Birthing Beautiful Ideas

I recently received a very thoughtful set of questions from reader Rachael N.:

I keep hearing this idea that women who have birth plans are women who end up having c-sections. I actually first heard it from my freestanding birthing center midwife, when I asked if she would recommend that I write a birth plan. On the one hand, I imagine that there may be some women who become so attached to their plan that they are unprepared for the unpredictability of labor itself. On the other hand, it sounds far more likely that the birth plan may be a convenient target for blame on those occasions when it was actually the system that did not serve the woman well. So my questions are: What’s up with this myth? Is there any actual research showing what the outcomes are when women have birth plans? And how should a woman build some flexibility into her birth plan, given that childbirth is an unpredictable process??

I’ve also heard and seen people express this sentiment before: namely, that women with birth plans (and, especially, long birth plans) are the ones who will end up with the most birth interventions.

Like many sweeping generalizations, I find that some of these sentiments gloss over a lot of much-needed nuance and sensitivity and attention to detail.  And this is troubling.  In fact, it does little, if not nothing, to empower or even help women who are preparing for the birth of their babies.

For instance, when Taffy Brodesser-Akner talked to Dr. Kimberly D. Gregory in an article in Self magazine, Dr. Gregory expressed the following reservations about birth plans:

“I think that birth should be a beautiful experience,” says obstetrician Kimberly D. Gregory, M.D. She’s the vice chair of women’s health care quality and performance improvement at Cedars-Sinai Medical Center in L.A. “It should be exactly the way you want it, and doctors should intervene only to preserve the health or life of you or your baby.“

Naturally, one would assume that Dr. Gregory advocates birth plans. When I ask her this, she laughs. “We always say, ‘If you show up with a birth plan, just get the C-section room ready,’” she says. “You get everything on that list that you don’t want. It’s like a self-fulfilling prophecy.” Dr. Gregory led an unpublished study that compared women who took traditional hospital birth classes with those who employed Bradley-like training and a birth plan. The birth-plan group trended toward a higher C-section rate and more interventions. “There’s a certain personality type that tends to be more anxious. Maybe the anxiety hormones themselves put them at risk,” Dr. Gregory theorizes. “It seems that being open and honest and choosing the right doctor is probably a better option than writing everything down. Walking in with this list appears to set up an antagonistic relationship.”

For what it’s worth, I think that Dr. Gregory’s statements (which, to be fair,were probably edited for purposes of the article) include a mix of sweeping generalizations and helpful distinctions.

On the one hand, even if the hospital staff is joking when they claim that showing up with a birth plan entails a trip to the OR, the joke itself raises questions about just whose self-fulfilling prophesies are being fulfilled.  Not all birth plans are created equally–some are the result of an online, cookie-cutter checklist, and others are the result of careful research that a woman and her partner have discussed with their care provider, the hospital staff, and their pediatrician.

On the other hand, Dr. Gregory’s points about the relationship between anxiety and labor and the importance of finding a supportive care provider are spot on.  For if one envisions the hospital as a battle scene in which one must use a birth plan as a defensive shield, one might very well set oneself up for disappointment, and even the self-fulfilling prophesies to which Dr. Gregory alluded.

I was also able to dig up one published study that examined the disparities between patients’ and medical personnel’s perceptions of outcomes in women who use birth plan.  (Note that this is different from the actual outcomes of women who use birth plans.)  And the results were pretty fascinating:

Sixty-five percent of medical personnel vs. 2.4% of patients reported that patients with birth plans had overall worse obstetric outcomes than patients without a birth plan. There were 65.7% of health care providers vs, 8.7% of patients who reported that women with a birth plan had an increased rate of cesarean section. In addition, 53.4% of health care providers vs. 9.9% of antepartum patients reported a perceived increased rate of chorioamnionitis for women with birth plans. Statistically significant differences were also found between health care providers and patients in terms of their perceptions of the effect of birth plans on operative vaginal delivery, postpartum hemorrhage, episiotomy and length of hospital stay.

I do not doubt that these perceptions exist or that (as Dr. Gregory commented) birth plans created out of anxiety or antagonism can contribute to more complicated labors.  (Fear or anxiety-based stress effects everything from pregnancy to birth to breastfeeding negatively.)  But I also think that they/we need to make some clearer distinctions before drawing any hard and fast conclusions about the relative usefulness (or uselessness) of birth plans.

You see, I can understand why certain attitudes or expectations about birth plans might be more of a hindrance than a help to birthing women and their partners.  But this is entirely different from claiming that birth plans themselves are somehow responsible for a higher rate of complications and/or medical interventions.  And if this distinction (i.e. the one between attitudes and expectations about birth plans and birth plans themselves) is not made abundantly clear in the sort of statements described above, then women might be led to think that any and all articulation of their preferences for birth are counterproductive, useless, and even dangerous.

In my humble opinion, this thought is what is actually counterproductive, and even dangerous.

And that’s because there is a lot about birth plans that is a “good thing!”

Researching your birth preferences is a good thing.

(Who wants to find out the risks, benefits, and side effects of narcotic pain medication during a contraction, or, worse, while their baby is receiving medication because of the respiratory distress caused by the narcotic pain medication?)

Articulating your birth preferences is a good thing.

(How will your partner and/or the nurses know that you don’t want them to offer you pain medication unless you tell them so?)

And discussing these preferences (as early as possible) with your care provider, your hospital staff, and your pediatrician is an even better thing!

(Who wants to get to the hospital, in active labor, only to find out that their care provider doesn’t “allow” intermittent monitoring after all?  Or that the hospital doesn’t have tubs in every labor and delivery room?  Or that the staff will call Childrens Protective Services if parents refuse the erythromycin eye drops?)

But in order to create an effective birth plan–one that will communicate one’s wishes without working against one’s wishes–it is important to be mindful of the following:

1) A birth plan does not replace the need for birth preparation.

Going to an online “birth plan mill” and checking off a bunch of boxes (“yes” to the epidural!  “no” to the episiotomy!)  is not the same as preparing for birth.

A good childbirth education class can help you prepare for birth by helping you to discern what the protocols are in your chosen birth location, what the risks, benefits, and alternatives are of any birth intervention, and how you can cope with both the expected and unexpected during labor.

So can a good book (or set of books). (Please see my recommended reading list on the right sidebar.)

Or a good website (such as Childbirth Connection, Lamaze International, or Mother’s Advocate).

Or a good doula or other birth professional.

But a birth plan really doesn’t help all that much you if you haven’t yet determined why you want what you want–why you prefer intermittent monitoring over continuous monitoring, why you want to eat and drink during labor, why you want something different from your care provider’s or your hospital’s typical protocol.

2) A birth plan does not replace the need for a supportive care provider who is on board with your desires and preferences for your birth.

Even a well-researched birth plan will generally not stand up to a care provider who doesn’t allow anything stated on the birth plan.  And this is why it is crucial to discuss your birth preferences–and even get your list of preferences signed–with your care provider well before labor begins.

For instance, if you would prefer to tear rather than to undergo an episiotomy, but your care provider has an 85% episiotomy rate, then you might consider finding a care provider who has a much lower rate.

If your care provider does not “allow” some of your birth preferences (such as intermittent monitoring, eating and drinking during labor, etc.), then you might consider asking if s/he will make an exception in your case (and sign your birth plan!), or you might consider finding another care provider who does support these preferences.

In other words, a birth plan itself will not magically change the way your care provider practices when it comes to your birth!

And a care provider who is on board with your preferences is worth much more than a piece of paper expressing these preferences.

3) A birth plan cannot plan your birth–but it can help you to articulate and express your desires and preferences for your birth.

This is why I (and many others) like to refer to birth plans as “birth preference lists.”

Birth is inherently unpredictable, whether you have an unexpected unassisted birth at home or an elective cesarean section that you have planned for from the moment you knew you were pregnant.

Thus, you cannot plan the birth you want–you can only plan for the sort of birth that you would like and remain open to the possibility that your plans and preferences might need to change in light of the particular circumstances of your birth.

This is not to say that articulating your birth desires and preferences is useless.  To the contrary, this is an exceedingly useful exercise, one that can motivate you to research your options and to get a better feel for what you can expect from your care provider and from your birthing location.

But your attitudes about and expectations for your birth plan should reflect these sentiments: namely, that you cannot control your labor.  You cannot control birth itself.  But you can and even should empower yourself to make decisions about what you want for your birth, and how you would like others to accommodate your desires and preferences for your birth, and how you plan to remain flexible and open to the unpredictability of childbirth.

And care providers should be able to respect these sorts of preferences without pegging you as taking a one-way train to the operating room.

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If you’re looking for a helpful guide on writing a birth plan, Melissa, the L&D nurse blogger from Nursing Birth, wrote two fabulous posts on birth plans: one covering the general topic of birth plans, and the other offering more specific tips and pointers for writing a birth plan/preference list.

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I’m also interested in hearing your thoughts!  Have you heard that “the women with birth plans end up with the most interventions”?  Have you seen that in your experience as a birth professional?  What advice would you/do you give to women about birth plans based on your experience?

You can see more of this discussion over on my Facebook fan page!

As many people might have seen in the news, on press releases, or on blog posts, the American College of Obstetrics and Gynecology (ACOG) just released a revised version of its VBAC practice bulletin.

This is big news.  It’s huge news.  And it’s particularly big and huge in light of the fact that two previous practice bulletins on VBAC (from 1999 and 2004) were instrumental in leading to the decrease in VBAC access and the swath of VBAC bans across the United States. What’s more, this current bulletin has the potential to reverse some of the effects of the previous bulletins.

And this is not because it will effect any immediate policy changes but because it gives women a tool to help them facilitate discussions with their care providers and/or their local hospitals so that they can advocate for their birthing options.

So while the current document is not perfect, it’s an improvement.  And a possibly giant improvement at that.

Just consider the introductory paragraph from the 2004 practice bulletin:

A trial of labor after previous cesarean delivery has been accepted as a way to reduce the overall cesarean delivery rate.  Although vaginal birth after cesarean delivery (VBAC) is appropriate for most women with a history of low-transverse cesarean delivery, several factors increase the likelihood of a failed trial of labor, which in turn leads to increased maternal and perinatal morbidity.  The purpose of this document is to review the current risks and benefits of VBAC in various situations and provide practical management guidelines.

And now the introductory paragraph from the new practice bulletin:

Trial of labor after previous cesarean delivery (TOLAC)* provides women who desire a vaginal delivery with the possibility of achieving that goal––a vaginal birth after cesarean delivery (VBAC)†. In addition to fulfilling a patient’s preference for vaginal delivery, at an individual level VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies. At a population level, VBAC also is associated with a decrease in the overall cesarean delivery rate (1, 2). Although TOLAC is appropriate for many women with a history of a cesarean delivery, several factors increase the likelihood of a failed trial of labor, which compared with VBAC, is associated with increased maternal and perinatal morbidity (3–5). Assessment of individual risks and the likelihood of VBAC is, therefore, important in determining who are appropriate candidates for TOLAC. The purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and provide practical guidelines for managing and counseling patients who will give birth after a previous cesarean delivery.

While some people may find the “managing” language to be off-putting, I think that the changes in this paragraph signal both an acknowledgment of women’s birthing preferences and desires and some much-needed nuanced distinctions regarding VBAC and repeat cesarean outcomes.  And an increased attention to detail and to women’s choices is a welcome difference.

Below, I’ve listed some additional major changes that ACOG has made to their practice bulletin on VBAC between 2004 and 2010.  If you are are having a difficult time finding a VBAC-supportive care provider in your area, you might be able to draw her or his attention to these changes in order to advocate for the birth that you want!

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On evaluating the risks and benefits of VBAC and elective repeat cesarean delivery

From the 2004 bulletin:

Neither elective repeat cesarean delivery nor VBAC is without risk.  Generally, successful VBAC is associated with shorter maternal hospitalizations, less blood loss and fewer transfusions, fewer infections, and fewer thromboembolic events than cesarean delivery.  However, a failed trial of labor may be associated with major maternal complications, such as uterine rupture, hysterectomy, and operative injury, as well as increased maternal infection and the need for transfusion.  Neonatal morbidity is also increased with a failed trial of labor, as evidenced by the increased incidence of arterial umbilical cord blood gas pH levels below 7, 5-minute Apgar scores below 7, and infection.  However, multiple cesarean deliveries also carry maternal risks, including an increased risk of placenta previa and accreta.

From the 2010 bulletin:

Neither elective repeat cesarean delivery nor TOLAC are without maternal or neonatal risk.  The risks of either approach include maternal hemorrhage, infection, operative injury, thromboembolism, hysterectomy, and death. Most maternal morbidity that occurs during TOLAC occurs when repeat cesarean delivery becomes necessary.  Thus, VBAC is associated with fewer complications, and a failed TOLAC is associated with more complications, than elective repeat cesarean delivery. Consequently, risk for maternal morbidity is integrally related to a woman’s probability of achieving VBAC…

…In addition to providing an option for those who want the experience of a vaginal birth, VBAC has several potential health advantages for women. Women who achieve VBAC avoid major abdominal surgery, resulting in lower rates of hemorrhage, infection, and a shorter recovery period compared with elective repeat cesarean delivery. Additionally, for those considering larger families, VBAC may avoid potential future maternal consequences of multiple cesarean deliveries such as hysterectomy, bowel or bladder injury, transfusion, infection, and abnormal placentation such as placenta previa and placenta accreta.

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On VBAC after multiple cesareans (or VBAmC)

From the 2004 bulletin:

Women who have had 2 previous low-transverse cesarean deliveries have traditionally been considered candidates for a trial of labor.  However, the few studies that address this issue report a risk of uterine rupture ranging between 1% and 3.7%.  In the only study that controlled for other potential confounding variables, the risk of uterine rupture during labor was nearly 5 times greater for women with 2 previous cesarean deliveries when compared with women who had 1 previous cesarean delivery.  Women with a previous vaginal delivery followed by a cesarean delivery were only approximately one fourth as likely to sustain uterine rupture during a trial of labor.  Therefore, for women with 2 prior cesarean deliveries, only those with a prior vaginal delivery should be considered candidates for a spontaneous trial of labor.

From the 2010 bulletin:

Studies addressing the risks and benefits of TOLAC in women with more than one cesarean delivery have
reported a risk of uterine rupture between 0.9% and 3.7%, but have not reached consistent conclusions regarding how this risk compares with women with only one prior uterine incision.  Two large studies, with sufficient size to control for confounding variables, reported on the risks for women with two previous cesarean deliveries undergoing TOLAC. One study found no increased risk of uterine rupture (0.9% versus 0.7%) in women with one versus multiple prior cesarean deliveries (66), whereas the other noted a risk of uterine rupture that increased from 0.9% to 1.8% in women with one versus two prior cesarean deliveries. Both studies reported some increased risk in morbidity among women with more than one prior cesarean delivery, although the absolute magnitude of the difference in these risks was relatively small (eg, 2.1% versus 3.2% composite major morbidity in one study).  Additionally, the chance of achieving VBAC appears to be similar for women with one or more than one cesarean delivery. Given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC, and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC.  Data regarding the risk for women undergoing TOLAC with more than two previous cesarean deliveries are limited.

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On suspected macrosomia (or “big baby”)

From the 2004 bulletin:

Although macrosomia (usually birth weight greater than 4000 g or 4500 g, regardless of gestational age) is associated with a lower likelihood of successful VBAC, 60-90% of women attempting a trial of labor who give birth to infants with macrosomia are successful.  The rate of uterine rupture appears to be increased only in those women without a previous vaginal delivery.

From the 2010 bulletin:

Women undergoing TOLAC with a macrosomic fetus (defined variously as birth weight greater than 4,000–4,500 g) have a lower likelihood of VBAC than women attempting TOLAC who have a nonmacrosomic fetus. Similarly, women with a history of past cesarean delivery performed for the indication of dystocia, have a lower likelihood of VBAC if the current birth weight is greater than that of the index pregnancy with dystocia. Some limited evidence also suggests that the uterine rupture rate is increased (relative risk 2.3, P <.001) for women undergoing TOLAC without a prior vaginal delivery and neonatal birth weights greater than 4,000 g . These studies used actual birth weight as opposed to estimated fetal weight thus limiting the applicability of these data when making decisions regarding mode of delivery antenatally.  Despite this limitation, it remains appropriate for health care providers and patients to consider past and predicted birth weights when making decisions regarding TOLAC, but suspected macrosomia alone should not preclude the possibility of TOLAC.

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On the “immediately availability” of obstetrical and surgical teams during a VBAC

From the 2004 bulletin:

Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.

From the 2010 bulletin:

A trial of labor after previous cesarean delivery should be undertaken at facilities capable of emergency deliveries.  Because of the risks associated with TOLAC and that uterine rupture and other
complications may be unpredictable, the College recommends that TOLAC be undertaken in facilities with staff immediately available to provide emergency care. When resources for immediate cesarean delivery are not available, the College recommends that health care providers and patients considering TOLAC discuss the hospital’s resources and availability of obstetric, pediatric, anesthetic, and operating room staffs. Respect for patient autonomy supports that patients should be allowed to accept increased levels of risk, however, patients should be clearly informed of such potential increase in risk and management alternatives.

It can sometimes be a mental hurdle for people to get past the idea that doulas aren’t only for women who choose a “natural” or drug-free birth.

It can be even more of a mental hurdle for people to get past the idea that doula support is only for women who are planning vaginal births!

But in reality, doula support can be quite valuable for women and families who are planning a cesarean section for the upcoming birth of their child (or children).  Here’s how.

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A doula can help you to create a cesarean birth plan.

Yes, you can create a birth plan or birth preference list for a planned cesarean section!

And a doula can help you to determine what preferences you would like to include on your list.  What’s more, she might even inform you of some options that you didn’t even know that you had!

For instance, would you like to specify that your urinary catheter to be inserted after the spinal epidural is placed?

Would you like someone to explain the surgery to you as it happens?

Would you like to have music playing during the c-section?

If your baby is healthy, would you like to be able to hold him or her while you are being moved to the recovery room (with assistance, if needed)?

Do you have any postpartum preferences, such as those related to breastfeeding or vaccines?

These items and more can all be included in a cesarean section birth plan or preference list.

(If you’d like to read more about cesarean birth plans, Morgan at Adventures in Diapering and Beyond created this example of a C-section Birth Plan for her readers.  She has had four c-sections herself and has some great experiential wisdom to offer here.)

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A doula can take the time to discuss your feelings about the c-section and offer any tips or advice on recovery well before the big day arrives.

Especially if this is your first cesarean section, you might have some fears or concerns about your upcoming surgery.  Well before your baby is born, a doula can help you practice relaxation techniques (such as breathing exercises or visualization) that you can use during the epidural or spinal placement, throughout the surgery, and during your recovery period.

Where appropriate, a doula can even help you to devise ways to alleviate your fears or concerns in your birth preferences list.  For instance, some women who become nauseous at the very thought of surgery might request that no one describe the cesarean section as it happens–or at least that any conversation between the medical staff be as least graphic as possible.

A doula can also help you to plan ahead to ensure that you to have your best recovery possible. Whether it’s demonstrating the breastfeeding positions (such as the football hold) that seem to be most comfortable to women recovering from a c-section, or recommending that you bring a breastfeeding pillow (such as a Boppy or My Brest Friend) to wrap around your abdomen even when you’re not nursing, or suggesting that you ask friends to offer to perform light housekeeping in lieu of bringing baby gifts, a doula might be able to offer you just the sorts of tips and advice that will make your initial recovery from major abdominal surgery as smooth as possible.

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A doula can support your husband, partner, or other support person while you are being prepped for surgery.

In many cases, a dad and/or a doula is not permitted to accompany a woman into the operating room during the initial preparation for surgery (including the spinal or epidural placement).

And in many cases, dads or partners are extremely nervous during this waiting period!

A doula can help a woman’s support person to remain calm while s/he is waiting for the “okay” to enter the operating room.  She can help to describe what will likely occur during the surgery, she can remind him or her of any “responsibilities” that s/he might have (such as taking pictures after the baby is born), or she can even just offer the general emotional support and encouragement that the dad or partner might need at that very moment.

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If your anesthesiologist and OB/GYN allow it, your doula can remain by your side during the surgery.

In some cases, care providers will allow a second support person (such as a doula) to accompany a couple during a cesarean section.

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This can be particularly helpful after the baby is born.  Oftentimes, the baby must be monitored in an area of the operating room that is relatively far away from the mother.  Sometimes, this monitoring is even performed in a separate nursery.  With a doula by your side, your husband or partner can go to be near the baby without having to worry about leaving you alone.

In addition, it can be particularly helpful for a woman to have a doula by her side while her uterus is being repaired.  To the surprise of many women, this is the longest part of a c-section, ranging anywhere from twenty minutes to a couple of hours, often depending on how many previous cesareans a woman has undergone.  Having continuous emotional support from a doula at this time can be exceedingly important for some women.

If you would like your doula present during your cesarean section, especially if you plan for your husband or partner to accompany you as well, please make sure to discuss this option with your care provider and with the hospital staff.  Often, the policies on this issue vary from doctor to doctor.

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Your doula can offer physical and emotional support in the recovery room.

The  initial recovery period can be quite stressful for a new mom.  Her spinal or epidural is wearing off, she may feel groggy from that or other pain medication she is now receiving, and she has very limited mobility.  And did I mention that she also has a new baby?!

A doula can help both a mom and her partner to have as peaceful a recovery as possible.  She can guide a mom through various physical comfort measures (such as guided breathing or visualization) if the mom is experiencing a lot of pain.  She can help with positioning, both for breastfeeding and for simply holding the baby.  She can take pictures, she can wipe away tears, and she can even set up an appointment to join you at the hospital later that day or the next to help you as you regain your mobility and begin the sometimes arduous task of walking.

And when desired, she can recommend local or national groups (such as ICAN) that can offer you peer-to-peer support in your physical and emotional recovery.

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So while doula support during a planned cesarean might look much different from doula support during a planned vaginal birth, it is still the same in spirit.  In other words, a doula can still offer physical, emotional, and informational support to you before, during, and after your cesarean birth.

And you might even be surprised find how much this support enhances your experience and eases your recovery!

This post is a part of my “Doulas are for All Types of Women” series honoring International Doula Month.  I’m also giving away a copy of The Birth Partner by Penny Simkin for International Doula Month.  Please see my original post in this series to find out how you can win!

Dear Taffy Brodesser-Akner,

Last night, I read the piece you wrote in the LA Times about “weighing the risks and rewards of vaginal birth after cesarean.”

I’ll admit–at first, I was a little perplexed by what you wrote.

Actually, there were times when I was even angry.  And then sympathetic.  And then perplexed all over again.

You see, I’m not sure that I’m all that comfortable with the roles that fear and pessimism played in your article.

It’s not that I would have wanted you to hide your fear and pessimism over your choice to attempt a VBAC.  These feelings are yours.  You own them.  You should not be expected to ignore them.

In fact, I think we do a disservice to any birthing woman when we tell her to obscure any negative feelings she has about birth, sweep them all under the rug, and just hope that they don’t pop up in the middle of labor.

But Taffy, you presented your fears and pessimism in a way that made it all too easy for those feelings to be exacerbated in or even transferred to other women considering VBAC.  You presented them in a way that may have even misinformed women about their birth options.  And that doesn’t seem to be offering any benefits to other birthing women either.

It all began with the tag line:

She knew the statistics about vaginal birth after a c-section, that only about 60% to 80% who try for a VBAC actually have one.  But she also knew that when the time came, she’d just have to decide for herself.

Now, I know that you probably weren’t responsible for writing this tag line.  Nonetheless, I still think that it accurately captures some of what you describe in your “first person” account of your decision to attempt a VBAC.

But does it accurately capture VBAC itself?

Considering that 67.7% of all women who try for a vaginal birth in the United States will actually have one–and this statistic includes women who do not have prior cesarean scars–is it truly fair to claim that only 60% to 80% of women who try for a VBAC actually have one?

In other words, the overall chance of having a vaginal birth after cesarean is very similar to the overall chance of having a vaginal birth after any labor.  This should leave less room for pessimism about VBAC–not more!

Of course, my sympathetic side knows that the fear and pessimism isn’t just about these numbers.  In fact, before my VBAC, I felt and faced those fears–not just the fear of uterine rupture, but the fear of feeling like a failure if I had a repeat cesarean, or of just ending up with a repeat cesarean period.

And we are not alone in experiencing these fears.

But I knew too that signing up for an elective repeat cesarean would give me a 100% chance of “ending up” with a c-section.  And I knew deep inside that ending up with a repeat cesarean would not make me a failure.  And I knew that based on my research, my values, and my preferences, I wanted a VBAC.

So I opted for the 20% – 40% chance of a repeat cesarean (rather than the 100% chance).

Speaking of chances, you seemed to characterize the desire to VBAC as simply the desire to have a chance to have a trial of labor after cesarean (or TOLAC).  You said that those of us who want or have wanted a VBAC simply wanted to “give it a shot.”

Taffy, for many of us, it is so much more than giving labor a shot.

Some of us want to give the benefits of labor a shot.

Some of us don’t want to give the risks of elective repeat cesarean a shot.

Most (if not all) of us want to give informed consent a shot.

Just like women who choose (and are not coerced into) an elective repeat cesarean–we want to give our decisions, our weighing of the risks and benefits of VBAC and repeat cesarean, a shot.

And in weighing those risks and benefits, it is impossible not to consider the risk of uterine rupture during a VBAC.  This is the extra risk that a cesarean scar gives us, and this risk is present regardless of whether we opt for a VBAC or an elective repeat cesarean.

And yes, the risk is greater for those of us who opt for a VBAC.  It’s an approximately .7% risk for women with one prior low-transverse scar–not 1%, as you stated.  And of those uterine ruptures, approximately 6% lead to a fetal or neonatal death.  This means that approximately .04% of all VBACs will result in a uterine rupture-related infant death.  Correlatively, this means 99.96% of all VBACs will not end in a uterine rupture-related infant death.

And to the physician who told you that the risk of uterine rupture is “100% when it’s happening to you,” please know that this person was essentially comparing apples to orange spaceships.  To reiterate, the statistical risk of a uterine rupture is approximately .7% for all women seeking VBAC with one low-transverse scar.  If a woman experiences a uterine rupture during a VBAC, her experience represents that statistic.  She is not a statistic.  Her baby is not a statistic.  Her personal experience is not a statistic.  And this is why she may feel emotionally like the statistic is 100% for her.

But mathematically, statistically, and realistically, this is not the case.

In my mind, this means that women seeking a VBAC should have a healthy fear–or at least an awareness–of uterine rupture and its signs and symptoms.  But the exceedingly low absolute risk itself shouldn’t convey an overall sense of pessimism about VBAC.

Similarly, the risks of c-section shouldn’t convey an overall sense of pessimism about this birth option.  But this doesn’t mean that we should gloss over or pooh-pooh these risks, as you seemed to in your article.

Repeat cesareans–especially third and fourth cesareans–also carry risks, and even serious and life-threatening risks.  The risk of placenta accreta–a complication that can lead to severe blood loss, hysterectomy, or even maternal death–increases from .31% in a second c-section to .57% in a third c-section to 2.13% in a fourth c-section.  Similarly, the rates of hysterectomy and blood transfusion increase with each subsequent cesarean section.

But through all of this risk/benefit analysis and weighing, I do see what you want.

I do understand what is driving a lot of your fear.

For you state that you just want someone to tell you “which option will give [you], with the least amount of intervention, the reasonable guarantee of a healthy child and a healthy [you].”

Oh Taffy, how I wish that every woman and child could have that guarantee!

And there’s nothing like being a parent to make you want to eliminate any and all risk from being born–from living.

But we can’t eliminate these risks.  None of us can.  Not even those of us without cesarean scars.  Not those of us who are first-time moms or seventh-time moms.  Not those of us who opt for vaginal births or cesarean sections.  Not those of us who birth in the hospital or in a birth center or at home.

It’s scary.  It’s daunting.  It can even be debilitating for some of us at times.

Taffy, what I don’t want for you is to obscure your fears.  Acknowledge them, accept them, and own them.

But I also want you to give birth with confidence.

I want you to start seeking information that will increase your confidence in your birth.  And you don’t have to continue looking up statistical data to do this.

There are books (like Birthing from Within: An Extra-Ordinary Guide to Childbirth Preparation).  There are blogs.  There are websites.  There are advocacy organizations.

There are women–other mothers who have had VBACs, other mothers who have had repeat cesareans–who can provide mother-to-mother support to you on your journey.

But please–so that other women can go forth on their birthing journeys with confidence too–try not to allow your fear to infect other women.  Please do not present the “facts” about VBAC with fear and pessimism.

We all deserve a bit better than that. 

You do too.

With warm wishes for a safe, happy, and healthy birth,

Kristen

Coinciding with the start of Cesarean Awareness Month, the CDC recently released its long-awaited preliminary data on birth statistics from 2008.

Not surprisingly, the cesarean rate rose for the twelfth straight year, from 31.8% in 2007 to 32.3% in 2008.

According to the CDC report, while the pace of the increase in cesarean births has “slowed somewhat in recent years,” the c-section rate itself has increased by 50% since 1996.  What’s more, this increase occurred among women “of all age groups, and most race and ethnic groups.”

There are good reasons to find this (preliminary) data alarming.

There are also good reasons to take a long, hard look at reversing the trend in rising cesarean rates.

The VBACtivist in me wants to point immediately toward the ways in which expanding access to and support for  vaginal birth after cesarean could help to reverse this trend.

But on a broader (though more-difficult-to-analyze) level, I want to look at the ways in which this trend could be reversed by dismantling a maternity care system that could even allow for a 10-year, 50% increase in cesarean section–one that increases a woman’s risk of birth-related mortality and morbidity in future births, and one that does not seem to be improving the current maternal mortality rate whatsoever.

A few days ago, I made a funny on Twitter.

Well, at least a few people (besides me) thought it was funny. You know.  All thirteen of us who find ourselves in the intersection of the Venn Diagram that represents the groups “birth junkies,” “people who know what ICAN is,” and “classic rock fans.”   (I’m also a member of the obscure group, “kids who listened to Quadrophenia obsessively during their formative years,” but that’s a story for a whole ‘nother post.)

In any case, what was really funny (to me) is that I didn’t even understand what this search phrase even meant until well after I tweeted about it.

You see, this person wasn’t concerned about Pete Townsend & Co. smashing guitars in the name of (unne)cesarean prevention.

They wanted to know why the WHO–the World Health Organization–is “against c-sections.”

Well, dear person who inspired one of my brighter comedic moments, I’m gonna dedicate this post to you.

Yes, under no authority to speak for or on behalf of the World Health Organization, I’m going to answer your question about why “the who is against c-sections.”

And the answer is:

The World Health Organization is not “against” c-sections.

I mean, why would an organization that is concerned with improving maternal and perinatal outcomes worldwide be against an obstetrical procedure that can be life-saving for both mothers and their infants?

But this does not mean that the World Health Organization supports the indiscriminate over- or under-use of cesarean section.

In fact, they are concerned with the “alarming increase” in cesarean section rates throughout the world.

They are concerned about the ways in which cesarean section increases the risk of maternal morbidity and mortality.

And in line with the United States’ very own “Healthy People 2010″ initiatives, they are concerned with reducing the (unnecessary) cesarean rate.

But they’re not against c-sections as a whole.  Necessary c-sections can and do improve maternal and perinatal outcomes!

So don’t get fooled again, person who found my blog.  The WHO isn’t against c-sections.  And if they are “against” anything cesarean-related, it seems that it would be unnecessary c-sections–those that are not medically indicated.

And that’s because, quite frankly, if there is no medical indication for a cesarean section, then the risks of an unnecessary c-section might very well outweigh any of its potential benefits.

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?)

*

“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!)

*

“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!

*

“…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.

*

“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.

*

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

*

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.

*

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.”

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

* 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.

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…

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.

I have arrived in Bethesda, Maryland for the NIH Consensus Development Conference on VBAC!

My arrival here means so much more to me than just crossing off one of the items on my “things I want to do before I turn 30” list.  (But that does mean a lot.  I’m a lover of to-do lists and an even bigger lover of crossing things off those lists.)

This is the first time that I’ve ever represented my beliefs and my passions on a national level.

Simply by sitting in on the conference, I hope that my presence–and the presence of the other VBACtivists here–represents my beliefs that:

• Unnecessary c-sections (including coerced and/or non-necessary repeat cesareans) put women at unnecessary risk in future pregnancies and births.
• Reducing the primary c-section rate is a crucial component of fighting for VBAC rights.
• VBAC is an absolutely defensible right (and a human right, as The Feminist Breeder so eloquently points out).
• Women deserve accurate and transparent information about their birth choices, especially when it comes to the information they receive from their care providers.
• Women deserve un-exaggerated information about the relative risks and benefits of VBAC and repeat cesarean–they don’t deserve scare tactics.
• All women have a fundamental right to bodily integrity and autonomy when it comes to the birth of their children.
• All women deserve evidence-based maternity care.
• All women deserve respectful maternity care.
• And women’s stories and experiences are exceedingly important when it comes to evaluating practices, guidelines, and policies regarding vaginal birth after cesarean.

And on that note, I have your stories–I have our stories–and I’m taking them with me to the conference.  I will do my damndest to share those stories and their spirit with the other conference attendees, whether during discussion sessions, one-on-one conversations with conference participants, or even during The Feminist Breeder’s VBACtivist luncheon.