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.

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

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

From CNN

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

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

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

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

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

From MSNBC

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

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

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

From the BBC

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

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

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

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

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

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

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.

Lamaze International’s research blog, Science and Sensibility, has announced a call for submissions for its second Healthy Birth Blog Carnival.  Whereas their first blog carnival showcased bloggers and other guest posters writing about letting labor begin on its own, this second carnival will feature posts on walking, moving, and changing positions during labor.

According to the Lamaze Healthy Birth Practice paper on this subject, research shows that:

…when compared with policies restricting movement, policies that encourage women to walk, move around, or change position in labor may result in the following outcomes:

• less severe pain,
• less need for pain medications such as epidurals and narcotics,
• shorter labors,
• less continuous monitoring, and
• fewer cesarean surgeries (Lawrence et al., 2009; Simkin & Bolding, 2004; Simkin & O’Hara, 2002).

In fact, no woman who participated in any of the research studies said that she was more comfortable on her back than in other positions (Simkin & Bolding, 2004). No study has ever shown that walking in labor is harmful in healthy women with normal labors (Storton, 2007).

So it is easy to see why walking, moving, and changing positions is a healthy birth practice!

For this post, I’d like to document and describe the ways that I walked, moved, and changed positions throughout my labor.  And this is because I think that it is important for women to have access to images of real women who are really laboring and who are really able to walk and move and change positions throughout their child’s birth.

Worth noting is that for most of my labor, I just followed my body’s signals and natural instincts when changing positions.  Sometimes, I also changed positions based on what my doula suggested. 

And for the entire time, I found my labor to be an intensely powerful, empowering, and healthy experience.

A few “stats” about my labor before I begin:

• Even though this was my second child, I was a “first-time laborer” since my first child was born via a pre-labor cesarean section.
• My labor began with my membranes rupturing.
• My contractions began approximately 1 1/2 hours after my membranes ruptured.
• My entire labor lasted a little over 14 hours (or 15 hours if one were to count the irregular, painless contractions I was having in the hour before my water broke).
• I labored at home for approximately 8 1/2 hours before leaving for the hospital.
• My cervix was 1-2 cm dilated and nearly 100% effaced by the time I was checked at the hospital.
• Three hours later, my cervix was dilated 4 cm.
• Just over one hour later, I was fully dilated.
• I actively pushed for about 35 minutes before delivering my healthy 8 lb. 3 oz. baby.
• And I moved and grooved all throughout my labor.

This is what it looked like.

Here I am in early labor, kneeling over the armrest of the couch.  Obviously, the contractions weren’t terribly intense at this point since I could still talk on the phone.  (I do believe, however, that I ended up throwing the phone onto the end table about ten seconds into my next contraction!)  Nonetheless, even though the contractions weren’t very intense, I still found that this position helped to relieve the discomfort that they caused.

What else does kneeling help to do?

It can help to relieve backache, it can encourage the rotation of the baby, it can help a mom to move and/or rock through her contractions, and it also provides a mom’s labor support team with access to her lower back for counter pressure.  One can also kneel over a birth ball or over the back of a raised hospital bed.

Here I am laboring on my side.  I was still in the early phase of my labor, so I wanted to relax as much as possible before the really hard work began.  I used one of my hypnobirthing deepening exercises to help me do just that.

How does side-lying help a mom during labor?

It helps to promote rest and relaxation in early labor, it can help to improve fetal oxygenation (especially when a mom is on her left side), it can help to slow down a precipitous second stage, and it can help to encourage fetal rotation.  It is also a good “alternative position” (instead of lying flat on one’s back) for a mom using epidural analgesia.

Here I am standing to stop for a contraction after walking around the house for a while.

Standing and/or walking throughout labor gives a woman the advantage of gravity to help the baby descend, it encourages the rotation and descent of the baby, it can help to bring on more productive contractions, and it also helps the baby to be well-aligned with the mother’s pelvis.  What’s more, it is yet another position that gives a mom’s labor support team access to her back for counter pressure and/or other touch-based comfort measures, if she desires them.

One of the other great standing movements is to slow dance with one’s partner, doula, or other labor support person.  (I slow-danced with my husband, Tim, right after this picture was taken!)  Besides providing emotional closeness(especially if one is dancing with one’s partner), dancing can offer a mother all of the benefits of walking or standing while allowing her to take some of her weight off of her feet.

Remember how I mentioned the “really hard work” that was on my horizon?

It had definitely begun by the time this picture was taken.

And laboring on my hands and knees felt like the most comfortable and most natural position for me to be in at this point.

Being on one’s hands and knees during labor can help to relieve backache (which I was definitely experiencing here), can encourage the rotation of the baby, and can also allow access for back massage and/or counterpressure.  Doing pelvic rocking while on one’s hands and knees is also an especially good exercise for encouraging the rotation of a baby in the occiput posterior position.

Here I am standing and leaning against the stairs.

As with most upright positions, this position gives moms the advantage of gravity, it can encourage more productive contractions, it can help with fetal rotation, and it can be more restful than standing alone (and putting all of one’s weight on one’s feet).

Since the stairs are pictured here, I should mention that I also made quite a few trips up these stairs during my labor.  Climbing stairs can also enhance rotation of the baby and pelvic mobility, and it may help to “speed” up one’s labor even more than walking does.

Worth noting is that most of those trips up the stairs were taking me to our bathroom, where I spent a good deal of time laboring on the toilet.  (For obvious reasons, I have no photos of this!)  Laboring on the toilet gives a mom the assistance of gravity while still allowing her to “rest,” and it may help her to relax her perineum.  (It is usually not recommended for moms who have trouble with hemorrhoids, however.)

Here I am sitting and swaying on my birth ball.  This proved to be tremendously helpful during the time that I labored at home.

In addition to offering a mom the advantage of gravity, swaying on a birth ball can help to enhance pelvic mobility.  It is also much more comfortable than merely sitting on a chair!

As you can see here, using this particular position with the birth ball also allowed me to gain the advantages of leaning, to receive some emotional support from Tim, and to get the back-relieving benefits of counterpressure from my amazing doula, Chris.  So this was really the “mother” of all laboring positions!  (Sometimes I can’t help myself when it comes to silly birth-puns…)

Here I am at the hospital, lying on my side just as I did at home during early labor.

I was strapped to the wires and transducers needed for the electronic fetal monitor (and didn’t have access to the telemetry unit yet), so my range of mobility was significantly limited.  And even though I needed to rest and “re-group” after a night of laboring and after discovering that I was “only” 1-2 centimeters dilated, the very fact that my range of motion was limited seemed to make coping with my contractions more difficult.

In fact, the time that I spent in the hospital bed, strapped to the monitors, was the only time that I ever considered asking for pain medication during my entire 14-hour labor.

But then I got in the water.

Oh, the water!  Take a moment to review the look on my face in the above picture and then the look on my face as in the picture to the right.  These pictures were taken within about three hours of each other.  And in the one to the right, I am a little less than two hours away from holding my baby in my arms.

Hydrotherapy during labor (which also includes laboring in the shower) can be very relaxing and can help to reduce the intensity of the pain of contractions.  Notably, women are generally advised to avoid getting into a tub or jacuzzi until they are at least 4 cm dilated since getting in the tub “too early” can contribute to irregular and/or less frequent contractions.

In addition, although these items are not visible in the above photograph, moms laboring in the water should also have access to a cold drink (my choice was Gatorade) and cool washcloths so as to help regulate their body temperature.

(Although a bigger tub–or an actual birthing tub–would have been preferable to the hospital’s small bathtub, I was still able to float in between contractions and to move my body during contractions.  In other words, I was still able to move and change positions while in the tub!)

I began pushing while lying on my side.  Although I did not find this to be the most comfortable and advantageous pushing position for me, pushing on one’s side does have some specific benefits.  In particular, this position encourages good fetal oxygenation, it is helpful for moms with elevated blood pressure or who are using epidural analgesia, and it allows the mother to rest in between contractions.

I eventually moved to my hands and knees while pushing and then rested in a sitting position in between contractions.

As one of the many optimal birthing positions, pushing on hands and knees can help to improve fetal heart tones, it can assist with fetal rotation (especially for a baby in the occiput posterior position), it is an excellent position for a woman expecting a large baby, and it can help a mom to avoid a laceration or an episiotomy.

And it was certainly a position that helped this first-time-pusher to deliver her 8 lb. 3 oz. baby after only 35 minutes of active pushing!

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.)