Ep 271: The Pain of a C-Section Without Anesthesia with Author Rachel Somerstein

Dr. Nicole (00:00): In this episode, I'm chatting with Rachel Somerstein about her traumatic experience having a c-section without adequate anesthesia and the book that that experience led her to write.

(00:17): Welcome to the All about pregnancy and birth podcast. If you're having a baby in the hospital, you are giving birth in a system that too often takes away power from women over what happens in their own bodies. I'm Dr. Nicole Calloway Rankins, a practicing board certified OBGYN, who's had the privilege of helping well over a thousand babies into this world. I've been a doctor for over 20 years, and I'm here to help you take back your power, advocate for yourself, and have the beautiful pregnancy and birth that you deserve. This podcast is for educational purposes only, and it's not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it. Hello there. Welcome to another episode of the podcast. This is episode number 271. Whether it is your first time listening or you have been here before, I am so glad you're spending some time with me today.

(01:11): Rachel Soine is the author of Invisible Labor, the untold Story of the cesarean section. It's just been published by Echo. She's an associate professor of journalism at SUNY Newpaltz, and her reporting has also appeared in the Washington Post, Boston Globe and The Guardian among other publications. She's also been featured on NPRs Fresh Air. Rachel holds a PhD from Syracuse University's Newhouse School, and she lives in New York's Hudson Valley with her family. Invisible Labor is her first book, and she was led to write the book after her experience having an unplanned c-section without adequate anesthesia. In the book, she weaves her personal narrative and investigative journalism with medical, social, and cultural history to reveal the surprising evolution of the C-section from its days being practiced on enslaved and unfit women to the ways modern medical technology promotes the C-sections overuse. She uncovers current day failures of our medical system and shows how pregnant people's pain and agency is often disregarded by physicians who motivated by fear of litigation or a hospital's commitment to efficiency, make consequential decisions on behalf of their patients.

(02:32): We have a great conversation about her experience with the C-section, how she realized that she had birth trauma and PTSD after that, how she worked through that trauma when she got pregnant again, how she approached things differently because of her first experience and how things unfolded differently with her second pregnancy and birth experience. She shares things that most people don't know about c-section births that she wishes more people knew. We chat about some evidence-based solutions to help bring down the number of medically unnecessary C-sections, and we end with why she is hopeful that we can make birth better, safer, and more joyful for everyone. You're going to love this conversation. Now, before we get into the conversation, just a quick reminder that I will be doing my free live birth plan class, make a birth plan the right way that is coming up soon. Grab your spot in this class at drnicolerankins.com / birth plan.

(03:35): It's a great opportunity for you to learn how to make a birth plan that actually works to help you have the birth that you want because just filling out those forms online and bringing that to the hospital is not going to cut it. I teach you a great way inside the class and at the end of the class, there is a q and a while I will answer all of your questions about pregnancy and birth. So again, come join me. You can register and grab your seat in the next live class at drnicolerankins.com / birth plan. Okay, let's get into the conversation with Rachel. Thank you so much, Rachel, for agreeing to come onto the podcast. I'm really excited to have you share your story and then how you came to write your book.

Rachel Somerstein (04:20): Thank you so much for having me. I'm delighted to be here.

Dr. Nicole (04:22): Yeah, so why don't you start off by telling us a bit about yourself and your work and your family, if you like. Sure.

Rachel Somerstein (04:28): So I am an associate professor of journalism, so I teach undergraduate students how to do journalism and then also how to think about journalism, and I'm also a writer and the author of Invisible Labor, untold Story of the Cesarean section, and I'm a mom of two children who are now eight and four.

Dr. Nicole (04:46): Okay. All right. So we have to hear about your birth experience because your first birth experience in particular, because I know that contributed a lot to what made you decide to write the book. So can you tell us about what happened with your first pregnancy and your first birth? Sure.

Rachel Somerstein (05:05): So my first pregnancy was basically uneventful. I'm fortunate that it was in good health going into it, it was pretty textbook, although for me it was textbook, but the experience of being pregnant the first time is doesn't feel textbook at all. So I was really tired. I had a lot of nausea, really common things that were new to me. And then I went into labor right around my due date and the entire pregnancy, which was textbook and uneventful. I expected to have a vaginal birth and people around me seem to think the same thing to the point that I did not even read the sections of the pregnancy books about c-section because I was not going to have one. And in retrospect, that was extremely naive and also reflects at the time I think my own internal stigmas about c-sections, which are not true that some people have.

(06:14): And as a result, when I ended up having an unplanned c-section, that was all completely surprising to me. And I think even if I had read the stuff, it still obviously would've been difficult. It was not a good birth experience. And being unprepared for the possibility of surgical birth was one big part of my pregnancy that I think is very, very common for first time moms. Unless you have something going on that would lead you to expect you might need a section. So that's one part of it. And then the second part, the traumatic part is that I went into the, I had been in labor, it was the middle of the night. My daughter was having heart rate decelerations, and the midwife who was taking care of me was like, I think it's time for a section. And so we went to the, and when the obstetricians started the operation, I said, I could feel that. And he said, you'll feel pressure. And I said, I could feel that. And he continued and the operation was extremely painful. And I write about that in the book.

(07:18): And I think one thing about this story that I've come to understand as I've spoken to other moms, regardless of what their experience was like, is that although it's shocking to hear that this happened, the not shocking part is that I wasn't listened to. I think that that experience is extremely common. Unfortunately, it's far more common for women of color than for women who are white. And I'll just say for people listening, I have white skin. And so I think that if you can connect to my story from that perspective and think about different times when you weren't listened to, then it can be something where you're like, oh, I actually could see how that could happen. And then not being prepared for a C-section at all too, I think is extremely, extremely common.

Dr. Nicole (08:07): Yes. Yeah, definitely. Definitely. So did you end up going under general anesthesia during your C-section?

Rachel Somerstein (08:15): Yes. So thank you for asking about that. So once my baby was born, which I don't remember because I think I was in shock, and also the anesthesiologist I'm sure gave me different medications at the time. He put me under general and then I woke up in recovery, but I was like, I don't think people realized I was awake. I heard the doula and midwife kind of talking about me. And I think one thing about that that is also too common is that sometimes people feel really disregarded in their births. They're just sort of a body and not a full person with feelings and fears.

(09:02): And I do want to say this was a very traumatizing experience for me and for my providers. My providers were my really shaken by this, from the nurses to the anesthesiologist to the midwife, and to the doula too, I'm sure. And as a person who talks to a lot of moms with birth trauma, I think that's something we sometimes don't remember, right, that of course it's the worst for the birthing person. Absolutely. And to be witness to something traumatizing is still traumatizing for providers. I mean, I'm telling you this and I'm sure that you have your own thoughts and experiences and ways of coping, but I think it's something that patients don't always think about that that's important too.

Dr. Nicole (09:53): Yeah, thank you for mentioning that. It is very traumatizing. I mean, as I've shared, as we've talked before and I've shared in my podcast my first C-section, I also had inadequate anesthesia and I could feel it when they started and definitely traumatized. It definitely changed the way that I thought about how to take care of women when they say they have pain during a C-section for sure, there is a lot of, oh, it's pressure. No, you're almost insistent. It's pressure. And it's like this person is screaming, stop it. So it can be traumatizing when you can see that someone is in a lot of pain. I would say an area where this is a little bit of an aside where we don't talk about it a lot is when someone has a stillbirth, obviously it's very traumatizing for the family, but it's very, I can still hear whales of people when you have to tell them that they had a stillbirth. So yes, thank you for acknowledging that. We do also experience trauma and we don't have a lot of things to help cope with it or things in place in a systemized way to help cope with it. And actually neither do birthing people. So as someone who experienced trauma, how did you realize that yes, this is birth trauma and maybe even PTSD? How did you come to that realization? So

Rachel Somerstein (11:11): It took me a really long time because I am one of these people who is put your head down and march through the snowstorm. And I would say, and I think this is really not unusual, I think a lot of people cope with trauma by just working harder. And so I did that for a while. And then,

Dr. Nicole (11:35): I mean, you were even weeks after your birth, the story where you went to a work event and you had to take the baby. And I mean that was very shortly after you gave birth and it was like you were just marching through. Yeah,

Rachel Somerstein (11:47): I didn't really have much of a choice in terms of having to get back to my job. And that's another reason among the many why we need paid leave is birth can go any number of ways. And I was really not ready to be out in public as a professional with my baby or even without my baby. And so even as I was, I should say, even as I was getting back to work so to speak, I was not able to bond with my daughter the way that I would have imagined that I would've been able to bond with her. And so things were showing up in my life that I didn't recognize as birth trauma. And because I was doing such a good job at my job and I was really on top of it as a parent too much, so I was way hypervigilant, which can sometimes fly under the radar as like you are like, wow, you really got it together, hyper competent when it was really vigilance.

(12:54): I think it wasn't until my daughter was about two and a half that I realized I felt really stuck in my life. I was like, do I want another baby? Do I want to keep working in my job? Do I want to move? I didn't even know what I wanted. And I went to therapy, talk therapy for those reasons. And then the birth came up. And then another thing that came up kind of like, oh, and by the way, when I went into have a colonoscopy because my father had colon cancer in his thirties, he survived. It's kind of amazing. But I had to do these early screenings when I was waiting in the surgical bay, I had a panic attack. And that made me also realize I can't just pretend this didn't happen. It's coming back to assert itself. And that's when I started talk therapy and ultimately EMDR, which is technique where you basically reprocess traumatic memories using eye movement and reflection and talking with the provider that when my therapist first suggested it, I was like, what is this? Is this real? And there was really not that much evidence about it's use in birth trauma. There was some evidence about its success for combat veterans,

(14:27): And it was really helpful for me. I mean, it really helped me a lot.

Dr. Nicole (14:31): Okay. Okay. So did you see someone who specialized in birth trauma or they just happened to specialize in trauma period? Or how did you come to find someone who was able to help

Rachel Somerstein (14:43): You? That's a really great question. So the talk therapist I met is not a birth trauma specialist and is also an excellent therapist. And I'll also say is culturally concordant. So I'm Jewish, and that's a big part of my identity. She's also Jewish. It's not like we're sitting there talking about Judaism, but can culturally, concordant care can understand where you're coming from. So that was really important, and I'm fortunate I could find her. And there are culturally concordant Jewish therapists, which is an issue also for moms of color. There are not enough therapists of color, period. It's a huge problem. And then she is the kind of person who recognizes her own limitations and said, you know what? I think EMDR would be great for you. I can't offer that. It's not my training. Here's some suggestions of people. And then I found someone like that. So I would say for people who are struggling with birth trauma, knowing that different therapists are specialists in different modalities, just like you would not go to a dermatologist if you had, I don't know, an orthopedic problem, you might be like, okay, if this is something that's really in my body, I need to go to a therapist who deals with more body, body-based, embodied kinds of treatment.

Dr. Nicole (16:11): Now, at some point you had to decide that whether or not you wanted to try to have another baby. So what made you decide, okay, yes, I am going to get pregnant again. And then how did you approach things to try to have a different experience?

Rachel Somerstein (16:28): So I was not sure for a long time if I wanted another baby and if the fear was kind of getting in the way. And then I realized really through talk therapy, I really did want another baby. And I write about this in the book a little bit. Once I realized that, then it wasn't like, okay, let's do it. Because I was so filled with fear really. But I met, my husband actually met a midwife who lives near us, and I didn't know this term at the time, but so-called Trauma-informed care she offers. And I think what was really helpful was that I got to meet her for the first time walking down the street. I didn't meet her for the first time in a medical office, so I was calmer. I get really scared when I go to the doctor now, more the midwife. And I read about this in the book too. One thing that I didn't see at the time, I called that luck and it was luck to some degree, but it was also the social determinants of health. I live in a town where there's a midwife who lives nearby. That's not an accident, that's not luck. That's the result of the zip code I was born into and things like this.

(17:58): And she is the kind of person who doesn't feel defensive. I think when a patient brings in trauma to the room, which sometimes can manifest in all kinds of ways that maybe don't reflect best on your character, maybe you're like, I don't know, kind of twitchy about it, or maybe you're really defensive about what you're recommending that or I don't trust you, or maybe you're snappish or these things that you're kind of as a person with birth trauma or any kind of medical trauma you're bringing into the room, you're not in charge of that. You don't sit down and be like, I'm going to be kind of a jerk to my provider. It just sort of happens. And she was really able to be present with me with my fear. And I also saw her for almost every visit, except for when I had to see a maternal fetal medicine specialist because I was over 35. And I also saw the ob, who works with her too, I should say. She attends S in a hospital. She's part of a practice of obs and midwives. And what she does, particularly for patients who have trauma, is she works with the schedulers to try to keep seeing, make sure she sees you almost if you want that right to see you almost every time. Because when you get bounced around, and I don't think this is just for people with trauma, you get bounced around, then you're always explaining what's going on.

Dr. Nicole (19:37): Sure,

Rachel Somerstein (19:38): Yeah. Can't develop the relationship.

Dr. Nicole (19:41): Definitely. Yeah, that's true. That's true. That's true. And then did you decide, or what was your thought process about trying for a vaginal birth or having another C-section? I don't want to put words into your mouth. Sure.

Rachel Somerstein (19:56): It was a really, really hard decision, and I think that for moms who've had a C-section, no matter how it went, I really think the question of whether to schedule a repeat section or try for a VBAC is one of the hardest things, and I think it's really underappreciated. First you have to think about what you feel comfortable with. Then it's like, what's even open to you? Not everybody has the option of trying for VBAC because the latest data says one out of five hospitals doesn't even offer them. So where do you live? Maybe that's a symbolic option and not a real one. And if it's a symbolic option, are you going to travel? And then there's the inner feelings. I was like, what if something goes wrong? If I try for a VBAC and I have the fear is uterine rupture, it's very, very uncommon. I knew I was having my baby in a hospital so that there would be people there who could intervene immediately, but it was really, really hard decision. And I ultimately felt that I wanted to give it a whirl chai. And I was supported in that, not only by my providers, but my husband. I was like, what happens if this goes badly? Let's say I have a uterine rupture and my baby has oxygen deprivation and brain damage. God forbid, what would my husband, will he blame me for being selfish, for wanting to try this?

(21:40): It was really, really hard. And one thing that happened during this is Covid started, and I live in New York state, and the governor at the time made a rule that you had to be alone during your birth. That got changed

Dr. Nicole (22:01): Because we realized that was a bit excessive.

Rachel Somerstein (22:03): Exactly. And I should say, listen, no, it was such a crazy time. And so there was so much fear and there wasn't enough personal protective equipment. I understand why that decision came down. And for me, I was like, I just cannot imagine my husband dropping me off at the hospital and me walking into a repeat section by myself. I just don't think I could withstand that. So ultimately, I felt it was safer for me to try for a vbac, and I already had one daughter who needed me, and that felt like the right decision, but it was hard. And the whole pregnancy, I told myself, you can change your mind. And my providers were like, you can change your mind. And that was so important to feel like I'm not locked in. Okay. And maybe you'll change your mind if things in your pregnancy change if it turns out that you develop preeclampsia or you develop gestational diabetes or whatever. I think being open was important for my sanity and also for reality because sometimes things change out of our control.

Dr. Nicole (23:17): Absolutely. Absolutely. Yeah. The only predictable thing about pregnancy and birth is that it's unpredictable. Exactly. Yeah. Things can happen at any point in time. We don't have a lot of as much control as we like to think we, especially as medical professionals. So yeah. So then how was your second birth experience then?

Rachel Somerstein (23:36): So you would think it would've been like, oh my God, and this was June, 2020,

Dr. Nicole (23:42): So that was right when things were getting

Rachel Somerstein (23:44): Ramped up. Exactly. I'm very lucky that it wasn't March, 2020 when we didn't. It was, oh my gosh, before the lockdown. It was just such a mess. People were in a lot of danger. So the birth was wonderful. I mean, I went into labor, actually. I went into prodromal labor a few days before my due date, which I didn't know what that was at the time, but it's like when the contractions are happening, they feel real, but you're not really progressing that much. And my in-laws had come to watch my daughter. My mom couldn't because she'd been injured, and my husband and I went to the hospital. It was a Saturday night, I had texted with my midwife, and we got there and my contractions totally stopped, and I was like, I don't think that this baby's ready to get born.

(24:50): And my midwife was like, let's get you hooked up to a monitor and see how he's doing. And we did. And she was like, he doesn't seem to be doing so well. Let's just sort of hang out and see what happens. And I remember feeling so upset because I was like, oh my gosh, this is going to end up. I'm not going to even have a chance to labor. This is too early. And then he, I stayed on the monitor and he kind woke up. It seemed like maybe he was just sleeping or whatever. I was like, can I go home? Is probably the most daring question I think I've ever asked. And my midwife was like, you can go home. I mean, of course you can always go home, but what's her medical opinion? Is this safe? Right? And so we did. And then a couple days later I went into labor and I just was like, I knew this is it this. And I had an appointment with her that morning and I was already at a four or six or something. I was pretty dilated, and I also had a headache and kind of the beginning signs of preeclampsia and she said, go straight to the hospital.

(26:08): This isn't like the other day with those numbers that you're not going home. And I was like, oh, I know that I don't. I can read the situation enough. And I labored there. I was really supported by the nurses and the midwife on call, and the OB on call was the OB who worked closely with my midwife who I had a nice relationship with. And then my midwife surprised me and came in after her shift in the office to be there for the birth. And I got to pushing and they had turned off the epidural and I could feel that my son wasn't lined up. And I should say my daughter hadn't been lined up either. Her head was kind of cocked and I had back labor with both. So there's something anatomically that's how babies are set up for me, I think.

(27:06): And then the midwife was like, would you be okay? Are you okay if I tried to turn his head? My water hadn't broken yet. And so there was sort of room to do that kind of thing. And I said, okay. And she tried and she couldn't do it. And then she asked the OB on call, and at first he was like, oh, she's a vbac. And she said to him, everybody's doing great. I have a feeling about this. And he said, okay. And he came in and moved my son's head, and then I pushed him out pretty quickly. It was amazing is that they have this, they trust each other, the midwife and the, they've worked together for probably almost 20 years. Both have incredible clinical skills and I trusted them

Dr. Nicole (28:03): Too.

Rachel Somerstein (28:05): And I felt so proud and so excited. And it was also scary still. I feel like sometimes vaginal birth and cesarean birth yet pitted against each other. What's better? And it's, for me, I felt obviously the C-section was traumatizing and scary for reasons because of the pain that I was feeling. But pushing a baby out is also scary, or am I going to rip hat birth is just this tremendous,

Dr. Nicole (28:38): It's a lot.

Rachel Somerstein (28:41): And my husband caught him and I was completely depleted after that birth. And I actually, I remember asking that would be like, am I okay? And he was like, we'll do labs and stuff like this, but I think you're just shot. And I think he's right. I put it all into

Dr. Nicole (29:06): That. Right, right. And almost like you've been holding your breath for nine months or however many totally been like, yes,

Rachel Somerstein (29:16): Absolutely. And how is this going to go? What's going to happen?

Dr. Nicole (29:22): You speak to an important point that some things are not in your control in terms of who you have as the doctor or the midwife. But one of the things that I think we've lost as obs is we should be able to do more than either catch a baby that's falling out or cut a baby out. We should have those skills to turn a baby or turn a breach baby or do forceps or whatever to help facilitate a birth. So I'm glad that you were able to have someone with some clinical expertise and who works together to help you have a vaginal birth. Do you feel like the recovery was easier physically?

Rachel Somerstein (29:58): It was. I will not lie. I had the tear. It was a minor tear first degree, and it still was minor, but I still felt like pushing the stroller was still hard at week seven.

(30:15): But after my C-section, my legs were swollen for so many weeks and I had a hard time just getting around. It's like you try to open the dishwasher or you, it's hard to sit up. And I was like I said, saying I was shot. That's how it felt. Everything. I was so physically depleted and I really needed my strength back and I needed to rest a lot, but I was able to pick up my baby and not feel like, ah, that's so tender or trying to breastfeed. So the recovery was no comparison. And I think that too though, as a second time mom, I was like, I didn't push myself the way I had the first time. I had these expectations. I would get back to things so quickly and partly I had to because of having to go back to work sooner. And also I just learned you'll get there. This is a blip in your life, this time of recovery and resting is the most important thing that you can do. And the world will be out there when you're ready for

Dr. Nicole (31:41): It. Absolutely. It'll all still be there. Exactly. Yes. Yes. So then what made you decide to, after your experience of your C-section decide to write a book about C-section? Not everybody has an experience and then decides like, okay, I'm going to write a book about it and kind of dive deep into things about C-section. And really it's about birth in general. There's a lot about the history of birth and the medicalization of birth and things like that. So what led you to that?

Rachel Somerstein (32:08): So I'm a writer, so partly that's my thing. And partly I realized that writing about what my experience would help me cope in addition to doing therapy. But then also I was like, the more I learned about C-sections as a way of trying to understand my experience, the more that I saw that they are a great way to look at our culture. The fact that they have become so common one out of three births in basically 50 years, why and how and who are they happening to disproportionately and why are we doing them more and more every year when there's widespread agreement that we should back that up a little bit and that people are working to it. This is not a controversial position to be taken. It's almost like I think about climate change. There's widespread agreement. Humans have caused it. People are working really hard to change that. Why can't we seem to do it, to do something? So those were some of the reasons. And then also I think my experience helped me almost look under the veil of

(33:33): At things like women's pain and the use of technology and social determinants of health, things that were, they're all along and that I didn't see. And so I saw there's more here than just my experience to explore in a book. And when I had my baby, I saw no stories about C-sections. I'm like, where are the stories about getting better from a c-section? Where are the stories about birth trauma? Even the stuff I saw was really like you, you puff in a taxi cab, your baby comes out. It's like people scream and then it's totally calm, and then you go home. And I'm like, not only does that not describe my experience, it actually doesn't describe virtually anybody's experience who I talked to. And I felt very alone. And so I wanted to write something that I would've needed at the time to feel less alone, and I wanted to expand our representations of birth.

Dr. Nicole (34:37): Yeah, yeah. And I know one thing you also mentioned is that you actually thought about that I thought was an interesting point. You actually thought about should you pursue legal action or anything for what happened. So tell us about what happened when you explored that.

Rachel Somerstein (34:55): So at first kind of didn't even think about it. And then two years after my daughter's birth was the beginning of me too and this sort of change in the cultural air of the lead women. And

(35:12): I also was coming to the end of the statute of limitations for when I could bring a lawsuit. And that coincided with when I was realizing I have PTSD, this is not over were. So I talked to a few lawyers and they ranged from dismissive, what's the big deal? It's like five minutes to more compassionate and explaining, because I hadn't had physical damage and my daughter didn't either, for which I'm grateful that I wouldn't really have a case. And I know in retrospect I probably could have looked further for representation. And I also know that if I had, it probably would've ended in a non-disclosure agreement, I would've gotten a settlement. And what would that have done? I didn't want money. Sure. I mean, everybody wants money. Money. That's how you pay your bills, obviously.

(36:15): But money would not have restored what I had lost. And it's also, I didn't exactly even want to punish anybody. This was a series of errors. It wasn't like my OB is a terrible person, or the anesthesiologist is a terrible person and they should pay. And so in writing a book, I felt I would come closer to achieving the kind of, I guess speaking out and witnessing and that I really wanted in a way that is so much more satisfying. Even honestly having this conversation or talking with other moms or other providers is so much richer than, first of all, you go through health talking about this thing in a very adversarial place. Here's a check. Now close your mouth. I mean, what would that do for anybody?

Dr. Nicole (37:22): So in the course of writing the book, what are two or three things that you learned about C-sections that most people do not know and you think they should know?

Rachel Somerstein (37:31): That's a great question. So one thing I think that's important to keep in mind is that they're not easy and that a c-section involves cutting or parting way of seven sections of tissue. And that as a result, even though you think, okay, I didn't push the baby out of my vagina, I'm not going to have issues with incontinence or whatever, first of all, you've had this tremendous, I guess better best word is trauma to all of these different tissues that are part of your pelvic floor. And you were pregnant for however many months leading up to it, which also affects your pelvic floor. So I wish I had done pelvic floor physical therapy after that first section.

(38:27): The message I got was like, I don't need it because I'd had a vaginal birth. So that's a really important thing. And all the occupational and physical therapist I spoke with for this project where you really, first of all, everybody needs it, right? If you've been pregnant, you can benefit from it. And even if you had a C-section, that doesn't mean like, oh, you've been spared or whatever. Exactly. And these issues can come back later in life. I thought this was so interesting as back pain or you can't hold in your pee. And these are things like as we get older, you might be like, oh, I'm just getting older. And it's like, well, actually it could be because of your C-section and you never restored the tissue. So that's one thing. And then I think a second thing is I said in the beginning of our conversation, I thought I would have a vaginal birth and I didn't want to a c-section, but the reasons I didn't want to c-section were not the good reasons to want to avoid one.

(39:27): I had this messed up stigma about c-section if they said something about your character, and it has nothing to do with your character as a mother. So one thing to know about them is that they can really shape future pregnancies in terms of issues with the placenta in terms of future secondary infertility or miscarriage. And that taken with together that can shape how many children you ultimately end up having. I didn't think I wanted to have a very large family, and I write about this too. I think I would've had maybe another child if it would've been possible. All this is conjecture, right? You'd say I should have. I would have. And it's like, let's see what would've happened. And for me, that was the trauma. I waited longer than I think I would've if I had not had a traumatic birth. But talking to other moms for this book sometimes and also talking to researchers, it can be harder to conceive again after a C-section. And if you have then a pregnancy that's higher risk because of a placenta problem, suddenly you have issues that wouldn't have come into play if you hadn't had that first section.

(40:49): And the third thing that goes along with all of that, I think, is that we have to respect it more. We don't respect c-sections in this culture, I don't think, both in terms of how much they affect the mom physically, emotionally, and also it can shape your life. It can shape your reproductive life. And I think providers actually understand that, right? I'm talking about the overall public culture. I was looking at different resources researching my book, and sometimes it's like the way c-section is described is like you just lie back and let everybody else do the work. And it's like it's more to it than that. It's not a pedicure. You know what I mean? It's not a massage. We should really respect it and respect what it can mean for the future of your family planning.

Dr. Nicole (41:40): Yeah, definitely. Definitely. And then what are some solutions to help bring down the C-section rate? That is definitely too

Rachel Somerstein (41:48): High. So I really loved what you mentioned earlier about clinical skills that obese can develop and study. And you've written about how you have done training in attending vaginal breach birth, which makes not only potentially increases people's options birth, but also is to my mind, a safety, incredible safety bonus. Or what happens if you show up at the hospital and there's a foot coming out, you really hope your provider has done that kind of training and recently not just as a theory in medical scope. So I think that, and I know that these kinds of skills like about how to turn a baby's head, how to do attend a vaginal breach birth, how to help a mother move during labor so that the baby is better positioned, which can be done even if you have an epidural. I had an epidural for both of my births.

(42:49): One, I was moved into different positions, one I wasn't. That really makes a difference for whether a person would have a potentially avoidable section versus a necessary one. A really interesting solution coming out of Penn actually is standardizing induction protocols. So this one researcher standardized how in a clinical trial, how providers would induce moms, which is so interesting. And what she found is that when this same protocol was followed, the C-section rate for black moms went down from 34 to 25%, stayed the same for white moms, and outcomes for babies were also better and no worse outcomes reported for anybody. And so that kind of standardization gets rid of implicit bias. And I mean, what an incredible outcome, like a 9% reduction, that's awesome, without again, sacrificing safety for anybody.

(44:05): And then another one that I think is really promising is group prenatal care. So there are some really exciting initiatives where you see your provider independently for checking your blood pressure and talking over anything that's coming up clinically. But then you meet with a group of other moms who are right where you are in terms of their pregnancies, and you spend about two hours talking with a provider who then is answering questions that would come up in any session, and you get the community component and the provider can really go deeper on in terms of education on things that there might not be time for otherwise. And this is something that's available in different parts of the country, and the outcomes, again, are great. In some cases it's lowered. C-section rates, higher satisfaction among the moms. I think lower preterm birth, the outcomes are good on many different kinds of metrics.

(45:15): And that's sort of my takeaway about this whole area is bringing down the C-section rate will make birth better for everybody because in order to do so, we're going to make birth safer for everybody. We'll make birth outcomes more equitable. Well, it's also about making sure there are more midwives who are available to meet the demand and the need across the country, but particularly among moms of color, that's the biggest gap is between what's available and what moms of color want. So that is going to also make birth better. Then you're like, I want to see this kind of provider. I want to see this provider in my community. Even if we don't talk about c-sections, that is a way to make birth a better experience.

Dr. Nicole (46:03): Yeah, definitely. Definitely. So then why are you hopeful that we can make birth better?

Rachel Somerstein (46:10): There are so many brilliant and hardworking providers and researchers and doulas and people who aren't even in medicine who are trying to do things like to incentivize quality maternal care. And I find that incredibly inspiring. And I think that the way news works is that the bad stories get attention. There's a terrible saying that I don't think is used that often anymore newsrooms, but the saying is if it bleeds, it leads like conflict murder.

(46:56): So what's foremost in our minds is these terrible stories, and there are many terrible stories I'm not trying to diminish, and just the number of people who are putting their heads toward improving birth is almost overwhelming, and they're not making headlines the way that the bad stuff is making headlines. So that's why I'm super hopeful. And I think also, I think the other reason is that the conversation is changing to take the sad things that maybe once felt shameful out of the dark and into the light. So you had mentioned earlier still birth or effects of birth trauma on providers, birth trauma period, all of miscarriage even this is coming out. And I think that once something bad happens to you and you feel like it's shameful and you can't talk about it, that increases the pain and it increases the isolation. The fact that the conversation around birth is changing, I think is also going to improve birth because well, no, you're not alone. And it's also like if you have a miscarriage or you have a C-section or you have a still birth, it's not your fault.

Dr. Nicole (48:18): Yeah, definitely. Definitely. So then as we wrap up, and I ask guests all these questions, what has been the most frustrating part of sharing this work in your book, being out there?

Rachel Somerstein (48:28): That's such a great question. I think that sometimes when people hear about what happened to me, they might think That is so scary. That will never happen to me. I can't hear anything about this anymore. And as I said earlier in our conversation, what happened to me is terrible. What happened to you is also terrible. It should not happen. But it can also point the ways to how some elements of it are too common and do need to change. And if we don't look at that, we can't change it.

Dr. Nicole (49:04): Right? Yeah. You can't fix what you don't acknowledge.

Rachel Somerstein (49:07): Exactly. Exactly. Yeah.

Dr. Nicole (49:10): So then on the flip side, what has been the most rewarding part of this work and sharing your

Rachel Somerstein (49:16): Book? I think hearing from people who feel like the book resonates with them or who feels seen talking with providers this fall, I'm going to be talking doing grand rounds at different medical schools. That is the greatest honor to feel that we can be part of. We meaning journalists, patients, moms, providers. We are part of the same conversation because we actually have the same goals of making birth safe and joyous. That's been incredibly, incredibly rewarding. Yeah.

Dr. Nicole (49:55): And then what's your favorite piece of advice that you would give to an expected mom or expected families?

Rachel Somerstein (50:02): I think that you said it earlier, which is the only thing you can expect is sort of the unexpected. And so to both be, you can have your plans and your wishes and your desires and to be open that birth might not look like that, but that if you can isolate what's important to you about what you want from birth and talk about that with your providers, you can probably find more satisfaction even in a situation that you didn't expect. So for instance, if I had known anything about c-sections, because I didn't, I think been able to tell my providers when they called for the section, or maybe my husband would've been able to because I was not in my rational mind. So somebody advocating for me would've been able to say something about I'm a very physically modest person. I don't like feeling totally naked in front of people would've been able to say, is there a way in the operating room that we can be sure that Rachel feels sort of covered? So even somebody who doesn't plan for a c-section, if they know that that for instance, is important to them, that could still be part of their birth. So expecting the unexpected and bringing through the line of, and still what's important to me to have happen or ways you want, I would like to be cared for.

Dr. Nicole (51:29): Excellent advice. So where can people find you? Where can people find your book?

Rachel Somerstein (51:33): So my website is rachel Somerstein.com. I'm on Instagram, I'm on Twitter sometimes. And the book, you can order it from Amazon or bookshop.org or Friends and Noble order your local bookshop.

Dr. Nicole (51:45): Okay. Alright. Thank you so much, so much for coming on and sharing your story. I really, really appreciate it. Thank you. And I know folks are going to find it useful.

Rachel Somerstein (51:51): Thank you so much for having me.

Dr. Nicole (52:00): All right. Wasn't that a great conversation? I really appreciate Rachel coming on and I admire how she took her story and turned it into a great book. You definitely want to go pick up your copy of Invisible Labor and read it. It's a really great read. Okay. Now, after every conversation when I have a guest on, I do something called Dr. Nicole's notes where I talk about my top takeaways from the conversation. Here are my Dr. Nicole's notes from my conversation with Rachel. Number one, you have to prepare for all possible outcomes during birth, including cesarean birth. Rachel didn't prepare for the possibility of cesarean birth and that ended up not being good in how she was able to manage the overall experience. You have to understand that C-section is possible. We certainly overuse C-section in our medical system. I 1000% acknowledge that, and we have to work to decrease the number of medically unnecessary cesarean births.

(52:55): But sometimes C-section is going to be medically necessary and it may be possible for you. And sometimes you can't know that until you get into the birth experience. Actually, most of the time you won't know that until you get into your birth experience. So you need to understand that C-section is possible, and you need to know things like the right questions to ask in order to understand if it's really medically necessary and what your options are. That's something that I teach inside the birth preparation course, my online childbirth education class. You can check out the birth preparation course at drnicolerankins.com / enroll. But really any good childbirth education class is going to teach you, and there are other options out there is going to teach you about being prepared for that possibility and those questions to ask so you don't feel quite so blindsided if it comes to that.

(53:48): The second thing that I want to say is that there is so much more to birth than just the mother and baby making it out physically alive. So much of our system is you should just be happy that you have a healthy baby. And that is so dismissive of the psychological and mental health that happens with having a baby too. So it's more than just like you're physically there and alive. That's the absolute floor. That's the absolute bottom basement of what we should be able to do. There's certainly something that's incredibly important about feeling good about your birth experience, feeling like you were respected, feeling like you were listened to, feeling like you were treated with compassion. All of those things are incredibly important, important in help setting the tone for your new journey into motherhood. So it's just not about being physically alive or you should just be happy that you and your baby are healthy.

(54:51): That's kind of the message that Rachel got when she went to seek malpractice options. No one's going to give you any money because everybody's physically healthy and it really is more to birth than that, and you should expect more from your birth than that. You deserve more from your birth than that. And then the last thing I want to say is make sure you understand your VBAC options. If you do have a C-section and you want to attempt a VBAC in your next birth, make sure you understand your options because the options are not equal for everyone. You really want to know that you have a doctor who's not just tolerant of a vbac, but is actually supportive of you having a vbac. You want to have someone who is skilled with managing labor. A skilled OB is really important and can help make the difference in your labor and birth experience.

(55:47): In Rachel's case, the second birth or the OB was able to turn the baby, which was really helpful. Her OB worked with midwives, so had some understanding of the importance of midwifery care. So you want to understand your VBAC options and set yourself up for a situation where you have the most supportive environment. Set yourself up for the highest chances of success, and you can learn more about that in episode 229 of the podcast where I talk about vbac. That is drnicolerankins.com/episode229. All right, so there you have it. Please share this podcast with a friend. Also subscribe to the podcast wherever you are listening to me right now. You can also leave me an honest review in Apple Podcast. I love to hear what you think about the show, and it helps other women to find the show when those reviews are there. You can also let me know what you think about the show on Instagram. I'm on Instagram @drNicoleRankins. Come follow me there for more great pregnancy and birth information and my dms are open. I love to hear from you. That's it for this episode. Do come on back next week and remember that you deserve a beautiful pregnancy and birth.