It's hard to compete with 20 billion years of evolutionary selection, but the current medical management of the birth of the fetus and the placenta attempts to do just that, albeit rather unsuccessfully. For eons, all animals including humans passed on genes and habits that ensured delivering a live healthy newborn without bleeding excessively or dying of postpartum hemorrhage at birth. Among mammals, bleeding to death would not result in successful reproduction, until recently, because a live mother was required to nurse the newborn. 

Abstract: A recently coined term, unneCesareans, describes the mode of delivery for 25% of low-risk first births in most Western countries. Evaluation of Cesarean Delivery, published by the American College of Obstetricians and Gynecologists (ACOG) showed a lack of evidence of improved medical outcomes with the widespread use of cesareans for low-risk, full-term first births, therefore, they are medically "unnecessary". Eighteen causes for this common practice have been documented in published research. Since UnneCesareans have multiple causes, a reverse in current trends is unlikely.

When I tell people that I am a homebirth midwife, they often respond by asking, "Why do women choose to give birth at home?" It would be wonderful if the answer would be that hospital outcomes are comparable to attended homebirths and homebirth is just more comfortable. But since US hospitals delivered 32% of low-risk women by cesarean surgery since 2007 and 1 in every 3000 of those died from the surgery, the answer is simple: to avoid dying in childbirth or being scarred for life by unnecessary surgery.

Then, the second question the listener naturally asks is, "Why do doctors do unnecessary surgery?" Many doctors and midwives are also concerned with this question and have researched it extensively. The following is a review of the recent research, most of it published since 2006, regarding the causes of unneCesareans.

How often does Amniotomy cause Cord Prolapse after 36 weeks?

Judy Slome Cohain, CNM

Abstract

Of the 33 English-language studies evaluating risk factors for cord prolapse, close to 80% evaluate every possible factor other than artificial rupturing of the membranes (amniotomy).  Of the 7 studies which evaluate amniotomy, 2 observational studies concluded amniotomy can cause cord prolapse, while 5 case controlled studies conclude amniotomy does not cause cord prolapse on the basis that amniotomy does not always cause cord prolapse, which is invalid logic.  Not looking before you cross the street also does not always result in being run over.  Intercourse with a woman with AIDS does not always result in contracting AIDS, but to conclude that AIDS is not transmitted by sexual intercourse is incorrect.  A comparison of amniotomy rates to cord prolapse rates at full term births found cord prolapse to increase with increasing amniotomy rates near term. Cord prolapse did not occur among 6000 attended full term labors when no vaginal exams or amniotomy were performed.

Cord prolapse, a cause of permanent disability and death, can be caused by amniotomy at or near term. To achieve optimal neonatal outcomes, the amniotic sac should not be ruptured artificially to speed up labor or induce labor.

Since the beginning of hospital birth, research supporting its use for low risk women has been lacking. The last 15 years has produced 17 studies all supporting attended planned homebirth as safer for low risk women. 

Research reveals that there are only 2 acute conditions that might occur at homebirth in which the mother or baby may have a better outcome had they planned a hospital birth, namely: Cord prolapse and Amniotic Fluid Embolism (AFE). Although tragic, cord prolapse and AFE occur rarely at homebirth, 1/5000 and 1/500,000 respectively, when balanced with the dozens of acute emergency conditions endangering the health of mother and baby that occur at planned hospital birth caused by intervening in the birth process, the scales tip easily in favor of planned attended homebirth for low risk women.  Acute conditions caused by hospital birth are discussed here, to allow low risk women to make informed choices as to place of birth.

Abstract: Case controlled studies show no benefit to inducing for postdates. Routinely inducing for postdates is based on 3 uncontrolled, retrospective studies showing 1/1000 less stillbirths while ignoring possible increases in brain damage to newborns as a result of induction. Induction or Elective cesarean for Precious pregnancies is justifiable.

Summary: To date, bioeffects studies in humans do not substantiate a causal relationship between diagnostic ultrasound exposure during pregnancy and adverse biological effects to the fetus. However, all epidemiologic studies were conducted with commercially available devices predating 1992, having outputs not exceeding 94 mW/cm2, whereas since 2002 obstetric ultrasound devices are allowed by the FDA to reach 720 mW/ cm2. Available evidence is insufficient to conclude that there is a causal relationship between obstetric diagnostic ultrasound exposure and adverse effects to the fetus. However, all agree there is a need for further investigation of potentially adverse developmental effects. Ultrasound produces heat in the tissues it irradiates. The fetus before 10 weeks has no blood circulation and therefore is unable to rid itself easily of the thermal effects of ultrasound until after 10 weeks gestation. The FDA in 2002, the SOGC in 2005, The American Academy of Family Practitioners in 2009 and ACOG in 2009  all agree that because of the potential for 'adverse effects’, prenatal ultrasound should not be offered or used routinely.  It is revealing that the term adverse effects is always used in favor of "dangers" of obstetric ultrasound.  A search for "Danger obstetric ultrasound" comes up with 0 hits on Medline whereas "Danger radiation" produces over 400."

Risk-benefit issues are extremely important in clinical practice. In situations where risks of adverse effects appear so low and clinical benefits are great,  there is no justification to withhold the use of ultrasound.

In the following cases, the benefits outweigh the possible risks:

1) To Turn Breech:  If the baby is breech, ultrasound dramatically improves outcomes of external version at 37 weeks.  When attempting to turn breech fetus without ultrasound, every once in a while a head down baby is turned to breech by accident.

2. Locating Placenta Before vbacs: To confirm placenta is not located in the scar, at term, prior to attempting vaginal birth after cesarean.  Fifty years ago, placenta accreta was rare, occurring 1 in 3,300 births.(Esh-Broder 2011) .   Today, the rates are much higher.  The highest reported rates are for IVF births for which the reported rate of placenta accreta in 1/60 (Esh-Broder 2011).  After one cesarean, the reported rate of placenta accreta is  between 1 in 150 to 1 in 300.(Marshall 2011)  If the placenta is deeply imbedded in the scar, then during repeat CS, the surgeons can attempt to save the uterus, or at least save the woman before she bleeds to death.  Placenta accreta is a known risk for hysterectomy but the actual rate of hysterectomy in the presence of placenta accreta has never been reported.

[Reprinted with the explicit permission of the author, Cohain JS. In-links added by GreenMedInfo.com. The Epidural Trip. Midwifery Today 2010:95:21-4, 65. © 2010 Midwifery Today]

[Cohain JS. Mars Attack. Midwifery Today 2008:88:24, 66-7. Copyright Midwifery Today. Reprinted with the explicit permission of the author]

Abstract: "Mars Attack" is new term coined to describe unjustified violation of women by care providers at the time of birth, as well as the purposeful abandonment of the peer review system by major obstetric journals and the abandonment of the use of research evidence by ACOG in their latest protocols, in order to justify continued use of this form of violence against women.

Birth rape has existed since the mainstream of doctors aggressively and systematically began their attempt to eliminate the power of midwives to assist at births 250 years ago. This change in the nature of birth assistance is symbolized by the way forceps was promoted around 1750. It was kept as the secret trick that doctors had over midwives.(1). Only MDs were allowed to see or use a pair of forceps. This ploy marked the genesis of doctors asserting power over women’s bodies and turning women into passive objects at the time of birth.

The term "birth rape" has appeared in this magazine and on some blogs (2), but is not well-accepted. Although the word rape has been used to mean abusive treatment and violation in contexts that do not involve intercourse, such as a rape of justice or soldiers raping the countryside, the vast majority of people are offended by application of the word rape to a medical procedure.