Showing posts with label cesarean. Show all posts
Showing posts with label cesarean. Show all posts
Monday, May 12, 2008
Tehelka Article on Alternatives to Hospital Births in Urban India
Here's an article in Tehelka -- an independent news magazine -- that I was interviewed for. The title, in my opinion, doesn't really reflect the content of the article, but oh well.
Tuesday, February 5, 2008
Wagner Article: Being Seduced to Induce
Being Seduced to Induce: What Women Should Know About Their OBs
By Marsden Wagner M.D.
Women will only agree to caesarean section if they are convinced it is safe for them and their baby. One of the first efforts of obstetricians promoting caesarean section has been to take the scientific evidence on risks of caesarean section and torture the data until it confesses to what they want it to say.
One example: Obstetric hype in popular and professional magazines says research shows 60% of women who have vaginal birth have urinary and faecal incontinence. But a careful reading of the research papers they refer to reveals something very different. The hype lumps all women with vaginal birth together instead of doing what the researchers did – dividing them into risk groups. When analysis of risk was done, they found that women at high risk for urinary and faecal incontinence have had large numbers of births; have had babies weighing over ten pounds at birth; and most importantly, have been the victims of unnecessary, aggressive obstetric interventions during their labour and birth.
What are these aggressive, invasive obstetric interventions that have been proven scientifically to cause permanent damage to the pelvic floor and urinary tract and also lead to more otherwise unnecessary caesarean section? One example is the use of powerful and dangerous drugs to start or accelerate labour, a practice that has doubled during the past 10 years. These drugs make labour abnormal with violent contractions that can damage the uterus and pelvic floor. The only reason women agree to such induction is because they are not told the truth about the drugs, for example that Pitocin (oxytocin), a drug used for decades to induce labour, doubles the chance the woman will have urinary incontinence in the future. By withholding such facts doctors seduce to induce.
Induction with drugs is not the only aggressive, invasive intervention that is frequently used in vaginal birth and is associated with damage to the urinary system, pelvic floor and rectal areas. Episiotomy has been scientifically shown to result in more pelvic floor damage than a natural tear. When an effort was made in the 1980s to reduce caesarean section in the United States, the rate of using forceps or vacuum extractor to pull the baby out went up—some doctors just can’t stop doing invasive interventions. And there is good data that using forceps or vacuum to pull the baby out has more risk of pelvic floor damage than any other form of birth.
Obstetricians have turned birth into a surgical procedure and done damage to women’s bodies and now suggest the solution is to promote yet even more radical and aggressive surgery; caesarean section. The solution is less unnecessary invasive surgical procedures during birth, not more.
[Re: the Midwifery Today E-News article, Issue 3:23]: The two obstetricians tried to say that vaginal birth can damage a woman, but they never pointed out the ways in which caesarean section can do harm not only to the woman but to the baby as well. The following excerpt from my article “Choosing Caesarean Section” in The Lancet of November 11, 2000, reviews some of the dangers associated with caesarean section, the alternative to vaginal birth that some doctors are trying to promote:
‘In addition to the increased risk the woman will die with an elective caesarean section, there are other risks for the woman including the usual morbidity associated with any major abdominal surgical procedure—anaesthesia accidents, damage to blood vessels, accidental extension of the uterine incision, damage to the urinary bladder and other abdominal organs.1 Some of these risks are common: 20% of women develop fever after caesarean section, most due to iatrogenic infections requiring diagnostic fever evaluation for both woman and baby.1
There are also risks women carry to subsequent pregnancies due to scarring of the uterus including decreased fertility, increased miscarriage, increased ectopic pregnancy, increased placenta abruptio, increased placenta previa.1,2, 3 Recently in the United States the widespread use of the unapproved drug misoprostol (Cytotec) for labour induction has created a new risk of caesarean section in subsequent pregnancies. Women attempting VBAC (Vaginal Birth After Ceasarean) who are given misoprostol have a rate of uterine rupture of 5.6% compared with a rupture rate of 0.2% for women attempting VBAC not given misoprostol, a 28-fold increase in risk of uterine rupture.4 For women choosing caesarean section, all of these risks exist in all of their subsequent pregnancies even if the original caesarean section was not an emergency. The increased risks of ectopic pregnancy, abruptio placenta, placenta previa and ruptured uterus are all life threatening to both woman and baby.
For whatever reasons women choose caesarean section, very few are clearly informed about foetal risks. In an emergency caesarean section where the baby has developed a problem during the labour, the risks to the baby of doing the caesarean section will likely be outweighed by the risks to the baby of not doing it. In an elective caesarean section where the baby is not in trouble, the risks to the baby from doing a caesarean section still exist, meaning the woman who chooses caesarean section puts her baby in unnecessary danger. That some women are choosing caesarean section strongly suggests women are not told these scientific facts.
The first danger to the baby during caesarean section is the 1.9% chance the surgeon’s knife will accidentally lacerate the foetus (6.0% when there is a non-vertex foetal position). (5) Obstetricians may be less aware of this risk — in one study only one of the 17 documented foetal lacerations was recorded by the obstetrician doing the surgery.5 A much more serious risk to babies born by caesarean section is respiratory distress. Many reports in the scientific literature document the caesarean section procedure per se is a potent risk factor for respiratory distress syndrome (RDS) in preterm infants and for other forms of respiratory distress in mature infants.1 RDS is a major cause of neonatal mortality. The risk of newborn RDS is greatly reduced if the woman is allowed to go into labour prior to the caesarean section. Another serious risk to the baby born by caesarean section is iatrogenic prematurity (the baby is premature because the caesarean section was performed too early). Even with repeated ultrasound scans, the standard deviation for estimating gestational age is large, creating errors in judging when to do an elective caesarean section. Doing the elective caesarean section after the woman goes into spontaneous labour would markedly reduce this risk as well. A vast literature documents the increased mortality and morbidity, including neurological disability, associated with premature birth.’
So beware. Surgeons try to sell surgery. Never forget that obstetricians are, after all, surgeons. Women must be extremely cautious in the face of this hard sell and get the facts from those who do not have a vested interest in surgery.
Thanks to Leila McCracken and www.birthlove.com
For more about Dr. Wagner.
1. Wagner M, 1994. Pursuing the Birth Machine: The Search for Appropriate Birth Technology, Sydney, Australia: ACE Graphics.
2. Enkin M, Keirse M, Renfrew M, Neilson J, 1995. A Guide to Effective Care in Pregnancy and Childbirth, 2nd ed, Oxford University Press.
3. Goer, H, 1999. The Thinking Woman’s Guide to a Better Birth. Putnam, New York: Penguin.
4. Plaut M, Schwartz M, Lubarsky S, 1999. “Uterine rupture associated with the use of misoprostol in the gravid patient with a previous caesarean section,” Am J Obstet Gyn 180:1535-42.
5. Smith J, Hernandez C, Wax J, 1997. “Fetal laceration injury at cesarean delivery,” Obstet & Gynecol 90:344-6.
First published in byronchild/Kindred, issue 1, March 02
By Marsden Wagner M.D.
Women will only agree to caesarean section if they are convinced it is safe for them and their baby. One of the first efforts of obstetricians promoting caesarean section has been to take the scientific evidence on risks of caesarean section and torture the data until it confesses to what they want it to say.
One example: Obstetric hype in popular and professional magazines says research shows 60% of women who have vaginal birth have urinary and faecal incontinence. But a careful reading of the research papers they refer to reveals something very different. The hype lumps all women with vaginal birth together instead of doing what the researchers did – dividing them into risk groups. When analysis of risk was done, they found that women at high risk for urinary and faecal incontinence have had large numbers of births; have had babies weighing over ten pounds at birth; and most importantly, have been the victims of unnecessary, aggressive obstetric interventions during their labour and birth.
What are these aggressive, invasive obstetric interventions that have been proven scientifically to cause permanent damage to the pelvic floor and urinary tract and also lead to more otherwise unnecessary caesarean section? One example is the use of powerful and dangerous drugs to start or accelerate labour, a practice that has doubled during the past 10 years. These drugs make labour abnormal with violent contractions that can damage the uterus and pelvic floor. The only reason women agree to such induction is because they are not told the truth about the drugs, for example that Pitocin (oxytocin), a drug used for decades to induce labour, doubles the chance the woman will have urinary incontinence in the future. By withholding such facts doctors seduce to induce.
Induction with drugs is not the only aggressive, invasive intervention that is frequently used in vaginal birth and is associated with damage to the urinary system, pelvic floor and rectal areas. Episiotomy has been scientifically shown to result in more pelvic floor damage than a natural tear. When an effort was made in the 1980s to reduce caesarean section in the United States, the rate of using forceps or vacuum extractor to pull the baby out went up—some doctors just can’t stop doing invasive interventions. And there is good data that using forceps or vacuum to pull the baby out has more risk of pelvic floor damage than any other form of birth.
Obstetricians have turned birth into a surgical procedure and done damage to women’s bodies and now suggest the solution is to promote yet even more radical and aggressive surgery; caesarean section. The solution is less unnecessary invasive surgical procedures during birth, not more.
[Re: the Midwifery Today E-News article, Issue 3:23]: The two obstetricians tried to say that vaginal birth can damage a woman, but they never pointed out the ways in which caesarean section can do harm not only to the woman but to the baby as well. The following excerpt from my article “Choosing Caesarean Section” in The Lancet of November 11, 2000, reviews some of the dangers associated with caesarean section, the alternative to vaginal birth that some doctors are trying to promote:
‘In addition to the increased risk the woman will die with an elective caesarean section, there are other risks for the woman including the usual morbidity associated with any major abdominal surgical procedure—anaesthesia accidents, damage to blood vessels, accidental extension of the uterine incision, damage to the urinary bladder and other abdominal organs.1 Some of these risks are common: 20% of women develop fever after caesarean section, most due to iatrogenic infections requiring diagnostic fever evaluation for both woman and baby.1
There are also risks women carry to subsequent pregnancies due to scarring of the uterus including decreased fertility, increased miscarriage, increased ectopic pregnancy, increased placenta abruptio, increased placenta previa.1,2, 3 Recently in the United States the widespread use of the unapproved drug misoprostol (Cytotec) for labour induction has created a new risk of caesarean section in subsequent pregnancies. Women attempting VBAC (Vaginal Birth After Ceasarean) who are given misoprostol have a rate of uterine rupture of 5.6% compared with a rupture rate of 0.2% for women attempting VBAC not given misoprostol, a 28-fold increase in risk of uterine rupture.4 For women choosing caesarean section, all of these risks exist in all of their subsequent pregnancies even if the original caesarean section was not an emergency. The increased risks of ectopic pregnancy, abruptio placenta, placenta previa and ruptured uterus are all life threatening to both woman and baby.
For whatever reasons women choose caesarean section, very few are clearly informed about foetal risks. In an emergency caesarean section where the baby has developed a problem during the labour, the risks to the baby of doing the caesarean section will likely be outweighed by the risks to the baby of not doing it. In an elective caesarean section where the baby is not in trouble, the risks to the baby from doing a caesarean section still exist, meaning the woman who chooses caesarean section puts her baby in unnecessary danger. That some women are choosing caesarean section strongly suggests women are not told these scientific facts.
The first danger to the baby during caesarean section is the 1.9% chance the surgeon’s knife will accidentally lacerate the foetus (6.0% when there is a non-vertex foetal position). (5) Obstetricians may be less aware of this risk — in one study only one of the 17 documented foetal lacerations was recorded by the obstetrician doing the surgery.5 A much more serious risk to babies born by caesarean section is respiratory distress. Many reports in the scientific literature document the caesarean section procedure per se is a potent risk factor for respiratory distress syndrome (RDS) in preterm infants and for other forms of respiratory distress in mature infants.1 RDS is a major cause of neonatal mortality. The risk of newborn RDS is greatly reduced if the woman is allowed to go into labour prior to the caesarean section. Another serious risk to the baby born by caesarean section is iatrogenic prematurity (the baby is premature because the caesarean section was performed too early). Even with repeated ultrasound scans, the standard deviation for estimating gestational age is large, creating errors in judging when to do an elective caesarean section. Doing the elective caesarean section after the woman goes into spontaneous labour would markedly reduce this risk as well. A vast literature documents the increased mortality and morbidity, including neurological disability, associated with premature birth.’
So beware. Surgeons try to sell surgery. Never forget that obstetricians are, after all, surgeons. Women must be extremely cautious in the face of this hard sell and get the facts from those who do not have a vested interest in surgery.
Thanks to Leila McCracken and www.birthlove.com
For more about Dr. Wagner.
1. Wagner M, 1994. Pursuing the Birth Machine: The Search for Appropriate Birth Technology, Sydney, Australia: ACE Graphics.
2. Enkin M, Keirse M, Renfrew M, Neilson J, 1995. A Guide to Effective Care in Pregnancy and Childbirth, 2nd ed, Oxford University Press.
3. Goer, H, 1999. The Thinking Woman’s Guide to a Better Birth. Putnam, New York: Penguin.
4. Plaut M, Schwartz M, Lubarsky S, 1999. “Uterine rupture associated with the use of misoprostol in the gravid patient with a previous caesarean section,” Am J Obstet Gyn 180:1535-42.
5. Smith J, Hernandez C, Wax J, 1997. “Fetal laceration injury at cesarean delivery,” Obstet & Gynecol 90:344-6.
First published in byronchild/Kindred, issue 1, March 02
Thursday, July 26, 2007
Statement from ICAN Regarding the Deaths of Two New Jersey Women
The women of the International Cesarean Awareness Network offer their deepest sympathies to the families of Melissa Farah and Valerie Scythes, two New Jersey women who died after undergoing cesarean surgery.* This tragedy affects not just these new families; it is a tremendous loss to the community.
While any birth poses small but measurable risks to mothers and babies, it is well-established that cesareans increase the risk of a mother dying by 3-4 times. Common causes of maternal death by cesarean include: hemorrhage, infection, post-operative blood clots, and adverse reactions to anesthesia.
The World Health Organization states that a cesarean rate of above 10-15% cannot be justified and rates higher than that pose a health risk to mothers and babies. In the United States, the cesarean rate is 30.2% and in New Jersey it is 37%, the highest in the country. These rates suggest gross overuse of the surgery. Medically valid reasons for a cesarean section include:
• Complete placenta previa at term
• Transverse lie at time of labor
• Prolapsed cord
• Abrupted placenta
• Eclampsia or severe preeclampsia with failed induction of labor
• Large uterine tumor which blocks the cervix
• True fetal distress confirmed with a fetal scalp sampling or biophysical profile
• True cephalopelvic disproportion
• Initial outbreak of active herpes at the onset of labor
• Uterine rupture
• Failed induction with fetal distress
Women who are advised cesarean sections because of the following reasons should explore all their options since medical opinions differ in these areas:
• Macrosomia (large baby)
• Maternal age
• Assisted reproductive technology
• Cephalopelvic disproportion (CPD)
• Dystocia • Failure to progress
• Breech
• Fetal distress
• Prolonged pushing stage
When a cesarean is medically necessary, it can be a lifesaving technique for both mother and baby, and worth the risks involved. When the surgery is overused without sound medical justification, however, it puts mothers and babies in harms way. Because of the increased risk associated with surgical delivery, ICAN works to reduce the number of cesareans that are medically unnecessary. Women can help reduce their risk of a cesarean section by following these tips:
• Choose a care provider with a low cesarean rate. Midwives can safely care for healthy low-risk women and have very low cesarean rates.
• Educate yourself on your birth options and your rights
• Hire a doula or labor assistant
• Avoid induction except for clear medical reasons
• Avoid common medical procedures which increase your chance of a cesarean
• Ask questions and explore all your options if you're told you need a cesarean because your baby is too big, you've gone "overdue," or your labor is moving slowly.
While any birth poses small but measurable risks to mothers and babies, it is well-established that cesareans increase the risk of a mother dying by 3-4 times. Common causes of maternal death by cesarean include: hemorrhage, infection, post-operative blood clots, and adverse reactions to anesthesia.
The World Health Organization states that a cesarean rate of above 10-15% cannot be justified and rates higher than that pose a health risk to mothers and babies. In the United States, the cesarean rate is 30.2% and in New Jersey it is 37%, the highest in the country. These rates suggest gross overuse of the surgery. Medically valid reasons for a cesarean section include:
• Complete placenta previa at term
• Transverse lie at time of labor
• Prolapsed cord
• Abrupted placenta
• Eclampsia or severe preeclampsia with failed induction of labor
• Large uterine tumor which blocks the cervix
• True fetal distress confirmed with a fetal scalp sampling or biophysical profile
• True cephalopelvic disproportion
• Initial outbreak of active herpes at the onset of labor
• Uterine rupture
• Failed induction with fetal distress
Women who are advised cesarean sections because of the following reasons should explore all their options since medical opinions differ in these areas:
• Macrosomia (large baby)
• Maternal age
• Assisted reproductive technology
• Cephalopelvic disproportion (CPD)
• Dystocia • Failure to progress
• Breech
• Fetal distress
• Prolonged pushing stage
When a cesarean is medically necessary, it can be a lifesaving technique for both mother and baby, and worth the risks involved. When the surgery is overused without sound medical justification, however, it puts mothers and babies in harms way. Because of the increased risk associated with surgical delivery, ICAN works to reduce the number of cesareans that are medically unnecessary. Women can help reduce their risk of a cesarean section by following these tips:
• Choose a care provider with a low cesarean rate. Midwives can safely care for healthy low-risk women and have very low cesarean rates.
• Educate yourself on your birth options and your rights
• Hire a doula or labor assistant
• Avoid induction except for clear medical reasons
• Avoid common medical procedures which increase your chance of a cesarean
• Ask questions and explore all your options if you're told you need a cesarean because your baby is too big, you've gone "overdue," or your labor is moving slowly.
Saturday, June 30, 2007
Active management of long labors
The other day I had the privilege of attending a Metropolitan Doula Group (MDG) meeting at which midwife Cara Muhlhahan spoke about managing long labors. [I'm in New York for 2 weeks, heading to Texas for some family time, and then back to Bangalore at the end of July.]
Cara emphasized the importance of not pathologizing long labors. When the baby is in the occiput posterior (OP) position (back of the baby's head is facing the back of the mother, accounting for about 15-30% of labors), latent labor can last three to four days while the baby's head molds to fit into the mother's pelvic opening. Long labors are not harmful to mothers or babies, rather, they are physiologically normal. The head must mold before the cervix can open, and it's best to simply wait it out without wearing the mother down or suggesting that the she is at fault.
Cara pointed out that women are looking for any excuse to believe they are inadequate. It's no wonder sometimes, when you look at hospital practices, in the case of long labors, for example. Most doctors would never let a woman labor for three days. She would be called in to the hospital, given Pitocin to augment the labor, and the cascade of interventions would begin, potentially leading to a cesarean birth.
We know this happens often in many hospitals, including those in Bangalore, where cesarean rates tend to reach 70%. (The world health organization (WHO) recommends a safe target rate of 10-15%.)
It was pretty amazing to be back at an MDG meeting; more than twenty doulas attended, including a few from the Brooklyn group I'd been hosting at my apartment in New York last year. I miss going to regular meetings and consistently having opportunities to share information and get support and inspiration from like-minded colleagues in the birthing field. I hope this blog serves to connect people interested in normal birth, both new and expectant mothers as well as childbirth professionals.
Cara emphasized the importance of not pathologizing long labors. When the baby is in the occiput posterior (OP) position (back of the baby's head is facing the back of the mother, accounting for about 15-30% of labors), latent labor can last three to four days while the baby's head molds to fit into the mother's pelvic opening. Long labors are not harmful to mothers or babies, rather, they are physiologically normal. The head must mold before the cervix can open, and it's best to simply wait it out without wearing the mother down or suggesting that the she is at fault.
Cara pointed out that women are looking for any excuse to believe they are inadequate. It's no wonder sometimes, when you look at hospital practices, in the case of long labors, for example. Most doctors would never let a woman labor for three days. She would be called in to the hospital, given Pitocin to augment the labor, and the cascade of interventions would begin, potentially leading to a cesarean birth.
We know this happens often in many hospitals, including those in Bangalore, where cesarean rates tend to reach 70%. (The world health organization (WHO) recommends a safe target rate of 10-15%.)
It was pretty amazing to be back at an MDG meeting; more than twenty doulas attended, including a few from the Brooklyn group I'd been hosting at my apartment in New York last year. I miss going to regular meetings and consistently having opportunities to share information and get support and inspiration from like-minded colleagues in the birthing field. I hope this blog serves to connect people interested in normal birth, both new and expectant mothers as well as childbirth professionals.
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