Doulas and Cesarean Section

I recently found this in response to a query about finding doulas on a local expectant mother listserv:

Word to the wise...when choosing a doula, make sure that the contract you sign does not state that they can keep your money (or half of it) if you end up going into pre-term labor or have a c-section.

Not taking anything away from the mother who went through this, but is a doula really irrelevant within the confines of a cesarean section? While I understand that many hospitals have in place protocols that allow for only one support person in the operating room, can a doula enhance your experience when you have a cesarean birth?

According to this checklist on Pregnancy Today, a doula can help in many ways though the process of cesarean; be it scheduled or emergency. If the doula is comfortable with the process and knowledgeable, she can in fact enhance the process. For many families they are so wholey unprepared so it can be a blessing to have an objective support person there who is not part of the medical team to help guide you and your partner through the process. Here is one mother's story about how her doula facilitated her cesarean birth. She was thankful for her doula.

So perhaps instead of amending the contract to state that the doula will not get paid in the case of the cesarean birth, you should have an open and honest conversation with the doula you are interviewing about her services if you end up with a cesarean. Many mature and responsible doulas are able to work with clients appropriately and interface with the hospital staff to make the process a little less scary and clinical.

Defining "Unnecessary"

Many women feel that their cesarean section was "unnecessary". They felt that, given a different set of criteria and birth setting, they should have been allowed to have a vaginal birth. Recently a obstetrician wrote this piece titled "The Myth of the Unnecessary Cesarean". In this article he explains how he finds the term tiring and incorrect. But for many women, his arguments fall flat.

He argues that one could not conclusively say the cesarean was necessary or unnecessary since you cannot guarantee birth outcome either way. Sure, "hindsight is 20/20" plays a big role in the term "unnecessary", but that does not mean it cannot be a legitimate term. If the cesarean, that was medically indicated at the time of incision, was precipitated by a series of interventions that were NOT indicated, would this not be deemed unnecessary? No one is saying that definitively the woman would have gone onto a vaginal birth. They are just saying given the terms of their OWN birth, they felt it was not necessary to have been coerced/rushed into the cesarean.

And as to elective cesareans, it could be said that many of them are "unnecessary" as well. It could be possible that a woman who is having an "elective" cesarean was not given true informed consent (realities of risk for this pregnancy, future pregnancies and a realistic expectation of recovery) or was expected/forced to have a repeat procedure due to lack of support for VBAC (vaginal birth after cesarean).

Birthing Beautiful Ideas also has an eloquent post devoted to this topic. I think this blogger also understands the sentiment of women who have had cesarean birth and the emotional/physiological/psychological impact of an "unnecessary" one.

Multiple Cesareans Present Increased Risk to Placenta

This video from NBC 4 in NYC is making the round on the blogs. It tells the story of a NJ woman who discovered she had placenta percreta (placenta growing through the uterine wall) and placenta previa (placenta covers the opening of the cervix) during her pregnancy. She had 3 prior cesarean births and did not realize that they presented an increased risk for placental abnormality.

She luckily found out about the complication before birth as it would have presented an issue for increased risk of hemorrhage and/or hysterectomy. The comments from both the mother and the physician interviewed are important.

The mother comments, "if you haven't given yourself the chance at labor, you should". This is a woman with 3 previous cesareans. While we do know her circumstances exactly, we can guess that her 2nd and 3rd cesareans were scheduled. If she were given the chance to have a trial of labor and successful VBAC, her odds of developing placental abnormalities would not be as high.

And the doctor comments, "if we don't do anything about decreasing cesarean section rates in this country we are going to have a lot of mothers who are going to lose their lives". NJ had a cesarean section rate of 40% in 2009.

Update:

According to Rixa's Stand and Deliver blog, the journalist quoted the 40 deaths wrong. There were 42 maternal deaths total, with 12 of those being attributed to "preventable loss" such as placenta acreta. This is still a disturbing number of deaths.

Test to Predict Necessity of Cesarean?

According to this BBC article, there are now European companies using a test to determine if a prolonged labor will result in cesarean section. They base the outcome on the presence of lactic acid in the body. The higher the acid, the more likely it is that the uterus will become fatigued and not be able to birth.

Could this test be a good thing that would allow mothers to go one with longer labors if their acid levels remain low or another tool to further burden women with more unnecessary cesarean sections? Looking at the article it seems like it would swing more towards the latter. The doctors interviewed did not seem to grasp what could be the cause behind the increases in prolonged labors: artificial inductions, no positional change, lack of motility, etc. Perhaps they should look into fixing the standard hospital birth experience before coming up with more technology to interfere with a natural life process.

My Body Rocks Cesarean and VBAC Workshop

Karen Brody, playwright and activist who created "Birth", is holding a workshop in the DC Metro area for women who would like to tell their cesarean and/or VBAC story. This workshop combines storytelling, movement therapy and yoga nidra.

For more information please visit her website. She also offers a pregnancy circle. I had an opportunity to talk to Karen recently about this workshop and it sounds like a wonderful opportunity for all mothers who had cesarean births and VBACs.

http://www.mybodyrocksproject.com/index.html

VBAC Success Predictor Tool: Helpful or Junk

There is a tool on this website for the purpose of prediciting your potential percentage of success for VBAC. While many would consider such a tool suspect, it can be useful as just another reminder that VBAC is possible a lot more than the standard 4%-10% that we find in most areas.

But with such factors as "BMI" and race as the only determining factors, one can wonder if perhaps they are missing the point. For many women who prepare for VBAC there are several things (emotional and mental support, supportive practitioner and increased healthy lifestyle to name a few) that help them acheive success. And for others still the same set of criteria do not ensure success.

It is hard to imagine that you could plug in a set of numbers and yes/no answers and come up with a set way to determine who will be successful. But it is just another tool, even if it isn't the most useful.

ACOG Articles Highlighting a Potential Change in Perspective

In this recent post on Our Bodies Our Blog, two recent articles regarding the American Congress of Obstetricians and Gynecologists and their take on the recent forums and studies on VBAC and the rising cesarean rate.

The first is an article from Obstetrics and Gynecology. It highlights the fact that the current VBAC policy of ACOG limits, if not outright denies, the option of vaginal birth after cesarean for most women. It also touches on the subject of informed consent.

The second article is a synopsis from an address given to the ACOG annual meeting. The physician giving the commentary discusses the need to tone down and reassess the current use of induction and cesarean surgery. His tone is encouraging to those who hope to see current trends in maternal care reversed and women given the opportunity to have a say in their own care.