C-Sections, inductions, oh my!

Parentberries
1

Hey again,

So as this pregnancy is (very) slowly becoming more and more real, and seeming like it’s healthy and going to stick this time, I’ve started to let my brain wander to the delivery stuff. Not something I’ve let myself think much about before because I just didn’t want to so early on. But I know that there’s a LOT to think about so I also don’t want to save it all for the last minute!

So I’m hoping to be able to go the route of a vaginal delivery for my first baby, I’m open to an epidural if I’m even able to get one (have a fused spine so I’ve heard some say it can’t happen, not confirmed yet though). But I really, really don’t want any medical intervention in terms of inducing or hurrying along the labor or any of that (unless it’s the only option in terms of my life and baby girl’s life, of course). I know that you can find c-section statistics for states and hospitals and I’ve found those, but I’m wondering about specific doctors… [name]How[/name] do you find out how often your own OB performs c-sections and/or inductions? [name]Do[/name] you just flat out ask during a visit? I’m a bit concerned about getting correct (detailed) information and also about not offending anyone I guess. I like my OB and would prefer to not have to change at this point in the game. So when did you bring these things up with your doctor? I’m only 16 weeks, should I not even be bothering with this stuff yet? Any tips or advice on this topic would be greatly appreciated! Thanks Berries!!!

2

My only recommendation would be to talk to your OB about your concerns and see what he/she says. You don’t have to out and out ask what their numbers are, but I’m sure they would give them to you if you really want to know. OB’s understand that new moms have a lot of decisions to make as well as fears to dispel, so I’m sure your doctor would be happy to talk through all of this with you. Make sure and write down a list of the questions you want to ask, so you don’t forget anything. I always forget stuff when I’m in the doctor’s office :slight_smile:

3

That is fantastic advice Whit32, thanks so much! I know it’s totally reasonable stuff to bring up, I just have to not let myself chicken out. And writing down the questions before would definitely help! :slight_smile:

4

Labor is induced for all sorts of reasons, none of them arbitrary (save so-called social inductions)-- the top two reasons are post-dates and a worrisome growth pattern or stress test for the baby. If you feel like sharing, what is it about induction in particular that you dread?

Individual physicians keep statistics of varying degrees of exactitude on their practice patterns. For example, surgeons keep tabs on their wound infection rate or re-admission rate, but unless the hospital, practice group or academic institution demands it, is entirely voluntary. Your OB might have exact data on their percentage of births which result in c-section or on induction rates, but probably not. Blanket statements are unlikely to be particularly useful, too, since what you really want to know is how many patients like you end up with either of those things. A more useful question-- which you are perfectly within your rights and would be quite sensible to ask-- is how many of his/her low-risk nulliparous patients ave a section? What are the most common reasons in this persons practice to induce/section?

It’s definitely not too early to gather information, but is way too early to start stressing! I know it’s hard, believe me, but you really just have to wait to see how your pregnancy plays out before you an start formulating a realistic plan.

5

Thanks very much [name]Blade[/name]! You make a lot of good points, as usual. In terms of induction, what scares me is all of the information I see that seems to indicate induction generally ends up causing more problems than it solves. Obviously, I don’t have data on-hand to back this up, that’s just the anecdotal info I hear from friends and read on boards and such. I just really hate the overall perception of birth here in [name]America[/name] as a medical issue that inherently requires intervention. Watch any tv show, a woman goes into labor, people start screaming and yelling to call 911 like she’s having a heart attack. Most of my family (and my husband’s) is in the Netherlands and it’s still quite normal there to give birth at home and to trust that a woman’s body knows what to do; I appreciate that.

Anyway, you’re right. It’s time to start gathering the info - but not yet time to start worrying about it. I’m still worrying enough about the health of the baby and success of the pregnancy that I certainly don’t need to add any additional stresses! Thank you! :slight_smile:

6

[name]Plenty[/name] of women are induced unnecessarily, in the US more so than many other countries. The excessive medicalisation of childbirth there would worry me, quite frankly! I would go ahead and ask your care provider their stats. They should have nothing to hide anyway if they’re good. We have midwifery-based model of maternity care in NZ but it is pretty standard to ask your midwife their stats on birth outcomes and rates of intervention. I asked at my first appointment, which is also standard. You want to know where you stand as soon as possible so that you have time to move to someone else if you don’t like what you’re hearing.

Also, if you don’t want a c-section, it is worth bearing in mind that you increase your likelihood of needing one if you have an epidural.

7

Chances are that if your OB/Midwife has a good record they will be thrilled to share it with you. At my very first appointment, my midwife told me that only 5% of their labors result in emergency c-section (I take it with a grain of salt since I know that they hand pick low risk patients, but its still a very good percentage). I’d say get all the information that you can now. It is much easier to switch doctors now than later and most of your visits are in the last 10 weeks anyways. My experience is that most doctors have opinions on how things should be done, but aren’t so pushy that they aren’t willing to work with reasonable requests.

It is much easier to switch doctors now than later

8

@milasmama: See, that’s more along the lines of the impression I’ve been under. I don’t want to argue with anyone but it seems to me like lots of women are induced here in the U.S. for reasons that aren’t considered critical to the health and safety of mom or baby. And I know inductions are more likely to end up in c-section. I also do know that having an epidural increases your risk of a c-section, that’s why I said I’m “open to it” but I’m not necessarily including it in my plans. I know myself, and reality, well enough to know that it’s something I’ll have to decide at that time, based on how I’m feeling. I don’t feel the need to try to ban it from even being possible, I’ll play that by ear along with my husband and doctor.

@skarbassoona: thanks for your thoughts! I know it’s easier to switch now than later, that’s why I’m trying to gather info now and get my nerve up. That way I’ll be ready at my next appointment in a few weeks! :slight_smile:

9

Unfortunately, @milasmama, these are canards circulated as gospel truth by those in the natural childbirth community, but they suffer from being completely false.

  1. Having epidural analgesia does not stall out labor, nor does it increase the chance of c-section. This has been repeatedly proven by multiple high-level, good-quality studies, over the last decade. I think, since it contradicts a lot of dearly-held ‘truths’ by certain elements of the natural childbirth world, these studies are simply ignored.

  2. Most obstetricians do not perform social inductions, with rare exceptions (i.e. husband is being deployed for the military). The most common reasons to induce in the US are a) post-dates [which is backed up by sterling evidence showing a doubling of the rate of in-utero fetal demise from the 40th week to the 41st, and a tripling in the 42nd week] and b) worrisome growth scan or fetal compromise evident on NST & BPP and c) medical complication in the mother, most typically pre-eclampsia, gestational hypertension or fetal macrosomia from gestational diabetes.

  3. Homebirth in low-risk women in the Netherlands has a higher death rate for babies than high-risk women delivered by Dutch obstetricians in the hospital. The Netherlands is significantly revisiting its practice model given the new data for baby death & lifelong disability that has come out since 2010.

Are there unnecessary inductions? Doubtless! Are there c-sections performed where a healthy baby could have been delivered vaginally? For sure! The question is, which ones? Well, the only way you would know for 100% sure is if you could do it all over again, run both arms of the “experiment” at the same time (induction & no induction, vaginal birth & c-section) and see which outcome ensued. What we know is that 100% of babies who are actually in trouble act like they’re in trouble, so by intervening when you see trouble, you catch all of them. However, a certain percentage of babies who are not in trouble act like they’re in trouble temporarily, so by intervening when you see trouble, you’re also catching them. Those are the unnecessary ones, but no one has a way to tell them apart, and most people (patients and practitioners alike) feel that it’s worth erring on the side of caution.

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@blade: I have heard a little bit about the changes in birthing in the Netherlands (my sister-in-law gave birth about 2 weeks ago, as well as about a year and a half ago, as have 4 of my cousins, so we’ve talked it quite a bit)… but their infant mortality rate was 3.69 in 2011 compared to our 5.9. And I’m not sure about comparing high risk births to low risk, that seems specious - but I get what you’re saying. This is exactly why I wanted to start this conversation, because I knew there would be widely varying takes on it. My belief that the U.S. has gotten a bit off the path and can definitely learn from other first world countries won’t change regardless - but I live here so I have to work with what I’ve got!

Thanks everyone! :slight_smile:

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Doesn’t The Netherlands have one of the highest infant mortality rates in the EU, even compared to “poorer” countries? You can’t really compare it with the US (totally different health systems), but I’ve often heard it being used it as a “bad example” in Europe.

Personally, homebirths are one of those “first world problems” I can’t ever understand. Millions of women around the world die in childbirth or suffer immense complications while western poor little rich girls go through unnecessary risks every year because they don’t feel “comfortable” on a hospital.

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@blade The information about epidurals not stalling labor is very interesting and helpful! Thanks!

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@sugarplumfairy: I’m not sure where you got that info about the Netherlands but it’s not correct from what I know from my family experiences and my research. Brussels, Belgium was in the news at one point for having a higher than expected rate but that’s a separate country completely. [name]Infant[/name] mortality rates are easily found via google, you can see them for European countries here, as of 1/1/2012, and you can see the Netherlands is towards the bottom with 4: Infant mortality rate by country - Thematic Map - Europe

Worldwide infant mortality rates can be see here for 2011: List of countries by infant and under-five mortality rates - Wikipedia

@marys33: Agreed, good to hear that there’s a possibility that epidurals don’t actually stall labor because I’ve always heard the opposite! :slight_smile:

14

@cvdutch-- the Netherlands currently has a system, as you doubtless know, where low-risk women (defined by singelton pregnancies and the lack of anatomical/physiological/medical/prior obstetric complications) are cared for by nurse-midwives, and higher-risk patients (with any of those problems) are cared for by obstetricians. This is similar to many Western European countries. What makes [name]Holland[/name] unique, however, is the percentage of midwife-attended births which occur out of hospital. Please don’t quote me on this, but it’s somewhere in the order of 20-25%. This is much, much higher than other Western European countries where the percentage doesn’t top 2-4% (and the US where is it less than 1.5% nationally). Previously it was upheld as a shining example of the safety of “risking out” healthy women to have a homebirth. However, since 2010 a lot of alarming new data have come out showing that the low-risk healthy group has a higher rate of baby death than the high-risk sick group. If it were the other way around, you would still have some questions about the safety of homebirth (i.e. is cherrypicking patients acceptable given that, presumably, if the same healthy women gave birth in the hospital there would be almost no baby deaths, whereas at home there are some baby deaths? [name]How[/name] many baby deaths are OK?). But in fact it’s black-n-white the opposite-- even the cherry-picked patients have worse outcomes.

[name]Infant[/name] mortality is a statistic that includes all deaths from hour zero of life to day 364 of life. [name]Infant[/name] mortality will include premature babies, babies with several congenital abnormalities, babies murdered or killed in car wrecks, babies with chromosomal problems-- as well as babies injured by birth. Since the US actually out-performs every other country on the critical care of the extremely premature newborn, and since the US frequently offers “heroic therapy” in terms of operations, lengthy ICU stays, etc than other cost-conscious countries, and since the US has a larger proportion of people not willing to terminate pregnancies for congenital anomalies or chromosomal problems… and, most importantly, since the US has a much more heterogenous population than the countries of Western Europe & Aus/NZ, the US has an apparent higher infant mortality rate. The kicker, btw, is that the US counts all children born alive, even if they draw one breath before dying, as “live births,” and they go into the infant mortality rate. Most Western European countries count these children as stillbirths (which I can’t really wrap my mind around, honestly).

However, this is the wrong statistic to look at if you want to just debate birth-related policy and look at intra- and post-partum outcomes. The correct statistic is perinatal mortality, which includes stillbirths after 24 weeks gestation up through infant deaths in the first 7 days of life. Although it’s not perfect-- you’ll still capture a lot of children with severe anomalies and other conditions incompatible with life which had nothing to do with the safety of how they were born-- it’s much better.

@marsy33 here are the papers if you would like to read them (unless you have an institutional login-- you said you were a master’s student-- you might be stuck with just the abstracts). Note how old they are!

The effects of epidural analgesia on labor, maternal, and neonatal outcomes: a systematic review - PubMed [the maternal hypotension from epidural use is definitely a real side effect]
The influence of epidural analgesia on cesarean delivery rates: a randomized, prospective clinical trial - PubMed [randomized controlled trial]
Does epidural increase the incidence of cesarean delivery or instrumental labor in Saudi populations? - PubMed [randomized controlled trial]
Labor analgesia and cesarean delivery: an individual patient meta-analysis of nulliparous women - PubMed [meta-analysis of 2400 patients]
Does epidural analgesia prolong labor and increase risk of cesarean delivery? A natural experiment - PubMed [official NIH study, demonstrating the length of the second stage increases by only ~30min]

15

@blade: as always, thanks for the detailed info! [name]How[/name] do you manage to carry all of this around in your brain? That’s why I didn’t go on to be a doctor, my brain gets tired just reading it all. :slight_smile:

16

[name]Just[/name] a quick note to say that while aiming for natural birth is the norm and preparation and education are excellent, please don’t beat yourself up if you end up having a c-section or induction. The birth is one day, then you have the rest of her life.

[name]Agnes[/name] wasn’t moving the day of my 39 week check-up and was delivered by section two hours after I walked in for a quick appointment. It saved her life and was fine (ruined my lunch plans though!). Talk to your doctor, no one goes into obstetrics hoping to have a high c-section rate but some one specializing in high risk pregnancy may be a great doctor but have very high stats due to the profile of their patients.

Good luck!

17

Too sweet. :slight_smile: trust me I have to look up the papers and everything. I just think all of this is really interesting and want people to have accurate info to base their decisions on.

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According to the UN the Netherlands ranks 18th in the world in terms of first-year infant mortality and the US ranks 34th. The US also has by far the highest first-day death rate in the industrialised world, which is possibly a more accurate measure of the maternity system (given that other factors like poverty affect the first year of life).

From the Save the Children’s annual Mother’s Index report:

“The US ranks number 46—the worst among developed countries—in maternal health, and 41st in child well-being. Overall, the US ranks as the 30th “best place to be a mother,” just above Japan and South Korea, but below all of Western Europe, Slovenia, Poland, Belarus, and numerous other countries.
An American woman faces a 1 in 2,400 risk of death during childbirth. Only five other industrialized countries—Albania, Latvia, Moldova, the Russian Federation, and Ukraine—fare worse on maternal death rates. A woman in the US is more than 10 times as likely as a woman in Estonia, Greece or Singapore to eventually die from a pregnancy related cause.”

Give me a home birth in the Netherlands vs a hospital birth in the US any day of the week.

19

We’re never going to agree on that.

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See this graph: http://epp.eurostat.ec.europa.eu/tgm/graph.do?tab=graph&plugin=0&pcode=tps00027&language=en&toolbox=sort

The Netherlands does rather poorly when compared to other EU countries, despite the fact that it’s one of the richest countries in Europe.

No one is talking about the US, I suppose we can all agree that your health system is a disgrace and (as @blade pointed out) infant mortality is measured differently anyway. A hospital birth in The Netherlands might be preferable to one in the US, but if you have any sort of complications even a camp hospital in Mozambique would be preferable to a homebirth in [name]Amsterdam[/name], as long as there’s a doctor around.