Childbirth: should we err on the side of caution or err on the side of risk?

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I’m pretty confident that over the next several decades we will reduce the risk of childbirth in dramatic ways. After all, we understand the problems that we face; it’s just a matter of creating the technology that will provide the answers we need.

We know, for example, that the biggest threat to babies is lack of oxygen during labor. We don’t have a way of directly measuring the amount of oxygen that the baby is receiving so we are forced to approximate using existing technology, measuring the fetal heart rate instead. Because the fetal heart rate provides only an indirect, and often inaccurate, picture of fetal oxygenation, obstetricians end up performing unnecessary C-sections for presumed fetal distress that wasn’t distress at all. When we can accurately measure the amount of oxygen in the fetal blood stream, the only C-sections done for fetal distress will be necessary C-sections and the C-section rate will drop dramatically.

The history of obstetrics over the past 100 years is a history of identifying specific risks and then creating treatments to abate those risks or preventive strategies to remove the risks entirely. For example, pre-clampsia/eclampsia has always been a leading killer of mothers and babies. We still don’t understand the cause of the disease, but we do understand the warning signs and we have created treatments and preventive strategies that have dramatically decreased the death rate of pre-eclampsia/eclampsia for mothers and babies.

The evolution of obstetrics, and the dramatic decrease in death rates that have resulted, are a result of technology. In other words, the less we trust birth, and the more we trust technology, the fewer babies and women die. It is simply a matter of time before we have better technology that will help us achieve lower rates of death and injury by more accurately targeting treatments and preventive measures.

The real question for those who care for pregnant women is this: what do we do in the meantime?

When we have imperfect information, and when the lives of babies and mothers are on the line, should we err on the side of caution or err on the side of risk?

The answer to that question delineates the central difference between obstetricians and homebirth advocates. Obstetricians err on the side of caution. They’d rather do perform unnecessary tests, procedures and C-sections in an effort to prevent all preventable deaths. Homebirth advocates err on the side of risk, either by pretending there is no risk (“trust birth”), by ignoring risk (refusing routine tests and interventions), or by treating complications when they happen instead of preventing them (“the hospital is only 10 minutes away”). They’d rather risk preventable deaths than submit to anything that was unnecessary in retrospect.

When homebirth advocates lament obstetricians playing the “dead baby card,” they are making fun of doctors who would rather err on the side of caution. And they are implicitly advising women to err on the side of risk. They basically tell women to gamble the lives of their babies because the chances of disaster are relatively small.

Obstetricians are the equivalent of the people who tell you to board up your windows at the approach of a hurricane, reasoning that boarded up windows won’t break in the event that they are stressed to their limits by wind gusts. Homebirth advocates are the people who tell you not to board up your windows on the theory that you can save lots of time, effort and money by betting that your personal windows are not necessarily going to break in a hurricane, since the odds of a specific set of windows breaking is fairly low. Those who board up their windows are erring on the side of caution. Those who “trust hurricanes” are erring on the side of risk.

Obstetricians are the equivalent of the people who tell you to wear a helmet when riding riding a bicycle, reasoning that people who wear helmets are much less likely to suffer brain injuries if the motorcycle crashes. Natural childbirth advocates are the people who protest helmet laws on the theory that most of the time you won’t get into a crash and it’s so much more enjoyable to feel the wind rushing through your hair. Helmet laws err on the side of caution; those who protest helmet laws err on the side of risk.

So if you are thinking about homebirth, think about this: the day of birth is the single most dangerous day of the entire 18 years of childhood; the risk of death is never higher. Whether you wish to acknowledge it or not, childbirth puts your baby’s life on the line.

The question you need to ask yourself when contemplating the risk to your baby is:

Do you want to err on the side of caution and head to the hospital, or would you rather stay home and err on the side of risk?

145 Responses to “Childbirth: should we err on the side of caution or err on the side of risk?”

  1. Scientispete
    April 25, 2014 at 5:42 am #

    OT : I know there are a lot of OB’s on here so: My wife is mid way through pregnancy with our second child, the first was a c-section due to brow presentation. We are (well, she is!) trying to decide if it is best to have an elective section or VBAC. Decent statistics on the risks of each seem hard to come by.

    We are in the UK where maternity services are midwife led, and we are being strongly pushed towards VBAC with our midwife very dismissive of our concerns, and unprepared for our questions on comparative risk.

    Our current plan is to schedule a c-section for term + 7 and is labour comes spontaneously before then, go for a trial of labour.

    Can anyone link to a decent breakdown of risk of repeat c-section, VBAC, and VBAC (induced)?


    • Dr Kitty
      April 25, 2014 at 7:16 am #

      Ask to speak to a consultant, you have a right to .
      Preferably by making an appointment with their secretary, not by having the MW grab them during your appointment.

      VBACs are safest with CEFM and an epidural in place so that there is no delay if you have to convert to CS.

      TOLAC resulting in an emergency CS is obviously riskier than either successful VBAC or ERCS.

      If you’re happy to risk the .5% risk of rupture, the 10-20% risk of emergency CS and the 5-10% risk of vacuum or forceps inherent in a TOLAC then go for it, but when judging between VBAC and ERCS safety you have to take into account that a failed TOLAC or a complicated VB are possible outcomes, as well as an easy, straightforward VB.

      Maybe speak to your GP?
      They may be more accessible.

    • andrusha
      April 26, 2014 at 1:15 am #

      My 2 cents worth is this.
      How many more children do you plan to have? The main problem with caesarean section are the risks in subsequent pregnancies especially after multiple CS. The main one is risk of placenta accreta, which can be very complicated, I leave it to you to look it up. As a registrar training in the 1980s (with CS rates of about 15%), I never saw a caesarean hysterectomy at my large teaching hospital. Now at the same hospital where I am a consultant and the rate is 35%, we see a caesarean hysterectomy for placenta accreta every couple of months. The risk in a pregnancy where the woman has not had a previous uterine incision is less than 1/10,000. After one CS it is 1/1000 in the next pregnancy. After 2 CSs it is 1/100 and after 3 it is 1/10. So if you are planning to have more children after this one I would encourage you to consider a properly monitored VBAC in a hospital where you have access to immediate caesarean delivery. If you don’t plan to have more children, the pros and cons more or less balance out, as long as, once again, any planned VBAC takes place in an appropriate facility

    • andrusha
      April 26, 2014 at 1:21 am #

      Kaczmarczyk M, Spare´n P, Terry P, Cnattingius S. Risk factors for uterine rupture and neonatal consequences of uterine rupture:

      a population-based study of successive pregnancies in Sweden. BJOG 2007;114:1208–1214.

    • Siri
      April 26, 2014 at 9:27 am #

      Did your wife labour with her first baby, and if so, what dilatation did she reach? Women who have gone through first stage of labour are likely to dilate more quickly next time, especially if they reached full dilatation but didn’t push the baby out. Individual circumstances count for a lot, so you need proper counselling from someone who has the full picture. Good luck!

      P.s. Purely anecdotally, I have often seen women after a VBAC that ended in vacuum or forceps practically skipping down the ward, ecstatic at the difference with regard to pain and mobility. I had a forceps birth, and it wasn’t nice; for (some) women to regard them as relatively easy to recover from, recovery from c/s must be much more painful! But then I haven’t had a c/s, and your wife has, so at the end of the day she’s got to do what seems right for her.

  2. hmm hmm
    April 24, 2014 at 9:28 pm #

    An interesting contrast with recent homebirth deaths discussed here, in terms of how the case was dealt with afterward. A missed uterine rupture in hospital. One assumes mom would not have survived had she been at home.

    “Since Ireland’s death, nurses and doctors have been involved in uterine rupture simulation drills so that if, or when, a similar situation is encountered, health providers would be better prepared. Another emergency drill simulation is planned for more health providers in May.”

    • Gene
      April 25, 2014 at 6:29 am #

      When I was laboring with my last, my OB warned me that the floor was planning to run “dystocia drills” because we knew he was going to be big (and he was). So an ENTIRE L&D FLOOR knew I was at higher risk and was reviewing protocols and practicing in case my baby got stuck. We ended up not needing it, but the thought of an entire department at the ready (and reviewing steps, etc) just in case… It was comforting. Do CPMs even prep? Flip through a book? Or do they just “trust birth”?

      • Medwife
        April 25, 2014 at 5:36 pm #

        No, see, if you think about complications too hard you MANIFEST them.

        • Mishimoo
          April 25, 2014 at 11:43 pm #

          This is why I love this site: If I didn’t read the stuff Dr Amy writes, I would probably feel guilty about the late decels with my last baby simply because the phrase popped into my head while I was pushing.

      • CognitiveDissonaceHurts
        April 26, 2014 at 7:26 am #

        I have been shocked to hear some say that SD doesn’t exist when a woman labours instinctively. It is a problem brought on by hospital birth practices!!!!

  3. hmm hmm
    April 24, 2014 at 9:17 pm #

    It’s the three little pigs! (the fairy tale). The CPM, the CNM and the MD. Fits to a T! CPM even comes running to her brothers’ house when the big bad wolf blows her straw one down.

  4. sleuther
    April 24, 2014 at 8:07 pm #

    Atul Gawande wrote an excellent piece for the New Yorker on C/S and risk. One of the points he raised was that C/S is much easier to train on and supervise newer practitioners on, whereas forceps are very hard to train new practitioners on and rely much more on a “feel” that’s hard to convey to a supervising OB. So even though forceps and various maneuvers for, say, breech delivery CAN be very effective in the hands of a master of the craft, overall results are more iffy – not everyone can do it well – and who wants to be the patient getting practiced on by the newbie doctor? Hence the popularity of C/S….Which in turn leads to even fewer maestros of the older methods.

    There’s a lot of talk about lawsuits and ‘nobody ever got sued for doing a C/S,’ and that’s certainly a factor, but the general trend towards consistent, repeatable results has got to contribute to it. Why spend years training an OB on the difficult-to-describe force to apply with forceps when a C/S can do the job as well or better overall, and more predictably? And if something’s going badly, it’s clear much sooner?

    Here’s Gawande’s article:

    • Sue
      April 25, 2014 at 5:09 am #

      How many of the risk-assessments of C/S contain a balance with the risk-reduction for reducing instrumental births?

  5. Certified Hamster Midwife
    April 24, 2014 at 4:12 pm #

    OT: Yo, Ricki Lake, this is how a celebrity makes a difference for new mothers by making a documentary. Take notes.

  6. fiftyfifty1
    April 24, 2014 at 2:57 pm #

    I’m not so sure that the c-section rate will go down once we have a way of looking at oxygenation directly. Fetal distress is one indication for c-section, but certainly not the only one. Even if we could remove all the “false alarms” from this group, how much would the overall rate really drop? And what is a “false alarm” anyway? It’s possible that we may find that even modest lack of oxygen during delivery correlates with measurable, although small, loss of IQ. Today’s parents wouldn’t tolerate that. In addition, the pelvic floor is becoming more talked about, and mothers continue to get older and heavier and thus more prone to c-section for failure to progress. So I don’t predict that overall CS rate will drop.

    But I agree that such a technology would be nice for the minority of women who desire large families. Preventing C-sections in this group is truly important.

    • Ellen Mary
      April 24, 2014 at 3:13 pm #

      In order to *guarantee* a small family (and guarantee that a woman won’t find herself in the situation where she is pregnant after a 2 or 3rd section), one or both partners basically must be willing to engage in sterilization or at the very least have an IUD placed. Other methods of BC just can’t produce guarantees. Simply desiring not to have a large family does not prevent conception. So in order for 2 or 3 Cesareans to be ‘safe’, another procedure is implied (tubal, vasectomy, or at very least IUS insertion).

      • T.
        April 24, 2014 at 3:51 pm #

        Yes, I agree that consueling for permanent or semi-permanent sterilization is important for women who desire one.

      • fiftyfifty1
        April 24, 2014 at 8:19 pm #

        I don’t get your point. Are you saying that after 2-3 c-sections a woman has to have either sterilization of one of the couple or an IUD or else it is “unsafe”? Because how many c-sections a woman can “safely” have depends on the individual woman. Some show a lot of scar problems, some almost none at all. In addition, there are other forms of birth control that provide near guarantees in addition to sterilization and IUD. Nexplanon is actually the method with the lowest failure rate over all- even better than sterilization. Depo Provera is another near 100% method, as well as combo methods such as OCPs plus condoms, or even plain OCPs in a very med-adherent woman with no other risk factors for failure (i.e. obesity or antibiotic use).

        • Dr Kitty
          April 25, 2014 at 3:30 am #

          My mother’s OB told her he would tell her when he didn’t think it would be a good idea to have another CS. The most he’d done on one woman was eight.
          He called time after my mum’s fourth CS.

          MOST women in developed nations choose to have two or three children. CS isn’t imposing limits on the majority of women that they wouldn’t have imposed themselves.

          For many couples the solution is vasectomy.
          I carry the babies and endure labour or abdominal surgery two or three times: you have a minor day procedure.

          Most men know they’re getting the better end of that bargain.

          • Mishimoo
            April 25, 2014 at 3:43 am #

            Speaking of which, only one week to go until my husband has his vasectomy done!
            He’s a bit nervous due to his fear of needles and I’m a bit miffed that I have to sign paperwork to allow him to have it.

          • The Bofa on the Sofa
            April 25, 2014 at 7:59 am #

            Honestly, I remember almost nothing of my vas. The urologist gave me a combination of vicodin/valium to take beforehand, and so by the time the procedure came, I was largely oblivious.

          • April 25, 2014 at 11:09 am #

            My husband says get tighty whiteys that are a size too small and wear two pairs. And get a really good old fashioned ice pack, the kind that looks like a bag with pleats around a threaded cap.

          • Dr Kitty
            April 25, 2014 at 11:12 am #

            Sitting on a bag frozen peas or sweet corn works too.

          • April 25, 2014 at 11:14 am #

            He found the peas unsatisfying, and says the ice bag was better insulated and best filled with crushed ice. And he adds not to add salt to the ice even if it seems like a good idea at the time 😉

          • Box of Salt
            April 25, 2014 at 6:16 pm #

            Adding salt lowers the melting point. Do you want your ice to be colder, or just last longer? If it’s last longer, the only option is to replenish the ice once it melts.

          • Siri
            April 25, 2014 at 11:46 am #

            Haha, now I have an image in my head of Bofa running around playing sports with a bag of frozen peas strapped to his googles. The human imagination is truly a thing of beauty…

          • The Bofa on the Sofa
            April 25, 2014 at 1:03 pm #

            I tried sweet corn, but it didn’t work. But the only corn we had in the house at the time was cans of creamed corn, so that might have had something to do with it.

          • The Bofa on the Sofa
            April 25, 2014 at 11:30 am #

            I get the part about the tighty whiteys.

            The week after my vas was the one time in my life where I found an athletic supporter to actually make a difference. I’ve worn them all the time for sports, but it never seemed to make much of a difference (until I started wearing a cup with it, where it very important (and did prevent some very bad things)). But after my vas, I tried to go without the supporter and, nope, it didn’t work.

          • Mishimoo
            April 25, 2014 at 11:59 pm #

            Thanks for the advice! I’ll pick some up before the day.

          • Young CC Prof
            April 25, 2014 at 11:30 am #

            I know a guy who started trying to get a vasectomy when he was 25, single and childless. It took like 10 years for him to find a doctor who would do it rather than warn, “What if you change your mind?”

            He never did change his mind, and is now happily living in a relationship with a woman who has also never wanted children.

          • Mishimoo
            April 25, 2014 at 11:46 pm #

            I’m glad that he was finally able to get it done, though it really is awful that it took so long to find a doctor who was willing to do it. Also, yay for happiness!

          • Busbus
            April 26, 2014 at 2:44 pm #

            Wow, I didn’t know that was an issue here in the US! Where I’m from, in Europe, relative’s partner had a vasectomy as a 20-year old (he was serious about it, I guess!). As far as I know, he has never regretted it. They got together when my relative’s own kids where adults, so it didn’t bother her. I can see how you would be worried that someone might change their mind, but I think some people just know what they know.

          • anion
            April 25, 2014 at 5:34 am #

            Ethel Kennedy had ELEVEN c-sections.

          • OBPI Mama
            April 25, 2014 at 6:04 am #

            What?! Wow! And here I am contemplating a 4th c-section and nervous…

          • anion
            April 25, 2014 at 11:14 am #

            AND she did it in the 50s/60s, with the old vertical incision. 🙂

          • Young CC Prof
            April 25, 2014 at 10:12 am #

            The risks of maternal mortality or serious morbidity increase with the number of c-sections, and increase a lot after the third one, to the point that a reasonable person would be concerned.

            But, if the first three went OK, they are STILL sometimes manageable, like scheduling RCS for 37 weeks instead of 39 to reduce the chances of spontaneous labor. It’s not like your uterus automatically self-destructs in a fourth pregnancy.

            Though that would be sort of cool, in a horrible way.

          • Dr Kitty
            April 25, 2014 at 11:11 am #

            If you have dreadful adhesions and uterine window after 2 CS, you’ll be advised not to have another (not that that advice stopped my SIL from having a third baby- and all went well with her ERCS at term).

            Or you can have minimal adhesions and a nice thick lower segment after 4 CS and be good to go for 5 or 6.

            General risks are higher, but individual risk can vary, which is why you need to talk to the OB who did your last CS to find out what they think your personal risks are.

          • araikwao
            April 25, 2014 at 6:20 pm #

            But let’s also keep in mind that the general risks include a risk of placenta praevia that is higher than the risk of rupture with VBA2C. And with that, an 11% risk of concurrent accreta. And that the risks of praevia, accreta, and praevia plus accreta go up pretty dramatically after 3 CS.
            No option is without risk, I just think it is not accurate to paint CS as the answer to all woes, as it has its own set of problems which can also be catastrophic. (I heard about a situation locally where a woman had placenta percreta with her ??3rd or 4th pregnancy, and ended up with a 4-week ICU stay, and both bladder and colostomy bags. Pretty much an iatrogenic condition from what I was told of her past obstetric history, and definitely not what anyone signs up for with pregnancy or childbirth.)

          • April 25, 2014 at 11:06 am #

            My husband felt that way and was quite happy to get his vasectomy. I was so pleased and grateful it made me fall more in love with him than ever (it was when I was 6 months postpartum). He was very open that it was as fair as possible given I had to gestate and birth, and the pain was reasonable. Poor guy had residual pain for 1.5 years, but is now fully healed up. He still thought it was fair, especially since I only fully recovered (as much as I ever will) after 3 years! (I had a really, really rough pregnancy. The birth was easy enough, my c section recovery a breeze, but my body and hormones were pretty wrecked for a while)

          • The Bofa on the Sofa
            April 25, 2014 at 11:37 am #

            I promised my wife that when she went off birth control when we were TTC with our second, that she would never have to take it again.

            I have lived up to that part of the bargain, but I now regret that, because this perimenopause is messing with her big time. Can we go back to the time where her periods were every 28 days, and she knew when they were coming, as opposed to this every 23 day crap? We don’t need BC, just some regulation.

            She was always irregular before we were married, but it was the to tune of 29 days on average. Now, it’s irregular to the tune of 23 days.

            I thought menopause was supposed to be slowing down, as opposed to more often?

          • fiftyfifty1
            April 25, 2014 at 12:00 pm #

            Often they get closer together for a few years before the final year when they stop.

          • Susan
            April 25, 2014 at 12:23 pm #

            I had that experience but it was more like closer for the last 15-20 years….they were regular 28 days in my twenties.

          • The Bofa on the Sofa
            April 25, 2014 at 1:01 pm #

            I don’t think she’s that close to the end. I realize YMMV, but she’s only early 40s, so a little young to thinking about the end in general.

          • Medwife
            April 25, 2014 at 5:29 pm #

            Mirena IUDs are an option for women with heavy, irregular periods, and they last 5 years, which is pretty good for someone with 5-10 years of irregular menses to look forward to (sorry!). Bleeding is way more irregular for a few months (up to six) but generally tends to getting lighter and lighter, and by a year many women don’t bleed at all. Something to consider!

            But really, your wife should talk to her GYN rather than suffer. There are quite a few things that could help her!

          • Dr Kitty
            April 25, 2014 at 5:54 pm #

            I LOVE Mirena!
            And that is despite having to have two of them put in under general anaesthetic and the second one removed under sedation (Apparently I was singing in the OR… So glad I don’t remember).

            I doubt my husband or OB will be OK with me going for a third in future, given the previous difficulties, but I wholeheartedly recommend them.

          • Medwife
            April 25, 2014 at 8:31 pm #

            I know, I’m blown away by the awesomeness that is the IUD. I wish more women were open to the idea but I find a lot of “it’s weird to have something stuck in my uterus” out there. Plus those damn lawsuit commercials.

          • Guesteleh
            April 26, 2014 at 10:52 am #

            I didn’t do well on an IUD, I almost fainted after they put it in and then I had crimping and pain for a year before I took it out. Hormonal methods don’t work for me either. It was a serious screw until my husband got snipped.

          • Dr Kitty
            April 26, 2014 at 12:02 pm #

            The first one was put in at the time of some endometriosis surgery, before I got pregnant.

            The second one, despite a cervical block and a very skilled Dr, my cervix refused to dilate, so I got it in under GA (I don’t mind GAs, I don’t get nauseated or tired or anything, it’s just like taking a nap).

            Then the second one got stuck behind some endometriosis on my cervix, and again, despite an attempt to remove it in the office with a cervical block, it eventually had to be removed in theatre with the help of fentanyl, Midazolam and a fair bit of surgical skill.

            Once in, no periods, no pain, no PMS, I LOVE them.
            But yeah…don’t think I’ll be getting another…maybe Nexplanon…

          • Haelmoon
            April 26, 2014 at 1:48 pm #

            I loved my IUD, but it unfortunately didn’t love me. I was one of the unlucky ones who it didnt work. I had two very complicated pregnancies (and rough neonatal courses for my little ones) and we decided that was enough. Then came along number three, I have a picture of her a 5 weeks beside the IUD. 1 in 3000 often seems to be me!!
            In spite of my personal failure with the IUD, I still love them for my patients and highly recommend them.

          • toni
            April 26, 2014 at 6:18 pm #

            What do they do when you conceive with an IUD in place? Do you pass it or does it just stay in there with the baby?

          • Haelmoon
            April 26, 2014 at 8:46 pm #

            I had it pulled right away. There is a risk of miscarriage by doing so, but there is a risk of abruption and PPROM if it is left in. The irony is that I had abruptions and PPROM in spite of taking it out. My little Mirena baby delivered at 29 weeks, but I had all of mine early with complications.

          • Trixie
            April 25, 2014 at 9:22 pm #

            I’ve had 23-24 day periods my whole life since age 10, when not on the pill. Sucks.

          • CognitiveDissonaceHurts
            April 26, 2014 at 7:21 am #

            I’ve been having a really rough perimenopause with hemmoraging every month….more frequent or long lasting periods….currently waiting to see a gyn after bleeding 6 weeks out of 8. It sure hasn’t been easy on us as a couple. 🙁

          • The Bofa on the Sofa
            April 26, 2014 at 8:35 am #

            That and out of town visitors…

          • Captain Obvious
            April 27, 2014 at 10:53 am #

            I know this has nothing to do with Homebirth, but this is such new news that I wish Dr Amy could write a post about some of these papers showing the high grade serous ovarian cancer is thought to actually have a precursor lesion originate from the Fallopian tube! Just like cervical cancer has precursor lesions of ASCUS and CIN, high grade serous OC starts for a mutation in the P53 gene in the Fallopian tube which can be detected microscopically (with a salpingectomy), these P53 signatures then proceed to STIN (serous tubal intraepithelial neoplasm), to STIC (in situ serous tubal intraepithelial carcinoma), to invasive ovarian carcinoma or peritoneal carcinoma. That is why women can still get this ovarian cancer like cancer of primary pelvic peritoneal carcinoma after hysterectomy. This will change how we counsel women about tubal locations and whether to perform a BSO or just a salpingectomy at time of hysterectomy. The Nurses Health Study and Mayo studies have shown more cases of CAD, other cancers, menopausal symptoms, mood issues, etc with women having their ovaries taken out than women leaving them in. So it may actually be better to leave the ovaries in for certain patients and just take out the tubes instead.
            A lapararoscopic bilateral salpingectomy with Novasure will provide contraception, bleeding control, and ovarian cancer prevention.

          • CognitiveDissonaceHurts
            April 27, 2014 at 3:45 pm #

            So, do you not think that in cases of abnormal bleeding, doing a uterine biopsy is enough investigation?

          • Captain Obvious
            April 27, 2014 at 3:49 pm #

            Usually perform a transvaginal sono, and can rule out uterine hypertrophy, adenomyosis, fibroids, endometrial polyps, and ovarian cysts. If sono is fairly normal, I goto OR and perform hysteroscopy, D&C, and then Novasure. The D&C gets me a tissue sample. If I suspect cancer at all by sono, I may perform an EMB in the office before going to OR, but usually don’t need one prior to OR.

          • CognitiveDissonaceHurts
            April 27, 2014 at 3:56 pm #

            I had never heard of Novasure before (just looked it up). Why do you prefer this to other types of treatment?

          • Captain Obvious
            April 27, 2014 at 4:08 pm #

            Novasure is an endometrial ablation. A global therapy to endometrial cavity that only takes 90 seconds with good results. Thermachoice takes 8 minutes with worse results. Endoloop resectoscope ablation takes too long.

          • FormerPhysicist
            April 27, 2014 at 9:26 am #

            She needs to talk to her Gyn. I can’t go back on hormonal bc, but I had an endometrial ablation, and it’s wondrous.
            I have totally forgiven my husband for not wanting to get the vas, since I had the ablation at the same time I had my tubes tied. (His motivation was I already had a doctor I knew and trusted.)

          • Captain Obvious
            April 27, 2014 at 10:39 am #

            I tell my patients this exactly. Play the martyr and be the one to have surgery and get a tubal sterilization. You can get an ablation at the same time which benefits you! And further more, the pathogenesis of high grade serous ovarian cancer has been linked to originate from the distal ends of the Fallopian tubes!!! So for the past year and half, I have been performing bilateral salpingectomies instead of just a mid ampullary tubal cautery. This way here, you get sterilization, bleeding control, and some ovarian cancer prevention all in one same day surgery.

      • The Computer Ate My Nym
        April 25, 2014 at 9:26 am #

        Other methods of BC just can’t produce guarantees.

        While you’re right that tubal ligation, vasectomy, and IUD have low failure rates, they don’t guarantee no conceptions either: any procedure can fail. First trimester abortion performed by a competent practitioner almost never results in a continued pregnancy and live birth. And barrier protection with abortion as a backup has traditionally been the safest method of birth control for a woman. So that’s another option for people who want a small family, which most people do, regardless of c-section status.

    • thankfulmom
      April 24, 2014 at 11:42 pm #

      Very true about it being important to prevent having a C-section for those who desire a large family. I had severe pre-eclampsia with my first child and after the first unsuccessful day on pitocin I said to my OB “how about a nice C-section?” He replied “That’s a cop out.” I’m very thankful he wasn’t overly quick to do one because I did go on to have a very large family. The majority of my pregnancies were complication free. The cord prolapse at one delivery was the most frightening delivery! Thankful for the people who choose to get an extensive specialized education to learn how to care for pregnant moms and premature babies.

      • Renee Martin
        April 27, 2014 at 4:00 am #

        Calling a CS for severe pre e “a cop out”? Yikes.
        Sounds more like LUCK, and much less like provider skill.
        I am very glad you were lucky!

    • Lion
      April 26, 2014 at 2:26 am #

      I may be asking a bit of a stupid question here because of my lack of understanding of statistics, but, asking anyway. Dr Amy has previously mentioned that the slight decrease in IQ from formula feeding (I am purposefully assuming breastfeeding as the default way of feeding for this question as it is human milk) of around eight points is so negligible, even if it exists, that it is silly to mention it as a benefit of breastfeeding (I am paraphrasing), so if comparing that to the question you pose here about the possibility of modest lack of oxygen perhaps being correlated with a small loss of IQ and being unacceptable to parents, why would a small loss from formula feeding be considered acceptable.

      Yes, I know I am leaving out that some women struggle with breastfeeding or get such poor advice that that it causes problems. Also I am not sure if I am comparing population wide differences in IQ from breastfeeding with individual differences from lack of oxygen. It was just that reading this question made me think of this. I have a feeling my lack of grasp of some of the information might be making me ask a question may appear rather silly to someone who has greater understanding but I am actually interested in the answer. I am not some crunchy nutter trying to make a point so would rather not be attacked by anyone, I am asking a genuine question because this question made me wonder. I live in a different country where the dynamics are quite different. It is a developing country and breastfeeding here can literally be life saving because of the very high risk of diarrhea from lack of access to clean water and electricity to boil water and formula gets diluted

      • Lion
        April 26, 2014 at 2:31 am #

        To reduce costs, which leads to growth problems. There are also no facilities for sterilizing bottles and teats, and tears that are ripped and moulds get used sometimes. Those of us who are middle class and breastfeeding donate milk which is pasteurized and given to those babies whose mothers experience problems with initiating breastfeeding or who struggle to establish an adequate supply, which thankfully isn’t that common but does happen (sorry, I don’t have figures. I do volunteer helping mothers to breastfeed , but it is on the side of showing them how and resolving problems, I am not involved in collecting or analyzing data).

        Just thought I would mention that it is a very different situation to a developed country so we don’t have this polarization between formula feeders and breast feeders that an outsider to the USA sees in blog comments on any mother or parenting or birth related site.

        Sorry, I could type no further so had to continue separately.

        • Lion
          April 26, 2014 at 2:35 am #

          Sorry, auto correct problems – teats that ripped or are mouldy. Also here babies and children can and do die from diarrhea because of difficulty getting transport to hospitals for hydration or getting there so late because “traditional medicine” was tried first.

        • Young CC Prof
          April 26, 2014 at 9:23 am #

          OK, it wasn’t 8 points, it was 3 points, and any breastfeeding study is complicated because, in many parts of the developed world, it is the rich with lots of money to spend on education who are most likely to breastfeed. So, that 3 point difference may not even be real.

          But yes, where access to clean water is unreliable, the infant feeding question is completely different. For the reasons you mentioned, absolutely you want to breastfeed if at all possible and avoid formula unless there is no other choice, like if the mother is dead or simply cannot produce milk.

          • Lion
            April 26, 2014 at 9:46 am #

            Thanks. Wonder where I got eight from. Was stuck in my mind. How would that compare to slightly lowered IQ from slightly reduced oxygen at birth though?

          • Lion
            April 26, 2014 at 9:50 am #

            Sorry, left off the line “if it is real”. Very slow internet today.

          • Young CC Prof
            April 26, 2014 at 10:03 am #

            I don’t think we know that. We do know that substantial oxygen deprivation can result not only in cognitive deficits but in motor issues, like CP, but we don’t even know if there IS a brain effect of slight oxygen deprivation, much less what it looks like.

          • Lion
            April 26, 2014 at 12:56 pm #


        • fiftyfifty1
          April 26, 2014 at 9:54 am #

          Yes, at least here in the US, parents (especially upper class ones) are very motivated to maximize their children’s IQs. Thus the high pressure to breastfeed that you see among upperclass mothers, because studies have found a correlation between breastfeeding and IQ, along the lines of about 3-4 extra points. It turns out that these extra IQ points are likely just an artifact of residual confounding. These points disappear in randomized studies like the Belarus PROBIT study and in discordant sibling studies. But even if it is just correlation and not causation, upper class women are not willing to take the chance. It’s become rather ridiculous. That’s why I think that CS rate may go up not down. If elective CS shows even a 1 or 2 point improvement in IQ, that will be enough to motivate many parents.

          • Lion
            April 26, 2014 at 12:55 pm #

            Thanks, I think that puts it in context for me.

    • CognitiveDissonaceHurts
      April 26, 2014 at 7:11 am #

      Does anyone have any good resources about the pelvic floor? I remember reading that Kegels weren’t necessarily the solution to weakness. Whether or not that is true, I’m not sure.

  7. April 24, 2014 at 2:06 pm #

    A woman that I am acquainted with is a good example of being in the hospital- just in case. Her 8th (!) child brought some complications that COULD NOT have been anticipated or dealt with at a home delivery. The prior 7 deliveries had all been vaginal deliveries with only a few minor complications along the way. Some with pitocin, some without. Some with epidurals, some without. All were hospital births.

    She went into spontaneous labor with #8 and headed to the hospital. Membranes spontaneously ruptured on the way there. She had no pitocin and no epidural. Things seemed to be progressing very quickly, as you would expect with someone that had given birth seven times previously.

    After about 30 minutes in the hospital, she said “I think an arm just came out, or something. It feels weird.” Nurse ran over to check. There was a prolapsed cord. She was rushed down the hall, the OB on call performed an emergency c/section, baby was out in a matter of minutes and passed off to a team of NICU staff. Baby went home with mom a few days later, and is now a healthy school-age child with no aparent injury.

    What do homebirth midwives say when a prolapsed cord occurs? “That was a very rare complication. There’s nothing that could have been done” OR “Enjoy your 7 children, this one just wasn’t meant to stay earth-side” OR “88% live births is a pretty good success rate” OR “Have another one so that you can experience a healing VBAC.”

    What does an obstetrician do when a prolapsed cord occurs? Rescues the child!

    • Dr Kitty
      April 25, 2014 at 11:17 am #

      Well, I know a CPM WON’T catheterise, instil 500mls of saline to fill the bladder and clamp the catheter while holding the presenting part off the cord…

  8. C T
    April 24, 2014 at 1:51 pm #

    Is this abstract talking about the kind of medical progress you envision in being able to measure fetal blood oxygenation?

    • Young CC Prof
      April 24, 2014 at 2:33 pm #

      That is a really interesting possibility. Of course, it appeared to be done with MR? Not sure how practical that is in active labor. But still very exciting.

    • Julia
      April 24, 2014 at 3:19 pm #

      I don’t think putting women in labor in an MR scanner for prolonged periods is practical or desirable and it would also be cost prohibitive to do this as a routine measure. But some interesting scientific information could come out of studies that correlate heart rate patterns or other variables with oxygenation and thus get a better idea how these parameters correlate with fetal distress. This might help in narrowing down who really needs a c-section.
      (My husband is an MR physicist and I’ve spent many a claustrophobic hour as a volunteer for him. Being in an MR scanner while heavily pregnant sounds utterly miserable…)

  9. k_cayte
    April 24, 2014 at 1:42 pm #

    I’ll take preventive measures, thanks. The ultrasound (that NCBers say “doesn’t improve outcomes”) for my first baby identified a possible bowel obstruction. We knew before my son was born that he might need surgery. Thankfully he passed stools easily and everything was fine.

    I hate needles but I happily took IV antibiotics when my GBS test came back positive with my second baby so that I wouldn’t have to worry about passing infection to my daughter.

    Who wouldn’t want to protect their baby?

    • Young CC Prof
      April 24, 2014 at 2:16 pm #

      Nope, ultrasounds don’t improve outcomes at all. Like the ultrasound that diagnosed my son with growth restriction at 32 weeks so he could be delivered, small but healthy at 37 weeks. Dissection of the placenta after the fact found that he was pretty much out of time.

      • Mac Sherbert
        April 24, 2014 at 2:29 pm #

        They certainly don’t help identify breech babies (sarcasm). My DS was breech, but they couldn’t tell just by an exam. (Seriously, missed by two labor nurses with 20+ years experience and my OB kept saying he probably wasn’t, but better to check.)Thanks to that ultra-sound the problem was found and I had nice c-section. Of course, Breech is just variation of normal. I should have risked his brain cells and continued with labor.

        • Jessica S.
          April 24, 2014 at 7:19 pm #

          Who doesn’t like to play a game of “Which End Is It?” as said end is about to emerge? Ultrasounds are major buzz kills! 😉

          • CognitiveDissonaceHurts
            April 26, 2014 at 6:58 am #

            I don’t really understand how they can’t tell if it is a bum or a head.

          • Young CC Prof
            April 26, 2014 at 9:29 am #

            Actually, it’s not always that obvious. My obstetrician once told me my baby was head down, but I’m fairly sure he was persistently frank breech from about five or six months onward. (I wasn’t sure that day because I’d felt something very weird the previous night that I thought might have been him turning, and he hadn’t kicked much since. Inside a few hours, though, he was back to kicking me in the bikini line.)

            If he’s any kind of breech with feet down, Mom ought to know. But if he’s frank breech, he’s still kicking high.

      • Amy M
        April 24, 2014 at 2:44 pm #

        Yeah, all those extra u/s I had to watch out for TTTS, what a waste of time. We were lucky, it never became an issue for us, but they can do in-utero surgery to correct if they know about it.

      • Marguerita
        April 24, 2014 at 3:38 pm #

        Well, I can’t talk about outcomes just yet but they certainly improved my baby’s chances of survival with transposition. From 0% to about 98%.

        • araikwao
          April 24, 2014 at 4:50 pm #

          If you’d just eaten more kale.. *eyeroll*

          • Marguerita
            April 24, 2014 at 5:57 pm #

            Some of my family members are convinced that I must have been thinking the wrong thoughts 🙁

            Looking back at what I wrote I guess it’s inaccurate since the they would have figured out she has TGA in the hospital even if it wasn’t known in advance. I still appreciate knowing though.

          • Young CC Prof
            April 24, 2014 at 6:04 pm #

            This way, you’re already on the radar and they’ll start preparing for your daughter’s treatment the minute you go into labor. Easier all around, probably less chance of complications.

          • Ceridwen
            April 24, 2014 at 7:25 pm #

            My aunt and uncle had 2 children with transposition. The first was undiagnosed until after birth. She died before she was two. The second was diagnosed during pregnancy. They were prepared and he got surgery at a much younger age than his sister. Unfortunately he does have some major impairments, but he’s alive and in his 20s. Not a perfect outcome, but his parents certainly preferred it to the outcome they had with their first child and knowing beforehand definitely helped.

          • Marguerita
            April 26, 2014 at 3:32 pm #

            Can you say more about his impairments?

            I know that TGA is associated with a 10 point IQ difference as a population and with certain abnormalities in the brain that are being researched with MRI (yep, I’ve been in that weird machine). There’s a higher risk of learning disabilities and ADHD. Overall though, they have a good quality of life. The doctors we spoke to gave us the example that there are doctors who survived TGA and added “We’d like to think that’s a good thing”.

          • Ceridwen
            April 29, 2014 at 1:24 am #

            I can’t tell you specifics (as we live a long way away from them and his parents are odd and don’t interact with us much). It’s obvious from being around him for a minute or two that there are mental impairments. He’s able to read and write and post on Facebook but it was obvious from the time he was a baby that he wasn’t meeting milestones on track. I know as a young child he had pretty substantial gross motor impairments.

            It’s definitely more than just learning disabilities or ADHD. But I don’t think his situation is typical for TGA (at least now nowadays).

    • Meredith Watson
      April 24, 2014 at 10:17 pm #

      I agree. Who wouldn’t? My daughter suffered from a GBS infection after a precipitous labor. (I received only one dose of antibiotics shortly before she was born). After spending a week with her in the hospital while she received IV antibiotics and had her heplock reinserted countless times, I thought exactly the same thing. Why risk that happening to your baby just so you won’t have to get an IV? Like you, I would happily suffer much more discomfort than that to prevent any harm from coming to my baby.

  10. Zornorph
    April 24, 2014 at 1:42 pm #

    One day we’ll be able to beam the baby out of the womb like in Star Trek and that will really blow these people’s minds.

    • Busbus
      April 24, 2014 at 2:05 pm #

      I would LOVE that. Hehe.

    • April 24, 2014 at 4:17 pm #

      You know, it was considered dangerous to beam a baby out in the Trek verse? Can’t remember if it was TNG or Voyager but it was a Klingon/Human baby and they beamed him out because his forehead ridges became lodged during birth.

      Such. A. Dork.



      • Certified Hamster Midwife
        April 24, 2014 at 4:18 pm #

        On the other hand, I bet vaginal birth goes pretty well for the Coneheads of SNL.

      • The Computer Ate My Nym
        April 25, 2014 at 9:30 am #

        You’d think the ridges would be soft at birth and harden in the first few years of extra-uterine life. Sort of like the change from fetal to adult globin or closing of the fontanelles. It would make more sense evolutionarily. Or maybe all Klingon births are done by c-section, kind of like bulldogs are IRL. Probably without anesthesia, given the culture. (Extra-dorkage!)

        • April 25, 2014 at 11:12 am #

          I just have to comment that I don’t like this comment, I love it and wish to send it flowers.

          • Siri
            April 25, 2014 at 11:36 am #

            And you a married woman, Kq! Tsk tsk. Does your husband approve of you flirting shamelessly with random comments?

        • Siri
          April 25, 2014 at 11:33 am #

          Ktarian, m’dear; not Klingon. Sheesh. Must I police EVERYTHING?

          • April 25, 2014 at 12:28 pm #


          • Box of Salt
            April 25, 2014 at 5:21 pm #

            Again, not silly Klingon ridges, the poor kid had forehead SPIKES! Since the Dad was never on the show, we have no idea what true Ktarinas look like. Nor how they reproduce amongst themselves.

          • Box of Salt
            April 25, 2014 at 5:22 pm #

            How do unicorns give birth? Or do the horns grow in later? Naomi’s set were there in utero.

        • Box of Salt
          April 25, 2014 at 5:40 pm #

          TCANM: I imagine Klingon women would out do the most extreme NCB-er’s here on earth – they actually are warriors, after all. And if they need a c-section, not only would it be without anesthesia, they’d also perform it on themselves.

        • VeritasLiberat
          April 25, 2014 at 8:53 pm #

          That’s how it with hedgehogs — the spikes are soft at birth.

      • Box of Salt
        April 25, 2014 at 5:18 pm #

        Star Trek Voyager. The baby was Naomi WIldman, whose father – not on the ship – is an alien with forehead spikes, not mere ridges. I don’t recall what his alien race was called. IMBD refers to him as a “Ktarian named Greskrendtregk.” Her mother was Ens Samantha Wildman, a science officer, who does not survive the series.

      • MLE
        April 26, 2014 at 10:03 am #

        Also O’Brien’s baby on Deep Space Nine was beamed out of his wife and into Kira.

  11. April 24, 2014 at 1:09 pm #

    Ideally it would be nice to predict with certainty the outcomes of both modes (including pelvic floor damage or adhesions) – and to allow women to decide for themselves what they prefer. There might even be some real advantages to a world where “birth” either vaginal or cesarean just does not need to happen – where no one is limited by fertility or pregnancy, and no babies are adversely impacted by the actions or inactions of their morthers. I wonder if a thousand years from now, if they’ll look at how we had babies and be stunned at how antiquated it all is, and how it created a world where men and women weren’t anywhere near equal.

    • T.
      April 24, 2014 at 3:51 pm #

      I am waiting for the glass uterus myself. I know they are working on it. 😛

      • Lost
        April 24, 2014 at 6:00 pm #

        Uterine incubator (iirc). LM Bujold, Vorkosigan series of books.

        • Young CC Prof
          April 24, 2014 at 6:02 pm #

          Uterine replicator. Real fan of LMB myself.

          • Karen in SC
            April 26, 2014 at 5:49 pm #

            But only on his mother’s homeworld. His father’s homeworld was much more old-fashioned.

          • Young CC Prof
            April 26, 2014 at 10:08 pm #

            Actually, Bujold has written a bunch of books, at least two series, and all reflect a solid understanding of the fact that the process of human reproduction kind of sucks.

      • The Computer Ate My Nym
        April 25, 2014 at 9:32 am #

        Is there an active attempt to make a uterine replicator (yes, using Bujold term on purpose)? I know there was at least one attempt some years ago, but it got cut for lack of funding and I hadn’t heard of anyone trying it again…

      • CognitiveDissonaceHurts
        April 26, 2014 at 6:50 am #

        Anyone remember Logan’s Run with Michael York?

  12. Young CC Prof
    April 24, 2014 at 12:10 pm #

    Of course, some NCB sources drastically overstate the risks of certain interventions. After all, just a couple generations ago, the risk to the mother in a c-section really was so high that doing one just on the small chance that the baby was in trouble was unthinkable. (Yes, we didn’t have electronic fetal monitoring then, I’m just saying.)

    What NCB’ers really need to understand is that:

    1) There is no cascade of interventions, and “small” interventions such as pitocin drip or AROM often lead to an uncomplicated vaginal birth soon after.

    2) Most women who have a c-section do NOT have a really terrible recovery, and very few have long-term problems as a result.

    • April 24, 2014 at 12:39 pm #

      As a matter of fact, women who are not progressing in labor because of weak and/or contractions are MORE likely to wind up with C/S if they DON’T get pitocin.

    • Trixie
      April 24, 2014 at 1:52 pm #

      And this is another reason why home birth was a less disastrous choice in the ’60s and 70s — because the difference between home and hospital birth safety was probably smaller than it is today.

    • Sullivan ThePoop
      April 24, 2014 at 1:57 pm #

      Yeah, that whole cascade of interventions thing is just nonsense. Even though it is anecdotal I have known several people to go to the hospital in full naturally brought on labor where it didn’t progress and they ended up with a C-section and several people who needed a whole slew of interventions that went on to have vaginal birth. Then they try to say silly things like they induce too early and it ends in a C-section, but if they just did the C-section without trying to induce first I am sure they would be screaming about that too. In those cases I am sure the baby needed to come out for whatever reason and the conditions were just not right to have the baby vaginally.

      • Young CC Prof
        April 24, 2014 at 2:13 pm #

        If you are, say, 38 weeks pregnant with preeclampsia and the doctor has determined that, for your safety, the baby must come out within the next couple days, you have two choices. Go straight to c-section, in which case there is a 100% chance you will have a c-section, or try induction of labor, in which case there is a less than 100% chance of c-section.

        Of course, you could do nothing, and accept a substantial probability of death to mother and child, but that’s a really dumb idea.

        • Jenifer Payne
          April 25, 2014 at 9:45 am #

          That was my exact scenario with my last child. I chose the induction, labored for quite awhile (my cervix was closed and thick), but we ended up with a successful vaginal delivery. I don’t know WHY it is that people are so convinced an induction will end in c-section. I’ve had six babies, been induced three times (and pit drips four times), and had ZERO sections. SMH. Though truthfully and in hindsight, I wish I’d been offered a c-section with my last — that labor/delivery was kind of rough.

    • KT
      April 24, 2014 at 3:17 pm #

      I can agree on the terrible recovery part, and I’m sure the few having long-term problems part is also true, but that doesn’t mean we should accept the long-term problems. When I was facing down recurrent pregnancy loss testing trying to figure out what could be causing my RPL when I had no issues carrying my first to term, my c-section scar causing adhesions definitely haunted the back of my mind as I’d read more than one horror story from other RPL or IF women. Yes, c-sections are a wonderful thing when necessary. But just because the risks are rare is no reason to be blase about them.

      • Young CC Prof
        April 24, 2014 at 3:28 pm #

        Yeah, barring the unusual case of a serious surgical mishap, scar as potential complication in future pregnancies is the major long-term concern, as I understand it. However, there are quite a few women who seem to really OVERestimate the maternal risks.

    • CognitiveDissonaceHurts
      April 26, 2014 at 6:47 am #

      I would love Dr A to write a post “There is no cascade of interventions” and deal with that topic from that perspective.

      This is what I feared in childbirth the most and made me be willing to endure horrific pain as a result. I know I am not alone in this.

  13. Lisa Thompson Graves
    April 24, 2014 at 11:59 am #

    My 2nd pregnancy was completely normal, other than my son being transverse until 36 weeks. My OB said, “Come back in three days, and If he hasn’t gone head down by then we’ll talk about trying to flip him,” and I, having SEEN that episode of A Baby Story, was all, “Um, no. No, we won’t.” Luckily, by the next visit, he was head-down, and I was dilated to 4cm. I made an appointment for the next week, and we all laughed, because no way was I going to make that. 4 cm!

    The next week on Monday morning, I was back in the office, still pregnant (38w), still at 4cm. I told my doctor that he had to do induce me the next day. My mom could only come that week. He said okay, that’d he wouldn’t use pitocin, just come in and break my water. That should be enough to kick start things. I mean, come on. 4cm!

    The next day, after breaking my water and giving me a “boost” of pitocin and 2 hours of pushing, I still couldn’t get my son below a +2. He just would not descend. I asked (and by “asked” I mean SCREAMED) for a c-section and my doctor sighed and said OK. Lo and behold, he was presenting OP (his head was as far back as it would go) and had to be popped off my pelvic arch where his face had made almost a vacuum seal. He also had two true knots in his cord.

    I guess I *could* have tried to labor and get him out, They would’ve used forceps or a vacuum extractor and I would’ve had a “real” birth. But was that worth the risk? It wasn’t to me. I wanted my BABY, not a vaginal birth.

    • Therese
      April 24, 2014 at 12:48 pm #

      No, you still wouldn’t have had a “real birth”. You were induced at 37 weeks with no medical reason! That pretty much permanently invalidates the birth even if you still manage to get the baby out vaginally.

      • inyri
        April 24, 2014 at 12:54 pm #

        Is that meant to be a joke? It’s childbirth, not a passport. It can’t be invalidated.

        • Jocelyn
          April 24, 2014 at 1:14 pm #

          Yes, I’m sure that Therese is joking.

          • Therese
            April 24, 2014 at 1:29 pm #


  14. Julie
    April 24, 2014 at 11:55 am #

    Third time mom here, due August 10. Had a c-section with my last baby for FTP, contemplating VBAC vs. RCS. OB doesn’t have a preference, and I really don’t either, other than I think a VBAC might be more convenient recovery-wise with a 3-year-old. I had a really bad NB with my oldest, and the recovery from multiple severe tears was much, much worse than my c-section, but I didn’t have the lifting/driving restrictions. Anyhow, whatever happens, I’m erring on the side of caution! If the OB thinks an RCS is the best bet, RCS it will be.

    I’ve got a question, though. I occasionally browse one of the VBAC boards on a popular site and one of the moms there keeps quoting this statistic of RCS being “4-7 times more likely to KILL YOU.” Does anyone know where she got that? Everything from the scientific literature I’ve read lists risks of RCS vs. VBAC about the same, with *slightly* more risk to the mother in RCS vs. *slightly* more risk to the baby in VBAC. Nothing I’ve seen is even close to 4-7 times more risk of death! Granted, I take everything she says with a grain of salt — I don’t trust anyone who advocates lying to their HCP about their LMP to “buy more time” with due dates — but this one is really throwing me for a loop. Is she just nuts, or is that a valid figure?

    • FormerPhysicist
      April 24, 2014 at 12:04 pm #

      I am not a medical professional, but I can tell you that I found a scheduled repeat c/s so much easier to recover from than a c/s after FTP. I didn’t find it a hard recovery, even with a four-year-old.

    • Young CC Prof
      April 24, 2014 at 12:05 pm #

      Technically, sort of, but with a couple caveats.

      Caveat the first, to say 4-7 times more likely is very deceptive if you don’t mention that the absolute risk is tiny in both cases. One meta-analysis found something like a 13 per 100,000 risk of death with RCS versus a 3-4 per 100,000 risk with trial of labor, so the absolute difference in risk is one in 10,000, which is similar to your risk of dying in a car accident in any given year. The absolute difference in risk to the baby is actually larger than that, although still quite small. (As long as you try your VBAC under safe hospital conditions.)

      Caveat the second, many of the women who did RCS may have been at higher risk to begin with than women who tried VBAC, and may have had specific indications, like placenta previa or accreta. (Women with those conditions MUST have a c-section, but even with a c-section they are at substantial risk of hemorrhage.)

      So, the risk of death is probably a little higher, but the difference in risk is very small.

    • Mel
      April 24, 2014 at 12:15 pm #

      It is a valid figure, but badly misleading.

      Here’s a website with the statistic summaries of maternal mortality outcomes:

      Yes, women who have repeat CS are roughly 4x more likely to die than women who have trial of labor. The major problem/confounding factor is that there is no double-blinded study possible. Since these are all retrospective cohorts – groups created after labor and delivery based on what happened – the RCS and ERCS groups likely had moms who were higher risk for maternal mortality to start with. These higher risk factors would likely prevent them from having a trial of labor in the first place and so would bias the RCS/ERCS group towards a higher mortality rate due to those pre-existing problems.

    • Mac Sherbert
      April 24, 2014 at 2:23 pm #

      FYI – When I had my RCS I was worried about the drive restrictions as well as I had a 4 year old to get to preschool, etc. However, I had a great recovery and was cleared to drive almost right way as long as I was off pain meds. As for the lifting…I probably did that before I should have, but don’t have any long terms problems from it.

      When I had to make the choice between RCS or VBAC I took a wait see approach. I decided if I went into labor and everything progressed then try VBAC, or if things aren’t going well or I didn’t go into labor by a certain date then RCS. I ended up with RCS as labor never started and I’m glad it turned out that way.

      Good luck either way. I know it’s a hard choice.

      • Jessica S.
        April 24, 2014 at 7:44 pm #

        This is exactly what I’m thinking for my second, due in July: if I go into labor before my due date, great. But if not, scalpel* please. 🙂

    • Jenny_from_da_Bloc
      April 24, 2014 at 7:31 pm #

      Don’t believe that garbage! I’m 17 weeks currently and will definitely have a repeat cs. If that info was true nobody would have a repeat cs, ever! Plus, look at people like Victoria Beckham who had 4 cs and I know a woman who has had 5 cs with no complications. I would be more worried about taking care of a newborn and 4 y.o with a torn perineum. My primary cs was due to a severe spinal injury and a fused pelvis, luckily I changed OBs at 30wks because he was just too old school and refused to do the cs without a trail labor on my neuros advice and his midwife kept insisting that my spine and pelvis had nothing to do with delivering a baby(LOL).The OB who delivered my son said I saved his life by fighting for the cs because he would have never made it past my pelvis and would have died or been severely brain damaged “almost positively” because he had a 17in head and was OP

      • FormerPhysicist
        April 24, 2014 at 7:33 pm #

        *headdesk* You had to change OBs to get a primary c/s with a spinal injury and fused pelvis? When your neuro recommended the c/s? I’m glad you did, and got your c/s, but sheesh.

        • Jenny_from_da_Bloc
          April 24, 2014 at 7:36 pm #

          Yeah, dude was totally insane and even told me it won’t hurt to try and have a natural delivery lmao! I’m a respiratory therapist and have seen too many birth disasters to take chances with my babies!

          • Sue
            April 25, 2014 at 5:15 am #

            It would HURT? Hurt whom?

    • Sue
      April 25, 2014 at 5:21 am #

      I found this review in Obstetrics and Gynaecology June 2010:

      Vaginal Birth After Cesarean: New Insights on Maternal and Neonatal Outcomes

      ”Although rare in both elective repeat cesarean delivery and trial of labor, maternal mortality was significantly increased for elective repeat cesarean delivery at 0.013% compared with 0.004% for trial of labor. The rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between trial of labor and elective repeat cesarean delivery. The rate of uterine rupture for all women with prior cesarean was 0.30%, and the risk was significantly increased for trial of labor (0.47% compared with 0.03% for elective repeat cesarean delivery). Perinatal mortality was also significantly increased for trial of labor (0.13% compared with 0.05% for elective repeat cesarean delivery).”

      As we have always said, cesarean delivery improves neonatal mortality at the cost of a very small increase in maternal mortality. I suspect the decrease in neonatal MORBIDITY (especially hypoxic injury) must also be significant. I haven’t seen in quantified.

      • Young CC Prof
        April 25, 2014 at 10:05 am #

        I skimmed the full text of a long literature review (might even have been that one) and basically they looked at the research into a bunch of measures of neonatal morbidity, and for most of them they found a decrease for ERCS, but the studies were small and the difference was not statistically significant.

        The exception, of course, was transient tachypnea of the newborn, which is more common among babies born by no-labor cesarean. (Of course, TTN is usually pretty straightforward to manage medically and rarely results in lasting harm.)

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