Medicine
A recent essay in the "Narrative Matters" section of Health Affairs by physician and health policy researcher Carla Keirns highlighted the challenges that even a highly educated, well-informed patient faces in achieving the desired outcome of a vaginal childbirth, especially if her pregnancy is classified as high risk. Dr. Keirns, whose pregnancy was complicated by "advanced maternal age" (40) and gestational diabetes, narrowly avoided a Cesarean delivery by obstetricians who often seemed to be "watching the clock" more than assessing her individual circumstances. She observed how the "Cesarean culture" of medical practice overshadows the ideal of shared decision-making about delivery preference:
I was naked and uncomfortable, had invasive lines in place, and hadn’t slept or eaten in three days. If a doctor I trusted, instead of one I didn’t know, had suggested a cesarean forty-eight hours into my labor induction, I might have agreed. If they had told me that my baby’s life or health was in jeopardy, I would have consented to anything. The vision of the empowered consumer, or even the autonomous patient, is laughable under these circumstances.
American Family Physician's February 1st issue featured a review article on counseling and complications of Cesarean delivery and a concise summary of the American Academy of Family Physicians' updated clinical practice guideline on planned vaginal birth after Cesarean (VBAC). The review article, authored by Drs. Jeffrey Quinlan and Neil Murphy, noted that Cesareans represent nearly one-third of all deliveries in the U.S., with the most common indications being elective repeat Cesarean delivery (30%) and dystocia or failure to progress (30%).
Once a woman has had one Cesarean delivery, she faces considerable pressure from the medical system to choose repeat Cesarean deliveries in subsequent pregnancies. A 2014 article in The Atlantic explained why the dictum "once a Cesarean, always a Cesarean" increasingly holds true despite good evidence that planned VBAC is safe for, and desired by, most women. After the American College of Obsetricians and Gynecologists (ACOG) published guidelines in 1996 (later challenged by the AAFP) recommending that in-house surgical teams be "immediately available" during planned VBAC, many hospitals stopped allowing women to attempt labor after a Cesarean. Even though ACOG now acknowledges that there is no evidence that hospitals with fewer resources have worse maternal or neonatal outcomes from planned VBAC, these restrictive institutional policies have remained in place.
After our first child was born by Cesarean section, my wife, who is also a family physician. proceeded to have three consecutive uncomplicated vaginal deliveries after the age of 35. To change the culture of medicine to support this kind of outcome, and to reduce the overall frequency of Cesarean deliveries, patients, physicians, and hospitals must advocate for aligning medical protocols with the best evidence and putting mothers and babies back at the center of care.
**
This post first appeared on the AFP Community Blog.
- Improving One's Chances For A Successful Vaginal Delivery
Two of the most important questions that pregnant women have are: 1) How can I improve my chances of having a normal (vaginal) delivery? and 2) Does where I plan to have my baby make a difference in birth outcomes? In the August 1st issue of American...
- What Pregnancy Care Costs, And Related Writings
Elisabeth Rosenthal's New York Times story on the staggering costs of maternity care in the U.S. featured a short interview with my wife, a family physician who last year gave birth to our third child with a nurse-midwife 12 minutes after arriving...
- Vbac Redux
Several months ago, I wrote in this blog about the precipitous decline of vaginal births after Cesarean (VBAC) in the U.S., which I attributed in part to the the internalization by obstetric specialists of the medical maxim "hearing hoofbeats, thinking...
- The Decline Of Vbac: Hearing Hoofbeats, Thinking Zebras
My daughter, who turns two years old in June, is becoming something of a medical rarity. This isn't because she is showing signs of a late-developing handicap or extraordinary ability for her age - it's because she came into the world as a vaginal...
- Does The Type Of Birth Affect Postpartum Health?
My first child was born surgically via cesarean section, while my second arrived naturally by what maternity care providers call a “normal spontaneous vaginal delivery.” Surgical deliveries are rapidly becoming the norm rather than the exception in...
Medicine
Once a Cesarean ... now, a vaginal delivery
A recent essay in the "Narrative Matters" section of Health Affairs by physician and health policy researcher Carla Keirns highlighted the challenges that even a highly educated, well-informed patient faces in achieving the desired outcome of a vaginal childbirth, especially if her pregnancy is classified as high risk. Dr. Keirns, whose pregnancy was complicated by "advanced maternal age" (40) and gestational diabetes, narrowly avoided a Cesarean delivery by obstetricians who often seemed to be "watching the clock" more than assessing her individual circumstances. She observed how the "Cesarean culture" of medical practice overshadows the ideal of shared decision-making about delivery preference:
I was naked and uncomfortable, had invasive lines in place, and hadn’t slept or eaten in three days. If a doctor I trusted, instead of one I didn’t know, had suggested a cesarean forty-eight hours into my labor induction, I might have agreed. If they had told me that my baby’s life or health was in jeopardy, I would have consented to anything. The vision of the empowered consumer, or even the autonomous patient, is laughable under these circumstances.
American Family Physician's February 1st issue featured a review article on counseling and complications of Cesarean delivery and a concise summary of the American Academy of Family Physicians' updated clinical practice guideline on planned vaginal birth after Cesarean (VBAC). The review article, authored by Drs. Jeffrey Quinlan and Neil Murphy, noted that Cesareans represent nearly one-third of all deliveries in the U.S., with the most common indications being elective repeat Cesarean delivery (30%) and dystocia or failure to progress (30%).
Once a woman has had one Cesarean delivery, she faces considerable pressure from the medical system to choose repeat Cesarean deliveries in subsequent pregnancies. A 2014 article in The Atlantic explained why the dictum "once a Cesarean, always a Cesarean" increasingly holds true despite good evidence that planned VBAC is safe for, and desired by, most women. After the American College of Obsetricians and Gynecologists (ACOG) published guidelines in 1996 (later challenged by the AAFP) recommending that in-house surgical teams be "immediately available" during planned VBAC, many hospitals stopped allowing women to attempt labor after a Cesarean. Even though ACOG now acknowledges that there is no evidence that hospitals with fewer resources have worse maternal or neonatal outcomes from planned VBAC, these restrictive institutional policies have remained in place.
After our first child was born by Cesarean section, my wife, who is also a family physician. proceeded to have three consecutive uncomplicated vaginal deliveries after the age of 35. To change the culture of medicine to support this kind of outcome, and to reduce the overall frequency of Cesarean deliveries, patients, physicians, and hospitals must advocate for aligning medical protocols with the best evidence and putting mothers and babies back at the center of care.
**
This post first appeared on the AFP Community Blog.
- Improving One's Chances For A Successful Vaginal Delivery
Two of the most important questions that pregnant women have are: 1) How can I improve my chances of having a normal (vaginal) delivery? and 2) Does where I plan to have my baby make a difference in birth outcomes? In the August 1st issue of American...
- What Pregnancy Care Costs, And Related Writings
Elisabeth Rosenthal's New York Times story on the staggering costs of maternity care in the U.S. featured a short interview with my wife, a family physician who last year gave birth to our third child with a nurse-midwife 12 minutes after arriving...
- Vbac Redux
Several months ago, I wrote in this blog about the precipitous decline of vaginal births after Cesarean (VBAC) in the U.S., which I attributed in part to the the internalization by obstetric specialists of the medical maxim "hearing hoofbeats, thinking...
- The Decline Of Vbac: Hearing Hoofbeats, Thinking Zebras
My daughter, who turns two years old in June, is becoming something of a medical rarity. This isn't because she is showing signs of a late-developing handicap or extraordinary ability for her age - it's because she came into the world as a vaginal...
- Does The Type Of Birth Affect Postpartum Health?
My first child was born surgically via cesarean section, while my second arrived naturally by what maternity care providers call a “normal spontaneous vaginal delivery.” Surgical deliveries are rapidly becoming the norm rather than the exception in...