionally misleading for just poor comprehension.

    • Roadstergal

      2/3 of people damage a woman’s genitals to be born!

    • Gæst

      Exactly. When I fill out medical histories for my kids and it asks if they have ever had major surgery, I do not tick “yes” for them. I tick yes for me.

  • Empress of the Iguana People

    I really really wished i’d asked for a c-section during the pushing phase of labor, particularly when kid 2’s head was half in and half out for a minute between pushes. Don’t much care otherwise.

  • Sarah

    ‘Natural’ section rate, ffs. The mind boggles. One can only hope she wasn’t speaking in English and something was lost in translation.

    • Indeed. The natural C-section rate is 0%. That’s one reason that the natural rate of maternal mortality is 1%.

      • fiftyfifty1

        Well, the natural maternal mortality rate is even higher than that if we count natural as being no medical or technical help whatsoever.

        • Roadstergal

          Modern midwifery is unnatural.