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.

by Dr. Kelly Brogan
The modern woman is task-oriented. She lives in a world demanding of her competence, attention, and efficiency. We use technology, tap into our communities, plumb the depths of our reserves to navigate an often hyper-masculinized world while retaining our most vital feminine powers. The power that fundamentally defines our exemption from this contemporary lifestyle trajectory is baby making. This primal empowerment forms the bedrock of a woman’s most untouchable gifts. We have lost sight of this fact; however, and have allowed our inner compass to be co-opted. It’s certainly no wonder, that after 9 months of hyper-medicalized pregnancy “management” (often following months to years of assisted reproductive technologies), birth is considered another task on the to-do list to complete. As a type-A taskmaster, myself, I understand the lure of a predictable and painless depositing of your newborn after the long and fear-punctuated journey of pregnancy.

I’m here to tell you; however, what your obstetrician won’t.

Labor is a physiologic process that recruits neuro chemical, endocrine, and immune systems into a dance that we barely have the tools to conceptualize. When we meddle with this, when we attempt to standardize it, we put women and their babies at grave risk – physically, psychologically, and even spiritually. We rob women of an opportunity for psycho spiritual transcendence. As a science-minded medical doctor, I don’t wield this phrase with ease! The process of conception, gestation, and birth cannot, however, be reduced to daily activities and routine life occurrences. There is something built into our consciousness that makes room for its own expansion around these life transitions. The process of bodily separation – woman from her newborn – involves a passage through a space of trance-like awareness. I can only describe it as the sensation of floating and grounding, simultaneously. It is an experience that demands we move out of the space of our mind and into a space of sensation without judgment. It is being present, truly present, to behold a glimpse of what we are capable of as mammals and most importantly, as a human female.

In this way, a natural birth is an opportunity for redefinition and reconnection to one’s most core self. It is the way women were intended to pass through the gates of motherhood, to the next chapter of their actualization. If you buy the potential significance of these considerations, you may want to know what represents your greatest obstacle and impediment in achieving this life milestone. You may be surprised to learn that it is epidural anesthesia. This discussion is meant to shine a light on elective epidurals – that, “Why not? Who wants to feel crazy intense pain?” choice that 2/3rds of women (and up to 90% in some hospitals) opt for every day. In my opinion, the epidural intervention is the most reprehensible of all – because of its largely dismissed risk profile, and because of its auspicious position in a cascade of interventions, unnecessary, ill-conceived, and rife with unintended consequences including death. If we can empower women to question the validity of this procedure, then they can retain the right to preserve the integrity of their birth experience.

What’s the big deal with Epidurals?
A 60% rise in C-sections since 1996 is prompting the American College of Obstetricians and Gynecologists to fidget self-consciously in their white coats. A study revealing the prolongation of the second stage of labor thanks to epidurals has been influential in identifying the iatrogenesis – doctor-caused harm – at the root of the cesarean problem.
It appears that, thanks to an antiquated but still sanctioned construct – Friedman’s curve – the hospital clock starts ticking loudly upon arrival, and the alarm goes off after 3 hours of second stage labor with a epidural. At this non-evidence-based juncture, interventions including IV fluids, continuous monitoring, food and drink restriction, and immobilization conspire to invite pitocin, forceps, vacuum, episiotomy, and surgery into the delivery room. Obstetrics is vulnerable to practicing consensus medicine – habitual practice that is not predicated on sounds science. As I discuss here, metanalysis has demonstrated that only 30% of current obstetrical recommendations are based on quality data. What’s the rest based on? Fear-mongering and personal opinion? Let’s look at what the evidence suggests about the risks of epidurals, considering that up to 41% of women never properly consented for this intervention. Epidurals are offered with a plethora of accoutrements including catheters for involuntary urination, blood pressure monitoring and IV fluids for changes to vascular physiology, and continuous fetal monitoring because of risk to the baby of decreased oxygen flow (1, 2). The changes to natural labor progression are compounded by risk of fever in the mother that leads to further separation of mom and baby after birth, secondary to testing and assessment for infection. This separation represents a stress to the shared adaptation to early postpartum life and may predispose to psychiatric pathology in both mom and baby through early epigenetic influences on gene expression (3,4,5). This separation may also interfere with breastfeeding establishment. In this way, epidurals may be directly and indirectly responsible for breastfeeding struggles(6,7). Breastfeeding appears to prevent the onset of postpartum depression if it is established within 3 months, in addition to being a continual source of immunologically essential information trafficked from mom to baby.

Shooting Up You and Your Baby
Epidurals are a delivery method for narcotic pain-killers that pass through the placenta to the baby and have largely unpredictable effects on the birthing woman. Evidence supports risks to the baby including reduced tone, poor feeding, jaundice, withdrawal, and sensorimotor impairment (8). Physiologic risks to the mother include acute and persistent problems such as numbness, tingling, dizziness, respiratory paralysis, cardiac arrest, nerve injury, abscess, and death (9,10).

Hurrying Up
When epidurals lengthen the second stage of labor, Pitocin, or synthetic mimic of the brain hormone, oxytocin, is delivered to augment the process. Because Pitocin does not cross the blood-brain barrier, it does not stimulate endorphin release. It also interferes with feedback loops suppressing natural oxytocin production while hyper-stimulating the uterus without appropriate relaxation between contractions. The significance of this is just being revealed and may even reach to risk factors for autism.

Cutting Up
The increased risk of c-section (11,12) in the wake of epidural anesthesia is easily explained by relaxation of pelvic muscles that detach a woman from the instinctive guiding forces of an uninhibited labor, by the baby’s increased distress secondary to narcotic exposure and malposition, by the recruitment of Pitocin which causes uterine and therefore fetal distress, and fetal monitoring which, while superficially reassuring results in increased interventions (2-3x c-section rate) without improved outcomes. Your doctor may fail to mention that a surgical birth brings with it these risk considerations: protracted recovery, infection (including necrotizing fasciitis), organ damage, adhesions, hemorrhage, embolism, hysterectomy, wound dehiscence, early infant separation, higher risk of respiratory problems for baby, and an exponentially increased risk of placenta accreta, a potentially lethal complication of surgical birth, contributing to a 3.6 fold increase in maternal death after cesarean relative to vaginal birth. Of primary interest to clinicians who appreciate the role of the gut microbiome in child and adult health, abdicating a vaginal transfer of beneficial bacteria may set the stage for chronic disease including a 20% increased risk of obesity.

Opting out of epidural anesthesia: Choosing to feel
What are the best ways to help your body, mind, and spirit align for this tumultuous but life empowering journey?

Movement – Staying active during pregnancy is optimal mind-body medicine. Yoga, home-based routines, and swimming in unchlorinated water are excellent choices, at least 3 times weekly.
Chiropractic – With advanced perinatal training, holistic chiropractors are critical experts in proper alignment and nervous system support to facilitate a physiologic birth.

Acupuncture – Applied before and even during labor, acupuncture can gently and effectively facilitate a healthy labor and delivery. According to a Cochrane Review, acupuncture and hypnosis meet evidence-based efficacy criteria for pain management in labor.

Controlled Breathing/Meditation – Perhaps the most important tool for a new mother, learning to engage the relaxation response in pregnancy will help you to know what it feels like to be present to the labor experience, to go inward, quiet your mind, and release fear. Hypnobabies and hypnobirthing are well-regarded methodologies.

Diet – The physical experience of labor and delivery is best supported by stocking the shelves up front for a healthy hormonal response with minimization of inflammation and maximization of nutrient-density. Eat sustainable, organic meat, fish, eggs, veggies including root vegetables and squash, fruit, nuts, and seeds. Leverage the complexity of food-based information to promote optimal gene expression in that growing baby, and support a healthy delivery and postpartum experience.

Doula – Preparation for labor, and support for mother and spouse have been traditionally left in the hands of a woman’s most doting partner, a doula. No woman should birth in a hospital without this advocate. Evidence supports a doula’s ability to help you achieve an intervention-free birth.

While my most heart-filling emails every day are from my home birthing patients, I aim to sit in a place of true advocacy for the women that I treat and advise. I believe in informed consent, and I observe that this is not occurring in hospitals today. Explore resources that will help to expose you to the known risks and popularized benefits, so that you are making your own decision with your eyes wide open. As most women who have experienced natural birth would attest – just when you think you can’t do it and your mind demands surrender – you meet your baby, and the world stands still in a moment of unparalleled beauty and wonder.

About The Author
As an undergraduate at M.I.T., Dr. Kelly Brogan studied Cognitive Neuroscience and worked with Harvard undergraduates to create a public forum for the discussion of alternative medicine, directing conferences for the Hippocratic Society. She attended Cornell Medical School where she was awarded the Rudin Scholarship for Psychiatric Oncology and began her work in Reproductive Psychiatry, which she went on to train in during her residency at NYU/Bellevue. A strong interest in the interface of medicine and psychiatry led her to pursue a fellowship in Consultation Liaison/Psychosomatic Medicine at NYU/Bellevue/VA Hospital. Since that time, she remains on faculty and has focused her efforts on her private practice where she cares for women across the life cycle including pregnancy and postpartum. A passion for holistic living, environmental medicine, and nutrition are the bedrock of her functional medicine practice. She has published in the field of Psycho-Oncology, Women’s Health, Perinatal Mental Health, Alternative Medicine, and Infectious Disease. She is Board Certified in Psychiatry, Psychosomatic Medicine, as well as Board Certified in Integrative and Holistic Medicine.

You can learn more about her at http://www.kellybroganmd.com, and connect with her on Facebook, Twitter, and through her monthly newsletter.

Sources:
1 http://www.ncbi.nlm.nih.gov/pubmed/15957994
2 http://www.ncbi.nlm.nih.gov/pubmed/12011872
3 http://www.ncbi.nlm.nih.gov/pubmed/24552992
4 http://www.ncbi.nlm.nih.gov/pubmed/12011872
5 http://www.ncbi.nlm.nih.gov/pubmed/23972903
6 http://www.nutricionhospitalaria.com/pdf/6395.pdf
7 http://www.internationalbreastfeedingjournal.com/content/1/1/24
8 http://www.ncbi.nlm.nih.gov/pubmed/12011872
9 http://onlinelibrary.wiley.com/doi/10.1016/S0091-2182%2897%2900052-9/abstract
10 http://www.ncbi.nlm.nih.gov/pubmed/17447690
11 http://www2.cfpc.ca/local/user/files/%7B8030D89F-B698-4F9D-B6A7-190AD9866E59%7D/Kotaska%20Klein%20epidural%20oxy.pdf
12 http://summaries.cochrane.org/CD000331/epidurals-for-pain-relief-in-labour

– See more at: http://www.thehealthyhomeeconomist.com/epidurals-wolf-sheeps-clothing/#sthash.Wwo7fPmo.dpuf

Tag: hypnobirthing

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.

A Reproductive Psychiatrist’s Perspective on the Effects of Epidurals