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/