If I Was a Betting Woman...

Twelve days late, for the third time.  Same weight gain for momma; for the third time.  Birth weight identical to one sibling and 2 ounces less than the other.  If I was a betting woman, I would start placing bets on my pregnancies.  That is if there were going to be a fourth one.  I am (almost) positive this is the last baby for us.  I think. 

Little Miss has arrived.

2nd VBAC

VBAC Series: April is Cesarean Awareness Month

April is Cesarean Awareness Month.  This seems to be designated by the International Cesarean Awareness Network, but I can't really find anything about its origin. 

Part of awareness is knowing your hospital's cesarean section and VBAC rates.  Leap Frog Group collects information from hospitals about their first time cesarean section rate.  This is under the classification of cesarean section, which is not immediately obvious that it is referring to only first time mother's whose baby is in the head down position.   

Consumer Reports recently reported on the variation in hospital’s first time cesarean section rate based on the Leap Frog Group data.  Neighboring hospitals may have very different cesarean section rates.  While some hospitals may claim they have a higher risk population driving their cesarean section rate, this statistic is based on low risk mother's only, leaving no room for that argument. 

While many larger New York City hospitals declined to submit their data to Leap Frog Group, New York State collects similar information.  However, in the NYS data there does not seem to be a difference between high or low risk mothers.  Additionally, primary cesarean section rate may also include mom's who had a previous vaginal delivery, but had a cesarean section in a following pregnancy.  Even without the separation of low risk to high risk pregnancies, the data is somewhat telling, especially between large academic medical centers where patient population should be similar.  NYS data also contains information on their VBAC rate, defined as the number of women delivering vaginally with a previous cesarean section, the denominator is all women delivering with a previous cesarean section. 

Other states may have cesarean section data available.  In a quick search New Jersey and Massachusetts seemed to have reports on the information, rather than an interactive website.  Have information for your state?  Feel free to post a link to it in the comments below. 

Listening to Mother's III

Have you heard about the Listening to Mother's surveys?  In 2013 the third report was published, where over 1000 women in the United States were interviewed about their childbirth experience.  This report gives a snapshot of the state of maternity care in the United States.  

Some of the results are mind blowing!  One of the most startling results was about women being told their baby would be "big" at the end of their pregnancy.  In the shared decision making section, 32% of women reported they were told their baby may be big.  The majority of these mother's said their practitioner brought up an induction (62%) and 44% reported a discussion about cesarean.  In the end, the average size of the baby's actual birth weight was 7lbs 13oz.

Another startling response was that 47% of first time moms reported being induced.  Almost half! 

In teaching childbirth classes, there is often this disconnect where you sometimes feel like you are teaching women to fight for their rights.  Many elements in this report underscore the importance of women learning to be advocates for their care.  But is that fair?  Should a woman in labor or at the end of her pregnancy be expected to stand her ground when it comes to unnecessary interventions, or rather should it be expected that she will be offered good quality care based on evidence and putting her first?

I encourage you to check out the results and consider the state of maternity care in the US.

Episiotomy or Not?

Episiotomy use in the United States has decreased dramatically in the last few decades.  In the year 2000, about 30% of women still underwent an episiotomy during delivery.  Currently the recommendation is that episiotomy should not exceed 5-8% of use during vaginal deliveries.

So what is an episiotomy?  Essentially it is a cut made is the delivering woman’s vaginal opening while she is pushing out the baby.  Historically, there were thought to be multiple benefits to this procedure.  Most, if not all, have not been supported by research.  In fact, woman who have an episiotomy tend to have more pain after delivery (and during the procedure!), further risk of tearing, and increased risk of pelvic floor dysfunction to name a few disadvantages to the procedure.

In 2006, yes 10 years ago, the American College of Obstetrics and Gynecology recommended against the routine use of episiotomies.  However, what we in the obstetric world know is this varies greatly by physician practice.  In fact, some research has found that private practitioners (as opposed to residents or hospital based physicians) have the highest rates of use.   

There are very few acceptable reasons for an episiotomy and even those aren’t always concrete.  I think most practitioners would agree that if a baby is in distress and the episiotomy will expedite the delivery, then yes an episiotomy is appropriate.  However, another reason often considered acceptable, is to prevent severe maternal perineal tearing.  This benefit would be difficult to prove.  How does the physician know how severely the woman will tear?  I haven’t heard or read a good prediction of tearing yet.

It is important to ask your practitioner what their episiotomy rate is.  They should know the answer to this question.  And if they claim they don’t, ask “50%? 33%? Less than 10%?”  Then I think the next question is, when would you do an episiotomy?  They should speak to expediting delivery when the baby is in trouble.  If you hear, “easier to repair, protect the pelvic floor, or every first time mom needs one” this should raise some red flags. 

Feel like you need more information about episiotomies? This is a summary of the ACOG recommendation.

Choices in Childbirth has more information about the procedure itself and how to potentially avoid the procedure.