In past articles, we have tried to pose these questions: Do childbirth educators and doulas still try to empower clients as women with powerful instincts? Has the move of childbirth education from independent/community based education to hospital based education diluted objectivity, leaving way for the promotion of the medical model without covering comfort measures, positioning or more natural nonpharmacologic labor enhancing techniques? And just as important, are the hospital staff who teach childbirth education (many of whom are not certified educators) aware of comfort measures, positioning or more natural nonpharmacologic labor enhancing techniques? And how does the rise in induction rates, some too early to have enough oxytocin receptors built up for success, relate to this rise in cesareans?

Among items at the center of the controversy is a study and accompanying editorial (by Dr. Michael Greene) (Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. NEJM, 2001:345: 3-8) published in the July 5th, 2001 issue of the prestigious New England Journal of Medicine. In a literature review of the study and editorial, Dr. Bruce Flamm (research chairman in the Department of OB/GYN Kaiser Permanente Medical Center Riverside CA and Clinical Professor in the Department of OB/GYN at the University of California Irvine Medical School, noted author and speaker) stated, " Finally, Greene's editorial concludes with the question, 'But doctor, what is the safest thing for my baby?' and states that given the Lydon-Rochelle et all findings, his 'unequivocal answer is: elective repeated cesarean.' Considering the overwhelming limitations of this study, this is an extremely bold statement. Furthermore, one must not forget that many, if not most, of the trials of labor in this study took place in hospitals where obstetricians and anesthesiologist were not immediately available. Importantly, the study interval of 1987 to 1996 predated recent recommendations suggestion rapid response time for patients undergoing trail of labor."

I recently found another interesting article regarding elective cesareans: Commentary: A Blatant Misuse of Power by Robert K. DeMott MD from www.vbac.com: "Why are we treating pregnancy as a disease? "Offering" cesarean delivery or consenting to perform it electively at term is irresponsible, dangerous, and ultimately unfair to many women. The lack of fairness centers about informed consent. Like it or not in medical care a great deal of perceived power and influence is present, and the advice of physicians is seriously heeded by many under our care. Are we truly able to relate all of the surgical risks of cesarean delivery versus a vaginal delivery to the majority of patients? I would suggest that only a small number truly understand the relative risks. The less informed woman is merely agreeing to our recommendation without true knowledge of the consequences. This is inherently unfair and a blatant misuse of power.

Fortunately, a sensible and knowledgeable woman will see through this guise and reject the offering. Insufficient scientific evidence is available to support routine elective cesarean delivery, and she will seek the normal physiologic process (labor) to protect herself. Less educated, more fearful, or less aware women will comply, however, consenting to scheduled cesarean delivery rather than proceeding to labor, and herein lies the societal unfairness of this wayward recommendation. Physicians have a duty to 'First, do no harm.'"

As we watch the pendulum swing, it is time to help opinions reach common, middle ground. It is definitely time for both childbirth educators and doulas to renew faith in informed consent and make the questions of informed consent available it to all clients. Common, middle ground is possible, but it takes patience, work and more patience. Make sound information available to clients about vaginal birth, cesarean birth and VBAC. And stay informed.