Birthing Beautiful Ideas

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?

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 #7a: An epidural can mask the signs of uterine rupture, so I do not permit my VBAC patients to have an epidural during their labors.

Scare tactic #7b: In case of an emergency cesarean, I require all of my VBAC patients to have an epidural in place in early labor.  That way, we will not have to wait for the anesthesiologist to get the epidural in place if a uterine rupture occurs.

Questions to ask your care provider in regard to 7a:

• How often is severe abdominal pain an indication of uterine rupture?  Is this the only or even the primary indication of uterine rupture?
• Does an epidural always obscure the pain of uterine rupture?
• Do I have any other pain relief or medication options during labor?
• Would I still have the right to request an epidural if I absolutely wanted it during labor?

Questions to ask your care provider in regard to 7b:

• How long does it generally take for an anesthesiologist to get an epidural or spinal in place?
• Are there any other anesthetic options besides an epidural or spinal if a uterine rupture (or other birth emergency) were to occur?
• What are the risks associated with epidural analgesia?
• What would happen if I were to refuse an epidural during labor?

A more nuanced analysis:

It should be noted that these limitations will not seem coercive to every mom who hears them.

For the mother who has planned and prepared for a drug-free childbirth, it will be highly unlikely that she will be deterred from seeking a VBAC upon hearing that she will not be “allowed” to have an epidural.  On the other hand, for the mother who has every intention of requesting epidural analgesia during her labor, it will be highly unlikely that she will be deterred from seeking a VBAC upon hearing that this medication will be required during her VBAC attempt.

But (and you can see where this is going), the mother planning and preparing for a drug-free childbirth who hears that she must have an epidural AND the mother who wants an epidural yet hears that she cannot have one might very well be scared away from attempting a VBAC.

And this is particularly disconcerting since neither requirement regarding epidurals has much basis in fact or necessity.

In fact, as reported on eMedicine’s overview of the research on uterine rupture (“Uterine Rupture in Pregnancy”), in cases of uterine rupture:

…sudden or atypical maternal abdominal pain occurs more rarely than do decelerations or bradycardia. In 9 studies from 1980-2002, abdominal pain occurred in 13-60% of cases of uterine rupture. In a review of 10,967 patients undergoing a TOL, only 22% of complete uterine ruptures presented with abdominal pain and 76% presented with signs of fetal distress diagnosed by continuous electronic fetal monitoring.^{(Johnson C, Oriol N. The role of epidural anesthesia in trial of labor. Reg Anesth. Nov-Dec 1990;15(6):304-8.)}

Moreover, in a study by Bujold and Gauthier, abdominal pain was the first sign of rupture in only 5% of patients and occurred in women who developed uterine rupture without epidural analgesia but not in women who received an epidural block.  (Bujold E, Gauthier RJ. Neonatal morbidity associated with uterine rupture: what are the risk factors?. Am J Obstet Gynecol. Feb 2002;186(2):311-4).  Thus, abdominal pain is an unreliable and uncommon sign of uterine rupture. Initial concerns that epidural anesthesia might mask the pain caused by uterine rupture have not been verified and there have been no reports of epidural anesthesia delaying the diagnosis of uterine rupture. A guideline from the ACOG from 2004 suggests there is no absolute contraindication to epidural anesthesia for a TOL because epidurals rarely mask the signs and symptoms of uterine rupture.  (ACOG. Vaginal birth after previous cesarean delivery. ACOG practice bulletin no. 54. Washington, DC: American College of Obstetricians and Gynecologists;2004).

In this respect, it seems unwise–if not cruel and in stark contrast to the evidence–to forbid a mother from requesting epidural medication during a VBAC labor simply because an epidural may “mask the signs of uterine rupture.”  (Notably, some women with epidurals in place even report experiencing the pain of uterine rupture when it occurs.)

What’s more, the studies on uterine rupture from the eMedicine overview also conclude that “prolonged, late, or recurrent variable decelerations or fetal bradycardias are often the first and only signs of uterine rupture” and occur in roughly 80% of uterine ruptures.  Accordingly, if any fear-based requirement were to be made of moms attempting VBAC, it should be continuous fetal monitoring and not epidural restriction–and even this requirement should be left up to the informed discretion of the mother, in my opinion!

Notably, there are other pain management options during labor besides epidurals.  Narcotic pain medication (such as Stadol or Demerol) can provide some relief during labor, but these medications do present serious risks to moms (including drowsiness and vomiting) and to babies (including central nervous system depression and respiratory depression).  But besides pharmacological pain-relief, there are numerous risk-free non-pharmacological pain-relief options during labor that moms can make use of, including but not limited to walking, changing positions, hot and cold packs, aromatherapy, doula support, and vocalizing.  These comfort measures can be helpful to a birthing mother even if she only needs some “tricks” to help in the time that she must wait for pain medication to be administered.

However, for the mother who does not want an epidural (and for the mother who does, for that matter), it is important to note that epidurals also have significant risks and negative side effects.  These risks include itching, nausea and vomiting, spinal headache, fever, and, more rarely, convulsions and cardiac or respiratory distress.  In addition, epidurals present a unique “risk” to VBAC-ing mothers since epidural analgesia can slow a baby’s heartrate, thereby giving off a “false alarm” that a uterine rupture has occurred.  These risks in and of themselves should give mothers solid ground on which to contest their care provider’s declaration that moms attempting VBAC must use an epidural.

Furthermore, it should be noted that while a symptomatic uterine rupture is an emergency and does require immediate intervention, this does not mean that an epidural must be in place “just in case” a uterine rupture were to occur.  For one, uterine ruptures occur in approximately .7% of all VBACs (and the study here cited includes induced VBACs.)  Despite the seriousness of this risk, the relative infrequency with which it occurs does not seem to warrant taking such an extreme measure as requiring a woman to have an epidural during her labor.

In addition, general anesthesia*–which takes effect very rapidly–is usually an option for a cesarean in which the mother and/or the baby are in severe distress (such as in the case of a uterine rupture).  Although not ideal  for the woman who wants to witness her child’s birth, general anesthesia does offer an alternative form of surgical anesthesia “just in case” a uterine rupture were to occur.  (Worth noting too is that a readily available anesthesiologist may be able to insert an epidural anesthesia within minutes so that a mother can still be awake for the surgical birth of her child, even in the event of an emergency.)

It it also worth pointing out, however, that the epidural analgesia that a mother receives during labor is generally not effective enough for a cesarean section.  Thus, the epidural medication must be increased*–a process that does take time–before a cesarean section.  And this means that having an epidural in place during labor will not guarantee that a cesarean surgery will be able to be performed immediately simply because the epidural is already inserted.

And finally, creating any sort of non-evidence-based requirement regarding epidurals for mothers attempting VBAC undermines these mothers’ patient rights and autonomy.  And while this “risk” of epidural-requirements or bans is mostly theoretical, it is a risk that should give every woman (and man) pause…and perhaps enough pause to challenge their care provider and/or seek out a new one.

*While I find ACOG’s educational pamphlet on pain relief during labor to be lacking in many respects (its patronizing descriptions of the side effects of medication and its warnings about eating before or during labor come to mind), I think that it does a decent-enough job of explaining the differences between the various analgesic and anesthetic pain relief options available to mothers in the U.S.

I have now written five posts on “VBAC scare tactics,” or “the (outrageous) statements [that] 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.“  I plan to write more–many more, in fact, because there are loads of unfounded “reasons” that OBs (and some midwives) give to women each day in order to deter these women from choosing a vaginal birth after cesarean rather than a repeat cesarean.

In each of my posts on VBAC scare tactics, I identify one particular scare tactic, supply a list of questions that a mother can ask her care provider in response to this scare tactic, and then provide an analysis and/or summary of the research that either challenges or even debunks the scare tactic and its insinuations.

Yet nowhere do tell a mother that she should leave her scare-tactic wielding care provider.

Nowhere do I tell her that should wait for labor to begin spontaneously.

And nowhere do tell a mother that she should attempt an intervention and drug-free childbirth.

And this is despite the fact that I think that these are wise and excellent choices for the vast majority of all births, and despite the fact that I think these choices give a woman the best chance of having a successful VBAC.  (And, let’s be honest, it’s also because I’m under no impression that someone is going to come across my blog and say, “Hey, that gal at Birthing Beautiful Ideas told me to do it, so by God, I’m gonna!”)

Nonetheless, despite what I think is wise and excellent and VBAC-success-producing, I also think that women should feel empowered to make their own decisions about the births of their babies.  They should be able to make their decisions autonomously, and from evidence and research that they have read and/or discovered.  And when a VBAC-supporter or natural-childbirth-supporter or anyone is too heavy-handed in his or her advice, then this heavy-handedness can diminish a woman’s sense of empowerment and autonomy.  It can even influence a woman to refrain from looking more closely at whatever it is that the advice is pertinent to.

(For what it’s worth, I think that my birth experience with A was so spectacular because I owned every decision I made about the birth, and I made those decisions from a place of empowerment and autonomy, from a place where no one ever told me categorically what I should or should not do.)

Even so, I think that it is reasonable for me to “lay my cards on the table,” so to speak, and elucidate what I think a woman should consider:

• If one’s care provider is hurling “VBAC scare tactics” left and right, then one should consider finding a new care provider.  I did.  I did it.  At nearly 37 weeks into my pregnancy no less.  And it was terrifying, and I cried for days…and I have never once regretted my decision.  Because A’s birth would have been so, so different–and certainly not so amazing and transformative–if I hadn’t reached inside myself and culled up all of my strength and stood up to an obstetrician who tried to coerce me into an unnecessary repeat cesarean.  (For those of you who do wish to transfer to a new care provider, here is good resource containing questions that you can ask when interviewing your new care provider.)

• Unless an induction is medically indicated or necessary, I think that all pregnant women should consider waiting for labor to begin spontaneously.  There are  real risks associated with inductions, whether or not the mother’s uterus is scarred.  There are also real disadvantages to induction since the mother must be hooked up to an IV and to continuous electronic fetal monitoring, thereby limiting her ability to change positions as a comfort measure and to use gravity as a way to “bring the baby down.”  What’s more, synthetic oxytocin (or pitocin) interferes with the body’s ability to release endorphins that can help to counteract the pain of labor, and it intereferes with the body’s own release of natural oxytocin, which helps to promote the mother’s bonding with the baby after birth.  So while induction may be a reasonable and even necessary way for labor to begin–even for a mom attempting VBAC, despite the extra risk that induction presents–there are numerous reasons that should give a mother pause before consenting to a non-necessary induction.

• And finally I think that all women should consider attempting an intervention-free and drug-free childbirth.  I’m certainly not saying that all women should attempt a “natural childbirth.”  But I think that all women should at least consider them.  Weigh the pros and cons of pain medications and interventions.  Or at least look at their options.  Or KNOW that there are options!   (They’re not for everyone, of course, and there are definitely, without a doubt, times and places for pain medications and medical interventions during birth–just so long as a mother can, if possible, participate in the decision to use those interventions and can make that decision from a place of empowerment and autonomy.)  But back to why women should at least consider or research a natural childbirth…  My reasons for this stretch beyond the multitude of physical and emotional benefits of a drug-free birth for both mom and baby.  They stretch far beyond the risks that accompany the various medical interventions used during labor and delivery.   For in addition to these reasons, I think that a drug-free and intervention-free birth can be one of the most amazing, inspirational, empowering, and transformative events in a mother’s life.  Especially when it is borne from a place of education and empowerment and autonomy and preparation.  And it’s not just for granola-crunchy and/or birth junkie types either–just check out Heather B. Armstrong’s most recent post about the natural birth of her second daughter over at dooce.com.  (I, like many others, have been stalking her blog every day for the past couple of weeks to get this latest installment of her birth story.)  As Ms. Armstrong so wisely says, for those of us who work toward and research about and are lucky enough to have a natural childbirth, these births have the ability to change our perspective on our entire lives.

And that’s something that every woman should know is possible.

The March of Dimes Perinatal Data Center has created a PeriStats database (accessible from the March of Dimes website) that grants one free access to US, state, county, and city maternal and infant health data.  They have graphs, maps, summaries, quick facts, and a whole wealth of information regarding various perinatal statistics.  For instance:

Want to know the VBAC rate for your county?  (They rightly include the VBAC rate as a maternal and infant health indicator.)

Want to figure out the preterm birthrate for your state?

Interested in a quick overview on prenatal screening?

Looking for a summary on birth outcomes in your state?

Then check out this site!  It’s truly a wonderful resource for expectant moms and birth advocates.

Many readers have probably already seen the following amazing, articulate, justifiably-angry, and well-informed consent form posted on various blogs, Facebook status updates, etc.  But it’s worth re-reading if you have seen it, and it is definitely worth reading if you haven’t.

The author is a mother who has been continuously denied the opportunity–yes, just the opportunity–to VBAC by her local (and, in some cases, state-wide) obstetricians and midwives.  And her brilliant work here should be required reading not only for all current birth-attendants  but also for all medical students, OB residents, and midwives-in-training.  In fact, I’m toying with the idea of sending it to my original obstetrician who tried to coerce me into an “easy, urinary-incontinence-preventing, relatively risk-free repeat cesarean” with my second baby.

I, the undersigned physician, have, in violation of the Consumer Bill of Rights and Responsibilities, the Emergency Medical Treatment and Active Labor Act, the Patient Self Determination Act, the ethical guidelines of the American Medical Association and the American College of Obstetricians and Gynecologists, Constitutional Law (the right to privacy and self determination protected by the 1st and 14th amendments), international tort law, and case law (of particular interest “In re A.C.”, 1987, “In re Fetus Brown, 689 N.E.2d 397, 400 (Ill. App. Ct. 1997)”, and “In re Baby Boy Doe, 632 N.E.2d 326 (Ill. App. Ct. 1994)”) and the Patient Rights as determined by this institution, deprived my client,________________, of her right to self determination and her right to bodily integrity by ignoring her repeated refusal for delivery by repeat cesarean section. I acknowledge that by refusing to honor my client’s denial of consent, I have not only violated the above laws, but I also affirm that I have used unwarranted and unethical pressure including emotional threats to my client’s and her unborn child’s life and safety, in my attempts to obtain such consent. I further affirm that I have stressed the risks of vaginal birth after cesarean, but neglected to inform my patient of the risks of delivery by repeat cesarean section. I further affirm that I understand, that should I resort to physical force, including but not limited to physical or chemical restraints to compel my client’s cooperation, I will be guilty of criminal battery, which is defined as “any form of non-consensual touching or treatment that occurs in a medical setting”.

In compensation for the above violations of my client’s rights, I hereby guarantee the following:

a healthy baby, born in perfect condition, with no physical, mental or developmental defecits whatsoever, whether arising from surgery or any other cause

no complications for the infant, including but not limited to: persistent pulmonary hypertension, transient tachypnea of the newborn, respiratory distress syndrome, iatrogenic prematurity, lacerations, or hematoma

a speedy, uncomplicated post-operative recovery for my client. Specifically, I guarantee that my client shall not experience nerve damage, organ damage, hemorrhage (whether sufficient to require transfusion or not), disability or disfigurement, intraoperative or postoperative infection of the wound or surrounding skin and tissues, post partum depression and post partum post traumatic stress disorder (PTSD), and other conditions not listed here.

Signed,

I recently discovered a couple of VBAC-relevant news items that I think are worth sharing.

The first is a segment from Mary Alice Williams on Religion & Ethics Newsweekly (here featured on PBS’s website).  Simply entitled “Dr. T,” it explores the role that faith plays in the work of Dr. Joseph Tate, an obstetrician in the Atlanta area.  Of particular interest to VBAC-advocates (or “VBACtivists,” if you like) is the fact that Dr. Tate is not only VBAC-supportive (and has attended a number of VBAmCs, or VBACs after multiple cesarean) but is also a subscribing member of the Atlanta ICAN chapter.

While this is not the first time that I had heard of Dr. Tate (his support for VBACs and natural birth is fairly well-known), I was intrigued to see the ways in which he ties his faith (Dr. Tate is an Orthodox Jew) into his practice of medicine.

(As an aside, the one “beef” that I have with the piece is the fact that part of Ms. Williams’s narration includes the line that “Dr. Tate risks VBACs all of the time.”  This line makes it seem as if Dr. Tate is engaged in some sort of cutting-edge, unstudied, revolutionary medical practice simply by following evidence-based medicine and “allowing” women to birth their babies vaginally.  While I do not wish to undermine the real risk of uterine rupture for moms attempting VBAC, I think that Ms. Williams’s line possibly exaggerates this risk–which, for the record, is less than 1%.  In fact, for this line to characterize the risk of VBAC accurately, there should also be included a statement along the lines that “Doctors who deny VBACs risk c-sections all of the time.”  An increased risk of infection, damage to the bladder and other internal organs, and future reproductive problems for the mother, and lacerations, iatrogenic prematurity, and “wet lung” for babies are real risks, after all!)

*gets down from soapbox*

The second “VBAC-relevant news item worth sharing” is an article from the LA Times entitled Childbirth: Can the US Improve? (Thanks to my email updates from The Business of Being Born for alerting me to this piece.)  Kudos for Lisa Girion for pointing out not only the exhorbitant costs of cesareans but also the health risks that c-sections pose to moms and their babies.  Additional kudos are deserved for addressing not only the benefits and risks of VBAC and unnecessary induction but also the fact that so many women are being denied VBACs–an issue that contributes not only to skyrocketing health costs but also to increased maternal and neonatal health problems.

My past week as a doula has been a week of heartache and triumph.  I attended two beautiful births with two incredibly strong, knowledgeable and inspiring mothers.

Although I couldn’t have known it ahead of time–although no one could have known it ahead of time–the birth I attended last Thursday turned out to be the first cesarean section I attended as a doula.  It was my third birth, and I suppose that just goes to show that the statistics have really panned out for me.  (Currently, the cesarean rate in the United States stands somewhere between 31-34%.)  One out of three.  One out of three…  (Yet I still ask myself, “Isn’t the cesarean rate supposed to be lower for doula-attended births…?”)

After laboring beautifully–completely unmedicated, mobile and upright through most of her labor, pushing for nearly four hours in a variety of positions, and greeting the majority of her labor with humor (yes–humor!) and grace–my courageous and inspiring client ended up with a cesarean for a posterior baby who would simply not descend (or rotate, for that matter).  While I’ve obsessively re-examined her labor to figure out just what I could have done differently as a doula, I don’t know whether I’m relieved or heartbroken to realize that I’m not sure that I could have done anything differently–especially since there were no signs that the baby was posterior until the last hour of pushing.

But that doesn’t change the aching and sinking feeling I felt when, after greeting the mother in recovery, she looked up at me with tears welling in her eyes and whispered, “Kristen, I tried.”  I cried with her and reminded her of just how strong and amazing and inspirational she was and of just how much she not only tried but did.

And I cried all the way home.

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I needed something “different” for my next client’s birth.  As I told my husband, “I need a triumphant birth!”  (How selfish of me to “need” something from my clients’ births, I know…)

I became understandably concerned when my next client informed me that one of the obstetricians in her group (a very high-ranking obstetrician in the US, for that matter) was pressuring her to have a cesarean because her baby was “measuring large.”  Yes, at an estimated 9 lbs. 13 oz., her baby was measuring  “large for gestational age.”  But this does not mean that she needed a cesarean, especially since a) she had already birthed a 9 lb. baby and b) she was planning on being upright, mobile, and unmedicated during her labor and delivery.  (Henci Goer has a great section on birthing “large” babies in her wonderful, educational book, The Thinking Woman’s Guide to a Better Birth.)

I am proud to say that my knowledgeable, incredibly strong-willed client refused the cesarean and declared that she wanted to “let nature take it’s course.”

I am even more proud to say that at 10:32 this morning, my knowledgeable, incredibly strong client birthed her 11 lb. 10 oz. baby after pushing for only seventeen minutes.  She avoided an unnecessary cesarean, she proved her obstetrician wrong, and she demonstrated her unwavering faith in her body in the process.  A triumphant birth indeed.

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So while the triumphant birth of this (yes, I’ll admit it) big baby in no way “cancels out” the heartache I feel over my other client’s cesarean section, it at least shows me that, as a doula, I can–and should–expect these emotional peaks and valleys all throughout my career.  I will assist mothers who have necessary cesareans, and, unfortunately, I will probably assist mothers whose cesareans could have been prevented.  I will assist mothers who “fight the power” and refuse to be unnecessarily sectioned, and I will assist mothers who might even opt for an elective cesarean.  I will assist mothers who birth big and small, healthy and unhealthy, and hospital-born and home-born babies.  I will assist mothers who feel empowered by their birth experiences, and I will assist mothers who grieve what they lost during their birth experience.

But if I can reflect at least at least one-tenth of the strength, courage, and inspiration that all of my mothers show to me, then I should feel as least partly triumphant about my own work as a doula.  One mother, and one baby at a time.