Birthing Beautiful Ideas

I think that a lot of people misunderstand what the concept of “birth trauma” is, and in misunderstanding it, they often dismiss it and/or its gravity.

I don’t think that these misunderstandings necessarily come from a place of callousness.  A lot of the time, I think the misunderstanding comes down to a matter of (incorrectly) universalizing what another woman says about her own experience–or even of forgetting that one’s own intimate, personal, and wholly unique experience of birth can be radically different from another’s intimate, personal, and wholly unique experience of birth.

When I say that people “incorrectly universalize” statements or sentiments about birth, I mean that they often say things like this:

Misunderstandings about birth trauma

• “All women who talk about their ‘birth traumas’ need to get over the fact that they ended up with a cesarean and not a vaginal birth.  Wallowing in the guilt over a birth experience is totally counterproductive, and it seems like a wasted effort to focus on feeling ‘robbed’ of an experience when you still get a baby at the end of the day!”

• “My own c-section wasn’t traumatic, and I find it highly offensive that anyone would suggest that all c-sections are inherently traumatic experiences.”

• “Here’s an example of a truly traumatic birth where the baby (and/or mom) was actually not healthy after the birth.  Any other woman who feel traumatized by her birth experience just need to focus on the fact that she has a healthy baby.”

• “‘I don’t care how traumatic a birth was, it wasn’t rape.  I had a c-section/I had a horrible vaginal birth/etc. and it certainly wasn’t rape, or even anything like rape.  All women should stop comparing their birth experiences to rape.”

Rectifying these misunderstandings takes an effort not only to point out that they are misguided but also why they are misguided (and why universalizing anyone’s experiences with or claims about birth is problematic):

Creating a better understanding about birth trauma

• Not all mothers are disappointed by their birth experience (whether vaginal or cesarean section), but this does not negate the possibility (and the reality) that some are.

• Not all mothers who are disappointed by their birth experiences would describe those experiences as traumatic, but this does not negate the possibility (and the reality) that some do.

• Not all c-sections are traumatic experiences for the mothers who have had them, but this does not negate the possibility (and the reality) that some are.

• All mothers who are disappointed by–and especially those who feel traumatized–by their birth experiences should be received with non-judgmental support. Validating a person’s feelings does not mean that one is allowing another to “wallow” in their “negativity.”

• Not all traumas involve life-or-death situations. And not all “traumatic” c-sections (or vaginal births, for that matter) are the result of life-or-death situations.

• Not all those who have experienced traumatic births would describe their experience as akin to rape. But some do.

• Not all those who describe their birth experiences as “birth rape” have had cesareans.  Some are describing vaginal births instead.

With the above points in mind, it would obviously be ludicrous (and even insulting) for someone to describe all c-sections as traumatic or as “birth rape” or even as disappointing.  This would be to engage in the same sort of “problematic universalizing” that I described above.

But it seems equally ludicrous and insulting to belittle or dismiss any mother who describes her birth(s) in this way.  And this might have something to do with the many ways in which “trauma” can manifest itself during a birth.

Sometimes, the trauma really does come down to a matter of life-or-death.  Sometimes, life (and medicine and all of the best efforts and intentions in the world) does not prevail over death.  And that is certainly not something that a person should be encouraged to “just get over.”

But other times, the trauma manifests itself when a person is “duped” into an early and unnecessary induction that leads to a c-section–a c-section that may have been prevented if (a healthy) labor had been allowed to start on its own, a c-section that may lead a woman to think that her body has failed her and her baby.

Even other times, this trauma manifests itself when (trigger warning) a woman is literally forced down onto the hospital bed so that her OB/GYN can insert an amniohook into her vagina, or when she is given a pudendal block against her will (neither of which are emergency obstetrical procedures).

And as far as I can tell, forcibly inserting instruments into a woman’s reproductive organs against her will is battery at the very least and, upon further interpretation, rape.

What’s more, the inherently sexual (which shouldn’t be confused with erotic) nature of childbirth can bring back past experiences with sexual abuse, and this in and of itself can lead to a traumatic birth experience.  (Trigger warning)  Repeated and/or rough vaginal exams, insensitive comments, having one’s arms “tethered” down during a cesarean, not being able to see the surgeons manipulating one’s reproductive organs–these can all be “triggering” and even re-traumatizing experiences for a woman.

So sometimes (if not many times) the traumas extend well beyond–far beyond, eons beyond–feeling “robbed” of an experience.

On that note, while I would agree that a healthy, living baby and a healthy, living mother are exceedingly important and should be the primary goal of any birth, these goals in no way cancel out the importance of a woman’s birth experience.  These goals in no way suggest that women cannot or should not have their own hopes and dreams for their birth experiences.  They in no way suggest that women cannot or should not regret their birth experiences, or even that they might never have the birth experience for which they hope and dream.

As I have pointed out elsewhere, we humans are complex creatures, and we can simultaneously feel overjoyed by our healthy babies and still feel devastated by the way those babies came into the world (or even by the effects their births have had on our sexual enjoyment).  Allowing this devastation to consume one’s life certainly is problematic and is probably a signal that one might want to seek out therapy and/or anti-depressants and/or a support group (such as Solace for Mothers or ICAN).  But simply feeling this devastation deeply does not seem to be indicative of a problem with one’s emotional life.

With this in mind, it is important to recognize because a woman’s birth experience is so profound and personal, and because trauma can manifest itself in so many ways during a birth, jokes about various birth experiences can be (unintentionally) insensitive.

For example, as a doula, I’ve attended two precipitous (or very fast) labors, and each woman experienced the birth radically differently: one was elated that her labor went by so quickly and without any complications, while the other was utterly traumatized by the speed of her labor, even though there were no complications for either her or her baby.  One would have laughed at a joke about “the ease of a fast labor,” and the other would have been deeply hurt by it (and actually expressed to me that she had been hurt by those jokes and didn’t know how to express herself to those presumably well-meaning people).

I’ve also had conversations with moms who have felt violated by their cesarean sections and those who were quite pleased with their c-section experience(s).  Many might bristle at and even be deeply hurt by a joke about their “tighter vaginas” or their “easy birth” while others might laugh right along with one of those jokes.

This is not to say that there is no place for humor in the healing process.  But it is to say that there are real times and places where jokes can end up hurting instead of humoring (and real times and places where even well-intentioned jokes warrant an apology).

In the end, I think it is always worth recognizing that birth is intimate and personal and can be the most empowering or the most traumatic experience of a woman’s life–but it is her experience to judge and process and celebrate and mourn.

And I hope that all birth advocates–and all people, for that matter–can ultimately push for these goals: for healthy moms and healthy babies, for care providers who give transparent and caring and sensitive advice to the women they encounter, for care providers who treat birthing women with dignity, for care providers who practice evidence-based medicine, and for women who can find a safe space to process their births, whether these births were exhilarating or disappointing, empowering or traumatic.

*Much of what was written here was inspired by two thoughtful and provocative blog posts (and my replies to those posts), one from Her Bad Mother, the other from Adjunct Mom.  I might not agree with all of their claims, but I appreciate their thought-provoking discussions nonetheless.

If you or someone you love has experienced birth trauma (or if they are experiencing signs of post-traumatic stress disorder following a birth), a tremendous source of online support for many women is Solace for Mothers. Birth Cut also has an online space where women can safely express their “cesarean rage“.

So have you heard the news that women who have had c-sections are “lucky bitches” because their vaginas are tighter than their vaginal-birthing sisters?

And have you read The Feminist Breeder’s (TFB) respectful, insightful, and altogether awesome response to this news (spouted forth by Kristen Chase in her recently published book, The Mominatrix’s Guide to Sex: A No-Surrender Advice Book for Naughty Moms)?

And have you read the honest and, at times, heartbreaking comments from TFB’s readers?  The ones who share their stories about painful adhesions that make sex unbearable or the numbness that has all but taken away what was once a site of sexual pleasure or the emotional scars that inhibit their sex lives or even the traumatic vaginal births that hamper sex in a way that has very little to do with vaginal “tightness”?

Read it.

Now I’ll admit, I haven’t read Chase’s book, so I can’t comment all that intelligently on the book in its entirety.  Nonetheless, I’m also not sure that putting the following Mominatrix quotations in context would help me to feel less offended by them.  For Chase writes that:

Quite frankly, women who have not had a vaginal birth will probably not experience as much of a change as those who have shot a baby or two out of their vag.  Consider yourselves lucky, you c-section bitches.

And then she goes on to claim that:

It doesn’t take a rocket scientist to figure out that if you’ve birthed a few seven or eight pounders your vagina will not return to its trim and virginal state without some effort. And even then, it still might be somewhat of a lost cause.

(Can I just leave my many problems with the focus on “trim and virginal” vaginas for another day, another post?  ‘Cause otherwise, this post threatens to balloon to a book-length treatise.)

In any case, after TFB wrote her post and received (and continues to receive) over one-hundred comments (including, graciously, one from Chase herself), Chase devoted her weekly radio show to the topic of “Sex after C-section.”  And I thought that was mighty bold and magnanimous of her.  I mean, she writes about sex, her book containing the offending claims is about sex advice for moms, so why not respond to TFB’s critique by devoting her show to responding with respect and care to those mothers who want and even need some good “sex after c-section” advice?!

Except the advice wasn’t…well, what many c-section mamas are looking for.

At least not the ones commenting on TFB’s blog.

Notably, Chase invited a radio-show guest who had experienced both a vaginal birth and a cesarean section, so this guest did have some perspective on comparing sex after both types of birth experiences.

But she also didn’t share many of the same physical and emotional problems that leave many c-section mamas wanting some good sex-after-cesarean advice.  And her lack of perspective left her advice itself a bit lacking and even infuriating at times.  (In addition to focusing primarily on ameliorating the appearance of one’s cesarean scar and feeling more confident about one’s post-cesarean body with make-up and lingerie–okaaaaaaay–she also belittled the feelings of those women who were traumatized by their cesarean experiences.)

Now don’t get me wrong–I’m thrilled that Chase’s guest did not and does have to suffer through these problems.  I’m thrilled that she and her baby were healthy after her necessary and emergent c-section for a cord prolapse.  I’m thrilled she could say that she “felt great” the day she came home from the hospital, didn’t feel “that much pain,” and didn’t think her birth experience was “that big of a deal.”  It’s really, truly fantastic.

And I only wish that all women who have undergone major surgery to birth their babies could say the same.

But they can’t.

And  in response to those women who can’t say the same–in response to those women who feel emotionally devastated by their cesarean experience–Chase’s guest also commented that she has never let her c-section experience “get in the way of who she is.”

To which Chase replied that “if [women] feel guilty about what happened, it’s not going to help [them] move forward at all.”

And then she encouraged listeners to get on with their lives and “have a giggle about it.”

And then followed that up by joking that the cesarean-birthers out there should “CELEBRATE THE FACT THAT YOU HAVE A TIGHTER VAGINA THAN ME!”

As well-intentioned as the humor in these comments might be, the comments themselves are not helpful to moms seeking sex-after-cesarean advice.

They are not helpful to women who have experienced birth trauma, either as a result of a cesarean or a vaginal birth.

And for a woman who is experiencing sexual dysfunction (let alone other physical problems) as a result of adhesions or post-traumatic stress disorder or postpartum depression or incision-site infection or emotional scars or secondary infertility, the celebration of a “tight vag” is of little comfort.

Which is why I’m going to devote some of my posts over the next few weeks to SEX AFTER C-SECTIONS.

Yes.  Me.  Writing posts about sex.

Because even though I’m far from a sex-columnist (ha!), I also think women deserve better than what Chase was offering her listeners this morning.

They deserve more respect, more sensitivity, more insight, and more knowledge about the many sexual complications that can occur after cesarean sections.

And I even have some ideas for a few upcoming posts:

Sex after C-section is Sex after Major Abdominal Surgery

Who Has Time for Sexual Healing when You Need Emotional Healing?

The Sexual Body (Beyond the Vagina)

Vaginal Dryness: It Doesn’t Just Happen to Vaginal Birthers

Numb on the Inside/Numb on the Outside

New Moms Need “Time to Themselves” (If Ya Know What I Mean)

C-sections and Secondary Infertility: You are Not Alone

And now I ask you, dear readers:

WHAT SORT OF “SEX AFTER C-SECTION” ADVICE TOPICS WOULD YOU ADD TO THIS LIST?

Updated to add: Danielle from Momotics has archived last night’s radio show, “Cesarean Mothers Speak Out,” featuring Desirree Andrews from Preparing for Birth (and the current President of ICAN) and Gina from The Feminist Breeder.   The show was a response to the earlier Mominatrix radio show, and it’s a must listen.

From the news that 27% of first-time, low-risk moms in the state of Ohio had cesarean sections in 2008 to the World Health Organization’s findings that elective cesareans are riskier than vaginal birth for both mothers and babies, cesarean sections have been a fairly frequent topic of discussion in the news over the past few days.

While I’m glad that word about the risks of unnecessary c-sections (and of high c-section rates in general) is getting out, I more than a little dismayed by the fact that most of these articles (and the health professionals interviewed in them) engage in some serious (though perhaps unintentional) mother-blaming when it comes to explaining the reasons for the climbing c-section rates throughout the world.

In fact, reading these articles might make it seem as if the c-section rate can be blamed on the ”facts” that we birthing women are all too fat and too old, carry too many babies, are too scared of labor, and are too stuck on the idea of picking our babies’ birth dates.

Don’t believe me?  Just read this report from the Newark Advocate:

Dr. Elizabeth Koffler, an obstetrician at [Licking Memorial Hospital], said the increase in the national rate, which is at 32 percent, has to deal with more women having twins or triplets and maternal obesity.

Women who request a C-section tend to have a fear of labor and also a fear of future complications, Koffler said.

I’ve said it before, and I’ll say it again, but that 27% c-section rate reported by the Ohio Department of Health DOES NOT INCLUDE BREECH BIRTHS, MULTIPLE BIRTHS, REPEAT CESAREANS, OR PRE-TERM BIRTHS. 

So all of those twins and triplets births cannot be blamed for the state’s inordinately high c-section rate.

What’s more, while it may be true that women who request cesarean sections harbor certain fears about complications from a vaginal delivery, maternal-request cesareans (which should not be conflated with elective cesareans in general) only account for an exceedingly small proportion of all c-sections performed in the United States. 

So maternal-request cesareans cannot be blamed for the state’s (or the nation’s) inordinately high c-section rate.

Adding fuel to the mother-blaming fire, a recent MSNBC article on the WHO’s findings on the risks elective cesareans reports that:

In the U.S., where C-sections are at an all-time high of 31 percent, the surgery is often performed on older expectant mothers, during multiple births or simply because patients request it or doctors fear malpractice lawsuits. A government panel warned against elective C-sections in 2006.

Oh, so birthing women are also too old and too sue-happy?  Got it.  Now I know why the nation has such an inordinately (and unhealthily) high c-section rate.

Perhaps you think that my reaction to these articles is more fittingly an overreaction.  Do I really think that the people interviewed for these articles come right out and say that women themselves are to blame for the c-section rate in this country?

What’s more, it shouldn’t go without saying that the article from the Newark Advocate (along with a similarly-themed article in the Mansfield News Journal) does make some worthwhile points about the importance of necessary c-sections, including those performed for “fetal hemorrhaging” or breech birth (with a birth attendant unskilled in breech birth, I might add).  So shouldn’t we be thankful for these necessary c-sections?

And my answers to these questions would be: No, the interviewees don’t directly blame mothers, and yes, we should be extremely thankful for these necessary c-sections.

But.

BUT.

If medical professionals continue to omit and/or neglect to mention the ways in which certain obstetrical practices may also be responsible for the cesarean epidemic in this and other countries, then they are inadvertently (or perhaps blatantly) placing the blame for the c-section rate squarely on the shoulders of birthing women.

And this is simply not the case.

What about failed inductions?

And forced repeat cesareans?

Inordinate standards for adequate labor progression?

The care provider who has a dinner or a golf game or a meeting to attend (which, I hope beyond hope, is just as rare as those maternal-request cesareans that have been blamed for the rising cesarean rate in the past)?

These (and other) problems are also significant contributors to the climbing cesarean rate.

But instead of playing the blame game, I think that it would be far more productive to carefully and critically examine those issues that contribute to unnecessary c-sections and to remedy those issues where possible.

Instead of blaming the rising c-section rate on obese mothers, let’s try examining (and fixing) the ways in which the modern maternity system mistreats obese mothers.

Instead of blaming the c-section rate on high-risk births, let’s look at the birth practices of Miami Valley Hospital in Dayton, OH, which not only specializes in high-risk births but also has the lowest c-section rate in for first-time, low-risk moms in the state of Ohio and has hospital representatives who know that “some hospitals are too quick to do C-sections” and that “there is a lower rate of admission to the neonatology critical care unit due to low rates of respiratory problems … and [that babies are] more likely to successfully breast-feed” after a vaginal birth.

Instead of blaming the 31.8% c-section rate in the US on maternal-request cesareans, let’s look at the ways in which many women are forced to undergo repeat cesareans when they would prefer to attempt a vaginal birth after cesarean.

Instead of insinuating that many women are too old, too big, too small, and too scared to birth their babies vaginally, let’s make sure that our labor inductions are not performed too early and too frequently, thereby leading to a slew of failed inductions and cesarean sections.

Let’s not blame the mothers.  Let’s just fix the system.

I recently came across a helpful (and birth-relevant) website created by the Ohio Department of Health: Ohio Hospital Compare.  On this site, users can search by county and/or by hospital to compare data on various hospital performance measures from all of the state

Based upon data from January 1, 2008 to December 31, 2008, these performance measures include the following information:

1) the rate of surgical site-infection in c-section patients at each particular hospital and

2) the rate of c-sections for moms having their first baby with no complications (i.e. the data excludes breech births, twins, and pre-term births).

According to the data, rate of surgical site-infection ranged anywhere from 0.00% to a whopping 6.93%, with the average rate of infection at all Ohio hospitals being 1.12%. 

While this data serves as a helpful reminder that there is a risk of infection for any woman undergoing a cesarean section, it also illuminates the fact that some Ohio hospitals have troubling rates of infection in mothers who have had c-sections.  And this is worth knowing if you are planning to give birth in an Ohio hospital!

Perhaps even more troubling than a few hospitals with troubling infection rates, however, is the data on the rate of cesarean sections for ”uncomplicated” first births.  According to the explanation on the  Ohio Hospital Compare website, this data is meant to convey:

the percent of babies delivered by c-section to moms having their first babies with no complications (i.e. babies [were] not breech, delivery was at full-term and mom was not having twins or multiples).

In other words, the percentage reported in the data on the website excludes moms who are having their second, third, etc. babies, it excludes repeat cesareans, it excludes pre-term babies, and it excludes babies born via cesarean section for breech or multiple births.

It excludes a whole lot of births.  And it includes only “uncomplicated” primary cesarean sections for moms having their first babies.

And what sorts of percentages or “scores” does the Ohio Health Compare site report?

With rates ranging anywhere from 6.69% (GO Miami Valley Hospital in Montgomery County!) to a ghastly 61.82% (what’s the deal, Wyandot Memorial Hospital?!), the average rate of primary cesareans for first-time moms with uncomplicated births at Ohio hospitals is 27.10%.

Let’s put that number in perspective.

According to the CDC, the national cesarean delivery rate was 31.8% in 2007.  That percentage includes breech, multiple, and pre-term births.  It includes repeat cesareans.  It includes moms having their second, third, fourth, etc. babies.  It includes all of those births that the data on the Ohio Health Compare site excluded.

And with an average rate of c-section for first-time moms with “uncomplicated” births standing at 27.10% in the state of Ohio–a rate that excludes all of the other c-sections mentioned above–I fear that the national cesarean delivery rate will rise (and probably has already risen) dramatically from the already-troubling 31.8% rate in 2007.

That’s why it’s so important that the Ohio Health Compare website includes the following information when you click for an explanation of this particular hospital performance measure:

This information is important because c-section delivery is associated with an increased risk of postpartum (after delivery) maternal death when compared with vaginal delivery.  Also, women who have c-sections are at an increased risk for fatal blood clots, infections, and complications of anesthesia.  Some hospitals now have c-section rates over 50%.  The goal should be to manage the first delivery well, so it can result in a vaginal delivery and avoid repeat c-sections in future births.  Research has found that many of these c-sections can be related to inducing labor and early admissions.

Lower percentages are better.

Preach it, Ohio.

Many women who want to have a vaginal birth after cesarean (or VBAC, pronounced “vee-back”) in the U.S. have faced some sort of opposition from their care providers when they have expressed their desire to VBAC.  Oftentimes, this opposition comes in the form of ” VBAC scare tactics.”

The (outrageous) statements are often misleading, exaggerated efforts by OBs (and yes, even midwives) to discourage women from VBAC and to encourage them to “choose” a repeat cesarean.  (Of course, it’s not really a choice if your provider won’t even “let” you VBAC, is it?)

And if you find yourself up against a barrage of scare tactics–as I once did–it can be exceedingly difficult to stake your claim and argue against the doctor (again, or midwife) who may or may not have your and your baby’s health prioritized higher than medico-legal concerns and who may or may not be hurling phrases like “catastrophic uterine rupture” and “dead baby” your way.

If you do find yourself facing such scare tactics, and if you do want to have a VBAC, there are some questions that your care provider should be able to answer when s/he hurls those scary and/or outrageous comments and standards your way.  And if s/he refuses to or even cannot answer these questions, then you might want to consider finding an alternative care provider–one who is making medical decisions based on research, evidence, and even respect for your patient autonomy and not on fear, willful ignorance, or even convenience.

I encourage all mothers who read this post (and others in my “VBAC Scare Tactics Series”) to  take the information contained herein as a springboard from which they can 1) continue their research on VBAC, 2) maintain a communicative relationship with their care providers, and 3) find a care provider who best supports the mother’s interests and plans for the birth of her child.

(To read my disclaimers about “why I am not anti-OB” and “why I take the gravity of uterine rupture seriously,” please see my posts on VBAC scare tactics (1) and (2) .)

Scare tactic #9: You’ve had more than one c-section?!  No.  No way.  You’re not going to find anyone who will attend a VBAC after multiple cesareans.  You need to schedule a repeat cesarean.

Questions to ask your care provider:

• What reason(s) do you have for refusing to attend a VBAC after multiple cesareans?
• Is the risk of uterine rupture increased after more than one cesarean?
• What are the comparative risks and benefits of VBA2C and third cesareans?
• Are there any increased cesarean risks when one has a third, fourth, etc. cesarean? 
• What is ACOG’s position on VBA2C (or VBAC after two cesareans)?
• What does the current research say about VBA2C?

A more nuanced analysis:

It is important to realize first and foremost that many women in the United States and Canada are able to find care providers (including obstetricians) to attend VBA2Cs and even VBACs after three or four cesareans.  In fact, you can find many of their inspiring birth stories online.

This does not mean that finding a VBAmC (or VBAC after multiple cesarean)-supportive care provider will be easy in many cases.  But it is still possible.

Nonetheless, many women seeking a VBAmC encounter a specific roadblock when they are planning their child’s birth: namely, they cannot find a care provider who will agree to attend a VBAC after two or more cesareans.  And the reasons that these care providers have for denying women the opportunity to attempt a VBAmC are varied.

One reason may be that the risk of uterine rupture for a VBA2C is higher when compared with the risk for a VBAC after one cesarean.  A recent systematic review and meta-analysis of VBA2C in the British Journal of Obstetrics and Gynecology, which examined twenty studies and included combined statistics for well over 55,000 births, found the rate of uterine rupture for VBA2C to be approximately 1.36%.  This is compared with an overall uterine rupture rate of approximately .7% for women attempting a vaginal birth after one cesarean.

When examining these rates, however, one should take into account the ways in which pitocin acts as a confounding factor when assessing the uterine rupture rate among all women attempting a vaginal birth after cesarean.  Although the overall uterine rupture rate for VBACs after one cesarean is approximately .7%, this rate drops to approximately .4%when one focuses solely upon VBAC labors that begin and proceed spontaneously–that is, without pitocin augmentation or induction (which increase the uterine rupture rate to approximately .9% and 1.1%, respectively).  It seems safe to assume, then, that the uterine rupture rate would probably drop below 1.36% (at least within the BJOG meta-analysis) for VBA2Cs if one were to factor out those labors in which pitocin was administered.

In that light, one of my favorite online resources on VBAmC, Plus-Size Pregnancy, offers a tremendously helpful overview of the research on uterine rupture during a VBA2C.  Part of this overview includes not only a look at the correlation between pitocin and uterine rupture but also a critique of the studies on VBA2C that do not distinguish between between induced, augmented, and spontaneous VBA2C labors in their results.  As Kmom, the site’s author, surmises, the rate of uterine rupture among spontaneous VBA2Cs would likely be significantly lower than 1.36% if studies on VBAmC were to make these distinctions.

What’s more, the increased rate of uterine rupture does not necessarily make VBA2C unsafe.  In fact, comparing the outcomes of VBA2Cs with third cesareans, the BJOG study also concludes that the maternal morbidity rate for the VBA2C group was similar to that of the group undergoing third cesareans.  Futhermore, although the authors note that the data regarding neonatal morbidity was “too limited to draw valid conclusions,” they also note that there were “no significant differences” in the NICU admissions rates and the asphyxial injury and neonatal death rates among the VBA2C, third cesarean, and VBAC after one cesarean groups.

In other words, when compared with the option of a third cesarean, VBA2C is comparably safe for the mother and for the baby.

It is also worth noting that the study shows not only a success rate (or rate of labors ending in vaginal birth) for VBA2C that is similar to the success rate of VBACs after one cesarean (76.5%) but also a high success rate: namely, 71.6%.  In other words, if you attempt a VBA2C you have a 71.6% chance of having a vaginal birth.   This rate is not only encouraging but also indicative of the fact that a second cesarean does not give one a “low” chance of delivering vaginally in the future.

Another reason that OB-GYNs in particular may refuse to attend VBA2Cs is that the American College of Obstetrics and Gynecology (or ACOG), in a 2004 Practice Bulletin on VBAC, only recommends VBA2Cs in cases where the mother has already given birth vaginally.  This practice bulletin cites three studies in its short section on VBA2C, all of which found the uterine rupture rate for VBA2C to range anywhere from 1% to 3.7%.  For reasons not explicitly articulated in the practice bulletin*, ACOG focuses primarily on a particular study from the American Journal of Obstetrics and Gynecology–i.e. the one with the 3.7% uterine rupture rate (Caughey et al. 1999).  They go on to claim that based on this study’s results, the risk of uterine rupture is nearly five times greater for women attempting VBA2C than for women attempting VBAC after one cesarean; but for women who have had a previous vaginal delivery before attempting a VBA2C (for instance, one vaginal birth and then two cesareans), the risk of uterine rupture is only one fourth of what it would be otherwise.

It is worth looking at this section of the practice bulletin with a critical eye, especially in light of the recent BJOG study (which, to be fair, was published five years after the ACOG practice bulletin).  One should ask why Caughey et al.’s findings differ so drastically from the more recent meta-analysis and systematic review of VBA2C.  One should ask if ACOG plans to update their practice bulletin according to the BJOG findings–especially in light of their conclusion that the maternal and neonatal morbidity rates for VBA2C and third cesareans are comparable.  (Not surprisingly, Kmom offers an excellent critique of the Caughey study on Plus-Size Pregnancy.)

Of course, if you have had a previous vaginal birth and are seeking a VBA2C-supportive care-provider, this portion of the practice bulletin should work to your advantage!  For it explicitly states that “for women with two prior cesarean deliveries, only those with prior vaginal deliveries should be considered candidates for spontaneous labor.”  At the very least, then, ACOG sanctions considering you as a candidate for VBAC.  (In my humble opinion, however, you ideally want a care provider who will do more than consider you as a candidate for birthing your baby in a way that is relatively safe, especially when compared to the option of a third cesarean!)

Finally, it is entirely within your right to insist that you would rather take on the relative risks of VBA2C than the relative risks of a third (or fourth, fifth, etc.) cesarean surgery.  While uterine rupture is a serious occurence (though one that is not always, or even often, catastrophic), the risks of cesarean surgery are also serious, and even potentially catastrophic, occurences.  When compared with a vaginal birth, a c-section carries an increased risk of hemorrhage, blood clots, and bowel obstruction for the mother; and an increased risk of breathing difficulties around the time of birth and childhood and adulthood asthma for the baby.  What’s more, one’s risk of hysterectomy, placenta previa and placenta accreta in future pregnancies increase significantly with each subsequent cesarean section. 

And avoiding these risks (and more) should give any woman grounds for contesting a repeat cesarean that she does not want.

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

*I can only guess that the writers of the practice bulletin chose to focus solely upon the third study since used Level II evidence, while the others used Level III evidence.  Updated to add: Nonetheless, it was also pointed out to me in a comment to this post that one of the authors of this study (Zelop) was also one of the authors of the practice bulletin, thereby raising suspicions of a conflict of interest in the bulletin’s reportings on uterine rupture and VBA2C.

The March of Dimes has designated November as “Prematurity Awareness Month.”  As part of their campaign to increase awareness about prematurity and its serious risks to newborns, they have called for bloggers to write posts about premature awareness and to publish those posts today, November 17.

Hundreds of bloggers have already written insightful, informative, and moving pieces about prematurity awareness, and many of them have dedicated their posts to those who have been affected by prematurity.

And while some of these bloggers have already touched on the point I am about to make–one that I have addressed briefly in other previous posts–I feel compelled to reiterate one small but important point: namely, that  labor induction and cesarean section performed prior to 39 weeks have been shown to contribute to serious neonatal complications, including (but not limited to) late prematurity and the many problems that accompany it.

In fact, a study published earlier this year in the New England Journal of Medicine concluded that:

As compared with [elective repeat cesarean] births at 39 weeks, births at 37 weeks and at 38 weeks were associated with an increased risk of the primary outcome (adjusted odds ratio for births at 37 weeks, 2.1; 95% confidence interval [CI], 1.7 to 2.5; adjusted odds ratio for births at 38 weeks, 1.5; 95% CI, 1.3 to 1.7; P for trend <0.001). The rates of adverse respiratory outcomes, mechanical ventilation, newborn sepsis, hypoglycemia, admission to the neonatal ICU, and hospitalization for 5 days or more were increased by a factor of 1.8 to 4.2 for births at 37 weeks and 1.3 to 2.1 for births at 38 weeks.

What’s more, a recent article published by MSNBC noted that many hospitals are limiting their birth attendants’ abilities to perform unnecessary inductions prior to 39 weeks because of the extra risks presented to babies (including iatrogenic, or doctor-caused, prematurity).

So if you are planning a repeat cesarean, or if you are considering an induction, and if there are no medical indications for an early c-section or induction, please consider waiting to schedule your baby’s birth until after 39 weeks.  (Or, if possible, consider waiting for labor to begin spontaneously!)

You will do your baby so much good just by waiting those few extra days until s/he is ready to be born.

(To learn more about prematurity in the United States, please visit the March of Dimes’s website.)

In one of the early chapters in Birthing From Within, the authors suggest that pregnant women should interview the “wise mothers” in their lives in order to gain a better understanding of the birth experience–to get a peek at other women’s insights into birth, to see how they have coped with the physical and emotional intensity of birthing.  The authors provide a list of questions that women can ask other mothers in their lives, questions asking what helped them most during the birth, what their spiritual experience of birth was, what they would do differently, what they would do the same, what they wish they had known beforehand.

Although I would not go so far as to consider myself a “wise mother” (and all that the term connotes), I do think that my birth experiences imparted some wisdom to me.  Or at least they made me wiser.  And, maybe on some level, the ways in which I was made wiser are worth sharing.

In the context of M’s birth–my first birth, which was an unplanned, pre-labor cesarean section–I answered the Birthing from Within questions as follows:

What helped you most when you gave birth?

Sheer willpower and the uncanny ability to remain cool, calm, and collected on the outside when there’s a storm raging on the inside.

I had planned (oh, those dear, sweet plans) on a spontaneous, drug-free, hypnobirthing-assisted labor.  I had planned on laboring with my husband, my mother, and my mother-in-law by my side.  And by the time I was nearing the end of my pregnancy, I was even excitedly anticipating those first few contractions.

But when a non-stress test revealed variable decelerations into the 60-70 beats-per-minute range, and when an ultrasound also confirmed these decelerations, and when the decelerations not only continued but also worsened during an oxytocin challenge test, my doctor determined that M would probably not tolerate labor well once it started.  So it was decided that M would arrive via cesarean section.

I had four hours from the start of my prenatal appointment to the first incision to get used to the idea that all of my plans for M’s birth were evaporating into the sterility of what was to become my–and his–birth experience.  And the shift in plans wasn’t made any less dramatic by the fact that M’s c-section was, by most stretches of the imagination, a necessary one.

So, as Ani DiFranco once sang, I learned like the trees how to bend, how to sway.

Flexibility.  It’s a mighty good tool to take to the birth of one’s child.

Surprisingly, my doctor even provided one of the most helpful aids in my emotional recovery from the cesarean.

For although he was patronizing and misleading and haughty with me as he tried to talk me into unnecessary repeat cesarean in the 36th week of my second pregnancy, I can still say that I appreciate him for “slowing down” my first son’s birth so that my husband could take pictures as my son was born. 

The doctor moved away the surgical instruments and the surgical team’s hands so that Tim could snap a quick shot of M’s head just as it emerged from my belly.  Just his head, just my belly, nothing else. 

Perhaps a grotesque photograph for some.

But for me, it was and is my one tangible link to M’s birth.  I was numb and paralyzed and scared and sick and anxious when he was born, and I could literally do nothing to actively bring him into the world.  I could not even see him being born.  So to have that photograph–to have that document of the moment of his birth–helped and still helps me to feel a deeper connection to his birth.

And finally: breastfeeding.  Breastfeeding is what helped me the most.  Hands down.

Admittedly, breastfeeding was a struggle in the recovery room.  The spinal medication had worn off.  I was groggy and tired.  My baby had been rooting for my breast while we were still in the operating room, and he didn’t even get to my arms until he was over one hour old.  He was so distraught, and I was in so much pain, that we had trouble getting that first latch.

But we persevered.  (And we persevered for weeks, through cracked nipples and colic and all.)  I told him that if I couldn’t give him the perfect birth, I would give him this.

It was what I could actively, happily, and empoweringly do for him.

And it helped me to become a more active, happy, and empowered mother. 

What was your spiritual experience of giving birth? 

It was a humbling experience.

The change of plans, the awesome flexibility required of me, and the tenacity I needed just to feed my child in those first weeks of physical recovery all humbled me in a powerful way.  It was not the spiritual journey that I had envisioned whenever I imagined M’s birth when I was pregnant, and it took time for me to accept the spiritual journey that had actually occurred.

What’s more, combined with some traumatic events following M’s birth, the circumstances of his arrival into the world contributed to months and months of spiritual bankruptcy (otherwise known as post-partum depression).  I am lucky to have come out of that darkness–to have emerged “on the other side” with my spirit intact.  And stronger.

But M’s birth also set me on the path toward one of the most spiritually powerful experiences of my life–my second son’s birth.  And if it weren’t for what M’s birth taught me–if it weren’t for those dark, cavernous places I had to confront within my soul–I’m not sure that I could have experienced the triumph of A’s birth with the level of depth that I did.  In some strange way, I am eternally grateful for M’s birth for that.

If you could do it over again, what would you do the same?

I would still offer my breast to my baby as soon as he was placed in my arms, and I would still fight just as hard as I did to develop and maintain a good breastfeeding relationship.

And, of course, I would want him to be just as healthy as he was (with 9/9 Apgars) from the moment he emerged from my body.

Is there anything you would do differently?

I would insist upon holding my baby in the operating room.  Skin-to-skin contact.  Earlier breastfeeding.  Just something so that it would not have felt as if they were placing a complete stranger in my arms when I first “met” him in the recovery room.

I would also have hired a doula.  Especially so that she could have stayed with me as my incisions were being repaired in the operating room.  At this point, Tim had gone with M to the nursery, so I was then separated from everyone I loved most in the world.  And there’s nothing like being in an operating room while having your uterus sutured and hearing the OR team make small talk and being separated from the one person with whom you have been as intimate as is humanly possible for the past nine months to make you feel like one of the loneliest people in the world.

I also would have been a better (and snarkier) advocate for myself.  To the pregnant nurse in the operating room who exclaimed to the rest of the surgical team, ”Gosh, I hope that I don’t have to have a c-section,” I would have said, “HELLO.  I am not a slab of meat on the operating table.  I am awake.  I am alive.  And when I woke up this morning, I was also hoping that I didn’t have to have a c-section!” 

Instead, I remained silent.  Afraid to talk, because I was afraid that I would start crying.  And that’s because I was all alone, save for the OR team.

What do you wish you had known beforehand?

I wish I had known that I could have asked to bring M closer to me in the operating room, especially as Tim was holding him.  I wish I had known that I might have been able to offer M the breast sooner after his birth.  That I could have nuzzled him closer, and maybe even had Tim bring him closer to me for some (even minimal) skin-to-skin contact.

In that same respect, I wish I had known that preparing for birth should not involve simply preparing for a vaginal delivery.  I wish I had known that I could make some personal requests for a cesarean section.  That I should have discussed my doctor’s c-section protocol with him and his partners well before M’s birth.

I wish I had known to attend my local ICAN meetings soon after M was born.

But I also wish I had known just how much M’s birth would transform me.  I wish I could go back to myself, as I lay on the table, and whisper in my ear, “This will make you stronger.  And you are already amazingly strong.”

In fact, I think that any woman who brings a child into the world should know this beforehand. 

Whether she has a vaginal birth or a c-section, a drug-free birth or an epidural-assisted birth, a spontaneous labor or an induced birth, a hospital birth or a homebirth, a birth after months of carrying a baby in her womb or a homecoming after months of carrying love for an adopted baby, she is amazingly strong.

Oftentimes when I see anything birth-related covered by the national news, I end up feeling very underwhelmed (to say the least).  One-sided coverage (mostly from ACOG’s perspective), exaggerated risks and benefits of various procedures or processes, and even a blatant lack of research on a given topic all seem to pervade the segments on pregnancy and birth that I’ve seen in recent years.

But the past week has been a relatively good week for transparent and seemingly fair (though, admittedly, not always cheery) coverage of a few birth-related issues.  And in my opinion, each of the following news pieces is worth checking out–not just for the decent news coverage but also for the helpful information.

From CNN

Senior medical correspondent and “Empowered Patient” columnist Elizabeth Cohen examines the relative risks and benefits of VBAC and cesarean section within the context of two current news stories: 1) the fact that some insurance companies have denied women health care coverage after considering their previous c-sections to be “preexisting conditions” and 2)  the story of Joy Szabo, a mother in Arizona who must travel 300 miles to the nearest “VBAC-supportive” hospital just to have her second VBAC (and who was threatened with a court-ordered cesarean by her local hospital if she attempted to have a VBAC there). 

All in all, I am impressed with Cohen’s discussion.  Could she have done a better job of reporting the risk of uterine rupture?  Sure.  (For what it’s wort, the rate of uterine rupture during a VBAC is less than 1% for most women: .4% if labor begins on its own, .9-1.1% if labor is augmented or induced with pitocin, creating a rate of approximately .7% for all VBAC attempts, induced or not.)

But Cohen does a superb job of addressing issues that are often overlooked in the coverage of cesarean sections and VBAC.  For one, she is careful to place the risk of uterine rupture alongside the risks of cesarean section.  This simple exercise in good reporting helps to dispel the illusion that VBACs are a “risky” option when compared with “easy” and “risk-free” cesareans.

In addition, Cohen points out that patient-chosen, non-necessary elective cesareans make up a very small percentage of the cesarean sections performed in the United States.  This is especially noteworthy in light of the fact that some medical professionals (though certainly not all) have often pointed to “too posh to push” cesareans as one of the primary reasons for the nation’s rising cesarean rate.  But their “mother-blaming” (in addition to being inherently misogynistic) simply doesn’t pan out when one considers the relative infrequency with which patient-chosen, non-necessary elective cesareans occur.

You can watch the following video to see more about what Cohen has to say about VBAC, c-section, the related issues:

From MSNBC

The very title of this article left me smiling: “Hospitals to crack down on induced labors.”

An even better title, however, would have been “Hospitals to crack down on UNNECESSARY and EARLY induced labors.”  Because as the article reports (and as studies have demonstrated), these inductions–especially those performed before 39 weeks–can lead not only to iatrogenic (or doctor-caused) prematurity but also increase a baby’s risk of NICU admission and increase first-time mothers’ risk of cesarean section.

So don’t worry–if you and/or your baby’s health requires an induction, hospital regulators and administrators are not going to deny you an induction.  But they may restrict your care provider’s ability to schedule convenience inductions–and that’s all with your and your baby’s health in mind.

From the BBC

And finally, this week the BBC news published an overview of maternal mortality across the world.  In their examination of the United States, they found that:

The US spends more money on mothers’ health than any other nation in the world, yet women in America are more likely to die during childbirth than they are in most other developed countries, according to the OECD and WHO.

The article points to the lack of health insurance and coverage, poverty, the staggering c-section rate, and obesity as potential contributing factors to this sad and disheartening state of affairs.  What’s more, it sheds brief light on the fact that African-American women are “three to four times more likely to die during childbirth than white American women,” even when one compares the outcomes of wealthy black women to wealthy white women.  (Notably, many people have speculated that the stress of racism has a significant effect on the disparity of maternal outcomes between black and white women in the United States.)

But what this article also illuminates is the fact that we must demand better maternity care for women in the United States (and in all countries, for that matter).  We need better prenatal care (which should include not offhand castigations about “gaining so much weight” but respectful and helpful nutritional counseling from the first trimester and beyond).  We need better labor and delivery care (with more emphasis on evidence-based maternity care and not on unnecessarily intervention-heavy birth).  We need health care coverage for all pregnant women (period).

At least that’s what the BBC article illuminated for me!

(For more on issues of maternal mortality in the United States, please see Ina May Gaskin’s Safe Motherhood Quilt Project.)

“At the end of the day, it doesn’t matter how the baby came out.  All that matters is that you have a healthy baby.”

It’s that dreaded “healthy baby line.”  The one I’ve written about before.  The one that others have addressed with admirable sensitivity and eloquence.

And I’ve been thinking about that line in a relatively new light lately.

My general position on the “healthy baby line” hasn’t changed.  I still think these sorts of statements are hurtful and demeaning and insensitive to women’s experiences.  To be fair, I also don’t think that people generally intend for these statements to be taken as such.

But in addition to the aforementioned response that I’ve given to the “healthy baby line”–a response that focuses on the emotional aspects of birth and new motherhood–I’d also like to add this point: Healthy babies do matter.  And that’s why I (and others) care so much about how they come out.

This is because unnecessary birth interventions that interfere with how babies “come out” can pose additional risks to moms and their babies.

This is not to say major birth interventions such as induction of labor or cesarean section are so risky that they should never be used.  To the contrary, when these interventions are necessary and/or medically indicated–for example, when a woman has a cesarean section for placenta previa, or when a woman’s labor is induced because of preeclampsia–they are wonderful and even life-saving uses of the medical technology that is currently available.

But when these interventions are used in the absence of necessity or medical indication, some parents may decide–and have the right to decide–that the possible benefits of these interventions might outweigh their risks.

Notably, some of these risks are relatively small.  Some of them may even be risks that moms and/or their partners examine and pore over and say to themselves, “You know, I think that the convenience of having an elective induction still outweighs the risks that it presents, and I am willing to take on those extra risks.”

And in these sorts of cases, they’ve made an informed decision.  And informed decisions–informed consent–are something that I not only respect but also champion as a fundamental right for all medical patients.

But before a parent can make an informed decision about unnecessary induction and/or cesarean section, they should know the following:

According to Childbirth Connection’s systematic review of the comparative risks of cesarean section and vaginal birth, cesarean section poses the following extra risks* to both mothers and babies:

• Physical problems in mothers: Compared with vaginal birth, cesarean section increases a woman’s risk for a number of physical problems. These range from less common but potentially life-threatening problems, including hemorrhage (severe bleeding), blood clots, and bowel obstruction, to much more common concerns such as longer-lasting and more severe pain and infection. Even after recovery from surgery, scarring and adhesion tissue increase risk for ongoing pelvic pain and for twisted bowel.
• Hospitalization of mothers: If a woman has a cesarean, she is more likely to stay in the hospital longer and is at greater risk of being re-hospitalized.
• Emotional well-being of mothers: A woman who has a cesarean section may be at greater risk for poorer overall mental health and some emotional problems. She is also more likely to rate her birth experience poorer than a woman who has had a vaginal birth.
• Early contact with, feelings toward babies: A woman who has a cesarean usually has less early contact with her baby and is more likely to have initial negative feelings about her baby.
• Breastfeeding: Recovery from surgery poses challenges for getting breastfeeding under way, and a baby who was born by cesarean is less likely to be breastfed and get the benefits of breastfeeding.
• Health of babies: Babies born by cesarean are more likely to:
  • be cut during the surgery (usually minor)
  • have breathing difficulties around the time of birth
  • experience asthma in childhood and in adulthood.
• Future reproductive problems for mothers: A cesarean section in this pregnancy puts a woman at risk for future reproductive problems in comparison with a woman who has a vaginal birth. These problems may involve serious complications and medical emergencies. The likelihood of experiencing some of these conditions goes up sharply as the number of previous cesareans increases. These problems include:
  • ectopic pregnancy: pregnancies that develop outside her uterus or within the scar
  • reduced fertility, due to either less ability to become pregnant again or less desire to do so
  • placenta previa: the placenta attaches near or over the opening to her cervix
  • placenta accreta: the placenta grows through the lining of the uterus and into or through the muscle of the uterus
  • placental abruption: the placenta detaches from the uterus before the baby is born
  • rupture of the uterus: the uterine scar gives way during pregnancy or labor.
• Concerns about babies in future pregnancies: A cesarean section in this pregnancy can affect the babies of future pregnancies. Studies have found that they are more likely to:
  • be born too early (preterm)
  • weigh less than they should (low birthweight)
  • have a physical abnormality or injury to their brain or spinal cord
  • die before or shortly after the birth

And in addition to the general risks of induced labor (such as an increased risk of NICU admission, forceps and vacuum-assisted delivery, and abnormal fetal heart rate), the use of synthetic oxytocin (or pitocin) itself carries a number of risks of which parents should be aware.  As reported in the RxList Drug Guide, pitocin can lead to the following adverse reactions in a mother:

Anaphylactic reaction
Postpartum hemorrhage
Cardiac arrhythmia
Fatal afibrinogenemia
Hypertensive episodes
Nausea
Vomiting
Premature ventricular contractions
Pelvic hematoma
Subarachnoid hemorrhage
Hypertensive episodes
Rupture of the uterus

Excessive dosage or hypersensitivity to the drug may result in uterine hypertonicity, spasm, tetanic contraction, or rupture of the uterus.

And according the same RxList Drug Guide, the pitocin can lead to the following adverse reactions in the fetus or neonate:

Bradycardia
Premature ventricular contractions and other arrhythmias
Permanent CNS or brain damage
Fetal death
Neonatal seizures have been reported with the use of Pitocin (all due to induced uterine motility)

and:

Low Apgar scores at five minutes
Neonatal jaundice
Neonatal retinal hemorrhage (all due to use of synthetic oxytocin in the mother)

It should go without saying that none of these lists are meant to frighten anyone about labor induction or cesarean section.  To reiterate, these invertentions can be wonderful, life-saving uses of medical technology.  What’s more, there are ways to make the experience of these interventions more mother-, baby-, and family-friendly.

Nonetheless, the risks that these interventions pose to mother and baby demonstrate just why it does matter how a baby “comes out.”

And that’s because how a baby comes out can have a significant affect on how healthy that baby is.

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

*Worth noting is that the Childbirth Connection’s systematic review of cesarean section and vaginal birth did find the following increased risks of vaginal birth (as compared with c-section): an increased incidence of perineal pain and incontinence for mothers, and increased risk (though still low risk) of nerve injury in babies.

Many women who want to have a vaginal birth after cesarean (or VBAC, pronounced “vee-back”) in the U.S. have faced some sort of opposition from their care providers when they have expressed their desire to VBAC.  Oftentimes, this opposition comes in the form of ” VBAC scare tactics.”

The (outrageous) statements are often misleading, exaggerated efforts by OBs (and yes, even midwives) to discourage women from VBAC and to encourage them to “choose” a repeat cesarean.  (Of course, it’s not really a choice if your provider won’t even “let” you VBAC, is it?)

And if you find yourself up against a barrage of scare tactics–as I once did–it can be exceedingly difficult to stake your claim and argue against the doctor (again, or midwife) who may or may not have your and your baby’s health prioritized higher than medico-legal concerns and who may or may not be hurling phrases like “catastrophic uterine rupture” and “dead baby” your way.

If you do find yourself facing such scare tactics, and if you do want to have a VBAC, there are some questions that your care provider should be able to answer when s/he hurls those scary and/or outrageous comments and standards your way.  And if s/he refuses to or even cannot answer these questions, then you might want to consider finding an alternative care provider–one who is making medical decisions based on research, evidence, and even respect for your patient autonomy and not on fear, willful ignorance, or even convenience.

I encourage all mothers who read this post (and others in my “VBAC Scare Tactics Series”) to  take the information contained herein as a springboard from which they can 1) continue their research on VBAC, 2) maintain a communicative relationship with their care providers, and 3) find a care provider who best supports the mother’s interests and plans for the birth of her child.

(To read my disclaimers about “why I am not anti-OB” and “why I take the gravity of uterine rupture seriously,” please see my posts on VBAC scare tactics (1) and (2) .)

Scare tactic #8: Look, I’m  the one who has earned the medical degree and I am telling you that you cannot attempt a VBAC.  Your only choice is a repeat cesarean.  Period.

Questions to ask in response:

• I appreciate all of your hard work!  So could you please share with me your medical, evidence-based reasons for why I cannot attempt a VBAC?
• Are you suggesting that you will ignore any questions I ask you regarding my desires for this birth or about the comparative risks of VBAC and repeat cesarean?
• Does your malpractice insurance company prohibit you from attending VBACs?  Are there any other bureaucratic or administrative (i.e. non-medical) reasons that force you to deny your patients the opportunity to attempt a VBAC?
• Where is the nearest exit?

A more nuanced analysis:

It is worth noting first and foremost that VBAC has been shown to be a relatively safe option for most women who attempt it.  The medical literature consistently shows uterine rupture–the main risk specifically associated with VBAC–to occur in less than 1% of all VBAC attempts.  The American College of Obstetrics and Gynecology (or “ACOG,” OB-GYNs’ organizational body) claims that VBAC is not only “a safe option for many women” but is also a way to help reduce the United States’ skyrocketing cesarean rate.  What’s more, even though the risk of uterine rupture is lower (though not eliminated) if one chooses an elective repeat cesarean instead of a VBAC, there are still risks specifically associated with repeat cesarean that are not necessarily associated with VBAC.

Thus, there is absolutely no reason for any care provider to quash any and all discussion about VBAC by injecting the “MD trump card” into a conversation.

That being said, the reasons as to why a care provider might use the “MD trump card” are varied.

Occasionally, it might be that the care provider’s malpractice insurance refuses to cover VBACs.  And perhaps s/he then hides behind the “MD trump card” because s/he is too embarrassed or even frustrated to admit that s/he must make medical decisions not based on the evidence but based on what insurance companies dictate.  This is certainly an instance of the sorry state of the current relationship between insurance companies and medical care in the United States–especially when it comes to obstetricians.

Nonetheless, if you are a woman wanting to attempt a VBAC, and your care provider’s malpractice insurance does not cover VBACs, then it is certainly a wise idea to begin seeking a new care provider.

More often than not, however, it seems that the “MD trump card” arises after a woman has posed various questions challenging other scare tactics that the care provider might have uttered. 

To use an example, suppose that a woman’s care provider tells a her that VBAC is synonymous with placing a child in a car without a carseat or safety belt.  (I know of multiple women who have reported hearing this sort of comment during their prenatal appointments.)  But since this mom has done her research on the relative risks of VBAC and repeat cesarean, she reminds her care provider that the risk of uterine rupture is approximately .7% for all moms attempting VBAC and that the risk of catastrophic uterine rupture is approximately .04-.255%.   Perhaps she even cites this study or this study from the New England Journal of Medicine from which she discovered these statistics!  And perhaps she declares that she has made the informed decision to take on the risks (and benefits) of VBAC rather than to take on the risks of repeat cesarean!

And in response, the care provider claims that s/he is the one with the medical degree and that s/he will decide what is best for this mom and her baby.

This response is unquestionably problematic.  For one, it fails to engage the mother’s responsible decision to research her plans for her child’s birth.  And even if the care provider suspects that a patient has misinterpreted medical research, it is the care provider’s responsibility to rectify this misinterpretation.

What’s more, using the “MD trump card” often illustrates a care provider’s possible (and perhaps probable) arrogance.  For even if  some care providers do not know about the recent studies on VBAC and uterine rupture, or even if their teachers or mentors during medical school or residency explicitly (and incorrectly) taught that VBAC was inordinately dangerous, and even if they are embarrassed about being challenged by their patients, this does not mean that they should obscure their (perhaps innocent) lack of knowledge about the facts of VBAC and uterine rupture by using their medical degree to trump any questions that their patients may have.

In other words, if they don’t know the answer to the questions their patients are asking, then they should inform their patients that they need some time to perform additional research.  

If their patients cite research that differs drastically from the research with which they are familiar, then they should ask their patients for a couple of days to review that research in more detail.

These responses respect true informed consent.  These responses honor patient autonomy.  And these responses support the sort of participatory medicine that midwife Amy Romano talks about in her recent article on e-Patients.net.

For what it’s worth, my MD dad always tells me that if a doctor refuses to answer your questions, then it’s time to find a new doctor!  We should want care providers who who engage with us and who listen to us (both of which are good tools for diagnosis, I might add).

So instead of heeding entirely to your care provider’s “MD trump card” or even to well-meaning friends or family members who tell you that, “Your doctor is the one who went to medical school, so S/HE knows best,” consider taking a participatory role in your medical care.  Find a care provider who is willing to discuss VBAC and repeat cesarean with you–who is willing to offer transparent information about both options, who does not use the “MD trump card” when you ask questions, and who will support you in whichever decision you make for your baby’s birth.

You will be participating in the decisions regarding your baby’s health for the rest of his or her life.  Why not begin by finding a care provider who supports you in actively participating in the way you bring that baby into the world?