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- Headed towards a cliff....

Last Updated: 6/9/2012

Okay, so WHAT IF....you are on a run in a new-to-you neighborhood and you are headed towards a cliff.  You are picking up speed now and I can see you from a distance and I KNOW for a FACT that if you do not change your direction you are going over the cliff and may end up dead.  You may NOT, but you will certainly fall off and there will be injury.  So I already tried to warn you once, but you said that you already talked to someone in that neighborhood that lives on that street and they said you're FINE....that direction is just FINE...and you trust that person cause it IS their STREET...they LIVE there.  They are one of the security guards for the neighborhood.  Plus you really LIKE them.  Should I just walk away and be done?  After all, I DID warn you so my responsibility is satisfied, isn't it?  Should I stand there and watch you and be ready to help you pick up the pieces?  Am I my brother's keeper?  So the fact of the matter IS that either that security guard is LYING to you, or he is mistaken.  Now what?  You would expect that I would KEEP TELLING YOU until you actually fall off the cliff, after all what kind of human being will let another human being harm himself in that manner without trying to help with all of his might?

If you have gone into your obstetrician's office at 36 weeks and been told you need a cesarean because your baby is too big, or too small, or in the breech position, or the cord is around his neck, or there is more than one baby or (insert another reason here)...then you are headed towards that cliff and you are now picking up speed.

Some valid reasons for a cesarean:

  • Complete placenta previa at term (the entire cervical os is covered with the placenta)
  • Transverse lie (baby is lying sideways across the top of the pelvis, *very* rare at term)
  •  Prolapsed cord (the umbilical cord, the baby’s lifeline, is being born before the baby)
  • Placental Abruption (the organ that sustains the fetus has torn away from the uterine wall)
  • Eclampsia or severe preeclampsia (illnesses often preventable with good nutrition)
  • Large uterine tumor which blocks the cervix (a "roadblock” for the baby’s descent)
  • True fetal distress confirmed through various means (EFM/IFM, ultrasound, CVS, etc.)
  • True CPD (baby ‘too big’- extremely rare and only associated with a pelvic deformity.)
  • Initial outbreak of active herpes at the onset of labor (primary outbreak with open sores)
  • Uterine rupture (this is extremely rare, most often associated with Cytotec usage and                                                                                                                     any induction of a VBAC mom)
  • Uncontrolled diabetes in mother
  • HIV or Hepatitis C
  • Heart disease
  • Baby with spina bifida or hydrocephalus

http://www.natural-pregnancy-mentor.com/reasons-for-a-c-section.html

Dr. Elliott Berlin, DC, Lowering the C-section Rates, TB Conference Session 2010

The Essential C-section Guide, Maureen Connolly & Dana Sullivan, pgs 8-11

                                                     Cesarean Rates in Ohio

I may have missed one or two but: breech birth, big baby, small baby, cord around the neck baby, multiple babies are NOT reasons for an automatic pre-emptive cesarean.  A cesarean is NOT just another way to have/birth a baby.  It should be reserved for life-threatening situations.  In those cases it is indeed a blessing to be able to utilize to save a life.  It is MAJOR surgery and has its own set of risks and they are NOT minor.  The risks should be weighed against the benefits when deciding whether or not the situation warrants such extreme measures.  The risks lie with the mother/baby.  They BELONG to them.  They are the ones who will live with the results of the decisions and procedures.  They risks should be considered and DECIDED by the mother, NOT the doctor.  He should be giving the mother ALL of the information and allowing HER to be the one who decides WHICH set of risks she wants to assume.  True informed consent involves ALL of the information and the ability to DECIDE.  If you are not able to say no, then you cannot truly say yes either.  You cannot make an intelligent informed decision when some of the information is missing.   You are having a disservice placed upon you when any physician wants to make decisions FOR you.  If he says, "you MUST XYZ" instead of, "here are your choices, here are the risks, which risks do you choose?" then you are not experiencing true informed consent.  If he tells you that breech babies are too risky for a vaginal birth without telling you what the risks are for a cesarean birth....and if he doesn't tell you that cesarean born breech babies typically do NOT do any better than vaginally born breech babies....then you are not getting the whole truth.

There are considerable risks to having a cesarean surgery.  If you think that you are removing the risk to the baby by having a cesarean, then you are mistaken.  You are just choosing a DIFFERENT set of risks.  Compared with vaginal birth, babies born by cesarean section are more likely to experience these immediate risks:

  • Accidental surgical cuts, sometimes severe enough to require suturing. 
  • Being born late-preterm (34 to 36 weeks of pregnancy) as a result of scheduled surgery. 
  • Complications from prematurity, including difficulties with respiration, digestion, liver function, jaundice, dehydration, infection, feeding, and regulating blood sugar levels and body temperature. Late-preterm babies also have more immature brains, and they are more likely to have learning and behavior problems at school age.
  • Respiratory complications, sometimes severe enough to require admission to a special care nursery, even in infants born at early term (37 to 39 weeks of pregnancy). Scheduling surgery after 39 completed weeks minimizes, but does not eliminate, the risk. 
  • Readmission to the hospital.
  • Childhood development of asthma, sensitivity to allergens, or Type 1 diabetes. 
  • Death in the first 28 days after birth.

http://www.lamaze.org/WhoWeAre/PositionPapers/PositionPaperTheRisksofCesareanSurgery/tabid/554/Default.aspx

Silent Knife, Cesarean Prevention & VBAC, Nancy Wainer Cohen & Lois J. Estner, pgs 26-40

If you are not also considering the risk to your FUTURE children then you are also making a decision without all of the information. With prior cesarean, women and their babies are more likely to experience serious complications during subsequent pregnancy and birth regardless of whether they plan repeat cesarean or vaginal birth. The likelihood of serious complications increases with each additional operation.

Compared with prior vaginal birth, prior cesarean puts women at increased risk of: 

  • Uterine scar rupture. Planning repeat cesarean reduces the excess risk, but it is not completely protective. 
  • Infertility, either voluntary (doesn’t want more children) or involuntary (can’t have more children). 
  • Cesarean scar ectopic pregnancy (implantation within the cesarean scar), a condition that is life-threatening to the mother and always fatal for the embryo. 
  • Placenta previa (placenta covers the cervix, the opening to the womb), placental abruption (placenta detaches partially or completely before the birth), and placenta accreta, (placenta grows into the uterine muscle and sometimes through the uterus, invading other organs), all of which increase the risk for severe hemorrhage and are potentially life-threatening complications for mother and baby.
  • Emergency hysterectomy. 
  • Preterm birth and low birth weight.
  • A baby with congenital malformation or central nervous system injury due to a poorly functioning placenta. 
  • Stillbirth.

Silent Knife, Cesarean Prevention & VBAC, Nancy Wainer Cohen & Lois J. Estner, pgs 26-40

The Risk of Cesarean Surgery position paper, Lamaze Int.

Why do I even talk about this?  Why do I even care?  I have HAD cesarean surgeries, 4 of them, in fact.  I also had a stillbirth.  Nobody EVER ONCE TOLD ME that having a cesarean puts me at greater risk of having a stillbirth in the future.  NOBODY EVER WARNED ME....NOBODY....NOT ONE PERSON EVER!!  No doctor (had 4 DIFFERENT OBs that did those surgeries).  One of those OBs was a man from my church.  He was somebody I considered to be a good friend.  I actually still do consider him a friend even though I don't see him much anymore.  I still like him and still respect him.  THAT SAID....he did NOT GIVE ME TRUE INFORMED CONSENT!  He didn't give me any choice, he said I had to do it.  During that particular surgery my omentum was not "unfolded" before my surgical site was closed and so now I have a lovely shelf and I will never have a flat belly.  I also have adhesions which occasionally make intercourse extremely uncomfortable.  There is also a place on my belly around the scar that is dead to feeling.  I reacted to the suture material and the bandages and had a very long healing process after the surgery.  It interfered with breastfeeding and with enjoying my baby. 

But NOTHING compares to losing a baby by stillbirth.  There are no words to describe that.  When you enter into the grief of losing a child you are in a whole new reality, a whole new normal.  If you are going to RISK that, you should at least KNOW about it.  If there is a REAL imminent danger to yourself or your baby then that MAY BE a risk that you want/need to take.  You should be the one who gets to compare all of the risks involved from ALL of the choices and decide for yourself which course of treatment you want to take.

My doctor said I don’t have any choice, I must have a repeat cesarean,  can they really force me to?  Many women have been threatened by their care providers that they would be put under general anesthesia and sectioned if they sought care in the hospital, even if they were close to delivering the baby naturally. While these threats are intimidating, they are not supported in either legal or ethical guidelines. If your care provider performs surgery in spite of your refusal, you are within your legal right to file criminal assault and battery charges and, if you or your baby suffer an injury, you may also sue for negligence. Professional ethical guidelines state that a physician may only drop you from his care after giving you 30 days notice. This means that if you are within 30 days of your likely delivery date, your care provider cannot terminate your care. In addition, if you are pregnant and are outside of that 30 day time frame, your provider must give you a referral and ensure you are transferred to a specific provider. Physicians who fail to meet these guidelines may be charged with patient abandonment, which is grounds for malpractice and constitutes a violation of ethical conduct that could result in loss of licensure. While there is always the possibility that the local court could grant an order forcing you to undergo a cesarean, these cases have become very rare in the aftermath of several court rulings declaring that such orders violate the rights of pregnant women. As a result of these rulings, both the AMA and ACOG have revised their ethical guidelines to state that court-ordered cesareans are rarely, if ever, justified, and are most definitely not justified in instances where the proposed treatment poses any risks to the mother. In all 50 states, hospital and doctor attended VBACs are legal and in some states it is legal for a midwife to attend an OOH (out-of-hospital) VBAC (Kamel, 2009c).  However, of the women interested in VBAC, 57% are unable to find a supportive care provider or hospital (Declercq, 2006).  This is due primarily to the 1999 ACOG recommendation that a doctor be "immediately available” to perform a cesarean, yet they provided no clear definition or standard for where the obstetrician and/or anesthesiologist should be or what they could be doing. As a result, hospitals developed their own definitions producing differing VBAC protocols and requirements. The most severe variety was the institution of VBAC in one-third of all American hospitals (ICAN, 2009), disproportionally affecting women living in rural areas.  As the new ACOG (2010) guidelines retracted this problematic proposal, hopefully VBAC will become a viable option to the many women who desire it (Kamel, 2010c).

Your Right to Refuse, What to Do if Your Hospital Has Banned VBAC, ICAN White pages PDF

http://vbacfacts.com/

Isn’t it better to have a scheduled non-emergency cesarean than an unplanned emergency surgery?  The only way to know for certain that your baby is ready to be born is to wait for labor to begin on its own.  Some physicians would prefer to schedule it for the purpose of scheduling and/or their own availability but that is not actually the best thing for your baby.  He will also benefit from the flood of hormones that are available to him only in the labor process.  Labor prepares the infant to survive outside the womb by clearing the lungs, regulating heat, nourishing cells and ensuring that there is a rich blood supply to the heart and brain (preventing asphyxia).  A catecholamine surge in the fetus serves as a highly effective protection system.  The "stress hormone surge” not only protects the infant during birth, but also enhances his ability to function effectively by facilitating normal breathing.  Cesarean born infants are predisposed to breathing difficulties especially when there has been little or no labor prior to the operation:  no labor, no catecholemines.  Fewer catecholemines, less respiration.  Less respiration, more problems.  Some researchers have advocated administering catecholemines to surgically delivered infants.  However, these have not been proven safe or effective.  Others recommend that the cesarean not be performed until the mother has gone through at least some labor.

Open Season, Nancy Wainer Cohen, pg 116

http://www.askdrsears.com/topics/pregnancy-childbirth/pregnancy-concerns/vaginal-birth-after-cesarean/questions-you-may-have

Breech presentation is defined as a fetus in a longitudinal lie with the buttocks or feet closest to the cervix. This occurs in 3-4% of all deliveries. The percentage of breech deliveries decreases with advancing gestational age from 22% of births prior to 28 weeks' gestation to 7% of births at 32 weeks' gestation to 1-3% of births at term.

 Types of breeches

Frank breech (50-70%) - Hips flexed, knees extended (pike position)

Complete breech (5-10%) - Hips flexed, knees flexed (cannonball position)

Footling or incomplete (10-30%) - One or both hips extended, foot presenting 

Kneeling (rare) - both knees are coming first, the feet are folded up behind the baby's thighs.


 

What to do about a breech presenting baby would depend mostly on when you found it.  If you find it prior to labor you can do several things to encourage baby to change his position.

 

1.      Go see a chiropractor with experience in the Webster's technique and have it done several times over a few weeks until the baby turns.

2.      Laying on your back on a board or using pillows so that your head is about 40 degrees lower than your feet.  Called the Breech tilt, seen here, Spinning babies has excellent information on positioning. 

3.      Play music, preferably with headphones, placing them low down on your uterus.

4.      Shine a very bright light low down on your uterus, or even between your legs. This encourages your baby to turn towards the light to investigate.

5.      Have someone (preferably the father) talk loudly but soothingly to the baby, low on the belly, close to the skin, telling the baby to turn around, to come towards the voice.

6.      Also, talk to the baby about turning around. Command her/him to turn! (This works especially well if the father does it.)

7.      Do 100 pelvic rocks an hour along with everything else.

8.      Sometimes doing somersaults in the water can turn a baby, also walking on hands in the pool.

9.     What about your thoughts and/or fears? Consider meditating about what might be holding you back from wanting to go into labor and try to rectify it so that the baby will feel safe enough to be born.

10.  Elephant walking is walking on hands and feet instead of knees. As soon as you try it, you will see why it would work! It's very difficult to do, but it definitely helps loosen the baby up and out of the pelvic ring. Some people feel the baby turn as soon as they start doing it.

11.   Stimulation of the acupuncture point bladder 67 (located on the little toe at the outer corner of the nail).  This point lies on the little toe, just on the outside aspect of the toenail.

12.   Lie on a pillow with your bottom facing the wall and your feet up against the wall and extend your legs to tighten.  Alternate lifting your bottom off the pillow and resting it again.  Your hips should be higher than your shoulders.  Do this as many as three times daily for 15 minutes at a time. 

13.   Homeopathic Pulsatilla in 200C potency or higher. Have the mother take one dose every 3 days while doing tilt exercises.

14.   Moxibustion:  This form of traditional Chinese medicine involves burning a moxa (mugwort) stick near a certain point on the small toe of the foot (bladder 67). You can find practitioners in a variety of settings including the acupuncture clinic and other practitioners.

15.   Acupuncture

 

http://spinningbabies.com/baby-positions/breech-bottoms-up/telling-if-babys-breech

http://www.americanpregnancy.org/labornbirth/breechpresentation.html

http://www.naturalqi.com/moxibustion_turning_breech_baby.html

If you are worried about a breech vaginal birth or if your provider refuses to allow you that option, I suggest you go to Lisa Barret's website and read everything she has written, and watch her videos.  You will see it is a do-able situation.  You will see gentle and safe births.  The times when you have injuries in vaginal breech births are when the provider intervenes and/or is not proficient in the skills necessary for a vaginal breech birth.  If your provider is not willing or skilled, you may look for one that is able.

 Some other resources:

http://www.birthingway.com/footling_breech.htm  planned breech home birth

http://musing-mommy.blogspot.com/2011/05/dont-schedule-cesareans-for-breech.html

There have been women that were forced to have surgery against their will.  Click here for Laura Pemberton's, testimony, forced by court order into a cesarean.   Fortunately her situation is rare, but I have know of other women being told one thing and then taken into the OR and forced into a surgery that they had neither agreed to or felt was needed.  It is important to have a relationship with a provider that you do trust/believe in.  That said, you must also realize that they are partially motivated by their own liability.  That is not their fault.  We live in an incredibly litigious society.  Obstetricians are especially vulnerable.  We expect and demand a perfect baby every time.  Sometimes that just is not possible.  Babies die.  It happens.  OBs are not God with the capability of saving every baby from every event.  Neither can they know which babies are going to NEED saving.  They don't get sued for doing too much though, they get sued for not doing enough.  Read midwife, Gloria LeMay's recent blog related to this issue.

Settle in your heart and mind which set of risks you choose for yourself and your baby.  Weigh the opinions of your provider carefully.  At the end of the day, you are the one who goes home with your baby and the consequences of the birth you've chosen.  While he may like you, he won't remember you for very long.  Demand full informed consent and research for yourself!  If he tells you "studies show" ask to see them or which studies. 

 

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