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Cesarean

Q1: Should my daughter have a cesarean because the ultrasound shows a big baby?
Q2: Should a woman have a cesarean birth after a fourth degree tear with her first child?
Q3: Cesarean due to a myomectomy (fibroid removal surgery)
Q4: Cesarean for long-term damage from a 4th degree tear?
Q5: Having a caesarean because of operations to remove fibroids and breastfeeding while taking iron
Q6: Overweight and cesarean
Q7: A question on what advice to give on weight gain from a midwife
Q8: Physical condition is important for overweight women
Q9: Posterior baby resulting in cesarean?
Q10: Cesarean for Retinal Detachment
Q11: Cesarean advised for potential shoulder dystocia recurrence
Q12: Mother and Baby Friendly Cesarean Birth
Q13: Lamaze classes & cesarean birth
Q14: Delayed cord clamping and cesarean surgery
Q15: Do I need to have a cesarean because the doctor thinks my baby is big?
Q16: Childbirth Connection answers question of why cesarean rate keeps going up
Q17: Fear and scheduled cesarean birth study
Q18: Time limits placed on women in labor
Q19: Advice on scheduled cesarean births
Q20: Risk of uterine rupture after one and after two cesareans
Q21: Does elective cesarean lower maternal death?
Q22: New study "Study Finds Disparities in Maternal Care Among U.S. Hospitals"


 

Q1: Should my daughter have a cesarean because the ultrasound shows a big baby?

Q:  My daughter is 40 weeks today had an ultrasound and everything was fine except they said it looks like baby could be 9 1/2 pounds. The lady did say there was a 1.5 pound error range. Of course as soon as my daughter saw one of her obstetricians he said we need to do a cesarean because of the weight and the baby hasn't dropped.

A:   The research literature does not support inducing labor for suspected big baby, let alone planned cesarean surgery. Here is what the American Congress of Obstetricians and Gynecologists, the U.S. ob/gyn's professional organization, has to say about inducing labor and planned cesarean in its Practice Bulletin on managing suspected fetal macrosomia ("big body"): "Current evidence . . . does not support a policy of early induction of labor in term patients with suspected macrosomia," and, "The sum of these reports does not support a policy of prophylactic cesarean delivery for suspected fetal macrosomia with estimated weights less than 5,000 g [11 lbs]." ACOG also acknowledges the inaccuracy of fetal weight estimates in the Bulletin.

Worse yet, studies of inducing for suspected big baby uniformly find that a woman is much more likely to have a cesarean when her doctor suspects the baby will be big than when the baby actually is big (usually defined as estimated weight more than 4,000 g or 8 lb 13 oz), but her doctor didn't suspect it and vice versa. That means that whether your daughter has a cesarean if she labors depends more on her ob's judgment than on whether her body is physically able to birth her baby, and her ob is of the opinion that she can't. (I can supply multiple citations on this point if you or your daughter would like to see them.)

I think your daughter should find out if there is anyone in her group who doesn't routinely recommend induction or planned cesarean for suspected big baby. If there is, I would have a heart-to-heart with that person and ask that she or he agree to attend your daughter in labor even if it isn't their shift. Also, has your daughter hired a doula, a woman trained and experienced in labor support? It is great if she has because that will give her and her partner someone in their corner who can provide emotional support and ideas for how to help labor progress. If any case, here are some tips for maximizing the chance of birthing a big baby:

  • Begin labor spontaneously.
  • Stay home until in active, progressive labor. If you go into the hospital and it turns out you are still in early labor, go back home. 
  • Stay active in labor.
  • Push in an upright position so that gravity is working for you.
  • Use pain coping techniques other than an epidural so that you can stay active and push effectively.
  • Refuse a cesarean based on arbitrary time limits for making progress.
  • Give birth on hands and knees. or be prepared to turn to hands and knees if the shoulders don't come easily. (This can be done even with an epidural with help.) A study showed this position is most likely to avoid injury to mother or baby if the shoulders do hang up.

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Q2: Should a woman have a cesarean birth after a fourth degree tear with her first child?

Q:  Hi! I'm a new doula and I am working with a mom who had a routine episiotomy with her first birth which then extended into a fourth degree tear. Seven months after her birth she had correctional surgery because the tear did not heal properly. She is pregnant again and was told by the surgeon who repaired the injury that she should plan a Cesarean the next time around. After talking with her new OB, who is supportive of natural and low/no-intervention birth, she has decided to plan a vaginal birth. Her doctor encouraged her to hire a doula and plan to labor and deliver in ways that support the perineum to help prevent another tear. I am trained and well read but I could use some expert suggestions.

A:  I have good news for your client. The key factor to avoiding another anal tear is to not have an episiotomy. To a lesser extent, giving birth spontaneously is also protective. I have two studies looking at anal sphincter injury rates at the next birth after having one at the first birth:

Martin S, Labrecque M, Marcoux S, et al. The association between perineal trauma and spontaneous perineal tears. J Fam Pract 2001;50(4):333-7.

Peleg D, Kennedy CM, Merrill D, et al. Risk of repetition of a severe perineal laceration. Obstet Gynecol 1999;93(6):1021-4.

Martin et al. found that only 1% of 1,900 women having no episiotomy at the second birth had a repeat anal tear. This was the case even though 18% of the group had a vacuum extraction and 2% had a forceps delivery. Peleg et al. found that 2% of 290 women giving birth by their own efforts and not having an episiotomy had a repeat anal injury. No women having instrumental deliveries and no episiotomy had an anal tear, but there were only 17 women in this group. Among women having an episiotomy and a spontaneous birth (n = 376), the repeat anal tear rate rose to 11%, and it soared to 21% in women having both an episiotomy and an instrumental vaginal delivery (n = 56). A care provider who supports normal birth would surely refrain from episiotomy, but it wouldn't hurt to ask.

Other strategies to avoid a repeat anal injury based on the obstetric research would be:

  • Avoid an epidural. Epidurals increase the need for instrumental vaginal delivery and episiotomy.
  • Give birth in a position other than recumbent or semi-recumbent, in other words, upright, side-lying, or hands and knees. Women are more likely to have episiotomies and instrumental deliveries when they deliver on their backs.
  • A recent study found that neither warm compresses nor perineal massage at the time of the birth reduced tears in women attended by expert midwives who performed an episiotomy less than 1% of the time, but easing the head out in between contractions did. If she likes the sensation, though, warm compresses may help your client relax the perineum.

Common sense says to keep the legs comfortably apart for the birth. If the perineum is already at full stretch because her legs are wide apart, the perineum will have nowhere to go. Your client is likely to need extra reassurance at the time of the birth when she feels the burning sensation as the head comes through the vagina. Phrases such as "Let the baby come," "Ease the baby out," "Let go around the baby," or "Breathe the baby out," may prove helpful.

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Q3: Cesarean due to a myomectomy (fibroid removal surgery)

Q:  I have to have cesarean due to a myomectomy (fibroid removal surgery). Is Lamaze class still recommended although I'm not having a natural birth?

Lamaze classes are primarily intended to prepare you for coping with labor and for making informed decisions about labor. This would not apply to you if you are planning a cesarean. However, the International Cesarean Awareness Network has created a document that can help you prepare for a positive, family-centered cesarean experience. You will find it here. (not available)  Two other resources we can use:

From ImprovingBirth.org A Family-Centered Cesarean: Taking Back Control of My Son’s Birth

http://www.improvingbirth.org/2013/04/a-family-centered-cesarean-taking-back-control-of-my-sons-birth/

From You Tube: The Natural Cesarean
https://www.youtube.com/watch?v=m5RIcaK98Yg

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Q4: Cesarean for long-term damage from a 4th degree tear?

I had an epidural and episiotomy with my first child and ended up with a bad 4th degree tear.  I haven't had any more kids yet but I was talking with my new doctor and they said definitely schedule a Cesarean for the next delivery.   If I had known that I would have gotten a tear I would have just skipped natural birth all together.  The irreversible damage that I still live with to this day has had a major effect on my physical, mental and emotional health. My daughter got stuck behind my pubic bone and the doctor broke her collarbone just to get her out of me.  Vaginal birth is not worth it.

A:  I am sorry you have had this difficult experience. It may, however, have been avoidable, and you may wish to know this because cesarean surgeries have their own potential harms for you, the baby, and all future pregnancies. For one thing, studies show that episiotomy neither prevents nor relieves shoulder dystocia (when the baby's head is born, but the shoulders hang up behind the pubic bone). There is, if you think about it, no reason why it should, seeing as shoulder dystocia is not a soft tissue problem. You may also be able to avoid repeating the shoulder dystocia by giving birth on your hands and knees.
Whatever you decide for your next birth, you say you have experienced mental and emotional distress as a result of your experience. You may want to know about Solace, a peer support website for women who have had a challenging birth experience.

Additional resources:

Bruner JP, Drummond SB, Meenan AL, et al. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med 1998;43(5):439-43.

Dandolu V, Jain NJ, Hernandez E, et al. Shoulder dystocia at noninstrumental vaginal delivery. Am J Perinatol 2006;23(7):439-44.

Gurewitsch ED, Donithan M, Stallings SP, et al. Episiotomy versus fetal manipulation in managing severe shoulder dystocia: a comparison of outcomes. Am J Obstet Gynecol 2004;191(3):911-6.

Youssef R, Ramalingam U, Macleod M, et al. Cohort study of maternal and neonatal morbidity in relation to use of episiotomy at instrumental vaginal delivery. BJOG 2005;112(7):941-5.

Another related question about 4th degree tear and cesarean

Q: I had a spontaneous fourth degree tear with no episiotomy with my first.  Apparently, it is very rare.  Unfortunately, there is no way they know you're going to tear like that until the baby's head is crowning and at that point, it is too late to do anything about it.  I am pregnant with number two now and I still have not decided on whether I will have the cesarean or try it again vaginally.  The Ob practice I go to will support whatever I chose to do, but I can tell that they would probably chose the cesarean for me if they could.  I still have a little time to decide, so we'll see.  I'd like to add that I didn't have vacuum or forceps to assist with the delivery either.  In any case, I'm not upset with anyone about the outcome.  I healed up very well thankfully, which is why I am probably considering doing another vaginal delivery. 

A: If I may put in an oar, I would suggest you go for the vaginal birth. The deep tear is not likely to repeat. Among four studies I have on the issue, the repeat rate of anal injury ranged from 1% to 5% in women who had neither episiotomy nor instrumental vaginal delivery at the second birth. In other words, your odds are between 95 and 99 to 1 that you won't have a repeat. On the other hand, cesarean surgery poses a long list of excess risks to you and your baby and to any future babies as well. You will also be less likely to tear deeply if you give birth lying on your side or at the very least that you birth with your legs comfortably apart and not so far open that your perineum (the tissue between the vagina and the anus) is already at full stretch. Also, once the head is crowning, let the contraction do the work and breathe, rather than push, and ease the head out in between contractions.

Edwards H, Grotegut C, Harmanli OH, et al. Is severe perineal damage increased in women with prior anal sphincter injury? J Matern Fetal Neonatal Med 2006;19(11):723-7.

Martin S, Labrecque M, Marcoux S, et al. The association between perineal trauma and spontaneous perineal tears. J Fam Pract 2001;50(4):333-7.

Peleg D, Kennedy CM, Merrill D, et al. Risk of repetition of a severe perineal laceration. Obstet Gynecol 1999;93(6):1021-4.

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Q5: Having a caesarean because of operations to remove fibroids and breastfeeding while taking iron

Q:  I really want to have a healthy and safe pregnancy for both of us. I am now halfway thru the pregnancy. My gynecologist told me that I needed a caesarean for any pregnancy because I have had two operations to remove fibroids. We weren't sure I would conceive, but I did  - about 6 weeks after the second operation. My husband and I are delighted, but I wish I could have a normal birth. My family doctor says no, and she has sent me to an obstetrician, who also says I will need a caesarean. What advice would you give? Also, since we live in a small community we will be going to a city almost two hours away, where the obstetrician delivers, because the small hospital near my home doesn't have a paediatrician, and the baby may have some issues because it will not be full term.

Q:  And I have another problem - I have colitis, and as a result I have been taking iron pills for a long  time. My internist said I shouldn't stop taking the pills because I am now on a dose that seems to work well, after many years of difficulty. He feels that if I stop the pills that the complications and childbirth may make me really ill and affect the baby.  Now I am reading so much about how important breastfeeding is - and many articles about pregnancy make it seem like mothers who don't breastfeed are evil. It is really bothering me. I'm thinking about stopping the medication on my own ; the internist hasn't contacted me since I said that I was pregnant and couldn't go for an appointment, and my family doctor and  obstetrician really haven't discussed the  colitis with me . My husband thinks I should talk it over with them now -  and not wait until later. I told my mom; she isn't exactly excited about my idea but she breastfed us and  has always told me, before we knew that the iron would affect it, how pleasant and enjoyable she found nursing to be.

So I am very confused, and when I think about not nursing I am sad and upset, and I don't want to risk the baby's health or mine by not taking the colitis medication but I also want to experience nursing, both for the baby’s well being and to be the best mom I can be. What advice can you give? Are there any websites that I can go to get various perspectives  on both topics?  I'm looking forward to hearing from you. I feel that there are very few people who will understand these concerns that I have.

A:  It is not likely that you will find an ob willing to allow planned vaginal birth after having had uterine surgery, especially since your options are so limited. If you are still interested in vaginal birth, the best I can recommend is finding an ob to consult who attends vaginal births after cesarean (VBACs), and ask her or him to evaluate your case. The International Cesarean Awareness Network (ICAN) might be able to help you find the closest VBAC-friendly ob. That way, if the ob recommends planned cesarean, you can have confidence that it isn't just an automatic answer.

If you are ok with the planned cesarean, the references below can help you plan a family-centered experience.
http://www.improvingbirth.org/2013/04/a-family-centered-cesarean-taking-back-control-of-my-sons-birth/

From You Tube: The Natural Cesarean
https://www.youtube.com/watch?v=m5RIcaK98Yg

Also, to minimize the possibility of your baby experiencing respiratory problems, it is recommended that in the absence of strong medical indication for delivering the baby sooner, the surgery should be scheduled after 39 completed weeks of gestation, that is, no sooner than the week before your due date.

As for breastfeeding, I am not clear on why you are being told not to breastfeed. Certainly iron pills are no obstacle, and most medications can be continued while breastfeeding. I think your best source of information is La Leche League. I searched their website on "medications" and came up with information at: http://www.llli.org/faq/medications.html and http://www.llli.org/nb/nbmarapr08p32.html that should prove helpful. 

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Q6: Overweight and cesarean

Q:  I have a friend who is finally pregnant after 5 years of infertility.  She went to her doctor's appointment today and was told that if she gained any more weight she would need a cesarean.  She admits that she is overweight, but has been vigilant in her diet and is exercising daily, unfortunately she can't seem to keep the weight off.

Is there any reason that being overweight would automatically equal cesarean?

A:  No, but her doctor's statement is a good reason to find another care provider ASAP. Her doctor's belief in her inability to birth vaginally is extremely likely to become a self-fulfilling prophecy. The research is rock solid that cesarean rates depend far more on the individual care provider's judgment and practices than on factors that have to do with the woman. http://plus-size-pregnancy.org/ is a web site dedicated to pregnancy and birth in women of size that should prove helpful to your friend. By coincidence, this blog:  http://www.wellroundedmama.blogspot.com/on the site's associated blog, "The Well-Rounded Mama," is on finding a care provider.

While I'm at it, it sounds like your friend is taking good care of herself. She should know, though, that high BMI women should not attempt to lose weight or hold the line while pregnant. They should gain weight, but not as much as the average or low BMI woman.

Finally, if she has had difficulty conceiving, she may be especially vulnerable to the "premium baby" argument that a cesarean will be safest and best for her baby. This is absolutely false. Here is a link to a page on the Lamaze website on what best promotes safe, healthy birth: http://www.lamaze.org/HealthyBirthPractices

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Q7: A question on what advice to give on weight gain from a midwife

Q: I'd like to know more about healthy weight gain in an obese expectant woman.  I'm a midwife and have always recommended little to no weight gain in my obese mamas.  I had one woman who was 5' 4" 315 lbs. and planning her 3rd birth at home after 2 in the hospital.  She lost 13 lbs. during this pregnancy and I actually told her this was okay.  Unlike her 1st and 2nd babies who came 3 and 4 weeks early, she took this one to 40 weeks and it weighed 9 pounds (her others were 6 1/2 and 7).  Was this just unusual?  My women are all healthy Mennonite women who eat well and exercise.  I have example after example of women who gain little and have healthy outcomes.  I'm currently worried about my advice to a woman who is 4'10" and weighs 175 lbs.  I'm asking her not to gain weight at all and she has lost 2 or 3 lbs. by 26 wks.  She is expecting her 4th baby and all have been cesarean and she is planning another cesarean.  In my 11 years as a midwife, my nutritional advice has always been the same with overweight or obese women and the outcomes have always been apparently, great.  I'd hate to think I'm doing something harmful to these women or babies. I would really appreciate your advice. 

Oh, and as a side comment...I was an OB nurse for 10 years prior to becoming a midwife.  There is a strong bias against overweight women on the OB floor.  We always talked about how long we'd have to wait before the decision was made to have a cesarean.  We truly believed an overweight woman's body truly couldn't accomplish a natural birth.  It's a sad time in my "education."

A:  Many women of size gain little or no weight in pregnancy and are perfectly fine.  However, research shows there is room for concern in promoting limited weight gain as a goal for all women of size.

A very low weight gain increases the risk for prematurity, small-for-gestational-age babies (SGA), and possibly stillbirth.  Although the association between low weight gain and these outcomes is less strong in "obese" women, the risk IS still increased and caution is therefore prudent.  I particularly worry about the recent trend telling women of size to gain NO weight or even to LOSE weight during pregnancy.

Weight gain in women of size is highly variable. I've been collecting informal data via my website and casual surveys among women of size for years and my data -- plus data from official studies -- seems to confirm that weight gain in women of size is all over the map.  On average, they definitely gain less than women of average size, but if you look at individuals the results are highly varied.  A few lose weight during pregnancy, some gain almost nothing, most gain around 10-15 lbs., many gain 15-25 lbs., and a few gain more. 

Doctors usually assume that differing weight gains result from differences in caloric intake and habits, but I don't see that.  It's not irrelevant, but there's certainly not the direct connection many care providers expect.  A high BMI woman who gains 20 lbs. doesn't necessarily have worse habits than another who gains almost nothing.  There are a lot more variables than that. 

Women of size probably gain less on average because we already have fat reserves and physiologically do not need more for pregnancy.  Also, many find that pregnancy revs up an otherwise-sluggish metabolism, which leads many of us to gain less.  However, women who are chronic dieters or who have recently lost a lot of weight tend to have much higher weight gains.  And there are many other factors too....which is why prenatal gain is SO variable in women of size and doesn't necessarily coordinate with habits and intake.

Degree of "obesity" is another variable to consider.  Recent research shows that class I obese women (BMI 30-35) who gain very little weight are at far more risk for poor outcomes than class III obese women (BMI 40+) who gain little.  But that doesn't mean that no gain or weight loss in "morbidly obese" women is benign either.

Studies on restricting weight gain in women of size show varying rates of success.  Some find that regular nutritional consults and regular exercise help high BMI women gain less, but they also find that even on such a program, many "obese" women gain more than 15 lbs, despite doing everything "right." It's not just about intake and habits. 

Alarmingly, several of these studies found that the rate of too-small (SGA) babies increased in the women who gained little in pregnancy, but the authors consistently shrug off this finding as unimportant.  Many of the studies also conveniently do not examine prematurity or stillbirth rates, or are not large enough to conclude that no-gain interventions are safe. None of the studies involve long-term follow-up of babies exposed to restricted intakes, and few monitor the mothers for ketones (some research shows high or consistent levels of ketones may lead to cognitive impairment in the child). 
Therefore, I have strong reservations about strictly limiting weight gain in women of size. Personally, I think a dogmatic approach -- placing the goal on what the scale says rather than the daily nutrition and exercise of the mom -- is the wrong emphasis.  Don't manipulate a woman's nutrition to meet an arbitrary weight gain goal.  Instead, emphasize excellent nutrition and regular exercise, and trust the woman's body to gain what it needs.

A post from another reader with resources on pregnancy and BMI:

I am following the discussion and wanted to alert readers to the CMQCC website page on Pregnancy and BMI resources at: https://www.cmqcc.org/resources/maternal_data_committee/obesity_bmi_resources .  Please send additional resources to info@cmqcc.org to be considered for addition.   There are a range of issues that maternity providers need to consider when a woman with high BMI (>35) is admitted to the hospital. (I assume the issues are different for the home birth group).   I learned a lot about these systems factors at a recent maternity conference sponsored by an integrated/preventative focused health system.  From having the right size blood pressure cuff to ensuring that beds/tables and in-wall toilets can accommodate the woman's weight to concerns about administering an epidural safely to issues of staff safety in moving and physically supporting heavy women in labor and being sensitive to the weight issue as an emotional factor -- there are a lot of important issues and concerns that go into preparing a safe environment for a heavy patient.

We are currently doing analysis on three years' worth of linked data on California women's birth outcomes (vital stats-birth certificate and hospital discharge data) to examine the relationship between pregnancy BMI and birth outcomes.  This is the first ever large scale study of this type and was made possible when California added "pre-pregnancy" weight on the birth certificate in 2005.  Stay tuned for more on this as we complete our analysis.

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Q8: Physical condition is important for overweight women

Q:  Overweight women do not NEED cesareans!  I had 3 vaginal deliveries.  I am obese, have been for all three pregnancies.  Stressing fitness is the issue, rather than weight.  I have lost significant weight with all three pregnancies (not from trying) and I am CONVINCED that it is related to hormonal issues.  When my body is pregnant, my hormones stimulate my metabolism and I burn more calories.  I certainly do not exercise more during pregnancy but I feel better and my body is healthier during pregnancy than it is not pregnant.  If we would teach women to birth upright and get their muscles fit in the lower body before and during pregnancy we would have women who can birth their babies without intervention.  When the abdominal and groin area are completely out of shape, women CAN NOT push their babies out effectively, ESPECIALLY when they are laying on their backs.

Obese women are not all obese for the same reasons.  Just like some skinny women are naturally skinny and some are anorexic, there are reasons for obesity.  We are treated like imbeciles, like lazy oafs, like uneducated trailer trash because of our weight and this is unreasonable.  Overweight women need to focus on getting their muscles in shape for the delivery process rather than focusing on NOT eating something.

Just think, a large women who could hold her own weight.  The OB nurses would not have to worry about physically supporting her, only emotionally and medically.  That would be a nice change.

A:  You make some excellent points. I would add that the most important thing a woman of size can do to prevent a preventable cesarean is find a careprovider who doesn't think high BMI = cesarean.

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Q9: Posterior baby resulting in cesarean?

Q:  I was all set to have a natural birth. As is came closer to the due date (2 weeks out) preclampsia came about. The midwives were mentioning inducing, I held it off until I was spilling a large amount of protein. A couple of months out I would ask which way my baby was facing (my family has a history of 9 lb+ babies so I knew to have a natural birth it might be important to make sure he was faced correctly). When they began to discuss inducing, I was insistent that I find out which way he was facing. To which both midwives repeatedly said I should not worry about it because they have previously delivered babies posterior facing. On several occasions I asked, and they had the same reply. I responded to the pitocin 'well' fully dilating within 4 hours. At the end I was in a cesarean; the baby had to be vacuumed out of the cesarean with him having a big bruise resulting in bad jaundice. He stopped breathing the first night having apnea. They told me it was from the strenuous birth. So he was in the NICU at 8lbs 11oz getting an IV in his ankle, to which the nurse told me "I put the IV in wrong, the fluid leaked into his tissue." Resulting in a scar covering half his ankle now. (He is 9 months now.). It seems to me that if the midwives would have just checked which way he was facing, my body was prepared to get him out. Is it a standard thing that the midwives should have checked which way my baby was facing before starting me on pitocin? Thank you so much for taking some time to look at this.

A:  It sounds like you have had a difficult and distressing experience. I hope it comforts you somewhat to know that it doesn't help to know which way the baby is facing in pregnancy because babies continue changing which way they face even during labor. Having a baby in the favorable facing-your-back position at the onset of labor is no guarantee that the baby will stay that way.
http://www.ncbi.nlm.nih.gov/pubmed/15863533?dopt=Citation

As to why the baby was delivered through the cesarean incision by vacuum (which can cause a big bruise called a cephalohematoma) and that the difficult labor led to the apnea episode, I would take those with a grain of salt. The necessity for a vacuum delivery and the reason for the apnea episode may be true, but some obs are frequently or routinely resorting to vacuum delivery at cesareans and it is not uncommon for women who have made less mainstream decisions about their birth and have had the birth not turn out as planned to be told by disapproving mainstream medical staff that their decision or their care provider's care led to the problem.

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Q10: Cesarean for Retinal Detachment

Q:  I have a client who has been advised to have a cesarean for her first baby as she has a history of retinal detachment. This doesn't make any sense to me. Do you have any research on this?

A:  I don't have any research on this, but I can suggest questions your client should be asking whomever is giving her this advice:

  • What is the likelihood of retinal detachment?
  • What causes it? If, for example, it is caused by the increases in blood pressure during Valsalva maneuver pushing, the solution is to engage in spontaneous pushing, which is a better idea anyway.
  • If it happens, is it treatable? How likely is it that I will suffer permanent harm?

As for the other side of the equation, "What are the risks of cesarean surgery?", here is a link to a pamphlet that covers that base.
http://motherfriendly.org/Resources/Documents/TheRisksofCesareanSectionFebruary2010.pdf
As you can see, they are numerous and potentially severe so unless the risk of permanent blindness is high and unavoidable, I would stick with planned vaginal birth if I were her.

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Q11: Cesarean advised for potential shoulder dystocia recurrence

Q:   This is my third pregnancy; I'm at 37 weeks, and the OB just now recommended that we schedule a Cesarean for 2 weeks from now because 1) my previous two births had shoulder dystocia issues and 2) the baby is now breech.  I'm working on getting the baby to turn around through various exercises, and the OB offered to try an external version. But, she seemed mainly concerned with another shoulder dystocia occurring.  My first baby got stuck (I'm not sure for how long) and needed chest compressions for 90 seconds before she started breathing.  She was 9.5 pounds.  My second baby didn't seem to get stuck, but we discovered a day later that his collarbone was broken during delivery. He was 10.5 pounds.  I didn't and don't have gestational diabetes.  From reading the posts on the forum, I think I'm supported in my decision to go ahead with trying another natural birth with the added maneuver of delivering in a hands and knees position.  I guess I'm just checking that this is still a good idea!  Thanks!

A:  Not being a doctor or a midwife, I cannot give you advice on what do do. I can say, though, that hands and knees has been shown to be a safe, effective way of resolving shoulder dystocia, although you get no guarantees. On the other hand, cesarean surgery isn't risk free either. If you decide on vaginal birth, discuss your plan to use hands and knees with your care provider. Most doctors have never heard of it. Here is a study if your doctor wants to know more:

Bruner JP, Drummond SB, Meenan AL, et al. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med 1998;43(5):439-43.

P.S. I hope you can get that baby turned. I would do it sooner rather than later. And you may also want to look for a chiropractor who knows the Webster Technique. (This is a pelvic adjustment that makes more room for the baby to turn.) Care providers who will do vaginal breech births are as scarce as hens' teeth, and the fact that your babies are so big is not optimal for vaginal breech. Many only know of the McRoberts maneuver to correct shoulder dystocia.

As for hands-and-knees as a birth position, if your doctor is not familiar with it, her saying that the McRoberts maneuver is better may just be human nature preferring the familiar to something unfamiliar. Were I in your position, I would politely insist that she get a copy of the study and go over it together with you. Start with the old sales technique of making a statement with which the person you want to convince cannot disagree. In this case it is, "I know that we both want the safest birth for this baby. I want to make sure that we have settled on the best option for a birth position given that I have had a problem before."

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Q12: Mother and Baby Friendly Cesarean Birth

Q:  What can you request from your care-provider to make a cesarean birth more mother and baby-friendly?

The International Cesarean Awareness Network has a great webpage on this issue at http://ican-online.org/pregnancy/family-centered-cesarean (can’t find this reference, however, there are two other resources:)

We now have information and experience available for you about mother and baby friendly birth. 

From ImprovingBirth.org A Family-Centered Cesarean: Taking Back Control of My Son’s Birth

http://www.improvingbirth.org/2013/04/a-family-centered-cesarean-taking-back-control-of-my-sons-birth/

From You Tube: The Natural Cesarean
https://www.youtube.com/watch?v=m5RIcaK98Yg

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Q13: Lamaze classes & cesarean birth

Q:  I have to have cesarean surgery due to a myomectomy (fibroid removal surgery). Is Lamaze class still recommended although I'm not having a natural birth?

A:  Lamaze classes are primarily intended to prepare you for coping with labor and for making informed decisions about labor. This would not apply to you if you are planning a cesarean. However, the International Cesarean Awareness Network has created a document that can help you prepare for a positive, family-centered cesarean experience. You will find it here. (can’t open; replace with)
Here is some information to help you prepare for a positive, family-centered cesarean experience.

Smith J, Plaat F, Fisk N. The natural caesarean: a woman-centred technique. BJOG 2008;115:1037–1042.  This can be found at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2613254/

From You Tube: The Natural Cesarean
https://www.youtube.com/watch?v=m5RIcaK98Yg

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Q14: Delayed cord clamping and cesarean surgery

Q:  Is delayed cord clamping a reasonable request for cesarean surgery?  What might be some reasons for refusal and what is the evidence?

A:  I am not a doctor or midwife, but it seems to me there would be no reason why early cord clamping would be needed at a cesarean delivery any more than it is at a vaginal birth. In fact, if the reason for the cesarean were that the baby was in trouble, early cord clamping could make a bad situation worse by depriving the baby of a substantial proportion of its blood supply and of continuing oxygenation via maternal circulation, which would create a margin of safety until the baby got up to speed with breathing.

Q:  I'm a big fan, homebirth obstetrician, consistently maintained a cesarean rate of less than 1%, etc. etc. but I doubt you will find any obstetrician that will delay cord clamping during C/S. You have the uterus cut wide open and bleeding freely. I'm pretty sure no one will trade massive maternal blood loss for more time with an intact umbilical cord. Even I wouldn't.

A:   The "natural cesarean" people describe delivering the head and waiting, which allows the baby to begin breathing while its torso "tamponades the uterine incision, minimizing bleeding" (p. 1038) http://www.ncbi.nlm.nih.gov/pubmed?term=smith+2008+natural+caesarean.  Once the baby begins breathing, the reduced resistance in the lungs would switch over the baby's blood circulation from fetal mode to newborn mode and that, combined with rising blood oxygen levels, would shut down circulation to the placenta just as it does after vaginal birth. With this strategy, immediate cord clamping after delivery would no longer pose a problem.

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Q15: Do I need to have a cesarean because the doctor thinks my baby is big?

Q:  I was advised to come to this board. I would like some advice as to how to approach my doctor when I go back in 3 weeks...
Background: I am 32 weeks 3 days pregnant. Have had absolutely no complications what-so-ever. In fact, I was not even sick during my first trimester. I plan to have a natural childbirth and I am taking classes so I can achieve that goal.

I was at the doctor this week for my monthly check up, and she measured my fundus and said that it was measuring 35 CM instead of 32 CM. She then proceeded to tell me that I 'might' be having a big baby. And if they baby seems to be over 10 pounds she wants to schedule me for a cesarean. I told her that I really did not want to have one and she told me that she has delivered babies that were 10 pounds before (vaginally), but she wants to schedule me for an ultrasound to find out more information. She didn't seem to be concerned with anything else going on (health).

She told us that she was totally on board with me having a natural childbirth and then after she measured me it seemed as though her view changed a little bit, but again, she stated that she has delivered 10 pound babies vaginally.

I put a call into her this morning, because I feel like I left the other day with few answers and more worries. If there is any advice you can give me that would be great.

A:  This doctor seems to fall in the category of "I don't want you to worry, but . . . ." And, of course, you do worry. Your confidence in yourself is undercut, and the process that sets you up to agree to unnecessary interventions is underway.

Your ob's behavior is a huge red flag. You need more solid information than her vague assurances that she supports your desire for natural childbirth. You need to know her cesarean rate immediately, because if it is what I suspect it will be, your best bet for the birth you want to have (and the birth that will be safest and best for you and baby) will be to change care providers, and many care providers won't take women late in pregnancy. The way to phrase the question is: "How often do you find it necessary to do a cesarean?" If you hear an answer of more than 15%, a percentage that is supported by a substantial body of research as being achievable without increasing harm to babies, you will know that you cannot rely on this ob's judgment about when a cesarean is necessary. Unfortunately, few obs have cesarean rates in this range. I expect yours will be at or exceed the national average, which is 29%, although I hope you will be pleasantly surprised.  If she doesn't know or won't tell you her cesarean rate, that is also a bad sign.

If you want information on choosing a new provider, go to the thread "pelvis too small," and you will find a list of links in my response. Likewise, you will find information on how women anticipating big babies can maximize their chances of a problem-free birth in the thread "big baby?

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Q16: Childbirth Connection answers question of why cesarean rate keeps going up

Below is the e-mail that was sent to me. As usual, Childbirth Connection has done a magnificent job of distilling a simple, clear, persuasive, non-confrontational response to a complex, controversial question.

A new web page on the Childbirth Connection website answers the question: Why does the national U.S. cesarean section rate keep going up? The page dispels two myths that continue to arise and identifies interrelated factors that are leading to record-level cesarean rates year after year. Please seehttp://www.childbirthconnection.org/article.asp?ck=10456

The page is available as a PDF handout for journalists, policy makers, students and others (first document in Quick Links box).

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Q17: Fear and scheduled cesarean birth study

Q:  I was puzzled by the conclusions of this study on fear and scheduled Cesarean birth; it says that women who got counseling for serious birth fears chose to have scheduled Cesareans more often. I am wondering if these women who start out with intense fear of childbirth have a history of sexual abuse, abortion and/or pregnancy loss or some other common factor. What do you think about this study? And what do we do about the fear? I find fear so pervasive among women. The whole thread here about big babies is a case in point.

I had slight blood sugar elevation (I won't call it "gestational diabetes"!) during my last pregnancy and my OB was convinced I would have a too-big baby and shoulder dystocia. I was planning a homebirth and seeing the OB concurrently. I was beset with fear for months. Finally, I discontinued OB care and delivered a perfectly healthy 10 lb. 2 oz. baby after one hour and twenty-three minutes of labor and just 3 pushes. I was on hands and knees and had spontaneously chosen to do pelvic rocking - the baby just shot out! But I had such terrible fear from this one lab test (and I was only a couple of points from the "normal" range on the blood glucose.) Even being a very naturally-oriented birther, the fear from this test and from my OB just pervaded my pregnancy - until labor and delivery went so fast and so well.

http://www.ncbi.nlm.nih.gov/pubmed/16709206

A:  First, some background: In Sweden, excessive fear of labor is recognized as being a problem worthy of diagnosis and treatment. Nearly all obstetric departments refer women to clinics for counseling if women express extreme fear of labor. This study surveyed 2662 women at 16 weeks of pregnancy and 2 months afterward. They compared 3 groups: A: 47 women with extremely negative feelings at 16 weeks who got counseling, B: 50 similar women who didn't, and C: 193 women who didn't have negative feelings at 16 weeks but who had counseling (presumably they developed anxiety later) with group D: 2372 women who neither had negative feelings nor got counseling. Here are the important results:

* As the news summary noted, women who had negative feelings and got counseling were more likely to have elective Cesareans but be more satisfied with the birth than women who didn't get counseling.

But there's more to it:

* Women who had negative feelings and didn't get counseling were twice as likely to have Cesareans in labor as any of the other groups (16% vs 8%). This did not reach statistical significance probably because the numbers are too small to detect even a doubling of rate.

* Counseling worked. Significantly fewer women who said they preferred a Cesarean at the time of the survey had an elective c/sec. In group A, at 16 wks, 56% wanted an elective c/sec, but only 30% had one. In group C the percentages were 18% vs 14%. In the two groups together, rates were 24% vs 17%.

* My calculation revealed that Cesarean rates didn't change very much in any group. This was a mixed parity group. In group A, 30% of women had a Cesarean in a prior pregnancy vs 38% in this pregnancy. In group B, 22% had a Cesarean in a prior pregnancy vs 20% in this pregnancy. In group C rates were 19% vs 21%, and in group D the rates were 11% vs 13%. (Note that it was assumed that women with a prior Cesarean would plan vaginal birth this time, not at all like it is in the U.S.)

A thought comes to mind: First, in Group A, 9 of 47 women had a previous c/sec and 14 had an elective c/sec while in group B 34 of 193 had a prior Cesarean and 27 had an elective c/sec in this pregnancy. It is possible that the combination of prior c/sec and negative feelings about labor would be more likely to tilt the decision toward elective repeat Cesarean.

I'm not sure what the implications are, but group C, which is much bigger than group A or B, has a different profile. At the time of the survey, only 18% wanted an elective Cesarean vs 56% of group A and 42% of group B. Group A then had a 30% elective Cesarean rate vs a 14% rate in group C. For comparison, the elective Cesarean rate in group B, the negative feelings-no counseling group, was 4%, and it was 5% in group D, the no negative feelings-no counseling group.

Citing earlier and current studies done in England and Sweden, the authors comment that the incidence of anxiety about labor may be rising. Unlike here, however, they want to treat this problem, not just send women off to surgery.

Take-home message: Women who have extreme fear of labor should be identified and undergo counseling. They will then be able to make a truly informed decision about birth route.

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Q18: Time limits placed on women in labor

Q:  Where is the research doctors use to limit the amount of time they allow women to labor? What is the quality of the research? Are there better studies that tell us otherwise?

A:  I am not aware of any research that supports setting arbitrary time limits for labor duration. How could there be? There is a wide range of "normal" around "average" and too many variables in each individual case to set hard and fast rules. To name a few, how is the laboring woman tolerating labor? How is the baby doing? What physical or psychological factors might be impeding progress? What measures have been tried to promote progress and with what result? At some point, clinical judgment dictates delivering the baby, but it is a subjective decision. The truth of this can be found in the large body of studies reporting much lower cesarean rates and equally good neonatal outcomes in low risk women cared for by midwives, and especially midwives at out-of-hospital births, than for similar women giving birth in hospitals. (The point is not that the caregiver was a midwife but the model of care midwives are more likely to practice.) Likewise, we have numerous studies showing extreme variation in cesarean rates among individual obstetricians also showing no relationship between higher rates and better outcomes. This tells us that patience and care that supports the unfolding of the normal process produces better results than forcing labors to fit into a timetable.

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Q19: Advice on scheduled cesarean births

I have a question about OB's doing elective cesarean for the "fear" of large babies. In my area it is quite common for elective inductions to be done for fear of large babies (even though we know it's not supported by research).

But over the past several months, I have been noticing some increasingly disturbing findings about some local health providers. I've had about 3-4 women in my recent classes who've emailed after their birth or have contacted me before their labors to ask for help in talking to their OB's about how "not to have a cesarean birth" because their doctors are worried that the babies might be too big. I definitely spend a good amount of time on this topic in my classes but for some moms, it doesn't sink in until it happens to them.
My latest report is this....I have a mom who is due in a few weeks and her OB "thinks" she'll  have a 9-10 pound baby and so wants to schedule a cesarean. This mom is coming to me for some advice. Because this is getting so common in my area, I think it be great for me to compile a stack of research that negates the use of scheduled cesareans just for the
"fear" of having a large baby.

I know ACOG released a statement about induction indications and "large baby" is not on there, but do they have one about cesareans as well? I've been on their sight and can't seem to find anything. I know there is info out there but was wondering if anyone has specific citations that I could start with.

A:  As it happens, I just responded on this issue by listing a couple of reviews addressing whether planned cesarean surgery for suspected macrosomia (usually defined as weighing more than 4000 g or 8 lbs 13 oz or as greater than the 90th percentile for gestational age) is a good idea. While you'll want to get those reviews, I'll save you the suspense: the answer is "no." The title of the thread is "Caesarean prescribed for potential shoulder dystocia." Let me add to that list the question of how well can we predict macrosomia. Here is the story on that:

Studies consistently report that ultrasound imaging and clinical estimates predict macrosomia poorly. Predictions are wrong 1/3 to 1/2 the time (Chervenak 1989Combs 1993Delpapa 1991;Johnstone 1996Levine 1992Pollack 1992). If a clinician thinks the baby is going to be macrosomic, he or she might as well flip a coin as order a sonogram.

But there's still more: two studies looked at the effect of ultrasound diagnosis of macrosomia on outcomes (Levine 1992Weeks 1995). Both found that when ultrasound led the ob to believe that women were carrying macrosomic babies, half had cesareans vs. less than 1/3 of women not thought to have macrosomic babies but who actually did. In other words, the ob's belief that a woman won't be able to birth the baby because it is too big substantially increases her risk of cesarean. With a tip of the hat to Stephen Colbert of Comedy Central's Colbert Report, this is a prime example of "truthiness" in obstetrics at work. My advice to your students would be to think twice and maybe three or four times about staying with a care provider who doubts their ability to give birth vaginally because of estimated fetal weight. Even if they turn down the cesarean, they're by no means out of the woods.

It is also worth noting that the cesarean rate for birth weights greater than 4000 g in the U.K. in 1958 was . . . drum roll . . . 3% (Francome 1993) or an order of magnitude less than it was in these 1990s studies even in the low cesarean rate group.

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Q20: Risk of uterine rupture after one and after two cesareans

Q:  What are the actual statistic percentages for uterine rupture during VBAC after one cesarean and after two cesareans?

A:  I've pasted in the results and conclusion of a systematic review of VBAC outcomes after 2 prior c/secs compared with after one and with outcomes after a 2nd repeat cesarean. Overall, 5666 women planned VBAC after two cesareans. Furthermore, likelihood of scar rupture depends on modifiable factors such as whether labor was induced or augmented. I would bet that with optimal care, rates would have been lower in both categories.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19781046

MAIN RESULTS: VBAC-2 success rate was 71.1%, uterine rupture rate 1.36%, hysterectomy rate 0.55%, blood transfusion 2.01%, neonatal unit admission rate 7.78% and perinatal asphyxial injury/death 0.09%. VBAC-2 versus VBAC-1 success rates were 4064/5666 (71.1%) versus 38 814/50 685 (76.5%) (P < 0.001); associated uterine rupture rate 1.59% versus 0.72% (P < 0.001) and hysterectomy rates were 0.56% versus 0.19% (P = 0.001) respectively. Comparing VBAC-2 versus RCS, the hysterectomy rates were 0.40% versus 0.63% (P = 0.63), transfusion 1.68% versus 1.67% (P = 0.86) and febrile morbidity 6.03% versus 6.39%, respectively (P = 0.27). Maternal morbidity of VBAC-2 was comparable to RCS. Neonatal morbidity data were too limited to draw valid conclusions, however, no significant differences were indicated in VBAC-2, VBAC-1 and RCS groups in NNU admission rates and asphyxial injury/neonatal death rates (Mantel-Haenszel).

CONCLUSIONS: Women requesting for a trial of vaginal delivery after two caesarean sections should be counselled appropriately considering available data of success rate 71.1%, uterine rupture rate 1.36% and of a comparative maternal morbidity with repeat CS option.

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Q21: Does elective cesarean lower maternal death?

Q: Recent reports show that elective cesarean delivery has a lower maternal death rate than vaginal birth. Do you know of these reports and if so have you looked at them and debunked them if needed?

A:  Elective cesarean surgery is not safer than vaginal birth. The contrary is true. Here is what a French study found:
Deneux-Tharaux C, Carmona E, Bouvier-Colle MH, et al. Postpartum maternal mortality and cesarean delivery. Obstet Gynecol 2006;108(3):541-8.

OBJECTIVE: A continuous rise in the rate of cesarean delivery has been reported in many countries during the past decades. This trend has prompted the emergence of a controversial debate on the risks and benefits associated with cesarean delivery. Our objective was to provide a valid estimate of the risk of postpartum maternal death directly associated with cesarean as compared with vaginal delivery.

METHODS: A population-based case-control study was designed, with subjects selected from recent nationwide surveys in France. To control for indication bias, maternal deaths due to antenatal morbidities were excluded. For the 5-year study period 1996-2000, 65 cases were included. The control group was selected from the 1998 French National Perinatal Survey and included 10,244 women. Multivariable logistic regression analysis was used to adjust for confounders.

RESULTS: After adjustment for potential confounders, the risk of postpartum death was 3.6 times higher after cesarean than after vaginal delivery (odds ratio 3.64 95% confidence interval 2.15-6.19). Both prepartum and intrapartum cesarean delivery were associated with a significantly increased risk. Cesarean delivery was associated with a significantly increased risk of maternal death from complications of anesthesia, puerperal infection, and venous thromboembolism. The risk of death from postpartum hemorrhage did not differ significantly between vaginal and cesarean deliveries. CONCLUSION: Cesarean delivery is associated with an increased risk of postpartum maternal death. Knowledge of the causes of death associated with this excess risk informs contemporary discussion about cesarean delivery on request and should inform preventive strategies.

You also have to consider that, in the U.S., at least, having the first cesarean means that it is a near certainty that all future deliveries will also be via cesarean surgery. Let us see how repeat surgery affects maternal deaths. The maternal death rate in

Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006;107(6):1226-32.
was 60 per 100,000 in women having more than one cesarean. The study years covered 1999-2002. The maternal death rate overall in the U.S. in 1999 was 13 per 100,000. That comes from

Chang J, Elam-Evans LD, Berg CJ, et al. Pregnancy-related mortality surveillance--United States, 1991--1999. MMWR Surveill Summ 2003;52(2):1-8.

Moreover, the gap is even wider than appears. Silver et al. only included deaths connected with delivery. This would leave out any maternal deaths that occurred before delivery secondary to cesarean scar-related problems or years later secondary to surgical adhesions. These include cesarean scar ectopic pregnancy, placental abruption, bowel torsion.

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Q22: New study "Study Finds Disparities in Maternal Care Among U.S. Hospitals"

http://hg-article-center.s3-website-us-east-1.amazonaws.com/0e/40/255f9dfa4bd497162aa0e9efc706/HealthGradesWomensHealthReport2012.pdf
A:  In the category of  "Patient choice Cesarean sections" does anyone know if  Healthgrades is calling  cesareans that get done after a woman has been in labor feeling tortured, starved, and flat on her back,  tethered to machinery for 24 hours , then diagnosed with "failure to progress" , and begging for a cesarean patient choice?  
I know I was begging!
If they have the audacity to classify what i went through and other women go through as "Patient Choice to have a c/section" I think my brain is going to explode from knowing this is how I was categorized.

I hear your anger, and it is justified. An ongoing problem with the Health Grades reports is the cavalier assumption that cesarean surgeries for which there is no medical indication all represent "patient choice" surgeries. The only data we have from asking women themselves comes from Listening to Mothers II, http://www.childbirthconnection.org/article.asp?ck=10068 , a survey carried out by Childbirth Connection of a nationally representative sample of 1600 women giving birth in 2005. In that population, 1 woman of the 252 who would have been eligible for an elective cesarean said she had a "patient request" surgery. That amounts to 0.4% of the eligible population or 4 per 1000. On the other hand, 9% of the women surveyed or 90 per 1000 reported feeling pressured by their obstetrician to agree to cesarean surgery. I have another study in which 13% of cesarean surgeries performed during labor or 130 per 1000 were by self-report "obstetrician choice" elective surgeries. Another 3% or 30 per 1000 were a joint decision between the laboring woman and the ob, but considering the unequal power relationship, those could reasonably be called "obstetrician choice" cesareans as well, bringing the total to 160 per 1000 or 40 times the number of patient request surgeries.
Kalish RB, McCullough L, Gupta M, et al. Intrapartum elective cesarean delivery: a previously unrecognized clinical entity. Obstet Gynecol 2004;103(6):1137-41.

So which do you think is the bigger problem: elective surgery at patient request or obstetrician request?

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The questions and answers offered in this section are from evidence-based information, and archived from the Lamaze Ask Henci forum that was available through 2014. For medical advice, please see your care provider.