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| 12/13/2005 11:06 PM |
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B"H
Dear Henci,
I am an educator and doula in a religious community where women typically give birth to many children. A phenomenon that I am seeing that is really worrying me is that when a women has a section, then a failed VBAC, and thus another section, and perhaps someone will do a VBAC after two C's , but then she can stop hoping of a vaginal delivery around here (and I bet just about anywhere in this country), on the grounds of safety, and yet the same OB looks her in the eye, knowing she's religious, and says, "No Problem. You can have ten children and I'll deliver them all by cesarean. It's fine." this gives me hives, Henci. I have not seen any research to prove any such practice; however, since you're on top of the research bit, I'd love to know if you have seen any such thing. I am trying to put together a local public speking engagement on cesarean awareness for local women, probably for the spring, and I need to get my ducks in a row.
Also, my doula client who just had her first section and was told these things had an oblique baby after 5 hours of labor, fully dilated, with ruptured membranes, and the doctor said he could not try for a version without any amniotic fluid. I suggested amnioinfusion, and he said it would all just pour right back out. I suggested tilting her. He said that wouldn't work. Then he sectioned her using a horizontal cut higher up than the usual low transverse cut and now broke the news to her two weeks postpartum that as far as he's concerned she will have to always endure a repeat cesarean. And this is our doc who will do a VBAC after 2 c's! Is all of this right? I just did'nt have enough experience to say otherwise and I felt so much desperation. On this note, do you think it would be wrong if I got a doppler or fetascope to assess position of baby in labor as a doula? It's helpful in diagnosing OP babies and then I could do something to help. With this women, if I had known her baby was malpositioned, I could have brought her into the hospital sooner and maybe they could have turned it. If I tell people that I'm not doing it from a clinical perspective, would I still be out of bounds as a doula? Is that so bad if I'm helping people?
WOuld appreciate some guidance. Haven't slept as well since this birth. It was like the energy got ripped off in midstream. gotta get to another one.
Thanks,
Shayna
By: shayna |
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| 12/15/2005 11:14 PM |
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The obs who say "no problem" to multiple c/secs are dead wrong. Here are the results from a recent study of 3191 women from a high parity population (Makoha FW, Felimban HM, Fathuddien MA, et al. Multiple cesarean section morbidity. Int J Gynaecol Obstet 2004;87(3):227-32.):
•Morbidity indicators significantly associated with number of cesareans (p-value for 1-2 cesareans vs. 3 or more cesareans):
o placenta previa: 3.9% 1 prior; 3.2% 2 prior; 5.1% 3 prior; 6.9% 4 prior; 9.4% 5 prior;
16.9% 6 or more prior (p < 0.005)
o placenta accreta: 0% 1 prior; 0% 2 prior; 1.1% 3 prior; 1.1% 4 prior; 5.3% 5 prior; 6.5%
6 or more prior (p < 0.001)
o previa with accreta: 0% 1 prior; 0% 2 prior; 22.2% 3 prior; 12.9% 4 prior; 50.0% 5
prior; 38.5% 6 or more prior (p < 0.001)
o severe adhesions: 0.2% 1 prior; 11.5% 2 prior; 26.0% 3 prior; 44.8% 4 prior; 54.5% 5
prior; 50.6% 6 or more prior (p < 0.001) Adhesions prolonged operating time and
increased likelihood of transfusion.
o hysterectomy: 0.1% 1 prior; 0.1% 2 prior; 0.7% 3 prior; 0.2% 4 prior; 1.2% 5 prior;
3.9% 6 or more prior (p < 0.04)
o bladder injury: 0% 1 prior; 0.3% 2 prior; 0.8% 3 prior; 1.3% 4 prior; 2.4% 5 prior; 3.9%
6 or more prior (p < 0.02) Likelihood of bladder injury related to number of cesareans,
adhesions, and hysterectomy.
o blood transfusion: 6.3% 1 prior; 7.2% 2 prior; 7.9% 3 prior; 10.3% 4 prior; 14.1% 5
prior; 19.5% 6 or more prior (p < 0.003)
• Composite morbidity scores for all indicators [estimated from bar graph]: 13.2 with 1 prior; 13.3 with 2 prior; 13.5 with 3 prior; 13.9 with 4 prior; 14.2 with 5 prior; 14.2 with 6 or more prior. After controlling for maternal age, parity, operator experience, and gestational age, number of cesarean sections remained a predictor of morbidity.
The babies of subsequent pregnancies don't fare so well either. Here's data on 434 women from Seidman DS, Paz I, Nadu A, et al. Are multiple cesarean sections safe? Eur J Obstet Gynecol Reprod Biol 1994;57(1):7-12. In this analysis of medical records, investigators set up two comparison groups for 154 women undergoing their fourth or greater cesarean: 132 women of similar age with 4 or more prior spontaneous births and 148 women undergoing their second or third cesarean. They included the vaginal birth control group to evaluate whether some of the complications seen with higher order cesareans had to do with grand multiparity per se. As you can see, it didn't.
• Perinatal outcomes: The investigators note that the excess in preterm birth was not due to poor timing of planned elective cesareans, but to non-elective preterm cesareans usually for preterm labor.
o gestational age < 37 wks: 16.2% study vs. 11.5% cesarean control vs. 2.3% vaginal
control (p < 0.05 for study vs. vaginal control)
o birth weight < 2,500 g: 16.1% study vs. 12.8% cesarean control vs. 5.3% vaginal
control (p < 0.05 for study vs. vaginal control)
o respiratory distress syndrome (RDS) Type 1 (not defined): 7.8% study vs. 5.2%
cesarean control vs. 0% vaginal control (p < 0.05 for study vs. vaginal control)
o RDS Type 2 (not defined): 5.3% study vs. 0.7% cesarean control vs. 0% vaginal control
(p < 0.05 for study vs. each of the control groups)
o admission to neonatal intensive care: 7.1% study vs. 4.1% cesarean control vs. 0.8%
vaginal control (p < 0.05 for study vs. vaginal control)
As for carrying a fetoscope, I don't recommend it, and if you are DONA certified, your role is specifically limited to labor support only. Listening to fetal heart tones even if it is only to assess position almost certainly crosses that line. (Any DONA-certified doulas out there who want to weigh in on this?) Fortunately, it isn't necessary. If you suspect the baby is OP, none of the strategies for coaxing the baby into the anterior position will do any harm if it turns out you were wrong. In any case, you described this baby as "oblique." That is crossways, not OP.
Finally, according to the research, the success rate for turning breeches in labor is extremely low if the membranes are ruptured. Oblique would seem to present the same problem.
I'm sorry for the frustration and distress this birth must have caused you as well as the consequences for your client. One thing you can do for her is to validate her feelings if she has negative feelings about the experience. She may be hearing from others that "the most important thing is a healthy baby." While that may be true, it isn't the only thing. One can acknowledge the rightness of the choice and still feel angry, disappointed, sad or whatever at the same time.
-- Henci
By: Henci Goer |
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