Book Review: Pushed by Jennifer Block.

Today I finished reading Pushed by Jennifer Block. It's one of the most informative, well-written, and disturbing books I've read in a long time. However, I also found it really inspiring. It's made me wonder whether a lifetime of defying authority hasn't been intensive preparation for someday becoming a midwife, where bucking the norm seems likely to become...well...the new norm.

Here are some of what I thought were the more interesting points in the book:

The lack of choice in a "patient-choice" C-section. Block (and others, including obstetricians, she interviews for the book) poses the question of whether doctors' sanctioning elective C-sections is less about honoring an actual demand from the patients (despite the visibility of cases like Britney and Posh spice, "regular" pregnant women aren't lining up for surgery left and right) than about giving physicians the opportunity to perform them at their own convenience--"without a second opinion, or rarely even a second thought." More on this topic.

If it is a choice, is it the lesser of two evils? What does that say about maternity care in America? Block points out the irony in the fact that if obstetricians are willing to on the record as saying that elective C-sections are safer than vaginal birth (which, in her book, many are and in fact do), what they are really saying is that laboring in this country is more dangerous than major abdominal surgery. She also says that if giving birth means being induced, strapped into bed, exposed to a host of unnecessary interventions, and ultimately winding up with a semi-emergent C-section anyway--which, with a nationwide rate of over 30% (an increase of 46% in the past 10 years), is a pretty good chance for anybody giving birth in the hospital--could we blame women if they were clamoring to literally just "cut to the chase"?

The selective use and abuse of statistics. The rising C-section rate is often (probably correctly) blamed largely on on the growing litigiousness of our society. The risks of stillbirth if a baby goes past its due date, of uterine rupture during a vaginal birth after a previous Cesarean (VBAC), and hypoxic brain damage if a baby's heart rate drops during labor have all been emphasized in support of why it's "safer" just to do a C-section. Issues like the increased risk of maternal death (four times more likely in an uncomplicated elective C-section than it is in a vaginal birth) and massively dangerous complications like stillbirth, placenta previa, and placenta accreta in subsequent pregnancies, have meanwhile not been publicized. Jeffrey King, the head of the American College of Obstetricians and Gynecologists' maternal mortality special-interest group, says in the book that "More cesareans lead to more repeat cesareans, and repeat cesareans are associated with higher risk of hemorrhagic complications, including placenta accreta leading to hysterectomy. It's almost like a runaway train. In the long run, this will lead to more maternal deaths."

The nationwide war on VBAC. One thing I took for granted working at UIHC was that when we finished up a C-section, the doctor would typically give the woman some variation on the following: "Your scar is the kind that's low and horizontal, so if you want to try a vaginal delivery next time, there's no reason that it shouldn't work out." Apparently this is not the case in much of the country, where the "reason it wouldn't work out" could include doctors who abandon care of patients who want to VBAC or judges who court-order Cesareans against a patient's will. Pushed includes incredible (and not in a good way) stories like that of Laura Pemberton, who labored at home until she was 9 centimeters dilated but got to the hospital and was forced against her will to undergo a court-ordered C-section. "The judge said that my unborn baby was in the control of the state and that it was the state's responsibility to bring that baby into this world safely...[he] pointed his finger at me: 'We are going to do the C-section, and we are going to do it tonight.'" Her case is the most extreme, but there are other, similar cases as well. She also talks about smaller indignities, such as doctors who don't get consent to break someone's water or strip their membranes--acts I've witnessed (and tried to rectify) already.

Pain in labor may itself serve a physiological function. Controversial, perhaps, but worth thinking about: Block talks to various professionals about the interesting idea that pain in labor is akin to that of getting a blister on your heel--it keeps you moving around to try to alleviate it. "It is not a side effect, rather it is a central component of normal birth--not something from which mothers should be distracted. Pain communicates, and sometimes it tells us important information." Without the discomfort, a woman tends to lack the natural, restless, perpetual motion which helps settle the baby into an advantageous position for its journey down the birth canal. I'm in no position to comment here because I haven't been through labor, and so I don't want to be seen as singing the praises of pain I know to be indescribable, but I will say I've seen a huge number of malpositioned (and subsequently C-sectioned) babies in women with epidurals--especially early epidurals.

Like the old folks say: Babies come when they're ready. To breathe. According to this Danish study, "It is plausible that hormonal and physiological changes associated with labour are necessary for lung maturation in neonates and that these changes may not occur in infants delivered by elective Caesarean sections." It's thought that possibly the baby's lung maturity somehow signals the mother's body to go into labor, and that labor itself then stimulates further development. So if you schedule a C-section (as opposed to one that happens after even a "failed" labor), your baby misses out on both.

Finally, synthetic oxytocin: you can't beat the real thing. I've often wondered why, with every women's magazine trumpeting the effects of oxytocin, the "love hormone," released when you breastfeed or make love or even share a meal together, women being induced into labor aren't on an endless, feel-good lovefest. (Far from it.) As it turns out, synthetic oxytocin (Pitocin) affects the uterus (causing contractions) when it's introduced into the bloodstream, but it doesn't cross the blood-brain barrier--so it can't affect mood the way the brain's own oxytocin does. Furthermore, it signals the brain to shut down its own production of oxytocin, depriving it of the effects of the massive doses that a woman's brain would normally be flooded with during and after birth to facilitate bonding and breastfeeding.

So. Much of this is controversial, but a great deal of it also seems statistically sound. All of it is food for thought. This isn't to say that women can't have normal or happy birth experiences today, but it does seem to point to the fact that doing so in the hospital is getting more and more difficult. I'm also not saying that I completely shun the technology that has saved the lives of so many mothers and babies and which people delivering babies in third-world countries would give anything for.

I am saying that I think it can be and has been misapplied to the point that we're often doing more harm than good.