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.

Remember the Obstetrics & Gynecology editorial on VBAC I wrote about a couple weeks ago?

As of just a few days ago, the online version of the editorial was not available to the public.

Until I wrote this letter:

Dear editorial staff at Obstetrics & Gynecology:

One of my friends recently (and generously) shared a copy of Dr. Scott’s
editorial (“Solving the Vaginal Birth after Cesarean Dilemma”) from the June
2010 issue of your publication.  As a doula, birth advocate, and mother who
had to fight hard to have a VBAC, I was heartened, even excited, by what Dr.
Scott wrote in his piece.  And as I’ve summarized the editorial to other
friends and fellow VBAC advocates, I’ve found that many others share my
enthusiasm.

I was wondering if there was any possibility that you could make the
editorial free to the public.  I don’t know what your protocol is for
expanding article availability in this way, but I do think that this piece
in particular would be enormously helpful for women who would like to
facilitate a reasoned and informed discussion about VBAC with their care
providers.

Sincerely,

Kristen Oganowski

And received this response yesterday evening:

Dear Ms. Oganowski:

Thank you for your message. We have considered your request. The editorial is now free to the public.

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THE EDITORIAL IS NOW FREE TO THE PUBLIC!!!

Now please go and enjoy it in its entirety if you haven’t been able to read it yet!

The June 2010 issue of Obstetrics & Gynecology–or “The Green Journal,” the American College of Obstetrics and Gynecology’s (ACOG) research publication–includes three articles that address vaginal birth after cesarean (VBAC).

One is a research article addressing maternal and neonatal outcomes associated with VBAC.

One is a letter, written by the president of ACOG (Dr. Richard Waldman), addressing the social and practice changes ACOG members can make to improve both their professional climate and the birthing climate for their patients.  (This letter is also a synopsis of his 2010 inaugural address.)

And the other is an editorial (entitled “Solving the Vaginal Birth after Cesarean Dilemma”) written by the journal’s editor-in-chief, Dr. James R. Scott, MD.

This editorial begins by addressing the NIH Consensus Development Conference on VBAC and the accompanying NIH Statement on VBAC.  And in the spirit of the NIH Statement, Dr. Scott’s piece was a (surprisingly) refreshing read.

In fact, in many ways Dr. Scott’s editorial simply reiterates many of the points made by the NIH panel in their statement on VBAC.

And this isn’t in any way a “bad thing,” in my humble opinion.

For in barely a page-and-a-half, he makes sure to point out that:

1. The “immediately available” language in the 1999 ACOG Practice Bulletin on VBAC had the “unintended consequence” of leading to a drastic reduction in the number of hospitals and care providers that support VBAC.
2. …”the overall risk for perinatal mortality and morbidity with trial of labor is similar to that for any nulligravid woman in labor.”  (In layperson’s terms, a “nulligravid” is a woman who has never given birth.  So what this means is that if you were to attempt a VBAC, you would face a  risk of perinatal mortality and morbidity that is similar to the same risk faced by a woman having her first baby.)
3. The “immediately available” standard seems incongruously applied to VBACs when one takes into account non-VBAC related obstetric emergencies such as cord prolapse and placental abruption.  Both of these emergencies, which can happen during any attempted vaginal birth, occur nearly as frequently as uterine rupture, and both have similar (if not “worse”) perinatal morbidity and mortality rates.  In this respect, the “immediately available” standard (which requires an OB/GYN and an anesthesiologist to remain “in-house” throughout active labor) is unfairly applied to VBACs.
4. Limited hospital staff resources make it impossible for the “immediately available” standard to be applied to all hospitals that offer labor and delivery services, both now and in the future.  Thus, the “solution” to the aforementioned incongruity isn’t to apply this standard to all vaginal births.
5. The choice between VBAC and repeat cesarean delivery is ultimately the woman’s choice.  And she should receive accurate information from her care provider so that she can make an informed decision.
6. OB/GYNs should “‘find a way’ for those [women] who want the option of VBAC.”  (Dr. Scott recommends that hospitals incapable of providing 24/7 anesthesia should consult the New England Perinatal Quality Improvement Network VBAC program for recommendations on safely supporting VBAC.)
7. We cannot fully address the issue of VBAC without also addressing (and finding ways to reduce) the rising primary cesarean rate.
8. And finally, “unless measures are instituted to reverse the rapidly rising cesarean rate, catastrophic complications from placenta accreta and percreta associated with multiple repeat cesareans soon may be a greater problem than uterine rupture.”

Dr. Scott is not the first person to make any of these claims.

In fact, many birth advocates have been making them for years.

But I’m happy to know that the editorial staff of Obstetrics & Gynecology is stating these claims loud and clear for all of their readers: that is, for all of the members of ACOG, many of whom currently deny their patients the opportunity to even choose a vaginal birth after cesarean.

Now let’s just hope that there is a noticeable uptake to Dr. Scott’s remarks.

Amy Romano and I are currently in the process of collecting and editing all of the fantastic contributions to the NIH VBAC Statement Primer.

As we get closer to publishing the primer on the new Lamaze community site, Giving Birth with Confidence, we’re also starting to think about the sorts of images we’d like to include in this project.

Although Amy and the site administrators at Giving Birth with Confidence do have a good number of stock images related to pregnancy and childbirth at their disposal, we’d like to keep with the grassroots spirit of this project and include some personal photographs in the primer.

And we’d like to receive some of these photos from you!

Do you have pregnancy pictures you’d be willing to share?

Cesarean section pictures?

Pictures of you during labor?

Pictures of you and/or your family with your VBAC baby?

Pictures from the NIH Consensus Development Conference on VBAC?

Pictures of you at an ICAN meeting, a birth rally, or any other pregnancy and childbirth-related event?

If you’d be willing to include any of these photos in the online version of the NIH VBAC Statement Primer (which, to reiterate, will be housed on the Giving Birth with Confidence site), then please send them via email to me at:

koganowski (at) gmail (dot) com

Just to be as clear as possible, these images will be shared on a public site, so please don’t send any photographs that you wish to keep relatively private.

I look forward to hearing from you!

Women making a difference! Jen Kamel (from VBACfacts.com), Desirre Andrews (president of ICAN and contributor to the primer), Gina Crosley-Corcoran (The Feminist Breeder), and yours truly at the NIH Consensus Development Conference on VBAC.

Dear Taffy Brodesser-Akner,

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

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

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

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

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

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

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

It all began with the tag line:

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

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

But does it accurately capture VBAC itself?

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

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

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

And we are not alone in experiencing these fears.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But I also want you to give birth with confidence.

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

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

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

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

We all deserve a bit better than that. 

You do too.

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

Kristen

Remember way back in mid-March when I returned from the NIH Consensus Development Conference on VBAC with a heapload of inspiration and energy to transform maternity care and access to VBAC in the United States?

I haven’t written much about my goals since then, but this doesn’t mean that the momentum I carried home from the NIH has fizzled out in the passing weeks.

Quite the contrary, in fact.

It’s just that I’ve been doing a lot of “behind the scenes” work.  (It should come as no surprise that my goals will take some hefty organizational efforts!)

And as it stands right now, it looks like the first of my goals to materialize will be the “NIH VBAC Statement Primer”–a proverbial “how-to” guide to help consumers use the  statement to their advantage.

To explain, the consensus statement has all sorts of amazing potential to transform thoughts on and access to VBAC in the United States.  (Simply describing VBAC as a “reasonable option” is amazing enough!)

What’s more, birthing women can and should be a part of this transformation!  But we also need to know how to use the NIH statement to fight for this much-needed change.

My hope is that the primer will offer just this sort of knowledge and empowerment to all women who even just consider VBAC as one of their birthing options.

Much to my excitement, lots of other birth advocates, organizations, and bloggers (including Amy Romano, with whom I’ve partnered up for this project) share my enthusiasm over these possibilities!

In fact, just last week, Mother’s Advocate even published on their blog a guest post from me about the NIH VBAC Primer!  (Head on over there to read more about my inspiration for the primer, and about our general time frame for this project.)

Until we get this thing written and published–and this may take a while, especially considering that the NIH panel has not yet released their final statement on VBAC–here is a very rough sketch of what we would like to be included in this primer.  Please let me know in the comments section if you have any questions, concerns, or other issues you’d like to see addressed in the primer.  Again, we want this to be something that women can really, truly  use to advocate for themselves and their births!

The NIH VBAC Statement Primer: An Outline

General

• An explanation of the purpose and scope of the primer, and of the NIH Consensus Statement on VBAC
• A definition of the terms used in the statement

Statistics and Research

• An outline of the risks and benefits of TOL (trial of labor), VBAC, and ERCD (as limited to the ARHQ report, the statement, and perhaps the research presented at the conference)
• A examination of VBAC success rates and prediction models
• A brief outline putting all obstetric emergencies (not just uterine rupture) into perspective

Analysis

• Ideal candidacy – How is this term defined in the statement?  What does this mean for women who are OR aren’t “ideal” candidates?
• The “immediately available” standard – What is the history of this standard?  What were the NIH panel’s recommendations regarding this standard?
• Inconclusive research – What “critical gaps” did the panel find in the research on VBAC?  What is the significance of this “inconclusiveness” for women seeking a VBAC?
• Legal rights and protections – What legal rights and protections do all pregnant women have?  How does the right to informed consent and refusal apply specifically to women who want a VBAC?  How do these rights and protections function in the context of the NIH Consensus Statement on VBAC?

Action

• Advice on “follow-up” local media pitches (e.g. regarding VBAC bans, changing policies and practices, etc.)
• Advice on how to pressure hospitals and care providers to publicize their TOL policies, their VBAC rates, and (for hospitals) their plans for responding to all obstetric emergencies-not just uterine rupture (per the NIH panel’s recommendations)

Advice on using the information in the primer

• Tips on discussing birth options with one’s care provider (or multiple care providers, if one is trying to find a “best fit”)
• Tips on seeking out support and educational organizations

Lamaze International’s fifth Healthy Birth Practice Paper is all about pushing: pushing in an upright position, pushing according to your body’s urges, pushing in a way that both maximizes a woman’s comfort and safety and encourages the rotation and descent of her baby.

It’s all about pushing in ways that research shows are healthy for moms and babies!

Nevertheless, despite the evidence supporting the “spontaneous pushing” (or physiologic pushing) that Lamaze and other birth advocates and researchers recommend, it’s not often that we actually see women pushing spontaneously.

As I’ve reflected upon my VBAC, however, I’ve realized that I did follow the healthy pushing practices set out by Lamaze International.  And this was not because I was a “better” pusher or a “better” birther than anyone else. And it wasn’t just because I knew that spontaneous pushing was healthy.

It was also because I had a support team who knew that spontaneous/physiologic pushing was healthy.

We knew that pushing in upright positions helps to facilitate a baby’s rotation and descent into the birth canal.

We knew that I needed to find the pushing position that worked best for me.

We knew that I needed time to rest in between pushes and in between contractions.

We knew that following my urge to push would decrease my likelihood of perineal and pelvic floor damage.

We knew that pushing in a calm and unrushed environment–and not pushing to a count of ten–would help to maximize my own and my baby’s oxygenation.

And they knew when to step back and allow me to do my work, and they knew when to step in and encourage me to change positions, to stay hydrated, or even to trust the process of birth itself.

This is what it looked–and sounded–like.

(It should be noted that I am publishing these videos with some hesitation–not because I am embarrassed about publicly displaying my “birthing behavior” but because I am offering what was perhaps the most vulnerable moment of my adult life up for public consumption.  Exposing that vulnerability is a bit daunting.  Nonetheless, I love these videos, and I love thinking about what they could help to share with other women and birth professionals.

And one more thing: these videos are not still images from my labor.  They are actual videos of the birth.  I grunt, I groan, I vocalize, and sometimes I even shriek. Birth is hard work.  But I want everyone to know–and especially those women who haven’t yet given birth–that these guttural, strange sounds were not scary to me.  Birthing was intense, and even painful, yes.  But the sounds were what helped me to cope with that intensity, with that pain.  So don’t be frightened when you hear me moaning like a beast!  I was just being a warrior!)

Transitioning from “grunty contractions” to feeling the overwhelming urge to push.

(This one includes the famous “10 cm picture!”)

Puuuushing.

(Adjust your volume accordingly.)

Birthing my baby.

(Again, adjust your volume accordingly.)

All apologies for the poor lighting in these videos.  I was willing to sacrifice a well-lit video for a dimly-lit place to birth, though!

So we all know that What to Expect When You’re Expecting is the preeminent source on pregnancy and childbirth for women in the United States, right?

I mean, copies of that books are everywhere right?  So it must be “the best,” right?

Well, that’s what some clever (and aggressive) marketing would have us think.  But it’s not necessarily true.

(And for the record, WTEWYE is not the “best” book on pregnancy and childbirth, in my honest opinion.  My “best books” are listed on the right.  Read them.  Inform yourself.  Empower your birth.)

Now, I’m not here to “take down” the whole book and all of its paternalistic and even mis-informative advice.  Others have taken on that critique long before I sat down to write this  post.

But I am here to offer a “critique” of the “What to Expect” website’s advice-ish page on VBAC.  (Yes, I’m blogging about the silly things people say about VBAC uh-gain.)

Because if women are reading the “What to Expect” site when they’re trying to make a decision between VBAC and repeat cesarean, then they are gaining some seriously misleading and unhelpful information about VBAC.

Just take a look at some of the statements I found on the site:

“Forty percent of women who had a prior cesarean section do end up having a repeat.”

This is a misleading statement, though perhaps unintentionally.  Of all women with prior cesareans in the United States, less than 10% currently even attempt a VBAC.  So this means that over 90% of women will “end up having a repeat.”

But even if the author of this page meant to convey the rates of VBACs that are successful or unsuccessful (or that end in a vaginal birth or a cesarean section), this statement is still misleading.  With VBAC success rates ranging between 6o% and 80%, it seems more accurate to state that “twenty to forty percent of women who had a prior cesarean section and who attempt a VBAC do end up having a repeat.”

Even better?  How about, “Sixty to eighty percent of women who try for a VBAC do end up having a vaginal birth.”  (See how much more accurate and positive that statement is?)

*

“Causes like fetal distress, preeclampsia, a breech position, or placenta previa don’t generally spill over from pregnancy to pregnancy, nor is having had a large baby before any reason to think you’ll have one this time (especially if you kept your paws off the Krispy Kremes and kept your weight gain under control). If the reason was a chronic condition like high blood pressure or diabetes, though, you’d better steel yourself for another surgery.”

Why don’t we throw in a few fat-slurs in there and call it a day!

GOOD LORD.

I mean, I appreciate some good “girlfriend advice” as much as the next gal,* but this seems more like advice from some passive-aggressive chick who likes to put down her overweight pals with snarky comments about doughnuts.

NOT!  HELPFUL!

Why not offer some information about prenatal nutrition and its role in helping women to achieve healthy pregnancies and healthy births?  (And for what it’s worth, being classified as “overweight” or “obese” does not necessarily mean that a woman isn’t eating a good prenatal diet!!!)

And why not point women who might need to “steel themselves up for another surgery” toward some cesarean support groups such as ICAN?

Otherwise, the advice here just seems insensitive, and even a bit mean.  (Or perhaps I’m the overly insensitive type?  Perhaps.  I do love me some Krispy Kremes after all!)

*

“Remember that there’s no advantage (moral or otherwise) to a VBAC, so even if you could try for one, you’re absolutely entitled not to go for it if the risks make you uneasy.”

Okay.  You know those cartoons where the character’s face turns red and then steam starts shooting out of their ears and there are all sorts of steam engine or train whistle sound effects?

That’s exactly what was going on inside my head when I read this sentence.

A moral advantage to VBAC?  You mean the sort of advantage where St. Peter is gonna be all like, “Well, lady, you’d be getting through these here gates to heaven if you had just chosen that VBAC over your repeat cesarean.  TOO BAD YOU DIDN’T TAKE THE MORAL PATH!!!”

Jay-zus.

No!  There isn’t a moral advantage to VBAC!  And there’s no moral advantage to repeat cesarean either!  (Although there are moral advantages to making sure that women are accurately and thoroughly informed about the risks and benefits of both of these birthing options!)

Look, I agree with the end of this statement: any woman with a scarred uterus is absolutely entitled not to go for a VBAC if the risk (of uterine rupture) makes her uneasy.

But, as should be obvious, any woman with a scarred uterus is absolutely entitled not to go for a repeat cesarean if the risks make her uneasy.

Oh, and there are some “otherwise” advantages to VBAC.  In fact, there are advantages for women (e.g. a lower maternal mortality rate when compared with elective repeat cesarean) and for their babies (e.g. a significantly lower rates of respiratory morbidity and NICU admission when compared with babies born via elective repeat cesarean)!

So don’t go telling women that there are no advantages!  Exclamation point!

*

“…they might want to keep you off the meds to avoid masking the pain that could point to potential rupture.”

Well, sure, they might.  I’ve heard of some individual practitioners having a “no epidural during VBAC” policy in place.

But it should also be noted that even ACOG notes that epidurals “rarely mask the signs and symptoms of uterine rupture.”  So while there may be good reasons to approach epidurals with some level of caution in any labor, there are also good reasons for women to question those “no epidurals during VBAC” policies.

*

“Finally, if it doesn’t work out (and remember one in five births are cesarean), try to take it in stride.”

No, remember this: One in three births are cesarean.

Mmmkay.  Thanks.

*

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

*

BLAAAARRRRRRGHHHH!  STEAM COMING OUT OF THE EARS AGAIN!!!!

I wrote about statements such as this one a long time ago.  In brief?

Healthy moms and healthy babies do matter.  They matter a whole hell of a lot.  But they’re not all that matters.

*

So in the end?  While I’m sure that the authors of WTEWYE are really, truly well-meaning individuals who just want to help out a pregnant women or two (million), I think my expectations of their advice have been tremendously lowered after reading their “lowdown on VBACs.”

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

* Your Best Birth: Know All Your Options, Discover the Natural Choices, and Take Back the Birth Experience is much better at the “girlfriend advice” on pregnancy and childbirth, in my opinion.

One of my previous doula clients recently mailed me a copy of a “patient safety update” that she received from her current OB/GYN practice.*

The topic of this particular patient safety update was vaginal birth after cesarean, or VBAC.**  And it was…”interesting.”

In fact, it was so “interesting” that I’ve transcribed the entire document below, for your reading “pleasure.”  (And just so I don’t color anyone’s opinion of the safety update before you read it, I’ve left my editorializing for the end.)

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

Patient Safety Update: Vaginal Birth After Cesarean (VBAC)

On a monthly basis the staff of **** meets to discuss current practice protocols and to review various patient safety issues raised by our staff.  We jointly discuss challenging cases from the preceding month as well as those due to deliver in the near future.  Our goal has always been to provide the safest medical care possible to our patients.  The topic for our recent meeting was a review of the safety implications of Vaginal Birth After Cesarean Section, more commonly known as VBAC.

Trends:

Fewer women are attempting a Trial of Labor after a Cesarean.  There are several potential reasons for this: medical and legal pressure; changes in patient and provider preference; changes in obstetrical practice; and publication of complications related to vaginal delivery and failed trial of labor.

The most serious concerns are increased risks of uterine rupture and perinatal death.  A recent study of 33,000 patients showed that the risks of uterine rupture, hysterectomy, thromboembolic disease (blood clots), transfusion, severe infection, and death are 56% greater in women attempting VBAC vs. Repeat Cesarean Section.***  Overall you would need to do 588 elective Cesareans to prevent one poor perinatal outcome.

Summary

588 Cesareans to prevent one poor perinatal outcome is acceptable to some but not to others.  Our group is evenly divided.  Some of our physicians do participate in VBACs and some do not.  As a result the following key points need to be understood by our patients.

If you definitely want to have a trial of labor and attempt a VBAC, you should consider transferring to a practice that supports VBACs completely.

If you want a VBAC and stay with the practice it must be understood that you will not be guaranteed the opportunity to have a VBAC attempt.  On certain days there might not be a physician who will participate in a VBAC trial of labor.

A trial of labor is definitely more risky for the baby than an elective Cesarean Section (much in the same way that labor is more risky than an elective cesarean section).  You must be willing to accept that risk in order to proceed with a trial of labor.

We regret any inconvenience this may cause to our patients planning to attempt vaginal birth after cesarean section.  We urge our patients to stop and contemplate the statistics listed above.  We plan to meet individually with the patients affected by this decision and address their individual concerns.

Thank you.

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

Oh, where to begin.

How about with this: I think that framing this issue as a “patient safety update” is problematic, to say the least.  For if I were to receive a letter from my care provider (OB/GYN or not) alerting me to a patient safety update, I would automatically think that the information contained therein would be primarily concerned with protecting me from harm.  With keeping me safe.

Thus, it seems reasonable to assume that many women who received this “patient safety update” have approached this document with the belief that the OB/GYNs at this practice had a safety concern about vaginal birth after cesarean.

And it seems quite obvious that the safety concern here places an extraordinary emphasis on the risks of VBAC (and labor, for that matter) without giving even a mere mention of the risks associated with repeat cesarean section.

It makes no mention of the current research concluding that babies born after VBAC have significantly lower rates of respiratory morbidity and NICU admission than babies born after elective repeat cesarean.

It makes no mention of the recent report concluding that elective repeat cesarean is associated with a threefold increase in maternal mortality when compared with vaginal birth after cesarean.

It doesn’t even mention any of the risks associated with repeat cesarean sections, including abnormal placentation in future pregnancies (which can lead to life-threatening problems), bowel obstruction, and blood clots.

I’m sorry (and I’m angry), but highlighting the risks of VBAC (and LABOR!) in a “patient safety update” on VBAC without even mentioning the risks of elective repeat cesarean does not offer transparent information to the women in this practice.  In fact, I’m not even sure that it best keeps patient safety in mind. 

How can a woman make a major decision such as this one without knowing the risks (and benefits) of both options?

How can she even go on to rationally weigh those risks and benefits when she has received a letter putting the fear of God into her about VBAC?

It should be stated that I wholeheartedly support a woman’s right to choose a repeat cesarean delivery over a VBAC.  Wholeheartedly.

But failing to present a woman with the risks and benefits of VBAC and repeat cesarean in a letter such as this one undermines her ability give informed consent to either option.

So at best–and despite the fact that the practice recommends that women seeking VBAC should switch to a more VBAC-supportive care provider–this letter is disingenuous.

And at worst, it strikes a major blow to women’s ability to give informed consent to what they do with their bodies in order to birth their babies.

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

*I want to extend a hearty thanks to my doula client for thinking of me after reading this “safety update.”  Quite simply, she rocks!

** I think it is no coincidence that this letter was sent out mere days after the NIH Consensus Panel released their statement on VBAC.

***It’s worth noting that a recent Agency for Healthcare Research and Quality Report determined that “the rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL [trial of labor, or VBAC attempt] and ERCD [elective repeat cesarean delivery].”    Even the 2004 Landon study, which this practice may have been referring to when they mentioned that “recent study of 33,000 patients,” concluded that while the rates of endometritis and blood transfusions were higher in women attempting VBAC than in women undergoing repeat cesarean, “the frequency of hysterectomy and of maternal death did not differ significantly between groups.”

Have I mentioned anything about that NIH Consensus Development Conference on VBAC yet?

(I kid, I kid.)

I realize that I’ve devoted six consecutive posts to the NIH VBAC conference.  That’s a lot, even for an obsessive person like me.  But I also really think that the conference was that important.

And before I ride off into the sunset and get back to writing about things like riding crops, lavender oil, and doctors who fail to woo me with their paternalism, I’d like to contribute one more serious thought to the conference and the consensus statement that it produced.

More specifically, I’d like to reveal the three main goals that this conference has spurred me to take on in the coming year(s).

And these goals are big.  They’re bigger than anything I can successfully do on my own, and I’d love to request others’ help in accomplishing them.

And that’s because I’m planning to:

1. Develop a “NIH Consensus Statement Primer” to help women use the consensus statement to their advantage.
2. Organize a conference on pregnancy ethics, primarily to meet Dr. Anne Lyerly’s call for a “more robust pregnancy ethics” but also to respond to the concerning statements about pregnancy, personhood, and autonomy made by Dr. Laurence McCollough.
3. Create an alliance between birth advocates and OB/GYNs to work together on tort reform.

I know.  It’s as if someone stuck a stick of dynamite under my ass and ten shots of espresso into an intravenous line in my arm and a little fairy next to my ear whispering sweet nothings about the future of birth advocacy.

And if these goals aren’t entirely clear to you yet, here’s my best shot at explaining what I have in mind at the moment:

The Primer

As I’ve mentioned before (and as others have argued elsewhere), the consensus statement is not perfect.  In my mind, the absence of any clear positions on VBAmC (or vaginal birth after multiple cesareans) or the right to informed refusal are serious deficiencies of the statement.

Nonetheless, there is a lot in the statement that women who want to a VBAC or who are even just considering a VBAC can use to their advantage, whether with their care providers, their hospital, their local media, or even their friends and family members.

The authors’ focus on providing transparent and accurate information about VBAC and repeat cesarean to women is of particular importance, as is their emphasis on the significance of the shared decision-making process when it comes to a woman’s birthing options.  What’s more, their call for the American College of Obstetrics and Gynecology (ACOG) to reassess their controversial “immediately available” anesthesiology standard gives women an important foundation with which to challenge their local care providers’ and/or hospitals’ “VBAC bans.”

And I, for one, think that it would be fantastic to create a short primer explaining just how women can use this wealth of information to advocate for themselves and their right to choose the way they birth their babies.

So to create such a primer, and to create one that could be an effective tool for change and advocacy, “we” would need to determine (among other things):

• Which parts of the statement are most compelling to OB/GYNs and other care providers
• Which parts of the statement are most compelling to hospitals
• Which parts of the statement are most compelling to the media
• Which parts of the statement coincide with, reflect, or even illuminate a woman’s right to informed consent and informed refusal
• How to make these “compelling” parts of the statement accessible to and usable by most women

The Conference

During her talk on “The Ethics of Vaginal Birth After Cesarean,” Dr. Anne Lyerly expressed the need for an “ethical framework specific to pregnancy”—one that could accommodate the relatively under-investigated concerns about autonomy, responsibility, decision-making, personhood, and values in relation to pregnancy and birth.

Not surprisingly, the philosopher in me lit up like a round of fireworks at Socrates’ backyard barbecue when I heard her talk about this topic.  I mean, I know a thing or two about philosophical conceptions of autonomy and personhood.  I even know a thing or two about pregnancy and birth.

And there’s also a part of me that knows a thing or two about organizing and presenting at conferences.

What better way to collaborate on developing an “ethical framework specific to pregnancy” and a “more robust pregnancy ethics” than to start with a conference that brings together those who work in academia, law, midwifery, medicine, and birth-work in general?

The list of resources needed to organize such a conference is a bit daunting, I’ll admit.  Off the top of my head, “we” would need:

• A location
• Interested speakers
• An interested audience
• Interested organizers
• Funds, funds, and more funds

Again, the idea is daunting.

But not impossible.

The Alliance

I’d like to preface this section by stating explicitly and without reservation that I would only participate in such a group just so long as its goals and/or actions did not throw women “under the bus” (or the knife), so to speak.

Nonetheless, one cannot ignore the number of times in which conference presenters and audience members mentioned medico-legal concerns and the fear of liability when discussing the current “VBAC climate.”  Even if these fears are partly irrational when specifically applied to VBAC, they are real fears, and they are really affecting care providers’ and hospitals’ decisions to refuse to attend and/or ban VBACs.

(For example, although the risk of uterine rupture is approximately .7% in a VBAC labor, and although only 6% of uterine ruptures result in a catastrophic outcome, many care providers’ views of the relative safety of VBAC are overshadowed either by malpractice insurance pressures or by stories of multi-million dollar lawsuits following those exceedingly rare catastrophic uterine ruptures.)

In my mind, it seems as if these fears are so embedded into the way that these doctors approach VBAC that solely “fighting” the fears with evidence-based medicine and/or the consensus statement itself will not be enough to change their policies and practices regarding VBAC.

But fighting these fears with a tempered, woman-friendly tort and/or legal reform might be a significant part of good pragmatic, strategic, and mutually beneficial “solution” to the current “fear of VBAC.”  (For what it’s worth, recommending a VBAC consent form in which women abdicate their right to sue following a uterine rupture is neither woman-friendly nor mutually beneficial.)

Returning to the issue at hand, my ears especially perked up during the NIH Conference when Eugene Declercq himself called for birth activists to form an alliance with OB/GYNs to work toward tort reform.  Professor Declercq is an incredible birth and maternity advocate who, as far as I can tell, has no reason to engage in “obstetrical apologism” regarding the lack of VBAC access in the United States.  In other words, I highly doubt that his recommendation was meant to throw birthing women to the wolves all in the name of the ever-elusive tort reform.  And, as should be obvious by now, I’ve taken his recommendation to heart.

Of course, forming and participating in such an alliance and/or coalition will involve some hard and heady work.  (For my part, it will involve me getting to know a thing or two more about our legal system!)  In fact, the very list of things that “we” would need to do would expand this already expansive blog post into an epic size.

But accomplishing any number of items on that list could have a profound (and positive) impact on birth advocates’ strategies for and ability to effect some meaningful change in the world of maternity care in the United States.