A Trip to the Anti-Spa

Frank hates haircuts. He hates them. He hates them more than he hates the doctor's office. As soon as we walk into the haircut place, he starts screaming. He doesn't stop screaming until 45 minutes after we leave. Yes, we hear THIS for an hour straight:




That's why we wait so long between haircuts. It's unfortunate, though, that Frank has hair that grows like a weed patch, because he needs haircuts.

BEFORE

AFTER

A FEW WEEKS LATER

The World According to Bel - August 21, 2009

... gazillion one, gazillion two, gazillion three, gazillion four, gazillion five, gazillion six gazillion seven, gazillion eight, gazillion nine, infiniti!

Infiniti one, infiniti two, infiniti three, infiniti four, infiniti five, infiniti six, infiniti seven, infiniti eight, infiniti nine, infabble!

Infabble one, infabble two, infabble three, infabble four, infabble five, infabble six, infabble seven, infabble eight, invfabble nine, one thousand!

One thousand one, one thousand two...

Still Single at Four

Belén initiated an interesting conversation with me the other day. On our way home from work and school, out of the blue she said, "Mom, I haven't found a boy I want to marry yet. I just don't want to marry any of the boys I know. What am I going to do?! I'll never find a boy to marry!"

You can about imagine what I was thinking. I laughed out loud. The sheer absurdity of her comment was funny, but it was made even more funny by how seriously devastated she was. She really was sad because she didn't want to marry any of the boys she knew, and she thought she would have to choose the least bad among them or not have a husband at all.

I love teachable moments as a parent. I used this one to explain that most of us don't meet our soul mates until we are adults or at least close to it. She found that surprising, and it reminded me of the perspective of a child. I remember being a kid and believing that my parents had known each other forever. It is hard to imagine your parents not knowing each other. Bel expressed concern that maybe there isn't a boy out there for her. I told her that I believe there is somebody out there for everybody and that she would find her soul mate someday. I told her that I believed her soul mate was probably wondering where she was right then, too. I watched in the rear view mirror as she turned to look out the window and seemed to let her imagination take her away.

And at that moment I realized that somewhere out in the world there is probably a little boy who will one day sweep my baby girl off her feet and marry her. I wonder what he is doing right now. I wonder if he, too, is sad that he has not yet met Bel. Then I thought better. If that little boy is out there somewhere, he is probably eating worms and throwing dirt at girls like Bel.

MEDSCAPE ARTICLE: When Will We Get It?

This is the final post on the Medscape article with Pamela Spry. (I know, already?!)

Today's topic is interesting. It's also quite frustrating. Dr. Spry talks about how slow our country is to respond to medical research. She cites our worsening maternal and infant mortality rates in this country and points out that we are not yet responding to these numbers. Her hope, like mine, is that education and awareness will prompt a shift in our maternity care system that will eventually lead to healthier births.

The Real Risks for Cesareans: An Expert Interview With
Pamela K. Spry, BSN, MS, CNM, PhD

by Dr. Katharine Hikel

(part 13)

Medscape: Obstetrics is a surgical specialty. So far, the significant numbers of women now practicing in the field have done little to change the surgical view of birthing women. Do you think there will be a tipping point away from the surgical approach to birth among obstetricians?

Dr. Spry: Sometimes it takes us years to figure out what we've been doing wrong; this is an alarming aspect of surgery, and few women are aware of the poor state of maternity care that we have in the United States. Many women assume that because they're birthing in the United States, they're getting quality care. Research and outcome studies suggest that this isn't necessarily the case, but I don't think our population knows that yet. We're seeing an increased number of maternal deaths. We haven't seen an increase in maternal deaths in this country for a long time. [An example of a delay in recognizing risk of accepted treatment is, that] in the 1950s, 1960s, and 1970s, we gave diethylstilbestrol to women to prevent miscarriage. It wasn't until the next generation, and even after the next generation -- 30 years -- that we got rid of that practice. So I think change will come. And I think that we need to continue to perform research, monitor maternal morbidity, and look at these statistics, and then we'll see a shift.

The other issue is that really adverse, terrible events are rare; maternal deaths are rare, even though they are increasing. So an obstetrician having a personal experience of a maternal death is infrequent.

Essential skills are being lost in obstetrics -- for example, breech deliveries or twins. However, they are preserved in the world of midwifery.

I hope that we get the message across that women want and need a positive birthing experience, and that they will choose a birth team that will support that goal. We would like for everybody to have a safe and healthy birth.

References

MEDSCAPE ARTICLE: Empowerment and Disempowerment

When I read this interview question and answer from Medscape's article on cesarean risks, I don't think the question is specific to cesareans. I think it is universal to all births where the mother is placed in a passive role or left without any decision making authority regarding her baby and her birth.

Some women are empowered by birth. They come out of the experience feeling as if they can do anything. Other women come out of their birth experience feeling the opposite, usually if they perceived that they were not in control of the decisions being made during the birth. As a result, these women feel disgust toward themselves, about the way their birth went, or toward those who cared for them during the birth. These feelings often cross into how women view themselves as mothers.

What do you think?

The Real Risks for Cesareans: An Expert Interview With
Pamela K. Spry, BSN, MS, CNM, PhD

by Dr. Katharine Hikel

(part 12)

Medscape: As the concept of birth transitions from a physical, sexual, and societal passage to a billable surgical procedure, placing women in a more passive role, how is the overall well-being of women affected?

Dr. Spry: Within the maternity system, there's a distinct drive toward convenience: predictable process of labor and birth, maximized reimbursement, and limited liability. All of these factors can lead any care provider to make decisions that aren't necessarily based on the mother's and baby's needs. Women's decisions are affected as well, because without maximum reimbursement, they can't select a place of birth that they can't afford. I think it's critical for every birthing woman to recognize the realities of the environment and be prepared to advocate for herself, taking a more active role in her birth. This is something that Lamaze focuses on.

Studies have been done where a woman has experienced a kind of birth that she didn't want, and she felt that she had no control over it. Penny Simkin just gave an excellent talk on the risk of posttraumatic stress syndrome resulting from a birth in which a woman felt not in control, who felt decisions were made for her and were imposed on her. I think that sense of control is really important to the mental health and to the feeling of being competent and OK after birth.

References

MEDSCAPE ARTICLE: The Role of VBAC

As we continue to read Pamela Spry's response to Medscape questions on the issue of cesareans, we were bound to talk about the decline of VBACs (vaginal birth after cesarean). Dr. Spry believes that fear of litigation and high hospital insurance (covers litigation against hospitals) are the culprits of the decline of VBAC.

There was legislation proposed in the Minnesota legislature this year that would have guaranteed women access to facilities that would allow VBAC. It didn't pass in part because hospitals claimed that their insurance companies wouldn't cover them if they allowed VBAC.

The Real Risks for Cesareans: An Expert Interview With
Pamela K. Spry, BSN, MS, CNM, PhD

by Dr. Katharine Hikel

(part 11)

Medscape: What's your perspective on recent reports about the rate of repeat cesareans jumping from 65% to 90% between 1997 and 2006?^[22]

Dr. Spry: Again, I think it's litigation fear. There have been more and more restrictions placed on women who want to have VBACs. Some insurance companies won't cover clinicians or hospitals [if they provide a trial of labor after cesarean; and] there are certainly clinicians who won't do VBACs. Women are finding it more and more difficult to seek and have a vaginal birth after a prior cesarean.

I just went to a conference where I talked to a number of women whose previous experience was with c-section, but who wanted a vaginal birth. Some of them chose home birth for their next pregnancies because it was their only option.

References

MEDSCAPE ARTICLE: Private Insurance

For those of you who follow health care reform, this interview question to Pamela Spry by Medscape's Dr. Katharine Hikel will be of interest to you. This is just one more reason why our leaders need to look at evidence-based care for solutions to controlling health care costs and promoting better outcomes. Turns out that Medicaid mothers are less likely to have a cesarean than women with private insurance. It has to do with where the women give birth.

What does your health plan encourage you to do?

The Real Risks for Cesareans: An Expert Interview With
Pamela K. Spry, BSN, MS, CNM, PhD

by Dr. Katharine Hikel

(part 10)

Medscape: In 2005, surgical birth was the most common Medicaid-billed procedure, performed on women who are most likely at risk for the poorest aftercare, complications, and support. Why is this population at highest risk for c-section?^[21]

Dr. Spry: I don't think this statistic indicates that the Medicaid population is at highest risk if they were compared to the insured population. I think that a large part of the Medicaid population consists of pregnant women, because this is a time when they can get coverage. So Medicaid often ends at the 6-week postpartum exam. A childbearing woman would be more likely to be covered under Medicaid than a woman in her forties who needed gallbladder surgery.

There have been a couple of studies that looked at the cesarean delivery rate of women with private insurance delivering in private hospitals, and found that privately insured women had a higher surgical risk than the Medicaid population. The rate in New York was 30% for private vs 21% for Medicaid, if the Medicaid women delivered in a public hospital (a teaching hospital). So what has happened is that we've had somewhat of a shift of Medicaid patients moving into the private sector; they've shifted their deliveries from teaching hospitals to private institutions, and this has increased their probability for cesareans.

A study from Kaiser in California showed that this increased risk persists even after adjusting for patient demographics and clinical factors. The risk was associated not so much with Medicaid, but with delivering in a private institution. Teaching hospitals tend to follow evidence-based practice, and encourage women to deliver vaginally.

References

MEDSCAPE ARTICLE: Cesareans and Breathing

There is something to be said for the perfection of the human body. We often wonder why we have to experience labor. Well, there is a purpose. Actually, there are many, but we are talking about just one of them here. The squeezing of contractions helps clear the baby's lungs in preparation for breathing. Babies breathe better if they have experienced labor. Babies born vaginally breathe better than those born by elective cesarean. Dr. Pamela Spry talks about that in the Medscape interview we've been discussing. What she doesn't mention here is that babies born via cesarean who have experienced labor breathe better than babies who were not exposed to labor. In other words, even if babies don't pass through the birth canal, they seem to benefit from labor. Some labor is better than no labor, even if a cesarean is needed.

The Real Risks for Cesareans: An Expert Interview With
Pamela K. Spry, BSN, MS, CNM, PhD

by Dr. Katharine Hikel

(part 9)

Medscape: Even truly full-term infants born by cesarean end up in intensive care more frequently than their vaginally born peers. Is this because such infants born by cesarean are high-risk to begin with, or is the procedure itself responsible for this?

Dr. Spry: I think that it's both. I definitely think that some medically indicated surgical deliveries do end up with babies that were higher-risk to begin with. But if you compare low-risk babies that are born by cesarean with vaginal-birth babies, vaginal-birth babies do better. There is an increased likelihood of babies born surgically having problems with fluid in the lungs and less ability to clear it. So actually going through the birth canal seems to be better for the baby.

References

MEDSCAPE ARTICLE: Induction

I think this issue, addressed in the Medscape article with Pamela Spry I've been writing about, cannot be covered in a one paragraph response to an interview question. This issue is incredibly complex, and it's a hot issue right now. The American College of Obstetricians and Gynecologists (ACOG) just issued an opinion advising against elective induction prior to 39 weeks due to the medical risks associated with induction. There are risks with the procedure itself as well as the risk of forcing the birth of a premature baby or a baby whose lungs are not yet mature enough for breathing.

While there is support for ACOG's issuing a formal statement on elective induction, there are a lot of doctors and medical experts who are arguing that it doesn't go far enough. After all, given that most babies are born after their due dates, why 39 weeks? Some have responded that ACOG should have said 40, 41, or 42 weeks or should have advised against any induction that is not medically indicated. (When I can gather all the articles I've read recently on this issue, I'll post a rant and will link them all.)

As I said, Dr. Spry addresses this issue only briefly here. I wish she had expounded more. Oh well.

The Real Risks for Cesareans: An Expert Interview With
Pamela K. Spry, BSN, MS, CNM, PhD

by Dr. Katharine Hikel

(part 8)

Medscape: There's a marked trend toward inducing delivery -- vaginally or surgically -- before 40 weeks, with mounting evidence that this is risky business. Where is this coming from?^[20,21]

Dr. Spry: This increased induction rate has occurred for several reasons: the desire on the part of the women or the providers to arrange a convenient time for delivery. Again, it's a scheduling issue. Concerns about postmaturity, or a post-dates baby, with a fear of adverse outcome and litigation may have contributed to this. But despite the large number of women experiencing induction, one-half of the women who responded to the "Listening to Mothers" study said that they felt that labor should not be interfered with unless it's medically necessary. Eleven percent of the mothers also said that they had experienced some pressure from their care providers to have an induction. Lamaze gives this information to women to help them select their place of birth and communicate with their healthcare provider. These tools can assist women in having a safe and healthy birth.

References

MEDSCAPE ARTICLE: Postpartum Rest

So, I bet you are wondering if this interview with Pamela Spry is ever going to end. It will, but not today, and probably not even tomorrow.

There are so many factors that come into play with postpartum depression. Just one of them is the cultural pressures on women to get up and out immediately after their babies are born. When Bel was born, I was out and about and planning parties and shopping and having play dates and running around and... wearing... myself... out.

With Frank, I made no plans. I stayed home. I recovered. I bonded with my baby. I just took... it... easy. Isn't it amazing what we learn from our first-borns?

Should I launch into my pitch for decent maternity leave for American mothers? Nah. I won't. You can probably guess what I'd say, anyway.

Here is Dr. Spry's comments on the postpartum "lying-in" and postpartum depression.

The Real Risks for Cesareans: An Expert Interview With
Pamela K. Spry, BSN, MS, CNM, PhD

by Dr. Katharine Hikel

(part 7)

Medscape: The recovery period after any birth, from time immemorial known as the "lying-in" period, used to last several weeks after a birth. Now, even after surgical birth, women are up and around within a few days. Postpartum depression is another health consideration that has been much in the news lately. Do you think we have lost something with this shortened period of rest and recovery?^[19]

Dr. Spry: I do. Studies have shown that it's better for mothers and babies to stay together after birth. Experts agree that unless a medical reason exists, healthy mothers and babies should not be separated following birth. Interrupting, delaying, or limiting the time that a mother and her baby spend together may have a harmful effect on their relationship and on breast-feeding. Babies stay warm, cry less, and have a better start on breast-feeding if moms and babies are together.

[As for the question about depression], women with postpartum depression do experience difficulty bonding with their babies. But this could be a result of depression rather than the cause, so it's really hard to answer [whether a shortened period of recovery is related to causing postpartum depression]. Most people get 6 weeks off of work, but even in those 6 weeks, women are still running around [trying to take care of other children, do chores, and manage the household]. I don't know whether we, as a culture, discourage mothers and babies to be together in the postpartum period by no longer posting signs on the doors that say "Don't knock, baby sleeping!" I'm just not aware of any comparative studies on how different postpartum protocols correlate with postpartum depression.

References

MEDSCAPE ARTICLE: Home Birth is Child Abuse

Today's question presented by Dr. Katherin Hikel to Pameal Spry in the Medscape article I'm covering is especially close to home for me. (Yeah, lame pun.) Every time someone comments on my home birth by saying, "Yeah, well, we chose to have our baby delivered in a hospital because we wanted to ensure our baby was safe," I go berserk. First, babies are not delivered by anyone. Mailmen deliver mail, but nobody delivers a baby. Women give birth to babies, for crying out loud. Second, the implication in that statement is that women who give birth at home are making dangerous or irrational choices that put their babies in danger.

I've started to just smile and nod to those comments. You see, I know better. I know, because Andrew and I researched this issue extensively before choosing to give birth to Frank at home. The evidence shows that not only is home birth as safe as hospital birth for low risk mothers and babies, but the research is even showing that home birth may be safer than hospital birth. I am unaware of any credible research supporting the argument against home birth for low-risk pregnancies.

Anyone surprised? I was when I first learned this.

I am not saying that every woman with a low risk pregnancy should give birth at home. I am an advocate for informed choice, and women should be supported in their choices, including women who choose home birth. Now you know the facts, too, and can support the women in your life who make this choice.

The Real Risks for Cesareans: An Expert Interview With
Pamela K. Spry, BSN, MS, CNM, PhD

by Dr. Katharine Hikel

(part 6)

Medscape: A story in The New York Times recently reported that women who have c-sections seem to have fewer children. That story provoked over 200 comments, from women who have had all of their children by planned cesarean to women who had had births at home. A strong fear-driven contingent regarded childbirth as fraught with pain and danger, and that anyone who risked giving birth outside of a hospital was committing child abuse. Can you discuss any evidence comparing the risks to mothers and children between in-hospital and at-home births?^[18]

Dr. Spry: A number of studies have looked at this. Some of the criticism of these studies has been that hospitals end up with higher-risk women, so it's an unfair comparison. But there are studies of low-risk women who had a planned home birth with a qualified birth attendant, compared with low-risk women who chose hospital births; the outcomes for home birth were better or as good as outcomes for women who birthed in hospitals.

Each study limits what kind of comparisons are made, but certainly women with previous surgical uterine scars, medical complications, or breech babies are all considered high-risk.

References

MEDSCAPE ARTICLE: Are We Truly Informed?

Today's post on the Medscape article series I'm covering this week is about informed consent for cesareans. The heart of the issue is whether women choosing or agreeing to cesareans are truly informed of the risks. Of course, in a true medical emergency where a mother's or a baby's life or health is in danger, we all would choose a cesarean. I've always been grateful that we have access to cesareans for when we need them.

But that isn't the issue here.

The whole point of this question in the article is that we know that most cesareans are either not medically necessary or are caused by unnecessary interventions in birth. Knowing that, and knowing that may choices made in birth significantly increase the risk of cesareans, are women truly informed of the risks? Are the women in our country educated on this? If we aren't, why not?

The Real Risks for Cesareans: An Expert Interview With
Pamela K. Spry, BSN, MS, CNM, PhD

by Dr. Katharine Hikel

(part 5)

Medscape: What are the main risks these days with c-sections? Are these risks underplayed by obstetricians, and, if so, why?

Dr. Spry: Many of them were covered in the introduction. Any time we schedule a surgery or an induction, we are assuming that we know the baby's due date. Anything that's scheduled before a woman's estimated due date could result in a baby being born before it's ready. [And iatrogenic prematurity is a reality with any scheduled birth -- that is, due dates may have been calculated wrong and inadvertently, babies are born before they are actually term.] We're getting more research looking at the near-term preemie. We find that they have breathing and developmental problems and that the risk for death is increased. Certainly, cesarean delivery increases the risk for the baby being injured from the incision. Surgery also carries risks for women, such as blood loss, clotting, infections, severe pain, and adverse anesthesia-related events. This is something that we haven't focused on, and I'm not certain that informed consent includes this information -- that there are complications during future pregnancies and that it does risk future children. There is an increased risk for stillbirth with a second or third c-section, as well as placental problems like percreta and accreta (abnormal growth and attachment of the placenta into the uterus), increasing the risk for hemorrhage. Women may experience dire complications as a result -- bladder injury, hysterectomy, and maternal death. I don't know that I would describe these risks as "underplayed" by obstetricians, but rather that women are not prepared to ask the right questions that lead to informed decision-making.

It would be interesting to read the informed-consent documents for cesarean deliveries, and see what risks are included.

References

MEDSCAPE ARTICLE: Financial Incentives

Ah, another day, another section of the Medscape article The Real Risks for Cesareans: An Expert Interview with Pamela K. Spry, BSN, MS, CNM, PhD.

Today's question presents is an interesting perspective on compensation rates for medical providers, especially given the current atmosphere around health care reform. Industry leaders and political leaders are searching for ways to reimburse medical care based on outcomes as a means to reign in excessive health care costs. In other words, medical providers would be paid based on the quality of care, not the quantity of patients seen. I am not completely sold on the idea that Dr. Spry talks about, but it is an interesting idea.

The Real Risks for Cesareans: An Expert Interview With
Pamela K. Spry, BSN, MS, CNM, PhD

by Dr. Katharine Hikel

(part 4)

Medscape: The culture of hospital obstetrics seems designed for interventions, with cesarean procedures bringing in more money than natural delivery. Do you think hospital financial incentives are a reason for the rise in cesareans? Or would the costs for longer hospital stays with cesarean procedures balance out the revenues from them?^[17]

Dr. Spry: I think that sometimes financial concerns, convenience, or concerns over lawsuits do rule medical decision-making around childbirth. When women have a good understanding of what constitutes quality care, they are in a better position to ask for it from their care providers. Interestingly enough, I just returned from our nurse-midwifery convention in Seattle, and I heard a speaker address this very thing: reducing the cesarean rate. Among his suggestions was the provocative notion that providers should be reimbursed the highest rate for labor and vaginal birth after cesarean, followed by labor and vaginal birth, and the lowest reimbursement for scheduled, elective cesarean delivery. That way, providers would be compensated for their actual time involved in the process, and scheduled c-sections would have the lowest reimbursement. He thought that would make a difference.

References

MEDSCAPE ARTICLE: Fear! FEAR! FEAR!!!

Today is day three of my series on the Medscape interview with Pamela Spry. I really agree with Dr. Spry's position here. I do think that women seek medical interventions during birth out of fear of the unknown.

We are a culture that is not exposed to birth. Raise your hand if you've seen someone give birth. The only hands I see going up out there are fathers who watched their children be born, doulas, and my daughter, Belén. (I trust any exceptions will comment.) The closest most of us have to seeing birth before we ourselves are expected to give birth - or for fathers and partners, to support their wives while giving birth - is what we see on TV. You have no idea how many jokes doulas crack over "birth" on TV, whether we are taking about Rachel on Friends or the completely ridiculous portrayal of birth on TLC and The Discovery Channel. We cringe and kick the wall every time we have to counsel a pregnant woman who says that her friend (or sister, or coworker, or stranger in Target) told her about her birth and how horrible it was.*

What exposure do we have to just plain, normal birth?! Do any of us know that the grand majority of babies are just born without drama, without medical emergencies, or in some cases even without pain? Is it any wonder we American women are scared when we go into labor? Is it any wonder we relay on epidurals, Pitocin, and cesareans to "help" us?

I have shared with some of you, and will post about someday, my perspective that pain medication in labor doesn't treat pain - it treats fear.

But I digress again. Let's hear what Dr. Spry has to say about fear and cesareans.

The Real Risks for Cesareans: An Expert Interview With
Pamela K. Spry, BSN, MS, CNM, PhD

by Dr. Katharine Hikel

(part 3)

Medscape: Could fear be the reason for women agreeing to surgical birth? Are women enduring pain differently than in previous decades? Is the surgical scenario easier to contemplate than the unknowns of a natural labor and delivery?

Dr. Spry: Exactly. I think all of that has to do with the fact that our culture actually breeds fear around childbirth. We've got TV shows, popular culture, and horror stories from friends and families; women are taught to expect a negative experience and incredible pain. Lamaze is focused on trying to help women get the facts, know what to expect, and help take the fear out of the process. But the unknown parts, such as labor, its duration, birth, and even the unknown of when labor will start, makes it more appealing for some women to schedule a cesarean.

*My opinion, as a doula, is that births that are difficult, have medical emergencies, or venture off a birth plan can still be wonderful if the mother is empowered to make her own choices and is supported in the process. In other words, a birth does not need to be "perfect" to be wonderful. And births that aren't "perfect" don't need to be horrible experiences.

References

MEDSCAPE ARTICLE: Demand-Side Birth?

I am continuing my series on the Medscape interview with Pamela Spry. She is responding to a common explanation provided for America's extremely high rate of cesarean birth - that women are demanding cesareans and providers are simply responding to women's request for surgical birth.

As I always say, show me the money - er, the data!

The Real Risks for Cesareans: An Expert Interview With
Pamela K. Spry, BSN, MS, CNM, PhD
by Dr. Katharine Hikel

(part 2)

Medscape: Are rates of surgical delivery being driven up by women or clinicians? Is this the age of Blackberry birth -- scheduling everything ahead of time?^[16]

Dr. Spry: Actually, there are 2 parts to this question. One is, what has driven up the rate of repeat cesareans, and that answer is easy: there has been a big decrease in the availability of choosing to labor and deliver vaginally (VBAC) after having 1 or 2 previous cesarean births, causing a huge increase in the rate of surgical delivery [for repeat cesareans]. Compared with the early 1990s when VBACs were encouraged and acceptable, many hospitals, insurance companies, and clinicians now refuse to allow women to try laboring after a previous c-section because of perceived medical and legal risks.

The second part of the question is whether women or clinicians are responsible for the increase in the primary c-section rate, and I think that's more difficult to answer. In a study of more than 1500 women, we tried to determine just that. The research results indicated that only 1 woman in the study actually reported that she requested a cesarean, which leaves the decision for the vast majority of cesarean deliveries up to clinicians. So understanding when cesareans are medically necessary, as well as the risks involved, is important in achieving a safe and healthy birth.

Although it might be convenient, babies who are born before they are ready are at increased risk for major medical problems.

References

MEDSCAPE ARTICLE: Trending Away From Normal Birth - Or Are We?

I just learned of an article called The Real Risks for Cesareans: An Expert Interview with Pamela K. Spry, BSN, MS, CNM, PhD, by Katharine Hikel, MD, on Medcape OB/Gyn Women's Health. I found the article interesting for a few reasons. First, it's nice to read an article about birth practices that is evidence-based. Second, none of the information here was new to me, so it is reassuring to me that I've been presenting childbirth education sessions on accurate, current medical research. I occasionally present childbirth education sessions for The Childbirth Collective, an organization whose principals and philosophy rely on using only evidence-based information to educate parents and the community on childbirth and the postpartum period. In other words, you get objective information, not personal opinions. I strive for the same in my babbling here.

The article is fascinating and educational. I'm going to share it here, one question at a time. Each question is a post of its own, because they each require mental - and in some cases emotional - digestion. Today's post consists of the editor's introduction and the first question presented to Dr. Spry.

Enjoy. Absorb. Share.

The Real Risks for Cesareans: An Expert Interview With
Pamela K. Spry, BSN, MS, CNM, PhD
by Dr. Katharine Hikel

Editor's Note:

Cesarean section (c-section) is the most commonly performed surgery in the United States. The frequency of surgical birth has increased from 4% in 1965 to about 33% today, despite World Health Organization (WHO) recommendations that a 5% to 10% rate is optimal and that a rate greater than 15% does more harm than good.^[1-3]

Reasons for this increase have been discussed profusely:

• The surgical focus of obstetrics and the need to train residents;
• The low priority and few practical skills for supporting women's abilities to labor and give birth naturally;
• A rigid view of the duration of normal labor; and
• A low threshold of definition for 'labor dystocia' (the justification for up to 60% of cesarean births^[4]).

Surgical birth is also a 'side effect' of interventions associated with actively managed labor: induction, artificial rupture of membranes, labor medications, and fetal monitoring.^[5,6] Policies against vaginal birth after cesarean (VBAC) and, increasingly, unsupported 'supply-side' justifications such as "baby seems large," also drive the trend toward cesareans. A recent report by the Lamaze Institute associates surgical birth with obstetricians' personalities -- specifically their anxiety levels.^[7-9]

The risks for birth by surgery have also come under discussion. Maternal risks include a higher overall death rate, rehospitalization for wound complications and infection, placenta accreta and percreta (both with 7% mortality rate), placenta previa, uterine rupture with subsequent pregnancy, and preterm birth, with its own set of risks and complications for the newborn.^[10-15]

Pamela K. Spry, BSN, MS, CNM, PhD, the President of Lamaze International, a leading childbirth-advocacy group, spoke with us about the risks for birth by scalpel.

Medscape: Childbirth methods are often trend-driven. In the 1960s and 1970s, there was a big push for natural childbirth. What has driven women away from that method since then?

Dr. Spry: In the 1960s, women were rebelling against twilight sleep -- childbirth under heavy narcotics that required being strapped down to the delivery table. There was also the push for fathers to be in the delivery room, which wasn't allowed, and certainly not during heavily sedated birth. Now we have a widespread availability of local and regional methods of pain relief that let women be awake and aware, share the birth with their families, and basically rely on technology to assist them at birth. I think this drive has been somewhat alleviated, but there is still a push for natural childbirth. This is the reason women are still seeking classes, making birth plans, and choosing home birth and birthing centers.

"Natural childbirth" can mean different things to different people. For Lamaze, it means a birth that's allowed to happen on its own without the use of unnecessary medical interventions, to provide women the safest and healthiest birth possible.

References

1. The Childbirth Connection. Why does the national U.S. cesarean section rate keep going up? Available at: http://www.childbirthconnection.org/article.asp?ck=10456 Accessed June 18, 2009.
2. The Childbirth Connection. Relentless rise in cesarean section rate. Available at: http://www.childbirthconnection.org/article.asp?ck=10554 Accessed June 18, 2009.
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Hush Little Baby

Frank's consistently favorite book is called Hush Little Baby by Sylvia Long. It is an improved version of the classic lullaby of the same name. If you recall, the classic lullaby is sung by a mother offering to buy her baby things like diamond rings and horses with carts. She keeps promising to buy more items if the ones she initially buys break or spoil. Sylvia Long wanted a healthier version of the song for her children, one where the mother singing is encouraging her children to find comfort in the things around them, including their mother's love, rather than in purchased items. Her book is the new lullaby accompanied by beautiful drawings of a mother rabbit and her young child.

Frank and I have read-sung this book countless times over the last two years. He often requests it as his bedtime story, and he nearly always requests it as his lullaby song. (I sing him a lullaby every night when I tuck him in.) He can even sing the first line himself, now.

I enjoy Sylvia Long's version of the song. I hope you do, too. Here is it:

Hush little baby, don't say a word,
Mama's going to show you a hummingbird.

If that hummingbird should fly,
Mama's going to show you the evening sky.

As the nighttime shadows fall,
Mama's going to hear the crickets call.

While their songs drift from afar,
Mama's going to search for a shooting star.

When that star has dropped from view,
Mama's going to read a book with you.

When that story has been read,
Mama's going to bring your warm bedspread.

If that quilt begins to wear,
Mama's going to find your teddy bear.

If that teddy bear won't hug,
Mama's going to catch you a lighting bug.

If that lightning bug won't glow,
Mama's going to play on her old banjo.

If that banjo's out of tune,
Mama's going to show you the harvest moon.

As that moon drifts through the sky,
Mama's going to sing you a lullaby.

- Sylvia Long