Author Archives: Jen Kamel

About Jen Kamel

VBAC Facts was started in 2007 after the Founder/Director, Jennifer Kamel, had a VBAC. With her professional history as a commercial real estate Research Manager performing demographic and geographic analysis for international, national, and local companies, she was accustomed to compiling information, performing analysis, and presenting her findings in everyday terms. She directed her skill set to post-cesarean birth options and VBACfacts.com was born. The mission of VBAC Facts is to close the gap between what the best practice guidelines from ACOG and the NIH say about VBAC and repeat cesarean and what people generally believe. VBAC Facts does not advocate for a specific mode of delivery, birth attendant, or birth location.

Why I’m feeling conflicted about AB 1306: CNM Physician Supervision vs. Home VBAC Hurdle

Update September 2, 2016

This bill was not passed.

Update August 25, 2016 1:32pm

The Senate floor vote for this bill has been postponed until Monday.


Update August 25, 2016 9:57am

For those of you watching this issue closely, this bill will be up for a Senate floor vote today. You can watch the California Senate live here.


Update August 24, 2016 10:06pm

The Senate floor vote for AB 1306 is scheduled to happen tomorrow, August 25th. (Click here to see the current status of the bill.)

The California capital opens at 9am, so if you haven’t already called your state Senator to tell them how you feel about AB 1306, tomorrow is the time.

All you have to say is, “I’m calling to voice my support of [or opposition to] AB 1306.”

Click here to receive a reminder email tomorrow at 9am.

All my thoughts on AB 1306 can be found below.


Update August 24, 2016 11:06am 

I have thought about AB 1306 for so many hours since I initially opposed it last Friday and I’m feeling really conflicted about it.  Let me share with you why.

Removing physician supervision will improve the ability of CNMs to practice autonomously including offering VBAC in the hospital setting (where hospital policy permits) and in birth centers (provided the CNM opts to offer VBAC). This could be a good thing for VBAC families and a great thing for all the other people CNMs serve.

And so it’s really tough because it could negatively impact the small number of women who plan home VBACs by requiring them to have a VBAC consult with an OB.

So, what is the right decision?

Support this bill so CNMs can have a greater reach?

Or oppose this bill because of this requirement?

My mission is to increase access to VBAC in all birth settings. Is it enough that this may increase hospital VBAC access – where most women birth – as well as birth center VBAC while possibly making home VBAC harder to achieve?

Here is the specific language from AB 1306 (Sec 6, 2746.5(B)):

If a woman wants a home VBAC and she ‘still desires to be a client of the certified nurse-midwife, the certified nurse-midwife shall provide the woman with a referral for an examination by a physician and surgeon trained in obstetrics and gynecology. A certified nurse-midwife may assist the woman in pregnancy and childbirth only if an examination by a physician and surgeon trained in obstetrics and gynecology is obtained and, based upon review of the client’s medical file, the certified nurse-midwife determines that the risk factors presented by the woman’s condition do not increase the woman’s risk beyond that of a normal, low-risk pregnancy and birth. The certified nurse-midwife may continue care of the client during a reasonable interval between the referral and the initial appointment with the physician and surgeon.’

This is why I’m conflicted:

44% of CA hospitals outright ban it. They do not “allow” their physicians to attend VBAC. What happens if those hospitals decide, they will not “allow” their physicians to even consult with families seeking out-of-hospital (OOH) VBAC? Or physicians say that their malpractice insurance will not “allow” them to consult with OOH VBAC families? Where does that leave OOH VBAC families?

Right now, the VBAC rate in the state of California is only 9%. This bill could increase VBAC access in birth centers and hospitals assuming that hospital policy “allows” CNMs to attend VBAC.

As it stands, 91% of California families have repeat cesareans and the overwhelming majority of those are due to VBAC bans, misinformation and being unable to find a supportive provider.

But here’s the tough part: OBs who are staunch supporters of VBAC have told me that they would never have a consultation with a woman planning a home VBAC because they don’t, in any way, want to be connected with something that could be construed as validating, okaying, or approving home VBAC.

Even though the legislation isn’t asking OBs to approve of home VBAC, that is what OBs see. And the overwhelming majority of OBs – who support hospital VBAC and may even philosophically agree with OOH VBAC – would not participate in VBAC consults for women planning home VBACs.

This is mitigated a bit by the fact that women can have these consults via a chart review and Skype. So regardless of where they live in the state, they could reach the handful of OBs willing to participate in a VBAC consult.

But having the VBAC consult in the legislation means that as OB allies die, or as hospital policies tighten, or malpractice insurance fears increase, the legislation holds firm. That is not a good thing. It leaves women standing out in the cold on their own. And forces them to go back to the hospital system, where, as we see from the current California VBAC rates, they will likely acquiesce to a cesarean or be forced into a cesarean per hospital policy that is presented as equivalent to law unless CNMs are able to measurably increase VBAC access in the hospital setting.

CNMs can tell families that the prior cesarean is “unlikely to impact this pregnancy” and then talk about the unlikely though possibly dire consequences if a uterine rupture occurs out of the hospital. And talk about transfer protocols as you would with any other patient. Women don’t need to talk to an OB in order to get that information.

So while this bill does include home VBAC in the language, access to home VBAC is assuming that the pregnant person can find a OB who is willing to provide them with this consult. While the option is there, the ability to exercise that option is based on the kindness and ethics of a few OBs. And when they are gone, or the climate changes, women bare the brunt of their absence.

A VBAC consult does not make pregnancies safer. It will not improve outcomes. It only undermines the professional training of CNMs and the autonomy of patients.

And all the while, this bill also removes physician supervision from CNMs. And that is a very good thing.

So, do we say to home VBAC families, “Best of luck to you?” and, “Removing physician supervision for CNMs is worth this trade?” and then hope and pray that these women can find an OB willing to provide them with this consult?

I’m sharing with you the pros and cons as I see them so you can make your own decision.

It’s not too late to contact your state Senator and tell them, “I’m calling to voice my support of [or opposition to] AB 1306.”

Does your state require families planning home VBACs to have a consultation with an obstetrician? If yes, I’d like to ask you a few short questions.


Update Friday August 19, 2016 10:21pm

Thank you to those that contacted your Assembly Member today! The deadline to amend the bill to exclude the VBAC consult was Friday.

The next step is to oppose the Senate floor vote which is expected to happen next week (the week of Aug 22nd).

Please contact your state Senator on Monday, August 22nd, and tell them, “I’m calling to voice my opposition to AB 1306.” That’s it.

If you click the yellow button below, I’ll send you a reminder email Monday morning when the capital opens at 9am.

Be notified when legislation threatens VBAC access!


August 18, 2016 by Jen Kamel

Yesterday I was in Sacramento attending the Midwifery Advisory Council meeting at the California Medical Board.

At that meeting, I learned about a piece of legislation that will decrease VBAC access in California.

TODAY IS THE LAST DAY TO VOICE YOUR OPINION!

If access to midwifery care for women who have had a prior cesarean section is important to you, then please register your opposition to AB 1306 unless amended to exclude VBAC consult with your Assembly Member or with it’s author – Assembly Member Autumn Burke.

AB 1306 would remove physician supervision for Certified Nurse Midwives (CNMs).

This is a good thing.

But here’s the bad part: it puts into statute (law) a requirement that any woman seeking to deliver with a CNM outside a hospital AND who has had a prior cesarean delivery must first have a consultation with a physician (AB1306 Sec 6, 2746.5(B)).

Be notified when legislation threatens VBAC access!

It is this requirement for consultation that is at issue for the following reasons:

• All women are capable of determining for themselves and their families, together with their midwife or health care provider, what measure of risk is appropriate for them. Requiring a physician consultation before they are able to continue midwifery care undermines patient autonomy.

• Certified Nurse Midwives (CNMs) are highly trained health care professionals. They are quite able to determine, together with their client, when a particular woman would benefit from a consultation with a physician.

Requiring a physician consultation for every woman with a prior cesarean delivery does nothing to increase her safety in the current pregnancy. There is no way for a physician (or anyone else) to predict which pregnant woman is going to have difficulty with her current birth because she had a cesarean delivery in a prior pregnancy.

Requiring a physician consultation puts an increased burden on women. It may delay prenatal care, a known risk factor for prematurity, low birth weight and poor outcomes. It is costly and time consuming in the absence of evidence for benefit.

While collaboration between care providers is the ideal, in many areas of California midwife/physician collaboration is not possible because there are no physicians willing to form this relationship. This reduces access to midwifery care and in many instances it also reduces access to successful vaginal birth after a prior cesarean.

Putting precise wording, regarding any medical condition, into statute disallows health care providers the use of the most recent research when helping clients make decisions regarding their care. Putting into law, the requirement for a physician consultation when a woman has had a prior cesarean delivery, will not allow women and their midwives to take into account the growing body of evidence surrounding the practice of a trial of labor after a previous cesarean (TOLAC), prior to determining the need for a physician consultation.

I fully support CNMs and the important care that they provide to California families. But this bill is problematic because of how it will impact VBAC access for those who want an out-of-hospital VBAC with a CNM.

Once again, call your Assembly Member or AB 1306’s author – Assembly Member Autumn Burke – TODAY and say, “I’m calling to voice my opposition to AB 1306 unless amended to exclude VBAC consult.” That’s it.

If you want to say more, you can add, “…because it restricts a woman’s right to choose her care provider and mode of delivery.”

I already called my Assembly Member and it took me exactly 36 seconds.

I hope you do the same.

If you live outside of California, please leave a comment on the author’s Facebook page so others who are learning about the bill realize the implications it will have on VBAC access unless amended.

Be notified when legislation threatens VBAC access!

Judgment in the birth community: Fitting in after a cesarean

A woman who had four cesareans, after planning VBACs and home births, recently contacted me. She didn’t know where she fit into the birth community.

My heart went out to her because there have been periods in my life when I have felt isolated and alone. And it’s a crappy feeling.

I replied to her:

A vaginal delivery is not required to participate in the birth community. There are many cesarean moms just like you who are seeking compassion, connection, and understanding. You could be a soft place for other women to land as they mourn (or celebrate!) their cesarean deliveries.

The mission of VBAC Facts goes above and beyond our personal birth preferences. Really, the goal is education and access to VBAC.

The goal *is not* for everyone to have a VBAC because, as you know, there are many reasons why someone would have a cesarean birth, including scheduling an elective cesarean. And that is that parent’s choice! And those mothers are no less of a parent, advocate, or sister to those within the birth community.

I know one woman who had four cesareans and runs an ICAN chapter. Again, it’s not about how her births played out, but rather education and, ultimately, respecting the choices other parents make while holding space for them when birth doesn’t go as planned.

If you are feeling rejected, perhaps you need to find a new group of people to hang with! 🙂

We all don’t have to birth the same to support each other

The judgment that this mom is experiencing is why I spend so much time in my workshop, “The Truth About VBAC” talking about individualized risk assessment. This is a fancy way of saying, “There are a lot of different reasons that go into why someone plans a specific type of birth.”

I discuss this subject at great length, including all the factors that one might consider and the fact that both VBAC and repeat cesarean are valid options.

I really want to assure students that there is no Right Way to Birth. Only what is Right for Them.

Releasing the judgment about how other people birth

I also want to explore the subject so that people who staunchly believe that there is a Right Way to Birth can see how there are so many reasons why someone might choose to birth differently than them… and possibly release that judgment.

(That’s also why I recently revamped the VBAC Facts homepage to feature two cesarean births.)

The whole point is: How you birth, is up to you. It’s frankly no one else’s business. Not mine. Not your girlfriend’s. Not the PTA president’s. It’s Your Birth.

And no matter what birth you choose, if you believe that parents should have access to VBAC, VBAC Facts is your birth community.

I have said this so many times in so many venues and yet I still receive comments like this from email subscribers:

I’m leaning toward repeat c-section. I already feel you scrunching up your face. I feel shamed for going with repeat c-section. People assume I am ignorant to the facts. They assume a lot of things. I feel like I have to justify this decision to everyone.

Ouch. Dear reader, I don’t feel that way at all. It hurts my heart that what should be a joyous time in your life is filled with deflecting the unsupportive opinions of others. Regardless of how you birth, your choices should be respected because it’s Your Birth.

Supporting access and respect, not dictating outcomes

It’s tough because there is so much judgment and so much defensiveness when it comes to birth and even what advocacy really means.

For me, VBAC advocacy is about access to VBAC, which is very different than saying, “I think everyone should have a VBAC.” And because my focus is access and not a specific mode of delivery, I don’t judge women who plan to have a repeat cesarean section. Full stop.

One of the reasons why I started VBAC Facts is that I saw people cherry picking information, misinterpreting the conclusions of medical studies, and basically manipulating the facts in order to convince other people to make the same birthing decisions they did.

Because they judged those that birthed differently than them.

How what other people think can impact your options

I created VBAC Facts, and I ultimately developed educational programs, so parents, birth professionals, and even medical providers could get the actual facts. The actual statistics. The actual recommendations. Rather than basing their opinion on someone else’s personal risk assessment of what was “safe” or “risky.”

And sometimes what other people think – like the Head of Obstetrics at your hospital or your hospital administrator – can set of the tone of your facility and even if they “allow” you to attend VBAC.

And for pregnant people, it can be the well-intended, but misinformed opinion of their friends and family. And that judgment and disapproval is enough to persuade some mothers to schedule a repeat cesarean just to keep the family peace.

It’s all about learning the facts so you can make your own decisions… and giving others the space to make theirs. And once people realize that there is no Right Way to Birth and that everyone knows the Right Way for Them, we can truly celebrate how we each start and grow our families without judging each other for how we do it. That’s what I call #factsoveragenda.

How do you describe your birth community? As a cesarean parent, how were you received and did you feel supported? If not, where did you go to find support?

When you are the statistic: Uterine rupture loss

Above: “I donated my wedding dress to be made into gowns for deceased infants to be buried in. I had pictures done in my dress before I donated it. This is one of my favorites.” – Kaila Flory

Kaila Flory lost her baby to a uterine rupture eight months ago. She recently reached out to me and gave me permission to share her story and pictures of her son Beau.  She is currently raising money to purchase Cuddle Cots in Beau’s memory. Cuddle Cots are refrigerated bassinets that enable loss parents to spend more time with their child. While t-shirt sales end on April 22, 2016 at midnight EST, you can donate anytime. Even just $10 will get her closer to her goal. Buy a t-shirt and/or donate here.  Connect with her Facebook page here

Women who have had uterine ruptures and lost their babies have endured some of our greatest fears. But they are part of our community as well. When the VBAC Facts Community, a Facebook group, was open to the public, we welcomed and embraced the parents who joined us after their loss. Often they felt like they were no longer part of the birth community. They didn’t know where they fit in. They felt isolated and yet they wanted to share their story. We had many loss moms as members and many parents who were planning VBACs wanted to hear their stories.

What follows is Kaila’s story.

Kaila’s Flory’s first son was born by cesarean after being induced for intrauterine growth restriction. When she was 38 weeks and a few days pregnant with her second son, 26-year-old Kaila started having cramps around 1 a.m. “Luckily I had stayed with my dad, so I was not alone with my 3 year old. My husband was at Basic Training. Then a contraction came. Ok, I thought, this is real. It’s time. Then another came. It had only been like a minute or 2. Then severe pain came over my abdomen, and my face and limbs went numb.”

Her father called the paramedics and she was rushed to the hospital, where a STAT c-section was ordered. She nearly bled to death.

Beau-&-Kaila

“This is the only photo I have of myself holding him. I requested people to not take my photo, but I am so glad my best friend took this with her phone. THIS is what raw, real pain looks like. This is why I want people to have Infant Loss Awareness.”

She says:

While I wholeheartedly believe that women should be given the option for VBACs, I also believe women need to consider their child’s health as the most important in this situation. I would have loved to have 3 weeks of pain just to have my son in my arms. I know it is not my fault, and that they do not, normally, schedule a c-section until 39 weeks, but part of me still feels guilty.

When Kaila contacted me, my heart broke. I emailed her back:

Kaila,

Thank you so much for sharing your story with me and I am so sorry about your loss.

I want you to know that I hear you. I really hear you.

I talk quite a bit about how these small numbers represent real women and real babies and it doesn’t matter how small the risk is, if it happens to you, if you are that number, it’s devastating.

The difficulty is that there are serious risks both ways. With VBAC, we have uterine rupture. With repeat cesareans, we have accreta.

Accreta results in more maternal deaths, more maternal complications and comparable infant deaths and complications to uterine rupture. Accreta requires a more sophisticated response of which many hospitals are unable to offer which results in more deaths and complications. Many women are never told about the risks of accreta which prohibits them from making an informed decision. [View my sources and read more about accreta here.]

I discuss uterine rupture and accreta extensively in my workshops including how often it happens, variables that can impact the rate, and outcomes for mother and baby because there is so much confusion about where the risk lies and what could happen.

The other difficulty is that no can predict how an individual birth will play out. Will you be the one to have a uterine rupture? An accreta? And in either of these situations, will you be the one to lose your baby? Or will you have a safe VBAC or repeat cesarean with a healthy mom and baby? There are no guarantees in life and no crystal balls.

Some women who lose their babies to uterine rupture say, “Don’t plan VBACs.”

Some women who lose their babies to accreta say, “I wish I had access to VBAC.”

So the question is, if there are serious complications either way, who should make the decision on how to birth?

It always comes down to the mother.

Given the small chance of a bad outcome, women should have the option to decide what set of risks and benefits are tolerable to them. They should not be forced into cesareans or mislead into VBACs. This needs to be their decision based on information. Part of the reason why I started VBAC Facts is that I, as a consumer, wanted more information and it wasn’t easy for me to find.

To bring it full circle, I hear you.

Have you had the opportunity to connect with other loss moms? I have compiled a resource page here.

I know it may ring hollow, but you are not to blame. Sometimes things happen that we cannot predict and that are outside of our control and I’m so very sorry you were the statistic.

I’ll keep you in my heart Kaila. <3

Warmly,

Jen

Kaila replied:

I will be honest with you, my doctor did not mention accreta once. Wow that is scary too. 🙁 I don’t wish that or a rupture on anyone. Thank you so much for responding to me. And thank you for advising women on what to do after a C-section. If you ever want to use my story, please let me know. I would be happy to share it for statistic purposes. Thanks so much! 🙂

So I’m sharing Kaila’s story today. As I said in my email to her, I talk about the risks of uterine rupture and accreta in my workshops because they are both real risks on either side of the equation. Sadly, a small number of people will experience this reality, and they deserve our support and compassion.

I do hope you will support Kaila’s Cuddle Cots fundraiser. Even just $10 will get her closer to her goal. Donate here. Connect with her Facebook page here.

Learn more about Infant Loss Awareness here.

Calling women who plan home VBACs “stupid” misses the point

I’m in an online group for labor & delivery nurses where the discussion of vaginal birth after cesarean (VBAC) at home came up. While some understood the massive VBAC barriers many women face, others simply said, “Find a hospital that supports VBAC.”

I left a late-night comment stating that “finding another hospital that supports VBAC” is just not a reality in many areas of the country. It’s literally not possible. Not even in the highly populated state of California. (Barger, 2013)

I also suggested rather than calling women stupid or debating the validity of the decision to have a home VBAC​, we should consider why women make this decision.

First, it is not one they take lightly.  Every parent wants a safe, healthy birth for themselves and their baby. It takes more research, work, and energy to plan a home VBAC—and it usually means thousands of out-of-pocket dollars up front. It is most certainly not the easy way out.

Women choose out-of-hospital birth due to disrespectful and abusive care, including obstetric violence and forced/coerced cesareans, delivered by hospitals. Parents also choose out-of-hospital VBAC due to VBAC bans and restrictive VBAC policies (i.e., repeat CS scheduled at 39 weeks, labor can only last 12 hours, baby must weigh less than _____, no induction/ augmentation, etc.).

These are serious issues:

Disrespectful care.

Abusive care.

Obstetric violence.

Forced/coerced cesareans.

VBAC bans.

Restrictive VBAC policies.

And this isn’t a comprehensive list of why women choose home VBAC, but it’s the ones that many nurses, providers, and administrators have control over.

In my comment on the nurses’ group, I posted the link to my California Medical Board testimony addressing these barriers and the resulting importance of access to out-of-hospital VBAC.​

We shouldn’t be asking why women are so stupid and reckless.  We should be asking:

“What can we do to make women feel safe coming to our hospital to give birth?”

And:

“How can we increase access to VBAC in all hospital settings?”

I also suggested that coming from a place of judgment on this option may very well color the tone of their communication. Even if they’re not using the words “stupid” or “reckless,” parents will pick up on what’s not being said. That’s not good for the provider-patient relationship. People want to be heard, understood, and respected. All of us.

It’s important to hear parents when they talk about their past hospital experiences, without being defensive.

Hear them and see it as an opportunity to make a change. Consider, how can you make a difference in your practice and facility?

If this were any other business, we would probably say that this is a services and marketing problem.

If you have a restaurant, and you start to lose customers to a competitor, you figure out why your customers are leaving and appeal to that.

You don’t slam the other restaurant.

You don’t call your customers stupid because someone else is offering a product that they like better.

Even if you would never personally eat there, that other restaurant is offering something that people want. And they are leaving your restaurant to get it.

So, find out what that thing is and change it.

Yes, I said all that in this nurses’ group.  The next morning, I checked to see how my comments were taken, because I know from experience that not everyone wants to hear or acknowledge the realities I outlined.

I smiled to see that the conversation had remained respectful, even from some folks who disagreed with me.  There was no name calling. No personal attacks.  My comments even had a couple likes!

It is possible to disagree without being disagreeable. And I think it’s so important to consider that many women around the country do not have access to respectful care in a facility that supports VBAC.

What are some other reasons that women choose out-of-hospital birth? Leave your comment below.

Learn more:

Askins, L., & Pascucci, C. (n.d.). Retrieved from Exposing the Silence Project: http://www.exposingthesilenceproject.com/

Barger, M. K., Dunn, T. J., Bearman, S., DeLain, M., & Gates, E. (2013). A survey of access to trial of labor in California hospitals in 2012. BMC Pregnancy Childbirth. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636061/pdf/1471-2393-13-83.pdf

Kamel, J. (2014, Dec 17). What I told the California Medical Board about home VBAC. Retrieved from VBAC Facts: http://vbacfacts.com/2014/12/17/what-i-told-medical-board-home-vbac-part-1/

Kamel, J. (2016, Jan 6). “No one can force you to have a cesarean” is false. Retrieved from VBAC Facts: http://vbacfacts.com/2016/01/06/no-force-cesarean-false/

Pascucci, C. (2014, Feb 17). Home Birth vs. Hospital Birth: YOU’RE MISSING THE POINT, PEOPLE. Retrieved from Improving Birth: http://improvingbirth.org/2014/02/versus/

 

“Hospitals offering VBAC are required to have 24/7 anesthesia” is false

In 2010, I was sitting next to an OB/GYN during a lunch break at the National Institutes of Health VBAC Conference. She was telling me about how she had worked at a rural hospital, without 24/7 anesthesia, that offered vaginal birth after cesarean (VBAC).

I asked her what they did in the event of an emergency. “I perform an emergency cesarean under local anesthetic,” she plainly stated. She explained how you inject the anesthetic along the intended incision line, cut and then inject the next layer and cut, all the way down until you get to the baby.

It certainly wasn’t ideal, but it was how her small facility was able to support VBAC while responding to those uncommon, but inevitable, complications that require immediate surgical delivery.

CLICK to share on Facebook.

CLICK to share on Facebook.

They had everything a hospital needs to offer VBAC: a supportive policy, supportive providers, and motivation to make VBAC available at their hospital.

From a public health standpoint, it’s to our benefit to offer VBAC because repeat cesareans increase the rate of accreta in future pregnancies as well as hysterectomy and excessive bleeding.

And rural hospitals are NOT capable of managing an accreta because it requires far more than (local) anesthesia and a surgeon. (Read more on how morbidity, mortality, and ideal response differs between uterine rupture & accreta.)

When I hear of smaller, rural hospitals telling women that they can’t offer VBAC because “ACOG requires” 24/7 anesthesia, I think of that OB/GYN and ACOG’s (2010) guidelines which state

Women and their physicians may still make a plan for a TOLAC [trial of labor after cesarean] in situations where there may not be “immediately available” staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk.

So, yes, it is possible and reasonable to offer VBAC without 24/7 anesthesia.

It is ideal? No.

But do you know what else is not ideal?

It’s not ideal to have VBAC bans mandating repeat cesareans that expose women to the increasing risks of surgical birth across the board as a matter of policy—risks that can be far more serious and life-threatening than the risks of VBAC.

It’s not ideal to have any vaginal delivery at a hospital that doesn’t offer 24/7 anesthesia, because any woman giving birth may require emergency surgery.

It’s not ideal to have a cesarean (scheduled or emergency) at a hospital that doesn’t have a blood bank.

It’s not ideal nor realistic to have every pregnant woman drive hours in labor to larger hospitals that offer blood banks, 24/7 anesthesia, and various obstetric sub-specialties for planned VBAC.

It’s not ideal to have state troopers attending roadside births for some of those women.

And it’s deadly for rural hospitals to be managing a surprise accreta.

So, we have to come up with better options.

We can’t continue to pretend that banning VBAC is in the best interest of families.  It does not serve our communities in the long run because it simply exposes the ones we love to a more serious complication in future pregnancies.

Learning how to perform a cesarean under local anesthetic makes hospitals—regardless of geography—safer places to give birth. It enables them to perform cesareans more quickly when they don’t have an anesthesiologist in the hospital but the baby needs to be born NOW.

This could make a huge difference in the outcomes for any laboring mom—VBAC or non-VBAC—as well as her baby.

Learn more about VBAC barriers and watch me debunk the four reasons why hospitals ban VBAC in my workshop, “The Truth About VBAC.”

Does your rural hospital offer VBAC or not?

Does your urban or suburban hospital offer VBAC or not?

Leave a comment below!

References

American College of Obstetricians and Gynecologists. (2010). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology, 116 (2), 450-463,http://m.acog.org/Resources_And_Publications/Practice_Bulletins/Committee_on_Practice_Bulletins_Obstetrics/Vaginal_Birth_After_Previous_Cesarean_Delivery

Kamel, J. (2015, April 2). Too Bad We Can’t Just “Ban” Accreta – The Downstream Consequences of VBAC Bans. Retrieved from Science & Sensibility: http://www.scienceandsensibility.org/placenta-accreta-vbac-ban/

Kamel, J. (2010, July 22). VBAC ban rationale is irrational. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/22/vbac-ban-rationale-is-irrational/

Komorowski, J. (2010, Oct 11). A Woman’s Guide to VBAC: Putting Uterine Rupture into Perspective. Retrieved from Giving Birth with Confidence: http://www.givingbirthwithconfidence.org/p/bl/ar/blogaid=181

“No one can force you to have a cesarean” is false

Update: Since this article was originally published, it has been updated with several new resources (listed at the bottom) as well as a video.

 

hospital-bed

 

“No one can force you to have a cesarean.” I see this all the time in message boards.

Don’t worry about

… the VBAC ban

…your unsupportive provider

… your provider’s 40 week deadline

… [insert other VBAC barrier here]

no one can force you to have a cesarean.

That’s just not true.

Let’s start with what is ethical and legal: Yes, no one can legally force you to have a cesarean.

ACOG even says in their latest VBAC guidelines that “restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will.” So even if your facility has a VBAC ban, they still cannot force you to have surgery… legally or ethically.

But then you have reality: It happens all the time, but it may look different than you expect.

It’s often NOT a woman screaming “I do not consent” as she is wheeled into the OR, though that has happened.

It’s through lies. It’s through fear.

“The risk of uterine rupture is 25%.”

“Do you want a healthy baby or a birth experience?”

“Planning a VBAC is like running across a busy freeway.”

Hospital policy and provider preference are presented as superseding the woman’s right to decline surgery.

“No one attends VBAC here.”

“It’s against our policy.”

“We don’t allow VBACs.”

Or unreasonable timelines are assigned giving the woman the illusion of choice.

“You have to go into labor by 39 weeks.”

“Your labor can’t be longer than 12 hours.”

“You have to dilate at least 1 centimeter per hour.”

Or it can be a slow process where a seemingly once supportive provider quietly withdraws support exchanging words of encouragement with caution. Dr. Brad Bootstaylor, an Atlanta based OBGYN, describes how this can unfold at 4:00 in this video after a woman describes her experience:

Or, if the birthing parents don’t listen, it can escalate to calling social services, ordering a psychiatric evaluation, or even getting a court order for a forced cesarean.

It can be as simple as, “Your baby is distress.” How do you know if this is true or not? Are you willing to take that risk?

Some people suggest that parents should learn how to interpret fetal heart tones so they can evaluate their baby’s status. But I think this is a wholly unreasonable expectation for non-medical professionals, especially when one is in labor. It is as much an art as it is a science.

In short, coercion frequently isn’t by physical force. It’s through manipulation. This is why it’s worth your time and effort to search for a supportive provider who you trust to attend your birth.

Don’t just think, “Well, I can hire anyone and simply refuse.”

Sometimes it’s not that simple as Rinat Dray, was forced to have a cesarean, and Kimberly Turbin, who received a 12-cut episiotomy while yelling “Do not cut me,” know all too well.

And this is why understanding the complete picture is important. It’s not enough to ponder how things are “supposed to be” or how we want them to be, but how they actually are. The difference between perception and reality is huge. Learn more in my online workshop, “The Truth About VBAC.”

Have you seen a situation like described above play out? Share it in the comment section.

Continue the conversation & share on Facebook here:

There is a huge difference between what is legal, what is ethical, and what actually happens. #forcedcesareans #ethicalvsreality #vbacfacts

Posted by www.VBACFACTS.com on Wednesday, January 6, 2016

 

Learn more:

ACLU. (n.d.). Coercive and punitive governmental responses womens conduct during pregnancy. Retrieved from ACLU: https://www.aclu.org/coercive-and-punitive-governmental-responses-womens-conduct-during-pregnancy

Cantor, J. D. (2012, Jun 14). Court-Ordered Care — A Complication of Pregnancy to Avoid. New England Journal of Medicine, 366, 2237-2240. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMp1203742?

Hartocollis, A. (2014, May 16). Mother accuses doctors of forcing a c-section and files suit. Retrieved from The New York Times: http://nytimes.com/2014/05/17/nyregion/mother-accuses-doctors-of-forcing-a-c-section-and-files-suit.html?referrer=&_r=0

Human Rights in Childbirth. (2015, Jan 14). Rinat Dray is not alone, Part 1. Retrieved from Human Rights in Childbirth: http://www.humanrightsinchildbirth.org/amicusbriefpart1/

International Cesarean Awareness Network. (n.d.). Your right to refuse: What to do if your hospital has “banned” VBAC. Retrieved from Feminist Women’s Health Center: http://www.fwhc.org/health/pdf_about_vbac.pdf

Jacobson, J. (2014, Jul 25). Florida hospital demands woman undergo forced c-section. Retrieved from RH Reality Check: http://rhrealitycheck.org/article/2014/07/25/florida-hospital-demands-woman-undergo-forced-c-section/

Kamel, J. (2012, Mar 2). Options for a mom who will be ‘forced’ to have a cesarean. Retrieved from VBAC Facts: http://vbacfacts.com/2012/03/02/options-mom-forced-repeat-cs/

Maryland Families for Safe Birth. (2015, Jan 28). The truth about VBAC: Maryland families need access. Retrieved from YouTube: https://youtu.be/C5nymk3IGqE

Paltrow, L. M., & Flavin, J. (2013, April). Arrests of and forced interventions on pregnant women in the United States, 1973-2005: Implications for women’s legal status and public health. Journal of Health Politics, Policy and Law, 38(2), 299-343. Retrieved from http://jhppl.dukejournals.org/content/early/2013/01/15/03616878-1966324.full.pdf+html

Pascucci, C. (2015, Jun 4). Press Release: Woman charges OB with assault & battery for forced episiotomy. Retrieved from Improving Birth: http://improvingbirth.org/2015/06/preview-woman-charges-ob-with-assault-battery-for-forced-episiotomy/

Shoulder pain is a symptom of uterine rupture

I’ve written before about the symptoms of uterine rupture as well as how having an epidural does not interfere with the diagnosis of uterine rupture.

The focus of this Quick Fact is how shoulder pain can be a symptom of uterine rupture.

How can an uterine rupture cause shoulder pain?

Image Source: http://wesleytodd.blogspot.com/2013/10/ablation-for-recurring-af-i.html

Image Source: http://wesleytodd.blogspot.com/2013/10/ablation-for-recurring-af-i.html

Internal bleeding from uterine rupture can cause referred pain through the phrenic nerve which can present in the shoulder.

Shoulder pain is sometimes not included in lists of uterine rupture symptoms, but I have seen it cited multiple places (see below) and have had conversations with OBs, nurses, and anesthesiologists who have experienced uterine ruptures with shoulder pain.

I’m also aware of two cases where the uterine rupture diagnosis was delayed because staff was not familiar with the incidence of referred pain.

Anyone who works with birthing women should be aware of the symptoms of uterine rupture including referred pain.

Please note that not every uterine rupture causes shoulder pain and not all shoulder pain is a symptom of uterine rupture.

Where can you learn more?

I discuss uterine rupture – factors, symptoms, rates, and outcomes – at great lengths in my online workshop, “The Truth About VBAC: History, Politics, & Stats

The following quotes addressing shoulder pain & uterine rupture are from case studies and textbooks. Want more? Google uterine rupture referred pain or uterine rupture shoulder pain.

“APH [brisk antepartum haemorrhage], as in this case, often indicates uterine rupture and may occur in association with shoulder tip pain due to haemoperitoneum.” (Navaratnam, 2011)

“Management of uterine rupture depends on prompt detection and diagnosis. The classic signs (sudden tearing uterine pain, vaginal haemorrhage, cessation of uterine contractions, regression of the fetus) have been shown to be unreliable and frequently absent but any of the following should alert suspicion… Chest or shoulder tip pain and sudden shortness of breath.” (Payne, 2015)

“Signs and symptoms of uterine rupture may include… referred pain in the shoulder (with epidural anesthesia)” (Murry, 2007 p.283)

“Jaw, neck, or shoulder pain can be referred pain from a uterine rupture.” (Murry, 2007, p.76)

“Shoulder pain (Kehr’s sign) is a valuable sign of intraperitoneal blood in subdiaphragmatic region. Even a small amount of blood can cause this symptom, but it is important to realize that it may be 24 h or longer after the bleeding has occurred before blood will track up under the diaphragm, and some cases of acute massive intraperitoneal bleeding may not initially have shoulder pain.” (Augustin, 2014, p. 512)

“Shoulder tip pain may be experienced if significant haemoperitoneum is present, due to irritation of the diaphragm (i.e. referred pain through phrenic nerve).” (Baker, 2015, p.373)

References

Augustin, G. (2014). Acute abdomen during pregnancy. Switzerland: Springer International Publishing. Retrieved from https://books.google.com/books?id=mq8pBAAAQBAJ

Baker, P. N., McEwan, A. S., Arulkumaran, S., Datta, S. T., Mahmood, T. A., Reid, F., . . . Aiken, C. (2015). Obstetrics: Prepare for the MRCOG: Key articles from the Obstetrics, Gynaecology & Reproductive Medicine journal. Elsevier Ltd. Retrieved from https://books.google.com/books?id=DcqqCgAAQBAJ

Murray, M. (2007). Antepartal and intrapartal fetal monitor. New York, NY: Springer Publishing Company, LLC. Retrieved from https://books.google.com/books?id=_4jYJUGG56cC

Murray, M., & Huelsmann, G. (2008). Labor and delivery nursing: Guide to evidence-based practice. New York, NY: Springer Publishing Company. Retrieved from https://books.google.com/books?id=q22jEEZo7rwC

Navaratnam, K., Ulaganathan, P., Akhtar, M. A., Sharma, S. D., & Davies, M. G. (2011). Posterior uterine rupture causing fetal expulsion into the abdominal cavity: A rare case of neonatal survival. Case Reports in Obstetrics and Gynecology, 2011. Retrieved from http://www.hindawi.com/journals/criog/2011/426127/

Payne, J. (Ed.). (2015, Mar 17). Uterine rupture. Retrieved from Patient: http://patient.info/doctor/Uterine-Rupture

Applying medical research to clincial realities

Isabel recently asked over on Uterine rupture rates after 40 weeks:

“I wonder however if there are studies that compare the method of induction. My Doula said that the increase rates of uterine/ scar rupture was due to using high dosages of Pitocin, but now the induction uses lower dosages and administered at longer intervals. Do you know something about this?
Thank you”

 

Isabel,

Great question.

A few factors to consider:

1. Induction protocols can vary by provider, including some providers who don’t induced planned VBACs at all.
2. Induction guidelines can vary by hospital.
3. Women can react to the same drug/dose differently.
4. Some studies do compare the uterine rupture rates among spontaneous, induced, and augmented planned VBACs.

Medical studies on induction are only relevant to your situation if your provider follows the same protocol outlined in the study. However induction protocols are often not spelled out in detail unless that is the focus of the study.

When reading medical research, make special note of the sample size. We need ample participants in order to accurately capture and report the incidence of uncommon events such as uterine rupture. I typically like to see at least 3,000.  

Also remember that it’s ideal to have a experimental group (who receives the induction protocol) and a control group (who does not receive the induction protocol) in order to measure the difference in outcomes, such as fetal distress, uterine rupture, hemorrhage, cesarean hysterectomy, etc. Ideally, we would have a couple thousand, at least, in the experimental and control group.

In terms of the trend that induction now uses lower dosages and is administered at longer intervals, that may be true in some practices, but I would always confirm and not assume.

Anecdotally, I have heard a wide range of induction protocols reported just as research has identified similar variations among cesarean and episiotomy rates that are not linked to medical indication. This California Healthcare Foundation infographic clearly illustrates how hospitals differ:

Tale of Two Births

CLICK to share on Facebook

In terms of specific studies comparing the method of induction, the first resource that comes to mind is the Guise 2010 Evidence Report.

Search for the word Cytotec and there is a discussion comparing rates of rupture by Pitocin, prostaglandins, and Cytotec.

Pitocin is associated with the lowest rate of rupture among the chemical agents which is likely why ACOG (2010) recommends Pitocin and/or Foley catheter induction in planned VBACs when a medical indication presents. (Learn more about what the Pitocin insert actually says.)

There may be more recent studies out there. Google Scholar is a good place to start. You can often obtain the full texts of medical studies at your local library, university, or graduate school.

Also, if you subscribe to Evidence Based Birth’s newsletter, she will email you a crash course on how to find good evidence.

I hope this helps!

Jen

What is the induction protocol at your facility? Does it differ for those with a prior cesarean? Let me know in the comment section.

____________________

American College of Obstetricians and Gynecologists. (2010). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology, 116 (2), 450-463, http://dhmh.maryland.gov/midwives/Documents/ACOG%20VBAC.pdf

California Healthcare Foundation. (2014, Nov). A Tale of Two Births: High- and Low-Performing Hospitals on Maternity Measures in California. Retrieved from California Healthcare Foundation: http://www.chcf.org/publications/2014/11/tale-two-births

Guise, J.-M., Eden, K., Emeis, C., Denman, M., Marshall, N., Fu, R., . . . McDonagh, M. (2010). Vaginal Birth After Cesarean: New Insights. Rockville (MD): Agency for Healthcare Research and Quality (US). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK44571/

Friedman, A. M., Ananth, C. V., Prendergast, E., Alton, M. E., & Wright, J. D. (2015). Variation in and factors associated with use of episiotomy. JAMA, 313(2), 197-199. Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=2089343

Kozhimannil, K. B., Arcaya, M. C., & Subramanian, S. V. (2014). Maternal Clinical Diagnoses and Hospital Variation in the Risk of Cesarean Delivery: Analyses of a National US Hospital Discharge Database. PLoS Med, 11(10). Retrieved from http://journals.plos.org/plosmedicine/article?id=10.1371%2Fjournal.pmed.1001745

New Research on Home Birth with an Obstetrician

male-doctor-thumbs-up-squareOver the last five years Dr. Stuart Fischbein, a Southern California obstetrician, has attended 135 home births. These deliveries included VBACs, vaginal breech and vaginal twin deliveries.

A summary of these births has been recently published.

Here are some highlights along with a few additional resources I compiled where you can learn more.

On patient selection:

“This model was not limited by strict protocols and allowed for guidelines to be merely guidelines. Women over 35, VBAC, breech and twin pregnancies were not excluded from this series simply because those labels existed. Each client was evaluated on her own merits and the comfort of the practitioner.”

On informed choice and the limitations of hospital birth:

“Home birth is not for everyone but informed choice is. The patronizing statement, “home delivery is for pizza”, is unprofessional and has no place in the legitimate discussion. Some suggest making hospital birth more homelike. While this may be a beginning and deserves investigation, it fails to recognize the difficult balance between honoring normal undisturbed mammalian birth and the reality of the hospital model’s legal and economic concerns and policies.”

On collaborative care:

“Pregnant women deserve to know that midwifery style care, both in and out of hospital, is a reasonable choice. A collaborative model between obstetrician and midwife can provide better results than what is occurring today.”

On lost skills:

“It would be wise to put the constructive energy of our profession towards the training of future practitioners in the skills that make obstetricians truly specialists such as breech, twin and operative vaginal deliveries.”

On the growth of home birth:

“Home birth will continue to grow as educated women realize that the current hospital model has many flaws.”

On our ethical obligation to provide a smooth home to hospital transfer:

“Cooperation, respect and smooth transition from home to hospital honors the pregnant woman and is our ethical obligation.”

_____________

California Healthcare Foundation. (2014, Nov). A Tale of Two Births: High- and Low-Performing Hospitals on Maternity Measures in California. Retrieved from California Healthcare Foundation: http://www.chcf.org/publications/2014/11/tale-two-births

Fischbein SJ (2015) “Home Birth” with an Obstetrician: A Series of 135 Out of Hospital Births. Obstet Gynecol Int J 2(4): 00046. DOI: 10.15406/ogij.2015.02.00046. Retrieved from Obstetrics & Gynecology International Journal: http://medcraveonline.com/OGIJ/OGIJ-02-00046.pdf

Johnson, N. (2010, Sept 11). For-profit hospitals performing more C-sections. Retrieved from California Watch: http://californiawatch.org/health-and-welfare/profit-hospitals-performing-more-c-sections-4069

Kennedy, M. (Director). (2015). Heads Up! The Disappearing Art of Vaginal Breech Delivery [Motion Picture]. Retrieved from http://www.informedpregnancy.com/#!heads-up/cef1

Klagholz, J., & Strunk, A. (2012). Overview of the 2012 ACOG Survey on Professional Liability. Retrieved from The American Congress of Obstetricians and Gynecologists: http://www.acog.org/-/media/Departments/Professional-Liability/2012PLSurveyNational.pdf

What I told the California Medical Board about home VBAC

california state seal

A little backstory

Back in October, I attended my first Interested Parties Meeting held by the Medical Board of California regarding new midwifery regulations as required by AB1308. (Read more about AB1308 here and here.)

Up for discussion was which conditions or histories among women seeking a home birth with a Licensed Midwife (LM) should be required to obtain physician approval.

A prior cesarean was on the list of over 60 conditions or histories and home VBAC was the one subject that generated the most comment and discussion that day.

What does AB1308 mean in terms of home VBAC in California?

There has been a lot of confusion regarding what AB1308 means in terms of home VBAC in California. In an effort to clear things up, Constance Rock-Stillman, LM, CPM, President, California Association of Midwives said this on January 23, 2014:

AB 1308 went into effect on 1/1/14, but there is nothing in the new legislation that says LMs cannot do VBACs.

LMs can do VBACs.

We just need to define in our regulations what preexisting conditions will require physician consultation. [Which is what the October 15 and December 15th Interested Party meetings were about.]

Until the new regulations are written LMs should continue to follow their current regulations which only require LMs to provide certain disclosures and informed consent to clients.

Please let the community know that if they want to have a say in whether or not VBACs with California LMs require a physician consultation, they should come to the Interested Parties meeting that the medical board will be holding and tell the board how they feel about it.

The medical board is a consumer protection agency, so they need to hear what consumers want to be protected from.

We will let you know as soon as the meeting is scheduled.

[Ms. Rock-Stillman responds when questioned by those who have not been involved it the creation of this legislation yet insist this legislation removes the option of home VBAC entirely:]

I’m in my third year as president of the California Association of Midwives, and I’m a practicing Licensed Midwife.

I have been at every Midwifery Advisory Counsel meeting and at the Capitol 30 times last year.

I’ve spoken in legislative committee hearings.

I’ve sat in weekly meetings with CAM’s legal counsel who worked side-by-side with us on the legislation.

I’ve been in Assemblywoman Susan Bonilla’s boardroom with ACOG and at every one of the public events where Susan Bonilla promised that the LMs would still be able to do VBACs.

So I think I qualify as a knowledgeable stakeholder in this issue.

Yes, we intentionally left VBAC out of the list of prohibited conditions, so at this point there is no question as to whether or not we can do VBACs. The only part that’s in question is whether or not all VBACs will require physician consultation.

Regulations that clarify under what circumstances physician consultation will be required will be written by the California Medical Board.  This is a process that takes time. Maybe even a year or more.

The regulations that will be adopted will be based on evidence and input from all the stakeholders.

This is why I think it’s so important that midwives and consumers be at the meetings to insure their voices get heard.

At the last Interested Parties meeting that the medical board held, I asked what we were suppose to do until the new regulations are written and we were told that we should follow our current regulations and our community standards until new regulations are adopted.

Why I attended

My intention in attending the October 15, 2014 meeting was to amplify the voice of the consumer.  I think sometimes it’s difficult for OBs who attend VBACs, or for those who live in communities where they have access to hospitals that attend VBAC, to understand that not everyone lives in that world.

Some live in a world where if they want a VBAC in a hospital with a supportive midwife or doctor who takes their insurance, that means driving over 50 miles each way for prenatal care and delivery while they literally drive by other facilities that offer labor and delivery, but ban VBAC.

Or it means acquiescing to a unnecessary repeat cesarean whose risks compound with every surgery. Or it means planning an unassisted birth which comes with its own set of risks. This is a tremendous burden.

As VBAC and repeat cesarean both carry risks and benefits, and women are the ones who bear and endure those risks, they should be the ones who choose which mode of delivery is acceptable to them.

I celebrate when women have access to supportive hospital-based practitioners.  But the reality is, many women do not enjoy that privilege and yet they still wish to avoid the serious complications that come with each cesarean surgery.

Who else was at the meeting?

Other people in the room included the Senior Staff Counsel of the Medical Board, an OB-GYN representing ACOG, an ACOG lobbyist, Constance Rock-Stillman along with many other CAM representatives and midwives, California Families for Access to Midwives, a few other consumers, and me.

Senior Staff Counsel was tasked with writing these regulations and as the meeting progressed, items were reworded or removed from the list.

My statement

Only having five minutes to speak means that as soon as you take your seat, adjust the microphone, and look into the eyes of Medical Board, you have to establish yourself as a credible source.

And then you start to speak. You have to be clear and concise with an unwavering voice. The Medical Board is your captive audience and you need to use every second weaving the facts with the personal experiences of mothers, midwives, and doctors so you can convey the whole story.

Often Medical Boards are not well versed on Licensed Midwives, home birth, and the politics of VBAC, so there is a lot of education that has to quickly happen in a few short minutes. You must maximize your time and, while talking at a normal pace, swiftly move from fact to fact continually highlighting yet another piece of evidence that supports your case.

Those that sit on Medical Boards often have access to whatever medical care they need. So sharing the challenges real families throughout the state face when trying to obtain a VBAC is crucial.

With all those factors in mind, I focused on the importance of VBAC access, the politics of hospital VBAC, and the public health implications if families can’t access VBAC.

Throughout my entire presentation, I emphasized how increasing VBAC access was aligned with the mission of the Medical Board: to protect consumers.

It was quite challenging to adequately convey these key points in such a brief format. But as I looked into the eyes of each board member during my presentation, I felt heard. I knew they were receiving the message I intended and that all the hard work that went into preparing for that day made a difference.

Legislative consulting is yet another way that I serve the mission of VBAC Facts. To schedule a legislative consulting call, please click here.

Home VBAC threatened for California families

There has been a lot of confusion regarding AB1308, the legislation that went through at the beginning of this year in the state of California. It said that LMs were no longer allowed to attend home births some situations (such as breech, beyond 42 weeks gestation, etc) and other situations required a physician to sign off on the home birth.

It’s these regulations that are currently being written by the Medical Board with input from ACOG, CAM, CFAM, and VBAC Facts. It is under discussion whether a prior cesarean should be included on this list of conditions that would necessitate a physician’s approval in order for the woman to plan a home VBAC.

On October 15, 2014, I flew to Sacramento and attended a Interested Parties Meeting at the California Medical Board.  I spoke on behalf of California women who want home VBAC to remain an option in our state. You can read a summary of that meeting here and listen to a partial recording of the meeting here.

There is going to be another meeting on December 15th from 1-4pm in Sacramento (agenda) and I will be there once again representing consumers.  I will be preparing a short testimony.  If you are a California resident and would like to attend the meeting, please do.  If you can’t, but want your voice to be heard, please email me the following information:

1. Why home VBAC is important to you

2. Your name

3. Your county

More information from the California Association of Midwives and California Families for Access to Midwives

 

VBAC: A husband’s experience and lessons learned

“I have just seen so many women who have husbands who aren’t supportive because they don’t understand. My husband would love to help more men understand.”

A couple recently shared their VBA2C (vaginal birth after two cesareans) journey with me.  It touched my heart.  My the time I was done reading it, I had tears in my eyes.

So many women do not feel that VBAC is an option for them because their partner isn’t on board.  Now I know there are women who will birth how they please regardless of their partner’s feelings or thoughts, but there are many women who wish to bring their baby into the world while preserving their relationship.  And, what typically happens in these scenarios, is that the woman puts the desires of her partner above her own and she schedules a repeat cesarean.  Often, the challenge of educating and convincing their partner is just to great in the face of the conventional wisdom that states VBACs are just plain dangerous.

Just the other day, I was talking to a couple in their 40s who didn’t have children.  Yet despite the fact that they were not in the “world of childbearing,” they thought “once a cesarean, always a cesarean.”  This falsehood is so ingrained in our society that even those without children know it by heart and believe it to be true.

The absence or presence of social support is a huge factor in whether a woman plans a VBAC or a repeat cesarean.  This is why it is so important for partners and people of non-childbearing age, such as the birthing woman’s parents, grandparents, and extended family, to know that the American College of OBGYNs and the National Institutes of Health say that VBAC is a safe, reasonable, and appropriate choice for most women with one prior cesarean and for some women with two prior cesareans.  When friends and family members are undereducated about VBAC, it negatively impacts the birthing mom.  Many women are simply not willing to create family drama in order to plan a VBAC.  And the seeds of resentment are planted.

And then there are men that want to support their wives, but don’t know how.  They feel trapped between a growing mistrust of their doctor and the desire for a good outcome for their wife and baby. Today I spoke with a father who said that he “felt powerless” as his wife was bullied into a cesarean. He really believed that he should be able to completely trust his wife’s OB, but as her labor progressed, he did so less and less.  And yet, he didn’t know what to do.

Men need to hear the experiences of other men as partners are such a critical part of the birthing woman’s support team.  For many women, when their partners are on board, they have the emotional sustenance required to plan a VBAC in a country where over 90% of women have a repeat cesarean and women planning VBACs are often bombarded with stories of “VBACs gone wrong.”

I hope you enjoy the words of this engineer, this military man, this caring father, as he graciously articulates his VBAC journey.

I would love to share more VBAC stories from the partner’s perspective.  You can submit your birth stories via email.

_____________________________________

One of the most important life choices is the freedom to choose what one wants for their own health and their body.  For my wife, it was the choice to have a VBAC after two c-sections and the need for her husband’s support to make it happen.  This is a short story about a husband’s lesson learned and incredible experience of sharing a VBAC birth with his wife.

Our first child together was a cesarean because the labor would not progress and ultra sound pictures indicated a large head.  The doctor feared complications due to the large head and the concern over my wife’s first vaginal birth 9 years earlier that resulted in a 4th degree tear.  Our going in game plan was always as natural as possible.

Before we decided to start a family, my wife relayed her desire to have a natural birth when the time came. She described the challenges in her first birth that resulted in a painful 4th degree.  She relayed that in retrospect, the 4th degree tear could have been prevented had the atmosphere of the delivery room been more supportive, more relaxed and the doctor vetted more carefully prior to delivery.

All doctors are not created equal.  A medical degree does not guarantee that two doctors will have equal outcomes. And with my wife’s first child years before I was in the picture, there was good evidence to support her claim that both support structure and doctor helped lead to a painful labor.

“I could not understand the true emotional implications”

When our son was born cesarean, there was a disappointment that only she could truly understand. I was simply happy to have a healthy son.   I remember her making a comment about cheating me out of the experience to have a natural birth, as if her body had failed what it was made to do.  I reminded her that natural or cesarean, it was all the same to me as I just wanted wife and baby to be healthy.  How this was accomplished was not important to me.  But, to my wife the cesarean felt like a violation of her choice and cheated her out of the way nature created the female physiology to behave after 9 months of baby development.

I admittedly could not understand the true emotional implications that having a cesarean had on my wife until she went through her second cesarean.  When we decided to have baby number two together, my wife’s third, our doctor immediately said that since our son was born cesarean that our next child would have to be delivered cesarean too. We argued the point and our doctor, whom we loved and took care of all the children and my wife, finally gave us the option to find another doctor because the hospital “protocol” required that under the circumstances (quoted as saying the 4th degree and then a cesarean) dictated a second cesarean regardless of how the pregnancy was to progress.  This catch-22 complicated several factors for us.

“Our doctor, whom we loved, gave us zero options”

First, our doctor, whom we loved, gave us zero options.  She was a great person, wonderful doctor, but she was strapped to the protocol of the local hospital or their medical group that tells patients what they will do as opposed to giving the patient real options and choices on their health care.  I mentioned to my wife that we could switch doctors for this pregnancy but found that it may complicate our life because we were getting good care just miles from our house with the current doctor.  In the end, we stuck with the doctor we liked.  The lesson learned was that I should have told the good doctor to either grow a pair and stand up to the hospital’s myopic protocol and allow us the opportunity to do it our way or we should have just cut ties and got a new doctor who supported our VBAC wishes.  In the end, my wife’s freedom to decide should have been more important than our comfort zone with the local doctor.

I reluctantly supported our doctor and their protocol for a second cesarean.  I could tell my wife was disappointed, but she did not fight me.  This is one of those critical marriage lessons that go both ways.  Since there was little objection, just subtle and maybe even lingering apprehension to not make the decision to switch, we stayed with the plan.  Looking back, my wife’s apprehension to switch doctors was due to lack of VBAC education and lack of support from any of her caregivers, including me.  She just couldn’t understand why she was being forced into major surgery.

Later, after our daughter was born, I realized how much the inability to have the option of a natural birth meant to my wife.  The night before the scheduled cesarean, it appeared my wife was going into natural labor.  In retrospect, considering the labor signs and the small size of the baby, there is little doubt that she could have delivered vaginally.  My wife mentioned this to me the night before the c-section when she was having contractions and said, “I can do this naturally.” My response was, “No, we already have this scheduled for a cesarean in the morning and the doctor said that they would not do it.”  This response was naive and void of any empathy or realization of what that lack of support meant to my wife.  We went into surgery and it wasn’t until she was pregnant with our third that I realized how much the second cesarean had left her with some lasting emotional stress and even low grade secret resentment toward me for not supporting her or understanding her feelings on the topic better.  Whether she’ll admit it publicly, she harbored feelings against me for not supporting her, for the medical community’s lack of birthing choices, and to the doctor who we loved but had a hard time saying no to.

“I realized I let my wife down”

When I finally realized how critically important it was to have the freedom and choice to labor naturally, without absolutes dictated by the medical community or their “legal directives,” did I realize that I let my wife down. When the clue light came on I was set on supporting her on a VBAC, but it didn’t start that way.  My awakening did not come immediately when we found out we were having a third baby.

The pregnancy of our last child coincided with the pop up surprise news that I had to leave on a one year deployment to Afghanistan. In January 2012, I found out I was leaving the first week in April for a one year deployment and days later my wife announced she was pregnant.  What great timing.  Now my wife had to be a pregnant single mom to 3 children for an entire year.  Fortunately, we found out that due to the length of the deployment I was allowed 15 days of leave any time after 90 days in theater and therefore we started planning on my arrival for leave to coincide with the birth of our new baby.

“A selfish desire to try”

My wife quickly relayed her wishes about how this pregnancy would go.  She said to me bluntly that we’re doing this naturally. I quickly shot back with absolutely not.  My engineering brain quickly argued with her that we had three data points that indicated this was not a good idea: a 4th degree tear from forceps and 2 cesareans.  I told her that I did not want to take the chance of having my wife or baby put at risk because of a selfish desire to try and prove something to me or the world that she could do this naturally.  I had read medical reports of women’s uterus rupturing and dying from bleeding after attempted VBACs.  I feared what could happen.  But, I never knew the more thorough and recent facts of what my wife wanted to do.  She knew that I was a man who required facts to make critical decisions so she turned away from this conversation and re-engaged me at a later time with literature that showed a VBAC after 2 cesareans is not as dangerous or risky as I originally thought.  She showed me numerous medical associations that supported VBACs of all types.  I did a little more research and realized that from a technical perspective; it was possible assuming the pregnancy progressed normally without anomalies.

“It was at this moment that guilt set in”

When my wife dropped this data in my lap and looked at me with a long, deep stare that pierced right through me, my awakening had begun.  I realized that she wanted to have the choice to deliver this baby naturally without anyone in the medical profession telling her no unless there was a clear smoking gun for why it wasn’t possible, like high probability of death to baby or mom.  I knew she needed my support to make this work.  I decided at that moment that I would support her wish to have our baby without surgery.  I knew if anyone could do it, she could.  And I knew that there was no reason why we shouldn’t try to do it naturally.

It was at this moment that guilt set in for not doing something about my wife’s desire to try and have our daughter (second c-section) naturally.  I could have pulled my alpha male tricks and told the hospital to pack sand and that we were going to labor naturally and they’d have to follow our wishes or put us in the parking lot.  But, I didn’t do that and I was determined to redeem myself for not understanding how she truly felt.

“The only doctor we could find was a 2.5 hour drive without traffic”

The plan was complicated.  The only doctor we could find that took our military insurance and would entertain our idea of a VBAC with my wife’s past birthing history was in Los Angeles, a 2.5 hour drive without traffic from our desert home.  The doctor seemed too good to be true.  Our doctor, Dr. W, was personable, professional, and most importantly very supportive.  There was no talking down or psychological political play to try and convince us that our decision was not wise.  I told him that if there was no real reason why the baby couldn’t come into this world naturally, then we wanted his support for a VBAC.   He said he’d support our wishes as long as mom and baby were healthy, and the American College of Obstetricians and Gynecologists (ACOG) supported VBAC.

This seemed too good to be true because our impression was that California was much more litigious than Washington State from where we had our last two children and the previous c-sections.  We assumed we would have fewer choices in California because California is a highly regulated state.  In our case, it took a very experienced doctor with the courage and trust to allow us to proceed with our desire to have a natural baby.  He was under pressure from both the hospital and his own reputation if things went badly, but he took a chance and gave us the benefit of the doubt to respect our right to choose.

“I wasn’t worried about the rocket attacks from insurgent forces, I was worried about my wife.”

While in Afghanistan, I wasn’t worried about the every 8 to 10 day rocket attacks from insurgent forces, I was worried about pregnancy issues and my active wife.  She was now a pregnant single mom, raising a teenager and two children, running 3 houses (we own two in WA State) and maintaining an aircraft.  With our son, my wife was put on bed rest at 29 weeks due to pre-term labor and in the end because the labor did not progress she had the first cesarean.  The surgery was an experience she did not ever want to repeat but ended up repeating with our daughter.  While I received the daily reports via emails, skype sessions and pictures, I prayed for her and the kids’ safety and health.  I was slated to fly home on or around the 5th of October and be present for the birth, due date October 11th.

There is no doubt that the 15% increase in grey and white hair while deployed was due to the reports of life at home.  While pregnant, my wife traveled to Florida, Georgia, and Colorado, traveled and hiked the forest on the Pacific coast with all the kids.  And at 8 months pregnant I would get pictures of her painting various rooms in the house and even using a chain saw to do yard work.  I pleaded with her to hire the labor and help as I was scared something was going to happen.  She was simply not a sit on the couch woman.  She was on the go all the time.

With our second daughter, my wife fell out of the car 10 days before the scheduled C-section and shattered her left 5th metatarsal. Ten days after breaking her foot, she had the c-section, then 2 weeks later she was in a car and we were moving from Washington State to California and into temporary housing, headed to our next California duty station.  She had a cast on her foot for 4 months. This experience was painful both emotionally and physically.  Now, 8000 miles away, I was afraid something similar might happen but even worse since I would not be there to help.

“Preparing her mind and body for a successful VBAC”

Simultaneously while my wife traveled with the kids, painted, and did yard work with chain saws, she took numerous steps to ensure that the VBAC would succeed.  Of her many objectives, one was to ensure that the baby would not be occiput posterior as her first and only vaginal birth yielded a decade earlier and a contributor to the 4th degree tear. She also contacted and connected with various people who gave her more information on how to best prepare for a VBAC.  She had chiropractic appointments to help loosen up her hips and to prepare her body for natural labor.  She read more medical data, communicated and worked with people like our doula, who volunteered her services free to military members.  The doula could be instrumental in helping many women and seems to be an underutilized service.  Our doula volunteered with Operation Special Delivery for families of deployed military members, free of charge.  Free expert doula care is something that does not exist and therefore we were fortunate to be in the right part of the country at the right time when a humble, caring and experienced woman was offering her doula services free to military spouses.  This too was a unique windfall and something that feels more like a blessing than pure luck.

Through my wife’s various connections, proactive appointments, nightly stretching rituals, she was preparing her mind and body for a successful VBAC.  People such as our doula volunteered hours talking about the game plan for VBAC day.  There was a real possibility that my leave period could have been canceled or late, because anything in the military is possible. Therefore, our doula was necessary to coach and represent my wife’s interest in the event that I couldn’t get home.  With both me and our doula in the room with my wife we were able to support her and time share in helping her along.  Fortunately, we both shared the same objectives and wanted the birthing room to be sterile of negativity and only wanted supportive hospital staff to interface with my wife.  This was a critical aspect of the successful VBAC.  The doula’s warrior like spirit and endurance meant that I had help and an advocate by my side the entire time.  By the time the baby arrived, all three of us, the doula, my wife and I had been up for almost 36 hours since we never got to sleep the night contractions started. My wife text messaged our doula when the contractions got bad and she stayed up on standby until my wife told her that we were headed into the hospital.  Our doula arrived shortly after we arrived at the hospital and stayed through the entire experience.

“What was important was her health and the baby’s, not my convenience of being home”

Thankfully, my wife’s pregnancy was just about as perfect as one could hope for.  She had terrible heart burn, the normal stuffy nose and difficulty sleeping at night, due to the physiological challenge of having a baby grow against the bladder, making nightly trips to the bathroom routine.  All this was normal and when I finally arrived in Los Angeles on October 7, we were ready to have a baby.  There were no indications that the pregnancy could not continue into normal labor.  Now, the next step was simply getting my wife into labor.  She tried acupuncture, lots of walks and when I arrived, we tried the husband-wife techniques that usually help stimulate labor.  But, after a few days home, there were no signs of labor and my wife was getting frustrated.  She so desperately wanted me to experience this with her and my window home was short.  I told her what was important was her health and the baby’s, not my convenience of being home.  The strict military protocol didn’t have flexibility in the return schedule: unless it was a major medical emergency, I was slated to leave on the 16th day after I arrived home.  So if the baby came late, then I would have very little time with the baby.  If the baby had to be delivered via yet another c-section, my wife would be in dire need of help because she’d be hard down with NO family scheduled to be around after I left. This iteration of the various scenarios had me the most concerned. I was sick to my stomach thinking about this situation; leaving my wife days after a c-section with a house full of kids was unthinkable.  I knew I’d have to come up with some creative way to get her immediate help at home.

Another scenario that had me concerned was the baby being 7-9 days late, as was the case with a friend during the same period.  The reality of me coming home and then leaving with no baby was a possibility and then having to deliver just hours or days after I left to return to Afghanistan was a horrible thought too. In this scenario, the probability of complications increased because the possibility of the baby growing too big and then again requiring a c-section increased significantly.  When my wife began to panic a little about having no signs of labor, I tried my best to reassure her that everything would work out.  In my statistically oriented mind, I knew the odds were against us.

“Contractions were coming about 4-5 minutes apart and they were getting stronger”

Lying in bed on the 8th of October, my wife was upset at the possibility of our grand plan not working out and I assured her that this baby was coming and it would come on the due date.  Early in the afternoon on October 10, my wife started to have small contractions.  By around 10 pm they were getting more significant.  Just after midnight on October 11, the baby’s due date, the contractions were coming about 4-5 minutes apart and they were getting stronger.  Then with the first real sign of labor, the bloody show, we decided to leave for the hospital, which was about a half hour drive from our hotel.

My father had flown into town a few days before I arrived from Afghanistan.  He was the cat herder; he took care of our 4 and 2 yr old.  My father at 68 years old has the amazing stamina to handle two energetic kids. We left at around 0130 in the morning on October 11 and left my father to pack up the entire little cottage we were renting at a local air force base in LA.  When we got to the hospital, my wife’s contractions became very strong and painful. I remember my wife saying labor will be hard for me because I’ve never seen her in real pain and I’m not good with seeing her in pain.  I didn’t know what she meant until she started to go into active labor.  Our doula met us at the hospital.  Between the doula and me, we helped coach my wife through 17 hours of painfully slow labor.

My wife’s labor pains came strong and painful.  She was right; I’d never seen her in that much pain before.  She had painful contractions for hours and hours.  Her first cervical check revealed she was only 1-2 centimeters.  She became frustrated again – after all that work and pain we assumed she would have been considerably further along. Since my wife had two c-sections previously, the staff was trigger happy to react to any anomalies seen in my wife or the baby.  Their threshold for pregnancy challenges was low.  If the monitors weren’t on at all times, they’d come into the room quickly and impatiently.  Our doula and I had to tell the staff to stop over-reacting.  They settled down a bit, but they reminded me that there wasn’t much wiggle room for the monitor rules.  The previous night, a woman’s uterus ruptured just after birth and she almost died in a room next to ours.  So the staff was even more on edge than usual.

Therefore, we had additional pressure to ensure my wife was relaxed but yet progressing.  After 13 hours of labor, she was exhausted and the pain was beginning to take its toll.  Her dilating slowed at around 6 centimeters.  The anesthesiologist recommended an epidural in case my wife needed a c-section.  They could put one in without administering medicine.  We did not want an epidural to prevent my wife from being able to position on all fours or sitting on the port-a-potty they brought in for her to labor on.  But, the pain was so bad, that it was preventing her from relaxing and she was simply running out of energy.

At 8 cm the epidural was in, we made the decision to administer a very low amount of pain relief, just enough to take the edge off.  This technique worked and the small amount of pain relief helped my wife regain some confidence as it reduced her pain level. They put in enough pain meds for 1 hour of relief.  The doctor said the water bag needed to be broken to further progress.  Several hours after the water broke the doctor came in and checked her.  She was 10 centimeters now, the magic number to begin the delivery.

After 15 hours of labor, the baby had to be delivered now.  The doctor recognized how tired my wife was and he ensured no more epidural medicine was administered because he needed her strength to push the baby out if we were to do this naturally.  He pulled me aside and told me the baby’s threshold heart rate was down 30%, something I had observed and was concerned about. Dr. W told me that it was time to get the baby out and it was coming out one of two ways.  He said when he comes back, we’re having the baby.  He couldn’t let the heart rate deteriorate any further and said the baby is plus 1 and not happy about being stuck in that position.

“The natural urge to push wasn’t happening”

I went immediately to my wife, who was exhausted and told her when Dr. W comes back in, it’s time to push.  I calmly gave my wife a pep talk, but she was too tired to respond and her lack of response had me worried.  But, she listened.  Both our doula and I could tell that my wife was having a hard time pushing. The pain was difficult to push through and for some reason the natural urge to push wasn’t happening like my wife envisioned it would happen.  Her body made it to 10cm, slowly, but wasn’t sure what to do now.  The natural urge to push wasn’t occurring.  But, it was time to push anyway.

I didn’t want to seem panicked, but I told my wife several times when the good doctor comes back, he’s either taking you to the OR or you’re going to have to push this baby out.  A delivery nurse came in first and she wanted to observe my wife push and immediately gave her some corrective technique.  Then Dr. W came in and did the same assessment and recognized some technique issues and then he turned into an assertive drill instructor, telling my wife to push.  Both the labor nurse and the doctor’s quick technique advice were key.

“Is that the baby’s head?”

After one of my wife’s strong pushes and while I was holding her right leg back I noticed something unusual looking next to the doctors finger that was positioned about a half inch inside my wife’s vagina. I couldn’t make out the object initially but once my tired brain thought of all the possibilities I realized that it looked like a mat of wet hair.  I asked the doctor, “Is that the baby’s head?” He said yes it is. I was filled with energy and excitement that I hoped would jump to my wife when I told her the news of what I had just witnessed.  I couldn’t believe I was staring at the top of our child’s head.  We made it I thought!  I told my wife I could see the baby’s head.   She pushed harder and after about 3-4 good pushes, our baby came right out.  It was the most amazing thing I’ve ever witnessed.

Once the baby was out, they placed her on my wife’s bare chest. After several minutes we realized that we never checked to see what the sex was.  My wife lifted her up, moved the umbilical cord and I think we were both surprised to see a little girl part.  We did not want to know the sex of the baby until he or she was born.  We assumed we were having a boy because of how strong the baby was during the pregnancy and how much the baby looked like our son from the 3-d ultra sounds.

“She felt so good that we requested to leave the hospital at the absolute minimum stay period.”

Lucy Rose was born at 7:47pm on October 11, 2012.  She was 7 pounds 1 ounce.  My wife had no tearing and her uterus showed no signs of trauma from the VBAC.  She felt so good that we requested to leave the hospital at the absolute minimum stay period.  The baby was born at 7:47 pm and we told the hospital we’d stay exactly the required 24 hour monitoring period. By 8pm, 24 hours later, we were loading up the car and heading back to our desert home, 2.5 hours from the hospital.  We arrived at our home around 11:30pm.

This was the first time I had been home since April 7th and it was so nice to be back.  No hospital nurses checking vitals every 2 hours and the comfort of our own nest.  The next 10 days at home with the baby, my wife and kids were absolutely wonderful.  Due to the natural birth, my wife was immediately mobile.  Unlike the previous two births, it was great seeing my wife smile, happy and glowing and able to move without pain.  She loathed the c-section and dreaded the possibility of having to go through that again, especially without the help of her husband.  Thankfully, we were able to have a successful VBAC preventing my wife from having to relive another c-section.

“She came in and began lecturing us on the dangers of a VBAC.”

When we arrived at the hospital, the birthing process started out badly.  The first nurse we dealt with was what I would consider bluntly, an idiot.  She came in and began lecturing us on the dangers of a VBAC.  I quickly told her to stop and leave. This same nurse came in again and tried to make more negative commentaries and this time our doula rolled in and told her to essentially shut up and do her job.  I pulled this nurse out and told her that we weren’t going to have any negativity in the room.  I told her that we weren’t 16 year old idiots; we were well informed and educated people who most likely knew more about the risks than she did.  I had thoughts of leaving the hospital due to the initial behavior of the nurses.  In all honesty the staff on duty when we arrived was absolutely horrible. They were unfriendly and unprofessional.

But at shift change, something wonderful occurred.  The next shift yielded very competent, supportive and professional nurses who understood that our path through this experience was going to be nothing but positive and supportive.  Two of our nurses were also doulas.  We had great health care providers through the rest of the stay at the hospital.  No more myopic lectures about the risks but instead an all out effort to support my wife through this delivery.  There is no way we could have made it through this experience without the help and support of true and knowledgeable nurses who understood compassion and realized that the patient is first and foremost.

“My initial thought was that this hospital was going to be a disaster but I was happy to be wrong.”

My initial thought was that this hospital was going to be a disaster but I was happy to be wrong. We fortunately experienced a well organized and supportive hospital where our experience was wonderful and our dream of a natural birth and of a successful VBAC was realized.  The ability to have a natural birth allowed my wife to function immediately after the birth, something that would be crucial when I left again for another 5 months.  My 9 days at home after Lucy was born, allowed my wife to rest and regain her strength.  Then when I left, she would be able to successfully handle the newly expanded family.  If she had had a c-section, our lives would have been even more complicated and challenging.  Alleviating this variable was crucial and it was extremely important in allowing my wife the choice and freedom to labor as she desired.

“Having hospital protocol tell you what you can do with your body is a crime.”

Having hospital protocol tell you what you can do with your body is a crime.  It was a crime with our second baby and one that I unfortunately did nothing to stop.  I was guilty of not recognizing the deep and complicatedly emotional desire and need to have that choice.  I was guilty for not carefully listening to my wife.

But, I was fortunate to have had a second opportunity to ensure she was able to have that choice.  When I saw and finally understood my wife’s deep desire and passion to have a VBAC, something that I can’t really explain, but instead felt – I knew she could in fact do it and that I needed to help pave the way to ensuring it was possible. That meant I needed to knock down the obstacles that got in our way, like doctors saying no or nurses trying to convince us that our decision was dangerous and risky.  I listened to my wife, and we thank God that we found a doctor who trusted us.

Ultimately, faith, education and research, proper planning, incredible support that we received from people like Dr. W and our doula, and the great nurses who helped make this a success were critical to the successful VBAC.   We heard it before “you’ve had one, so now you need to have them all c-section.” This we now know is myth and one myth that removes the woman’s choice to attempt a VBAC.  Our hope is that other women and couples will have the same support and success as we experienced.

You need to talk to the doctor/midwife face-to-face

Trying to find a VBAC supportive health care provider can be (very, very) difficult process.  Understandably, some women choose to call various providers rather than meet with them face to face. This woman’s experience illustrates the pitfalls of this method.

While VBAC is not a household term, it should be a familiar one among an OB’s front office staff.  Perhaps this will prompt more providers to have a quick discussion with their staff about VBAC and maybe even pass out a copy of the Quick Facts page (high res PDF) so that everyone who interacts with patients has a basic working knowledge of the topic.

Of course, this is the experience of one mom at one OB’s office and certainly doesn’t reflect on all the dedicated and intelligent individuals who work at OB’s offices throughout the world… simply this one.

For tips on interviewing care providers, including how to present yourself and specific questions to ask, go here.

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Well, GREAT little anecdote for you all… In my search for an OB who will at least consider a VBA2C I ended up talking to a lady office assistant via phone yesterday. It went as follows:

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Me: “Hi! *general convo* Is the doctor VBAC friendly?”

Lady: “Is she friendly?”

M: “No, will she consider a VBAC?”

L: “Um, what’s a VBAC?”

*I hear another nurse in the background, say ‘Yes, we do VBAC’*

M: “Wait, did she say you guys will do a VBAC?”

*Nurse in the background says to lady on the phone, ‘Wait, has she had a c-section?’*

L: “Um, have you had a c-section?”

M: “Yes, of course.”

L: “Oh, the other nurse said if you’ve had a c-section we can’t give you a VBAC.”

M: “Ok, I think you need to know, VBAC stands for Vaginal Birth After Cesarean. It would be impossible to have a VBAC without previously having had a c-section.”

L: “Oh! I didn’t know that!”

*general pleasantries and I hung up*

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When you called your local health providers, what information did the front office staff share with you?  One mom said, “We’ve done surveys in Orlando by calling all the OB offices in town (I know, huuuge undertaking, right?!). We have been told vbac is illegal, that there is a 50% chance a baby will die, and all kinds of other outrageous statements, all from the person *answering the phone*.”

Resources for processing traumatic births and losses

A dear woman contacted me.  15 months after her cesarean, it was still hard for her to read my posts without crying.  This simply broke my heart.  She is not alone.  There are many women who carry the grief and pain of their traumatic vaginal or cesarean births or the loss of their baby.  Every. Day.

So I asked on Facebook for resources for women who are in the midst of the processing and grieving.  Here is the list.  If you know of more, whether they are on-line or in person groups, for free or a fee, please leave a comment.

None of these groups or individuals have been checked out or endorsed by VBAC Facts.  This is simply a list of resources for you to check out.

It saddens me to say this but there are individuals and groups who find and share the stories of loss moms in order to berate them.  Please be careful when sharing information on the internet as anything you post on-line can be easily shared with others outside your closed/private internet group.  There is no such thing as privacy on the internet.  Being anonymous and not providing your home address or identifying information are ways to get around this.

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Stillbirthday has a comprehensive list of immediate resources (like crisis hotlines, books, and websites) and long term resources (like workshops and retreats.)

There are support groups for women who have experienced uterine rupture. Here is a list: http://www.honoredbabies.org/resource-center/grief-support.htm

I know there is one local to me (Renfrew county, Ontario, Canada) but it’s not available through the Internet.

Solace for Mothers

Barbara-ann Horner: I volunteer for Postpartum Support International and most moms who call experience a traumatic birth message me i can find more resources or chat if you’d like

ICAN, the International Cesarean Awareness Network, is awesome. You can go to their website ican-online.org and there’s a ton of info and local support groups to join. I joined one after experiencing a very traumatic cesarean section and it’s been so helpful in the healing process.

The Dunamas Center does a lot of work with birth trauma.

Merrell Holliman-Carlson: I am a leader of the Ocala Birth Network, we have a FB page and also monthly meetings, we are in Marion County, FL but have several online members who are out of state, we provide information and resources for expectant moms as well as a ‘safe’ outlet for traumatized moms. A lot of us have dealt with unnecesareans and bad inductions, some have VBAC’d and others hope to. You are MORE than welcome!

http://www.humanizebirth.org/ has some resources and you can contact the ladies running the page and have our story added to the campaign as well, there is also a facebook page and group for women to share their stories and talk to others who have been through traumatic birth events as well

BEBA clinic (Ray Castelino)

Babycenter has a “Disappointing Birth Experiences” board….

Online, I recently found the Birth Trauma Association. They’re wonderful! They also have a group on Facebook.

Jamie Bodily: I offer individual sessions in the St. Louis area but no group at this point.

I know Nancy Wainer offers group workshops in the Massachusetts  area. Janel Mirendah also works in group or individually on birth trauma, she did a workshop when she came to do a screening of The Other Side of the Glass.

Yes, Mother to Mother! “Mother to Mother – Postpartum Depression Support St. Louis.  Mother to Mother provides telephone support and encouragement to women with postpartum adjustment disorder (PPAD). Mother to Mother is the only service of its kind in the St. Louis metropolitan area. We serve all women in the state of Missouri and parts of Illinois, free of charge.”

@backline is a great resource. They have a free talkline for birth or miscarriage trauma.

Birthing From Within Birth Story. Listening is amazing.

Birthtalk in Australia!!! They do free group sessions in Australia (Queensland) & personal sessions (also via Skype for international). They are the best

There’s a Birth Crisis group, as well as a CBAC group out there, I know both those group owners and they work hard to keep it safe.

A lady I know who had a stillbirth at 36 weeks is on a site called www.facesofloss.com. “Faces of Loss, Faces of Hope: Putting a face on miscarriage, stillbirth and infant loss.”

Geneviève Prono: I have been helping women heal from a traumatic and difficult birth and prepare for another birth, for twenty years. I do in person and group sessions by skype and am currently writing a book and putting some programs in place. The site in French (apparently google translates it) www.chrysalidefrance.com. What brought me to this three c-sections followed by three VBACs.

Tiffany Hoffman: I do individual birth trauma resolution as well as those who have had difficult or disappointing birth experiences. I have also created a birth trauma workshop, so that women who don’t live here can travel for a weekend intensive to start the healing process. They also learn several ways to continue processing their experience and feelings on their own. My website is www.sacredbirthspace.com

Linda Llone Hinchliffe: Our Birth Choices group offer emotional support to anyone who needs it…

Birth Matters of Fort Wayne, IN offers a Traumatic Birth Healing/Healing for Birth class several times a year. From personal experience – it’s just what my husband and I needed.

There’s a group in Virginia called Mothers Healing Together.

Lexi Abeln: I facilitate a free support group in Camp Hill, PA called Birthlight.

Birth after Caesarean Support and Information Group in Townsville, Queensland, Australia

Canaustralia.net — Empowering birthing women to make informed decisions about childbirth after caesarean

There’s a yoga studio local to me in Pittsburgh, PA that does a traumatic birth workshop.

Precious sleeping angles – group on Facebook

Stillbirth support – group on Facebook

Resources for men

Grieving fathers – group on Facebook

You can also following the two threads I posted on my Facebook profile page and fan page about this for more information or to contact the individuals above who offer counseling.

Do you have a resource you would like to add to the list? Please include it in the comments.

Induction is wrong, wrong, wrong… wait, what?

I hear all the time how induction in VBAC is contraindicated. This is false. This is the kind of misinformation that materializes when we demonize all induction rather than specifying that elective inductions are not worth the increased risks.

It’s important to use clear, specific language when we talk about birth because there is a lot of confusion among moms, advocates, doulas, and health care providers about VBAC and induction. When I point out the lack of clarity many people have on the topic to “anti-induction advocates” (for the lack of a better term), they respond with the fact that their focus is warning moms about elective inductions, which is absolutely needed. And they genuinely believe that people are aware of the distinction between elective and medically-indicated inductions. However, that has not been my experience, in fact it’s been quite the opposite.  There are many people who don’t understand the why, when, and how of inducing VBACs and that is impacting the abilities of women to make informed decisions and exercise their right of patient autonomy.

First, you can induce VBACs

To be clear, medically indicated induction in a VBAC is not contraindicated! Yet, many, many, many people persist that it is citing ACOG (1) and the Pitocin insert (2). ACOG clearly says in their latest VBAC guidelines (3) that “induction remains an option” in a mom planning a VBAC via Pitocin or Foley catheter. The Pitocin drug insert (2) does state, “Except in unusual circumstances, oxytocin [Pitocin] should not be administered in the following conditions” and then lists “previous major surgery on the cervix or uterus including cesarean section.” However, despite conventional wisdom, a prior cesarean is not listed under the contraindications section.  Further, the drug insert recognizes the value of individualized care:

The decision [to use Pitocin in a woman with a prior cesarean] can be made only by carefully weighing the potential benefits which oxytocin can provide in a given case against rare but definite potential for the drug to produce hypertonicity or tetanic spasm.

This is in line with ACOG’s latest VBAC recommendations (3) where they say, “Respect for patient autonomy supports the concept that patients should be allowed to accept increased levels of risk…” So this is information a woman can use to make an informed decision if she is faced with a medical condition that requires sooner rather than later delivery of her baby, but not necessarily in the next 15 minutes.  To induce, have a cesarean, or wait for spontaneous labor when facing a true medical issue is a decision for the mom to make in conjunction with her supportive heath care provider based on the evidence of her risks, benefits, and options.

My point is, if you just read bits and pieces of the insert, or a few key quotes from an anti-induction article, you are going to miss the full story; much like how reading the full text of a study gives you context and details that you lack by just reading the abstract.  Read my article (4) for more information on inducing VBACs.

Yet, misinformation persists

Ok, so now you know that induction remains an option per the Pitocin insert, ACOG, and respect for patient autonomy.  Now check out these quotes, from the last couple days, from six different people. If I were to keep a list of comments like these, just referring to induction and VBAC for a month, I would literally have dozens if not hundreds.  Misinformation is rampant:

“pitocin is CONTRAINDICATED for vbac bc the risk of uterine rupture”

“I thought it was unsafe to use pitocin with a vbac.”

“vbac should never be induced!”

“It is unsafe for prev surgical births. It says so in the PDR, or at least it did.”

“Not supposed to induce with a VBAC.”

“Never never never have an induction, especially with any kind of vbac!! Oh my goodness. it drastically raises your chances of uterine rupture!! Holy toledo. If you don’t know the risks involved with inductions, especially in vbacs, don’t offer the advice! Smh. Pitocin is completely contraindicated for vbacs, I’m pretty sure it even says that on the insert.”

“Are you actually trying to argue that induction of labour on a VBAC is OK???WOW…that is not evidence based AT ALL. Every study that has been done comparing the two shows a clear rise in risk associated with induction of labour and rupture. I am ALL for choice no matter the case, but I think every women has a right to INFORMED choice and you clearly are not. UNLIKE.”

Note the tone of these comments.  There is no room for negotiation.  Do you get the sense that they are just referring to elective inductions or all inductions? The message I get from these comments is loud and clear: these individuals believe that VBACs should not be induced. Period.

“Well, I would choose an induction…”

What is especially ironic is that some women who speak this way in public, privately share with me, that they themselves would opt for an induction over a repeat cesarean. Though do you see room for that option in any of the comments above?  They preserve that choice for themselves and yet pound the party line that all induction is always wrong and publicly deny that option to other women… for what purpose?  To maintain ad nauseam that induction is an evil, evil thing? Yes, apparently that is the case.

The last person’s comment was in response to me sharing my article (4) and saying that induction with medical indication does and should remain an option for moms planing VBACs.  Her reply equates my actions of sharing this reality with advocating against informed choice. How is keeping women in the dark about their options supporting the notion of informed consent? That faulty logic deserves a capitalized “WOW” with excessive exclamation points.

This is not the first person to say something like this to me. People so staunchly (and incorrectly) maintain that VBACs should never be induced because they have been indoctrinated to believe that induction is always wrong, it always introduces more risks.

More risk than what?

But the key question is: More risk than what? That is always what women should ask.

More risk than having a fetal demise before labor, partial placental abruption, or serious uterine infection and remaining pregnant? OK, so let’s say that is the truth.

Then any time any scarred woman has any of those medical conditions as well as those listed in my article (4), and they agree that remaining pregnant has higher risks that delivering the baby, they should have a cesarean, right? Even if vaginal birth remains an option, albeit via an induced labor?  Even if baby needs to be born sooner rather than later, but not necessarily in the next 15 minutes?  Those moms shouldn’t have a choice, they shouldn’t have a say, they should just go straight to cesarean?  How is that preserving choice for women?

Don’t misrepresent the facts

That is what these (extreme) “induction is wrong” proponents don’t understand. Induction has its place, as does every other medical intervention, and if you want to go straight to cesarean, rather than having a medically-indicated induction, fine.

But don’t misrepresent the truth to other women.

Don’t misrepresent what ACOG (1) or the Pitocin insert (2) says.

Don’t misrepresent the risks of Pitocin by listing a mish-mash of complications with no rates.  (How are women to understand the risks if you don’t tell them how frequently those emergencies occur?)

Don’t say things that can be disproved with a single mouse click like inducing VBACs is against evidence based medicine.

Don’t undermine a woman’s legal right to autonomy (5) by perpetuating the myth, that all induction, including when medically indicated, is wrong, wrong, wrong.

Don’t dictate specific actions while withholding facts that would enable women to make their own decisions, even if they are different that what you would prefer.

Medically indicated induction = choice

People don’t appreciate that standing for medically indicated induction is standing for women to have a choice: induction vs. repeat cesarean. Without induction, there is no choice when a valid medical reason presents. By eliminating the option of induction, women are mandated to the increasing risks (6) of repeat cesarean. And yet people who persist in their agenda say things like this to me (naturally, the following was asserted after I shared my article (4) and they didn’t read it),

Does inducing a VBAC increase the chance of rupture??? YES. Does a women, and should a women have the right to choose that irregardless of that FACT??? YES. Is the most important thing informed consent?? I believe it is.

Clear language provides clarity

So if people think that, then they should use clear, unambiguous language like, “Induction remains an option when a medical indication presents” or “Elective induction isn’t worth the increased risks” rather than flat out declaring “pitocin is contraindicated” (false) and claiming that induction in a VBAC is not evidenced based (false) as this very commenter did earlier in the thread. If someone maintains that it should be a woman’s choice, then they should share substantiated facts, context, statistics, and references, not erroneous blanket statements.

Women can make informed decisions only when they are informed

To provide information supports choice and informed consent. To dictate a specific action while misrepresenting the evidence eliminates choice and prohibits informed consent . I do not dictate to other women what they should do (7).

If you read my article (4), you will see that I list the reasons for medically indicated induction as well as provide an extensive review of studies illustrating the increased risk of uterine rupture. I do this rather than simply saying, “the risk of rupture is higher and thus you shouldn’t do it” because providing facts with context puts the choice in the hands of the mom, rather than me (or anyone else) dictating to her what she should do.

Some women will accept that higher rate of rupture in order to have a vaginal birth. Others will choose to accept the risks of a repeat cesarean section. Those are choices for women to make for themselves based on facts, not on misrepresentations of what other women (incorrectly) think is contraindicated.

“Induction is wrong” & patient autonomy

People who advocate that “induction is always wrong” don’t understand the implications of their assertions. By arguing against inductions, which in the minds of many include medically indicated inductions since no distinction is made, they are effectively advocating for more cesareans and against informed consent and patient autonomy. The mission of VBAC Facts is to make hard-to-find, interesting, and pertinent information relative to post-cesarean birth options easily accessible to the people who seek it. I advocate for informed consent and patient autonomy and that is why I share evidence (4) rather than dictating what others should do. I only hope that this reasoning and evidence based position spreads because there are far to many people out there who persist in the inaccurate philosophy that inductions in a VBAC are always wrong even in the face of a valid medical reason. This does not support choice, women, or birth.

I profusely apologize for the excessive underlining in this article, but I think you will agree, that it was absolutely necessary.

Sources

1. Kamel, J. (2010, Jul 21). ACOG issues less restrictive VBAC guidelines. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/21/acog-issues-less-restrictive-vbac-guidelines/

2. JHP Pharmaceuticals LLC. (2012, Sept). Pitocin official FDA information, side effects and uses. Retrieved from Drugs.com: http://www.drugs.com/pro/pitocin.html

3. American College of Obstetricians and Gynecologists. (2010). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology , 116 (2), 450-463. Retrieved from Our Bodies Our Blog: http://www.ourbodiesourblog.org/wp-content/uploads/2010/07/ACOG_guidelines_vbac_2010.pdf

4. Kamel, J. (2012, May 27). Myth: VBACs should never be induced. Retrieved from VBAC Facts: http://vbacfacts.com/2012/05/27/myth-vbacs-should-never-be-induced/

5. Kamel, J. (n.d.). Legal stuff. Retrieved from VBAC Facts: http://vbacfacts.com/category/vbac/legal-stuff

6. Kamel, J. (2012, Dec 9). Why cesareans are a big deal to you, your wife, and your daughter. Retrieved from VBAC Facts: http://vbacfacts.com/2012/12/09/why-cesareans-are-a-big-deal-to-you-your-wife-and-your-daughter/

7. Kamel, J. (2012, Dec 7). Some people think I’m anti-this/ pro-that: My advocacy style. Retrieved from VBAC Facts: http://vbacfacts.com/2012/12/07/some-people-think-im-anti-thispro-that-my-advocacy-style/

 

Why cesareans are a big deal to you, your wife, and your daughter

surgery-surgical-instrumentsI hear a lot, “What’s the big deal about cesareans? What difference does it really make if you have a cesarean?” Of course, if a cesarean is medically necessary, then the benefits outweigh the risks. But in the absence of a medical reason, the risks of cesareans must be carefully considered.

“Once a cesarean, always a cesarean”

If a woman has a cesarean, she is very likely to only have cesareans for future births. This is because while 45% of American women are interested in the option of VBAC (1), 92% have a repeat cesarean (2). Let me say that another way. Only 8% of women with a prior cesarean successfully VBAC.

One might interpret this statistic to mean that planned VBACs often end in a repeat cesarean. However, VBACs are successful about 75% of the time (3-7). The VBAC rate is so low because of the women interested in VBAC, 57% are unable to find a supportive care provider or hospital (1). And I would argue further that even among the women who have a supportive care provider, those women are so bombarded by fear based misinformation masquerading as caring advice from friends and family, they have no chance.  It is shocking to learn how ill-informed both women planning VBACs and repeat cesareans are about their birth options even upon admission to the hospital.  There is a fundamental gap in our collective wisdom about post-cesarean birth options.

Cesareans make subsequent pregnancies riskier

What’s the big deal, right? Who cares if you have a cesarean without a medical reason?

Forget about the immediate risks to mom and baby that cesareans impose. Just set that all aside for a moment.  Much of the risk associated with cesareans is delayed.  Most people are not aware of the long term issues that can come with cesareans and how these complications impact the safety of future pregnancies, deliveries, and children.

It is a well-established fact that the more cesareans a woman has, the more risky subsequent pregnancies and labors are regardless if the mom plans a VBAC or a repeat cesarean.  This was discussed at great lengths during the 2010 National Institutes of Health VBAC conference and was one of the reasons why ACOG released their less restrictive VBAC guidelines later that same year.

Many moms chose repeat cesareans because they believe cesareans are the prudent, safest choice. The fact that cesareans, of which over 1,000,000 occur in the USA each year, increases the complication rates of future pregnancies is often not disclosed to women during their VBAC consult.

A four year study looking at up to six cesareans in 30,000 women reported a startling number of complications that increased at a statistically significant rate as the prior number of cesareans increased:

The risks of placenta accreta [which has a maternal mortality of 7% and hysterectomy risk of 71%], cystotomy [surgical incision of the urinary bladder], bowel injury, ureteral injury [damage to the ureters – the tubes that connect the kidneys to the bladder in which urine flows – is one of the most serious complications of gynecologic surgery], and ileus [disruption of the normal propulsive gastrointestinal motor activity which can lead to bowel (intestinal) obstructions], the need for postoperative ventilation [this means mom can’t breathe on her own after the surgery], intensive care unit admission [mom is having major complications], hysterectomy, and blood transfusion requiring 4 or more units [mom hemorrhaged], and the duration of operative time [primarily due to adhesions] and hospital stay significantly increased with increasing number of cesarean deliveries (8).

Because the growing likelihood of serious complications that comes with each subsequent cesarean surgery, including uterine rupture, this study concluded,

Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery (8).

This is because the risks of placenta accreta and previa in particular increase at a very high rate after multiple cesareans (9).

The largest prospective report of uterine rupture in women without a previous cesarean in a Western country,” concurred:

Ultimately, the best prevention [of uterine rupture] is primary prevention, i.e. reducing the primary caesarean delivery rate. The obstetrician who decides to perform a caesarean has a joint responsibility for the late consequences of that decision, including uterine rupture (10).

“Well, I just plan on having two kids…”

Unfortunately, many women don’t think about these future risks until they are pregnant again. And we all know the great difference between intended and actual family size.

According to the CDC, 49% of American pregnancies are unintentional (11). Thus, these theoretical risks quickly and suddenly become a reality for hundreds of thousands of American women every year. How women birth their current baby has real and well-documented implications and risks for their future pregnancies, children, and health.

VBAC bans and emergency response

In light of these increasing risks, VBAC bans do not make moms safer (12). Hospitals are either prepared for obstetrical complications, like uterine rupture in moms who plan VBACs and placenta accreta, previa, and cesarean hysterectomies among moms who plan repeat cesareans, or they are not. It is hard to understand how hospitals can claim that they are simultaneously capable of an adequate response to cesarean-related complications and yet they are unable or ill-equipped to respond to complications related to vaginal birth after cesarean.  Especially in light of the fact that we know motivated hospitals currently offer VBAC even in the absence of 24/7 anesthesia (13).

A recent Wall Street Journal article discusses how hospitals are trying to create a standard response to obstetrical emergencies:

The CDC is funding programs in a number of states to establish guidelines and protocols for improving safety and preventing injury.  And obstetrics teams are holding drills to train doctors and nurses to rapidly respond to maternal complications. They are using simulated emergencies that include fake blood, robots that mimic physiologic states, and actresses standing in as patients (14).

Because hospitals vary so greatly in their ability to coordinate a expeditious response to urgent situations,

Vivian von Gruenigen, system medical director for women’s health services at Summa Health System in Akron, Ohio, advises that pregnant women discuss personal risks with their doctor and ask hospitals what kind of training delivery teams have to respond in an emergency. ‘People think pregnancy is benign in nature but that isn’t always the case, and women need to be their own advocates,’ Dr. von Gruenigen says.

Impact of VBAC on future births

Counter the increasing risks that come with cesareans to the downstream implications for VBAC. After the first successful VBAC, the future risk of uterine rupture, uterine dehiscence, and other labor related complications significantly decrease (15). Thus, family size must be considered as VBAC is often the safer choice for women planning large families.

Bottom line? I defer to two medical professionals and researchers:

“There is a major misperception that TOLAC [trial of labor after cesarean] is extremely risky” – Mona Lydon-Rochelle PhD, MPH, MS, CNM (16-17).

In terms of VBAC, “your risk is really, really quite low” – George Macones MD, MSCE (16-17).

Women deserve the facts

Women are entitled to accurate, honest data explained in a clear, easy to understand format (18). They don’t deserve to have the risks exaggerated by an OB who wishes to coerce them into a repeat cesarean nor do they deserve to have risks sugar-coated or minimized by a midwife or birth advocate who may not understand the facts or whose zealous desire for everyone to VBAC clouds their judgement (19-20).

If you would like to get the opinions of actual VBAC supportive medical professionals who support a woman’s right to informed consent, there are several obstetricians and midwives who you can talk to on the VBAC Facts Community.

Take home message

Cesareans are not benign and the more you have, the more risky your future pregnancies become regardless of your preferred mode of delivery.

Almost half of the pregnancies in America are unintentional.

If hospitals can attend to cesarean-related complications, they can attend to VBAC-related complications.

_________________________________________________

1. Declercq, E. R., & Sakala, C. (2006). Listening to Mothers II: Reports of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection. Retrieved from Childbirth Connection: http://www.childbirthconnection.org/article.asp?ck=10068

2. Osterman, M. J., Martin, J. A., Mathews, T. J., & Hamilton, B. E. (2011, July 27). Expanded Data From the New Birth Certificate, 2008. Retrieved from CDC: National Vital Statistics Reports: http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_07.pdf

3. Coassolo, K. M., Stamilio, D. M., Pare, E., Peipert, J. F., Stevens, E., Nelson, D., et al. (2005). Safety and Efficacy of Vaginal Birth After Cesarean Attempts at or Beyond 40 Weeks Gestation. Obstetrics & Gynecology, 106, 700-6.

4. Huang, W. H., Nakashima, D. K., Rumney, P. J., Keegan, K. A., & Chan, K. (2002). Interdelivery Interval and the Success of Vaginal Birth After Cesarean Delivery. Obstetrics & Gynecology, 99, 41-44.

5. Landon, M. B., Hauth, J. C., & Leveno, K. J. (2004). Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery. The New England Journal of Medicine, 351, 2581-2589.

6. Landon, M. B., Spong, C. Y., & Tom, E. (2006). Risk of Uterine Rupture With a Trial of Labor in Women with Multiple and Single Prior Cesarean Delivery. Obstetrics & Gynecology, 108, 12-20.

7. Macones, G. A., Cahill, A., Pare, E., Stamilio, D. M., Ratcliffe, S., Stevens, E., et al. (2005). Obstetric outcomes in women with two prior cesarean deliveries: Is vaginal birth after cesarean delivery a viable option? American Journal of Obstetrics and Gynecology, 192, 1223-9.

8. Silver, R. M., Landon, M. B., Rouse, D. J., & Leveno, K. J. (2006). Maternal Morbidity Associated with Multiple Repeat Cesarean Deliveries. Obstetrics & Gynecology, 107, 1226-32.

9. Kamel, J. (2012, Mar 30). Placenta problems in VBAMC/ after multiple repeat cesareans. Retrieved from VBAC Facts: http://vbacfacts.com/2012/03/30/placenta-problems-in-vbamc-after-multiple-repeat-cesareans/

10. Zwart, J. J., Richters, J. M., Ory, F., de Vries, J., Bloemenkamp, K., & van Roosmalen, J. (2009, July). Uterine rupture in the Netherlands: a nationwide population-based cohort study. BJOG: An International Journal of Obstetrics and Gynaecology, 116(8), pp. 1069-1080. Retrieved January 15, 2012, from http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02136.x/full

11. National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. (2012, Apr 4). Unintended Pregnancy Prevention. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/index.htm

12. Kamel, J. (2012, Mar 27). Just kicking the can of risk down the road. Retrieved from VBAC Facts: http://vbacfacts.com/2012/03/27/just-kicking-the-can-of-risk-down-the-road/

13. Kamel, J. (2010, July 22). VBAC ban rationale is irrational. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/22/vbac-ban-rationale-is-irrational/

14.  Landro, L. (2012, Dec 10). Steep Rise Of Complications In Childbirth Spurs Action. Retrieved from Wall Street Journal: http://online.wsj.com/article/SB10001424127887324339204578171531475181260.html?mod=rss_Health

15. Mercer BM, Gilbert S, Landon MB. et al. Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstet Gynecol. 2008 Feb;111(2):285-291. Retrieved from: http://journals.lww.com/greenjournal/Fulltext/2008/02000/Labor_Outcomes_With_Increasing_Number_of_Prior.6.aspx

16. NIH Consensus Development Conference. (2010). Vaginal Birth After Cesarean: New Insights. Bethesda, Maryland. Retrieved from http://consensus.nih.gov/2010/vbac.htm

17. Kamel, J. (2012, Apr 11). The best compilation of VBAC research to date. Retrieved from VBAC Facts: http://vbacfacts.com/2012/04/11/best-compilation-of-vbac-research-to-date/

18. Kamel, J. (2012, Dec 7). Some people think I’m anti-this/ pro-that: My advocacy style. Retrieved from VBAC Facts: http://vbacfacts.com/2012/12/07/some-people-think-im-anti-thispro-that-my-advocacy-style/

19. Kamel, J. (n.d.). Birth myths. Retrieved from VBAC Facts: http://vbacfacts.com/category/vbac/birth-myths

20. Kamel, J. (n.d.). Scare tactics. Retrieved from VBAC Facts: http://vbacfacts.com/category/vbac/scare-tactics/

When all people can see is black or white

The way I do things

VBAC Facts communicates differently than many others who speak or write about birth. Rather than advocating for a specific decision, I advocate for access to information. Specifically, the mission of VBAC Facts is to close the gap between what the best practice guidelines from ACOG and the NIH say about VBAC and repeat cesarean and what people generally believe.

In meeting this goal, VBAC Facts makes hard-to-find, interesting, and pertinent information relative to post-cesarean birth options easily accessible to the people who seek it. VBAC Facts does not advocate for a specific mode of delivery, birth attendant or birth location. Because of this stance, sometimes people are a little confused. They are accustomed to outspoken advocates (arguing for either the pro or con) urging them to have a certain type of birth at a prescribed location with a specific type of birth attendant – or none at all.

VBAC Facts is occasionally labeled as pro-this/ anti-that because I periodically will not agree with someone. If someone supplies incorrect statistics, uses faulty logic, or uses the dreaded terms “always/never,” I pipe up and give my perspective and a source corroborating my stance.  You may (or may not) be surprised how often this interjection is interpreted as anti- or pro-[insert method of birth, place of birth or type of birth attendant here.]

Perhaps people interpret my realistic/ practical approach to things as anti-_________.  I like to debunk myths. I like to question the conventional wisdom. This can frustrate people because these myths give them (misplaced) confidence. Conventional wisdom can be confused for evidence because “everyone knows _____ is true.”

I acknowledge the various risks and benefits that come with our birth choices. I do this because I think that women are intelligent enough to hear “these are the risks and benefits of XYZ” rather me dictating “make XYZ choice.”

I also tend to avoid the often hollow sounding, “It will all be fine” or “I had a VBAC, so should every woman!”  To some people, that comes off as anti-this/pro-that… but for me, it’s a fair look at our choices.

I think sometimes people start to look at a specific mode of birth/ birth location/ type of birth attendant with rose-colored glasses.  They try to minimize the risks associated with their “choice of choice” in an attempt to advocate for others to make similar decisions whether that is VBAC, repeat cesarean, home or hospital birth.  (Everyone has an agenda!!)

But minimizing risks deprives women of their right to informed consent and that is really no different than individuals who exaggerate risk. I don’t advocate for women to birth a certain way in a certain location.

A big part of my philosophy is based on the fact that I have a website and a large readership.  I don’t want anyone to ever come back to me after a bad outcome and say, “You misled me.”  I feel an obligation to be honest and truthful about the pros and cons of options as well as the quality and quantity of research available to us.  Women often feel misled by their HCPs [health care providers].  I don’t want to be part of that misinformation machine.

My mission is simple: to make hard-to-find, interesting, and pertinent information relative to post-cesarean birth options easily accessible to the people who seek it.

I do this because I think the information speaks for itself.  It doesn’t need a cheerleader!  It doesn’t need someone to stretch the truth!  Just someone to say, “Read this!”

My tips for birth advocates

Someone recently posted in a group asking how they can get involved with birth advocacy. Other members and myself directed them to a variety of organizations like ICAN, Improving Birth, the National Advocates for Pregnant Women, the ACLU, and Human Rights in Childbirth.

There are many roads to the same destination. You can advocate right now by going on message boards and simply pointing people to accurate information when they ask questions. Sometimes all they need is to see a little bit that suggests what they have accepted as “truth” is the opposite of what major medical organizations, public health professionals, and medical researchers support and recommend.

Take home message

I have said many times, “Birth is not one size fits all.” As ACOG says, two women can look at the exact same information and make very different choices. There is not a Right or Wrong decision for all women, just a right or wrong decision for a specific woman. That is her decision to make based on information, not bullying or hysteria.

 

Evening primrose oil: “Don’t use it if you are pregnant?”

Many moms and midwives use evening primrose oil (EPO) for cervical ripening. So I was absolutely shocked at the complete lack of evidence on the effectiveness and safety of EPO use among pregnant women.

There are only two studies that examine the oral use EPO and its ability to ripen the cervix during pregnancy.  There are no studies on the vaginal use of EPO. In short, there is insufficient clinical evidence documenting the risks and benefits of EPO and without that information,  the question is, should pregnant women take it?

The available evidence on EPO

Paula Senner gives an excellent review of the first study (Dove 1999) in her Quantitative Research Proposal entitled, “Oral Evening Primrose Oil as a Cervical Ripening Agent in Low Risk Nulliparous Women” (emphasis mine),

The study group consisted of 54 women who took oral evening primrose oil in their pregnancy (500 mg three times a day starting at 37 weeks gestation for the first week of treatment, followed by 500 mg once a day until labor ensued), and the control group was composed of 54 women who did not take anything. Antepartum and intrapartum records of all women were reviewed focusing on the above identified criteria.

Results showed no significant differences between the evening primrose oil group and the control group on age, Apgar score, or days of gestation (P>.05)… This retrospective chart review showed no benefit from taking oral evening primrose oil for the purpose of reducing adverse labor outcomes or for reduction of length of labor.

The study’s abstract gives us more details on the its findings (emphasis mine):

Findings suggest that the oral administration of evening primrose oil from the 37th gestational week until birth does not shorten gestation or decrease the overall length of labor. Further, the use of orally administered evening primrose oil may be associated with an increase in the incidence of prolonged rupture of membranes, oxytocin [Pitocin] augmentation, arrest of descent, and vacuum extraction.

The second study found that while women who took EPO experienced a greater degree of cervical ripening, that did not result in a shorter pregnancy or labor: “There was no significant difference in the interval from onset or end of treatment to onset of labor between the two groups” (Ty-Torredes, 2006).

So one study on oral EPO found that it doesn’t work as we thought it did and it offers considerable risks.  The other study found that it does result in some cervical ripening, but that did not translate into shorter pregnancies or labors.

As a result, a December 2009 article published in the American Family Physician recommended,

The use of evening primrose oil during pregnancy is not supported in the literature and should be avoided.

Medline Plus, a website published by the US National Library of Medicine and the National Institutes of Health, published an April 2012 article on EPO.  Medline echoes the sentiments of the American Family Physician article when it said there was,

insufficient evidence to rate effectiveness for [EPO during pregnancy and] research to date suggests that taking evening primrose oil doesn’t seem to shorten labor, prevent high blood pressure (pre-eclampsia), or prevent late deliveries in pregnant women… [Further,] taking evening primrose oil is POSSIBLY UNSAFE [their emphasis] during pregnancy.  It might increase the chance of having complications. Don’t use it if you are pregnant [emphasis mine.]

Bleeding issues could complicate cesareans

Research on the use of EPO for other aliments among non-pregnant people has suggested there could be a possible association between the use of EPO and bleeding problems during surgery.

As a result, Medline recommends that people don’t use it at least 2 weeks before a scheduled surgery.

This poses a special problem for women using EPO during the last weeks of pregnancy. Since we cannot predict who will have a vaginal birth and who will have a cesarean, it is important to consider that EPO could contribute to hemorrhage during a cesarean and possibly even during a normal vaginal delivery.

We just don’t know because there is a lack of data.

Dosages and mode of delivery

Another hole in the research and our knowledge relates to dosage.

I see women reporting an incredible range of dosages on the internet. What is safe?

There are no clinical studies documenting how much women should take. Maybe X dose of EPO is good, but Y dose introduces XYZ risks.

How long should women take EPO? The last month of pregnancy? The last two weeks?  (Remember, we just read how there is a possible bleeding issue.)

Should they take it twice a day or once a day? Does the body absorb or metabolize EPO differently if it is administrated vaginally or orally?

We just don’t know the answers to these questions.

What about our bodies’ innate ability to birth?

It comes down to the fundamental question: Do our bodies need something to help us go into labor?

Many natural birth advocates reject the routine use of Pitocin augmentation during labor because they say our bodies know how to birth. Yet it’s often women from this same mindset that use EPO.

Either pregnant people as a whole need something to help them go into labor – whether that is EPO or Pitocin – or they don’t.

Are we less leery of EPO because it comes from a flower? Because it’s not produced by “big pharma?”

Because midwives suggest it more than OBs?

Because we can purchase it over the counter? Because it’s a pill, not an injection? Because we can administer it to ourselves in the comfort of our home?

Because it is used so routinely that no one questions it? Or is it simply because we all assume since everyone takes it, the evidence must be on the side of EPO?

On (the lack of) evidence: Holding ourselves to the same standard

When I have shared the lack of evidence on EPO’s ability to ripen cervi or prepare a woman’s body for labor, sometimes women reply with “But there is no evidence to suggest it won’t help either.”

American OBs used this same rationale when they induced scarred moms with Cytotec in the 1990s. There were no published medical studies on Cytotec induction in scarred women, so we didn’t know the risks and benefits. But people used it because we knew it caused uterine contractions. What can go wrong, right?

But the problem is, when there is a lack of clinical evidence on large populations of women, we are sometimes surprised with dire outcomes that no one could have predicted as was the case of Cytotec.

We cannot look back at that period and think, “How could they have done that” when we are now doing the same thing with EPO: using a chemical without evidence of its benefits and harms.

Some rail against “the medical system” because Pitocin/ultrasound/etc hasn’t been “proven safe,” yet we use EPO with no evidence that it does what we think it does, no evidence that it is safe, and the limited evidence we do have says that it’s associated with a variety of complications.

As Hilary Gerber D.O. aka Mom’s Tin Foil Hat says,

As someone who spent many years in the natural supplements industry, I agree that we need to hold natural products to the same scrutiny.

Also, most EPO is extracted with solvents like hexane. I am much more supportive of natural products or interventions that have been used in that form or method for generations (e.g. sexual intercourse at term, ingesting a substance that is a common food item, etc) than a chemically extracted, concentrated, unstudied substance.

Anecdote vs. evidence

OBs who used Cytotec on women with a prior cesarean in the 1990s inevitably would have said, “I haven’t had a bad outcome yet,” and I suspect that many people who use EPO now would say the same thing.

When we have one woman who used EPO and had an arrest of descent, do care providers recognize that this could be as a result of the EPO?

When we have one women who used EPO and it worked as expected, how can we determine her labor progressed because of the EPO?

When you have a small sample size, it’s hard to make a connection.  It’s even more difficult to connect EPO to it’s possible list of complications when not many care providers are aware of the lack of evidence on EPO and the findings of this one lone study.

Is our limited experience, with relatively few patients, without meticulous record keeping that can detect patterns across groups of patients, sufficient evidence?  I don’t think so.

We would likely need thousands of women in order to create a sample size powerful enough to detect – or rule out – common and more rare EPO complications in addition to answering the many questions I posed above.

Take away message

I’m not saying to use EPO or not.

I’m simply pointing out how little we know about this commonly used substance and questioning if that should make a difference in how we view and/or use it.

There is limited evidence on EPO’s ability to ripen the cervix and aid with labor.  We have two studies on the oral use of EPO that looked at this question and none on the vaginal use of EPO among pregnant women.

One study found that EPO doesn’t ripen the cervix and poses considerable risk.  Another study found that EPO does ripen the cervix but those women did not go into labor sooner than the women that didn’t take EPO.

We have no evidence on an appropriate or safe dosage (if that exists).

We have no evidence on the risks and benefits of oral vs vaginal administration.

In order to make the association between EPO and complications, care providers need to be aware of the complications with which EPO may be associated.

We need more large studies to confirm or refute the notion that EPO = ripen cervix = shorter pregnancies. Without that information, we are using a product that we know very little about.

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Bayles, B., & Usatine, R. (2009, Dec 15). Evening Primrose Oil. American Family Physician, 80(12), 1405-1408. Retrieved from http://www.aafp.org/afp/2009/1215/p1405.html

Dove, D., & Johnson, P. (1999, May-Jun). Oral evening primrose oil: its effect on length of pregnancy and selected intrapartum outcomes in low-risk nulliparous women. Journal of Nurse-Midwifery, 44(3), 320-4. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10380450

Gerber, H. (2012, November 13). Facebook comments on evening primrose oil.

McFarlin, B. L., Gibson, M. H., O’Rear, J., & Harman, P. (1999, May-Jun). A national survey of herbal preparation use by nurse-midwives for labor stimulation. Review of the literature and recommendations for practice. Journal of Nurse Midwifery, 44(3), 205-16. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10380441

Medline Plus. (2012, Apr 10). Evening primrose oil. Retrieved from Medline Plus: A service of the U.S. National Library of Medicine & National Institutes of Health: http://www.nlm.nih.gov/medlineplus/druginfo/natural/1006.html

Senner, Paula. (2003, December). Oral Evening Primrose Oil as a Cervical Ripening Agent in Low Risk Nulliparous Women. Retrieved from Frontier School of Midwifery and Family Nursing, Philadelphia University: http://www.instituteofmidwifery.org/MSFinalProj.nsf/a9ee58d7a82396768525684f0056be8d/f44c26c0836acbb585256dd1006b2a22?OpenDocument

Ty-Torredes, K. A. (2006). The effect of oral evening primrose oil on bishop score and cervical length among term gravidas. AJOG, 195(6), S30. Retrieved from http://www.ajog.org/article/S0002-9378%2806%2901323-8/fulltext

Wagner, Marsden. (1999). Misoprostol (Cytotec) for Labor Induction: A Cautionary Tale. Retrieved from Midwifery Today: http://www.midwiferytoday.com/articles/cytotecwagner.asp

Myth: 50% of uterine ruptures occur before labor

Becky recently ask this question:

I read somewhere that the risk of uterine rupture is actually higher during pregnancy than during birth. Does anyone have a source for this?

Becky,

I had heard the same thing many times. However, no one who shared this stat with me could ever cite a study substantiating it. I looked and looked on and off for years and never found it.

Instead, I found “Uterine rupture in the Netherlands: a nationwide population-based cohort study” (Zwart, 2009), “the largest prospective report of uterine rupture in women without a previous cesarean in a Western country.” Zwart differentiated between uterine rupture and dehiscence and included 97% of births in The Netherlands between August 1, 2004 and August 1, 2006. All told, Zwart studied 358,874 total deliveries, 25,989 of which were TOLACs.

I have referenced Zwart before when comparing scarred vs. unscarred rupture rates and scarred vs. induced, unscarred rupture rates. Zwart also included data on pre-labor rupture which I will share with you as well.

Scar rupture before labor

Zwart reported that 9% (1 in 11) of scar ruptures (women with prior cesareans) happened before the onset of labor. When we take 9% of the overall scar rupture rate of 0.64% (1 in 156)*, we get a 0.0576% (1 in 1736) risk of a scar rupture before labor.

Unscarred rupture before labor

Zwart (2009) found 16% (1 in 6.25) of ruptures in women without prior cesareans (unscarred ruptures) occurred before labor and an overall unscarred rupture rate of 0.007% (1 in 14,286)*. When we multiply these two numbers, we get a 0.00112% (1 in 89,286) risk of uterine rupture in an unscarred uteri before labor.

Here is a table comparing the numbers:

Overall UR Rate % of URs that Occur Pre-Labor Pre-Labor UR Rate
Scarred Uteri 0.64% 9% 0.0576%
Unscarred Uteri 0.007% 16% 0.00112%

The war of the studies

Remember, all these stats are based on one study. Other studies might find different rates. However, I think Zwart would have the most accurate rates to date as it is “the largest prospective report of uterine rupture in women without a previous cesarean in a Western country.” This is an important factor because uterine rupture in an unscarred woman is an extremely rare event. We need tens of thousands of women in order to get an accurate number. The fact that Zwart includes over 300,000 unscarred women is huge.

Take home message: The risk of uterine rupture before labor is extremely rare especially for unscarred women.

* This statistic includes non-induced/ augmented, induced, and augmented labors.

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Zwart, J. J., Richters, J. M., Ory, F., de Vries, J., Bloemenkamp, K., & van Roosmalen, J. (2009, July). Uterine rupture in the Netherlands: a nationwide population-based cohort study. BJOG: An International Journal of Obstetrics and Gynaecology, 116(8), pp. 1069-1080. Retrieved January 15, 2012, from http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02136.x/full

Thoughts on VBA3+C (VBAC after three or more prior cesareans)

Note regarding “TOLAC.”  When reading from medical texts, remember that you are no longer in the land of emotion and warm fuzzies.  Rather, envision that you have been transported to another world, a clinical world, where terms like TOLAC/TOLAMC, or trial of labor after (multiple) cesareans, are used.  I don’t think that most care providers understand the emotional sting that many women seeking VBAC associate with the term TOLAC.  It’s important for women to understand the language care providers use so that they can translate TOLAC into “planning a VBAC” and not feel slighted.  You might want to read this article which describes what the term TOLAC means, how it’s used in medical research, and why it’s not synonymous with VBAC.

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A mom recently asked, “Does anyone have some facts on VBA3C?”

I provided this collection of info…

Who makes a good VBAC/VBAMC candidate?

ACOG’s 2010 VBAC recommendations affirm that VBA2C (vaginal birth after two cesareans) is reasonable in “some” women.  But they remain silent on VBAMC (VBAC after multiple cesareans.)

Some have interpreted that silence to mean that ACOG does not recommend VBAMC, yet ACOG is clear that women shouldn’t be forced to have cesareans.

Between what they say about VBA2C and who is a good VBAC candidate, we might be able to discern who might be a good VBAMC candidate.

A couple things to keep in mind while reading…

Reason for prior cesarean/history of vaginal birth.  Research has shown that women who have had cesareans for malpresentation (breech, transverse lie, etc) and/or a history of a prior vaginal delivery would have the highest VBAMC success rates.

Scar type.  Low transverse incisions (also called bikini cuts) carry the lowest risk of rupture in comparison to classical, high vertical and T/J incisions.  With the likely increased risk of uterine rupture in a VBAMC, having low transverse scars is a way to minimize that risk as much as possible.

What does ACOG say about VBAC?

In ACOG’s 2010 VBAC guidelines, it describes the qualities of a good VBAC candidate:

The preponderance of evidence suggests that most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about VBAC and offered TOLAC.  Conversely, those at high risk for complications (eg, those with previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise contraindicated are not generally candidates for planned TOLAC.  Individual circumstances must be considered in all cases, and if, for example, a patient who may not otherwise be a candidate for TOLAC presents in advanced labor, the patient and her health care providers may judge it best to proceed with TOLAC.

What does ACOG say about VBA2C?

In those same guidelines, ACOG specifically addresses VBA2C:

Given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC, and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC.  Data regarding the risk for women undergoing TOLAC with more than two previous cesarean deliveries are limited (69).

The power of context and training

How a provider approaches VBAMC depends a lot on their training as well as the support of their hospital administration. In the video below, Dr. Craig Klose discusses the merits of vaginal birth after cesarean and the various factors that may impede women obtaining VBAC.

One thing that stood out to me was Dr. Klose’s comments on VBAC after multiple prior low transverse cesareans (TLC). To sum, he says that he was taught that multiple LTCs were “no biggie” and he has attended up to VBA5C. This is the power of training and context!

ACOG guidelines, your legal rights, and “forced” cesareans

As attorney Lisa Pratt asserts, “ACOG guidelines are just that, guidelines, they are not law; while it is nice when they put out a guideline that supports your factual situation, falling outside of their recommendation does not mean you must consent to something you do not want.”  You can read in the article, “VBAC bans, exercising your rights, and when to contact an attorney.”

Further, ACOG’s 2010 VBAC guidelines also says that women cannot be forced to have cesareans even if there is a VBAC ban in place:

Respect for patient autonomy also argues that even if a center does not offer TOLAC, such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery.

You may also wish to review your options when encountering a VBAC ban and the story of a mom seeking VBA2C who was threatened with a “forced” cesarean when her OB group withdrew support at 38 weeks.

Making a plan and moving forward

Your best bet is to review your medical records with several VBAC supportive care providers and get their opinion.  Obtain a copy of your medical records and operative reports from each prior cesarean, get the names of VBAC supportive providers, and ask the right questions.

If you want to get up to speed quick on VBAC, repeat cesarean, hospital birth, home birth, and VBAC bans, the best way is via my online program, “The Truth About VBAC.”

Emotional healing from traumatic births

When I posted this on Facebook, I was surprise how many women felt alone with their emotions. I decided to share this via the website so women will know they are not alone on this journey.

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Here at VBAC Facts, I focus primarily on facts, research, and logic. But as any mom preparing for birth can tell you, information is only part of the equation. Knowing the facts is important, but it’s not the whole enchilada.

Many women are carrying the emotional baggage of their traumatic vaginal or cesarean births. How we feel about our past pregnancies and deliveries influences our outlook for our future labors. This unprocessed anger and disappointment can negatively impact how future births unfold.

I interact with post-cesarean women on a daily basis and can personally attest to how important this work is. Women often feel betrayed and lied to by the medical establishment while simultaneously wondering if their bodies are broken and incapable of birth. Without trust in our care providers and confidence in our bodies, how can we birth?

At the 2012 VBAC Summit, Christy Farr of Seeds and Weeds Coaching offered practical and easy first steps for identifying and rectifying these emotional roadblocks.

For women who care to dig a little deeper, working within a compassionate, direct, and supportive framework like Christy’s can help free them from their past and pave the way to an unhindered birth.

Connect with Christy via her website or Facebook.

Get a flavor for how Christy communicates via her session, “Towards Healing: Unpacking the Baggage of a Traumatic Birth” which is available for download.

VBAC bans, exercising your rights, and when to contact an attorney

legal-gavel-booksA mom recently left this comment and I thought many other women likely have the same question. Keep in mind that this article does discuss America law which may not be applicable to other countries.

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Jen,

First thank you for your site!

I’m under the care of an OB who practices at a hospital that does not “allow VBACs” but has stated the only way to deliver at said hospital is to show up in labor & pushing.

Quoting from your site quoting the ACOG bulletin:

The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC.

If a patient (Me 3 prior sections), presents one’s self in labor at said hospital and declines a section, the hospital then has to heed the wishes of the patient? Am I understanding this correctly? Does the hospital have the right to stop contractions and section the patient? This is what I’m hearing in my birthing community and I really cannot believe a hospital would/could do that.

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Hi Thia!

Many women believe that all one must do to prevent an unwanted cesarean is declare, “I do not consent!” While technically true, you are entitled to control what happens to your body, the reality is, it often doesn’t play out that way. A hospital does not have a legal right to perform a cesarean on you without your consent. However, it still happens either by coercion or lies and even more rarely, by court order.

I think part of the problem is, many women are not familiar with ACOG’s guidelines. As a result, they don’t understand what ACOG recommends and discourages. (For example, many women believe that VBACs should never be induced. That is false.) Women frequently take their OB’s word as the truth. However, ACOG’s recommendations are often obscured by unsupportive care providers to mimic what the care provider wants the mom to think ACOG says. In other words, unsupportive care providers want moms to think that their options are limited per ACOG and that is just not the case.

The fact that you are doing your research gives you a massive advantage over women who just take their OB’s word for it. I highly recommend you review the article I wrote about a mom who was threatened with a forced cesarean after her OB withdrew support of her planned VBA2C at 37 weeks. It includes legal and media contacts. Through the help of the ACLU, ACLU Women’s Rights Project, National Birth Policy Coalition, and National Advocates for Pregnant Women, the mom was granted a trial of labor. I use the (demonized) term TOL because the mom ultimately did have a medically necessary cesarean during labor due to a placental abruption. However, the mom was still happy that she had the opportunity to labor.

That is as much as I can say as a non-attorney. I consulted with the brilliant Lisa Pratt who is an attorney specializing in the legal issues that uniquely affect women during pregnancy and childbirth. She said,

This answer is true for all women, not just this one. If she needs legal advice specific for her situation then she should consult an attorney. You have the right to refuse any treatment you do not want. I am sure that what she is hearing is the same horror stories that we hear of a mom being harassed by the doctor and staff to consent to a c/s or threatening to seek a court order or call CPS. I know this is a scary thought to have to deal with any of these scenarios, but fear of something happening should not keep you from exerting your legal rights, unless you really are okay with what you are consenting to. You cannot assume that the staff is not going to honor your refusal. They are people just like us, some are jerks and some are ethical and will follow your refusal, but you won’t know what you are dealing with until you are in the moment. ACOG guidelines are just that, guidelines, they are not law; while it is nice when they put out a guideline that supports your factual situation, falling outside of their recommendation does not mean you must consent to something you do not want.

You can learn more about Lisa, and schedule a phone consultation if you have further questions, via her website.

Lisa presented at the 2012 VBAC Summit in Miami. Her session, “A Legal Guide to VBAC,” is available for download.

Warmly,

Jen

Does the term “TOLAC” tweak you?

On the acronym TOLAC (trial of labor after cesarean)….

Some studies break out statistics in four ways.

1. ERCS/D (elective repeat cesarean section/ delivery)
2. VBAC (vaginal birth after cesarean)
3. CBAC (cesarean birth after cesarean aka cesarean after planned VBAC)
4. TOLAC (VBAC + CBAC stats)

Because we are unable to predict who will have a VBAC or CBAC, the TOLAC stat enables us to review outcomes from a variety of angles:

  • TOLAC vs. ERCS
  • VBAC vs. ERCS
  • CBAC vs. ERCS

Some women find the TOLAC acronym offensive, because it implies “trying,” so practitioners sensitive to this may way to use the phrase “planning a VBAC.”   Understanding that TOLAC isn’t a dig at moms, but just a straightforward, objective term that care providers use, can (hopefully) take the sting out of the word.

Remember, your care provider is not your girlfriend.  They use clinical terms because that is the language of their world. They speak like clinicians because they are clinicians. All that said, providers who are aware of how the term TOLAC is received by some women use the term “planned VBAC.”

So moms, you use the language that works for you! Just remember that TOLAC is really more of a clinical term and when your provider uses it, it doesn’t necessarily mean that they are a jerk.  They just may have forgotten to code switch from clinical to sensitive language.

Moms don’t typically say, “I’m so excited for my TOLAC!” However, if you do, you might make your provider laugh and connect with them on a human level.

Two points for the person who knows how this picture is relevant…

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New VBAC documentary “Trial of Labor”

trial-of-labor-documentary

I’m so excited for the latest VBAC documentary, “Trial of Labor,” to come out!

One of the filmmakers, Robert Humphreys, attended a class I taught in Los Angeles in March 2010 so I feel a special connection to this project which has ICAN’s stamp of approval.

There is still time for you to help bring this important movie and topic to the public.  Mr. Humphreys, together with Dr. Elliot Berlin, a popular Los Angeles chiropractor, are looking to raise the last of the funds required to complete this movie.  You can contribute as little as a dollar.  As I write this, they have raised over half of their goal.  This pledge drive will continue until Friday August 24, 2012 12:00am EDT.

We need to counter the incorrect conventional wisdom that VBACs are excessively risky and cesareans are the only prudent choice.  We need to clarify that both VBACs and cesareans have REAL benefits and REAL risks.   We need to reinforce the idea that it should be up to each mom to evaluate those risks and benefits to herself, her baby, as well as her future fertility, pregnancies, mode of delivery options, and long term health.  We need to share the American Congress of Obstetricians and Gynecologists’ latest VBAC guidelines as well as the documents and lectures from the 2010 National Institutes of Health VBAC Conference.  It’s only through education will women be able to make an informed choice.

You can also help spread the word by liking the “Trial of Labor” fan page on Facebook and blogging about the movie!

False comparison: Fatal car accidents and VBAC

RETRACTION/ CORRECTION: I originally posted this article challenging the thought that you are more likely to die in a fatal car accident than during a VBAC.  I tried to crunch the numbers in the way that I felt most accurate.  However, it has been bugging me ever since because there is no accurate way to compare these two events and I should have emphasized that more. We can accurately and fairly compare the risks of VBAC to the risks of a repeat cesarean or the risks of a first time time mom.  However, it is a misleading to compare the risks of birth to non-birth events because they are to different.  While I did discuss this at great length at the end of this article, the title I originally chose (Myth: Mom more likely to die in car accident than VBAC) just continued to feed this false comparison.  I have since updated the article and title.  I apologize for any confusion I caused.

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On fatal car accident statistics: There are many, many variables that factor into an individual’s risk of dying in a car accident.  The most accurate way to calculate your risk is by miles driven.  To learn more, please refer to the National Motorists Association’s document “Understanding Highway Crash Data.” I use the figures below in order to get an average rate for the purpose of discussion.

On terminology: Read why I use the term TOLAC.

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Prepare yourself for yet another installation to the Birth Myth series.  I’ve heard this sentiment many times over the years and I’m sure you have too.   The well-meaning people who share this “statistic” simply desire to give moms seeking information on VBAC some encouragement:

If your husband is worried about you dying during a VBAC, tell him you are four times more likely to die in a car accident on your way home from work today.  Sorry if that sounds morbid, but the odds of the mother dying in a VBAC are truly minuscule.

Another article (filled with inaccurate statements, contradictions, and oodles of statistics without sources) recently making the rounds on Facebook says one of the risks of hospital birth is the 1:10,000 risk of a fatal car accident on the way to the hospital.

While these statements are very comforting, as birth myths tend to be, they are false comparisons.  We can accurately and fairly compare the risks of a TOLAC to the risks of a repeat cesarean or the risks of a first time time.  However, it is a misleading to compare the risks of birth to non-birth events.

Comparing unlike risks

Many birth advocates try to weigh the event of uterine rupture against other life events in an attempt to give context, but this is a misleading and inaccurate comparison.  Andrew Pleasant in his article entitled, Communicating statistics and risk, explains:

Try not to compare unlike risks.  For instance, the all-too-often-used comparison ‘you’re more likely to be hit by a bus / have a road accident than to…’ will generally fail to inform people about the risks they are facing because the situations being compared are so different.  When people assess risks and make decisions, they usually consider how much control they have over the risk.  Driving is a voluntary risk that people feel (correctly or not) that they can control.  This is distinctly different from an invisible contamination of a food product or being bitten by a malaria-carrying mosquito.

Comparing the risk of a non-communicable disease, for example diabetes or heart disease, to a communicable disease like HIV/AIDS or leprosy, is similarly inappropriate.  The mechanisms of the diseases are different, and the varying social and cultural views of each makes the comparison a risky communication strategy.

Take away message: Compare different risks sparingly and with great caution because you cannot control how your audiences will interpret your use of metaphor.

Comparing lifetime/annual risk to your risk of something happening over a day (or two)

Your annual or lifetime risk of something happening will often be higher than your risk of a birth related complication.  But this is because the annual risk of something measures your risk for 365 days.  The lifetime risk of something is often based on 80 years.  You are likely to be in active labor for one day, maybe two.  To compare the risk of something that happens over 1-2 days to the aggregate risk of something that could happen any day over 365 days or 80 years is unfair and confusing.

Look at something like your lifetime risk of breast cancer which is often quoted as 1 in 8.  So one could easily say, “Hey, I have a greater risk of breast cancer over my lifetime than I do have a uterine rupture!”  But, let’s look at this a bit more:

Again, I refer to Andrew Pleasant’s article, Communicating statistics and risk:

An oft-reported estimate is the lifetime breast cancer rate among women. This rate varies around the world from roughly three per cent to over 14 per cent.

In the United States, 12.7 per cent of women will develop breast cancer at some point in their lives. This statistic is often reported as, “one in eight women will get breast cancer”. But many readers will not understand their actual risk from this. For example, over 80 per cent of American women mistakenly believe that one in eight women will be diagnosed with breast cancer each year.

Using the statistic ‘one in eight’ makes a strong headline but can dramatically misrepresent individual breast cancer risk.

Throughout her life, a woman’s actual risk of breast cancer varies for many reasons, and is rarely ever actually one in eight. For instance, in the United States 0.43 per cent of women aged 30–39 (1 in 233) are diagnosed with breast cancer. In women aged 60–69, the rate is 3.65 per cent (1 in 27).

Journalists may report only the aggregate lifetime risk of one in eight because they are short of space. But such reporting incorrectly assumes that readers are uninterested in, or can’t comprehend, the underlying statistics. It is critically important to find a way, through words or graphics, to report as complete a picture as possible.

Take away message: Be extra careful to ensure your readers understand that a general population estimate of risk, exposure or probability may not accurately describe individual situations. Also, provide the important information that explains variation in individual risk. This might include age, diet, literacy level, location, education level, income, race and ethnicity, and a host of other genetic and lifestyle factors.

To compare events that are so different like the risk of a fatal car accident and the risk of TOL maternal mortality is inaccurate and doesn’t help moms understand their options.  Your risk of a car accident depends on how much you drive, when you drive, if you are distracted or on medication, etc, etc, etc.  The variables that impact your risk of dying during a  TOLAC are very different.  However, one way these two events are similar:  Sometimes we can make all the “right” or “wrong” decisions and the element of luck will sway us towards a good or bad outcome.

The problems with birth myths and false comparisons

False comparisons and birth myths like this are shared with the best of intentions.  So often the risks of VBAC are exaggerated for reasons having nothing to do with the health of baby and mom.  Birth advocates share these myths (which they believe to be true) as a way of boosting the morale of moms seeking VBAC as these moms are constantly faced with a barrage of unsupportive comments from family, friends, and even care providers.

The problem is, women make plans to have (home) VBAC/VBAMC based on these myths.  They make these plans because birth myths make the risk of VBAC, uterine rupture, infant death, and maternal death look practically non-existent.  That is dangerous.

Perpetuating these myths impedes a mom’s ability to provide true informed consent.  If a mom thinks her risk of uterine rupture is similar to a unscarred mom or a unscarred, induced mom, or less than her risk of getting struck by lighting or bitten by a shark, she does not have accurate picture of the risk.  And if she doesn’t understand the risks and benefits of her options, she is unable to give informed consent or make an informed decision.

Birth advocates get all up in arms about the mom who plans an elective, primary cesarean section without “doing her research.”  Or the mom who consents to an induction at 38 weeks because her OB “said it was for the best.”  Or when an OB coerces a mom into a repeat cesarean by saying the risk of uterine rupture is 15%.  Shouldn’t we be just as frustrated when moms plan (home) VBACs based on misrepresentations of the truth?  Shouldn’t we hold ourselves to the same standard that we expect from others?

The second problem with perpetuating these false comparisons and myths is that once women learn the true risks, they seem gigantic in comparison to the minuscule risk they had once accepted.  Now VBAC seems excessively risky and some loose confidence in their birth plans.  Birth advocates do not support moms by knowingly perpetuating these myths.  The reality is, the risks of VBAC are low.  We don’t need to exaggerate or minimize the benefits or risks of VBAC.  If we just provided women with accurate information from the get go, they would be able to make a true, informed decision.

The third problem is that we really look dumb when we say stuff like this.  If we want to be taken seriously, we really need to double check what we pass on.  I encourage you to ask for a source when someone says something that sounds to good to be true or just plain fishy.  (And hold me to the same standard!)  I often ask people for a source for their assertions… with varying results.

Sometimes people have a credible source available and share it with me.  I learn more and it’s all good.  Other times, people get angry.  They think I’m challenging them or trying to argue with them.  But the truth is, I’m just trying to learn. What I have found is, when people get angry, it’s sometimes because they don’t have a source and they are insulted that I didn’t accept their statement at face value.  They have just accepted what a trusted person told them as the truth and expect me to do the same.

Doesn’t it strike you as odd that some people encourage the continual questioning OBs and the medical system, yet expect you to accept what they say as The Truth no questions asked?   “Question everyone but me.”  Why?  Why is it when we question an OB, that’s a good thing, yet when we hold our birthy friends and colleagues to the same standard, that is being argumentative?  I say, ask for the source.  From everyone.

Take away messages

It is inaccurate and misleading to compare two events that are as different as a fatal car accident and TOL maternal mortality.  Period.

Let’s stop this false comparison and bring us back to what we should be comparing TOLAC/VBAC to: the risks of a repeat cesarean.

When women plan a VBAC based on false information,  their confidence can be shattered when they learn that the risk of uterine rupture and maternal death are much higher than they were lead to believe.

When women plan a VBAC based on false information, they are deprived of their right to informed consent.

While the risk of scar rupture is very different than the risk of a fatal car accident, it is similar to other serious obstetrical emergencies such as placental abruption, cord prolapse, and postpartum hemorrhage.

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Guise J-M, Eden K, Emeis C, Denman MA, Marshall N, Fu R, Janik R, Nygren P, Walker M, McDonagh M. Vaginal Birth After Cesarean: New Insights. Evidence Report/Technology Assessment No.191. (Prepared by the Oregon Health & Science University Evidence-based Practice Center under Contract No. 290-2007-10057-I). AHRQ Publication No. 10-E003. Rockville, MD: Agency for Healthcare Research and Quality. March 2010.   http://www.ahrq.gov/downloads/pub/evidence/pdf/vbacup/vbacup.pdf

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For those who are interested in the reasoning and mathematics from the original article:

But, if we were going to compare the unlike risks of a fatal car accident and TOLAC, this is how I would do it: compare the daily risks of the events.

Maternal death and TOL

Per the report presented at the 2010 NIH VBAC conference entitled Vaginal Birth After Cesarean: New Insights (Guise, 2010):

Overall rates of maternal harms were low for both TOL [trial of labor] and ERCD [elective repeat cesarean delivery]. While rare for both TOL and ERCD, maternal mortality was significantly increased for ERCD at 13.4 per 100,000 versus 3.8 per 100,000 for TOL . . . The rate of uterine rupture for all women with prior cesarean is 3 per 1,000 and the risk was significantly increased with TOL (4.7/1,000 versus 0.3/1,000 ERCD).

Put another way, there is a 0.0038% (1 in 26,316) risk of maternal death during a trial of labor.  For a mom to die is very rare.

Risk of a fatal car accident

Of the 311,000,000 people living in the US (US Census, 2012), about 40,000 die annually (Beck, 2006) from car accidents in the United States which gives us a annual rate of 0.0129% (1 in 7,752).  (But remember, this is a very rough representation of the risk due to all the factors I previously mentioned.)

Many women look at this number and say, “See, you are more likely to die in a car accident than during a TOL.”

But remember, 0.0129% (1 in 7,752) is the annual rate of Americans dying due to car accidents.

To compare something like your annual risk of a fatal car accident to your risk of dying during a TOL is an unfair and inaccurate comparison.   It would be more accurate (though still a false comparison) to compare your daily risk of a fatal car accident (because most people travel in a car every day) to the risk of maternal death during a TOL because you are not in labor every day for a year.  Let me explain.

Comparing TOL maternal mortality to fatal car accidents

Often this false comparison is expressed as, “You are more likely to have a fatal car accident on the way to the hospital than have a uterine rupture or die during a VBAC.”  But the risk of a fatal car accident on the day you drive to the hospital is not 1 in 7,752.  That is your risk over a year.  We have to estimate your risk on that day you drive to the hospital by dividing 0.0129% by 365 days which equals 0.00003534% or 1 in 2,829,458.

No matter what stat we use from any study, the risk of maternal mortality during a TOL is much greater.  (But remember, this is a false comparison anyways!)

Guise’s data pegs the risk at 0.0038% or 1 in 26,316 which is 107.5 times greater than the risk of a fatal car accident as you drive to the hospital in labor.  This does not mean that the risk of dying during a TOL is so large, but rather our daily risk of a fatal car accident is so small that it’s literally theoretical.  (Read Kim James’ “Understanding obstetrical risk” for more.)

What about the risk of uterine rupture?

Using the 0.47% (1 in 213 TOLs) risk of scar rupture (Guise, 2010), the risk of a fatal car accident is 13,283 times smaller.

Why don’t we spread the risk of rupture/maternal mortality across the entire pregnancy?

After I initially published this article, someone left this great comment on Facebook:

I get this, but I also get why using annual stats of car accidents would be accurate when you are looking at uterine rupture rates themselves and not just during TOL, since a risk of rupture exists throughout pregnancy and not just during labor and mom would be pregnant for approximately 10 months or more.

I wondered about the best way to crunch the numbers because these events are so different and thus so difficult to compare.  In the end, it is a false comparison, but here was my original thinking….

Most Americans are in a car everyday, so they have that risk – no matter how small – every day unless they are not in a car in which case their risk is zero.  The risk is primarily associated with being in a car.

The risk of uterine rupture and maternal mortality is primarily associated with being in labor, so we can’t spread the risk of rupture/maternal mortality across the whole pregnancy because the risk of rupture/maternal mortality is not the same from conception to delivery.

One study examined 97% of births that occurred in the The Netherlands from 1st August 2004 until 1st August 2006 and found that 9% (1 in 11) of scar ruptures happened before the onset of labor. When we take 9% of the overall rate of scar rupture 0.64% (1 in 156) (including non-induced/augmented, induced, and augmented labors), we get a 0.0576% (1 in 1736) risk of pre-labor scar rupture and a 0.5824% (1 in 172) risk of rupture during labor (Zwart 1009). Since the risk of rupture is not the same over the entire pregnancy and labor, we cannot accurately calculate a daily risk of rupture.

In other words, the risk of rupture is rare before labor (0.0576% or 1 in 1736) and then becomes uncommon when labor begins (0.5824% or 1 in 172).  Even though we could go into labor anytime during pregnancy, the risk before we go into labor is so small in comparison to the risk when we actually go into labor.

Can you feel a uterine rupture with an epidural?

woman-laboring-hospitalSome care providers discourage epidurals in VBAC moms fearing that it will mask the symptoms of uterine rupture (namely abdominal pain) and delay diagnosis resulting in a poor outcome for baby and to a lesser extent, mom  Other care providers suggest or even require VBAC moms to have an epidural so that a cesarean can quickly take place if needed.  Which philosophy does the evidence support?

Review of 14 VBAC studies

I recently came across a study entitled “The Role of Epidural Anesthesia in Trial of Labor” (Johnson, 1990) that reviewed 14 VBAC studies.  Johnson found among scarred women who ruptured, a greater percentage of women with epidurals reported abdominal pain than women without epidurals.

  • 5 of 14 (35.7%) patients with an epidural who ruptured had abdominal pain.
  • 4 of 23 (17.4%) patients without an epidural who ruptured had abdominal pain.

Interestingly, only 22% of the women who ruptured in that study reported abdominal pain and Johnson concluded, “Thus abdominal pain is an unreliable sign of complete uterine rupture.”  But is it?  69% of women in Zwart (2009) reported abdominal pain. (I write about Zwart here and here.)

One difference between the studies is Zwart included significantly more scarred moms than Johnson: 26,000 versus 10,976.  The second different is that Zwart also included 332,000 unscarred women representing 93% of the sample population.

Unscarred moms, uterine rupture, and abdominal pain

I’m curious if the reason why Zwart reported such a high level of abdominal pain was because it included so many unscarred moms.  I wonder if unscarred moms are more likely to report pain and if so, why would that be.  Zwart combines the symptoms for scarred and unscarred rupture into one chart.  If they broke that chart out by scarred vs. unscarred rupture symptoms, would we see any major differences? Generally, unscarred rupture does more damage to the uterus and is more likely to result in an infant death (Zwart, 2009), so maybe because there is more damage, women report more abdominal pain?

Most common UR symptom: fetal heart tone abnormalities

I checked out  eMedicine’s article “Uterine Rupture in Pregnancy” and was fascinated to learn that several studies concur with Johnson.  They also found that abdominal pain is reported at a much lower rate than fetal distress/ abnormal fetal heart tones:

…sudden or atypical maternal abdominal pain occurs more rarely than do decelerations or bradycardia. In 9 studies from 1980-2002, abdominal pain occurred in 13-60% of cases of uterine rupture. In a review of 10,967 patients undergoing a TOL, only 22% of complete uterine ruptures presented with abdominal pain and 76% presented with signs of fetal distress diagnosed by continuous electronic fetal monitoring. [This is the Jonhson study.]

Moreover, in a study by Bujold and Gauthier, abdominal pain was the first sign of rupture in only 5% of patients and occurred in women who developed uterine rupture without epidural analgesia but not in women who received an epidural block.  (Bujold E, Gauthier RJ. Neonatal morbidity associated with uterine rupture: what are the risk factors?. Am J Obstet Gynecol. Feb 2002;186(2):311-4).  Thus, abdominal pain is an unreliable and uncommon sign of uterine rupture. Initial concerns that epidural anesthesia might mask the pain caused by uterine rupture have not been verified and there have been no reports of epidural anesthesia delaying the diagnosis of uterine rupture.

A 2012 study out of the UK (Fitzpatrick, 2012) also reported that 76% of uterine ruptures were accompanied by fetal heart rate abnormalities in comparison to 49% reporting abdominal pain.

ACOG’s stance on epidurals

It’s important to note that ACOG does support the use of epidurals in VBACs:

Epidural analgesia for labor may be used as part of TOLAC, and adequate pain relief may encourage more women to choose TOLAC (109, 110). No high quality evidence suggests that epidural analgesia is a causal risk factor for an unsuccessful TOLAC (44, 110, 111). In addition, effective regional analgesia should not be expected to mask signs and symptoms of uterine rupture, particularly because the most common sign of rupture is fetal heart tracing abnormalities (24, 112).

Remember that fetal heart tracing abnormalities were detected in 76% of the ruptures in Johnson ad 67% of the ruptures in Zwart.

I couldn’t find any mention of epidurals masking rupture pain in the Guise 2010 Evidence Report, but found that the Johnson study was excluded from their report because “No full-text paper, opinion or letter with no data.”  Interesting.

Uterine rupture symptoms

A list of uterine rupture symptoms and their frequency per Medscape’s article on uterine rupture.

  • “80% Prolonged deceleration in fetal heart rate or bradycardia
  • 54% Abnormal pattern in fetal heart rate
  • 40% Uterine hyper-stimulation
  • 37% Vaginal bleeding
  • 26% Abdominal pain
  • 4% Loss of intrauterine pressure or cessation of contractions”

A couple notes.  One, abdominal pain is not a consistent or reliable symptom of UR.  Two, there is a level of interpretation that goes into diagnosing abnormal fetal heart tones even among people who have extensive medical training.

Additional symptoms that I have collected from other sources include:

  • Baby’s head moves back up birth canal
  • Bulge in the abdomen or under the pubic bone (where the baby may be coming through the tear in the uterus)
  • Uterus becomes soft
  • Shoulder pain

Risks and benefits of epidurals

As with every option available to you regarding birth, it’s always good to be knowledgeable on the risks and benefits of epidurals so you can make an informed choice.  Three excellent resources are this article by Sarah Buckley MD, the PubMed Health Epidural Fact Sheet and this review of epidural research by the Cochrane Library.

Take home message

The limited information available tells us that epidurals do not mask abdominal pain from uterine rupture.

The most common symptom of uterine rupture is fetal distress diagnosed by fetal heart rate abnormalities.

Epidurals may be used during a trial of labor after cesarean per ACOG.

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As always, if you can offer further research or perspective on this topic, please leave a comment.  Our knowledge is constantly growing and we can only work with the best information available to us now.  Who knows what future research will tell us?

Myth: Two numbers less than 1% are similar

I have often heard, “If two numbers are less than 1%, they are similar.”  Typically
this is expressed while comparing the risks of rupture in an unscarred versus scarred uterus.   But is this true?  How different can two numbers less than 1% be?calculator-983900_1920

Two numbers less than 1% are no more similar than two numbers greater than 1%

Just because two numbers are less than 1%, that doesn’t make them any more similar than two numbers greater than 1%.  A 2% risk of something happening is very different than an 89% risk.  While they are both greater than 1%, they represent drastically different levels of risk.

2% = 1 in 50 risk

89% = 1 in 1.12 risk

89% represents a 44 times greater risk than 2%.

What about numbers less than 1%?

It might seem rational that since numbers less than 1% are so small, that there wouldn’t be as much of a difference between them.  But numbers less than 1% work in the same way as those greater than 1%.   Let’s run a few and measure the difference.

1 in 100 represents 1%.

1 in 1,000, is the same as 0.1%, and is 10 times smaller than 1%.

1 in 10,000, is the same as 0.01%, and is 100 times smaller than 1%.

1 in 100,000, is the same as 0.001%, and is 1,000 times smaller than 1%.

1 in 1,000,000, is the same as 0.0001%, and is 10,000 times smaller than 1%.

Comparing small risks

According to Zwart* (2009), the risk of uterine rupture in:

– an unscarred mom is 1 in 14,286 (0.007% or 0.7 in 10,000) and

– a scarred mom is 1 in 156 (0.64% or 64 in 10,000).

(Both statistics include non-induced/augmented, induced, and augmented labors.)  Even though both numbers are less than zero, they represent very different levels of risk.  In fact, the risk of rupture in an unscarred mom is 91 times smaller than a scarred mom.  It’s not that the risk of rupture is excessively high in a scarred mom, but that it is so very, very, very low in an unscarred mom.

Using the language from Kim James’ handout Understanding Obstetrical Risk, the risk of rupture in an unscarred mom would be described as “very rare” whereas the risk of rupture in a scarred mom would be described as “uncommon.”

Take away messages

Just because two numbers are less than 1% does not mean that they are similar.  Numbers below 1% represent just as much of a range as numbers greater than 1%.

While the risk of scar rupture is very different than the risk of unscarred rupture, it is similar to other serious obstetrical emergencies such as placental abruption, cord prolapse, and postpartum hemorrhage.
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* Zwart (2009) differentiated between uterine rupture and dehiscence, featured 358,874 total deliveries, 25,989 of which were trials of labor after a cesarean.  Zwart included 97% of births in The Netherlands between August 1, 2004 and August 1, 2006, making it “the largest prospective report of uterine rupture in women without a previous cesarean in a Western country.”

Zwart, J. J., Richters, J. M., Ory, F., de Vries, J., Bloemenkamp, K., & van Roosmalen, J. (2009, July). Uterine rupture in the Netherlands: a nationwide population-based cohort study. BJOG: An International Journal of Obstetrics and Gynaecology, 116(8), pp. 1069-1080. Retrieved January 15, 2012, from http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02136.x/full

Myth: VBACs should never be induced

Note: When I refer to a spontaneous labor, I mean a non-induced/augmented labor. Also, given that the risk of rupture increases with induction, a hospital is the best location for an induction.

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Many of the comments left at the Forced Cesarean mom story questioned the safety of inducing a VBAC mom. Many people believe that is it excessively dangerous and that VBACs should never been induced or augmented. This is just not the case.

Spontaneous labor is always preferable to induced or augmented labor but there are medical conditions that can necessitate the immediate birth of a baby. It’s nice for those women for whom vaginal birth is still an option to have a choice: gentle induction/ augmentation or repeat cesarean. Of course, reviewing the risks and benefits of available options, including doing nothing, is essential. Some women might be more comfortable scheduling a cesarean whereas others might want to give a gentle Pitocin and/or Foley catheter induction a go.

ACOG’s stance on inducing VBACs

The latest 2010 VBAC Practice Bulletin No. 115 produced by the American Congress of Obstetricians & Gynecologists (ACOG) asserts:

Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC [trial of labor after cesarean]… However, the potential increased risk of uterine rupture associated with any induction, and the potential decreased possibility of achieving VBAC, should be discussed… Misoprostol [Cytotec] should not be used for third trimester cervical ripening or labor induction in patients who have had a cesarean delivery or major uterine surgery.

Stuart Fischbein MD, a vaginal breech/twins and VBAC supportive Southern California OB, recently shared this on my Facebook page,

According to ACOG, prior low transverse c/section is not a contraindication to induction (other than the use of Misoprostol [Cytotec]) so a Foley balloon or Pitocin may be used safely in these women. The problem arises when a practitioner does not believe in doing inductions on women with prior c/section. Despite the evidence and the ACOG clinical guideline the reality is that many doctors will just not want to deal with it.

“Many doctors will just not want to deal with it” for a variety of reasons including experiencing a recent uterine rupture or lawsuit and pressure from hospital administrators or other OBs in their practice. It’s good to know from the beginning if your care provider is open to a gentle VBAC induction and under what conditions they would recommend induction. (See below for the Mayo Clinic’s reasons for induction.) This is why I suggest asking care providers when you first meet with them: “Under what circumstances would you induce a VBAC?” and “What induction methods do you use?”

Medical reasons for induction

While many women are induced for non-medical reasons, such as being pregnant for 40 weeks and one day, there are many medical conditions where induction is a reasonable option. According to the Mayo Clinic’s article Inducing labor: when to wait, when to induce dated July 23, 2011:

Your health care provider might recommend inducing labor for various reasons, primarily when there’s concern for your health or your baby’s health. For example:

  • You’re approaching two weeks beyond your due date, and labor hasn’t started naturally
  • Your water has broken, but you’re not having contractions
  • There’s an infection in your uterus
  • Your baby has stopped growing at the expected pace
  • There’s not enough amniotic fluid surrounding the baby (oligohydramnios)
  • Your placenta has begun to deteriorate
  • The placenta peels away from the inner wall of the uterus before delivery — either partially or completely (placental abruption)
  • You have a medical condition that might put you or your baby at risk, such as high blood pressure or diabetes

ACOG’s 2009 recommendations on induction lists the following reasons:

  • Abruptio placentae [placental abruption]
  • Chorioamnionitis [infection in your uterus]
  • Fetal demise [baby has passed away]
  • Gestational hypertension
  • Preeclampsia, eclampsia
  • Premature rupture of membranes
  • Postterm pregnancy [after 42 weeks]
  • Maternal medical conditions (eg, diabetes, mellitus, renal [kidney] disease, chronic pulmonary disease, chronic hypertension, antiphospholipid syndrome)
  • Fetal compromise (eg, severe fetal growth restriction, isoimmunization, oligohydramnios)

Big babies & going overdue

ACOG’s latest VBAC Pratice Bulletin No. 115 states that going over 40 weeks or suspecting a “big baby” should not prevent a woman from planning a VBAC. I suggest asking your care provider at your first appointment about what they would recommend doing if you go past 40 weeks, past 42 weeks, or if they believe your baby is large. They may suggest a cesarean, a gentle induction, or they be open to waiting for spontaneous labor. Then you decide how you feel about their answer. If you decide that their answer is not a good fit for you, you can weigh that against the responses of other VBAC supportive care providers in your area.

Uterine rupture rates in induced/augmented labors

There are two primary factors when looking at uterine rupture during an induction: the drug and the dose. Keep in mind that while the risk of rupture generally increases as the dosage increases, two women can respond very differently to the same dose of the same drug. According to JHP Pharmaceuticals, LLC, the manufacturer of Pitocin,

Oxytocin has specific receptors in the myometrium and the receptor concentration increases greatly during pregnancy, reaching a maximum in early labor at term. The response to a given dose of oxytocin is very individualized and depends on the sensitivity of the uterus, which is determined by the oxytocin receptor concentration.

Additionally, they assert that Pitocin should not be used for induction without medical indication:

Elective induction of labor is defined as the initiation of labor in a pregnant individual who has no medical indications for induction. Since the available data are inadequate to evaluate the benefits-to-risks considerations, Pitocin is not indicated for elective induction of labor.

Many women point to the fact that the Pitocin drug insert states, “Except in unusual circumstances, oxytocin should not be administered in the following conditions” and then lists “previous major surgery on the cervix or uterus including cesarean section.” However, a prior cesarean is not listed under contraindications and the drug insert is clear:

The decision [to use Pitocin in a woman with a prior cesarean] can be made only by carefully weighing the potential benefits which oxytocin can provide in a given case against rare but definite potential for the drug to produce hypertonicity or tetanic spasm.

The elevated risk of rupture due to induction has been documented in several studies. Landon (2004) found that spontaneous labors had a 0.4% rate of rupture. That increased 2.5 times for induced labors (1.0%) and 2.25 times for augmented labors (0.9%).

Landon further broke out rupture rates by type of induction:

  • 1.4% (N = 13) with any prostaglandins (with or without oxytocin)
  • 0% with prostaglandins alone
  • 0.9% (n = 15) with no prostaglandins (includes mechanical dilation with a foley catheter with or without oxytocin), and
  • 1.1% (N = 20) with oxytocin alone.

Overall, they found 0.7% of women experienced an uterine rupture with an additional 0.7% experiencing a dehiscence.

Landon (2004) did a great job in providing rates of rupture per drug, but we don’t know the dose used in the induced/ augmented labors that ruptured versus those that didn’t rupture.

ACOG quotes a couple studies in their 2010 VBAC Practice Bulletin (emphasis mine):

One study of 20,095 women who had undergone prior cesarean delivery (81) found a rate of uterine rupture of 0.52% for spontaneous labor, 0.77% for labor induced without prostaglandins, and 2.24% for prostaglandin induced labor. This study was limited by reliance on the International Classification of Diseases, 9th Revision coding for diagnosis of uterine rupture and the inability to determine whether prostaglandin use itself or the context of its use (eg, unfavorable cervix, need for multiple induction agents) was associated with uterine rupture.

In a multicenter study of 33,699 women undergoing TOLAC, augmentation or induction of labor also was associated with an increased risk of uterine rupture compared with spontaneous labor (0.4 % for spontaneous labor, 0.9% for augmented labor, 1.1% for oxytocin alone, and 1.4% for induction with prostaglandins with or without oxytocin) (4). A secondary analysis of 11,778 women from this study with one prior low transverse cesarean delivery showed an increase in uterine rupture only in women undergoing induction who had no prior vaginal delivery (1.5% versus 0.8%, P=.02). Additionally, uterine rupture was no more likely to occur when labor induction was initiated with an unfavorable cervix than with a favorable cervix (91). Another secondary analysis examined the association between maximum oxytocin dose and the risk of uterine rupture (94). They noted a dose response effect with increasing risk of uterine rupture with higher maximum doses of oxytocin. Because studies have not identified a clear threshold for rupture, an upper limit for oxytocin dosing with TOLAC has not been established.

Induced labor is less likely to result in VBAC than spontaneous labor (44, 47, 92, 99). There is some evidence that this is the case regardless of whether the cervix is favorable or unfavorable, although an unfavorable cervix decreases the chance of success to the greatest extent (91, 100, 101). These factors may affect patient and health care provider decisions as they consider the risks and benefits of TOLAC associated with labor induction.

Given the lack of compelling data suggesting increased risk with mechanical dilation and transcervical catheters, such interventions may be an option for TOLAC candidates with an unfavorable cervix.

The Guise 2010 Evidence Report is another excellent resource that reviewed VBAC research published to date. It talks extensively about uterine rupture in induced births on pages 58 – 69 and concluded (emphasis mine):

The strength of evidence on the risk of uterine rupture with pharmacologic IOL [induction of labor] methods was low due to lack of precision in estimates and inconsistency in findings. The overall risk of rupture with any IOL method at term was 1.5 percent [1 in 67] and 1.0 percent [1 in 100] when any GA [gestational age] is considered. Among women with GA greater than 40 weeks, the rate was highest at 3.2 percent [1 in 31]. Evaluation of the evidence on specific methods of IOL reveal that the lowest rate occurs with oxytocin [Pitocin] at 1.1 percent [1 in 91], then PGE2 [prostaglandin E2] at 2 percent [1 in 50], and the highest rate with misoprostol [Cytotec] at 6 percent [1 in 17]. These findings should be interpreted with caution as there was imprecision and inconsistency in the results among these studies. The risk of uterine rupture with mechanical methods of IOL is understudied. Other harms were inadequately reported to make conclusions. Relative to women with spontaneous labor, there was no increase in risk of rupture among those induced at term. However, the available evidence on women with induced labor after 40 weeks GA indicates an increased risk compared with spontaneous labor (risk difference 1.8 percent; 95 percent CI: 0.1 to 3.5 percent). The NNH [number needed to harm] in this group is 56 (for every 56 women greater than 40 weeks GA with IOL during a TOL [trial of labor], one additional rupture will occur compared with having spontaneous labor).

So the bottom line is: more large, good quality studies that control for induction are needed.

What is too risky?

As ACOG (2010) states in their latest Practice Bulletin:

Respect for patient autonomy supports the concept that patients should be allowed to accept increased levels of risk, however, patients should be clearly informed of such potential increase in risk and management alternatives.

I agree and believe that each individual woman has the right to informed consent and, together with her care provider, can make the best decision for her individual situation. I think it’s hard to argue that women seeking VBA2C, home birth, or unassisted birth should have the right to accept the elevated levels of risk that come with those decisions and yet say that the elevated risk that comes with induced VBACs is unacceptable.

Keep in mind that while the risk of rupture is higher in an induced VBAC, the risk is similar to the risk of rupture in a VBA2C (0.9% per Landon 2006). So it’s hard for one to support VBA2C and yet demonize a VBA1C induced for medical indication by saying the risk of rupture is to high.

It is also important to note that 90 out of 91 Pitocin induced TOLACs do not rupture (Landon, 2004 & Guise, 2010). So while the risk is generally higher in induced/ augmented labors, the overall risk is still low and occurs at a rate comparable to other obstetrical emergencies.

Myth: Most ruptures occur in induced/augmented labors

It’s imperative that women seeking VBAC understand that the single factor that increases their risk of uterine rupture the most is their prior cesarean section. And while having your labor induced/augmented does increase your risk of rupture, please do not believe the myth that a spontaneous labor provides complete protection from uterine rupture.

To disprove this myth, I direct you to “the largest prospective report of uterine rupture in women without a previous cesarean in a Western country” which found that most ruptures occur in spontaneous labors (Zwart, 2009). Zwart differentiated between uterine rupture and dehiscence and found (emphasis mine):

of the 208 scarred and unscarred uterine ruptures, 130 (62.5%) occurred during spontaneous labor reflecting 72% of scarred ruptures and 56% of unscarred ruptures.

It is interesting to note that 16% of unscarred ruptures (representing 4 unscarred women) and 9% of scarred ruptures (representing 16 scarred women) happened before the onset of labor (Zwart, 2009).

What I would do

If there was a medical reason for my baby to born (as detailed by the Mayo Clinic above), and it was the difference between a VBAC and a repeat cesarean, and I had a favorable Bishop’s score (download the app), I would consent to a foley catheter and/or low-dose Pitocin induction (not Cytotec or Cervidil).

If I was induced or augmented with Pitocin, I would be comfortable with continuous external fetal monitoring. Some hospitals do offer telemetry which is wireless monitoring giving you more freedom of movement. I’ve even seen telemetry in tube tops (naturally I can’t find a link to it now, if you have a link, can you leave a comment?) and units that can be worn in birth tubs. It’s good to call the hospital beforehand to determine what kind of telemetry monitoring units they offer and to confirm that it’s not lost in a closet.

Final thoughts

There is no doubt that Pitocin is overused in America and often results in unnecessary emergency cesareans. However, it’s important not to cloud the two issues: medically unnecessary inductions and inductions with medical indication. There are situations where induction/ augmentation are reasonable and can give the mom one last option before having a cesarean. Thankfully, a low-dose Pitocin and/or foley catheter induction “remains an option” in women planning a VBAC according to ACOG. I think that is a good thing.

Further reading

Woman has 4th cesarean and requires 33 gallons of blood

Update: This powerhouse of a woman has since started the non-profit organization “Hope for Accreta Foundation.”


What a miracle this woman survived!  This was her fifth baby and fourth cesarean.

She had a complication known as placenta percreta which is when “the placenta attaches itself and grows through the uterus, sometimes extending to nearby organs, such as the bladder” (March of Dimes 2012).  The risk of having placenta accreta, increta, or percreta during a fourth cesarean or a VBA3C (vaginal birth after three cesareans) is 2.13% (1 in 47) (Silver 2006).

Image credit: Wikipedia

Image credit: Wikipedia

Most women planning a VBA1C (vaginal birth after one cesarean) are aware of the risks of uterine rupture.  However, women planning their first vaginal birth or VBA1C need the WHOLE picture so they can really work to prevent an unnecessary cesarean.  They need to understand the risks and benefits of VBAC versus repeat cesarean for mom and baby now as well as how current choices impact mom’s future health, fertility, delivery options, and complications that present in subsequent births.

A huge part of this – I believe – is hiring a vaginal birth/VBAC supportive care provider because once a woman has that first cesarean, her options narrow, and they do so even more drastically after that second cesarean.  As her options narrow, her risks increase and unlike uterine rupture which you can circumvent through a repeat cesarean, the risk of accreta, percreta, and increta are not as easily mitigated.

By avoiding one complication, we are increasing our risk for another serious complication in future pregnancies.  For women who plan for large families, this should be on your radar and every practitioner should be discussing intended family size with their patients so that it can be taken into consideration.

Read more about placenta abnormalities, the risks of multiple cesarean sections, the marketing of risk, and how reversing VBAC bans would make birth safer for everyone.

And please donate blood. These women need it.

Woman survives crisis delivery with 33 gallons of donated blood

Posted on April 11, 2012 at 9:46 PM

SAN ANTONIO — University Hospital is sharing an incredible story of survival. A San Antonio woman was saved during a crisis baby delivery. But it took more than 33 gallons of blood.

Two-month-old Addison Walker came into the world in an unusual way. Her mother, Gina, had a rare pregnancy condition called placenta percreta. The placenta invaded through the uterine wall into the bladder, causing massive bleeding during a delivery operation.

Doctors at University Hospital recalled the February eight-hour operation.

“Unfortunately, Ms. Walker had blood loss that superseded anything that we could have prepared for,” said Dr. Jason Parker, U.T. Health Science Center OB/GYN.

Walker lost more than ten times the amount of blood surgeons anticipated. She needed more than 33 gallons. That’s 540 units to keep her alive.

“After I watched cooler after cooler after cooler with my wife’s name on it full of blood going up and down the hallways, yeah, I did get worried,” recalled Gina’s husband Dustin. Read more.

A couple comments left on Facebook:

University is a Level 1 trauma center.  It is the trauma center in San Antonio.  Only other hospital that takes the worst of the worst is SAMMC [San Antonio Military Medical Center] which is the military hospital.  University takes all the gunshots, stabbings, multiple injury accidents, etc…. And these come in multiple times a day.  If any hospital has 100+ units on hand it would be that hospital.  Even if it didn’t, it is literally a couple hundred yards from a half dozen other hospitals that could dip into their supply.

It’s approx $1060 per unit of blood from the blood bank, not including the one time cost of all the testing, which is about $400-500. (These costs depend on the facility, but are a ball park.) Think about what the cost of the blood alone was…

I laboured just fine with my attempted VBA3C but the labour pains at the end were intense and I needed some meds of sorts so I went off to the hospital only to be bullied into the surgery room. All stats were excellent with me and my baby (and noted by the doctors in surgery that my little girl was down the birth canal and had I only been given something to help with pain, I would have pushed her out just fine). Because of that unnecessarian I had to endure a 6 hour reconstructive surgery to fix the mistakes of all the other batched c-sections and to repair the fistula left by the 4th C. But in the meantime I got the pleasure of toting around a catheter for the 5 months in between surgeries. That’s on top of the other procedures, tests and pain I had to go through. All of this could have been avoided had the doctors not allowed me that very first c-section and all the others that were not required. I kick myself in the butt for not educating myself right from the beginning, but how was I to know the doctors wouldn’t be educated either!

I desire to go on to have more children, but am terrified for things like this article speaks of.

Chipping away at the “too posh to push” myth

glamourous-womanSome new research questions the idea that women who are “too posh to push” are responsible for America’s rising cesarean rate. The work of University of Arizona sociologist Louise Roth has been featured in an University of Arizona UA News article dated April 13, 2012.

Watch for Roth’s research which will be “published in the May issue of the sociology journal Social Problems, published by the Society for the Study of Social Problems.”

I’ve highlighted a few passages for those who like to skim.

By Jeff Harrison, University Communications, April 13, 2012

UA sociologist Louise Roth says the increasing number of cesarean deliveries negatively impacts the health of women and their children and health-care costs.

University of Arizona sociologist Louise Roth wonders why women, at least according to news reports, are increasingly opting to give birth by cesarean section, rather than via natural delivery. Stories have focused on better-educated and more well-to-do women having the surgical procedure, a phenomenon dubbed “too posh to push.”

Roth, an associate professor of sociology who is interested in the effects of malpractice and, more generally, on the impact of the organizational environment on maternity care, looked at the data surrounding the issue and found herself totally stumped.

“I’d been reading a lot in the news about how women were choosing to have cesareans, and what I discovered was that women you would expect would have more cesareans – if that story were true – were not the women who were more likely to have them,” Roth said.

“In fact, the women who were most likely to have cesareans were low-education, Black and Hispanic women, which was not what I expected based on the ‘too-posh-to-push’ story. That was the impetus of this paper. I started playing with the data and found this finding that seemed counter-intuitive to me, and so I decided to investigate further.”

The results of her study will be published in the May issue of the sociology journal Social Problems, published by the Society for the Study of Social Problems.

Roth said the disparities in the rates of cesareans are an important issue because the procedure is tied to maternal deaths and the cost of health care. One key issue is understanding the “pervasive racial-ethnic and socioeconomic disparities in maternity care (and) health care more generally, yet there has been little scrutiny of how overuse of cesarean deliveries might be linked to these disparities.

Roth poured through a year’s worth of data, approximately 4 million recorded births in 2006, the most recent year available. Black, Native American, Hispanic and women from lower socio-economic backgrounds were less likely to have needed cesareans or more likely to have medically unnecessary cesareans.

Either scenario has potentially negative outcomes for both the mother and child. While maternal deaths are statistically low, they still are a concern to public health officials – and deaths from c-sections are four times higher than from vaginal births. Likewise, infants born earlier than 36 weeks, whether naturally or via c-section, are at higher risk for respiratory ailments.

What then is driving the increase in surgeries? Roth asked several researchers, including one who studies cesareans, if this trend was because women want them.

“I think the answer is ‘no.’ Women can have different preferences, but those who have the most ability to exercise those preferences seem to exercise them in the direction of avoiding cesareans rather than choosing them,” she said.

What’s more, lack of prenatal care does not seem to be a factor, and Roth noted that women who get more prenatal care are more likely to have cesareans.

There are other confounding issues. Some studies suggest women in a higher socio-economic status are more likely to get cesareans because they are getting more care than would otherwise be warranted. Other literature report that minority women are more likely to get cesareans.

“I have a statistical model where I account for all of those clinical indications. And when we look at the cases where the clinical indications don’t appear to be there, who is more likely to end up with a cesarean delivery?”

“One thing I find is that if you just look at education alone, with rising education, there are more cesareans, which would suggest that it is the more affluent women who are being overtreated,” Roth said.

“But that is because they are older and maternal age is correlated with cesarean delivery. Once you take that into account, you see that education is actually associated with a much lower probability of having a cesarean.”

A woman who is the same age but has less education is actually more likely to have a cesarean delivery, she said.

“There is that confounding effect that if you look at education alone, without accounting for all those other factors, you might think the ‘too-posh-to-push’ story might be correct. But once you look at everything together, you see that it is not. In fact, it’s the opposite. The ‘posh’ women are more likely to avoid the cesarean.

From a public policy standpoint, Roth said the rising number of cesarean deliveries significantly contributes to the high cost of health care, as well as increasing the risks for women in subsequent pregnancies. Insurance companies and Medicade plans pay more for cesarean deliveries. Hospitals are able to charge more for them.

One goal of her research is dispelling the myth that cesarean deliveries have increased are because women are choosing to have them.

“The most recent data, the last two years suggest that the increase is close to a third, so it is very high, and higher than would be clinically recommended. There also are things that suggest that practice patterns are the cause of this, not the choices that women make,” Roth said.

“In a larger way, there hasn’t been that much attention paid on the beginning of life and the unnecessary costs that are incurred at the beginning of life through these practice patterns.

“There is some discussion of end-of-life care, but not that much on maternity care and how the maternity care system could be made more cost-effective and lead to public health improvements. These things have implications, especially in subsequent pregnancies.”

Contact Info
Louise Roth
UA Department of Sociology
520-621-3531
lroth@email.arizona.edu

The best compilation of VBAC/ERCS research to date

“There is a major misperception that TOLAC [trial of labor after cesarean] is extremely risky” – Mona Lydon-Rochelle PhD, MPH, MS, CNM, March 2010

In terms of VBAC, “your risk is really, really quite low” – George Macones MD, MSCE, March 2010

Both Drs. Macones and Lyndon-Rochelle are medical professionals and researchers who made these statements at the 2010 NIH [National Institutes of Health] VBAC Conference. Now you may think, “Wait a sec. Everything I’ve heard from my family, friends, and medical provider is how risky VBAC is and how cesareans are the conservative, prudent, and safest choice.” Why the discrepancy between the statements of these two prominent care provider researchers and the conventional wisdom prevalent in America?

It’s likely that your family, friends, and even your medical provider are not familiar with the latest and best compilation of VBAC research that was released in March 2010. It’s also possible that they are not familiar with the latest VBAC recommendations published in July 2010 by the American Congress of Obstetricians and Gynecologists (ACOG). Additionally, there are often legal and non-medical factors at play that influence how care providers counsel women on VBAC, including pressure from hospital administrators.

When I come across any VBAC study, I always wonder if it made the cut to be included in the 400 page Guise 2010 Evidence Report that was the basis for the 2010 NIH VBAC Conference. Guise 2010 reviewed each published VBAC study, performed a quality assessment, and assembled an excellent review of the VBAC literature to date:

Quality assessment is an assessment of a study’s internal validity (the study’s ability to measure what it intends to measure). If a study is not conducted properly, the results that they produce are unlikely to represent the truth and thus are worthless (the old adage garbage in garbage out). If however, a study is structurally and analytically sound, then the results are valuable. A systematic review, is intended to evaluate the entire literature and distill those studies which are of the highest possible quality and therefore likely to be sound and defensible to affect practice.

Guise focused on these key questions: “1) a chain of evidence about factors that may influence VBAC, 2) maternal and infant benefits and harms of attempting a VBAC versus an elective repeat cesarean delivery (ERCD), and 3) factors that may influence maternal and infant outcomes.” Ultimately, this 400 page document was distilled into the 48 page VBAC Final Statement produced by the NIH VBAC Conference.

This is wonderful because people who want the big picture, can read the VBAC Final Statement whereas those who want to know the exact figures, how studies were included/excluded, and the strength of the data available, can read the Guise 2010 Evidence Report.

You can get a feel for the topics presented at the NIH VBAC Conference by reading the Programs & Abstracts document. If you want more detail, you can watch the individual presentations. I was there for the three day conference and it was eye opening. I wish more medical professionals and moms were aware of this information as they are excellent resources for anyone looking to learn more about VBAC.

Everyone wants to know the bottom line: what is the risk of death or major injury to mom and baby. Here is an overview of maternal and infant mortality and morbidity per Guise (2010). It’s important to remember that the quality of data relating to perinatal mortality was low to moderate due to the high range of rates reported by the strongest studies conducted thus far. Guise reports the high end of the range when they discuss perinatal mortality which was 6% for all gestational ages and 2.8% when limited to term studies. This is a long way of saying, we still don’t have a good picture of how many babies die due to uterine rupture.

It’s also important to remember that the statistics shared in Guise (2010) are for all VBACs. They include all scar types, women who have had multiple prior cesareans, induced/augmented labors, etc. It would have been helpful if they had broke out the data in these ways as we know we can reduce the risk of rupture (and thus perinatal mortality) through spontaneous labor.

While rare for both TOL [trial of labor after cesarean] and ERCD [elective repeat cesarean delivery], maternal mortality was significantly increased for ERCD at 13.4 per 100,000 versus 3.8 per 100,000 for TOL. The rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL and ERCD. The rate of uterine rupture for all women with prior cesarean is 3 per 1,000 and the risk was significantly increased with TOL (4.7 1,000 versus 0.3 1,000 ERCD). Six percent of uterine ruptures were associated with perinatal death. Perinatal mortality was significantly increased for TOL at 1.3 per 1,000 versus 0.5 per 1,000 for ERCD… 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… The occurrence of maternal and infant mortality for women with prior cesarean is not significantly elevated when compared with national rates overall of mortality in childbirth. The majority of women who have TOL will have a VBAC, and they and their infants will be healthy. However, there is a minority of women who will suffer serious adverse consequences of both TOL and ERCD. While TOL rates have decreased over the last decade, VBAC rates and adverse outcomes have not changed suggesting that the reduction is not reflecting improved patient selection.

Women are entitled to accurate, honest, and high quality data. They don’t deserve to have the risks exaggerated by an OB who wishes to coerce them into a repeat cesarean nor do they deserve to have risks sugar-coated or minimized by a midwife or birth advocate who may not understand the risk or whose zealous desire for everyone to VBAC clouds their judgement. Sometimes it can be hard to find good data on VBAC which is why I’m so thankful for the 2010 NIH VBAC Conference and all the excellent data that became available to the public as a result. There are real risks and benefits to VBAC and repeat cesarean and once women have access to good data, they can individually choose which set of risks and benefits they want. I think the links I have provided above represents the best data we have to date.

Confusing fact: Only 6% of uterine ruptures are catastrophic

It is important to note that the information shared in Guise (2010), the 400 page Evidence Report on which the 2010 NIH VBAC Conference was based, collected the best data we have available on trial of labor after cesarean.  That said, they reported, “Overall, the strength of evidence on perinatal mortality was low to moderate” due to the wide range of perinatal mortality rates reported by the studies included in the report.  Bottom line: We still don’t have an accurate idea of how deadly uterine rupture is to babies.  This is a topic on which Guise recommended future researchers focus.  I highly recommend that anyone interested in TOLAC (trial of labor after cesarean), especially those who blog or share information on social networking sites, review this very important document as it is a fascinating analysis of the best research we have to date on TOLAC.


How many times have you heard, “Only 6% of uterine ruptures are catastrophic” or “Uterine rupture not only happens less that one percent of the time, but the vast majority of ruptures are non-catastrophic?” But what does that mean? Does that mean only 6% of uterine ruptures are “complete” ruptures? Result in maternal death? Infant death? Serious injury to mom or baby? This article will explain to you the difference between uterine rupture and uterine dehiscence as well as explain the source and meaning of the 6% statistic.

Distinguishing between uterine rupture and uterine dehiscence

First, it’s important to understand what a uterine rupture is and how that differs from a uterine dehiscence. Uterine rupture, also called true, complete, or even (to further add to the confusion) catastrophic rupture, is a opening through all the layers of the uterus. Per a Medscape article on Uterine Rupture in Pregnancy:

Uterine rupture is defined as a full-thickness separation of the uterine wall and the overlying serosa. Uterine rupture is associated with (1) clinically significant uterine bleeding; (2) fetal distress; (3) expulsion or protrusion of the fetus, placenta, or both into the abdominal cavity; and (4) the need for prompt cesarean delivery and uterine repair or hysterectomy.

Whereas a uterine dehiscence, also called a incomplete rupture or a uterine window, is not a full-thickness separation. It’s often asymptomatic, does not pose any risk to mom or baby, and does not require repair. Again, I refer to Medscape:

Uterine scar dehiscence is a more common event that seldom results in major maternal or fetal complications. By definition, uterine scar dehiscence constitutes separation of a preexisting scar that does not disrupt the overlying visceral peritoneum (uterine serosa) and that does not significantly bleed from its edges. In addition, the fetus, placenta, and umbilical cord must be contained within the uterine cavity, without a need for cesarean delivery due to fetal distress.

When reading medical studies, look for how they define uterine rupture in the “Methods” section. While some medical studies combine the statistics for rupture and dehiscence, ultimately reporting an inflated rate of rupture, other studies distinguish between the two events.

So, what does the 6% statistic mean and where did it come from?

The statistic “Only 6% of uterine ruptures are catastrophic” is from the Evidence Report (Guise 2010) which was the basis of the 2010 NIH VBAC Conference and it refers to the rate of infant death due to uterine rupture. Here is the exact quote:

The overall risk of perinatal death due to uterine rupture was 6.2 percent. The two studies of women delivering at term that reported perinatal death rates report that 0 to 2.8 percent of all uterine ruptures resulted in a perinatal death (Guise 2010).

In other words, of the women who had uterine ruptures, 6.2% (1 in 16) resulted in infant deaths. When we limited the data to women delivering at term, as opposed to babies of all gestational ages, the risk was as high as 2.8 (1 in 36)%.

When we look at the overall risk of an infant death during a trial of labor after cesarean, the NIH reported the rate of 0.13%, which works out to be one infant death per 769 trials of labor.

The source of the confusion

The problem with this statistic is that some people have misinterpreted it to mean that only 6% of ruptures are true, complete uterine ruptures. In other words, if we take the 0.4% (1 in 240) uterine rupture rate (Landon, 2004), they believe that only 6% of those ruptures or 0.024% (1 in 4166) are true, complete ruptures. This is false. The 0.4% uterine rupture statistic measured true, complete, uterine ruptures in spontaneous labors after one prior low, transverse (“bikini cut”) cesarean.

So how many dehiscences did Landon (2004) detect? Landon reported a 0.7% uterine rupture rate and a 0.7% dehiscence rate. (Note that these statistics include a variety of scar types as well spontaneous, augmented, and induced labors.) So Landon found that dehiscence occurs at the same rate as uterine rupture.

I think the best way to avoid confusion is to use very clear language: 6.2% (1 in 16) of uterine ruptures result in an infant death. Put another way, for every 16 uterine ruptures, there will be one baby that dies.

Elapsed time and infant death

What determines if a baby dies or has brain damage? Some research on infant cord blood gases has suggested that if the baby isn’t delivered (almost always by CS) within 16 – 17 minutes of a uterine rupture, there can be serious brain damage or death to baby. You can watch a presentation from the 2010 NIH VBAC Conference entitled “The Immediately Available Physician Standard” by Howard Minkoff, M.D. for more information or read his presentation abstract.

Now you know the difference between uterine rupture, uterine dehiscence and the meaning of the 6% statistic. It’s helpful to understand the terminology used in relation to uterine rupture otherwise it can be very confusing as you wade your way through the statistics! It’s also very important for people to use specific words whose definitions are clear instead of words such as “catastrophic” that could mean multiple things.

Afterward – The big picture

The following are excerpts from the Evidence Report (Guise 2010) , the 400 page evidence report assembled for the 2010 NIH VBAC Conference. The limitation of Guise (2010) is that these stats are for all VBACs – all scar types, multiple prior cesareans, induced/augmented labors, etc. It would have been helpful if they had broke out the data in these ways.

While rare for both TOL [trial of labor] and ERCD [elective repeat cesarean delivery], maternal mortality was significantly increased for ERCD at 13.4 per 100,000 versus 3.8 per 100,000 for TOL. The rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL and ERCD. The rate of uterine rupture for all women with prior cesarean is 3 per 1,000 and the risk was significantly increased with TOL (4.7 1,000 versus 0.3 1,000 ERCD). Six percent of uterine ruptures were associated with perinatal death.” Perinatal death due to UR from term studies was 2.8%. “Perinatal mortality was significantly increased for TOL at 1.3 per 1,000 versus 0.5 per 1,000 for ERCD… 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… The occurrence of maternal and infant mortality for women with prior cesarean is not significantly elevated when compared with national rates overall of mortality in childbirth. The majority of women who have TOL will have a VBAC, and they and their infants will be healthy. However, there is a minority of women who will suffer serious adverse consequences of both TOL and ERCD. While TOL rates have decreased over the last decade, VBAC rates and adverse outcomes have not changed suggesting that the reduction is not reflecting improved patient selection.

A systematic review strives to be patient-centered and to provide both patients and clinicians with meaningful numbers or estimates so they can make informed decisions. Often, however, the data do not allow a direct estimate to calculate the numbers that people desire such as the number of cesareans needed to avoid one uterine rupture related death. The assumptions that are required to make such estimates from the available data introduce additional uncertainty that cannot be quantified. If we make a simplistic assumption that 6 percent of all uterine ruptures result in perinatal death (as found from the summary estimate), the range of estimated numbers of cesareans needed to be performed to prevent one uterine rupture related perinatal death would be 2,400 from the largest study,204 and 3,900-6,100 from the other three studies of uterine rupture for TOL and ERCD.10, 97, 205 Taken in aggregate, the evidence suggests that the approximate risks and benefits that would be expected for a hypothetical group of 100,000 women at term gestational age (GA) who plan VBAC rather than ERCD include: 10 fewer maternal deaths, 650 additional uterine ruptures, and 50 additional neonatal deaths. Additionally, it is important to consider the morbidity in future pregnancies that would be averted from multiple cesareans particularly in association with placental abnormalities.

Placenta problems in VBAMC/ after multiple repeat cesareans

I thought that I would take the data from the Silver (2006) that I’ve previously discussed and share it in a different way that would be helpful to women with multiple prior cesareans.  (You might find it worthwhile to read this article specifically, where you can view the data below in graphs, as well as other articles on placental abnormalities first.)  Remember that accreta is when the placenta abnormality deeply attaches into the uterus requiring surgical removal.  There is a 7% maternal mortality rate with accreta as well as a high rate of hemorrhage and hysterectomy.   One of the factors that determines your risk of accreta or previa is your number of prior cesareans.

Whether a mom has a repeat cesarean or a VBA1C, her risk of accreta (including increta and percreta) and previa in that pregnancy are:

risk of accreta: 0.31% (1 in 323)
risk of previa: 1.3% (1 in 77)
risk of accreta if previa is present: 11% (1 in 9)

Whether a mom plans a third cesarean or a VBA2C, her risk of accreta and previa in that pregnancy are:<

risk of accreta: 0.57% (1 in 175)
risk of previa: 1.14% (1 in 88)
risk of accreta if previa is present: 40% (1 in 2.5)

If a mom plans a fourth cesarean or a VBA3C, the risk during that pregnancy increases to:

risk of accreta: 2.13% (1 in 47)
risk of previa: 2.27% (1 in 44)
risk of accreta if previa is present: 61% (1 in 1.6)

The jump in risk from two prior cesareans to three prior cesareans is pretty huge…

If mom plans a fifth cesarean or a VBA4C, the risk during that pregnancy increases to:

risk of accreta: 2.33% (1 in 43)
risk of previa: 2.3% (1 in 43)
risk of accreta if previa is present: 67% (1 in 1.5)

If mom plans a sixth cesarean or a VBA5c, the risk during that pregnancy increases to:

risk of accreta: 6.74% (1 in 15)
risk of previa: 3.4% (1 in 29)
risk of accreta if previa is present: 67% (1 in 1.5)

Here are some stats to consider:

Silver (2006) found the following rates of accreta (including increta and percreta), during the first, second, third, fourth, fifth, and sixth cesareans: 0.24%, 0.31%, 0.57%, 2.13%, 2.33%, 6.74%.  (View a graph of this data.)

In other words, your risk of placenta accreta increases from first to sixth cesarean delivery:
1 in 417,
1 in 323,
1 in 175,
1 in 47,
1 in 43,
1 in 15.

Read more about accreta.

The studies that have been conducted (that I’m aware of) on uterine rupture in VBAMC are kind of small (including hundreds, not thousands of women).  So I don’t think we have an accurate idea of VBA3C rupture risk.  This site is a great resource.

Update:  When I posted a link to this article on Facebook, a mom left this comment:

Thank you for posting. My friend had 2 previous c-sections, and with her 3rd pregnancy had the bad luck of having both placenta accreta and placenta previa (both risks of repeat c-section). Her pregnancy was awful..lots of bleeding, hospitalizations, steriods and other drugs to help hold onto the pregnancy and bedrest at 20 weeks. They couldn’t do cerclage because of the placenta previa). In the end she had a healthy baby, but a 5 hour c-section surgery where she lost a lot of blood and needed a blood transfusion of 6 units of blood. She had to have a hysterectomy and also they removed part of her bladder because her placenta had embedded so far it was attached to her bladder! She was pissed that her doctor never warned her of the risks of repeat c-sections. She is 39 years old.

[and]

yes, you can share my comment. again, my friend ultimately is ok bec she was planning on having her tubes tied after this 3rd unplanned pregnancy — but she was upset initially bec her OB never shared with her any of these risks of repeat c-section…and she said “had I known, I would have really pushed for a vbac with #2”

These are the complication rates that Silver 2006 found in 30,000
women during multiple cesareans.The rates quoted were what he found during the third CS but, I think
the accreta and previa rates illustrate the risks that are present
during a third pregnancy after two prior CS.In other words, whether a mom has a third CS or a VBA2C, her risk of
accreta and previa in that third pregnancy are:

risk of accreta: 0.57% (1 in 175)
risk of previa: 1.14% (1 in 88)
risk of accreta *if* previa is present: 40% (1 in 2.5)

If she has a third CS and becomes pregnant again, the risk during that
fourth pregnancy increases to:

risk of accreta: 2.13% (1 in 47)
risk of previa: 2.27% (1 in 44)
risk of accreta *if* previa is present: 61% (1 in 1.6)

Compare that to the risks in a first pregnancy:

risk of accreta: 0.24% (1 in 417)
risk of previa: 6.4% (1 in 16) [yes, that figure is correct, previa was the reason for many of these women’s primary CS]
risk of accreta *if* previa is present: 3% (1 in 33)

That means the risk of accreta increases 887% from the first pregnancy – a huge jump.

So, if it was me, getting that ultrasound and knowing I didn’t have these complications would give me huge peace of mind.

Just kicking the can of risk down the road

This is why cesareans should not be casual or performed for the convenience of anyone.  They should be reserved for real medical reasons so that the benefits of having the cesarean outweigh the risks.  And there are real risks to cesareans, but since the ones list below are future risks, they may seem less real.  Per a November 2011 study published in the Journal of Maternal-Fetal and Neonatal Medicine:

If primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually. The rise in these complications will lag behind the rise in cesareans by approximately 6 years.

Placenta previa and accreta are nothing to mess around with.  Accreta in particular has a very high maternal mortality rate and many mothers end up having cesarean hysterectomies.   I write more about accreta here.

Many women do not think these complications are applicable to them as they don’t plan on more children after their two cesareans.  But I know many women, and I’m sure you do too, who were not planning on more children, but got pregnant nonetheless.  Unless you or your partner get sterilized or practice abstinence (what fun!), the chance of you getting pregnant is there.

By performing routine scheduled repeat cesareans, we do reduce the risk of uterine rupture in the current pregnancy, but we are also increasing the risks of accreta, previa, maternal death as well as uterine rupture in future pregnancies.  In addition, another large study found

[t]he risks of placenta accreta, cystotomy [surgical incision of the urinary bladder], bowel injury, ureteral [ureters are muscular ducts that propel urine from the kidneys to the urinary bladder] injury, and ileus [disruption of the normal propulsive gastrointestinal motor activity], the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries.

And this is especially relevant in rural hospitals which institute VBAC bans because they don’t offer 24/7 anesthesia.  Even though the “immediately available” clause was removed in the latest (2010) ACOG VBAC Practice Bulletin, many of these bans still stand.

However, in order to rapidly respond to the potentially sudden diagnosis of accreta, previa, or abruption, the hospital will have to enact many of the same ideas provided at the 2010 NIH VBAC Conference on how a hospital without 24/7 anesthesia can safely offer VBAC and respond to uterine rupture.  So why not just institute those ideas from the get-go and offer VBAC to those who want it?  (I know, I know: medico-legal reasons, which the NIH also addressed, but that is another post.)  From VBAC Ban Rationale is Irrational:

 As David J. Birnbach, M.D., M.P.H (2010), who presented on the impact of anesthesiologists on the incidence of VBAC [at the 2010 NIH VBAC Conference] asserted:

Lack of immediate available of anesthesia may not always be a key factor in outcome [during a uterine rupture], especially in cases where the obstetrician is not present. Many cases of uterine rupture can be stabilized while the anesthesiologists becomes available, and examples have been suggested of ways to reduce the risk associated with such a crisis. These include antepartum [prenatal] consultation of VBAC patients with the anesthesia departments, development of cesarean delivery under local anesthesia protocols, finding methods of improving communication on labor and delivery suites, practice “fire-drills,” and development of protocols matching resources to risk.

I urge you to watch Dr. Birnbach’s presentation along with all the presentations from the 2010 NIH VBAC conference.

Read more about the how the risk of serious complications increase with each cesarean surgery.

Below is Silver’s (2006) study abstract:

J Matern Fetal Neonatal Med. 2011 Nov;24(11):1341-6. Epub 2011 Mar 7.

The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality.

Solheim KN, Esakoff TF, Little SE, Cheng YW, Sparks TN, Caughey AB. Source Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA. Abstract

OBJECTIVE: The overall annual incidence rate of caesarean delivery in the United States has been steadily rising since 1996, reaching 32.9% in 2009. Primary cesareans often lead to repeat cesareans, which may lead to placenta previa and placenta accreta. This study’s goal was to forecast the effect of rising primary and secondary cesarean rates on annual incidence of placenta previa, placenta accreta, and maternal mortality.

METHODS: A decision-analytic model was built using TreeAge Pro software to estimate the future annual incidence of placenta previa, placenta accreta, and maternal mortality using data on national birthing order trends and cesarean and vaginal birth after cesarean rates. Baseline assumptions were derived from the literature, including the likelihood of previa and accreta among women with multiple previous cesarean deliveries.

RESULTS: If primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually. The rise in these complications will lag behind the rise in cesareans by approximately 6 years.

CONCLUSIONS: If cesarean rates continue to increase, the annual incidence of placenta previa, placenta accreta, and maternal death will also rise substantially.

http://www.ncbi.nlm.nih.gov/pubmed/21381881

Options when threatened with a “forced” cesarean

3/26/12- The ACLU has posted an article on their blog regarding this case where they released the letter they faxed to the OB group on behalf of the “forced CS” mom. This letter is an excellent resource for any person who works with pregnant women as it reviews the case law and illustrates that “a pregnant woman, like all other persons, has the right to refuse any and all medical interventions that she does not want, even if her doctor disagrees.  In a case called In Re A.C., brought by the ACLU 25 years ago on behalf of a woman forced by court order to undergo a life-threatening C-section, the judge explained: ‘[I]n virtually all cases the question of what is to be done is decided by the patient – the pregnant woman – on behalf of herself and her fetus.'”

A Little Background

On March 2, 2012, a doula contacted me because a GBS positive client was seeking a VBA2C. Her OB group was supportive until they withdrew support of her VBA2C plans at 37 weeks due to factors that had nothing to do with her. I suspect that the OB group – who was known to be VBAC & VBA2C supportive – had a lawsuit/ uterine rupture/ bad outcome that made them so abruptly change their VBAC policy. Nothing developed during the mom’s pregnancy that suddenly made her a poor candidate for VBA2C.

With the mom’s permission, her doula contacted me to help them determine their options. (Below you will find the initial email I received from the doula.) I’m not an attorney or a medical professional, so I could not advise them. I turned to Facebook to collect options and opinions. Through those posts, I was directed to people who could help them – OBs, midwives, reporters, legal organizations, and attorneys. Now it was up to the mom whether she wanted to contact those people/orgs to get their opinions and advice.

Her name and her doula’s name were not made public so that the mom could make this decision without the public eye directly on her and all that comes with that.

What follows below is a brief timeline of the events and then there are emails that follow sharing more detail.

The National Advocates for Pregnant Women becomes involved

Update 3/3/12 12:08 PST- I contacted the National Advocates for Pregnant Women last night and the Executive Director Lynn Paltrow replied early this morning with lawyer referrals and a review of the case law. I have included her email below with her permission. This is good information for anyone who works with pregnant women.

1:01 PST- Mie Lewis of the ACLU Women’s Rights Project recently expressed interest in taking on cases like these. Mie Lewis is in New York city and would be an excellent resource for any other women who experience similar situations.

For women in South Carolina, you can contact your state chapter of the ACLU:

Susan K. Dunn
Legal Director
ACLU, South Carolina
P.O. Box 20998
Charleston, SC 29413-0998
843-720-1425

Elizabeth Cohen, Senior Medical Correspondent for CNN and CNN’s Sabriya Rice are two reporters who have written about birth and might be worth contacting if you find yourself in a similar situation. Check out “Mom defies doctor, has baby her way” dated December 16, 2010 to get a feel for their writing.

3/5/12 6:40 PST – I learned last night that the mom was able to get her cesarean rescheduled two days later for March 7th.

ACLU, NAPW, & NBPC fax a letter to the OB group, mom has preoperative appointment

3/6/12 4:15 PST – The mom’s doula contacted me with an update. Today the mom and the doula attended the mom’s preoperative appointment for her scheduled cesarean on March 7, 2012. Early this morning, a letter composed by members of the ACLU, ACLU Women’s Rights Project, National Birth Policy Coalition, and National Advocates for Pregnant Women was faxed to the OB group. (You can read the letter here.) The mom and doula also brought a copy of the letter to the appointment. From the doula’s statement: “[The OB] said that this was clearly a misunderstanding and miscommunication and that it didn’t deserve legal attention. That right there tells me that the point and purpose of the letter had worked!!”

When the OB referenced ACOG’s VBAC recommendations and the fact that they do not support VBA2C, the mom asked for the date of the recommendations the OB was using. Turns out he was not aware, and was shocked to learn, that ACOG released a new VBAC Practice Bulletin in 2010 stating, VBAC is a “safe and appropriate choice for most women” with one prior cesarean and for “some women” with two prior cesareans.

This is why it is crucial for women to be informed and resourceful! What if this mom was like most moms who choose whatever mode of delivery their OB recommends without understanding the risk and benefits of their options? She would have had a cesarean at 40 weeks per an outdated ACOG VBAC Practice Bulletin.

Instead, the cesarean date has been moved back to 41 weeks (March 17th) and if mom doesn’t go into labor before that, she is OK with having a cesarean on that date. You can read the full letter from the doula detailing the pre-operative appointment below.

Mom goes into labor

3/7/12 – I’m informed that the mom’s water broke and am in communication with the doula throughout the day. Several hours after spontaneous rupture of membranes, contractions start and labor progressed, but then fizzled out. “Dr S. decided that because she had come this far only to hit a wall that wasn’t moving after trying all natural approaches, he would start a very, very, very low dose of Pitocin [starting at 2 milliunits/hour with a maximum of 4 milliunits/hour] through her IV.” Things start picking up again, but then some fetal distress was detected and Pit was backed off and finally turned off completely. Fetal heart tones stabilized but at a lower baseline than before.

Suddenly fetal heart tones drop and then disappear. A STAT cesarean is called, mom was put under general anesthesia, and within TEN MINUTES, the baby is born. Mom was fine as well.

A placental abruption was diagnosed during surgery. An abruption is when the placenta detaches from the uterine wall before the baby is born. This deprives the baby of oxygen and mom is at risk for hemorrhage. Full abruption is very dire for baby. While there is about a 6% chance of infant death or oxygen deprivation after an uterine rupture (Landon, 2004), there is a 12% risk of infant death after a placental abruption (Ananth, 1999). That is a grim statistic.

I am extremely thankful that this mom birthed where she felt safest which was in the hospital despite the many who suggested she plan a last minute home birth.  While I am supportive of home birth and I myself had a home birth, that doesn’t mean that I think all complications can be easily managed at home.  There are complications that are better served in the hospital environment.  Had she planned a home birth, she could have been totally fine, transferred in time, or she could have had a bad outcome.  The fact is, we don’t know.   I do think women who have placental abruptions have better odds in the hospital.

As the doula said of the mom,

She is very thankful she didn’t take the suggestions of some – to call in an underground midwife, to have a home birth, to go to another state and deliver, to labor at home until she was feeling pushy. Any of those suggestions could have had deadly consequences for Emily and her baby. She is thankful that she was given the opportunity to attempt a vaginal delivery, and she is thankful that her body tried to labor. Ultimately though, she is so very thankful that there was an amazing medical team who jumped right into action and essentially saved the lives of both her and her sweet baby girl. She let me know that if she could go back in time, there is nothing she would have changed.

In the mom’s own words:

I don’t think I would have done anything different. I might have said hey lets keep it [the pitocin] at two [milliunits] but hey it [the abruption] would have happened either way. It was God’s way of saying, hey this baby needs out and isn’t coming out the normal way. I let you try it now it is time for you to go ahead and meet her.

Mom is up and around the day after surgery and not needing pain medication! Hopefully this means she will have one of those easy cesarean recoveries of which I am forever jealous! Baby is breastfeeding well. I wish this mom and baby a quick recovery and a happy, happy babymoon!

You can read the doula’s full account of the birth here.

Follow Up

I’ve received a few comments questioning the use of Pitocin in a VBAC and even some comments suggesting that if the mom was at home, the abruption wouldn’t have happened because she wouldn’t have had the Pitocin.

In terms of Pitocin in VBAC moms: 99% of VBAC induced/augmented labors do NOT rupture (Landon, 2004). I haven’t seen rupture rates in VBA2C induced/augmented labors. With induction or augmentation, the increased risk of rupture comes from the drug and the dose. I do not know if the dose given to the mom is in the “danger zone.” I’d appreciate any studies that have measured Pitocin augmented uterine rupture rates and abruption rates by dose in VBAC labors.

But please know, that most ruptures occur in spontaneous labors. Zwart (2009) is a Netherlands based study that included 358,874 total deliveries, making it “the largest prospective report of uterine rupture in women without a previous cesarean in a Western country.” It also differentiated between uterine rupture and dehiscence. Zwart (2009) “found of the 208 scarred and unscarred uterine ruptures, 130 (62.5%) occurred during spontaneous labor reflecting 72% of scarred ruptures and 56% of unscarred ruptures. 28 (13.5%) ruptures occurred during cervical prostaglandin induction. 22 (10.6%) ruptures occurred during oxytocin (Pitocin) induction.” 40% of scarred ruptures occurred during prostaglandin induction. Read more here.

In terms of Pit causing the abruption, none of us know whether that is true to not.  Certainly most women who have Pitocin do not abrupt.  Further, people said that if she was at home, she wouldn’t have been augmented, and she wouldn’t have abrupted.  None of us know that.  Some people believe the myth that nothing can go wrong in a spontaneous “unmessed with” birth.  That is a dangerous and false belief.  All complications are not the result of “interventions gone wrong.”  Sometimes you can do everything “right” and still have a complication/ bad outcome.  Here is one mom’s story of her placental abruption at home (trigger warning).  She survived, her baby girl Aquila did not.  I share this story solely to illustrate the severity of placental abruption and how having a competent care provider and immediate access to operating rooms, surgeons, and blood products can literally make the difference between life and death.  Abruption can be a very serious complication.  Most women who have home births will not have a placental abruption or any other complication that requires immediate access to surgery, but those who do will greatly benefit from a qualified care provide who can facilitate immediate transfer to a hospital.

A quick google search found this study which found a slight increase of abruption risk per mode of delivery: 1.06% during the third cesarean vs 0.91% during the third vaginal delivery. I’d be interested in reading other studies people have handy. It did not control for induction or augmentation, so if you have a study that does control by drug and dose, please share.

The OB suggested the Pit and the mom consented.  I do think that is the point.  I do think women should be given the option of augmentation/induction rather than just “required” to have another cesarean as many OBs do. As Dr. Stuart Fischbein, a breech & VBAC supportive Southern California OB, recently shared on my Facebook page,

According to ACOG, prior low transverse c/section is not a contraindication to induction (other than the use of misoprostol [Cytotec]) so a foley balloon or pitocin may be used safely in these women. The problem arises when a practitioner does not believe in doing inductions on women with prior c/section. Despite the evidence and the ACOG clinical guideline the reality is that many doctors will just not want to deal with it.

I actually was impressed that the OB gave the mom the option of a gentle augmentation. It’s certainly better than just saying, “Your time in up.” I don’t know if I would have made a different choice being in this mom’s position: VBA2C, GBS+, contractions sputtering out… It’s really hard for me to say what I would have done. Yet it has seemed very easy for people  sitting at their computer the morning after to make judgements as they do not have to deal with the real risks or consequences. Sometimes you can do everything “right” and still have a bad outcome. Fortunately, the abruption was detected, surgery was performed, and everyone survived.

———————————

3/2/12 – [This is what I wrote upon receiving the doula’s initial email.] I just received this email tonight and need ideas quick. This term mom seeking VBA2C is in the the Columbia area of South Carolina. Her OB was supportive until 37 weeks. Her cesarean is scheduled for March 7, 2012. She was told that if she shows up in labor, she will be “forced” to have a cesarean. Does anyone know of a care provider in her area that would be willing to accept a new client this late in pregnancy? What other options does she have? Additionally, I’m looking for information on the legality of a hospital/OB “forcing” a c/s? What happens if she shows up at the current hospital and refuses to sign the c/s consent form? What exactly CAN they do??

Jen,

I need some quick help with a client of mine and was wondering if you’d lend an ear and offer up any words of wisdom as I know you are an amazing resource to VBAC.

I have a client who is due today. She had a primary c/s 4 years ago exactly on her EDD for a breech baby. She had a RCS 15 months ago because she was carrying twins.

She is seeing the same practice who did her first two c/s, so they are well versed in her medical history. She had double layer sutures both times, good space between deliveries, deliveries were due to breech & twins and not FTP, CPD, ect… She was deemed a good candidate for VBA2C and has been planning once since.

At her 37wk check-up, the OB told her that the staff had changed their minds and could no longer offer her a VBAC. She questioned the reasoning and he said it was just too risky. She was completely blindsided by this and broke down crying – the OB left the room.

Back to her 38wk appointment and she found out the OB had scheduled her RCS for 2 days after her EDD. She confronted the OB (this time a different one than she saw the week prior) and the OB said she didn’t see any reason why she couldn’t be offered a TOLAC. Relieved, my client went on about her business. Pregnancy has been great. Minimal weight gain, no GD, BP always great. She is GBS +. She received a phone call two days later and the OB said each OB on staff had met and it was decided that a VBA2C was too risky and she wouldn’t be allowed to have a TOLAC. My client was furious, and rightly so. She tried to get in touch with the OB but played phone tag back and forth.

Her 39wk appointment came – this time with a different OB yet again. He was a total jerk. Laughed when she told him she wanted a chance to labor. She showed him the current ACOG guidelines which support VBA2C with the right circumstances (which she has) and he disregarded it and showed her a paper on the risk of VBAC. She argued yet again and said she wouldn’t consent to a c/s unless she or the baby were in danger. He told her that if she showed up to L&D in labor they would “force” her to have a c/s. Yes, he actually told her they’d “force” her. She left a crying, hurt, furious mess.

The next day she called to request her records and the OB told her again – if she delivered with their practice, it would be VIA c/s – end of story. If she didn’t want to comply, they’d (legally) find another practice to take her (HIGHLY unlikely considering she’s due today)…

She hasn’t been back since but has a section scheduled for the 5th that she intends to cancel. I am virtually her only support. Her MIL has 2 c/s, her mother had 3 c/s and thinks she’ll die if she attempts a vaginal birth. Her husband says he has to know when the baby is coming so he can plan to get off of work – so he is fine with the section and not supportive or helpful much.

We have had massively long talks over the past few days and what it boils down to is that she has two choices essentially.

#1 – Show up in labor at her current hospital and have to fight like hell to be able to labor. Almost certainly have the OB on call make the process very difficult. She voiced a concern that the OB may be so pissed off that she’s refusing a c.s that they’ll find some reason to section – “fetal distress”, baby too big, baby not fitting, failure to progress, ect… She also worries exactly what they truly mean by they’ll “force” her to have a c/s. She worries they’ll do something extreme like call DSS/CPS. She’s heard a horror story of a court-ordered c/s. I told her that all that worry, stress, and anxiety during labor will do absolutely nothing good for her well being and progress.

#2. Show up at a different hospital and deliver with the hospital OB. Problem here is she has no record of prenatal care, no surgical records to show suture status, time between sections, ect… She requested her records from the current OBs office, but no one is getting back to her (and I doubt they will…). I know they’ll look down on that and potentially try to coerce into a section due to that. She feels she’d face the least opposition going this route, but has concerns.

I’m exhausted and so is this mama. She is still firm in her choice that a VBAC is the best and safest option for her and her child and I fully support that. I’m not even sure what the right option is at this point or where to turn or what to do. I’m trying to let the mama guide but she’s looking to me as if I can somehow make this entire situation go away… I wish I had the answers, but I don’t.

I was just wondering if you had any information on the legality of a hospital/OB “forcing” a c/s? What happens if she shows up at the current hospital and refuses to sign the c/s consent form? What exactly CAN they do?? Have you had any experience in with cases like this?? What option do you feel would be best (#1 or #2) and how should I direct the mama to handle the staff? What is my role here? I’m just at a loss and felt I needed to seek counsel…

Thank you for listening, I know it was so long..

3/3/12 – I receive an email from Lynn Paltrow, Executive Director for the National Advocates of Pregnant Women:

Dear Jen:

By this email,I am cc’ing two lawyers in South Carolina, Susan Dunn and C. Rauch “Rock” Wise, and SC activist Sally Hebert as well as other people out of state who may have useful suggestions, including Farah on our staff who is especially knowledgeable about cases involving threats of forced cesarean surgery. I know a great deal about the law in South Carolina but am not admitted to practice there, so any legal questions should be directed to lawyers admitted to the bar in South Carolina.

I can, however, share with you some general background. As a matter of constitutional law, medical ethics, and human rights, doctors may not force their patients — including pregnant ones — to undergo procedures they do not consent to.

As a policy matter, both the American Medical Association and the Ethics Committee of the American College of Obstetricians and Gynecologists have taken express positions opposing court ordered interventions against pregnant women and against effort by hospitals and doctors to seek such orders. The American College of Obstetricians and Gynecologists has issued a formal opinion stating that “actions of coercion to obtain consent or force a course of action limit maternal freedom of choice, threaten the doctor/patient relationships, and violate the principles underlying the informed consent process.” See American College of Obstetricians and Gynecologists Committee Opinion No. 55, Patient Choice: Ma­ternal-Fetal Conflict (1987) (And more recent opinions 2005); Report of American Medical Association Board of Trustees, Legal Interventions During Pregnancy, 264 JAMA 2663, 267 (1990) (“Judicial intervention is inappropriate when a woman has made an informed refusal of a medical treatment designed to benefit her fetus.”)

Appellate cases decided on full records and addressing the issue of court ordered interventions on pregnant women have held that the medical and constitutional principles of informed consent, bodily integrity, and patient privacy and autonomy require that pregnant women have the right under the common law and the constitution to accept or refuse medical treatment, like all other patients. See In re A.C., 573 A.2d 1235, 1253 (D.C. 1990) (en banc) (vacating a court-ordered cesarean section that was listed as a contributing factor to the mother’s death on her death certificate); In re Fetus Brown, 689 N.E.2d 397, 400 (Ill. App. Ct. 1997) (overturning a court-ordered blood transfusion of a pregnant woman); In re Baby Boy Doe, 632 N.E.2d 326 (Ill. App. Ct. 1994) (holding that courts may not balance whatever rights a fetus may have against the rights of a competent woman, whose choice to refuse medical treatment as invasive as a cesarean section must be honored even if the choice may be harmful to the fetus). Cf. Stallman v. Youngquist, 531 N.E.2d 355, 359-61 (Ill. 1988) (refusing to recognize the tort of maternal prenatal negligence, holding that granting fetuses legal rights in this manner “would involve an unprecedented intrusion into the privacy and autonomy of the [state’s female] citizens”).

Nevertheless, South Carolina stands out in the nation for having judicially created law that treats viable fetuses as if they are separate persons. As a result, certain women have been found guilty of child abuse for risking harm to their unborn children. None of these cases in South Carolina, so far, involve women who have refused cesarean surgery. These decisions, do apparently embolden doctors to believe they can impose their view of what is best on their patients.

Theoretically, it might be possible to go to court to get a Temporary Restraining Order –ordering the hospital not to do as they have threatened. If Susan or Rauch or another South Carolina attorney and the client wish to and are able to go this route, our office may have some draft/model papers that would help with such an effort and we would be happy to consult with/advise/share information with that lawyer.

Regardless, however, of what rights this woman has on paper, she has to deal with the stress of this situation and ensuring that she has access to the health care she does need and want. I cannot advise on what medical course she should take.

I can say though that, however she proceeds NAPW would be very interested in also exploring how we could help if she wishes to challenge these actions after the birth or bring them to public attention. Similarly, if child welfare is called,(something else that would not be supported by constitutional law etc– but is a scary, if remote, possibility) NAPW would be interested in helping her local counsel.

I will be on a plane this morning, but my cell phone is below in the signature block. When it gets a bit later, I will try and reach some of the South Carolina folks by phone to give them the heads up about your email.

Please, in any event, let us know what happens. We will be worrying about this Mom.

Sincerely,

Lynn M. Paltrow
Executive Director
National Advocates for Pregnant Women
15 West 36th Street, Suite 901
New York, New York 10018
212-255-9252
212-255-9253 (fax)
917-921-7421 (cell)
lmp@advocatesforpregnantwomen.org
www.advocatesforpregnantwomen.org
Be a “Fan” of NAPW on Facebook
Follow me on Twitter.Mel

3/6/12 4:15 PST – Update from mom’s doula:

Thank you everyone – especially Jen – for uplifting this mother in your thoughts and prayers and helping us join together as a community to help this wonderful mother out!

Last night, four wonderful women got together and composed a letter to the mama’s OB/GYN practice. These women were members of ACLU, ACLU Women’s Rights Project, National Birth Policy Coalition, and National Advocates for Pregnant women. Thank you so much Jen for contacting these women on the behalf of my client and myself. The letter was absolutely wonderful and explained in detail the things the practice were doing were wrong among many other things – it was very detailed!!! The letter was faxed to the practice first things this morning and a copy was sent to myself and my client.

When we arrived at the consultation, the practice had already received and read the letter and it was in my client’s chart. We were ushered directly to the OB’s office instead of an exam room. We sat down and began to discuss the issues at hand. I was providing moral support while my client took the lead. The OB explained that he believed this was all simply miscommunication. He said that while they have very strong feelings on things such as this, they could not and would not force her to do anything and that no one would come and drag her out of bed tomorrow for her scheduled cesarean. He said that this was clearly a misunderstanding and miscommunication and that it didn’t deserve legal attention. That right there tells me that the point and purpose of the letter had worked!! I knew when I read the letter that it was either going to upset the practice tremendously and they would seek a court order for a cesarean, call DSS/CPS for her endangering her child’s life since SC is a personhood state, or something similar. Alternatively, the letter may shake them into reality and make them realize they are dealing with a mother who is fully informed of her rights and ready to take action and they would back down. Thankfully, the second option ended up happening!! You could tell it was obvious he was shocked that someone went to such lengths to get their attention and fight for what they wanted.

He had the ACOG guidelines book on his desk bookmarked to the VBAC policy and showed us that VBAC after two or more cesareans is contraindicated and the ACOG doesn’t support it. He explained the risk of rupture was 1-2.6% after 2 cesarean section. He explained the risk and that if my client were his wife, he would advise she have a RCS. He was very calm and we remained very calm as well. He said that now the ball was in her court. When he was done explaining his position, my client began to explain hers. Her first question was the publication date for the VBAC ACOG guidelines he had looked up because she believed they were out of date. He looked surprised to be challenged and we took out my binder that had the most recent, revamped ACOG recommendation that is to allow a TOLAC in mothers with two prior low transverse uterine incisions. He was shocked and had no idea that the guidelines had changed…. No wonder our system is so in need of VBAC support – the doctors don’t even know their own governing body’s recommendation!! She explained that she understood the risk involved, but she also understood the risk of a 3rd cesarean section and all she wanted was their blessing to have a trial of labor. She explained that she wouldn’t hesitate to agree to a cesarean section should there arise a true need. They talked further and agreed that she would be allowed to be left alone until 41 weeks – March 17th (they have her EDD as March 11th) to go into labor and be allowed a TOLAC. No induction methods would be used. If no labor and no changing cervix by March 17th, a cesarean will be scheduled and the mom is ok with this.

Everything looks great at her appointment – she’s had no cervical change and the baby is very high still – baby is floating according to the doctor. She’s going to work to bring her baby down and prepare her body for labor. She feels as if a weight has been lifted from her shoulders and she can finally relax. We both agree that being stress-free will do a world of good and we pray she goes into labor on her own before the 17th. Send her good thoughts and prayers that her body kicks into gear and decides it is time to have a baby!!

I am elated that this took such a wonderful turn!! It was such a dark time for quite awhile! Thank you everyone for the continued support and I will keep everyone updated with the mother’s permission!! Hopefully she has a wonderful story to tell very soon!