GREAT piece by a female specialist in high-risk pregnancy on c-sections

Sorry You Were Tricked Into a C-Section (Slate Magazine, 7/09/2014)

What disapproving friends don’t understand about cesarean births.

There are two general ways to have a baby.  I mean, there are variations—forceps! hypnobirthing! epidural!—and those are almost infinite. But in general, the baby either comes out through the vagina, or it comes out through the abdomen. The second option is called cesarean birth.

Almost by definition, that option is less desirable for everyone in the delivery room. It can have adverse effects on maternal health, either immediately or long-term. And despite a widespread misapprehension that cesarean birth is “safer for the baby,” there is growing data showing that cesarean sections have disadvantages for them as well.

You’d think any woman who has recently had major abdominal surgery and has a newborn to care for would have enough to deal with, but too often there’s more. This is what I see a fair amount of the time: A woman who has had a cesarean birth gets comments from her friends—online friends, IRL friends—mostly congratulations, but also messages of regret. Coming from everywhere are intimations that the surgery wasn’t warranted, suggestions that something underhanded occurred. Her friends and relatives point out that the cesarean birth rate in this country is too high. It can’t be the case that all of those surgeries are necessary.

So her friends and relatives tell her, outright or through subtext, that she must have been snookered. She was fooled and then underwent some shady butchery. Perhaps the fate of her child was held hostage: “Something might happen to the baby,” she was told, and under these manipulations, she allowed herself to be cut. But, her friends say, it wasn’t right.

I am a doctor who takes care of pregnant women, and I have been delivering babies for a long time. I enter an operating room to do an unscheduled cesarean birth with sadness. This isn’t an appendectomy or a hernia repair; all we need to do is get a baby born and, in general, nature has given us a highly effective method for achieving that. For one reason or another—problems with the placenta, infection, bleeding, time—that method is not working today. Maybe it would have worked in another age, if a birth attendant would have waited even longer or worried less about the baby; maybe it would work today if our tolerance for any intrapartum risk were higher. I can’t argue with that. I practice within the norms and standards of my time; within those guidelines, I try to stay out of that operating room as much as I can. Here we are, though, I think as we enter the surgical suite. And I so very much wish we weren’t.

There are ways in which a postpartum woman’s Facebook friends are correct—the cesarean birth rate in this country is too high. The public health minds of this generation are working on this problem. But the going is slow, for many complicated and systemic reasons: tort reform, availability of hospitals that can muster the resources to participate in a vaginal birth after an earlier cesarean, reimbursement rates—the list is long.

Those Facebook friends may have their hearts and motives in the right place. Patient empowerment and education is probably the key to this problem, as it is so often in public health. Some women request cesarean birth, possibly thinking it is safer or easier or more posh. So, much like peer pressure to breast-feed, peer pressure against cesareans may have some utility in making them less desirable and ultimately less common.

But let’s not lose sight of what the cesarean birth is: a method of getting a baby out of a human. Its advantages are that it’s generally fast, and it’s generally quite safe under the right circumstances, especially after refinements in associated technologies such as anti-sepsis and anesthesia. Worldwide, it’s one of the most common surgeries performed; it has saved countless lives.

At its root, it is technology. And like all technologies, back to the invention of fire, it’s power. It’s not good, and it’s not evil. Technology can be awful or wonderful, depending on how judiciously it is wielded by well-meaning but fallible humans. We should use this particular technology in smarter ways; we should almost definitely be using it less. But we should spend a moment being grateful for this option.

Because this is the other thing to know about the data showing vaginal delivery is better: That’s correct for a lot of people, for low-risk people. But not for everyone. The underlying truth is that the human body is wonderful and that labor almost always goes well. That almost, that not-quite-always, is where I do a lot of my work. And I know that some of these women would have been lost to bleeding, or infection, or obstructed labor in the time before safe cesarean birth; even more of their babies would not be with us today. They are here because we have a technology that sometimes is the best way.

And even in this age of overuse and uncertainty, I can celebrate that. And so can you. And so, I hope, can that postoperative woman, home with her baby, worrying about what her friends think.

I enter an operating room to do an unscheduled cesarean birth with gratitude. Gratitude so large and specific that perhaps it should just be called relief. Perhaps I have been watching this baby for hours. Or perhaps it wasn’t like that at all; perhaps the patient came in 10 minutes ago, dripping blood past the reception desk from a placenta in the wrong place. Or perhaps it was this uterus or this placenta, or this fever—for whatever reason things have not gone as they should. So here we are. How lucky are we—how lucky is this mother and this baby, but also, selfishly, me—that we have another way. How lucky that I walk into that operating room reasonably sure that all three of us will come out, breathing, at ease.

Chavi Eve Karkowsky is a specialist in high-risk pregnancy, also known as maternal-fetal medicine, in New York City.