Beyond Blame: Yes, Too Many C-Sections, But No, Not Bad Moms

WBUR reporter Martha Bebinger recently published a story on childbirth quality data to help pregnant women and their families compare hospitals across Massachusetts. Here, she shares a personal reaction to some of the more troubling feedback she got about Cesarean sections.

The moment of birth during a Cesarean section (Wikimedia Commons)

The moment of birth during a Cesarean section (Wikimedia Commons)

I am not a bad mother because I had a Cesarean section. If you had one, neither are you.

Most if not all doctors who have high rates of C-sections are not bad doctors.

C-sections happen as a result of many decisions, some good, some bad.

In some cases (possibly mine) they save the life of the mom and baby. In other cases they are avoidable if not unnecessary.

If we want fewer of them, we have to look at all the steps that lead to a C-section and find the decisions that most often lead to missteps. Pointing fingers at moms, docs, hospitals or anyone else (partners, lawyers, etc.) won’t help.

That’s my water cooler summary on C-sections after several months of looking at childbirth quality measures and C-sections in particular.  I hated hearing from moms who felt like we belittled their experience by suggesting that there are too many C-sections.

Our point in the series was to alert everyone to the range of C-section rates and to help mothers be more aware of the factors that lead to a C-section. It is up to the medical system as a whole to analyze what goes wrong and reduce the number of C-sections. The last thing we wanted to do was to blame mothers.

Here’s my C-section story. I’d love to hear yours.

In my mid thirties, when I finally decided to have child, I also decided that I really wanted to give birth.  Conception and pregnancy were the beginning and middle of an experience I wanted to be right there in the thick of to the end. I only planned to give birth to one child, so I wanted to choose the package, which in my case was a vaginal delivery.

I signed on with a small office with one OB and one midwife. I toured the natural birth center at my local hospital and I got the hospital administration to agree that my acupuncturist could be on hand, with needles for my delivery.

Then, one gray November day, I got to 10 centimeters over the space of about 12 hours and heard my OB say “oh my.” My son was breech.  It was hard to absorb this news in between contractions.  Dr. Vigliani, whom I love, did some calculations and decided my son was too big to try to pull out feet first.  The timing got a little dicey and I had an emergency C-section.

I was sad to miss the natural birth experience, but I left the hospital with a beautiful, healthy, bouncing (9.8 oz.) baby boy.  I decided not to dwell on how he came out.  It did not occur to me to feel guilty about having a C-section.  I tried for a vaginal delivery, it didn’t work out.  It wasn’t my fault or anyone else’s.  Would anyone have expected me to risk pushing out the body of my son only to have his head get stuck?  In an earlier era, we might both have died.

So when I hear doctors say hospitals are doing too many C-sections, I never imagine that these experts are talking about me. I’ve always assumed, perhaps naively, that I’m firmly in the “up to 15%” group of C-sections the World Health Organization says may be medically necessary. If I’m wrong, I don’t care. Everything turned out just fine.

 

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  • SouthShoreGirl

    I am late to the conversation but found this article while researching a new OBGYN for when we plan to get pregnant with our second child. I am very interested in this subject given my circumstances. I just wanted to share my story. I am a healthy 32 year old first time mom. I gave birth to a beautiful baby girl this past November and ended up having to have an unplanned C-section much to my dismay. My water broke on a Sunday. Since I was not having contractions, they let us go home and told me to come back in the morning. I was told that 95% of women go into spontaneous labor on their own within 24 hours of their water breaking. Unfortunately, I was in the 5%. We went back the next day and they proceeded to try cervical “softeners” and I began to have mild contractions. They were worried about infection due to my water breaking over 24 hours prior. Eventually, we were moved to labor and delivery and I was ultimately given pitocin to quicken my labor. (Pitocin is a subject to be written about all on its own!) I requested an epidural that repeatedly wore off and had to be redone. I pushed for six hours but not consistently (my first red flag). They said I should rest and take a nap when baby girl wasn’t progressing. I went through shift changes of nurses and doctors. Docs all had a differing opinion. Unfortunately, my doctor who I trust was not on call and not available. On Tuesday, two days later, the third doctor I saw told me I would HAVE to have a C-section since my pelvis was too small. No other doctor mentioned this was even on the table and I was heart broken. I know some women can’t understand why a women feels bad about a surgical delivery and I can’t explain it myself. I think it was just a vision I had in my head of vaginally delivering our baby to my husband and it was my “badge of honor” to do so. After a quick discussion, we agreed to proceed (we were not given a choice regardless). There were severe complications during my C-section where they nearly needed to give me a hysterectomy to stop the hemorrhaging due to a torn uterine artery. I ended up with an internal bleed that required another internal procedure and it took months to recover. I was in a fog the first months of having baby girl home and without ever a history of depression, I suffered deeply. I am happy to say Mom, Dad and Baby Girl are happy and healthy today but I have done endless research on the topic of “Are certain C-sections really necessary?” I have found that it is very uncommon to have a pelvis that is too small. I wasn’t given the option of changing position, or investigating alternatives. Bottom line: Was mine really necessary and did it cause unnecessary damage that honestly could have killed me?

  • Judah

    My wife gave birth unmedicated, all natural vaginal delivery at Newton / Wellesley. I caught our girl and cut the cord. She smiled at me as I said “Hi, I’m Dad” while lifting her to her Mom. I don’t think we would have been successful without taking a course in The Bradley Method. It taught me (a guy) a lot about the birthing and labor process, what to expect when dealing with the medical professionals who are concerned about liability both before/during/after birth, and how to best support my incredible wife.

    I would encourage anyone who is serious about vaginal birth and wants to enter the hospital (or birthing center or home) with the knowledge to inform what will and may happen to check out the Bradley Method. Thanks Anne Marie and the midwives from Harvard Vanguard. Newton Wellesley nurses also left us mostly alone for 2 days with appropriate lactation support. Overall, one needs to be educated and in control of the birthing environment and team to succeed in all natural, unmedicated vaginal delivery. Otherwise you are going to get interventions that domino to a C-section. In fact, we had to sign a declaration that we knew the risks of vaginal birth. It is apparently easier and less risky for doctors to actively manage your birth using chemical and physical interventions to reduce their financial and legal risk. That said I agree with C-sections of course; they are just done too much for poor reasons to people who may not understand all options – and who haven’t done exercises like kegel’s to increase the potential of a vaginal delivery

    • Martha Bebinger

      Nice story and guidance Judah! Best to you and your family.

    • Maile Shoul

      But often, one IS ‘educated and in control of the birthing environment’ and she still has a c-section. I took Hypnobirthing and Hypnobabies courses, had a doula, saw a midwife at Mt. Auburn, and ended up having a c-section after over 30 hours of labor. I know many other moms in the same situation. Your comment implies that women who have c-sections just didn’t try hard enough at having a natural delivery. The fact that your wife had an unmedicated birth is not just because you took the Bradley method. A lot of it was just pure chance.

      • Judah

        I’m glad you had a healthy baby; to each their own. I totally disagree with your assertion about “pure chance.” You are wrong. Success rate for Bradley is 86%-90% unmedicated, all natural. That rate is too large for “pure chance.” Bradley’s principles are based on 1000′s of years of birthing history across cultures; I don’t think we can say the same for “hypnobirthing.” Furthermore I don’t think Bradley caused anything; it simply increased our chances because not only did my wife physically and mentally prepare (without hypnotics) so did I. We knew what to expect and made informed decisions to avoid a cascade of interventions leading to a C.

  • Christine

    This is not the comment you were asking for, but there is definitely a conversation to be had around the skills required to deliver a breech baby vaginally, and safely. (Along with evaluating the criteria where this route is a safe option.) If I had been in your situation, I too would have been comfortable with the choice to deliver surgically and not thought twice about it. But my second son was a surprise frank breech that could not be delivered surgically because of a precipitous birth where he was practically out by the time his position was determined. Fortunately I was attended by someone who knew how to manage this situation and deliver my son without injury. I also caught grief for choosing to deliver at home and a lot of insinuation that had I been in the hospital they “would have known he was breech and sectioned me.” The ‘what ifs’ in my situation are interesting but as things worked out, I had a friend have a surprise frank breech of her own in a hospital setting and I got to watch how her baby was delivered vaginally and see how her breech was missed, even with an u/s done. For me, the answer is not a bunch of strict protocols but making sure birth attendants are prepared and open to all options, even those where a midwife may be the most skilled at handling a delivery. OB/Gyns are critical and highly skilled, but I’m not convinced vaginal birth complications are always their strong suit, especially in this day and age where they see so few vaginal breech deliveries. It really does go back to our broader care system. Even moms that birth naturally can catch wreck on the internet for “doing it wrong.”

    • Martha Bebinger

      Very interesting Christine. I’m not sure I understand your last sentence, but thanks for the breech perspective!

      • Christine

        Just that meant to say post birth guilt, insecurity or bad mother accusations happen a lot online, even among moms that birthed naturally. Everyone willl have their own idea of what it means to have a successful birth.

        • Martha Bebinger

          Got it Christine – thanks again!

  • Kathrine Lovell

    Thanks Martha for your story.xxok

    • Martha Bebinger

      Hi Miss Kitty! Thanks!

  • Cythina Lang

    The traditional on-the-back position than most women assume for hours during the delivery can cause the baby to compress its own blood supply with its weight. Then the heart rate starts dropping, etc. Often, changing the position will solve the problem without any further need for interventions. Doctors who won’t try this end up with higher rates of perfectly avoidable C-sections.

    • Paula CNM

      Anyone in the childbirth community (even DOCTORS) is aware of this fact and do NOT have women assume a FLAT on the back position for any amount of time in labor. A woman who is recumbent in bed (say, with an epidural) is discouraged from being completely flat for this very reason. Simply tilting a women with a pillow under her side solves this problem.

      • Cythina Lang

        There are several women who posted on this thread that the decision to have a C-section was made after the baby’s heart rate dropped. How many of them wrote that other things, such as changing position were tried first? I bet that for many of them, it was not tried.

  • Cythina Lang

    To say that a C-section is necessary “because that’s what the doctor said” is disingenuous. If your doctor has a high rate of doing C-sections (and this is something that can and should be checked before you choose one), then they will prefer it in many situations where other doctors can and will deliver vaginally just fine.

  • Cythina Lang

    Thank you for the story. I am curious, what happened to the midwife that your office had? Was she there at the time when the breech position was discovered? Part of midwives’ training is to rotate babies into the right position right there in your womb, if possible. They can’t do it every time, but often enough. That’s what mine did… So if one was not even consulted, then this was possibly a very avoidable C-section.

    • Paula CNM

      the time for “rotating babies into the right position” is usually no later than 38 weeks or so. At 10 cm dilated, it’s waaay too late. And also, if it involves external cephalic version, not really within the scope of practice of any responsible CNM.

      • Cythina Lang

        The rotation I am talking about takes place with the midwife’s hand inside you, after you are dilated — NOT at 38 weeks. They physically manipulate the baby into place inside there. As I said, this is part of midwife training, but I am not sure any doctors can do it.

    • Martha Bebinger

      I can’t remember for sure, but I believe that the doc was on hospital duty that day, not the midwife. The midwife was not in the room when the breech position was discovered.

  • Amanda Sina Griffith

    I had an emergency C-section with my first daughter when my water broke at 35 weeks. By the time I got to the hospital, her heartbeat was erratic and she had turned breech so they had to take her. 14 months later, I delivered my second by C-section too. The doctor offered a VBAC but discouraged it so when I went into labor at 36 weeks, they immediately did a C-section. I’m now pregnant with my third but after an ectopic pregnancy and loss of tube in November ’12, I don’t even have the option of a VBAC because of scar tissue. I feel guilty that I haven’t experienced labor but I keep trying to remember that it’s a healthy baby that really matters most of all!

    • Martha Bebinger

      Best of luck Amanda!

  • jad311

    I had a C section due to placenta previa, a condition in which the placenta covers the cervix. Without a C-section my son would have died and I could have bled to death. 8 hours prior to my scheduled C-Section, I started bleeding, had an emergency c-section and left 4 days later healthy and with a healthy baby. That is all that matters. I had my baby at Mt Auburn, a hospital with a low C-Section rate, I almost feel bad “upping” their numbers, but I’d much rather the maternal mortality rate be low.

    • SR

      And that is why there is, absolutely, a time and a place for cesareans!

      Docs should really make an effort to keep c-sections limited to those truly necessary cases, and do everything they can along the way to encourage a successful vaginal delivery (e.g. have patience and not induce labor until 42 weeks in otherwise healthy moms).

      I had a c-section with my first (premature and footling breech), VBAC with my second. I’m so glad that the medical technology was there when I needed it, and also very glad that I got to have what, in my eyes, was a more gentle (though there was a lot of screaming, lol…) birth experience with my second.

      So glad you and your babe got the delivery you needed and were fine and healthy – as I’m certain all the folks at Mr Auburn were as well, without question!

  • Melissa Weisshaus

    I called in to the show the other day to give my story, but there wasn’t time. I’ll give it here and now :).

    Glossing over many details, my story has to do with age: a while back, a study was performed (and then repeated more recently) which showed that for women over 40 the rate of stillbirth rises sharply after 40, and then 41 weeks’ gestation. I was to be nearly 44 at the time of my delivery, and therefore I essentially had to agree to being induced. The first, “gentle” attempt at induction produced no results. The second, pitocin induction produced intense, painful results; my water broke after 14 hours, and I begged for an epidural after 28 hours (after which I slept for 8 hours).

    At 2am on the second night, after the midwives had me turn onto my other side and put my leg up on a table (quite the comical image, I’m sure!), I felt a sharp pain in my side (with an epidural, there essentially shouldn’t be any pain). Suddenly, a flurry of people appeared in my room and quickly related the following details: the baby’s heart rate was decreasing, my contractions were slowing down, and my cervix was still not dilating beyond the 3cm that the midwives had coaxed it to open the previous day. I replied, “it sounds like you’re saying that I need a c-section, so why are we waiting?”

    What I remember actually thinking at the time was simple: right now, he’s alive. Who knows what might happen in 5, 10, 200 … minutes?

    And so, 45 minutes later, my son was born, with an Apgar of 9 on both ratings, and stats of 9lbs, 1.5 oz and 22 inches long. And, with a huge head — a bit pointy on top from having tried to get past a 3cm dilated cervix. :)

    I will never know what might have happened had I not been induced, and the issue essentially forced. I will never know if I might have been a statistic on the side that says waiting beyond 41 weeks can be safe, or on the side that further justifies the results of the study that urges women over 40 years of age to not go beyond 40 (or 41) weeks. All I know is that today, my son is amazing, gorgeous, healthy, happy, and *alive* by any definition, and I am his mama. And I wouldn’t have him, or me, any other way.

    • Martha Bebinger

      Thanks Melissa – wishing you many, many happy years of motherhood!

    • Fabulous Redhead

      My story is similar to yours. I was 40, nearly 41 at the time of my son’s birth, and I was told about that same study by my nurse-midwives. My labor started naturally almost exactly 12 hours after insertion of the Cervadil pessary, so I didn’t get the Pitocin, but my dilation proceeded very slowly and my labor pains became so intense that I ended up asking for an epidural. That at least allowed me to get some sleep.

      After about 30 hours of labor, I was finally fully dilated; I spent 4 hours pushing with no progress whatsoever. It turned out that my son’s head was in high military position instead of tucked down like it should have been, resulting in his head hitting my pubic bone with every contraction and push, eventually causing him to go tachycardic. And so, when the obstetrician on duty was consulted and a C-section was suggested, I quickly agreed. He was 8 lbs, 12 oz, about 22 inches, and also had a pretty large head that was elongated from 4 hours of attempting to exit and failing, but he was perfect and healthy despite the difficulty. (I, on the other hand, was pretty wrecked by the C-section and, later, by nasty allergic reactions to all the adhesives and gels that had been on my skin for the previous 2-3 days and extreme constipation resulting from heavy post-surgical narcotics. It took me 3 months to start feeling like myself again.)

      I have occasionally wondered if he might have been correctly positioned for birth if we had just let things proceed naturally, and whether we might have been spared the ordeal that my labor became. However, I don’t spend much time dwelling upon it. Two and a half years later, my son is healthy, bright, beautiful, and full of mischief and humor. And I don’t feel like I’m any less his mama, nor a worse one, because I wasn’t able to have the natural birth for which I’d originally hoped. We are both alive and well. That’s what counts.

  • Jannatha Coffin-Malia

    I also had an emergency c-section in 2007. I had planned vaginal birth and an epidural, but I had not planned on having a reaction to the epidural. Unfortunately, when it was administered, my son’s heart rate and my blood pressure dropped dangerously low. I continued pushing (about 3 hours total), but my doctor deemed that it was too risky for me to continue since it was compromising both of our health. I think it shows just how “brainwashed” we are to believe there’s something wrong with us if we aren’t able to deliver naturally. I immediately started crying when she said I needed a section and promised to “try harder.” Thankfully, I have a great OB/GYN who assured me I had tried my hardest, but this was what was best for me and my child. My 9.1 pound healthy baby boy was born via c-section. Now that he’s 6, I rarely concern myself with how he came into the world. I am concerned, however, at my friends who are trying vbac despite their doctor’s warnings. Thanks for reminding us that there is no stigma to bringing your child into the world, however that is!

    • SR

      I respect your concern for your friends, but please know that most women with prior cesareans have a great chance of having a successful VBAC. While there are some cases in which it is really medically necessary to have a repeat cesarean, there are a lot of cases in which it is NOT medically necessary, yet doctors still push patients to go that route because of fears of uterine rupture. Yes, uterine rupture is a risk, and worth considering. Is it the only risk worth considering? No. Repeat cesareans also come with significant risks that are less talked about and less known. (In fact, uterine rupture is also a risk during elective repeat cesareans 0 0.4-0.5% as opposed to 0.7-0.9% for VBACs. – ACOG Practice Bulletin)

      That ACOG Bulletin sums up that, “Most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about VBAC and offered TOLAC.”

      http://www.acog.org/~/media/Practice%20Bulletins/Committee%20on%20Practice%20Bulletins%20–%20Obstetrics/pb115.pdf?dmc=1&ts=20130415T1216109630

      • Jannatha Coffin-Malia

        I’m talking about friends who have been specifically told, for various reasons, that they should not attempt VBAC. I have another friend who recently had her 3rd child VBAC after 2 previous c-sections and was just fine :-)

  • Kezza

    I had a similar experience for my first kiddo. I did a lot of reading (too much?) and decided to try hypnobirthing. Took the classes, practiced meditation (not usually my thing), listened to the CDs and got as ready as I could — and then things just didn’t go as planned. Hey, it happens! I gave it my best, with whole-hearted support from my doctor and the hospital staff, and the baby just. wouldn’t. budge. So the decision to have a c-section in the end, after 30ish hours of labor, was mine and my husband’s alone. I haven’t spent a moment beating myself up for it, and I have no regrets.

    For my second child, born just 6 months ago, I read about the pluses and minuses of VBAC until my head spun. My doctor, one of the best VBAC docs in the area, said she would support whatever decision I made. In her words, it was practically six of one, half-dozen of another — VBAC being a little safer for the mother, and a second c-section being a little safer for the baby. We set a date (after my due date) and let fate decide. If he came before then, we’d try a vaginal birth, and if there was no action by then, a c-section it was. One week after my due date, my second son was born via caesarean. I healed very quickly, was home in three days and now have two healthy, sweet boys to drive me crazy. Could I have done it by VBAC? Sure, maybe. Or maybe not. For me, the process was not the point. The result was.

  • pyewacket

    I had a “planned” c-section. I had had a c-section for my first son for failure to induce – 15 days past his due date and 49 hours of induction, and I never got beyond 1 cm of dilation. For my second, I could try for a VBAC. But I looked at the odds and realized that it was really, really unlikely I would be successful. Successful VBACs are most common for younger mothers (I was 40), for mothers of average BMI (I was overweight), and for mothers whose previous labors had gotten fairly far along (mine never started). Also, my son was transverse – the doctors were a little worried in case I progressed too quickly. Given that the c-section with my first son was perfectly fine – an easy recovery for both baby and me, no complications – and the worst part of that delivery was the exhausted, miserable state my husband and I were in after two days of being in the hospital, I thought a planned c-section would save me that misery. Also, doctors tend to prefer planned to emergency c-sections if that’s what the choices are.

    And then my son had fluid in his lungs, a common problems with c-section babies, and I didn’t get to hold him for hours and hours, and he was in the NICU for three days, and didn’t gain weight as quickly as he should, and I spent months asking myself if I did the wrong thing. I still don’t know.

    • SR

      So sorry you had to go through that. It’s hard to have to question yourself – I have as well, about my first birth – but I don’t know that we can ever really find answers. I wish you peace though!

  • kaydo

    I had similar expectations of childbirth, with similar results. I labored for 23 hours and pushed for 2 hours before my son’s heart rate started to drop, and my doctor determined that I needed an emergency c-section. I didn’t have time to think about it, and did not enjoy the experience (it was painful, and my teeth chattered uncontrollably the whole time), but I was exhausted and relieved that my son (all 10 pounds, 3 ounces of him) was born healthy. (We knew he was going to be big but, in hindsight, I’m not sure I would have been able to deliver him vaginally anyway.) One thing that DID bother me, however, and which I never see discussed, was that no one told me that if I had a c-section, I would not see my son immediately. It was bad enough that I was missing out on the experience of him being laid on top of me after birth (as I had always envisioned) but I assumed with a c-section that they would lift him up for me to see, over the curtain, and they did not. They whisked him away, cleaned him, and brought him to me swaddled. To this day, it still bothers me that I didn’t see him right after being born. I asked my OB about it later and she said it was hospital policy not to take the baby out of the sterile zone unless the mother asks in advance; but no one had ever told me this. To this day, I make it a point to tell my pregnant friends that if they want to see their baby, they should alert their doctor in advance that they want the baby lifted up after a c-section. Four years later, it still bothers me that I didn’t get “that moment” of seeing my son’s birth.

  • spaztastic

    I had a c-section as well. My water broke at 5 PM and the following day at 1030 PM I still hadn’t gotten to 9 CM. I actually wish I had gotten the c-section earlier. I feel like the length of time I went after my water broke contributed to the major complications that happened to my son at his birth.

  • Ducky

    I too had a c-section. My son was in breech as well. I am not sure if I could have delivered naturally, but I think it is unusual to do it these days.

  • KayZee

    I had a planned C section because my son was breech and not moving. He stayed breech for months. And he wasn’t feet first – he was butt first. But I went into labor early and once they realized he was still breech with no intention of moving, it was considered an emergency C. It was not my preference to have a C section – planned or emergency. I also delayed my recovery by trying to do too much too soon and be a hero about pain killers. I have no idea whether or not I’m a candidate for a Vbac the next time around, but it may not be up to me. I trust my doctor to advise me – and I never, ever consult the internet about my choices.

  • Jojo Wright

    I use to hang out on the parenting boards when expecting my son. Saw a high

    number of moms who were having planned c-sections. It would be interesting to see how many are of the planned type.