Monday
May312010
Monday Open Thread
Monday, May 31, 2010 at 1:43PM
Today’s open thread is hosted by Betty White. What’s happening? Anything you want us to write about or research?
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Reader Comments (36)
There's a good article in the Philadephia Inquirer by an MFM specialist...
The case points out a fundamental truth about surgical delivery: a first cesarean for most women leads to a cesarean with every pregnancy. And while a first section is quick, easy to perform, and rarely complicated, each repeat surgery carries greater risk.
More and more women are finding themselves on the C-section path. Almost one in three babies was delivered by cesarean in 2007, the most recent year for which data are available, an increase of more than 50 percent from a decade earlier.
At the same time, it's becoming harder for mothers to avoid repeat surgery. The number of vaginal births after a C-section fell by two-thirds, to fewer than 10 percent, over the same time period. This year, the National Institutes of Health estimated that since 1996, one-third of hospitals and one-half of doctors who offered vaginal births after a C-section no longer do so.
"There can be tremendous morbidity after three or four or five prior cesarean deliveries," said Gary Cunningham, an OB-GYN professor and former department chair at Southwestern Medical School in Dallas, who chaired the NIH panel.
"Women need to be counseled appropriately and accurately so that they can make an informed decision," Cunningham said. "But this doesn't do much good if she cannot find an obstetrician or hospital that will allow a trial of labor."
This might be an odd question, and I'm not sure if any research has been done on it or anything, but it's just a concept that occurred to me. I'm going to school for biology, to eventually end up in a Genetics/Developmental Biology PhD program, and so I've been reading a little about chaos theory. Nature is full of fractal patterns, including the human heartbeat, which was assumed to be rhythmic. When you try to force the human heartbeat to be rhythmic, it can stop altogether and the person will die. This was only recently discovered. So my question is, does anyone know if labor and contraction patterns are actually fractal? And if so, could this be a reason that Pitocin induced labors are more painful, or even a source of other issues that come with induction? This is really just a curious question, but I thought perhaps one of the wonderful commenters here might know of any studies or research done that is relevant to the question.
Thanks!!
I've been wondering whether there is a conflict between the interests of malpractice insurance and health insurance providers. On a simplistic level, it seems to make sense that since the conditions of malpractice insurance policies lead to more cesarean sections, and c-sections are more expensive for the health insurance companies, that malpractice and health insurance providers wouldn't be on the best of terms about it. My cynical guess is that the same folks are running both and have set the system up to work for the most profitable ultimate bottom line. If that isn't the case, though, then I find it baffling that health insurance companies wouldn't have a vested interest in more deliveries happening vaginally. While I think money is one of the worst reasons to determine how birth happens, it does seem to be a primary factor. Any readers or contributors here have some insight into insurance land?
Ginny, that is something to think about!!! Well, I am pretty sure pitocin-induced labors usually hurt more because they make the uterus contract harder and faster than it would naturally. But what you said about labor progressing in a fractal pattern rather than a rhythm that doctors tend to want to be able to predict and track... well that's something to think about.
I know we all know about women being refused VBACs, does anyone out there know of a women refused a repeat section? I'm be curious to hear that story!
..."baffling that health insurance companies wouldn't have a vested interest in more deliveries happening vaginally"
It seems odd that this would not be the case. Why, for instance, are health insurance companies so hesitant to cover home birth? My mw said that it was because doctors with the ins. co. decide what they do and don't cover, and they are dedicated to keeping home-birth on the fringes and by-and-large refuse to cover it [birth-center births are similar, but to a lesser extent], even though it has equal neonatal outcomes, better maternal outcomes, not to mention costing much less. So "the old boys network" is one factor. The other factor may be that doctors bill most if not all C-sections as ultimately necessary. How can an insurance company prove that a particular FTP/CPD case was inaccurate, or that a baby did not actually have fetal distress, or that a woman didn't suddenly spike high blood pressure, or any other reason or excuse for a C-section? However, with health insurance companies having started to refuse to cover women who have had previous C-sections, it would be hard to make the case that they actually *want* women to have C-sections.
Ginny - I'm very interested now in the fractal idea
Kathy, I spent (too much) time about a year ago reading article after article about the rise in the c/s rate in the mid 80's and the reaction of doctors, "the public" and insurance companies (as filtered through the media). Let me see what I saved on my hard drive because I remember holding it against the same articles that I think you've read over the last couple of years and it was interesting.
On another recent Monday thread, someone posted wondering about her friend having a very small baby, I can't recall if she was induced or had a scheduled c/s. I found this while surfing this morning.... seems related.
http://www.themidwifenextdoor.com/?p=845
mj, it seems to me that no one is turned down for requesting a C-section for any reason, even as an elective primary section. I have heard from a few (very few) women who were pressured by a doctor or nurse about to try a TOL/VBAC instead of the repeat C-section they were seeking, but none of them seemed to have been forced into a TOL they didn't want, so it was only a minor irritation to them.
Come to think of it, it seems like very few women are dissuaded from seeking labor induction at term, either, Bishop's score be damned. It seems we only run into practical roadblocks to delivery when we want to take the time to wait for spontaneous labor to happen and see it through even if it is puttering along. You know, the way it commonly happens when Mother Nature takes her course.
I had great dialogues with the Nursing staff after my baby was born 4/19. She claims anesthesiologists are the VBAC kiljoys b/c they REFUSE to be on call for 24 hours a day. I think we need to investigate this and get some REASONABLE doctors to share about whether or not this is true and start a dialogue about what can be done through activism to change/reverse this horrible trend. She was very proud of their VBAC rate and saddened when VBACs were banned.
I also would like to hear a doctor who had a career during the good times of VBACs (1990s) share about the number of uterine ruptures etc. Often I see that the risk is "small" and rare but what does that really look like.- I would like some anecdotal stuff I think.... really just to see if docs are in favor as they claim they are yet prohibited by hospital policies. (is this true?)
and more contests and satire would be fun....summer fun times
In my area (a midwestern city), literally none of the hospitals have VBAC bans, but there are only a few doctors who are truly pro-VBAC. I've always guessed a big part of the problem to be malpractice insurers, or hospitals that require the OB to be physically present during the whole labor leading to VBAC.
KK-
"the way it commonly happens when Mother Nature takes her course."
This is exactly what I kept trying to tell everyone who wanted me to deliver on a time table. My daughter was born 9 days late, after a long and frustrating labor. I was stuck at 3cm for over 24hrs, which is exactly where I got stuck with my first baby and I was sent to surgery after 6hrs. Luckily this time around I had my wonderful doula who watched over me while I labored at home for that first 24hrs. She encouraged me by telling me how great I was progressing (effacing slowly and changing baby's station) and when we finally did make it to the hospital I was over the hump at 5cm. I really wish I could have delivered at home, but the laws in my area make it impossible for a HBAC to be attended, and I was too skittish to have an unassisted birth.
Is there any information out there about what state laws involve VBAC and HBAC and homebirth in general? I would love to know what kind of laws are out there and if there are any movements to change them. I do plan on having more children someday so I want to know what I am up against (the only reason I knew I couldnt homebirth was because my doula told me about the law).
I am worried that the Australian government will blacklist sites like this one since they are determined to censor at the ISP level regardless of what the public has to say about it. The backlash against midwifery and evidence based care has coincided with the growth of info on the net, and if they can block access, then women will eventually forget that there is any way other than the AMA's preferred methods, especially if they can put the boot to the independent midwives' necks. They say that for every dollar that is spent on health research, that 3 dollars trickles back into the community. To keep this up they need participants, and can't have women opting out of studies in large numbers.
The idea of censoring health information is an unpalatable one. I believe that we all have the right to research healthcare practices in order to inform ourselves about our options. That includes reading about alternative treatments, and woo. If the AMA is able to control healthcare information, then we are all up a creek with no paddle. It's bad enough that we don't have access to reliable statistics, but it would be even worse to loose the dialog around what goes into making those statistics, especially since birth is just the beginning of our lifelong dance with healthcare.
I also read recently that some laypeople have no problem with ob's cutting to save their insurance policies. This is something that needs to change. Although I can sympathise with what it must be like to have the possibility of a lawsuit hanging over my head, I think that is worse to offensively cut women and risk a maternal death. It really says something about where we are as a society when we say that women's lives are worth less than a $150,000 insurance policy. I think, personally, that women's lives are worth more than babies' lives any day, and that it's a far greater loss when an able woman dies a preventable death during childbirth, yet the dead mommy card holds little weight. I think it might be "traditional" values of male ownership of women and "save my unbaptised heir" thinking that are the holdovers here.
As for future topics, I'm interested in women who have had fibroids removed and if they are encouraged to go for vaginal births or seen as automatic c/s, and what the evidence shows. I only did a little light googling and did find one woman's blog on this. She did a bunch of research and convinced her OB she could birth vaginally and did. While they worry about uterine rupture, she found that ruptures were more likely to happen (although still rare) in the second trimester, well before a c/s would be scheduled anyway. If I'm remembering correctly.
Anon-- you really think the Australian gov't will try to block certain websites? Wow. I ended up back on this blog today http://www.homebirth.net.au/ which is such an amazing resource. I completely agree that our social values around birth are effed up.
I'm curious if there are any institutions that have successfully lowered their c-section rate? I know some hospitals have lower rates than others, but my perception of those in the Seattle area is that all the hospitals have been ranked similarly for some time...everyone's rate has risen a little, rather than any hospital managing to lower or even tame the rate of increase.
If there are hospitals that have successfully lowered the rate, how? Did it take a visionary at the top? A new head of the hospital or OB unit? A change in reimbursement? Hiring more midwives? A consensus for change amongst existing OB staff (and if so, why did it happen?)
@ Another Rachel
http://hoydenabouttown.com/20100530.7572/iinet-censorship-and-conroys-lies/
SMH: Filter goes ahead regardless:
“The government’s $128.8 million Cyber Safety policy includes forcing internet service providers to block access to a secret blacklist of website pages identified as ”refused classification” by the Australian police. Web pages will be nominated for blacklisting by Australian internet users who come across illegal or ”unacceptable” websites.
@
”This is a policy that will be going ahead,” Senator Conroy said. ”We are still consulting on the final details of the scheme. But this policy has been approved by 85 per cent of Australian internet service providers, who have said they would welcome the filter, including Telstra, Optus, iPrimus and iinet.”
Women who have had uterine surgery for fibroids are at roughly the same level of uterine rupture risk as women with classical incision c-section scars. However, that risk is not the 4-9% number given as 'standard for classical incisions', but closer to 2-3% and this information is not widely known or easily found.
That said, it is very difficult to find good quality data on women conceiving after myomectomy and hysteroscopy surgeries to remove fibroids and then having trials of labor. This is because the studies that even look at this stuff lump women with relatively uterus-preserving fibroids that dangle outside or inside the uterus or sit on the surface with women who have fibroids that have to be carved out of the uterine wall or lining. It all gets lumped together and so it's actually pretty hard to untangle just how risky a trial of labor is if you are pregnant post-fibroid surgery and want to deliver vaginally. What data there is suggests a 2% or so risk of uterine rupture and a successful vaginal delivery rate with a wide range of 60-80%. But that is combining the range from women with little or no uterine scarring at all towomen with extensive surgical scarring to remove fibroids. Interestingly, there is a little bit of case study data of women with upper-uterus and fundal surgery to remove fibroids (the kind of thing that sends doctors rushing to section you and has midwives rushing to risk-pool you out of their client base) having no problem beyond the vagaries of labor completing a complication-free vaginal delivery *provided labor is allowed to spontaneously start*.
That also said, with myomectomy (the most invasive surgery to remove fibroids), elective c-section, usually at 36-38 weeks is standard. Women generally don't even question it because the demographics are so very different than VBAC pursuers. I.e., women who in many cases didn't even think they would ever get pregnant successfully, vs. women who were pregnant and were cut open for delivery. I certainly want someone to blog about this and do some more digging for the data, so long as it's not me.
Mari, thanks so much. Looks like you've been looking into it a lot already.
Anon-- holy cow. My brother lives in Perth, I will ask him about this. I remember him saying that The Simpsons cartoon was censored on TV because the Itchy and Scratchy segments were too violent. This internet thing has much more of a Big Brother vibe around it. Really nuts.
I was reading this article pointed out to me by a friend- it's links celiac's disease with a tendency for cesarean section. I think it's interesting, but I'd be interested in knowing more details about this study- I wonder if the study controlled for whether the infants were breastfed? We all know that babies born by c-section are less likely to breastfeed, and since celiac's does have a genetic component, were the outcomes better for the babies that were breastfed even if the mothers did have celiac's?
http://www.celiac.com/articles/22132/1/The-Cesarean-Section-and-Celiac-Disease-Connection/Page1.html
I kind of worry about the ramifications of this study, though, because it sounds like mothers who have celiac's might start to be treated as "high-risk" which would also possibly make cesarean even more likely for them.