Sections
Perhaps it's fitting that this week containing the Ides of March also brought to my attention two articles about cesarean sections, the operation Julius Caesar was supposedly born by and to which he lent his name. The first article, called "Cesarean delivery and the Risk Benefit Calculus", by Drs. J.Ecker and F. Frigoletto of Boston, is in the March 1 New England Journal of Medicine. It gives a brief review of cesarean sections and includes some fun facts about them.
In 1937, the percentage of deliveries done via C-section at Boston City Hospital was 3%. In 2005, national rates of C-section are slightly more than 30%. In 1937, 6% of primiparous women - women having their first baby - who delivered via C-section died following the surgery. Fortunately, the mortality rate following C-section now is much less. I'm not sure of the exact number, but it's something like one in every several thousand sections. The authors suggest some reasons for the increased rate of C-sections, including a decline in the number of vaginal breech births - a C-section is nearly always done now in such deliveries; an increased number of multiple gestations (twins and triplets, etc.); decreased numbers of forceps and vacuum deliveries; and lower rates of vaginal births in women who previously had C-sections.
Anecdotally, fifteen to twenty years ago there seemed to be a big emphasis among obstetricians on trying to decrease the rates of cesarean sections, and I simply don't see that attitude any more. I don't blame my obstetric colleagues, because they have a pretty tough job. I just think that with newer data showing harm after breech vaginal deliveries and vaginal deliveries following C-sections, a relatively high rate of sections is simply accepted as a cost of decreasing neonatal injuries.
Speaking of neonates, the second article I noticed is in the March Journal of Pediatrics. The article, by a group from Italy, shows that the incidence of pneumothorax - a collapsed lung - in neonates is greater following cesarean sections than it is following vaginal deliveries. Also, in term babies delivered via C-section, the incidence of pneumothorax is greatest for babies born at 37 weeks, less for those born at 38 weeks, and even less for those born at 39 weeks. None of this will greatly surprise neonatologists. We can pretty much tell you from personal experience that the chance of a baby having respiratory problems is greatest following a C-section not preceded by labor, less if the C-section had labor preceding it, and even less following vaginal birth; and if born via C-section, the more mature the baby is, without going post-term, the better his chances of not having breathing problems.
Tough questions regarding C-sections come when a very premature baby, say at 23 to 24 weeks, needs to be delivered. Given the baby's lower chances of survival, is it justified to put the mother through the greater risk of a C-section versus vaginal delivery if the baby's condition warrants immediate delivery? I'll let my OB friends make that call - most of them seem willing to do C-sections at 24 weeks gestation but less so at 23 weeks - but would like to point out that when 30% of all deliveries are done via C-section, nearly every woman knows one or more persons who have had one and did fine, so it's tough to convince those moms of the added risks of a C-section versus vaginal delivery. I know, a C-section at 23 weeks has more risks than one at term, but still, the moms will usually gladly accept a greater risk to themselves if it means any advantage for their child.
In 1937, the percentage of deliveries done via C-section at Boston City Hospital was 3%. In 2005, national rates of C-section are slightly more than 30%. In 1937, 6% of primiparous women - women having their first baby - who delivered via C-section died following the surgery. Fortunately, the mortality rate following C-section now is much less. I'm not sure of the exact number, but it's something like one in every several thousand sections. The authors suggest some reasons for the increased rate of C-sections, including a decline in the number of vaginal breech births - a C-section is nearly always done now in such deliveries; an increased number of multiple gestations (twins and triplets, etc.); decreased numbers of forceps and vacuum deliveries; and lower rates of vaginal births in women who previously had C-sections.
Anecdotally, fifteen to twenty years ago there seemed to be a big emphasis among obstetricians on trying to decrease the rates of cesarean sections, and I simply don't see that attitude any more. I don't blame my obstetric colleagues, because they have a pretty tough job. I just think that with newer data showing harm after breech vaginal deliveries and vaginal deliveries following C-sections, a relatively high rate of sections is simply accepted as a cost of decreasing neonatal injuries.
Speaking of neonates, the second article I noticed is in the March Journal of Pediatrics. The article, by a group from Italy, shows that the incidence of pneumothorax - a collapsed lung - in neonates is greater following cesarean sections than it is following vaginal deliveries. Also, in term babies delivered via C-section, the incidence of pneumothorax is greatest for babies born at 37 weeks, less for those born at 38 weeks, and even less for those born at 39 weeks. None of this will greatly surprise neonatologists. We can pretty much tell you from personal experience that the chance of a baby having respiratory problems is greatest following a C-section not preceded by labor, less if the C-section had labor preceding it, and even less following vaginal birth; and if born via C-section, the more mature the baby is, without going post-term, the better his chances of not having breathing problems.
Tough questions regarding C-sections come when a very premature baby, say at 23 to 24 weeks, needs to be delivered. Given the baby's lower chances of survival, is it justified to put the mother through the greater risk of a C-section versus vaginal delivery if the baby's condition warrants immediate delivery? I'll let my OB friends make that call - most of them seem willing to do C-sections at 24 weeks gestation but less so at 23 weeks - but would like to point out that when 30% of all deliveries are done via C-section, nearly every woman knows one or more persons who have had one and did fine, so it's tough to convince those moms of the added risks of a C-section versus vaginal delivery. I know, a C-section at 23 weeks has more risks than one at term, but still, the moms will usually gladly accept a greater risk to themselves if it means any advantage for their child.
posted by neonataldoc at 1:21 PM
28 Comments:
cI vaginally delivered a 24 weeker in April. There was a time when I was told my baby was in fetal distress and my perinatologist discussed the pros and cons of C-section clearly stating that the cons out weighed the pros. I was fine with the C-section, as you noted in your blog, I would do anything for my baby. In fact I was screaming to get it thinking it might save my already fragile baby. My dr. was so against it that he pulled my husband aside and asked him to not allow the C-section saying that it was not worth risking my well being for a 24 weeker. My husband reluctantly agreed with the dr and when I heard that they weren't going forward with C-section I pushed that little baby out. NICU wasn't even present (a whole 'nother story!). Thankfully she survived without any brain bleeds and is home with me today. I don't know what her future will hold and it makes me sick sometimes to think about the challenges she might face. Although I did not agree with my perinatologist on many issues (he did not want us to resuscitate our baby) I do think he made the right call about avoiding the C-section and for that I am thankful.
Really interesting stuff. My 28 weeker was a matter of debate between 2 peris for c section vs vaginal delivery. 1 peri said his size (he was IUGR and 1.5 lbs) meant C section to save his life and the other argued against the risk to me. Ultimately I developed HELLP syndrome the night of his delivery and there was no choice in the matter. I had a crash c section to save us both.
I have had 2 C-sections, my son was breech (doc tried to turn him--ouch!), and my doc didn't want to risk a vaginal birth with my daughter (since I'd already had 1 section). Is it true that some docs will do repeat sections over VBACs because of mal-practice? I can't blame them if that is true...America has become sue crazy. Anyway, it's been in the news a lot lately about women having elective C-Sections....they are nuts....having my stomach muscles sliced thru didn't feel so great. I'm not against Sections or anything...I will do what my doc thinks is best because I trust him....but given a choice, I wouldn't have had one...recovery sucked (and I'm a pretty fit person).
Don't have much of an opinion here but I do want to say that is sure unfair that Caesar gets all the credit through history when it was his poor mother, Aurelia Cotta, who was sliced open! From now on, I am going to call them Aurelian sections!! People won't know what I'm talking about, but it will make me feel better (or at least give me a chuckle).
"I know, a C-section at 23 weeks has more risks than one at term, but still, the moms will usually gladly accept a greater risk to themselves if it means any advantage for their child."
Forgive me my ignorance, why higher risk at 23 weeks vs. term? I requested c-section over vaginal delivery when I went into labor, asking the doctor which would increase our son's chance. I believe it spared him a brain bleed, combined with the follow up NICU care to minimize stimulation. When planning for our next pregnancy, our doctor advised a VBAC if I got to term. We did, and delivered at a birth center. My 2 year old preemie and 6 month old term kiddo are both doing great.
I too am curious about the higher risks of a c-section at an earlier gestation. I had a c-section with my son at 24 weeks, although it was for my health not his. We didn't have time to discuss the risks and I was basically told that none of them were worse than what was going to happen to me if they didn't deliver (I had class 1 HELLP).
Correct me if I'm wrong, Neo Doc, but I assume you meant that any birth at 23 weeks is higher risk than at term. The precise risks/benefits of a cesarean versus vaginal delivery for preemies is still subject to considerable debate and there is very little consensus given the complex factors that influence the decision. What your OB may have said could well reflect personal preference and skill, rather than the latest scientific evidence.
Consider breech births. More than 95% are delivered by cesarean in the US and between 60% and 90% in many European countries following a landmark randomized trial known as the Term Breech Trial in 2000. This trial was so heavily debated (and flawed according to some), that six years after its publication, an article in ACOG's flagship obstetric journal called for the trial's recommendations to be withdrawn. See Glezerman et. al in AJOG Jan 2006; 194: 20-25. The trial's authors themselves adjusted their major conclusion two years after the fact and found no difference in mortality or developmental delay between the babies in the planned cesarean group those in the planned vaginal group.
Moreover, studies from France and Norway show much higher rates of vaginal deliveries of breeches babies, with far better outcomes than in the US. How so? Because European doctors are more familiar with vaginal breech deliveries, and follow a strict set of obstetric protocols to ensure the safety of the delivery. These protocols include pelvimetry, little or no induction or augmentation, and skillful obstetric techniques to assist the delivery. In the US by contrast, Pitocin is overused in breech deliveries and fewer and fewer doctors have trained in these techniques.
This is what I discovered, when I was pregnant with twins, the second of whom was breech. While the is still out on whether cesareans are best, I was unable to find a doctor willing to even consider a vaginal delivery. Luckily, I fell into the hands of an OB who was happy to deliver me vaginally at 26 weeks. I think the labor and the delivery were largely responsible for their fortunate outcomes in the NICU.
I have since read that contractions force fluid out of the lungs and hormones produced during labor actually hasten lung development just like surfactant. Research has shown that the absence of labor during cesareans is one of the reasons that near term infants delivered by cesarean wind up in the NICU and are far more prone to RDS (respiratory distress syndrome).
There is as much art as science in obstetrics, and I only wish that doctors could be as frank as Neo Doc about the the complexity and the debate around these issues. Perhaps they are uncomfortable admitting ambiguity or perhaps they think we parents are too stupid. I hope it is the former. Apologies for tooting my own horn here, but see my blog "breech mama" for more if you are interested.
You might like these stats too
http://www.inamay.com/statistics.php
Neonatal Doc,
For some reason, the post on nurses calling in sick is gone? I wanted to show it to a friend of mine, but it seems to have disappeared?
Thanks!
We can pretty much tell you from personal experience that the chance of a baby having respiratory problems is greatest following a C-section not preceded by labor, less if the C-section had labor preceding it, and even less following vaginal birth
If c-section micropreemies have a higher risk of respiratory problems than vaginally born micropreemies, wouldn't it follow that doctors should be advocating vaginal births for these babies? These kids already have so much stacked against them - do we add a higher risk of breathing issues on top of everything else?
I delivered my 25-weeker by c-section; I don't remember vaginal birth even being presented to me as an option at that point. As you said in your article, I'd have done anything to increase my son's chances. I can't help wondering, now, if he'd have had a better chance of survival with a vaginal birth. Maybe I'm reading things wrong here - but I've always been led to believe that c-sections are safer for preemies than vaginal births.
I'm a mom to a former 29+2 weeker and I am in the beginning of what appears to be another risky pregnancy.
My son was born vaginally and I hope this one will be as well. However, because at just 10 weeks pregnant, my blood pressure has already risen, I know that the chances of me requiring a c-section are increased.
As much as the thought of a c-section scares me, I'd gladly do so if it meant saving my child's life.
Thank you for your blog. I've found a good deal of useful information. It's nice to know that the neonatoligists don't just forget about their patients when they go home.
I cannot think of a sensitive way to say that the natural laws, which include survival of the fittest, must be in play here.
Probably a hefty percentage of what we do in medicine flies in the face of those laws.
And we want it that way. We want to save lives that would otherwise be "selected out". You can talk rather ojectively about "conquering a disease," as Ex Utero did recently when he said prematurity was a disease that he wanted to go away. But for parents, it is not so much a disease as it is OUR OWN CHILD. And we want to keep them, sometimes on any terms.
Our kids are not the fittest and many won't live independently, that is, survive, without a complext network of support that gets more complex as they get older. So, at some point, we became willing to circumvent the "natural laws" to keep them going, and once we did that, we were committed to keep on circumventing. "Oh, the tangled webs we weave . . ."
C-sections, to me, are just that. We have found a way to fool mother nature. I won't put words into Helen's mouth, but her stance and the stance of others who frequently respond here, are about the wisdom of circumventing,from my point of view.
I will give away my age by asking if anyone remembers the commercial that said "It's not nice to fool Mother Nature." The unhappy consequences, in part, put us in the ethical dilemma of figuring out where to draw the line with c-sections and respiratory problems in preemies and micropreemies . . . Okay, we gave them a respiratory advantage, but their heads "pounded on the perineum"--what a Sophie's Choice!!!
Clark may think he has a corner on the market of skepticism, but I make my skeptical claims about the saving grace of c-sections. Not only do I object to a c-section rate of nearly 50% at one of the hospitals in my area, but I think we are on a slippery slope with this kind of thinking, studies about better outcomes notwithstanding.
Chris and Vic
My son was born at 24weeks vaginally. I too have also heard that for micropreemies it is better to be born by c-section.
However with Ashton I did not have time for that. My entire labor was only about four hours. When I got to the hospital by ambulance where there was the NICU he was delivered about twenty minutes after getting there.
After he was born at 1lb9oz he had a massive bruise on his head for days. He suffered grade II bleeds bi-laterally.
I have to say out of the many moms that I met in the NICU there was only one other that delivered naturally.
Oh, and I also wanted to add that Ashton had severe respiratory problems. He just came off of oxygen at the age of 19months.
I'm the anonymous with the first comment about my vaginal delivery of my 24 weeker. I also delivered a 23 weeker vaginally who did not survive. I will say that I agree with Chris & Vic about natural selection and I also believe that my baby had a leg up by being delivered vaginally. I have read studies about the body under stress and how it compensates for the stress...meaning my body felt the contractions, the labor and knew that the baby was coming out and in turn sped up her development. Mind you, I was in labor at week 20 so I had 4 weeks of this 'anxious environment' and I also received dexamethasone, which I believe helped prevent brain bleeds---ND, please correct me if I'm wrong but isn't there some evidence of this being true, dexa is better than betamethasone?
Although I have a surviving micro preemie and I am so thankful for that I don't think saving 23 and 24 weekers via c-section is right or ethical. At some point you have to obey your body.
There is no good evidence that a policy of automatic delivery by c-section benefits the micropremie. In fact, some of the worst birth-associated trauma I've seen for these little ones has been from c-sections. Lots of bruising, sometimes requiring transfusion. Even though it seems like labor sort of squeezes them, there's no evidence that I'm aware of that vaginal delivery increases their risk for brain bleeds.
In terms of c-section for 23 weekers, I encourage patients to consider not having one. There's no evidence that it changes any outcomes for these little babies. The c-section is higher risk because the uterus is much different at 23 weeks than at term, and it bleeds more. It is also more likely to rupture and a 23 week c-section exposes the woman to the risk of a uterine rupture with subsequent pregnancies. 10% of these scars will rupture if the woman goes into labor... and a smaller but still significant proportion can rupture before labor. Of those who rupture, in 50% either the baby or the mom will die or be permanently injured. So, a 23-25 week c-section isn't a trivial thing. Ultimately I allow the patients to make the decision, but in our institution, we have such a low survival rate for 23 weekers that I honestly can't say that I can change that survival rate in any way with a c-section.
Then again, I'm a bit of a throwback. I offer women vaginal breech deliveries if they're good candidates. Your mileage may vary.
I was never given the choice. I had PROM at 23.0 weeks. I sat in the hospital until I developed an infection at 25.5 weeks. I had an amnio because of suspected infection. From the time the needle was out of my abdomen (filled with black fluid), to the time that Paige was out of my body, was under 20 minutes. I did NOT want a c-section. I had a client who was paralized from a spinal, just one month before. I begged but no one would listen. Paige was breech and the only spot of amniotic fluid I had left was black and green with infection.
Paige was vented for less than 24 hours and has better lungs than me.
My 2nd pregnancy was also a c-section (at 35.4 weeks) thanks to the first one.
My recovery was very fast and easy with both of them.
I'd like to emphasize that I don't think that women have to defend the cesareans they have have had for any number of good reasons. There is enough blaming of mothers in our culture, already, thank you. If anything, the OBs should be defending their practices, but on the basis of evidence not opinion or preference. Thanks midwife with a knife for adding more detail about the micropreemies. Hopefully there are more OBs like you out there.
Just because mothers will do anything for their babies---as anonymous said in the first comment---does not mean that we do not deserve to hear the full debate about the risks/benefits and what lies in store for our preemies or micropreemies.
In terms of the safety of vaginal deliveries, I would imagine that a 26 weeker (my case0 might be quite different from a 24 or 23 weeker. Many studies do not make that distinction, but simply refer to VLBW babes, ie. those under 1500 gms. Several of the twin studies I looked at note that there is no clear consensus on the benefits of planned cesarean over vaginal deliveries for twins under 1500 grams, but did not stratify by weight or age. See Caukwell S, Murphy D AJOG 2002; 187: 1356-61. and Hogle KL, Hutton EK, McBrien KA, Barrett JF, Hannah ME. AJOG 2003; 188: 220-227.
Another study that included all of Israel's 28 neonatal units concluded that mode of delivery had no effect on the rate of RDS or chronic lung disease in second twins, but that gestational age was far more important a factor. See Shinwell ES, Blickstein I, Lusky A, Reichman B. Archives of Disease in Childhood Fetal and Neonatal Edition 2004; 89.
So vaginal birth alone may not be able to prevent RDS, especially if if the infant is very premature. Shannon and other comments confirmed this experientially.
I jut wanted to point out the considerable debate in the twin literature around the presumed safety or benefit of elective cesareans. Many of us with twins assume (as I did until I read otherwise) that cesareans are safer than vaginal deliveries for twin preemies. Given that twin births are often more complex than singletons, I thought it notable that there is still debate about the safety of cesareans vs vaginal delivery for twins.
I had a C-Section with my 23 week twins this past September, first they were breech, but even if they weren't, I wanted what I was told was the best shot at saving them. I knew they were breech when I went into the hospital with preterm labor, (but 23 weekers move like crazy), options were discussed, and I consented to a section if they were to be born soon (obviously the idea was to try and stop my labor). Well after the NICU consult and the talk with my OB, I could tell my OB was not 100% keen on the idea. I'm assuming she didn't think sectioning 23 week twins was worth it for my well being. I was 23 at the time and planned on having more children (still do in fact), and she knew all of this. When I told her I wanted a C-section no matter what to try and save my twins, (I was told by the NICU team it would give the twins the best shot...reading what I've read since does not convince me of this), my OB told me that I would have to have c-sections for all of my future pregnancies, that it would be a vertical incision on my uterus as opposed to a normal horizontal one...thereby increasing the risk of uterine rupture in later pregnancies, that I was more at-risk for uncontrolled bleeding, and was in for a painful recovery. At the end of the conversation she said "there are a lot of risks, we should talk about it more if delievery becomes imminent." Well, she wasn't working 3 days later when I suddenly went from 3 centimeters to 10 without being checked in between. My daughter's foot was kicking the on call OB as she checked my cervix. Needless to say, my OB and I didn't have our talk. But, like I said, it wouldn't have mattered since I was told it was better to have one from the NICU team. An ultrasound was done and it showed they were still breech, (duh you felt my daughter's foot kicking you...), and I was immediately rushed to the OR and gave birth by emergency classical C-section (vertical incision on my uterus). I know future pregnancies will be at higher risk, I know I will have to be sectioned again, I know the risk of uterine rupture, and I know I probably should only have one or two more pregnancies because of my decision. But, I guess you're right, when you consent to having your 23 weeker(s) (or micropreemie(s) in general) treated, the focus is on giving them the best shot; and if you're told it is to have a C-section to avoid brain bleeds, get them out sooner if they are in distress, etc. I can imagine most moms would consent to the section. I know even the decision to treat 23 weekers is a debate in and of itself, and I have done a lot of reading and soul seraching with regard to this issue, (AFTER I made the decision, don't even get me started on the whole...how do you expect a mother in labor to make that kind of decision?), and although I still have meltdowns and have been known to excessively worry about the future, at the end of the day I can live with my decisions, and am happy I made them. My twins are home with us now and are doing well. I know the statistics, I've heard of horrible outcomes, but I was a willing and informed participant in my children's care from the time I decided to be sectioned, and that is what is most important. Drs and parents have to communicate. I know a lot of parents blame Drs for not telling them everything, and I am thankful I didn't have that experience. But parents also need to ask questions and do their part as well. Every parent should read these blogs before they even hit their 2nd trimester...in the midst of preterm labor pains, shock, and fear there is no time for 100% informed decisions. But wait a minute...even if there was time, would it change things? You have a medical team telling you there is a chance, you've seen the pictures and video clips of the miracles. Yours could prove the statistics wrong...right? Bottom line, you love this baby and you WANT him/her. Is an expectant mother in any position to decide to let her child die? I don't know. I think I'd argue that hindsight is a little clearer than foresight when it comes to this. So the debate continues...
*side note: my recovery was fine, I didn't even fill the prescription for pain meds upon discharge...not even the Motrin*
Buddhistmama wrote: "I'd like to emphasize that I don't think that women have to defend the cesareans they have have had for any number of good reasons."
After reading your post I went and re-read mine. I am not sure if you were talking about me but I wanted to clarify. My post did sound like I was defending the c-section, which I didn't mean to do. (after a week of dealing with my OCD preemie and a severe case of hives, I cannot be held to anything I say-hehe)
From the moment I got pregnant, I started saying that I would not have a c-section, under any terms. (HA! I guess I actually thought I was in control-lol). I guess my midwife got tired of hearing me be so worried about it. She confided in me that she had 4 children, all *elective* sections! Yikes!
Then, to have a client who was paralyzed from a spinal, I was terrified. I passed out from the anxiety as they were preparing me. Poor docs!
With my son (only 10 months ago) I told every doc that I was worried about the spinal. They all told me that they had never seen anyone become paralyzed from a spinal, although they had all heard about one or two. The day of my delivery I told the anaesthesiologist of my fears of being paralyzed. Poor guy. Talk about pressure. He did great and ended up being our best doc in the hospital (besides my awesome OB).
So, to make a short story long (I'm good at that). I am all for letting our bodies do their thing. I agree 100% with what Chris was saying in her early comment.
I remember the commercial that says, "It's not nice to fool Mother Nature." Wasn't it for margarine or something?
I'm not an obstetrician, and have not reviewed this subject exhaustively recently, but, although there may be some controversy, for extremely preterm babies a C-section is considered better if they are breech or transverse presentation but not if they are vertex, in which case vaginal delivery is just as good.
Midwife with a knife explains why C-sections at 23 weeks are riskier for the mom better than I could.
Anonymous 6:11, it's the other way around. Betamethasone is better than dexamethasone.
Elisabeth, it's a long story....
Midwife with a knife, more questions in response to your post - has anyone gathered evidence on outcomes for the 23 weekers delivered c-section vs. vaginal? I would like to read the study, I searched for info but I'm sure you have far more access to journals than me.
As for subsequent pregnancies, I found almost no information about pregnancy after micropreemie - let alone regarding risks of VBAC. Where did you find 10% of the scars rupture in labor after a micropreemie c-section? I asked specifically about the risk of it rupturing before labor, at any point after I passed 23 weeks, and my specialist had no information on that. And you said in 50% of the cases of rupture the mother or baby die or are permanently injured?? The statistics I was given were that less than 1% of women have uterine rupture, less if there has been a prior vaginal delivery, and maternal or fetal death from uterine rupture are rare. (The number I was given, since I have two prior vaginal deliveries and then a low transverse incision at 23 week section, was that I had about a .46% risk of uterine rupture.)
So, please share with me your information because apparently my sources are horribly misinformed. Since I hope for one more baby and planned a VBAC again, I would really appreciate reading these studies with such dramatically different statistics than what I was quoted. Or if anyone else has more info?
Sorry, another addition - when discussing delivery method at 23 weeks, I know statistics vary. If I was told our son had a 10% survival rate I don't know that I would have requested the c-section. But our peri team & NICU docs visited with us numerous time (I was living at the hospital) and said the statistics for their hospital were 50% survival at 23 weeks. If a c-section was going to bump that up even more, I wanted to sway those odds in our favor.
Like Elizabeth, I was puzzled by the disappearance of the tremendous response you got to your "Sick" post.
Actually, as a nurse, I was taken aback by the post. And I was doubly taken aback by its removal.
You say to Elizabeth that it is a long story.
I can only imagine that you took even more heat than the 39 responses you got from the readers/responders to that post.
I may be out of line, but I also imagine that once you go-public, as you did with your blog, and as you did in the newspaper article, you get back-talkers. The 39 responders to your post are your loyal opposition, Neonatal Doc, as well as your back-talkers.
You have freedom of speech on your side--you can say what you want, without identifying details, and so can we, your loyal opposition.
In support
Chris and Vic
heidi: The <1% figure is true for what's called a low transverse c-section. For a classical cesarean section (usually required at gestational ages <28 weeks because of technical issues which I won't bore everybody with), the risks are much greater (~10%) because vertical incisions don't heal as well. That's why people with classical c-sections aren't usually allowed to VBAC.
neonataldoc: Unless there's a study I'm not aware of, nobody's been able to show that a c-section for breech at 23-25 weeks improves fetal outcome. At 26 weeks, the outcomes start to be good enough that it is a little easier to make a difference. Having said that, a vaginal breech before the fetus weighs 1500 gms risks head entrapment because the head is bigger than the buttocks until about 1500gm, it is simply the unfortunate fact that the outcomes are so poor at 23 weeks that c-section doesn't make a statistically significant difference.
http://www.washingtonpost.com/wp-dyn/content/article/2007/03/16/AR2007031602097.html
---Anyway, it's been in the news a lot lately about women having elective C-Sections....they are nuts....
You know, I used to think this, too. But the surgery risks when you *don't* have general anesthesia are very very small.
---having my stomach muscles sliced thru didn't feel so great.
See, this is why anecdotal information is not very useful. I had a C section after a failed induction after my water broke on my due date at 40 weeks. I had *no pain* after the C section. I had discomfort, and i took ibuprofen for it, and that was that. no narcotics. I have had no problems with my bladder, no problems with back pain. I don't know why I had no pain--great surgeon? great uterus? the prior 12 hours of labor? no idea. What I do know is that none of the darn obgyns know either.
-- I'm not against Sections or anything...I will do what my doc thinks is best because I trust him....
I have stopped trusting my docs to make decisions based on evidence. I trusted my doc was the best surgeon in my metro location because i did my homework; I would again pick the best surgeon as my OB, even though it makes him more likely to be c-section-happy. Why? because I had no complications.
--but given a choice, I wouldn't have had one...recovery sucked (and I'm a pretty fit person).
see, my recovery was a piece of cake. Does that mean our own bodies dictate more than something else? I have no idea. But I was scared of labor, and I had a terrible time being induced. Given my recovery, I would again pick a C section. I no longer think women who want epidurals are insane, even though that whole back-stabbing thing is awful. I no longer think women who want surgery are insane, given labor pains. Some women don't have that. Would that any doc knew why...
I just stumbled across this blog and have found the comments very interesting. I have a question that maybe you all can answer for me...? I had a c-section due to fetal distress after PPROM at 28 weeks (first and only pregnancy so far). How does this affect my chances of going full-term in future pregnancies? I know the uterus is very capable of stretching, but I can't help but worry about the integrity of the incision site when I "stretch" beyond the 28 week point. Is there any evidence one way or the other? Ideally, I'd like to avoid another c-section, but a healthy, full-term baby, no matter how it is delivered is the priority for me.
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