Category Archives: Home birth

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/

 

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

 

What can you do when your hospital bans VBAC?

Amber recently left this comment on the Quick Facts page:

i am pregnant for the second time my first child was delivered by c-section my goal is to have my second child natural but the obgyns in my area will not allow someone who has had a c-section to have a natural birth they said it is hospital policy what would you recommend?

Amber,

First educate yourself and then you can take action. You have many options.

I suggest you review the following documents and provide a copy to your health care provider: the most recent ACOG VBAC guidelines, the National Institute of Heath’s 2010 VBAC Statement, and the article VBAC ban rationale is irrational.

Next, read through the steps of planning a VBAC and familiarize yourself with the misinformation that some OBs have used to persuade women to schedule repeat cesareans, so if you hear these same lies, you can identify them: Another VBAC Consult Misinforms, Scare tactics vs. informed consent, VBACing against the odds, and A father says, Why invite the risk of VBAC?.

Additionally, it’s important to know that there are many birth myths rampant on the internet that misrepresent the primary risk of VBAC by minimizing the risk of uterine rupture such as “the risk of uterine rupture in a VBAC mom is similar to (or double) that of an unscarred mom’s risk,” or “the risk of uterine rupture in an induced, unscarred mom is the same as a VBAC mom,” or “a VBAC mom is more likely to be bitten by a shark or struck by lightning than have an uterine rupture.” Again, all these statements are false. And if you see a blog report really low uterine rupture or mortality rates, it’s likely the result of incorrect math.

On to your question. . . Unfortunately, I don’t have any personal experience of pursuing a VBAC in a VBAC ban hospital because I planned a home VBAC in order to avoid all that (almost certain) drama in the hospital. So, I went to my Facebook peeps and got their suggestions and they did not disappoint!

Here are their ideas in their own words…

1. Let hospital administrators and the board of directors know.

Mamas that are passing on a hospital because of their VBAC policy, need to then write the hospital administrators and the boards of directors to tell them that they birthed at XXX Hospital instead of theirs because of their VBAC policy. Hospitals need to hear that they are losing births (aka $$$) because of their policies.

2. Find an ICAN chapter near you.

She needs to get in touch with her closest local ICAN chapter TODAY. They will know details on the exact situation in her area. She should not put stock in what one person tells her- there is a lot of misinformation and myth out there. She can find both a local chapter and information about fighting a VBAC ban at www.ican-online.org

3. Sign a waiver and exercise your legal right to refuse surgery.

I had a VBAC at a hospital where no doctor staff supported it but low and behold all the nurses were amazing! I went in at 5 cm and 3 hours later baby was in my arms. Strong support is a must – I had a midwife, my husband, mom and sister. Stay focused. Don’t sign anything- except the refusal of c/section form- get in there and push your baby out!

and . . .

I would encourage her to ask to see this policy & ask if she would be allowed to sign a waiver. Ask friends if anyone they know has VBAC’d there or at another area facility. I had an experience in my last VBAC where I was told of a “policy” that didn’t really exist except in that person’s mind.

and . . .

Under the right to informed decision making she has the right to say “no thank you”. Absent a court order for a cesarean they cant force her. I’m not a huge fan of the “show up pushing” crowd, but it may appeal to her. Or she could labor in a nearby hotel with a midwife or montrice to monitor the baby and then go in to the hospital at the last minute. Again, not a fan but we’re looking at options here.

and . . .

Regarding stories of VBAC-ban hospitals. I don’t have experience myself, as my VBAC was done with a CNM at a supportive facility – but I’ve attended a VBAC at a local hospital with a VBAC ban. Mama had a RCS [repeat cesarean section] scheduled (though she didn’t intend on going in) but went into spontaneous labor 6 days prior. She labored at home several hours until contractions were about 3 minutes apart. When we arrived and they realized she had a previous c/s, they began calling in a team to prep the OR.

The mama was beyond calm – and in the middle of labor – requested to speak with the staff. The nurses (there were maybe 4 in there?), the attending OB, and the anesthesiologist (who had already been paged for the spinal for surgery) were in her room (ready to wheel her to the OR). Between contractions, she quickly and quietly explained that she was aware it wasn’t typical policy to attend a VBAC, but she was there and it was their legal duty to treat her and she was exercising her legal right to refuse unnecessary surgery.

The nurses looked shocked, the anesthesiologist said something about he was clearly not needed, and the OB (who I swear was VBAC accepting but just was staffed at a VBAC-ban hospital) told her that she was correct, they had to treat her and couldn’t force her to do anything unless her baby was in danger but she’d need to sign quite a bit of paperwork documenting the situation. He had the most odd grin/smirk on his face while he said that as if to somehow thank her for having the nerve to stand up for herself. He left the room and we didn’t see him again until she was crowning.

I in no way, shape, or form feel that that scenario is typical of a VBAC-ban situation, but it was certainly enjoyable and entertaining to have experienced that with my client.

and . . .

I just refused the c-section at a VBAC ban hospital. With my first, I pushed for 4 hours, and he didn’t get past the 0 station (he was presenting transverse) — We lived too far away from the hospital for a homebirth at our own home, but I hired the homebirth midwife for concurrent care. She was going to monitor us at a hotel near the hospital for labor, but thankfully everything went so fast we just met her at the hospital. She served as doula there. I found out from an OB nurse that one of the OBs did support a woman’s right to refuse (though not enthusiastically). I knew I needed care I could trust, so that the only c-section I got was medically necessary. You can read where my midwife tells our story here.

You have every right to refuse an unnecessary c-section, I’d just HIGHLY recommend laboring out of the hospital, and having a doula or knowledgeable advocate with you!

and . . .

This is my advice for VBACing at a banned hospital –

– Sign your informed refusal ahead of time, and be aware that when presented with the risks of VBAC, it will majorly underplay RCS risks; it might be a good idea not to bring your husband to this appointment if he’s feeling nervous about VBAC. [Or have your husband read this article beforehand.]

– Don’t let them give you a late term ultrasound for anything other than a medical problem (in other words — refuse the late ultrasound for size)

– Plan to labor out of the hospital; use a monitrice if you are nervous about that, or a good doula

– Have a smart advocate with you at the hospital so you don’t have to fight any battles yourself and can just focus on laboring

– Get good prenatal care — I did acupuncture and chiropractic, and both of those people had offered to help me in labor if I needed; having that support and belief was very empowering, because my OB absolutely didn’t think we “could” VBAC

– Own your decision; don’t be wishy-washy… be stubborn… this is YOUR BODY. I had a personal mantra that I repeated to myself over and over, “I will only have a medically necessary c-section.”

– Learn ways to get through labor naturally; I really liked the strategies in “Birthing from Within” — even more than hypno or Bradley techniques

– Show up in advanced labor (I was complete when we got to the hospital)

– Know your personal hang-ups — I pushed for 4 hours with my son and am SO GLAD that I labored down in a small bathroom until my urge to push was really strong and spontaneous; I am so glad I wasn’t on the bed pushing for a long time, because this would have brought back too many bad memories and made me feel panicky, tired, and out of control. When I got on the bed to push, I was practically crowning. THAT was very empowering for a “failure to descend” mama

To bottom line – do what you have to to get the care you need, even with limited options; own your body and decision, and give yourself every advantage and tool that you can to help ensure success.

and a VBAC supportive OB who worked in a VBAC ban hospital says:

I’m supposed to tell patients that they have to go elsewhere if they want a VBAC, that they can’t stay in their own community, that they have to drive 50 miles. … I’m not supposed to tell them that they have the option of showing up in labor and refusing surgery. The hospital actually put in writing that I should avoid telling them that. They’re telling me to skew my counseling, and they have no shame in doing so.

4. Ask a different person at the hospital.

Remember that not everyone is knowledgeable about VBAC or a specific hospital’s VBAC policy, even if they work at that hospital.

I have heard an OB tell a mother that her only option was repeat cesarean because the hospital didn’t allow VBAC. The director of Maternal Child Health said it absolutely wasn’t true and gave her the names of VBAC friendly providers.

5. Find another hospital via the VBAC Policies by US Hospitals database compiled by ICAN.

Remember you are buying a service. Why pay for something you don’t want. Shop elsewhere.

6. Find another provider and ask these questions.

7. Birth in another city, county, or state.

Know what you’re comfortable with, hire a doula as well as a midwife or doctor especially if you have a hospital birth, and do your research so you know your rights and options. I’m currently about to “relocate” to Seattle at 37 weeks, from Juneau, AK where there is a hospital VBAC ban at our one hospital in town so I can try to have a VBAC in a more supportive environment. I didn’t think I wanted to fight the VBAC ban while in labor, I’d rather do my political activism in a clearer state of mind! It has been a stressful journey but I know I’m doing what’s right for me so I’m feeling really good about things now. I know this isn’t an option for many and a few women since the beginning of 2011 have refused repeat c/s at our hospital. Good luck!

and . . .

Go somewhere else. . . I traveled 40 mins for my vbac in 2010 because the 6 hospitals around here wouldn’t let them either.

and . . .

I even know a family who crossed state lines to have her baby the way she desired because her states laws wouldn’t allow her.

Joy Szabo said

I found a sane doctor 5 hours away. I got slightly famous for it, too.

and I’ve heard of women traveling to Mexico to VBAC at Plenitude with Dr. José Luis.

8. Consider a homebirth.

Fighting the hospital system while trying to push out a baby is not a simple task. Yes, a support team can be a big help. Personally, I felt more comfortable staying home than going to the hospital with my boxing gloves. It’s a personal choice and she’ll have to see what she’s most comfortable with. At the end of the day, I played out both options in my mind and went with the one that I felt most at peace with.

and. . .

Hello, my personal story in a nutshell… iatrogenically necessitated c/s with my first. For #2, it was a last minute change of plans… I’m a physician and I discovered through the grapevine that OB was planning to resection me without medical indication so #2 turned into planned HBAC. Homebirth VBAC successful with my second. The second was so beautiful, so peaceful, so uncomplicated!

9. Connect with resources for more ideas.

Stratton, B. (2006). 50 Ways to Protest a VBAC Denial. Retrieved from Midwifery Today: http://www.midwiferytoday.com/articles/50ways_vbac.asp

A good closing thought:

The term “will not allow” always bothers me. Perhaps they “won’t attend a VBAC” but they definitely can not stop you. Stand up for your rights. Show them the ACOG recommendation which is to allow a trial of labor! Seek out support. Call every OB you can think of. Look into a midwife. Hire a doula. You can do this.

Do you have more ideas?

Did you deliver at a VBAC ban hospital?

What was your strategy?

Are you a health care provider at a VBAC ban hospital and have some insight?

Myth: Risk of uterine rupture doesn’t change much after a cesarean

1/18/12 – The difference in uterine rupture (UR) rates between unscarred and scarred uteri is significant: 1 in 14,286 in an unscarred uterus and 1 in 156 in a scarred uterus.  Another way to express this is: 0.7 in 10,000 (0.007%) in an unscarred uterus and 64 in 10,000 (0.64%) in a scarred uterus.  This 91 times greater risk does not mean that the risk of UR is so large in a scarred mom, it’s that it’s so very, very small in an unscarred mom.

________________________________________

I came across a couple different bits of (mis)information the past day that have really concerned me. In both situations, people, one of whom is a certified professional midwife (CPM), give false information regarding how a cesarean affects one’s risk of uterine rupture in future pregnancies.

First, a women with a prior cesarean asks for uterine rupture rates after a cesarean, “preferable one with stats” on Facebook. One woman gives this reply:

… almost all cases the risk of rupture is less than one percent, even after multiple sections, or special scars such as an inverted T. The risk is roughly double what it is for an unscarred uterus, but considering the tiny numbers it doesn’t really make a difference, especially since the vast majority of ruptures are not catastrophic in nature, something that is not differentiated in study results.

(There are several things that are false in this statement, but I’ll save those for another post.) Then later in the day, I came across this comment from a CPM’s website:

Will you do a vaginal birth after cesarean?
Yes. Studies have shown that there isn’t much of a difference in uterine rupture rates in someone that has had a previous cesarean and someone who has never had one. A lot of my clients are VBAC’s or attempted VBAC’s. I am completely comfortable with this.

Both of these representations of uterine rupture after a cesarean are erroneous. It’s especially disturbing that a midwife who is counseling VBAC moms and attending their births at home, is giving her clients grossly incorrect information. The risk of a uterine rupture does much more than double after a cesarean as the risk in an unscarred uterus is infinitesimal in comparison to a scarred uterus.

Comparing the risk of uterine rupture: Prior cesarean vs. no prior cesarean

I started looking around and quickly found Uterine rupture in the Netherlands: a nationwide population-based cohort study (Zwart, 2009) which contains the data I needed to compare the rates of rupture in unscarred vs. scarred uteri. You can read the study in its entirety here.

This study included 358,874 total deliveries, making it “the largest prospective report of uterine rupture in women without a previous cesarean in a Western country.” It also differentiates between uterine rupture and dehiscence which is really important because we want to measure the rate of complete rupture. (Remember how the lady from Facebook made the statement, ” the vast majority of ruptures are not catastrophic in nature, something that is not differentiated in study results.” That portion of her statement was also false.)

Zwart (2009) looked at 25,989 deliveries after a cesarean and found 183 ruptures giving us a 0.64% uterine rupture rate or 64 per 10,000 deliveries. 72% of those ruptures occurred in spontaneous labors. Of the 183 ruptures, 7.7% resulted in infant deaths representing 14 babies dying. This gives us a rate of infant mortality due to uterine rupture after a cesarean of 0.05% or 5 in 10,000 deliveries.

Zwart also looked at 332,885 deliveries with no prior cesarean resulting in 25 ruptures giving us a 0.007% uterine rupture rate or .7 per 10,000 deliveries. 56% of ruptures occurred in spontaneous labors. Of the 25 ruptures, 24% resulted in infant deaths representing 6 babies dying. This gives us a rate of infant mortality due to uterine rupture in an unscarred uterus of 0.0018% or 0.18 in 10,000 deliveries.

This study found that the risk of uterine rupture is 91 times greater in a woman with a prior cesarean vs. a woman without a prior cesarean. Not double, not similar, but 91 times greater.

It is important to note that, “severe maternal and neonatal morbidity and mortality were clearly more often observed among women with an unscarred uterine rupture as compared to uterine scar rupture.” Meaning, if an unscarred mom ruptures, her baby is more likely to die than a scarred mom. We see this when we compare the 24% of unscarred ruptures that resulted in an infant death vs. the 7.7% of scarred ruptures that resulted in an infant death which represents a 3 fold greater risk.

However, due to the fact that uterine rupture occurs more frequently in a scarred uterus, the risk of infant mortality due to uterine rupture after a previous cesarean was 27.8 times greater than the risk of infant mortality after a rupture in an unscarred uterus.

In other words, while ruptures in unscarred uteri are more deadly to infants, more infants die due to ruptures in scarred uteri because they occur more frequently.

OBs are often vilified (rightfully so) for giving women inflated rates of uterine rupture and I’ve documented several examples here: Another VBAC Consult Misinforms, Scare tactics vs. informed consent, Hospital VBAC turned CS due to constant scare tactics, and A father says, Why invite the risk of VBAC?.

As a result, women seek out midwives thinking that they will be a source of accurate information and judicious support. But what happens when your midwife tells you that your risk of uterine rupture has not increased as a result of your prior cesarean section? If you have done your homework, hopefully you find another midwife fast. I would really question the skills and knowledge of a midwife who is so unknowledgeable on the risks of VBAC and yet attends VBAC births in an out-of-hospital setting.

But suppose your haven’t done your homework, you trust your midwife, and you move forward with your plan to have a VBAC at home based on the incorrect statistics she supplies. I can’t begin to imagine the rage I would feel if I decided to have a home VBAC based on false information provided by my care provider, and then the unimaginable happened, and I ruptured, and then I learned the truth: that my risk of uterine rupture increased 91 times as a result of my prior cesarean. I would be beyond angry. I would feel so betrayed.

It’s unfortunate when a woman chooses a mode of delivery based on false information. Whether it’s a a woman deciding to have a repeat cesarean due to the exaggerated risk of uterine rupture provided by her OB or a woman deciding to have a (home) VBAC due to her midwife playing down and underestimating the risk of uterine rupture. It is just as bad to minimize the risk of uterine rupture as it is to inflate the risk.

While the risk of rupture in a spontaneous labor after one prior low transverse cesarean is comparable to other obstetrical emergencies, it is important for women weighting their post-cesarean birth options to know that their risk increased substantially due to their prior cesarean. It is important for them to understand the risks and benefits of VBAC vs. repeat cesarean. It is important for them to have access to accurate information and be able to differentiate between a midwife’s/blogger’s/doula’s/birth advocate’s/person on Facebook’s hopeful opinion vs. documented statistics.

I implore those who interact with, and have impact on, women weighing their birth options: do not pass along information, no matter how great it sounds, if you don’t have a well-designed scientific study supporting it. If you hear a statistic you would love to use and share, just ask the person who gave you this information,”What is the source?” and use the citation anytime you quote the statistic. But if the person doesn’t have a well-designed scientific study, be wary and don’t use the stat. This way, we can reduce the rumor and increase the amount of good information on the Internet. I know, a lofty goal.

Read more birth myths debunked including Lightning strikes, shark bites, and uterine rupture and Myth: Unscarred mom induced (with Pit) as likely as VBAC mom to rupture.

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

rutpures in scarred uteri

Neonatal nurse has a homebirth VBAC

This is a great birth story, published with permission, of a woman who had a cesarean for “small pelvis” and then VBACed a larger baby at home!  Since she is a neonatal nurse, it’s interesting to read why she chose HBAC and how she thinks her birth would have gone differently had she labored in a hospital.


I just wanted to let everyone know that I gave birth to a healthy baby girl Wednesday June 11th. I had a C/S with my son 2 years ago.

He was 8lbs 2oz and I was told that my pelvis wasn’t big enough to birth an 8lb baby. Well my VBAC baby was 9lbs 2 oz. Exactly a pound bigger than they told me. I knew I wasn’t broken.

I chose to have a homebirth  because I felt I would always have to fight for what I wanted in the
hospital. My labor went great. Started around 3am contractions coming 10 minutes apart. Then progressed to 3-5 min apart at around 6:30am.

My midwife got there around 7:30am. Later I wanted to go into the birthing tub to try to get through the contractions. My midwife wanted to check to see how far I was. 4cm and 100% effaced. She told me to try to hold off on the tub because it would be better when I am
further in labor. I then took a hot shower.

For me the contractions were more bearable standing up. When one would come on I would bend my knees and lean over onto either the couch, my bed or my husband. The worse position for me to labor on was my back and my side.

After the shower I asked if I could go into the tub again. She checked me and I was 6cm with a bulging bag. I did go into the tub which for me didn’t make much difference in the contractions. But at that point I stayed in there for quite a while because it took too much energy for me to
move.

For me the worse part was going from 6 cm to complete. I thought it would have been the pushing part but it wasn’t. In the tub I did feel like pushing a little bit. We couldn’t tell if my water had broken since I was in the tub. I decided to get checked in the tub to see if the water had indeed broken and plus since I was feeling “pushy.” Still at 6cm but the bag was bulging more.

They think that was why I was feeling like I had to push. They let me push a couple of pushes to see if that would break my water but it didn’t. Then they told me not to push and just try to breath through the contractions. My water still wasn’t breaking and it was the hardest thing trying not to push when that overwhelming feeling was there. They gave me the option of breaking my water and felt that once they did that the baby’s head would apply to the cervix and help with dilation. I agreed. They broke the water and sure enough baby’s head came right
down and I was 8-9cm.

The pushing feeling let up and I labored more for a while. I then started feeling pushy again and they decided to check to make sure I was fully dilated before I fully pushed. I just had an anterior lip. Again they told me not to push so that the anterior lip would pull back over the baby’s head and not swell. I was dying to push but breathed through each contraction for an hour or two. (I lost all sense of time so I don’t know exactly how long it was.)

The best position for me was on my hands and knees but they said that with the anterior lip that the position was actually making it worse. They wanted me to lie on my back to help take pressure off the cervix to facilitate it moving around the baby’s head.

Lying on my back was so unbearable but I did it to help with the dilation. The midwife decided to try to help push the cervix over the head. She told me to push while she held it out of the way. Finally her head came down and I could fully push to my heart’s desire. That felt great.

They asked if I wanted to go back to the hands and knees position since the cervix isn’t an issue now but I said I just could not bear to move to another position. Then the “ring of fire came” Boy did that burn.

Finally her head came out and, surprise, so did a hand. They said that her hand was across her face. They pulled the hand out along with the head and since one shoulder was in and one was out she was having a little bit of trouble maneuvering.

They wanted me to flip to my hands and knees to open up the pelvis more. I thought they were crazy. Me trying to flip over with a head hanging out. I knew that I just had to do it as quickly as I could or it wouldn’t have gotten done. My husband said he had never seen me move so quickly in my life. I pushed a little more and she was out!

Amazingly I had no tears. Personally I thought that was pretty amazing to have my first full term vaginal birth of 9lbs 2oz with no tears what-so-ever!

So to all of those women who have been told that you would have died in childbirth because you couldn’t push out your own baby YOU CAN! I am proof that I delivered a baby 1 pound bigger than what they said.

I am a nurse who works in labor & delivery so I see all of the unnecessary interventions that they do.

I was pondering about my birth. If I would have chosen a hospital birth I probably would have ended up with another c/s or an episiotomy. There were times during my birth where I thought, “Am I crazy? I can’t deal with this pain!” The midwives and doula helped me through the intense contractions.

If I was at the hospital they would have bullied me into an epidural and therefore I wouldn’t have been able to move around to get her to come down. Also I wouldn’t have been able to feeling the progression of her head coming down when I pushed.

With my son I pushed and couldn’t really feel any progress so mentally I was losing hope. With this birth it didn’t feel like I pushed for an hour because I could feel the accomplishment of her
coming down. I see this happen all of the time at the hospital.

If a mom isn’t pushing quick enough for the doctor or they think the head is too big then they will automatically do an episiotomy. They probably would have done that and it just shows that it would have been for nothing and I would have had a longer recovery time.

So therefore I am grateful that I found homebirth and such wonderful midwives. I hope this inspires all of you who are having the normal feelings of “what if I can’t do it.” Good luck
to your future births, You CAN do it!

Florida law mandates that insurance covers homebirth

Found this blog where another woman uses Florida law to get her insurance to cover her homebirth.

Here is Florida Statute Number 627.6574, but it’s section 7 that spells it out very clearly.  I’ve bolded it for your reading pleasure….

1) Any group, blanket, or franchise policy of health insurance that provides coverage for maternity care must also cover the services of certified nurse-midwives and midwives licensed pursuant to chapter 467, and the services of birth centers licensed under ss. 383.30-383.335.
(2) Any group, blanket, or franchise policy of health insurance that provides maternity and newborn coverage may not limit coverage for the length of a maternity and newborn stay in a hospital or for followup care outside of a hospital to any time period that is less than that determined to be medically necessary, in accordance with prevailing medical standards and consistent with guidelines for perinatal care of the American Academy of Pediatrics or the American College of Obstetricians and Gynecologists, by the treating obstetrical care provider or the pediatric care provider.
(3) This section does not affect any agreement between an insurer and a hospital or other health care provider with respect to reimbursement for health care services provided, rate negotiations with providers, or capitation of providers, and this section does not prohibit appropriate utilization review or case management by an insurer.
(4) Any group, blanket, or franchise policy of health insurance that provides coverage, benefits, or services for maternity or newborn care must provide coverage for postdelivery care for a mother and her newborn infant. The postdelivery care must include a postpartum assessment and newborn assessment and may be provided at the hospital, at the attending physician’s office, at an outpatient maternity center, or in the home by a qualified licensed health care professional trained in mother and baby care. The services must include physical assessment of the newborn and mother, and the performance of any medically necessary clinical tests and immunizations in keeping with prevailing medical standards.
(5) An insurer subject to subsection (1) shall communicate active case questions and concerns regarding postdelivery care directly to the treating physician or hospital in written form, in addition to other forms of communication. Such insurers shall also use a process that includes a written protocol for utilization review and quality assurance.
(6) An insurer subject to subsection (1) may not:
(a) Deny to a mother or her newborn infant eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the policy for the purpose of avoiding the requirements of this section.
(b) Provide monetary payments or rebates to a mother to encourage the mother to accept less than the minimum protections available under this section.
(c) Penalize or otherwise reduce or limit the reimbursement of an attending provider solely because the attending provider provided care to an individual participant or beneficiary in accordance with this section.
(d) Provide incentives, monetary or otherwise, to an attending provider solely to induce the provider to provide care to an individual participant or beneficiary in a manner inconsistent with this section.
(e) Subject to paragraph (7)(c), restrict benefits for any portion of a period within a hospital length of stay required under subsection (2) in a manner that is less favorable than the benefits provided for any preceding portion of such stay.
(7)(a) This section does not require a mother who is a participant or beneficiary to:
1. Give birth in a hospital.
2. Stay in the hospital for a fixed period of time following the birth of her infant.
(b) This section does not apply with respect to any health insurance coverage that does not provide benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn infant.
(c) This section does not prevent a policy from imposing deductibles, coinsurance, or other cost-sharing in relation to benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn infant, except that such coinsurance or other cost-sharing for any portion of a period within a hospital length of stay required under subsection (2) may not be greater than such coinsurance or cost-sharing for any preceding portion of such stay.

Finding a VBAC Supportive OB or Midwife

When looking for a VBAC supportive provider, the absolute best place to start is locally. Attend a local ICAN chapter meeting or connect with them online. Chat with doulas, childbirth educators, and nurses who work in your community. They have the unique experience of observing providers over long periods of time, so they can give you the inside scoop. I also think it’s worth your time to call your local hospital and talk to the L&D nurse manager. As them who attends VBAC.

Here are some additional resources:

Note that some of the groups are not explicitly about childbirth. However, there is a tremendous amount of overlap between say, those who homeschool, plan homebirths and those who plan VBACs.

Also, those who have unmedicated births, or VBAC, or homebirth, are more likely to breastfeed beyond the first year, which is called ‘extended breastfeeding,’ and go to La Leche League meetings. They are also more likely to seek out fellow crunchy moms at Holistic Moms groups or attachment parenting groups.

You might have never considered yourself ‘crunchy’ because you think that only hippies are crunchy, but rest assured, VBACs, homebirth, homeschooling, and extended breastfeeding are things that appeal to the super liberals, the super conservatives, and everyone in between. No matter where you are on the political spectrum, you will find someone just like you in these groups.

Also keep in mind that there are traveling midwives, so if there are no care providers in your area, this is an option. Check out the ICAN email support group for referrals.

Once you have found a provider, you are going to want to ask a ton of questions. Call and make an appointment to discuss VBAC. Don’t go in for an exam and try to have an intelligent conversation while sitting on an exam table wearing a thin paper gown. This is not a position of power. Remember, you are hiring someone to support you with your VBAC.

Please interview at least as many vendors as you would to paint your house or install your air conditioning. This is a huge decision and you will be very happy if you take the extra time to screen your care provider.

Since finding a VBAC supportive care provider can be a lengthy process, I would recommend starting your search before you even become pregnant. That way you won’t feel like you are on a timetable or be fighting morning sickness and exhaustion. And won’t it feel nice to have all your ducks in a row so when that little plus sign appears, you feel excited and supported? But, if you are already pregnant and looking, it’s not too late. Take the time to find a provider, you won’t regret it!