After several natural-focused birthing classes, Amy Twiggs went to the hospital prepared to deliver her first baby with very limited medical intervention.
(Media-Newswire.com) - After several natural-focused birthing classes, Amy Twiggs went to the hospital prepared to deliver her first baby with very limited medical intervention.
"( The teachers ) told me if you have anything other than a natural birth, it's because you're pretty much weak, and not strong enough to deal with pain," said the St. George mother. "I had it in my head, I was a gymnast, I was strong enough to deal with the pain."
Yet, after pushing for 36 hours with no signs of progress, she ended up with an emergency cesarean section.
She remembers fellow birthing classmates telling her the doctors had just been impatient, and so had she.
"It is frustrating to hear those comments, but it doesn't bother me anymore," said Twiggs, who has ended up needing emergency or planned c-sections for her three other children. "I did the best I could. I would have died if I was a pioneer. I'm glad I'm alive with a baby."
Outcomes like Twiggs' are becoming more and more common. In fact, in 2009, the cesarean delivery rate was at 32.9 percent — the highest ever in the United States, and it's likely to get even higher.
That means 1.36 million of the 4.13 million babies in 2009 were born in operating, rather than delivery, rooms.
The high c-section rate was one of the highlighted findings in the recently released report, "Women in America," from the White House Council on Women and Girls and a number that continues to generate concern among doctors, professionals and mothers who worry that perhaps the procedure is being employed too liberally.
"It's a case of a valuable intervention that's getting overused," said Eugene Declercq, a professor of community health sciences at Boston College and a public health researcher who has studied c-sections specifically for the last decade. "The issue is not whether ( a c-section is ) good or bad, but when it's being used and in what context."
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In the past, a woman delivered via cesarean section for several specific reasons: labor abnormalities, a prior c-section or an abnormal fetal heart rate.
Labor abnormalities might include a woman whose cervix won't dilate all the way, or a woman whose pelvis is too small to allow a baby's head to pass through. Twins or a baby in a breech or horizontal position could also be reasons. An abnormal fetal heart rate would indicate the baby isn't tolerating the stress of labor.
Once such factors were identified, a woman was prepared for the operation. Yet, over the years, doctors have begun recommending c-sections under less strict thresholds, explained Robert Silver, chief of the Division of Maternal-Fetal Medicine at the University Hospital.
He points to a combination of factors, like the fact that younger doctors aren't being trained to use forceps for more difficult vaginal deliveries and thus turn to c-sections, as well as the increasing number of women who want elective inductions, which, if done at the wrong time, can lead to c-sections.
However, the American Congress of Obstetricians and Gynecologists has been counseling doctors to say no to requests for elective inductions, which are often made before 39 weeks simply because the mother is uncomfortable and tired of being pregnant. Such inductions can be detrimental to both baby and mother, said Catherine Wheeler, an OB/GYN at the University Hospital, Director of the Women's Life Center and co-chair of the Utah Women's Health Coalition.
The cesarean rate is also climbing because the increasing age of first-time mothers along with increasing obesity rates for women, which can lead to gestational diabetes, longer pregnancies and bigger babies — often requiring a c-section delivery.
And if a woman's first baby comes by c-section, it's likely she'll have c-sections for other children, thus reinforcing the high percentages of cesarean births.
For doctors, an ever-looming issue is time — a balance between the 10, 12 or even 20-plus hour vaginal delivery versus a relatively short, planable c-section.
"I don't think it's, 'I'll get paid more,'" Silver said, 'But it's 'I'm going to spend six to eight times as long doing a vaginal delivery and there's medical liability and unpredictable time.'"
In fact, medical liability is one of the biggest, most powerful factors in the growing rate of c-sections, healthcare professionals say.
"We go to school, spend all this money, support our families on this income and there's always this fear that something will happen and some lawyer will take it away," said Jennifer Krebs, a certified nurse midwife at the Central Utah Clinic's Women's Center.
If something goes wrong during a delivery and a doctor or nurse ends up facing a lawsuit, their best protection in court is to say that they used all the medical interventions possible, Krebs said.
"These fears are pretty real," she said. "Nobody gets sued for doing a c-section."
When Wheeler talked with her patients about the possibility of a c-section, she explained to them what she did and didn't know about the situation and then they made the decision together.
"I think the doctors and other providers are trying to do the best thing for their patient," she said. "They don't want a baby to be harmed, they don't want a mom to be harmed, and they don't want any questions about it."
Yet not everyone is happy with a c-section.
Katie Hover admits she was "seriously clueless" when she went in as a 23-year-old to have her first child. Although she was induced, her body wasn't ready and hours of pitocin didn't get her any closer to delivery. Instead, the contractions just stressed out her baby.
So, she had a c-section, followed by emotional guilt from feeling like she hadn't done all she should have and a lengthy six-week recovery.
"I wished that when I failed to progress, ( doctors ) would have stopped and reevaluated and not just kept on their course that wasn't working," she said. "We have to be our own advocates."
Because Hoover believed her c-section wasn't medically necessary, she later did hours of research and created a desired delivery plan before she had her next three children, all of whom were delivered vaginally.
Silver encourages such empowerment, saying that many women leave everything in the doctor's hands, which can be good and bad. He wants women to be educated, yet also be flexible.
"Some women come in with a total bias against c-sections…and feel so strongly that they want a vaginal birth that sometimes they put themselves in situations that are harmful," Silver said. "I think it's good to be skeptical of c-sections, but not be anti c-section. At times, it's the very best option and at times, it's the only safe option."
In Hoover's situation, she found other options and became part of a relatively small group of women who have had a vaginal birth after a cesarean delivery, also called a VBAC.
According to The American Congress of Obstetricians and Gynecologists, the rate of VBACs went from just over 5 percent in 1985 to nearly 28 percent in 1996, but has been on a steady decline ever since and is currently sitting just under 9 percent.
Many doctors, hospitals and insurance companies are leery of VBACs or even TOLACs — trial of labors after cesareans — because of the risks involved, including uterine rupture and severe hemorrhaging if the placenta has grown through the original c-section scar. Rural hospitals are especially hesitant to allow for VBACs because they don't often have emergency c-section capabilities.
"Women who want a VBAC should have access to ( one ) and right now, access is a problem," said Kimberly Gregory, vice chair of the Women's Healthcare Quality and Performance Improvement Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center in Los Angeles and a professor at the David Geffen School of Medicine at the University of California, Los Angeles and the UCLA School of Public Health.
Gregory said that despite the rare problem of uterine rupture associated with VBACs, the system has "overcorrected" itself, because rupture happens in less than 1 percent of cases.
"That's a complication rate that is consistent with a lot of other complication rates that can happen in labor and life that we accept," she said.
A c-section also carries its own set of risks, including the potential for blood clots, infection, issues with the placenta and the possibility of cesarean hysterectomies, which Wheeler said doctors are seeing in much higher numbers now than they were 10 and 15 years ago. Babies can also develop respiratory infections because fluid wasn't squeezed out of their lungs by uterine contractions.
Yet, despite the high numbers of c-sections across the country, Utah's doctors and mothers are staying conservative, at only www.cdc.gov/nchs/data/databriefs/db35.pdf 22 percent in 2007. New Jersey is the highest state with a c-section rate just over 38 percent.
Keeping a low percentage is good, doctors say, especially in Utah where women have more children than the average American — a practice that becomes especially dangerous with repeat c-sections.
"( Women in Utah ) try to avoid the first cesarean," said Declercq. "And of course, if you practice to avoid the first, or if you practice to do the VBAC, the nature of your practice will result in doing more vaginal births."
Declercq suggests that the nature and culture of hospitals be adjusted to include more nurse midwives who are trained in low- to moderate-risk births, thus leaving doctors free to focus on high-risk births for which they're aptly trained.
That way, doctors don't feel pressured to rush into c-sections because a delivery is going longer than planned and other patients are waiting.
That sounds good to Krebs, who while she greatly respects and relies on the doctors she works with, knows that she has a bit more time to devote to her laboring mothers.
"As midwives we make a very serious attempt in our practice to be very, very patient," Krebs said. "As long as we're not concerned about baby's well being, we're happy to break out the knitting and sit by the bed."
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