Birthing Beautiful Ideas

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

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

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

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

Just consider the introductory paragraph from the 2004 practice bulletin:

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

And now the introductory paragraph from the new practice bulletin:

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

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

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

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

From the 2004 bulletin:

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

From the 2010 bulletin:

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

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

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On VBAC after multiple cesareans (or VBAmC)

From the 2004 bulletin:

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

From the 2010 bulletin:

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

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On suspected macrosomia (or “big baby”)

From the 2004 bulletin:

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

From the 2010 bulletin:

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

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

From the 2004 bulletin:

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

From the 2010 bulletin:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

And the answer is:

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

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

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

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

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

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

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

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

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

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

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

Ahem.

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

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

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

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

Consider it my own personal public pep talk.

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

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

Here goes nothing…

So: do ya fancy yerself a sex writer?

Hells no.

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

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

Well, for one, I promised.

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

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

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

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

The end.

Do you hate the Mominatrix?

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

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

But the Mominatrix drama is really beside the point.

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

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

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

Isn’t that enough?

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

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

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

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

Just stay tuned…

Anyone who has read my VBAC story might remember that my VBAC itself occurred after I switched care providers at nearly 37 weeks into my pregnancy.

Obviously, this is not something that one does “on a whim.”

It’s hard to do anything on a whim when you have an eight-pound person tucked inside your midsection!

And so my decision to seek a new care provider in the last four weeks of my pregnancy was not a “whim” decision but was instead a decision informed by my own careful (yet harried) reflection and research.

And it was a decision I made in reponse to the blatant misinformation about VBAC and repeat cesarean that my original OB/GYN had given me in an attempt to “talk me into” an (unnecessary) repeat cesarean.

So in the the spirit of my request for your stories about the lies, misinformation, and/or miscommunication you’ve experienced when it comes to VBAC, I’m going to share my own story of “Very Bad At Communication” here:

It all started when my obstetrician informed me that he “needed” to do an ultrasound at my 36 week appointment so that he could measure my lower uterine segment.  As he told me, if my lower uterine segment (LUS) was “too thin,” we would need to schedule a repeat cesarean.  If it was not “too thin,” then I could “attempt a trial of labor.”

(For what it’s worth, I’ve found that care providers who use phrases like “attempting a trial of labor” tend not to demonstrate much confidence in vaginal birth after cesarean.)

The warning bells started blaring in my head when he told me that, “You know, just last week, a mom came in here, and we measured her LUS, and it was too thin for a VBAC.  She’s gonna have to do a c-section.”

Why did he share that information with me?

I’m guessing it was his own way of telling me not to get my hopes up (because he was going to shatter them no matter what the ultrasound showed?).

And then I had the ultrasound.

The sonographer determined that my LUS was measuring approximately 3.7 mm thick.

And I, I who had done myVBAC research–I who had scoured PubMed for articles on VBAC, including the then-published articles on using LUS measurements to predict uterine rupture–celebrated for a brief moment, because most studies on this topic recommended anywhere from 1.5 mm – 3.5 mm as a “safe cut off point” for attempting a VBAC.

Even if those studies were flawed in some ways, 3.7 mm still made me safe in their eyes!

Except then my OB/GYN told me that my LUS needed to be 5 mm thick in order to safely attempt a vaginal birth.

The devastation started creeping in.  Those “warning bells” were trying to tell me something after all.  (And they had probably been ringing all throughout my pregnancy, but that’s another issue entirely.)

The sonographer noted the immediate change in my expression and attempted once more to measure my LUS, just to see if there was any one point that was 5 mm thick.

And there wasn’t.

I immediately tried to ask about the other studies I had read, but my OB/GYN interrupted me mid-question and said, “Kristen, I’m sorry, we need to schedule a repeat cesarean.”

I tried again.  “Well, what is the risk of uterine rupture with a LUS measuring less than 5 mm?”

His response?  “The risk of uterine rupture during all VBACs is 2%.”  (By the way, that’s not true.  And it didn’t answer my question.)

I tried again.  “Hmm, that seems pretty high!  And doesn’t pitocin…”

He interrupted me.  “The risk of uterine rupture during all VBACs is 2%.  Period.  And anyway, you never know if you’ll need pitocin!”

(I was trying to ask him about how pitocin affects the risk of uterine rupture.  For what it’s worth, pitocin augmentation and induction have been shown to increase the uterine rupture rate from approximately .4% to .9% and 1.1%, respectively.)

I tried again.  “Well, what are the risks of repeat cesarean as compared to VBAC?  Will having this c-section have any negative effect on my future pregnancies or births?”

His response?  “No, repeat c-sections are no big deal!  You can have as many of them as you want!  And hey!  Now you don’t have to worry about incontinence issues in the future!”

(Note: just six months prior, he had informed me about how he only recommends VBACs to women who want more than two children since third, fourth, etc. cesareans can carry so many extra risks and complications.)

I tried again, people! “But didn’t you say…”

And here’s where he threw down the gauntlet.

Well, first he turned to my husband and chuckled, “I’m really making her angry, aren’t I?”

And then he said, “Look, Kristen, we need to schedule your repeat.  Period.  There’s no more discussion.  Now, let’s see, you’re due on May 27th, I’m going to Italy at the beginning of May…how does May 20th look?”

I was stunned.  (And pisssssed!  Seriously, that patronizing crap he pulled with my husband was totally uncalled for.  And it’s what infuriated Tim the most throughout the entire “conversation.”)

But I was also searing with the hormonal rush that is the last few weeks of pregnancy.  I was on the absolute precipice of tears.  And I held myself together just long enough to mutter, “Well, we’ve got a two-year-old, so we’re gonna have to find a babysitter before we schedule anything.”

And Tim and I left that office so fast that we forgot our jackets in the waiting room.

The rest is history.

With the help of our doula, we found a new care provider.

I went on to have not only a successful VBAC but also my hospital’s first waterbirth.

And I was eternally grateful that I had made the terrifying yet empowering decision to switch to a more supportive care provider at such a late stage in my pregnancy.

(And, to his partial credit, my original OB/GYN even called me at home–and my husband on his personal cell phone–to tell me that he had “gone and done his research” and “discovered” that my LUS measurements were “alright for a trial of labor afterall.”)

But what if I hadn’t done all that research?

What if I had allowed myself to fall prey to my original OB/GYN’s non-evidence-based claims about VBAC and uterine rupture?

Should I have even been expected to have read those relatively obscure studies on LUS measurements anyway?

Thinking about the potential answers to those questions make me realize just how exceedingly important the issue of VBAC-related patient counseling is.

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?