Birthing Beautiful Ideas

We can call it “poor communication skills.”

We can refer to things like “misinformation” and “misrepresentation” and “misguided intentions.”

We can even call out some of ‘em for what they really are: “lies.”

Yes, when some women discuss vaginal birth after cesarean (or VBAC) with their health care providers, the information they receive can be mangled by everything from poor communication to outright falsehoods.

You can take a look at my own VBAC Scare Tactics series, where each post has been “inspired” by actual misguided scare tactics that women have encountered in their quest to find a health care provider to attend their child’s birth.

You can scour My OB Said WHAT?!? to find some (outrageous) instances of this misinformation.

You can search any number of VBAC-relevant message or support boards to find women reporting the false or exaggerated or misguided claims that their OB/GYNs or midwives have made about VBAC.

You can also ask nearly any woman who has ever attempted to find a VBAC-supportive care provider, and most of them will probably have some VBAC-related whoppers to share.

Want some examples?

There are loads of women (and their friends, relatives, and other loved ones) who think that or who have been told that “VBAC only has a 70% success rate, so why would you want to risk your baby’s health like that?”

The truth is that the “70% success rate” means that (approximately) 70% of VBAC attempts will end in vaginal birth and 30% will end in a cesarean section.  This does not mean that 30% will end in uterine rupture–only .7% of women attempting VBAC experience uterine rupture, and the majority of those ruptures are not catastrophic.  Making an informed decision regarding VBAC and repeat cesarean involves receiving accurate, non-misleading information about the difference between VBAC success rates and uterine rupture rates.

There are women who have been told (or who have engaged in conversations that have implied) that VBAC carries an exhorbitantly large risk and that repeat cesarean carries little to no risk.  VBAC consent forms are generally good at “mis-communicating” this information.

The truth is that neither VBAC nor repeat cesarean is without risk.  The main risk associated with VBAC is uterine rupture, which occurs in approximately .7% of VBACs.  Repeat cesarean, however, is associated with a number of risks, including incision-site infection, hemorrhage, bowel obstruction, and an increased risk of placenta previa, accreta, and percreta in future pregnancies for the mother; and iatrogenic prematurity, respiratory problems, and lacerations for the baby.  Preserving patient autonomy regarding VBAC and repeat cesarean involves ensuring that women know the risks associated with both VBAC and repeat cesarean before they enter the hospital, regardless of their birthing choice.

Women have been told that VBAC is very unsafe for babies and that VBAC is downright silly since it is only about a woman seeking out a certain “experience” at the expense of her baby’s health and safety.

The truth is that current research concludes that babies born after a VBAC have lower NICU admission rates and fewer respiratory problems than babies born via elective repeat cesarean. And the truth is that VBAC is never just about a woman seeking a certain “birthing experience” at the expense of her baby’s health and safety–there are many other reasons that women choose VBAC over repeat cesarean.  VBAC is a safe and healthy option for many women, and actively discouraging VBAC might very well compromise maternal and neonatal health and safety when one takes into consideration the benefits of vaginal birth for moms and babies and the risks that repeat cesarean(s) pose to a woman’s future reproductive health.

My thoughts in a nutshell?

I think that care provider-initiated misinformation about VBAC eats away at informed consent and patient autonomy and maternal and neonatal health.

And I think that in many cases, health care providers need to be counseled on their counseling when it comes to VBAC.

This why I’d like to take these thoughts to the NIH Consensus Development Conference on VBAC in March.  And I’d like YOUR stories to help me do so!

Have you been lied to about vaginal birth after cesarean?

Did you face “VBAC scare tactics” during your pregnancy (or pregnancies)?

Were you misinformed about the relative risks (and benefits) of VBAC and repeat cesarean?

PLEASE SHARE YOUR STORY HERE SO THAT YOUR VOICE CAN BE HEARD AT THE NIH CONFERENCE!!!

Because advocating for women’s birthing choices isn’t just about making sure that health care providers are doing the right things–it’s also about making sure that health care providers learn and say the right things.

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

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

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

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

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

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

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

Questions to ask your care provider:

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

A more nuanced analysis:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

And now for a continuation of my responses to the Birthing from Within “wise mother” interview questions, this time applied to my second son’s birth–a hospital VBAC waterbirth.

What helped you most when you gave birth?

My labor support team–my husband, my mother, and my doula–all of whom provided me the right sort of encouragement and comfort and the right amount of space and privacy when I needed it.

My OB/GYN, who is truly what Ina May Gaskin refers to as an MD–a “midwife in disguise.”  Even though he had only met me once before, I knew that he believed not only in my body’s ability to birth my baby but also in birth itself.  It’s no wonder, then, that he supported my waterbirth (and the hospital’s first waterbirth) and used the second stage of my labor as an opportunity to teach the nurse about the benefits of mother-directed pushing.

My mother-to-mother support networks, which included both the women of my local ICAN chapter and the women on the Babycenter VBAC Support Board.  Their invaluable knowledge and inspiring stories and unwavering support accompanied me not only throughout my pregnancy but also throughout my labor.  In fact, I was reading their encouraging messages to me in between contractions while laboring at home!

And finally–and perhaps most importantly–the wealth of knowledge about birth and VBAC that I had gained by the time I felt that first gush of fluid that let me know my baby was coming.  I certainly wasn’t as knowledgeable about birth then as I am now (as a trained and nearly-certified doula), but I did know enough to let me feel absolutely confident in my birthing decisions.  I poured over books and websites on pregnancy and childbirth.  I researched the various risks and benefits associated with VBAC and repeat cesarean.  I hired a doula.  I investigated a multitude of comfort and coping measures for labor.  I read positive birth stories.  I practiced prenatal yoga and hypnobirthing and tried to eat a well-balanced diet (while fitting in a few french fries along the way, of course).

And the more I learned, the less I feared.

And somewhere along the way, the more I learned, the more I enabled myself to experience my birth joyfully, and with trust in myself and in my abilities.

What was your spiritual experience of giving birth?

It was, to be quite honest, shocking.  At least to me.

I’ve never felt quite comfortable discussing my thoughts on God and spirituality with people other than my husband and my very, very close friends.  I am a skeptical, snarky, philosophically-trained egghead who is in no hurry to be the object of proselytizing from believers or of sneering disdain from non-believers.

But.

If there is a God, I’ve never felt closer to her than I did after A’s birth.

For a few crystalline moments after A was born, the rest of the room melted away and it was just me, A, and the entire brilliance and beauty of the world.  And the moment was holy and pure, holier than anything I’ve ever experienced in a church or a synagogue or any other traditional place of worship I’ve attended.

And if there is a God, I hope s/he doesn’t mind me saying this:

Oxytocin is the shit, man. 

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

The preparation for his birth–the yoga, the research, the hypnobirthing, the meetings with my doula, the ICAN support meetings, the VBAC support boards–would remain the same, exactly the same.

The progression of my labor–from that gush of amniotic fluid to the gradually intensifying contractions at home to the requiring-all-of-my-focus contractions in the hospital to the wavering and quavering contractions in the water to the moment my baby boy was in my arms–would also remain the same, exactly the same.

And what my labor taught me–the power and confidence that it bequeathed to me–would certainly remain exactly the same.  (I almost wrote in the previous paragraph that I would settle for a couple fewer contractions, or maybe even one or two fewer hours in my labor, but I must admit that each contraction and each hour both took and gave me an added strength that I still carry with me today.  And I wouldn’t want to change that one bit.)

Is there anything you would do differently?

I would have switched to the OB/GYN who attended A’s birth well before I was even pregnant with A.

I would have spared myself the agony of fearing that I would need an unnecessary repeat cesarean, and of fearing that 36 weeks was far too late to change care providers.

I would have spent my entire pregnancy with a group of midwives and a doctor who trusted in birth, who believed in the safety of VBAC, and who did not doubt my ability to birth my baby.

I would have had an empowered prenatal experience in addition to having an empowered birth. 

What do you wish you had known beforehand?

I wish I would have had a better knowledge about “progress” during labor.  I wish that I had liberated my mind from the idea that cervical dilatation is apotheosis of labor progression.

When I arrived at the hospital and discovered that I was “only” 1-2 cm. dilated after laboring for nearly nine hours, I became very discouraged.  In my mind, nine hours of contractions that were now 3-4 minutes apart and that demanded every ounce of my attention should have dilated my cervix much more than a measly 1-2 centimeters.

But what I didn’t know is that those nine hours were certainly not “wasted hours” of contractions.

Because my cervix was almost 100% effaced upon arrival at the hospital.  A far, far cry from the 0% effacement at my prenatal appointment earlier in the week.  Those contractions were thinning out my cervix!

And the baby was now at -1 station instead of -3 station, as he was at my prenatal appointment.  Those nine hours of labor were moving my baby down!

And, from what I can tell, my baby was also rotating from a posterior to an anterior position.  My body was working hard to rotate my baby into an optimal position for birth!

Cervical effacement.  Changes in the station of the baby.  Rotation of the baby.

In my opinion, these forms of progression are just as important and worthy of celebration as cervical dilatation.

So even though the early hours of my labor did not follow the textbook-style “1 centimeter every one-to-two hours” dilatation that most obstetrical care providers refer to when assessing a woman’s progress during labor, this did not mean that my body was dysfunctional or inadequate.

My body was not following a textbook. 

And thankfully, no one tried to force a textbook-style labor upon my body.

Because five hours after I discovered that my cervix was “only” 1-2 cm. dilated, I was holding my baby in my arms.

After months and months of a persistent cough, my son, M, has finally been diagnosed with bronchial asthma.  And while I’m sad that he has to deal with this condition for the next few years (or at least I hope for only a few more years), I’m also happy that he at least has options for treating his cough.

What’s more, I’m also thrilled with the way his new pediatrician handled his treatment options.  In fact, my interaction with her had me day-dreaming about what her approach to informed consent would look like if it were mapped onto the ways that OB/GYNs (and even midwifes) tend to approach the option between VBAC and repeat cesarean.

But before I recount my day-dream, I should give you a picture of what my interaction with M’s pediatrician looked like:

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Dr. S: Based on what you’re telling me, it sounds like your son probably has bronchial asthma, or what some people call “cough asthma.”  *Explains a bit about what it is.*

Me: What sorts of treatments do you recommend?

Dr. S: There are generally two options: Singulair, a medication traditionally used to treat the symptoms of asthma, or Boswellia, an herbal medication that I have also recommended to many of my patients.  From my experience, both seem to treat bronchial asthma equally well.  That being said, there have been many parents who have told me that they have preferred Boswellia since it doesn’t seem to have the same sorts of negative side effects that Singulair does.

Me: What are some of those negative side effects?

Dr. S: Mainly, some parents report that their children experience significant mood changes while taking Singulair.  And this is one of the side effects associated with the drug.

Me: Oh, okay.

Dr. S: *Explains the dosage and administration of each drug, the risks/benefits of each drug, also addresses where we could safely purchase Boswellia.*  Do you have an idea about which treatment you would like to use?

Me: My gut reaction tells me Boswellia, but would it be alright if I went home and researched it first?

Dr. S: Of course!  I actually encourage that.  Why don’t you call me in a couple of days when you make your decision, and then we can talk about how we will proceed from there.

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And then I started dreaming of what a prenatal appointment would look like if a doctor or midwife were to take the same empowering, informed-consent-supporting attitude that my son’s pediatrician took to his asthma treatment.

Dr. OB/GYN: Congratulations on your pregnancy!  Since you had a cesarean for your last birth, have you thought about what you would like for this birth?

Pregnant mama: Do you mean VBAC or a repeat cesarean?

Dr. OB/GYN: Yes!  Both are relatively safe options, although each one carries particular risks and benefits.

Pregnant mama: Can you tell me a little more about that?

Dr. OB/GYN: Of course.  The main risk associated with VBAC is that the uterine scar will begin to separate during labor.  This risk of “uterine rupture” is very small–only .7% for all VBACs, and only .4% if your labor begins on its own. 

Pregnant mama: Uterine rupture sounds very serious.  What about repeat cesarean?

Dr. OB/GYN: You’re right, uterine rupture is serious, but it is only “catastrophic” in approximately .05% of all VBACs.  So the risk itself is very, very small.  We may monitor you a bit more carefully in the hospital, but we can also take steps to make sure that you can still be upright and mobile during your labor.  And repeat cesareans, although relatively safe, also have serious risks.  For instance, each subsequent cesarean increases your risk of serious placental complications, such as placenta previa and accreta.  In addition, a recent study has shown that babies born after VBAC have lower NICU admission rates and fewer respiratory problems than babies born via elective repeat cesarean.

Now, this isn’t meant to scare you!  But it’s always good to know that there are risks associated with both options.

Pregnant mama: Do I have to decide right now?

Dr. OB/GYN: Of course not!  I encourage you to take the next few weeks to do some research on VBAC and repeat cesarean, and then we can discuss your plans during your next appointment.  (Editorial note: In a super-ideal world, the OB/GYN would also give the mom a couple of pamphlets on cesarean section and VBAC from ICAN.  A girl can dream, can’t she?)

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But I know from experience that these sorts of prenatal appoinments often look a little bit more like this.

Dr. OB/GYN: Congratulations on your pregnancy!  So, when are we going to schedule your repeat cesarean?

Pregnant mama: Well, what about VBAC?

Dr. OB/GYN: VBAC?!?!?!  Why would you ever want to do a thing like that?!?!?!  I.  DON’T.  DO.  VBACs.

As brought to my attention by the ever-trusty e-news updates from ICAN, the British Journal of Obstetrics and Gynecology has published in its September 2009 issue a systematic review and meta-analysis examining VBA2C (or vaginal birth after two cesareans).  Specifically, this review analyzes the success rates and adverse outcomes of VBA2C versus VBAC (after one cesarean) and versus repeat third cesareans.

After examining twenty studies, which combined included statistics for well over 55,000 births, the authors of this meta-analysis arrived at the following conclusions:

Main results: VBAC-2 success rate was 71.1%, uterine rupture rate 1.36%, hysterectomy rate 0.55%, blood transfusion 2.01%, neonatal unit admission rate 7.78% and perinatal asphyxial injury/death 0.09%. VBAC-2 versus VBAC-1 success rates were 4064/5666 (71.1%) versus 38 814/50 685 (76.5%) (P < 0.001); associated uterine rupture rate 1.59% versus 0.72% (P < 0.001) and hysterectomy rates were 0.56% versus 0.19% (P = 0.001) respectively. Comparing VBAC-2 versus RCS, the hysterectomy rates were 0.40% versus 0.63% (P = 0.63), transfusion 1.68% versus 1.67% (P = 0.86) and febrile morbidity 6.03% versus 6.39%, respectively (P = 0.27). Maternal morbidity of VBAC-2 was comparable to RCS. Neonatal morbidity data were too limited to draw valid conclusions, however, no significant differences were indicated in VBAC-2, VBAC-1 and RCS groups in NNU admission rates and asphyxial injury/neonatal death rates (Mantel-Haenszel). Conclusions Women requesting for a trial of vaginal delivery after two caesarean sections should be counselled appropriately considering available data of success rate 71.1%, uterine rupture rate 1.36% and of a comparative maternal morbidity with repeat CS option.

Although I do not have access to the full text of the article, I do think that the abstract linked above yields some highly significant information regarding the comparative risks of VBA1C, VBA2C, and third repeat cesareans–and especially between VBA2C and repeat third cesareans.

For one, although the uterine rupture and hysterectomy rates were found to be higher for VBA2C than for VBA1C, the success rates (or those that ended in vaginal births) were strikingly similar: 71.1% for VBA2C and 76.5% for VBA1C.

Comparing VBA2C and repeat third cesareans yields far more intriguing results (at least in my opinion).  For while the blood transfusion and febrile morbidity rates for both groups were similar, if not nearly identical, the hysterectomy rate was higher in the repeat cesarean group than in the VBA2C group.

What’s more (and this bears repeating from the above-cited paragraph), “Maternal morbidity of VBAC-2 was comparable to RCS. Neonatal morbidity data were too limited to draw valid conclusions, however, no significant differences were indicated in VBAC-2, VBAC-1 and RCS groups in NNU admission rates and asphyxial injury/neonatal death rates.”

And while it would undeniably be more helpful to analyze this data in its entirety, or as it is written in the full text of the article, the conclusion itself should serve as a fertile ground on which women and their care providers can more fruitfully discuss the benefits and risks of VBA2C (as opposed to a third cesarean).

(It should go without saying that there is a “VBAC scare tactic” post regarding VBA2C (or VBAmC) on my horizon!)

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.

The June 2009 issue of Obstetrics and Gynecology featured an article on “Neonatal outcomes after elective cesarean delivery” (Beena Kamath, et al).  For those interested in the latest studies and research on VBAC and repeat cesarean, this is an article worth checking out!

Here is a summary of the study’s findings:

OBJECTIVE: To examine the outcomes of neonates born by elective repeat cesarean delivery compared with vaginal birth after cesarean (VBAC) in women with one prior cesarean delivery and to evaluate the cost differences between elective repeat cesarean and VBAC.

METHODS: We conducted a retrospective cohort study of 672 women with one prior cesarean delivery and a singleton pregnancy at or after 37 weeks of gestation. Women were grouped according to their intention to have an elective repeat cesarean or a VBAC (successful or failed). The primary outcome was neonatal intensive care unit (NICU) admission and measures of respiratory morbidity.

RESULTS: Neonates born by cesarean delivery had higher NICU admission rates compared with the VBAC group (9.3% compared with 4.9%, P=.025) and higher rates of oxygen supplementation for delivery room resuscitation (41.5% compared with 23.2%, P<.01) and after NICU admission (5.8% compared with 2.4%, P<.028). Neonates born by VBAC required the least delivery room resuscitation with oxygen, whereas neonates delivered after failed VBAC required the greatest degree of delivery room resuscitation. The costs of elective repeat cesarean were significantly greater than VBAC. However, failed VBAC accounted for the most expensive total birth experience (delivery and NICU use).

CONCLUSION: In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay.

LEVEL OF EVIDENCE: II*

The study does report that the group of unsucessful VBAC attempts (or those that ended in cesarean delivery) experienced the highest rates of chorioamnionitis (or inflammation of the amniotic membranes) and non-reassuring fetal heart tones as compared to the other groups in the study (i.e. those whose VBACs were successful and those who had elective repeat cesareans).  This does not seem entirely surprising, however, since both problems are more likely to occur during labor rather than before labor.  It’s also not surprising that these problems occurred more frequently in the group of unsucessful VBACs since non-reassuring fetal heart tones can often lead a care provider to call for a cesarean, especially with a mom attempting VBAC.

Also noteworthy is that the study reports that “neonates born by failed VBAC required the most significant measures of delivery room resuscitation, including bag or mask ventilation and endotracheal intubation, than did the other three groups.”  Thankfully, these infants took up the smallest percentage of the study’s population, especially considering that the VBAC group experienced a 74% success rate.

However, it is especially noteworthy that when the authors reported that the elective cesarean group had nearly double the rate of NICU admission and oxygen supplementation as compared to the VBAC group, they were including failed VBACs in the “VBAC group” population.  In other words, these rates were nearly doubled even though the “VBAC group” included those infants who “required the most significant measures of delivery room resucitation.”

And this is why the authors go on to note that

The differences seen between the intended elective repeat cesarean delivery and VBAC groups take on greater significance when one notes that the intended VBAC group includes neonates born after failed VBAC delivery, who required the greatest measures of resuscitation due to fetal distress, characterized by nonreassuring fetal heart tones and meconium-stained amniotic fluid. At the other extreme, neonates born after successful VBAC had the lowest rates of admission to the NICU, shortest hospital stay, and the lowest incidence of ongoing respiratory support.

For those interested in examining this study in more detail, check it out here.  In my humble, VBAC-supporter’s opinion, it’s an interesting and informative read!

*Worth noting is that the evidence in this study was reported as “Level II evidence,” which means that it came from a well-designed and controlled trial without randomization.  (Randomization would have qualified it as a “Level I” study, but this would have also meant that the researchers would have had to have randomly assigned women either to elective repeat cesarean or to VBAC.  And at least to my layperson’s mind, this seems like it could lead to all sorts of ethical quandaries.)

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 #6: Here in your chart, it says that your cesarean was for failure to progress.  Oh, and there’s also a note here about cephalopelvic disproportion.  You’re not really an ideal VBAC candidate since your cesarean wasn’t for fetal distress or breech presentation, so we need to schedule a repeat cesarean.

Questions to ask your care provider:

• Does this mean that you will not support my VBAC attempt if I refuse a repeat cesarean?
• Do either of those “diagnoses” make a VBAC attempt riskier than it would be for a mother who had a c-section for fetal distress or breech presentation?
• What is the VBAC success rate for women whose cesareans were for cephalopelvic disproportion (CPD) or failure to progress (FTP)?
• Were there any contributing factors–such as induction, fetal malpositioning, maternal immobility, labor time limits, or ruptured membranes–that could have inhibited my labor progression and led to a cesarean for CPD or FTP?
• How was the diagnosis of CPD or FTP made?

A more nuanced analysis:

Firstly, you can find an excellent resource on CPD and VBAC on ICAN’s White Papers.  I strongly recommend this resource to anyone who is questioning their care provider about a CPD or FTP diagnosis or wanting to attempt a VBAC after one or both diagnoses.

Secondly, it is my position that a previous CPD or FTP should not disqualify a mom from attempting VBAC, that there can be other preventable factors that contribute to these diagnoses, and that women should question their care providers about these diagnoses, especially if they are facing opposition to their desires to have a VBAC.  And yes, these diagnoses may be wrong and/or simply illustrative of a care provider’s impatience.

So what exactly is CPD?

CPD itself refers to a disproportion between the baby’s head and the mother’s pelvis.  In other words, it suggests that the baby’s head (or at least the presentation of the baby’s head) is too large to pass through mother’s pelvis.

A CPD diagnosis can be made before labor, often when a care provider decides that, based on an ultrasound estimation of the baby’s weight and/or a measurement of the mother’s pelvis, the baby is too big to fit through the mother’s pelvis.  It is worth noting, however, that near-term estimates of fetal weight and size can be “off” by a pound or more in either direction.  So a baby who is estimated to be 8 lbs. may actually less than 7 lbs. or more than 9 lbs.  What’s more, unless a mother has uncontrolled gestational diabetes or has suffered a severe pelvic injury or has experienced malnutrition, there is little evidence–especially pre-labor–that even a “big” baby cannot fit through her pelvis.

In addition, the  hormone Relaxin is released in increasing amounts in the mother’s body during pregnancy (particularly during the last few weeks of pregnancy), and this hormone helps to loosen the joints in  her pelvis for the delivery of the baby.  Accordingly, the increased “looseness” of her pelvis might not be accounted for in pelvic measurements taken by the mother’s care provider.

CPD is also (and often) diagnosed during labor.  This generally occurs when a mother’s labor is not progressing “adequately”  (a term I use lightly) and the use of synthetic oxytocin (or pitocin) is not successful in aiding this progression.  It is thus implied that the “poor progress” is a result of a disproportion between the baby’s head and the mother’s pelvis.

Many practicioners and researchers distinguish between “absolute” and “relative” CPD.  (Please see ICAN’s White Papers on CPD for a further elaboration of–and potential problems with–this distinction.)  Truly absolute CPD is very rare and generally occurs when a mother has sustained a permanent pelvic injury and/or extreme malnutrition at some point in her life.  (I emphasize “truly” since many women who have been diagnosed with “absolute” CPD have gone on to have vaginal births, thus proving that the CPD was not so absolute after all!)  In cases of truly absolute CPD, vaginal birth, while not impossible, may be improbable. 

Relative CPD, however, is often diagnosed when there are other factors contributing to the baby’s supposed inability to pass through the mother’s pelvis.  As pointed out on the ICAN resource for CPD, these contributing factors include:

Position of the baby’s head – The baby may have his head straight or tilted back instead of flexed with chin to chest. The baby’s head may also be asynclitic (tilted to the side).

Nuchal arm or hand – The baby may have her hand(s) or arm(s) raised to her head.

Posterior position – Baby is facing mother’s front instead of back.

Other malposition of the baby’s head – The back of the baby’s head may be facing sideways and has arrested in that position (transverse arrest). Occasionally, this happens as the baby tries to turn during labor into a more favorable position. Also brow or face presentations, where other parts of the baby’s head present first instead of its crown, may cause the baby to not be able to descend.

Misalignment of the pelvis – The mother’s pelvis could be misaligned due to many factors (mild pelvic jarring due to falls, sports injuries, or car accidents). Many women report this to be generally well-treated with chiropractic care.

Restriction of movement – Limitations on mother’s mobility in labor are very common due to hospital policy, epidural anesthesia, and/or continuous fetal monitoring.

Rupture of membranes – The breaking of the mother’s waters, either naturally or artificially by her care provider, can cause the baby to drop into the pelvis in an unfavorable position. An arbitrary and artificial time limit being placed on labor may not allow the laboring woman’s body enough time to birth.

I would also add to this list that induction–especially with combined with one or more of the above-mentioned situations–can contribute to a CPD and/or FTP diagnosis.  Particularly when a mother’s cervix is unfavorable for an induction, her body (let alone her baby) may simply not be ready to go into labor.  Thus, an “inadequately” progressing labor may have nothing to do with a failure to progress or a disproportion between her baby’s head and her pelvis–it may be the result of a failed induction.  It is a failure of technology–not of a mother’s body.

And some, if not many, diagnoses of CPD and/or FTP, with or without induction, may also be the result of a failure to wait (given the absence of maternal and/or fetal distress) on the part of the care provider.  And this is why the concept of “adequate labor progression” can be such a tenuous concept, for not every woman’s labor will progress according to a subjectively-determined timeframe.

Notably, while some studies have found that moms with a prior CPD or FTP diagnosis have a lower VBAC success rate than moms who had cesareans for other reasons (such as breech presentation or fetal distress), none of these studies suggest that a CPD or FTP diagnosis contributes to a higher risk of uterine rupture.  So in this respect, VBAC itself is not riskier for moms with these diagnoses. 

There is also no guarantee that CPD or FTP will repeat themselves in subsequent labors, especially if one can attempt to prevent the interventions or situations that can contribute to CPD or FTP.  (And sometimes this just means choosing a different care provider!)

This is particularly worth noting since the reason that some care providers will deny a VBAC to a mom who had a cesarean for CPD or FTP yet “allow” a VBAC for a mom whose cesarean was for breech presentation or fetal distress is that they think that CPD and FTP (unlike breech presentation of fetal distress) are likely to re-occur in subsequent labors.  One of the many problems with this reason comes down to a matter of how these care providers define “likely,” especially since a majority of women with prior CPD or FTP diagnoses can go on to have successful VBACs.

In fact, a study in the 1987 issue of the American Journal of Public Health found that the VBAC success rate for moms with a previous CPD diagnosis to be approximately 65%.  Another study published in a 1998 issue of Obstetrics and Gynecology found a 68% VBAC success rate for moms with a previous CPD diagnosis (Obstet. Gynecol., 92(5): 799-803. Nov 1998.).  There are even other studies (referenced in the ICAN resource) which report an 80% VBAC success rate for women with a previous CPD diagnosis, and a 56% VBAC success rate for women who underwent two cesareans for supposed CPD.

Accordingly, a CPD diagnosis certainly does not mean that VBAC success is impossible–or even improbable!  Nor does it mean that CPD is necessarily a permanent diagnosis.  You have options.  And in this respect, ICAN gives the following recommendations to help lower your risk of a CPD diagnosis:

Some women report that chiropractic care throughout and between pregnancies is helpful in avoiding CPD. Look for a chiropractor who has experience working with childbearing women and utilizes in-utero constraint techniques.

If you want to be mobile in labor, listen to your body. Don’t remain strapped to the bed; insist on getting up and moving around.

Learn labor positions that aid in opening your pelvis.  Consider reading & using The Pink Kit, a childbirth education tool useful for any woman planning a VBAC. It can help a woman find the best birth positions for her particular pelvic shape and size.

Learn the position of your baby and how to encourage your baby to be in the optimal position. Read the material at Spinning Babies website.

Have a doula. Research shows that a birthing woman with continuous labor support is more likely to have a shorter labor and a spontaneous vaginal birth.

And then, once you’ve asked all your questions and researched your options and determined your goals and plans for your next birth, watch this video:

It will inspire and astound and encourage you.  (And probably make you cry.)

*Note: the soundtrack for the video was disabled because of copyright issues.  But if you have it available, you can play The Stone Roses’ “She Bangs the Drums”–or another favorite, empowering song of yours–in the background while you’re watching it.

Back when I was an angsty 16-year-old, I made a habit of launching into self-righteous political tirades…oh, about forty-seven times a day with my friends and family members.  I was opening my eyes to the injustices of the world, discovering the hypocrisy of the beast that is humanity, and trying to change people’s minds the best way I knew how:

BY ATTEMPTING TO LOBOTOMIZE THEM WITH MY HOLIER-THAN-THOU, HEAVY-HANDED PROCLAMATIONS AND CASTIGATIONS.

But I’m not that girl anymore.

(Really, Mom and Dad.  I’m not.)

I’ve grown.  I’ve matured.  And I’ve learned that smacking someone upside the head with LECTURES and SPEECHES and RANTING only has the effect of beating someone further…and further…and further into the position that they already hold.

Seriously.  You can’t beat the “light” (which may or may not be your own point of view) into someone.

And so yesterday, I came across this article, “Pushing Back: Has the Natural Childbirth Movement Gone Too Far?”, and after reading it I thought to myself, “Crap.  CRAP.  Have I recently come across as one of those pro-VBAC or pro-natural childbirth folks who seems to be trying to beat my own position into others?!”

I am not that girl.  I don’t WANT to be that girl.

(If you do read the article, let’s just put aside the last few sentences in which the author casts VBAC as akin to Russian Roulette.  Let’s just put those sentences in a neat little compartment, stow them away, and remember that uterine rupture, while a real risk, only occurs in approximately .7% of all VBAC attempts, spontaneous or induced.  And that the VBAC success rate–which represents the number of VBACs that end in a vaginal birth–is a different concept entirely than the uterine rupture rate.)

Am I swinging my lecturing, heavy-handed sticks?  I hope not…

Because here’s the thing:

I don’t think that it is productive to use a “one-size-fits-all” approach when it comes to a woman’s decision between choosing a VBAC or a repeat cesarean.  And I do not take this approach.  I think that as long as a woman has access to transparent and unexaggerated evidence and information about VBAC and repeat cesarean, and as long as she has the unobstructed opportunity to reflect on what would be best for her and her family, then she has the tools to make a good decision to opt for a VBAC or a repeat cesarean. 

But I also don’t think that many women are given transparent and unexaggerated evidence and information about VBAC in the United States.  And when care providers continue to deny women the opportunity to choose a VBAC, and when more and more hospitals are instituting VBAC bans (whether formal or “de facto”), then women don’t have a real opportunity to reflect on what is best for them and their families.  Because they only have one option, and that is a repeat cesarean.  And while that may be the right option for some women, it is certainly not the option that all women would choose.

In that same vein, I don’t think that it is productive to be so vehemently pro-natural childbirth that one suggests that women should ignore everything that the medical community tells them.  Or that women who have labor interventions or pain medications during childbirth are somehow “failures.”  Or that women who choose a VBAC or a natural childbirth or breastfeeding are somehow morally better than those who choose a repeat cesarean or pain medication or formula-feeding.  In fact, I find all of these suggestions to be quite appalling.  (For what it’s worth, I don’t think that there are very many natural childbirth-supporters who truly hold these positions.  Oftentimes, I wonder if their/our passion and pride in their/our accomplishments come off as pontification and self-righteousness.  And I, for one, apologize if I’ve ever come off that way.)

But (and it’s a big but) I nonetheless encourage women TO ASK THEIR CARE PROVIDERS QUESTIONS.  Research birth.  Study birth.  Learn about birth.

I’m not at all suggesting that we should not listen to our care providers.  But we have a right and a responsibility to ask them questions about what may happen to our bodies at the time of our children’s births.  Because we’re dealing not only with our uteruses and our vaginas–which, depending on our care provider’s cesarean and episiotomy rates, may be cut unnecessarily–but also with our future reproductive health and with our children’s health and safety.

In addition, I think that we have a right and a responsibility to research the various risks and benefits of the interventions and medications that may be used during labor and delivery.  Cervidil.  Pitocin.  Epidurals.  Narcotic pain relief.  Amniotomy.  Cesarean section. Episiotomy.  And many others.

There are benefits and appropriate uses and times and places for nearly all medications and interventions during birth, but there are real risks to them as well.  And it is our responsibility as mothers to know these risks before our labors so that we can make an informed decision to use them and so that–as Nursing Birth and Henci Goer point out as their mission to educate child-bearing women–none of us ever has to say “But I didn’t know that was a risk” or “I would never have agreed to that if I knew that could happen.”

Finally, while I would never suggest that all women should attempt intervention and drug-free childbirths, I have suggested that all women should consider them.  And perhaps this came off as being too…you know…angsty-16-year-old-Kristen-y.

Nevertheless, there are practical reasons that one should research non-pharmacological comfort measures for birth.  And these extend beyond the various risks associated with pharmacological pain-relief.  For even if a mom wants to sign up for the epidural as soon as she walks through the hospital doors, she will most likely have to endure a few (and perhaps quite a few) epidural-free contractions until the anesthesiologist is prepared to administer the requested medication.  And if a mom’s partner knows how to apply counterpressure, or if she can reposition herself to relieve the pain of her contractions, or if she can make use of any one of the many, many non-pharmacological comfort measures that are available, then those moments while she waits to the epidural will be much more comfortable than they would be otherwise.

What’s more, these sorts of pain-relief options can even be helpful for a mom who is recovering from a cesarean section!  (I know that I was using my hypnobirthing visualizations in the recovery room as the spinal began to wear off and the nurse began applying manual pressure to my uterus.  OUCH!)

But as I also mentioned in one of my previous posts, I think that a birth in which the mother has researched her options and has chosen her options and owns her birth choices can be one that is utterly transformative and amazing and inspiring.  I’ve had this sort of experience.  I had it with A’s birth.  And let me tell you, one of the reasons I am so passionate about birth and birthing women now is that I want all women to experience the gift that his birth gave to me.  It was just that powerful.  Just that beautiful.

And my friend Ren said it best when she wrote (in response to Heather Armstrong’s recently-posted birth story):

Armstrong makes a big pile of money off of her blog because tons of people read it, and I couldn’t be happier for her right now, because I love that she just told all those thousands of women: YOU HAVE OPTIONS.   You should study.  You should prepare.  You should make the decisions yourself.  Your birth should be your own.  Not a doctor’s.  Not a midwife’s.  Not a doula’s.  Those people can support you and help you in many ways, but you should not turn over the birth of your child to someone else, no matter what degrees or certifications they may have.  And if you choose to have interventions (induction, drugs, whatever), you should choose them based on the research you have done for yourself. I don’t think women hear this enough.  No, I know women don’t hear this enough.  So I am grateful and glad for people like Armstrong who are saying it, loudly.

Because, as Armstrong relates and as I can personally attest, if you do the preparation work and do what you can to own your birth experience, it can be a miracle in your life.  Religious.  Spiritual.  Utterly transformative.  And not just because now you have this kid to contend with.  The kid is a separate miracle. The birth experience is something different.  Something extra.  Something for you (and hopefully your partner, as well).  If you choose to make it so.

And I hope you do.

In a non-pontificating, non-self-righteous sort of way, of course.