Birthing Beautiful Ideas

I have a flickr page.  I use it to share photos with friends and family, and while it is public (YOU try explaining how a user name and password works to my grandmother), I don’t want to make it any “more” public by sharing it here.  I’m sure you all are nice and dandy readers, but who knows–YOU could be “that guy” who found my blog by searching for “porn with women pushing in stirrups.”

And I DON’T WANT THAT GUY (or gal, don’t want to make sexist assumptions about my creepy readers) SEEING MY FLICKR PICTURES!

Anyway.

I fear that I may have recently misrepresented myself on that flickr page.

No, I haven’t posted a cleverly staged picture of me with my life-size cardboard cut-out of Edward Cullen with the caption that I have left my husband for Robert Pattinson, who claims that he just couldn’t resist my overwhelming animal magnetism.

But I have posted a few photos of the kids playing some admittedly adorable and creative games that came straight out of this here mama’s brain.

You know.  Games where I hide a bowl filled with “jewels” in the playroom and then create a treasure map for the kids and then the kids go on a “treasure hunt” all while wearing pirate hats.  Or games where I tuck little dragons, unicorns, and fairies away in the garden, and then the kids go searching for them all while dressed up as knights.

(Yeah, I suppose those games are pretty cool.)

In any case, after seeing pictures of the kids playing these games, some of my friends are now under the impression that I am some sort of uber-creative supermom.

And here’s where I need to correct their impression of me: I’m not an uber-creative supermom.

(The term “supermom” conjures up all sorts of ridiculous perfectionist images of motherhood, and for the sake of my mental health, I give a mean and nasty “stink-eye” to any and all perfectionist images of motherhood.)

But I have found some uber-creative ways to entertain my kids.  And I do this in part so that they are entertained “enough” for me to get some “mommy time” each day.

(“Mommy time” is like happy hour, except the coffee and quiet of the kitchen replace the tequila and noise of the bar.)

How do I do it?

Two words: story. hour.

Just like our local library’s story hour, I hold a “story hour” in our home for my audience of two a few times each week.

I pick a theme.  (Pirates, knights and dragons, grandparents, and babies have been some of our more recent themes.)

I choose four books that relate to that theme.

A snow-themed story hour

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I find a song on YouTube that relates to our theme.

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I come up with a craft that relates to the theme.

For the forest-animal theme, we crafted homes for the kids' "animal" collection.

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I create a small game or activity that relates to our theme.

ARRRGH! THAR be the treasure!

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And I find a movie that relates to (you guessed it) the theme.

And these story hours are, quite frankly, magical.

The kids learn.  They play.  They squeal.  They listen.  All three of us have a blast!  And by the time we get to the movie (which is always, always our story hour finale), the kids are so freakin’ entertained and educated and lavished with attention that Mommy ends up getting a good (uninterrupted) hour or two to work, clean, make phone calls, or even just snuggle up on the couch and enjoy a movie with her two little boys.

And that doesn’t make me an uber-creative supermom.

It just makes me a book-loving, game-loving, sorta-selfish, sorta-creative mom who a) loves spending time with her kids but also b) loves and needs some time to herself every once in a while.

And our story hours (and all of the uber-creativity that they encompass) let me do both.

So we all know that What to Expect When You’re Expecting is the preeminent source on pregnancy and childbirth for women in the United States, right?

I mean, copies of that books are everywhere right?  So it must be “the best,” right?

Well, that’s what some clever (and aggressive) marketing would have us think.  But it’s not necessarily true.

(And for the record, WTEWYE is not the “best” book on pregnancy and childbirth, in my honest opinion.  My “best books” are listed on the right.  Read them.  Inform yourself.  Empower your birth.)

Now, I’m not here to “take down” the whole book and all of its paternalistic and even mis-informative advice.  Others have taken on that critique long before I sat down to write this  post.

But I am here to offer a “critique” of the “What to Expect” website’s advice-ish page on VBAC.  (Yes, I’m blogging about the silly things people say about VBAC uh-gain.)

Because if women are reading the “What to Expect” site when they’re trying to make a decision between VBAC and repeat cesarean, then they are gaining some seriously misleading and unhelpful information about VBAC.

Just take a look at some of the statements I found on the site:

“Forty percent of women who had a prior cesarean section do end up having a repeat.”

This is a misleading statement, though perhaps unintentionally.  Of all women with prior cesareans in the United States, less than 10% currently even attempt a VBAC.  So this means that over 90% of women will “end up having a repeat.”

But even if the author of this page meant to convey the rates of VBACs that are successful or unsuccessful (or that end in a vaginal birth or a cesarean section), this statement is still misleading.  With VBAC success rates ranging between 6o% and 80%, it seems more accurate to state that “twenty to forty percent of women who had a prior cesarean section and who attempt a VBAC do end up having a repeat.”

Even better?  How about, “Sixty to eighty percent of women who try for a VBAC do end up having a vaginal birth.”  (See how much more accurate and positive that statement is?)

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“Causes like fetal distress, preeclampsia, a breech position, or placenta previa don’t generally spill over from pregnancy to pregnancy, nor is having had a large baby before any reason to think you’ll have one this time (especially if you kept your paws off the Krispy Kremes and kept your weight gain under control). If the reason was a chronic condition like high blood pressure or diabetes, though, you’d better steel yourself for another surgery.”

Why don’t we throw in a few fat-slurs in there and call it a day!

GOOD LORD.

I mean, I appreciate some good “girlfriend advice” as much as the next gal,* but this seems more like advice from some passive-aggressive chick who likes to put down her overweight pals with snarky comments about doughnuts.

NOT!  HELPFUL!

Why not offer some information about prenatal nutrition and its role in helping women to achieve healthy pregnancies and healthy births?  (And for what it’s worth, being classified as “overweight” or “obese” does not necessarily mean that a woman isn’t eating a good prenatal diet!!!)

And why not point women who might need to “steel themselves up for another surgery” toward some cesarean support groups such as ICAN?

Otherwise, the advice here just seems insensitive, and even a bit mean.  (Or perhaps I’m the overly insensitive type?  Perhaps.  I do love me some Krispy Kremes after all!)

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“Remember that there’s no advantage (moral or otherwise) to a VBAC, so even if you could try for one, you’re absolutely entitled not to go for it if the risks make you uneasy.”

Okay.  You know those cartoons where the character’s face turns red and then steam starts shooting out of their ears and there are all sorts of steam engine or train whistle sound effects?

That’s exactly what was going on inside my head when I read this sentence.

A moral advantage to VBAC?  You mean the sort of advantage where St. Peter is gonna be all like, “Well, lady, you’d be getting through these here gates to heaven if you had just chosen that VBAC over your repeat cesarean.  TOO BAD YOU DIDN’T TAKE THE MORAL PATH!!!”

Jay-zus.

No!  There isn’t a moral advantage to VBAC!  And there’s no moral advantage to repeat cesarean either!  (Although there are moral advantages to making sure that women are accurately and thoroughly informed about the risks and benefits of both of these birthing options!)

Look, I agree with the end of this statement: any woman with a scarred uterus is absolutely entitled not to go for a VBAC if the risk (of uterine rupture) makes her uneasy.

But, as should be obvious, any woman with a scarred uterus is absolutely entitled not to go for a repeat cesarean if the risks make her uneasy.

Oh, and there are some “otherwise” advantages to VBAC.  In fact, there are advantages for women (e.g. a lower maternal mortality rate when compared with elective repeat cesarean) and for their babies (e.g. a significantly lower rates of respiratory morbidity and NICU admission when compared with babies born via elective repeat cesarean)!

So don’t go telling women that there are no advantages!  Exclamation point!

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“…they might want to keep you off the meds to avoid masking the pain that could point to potential rupture.”

Well, sure, they might.  I’ve heard of some individual practitioners having a “no epidural during VBAC” policy in place.

But it should also be noted that even ACOG notes that epidurals “rarely mask the signs and symptoms of uterine rupture.”  So while there may be good reasons to approach epidurals with some level of caution in any labor, there are also good reasons for women to question those “no epidurals during VBAC” policies.

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“Finally, if it doesn’t work out (and remember one in five births are cesarean), try to take it in stride.”

No, remember this: One in three births are cesarean.

Mmmkay.  Thanks.

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“The happy ending — healthy you, healthy baby — is really all that matters.”

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BLAAAARRRRRRGHHHH!  STEAM COMING OUT OF THE EARS AGAIN!!!!

I wrote about statements such as this one a long time ago.  In brief?

Healthy moms and healthy babies do matter.  They matter a whole hell of a lot.  But they’re not all that matters.

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So in the end?  While I’m sure that the authors of WTEWYE are really, truly well-meaning individuals who just want to help out a pregnant women or two (million), I think my expectations of their advice have been tremendously lowered after reading their “lowdown on VBACs.”

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* Your Best Birth: Know All Your Options, Discover the Natural Choices, and Take Back the Birth Experience is much better at the “girlfriend advice” on pregnancy and childbirth, in my opinion.

I’ve got another VBAC-related ranty-post coming your way (I’ll give you a hint: What to Expect When You’re Expecting + VBAC = KRISTEN’S BRAIN EXPLODES), but to save myself from the image of the little old lady yelling at passersby to “GET OFF MY LAWN!!   AND STOP UNDERMINING WOMEN’S AUTONOMY WHILE YER AT IT!!”, I’m going to write about the books that have influenced me the most.  (Or, in my case, books that changed my life.)

It’s something my friend did on her blog.  Ta-Nehisi Coates did it too.  In fact, lots of bloggers have done/are doing it.

I’m gonna do it too, not because I’m like the kid who jumps off the bridge with all of her friends, but because I think it’s a lovely idea.

And the world needs more lovely ideas.

Ten Books That Changed my Life

The English Patient – Michael Ondaatje
I have a fondness for writers whose prose reads like poetry, and Ondaatje is one of those writers.  I also wrote parts of my senior honors thesis on The English Patient and its story of love, and tragedy, and moral ambiguity,  In fact, thinking about this book takes me back to a time in which my thoughts about these things (love, tragedy, and moral ambiguity) were pretty simple/simplistic.  Both in an embarrassing and endearing way.  And I also love a good dose of nostalgia every now and then.

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Ulysses – James Joyce

Am I pretentious for putting this one on here?  Oh hell, I don’t know.  GET OFF MY LAWN!!!  AND STOP COMPLAINING ABOUT MY BOOK CHOICES!!! All I do know is that one of my favorite memories of living in Chicago is riding the bus home from work and fighting back the tears as I finished the book and marveled over the sheer beauty of Molly’s monologue.  Yes I said yes I will Yes.

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The Road – Cormac McCarthy

Add this one to the “list of books that made me cry too.”  And the list of authors whose prose reads like poetry, for that matter.  When I read The Road, I was pregnant with A.  Yes, I read a story about a brutal, post-apocalyptic world and a father and son’s journey through it when I was “with child” and under the influence of all the hormonal storms that go with that.  And to be honest, I didn’t think that I could fall further into despair as a reader.  Despair about “humanity,” about the world into which I did and would birth my children.  But then McCarthy left me with a glimmer of hope by the novel’s end.  It was an unexpected hope, and it wasn’t a naive hope, and it was the sort of hope that left my copy of the book quite literally tear-stained.

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The Awakening (Norton Critical Editions) – Kate Chopin

I apologize for not being able to address this novel without a pun, but this was really the first book that served as one of my personal “feminist awakenings.”  Sure, there were films and conversations and life experiences that started some of the feminist fire in me before I read this book in high school, but this one introduced me to the literary side of feminism.  And it was also during an in-class discussion of this book that my normally reserved high school English teacher slammed her hand on my desk and said, “KRISTEN, you can’t let these GUYS dominate the conversation here.  If you have something to say, IT IS WORTH SAYING.  Speak.  Up.“  Thank you, Mrs. Brown.  And Kate Chopin too.

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Ina May’s Guide to Childbirth – Ina May Gaskin

Can I confess something?  I actually didn’t read this until after both of my children were born.  But it still changed my life–as a doula, as a mother, as someone who may give birth again, and as a person in general.  Ina May Gaskin is a (inter)national treasure.  Period.

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Operating Instructions: A Journal of My Son’s First Year – Anne Lamott

When I was pregnant with M, my friends threw a “book shower” for me, and this was one of the gifts that I received.  Since then, it traveled into so many mothers’ hands now that I don’t even know where my copy is.  And that doesn’t bother me in the slightest.  This book helped to prepare me for the realities of new-parenthood more than any traditional parenting book out there.  I needed to see how shocking that first year was going to be, but I needed to hear it from someone who was brutally honest and kind and laugh-til-you-cry funny and devastatingly in love with her child.  Anne Lamott is all of these.

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The Ethics Of Ambiguity – Simone de Beauvoir

It was the book that inspired me to become a philosophy major, and now it’s the subject of my dissertation.  ‘Nuf said.

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Harry Potter Paperback Box Set (Books 1-7) -J. K. Rowling

What can I say?  I am a girl forever changed by games of Quidditch and adventures at Hogwarts and the deep enduring friendship of Harry, Ron, and Hermione.  And this is remarkable given that I am a relative newbie to the world of Harry et al., having read the series for the first time only last summer.  Please forgive me: it was a typical Muggle mistake.

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All of those books I picked up in the sociology section of borders – Sociologists et al.

(There’s no Amazon link for these, just so ya know.)  When I was 15, my mom would drop my younger sister off at modeling class (mmm hmm), and then she and I would go out to lunch (veggie burger, every single week) and then to Borders until my sister’s class was over.  For some reason, I was drawn to the books in the sociology section.  And from there, my mind (and my politics) broadened far beyond the cozy white, middle-class world that I was used to.

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The Twilight Saga Collection – Stephenie Meyer

YOU LAUGH!  You think I’m joking.  But I honestly can’t think of another book that had such a profound effect on my sex life, and I don’t know if it’s because it took me back to those years of anguished teenage lust or because I have a raging crush on Robert-Pattinson-as-Edward-Cullen, but it influenced my life.  Ahem.

One of my previous doula clients recently mailed me a copy of a “patient safety update” that she received from her current OB/GYN practice.*

The topic of this particular patient safety update was vaginal birth after cesarean, or VBAC.**  And it was…”interesting.”

In fact, it was so “interesting” that I’ve transcribed the entire document below, for your reading “pleasure.”  (And just so I don’t color anyone’s opinion of the safety update before you read it, I’ve left my editorializing for the end.)

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Patient Safety Update: Vaginal Birth After Cesarean (VBAC)

On a monthly basis the staff of **** meets to discuss current practice protocols and to review various patient safety issues raised by our staff.  We jointly discuss challenging cases from the preceding month as well as those due to deliver in the near future.  Our goal has always been to provide the safest medical care possible to our patients.  The topic for our recent meeting was a review of the safety implications of Vaginal Birth After Cesarean Section, more commonly known as VBAC.

Trends:

Fewer women are attempting a Trial of Labor after a Cesarean.  There are several potential reasons for this: medical and legal pressure; changes in patient and provider preference; changes in obstetrical practice; and publication of complications related to vaginal delivery and failed trial of labor.

The most serious concerns are increased risks of uterine rupture and perinatal death.  A recent study of 33,000 patients showed that the risks of uterine rupture, hysterectomy, thromboembolic disease (blood clots), transfusion, severe infection, and death are 56% greater in women attempting VBAC vs. Repeat Cesarean Section.***  Overall you would need to do 588 elective Cesareans to prevent one poor perinatal outcome.

Summary

588 Cesareans to prevent one poor perinatal outcome is acceptable to some but not to others.  Our group is evenly divided.  Some of our physicians do participate in VBACs and some do not.  As a result the following key points need to be understood by our patients.

If you definitely want to have a trial of labor and attempt a VBAC, you should consider transferring to a practice that supports VBACs completely.

If you want a VBAC and stay with the practice it must be understood that you will not be guaranteed the opportunity to have a VBAC attempt.  On certain days there might not be a physician who will participate in a VBAC trial of labor.

A trial of labor is definitely more risky for the baby than an elective Cesarean Section (much in the same way that labor is more risky than an elective cesarean section).  You must be willing to accept that risk in order to proceed with a trial of labor.

We regret any inconvenience this may cause to our patients planning to attempt vaginal birth after cesarean section.  We urge our patients to stop and contemplate the statistics listed above.  We plan to meet individually with the patients affected by this decision and address their individual concerns.

Thank you.

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Oh, where to begin.

How about with this: I think that framing this issue as a “patient safety update” is problematic, to say the least.  For if I were to receive a letter from my care provider (OB/GYN or not) alerting me to a patient safety update, I would automatically think that the information contained therein would be primarily concerned with protecting me from harm.  With keeping me safe.

Thus, it seems reasonable to assume that many women who received this “patient safety update” have approached this document with the belief that the OB/GYNs at this practice had a safety concern about vaginal birth after cesarean.

And it seems quite obvious that the safety concern here places an extraordinary emphasis on the risks of VBAC (and labor, for that matter) without giving even a mere mention of the risks associated with repeat cesarean section.

It makes no mention of the current research concluding that babies born after VBAC have significantly lower rates of respiratory morbidity and NICU admission than babies born after elective repeat cesarean.

It makes no mention of the recent report concluding that elective repeat cesarean is associated with a threefold increase in maternal mortality when compared with vaginal birth after cesarean.

It doesn’t even mention any of the risks associated with repeat cesarean sections, including abnormal placentation in future pregnancies (which can lead to life-threatening problems), bowel obstruction, and blood clots.

I’m sorry (and I’m angry), but highlighting the risks of VBAC (and LABOR!) in a “patient safety update” on VBAC without even mentioning the risks of elective repeat cesarean does not offer transparent information to the women in this practice.  In fact, I’m not even sure that it best keeps patient safety in mind. 

How can a woman make a major decision such as this one without knowing the risks (and benefits) of both options?

How can she even go on to rationally weigh those risks and benefits when she has received a letter putting the fear of God into her about VBAC?

It should be stated that I wholeheartedly support a woman’s right to choose a repeat cesarean delivery over a VBAC.  Wholeheartedly.

But failing to present a woman with the risks and benefits of VBAC and repeat cesarean in a letter such as this one undermines her ability give informed consent to either option.

So at best–and despite the fact that the practice recommends that women seeking VBAC should switch to a more VBAC-supportive care provider–this letter is disingenuous.

And at worst, it strikes a major blow to women’s ability to give informed consent to what they do with their bodies in order to birth their babies.

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*I want to extend a hearty thanks to my doula client for thinking of me after reading this “safety update.”  Quite simply, she rocks!

** I think it is no coincidence that this letter was sent out mere days after the NIH Consensus Panel released their statement on VBAC.

***It’s worth noting that a recent Agency for Healthcare Research and Quality Report determined that “the rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL [trial of labor, or VBAC attempt] and ERCD [elective repeat cesarean delivery].”    Even the 2004 Landon study, which this practice may have been referring to when they mentioned that “recent study of 33,000 patients,” concluded that while the rates of endometritis and blood transfusions were higher in women attempting VBAC than in women undergoing repeat cesarean, “the frequency of hysterectomy and of maternal death did not differ significantly between groups.”

So I promised nearly two months ago that I would write a series on “Sex after C-section.”

And here I am, without any “Sex after C-section” posts to show for it.

Ahem.

It’s not that I haven’t tried writing any of these promised posts.  I have many drafts, oh yes I do.

It’s just that each time I get to the point where I’m about to finish one of these posts, I get cold feet (cold ovaries?  cold labia?  no, no, they sound like a couple of delicacies that the “IT PUTS THE LOTION IN THE BASKET” guy from Silence of the Lambs would serve at his brunch buffet.  cold feet it is) and just cannot. hit. publish.

It’s not that sex makes me nervous.  But writing about sex does.

So  in order to get the hell over myself and my fears about writing about sex!, I’m going to do a little interview with myself.  About sex.  And c-sections.  And my thoughts on writing about sex after c-sections.

Consider it my own personal public pep talk.

And here’s hoping that after this “interview,” I’ll be able to “meet the needs” of all those folks who find my blog by searching for things like “vaginal tightness and cesarean section” and “sexual sensitivity after c-section” and “good sex after c-section.”

In fact, I really hope that I can meet the needs of those folks in the latter group.

Here goes nothing…

So: do ya fancy yerself a sex writer?

Hells no.

As I’ve said before (when I wrote about my dad, my father-in-law, and my Mormon friend Alex finding a riding crop under my bed), my personality includes the very strange juxtaposition of a lighthearted sense of prudishness and an altogether dirty mind.  So you can just imagine, as one side of me thinks about ways to integrate vibrators into adhesion healing, the other side of me is all like, “HEAVENS TO BETSY, NO!  YOU CAN’T SAY V*BRATOR!”

So why are you writing about sex after c-sections then?

Well, for one, I promised.

And I made this promise in light of some major misunderstandings and controversy surrounding sex, c-sections, and vaginas.

Long story short, the Mominatrix, in her recently published sex book, made some insensitive remarks about c-section mamas, the Feminist Breeder (TFB) responded to these comments, and then a shitstorm was a-brewin’ on teh internets.

Somewhere in the middle of the drama, I said, “Hey, why don’t I write some posts about sex after c-section?!  For all of those women who need and deserve some good advice?!”

And then I was quiet about it for nearly two months.

The end.

Do you hate the Mominatrix?

No, I don’t hate the Mominatrix.  I’m sure that Kristen Chase is, in fact, a very nice person.

But I do think that her c-section comments were (probably unintentionally) insensitive and borne of a place of serious misinformation.  I also think that the Mominatrix’s radio show response to TFB’s post missed an important opportunity to apologize to those who may have been hurt or offended by her comment.  (In my mind, it was so obvious that the radio show was a response to the TFB post that it was shocking that there was no mention of that post or a “Hey ladies, I’m sorry” nod to the hundreds of comments on it.)

But the Mominatrix drama is really beside the point.

Cesarean sections currently account for nearly one-third of births in the United States (a tremendous problem all on its own), yet there’s really a lack of good, thorough advice about sex after c-section “out there.”  (And hey, if y’all know where this good thorough advice is, point me there now so that I don’t have to freak out about writing this advice myself!)

Why do you think that you are qualified to write about this anyway?

I’ve had a c-section, and I’ve had sex after a c-section.  And I can read.  And write.

Isn’t that enough?

Um, okay, great.  When are you going to start writing these posts already?

Soon, alright?  Soon.  Just as long as this pep talk works.

Do you honestly think that vibrators can help with the healing process?

Sure, what could it hurt?  (Well, actually I need to ask a few professionals about this just to make sure that my ideas aren’t more of a hurt than a help.)

Just stay tuned…

(Now commences the twelve seconds out of the past month where I will not blog about VBAC, the NIH Consensus Development Conference, or the gazillion ideas that I have to change the world of maternity care in the United States.  Enjoy.)

There are times when the fact that I have neither octopus arms nor eyes on the back of my head really makes parenting two little ones a killer.

Just consider this little episode from today.

This afternoon, M (4) asked me to make him a baked sweet potato for lunch.  Somewhere in the midst of concealing my excitement (didn’t this kid just tell me two weeks ago that sweet potatoes were Satan spawn or something?) and mashing the potato with a fork, A (21 months) asked me to get him some more juice.

Silly me thought that I would carry my unwavering torch of parental justice (fool that I am) and finish addressing M’s desire for food before addressing A’s desire for more juice.  It was a simple equation, really: M asked for food first, A asked for a drink second, I thought I’d M’s request first, and then meet A’s request second.

LIBERTY AND JUSTICE FOR ALL!

No one was starving (both kids had recently eaten snacks), no one was dehydrated (A had just finished off a cup of milk not twenty minutes beforehand), there was no blood, no imminent death or danger, and the Earth was still spinning on its axis.  So I told A that I would be happy to get him more juice as soon as I was finished getting M his sweet potato.

He let me know he was “displeased” with my decision with one of his shrill whines that I think is roughly translated as, “WTF, Mom?!”  And then I had the audacity to tell him (in, I sweartogod, my very best June Cleaver voice) that “this was fair since M asked for his food first, sweetie” and that he “would get his juice soon!”

And then I went back oh-so-carelessly-and-mindlessly to mashing up that sweet potato.

I turned my back on the spurned almost-two-year-old.

And when I turned around, I kid you not, my little angel was standing by the pantry in a puddle of maple syrup, his head cocked back, mouth wide open, holding an open and upturned bottle of Aunt Jemima the same way a college kid holds a bottle of Tequila on a spring break trip.

And if that sweetie-pie had the dexterity to give me the finger, I’m sure he would also have been flipping me the bird and sneering, “I’ll give you juice, Mom.”

Ay-yai-yai.

Anyone know where I can get those eyes on the back of my head?

Have I mentioned anything about that NIH Consensus Development Conference on VBAC yet?

(I kid, I kid.)

I realize that I’ve devoted six consecutive posts to the NIH VBAC conference.  That’s a lot, even for an obsessive person like me.  But I also really think that the conference was that important.

And before I ride off into the sunset and get back to writing about things like riding crops, lavender oil, and doctors who fail to woo me with their paternalism, I’d like to contribute one more serious thought to the conference and the consensus statement that it produced.

More specifically, I’d like to reveal the three main goals that this conference has spurred me to take on in the coming year(s).

And these goals are big.  They’re bigger than anything I can successfully do on my own, and I’d love to request others’ help in accomplishing them.

And that’s because I’m planning to:

1. Develop a “NIH Consensus Statement Primer” to help women use the consensus statement to their advantage.
2. Organize a conference on pregnancy ethics, primarily to meet Dr. Anne Lyerly’s call for a “more robust pregnancy ethics” but also to respond to the concerning statements about pregnancy, personhood, and autonomy made by Dr. Laurence McCollough.
3. Create an alliance between birth advocates and OB/GYNs to work together on tort reform.

I know.  It’s as if someone stuck a stick of dynamite under my ass and ten shots of espresso into an intravenous line in my arm and a little fairy next to my ear whispering sweet nothings about the future of birth advocacy.

And if these goals aren’t entirely clear to you yet, here’s my best shot at explaining what I have in mind at the moment:

The Primer

As I’ve mentioned before (and as others have argued elsewhere), the consensus statement is not perfect.  In my mind, the absence of any clear positions on VBAmC (or vaginal birth after multiple cesareans) or the right to informed refusal are serious deficiencies of the statement.

Nonetheless, there is a lot in the statement that women who want to a VBAC or who are even just considering a VBAC can use to their advantage, whether with their care providers, their hospital, their local media, or even their friends and family members.

The authors’ focus on providing transparent and accurate information about VBAC and repeat cesarean to women is of particular importance, as is their emphasis on the significance of the shared decision-making process when it comes to a woman’s birthing options.  What’s more, their call for the American College of Obstetrics and Gynecology (ACOG) to reassess their controversial “immediately available” anesthesiology standard gives women an important foundation with which to challenge their local care providers’ and/or hospitals’ “VBAC bans.”

And I, for one, think that it would be fantastic to create a short primer explaining just how women can use this wealth of information to advocate for themselves and their right to choose the way they birth their babies.

So to create such a primer, and to create one that could be an effective tool for change and advocacy, “we” would need to determine (among other things):

• Which parts of the statement are most compelling to OB/GYNs and other care providers
• Which parts of the statement are most compelling to hospitals
• Which parts of the statement are most compelling to the media
• Which parts of the statement coincide with, reflect, or even illuminate a woman’s right to informed consent and informed refusal
• How to make these “compelling” parts of the statement accessible to and usable by most women

The Conference

During her talk on “The Ethics of Vaginal Birth After Cesarean,” Dr. Anne Lyerly expressed the need for an “ethical framework specific to pregnancy”—one that could accommodate the relatively under-investigated concerns about autonomy, responsibility, decision-making, personhood, and values in relation to pregnancy and birth.

Not surprisingly, the philosopher in me lit up like a round of fireworks at Socrates’ backyard barbecue when I heard her talk about this topic.  I mean, I know a thing or two about philosophical conceptions of autonomy and personhood.  I even know a thing or two about pregnancy and birth.

And there’s also a part of me that knows a thing or two about organizing and presenting at conferences.

What better way to collaborate on developing an “ethical framework specific to pregnancy” and a “more robust pregnancy ethics” than to start with a conference that brings together those who work in academia, law, midwifery, medicine, and birth-work in general?

The list of resources needed to organize such a conference is a bit daunting, I’ll admit.  Off the top of my head, “we” would need:

• A location
• Interested speakers
• An interested audience
• Interested organizers
• Funds, funds, and more funds

Again, the idea is daunting.

But not impossible.

The Alliance

I’d like to preface this section by stating explicitly and without reservation that I would only participate in such a group just so long as its goals and/or actions did not throw women “under the bus” (or the knife), so to speak.

Nonetheless, one cannot ignore the number of times in which conference presenters and audience members mentioned medico-legal concerns and the fear of liability when discussing the current “VBAC climate.”  Even if these fears are partly irrational when specifically applied to VBAC, they are real fears, and they are really affecting care providers’ and hospitals’ decisions to refuse to attend and/or ban VBACs.

(For example, although the risk of uterine rupture is approximately .7% in a VBAC labor, and although only 6% of uterine ruptures result in a catastrophic outcome, many care providers’ views of the relative safety of VBAC are overshadowed either by malpractice insurance pressures or by stories of multi-million dollar lawsuits following those exceedingly rare catastrophic uterine ruptures.)

In my mind, it seems as if these fears are so embedded into the way that these doctors approach VBAC that solely “fighting” the fears with evidence-based medicine and/or the consensus statement itself will not be enough to change their policies and practices regarding VBAC.

But fighting these fears with a tempered, woman-friendly tort and/or legal reform might be a significant part of good pragmatic, strategic, and mutually beneficial “solution” to the current “fear of VBAC.”  (For what it’s worth, recommending a VBAC consent form in which women abdicate their right to sue following a uterine rupture is neither woman-friendly nor mutually beneficial.)

Returning to the issue at hand, my ears especially perked up during the NIH Conference when Eugene Declercq himself called for birth activists to form an alliance with OB/GYNs to work toward tort reform.  Professor Declercq is an incredible birth and maternity advocate who, as far as I can tell, has no reason to engage in “obstetrical apologism” regarding the lack of VBAC access in the United States.  In other words, I highly doubt that his recommendation was meant to throw birthing women to the wolves all in the name of the ever-elusive tort reform.  And, as should be obvious by now, I’ve taken his recommendation to heart.

Of course, forming and participating in such an alliance and/or coalition will involve some hard and heady work.  (For my part, it will involve me getting to know a thing or two more about our legal system!)  In fact, the very list of things that “we” would need to do would expand this already expansive blog post into an epic size.

But accomplishing any number of items on that list could have a profound (and positive) impact on birth advocates’ strategies for and ability to effect some meaningful change in the world of maternity care in the United States.

The NIH Consensus Development Panel just released the revised draft of its Consensus Statement on Vaginal Birth After Cesarean.  (The final statement will not be released for another six weeks or so.)

After reading the revised draft, and after considering what I perceive to be its flaws–namely, a lack of discussion about VBAmC (or vaginal birth after multiple cesareans) and of the right to informed refusal–I still think that the statement itself represents a major step forward for women who want to and often have to fight to choose how they give birth to their babies.

And that’s because while I’m not sure that the statement will signal a sea change in policies and practices regarding VBAC (although I would certainly welcome such a change), I think that it gives women a powerful tool to use when discussing VBAC with their care providers.  I also think that it gives maternity care providers a powerful charge to re-evaluate their VBAC policies and practices.

Consider, for instance, the following remarks from the statement’s conclusion:

One of our major goals is to support pregnant women with a prior transverse uterine incision to make informed decisions about TOL versus ERCD. We urge clinicians and other maternity care providers to use the responses to the six questions, especially questions 3 and 4, to incorporate an evidence-based approach into the decision-making process. Information, including risk assessment, should be shared with the woman at a level and pace that she can understand. When both TOL and ERCD are medically equivalent options, a shared decision-making process should be adopted and, whenever possible, the woman’s preference should be honored.

We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL. Given the level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement relative to other obstetrical complications of comparable risk, risk stratification, and in light of limited physician and nursing resources. Healthcare organizations, physicians, and other clinicians should consider making public their TOL policy and VBAC rates, as well as their plans for responding to obstetric emergencies. We recommend that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to TOL.

Despite the fact that I would still like stronger language regarding the “shared decision-making process” in the first paragraph above, I think that the informed consent-centered language signifies an overall victory for VBAC supporters.  As far as I can tell, this is the first document in recent history that explicitly and strongly encourages care providers to take steps to 1) fully inform women of the relative risks and benefits of VBAC and repeat cesarean, to 2) make their own policies about VBAC and their VBAC rates public, and to 3) work toward eliminating current barriers to VBAC.

The panel cannot force care providers, hospitals, or medicial societies to make these changes, but it is quite clear that they think these changes should be made.  And to have the force of an NIH consensus statement behind those changes seems quite remarkable to me.

Now let’s use that force to our advantage.

The NIH Consensus Development panel released their draft statement on vaginal birth after cesarean (VBAC) today.  For the most part, I think that the statement itself signifies a major step forward for birthing women–especially those of us with cesarean scars.  And that in and of itself far exceeds my expectations of what such a statement could do.

I will leave my analysis of the statement, the public discussion of it, and the press response to it tomorrow.  (That is when I expect my brain and body to have recovered from three days of conference participation and six-and-a-half hours of driving home from Maryland!)

In the meantime, you can keep yourself apprised of the conference proceedings, the statement, and the press responses by checking out:

• The online version of the draft statement.
• The archived videocasts of Day 1 and Day 2 of the conference.  (If you’re interested, I appear on the Day 2 videocast around the 3-hour mark.  I’m “Kristen [Indiscernible], the ‘dula’ [sic] from Columbus, Ohio.”)
• The NIH press release on the conference statement, “Panel Questions ‘VBAC Bans,’ Advocates Expanded Delivery Options for Women.“
• The Associated Press piece on the conference statement, “Women Need Chance to Avoid 2nd C-section.”
• NPR’s coverage of the statement.
• The New York Times piece on the NIH conference and the conference statement.
• The audio playback of the press telebriefing, given this afternoon at 2 p.m., by calling 1-888-632-8973 in the United States and 201-499-0429 for international calls.  You can then enter the playback code 56036507.

The final draft should be available in approximately six weeks.

Attending the NIH Consensus Development Conference on VBAC has been more enthralling than I could have ever hoped, and here’s why: instead of hearing hours upon hours of what I expected today (i.e. exaggerated accounts of the relative risks of VBACs and benefits of repeat cesarean section), I heard this:

Women’s choices matter.

Whether it was Dr. Caroline Signore clearly implying that women should be the ones to determine what is and isn’t an acceptable risk level for VBAC or repeat cesarean section (RCS), or Dr. Kimberly Gregory acknowledging the importance of psychosocial factors and their relevance to a woman’s risk evaluation, or Dr. William Grobman describing a model to help predict individual VBAC success rates so that women can make more well-informed birth decisions, or simply every speakers’ claim that evidence-based policies and practices and informed consent and refusal are central to any discussion of VBAC, women’s rights and autonomy were respected and represented in the discussions today.

But can they be respected and represented in the panel’s consensus statement?

And such a statement actually affect the policies and practices of maternity care providers in the United States?

This all remains to be seen, but I for one am happy now just to bask in the glow of knowing that the charge to the panel–a panel who will very likely have a profound effect on my and others’ birthing futures–was one that recognized my right and responsibility to evaluate the risks and benefits of VBAC and RCS and to autonomously choose the way I bring my child into the world.

(Remember, you can keep up with the live webcast of the conference at http://videocast.nih.gov.)