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

Robin Jones-TropianoLeave a comment

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.

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A Must-Have for Breastfeeding Mamas and Some Surprising Natural Remedies…

Robin Jones-TropianoLeave a comment

For many new mamas, nursing can lead to discomfort, soreness and dry, chapped skin.  The first thing I always recommend is to gently massage breast milk into those sore nipples.  It acts as a natural emollient.  I also recommend a treatment called Lansinoh lanolin cream.  Lansinoh is a medical-grade lanolin balm that soothes, protects, and heals cracked skin and sensitive nipples.  It is all-natural, safe, and non-toxic and does not need to be wiped off before breastfeeding.  And, it is the only nursing cream endorsed by La Leche League International.  All good stuff.

Sometimes, getting into a rhythm with your baby and figuring out how much milk you need to produce can lead to a brief overproduction, and sore, warm breasts that seem on the brink of an infection.  If you don’t yet have an infection but are uncomfortable, try this.  I know your eyebrows will go up at the thought of putting cabbage leaves in your bra, but just stay with me, because IT WORKS:  take a cabbage out of the produce drawer of your refridgerator and wash 5 or 6 large leaves.  Dry them with paper towel until they are damp but not dry.  Put the leaves inside your nursing bra wherever your are swollen and tender.  Another veggie drawer trick:  put a handful of carrots in a food processor and grind them up.  Take the mashed carrot pulp and put it inside your nursing bra, again, wherever the tender spots are.  Messy, but very effective.  I’ve heard various vegetables can work, but these two are winners in my book from experience.

Any comments?  Anyone tried these remedies and found them helpful?  Let me know!

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Eat and drink, laboring mamas…

Robin Jones-TropianoLeave a comment

Once again, I’m reminded how important it is for a laboring mama to be adequately hydrated and have enough energy reserves to get through active labor, transition, and pushing.  A very smart British mama I just worked with made sure she had plenty of sandwiches, energy bars, and Vitamin Water from home that she could eat whenever she needed to during her overnight labor, resulting in a very productive hour or so of pushing her lovely boy out into the world.

Eat, drink, and have healthy, happy labors, mamas.

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“If a doula were a drug, it would be unethical not to use it.” – John Kennell, M.D., pediatrician

Robin Jones-TropianoLeave a comment

Dr. Kennell was one of the very first scientists to research and investigate the benefits of continuous labor support for birthing women, and along with Dr. Klaus, Penny Simkin, Annie Kennedy and Phyllis Klaus, founded Doulas of North America, which later became DONA International, a well-respected , worldwide doula organization committed to training both birth and postpartum doulas and providing a doula for every woman who wants one.

“Many, many thousands of women have birthed with the support of a doula, enjoying the benefits observed by Drs. Kennell and Klaus when they first started their research, and documented again and again since then; shorter labors, lower cesarean rates and reduced interventions.”  (Kennell, et. al 1991)

Reference: 

Kennell, J., Klaus, M., McGrath, S., Robertson, S., & Hinkley, C. (1991).  Continuous emotional support during labor in a US hospital.  JAMA:  the Journal of the American Medical Association, 265(17), 2197-2201.

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What You Don’t Know About Episiotomies Can Hurt You (The New York Times, 1/27/2013)

Robin Jones-TropianoLeave a comment
By JENNIFER MARGULIS

January 27, 2013 8:15 pm

When Cyndi Sellers’s son was born at a hospital in southern Oregon, the obstetrician on call rushed in with wet hair wearing a tie-dye T-shirt, as if she had just been swimming. After only a few minutes in the room, the doctor then cut an episiotomy so long that Cyndi’s mother — who was watching the birth — later described it as “horrifying.”

The doctor delivered the baby, stitched up Cyndi, and hurried out again. In the brief time the obstetrician was in the labor room, she managed to do so much damage that, almost three years later, Cyndi tells me when we talk on the phone, things “still don’t feel right down there.”

An episiotomy is a surgical cut from the vagina to the anus, on the area of a woman’s body known as the perineum. Once routine, it continues to be a “common obstetrical procedure,” according to the authors of the 23rd edition of Williams Obstetrics, the 1,385-page manual that serves as a textbook for obstetricians.

The reason for the episiotomy’s popularity in the 1950s, ’60s and ’70s, when my brothers and I were born, was that doctors believed that a clean downward cut on the laboring woman’s perineum was safer for the baby and better for the mother than letting a woman’s perineum tear during pushing. A straight cut was easier to stitch than a jagged tear, and doctors argued that a woman would feel less postpartum pain and have fewer future problems with pelvic-floor complications (like urinary incontinence).

More than half a dozen scientific studies done since the 1990s suggest that those doctors were wrong. Episiotomies are actually associated with more postoperative pain, a much greater likelihood of tears in the anus (ouch), and other complications. One study showed that women who had episiotomies were as much as six times more likely to report fecal or flatus incontinence than women who delivered with an intact perineum.

“The biggest problem with any type of episiotomy is the lack of control of the cut once it’s done,” explained Louana George, a registered nurse and certified professional midwife who delivered babies for 25 years. “It’s not unusual for a cut to extend unintentionally into the rectum, necessitating extensive suturing to repair the damage.”

Another midwife demonstrated the problem to me by taking a piece of paper in two hands and pulling it apart. The paper started to give but did not tear. Then she put a cut in the top of the paper and pulled again. This time the paper ripped cleanly in half. “That’s what happens to a woman’s perineum when you do an episiotomy,” the midwife explained, sending shivers up my spine.

“You have a greater chance of having a much more severe tear,” she went on. “Then there’s the problem that you’re cutting through muscle — when you tear it usually only goes through tissue — so it can cause significant damage that needs to be repaired and leave a woman with pain, numbness and lifelong problems with sex.”

Some cuts are necessary. If a woman has an unusually tight perineum (because of her anatomy or because tight scar tissue has grown over a previous episiotomy) and the tissue just isn’t stretching, an episiotomy may be indicated. If a baby close to being born is showing signs of distress and needs to be born quickly, an episiotomy can facilitate birth. Sometimes the practitioner can see that a very large head may cause a rectal or urethral tear, and a cut may help avoid that potential damage.

But these instances are few and far between. “If they have an indication, it is rare indeed,” Paul Qualtere-Burcher, an obstetrician who has participated in over 4,000 births and who teaches at the Albany Medical Center, wrote in an e-mail. Dr. Qualtere-Burcher can’t remember the last time he cut an episiotomy. “They clearly increase lacerations into the rectum, they hurt more and take longer to heal,” he explains.

Most American doctors still believe episiotomies help prevent injury in the case of stuck shoulders. But a new study examining 94,842 births over a 10-year period suggests that assumption is also wrong. “Despite historical recommendations for an episiotomy to prevent brachial plexus injury when a shoulder dystocia is encountered,” the authors conclude, “the trend we observed does not suggest benefit from this practice.”

Though it is no longer the “standard of care,” many obstetricians continue to perform episiotomies, arguably for the wrong reasons and often without asking consent.

“Fifty percent of the episiotomies I’ve done were because my supervising staff wanted to go back to bed,” one obstetrician, who recently finished her residency, told me. This doctor has a colleague, an obstetrician in private practice, who “loves epis” and cuts them during almost every vaginal birth.

The American College of Obstetricians and Gynecologists recommends that doctors rely on their “clinical judgment” when it comes to episiotomies. Pregnant women who would prefer to assess that judgement ahead of time (and to find a practitioner who won’t come at their privates with a pair of blunt-tipped scissors) should talk episiotomies before they’re in the delivery room.

Or they can follow my mom’s lead when she was giving birth to me in 1969. Alone in the delivery room, on her back with her feet in cold metal stirrups, she saw the doctor coming closer to her vagina with a scalpel.

“No!” she managed to cry before another contraction consumed her concentration. “I told you I didn’t want that! NO EPISIOTOMY!”

“O.K., lady,” the doctor said, laughing, putting down his knife.

Were you given an episiotomy during labor? Did your doctor ask consent? Do you think the cut was a necessary part of the birth?

Jennifer Margulis, Ph.D., is a senior fellow at the Schuster Institute of Investigative Journalism at Brandeis University and the author of the forthcoming “The Business of Baby: What Doctors Don’t Tell You, What Corporations Try to Sell You, and How to Put Your Baby Before Their Bottom Line.”