their CPD babies. What an inspiration!
New
ACOG VBAC Guidelines: Same Old, Same Old or a Step
Forwarrd by Carrie Murphy [12/7/16] -
Perhaps the most intriguing
difference is that the 2017 Bulletin drops the requirement
that staff be “immediately available” to provide emergency
care. Instead, it recommends that VBAC labors “be
attempted in facilities that can provide cesarean delivery
for situations that are immediate threats to the life of
the woman or fetus.” This may be a distinction without a
difference, but perhaps not. A sticking point for offering
VBAC has been the interpretation of “immediate” to mean
the woman’s OB had to be on site throughout her labor. The
new phrasing may open the way to alternative solutions.
NIH
Consensus Development Conference on Vaginal Birth After
Cesarean: New Insights [pdf
version]
March 8–10, 2010
Conclusions: Given the available evidence, TOL is a reasonable option for many pregnant women with a prior low transverse uterine incision. The data reviewed in this report show that both TOL and ERCD for a pregnant woman with a prior transverse uterine incision have important risks and benefits and that these risks and benefits differ for the woman and her fetus. This poses a profound ethical dilemma for the woman as well as her caregivers, because benefit for the woman may come at the price of increased risk for the fetus and vice versa. This conundrum is worsened by the general paucity of high-level evidence about both medical and nonmedical factors, which prevents the precise quantification of risks and benefits that might help to make an informed decision about TOL versus ERCD. We are mindful of these clinical and ethical uncertainties in making the following conclusions and recommendations.
[Ed: Yes, having had a previous c-section increases the risk in subsequent births for either the mother or the baby. When will we focus our energies on preventing that first c-section?]
Summary: VBAC is 'safe' and the ACOG "in house" rule for OB and
Anesthesiology had put unnecessary barriers up which caused
doctors and hospitals to stop offering VBAC care. This
rule did not make a difference in outcomes and should be
abandoned but the
NIH couldn't "make" hospitals change their policy. Bottom line
however was a strongly worded recommendation that normal birth
(VBAC) was better and safer than sarean Section. The research
for this decree has been available to the medical community for
some time, but still women who wanted a safer birth experience
and not major abdominal surgery were told "No" by most doctors
and hospitals. This forced them into a pregnancy fraught
with the stress of searching for a provider and hospital that
was "VBAC friendly", or worse, unwanted surgery.
DRAFT
NIH
CONSENSUS
STATEMENT
RELEASED
ON
VAGINAL
BIRTH
AFTER
CESAREAN DELIVERY [from Medscape]
The WHO has issued a
statement based on the conclusions of a panel of international
experts it convened in October of last year. These
included:
1. Caesarean sections are effective in saving maternal and
infant lives but only when they are required for medically
indicated reasons.
2. At population level [as opposed to individual hospital level
caesarean section rates higher than 10% are not associated with
reductions in maternal and newborn mortality rates.
3. Caesarean sections can cause significant and sometimes
permanent complications disability or death. . . . Caesarean
sections should . . . only be undertaken when medically
necessary.
Vaginal Birth After Cesarean: New Insights
Structured Abstract
Objectives: To synthesize the published literature on vaginal birth after cesarean (VBAC). Specifically, to review the trends and incidence of VBAC, maternal benefits and harms, infant benefits and harms, relevant factors influencing each, and the directions for future research.
Data Sources: Relevant studies were identified from multiple
searches of MEDLINE®; DARE; the Cochrane databases (1966 to
September 2009); and from recent systematic reviews, reference
lists, reviews, editorials, Web sites, and experts.
Conclusions: Each year 1.5 million childbearing women have
cesarean deliveries, and this population continues to increase.
This report adds stronger evidence that VBAC is a reasonable and
safe choice for the majority of women with prior cesarean.
Moreover, there is emerging evidence of serious harms relating
to multiple cesareans. Relatively unexamined contextual factors
such as medical liability, economics, hospital structure, and
staffing may need to be addressed to prioritize VBAC services.
There is still no evidence to inform patients, clinicians, or
policymakers about the outcomes of intended route of delivery
because the evidence is based largely on the actual route of
delivery. This inception cohort is the equivalent of intention
to treat for randomized controlled trials and this gap in
information is critical. A list of future research
considerations as prioritized by national experts is also
highlighted in this report.
Attorneys looking for VBAC ban victims.
As you are likely aware, many women are denied access to VBAC
(Vaginal birth after cesarean) because of hospital policies and
outright bans.
Attorneys with the Northwest Women's Law Center in Seattle are
looking at this issue.
One of them asked us to post the following:
I'm a lawyer with the Northwest Women's Law Center in Seattle.
I'm investigating possible legal responses to bans on vaginal
birth after cesarean at hospitals in the northwest states -
Alaska, Idaho, Montana, Washington and Oregon. If you are
currently pregnant and want to have a VBAC, but are facing a
hospital policy that would require you to have a c-section
regardless of whether you want it and whether it is medically
necessary, and are willing to consider working with a lawyer on
this, we'd like to talk with you. Please email us at
vbacbanhelp@ican-online.org . Our services will be provided free
of charge.
2/4/2010
Dear Mr. Robinson, et. al,
Just this Tuesday (2/2) on ABC evening news, there was a story about how badly CA is doing when it comes to maternal mortality. It was picked up on Wed. (2/3) in the San Francisco Chronicle - Pregnancy-related death rate on the rise. The report cited the California Watch research report that said "...the [maternal death rate] in California is higher than in Kuwait or Bosnia", " C-sections have increased 50 percent in the same decade that maternal mortality increased".
Even more troubling was the statement, " For the past seven months, the state Department of Public Health has declined to release a report outlining the trend".
I have been trying for a very long time to get your attention on this matter to no avail. I was really disappointed that there was nothing in print here in our area on 2/3 addressing this travesty. You could have contacted the non-profit Bay Area Birth Information (BABI - www.bayareabirthinfo.org, 408-674-2224) for a local angle if you thought that was even necessary.
Our yahoo group has been a-buzz about this, and mention was made about our local news MIA (see below).
This is the link to the original story by the California Watch health and welfare section. Where are our local reporters on this????
It is very similar to the SFGate story. Just in case anyone is interested in reading it. Maddy Oden was also interviewed for the story.
Most of you know that Maddy Oden's daughter Tatia Oden French and
her baby died after being induced with Misoprostol (aka: Cytotec,
"Miso") at Alta Bates in Oakland. No informed consent (about the
"off label" use or the known risks) were given by the hospital
staff. But, that is the "standard" of practice around here.
Sincerely,
Jeanne Batacan
ICAN's newly launched Hospital VBAC Policy
Database is a listing of every hospital in the U.S. with
information about the VBAC policy of that hospital. The user
has the ability to submit comments about a particular hospital,
adding to the information available to women searching for
information about specific hospitals.
The
Trouble With Repeat Cesareans Time Magazine, 2/19/09] Piece
on repeat cesareans, the
reporter's follow-up blog post and the press
release from ICAN about VBAC bans.
How
many C-sections can a woman safely have? from Roger W.
Harms, M.D. - Repeat C-sections appeal to many women. Beyond
three C-sections, however, the surgical risks must be
weighed carefully against the desire for subsequent pregnancies.
Lawyer Looking for Women Denied VBAC in Alaska, Idaho, Montana, Washington and Oregon
IMPORTANT! A surgeon performing a cesarean section may choose from among a number of different techniques. If you're planning a cesarean, it makes sense to discuss these choices with your surgeon, and if you're not planning a cesarean, it's even more important to have discussed these issues ahead of time, in case a cesarean becomes medically necessary.
There are two significantly different techniques used to close the internal incisions - single-layer vs. double layer closure. Single-layer closure appears to be more vulnerable to rupture in subsequent pregnancies.
There are two significantly different techniques used to close the external incision - suturing or stapling. Yes, stapling, as in "with a staple gun". Many people feel that the suturing facilitates better healing and leaves a scar that isn't quite so frankenstein-like as the stapled scar.
The fastest way is with a single-layer closure of the internal incisions followed by external stapling.
These are important choices. Educate yourself and talk with
your surgeon beforehand.
This raises a really significant question. If the strength
of the healed uterine scar is dependent on the quality of the
suturing, why is the liability for uterine rupture assigned to the
care provider with the subsequent pregnancy, rather than the
original surgeon?
This gentlebirth.org web page is mostly about avoiding Cesareans and planning VBACs, but there are women who cannot or choose not to plan future VBACs. There used to be an online support group for these women called novbac, but it seems to have disappeared. Here was their charter:
"This list's sole purpose is to support women who for whatever reason have been unable to have a VBAC after one or more c-sections. Although we do support VBAC, we feel a need to support the woman that cannot have a VBAC or has attempted a VBAC only to have a repeat c/s. This is a list to promote healing and to support our fellow mothers."The best replacement list I could find is birthingbycesarean at yahoogroups.
"This is a list for women who had a cesarean birth(s), who want to discuss their feelings, thoughts, and/or experiences regarding cesareans, labour, birth, HBAC, VBAC, the impact of a cesarean section on self & spouse/family, or any other topics you wish to discuss. This list is also available to women who have a possible c-section pending and want to discuss any issues that they presently coping with. "I would expect that we'll soon see support groups for women planning elective cesareans, despite the increased risks.
This book was written by a couple who know more about pregnancy
nutrition than anyone I've ever heard, met or read about.
Why Does Anyone Even Bother?
For the surgeons and hospital staff who provide care for births,
cesarean sections are so much easier, and they carry very little
liability. But for the mamas who want to be able to nurse
their babies without a painful abdominal incision and who want to
be able to be a part of their older child's normal life shortly
after birth, they are happy to "pay up front" with the work of a
vaginal birth.
You can read through their ICAN eNews Archive and join their online forum.
Donate to ICAN or join ICAN today to support their work and receive their excellent newsletter.
They maintain a referral service - Professional Subscriber Network for midwives, doulas, CBEs, chiropractors, massage therapists, hypnobirth therapists......
And . . . NEW in the UK . . . ukvbachbac
- A Yahoo! Group - A UK discussion group on vbac and home vbac for
interested mums, mums to be, midwives and anyone else with an
interest in avoiding unnecessary c-sections. Useful information
and articles can be found at caesarean.org.uk
Citizens for Midwifery – the only national consumer-based group promoting the Midwives Model of Care!
Join Citizens for
Midwifery today to support the midwifery model of care and
superior outcomes for mother and babies.
What Are Some Factors Driving Use of Cesarean Section in the United States? from Childbirth Connection's Listen to Mothers: Surveying the Experience of Birth from Childbirth Connection [8/28/13]
Vaginal
Birth After Cesarean - notes from the American College of
Nurse-Midwives 48th Annual Meeting from Medscape Nurses [Medscape
registration is free.]
I thought this video editorial did a very good job of explaining current VBAC issues, i.e. they're not really clinical!
From Medscape Ob/Gyn & Women's Health [Medscape registration
is free.]
Kaunitz on Women's Health
Trial
of
Labor
and
Vaginal
Birth
after
Cesarean: Maintaining Access and Choice [Posted 03/27/2009]
Andrew M. Kaunitz, MD
Why
does
the
national
U.S.
cesarean
section
rate keep going up? The page dispels two myths that continue
to arise and identifies interrelated factors that are leading to
record-level cesarean rates year after year.
Soaring
C-Section Rate Troubles Doctors - [Forbes magazine -
7/13/07] - It includes quotes from Marsden Wagner and discusses
the economic pressures contributing to this trend, the increased
risks of cesarean, and an observation by another obstetrician that
the overuse of this surgery runs counter to the sacred rule in
medicine of “First Do No Harm.” At the end, readers are
directed to ICAN for further information.
ANACS nurses endorse the booklet "What Every Pregnant Woman Needs to Know About Cesarean Section". This evidence based material is put out by the Maternity Center Association. Nurses are encouraged to bring this to consumers attention and to help educate women about cesarean sections. Nurses and consumers can download a copy for free!
Publicized by the Association of
Nurse Advocates for Childbirth Solutions (ANACS)
We
don't browbeat women into having caesareans - from the
UK
Elective
Cesarean
Surgery
Versus
Planned
Vaginal
Birth:
What Are the Consequences? and The
Problem with ‘Maternal Request' Cesarean from the Lamaze
Institute for Normal Birth.
"Although second stage caesarean section is sometimes
appropriate, many could be prevented by the attendance of a more
skilled obstetrician."
Where's my midwife? is
a grassroots organization seeking to increase access to midwives
in hospitals, free-standing birth centers and at home through
education and advocacy.
Previous
cesarean
delivery:
understanding
and
satisfaction
with
mode of delivery in a subsequent pregnancy in patients
participating in a formal vaginal birth after cesarean
counseling program.
Cleary-Goldman J, Cornelisse K, Simpson LL, Robinson JN.
Am J Perinatol. 2005 May;22(4):217-21.
See also: Significance
for Normal Birth from the Lamaze Institute for
Normal Birth
See also: Microbial
Colonization of Newborn Skin and Gut / Cesarean Effects -
Cesarean birth disrupts this crucial colonization
Elective
cesarean
sections
are
too
risky,
WHO
study says [Jan 11, 2010]
|
Researchers in Sweden believe they have discovered the DNA mutations explaining why children delivered by planned Cesarean section run a higher than average risk of contracting immunological diseases. [6/29/09] |
Many women are mis-led to believe that a cesarean is the
"pain-free" way to give birth. In the landmark study, Listening
to Mothers, the authors write about the "Myth of the
Pain-Free Cesarean. For women who had a cesarean, pain
in the area of the surgical incision was the leading postpartum
health concern, with five out of six of these mothers citing it as
a problem in the first two months and one in fourteen citing it as
a problem at least six months after birth."
C-
Sections a Critical Factor in Preterm Birth Increase
Great response from an OB/GYN to the "Choosy Mothers Choose..." story.
Dear Editors:
Your writer glamorizes a major surgical procedure that,if performed unnecessarily, can have serious outcomes for the mother and baby. This is not a face-lift,it is major abdominal surgery that has three times the maternal death rate as vaginal birth. Are the women who elect this [usually when prodded by their doctors] made aware of that? Are they also aware that their baby may be born too soon or too small and have long-term educational problems because their brains are not fully developed? Do they understand that,after the first cesarean, the next pregnancy has twice the stillbirth rate and can have life-threatening problems with the placenta because of the uterine scar? Do they know that there is no epidemiologic evidence that cesarean prevents future urinary incontinence and in fact can make future abdominal surgery more difficult due to abdominal adhesions?
My point is that most women with normal pregnancies who agree to elective induction of labor or scheduled cesarean haven’t a clue about some of the very negative consequences of the surgery. Cesarean section is a very important and life-saving intervention in some high risk situations. However there is plenty of evidence that vaginal birth has a toning and protective effect on the baby’s brain and results in babies with less asthma,chronic lung disease, and learning disabilities.
In my opinion,if this unfortunate trend continues, our society may find out in the near future that “It’s not nice to fool Mother Nature.”
Charles Mahan, MD, FACOG
Professor,USF Chiles Center for Healthy Mothers and Babies
Vaginal
birth
after
caesarean
section
versus
elective
repeat caesarean section: assessment of maternal downstream
health outcomes.
Pare E, Quinones JN, Macones GA.
BJOG. 2006 Jan;113(1):75-85.
CONCLUSIONS: These results indicate that long term
reproductive consequences of multiple caesarean sections
should be considered when making policy decisions regarding the
risk-benefit ratio of VBAC.
Caesarean birth triples maternal death risk
Postpartum
Maternal Mortality and Cesarean Delivery.
Deneux-Tharaux C, Carmona E, Bouvier-Colle MH, Breart G.
Obstet Gynecol. 2006 Sep;108(3):541-548.
RESULTS: After adjustment for potential confounders, the risk
of postpartum death was 3.6 times higher after cesarean than
after vaginal delivery (odds ratio 3.64 95% confidence
interval 2.15-6.19). Both prepartum and intrapartum cesarean
delivery were associated with a significantly increased risk.
Cesarean delivery was associated with a significantly increased
risk of maternal death from complications of anesthesia, puerperal
infection, and venous thromboembolism. The risk of death from
postpartum hemorrhage did not differ significantly between vaginal
and cesarean deliveries. CONCLUSION: Cesarean delivery is
associated with an increased risk of postpartum maternal death.
Knowledge of the causes of death associated with this excess risk
informs contemporary discussion about cesarean delivery on request
and should inform preventive strategies. LEVEL OF EVIDENCE: II-2.
Infant outcome worse with planned c-section [1/8/07] Newborns who are delivered via planned cesarean section are more likely to be transferred to the neonatal intensive care unit and to experience lung disorders compared with those delivered via planned vaginal delivery.
Planned
cesarean
versus
planned
vaginal
delivery
at
term: comparison of newborn infant outcomes.
Kolas T, Saugstad OD, Daltveit AK, Nilsen ST, Oian P.
Am J Obstet Gynecol. 2006 Dec;195(6):1538-43.
CONCLUSION: A planned cesarean delivery doubled both the rate of
transfer to the neonatal intensive care unit and the risk for
pulmonary disorders, compared with a planned vaginal delivery.
Babies born by Caesarean are three times more likely to die in first month
Infant
and
Neonatal
Mortality
for
Primary
Cesarean
and Vaginal Births to Women with "No Indicated Risk," United
States, 1998-2001 Birth Cohorts.
Macdorman MF, Declercq E, Menacker F, Malloy MH.
Birth. 2006 Sep;33(3):175-182.
Results: Neonatal mortality rates were higher among infants
delivered by cesarean section (1.77 per 1,000 live births) than
for those delivered vaginally (0.62).
Mothers
aren't behind a vogue for caesareans - [Boston Globe,
4/3/06]
Cesarean
Delivery on Maternal Request - 2003 Data from the National
Vital Statistics reports, Vol 54, Number 2, (116 pdf pages)
In 2003, the latest year statistics are available, there were
4,089,950 births.
In 2003 there were 51,602 VBACs.
There were 1,119,388 Cesarean surgeries.
The current rate of cesarean section, per the highest rate in the study quoted in the NIH papers, would place up to 103 women at risk of dying from or with or right after their cesarean. According to one study the worst rate of mothers dying due to cesarean deliveries was reported to be 92 per 100,000 such deliveries. ( a rate of 0 was also reported in a different study).
Some of these women had diseases such as eclampsia that killed
them. Many would have died from hemorrhage, stroke, anesthesia
complications, infection or a combination of these. Some of the
women who died in relation to their surgeries, had undergone their
Cesarean because there really was no better choice. Some who die
may have elected their section for personal or quasi-medical
reasons.
Look for a terrific rebuttal from Suzanne Arms at
http://BirthingTheFuture.com/
Consumer
Reports Questions Cesarean Frequency [12/30/05]
Risks Associated With Cesarean Delivery - [Medscape registration is free] If you're considering an elective cesarean, make sure you know the risks.
The risks associated with cesarean delivery can be divided into
those that are short term, those that are longer term, and those
that present risks to future pregnancies. There are also risks to
the newborn that need to be considered.
As
C-Sections Increase, So Do The Complications
C-section
studies from BirthRites
Neonatal
impact
of
elective
repeat
cesarean
delivery
at term: a comment on patient choice cesarean delivery.
Fogelson NS, Menard MK, Hulsey T, Ebeling M.
Am J Obstet Gynecol. 2005 May;192(5):1433-6.
"RESULTS: Neonates born by elective repeat cesarean are more
frequently admitted to advanced care nurseries than infants born
to mothers intending to deliver vaginally (risk ratio 3.58, 95%
confidence interval 3.35-3.58). CONCLUSION: The decision to
undergo scheduled cesarean delivery appears to negatively impact
immediate neonatal outcomes."
Now add to the doubled risk of a NICU stay after a planned c/s
the corresponding increase in the risk of interrupted
mother/father/baby attachment, increased child abuse and/or
neglect as a result of interrupted attachment, a significant
reduction in the initiation and duration of b/f, and
maternal/paternal depression/anxiety and the corresponding effects
of THAT on infant growth and development, and you have a long-term
ripple which is the stuff of horror movies. Yikes.
Cesarean Voices, A web
site by, for, and about cesarean born people - explores the
implications of having been born non-labor cesarean, of coming
into a human life here on earth without going through the
heretofore universal initiation and learning experience of the
journey down the birth canal.
Researchers describe the "novel clinical entity" of intrapartum elective cesarean, and find that it is more often proposed by the physician than the patient.
Intrapartum
elective
cesarean
delivery:
a
previously
unrecognized
clinical entity.
Kalish RB, McCullough L, Gupta M, Thaler HT, Chervenak FA.
Obstet Gynecol. 2004 Jun;103(6):1137-41.
CONCLUSION: This study documents a heretofore unrecognized
clinical entity: intrapartum elective cesarean delivery. Physician
characteristics, as opposed to patient characteristics or
intrapartum factors, are a major determinant of whether laboring
patients are being offered cesarean delivery.
API's
statement about the medical ethics of elective caesarean
sections
Women's
Health Care Professionals Issue Warning About Cesarean Section
on Demand - Research shows that the risk of maternal death
following cesarean section is five to seven times higher than
vaginal birth. Complications during and after the surgery may
include injury to the bladder, uterus and blood vessels,
hemorrhage, anesthesia accidents, blood clots in the legs,
pulmonary embolism, paralyzed bowel and infection. There are
serious risks also in subsequent pregnancies.
I am familiar with at least one fairly recent case (not my case),
circa 1992, from rural north central Missouri. Obese female
demands general anesthetic for elective repeat C-section.
Physician agreed. Just after induction of general, patient
arrested and expired about 24 hours later in ICU. Husband was in
OR and refused C-section (during cardiopulmonary resuscitation),
C-section not done later, fetal heart tones still present post
arrest, but gone before patient death. Large settlement (about
900,000)--husband's deposition denied any memory of refusing
C-section after cardiac arrest. I don't know what the indications
for the section were. No one is sure why the patient died. The
section was completely elective, patient was not in labor.
This review concentrates on 2 consequences of cesarean deliveries
that may occur in a subsequent pregnancy. They are the
pathologically adherent placenta and the cesarean scar pregnancy.
Borders N.
J Midwifery Womens Health. 2006 Jul-Aug;51(4):242-8.J Midwifery
Womens Health. 2006 Jul-Aug;51(4):242-8.
Four million women give birth each year in the United States, yet
postpartum health has gone largely unaddressed by researchers,
clinicians, and women themselves. In light of rising US cesarean
birth rates, a critical need exists to elucidate the ramifications
of cesarean birth and assisted vaginal birth on postpartum health.
This literature review explores the current state of knowledge on
postpartum health in general and relative to method of delivery.
Randomized trials and other published reports were selected from
relevant databases and hand searches. The literature indicates
that postpartum morbidity is widespread and affects the majority
of women regardless of method of delivery. Women who have
spontaneous vaginal birth experience less short- and long-term
morbidity than women who undergo assisted vaginal birth or
cesarean birth. To maximize postpartum health, providers of
obstetric care need to protect the perineum during vaginal birth
and avoid unnecessary cesarean deliveries. Clinicians must
initiate the discussion about postpartum health antenatally and
encourage women to enlist needed early in the postpartum period.
Flexibility in the schedule of postpartum care is essential. More
research from the United States is warranted.
Dangerous
delivery shows peril of multiple C-sections
Risks
of
adverse
outcomes
in
the
next
birth after a first cesarean delivery.
Kennare R, Tucker G, Heard A, Chan A.
Obstet Gynecol. 2007 Feb;109(2 Pt 1):270-6.
CONCLUSION: Cesarean delivery is associated with increased
risks for adverse obstetric and perinatal outcomes in the
subsequent birth. However, some risks may be due to
confounding factors related to the indication for the first
cesarean. LEVEL OF EVIDENCE: II.
CONCLUSION: A cesarean first birth is associated with increased risks of previa and abruption in the second pregnancy. There is a dose-response pattern in the risk of previa, with increasing number of prior cesarean deliveries. A short interpregnancy interval is associated with increased risks of previa and abruption.
The following information is from Volume 3, Issue 3 of Research Summaries for Normal Birth, July 2006, from the Lamaze Institute for Normal Birth:
Summary: This large retrospective cohort study examined the association between history of one or more previous cesarean surgeries and the risk of placental abruption or placenta previa in a subsequent pregnancy. Data were obtained from a Missouri state-wide dataset in which siblings were linked to one another and to their biological mothers. Missouri’s vital statistics recording system has been described as a “gold standard” for its reliability and validity in previous literature.
Risk for previa in the second birth was increased 50% among women with a previous cesarean surgery. Among women with two previous cesareans, there was a two-fold increase in the risk of previa in the third pregnancy. Risk for abruption in the subsequent pregnancy was increased 30% in both the second and third births when the prior birth was by cesarean. A pregnancy occurring within the first year after giving birth by cesarean was associated with further elevations of the risk for both previa and abruption. The researchers controlled for the effects of potential confounding factors such as maternal age, race and smoking status.
Significance for Normal Birth: This study adds to the growing body of research showing strong evidence of a dose-response relationship between cesarean surgeries and placental complications in subsequent pregnancies: the more cesareans, the more complications. The doubling of risk for placenta previa in women with two previous cesareans is particularly troubling because previa in the presence of a cesarean scar is associated with placenta accreta, a complication that results in very high maternal morbidity and mortality. The long-term reproductive risks of cesarean surgery are only beginning to be understood. As the evidence of harm accumulates, it becomes ever clearer that preventing unnecessary primary cesareans is a crucial measure for protecting the health of both mothers and babies.
See also: Birth Trauma
From Cesarean
The
Trouble With Repeat Cesareans By Pamela Paul Thursday, Feb.
19, 2009
[Ed: This is not a randomized trial; it would be unethical to
randomize women to induction or c-section. So I will point out
that women who have waters break before the onset of labor are
both more likely to be induced and to have babies develop
respiratory infection. Also, women with gestational diabetes
issues are more likely to have labor dystocia requiring
augmentation and possibly c-section; their babies are more likely
to have diabetes based on genes and gestational environment. It
would be helpful to tease out the information from elective repeat
c-sections and elective inductions, which is about as close to
randomization as you can get.]
Neonatal
Outcomes May Be Better With Vaginal Birth After Cesarean
Delivery
Laurie Barclay, MD
According to a study published in the June issue of Obstetrics and Gynecology, babies born via vaginal birth after a prior cesarean section (VBAC) have lower rates of respiratory morbidity and intensive care admissions compared with babies born by repeat cesarean section.
The retrospective cohort study was comprised of 672 women with one prior c-section in a singleton pregnancy at 37 weeks or more gestation, and compared both neonatal outcomes and monetary costs of the procedures.
Researchers found that babies born via repeat c-section had higher rates of intensive care admission and higher rates of oxygen supplementation for delivery room resuscitation than those babies born by VBAC. The highest rates of resuscitation, however, were in babies born by c-section after a failed VBAC.
And while a successful VBAC is definitely less expensive than a second c-section, the highest costs were associated with a cesarean after a failed VBAC.
The study's authors suggest that these results "[argue] for greater selectivity in performing a cesarean delivery in the first place, and certainly a greater need for counseling before a primary elective cesarean delivery."
Neonatal
outcomes
after elective cesarean delivery.
Kamath BD, Todd JK, Glazner JE, Lezotte D, Lynch AM.
Obstet Gynecol. 2009 Jun;113(6):1231-8.
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.
Caesarean
delivery
rates
and
pregnancy
outcomes:
the
2005 WHO global survey on maternal and perinatal health in Latin
America
José Villar a , Eliette Valladares
b, Daniel Wojdyla c, Nelly Zavaleta
d, Guillermo Carroli c, Alejandro Velazco
e, Archana Shah a, Liana
Campodónico c, Vicente Bataglia f,
Anibal Faundes g, Ana Langer h, Alberto
Narváez i, Allan Donner j, Mariana
Romero k, Sofia Reynoso l, Karla
Simônia de Pádua g, Daniel Giordano
c, Marius Kublickas m and
Arnaldo Acosta n, for the WHO 2005 global survey on
maternal and perinatal health research group
The Lancet 2006; 367:1819-1829
Interpretation - High rates of caesarean delivery do not
necessarily indicate better perinatal care and can be associated
with harm.
CDC
Says Cesarean Triples Neonatal Death Risk - . . . regardless
of risk factors, babies born by cesarean section face a risk of
death nearly three times that of vaginally born babies.
Here's the simplest version of the story:
Cesarean delivery can alter DNA
. . . The researchers noted genetic mutations in babies
delivered via Cesarean. . . .
The actual research:
Epigenetic
modulation
at
birth
–
altered
DNA-methylation
in white blood cells after Caesarean section (p 1096-1099)
T Schlinzig, S Johansson, A Gunnar, TJ Ekström, M Norman
Acta Paediatr. 2009;98:1082–1084; 1096–1099.
News Stories and Reviews:
Higher DNA Methylation in Cesarean-Delivered Newborns May Be Linked to Later Disease Development [Medscape registration is free.] "Moshe Szyf, PhD, professor in the Department of Pharmacology and Therapeutics, McGill University, Montreal, Quebec, Canada, regards this article as the first to demonstrate the effect of seemingly harmless interventions on our genome. "The DNA seems to record the changes to environments in early life. It will be interesting to see what fraction of these changes remain as a memory in our DNA for our life course," he said via email to Medscape Obstetrics & Gynecology."
C-section Births Cause Genetic Changes That May Increase Odds For Developing Diseases In Later Life - ScienceDaily (June 29, 2009) - good explanation plus excellent Related Stories
Genetic changes after Caesarean section may explain increased risk of developing disease - this is a little more technical. [from physorg.com]
Epigenetic
modulation at birth - altered DNA-methylation in white blood
cells after Caesarean section [ from news-medical.net]
ICAN President's Letter to
California Medical Board about VBAC - from Tonya Jamois,
4/20/05
Your Right to Refuse - What to do if your hospital has "banned" VBAC.
E-mail ICAN with the name
of the hospital and your city/state.
Barger MK, Dunn JT, Bearman S, Delain M, Gates E.
BMC Pregnancy Childbirth. 2013 Apr 3;13(1):83. [Epub ahead of
print]
RESULTS: All 243 birth hospitals that were contacted participated. In 2010, among the 56% TOLAC hospitals, the median VBAC rate among TOLAC hospitals was 10.8% (range 0-37.3%). The most cited reason for low VBAC rates was physician unwillingness to perform them, especially due to the requirement to be continually present during labor. TOLAC hospitals were more likely to be larger hospitals in urban communities with obstetrical residency training. However, there were six (11.3%) residency programs in non-TOLAC hospitals and 5 (13.5%) rural hospitals offering TOLAC. The majority of TOLAC hospitals had 24/7 anesthesia coverage and required the obstetrician to be continually present if a TOLAC patient was admitted; 17 (12.2%) allowed personnel to be 15-30 minutes away. TOLAC eligibility criteria included one prior cesarean (32.4%), spontaneous labor (52.5%), continuous fetal monitoring and intravenous access (99.3%), and epidural analgesia (19.4%). The mean distance from a non-TOLAC to a TOLAC hospital was 37 mi. with 25% of non-TOLAC hospitals more than 51 mi. from the closest TOLAC hospital.In 2012, 139 hospitals (57.2%) offered TOLAC, 16.6% fewer than in 2007. Since 2010, five hospitals started and four stopped offering TOLAC, a net gain of one hospital offering TOLAC with three more considering it. Only two hospitals cited change in ACOG guidelines as a reason for the change.
CONCLUSIONS: Despite the 2010 NIH and ACOG recommendations
encouraging greater access to TOLAC, 44% of California hospitals
do not allow TOLAC. Of the 56% allowing TOLAC, 10.8% report fewer
than 3% VBAC births. Thus, national recommendations encouraging
greater access to TOLAC had a minor effect in California.
50 Ways to Protest a VBAC Denial by Barbara Stratton
File a VBAC ban complaint
Dear Friends,
Barbara Stratton has been working hard to find a way to reverse
VBAC bans both in her own state of Maryland as well as
nationwide. Please read her letter below, explaining an
action many women can take that may not only help reverse their
local bans, but could also have an impact across the country.
Barbara writes:
One of the most promising approaches we have to reversing hospital
VBAC bans nationwide is to file complaints through the Medicaid
system and then appeal any denials to the federal level. If
successful, all hospitals nationwide that receive Medicaid funding
(most do) would be forced to reverse their VBAC bans.
So far, I've only known of a single woman to file one of these
complaints and she didn't appeal the initial denial. We need to
have these complaints come in from across the country from women
willing to file and then appeal any denials.
You don't have to receive, or have received Medicaid in the past
in order to file a complaint. The only qualifying factor is that
you live near a VBAC banning hospital and want to see that ban
reversed!
Simply call the hospital and verify that they receive Medicaid
funding. Then ask for the contact info for the Chief Compliance
Officer for Medicaid.
I can then email you a letter template that just requires you to
insert your info plus the compliance officer's info. Print it out,
mail it in and you are done.
See how easy that is?
Please email me directly if you are interested.
Thanks,
Barbara Stratton
womancareadoula@comcast.net
At least 30% of births in this country are by cesarean section,
including at least 20% of first births. That means there are a
large number of women who would benefit from being able to give
their best try at having a VBAC. Many of us can file the kind of
complaint Barbara describes, which could help so many women and
babies have a better birth.
Denied
VBAC? - [from Robin Elise Weiss at pregnancy.about.com] - A
vaginal birth after a cesarean (VBAC) is becoming more and more
rare these days and doctors and lawyers fight over the risks of
VBAC. For the women who have decided that they want a vaginal
birth, they may be told no. Here is what they can do to try to
find the birth they want.
Here's the article that was first used as the justification for ACOG's opposition to VBAC:
Risk
of
uterine
rupture
during
labor
among
women with a prior cesarean delivery.
Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP
N Engl J Med 2001 Jul 5;345(1):3-8
Risk/benefit of Delivery Mode After C-Section Should Be Individualized (News)
Vaginal birth after a previous cesarean section (VBAC) may be the
wisest choice for women planning to have two or more pregnancies.
However, another cesarean may be less likely to lead to problems
in women who intend to have no more than one additional pregnancy,
according to researchers.
Standing
up to the VBAC-lash: - A critique of the New England Journal
of Medicine VBAC study and implications for the future of the
medical model of childbirth by Jill MacCorkle
BMJ followup Vaginal delivery after caesarean section triples risk of uterine rupture(BMJ 2001;323:68 ( 14 July )
Women
respond to the Britsh Medical Journal about VBAC
Anti-VBAC Study and Refutations
A definite yes! to the suspicions of recent backlash.
I was recently labor coaching for a hospital birth - planned to be the first VBAC after three sections. The OB was known in the community to be very supportive of natural childbirth, but even he was trying to convince my client that a VBAC after three surgeries was taking some huge risk. He asked her to sign some "backlash" forms about how dangerous VBAC is.
Then, when my client arrived at the hospital in labor, she was informed by the hospital staff that they could not support her in her choice to have a vaginal birth. Some tense discussions followed, during which it became clear that the hospital intended to get a court order to force her to delivery surgically if she didn't make that choice. (It's ludicrous to call it a "choice" at this point.)
The perinatologist said that because there were no studies showing the safety of laboring with three uterine scars, they had to assume it was not safe and that it was putting the baby at risk. She told us that there is an increase in risk for laboring with 1 vs. 2 scars, and that they had to assume the possibility that there could be an enormous increase in risk between 2 scars and 3.
She actually told us that their working assumption was that the
risk of catastrophic rupture (in which the baby died) was 5%. Yes,
1 out of 20. My hope for her is that she finds herself in a
position to learn more respect for women's choices in birth.
The first c-sec is the major problem. I can't tell you how many women who had c-secs for their first baby told me it was because the baby was in distress yet it took 1-3 hours for them to go to surgery. When a baby is in true distress they have those ladies in surgery and open within 15 minutes. And mind you, once surgery was decided on no one checks dilation again or monitors any of the contractions.
And another problem is that they use those blasted machines to declare that a woman is in labor. No dilation (or maybe she is dilated 1-2 cms), no effacement but the dang machine says she is in labor so some yahoo comes in after a while and does AROM, because she is not moving along. Then augments. All the while (which by now it could easily be 8 hours) she has been on an IV with no food. These primips now have drugs forcing the labor process and the poor gal just can't handle it anymore. C-sec due to maternal exhaustion or fetal distress.
Best thing is to stop that first c-sec and the only way to lower
those numbers is by having midwives attend them. Our local
CNMs have lowered one hospitals c-sec rate to 14%. The
hostile hospital, which abhors midwives, has a rate of 29%.
I applaud those midwives because it has been a rough row to hoe
and one waited for years to get the respect due her.
Dr. Phelan has definitely changed his colors on VBAC. It is very ironic that his earlier medical research supports the safety of VBAC. In the last few years he has become a VBAC antagonist.
Not too long ago, someone posted an outrageous "VBAC consent" form filled with scare tactics and even inaccuracies. Guess who the author was? Yep- Dr. Phelan. He published this as a recommended consent form for all OB's to present to women during their pregnancies if they are considering VBAC.
He also published an article a couple years ago with a title
something like: Cesarean goal rate for the year 2000: 50%. It also
was an outrageous editorial.
LATimes, Sunday, January 25, 1998, Home Edition; Section: PART A; Page: A-1
Dr. Jeffrey Phelan, a noted obstetrician and fetal medicine specialist who along with Paul of County-USC helped pioneer the idea of vaginal birth for women who have had caesareans, makes no bones about rejecting the ideas he once proposed.
Phelan, co-director of maternal-fetal medicine at Pomona Valley
Medical Center and an attorney, recently called for increasing the
caesarean rate to 50% of all births.
See also: Homeopathy
for Recovering from Surgery or Anesthesia
* rocking in a rocking chair
* drinking hot lemon water
* walking
As your intestines begin to function again, you may have gas
pains. To ease your discomfort, eat light foods that are easy to
digest (toast, yogurt, soup). Get out of bed and walk around.
Movement helps stimulate your digestive system. Actually,
come to think of it, so does sucking on something - a lollipop or
popsicle would help, or heh, why not ask the nurses to get you a
pacifier to suck on! Seriously, that kind of sucking is what
stimulates babies to move their bowels every time they
nurse. :-)
Some naturopaths are offering a treatment to soften up scars from
c-sections. Apparently they inject saline fluid into the
scar area, which causes inflammation, which helps the scar tissue
to heal.
Chinese medicine recommends treating cs scars w/acupuncture as
they cross vital meridians and create obstruction.
The C-section scars create obstructions in key energy fields and
should be treated not only via acupuncture but also with some type
of topical drawing packs to get the scars to heal up with more
normal tissue than scar tissue. Dr. Bob Marshall has formulated Medi-Body
Packs, which work well for this purpose. You can buy them from
Premier Research Labs.
Treating all kind of scars is very effective with Myofascial
Release. We must think of scars as roots that continue to grow
within our body reaching and pulling our fascia in a 3D web!
You might try proteolytic enzymes like bromelain and papain
(anti-inflammatory and easy on the stomach). Also, there's a
product called Zyflamed that contains a nice handful of herbal
cyclo-oxygenase inhibitors(anti-inflammatories). I think their
formula is based on a good book called Beyond Aspirin.
I would highly recommend JBMFR (John Barnes
Myofascial Release) for C-section scars. I recently came
back from the Woman's Health Seminar in which we learned to do a
lot of internal work to treat all kinds of issues that we females
may encounter.
Reviewed and approved by Dr. Joyce Barrett, MD, from the ICAN
Advisory Board
Published: January 2014
Cesarean
Scar Care in the Post-Partum Period - sponsored by ICAN!
[Ed: This web page has disappeared, but I've left this information
in case it's helpful to someone else putting together a webinar.]
Presented by physical therapist Isa Herrera, MSPT, CSCS, Clinical Director of Renew Physical Therapy in NYC, this great online session will teach and guide you through the basics of cesarean scar care in the post-partum period.
This much-needed class is geared toward new moms and healthcare professionals alike who are looking to understand and implement some real-world techniques to get relief from pain, itching, burning, tingling… and also learn how to restore the abdominal muscles and posture so that you feel like yourself again.
Much of the great material to be included in this webinar is taken from Isa’s new book, Ending Female Pain, A Woman’s Manual. The book has been endorsed by filmmakers Ricki Lake and Abby Epstein, Dr. Jacques Moritz, and most recently by Jill Osborne of the IC-Network and NY Times best-selling author and gynecologist Dr. Christiane Northrup.
Highlights of this webinar include:
Understand how to locate scar adhesions and why they are so
important to eliminate
Learn mobilization and massage techniques for cesareans
Restore abdominal function after cesarean with safe abdominal
exercises
Learn the connection between Diastasis Recti and low back pain and
pelvic pain
Learn simple yoga stretches for indirect scar mobilization during
the early post-partum period
Postoperative
Care in Cesarean Delivery Clinical Practice Guidelines (2019)
- Enhanced Recovery After Surgery (ERAS) Society [Medscape
registration is free]
Nursing
the Caesarean Born, by Michel Odent, MD - Midwifery
Today Issue 69
You can request it from ResearchGate.
One of my first clients with a csection’s wound would not heal.
Gave heper sulph. 3 big red drops of blood came out. (That is a
good sign that the remedy is working). And the next day it was
closed. Healed normally after that.
My friend is a certified wound care nurse and recommends Juven
powder (oral nutrition powder) for post-surgical wound healing. It
works great.
Feeling pressure from hospital for more c-sections, she leaves By Cheryl Welch, Staff Writer
Dr. Helen Sandland closed her Wilmington practice and is moving
to Mississippi after New Hanover Regional Medical Center asked her
to perform more cesarean sections on her patients.
A
Facebook Group for Traveling Midwives - A network for
midwives who volunteer and/or work all over the world or dream to
do so. If you are a family in need of a midwife, please pm the
moderator with your request and it will be posted in this group.
Plenitud; embarazo, parto digno y lactancia (Plenitude;
pregnancy, birth with respect and lactation)
We are in Guadalajara, Mexico and offer bilingual
(Spanish/English) care for birth at a local rental home or at the
birth center - a little 4 room retreat within the 18 bed hospital
Valle de Atemajac. The hospital houses us but does not dictate our
policy. Our primary cesarean rate is 11% and our VBAC/HBAC rate is
85%.
Email contact info is Joni Nichols - joninichols@infosel.net.mx
Phone: 011 52 333 656 82222
The ob/gyn I work with is Dr José Luis Grefnes Sanchez.
In addition to our autonomous four bed water-birthing center within a hospital (part one of the story of how we created it was just published in Midwifery Today #75; Autumn 2005) we also attend VBAC at home. Barbara Harper describes us in the newest edition of Gentle Birth Choices.
We serve families from all over the United States, Canada and
Mexico. Travel to Guadalajara is a straightforward flight
from the US! There are no problems with acquiring US or Canadian
passports for the babies born to families coming from these
countries. Both countries have consulates in
Guadalajara. I typically offer one night's stay in my
home to give visiting families a base while they check out their
housing alternatives. We have a terrific bed and
breakfast/kitchenette option locally with good weekly and/or
monthly rates and we sometimes know of apartments or homes
available for short term rental.
donna mitchell in alabama will accept VBAC moms who will come
here..or may be able to travel. heartathome@att.net
On a quiet, beautiful and secure country estate, overlooking the
central valley of Costa Rica, Central America, Birth-my-baby offers two
modern homes for expectant mothers to have their babies in peace
and gentleness.
From Sherri Holley, CPM: "I travel all around the world for women
who cannot find a midwife to serve them. I do VBAC's,
breeches, and twins. I have practiced for 30yrs and have attended
over 2,000 birth as of 2008. lastfrontiermidmwife@yahoo.com
From Jane Gandy in Garland, Texas - As long as someone has been
getting prenatal care somewhere, I'm fine taking them at the end.
fruitofthewomb@att.net
From gail hart in Oregon, hdw4@msn.com
I don’t mind taking them at the end. Even if they haven’t had prenatal care!
It might be heresy to say this, but I think prenatal care – or lack of it – is pretty irrelevant if you are meeting a healthy mom with normal Blood pressure, at full term, with an appropriate-sized vertex baby, in good position, with good heart-tones.
I’ve actually met a couple of women for the first time when they
are in early labor.
It’s nice to have some bloodwork on them. Or at least to know
their blood type.
A woman with severe anemia will show it.
An Rh negative mom is probably the only sneaker, but generally it
isn’t a problem with the first pregnancy. And moms will usually
know if they are rh negative if they’ve ever had a baby before.
If they PASS a very thorough prenatal/labor exam – I don’t see lack of prior care to be an impossible hurdle.
I think the biggest issue is to try to convince them to let me
use eye meds for the baby (just in case)
From Suzanne Smith, CPM, in Orem, Utah, suzanne@betterbirth.com
I would accept such a client. Of course, I would prefer for
arrangements to be made early, not have her show up all of a
sudden at 37 weeks, but as long as she has been getting good care
and I can look at the other risk factors and find them acceptable,
I have no problem with a transfer in at 37 weeks.
From Deva Burgess in California - I also have taken ladies as
they were in labor. shstamidwife@finestplanet.com
From Judi Mentzer in California - Mentzer Maternity accepts anyone who comes to our door. Occassionally we have those who we have never seen prior to labor and may or may not have been seen by someone else. jmentzer@pa.net
We have met ladies in labor who have left others' care at the
last minute. I judge each case as it comes and handle those
ladies as I handle all ladies. If they need medical care
they will be referred. If not, they deliver. We have
had VBACs come in like that.
From Brenda Capps in southern California: I have and still do
take ladies last minute. If they are sincere I will help them. BCappsmidwife@cs.com
Ollie Anne Hamilton,
Great Falls, MT, 406 453 4915, E-mail: mwinmt@birthwithlove.com
In practice since 1977, will travel to most anywhere.
Sandi
Blankenship, BA, LM, Jensen Beach, FL, 772-359-1258, E-mail:
sandib2@juno.com
In practice since 1997, will travel overseas to attend a birth for
any woman expected to have a normal pregnancy, labor and birth,
including first-time and older mothers.
Lillian Alice Sanpere, LM,
CPM (I go by Alice), Tallahasee, FLorida, 850-681-6969 or
850-509-1540, E-mail: purplemidwife@yahoo.com
In practice since 1986, will travel to most anywhere,
internationally, will consider suitability for homebirth on an
individual basis. Speaks fluent english, spanish and fairly
good french.
Jerry Whiting,
Perris, CAlifornia 92570, 951-657-7734 Home, 909-553-5344 Cell,
E-mail: Jerry@homebirth-only.com
will travel anywhere to attend births for VBAC's, Primip's, Twins,
Breeches, The very young. In practice since 1999, 450 home
births.
donna mitchell in alabama will accept VBAC moms who will come
here..or may be able to travel. heartathome@att.net
Dismayed at the lack of VBAC-friendly institutions near
you? Don't just get mad - get active! Get involved
with ICAN and your
local birth circles or midwifery support groups. If you
don't have any in your area, start one. If you don't
do something, how will things get better for your sisters,
daughters and nieces?
Facebook: VBAMC,
VBAC, HBAC (Vaginal Birth After one or more C-sections)
Facebook: VBAC
Facts Community is a forum for parents, care providers, and
birth advocates to exchange information on post-cesarean birth options and also stay in touch
with the latest articles, classes, and events associated with VBAC Facts
Facebook: Official ICAN group!
Online ICAN chapter - ICAN stands for International Cesarean Awareness Network - most of the members are women who've had surgical births and are planning for VBACs. They have an inspiring journal published every few months. The online chapter is a great place to get information, inspiration and support. [NOTE - Dec., 2000 - It appears that many of the more knowledgeable supporters of VBAC have moved over to the HBAC list. In a recent discussion on the ican@fensende.com list, there were very few people who were able to interpret VBAC statistics in late of the current anti-VBAC hysteria. If you're looking for good, accurate information, your might do better to ask over at the HBAC list.]birthingbycesarean@yahoogroups.com - This is a list for women who had a cesarean birth(s) or to women who have a possible c-section pending and want to discuss any issues that they presently coping with.
HBAC@yahoogroups.com - This list is for people who are exploring the option of having a vbac at home. For more information.
vbac-hope@yahoogroups.com
- This is a Christian list offering support and hope for those
facing all aspects of Cesarean and VBAC, including HBAC (home
birth after cesarean). For more
information.
Be sure to read their Focus: Sex and the Myth of Cesareans from The
Clarion, Volume 33, February 22, 2006
VBAC -
Excellent Patient Education from Kent Midwifery Practice in the UK
(Kay Hardie and Virginia Howes)
Cesarean
& VBAC from Mothering
Magazine - Crucial information, to help you understand (and
advocate for) your right to birth safely and without surgery.
WHY DO SO MANY U.S. HOSPITALS PROHIBIT VAGINAL BIRTH AFTER A C-SECTION? by Carrie Murphy [12/7/16] - Stripping many women of the chance to have the type of birth they desire.
A
VBAC Primer: Technical Issues for Midwives by Heidi
Rinehart, MD [Midwifery Today Issue 57, Spring 2001]
VBAC:
Should you try, or avoid disappointment? by Gayle Peterson,
PhD
Q: I had a cesarean for my first child. I am pregnant again and
would love to give birth vaginally, but I am frightened. I'm very
concerned that it might be more difficult for me emotionally if I
try for a VBAC and fail, than if I just schedule a cesarean. What
is the best decision for me and my family?
Can Low Glycemic Diet Increase VBAC
Success?
Cohain JS. judyslome@hotmail.com
MIDIRS Midwifery Digest 2009:19:71
Vaginal Birth After One Previous Low-Segment Caesarean Section - clinical practice guideline from the Association of Ontario Midwives [337.4KB 20/11/2006 21:25] - note that they state:
"Recognition that hospital policies perceived by a woman as
restrictive may lead her to choose giving birth at home;"
"Home birth reduces the risk of iatrogenic consequences;"
The Royal College of Obstetricians and Gynaecologists Issues Practice Paper on VBAC
In this practice guideline, issued in February of 2007, the RCOG recommends the following to inform the care of women undergoing either VBAC or elective repeat cesarean section (ECRS):
VBAC
Success CD from HypnoBabies
This is taken from the Winter 2006 - Number 76 issue of Midwifery Today:
"The federal Emergency Treatment and Advanced Labor Act (EMTALA) requires hospitals to admit women in active labor and to abide by their treatment wishes until the baby and placenta are delivered. The act was originally passed to prevent hospitals from "dumping" patients who can't pay, but it's since been applied in all sorts of other ways and includes specific provisions that apply to laboring women.
The attorneys we've consulted on the VBAC ban issue have told us that hospitals are much more afraid of being found in violation of EMTALA than they are of malpractice suits because the act is routinely enforced and each violation subjects them to fines between $50,000 and $100,000.
I can't emphasize enough the importance to individuals who may find themselves in this situation of memorizing phrases such as "It's a violation of my rights under EMTALA to force me to undergo a cesarean," or "I'm invoking my right under EMTALA to refuse a, b, c." Whether the hospital in question says it bans VBACs is unimportant; according to EMTALA, you have the right to be admitted to a hospital once you're in active labor and, once admitted, you have the right to refuse any recommended treatment. You can also remind them that VBAC isn't a treatment, it's the natural culmination of a normal physiological process. Cesareans are the treatment.
Also, it's helpful to know that EMTALA begins to apply once you are anywhere within 250 feet of a hospital; you don't have to be in the emergency room. You can be standing in the hospital parking lot, and if they so much as touch you against your express consent, they are in violation of EMTALA. For anyone interested in reading more, we've compiled a legal primer on the rights of pregnant women at http://www.birthpolicy.org
Editor's Note: To learn more about this important subject, go to
http://www.emtala.com . There you
will find frequently asked questions (FAQ), as well as links to
the statue and case law."
Study backs natural birth after C-section (USA Today)
A study out today could lead to an increase in the number of pregnantwomen who try for a vaginal birth after a cesarean section.
Risk
of
Uterine
Rupture
With
a
Trial
of Labor in Women With Multiple and Single Prior Cesarean
Delivery.
Landon MB, Spong CY, Thom E, Hauth JC, Bloom SL, Varner MW, Moawad
AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M,
Carpenter M, Peaceman AM, O'sullivan MJ, Sibai BM, Langer O, Thorp
JM, Ramin SM, Mercer BM, Gabbe SG.
Obstet Gynecol. 2006 Jul;108(1):12-20.Obstet Gynecol. 2006
Jul;108(1):12-20.
CONCLUSION: A history of multiple cesarean deliveries is not
associated with an increased rate of uterine rupture in women
attempting vaginal birth compared with those with a single prior
operation. Maternal morbidity is increased with trial of labor
after multiple cesarean deliveries, compared with elective repeat
cesarean delivery, but the absolute risk for complications is
small. Vaginal birth after multiple cesarean deliveries should
remain an option for eligible women.
Elective Cesarean Surgery Versus Planned Vaginal Birth: What Are the Consequences? - Elective or "maternal request" cesarean surgeries pose serious and life-threatening complications for mothers and babies. Despite the risk, the popularity of elective cesarean surgery continues to rise-from 2001 to 2003, the rate increased by 36 percent.
For example, following a population of 100,000 healthy, low-risk first-time mothers, through three pregnancies, comparing outcomes based on whether they have elective cesarean surgery for the first delivery or plan vaginal birth.
With elective cesarean surgery:
57 more women will die
999 more women will have a hysterectomy
135 more women will have a uterine rupture and 7 babies will
die
63 more women will have a cesarean-scar ectopic pregnancy 45,900
more women will have dense adhesions (adhesions make subsequent
pelvic or abdominal surgery more difficult, increase the
likelihood of injuring organs or blood vessels during surgery, and
can cause chronic pain and bowel obstruction)
13,500 more women will experience wound (abdominal vs. perineal)
pain for 6 months or more
378 more babies will die in the womb (antepartum fetal
demise) without explanation after 34 weeks of pregnancy
7,830 more babies will be born preterm (before 37 weeks completed
gestation)
1,620 more babies will born weighing in the lowest 5% for their
gestational age
4,244 more babies will have respiratory problems serious enough to
require admission to intensive care
3,240 fewer women will have anal sphincter trauma (This assumes an
anal sphincter injury rate of 1%, a rate achievable with optimal
care [Albers 2005].) BUT
630 more women will have bladder injury
10,260 fewer women will have moderate to severe urinary
incontinence
BUT
0 fewer women will have later-life urinary incontinence (MCA 2004)
Vaginal
Delivery After Prior Cesarean Delivery May Have Low Absolute
Risk CME
VBAC info from an HMO! (circa 2001) -
This is a pro-VBAC handout.
Preliminary Births for 2004: Infant and Maternal Health - The cesarean delivery rate rose 6 percent in 2004 to 29.1 percent of all births, the highest rate ever reported in the United States (2). The rate has increased by over 40 percent since 1996. For 2003–04 the primary cesarean rate rose 8 percent, and the rate of vaginal birth after cesarean delivery (VBAC) dropped 13 percent. The primary rate has climbed 41 percent and the VBAC rate has fallen 67 percent since 1996.
Battle
lines drawn over C-sections (USA Today) - For some women,
birth has become the latest battleground for reproductive rights.
At a growing number of hospitals, women are being forced to
schedule a repeat cesarean section just because they already had
one. Doctors and hospitals say they fear lawsuits if they allow a
patient to attempt a VBAC and something goes awry.
This news account of a sad case of uterine rupture highlights that the ruptures tend to happen in the higher-risk cases: the woman had a vertical incision from her previous surgery, which just about everyone recognizes as an absolute indication for repeat c-section; her previous surgery was for CPD, although possibly caused only by malposition of the fetal head; her labor was induced with prostaglandins; she was not monitored during labor.
The article also clarifies, "While there are clearly cases when C-sections are necessary to protect the health of mother and baby, C-sections are associated with five times more postpartum cardiac arrests, five times more wound infections and twice as many anesthetic complications than in vaginal births. C-sections cost the health-care system 65 per cent more, partly because of longer hospital stays."
The lawsuit
brief is also available. [Cojocaru (Guardian Ad Litem)
v. British Columbia Women’s Hospital, 2009 BCSC 494, Date:
20090409, Docket: S032599, Registry: Vancouver (IN THE SUPREME
COURT OF BRITISH COLUMBIA)] This states that, she suffered from
constant pain for the half hour preceding more serious signs (of
fetal distress?).
VBAC.com - A woman-centered,
evidence-based resource
50 Ways to
Protest VBAC Denial - by Barbara Stratton
ICAN of Tacoma offers
downloads of brochures to give to your clients, friends or
family who may have had a cesarean or is trying to avoid one,
wants help planning a vaginal birth after cesarean, or wants to
get involved with protesting the VBAC bans.
Model predicts risk of emergency after previous cesarean
Consumer
Reports Questions Cesarean Frequency [12/30/05]
The
American Academy of Family Physicians Trial of Labor After
Cesarean (TOLAC), Formerly Trial of Labor Versus Elective
Repeat Cesarean Section for the Woman With a Previous Cesarean
Section
March 2005 A Review of the Evidence and Recommendations by the
American Academy of Family Physicians American
The American Academy of Family Physicians (AAFP) recently published these new recommendations regarding vaginal birth after cesarean (VBAC), which differ significantly from the current recommendations of the American College of Obstetricians and Gynecologists (ACOG).
Some of the most notable highlights are:
~ "TOLAC [Trial of Labor After Caesarian] should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes."
~ "Our recommendation significantly differs from current ACOG policy because we could find no evidence to support a different level of care for TOLAC patients. Without good-quality evidence, we believe that different levels of resources cannot be advocated because their potential for unintended harms cannot be evaluated against their purported benefits."
~ ". the ACOG policy suggests that one rare obstetrical catastrophe (e.g., uterine rupture) merits a level of resource that has not been recommended for other rare obstetrical catastrophes (e.g., shoulder dystocia, abruptio placenta, cord prolapse) that may actually be more common."
~ ". current risk management policies across the United States restricting a TOL after previous cesarean section appear to be based on malpractice concerns rather than on available statistical and scientific evidence."
ACOG currently recommends that an OB and an anesthesiologist should be "immediately available," widely interpreted as being on the premises throughout the trial of labor. ACOG recommendations were based on "expert opinion." In contrast, the AAFP recommendations are based on a comprehensive review of published medical studies, a much higher level of evidence for such recommendations. The ACOG recommendation of having a surgical team immediately available has possibly been one of the biggest limiting factors for hospitals allowing a VBAC, leaving women with limited or no options for avoiding a repeat cesarean section.
The AAFP guidelines certainly give family practice physicians
more incentive to allow their patients to have a VBAC than the
ACOG policy currently gives an Ob/Gyn. It will be interesting to
see how the AAFP recommendations will factor into the current
climate, and how useful they may be for women and birth advocates
working to change hospital policies.
Vaginal Births after C-section are
safer in Birth Centers in certain situations by Judy
Slome Cohain, CNM
Vaginal birth after c-section safe after due date [Reuters - 10/3/05]
Safety
and
Efficacy
of
Vaginal
Birth
After
Cesarean Attempts at or Beyond 40 Weeks of Gestation.
Coassolo KM, Stamilio DM, Pare E, Peipert JF, Stevens E, Nelson
DB, Macones GA.
Obstet Gynecol. 2005 Oct;106(4):700-706.
CONCLUSION: Women beyond 40 weeks of gestation can safely attempt
VBAC, although the risk of VBAC failure is increased. LEVEL OF
EVIDENCE: II-2.
Guidelines
for
Vaginal
Birth
After
Previous
Caesarean
Birth by Ashraf Fouda, MD, Ob/Gyn Specialist, Egypt -
Domiatt General Hospital
This
study
by
Pauline
Dillard,
M.S.,
focused
on Post Traumatic Stress Disorder (PTSD) differences between
women who have had cesarean sections versus those who have had
natural childbirth.
Hypnosis
for VBAC - from Maggie
Howell of Natal Hypnotherapy in the UK
"Have you had a ceasarean and want a vaginal delivery next
time? The VBAC (vaginal birth after a c-section) is a 2 part
CD which helps you overcome any trauma from your previous c
section and the prepares you for a natural vaginal delivery"
Maggie sent me a review copy of this CD, and I was VERY, VERY impressed with it. I have a background in hypnotherapy and am now a midwife, so I'm very sensitive to all the issues of hypnosis for VBAC, and I thought Maggie did an excellent job. The guided relaxation is exquisitely sensitive to the issues of VBAC, and I would think any woman planning a VBAC would benefit tremendously from listening to this on a regular basis. Maggie's website makes it easy to order these CDs from other countries, so don't hesitate!
Maggie's work is a gift to birthing women everywhere.
Some more resources from Henci Goer:
CIMS: www.motherfriendly.org/resources (scroll down to the fact sheet on c/sec)
Advice for Pregnant Women about C-Section, Vaginal Birth and Vaginal Birth After Cesarean (VBAC) from Maternity Center Association
3 in 10 U.S. Mothers Gave Birth by C-Section in 2004: Sharp, Continuing Rise Defies Best Evidence and Best Practice from Maternity Center Association
my article: "Rebuttal to rationales for denial of VBAC" http://hencigoer.com/articles/vbac/
The Maternity Center Association (MCA) is the oldest organization in the United States advocating on behalf of mothers and babies. They have recently developed three new tools to help pregnant women make informed decisions and meet their goals:
What Should I Know About Cesarean Section? — a new booklet to help prepare every pregnant woman to make informed decisions about this important matter
Should I choose VBAC or repeat c-section?
How
can
I
prevent pelvic floor problems when giving birth?
Could mode of delivery influence the neonatal immune response? - Cesarean section may increase the risk of diarrhea and allergy in susceptible babies, German researchers suggest.
Caesarean
section
and
gastrointestinal
symptoms,
atopic
dermatitis,
and sensitisation during the first year of life.
Laubereau B, Filipiak-Pittroff B, von Berg A, Grubl A, Reinhardt
D, Wichmann HE, Koletzko S; GINI Study Group.
Arch Dis Child. 2004 Nov;89(11):993-7.
CONCLUSION: Caesarean delivery might be a risk factor for
diarrhoea and sensitisation in infants with family history of
allergy. Further research in this area seems warranted as choosing
caesarean section becomes increasingly popular.
Birthing
the
Easy
Way
-Learning
the
Hard
Way - a book written by a woman who has had 5 VBAC's
My Cesarean Poem by Barbara
Stratton
Uterine
rupture
is
more
likely,
but
not
common, after previous caesarean section
BMJ 2004;329 (3 July), doi:10.1136/bmj.329.7456.0-a
"The risk of uterine rupture during labour in women who have had
a previous caesarean section is small. Reviewing 568 articles
published since 1980, Guise and colleagues (p 19) found that, in
women delivering vaginally after a previous surgical delivery, the
risk of uterine rupture during labour was increased by 2.7 per
1000 cases, the additional risk of perinatal death was 1.4 per 10
000, and the additional risk of hysterectomy was 3.4 per 10 000.
It would require 370 elective caesarean sections to avoid one
symptomatic uterine rupture in women who had a previous caesarean
section."
Vaginal
Birth
After
Cesarean
Birth
---
California,
1996--2000 from the CDC: "Because cesarean birth
is associated with higher maternal morbidity than routine vaginal
birth (2,3), two of the national health objectives for 2010 are to
reduce the cesarean birth rate among women at low risk to 15% of
women who are giving birth for the first time (objective no.
16-9a) and to 63% of women with previous cesarean births
(objective no. 16-9b) (4). A key strategy to reduce the repeat
cesarean birth rate is to promote vaginal birth after
cesarean (VBAC) as an alternative to ERCD."
VBAC safety: A closer look at the 2002 JAMA study by Henci Goer
The Assault on Normal Birth: The OB Disinformation Campaign by Henci Goer, which starts with a focus on the NEJM's July, 2001, VBAC study and accompanying editorial.
Is vaginal birth after cesarean risky?
Rebuttal to
rationales for denial of VBAC
Levine, Audrey, 2000 - Midwives as radical educators: preserving
informed choice in the midst of a VBAC-LASH available from Senior Research
Papers at Seattle
Midwifery School. [I'm encouraging them to put these
resources online. You could, too.]
Caesarean
Birth:
Making
Informed Choice - an online booklet available from Birthrites: Healing After
Caesarean Inc.
Victorious Birth After
Cesarean Cesarean and Traumatic Birth Support ~A site
for women who want to reclaim their birth and truly heal
spiritually and emotionally after a cesarean.
HBAC FAQ - Q&A about Homebirth After
Cesarean - Although this was written by a VBAC mom planning
a homebirth, the safety information should easily qualm fears
about VBAC'ing in a hospital! [Homebirth advocates would say
this isn't necessarily true, since many aspects of homebirth make
it safer for a VBAC, but most people who worry about VBAC won't
know that!]
"By their own words shall they be known" - a recent
discussion among obstetricians helps birthing women
understand their view of cesarean, VBAC and birth in general.
Elective
repeat
cesarean
delivery
versus
trial
of
labor: A meta-analysis of the literature from 1989 to 1999.
Mozurkewich EL, Hutton EK
Am J Obstet Gynecol. 2000;183:1187-11
Birthrites: Healing After Caesarean- Great Australian VBAC site (used to be BACUP - Birth After Caesarean Unlimited Possibilities). This site is amazingly affirmative. They offer a terrific Suggested Reading List and a Birth Visualization Poster that is truly inspired! (The poster can be ordered from a U.S. distributor, Birth With Love, either plain paper or laminated.)
They publish a quarterly journal/newsletter which is very inspiring and supportive - excellent for those in Australia and also available in other countries. (Annual subscription $15 for the US.)
They also have a feature - 'Ask an Obstetrician' - a forum set up
to answer your questions; they will be answered by a qualified
Obstetrician, who is very sympathetic to the valid choice of VBAC
for most women.
A
Butcher’s Dozen - by Nancy Wainer - an article about 12
labors that could easily have ended as cesareans under the medical
model.
What would you say are the top 5 VBAC books you would recommend
someone to read? [year 2001]
The VBAC Experience by Lynn Baptisti Richards
Natural Childbirth after Cesarean by Karis Crawford &
Johanna Walters
Birthing from Within by Pam England and Rob Horowitz
Silent Knife by Nancy Wainer Cohen & Lois Estner
Natural Childbirth the Bradley Way by Susan McCutcheon
1- Nancy Cohen's Silent Knife
2- Nancy Cohen's other book-- Open Season (if not
the above)
3- Gentle Birth Choices by Barbara Harper (AND see
the companion video!!!!)
4- Diana Korte and Roberta Scaer's A Good Birth, a Safe
Birth
5- Susanne Arms' Immaculate Deception
All five just make you spittin' determined to get your birth as
far away from the sharps as you possibly can. I'd temper
them with others like Birthing From Within, Rahima
Baldwin's Special Delivery, as well as Susan McCutchen's
excellent Natural Childbirth, The Bradley Way for the
practical aspects of getting physically ready for natural
childbirth.
Vaginal birth after cesarean - from National Guideline Clearinghouse, a public resource for evidence-based clinical practice guidelines.
They have 5
other guidelines related to VBAC and cesarean.
"Research Shows No Evidence to Support Increasing Cesareans" by Henci Goer, BA, LCCE, printed in GENESIS - The Lamaze Advocate, Summer, 2000. This is a very good article, similar to the one below but updated for the 2001 ACOG statements supporting a woman's right to choose a cesarean section. She quotes him, "Every other medical condition we give the patient the options to deal with it. This is the only area where we deny the patient the choice. It's not a matter of procedure, it's the principle of a woman's right to control her body." As Goer astutely observes later in the article, "Contrary to Harer's statement, the 'right' to a cesarean is the sole instance where obstetricians have ever championed a woman's right to determine any aspect of her care other than, perhaps, her right to refuse an epidural." Indeed, the issue of a woman's right to choose the circumstances of giving birth seems to disappear when the issues of VBAC and homebirth are on the table.
Cesareans:
Are
they
really
a
safe
option?
by Henci Goer - If you watched the recent segment on Good
Morning America [June, 2000] addressing the safety of cesareans
and the issue of a woman's right to choose this surgical
procedure, you probably ended up feeling quite confused.
[The BirthLove site is by subscription only - it's well worth the subscription fee.]
Leilah McCracken, author of The Revolutionary Passion of Mothering offers a collection of Birth Love Columns from the weekly Online Birth Center newsletter. Many of these are about cesarean and VBAC. In particular:
Midwifery
care
and
out-of-hospital
birth
settings:
how
do they reduce unnecessary cesarean section births?
Sakala C
Soc Sci Med 1993 Nov;37(10):1233-50
U.S. women beginning labor with midwives and/or in out-of-hospital settings have attained cesarean section rates that are considerably lower than similar women using prevailing forms of care--physicians in hospitals.
Vaginal
birth
after
cesarean
section:
the
demise
of routine repeat abdominal delivery.
Martin JN Jr, Morrison JC, Wiser WL
Obstet Gynecol Clin North Am 1988 Dec;15(4):719-36
Vaginal
Birth
After
Cesarean Homepage
American
College of Obstetricians and Gynecologists - Vaginal Birth After
Cesarean Guidelines
Vaginal
Birth After Cesarean Checklist
Robin
Elise Weiss' Vaginal Birth After Cesarean FAQ
MOTHERLOVE -
Childbirth Services VBAC pages
Faith
Gibson's Homebirth VBAC Consent Form
The
Trials of the Midwife
by Katie Granju - From Minnesota Parent, October 1997
A must-read article for anyone trying to understand why the
healthcare system in the U.S. continues to snub the midwifery
model, despite reduced Cesareans, proven safety, and lower costs.
I have Natural Childbirth After Cesarean by Crawford &
Walters and Birth After Cesarean by Bruce Flamm. These are both
excellent books. But the Vaginal Birth After Cesarean by Elizabeth
Kaufman is a depressing book for women who are planning for a
VBAC. This woman's point of view is that VBAC and vaginal birth
are not all they are cracked up to be. It disturbed me greatly so
I returned it to the book store. I got it by mistake when I was
looking for Lynn Baptiste Richards Vaginal Birth After Cesarean
Experience. I still can not find this book anywhere to purchase. I
think the positive VBAC stories described in this book would be
revealing and encouraging.
Ken Turkowski's VBAC Births and
Uterine Ruptures - has an extensive
bibliography and there are some useful Suggestions
for VBAC Delivery.
I checked out this bibliography, and it's huge. I am not sure how
unbiased it is. In particular, most of the interpretations of the
studies ignore the many possible problems resulting from Cesarean
sections. But it might be helpful to someone doing research.
No, it can't be unbiased. Read his sad birth story about Catherine Grace's Birth (VBAC, induced, epidural rupture, sad) . This is from his web page on VBAC Births and Uterine Ruptures.
The extreme poor care of the labor was this: While laboring the
woman gets a constant pain even between contractions, husband and
mother are questioning, hospital staff dismisses. Then husband and
mother notice what seems to the father a bulge of a fetal foot
sticking clearly out right through the uterus and into the
abdominal wall, brings it to the staff's attention but again staff
dismisses carelessly saying bulges like that are not uncommon
during labor. Finally a stat cesarean is ordered when during
descent the baby returns too far back into the uterus or actually
abdominal wall at this point.
Ken sent me to this site-some of you may remember that Ken and I struck up a cyber acquaintance through some message boards that he posted to- and while the idea of having VBAC research all in one handy reference sounded nice, it doesn't quite pan out that way. I posted about this site earlier with the disclaimer that it was a bit biased against what they term "TOL"-trial of labor. I agree that the conclusions reached in the majority of the studies seemed to ignore the morbidity from repeat cesarean. I also resented the intro. To quote directly from the site:
The problem of VBAC is essentially one of playing the odds. If a pt chooses TOL and is successful, they win-minimal morbidity, short stay and low cost. If VBAC is not successful, they lose: repeat CS after a long labor with increased risk for high morbidity, prolonged stay and high cost. On the other hand, if they choose repeat CS they play a sure thing: low morbidity, slightly longer stay and moderate cost. I encourage counseling patients about VBAC from a perspective of what is good for the patient rather that what is good for the hospital cesarean section rate.Low morbidity with an elective repeat cesarean? Oh really? Moderate cost? What color is the sky where HE lives? What is good for which "patient"? Baby? Mother? How does he determine this? Worth noting is the fact that while some of the studies, McMahons in particular, have received valid criticism for unjustified conclusion and poor methodology, none of the criticisms have been mentioned. I e-mailed Ken about this today. I feel that an unbiased source of VBAC information should include these criticisms.
In short, skepticism is healthy[GRIN]
Books and Newsletters about VBACs,
Unassisted Birth and Pleasurable Husband/Wife Childbirth
VBAC Abstract - Miller - Vaginal birth
after cesarean: a 10-year experience
Is Homebirth Appropriate for a VBAC?
Are there studies which demonstrate that cont EFM is superior
than intermittent monitoring in "high-risk" cases ?
Vintzileos AM, Antsaklis A, Varvarigos I, et al. A randomised
trial of intrapartum electronic fetal heart rate monitoring versus
intermittent auscultation. Obstet Gynecol 1993;81:899-907.
This study is an anomaly--the only RCT, as I recall, that finds a
better outcome with EFM. The biggest problem with it is a highly
suspect randomization scheme. They ended up with nearly 3 times
(as I recall without looking at it again) the number of patients
in the EFM group as the auscultation group. The randomization was
supposed to be by a coin toss, which is, of course, an inadequate
method. It is all to easy for the physicians to decide that this
patient "needs" EFM, and just repeat the coin toss until he gets
the desired outcome. In a response in Birth somebody
calculated the odds of getting such a lopsided distribution
randomly, and it was literally less than one in a million. There's
something rotten in Denmark with this study.
Getting a stubborn patient to say Yes - an article written by and for OBs about perception of VBACs and how to coerce laboring women to agree to routine treatment.
This is the actual practice of the theory expounded in "Patient Choice and the Maternal-Fetal Relationship".
Excerpt
from:
Patient
Choice
and
the
Maternal-Fetal
Relationship
American College of Obstetricians & Gynecologists, Committee
Opinion, No. 214, April 1999
Look for updates here
or hereor
here
These were the ideas that The Farm gave to me regarding encouraging a successful vbac. Some are new to me, so take what you need and leave the rest:
Here are some sources I found in the Midwifery Today newsletter archives.
-Rupture of the unscarred uterus occurs more often and does more
harm than rupture of the scarred uterus (Martin, M et al., Vaginal
birth after cesarean section: the demise of routine repeat
abdominal delivery, "Ob Gyn Clin North Am, Vol 15, No. 4 1988, pp.
719-736).
-The scar that has remained intact up to the threshold of labor is
very likely to remain intact through the birth (Macafee, C, Irish
J. of Med Science, Vol 38, 1958, p. 81).
-The possibility of other unforeseen events occurring which may
necessitate transport such as intrapartum hemorrhage, fetal
distress, or cord prolapse is about 2.7 percent, roughly ten times
the rate of rupture during labor (Enkin, M. et al., "Effective
Care During Pregnancy and Birth, New York: Oxford U. Press, 1989).
-In her literature review, Henci Goer ("Obstetric Myths Versus
Research Realities" p. 42) found reference to only 46 ruptures
during 15,154 labors, a rate of 0.3 percent (benign scar
separations are a more common occurrence). -thanks to Anne Frye
and her book, Holistic Midwifery Volume 1, Labrys Press 1995
Dr. Osterhaus in Oregon is doing some work with scar tissue
therapy, injecting water or saline into the scar and massaging it
to break up the scar tissue. This might be helpful for women
with painful abdominal scars.
Cesarean Art - for all the
scarred mothers
I talked with Dr. Flamm (author of numerous VBAC studies and the book "Birth After Cesarean: The Medical Facts") last night about an article he's letting the Clarion use. I picked his brain while we were talking about some of the topics that have recently come up on our line. From Flamm:
Rupture/Pitocin: Although there are times that judicious use of pitocin have helped some women accomplish VBAC, there is data which suggests that the risk of rupture does increase slightly with the use of pitocin (From me: nearly every incident of rupture I've heard of, Pit was used). Pitocin should only be used when necessary, not routinely.
VBAC with Low Vertical Incision: A large study is in progress right now, but available data suggests that VBAC is safe and recommended with a low, vertical.
VBAC after Multiple Cesareans: There isn't a huge amount of data, but what they have suggests that VBAC is safe with multiple cesareans, with no particular limit to the number.
VBAC with twins: Flamm's practice does VBAC with twin births as long as the presenting twin (not both!) is head down.
VBAC consent forms (see my other post) Flamm is sending me a copy
of the consent
form that Dr. Phelan published which is currently the
"latest trend" in the OB offices. We both agreed that it was an
unfair approach since risks of repeat cesarean is not included in
the consent form. [Here is an annotated version
of this consent form from Birthrites: Healing After
Caesarean Inc. ]
It seems that none of the docs in our area "allow" VBAC moms to
go past their due date
She has another option. She can ask her ob to show her the
research that supports performing an elective cesarean if she
exceeds her due date, or, if that is the plan, inducing labor. She
would also be wise to find out if this ob puts any other
unreasonable restrictions on her such as estimated birth weight
being over some particular limit or arbitrary time limits for
making progress in labor, and if so, to ask to see the evidence
that supports these. If no evidence can be provided for these
restrictions, she may wish to exercise her right to informed
refusal. If she would like to have the research supporting the
safety of VBAC and the harms of both any individual cesarean and
of accumulating cesarean surgeries, it can be downloaded free at http://www.ingentaconnect.com/content/lamaze/jpe/2007/00000016/a00101s1;jsessionid=3ks0o3kfncf66.victoria
Scroll down to Step 6.
If your OB won't "let" you go past your due date and won't induce
with pitocin, consider requesting that you be "induced" by
rupturing the membranes. This can work well with a 2nd baby,
especially if the cervix opened with your first birth. And
if it doesn't work, heh, what's the worst that can happen . . .
you won't progress and they might recommend a c-section.
Sigh.
Ultrasonography has a high negative predictive value, meaning that for the third of women with the thickest lower uterine segments, there is a very, very low chance of rupture. This may be a helpful technology to pursue if your OB is using the possibility of rupture as a significant factor in recommendations about your care. However, it should be noted that even for the women with the thinnest lower uterine segments, the risk of catastrophic rupture is still very, very small and can be offset through vigilant management during labor, i.e. having a labor attendant actually present in the room with you, instead of relying on the remote monitoring common in most hospitals.
Ultrasonographic
measurement
of
lower
uterine
segment
to
assess risk of defects of scarred uterus.
Rozenberg P, Goffinet F, Phillippe HJ, Nisand I
Lancet 1996 Feb 3;347(8997):281-4
and
Published
erratum
appears
in
J
Gynecol
Obstet
Biol Reprod (Paris) 1997;26(8):839
[Echographic measurement of the inferior uterine segment for
assessing the risk of uterine rupture]. [Article in French]
J Gynecol Obstet Biol Reprod (Paris) 1997;26(5):513-9
The research (what little there is) seems to indicate that for a
very small percentage of women, the doctors were able to predict
that their uteruses (uteri?) would be stable throughout labor
& delivery. For all the rest of the women, they were
completely unable to make a prediction. As my doctor put it, "I
get no usable information from an ultrasound of the scar."
This same doctor also pointed out that about 50% of ruptures occur
prior to the onset of labor. He said, "This is why I feel
comfortable with a trial of labor - since you've already accepted
50% of the risk."
I just read through the Spring, 2000, edition of Birth Gazette and wanted to respond to the article, "A New VBAC Concern".
I understand the concerns about an undocumented cesaraean surgery, but it seems somewhat draconian simply to turn away all mothers in this situation.
There do exist technologies that can help to provide good information even when an operative report isn't available:
This may help only a third of women, but it seems better than
nothing for those women who would otherwise be denied the
opportunity to pursue a home VBAC.
Would it be able to detect whether fetal parts had started to
come through the dehiscence?
While I have never actually seen a case of uterine rupture or
dehiscence along a C Section scar, I am sure we could see it,
especially if fetal extremities were protruding. Inspection of the
uterine wall is a part of detailed exams. There is quite a bit of
literature demonstrating the Dx of placental accreta, percreta,
etc. So I am confident that sonography could detect a breach in
the uterine wall. However, NONE of the 7 major and comprehensive
textbooks on OB sonography said anything about it.
There are two significantly different techniques used to close
the internal incisions - single-layer
vs. double layer closure. Single-layer closure appears
to be more vulnerable to rupture in subsequent pregnancies.
Single vs. double layer suture - a white paper by Gretchen Humphries
ICAN
Online Webinars - One Layer or Two: Much Ado About Something?
presented by Presented by Gretchen Humphries
A longer, better version is in the summer '03 issue of Midwifery
Today Magazine but when I search the MT website it only comes up
as an article that you can purchase (not read for free online).
See also: Uterine Rupture
A small uterine rupture won't even be detectable in most cases. It is only a problem if the baby starts to come through the opening in the uterus so that the uterus "thinks" the baby has been born and the placenta starts to detach from the uterine wall. This movement of the baby through the opening in the scar is call fetal extrusion.
Fetal extrusion is preventable. If you have dedicated one-on-one care for the laboring woman, preferably by a midwife trained to look for the signs of rupture, it is possible to mitigate the results of uterine rupture by holding the baby inside the uterus while awaiting a surgical birth. This will prevent the reduction in uterine size that precipitates placental separation or abruption.
Also, fetal extrusion is not possible as long as the baby's head is down in the pelvis, which is almost certain with upright positions.
Most cases of catastrophic uterine rupture occur with pitocin and
epidural and with the woman in a reclining position so that the
baby's head is not contained by the pelvic girdle.
Uterine
Rupture by Debbie Miller from Birthrites: Healing After
Caesarean
Uterine
rupture
after
previous
cesarean
delivery:
maternal
and fetal consequences.
Leung AS, Leung EK, Paul RH
Am J Obstet Gynecol 1993 Oct;169(4):945-950
This article discusses the sequence of events involved in
catastrophic uterine rupture. It implies that the most
serious danger is when the baby is pushed through the opening in
the uterus into the abdominal cavity, precipitating placental
abruption.
Women get good news about normal delivery after C-section - By Rita Rubin, USA TODAY [2/8/04]
The risk of complications from vaginal births after C-sections -
known as VBACs - is actually quite small, according to the most
definitive study on the subject. Liability concerns have spurred a
growing number of U.S. doctors and hospitals to ban VBACs. In
2002, only 12.6% of pregnant women with a prior cesarean section
delivered vaginally. That's only one-third of the government's
goal of 37% by 2010. Meanwhile, the overall C-section rate in the
USA has climbed to its highest level ever - 26.1% in 2002.
In contrast, multiple prior cesareans, short interpregnancy
interval, single layer uterine closure, prior preterm cesarean,
labor induction and augmentation have all been suggested in some
studies as factors which may increase the rate of uterine rupture.
While considering these risk factors is important in counseling
women regarding childbirth following cesarean delivery, the
infrequency of uterine rupture coupled with relatively weak
associations for most risk factors has prevented the development
of an accurate prediction tool for uterine rupture.
Interdelivery
Time
Affects
Uterine
Rupture
Risk
During
Trial of Labor After Prior Cesarean The risk . . . is
threefold higher if the interval since the previous delivery is 18
months or shorter, rather than 19 months or longer.
Short
interpregnancy interval: risk of uterine rupture and
complications of vaginal birth after cesarean delivery.
Stamilio DM, DeFranco E, Paré E, Odibo AO, Peipert JF,
Allsworth JE, Stevens E, Macones GA.
Obstet Gynecol. 2007
Nov;110(5):1075-82.
RESULTS: A total of 128 cases (0.9%) of uterine rupture occurred,
and 286 (2.2%), 1,109 (8.3%), 1,741 (13.1%), and 2,631 (19.7%)
women had interpregnancy intervals of less than 6, 6-11, 12-17,
and 60 months or more, respectively. An interval less than 6
months was associated with increased risk of uterine rupture
(adjusted odds ratio [aOR] 2.66, 95% confidence interval [CI]
1.21-5.82), major morbidity (aOR 1.95, 95% CI 1.04-3.65), and
blood transfusion (aOR 3.14, 95% CI 1.42-6.95). Long
interpregnancy interval was not associated with an increase in
major morbidity.
CONCLUSION: Short interpregnancy interval increases risk for
uterine rupture and other major morbidities twofold to threefold
in VBAC candidates.
Although this article is about home VBAC, it has a great summary
of general VBAC safety issues.
All evaluations of birth outcomes ignore statistics regarding
long-term outcomes, such as differences in childhood infections
and hospitalizations for breastfed vs. bottlefed babies, and how
cesarean rates affect those differences. They also ignore
avenues focused on prevention of uterine rupture through upright
labor positions, early detection of uterine rupture through
dedicated face-to-face care in labor, and mitigation of uterine
rupture through application of pressure over the rupture to
prevent fetal extrusion into the abdomen.
"Dr. Dermot W. McDonald of the National Maternity Hospital in Dublin Ireland suggested that the medicolegal pressure to perform a cesarean may abate only when mothers begin suing physicians for assault, alleging that they were not given fully informed consent...
"'If one went to the extreme of giving the patient the full details of mortality and morbidity related to cesarean section, most of them would get up and go out and have their baby under a tree,' [Dr. McDonald] said." [Neel J. Medicolegal pressure, MDs' lack of patience cited in cesarean 'epidemic.' Ob.Gyn. News Vol 22 No 10]
Irish physician McDonald's remarks accord with the 1990 findings
of British research statistician Marjorie Tew who concluded that
the British maternity system is run by obstetricians who "withhold
and pervert knowledge in order to maintain public ignorance and
delusion." [Tew M. Safer childbirth? A critical history of
maternity care. London: Chapman and Hall, 1990.]
VBAC, C-Section, and EFM: How Safe Are
They? by Jennifer L. Griebenow
Relative Risks of Uterine Rupture -
Several gems, including "The risk of cord prolapse is 1 in 37
(2.7%), or nearly ten times more likely than that of rupture. "
Anne Frye on VBAC and Uterine Rupture
The easiest introduction to the studies is Obstetric Myths vs. Research Realities by Henci Goer, since she has an entire chapter on VBAC:
She has the abstracts, which is all you can get from Medline anyway, and is generally the level of information that is most accessible to lay people. She also has the studies nicely grouped and summarizes and critiques the studies. It's really useful as an intro. to the world of VBAC studies.
Then, to get the most recent ones, you'll need to go to Medline.
It's easier if you read a basic
introduction.
Uterine
rupture
associated
with
the
use
of
misoprostol in the gravid patient with a previous cesarean
section.
Plaut MM, Schwartz ML, Lubarsky SL
Am J Obstet Gynecol 1999 Jun;180(6 Pt 1):1535-1542
The uterine rupture rate for patients attempting vaginal birth after cesarean section was significantly higher in those who received misoprostol, 5.6%, than in those who did not, 0.2% (1/423, P =.0001)Note that this uterine rupture rate of 0.2% without misoprostol is significantly lower than the 1.5% commonly quoted!
There is a very interesting report on rupture of the uterus from the largest hospital in Turkey (52,000 births in 3 years -- yikes!). They had a policy of routine repeat cesarean, but many women did not seek prenatal care and simply presented themselves during labor. If a woman with a previous cesarean presented in very late labor, she could avoid a cesarean, but otherwise once a cesarean, always a cesarean. They had a rupture rate of 1/1457 (0.068%), pretty low unless you remember that most women with previous scars were sectioned upon presentation to the floor in labor (must be a really chaotic place with all those deliveries) .
Of the 40 uterine ruptures, 10 were in unscarred uteri, mostly associated with prolonged labor and pitocin augmentation, with a mean parity of 3. The 30 ruptures in scarred uteri all occured with low transverse incision, 11 had more than one cesarean. The rate of rupture in >1 cesarean was 4 times that in those with 1 cesarean, but still less than 0.5% (but their overall rupture rate was really low, compared to other authors).
Rupture
of the uterus.
Saglamtas M, Vicdan K, Yalcin H, Yilmaz Z, Yesilyurt H, Gokmen O
Int J Gynaecol Obstet 1995 Apr;49(1):9-15
A little bit closer to home, some authors in LA reported on 10 years of vbac. There were 17,000 women with at least one prior cesarean, 13,500 with 1 (79%), 3,000 with 2 (17%), and 800 with 3 or more (4%) -- all of whom underwent a trial of labor. All women with previous cesarean were considered for trial of labor -- except known classical (unknown scar could TOL), previous uterine rupture, or contraindication to labor. They did a routine inspection of the scar after delivery and classified separations not requiring intervention as dehisences and anything requiring intervention as a rupture.
80% (11,000 of 13,500) of single previous cesareans underwent a TOL with an 83% success rate and rupture rate of 0.6% and a rupture-related perinatal death rate of 0.18 per 1000 trials of labor.
54% (1600 of 3000)of two previous cesarean had a TOL, with a 75% success rate and a rupture rate of 1.8% and a perinatal death rate of 0.63.
30% (240 of 800)of three or more prior cesareans had a TOL, with a success rate of 79% and a rupture rate of 1.2% and no rupture related deaths (of course, the numbers in this group are much smaller -- only n=240 who had TOL, so a larger group would be needed to really observe the risks-- although I wonder where you might find a larger group?)
Another interesting factoid is that of the total uterine ruptures in women with previous cesarean, 23% (n=22) were prior to labor onset or diagnosed immediately upon admission when fetal distress was noted. All the other 95 uterine ruptures were supposedly discovered at "non-emergency repeat cesarean". Does this mean that none of the TOLs resulted in obvious uterine rupture and fetal distress, but that when they decided to throw in the towel on the TOL, they found 95 ruptured uteruses? There were 3 rupture-related perinatal deaths in women undergoing TOL, but 5 rupture related perinatal deaths in the group that was discovered to be ruptured upon admission. They had one rupture related maternal death.
The authors conclude that a TOL is a reasonable option for 2 or more previous incisions, but is best reserved for motivated patients who understand and accept the increased risk of uterine rupture and decreased risk of success which is pretty much what we have been saying in our discussion.
Vaginal
birth after cesarean: a 10-year experience.
Miller DA, Diaz FG, Paul RH
Obstet Gynecol 1994 Aug;84(2):255-8
For those of you who are really interested in this subject, Public Citizen put out
a White Paper in 1994 (getting outdated, I know) called Unneccessary
Cesareans: Curing a National Epidemic. They have an
excellent analysis of the relative risks of TOL, failed VBAC,
successful VBAC, planned repeat cesarean -- for the mother and for
the baby. It cost $15 for a single state report (the national
report costs $60, but only has more raw data on individual
hospital cesarean rates and is unlikely to be worth the extra
money) and I have found it to be an in-valuable resource in the
vbac or not to vbac debate.
There is no value in treating VBAC moms with uncomplicated histories any different than any other mom. ACOG even agrees (sorry no handy references). 50% of the less than 1% of VBAC that have ruptured uteri (with low transverse scars) happen before labor and even the labor ruptures are unpredictable. The figure of 1% is probably too high and is in dispute because much of the data comes from the now out of vogue practice of manually exploring uteri after VBAC, when you might find a small window or separation that was of absolutely no consequence.
It is very clear that VBAC with a low transverse scar is very
safe. If I may quote a few juicy statistics from the Public
Citizen report on Cesareans:
| Maternal Deaths per 100,000 Births | |
| All Vaginal Deliveries | 9.8 |
| All Cesarean Sections | 40.9 |
| Uncomplicated Vaginal | 4.9 |
| Elective repeat Cesarean | 18.4 |
I have not seen ANY studies which indicate a higher rate with
multiple cesareans. if he has some, I'd like to see them . I don't
believe the stats he was showing you. The guidelines to doctors
from the American College of Obstetricians and Gynecologists state
that doctors should "counsel and encourage women" with previous
cesareans to plan VBAC over repeat cesareans as the safer choice.
The latest edition of the VBAC guidelines also includes VBAC as
safe for women with multiple cesareans.
There have been no reported MATERNAL deaths due to uterine rupture of a low transverse incision.
Although rare, there have been incidences of fetal death associated with rupture of low, transverse incision. From Flamm's book:
These papers reported on a total of 11,027 women who had attempted VBAC: 8,693, or 78.8 percent, of these women had successful vaginal births in spite of their previous cesarean operations.
As far as risks to the baby, there were two fetal deaths per ten thousand births due to low transverse uterine rupture. Thus, the risk of a baby dying because of uterine rupture appears to be less than one in one thousand. To put these numbers in perspective, remember that in the US, the perinatal mortality rate is around 1.2%. In other words, if a woman decides to have a natural birth after a previous cesarean section, she is essentially at no higher risk of losing her baby than any other woman.
Abstracts about Pit and Home VBAC
What I find very odd about all this fear about uterine rupture from VBAC is that they seem to forget that the risk of rupture is unaffected by laboring. The danger is introduced by the presence of a uterine scar, which, by the way, came from the previous surgery. In any case, the danger is very small, and attention to one's body is likely to notice it before it becomes a life-threatening problem.
If the risk of uterine rupture in subsequent pregnancies was
really so high, wouldn't they be doing more to avoid those first
cesareans?
When I did the state stats for the Oregon Midwifery Council a few
years back the rate was as follows:
Ceserean rate for total -- 2.8%
ceserean for mulitps -- .08%
for primes 5.8%
for vbac attempt - 11%
Once
a
Cesarean,
Always
a
Controversy
-
VBAC article by Dr. Bruce Flamm. MD
I know that we have had threads like this, before, but what is
the size of the biggest baby you've ever caught? i am still
reeling from the huge VBAC baby a few days ago -- 12 pounds 6
ounces. Her first was 9 pounds, and her second was 10 lb 8 ounces.
We don't routinely test for GD, and this lady didn't want to be
tested. We thought she was growing a smaller baby this time. She
was really careful with her diet, really didn't want a big baby
this time. We are usually pretty good at estimating weight. After
the birth, we watched this baby carefully, and she just seemed
fat. No problems whatsoever. I've had several 11 pound babies,
now, one recently that was born effortlessly, and posterior. I am
already impressed with the capacity of the human body to give
birth, but this was really amazing. I want to know the size of the
biggest VBAC baby ever delivered. Does anyone know? This baby has
to be in the running----
My largest VBAC was 11-7, spontaneous rotation from OP to OA. Had
c/s for cpd and sepsis of 8-7 the first time around. Actually, she
was heading for OR this time too....5 hrs stuck at 6 or 7 cm, got
fever, OR was busy. By the time OR was free her temp was ok and cx
was 8-9 so we proceeded. NSVD VBAC w/ first degree lac.
I will not work with a care provider who would think of an untried healthy pelvis as any different in its natural ability to birth its baby than any other pelvis is. To me also size of baby is a nonissue as I do not believe that babies grow too big to fit the pelvis of the woman it is growing in. In addition to this, I have never heard of a breech baby's head not getting out of a pelvis in a natural non interfered with delivery.
Last month I beautifully homebirthed my 9 lb. 6 oz. baby girl after two unnecessary scheduled cesarean surgeries for ten and eleven pound babies! My girl sailed out of me! I know I could have birthed all of my children as nature intended. I informed myself this pregnancy and baby size became a nonissue to me.
I want to see the too big baby myth, untried pelvis myth, and
breech baby indication for cesarean surgery myth debunked.
Marriage Problems after Cesarean
The Pain Continues - How A Cesarean Birth
Can Affect a Marriage
C-section, VBAC, HBAC . . . Ecstasy?
- "I believe that our increasingly joyous birth experiences
have been a
real blessing to him and to us as a couple. "
With VBAC births it is important for the midwife to work with the dad prenatally. a vbac father is in a horrible position because, despite the fact that his wife had an operation and a long recovery, he still got a live wife and baby at the end of it all. Vbac dads are often "fantasy bonded" to the medical system and terrified of childbirth in general.
the good thing is that they listen very carefully and really know
when the care is better and more thorough and when the
practitioner is authentically on their team. I find that if
the midwife talks to them very honestly, they can trust and be
fully supportive when the birth time arrives.
Primary
mode of delivery and subsequent pregnancy.
Mollison J, Porter M, Campbell D, Bhattacharya S.
BJOG. 2005 Aug;112(8):1061-5.
CONCLUSIONS: Following an initial delivery by CS, fewer women went on to have another pregnancy compared with SVD. The incidence of subsequent pregnancy is similar following instrumental and SVD.
I
didn’t realize the pressure to have a C-section until I was
about to deliver by Carla C. Keirns [1/5/15] - An MD talks
about her experience with a failed induction.
There's some thinking that taking large amounts of Tums may cause
the baby's head to harden so that it doesn't fit into or through
the pelvis. If anyone had a cesarean for a head that
wouldn't mold (sometimes called CPD, but typically showing as a
stall at 6 cm), please
e-mail me with information about your Tums intake during
pregnancy, the official diagnosis, how far dilated you got in
labor and whether your baby's head was molded much, some or not
at all. Thanks.
See also Monitoring Fetal Heart
Rate/Decels about unnecessary cesarean for fetal distress
Lack
of
progress
in
labor
as
a
reason for cesarean.
Gifford DS, Morton SC, Fiske M, Keesey J, Keeler E, Kahn KL
Obstet Gynecol 2000 Apr;95(4):589-95
Conclusion: Lack of progress in labor is a dominant reason for cesarean delivery. Many cesareans are done during the latent phase of labor, and in the second stage of labor when it is not prolonged. These practices do not conform to published diagnostic criteria for lack of progress.
10 positive things I learned from my c/s
VBAC Success - Story and Rates
Jenny's Tale - Saga of a Birth Gone Wrong
or Yes, It Can Happen To You
Jenny Strikes Back - A Set of Letters and
a Meeting about the Unnecessary Cesarean
Eight Hours of Torture - Horrible
Epidural Experience Ends in Cesarean
Kristi
- Our Miracle Baby - Mom Ignores Medical Advice to Abort A
Troubled Pregnancy and Births a Healthy Baby. Kristi was
also one of the first babies born naturally to a mother with
multiple previous cesareans.
[from someone whose wife had an unnecessary cesarean]
Where fetal distress is a diagnosis without a definition, a failure to progress is a diagnosis without a prognosis: there is no meaningful link between the length of labor and the outcome although there is a statistical link between the length of labor and the chances of something else going amiss. But the two things aren't the same; until something actually goes wrong which DOES require a surgical delivery there is no reason for surgical intervention.
FTP is also a completely arbitrary diagnosis. For example, the
person we are suing states in one of her affidavits that a "three
minute recovery from bradycardia is significant when there has
been a failure to progress," the clear implication being that my
wife was suffering from a FTP. But my wife was admitted in early
active labor, had dilated three centimeters or more since her
admission, it was our first child, and, get this, she had been in
the hospital for less than four hours before being brought to
surgery. Failure to progress? Ha. And how about you?
I don't know why the medical staff wasn't able to diagnose the
asynclitic head and correct it prior to the surgery, but it's hard
to imagine that this could possibly have been your fault. After
all, you hired them to help you.
Bingo! They are the "experts"--they should know how to help you
give birth, but IMHO, "they" don't. They don't know how. It was
not your fault, your problem, too big baby, baby's fault, etc.
Rupture of Membranes Causes Cord Prolapse
Mom Writes Letter to OBs Who Did
Unnecessary Cesareans
I think it is better to say that we all had childbirth losses and
that a loss is hard to take, no matter what it is.
You couldn't have said this any better. This is probably the most important thing I learned from the book "Ended Beginnings". We do not need to compare and measure our losses to see if we have the right to grieve (or if someone else has the right to grieve).
If a person has a feeling of loss, they HAVE lost something. Whether it is a huge loss- like that of baby whom they have already met and loved, or a "smaller" loss like a miscarriage at 6 weeks (wait- don't jump on me- I KNOW a miscarriage isn't a small loss. I've experienced that) you will still go through the same process of grieving and healing. It may not be as deep a loss, or as long a grieving period, but it is the same process.
If I had a friend who lost a uterus at age 23, I too would feel
that my loss of two cesareans and a miscarriage was small in
comparison. I was able to go on and have another baby and a VBAC.
She won't be able to do that. And yet, I don't think that a
traumatic birth experience, or even a disappointing one is a
insignificant loss. And for many women it is a devastating loss. I
understand what you were saying, especially out of love and
concern for your friend. Acknowledging her loss doesn't diminish
the losses of anyone else on this line, or yours either. Perhaps
your experience will enable you to be more supportive of your
friend than if you had had a normal birth.
You Should Be Grateful -by Gretchen Humphries - "You should be
grateful, after all, you’ve got a healthy baby". How many times
have we heard those words?' [Ed: birthlove.com is not
available at this time.]
I was wondering about how physical experiences may differ between
women who have had just stitches and women who have also had
staples. My doctor did not use staples for my c-section but my
sister did have staples and she appeared to have a longer, more
uncomfortable recovery.
I had staples with both my children. A few months after surgery I
felt something just wasn't right....I seemed too numb. I was told
by my ob that that happens and there's nothing they can do about
it. I'm 5 years past my last c/s and I still have no feeling three
inches above my scar. Lovely, isn't it? Like a permanent
paralysis. Bleeech.
I had staples w/ my c-section and had an unexpected allergic
reaction. I spiked a high temp and the incision site became red
and inflamed within a day. They were drawing vial after vial of
blood running many tests trying to figure out was happening to me
and I was not allowed (and I didn't know better) to nurse my baby
for 24 hrs. My understanding was that the hospital didn't believe
that I could be allergic to surgical steel...but when they finally
removed the staples it cleared up aft only about 12 hrs. Since
then I've talked to many people who say that surgical steel
actually contains some amount of nickel and that I could have had
the reaction to that. My first cousin also had a similar reaction
when staples were used on her after knee surgery. Just in case,
I'll always include in my birthplan that I want NO STAPLES!
I had stitches in my external incision. My scar, which is just
above my pubic hairline, has altered the shape of my abdomen by
pulling in the skin there. I have had to grapple with the pain of
this visible disfigurement.
Put me on the list for this complaint as well. In my first
c/section the cut was where you describe, but I'm so pudgy that I
don't see it :-), but my last c/section (and by golly, I mean my
last), the doc did an infraumbilical incision which is a few
inches below my belly button, very visible, it split open during
the healing process and now it pulls up in the middle so it looks
kind of like this __/\__ I do not like it. BTW I had staples both
times, 21 with my first and 22 with my second, my first incision
healed pretty well, my second was awful. And I still have scars
from the huge blood blisters I developed from being allergic to
the plastic tape.
My scar is lower down, but it looks exactly how you describe.
Sort of like an upside down tummy tuck, since it looks as if the
skin was pulled UP then stitched. It is sort of weird looking. I
am lucky though, because I am a bit chubby, and stretched from
baby, so you can't really see it.
I have a "tuck" there, but my scar is through the TOP cm of my
pubic hair, I'd rather it had be higher. The PAIN of the hair
growing back is BAD!!!
Cesarean Rate - A Grand Multipara's Plea
by Leilah McCracken
To the editor of the New England Journal of Medicine:
As a mother of six- and VBAC mother of four- I have to comment on the resistance of some obstetricians to the government's mandate to lower the incidence of cesarean delivery.
Cesarean sections are painful. After my section, gas pains ripped through my abdomen. My catheter hurt me when it was inside my urethra, and left sharp pains when it was out. I was a twenty-one year-old woman who had to pee in a bag, and hold her belly together before rolling over in bed. I was helpless to care for my new baby, and I will always remember his first days of life as grotesquely uncomfortable, and full of sorrow.
Cesarean sections are dangerous. Women are up to sixteen times more likely to die after a cesarean. Cesareans cause ileus, pulmonary embolism, and Mendelson's syndrome; and the formation of adhesions and intestinal obstruction. Women can have lifelong urinary troubles when the bladder is peeled away from the uterus, and bladder injuries are common as well. Women suffer emotionally as well.
Cesarean sections often involve a violent fetal extraction; trauma felt by babies during birth makes them five times more likely to commit violent suicide later in life.
And breech babies are best born vaginally.
There is no genuine "informed consent" for most women undergoing cesarean delivery.
More is known about how bedridden patients give birth than how women give birth: I have given birth as a patient five times; then I gave birth as a woman. I feel I was born a woman the day I gave birth to my sixth child at home, with my midwife, her partner, and my husband attending me, in love and quiet dignity. For the first time ever, I was joyful in birth, and left alone- no needles, knives, fingers, hooks, scissors, staples, drugs, tubes, synthetic hormones, medical students, nonsense.
It is cruel to keep childbirth lock-stepped in a model that
is not based on women's bodies, but on men's idealized notions of
reproductive efficiency: stations of descent, counting fingertips
for dilation, obsessively monitoring a woman's "progress", adding,
comparing- these things are all the medical ideal of birth-
predictable, graspable, manipulatable, efficient and fast...
But birth takes her own time. Birth comes when women feel
safe to let it come, and women cannot feel safe when under the
constant threat of attack by gloved hands and medical steel.
references:
http://www.bmj.com/cgi/content/full/317/7169/1346
(adults five times more likely to commit violent suicide after
traumatic birth)
http://www.bmj.com/cgi/content/full/317/7156/462
(see especially the "risks and benefits" section)
http://www.bmj.com/cgi/content/full/314/7086/993
( British Court of Appeals ruled that women have the absolute
right to refuse intervention, including cesarean section)
http://www.bmj.com/cgi/content/full/314/7088/1187
(emotional difficulties resulting from cesarean delivery)
http://www.bmj.com/cgi/content/full/312/7044/1451
and
http://www.bmj.com/cgi/content/full/312/7044/1433
(breech babies best born vaginally)
(Leilah McCracken's Web site - "The Revolutionary Passion of
Mothering" - contains a number of terrific, thought-provoking
articles. She especially recommends "Rape of the Twentieth
Century" wherein, "I detail my births (especially the section)
and, how cruel hospital birth truly is- for Moms and babes.)"
[Ed: birthlove.com is not available at this time.]
Telling Husband About Anger from Cesarean
How Natural Childbirth Can Heal Birth
Trauma for Older Siblings
Carol Ann's Birth - a cesarean for "failure to progress" followed by trouble bonding and breastfeeding.
Her next birth was a VBAC at home, where she tuned into her body
and birthed in a gloriously simple and elegant manner.
I have a question for all you VBACs out there. I'm sure that in
most cases you found your VBAC birth experience to be more
fulfilling than previous c/s. I'm wondering if you found that the
positive experience also affected the way you bonded with your
baby? I know you love all your children equally, but did any of
you feel "closer" or more "bonded" with the VBAC baby?
I definitely know that there was a difference in bonding with my cesarean baby and my homebirth VBAC! I believe it's such a trauma to your body and psyche to go through major surgery there is not much energy left to "bond" and devote to your newborn initially. We chose to keep our baby with us in our room after the cesarean, or what they call "rooming-in". As with most cesarean babies she had a lot of mucous and kept choking and after day two and being up for about 60 hours, we sent her to the nursery so we could get some sleep. Now I can tell you, my VBAC baby you could not have pried out of my arms, for any reason!
My husband even said to me after our VBAC baby was born and I
wouldn't let her even whimper without attended immediately to her
needs, "Gosh, our first baby cried a lot more when she was a
newborn and you didn't respond like this". I really felt guilty
about this. I was so in shock and trying to heal myself it was
harder to have the reserves to attend to her. We all have issues
that we will feel guilty about in parenting. I think it is good to
keep perspective about loving our children equally but not the
same. I pray that it will balance out and she will benefit in
other areas of my love for her and this will make up for the
initial loss of bonding. I wonder also if other parents have seen
a difference in personality that they attribute to being born
vaginally vs./ cesarean? I realize children are all going to have
different personalities, however I wonder if certain attributes
are common with cesarean born children?
Personally, the worst thing about my c/s was actually a side effect of the epidural. A recently published study from Brigham's says that 15 % of women that have epidurals develop a fever. Since the baby is in the mom, baby is born with a fever too. When a baby is born with a fever, infection is assumed. The child is sent to NICU for 3-7 days to have every orifice sampled and sent to the lab for tests. Out of this 15% of babies, less than 1% actually have an infection.
My daughter was even given 2 spinal taps, even though her fever
was gone an hour after her birth. My fever didn't drop so quickly,
so I didn't get to touch her until she was 3 days old. Valuable
time has been stolen from me and I can never get it back. I will
forever wonder what effect this has had on her ability to trust
her fellow human being. She certainly bonded well with the plastic
box though!
That's an absolute nightmare!! Sounds just like my first birth
and also like my bestfriends sister in law who had her baby (c/s)
a few days ago.I will forever feel the effects of being separated
from my first baby, going home 2 days before her, not being
allowed to nurse her etc., not to mention the ppd I had (and never
had with subsequent pregnancies) The separation delays the bonding
process and to me that's a crime.
Does anyone know what I need to request to have complete
information on my labor and surgery and my son's delivery/birth?
In theory, you probably have the right to a complete copy of your records. In practice, it's often difficult exercising that right. Your best bet is to get a doctor to file a request for a copy of your records and then get them from him/her. You might also contact a medical malpractice lawyer in your city for advice since they have a lot of experience getting medical records.
You can, of course, simply call up the patient representative or records department and ask them how to get a copy of your records. (It's wise not to mention the word lawsuit or express any dissatisfaction with your treatment- Getting a copy of your records is not necessarily a big deal --sometimes people who are planning both to move across the country and to have another child want to get a copy of the records before they move so that the new doctor won't have to wait....)
The hospital will probably ask you to provide them with a notarised letter requesting them to provide you with copies and they may charge you a retrieval and copying charge. Your request should specify that you want copies of ALL documents relating to both your treatment and any treatment given to your child including but not limited to FHMs tracings, L&D Notes, ante, intra and post partum progress and nursing notes, and all infant care notes and test results, etc.
Finally, once you get your records you should find someone to
look them over and make sure that everything that should be there
is there. Records often go amiss - especially when the patient
starts looking for them. An L&D Nurses or midwife who has
worked at that particular hospital are probably the best people to
review your documents for completeness - as well as to read
between the lines.
About Lawsuit for Unnecessary Cesarean
A
Plaintiff's Verdict: Meador v. Stahler and Gheridian
[1/1/07]
Cesarean Lawsuit Won by Patient
Ahhh, but there ARE women like this who feel it is ecstasy to deliver their baby with an epidural. MY one SIL is exactly like that. She said it was like watching a movie!!! Like having a baby SHOULD be that way????
Also, just recently I did postpartum work for two women who felt cheated because they got to the hospital too late and couldn't get it!!!
I could strangle them both!!! They have no clue what it is like
to have the labor from hell and then a c/s - well, the second one
does, but I don't understand her at all!!!
I was reading on a pregnancy newsgroup the other day and a woman
who just found out she was pregnant was wondering if she could
have the baby via c/s because she is not sure if she can handle
the pain. It's her first pregnancy. I don't mean to sound
judgmental of her and her choices, but I couldn't believe it! Who
on earth would choose to have a c/s just because they are afraid
of labor (I could understand it if there was a medical reason)! I
was so mad when I read that! If she wants a c/s so bad, I would
gladly trade my c/s for her vaginal birth any day!!
I soooooo agree with you! Infact, even though my very long labor
was extremely painful, I am really looking forward to my next.
Even if it is MORE painful. I actually think I could handle more
pain now. I feel like I'll wait until I pass out from pain before
I'll agree to another c-section!!! (or if the baby was in TRUE
trouble).
I'm not sure you ever get over the feeling of being robbed of the
precious first moments with your child. I can never get those
moments back. We can't dwell on them, but we don't forget.
My heart breaks because I know that this means, for many women,
that they will never know the joy that I experienced with my
earlier prior to my cesareans births. Many will never know what it
means, how it feels, what it does to ones soul, body, and mind to
push their child into the world.
I think that loss of initial contact with your infant is something that stays with you forever. That time is so precious and so crucial and to have that taken away from us is wrong and something that we will grieve. Even after having my HBAC and getting to hold my sweet newborn immediately, I grieved for the loss of that with my first daughter.
I think what helped me was to focus on the positives about the experience and to realize the way I have chosen to mother Hannah has made up for much of the birth trauma we both experienced. I know nursing my baby gave me confidence and belief in my body and was comforting to know that I may not have been able to "control" the birth but I could do this.
I often refer to my c-section with the analogy of having a broken
bone. It is mostly healed (after my homebirth!) however, on rainy
days or days when things aren't quite right, it aches.
Someone needs to tell this woman that a c/s is the beginning of days and weeks of pain, but labor is usually less than one day. When labor is over so is the pain, so you can tend to the baby. With a scheduled c/s you just postpone the pain until you have to take care of an infant while you can barely walk. Even with an episiotomy, sitting on a donut for a few days is nothing compared to the pain of trying to stand after surgery. (I would imagine.)
Maybe we can help discourage c/s by complaining about the
recovery period more. I know I don't want to sound like a whiny
baby. All of us survived and did walk again, but the misery of
recovery should be shared just as everyone else likes to share the
horrors of long labors.
SO TRUE!! Here I am, 2 months and a week after my c-section and
ouch! I am amazed at how sensitive the skin is around the incision
AND around on my stomach. It's still very sore. I had all that
gross oozing, & blood coming out for about three weeks. I
recall, you did too. I get real "jumpy" every time Scott puts his
hands even NEAR the area, because I'm afraid it's going to hurt.
And, the hard lumpy area that runs along the scar, doesn't seem to
have gotten any softer. Not as far as I can tell. AND, even though
the incision is about an inch below where the hair line starts, I
have blondish hairs "down there" so there's no missing the big red
line.
Having a c-section actually prolongs the pain of childbearing to
weeks, months and even years. This is what we need to be telling
anyone opting for a cesarean section voluntarily! What seems
easier at the onset is actually much more difficult.
At one time, before I knew anything about birth, I too thought I
would rather have a c-section. THEN, I saw a video of the
operation and quickly changed my mind. Women need to know that
childbirth doesn't have to be a horror like most of their friends
tell them. Yes, it usually involves some pain, but it is over a
lot quicker than if you have a c-section, and it is pain w/a
purpose, not a "hurt" pain. And they need to know that much of the
pain they hear about is avoidable. In fact, women who have
medication often describe labor as MORE painful than women who
have had natural births. This is due to interventions & being
confined to bed, as well as being unprepared. I wish there were a
way for us to reach many more women than we do. I never heard of
ICAN before I got pregnant, and nobody could give me info on
Bradley childbirth classes. I finally found a teacher and had to
drive 60 miles each way. There are so many ways we can get more
involved and reach out to these women - starting with the
hospitals. We can volunteer our services and write letters, making
it known what women want and need in birth.
I know this is going to be really hard to hear, but it has been a
very big theory of mine that there are actually some women out
there who want the added ATTENTION that a cesarean birth will get
them. Said it would be hard, but I have been around a LONG time
and have seen and heard.....
Yeah, people just think I'm crazy when I tell them I had natural
childbirth. You'd think they'd be interested, but it's almost like
you're a leper. I guess they don't want to feel like they're
expected to do it too.
I know how irritated you are - I have women come to my class
requesting cesareans also. They somehow think it is easier than a
vaginal birth - I let them know differently!!! But it is really
frustrating!!!
I know. I remember my own mother telling me (when I was pregnant)
that she wished I could have a c/s because (in her opinion) the
babies come out looking so beautiful. Can you believe it?
Incidentally, I didn't get much support from her after my c/s.
When I was depressed afterwards, she just thought I was being
whiny.
I did not want to repeat my cesarean! I do want to repeat my
natural birth!
Me too. I don't EVER want to repeat my c-s. In fact, I was so
upset by my first one that I was scared to death to even get
pregnant with my second. Some people (who don't
understand) will think this sounds too "harsh" but if I had had to
have a c-s with my second for whatever reason (the reason wouldn't
even have mattered), I wouldn't have had any more kids at all. I
would have had my tubes tied after my 6 weeks check up. For me, I
just could not handle it emotionally. Physically I was fine but
emotionally - I could not have handled having a second one. So
thankfully God allowed me to have a vaginal birth with my second
child and third. He knew !! Now if I had to have one (which is
incredibly not likely) with baby #4, I wouldn't be having any more
anyway so it wouldn't make much difference. Yes I would still be
devastated but it wouldn't keep me from having future children.
All I felt after my c/s was tired and depressed. I only saw my daughter through a window once in 3 days. The rest of the time I watched videotape, with no sound, through a camcorder. The viewfinder wasn't even in color. I can't imagine how depressed I would have been without that camera. I had nothing to do with that birth. I grew a perfectly healthy baby in a perfectly healthy body, but there was no joy and no sense of accomplishment. I was too happy to hear that test after test was negative to worry about how many times and in how many places her tiny body had been jabbed. No one should have 2 spinal taps in only 3 days of life, especially when she has NEVER met her mommy.
My home VBAC has given me the confidence to birth anywhere, but I
hope I never have to do it in a hospital again.
Anita Plans Homebirth after A Cesarean And a
Horrible VBAC
How did you HBAC moms come to the decision to homebirth? I really
really really want to have my next children at home but I am
scared of uterine rupture. I think this is mainly because I know
so little about it.
You are where you are right now, not where I am, or anybody else is, including your spouse, in terms of your thinking and your belief system, and your faith in your body, its ability to birth, and any physical, mental or spiritual difficulties that you might perceive with these processes.
Even though I can tell you what I think or believe or have grown to accept, telling you these things...doesn't bring you to where I am ...or to the same place as anyone else here. It is your personal journey or quest, not ours, and I hope that we all respect your need to make that journey yourself, and not be 'carried along' by anyone else's views or opinions.
I hope that you will listen to your heart, and also to the little one that is beating inside you when you are making your decisions about birth. I hope that you will learn to trust your own judgment and discernment, especially when it comes to assessing the vast amount of information that we are all firing at you. Much of what you hear here seems in contrast to what your medical & professional caregivers are telling you. I think that must feel like a horrible and confusing thing to deal with, and I hope that your own quiet sense of what is 'right' for you will help you to decide what to do.
Only you really know whether the dangers and fears that your caregivers are expressing are something that you embrace yourself.
I would like to share some thoughts for you to ponder on.
The decisions you make will be based on the information that you have, which includes the facts you choose to accept, reject, or ignore. Your decisions will be based on the beliefs you hold, and who or what you trust most, whether it be a doctor, a medical system, a spouse, a Creator, Nature, yourself or your baby. They will be dependent on the amount of responsibility you want to take, or give away, and the fears that you have.
I hope that you find the wisdom you will need to make your
decisions, and peace of heart after you have done so.
My HBAC was 2 weeks ago. A year ago, I never would have considered such a thing possible.
I went through 3 care providers during this pregnancy. DH and I toured 4 hospitals and a birth center. We knew that our best bet for a safe VBAC was non-intervention. The hospitals only had births w/o epidurals by accident and the BEST VBAC rate (out of 33 hospitals in 3 counties) was 46%. The birth center was so low tech that we saw no need to go. They didn't have anything that a midwife wouldn't bring to our home.
It took us a few months to come to our decision. There were lots of little steps that got us there. We researched together and made the decision together.
When you worry about rupture, remember these facts. ACOG thinks pitocin and epidurals are safe during VBAC. The rupture risk can't be too worrisome if the docs allow these two things. Also, some insurance companies require a trial of labor. If rupture was a big worry the money hungry insurance companies wouldn't take the financial risk. Thirdly, many professional midwives practice illegally. If they were worried about rupture, they wouldn't take the risk of "getting busted" during a transfer.
The more you read about birth, the more confident you will
become.
I do not want to say this to upset those who have never or never will have a vaginal birth or VBAC. I realize this may just never be for some of us and this is okay too. We can live with this and accept this also. God and nature look after all of us!
BUT, that said, for any candidates of vaginal birth: if you can at all muster the opportunity and ability for VBAC I say go for it 100% with your colors flying!!!!
After my homebirth after two cesareans I can't wait to do it
again either! This is the way we were meant to feel about
procreation! Awe and wonder at the accomplishment of the act of
childbirthing due to no one else but ourselves!
Home
VBAC: The Horns of a Dilemma [6/6/16] from childbirth-u.com
Home
Safe
Home:
A
VBAC
-
My
Way by Rachel Gathercole, Mothering Magazine, Issue
110, January-February 2002
In the year 2005, it is increasingly difficult in some areas of the United States for women to find a hospital that will support VBAC. Thus, more and more women are seeking to have VBACs at home, which can be safer for a lot of reasons, including upright positions that prevent catastrophic uterine ruptures.
Unfortunately, the legal environment for midwives is not that much better than for doctors who support VBAC. Here's one midwife's protocols re: eligibility for HBAC:
I do VBACs at home. Only if there was one section, and it's been 18 months since the last section, and they do not go past 42 weeks. They have the option of a third trimester ultrasound to evaluate placental location to r/o placental problems, though few actually do this. I do primary VBACS but prefer it if they've had one before. If there was a previous VBAC, the risk is of rupture is so small, I feel like she's about the same risk as any other client. I do listen more intently and would transfer more quickly if there were funky FHTs.
I have a birth center, but in Florida we can not by law do VBACs
in birth centers, but we can at home if we get a consult. There is
one doc that will do consult that reads "Have your baby at or near
a medical facility". People drive hours to get his "approval". I
have a very detailed informed consent that has my VBAC policy;
it's based on The New Mexico Midwives VBAC consent from 1999,
which was developed by their LM's profession association.
Studies
Supporting Homebirth VBAC
When I get a VBAC client and she is endlessly self-psychoanalyzing and beating herself up for having a c-sec I usually say "Look you made TWO big mistakes! First you were born in the wrong country and second you were born in the wrong century--if you'd been born and raised l00 years ago in France, for instance, you would have given birth vaginally."
When I teach my workshops, I tell the students there are two types of pelvises in allopathic medicine: l. contracted and 2. adequate
In midwifery, there are two types of pelvises as well: l. roomy,
ample 2. you could get a pony through there!
Studies
Show That Acupuncture Decreases Caesarean Rates [10/9/09]
Impact
of
early
admission
in
labor
on
method of delivery.
Rahnama P, Ziaei S, Faghihzadeh S.
Int J Gynaecol Obstet. 2006 Mar;92(3):217-20.
CONCLUSION: Later admission in labor increases the rate of
spontaneous vaginal delivery in low risk nulliparous women.
Cesarean
Section for All Twins? [from obgyn.net]
Epidural Ups Fever, C-section Risk
Mom with Previous Myomectomy Declines
Unnecessary Cesarean
Faith
Gibson's
pages
on
Informed
Consent
for
Special Circumstances
Here are 3 "Special Circumstances" informed consent documents for
home-based care and/or refusal of customary obstetrical protocols
for VBAC, Twins, Macrosomia
Active Management with Pitocin Does Not
Reduce Cesarean Rate
Things You Can Do To Avoid An Unnecessary
Cesarean
Fallacy of Gestational Diabetes Treatment to Improve Chances of VBAC
I don't think this is necessarily a bad way to set goals. There's
a fine line between goals that seem challenging and those which
seem so difficult that they are ignored. Better slow change than
none. If a practitioner cares enough to find out if his or her
practice is supported by the science, there's always Enkin et al.
Also, anything that causes pain for the mom is likely to interfere with the establishment of breastfeeding. A relaxed, comfortable breastfeeding relationship has lots of physical benefits and probably even more emotional ones for the baby.
Preliminary research indicates that it is the babies who start labor by producing certain hormones. Surgically removing the baby before labor starts may interrupt a delicate hormonal process that we don't yet fully understand.
Obviously, women choose a surgical birth for their babies because they believe that the tradeoffs balance out that way. But there are tradeoffs - sometimes unexpected ones.
I'd only heard this and didn't give it much stock until a child I know well happened to mention that she was having a lot of dreams about tunnels. I asked and she said, yes, she'd been born by cesarean. I then asked her younger sister, also born by cesarean, and she said that she also had a lot of dreams about tunnels.
I've heard there are rebirthing therapies to address these sorts
of issues.
Information about Hydrocephalus and
D&X
I was saying I'd love to have another one when Baby was only a
week or two old. My SIL commented that most women immediately
after a birth say "I never want another one" or they don't even
want to think about it; I was the opposite; that's all I could
think of; I was "high" on birth (and still am)!!
After my homebirth after two cesareans I can't wait to do it
again either! This is the way we were meant to feel about
procreation! Awe and wonder at the accomplishment of the act of
childbirthing due to no one else but ourselves!
As horrible as my labor was, after it was all over, one of my
friends said to me, "Never again, right?" I told them, "No way! I
want more!" This was the next morning. Everyone there thought I
was wacko. They just looked at my husband and said, "You're in
trouble."
So a woman can lose 750 cc of blood in a vaginal birth, and it's called a postpartum hemorrhage, but if she loses 750 cc of blood during a cesarean, it's NOT called a postpartum hemorrhage. WOW! Tom Lehrer would be proud of this New Math. Too bad the woman's body doesn't understand New Math.
This level of intellectual dishonesty is truly beneath educated
professionals. I'm just hoping the person who gave the
presentation was confused rather than dishonest.
The presenting Stanford OB said that Stanford DOES VBACs [though I would guess the particular OB still needs to be willing] and reiterated that the main reason other hospitals are not doing them is due to ACOG's policy that "OB and the team must be IMMEDIATELY (loosely defined, but basically in-house) and not just READILY (within 30 min) available in case of uterine rupture."
He also said (loosely rephrased) that vaginal birth is still the norm in the US unlike in Brazil, where Cesarean rate is over 90%. Elective maternal request Cesareans are currently between 4-18% in US and that insurance companies are starting to reimburse for them, even though they are not medically indicated.
He also said that the people who came up with the 15% guideline for trying to lower Cesarean rates, were smoking something, and that instead of trying to follow some "arbitrary" number, OB's should have maternal and fetal interests at hand.
The overall message was that there is very little good evidence on the topic of Cesarean vs Vaginal dilemma, but most "weak" or "absent" evidence shows that Cesareans have the following downsides, as compared to vaginal birth. The following rates increase, especially after repeat Cesareans:
placental complications (previa and accreta) in subsequent pregnancies; urinary and fecal incontinence later in life (though previously Cesareans were thought to protect from them); hemorrhage and hysterectomies in subsequent pregnancies; stillbirths in subsequent pregnancies; infant respiratory and pulmonary hypertension complications; infant prematurity (he pointed out that standard deviation for Neonatal Age dating is 21 days!!!- which means, the due date accuracy can be off by that much!!!);
Also, Cesareans require longer hospital stays, loss of control by the mother, and more postoperative pain/longer recovery. Also, sexual functioning was the same between CS and vaginal births at 6 months after delivery.
Rates of breastfeeding, of course decrease.
The possible benefits of Cesareans (followed by a reminder that
the evidence is weak), is less postpartum hemorrhage. But that was
about it... [Ed: See the snippet above about how postpartum
hemorrhage for a c-section is defined as < 1000 cc, twice the
amount considered a hemorrhage with a vaginal birth.]
Mode
of
delivery
and
risk
of
respiratory
diseases in newborns.
Levine EM, Ghai V, Barton JJ, Strom CM.
Obstet Gynecol. 2001 Mar;97(3):439-42.
CONCLUSION: The incidence of persistent pulmonary hypertension of
the newborn was approximately 0.37% among neonates delivered by
elective cesarean, almost fivefold higher than those delivered
vaginally. The findings have implications for informed consent
before cesarean and increased surveillance of neonates after
cesarean.
Lets look at the rates for cesarean shall we[GRIN] Maternal morbidity rates-this is illness following the procedure- are 5 to 10 times HIGHER for cesarean than vaginal birth. Morbidity rates include but are not limited to: operative injuries, operative and post operative hemorrhage, pulmonary emboli, venous thrombosis, anesthesia complications, and infection. There have been rates as high as 50% morbidity associated with cesarean section.
On to mortality:( NIH states that mortality rates are 4 times
HIGHER in cesarean deliveries than in vaginal birth and that
repeat cesarean carries 2 times the risk of maternal mortality
that vbac does. SO! Tell me again Obstetrical community about the
"risks" of vbac being "too high"!!! Notice they DON'T tell you
about the much HIGHER risks of elective repeat cesarean.
Relative Risks of Uterine Rupture - Eileen Sullivan's classic discussion of relative risk of uterine rupture is a must-read. Here's my favorite line: You're 6 times more likely to have a doctor who is an impostor than you are to suffer a rupture.
You can read more
about
Eileen and her wonderful
work with EFT for birthing women. And don't miss the wonderfully affirming
visual treat on her main web page!
Uterine
Rupture During VBAC Trial Of Labor: Risk Factors and Fetal
Response by Nancy O'Brien-Abel, RNC, MN
from Journal of Midwifery & Women's Health, Posted 08/06/2003
They wrote that once a uterine rupture occurs a window of 15
minutes is the upper limit of normal time to get the baby out
before brain damage occurs (note this language.. it is get the
baby out, not start the cesarean). This clearly is a standard
above the one previously published by ACOG. I am hard pressed to
accomplish this with in-house anesthesia coverage and a ready
operating room. It is my opinion that home VBAC regardless of the
number of prior cesareans is tempting fate. Perhaps one might get
away with it 990+ times out of a thousand. However, when the
uterine rupture does occur, if serious consequences result, the
question of violation of standard medical care would be easy to
substantiate.
I have to respectfully disagree with my colleague. Yes, uterine
rupture is a possibility during a labor when there is a scar on
the uterus. However, lots of other things can and do go wrong
during labors, without warning and with potentially serious
consequences (abruption, cord prolapse, shoulder dystocia,
amniotic fluid embolism, etc.). All labors carry potential risks,
however, based on numbers analysed by Bruce Flamm (the big
promoter of VBAC), a woman attempting a VBAC actually has a 50
times greater chance (statistically) of experiencing one of the
other obstetrical emergencies than she does of encountering a
uterine rupture. In other words, having a scar on your uterus
doesn't protect you from all the other things that might go wrong.
So why is VBAC so much more dangerous? Because you knew a rupture
might happen and then are responsible if it does? Hey, you know
something, potentially life-threatening things might happen during
any labor.
I hear you. You make salient points. I respectfully submit that
we should agree to disagree on this issue. I feel that this issue
is one not unlike the issue of abortion. Both side have strong
beliefs that despite hours of discussion will never result in one
converting to the other's opinion. It is good that we can have the
debate.
I agree that it is as irresponsible of us to insist that ALL births are safe and uncomplicated as it is for doctors to use scare tactics to coerce mothers to follow their protocol. There is a slight chance of rupture in VBAC moms. The risks are less than in repeat cesarean, but the incidence of rupture is around 0.5%. That isn't 0. Even more rare are fetal deaths, but there have been some. On the other hand, I have yet to receive any information that includes a maternal mortality from a VBAC rupture with a low, transverse incision. There are maternal mortalities with repeat cesareans, although that is also rare.
Constant fetal monitoring continues to be a controversial topic with VBAC- even among the experts. I just spoke with Dr. Flamm about this last week. Over the years we have had an ongoing debate about EFM and VBAC mothers. He does recommend EFM in VBAC labors. (I think he has even said constant EFM.) However, he practices with CNMs, including his wife who stated at our 1992 conference that they do not treat VBAC women in labor differently than non-VBAC mothers. They use intermittent monitoring. Although many doctors say they require constant monitoring, I have yet to act as a doula in the hospital where a mother was required to have constant monitoring unless she was put on pitocin or an epidural (which is required in most places for all mothers).
Dr. Flamm said that the most reliable method of determining a rupture in his experience was with the EFM. I asked about the asymmetric bulge, bleeding, and pain. He said those signs may or may not be present, but a DRAMATIC drop in heartones was more reliable.
It is absolutely true that the difference in attention and care given a laboring woman is very much more sporadic in the hospital than at home. It may also be true that other signs may be apparent to a more vigilant caregiver and mother.
Here is my opinion on the topic: I certainly recommend some intermittent monitoring whether by EFM or fetoscope. It may be that constant monitoring would catch a slightly greater % of a very small number, but I believe that constant EFM would greatly reduce the number of VBACs. I believe that a number of women I helped would not have had a vaginal birth if they had been confined to a monitor. I also have to look at Michel Odent's Pithiviers clinic, The Farm and other places that have absolutely outstanding statistics for vaginal birth, healthy babies, healthy moms. I know they don't require constant EFM.
It is a decision that each woman must make for herself. As we all
know there are no guarantees. I don't agree with many women's
choices, but I know that many doctors and other women didn't agree
with my VBAC plans 10 years ago. We can only offer the
information, the resources, and the data we have, and even our
opinions. Then each woman needs to take responsibility for her
choices.
[from ob-gyn-l]
I have a new patient: G7, all sections. Would you give her a
trial? We're following her for AP care, but it's been a 'given'
she'll just be sectioned by our OB back-up. I've never had a
patient with this many sections!
When I asked a similar question of Dr. Morrison when I rotated through Univ. of Mississippi OB service as a resident, I was told that the largest number of prior C-sections in a VBAC candidate was 13 (she had a successful VBAC). That was in 1992. At my residency, which was military (with lots of transfers of care, lack of records, etc.) we used to let patients with prior C-section and undocumented scars labor "under close observation" as long as the story of the C-section wasn't too scary ("I just didn't dilate").
I don't know if it's changing times or different practice
patterns here versus there, but my feeling is that the tide is
turning away from "Oh, anybody can VBAC" to "VBAC is okay in
carefully selected situations." (Might have something to do with
that NEJM article about VBAC that was published from here.)
I am unaware of any cases of VBAC after 7xCS. I wouldn't be too
optimistic about this one either ! But I doubt there is any
effective difference between 3xCS and six or seven. Therefore I'd
go for a VBAC (if she's motivated enough) in hospital !
I reported on the article in Journal club during my residency.
That is why I remember it. Some of the old literature is still
valid and worthwhile.
See also: Shoulder Dystocia - Breaking the Clavicle
Can
Shoulder Dystocia Be Prevented? [from obgyn.net]
It always peeves me when OBs encourage women to have sections for "big babies". Either the head will come out or it won't, but you can always do the section after you're absolutely sure the head won't come out. And if they're worried about the head coming out and then having a shoulder dystocia, well, make sure they know how to break the clavicle. It's a relatively minor injury for the baby and is said to heal well within two weeks.
And, truth be told, there is no way to predict shoulder dystocia. There are some minor statistical "associations" but they're almost insignificant.
Macrosomia and shoulder dystocia have medical liability
overtones. It is difficult to find fault with someone who views
induction as a prevention for macrosomia when you have survived a
difficult shoulder delivery with an unexpected large infant.
I disagree. Induction increases the c-section rate in macrosomia compared to awaiting spontaneous labor, with no compensatory benefit to infant or mother. (CA Combs et al, "Elective induction versus spontaneous labor after sonographic diagnosis of fetal macrosomia. Obstet Gynecol 1993; 81:492-6.)
And what about the patient who has the complication of the
c-section that turns out to have been unnecessary in retrospect?
Does that not weigh on you equally?
Yes, but again, the likelihood of a C section complication,
especially if scheduled and non-laboring, is quite low.
But so is the risk of significant morbidity from shoulder
dystocia.
I have scanned the articles my Sandmire; it seems that they grow
them big in Green Bay. The numbers are compelling, but he seems
rather cavalier about fractured clavicles, and non-permanent
brachial plexus injuries. While these may be minor to us in the
medical community, they are not minor to the patients.
Neither are the post-op pain, days in the hospital, expense,
scarring, blood loss, and infectious complications of c-section.
I certainly can now turn to the literature to defend both my
approach, and the non-C/S approach. However, as long as someone
out there advocates the sections, and assuming that he or someone
else would testify, I can justify performing sections on these
people.
You know that I detest and protest the idea that we make a
clinical decision based on a guess about what will look good in
court. But as long as you're doing it, and Sandmire (and several
others--see the other articles) are out there and willing to
testify, you could make precisely the same argument the other way:
you can justify not sectioning these people. (and they may
be testifying against you if you get the uncommon serious
complication from doing the section.)
Furthermore, I don't particularly wish to go to court and have my
expert argue with their expert, citing articles that we both know
support either side.
But this could happen either way! I'm not sure why you're not seeing that. No lawyer is going to take the case of a fractured humorous that left no residual effect 6 weeks later. So in terms of your lawsuit fears, the permanent injuries are the only ones that matter. And as these several studies show, the serious complications (which have litigation potential) of a section are very much in the same range as the permanent complications of shoulder dystocia. Thus, fear of malpractice is not a rational reason (and I'll even be nice and not mention whether it's ethical) for section here.
If you're damned if you do, and damned if you don't, then don't.
(Hey, that's kind of catchy. Maybe I should copyright it.)
In former years the ability to perform a difficult vaginal
delivery was essential part of obstetric practice. In current
practice one mark of a skilled obstetrician is the ability to avoid
difficult vaginal delivery.
And now, in current practice, one mark of a skilled obstetrician
is the ability to do a fast c-section, in time to get to dinner
and/or change of shift.
[from ob-gyn-l]
Has anyone had or heard of a cervical extension of a low
transverse incision during a Cesarean delivery, which extended
into the patient's vagina?
I always caution residents when doing a C-section, during the
second stage of labor, to make sure that the incision is high
enough to be in the lower uterine segment, because I have seen the
entire low (very low) transverse incision made entirely below the
cervix, i.e. a vaginal Cesarean.
That procedure is known as a laparoelytrotomy and was described in the literature around 1900. It was originally called a Gastro- elytrotomy. It was done intentionally at that time. If you can do it, it probably is preferable to a LTCCS. After a laparoelytrotomy, there is no uterine incision or scar. A vbac is much safer the next time.
I have seen lacerations(extensions of low transverse incisions)
that have gone down the vagina for 8 cm. The biggest problem is in
1st recognizing them and then in repairing them. They invariably
occur in the patient with a BMI > 50. I have never had to
repair one from below, although it might have been smarter to do
it that way on at least one that I can remember.
I had a colleague as a resident who did a low transverse incision. In fact he did it on the vagina during a CS at complete dilatation. A laceration may occur when the incision is low and baby's extraction difficult. The bladder may be involved as well.
We had the idea of creating a procedure that saves the uterus.
This woman had no scar on the uterus which avoids the questions
about VBAC.
Check out Thomas GT, Gastro-elytrotomy; a substitute for cesarean
section. Am J Obstet. 1871;3:125
Certainly if you have a patient who is completely dilated and the
cervix is retracted up that high Laparoelytrotomy is a good way to
go because it does avoid the uterine scar.
I can't buy that. Seems like a good way to injure the bladder or
ureter not to mention an extension into the broad ligament at this
level could be quite a problem.
Not So!! The bladder is down way below where you make your incision, because the cervix and vagina are up so high. Lateral extensions shouldn't occur They would either go on around the vagina or up or down but not laterally. Yes, I am aware that if you or I can think of it, it will happen to somebody somewhere. I have done this procedure about 25 times over the years(that I recognized). Only 3 of those were intentional.
If you have done more than 100 abdominal deliveries, I bet you
have done at least 1 and never known it. When it is pulled up like
this the vagina looks just like a thinned out lower uterine
segment. Unless you look in the vagina and see the cervix above
your incision, you won't know you did it.
There was an article about a year ago by Dr. Robert Goodlin in
Obstetrics and Gynecology I think discussing an operation in which
the baby was extracted through an incision in the vagina instead
of the lower uterine segment. The purpose was to avoid a scar on
the uterus. I forgot what he called the procedure but we did
discuss this on the list some time back.
Birth
Group,
CCA, Calls On WHO To Re-examine 'Outdated And Unsafe' 10-15%
Recommended Cesarean Rate - The Coalition for Childbirth
Autonomy is urging national government and local hospital policy
makers to be wary of implementing targets that aim to reduce
cesarean rates to a range recommended 23 years ago, as the
evidence reviewed at that time has been superceded by more recent
and relevant studies. The group consists of birth support and
information groups from three countries, including
http://www.electivecesarean.com (USA),
http://www.birthtraumacanada.org (Canada),
http://www.birthtraumaassociation.org.uk (England) and
http://www.csections.org (England).
Marlowes Challenge Court-Ordered
Cesareans (1/18/04)
http://www.bmj.com/cgi/content/full/314/7086/993
( British Court of Appeals ruled that women have the absolute
right to refuse intervention, including cesarean section)
Preganant
woman's rights get short shrift - OB and lawyer get court
order to force a woman to submit to a cesarean against her will.
[July 20, 2001 at Memorial Hospital in Jacksonville, FL. OB:
Neil Sager; Lawyer: Harry Shorstein, state attorney for Duval
County.]
We had a case like this in BC called "the baby R" case where the
mother was forced and intimidated into having a section for a 3rd
baby who was presenting frank breech. It was a case of
impoverished, single mother against rich, educated
obstetrician. A women's group took the case to court after
the cesarean and after her baby was apprehended and it was all
ruled unlawful so that set a precedent for women in Canada that
they can't be operated on against their will. Needless to
say, when the woman had her next baby, she had it at home with
local midwives.
I was recently labor coaching for a hospital birth - planned to be the first VBAC after three sections. The OB was known in the community to be very supportive of natural childbirth, but even he was trying to convince my client that a VBAC after three surgeries was taking some huge risk. He asked her to sign some "backlash" forms about how dangerous VBAC is.
Then, when my client arrived at the hospital in labor, she was informed by the hospital staff that they could not support her in her choice to have a vaginal birth. Some tense discussions followed, during which it became clear that the hospital intended to get a court order to force her to delivery surgically if she didn't make that choice. (It's ludicrous to call it a "choice" at this point.)
The perinatologist said that because there were no studies showing the safety of laboring with three uterine scars, they had to assume it was not safe and that it was putting the baby at risk. She told us that there is an increase in risk for laboring with 1 vs. 2 scars, and that they had to assume the possibility that there could be an enormous increase in risk between 2 scars and 3.
She actually told us that their working assumption was that the
risk of catastrophic rupture (in which the baby died) was 5%. Yes,
1 out of 20. My hope for her is that she finds herself in a
position to learn more respect for women's choices in birth.
The
Family Centered Cesarean: A Woman-Centered Technique by
Stephanie Stanley, Chapter Leader ICAN of Phoenix
What if
it is a cesarean birth?
The Ideal
Caesarean Birth - by Robert Oliver, M.D.
Caesarean
Birthing Your Own Child - Written by Paula Beckton - can now
be found as I
birthed my own child – via caesarean
By Paula Beckton|Tuesday, February 17th, 2015
For many women the thought of having a caesarean is terrifying,
the knowledge that after viewing your newborn child, you may be
unable to hold or even see your baby for at least an hour
(sometimes longer), can be devastating. Paula Beckton experienced
a ground breaking caesarean, where she helped assist in the birth
of her second child Oliver and not only was he not whisked away
immediately, but was placed on her chest for cuddles and
mother/baby bonding. This is her story...
Father's Touch Soothes Newborns - After C-Section Birth, Newborns Find Dad's Skin Soothing When Mom Isn't Available
They studied 29 Swedish men whose wives or girlfriends had just
given birth by C-section to healthy babies.
Immediately after the babies were born, the infants got five to 10
minutes of skin-to-skin contact with their mothers. Then the
babies spent the next two hours with their dads. [Ed. They should
also be skin-to-skin with dad to keep getting exposed to his skin
flora, which is about 90% the same as mom's. This is so much
better than having the baby pick up hospital germs as basic skin
flora.]
SOURCES: Erlandsson, K. Birth, June 2007; vol 34: pp 105-115.
News release, Blackwell Publishing.
some things I forgot.."touchy feely" things. Moms voice should be the first baby hears. Moms touch should occur as quickly as possible after birth. No "unnecessary roughness" My ped "tickles" the soles of the feet vs. slap and only suctions if the baby needs it.
The staff should let the Mom know what is going on every single step of the way. No leaving her or Dad in the dark and afraid! Anesthesia CAN and SHOULD be administered with Dad in the room. This separation is not only cruel, it is ILLEGAL! and only for the "safety" of the anesthesiologist-in case he screws up, no witnesses.
Cesarean birth CAN be "family friendly" and I think an even
greater effort is called for on the part of her care providers to
ensure she and the baby get off to a good start after the "insult"
of surgery.
More recently, an obstetrician in the UK is espousing a similar
approach to humanizing cesarean birth when vaginal birth is not an
option.
Every bit as magical - [12/3/05] A British doctor is challenging convention to pioneer the 'natural' caesarean. [Ed: It is ludicrous to use the word natural with a process that must take place in an operating room and involves making a 4-inch incision in a woman's belly. They might achieve more intellectual honesty by calling this a "more humanized cesarean", as it involves some of the key elements involved in a real natural birth, i.e. "as in nature":
Mexican
Indian woman performs self-Caesarean: 'If my baby was going
to die, so was I' - Ines Ramirez Perez
I remember a woman did this in portland oregon on the early 1980s. it was quite a sensation.
As I remember, the story in the papers went like this: She had a history of mental illness -- had been living in public housing downtown. A few weeks before her due date she went to the hospital and demanded they do a cesarean because she was tired of being pregnant. when they refused, she went home and did it herself! She wrapped the baby in blankets and put it in a regular backpack and went out into the streets to show her friends! . They called an ambulance. The story reported that she seemed healthy but a little pale and" in her usual state of mind". She was taken to the hospital where docs repaired her wound. they were amazed at how little blood she'd lost and how well she'd tolerated it. Both mother and baby did well with good care.