Babies Are Born In 1 Of 2 Ways: Through A Vagina Or Through An Incision. We Might Be Doing It Wrong.

The most important birth outcome is a healthy baby and mom. And when a C-section is the way to make that happen, of course, it makes sense. But how did we end up where one-third of women are having C-sections to deliver their babies?

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Childbirth is the most common reason for hospitalization in the United States and C-sections are the most common major surgeries that any American will undergo.

This is the final week where I guess what you would call "nesting". I'm trying to get everything done, but at the same time really focusing on getting ready for the birth. You know, I've decided to do something a little unusual, I am going to be trying to have a natural birth after having had a C-section.

This mom is doing fine and the baby's doing fine. What's the point of putting her through major abdominal surgery just to get the baby out?

Something is wrong. We don't know what the optimal number is but it's hard to believe, I mean, just at a gut level that one in three human beings need major surgery to have a baby.

My name is Chileshe Price and I'm a cardiologist. I'm also a mother to the most amazing little 2-year old. “Jacob, Jacob, you see your baby sister.” I'm the wife to my best friend and I'm due in a week and I don't desire to have a Cesarean again and so, even in this week where they say I'm nesting and getting ready for the baby, I'm also really getting ready for THAT situation.

Some people think what I'm doing is really crazy and this should just be in addition to everything else going on in her life, she's also pregnant, not a narrative of, in addition to everything else that's going on in her life, she's pregnant and she's choosing a VBAC.

There is a controversy with Cesarean Section and obviously, surgery with reward. You know you're taking home a baby so, that adds a different perspective to that. The VBAC is a legitimate way to try to decrease our Cesarean Section risk. It is something that I have offered over the last 25 years but not everybody feels the same way about the VBAC.

He was actually very difficult to find, hidden in the bowels of the internet. And then you want to know if he’s good and all of these things and he was. I had to use that as a proxy. What I wanted was for someone to say, "I heard what happened last time and I can do different."

If a successful VBAC, that risk is lower than a repeat Cesarean Section. Unsuccessful VBAC in terms of doing a C-section at that point is probably a little bit riskier than just a planned Cesarean Section. But all of this just comes down to balancing risks and benefits and our job is to try to ensure safety and success.

Homo sapiens have always needed help having babies. Gorillas deliver their own babies. We have big frontal lobes and we walk upright so, we have narrow pelvises and so, we've always needed help. And sometimes there's something happening and the baby needs to come out so, labor is stressful for everybody including the baby. And so, there are a lot of legitimate ,reasons to need a C-section and a lot of legitimate reasons to do a C-section. What we're trying to do is not get rid of C-sections but try to figure out what ones we can safely reduce. The first papers where they express concern about the C-section rate are in 1976. This is not a new thing and why aren't we making progress with this? Basically every five years the C-section rate first doubles then triples and quadruples then it quintuplets. This period in which it starts to go down for a little bit, that's when we start to promote VBACs.

I found it hard to find Dr. Bailey and I'm coming from the vantage point of being a working woman and I'm a mother. It's busy. I find that doctor and he tells me things that you know, I'm a doctor too and they're not written in the medical textbook. There's "Dr. Google" or "Dr. Internet", there's a lot written there but what if that is the truth? Come on, we want the truth. There's a lot of information out there but you want the truth.

She's just packing her labor and delivery bag.

You're going to put your legs out straight, figure out how the baby's lying so, we're going to go down here first. The baby's head is right between my two fingers. The baby's rear end is up top so we're going to have a head and going to have hands and feet. If you listen over here these are hands and feet. Listen over here it's the baby's heart. So, that confirms that the head is here, that the shoulder is indeed here, that the rear end is up top and the baby is facing me today. The (inaudible - 05:18) is in the proper position. 132, 136 - perfect heart rate, healthy baby.

I think a lot of it is how you sell the concept. I could truly sit down with any potential VBAC patient and probably, talk her out of it if indeed I just emphasize the tragedies, the risks, the bad outcome. As a physician, what you want to do is present a balanced story so there are risks to the vaginal birth after C-section and there are risks to a repeat Cesarean Section.

It has to be the right thing from a medical standpoint. The goal maybe shouldn’t be about trying to get a successful VBAC is to just make sure that I don't have a medically unnecessary Cesarean Section.

People say to me, in jest, "If I were you, I'd just schedule a C-section. You have a toddler, you're taking care of your husband." November 2013, something really profound happened in my family. My husband was diagnosed with cancer.

It's hard to prepare for the things that you don't know but we just challenge ourselves to want to think about it differently. We can't really have both of us off of our feet at one time.

I didn't choose to do a VBAC because of my husband's surgery. I made the decision when I first was pregnant which 2 months before his diagnosis was. Jacob turned out great. I met him all bundled up and clean a little later, a couple of hours later. There's a lot that I've forgotten that's just in the moment of just how difficult that was to rehabilitate from. I was out for six weeks. It was really painful and the fact that we just accept that here in the US is that's going to happen. That was another reason why I didn't want to have to be going through a surgery and be post-op.

I think a lot of women themselves might not have anything to compare their prior experience to. Moms are resilient. It's true they have to go home with a new born baby and an incision which isn't ideal but they deal with it and that becomes their normal. So when they think about doing it again they think "Well, I did it before". You know, when you're doing millions of C-sections, the number of major complications that you see is a lot. So when it needs to happen, it saves lives. When you're not making people better off, not only are you apparently burning $5,000,000,000 a year on unnecessary C-sections if you're the US, but you're physically harming patients. So the risk of major morbidity from a C-section compared to a vaginal delivery is 3 times higher. So, cumulatively they're low as absolute risks but they're relatively 3 times higher for a C-section. We're one of the only groups of surgeons that cut on the same scar over and over again and every time that you do that thing heal differently. There's a condition called Placenta Accreta which is when the placenta grows into an old cesarean scar from the prior C-section and that's a life threatening situation. This might be why the US is one of the only places on earth with a rising maternal mortality rate. It's low at about 17 in 100,000 but it's been steadily going up for 20 years.

So, then my follow up question to Dr. Bailey when I first met him was, "What are the secrets to success?" So he said, labor at home as long as you can and then he also said continuous birth support has been shown to reduce the need for Cesarean Section. I remember saying to him, "What do you mean by continuous birth support". And he said Doulas.

Midwives are medical care providers. Doulas are not. Doulas are there to support you emotionally, physically help you get information that you need so, you can feel empowered so, you can make informed decisions during the whole labor and birth process.

Doulas are interesting people. They're not there to deliver the baby. They're actually there to support the patient. As a matter of fact, the New England Journal of Medicine years ago had an article on natural labor and the one thing that was statistically significant was the presence of the Doula and being able to obtain natural child birth. So they've proven their worth statistically. It's a shame that more people can't utilize them.

All the stuff that I'm doing this week that is really specific to getting my body ready for labor, I remember I think it was Nicki who told me that baby was going to give the signal.

The baby is an active participant in this process. Positioning our bodies with the help of gravity, it helps the baby do its job better. This is the sacroiliac joint. This would be the sacrum, this is the beginning of the lumbar spine, these would be either side of the pelvis. This is the mobility that happens and opens and releases when the baby comes down through the birth canal.

I'm trying to keep the pelvis right.

When you go in for heart surgery, you understand that there is an associated risk level. When moms go in to have a baby, they just think that they're going to have a baby and they're going to go home and everything's going to be fine. So, it's a balance of the doctors being held accountable that the clients have all of the information so they have that informed consent but it's also the mom and her partner's responsibility to advocate for themselves, to get that information, to want to know what all of their options are.

And a lot of them don’t know that they can They don't realize that it's even an option because you don't question your care provider. You just don't question it and that's how we're here; I think that's how we got here.

The baby could come at any moment.

There are some hospitals in California that have an 83% rate of the primary C-section in first time moms. If you can stop the first one then you don't ever have to worry about the VBAC. So if the patient and the physician have time to talk about it, physicians really want to help patients. So if you have a discussion about the benefits and the risks. What are the benefits and the risks? What are the costs? Who talks about cost?

When you look at how we pay for maternity care, lo and behold, it's more or less the same how we pay for care everywhere else, it's just that we pay more every time more is done. While how we pay for maternity care is not the only thing responsible for the practice patterns we're seeing today. We pay a good 50% more for Cesarean deliveries than we do vaginal deliveries. The financial differential is bigger for the hospitals.

Who's the responsibility? People often use the term, it's hospitals. Hospitals have higher C-section rates. Remember that the fabric of the hospital is so much.

A lot of people think that it's patients demanding C-sections. That's less than 2%.

Is it the size of the hospital, the number of beds, for-profit/non-profit, urban/non-urban. There are small differences and they've increased 1% for every 6,000 births so that's not driving it. You also look at the health of the woman. Obesity rates have gone up. That could be part of it. Hypertension, Diabetes. When you remove all that you still have big variation.

Especially in the medical world we talk about medical malpractice risks and that might be part of it, but there are totally different health systems from us like Bangladesh and in sub-Saharan Africa, really on every other continent on earth where C-section rates are skyrocketing so there must be something else that's driving it.

So, the question gets down to, "What's happening at the level of the hospital in terms of the workforce?".

The textbook teaches you how to take care of the patient in front of you. The labor floor doesn't work like that because you have the patient in front of you but you also have three other women in active labor, you have your pager going off, you have people calling you at home that have questions and all that's happening at once. That's the real world and that's not in the textbook. As it turns out, C-sections are a way of decreasing your workload. Labor for anyone who has had a baby takes awhile. The first time can easily take 20 hours whereas, a C-section, especially the first time takes less than 30 minutes. When you have really high workloads, you have a way of offsetting the workload by expediting the whole process by doing a C-section. What's changed between 1965 and 2010 is the cost of time. Our professional society, the American College of Obstetrics and Gynecology, used to say that on average for a first time mom, if you have an epidural, 3 hours of pushing is normal and beyond 3 hours is not normal. And so the way we interpret that is that maybe it's time to do a C-section because it's not working.

The American College of Obstetrics and Gynecologists released new guidelines to help reduce the root causes of higher C-section rates, one of them is to let labor go longer.

They've recognized, we've recognized that perhaps some of the past practices have been not encouraging C-sections but perhaps C-sections were occurring because of criteria that we utilized in the past that we no longer have to utilize in the future so being allowed professionally to pursue low intervention allowing more time for the labor process is a good concept.

At 2:30 in the morning, whilst I was sleeping, my water broke. Pretty soon I started to get contractions that were taking my breath away. I'd never experienced anything like that ever before. Never. People carrying all the stuff around you, and there’s voices and you are going to the OR and the lights are getting bright, and Dana's in a HazMat suit, Christina's in a HazMat suit. Everybody's gowned up. (inaudible 15:34) I think the baby's coming. I am looking in his eyes and He says, Chileshe, I want you to push. And he’s put your chin to your chest and you need to curl your back and you need to push. And so, I push and her head crowns and he's like "O my goodness" and I remember him saying, "we're going to have a VBAC here". Another huge contraction came and I pushed and Zara was born. Just like that. Two minutes of pushing. And she was after a whole day of labor and all this stuff and she was born and I have to tell you instantly I forgot about all the pain and I remember it was like something was slipping away from me. You do forget at that instant because the joy of having had Zara naturally was just completely overwhelming.

There may be small errors in this transcript.

This video, "An Unnecessary Cut," was created by The New Yorker. Thumbnail image via Thinkstock.

Aug 27, 2014

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