Category Archives: Home birth/HBAC

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.”

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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 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 we [CPM/LMs] cannot do VBACs. We 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 we should continue to follow our current regulations and they only require us 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 Ca 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, 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

VBAC-relic

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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 allow 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.

Below is the five minute presentation I prepared and presented to the Medical Board on October 15, 2014.  As there was a limited time to speak, I sent a follow-up letter to the Medical Board which goes into more depth. I’ll be posting that soon.

My statement

Today I’m speaking on behalf of consumers regarding the importance of out of hospital VBAC. I will be focusing on the impact of requiring women seeking out of hospital VBAC to obtain physician approval. This proves problematic because very few physicians, if any, would be willing to sign off on a home VBAC due to liability concerns. This would effectively cut off the option of a vaginal delivery for many women throughout our state.

I’m Jennifer Kamel, Founder of VBAC Facts, an organization which seeks to close the gap between what best practice guidelines and the evidence says about VBAC vs. repeat cesarean and what people generally believe.

Some people may think reducing access to out of hospital VBAC is not a big deal. But 44% of California hospitals ban VBAC (Barger, 2013) despite the American College of OBGYNs (2010) and the National Institutes of Health’s (2010) assertion that VBAC is a safe, reasonable, and appropriate option for most women.

ACOG (2010) is clear, “Respect for patient autonomy argues that even if a center does not offer TOLAC, such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery.” But this recommendation is simply ignored by many facilities.

Consumers report that many facilities provide incomplete or misleading informed consent, maintain a strict VBAC ban, and ignore ACOG’s comments denouncing forced cesareans.  These facilities led women to believe that a repeat cesarean is their only option.

As a Sacramento area OB-GYN resident recently shared, “There is the routine overplaying of the risks of VBAC, and failure to mention the risks of repeat cesareans, or that ACOG considers VBAC safe and reasonable.”

With the cloud of legal liability hanging over our heads, I wonder about the culpability of the many facilities whose hospital policies mandate repeat cesareans and forbid VBACs yet who are also unprepared to manage the serious consequences of multiple repeat cesarean sections including placenta accreta, cesarean hysterectomies, and hemorrhage. (Heller, 2013)

VBAC is successful about 75% of the time, most women are candidates (ACOG, 2010), about half of women are interested in the option (Declercq E. R., Sakala, Corry, Applebaum, & Herrlick, 2013), and VBAC results in lower maternal morbidity and mortality rates in the current delivery as well as in future deliveries. Yet, VBAC is simply not occurring in many communities throughout the state of California resulting in a 9% VBAC rate statewide. (State of California Office of Statewide Health Planning and Development, 2013)

According to Barger (2013), a study looking at the prevalence of VBAC bans in California, “Among the 56% [of hospitals that offer trial of labor after cesarean or TOLAC], the median VBAC rate was 10.8% (range 0-37.3%)…According to the nurses surveyed, we found that about half of hospitals with continuous anesthesia coverage did not offer TOLAC, not because of an explicit hospital policy against it, but because physicians were unwilling to stay in the hospital with a woman attempting TOLAC.”  So even in facilities that offered VBAC, attaining one and avoiding surgery can be elusive.

It is within this climate that women choose out-of-hospital VBAC. For many women in the state, VBAC is simply not a viable option at their local facility. Barger (2013) found that “The mean distance from a non-TOLAC to a TOLAC hospital was 37 mi. [as the crow flies] with 25% of non-TOLAC hospitals more than 51 mi. from the closest TOLAC hospital. In 2012, 139 hospitals offered TOLAC, [which was] 16.6% fewer than in 2007.” So the trend is moving towards fewer hospitals offering VBAC.

For some women traveling to a hospital that offers VBAC and accepts their insurance is a huge burden consisting of coordinating work and school schedules, vacation and sick time, and the cost of travel and child care. We do not want to be in a position where state troopers are attending births on the side of the road.

As Dr. Elliott Main (2013), Medical Director of the California Maternal Quality Care Collaborative (CMQCC), has stressed, “In California, we are seeing a lot of hysterectomies, accretas, and significant blood loss due to multiple prior cesareans. Probably the biggest risk of the first cesarean is the repeat cesarean.”

Women should not feel like home VBAC is their only option, but for too many women their choice is limited to home VBAC or repeat cesarean. If a hospital VBAC is not a possibility and the choice of out-of-hospital birth is removed, that essentially forces women into either unwanted and unneeded repeat cesarean surgery, and the increasing risks that come with multiple prior cesareans, or into unassisted home births where they deliver without an midwife or doctor.

In light of the recommendations made by ACOG and the NIH and the realities of increasing maternal morbidity rates in the state of California due to multiple repeat cesarean sections, the objective should be making VBAC more accessible, not less.

Bibliography

American College of Obstetricians and Gynecologists. (2010, August). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology, 116(2), 450-463.

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

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlick, A. (2013). Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection. Retrieved from http://www.childbirthconnection.org/article.asp?ck=10450

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/

Heller, D. S. (2013). Placenta accreta and percreta. Surgical Pathology, 6, 181-197.

Main, E. (2013). HQI Regional Quality Leader Network December Meeting. San Diego.

National Institutes of Health. (2010, June). Final Statement. Retrieved from NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights: http://consensus.nih.gov/2010/vbacstatement.htm

State of California Office of Statewide Health Planning and Development. (2013, December 17). Utilization Rates for Selected Medical Procedures in California Hospitals, 2012. Retrieved from http://www.oshpd.ca.gov/HID/Products/PatDischargeData/ResearchReports/Hospipqualind/vol-util_indicatorsrpt/

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

 

myth versus reality

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

myth versus reality

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

Labor Note Cards

I’m currently visiting a friend who is expecting her first baby in late August.  I’m so excited for her and am trying to give her all the great books and resources that I have been distilled from the endless choices out there without overwhelming her with my excitement, information, and ability to talk endlessly about birth. 

When I was pregnant with my first, I created some Labor Note Cards and then promptly forgot about them.  I can’t even remember if we brought them to the hospital for my short labor before my CS. Then I’m pretty certain I came across them a couple years later, filed them away, and promptly forgot about them again when I had my home VBAC.  Fortunately, I remembered them when packing my huge suitcase full of materials and hand-me downs for my friend.

Labor cards are great because sometimes all those great things you read in books or learned in your childbirth prep class are quickly forgotten as soon as the excitement of labor takes over.  They also help your non-professional labor support – husband, friend, mom, sister, aunt – stay focused and full of ideas and supportive words when the intensity of the moment sucks all rational thoughts out of their brains.

These cards were created from a variety of sources.  As I read the birth stories in Ina May’s Guide to Childbirth, I started making a list on the inside cover of things that resonated with me: techniques, words, things I wanted either myself or my husband to remember.  Then I found further inspiration from the notes I took in my Bradley class and in the variety of books I read.

Looking through those cards today brought back so many sweet memories and I hope they facilitate the creation of sweet memories for my dear friend.  She’s pregnant and tired and not up to copy the cards tonight so I was thinking of doing it for her.  And then I figured if I was going to copy all that once, why not make it count and share it with the world?  Besides, I can type way faster than I can write.

This is about as crafty as I get, so get ready.  You need 3″ x 5″ index cards and a Sharpie.

I like 3″ x 5″ index cards because some of these are a little lengthy and you don’t want to have to write real small and make your labor support work harder than needed during labor.  I used a Sharpie marker because it’s easier to read than regular ball point pen.  Each dark bullet point goes on one card.

If you have any note cards to add, please leave a comment!

Labor Note Cards
  • Labor is hard work!
  • Relaxation is the key to a more comfortable labor
  • You don’t have to like it, you just have to do it!
  • Observe!  You must be aware of your wife’s tension to be able to help her release it.
  • Some words for relax:
    • melt
    • let go
    • release
    • float
    • sink into the pillows
  • Relaxation takes concentration
  • During contraction:
    • Cleansing breath
    • Abdominal breathing
    • Relaxation
    • Relax kegal
    • Cleansing breath
  • I love my baby and am capable of doing what is necessary to bring about a healthy birth
  • I am confident in my ability to birth naturally
  • One contraction at a time
  • You can always relax a little deeper
  • Tune into your body
  • Contractions are good for your baby!
  • With harder first state contractions breathing is: faster and deeper
  • 1st Stage Contraction Hints
    • Quiet peaceful atmosphere
    • Talk only as needed
    • Visualize what is happening to the baby
    • Eye contact can help during hardest contractions
    • Back pressure or rubbing
  • Nature doesn’t hurry
  • You are giving your baby the best possible start in life
  • I love you!
  • Back pain
    • hands & knees
    • counter pressure
    • heating pad
    • extra encouragement
  • We’ll be seeing out baby soon!
  • Breathing for 2nd Stage
    • 2 deep breaths
    • 3rd breath hold
    • relax kegal
  • Pushing hints
    • Listen to your body
    • Don’t push to soon
    • Steady, even pressure
    • Visualize the baby moving down
    • Don’t need to push with every contraction, but it usually feels better
  • Relax kegal
  • To coach in second stage: Don’t confuse the facial appearance of effort with that of pain
  • A little encouragement can spark a great endeavor
  • 5 Things to help me relax
    • Massage [I laugh as I write this now because I did not want to be touched at all during labor]
    • Warm water
    • Visualizing
    • Music
  • Self doubt means: YOU ARE ALMOST DONE!
  • Contractions – as they pull stronger, they are working better
  • Contractions are just muscles working
  • Face each birth like a bull, with full force, no fear or hesitation, with the attitude that you can do this.
  • Visualize your birth canal as a big, open cave beneath the surface of the ocean, with huge, surging currents sweeping in and out.
  • Peace
  • Your cervix is melting like butter
  • Don’t try to hold contractions back
  • Warm olive oil & washcloths
  • It’s up to you to set the tone
  • Blow raspberries
  • Look into someone’s eyes
  • I know I can.  I know I can.  I know I can.
  • Dry heave
    • pulls cervix open
    • pushes the baby down
  • Speak in a lower tone of voice
  • Stay in control by getting your energy together, set a pace, and haul ass the last lap.
  • Encourage the sensations and welcome the opening process
  • This is for my baby.  I want to open up.
  • Low grunts
  • Face relaxed, eyes open, lips flapping while exhaling during the most intense moments
  • Breathe and relax through the first part of a rush, then hold my breath and let the contractions lead me.
  • I can open another centimeter
  • Let go!  Surrender!
  • Don’t fight it.
  • Surrender
  • Go with the flow
  • Discharge negative thoughts
  • I just want to open up and let this baby out.
  • Perception affects reality
  • Change in attitude can alter our perception of it.
  • Relax your pelvic muscles
  • Urge to push will arise spontaneously
  • Laugh! = Most effective form of anesthesia
  • Singing will maximize the ability of the body’s sphincters to open
  • Speak loving and positive words
  • Pelvis becomes larger when you are on your hands and knees
  • MOO! [Drawing of cow]
  • If you think you are in labor and it’s late in the day, try taking a warm bath, drinking a glass of wine, and going to bed for a while.
  • Pee every hour
  • Move thighs from side-to-side during a contraction
  • Six needs
    • Dark & solitude
    • Quiet
    • Physical comfort
    • Relaxation
    • Controlled breathing
    • Appearance of sleep/eyes closed
  • Emotional map of labor:
    • Excitement
    • Seriousness
    • Self doubt -> almost done!
  • PEP
    • Praise
    • Encourage
    • Progress
  • Encouraging words
    • Fantastic
    • I’m so proud of you!
    • You’re doing great!
    • That was a good one!
    • You’re doing a great job!
    • The baby is moving down!
  • Between 2nd Stage Contractions
    • Position changes
    • Observant of needs – cool cloth, fan, rest, reassurance, energy (honey)
    • Water
    • Encouragement
    • Unbounded love & support
    • Praise
  • When the baby’s head is about to come out, slow down your pushing as much as possible
  • Breathe for your baby!
  • Crowning
    • Touch baby’s head
    • Burning sensation is okay
  • For the birth
    • Open your eyes!
    • Tell wife what is happening!
  • For the actual birthing of the head & shoulders (push to start them through)
    • Open your mouth and breathe
    • No panting or blowing
  • Put the baby to the breast – left side first to hear the heartbeat
  • After 3rd Stage
    • Before mom gets up – drink 16oz of orange juice
    • Start doing kegals

I’m pregnant and want a VBAC, what do I do?

I recently received this comment.

Hi…thank you so much for your site! Very informative. I live in Glendale and I had a c-section last year with my first daughter. I went in to be induced even though I wasn’t looking forward to it. No contractions. No mucus plug. No water broken. I guess I just wasn’t ready for labor yet. They hooked me up to an epidural because they said I was going to feel immense pain so I went with it. 26 hours went by and I never dilated so they gave me a c-section at citrus valley medical center. I saw them on your list for high c-section rate. Now, I am pregnant again (a year and a month later) I really want to have a VBAC! Any suggestions? I can see that you have touched many women…any information to spare would be awesome- Rose

Rose,

There are so many women who have experienced your exact story.  They trust their OB because, hey, they didn’t go to medical school, right?  So, here is your body, so obviously not ready to birth and yet we feel like if we force your body to birth by giving you drugs, somehow this will result in a normal labor.  Did your OB discuss the risks of induction?  How it increases the likelihood that you will need a cesarean either by the induction “not working” or your labor starting and then stopping or by the induction stressing the baby resulting in a “fetal distress” diagnosis?  I’m guessing no.  Let me make one suggestion.  If you want a VBAC, don’t go back to that OB and certainly don’t go back to Citrus Valley.  With a 28.7% primary cesarean rate, a 43.3% total cesarean rate, and a sad 1.5% VBAC rate, your chances of VBACing there are zero.  Put it another way: in 2006, there were 2105 cesareans and 17 VBACs there.  And I bet that if we knew your OB’s cesarean rate, it would probably be about the same as Citrus’ total cesarean rate.  So, you need a new care provider and a new location for your birth!  YOU CAN DO THIS!

So, first things, first.  Congratulations on your pregnancy! This is such an exciting time of your life!  But know that if you want a VBAC, this is not something that is just going to fall into your lap.  Especially if you want a hospital birth, you need to become informed, empowered, and ready for (a likely) battle.  If you pick a homebirth, you can relax a bit.  But more on that later.

Here are your marching orders!

1. Read. Rikki Lake’s My Best Birth is an excellent overview of birth.  Once you read that, if you are ready for more I recommend Ina May Gaskin’s Ina May’s Guide to Childbirth, Dr. Marsden Wagner’s Born in the USA, Henci’s Goer’s The Thinking Woman’s Guide, Jennifer Block’s Pushed, Tina Cassidy’s Birth in that order.  (While I want to give you all the great books I love, I also know that a lot of women only have time to read one or two.)

Please don’t waste your money or time on The Girlfriend’s Guide or What to Expect When You Are Expecting.  I’ve read them both and was so surprised that these are some of the top selling pregnancy books in the US.  They are dumb.  And lame.  And dumb.

Let me give you a recap of What to Expect: Can I take baths?  Can I exercise?  Can I have sex while pregnant?  Yes (not to hot), yes (not to strenuous), and yes (provided you have a normal pregnancy without a history of preterm labor.)

And The Girlfriend’s Guide?  Basically tells you to go to the hospital and get your epidural.  Oh, and your body is going to hell after a baby.  After I read that book, I was truly terrified of what my post-baby body would look like.

Seriously, skip them both.  There are so many great books to read, don’t waste your time on that dribble.  And yes, your boobs and butt will sag after having a baby, but at the end of your days, I don’t think you, or your children, will care one bit about your flabby boobs.

2. Home vs hospital. I had a homebirth, I had a good outcome and it was amazing.  You can read my birth story here: My HBAC Birth story.   But homebirth comes with real risks and even though the risk of uterine rupture is low, it does and will happen.  And in about 6% of uterine ruptures, the baby will die (Guise, 2010).  Chances are, you will be fine, but those statistics represent real moms and real babies.  With what we gain in homebirth (privacy, control, peace, limited pressure, etc), the primary thing that we lose is immediate access to surgical intervention.  You can read my extended thoughts on homebirth here: Why Homebirth.

So, read, think, reflect and decide what feels best. Of course, this also depends on your health and if you would qualify for a homebirth.

Someone suggested this to me when I was early pregnant with my VBAC son and I learned a lot: Imagine for a week that you are having a hospital birth. How do you feel? Are you nervous or at peace?  Are you excited or anxious?  Now do the same with  homebirth.

Other articles you might find interesting: Homebirth vs hospital birth for the number cruncher, OB lists reasons for rising cesarean rate, and Neonatal nurse has a homebirth VBAC.

2a. Hospital birth. If you chose to birth in a hospital, find the hospital with the highest VBAC rate.  Since you are in California, you can easily do this by going here: VBAC & Cesarean Rates of California Hospitals, 2007 and be sure to read Why if your hospital “allows” VBAC isn’t enough.

I think that if you want a hospital VBAC, your best bet is Kaiser.  Just looking at their 2006 California statistics, they had a 20.8% VBAC rate, a 15% primary cesarean rate and a 22.4% total cesarean rate.  Some Kaiser locations even permit CNMs (certified nurse midwives) to manage VBAC labors.  The national VBAC rate is 10% and in California it’s 9%, so 20% is excellent.

If you have a hospital birth and good insurance, you will likely save money in comparison to a homebirth (unless you have a PPO which may pay for some of your homebirth costs or you live in a state like Florida), but take that money you save and invest it in a doula.  I strongly recommend you have a doula if you have a hospital birth.  Labor requires concentration.  Dealing with medical professionals who may think you are a bit odd for wanting a VBAC requires concentration.  Your typical laboring woman does not have enough concentration and energy to deal with both things.  Read VBACing Against the Odds and Hospital VBAC turned CS due to constant scare tactics.

Hospitals vary greatly. Here is a wonderful birth story of a woman who VBACed at a Southern California Kaiser: The Birth Story of James Liam.

2b. Home birth. If you are at home, I think a doula is something you can get if you want, but skip if you don’t feel the need.  But this is really a personal preference.  At home, you have the freedom that you just don’t have at the hospital and you need not worry about hospital personnel trying to talk to you mid-contraction.

However, with homebirth you have other issues to attend to.  The most important thing when interviewing midwives is experience.  You need to know how many births she has attended and of those, how many was she the primary midwife (the responsible person at the birth as opposed to assisting a senior midwife.)  If you have an inexperienced midwife with limited informal or formal education, you are taking on additional risk that is really unnecessary.

Additionally, you want a midwife who has enough experience to know when to go to the hospital as well as the professionalism to interface, and even take crap from, hospital employees.  You and your baby’s well being should come well before her possible discomfort.  In states where it is illegal for a midwife to attend a OOH (out-of-hospital) VBAC, your midwife is not likely to present herself as your midwife if you transfer and this is understandable.

You also want to be aware of the birth myths that are sometimes propagated amongst midwives.  It is a massive red flag if your midwife repeats any of these myths to you.

I personally think that hiring a midwife who has experience and knowledge is more important than hiring one that you “click” with.  That really should come secondary to the ability to make quick decisions regarding your health as well as the health of your baby.

3. Find a provider. After you read The Three Types of Care Providers Amongst OBs and Midwives, Questions to Ask a Provider, Scare tactics vs. informed consent aka why I started this website, you can go to Finding a VBAC Supportive OB or Midwife and start using the resources listed there to find referrals for OBs or midwives.  I think the best way to find a care provider is through word of mouth.  I have heard many ‘bait & switch’ stories at 36 weeks. A provider says everything the mom wants to hear in the interview and then did a 180 once the woman was to far along in her pregnancy to expend the effort of finding another care provider.  It’s best to hear from multiple women, if possible, how a provider is during birth. 

4. Childbirth Education.  I think Bradley classes are great because you learn a ton.  The tone of a particular class can vary greatly depending on who is teaching it. I took the Hypnobabies Home Study course with my VBAC baby and I thought it was good, but it had a completely different emphasis.  I would also encourage you to find a “Truth About VBAC” workshop in your area.

Bradley had far more information about interventions, pros, cons, physiology and anatomy.  Hypnobabies was more about relaxation, visualization, positive thinking, calm, and peace.  My VBAC labor was very manageable until the last hour or so and I attribute that to maintaining a calm and peaceful state of mind, being in the peace of my own home, and, since I was drug-free and at home, having the freedom to move into the most comfortable position at the moment however and whenever I wanted.

There are many things that I enjoyed about Hypnobabies and if it’s possible, I would suggest doing both.  Hypnobabies is very clear that they don’t want you to take any other course and that they don’t want you to be exposed to the idea that childbirth is painful.  They even discuss pain like it’s a four letter word.  Pain doesn’t have to be negative though.

5. Finding support. 92% of women in the US have a repeat cesarean (Martin, 2009).  I personally believe this is due to misinformation, unsupportive medical professionals, a lack of social support, and hospital VBAC bans.  If you plan to VBAC, you are likely to come across many women who were lead to believe by their OBs that VBACs are to dangerous, illegal, or that “no one does them.” I know women in real life who knew one person who didn’t think they were complete whack-a-dos for planning a VBAC, and that person was me.

It can be hard and it can be isolating, but you can find support, you just need to know where to look.   Go back to the Finding a VBAC Supportive OB or Midwife list of resources and go to a couple La Leche League, ICAN, or Holistic Moms meetings.

And rest assured that even if you don’t know anyone in real life who supports your decision, you can find loads of support on-line.  Please don’t feel alone.  It can be so hard when you are so excited about your upcoming VBAC and the rest of the world is looking at you like you are crazy.  But you are not.

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 an RN in labor an delivery and 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 Dr 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. Any of
you who are contemplating homebirth vs hospital try your best to do
homebirth. Don’t let money be an issue. After all is said and done
money is money. You can always earn the money back but not the
experience of a wonderful birth. 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.

womanlooking

Finding a VBAC Supportive OB or Midwife

There are a ton of resources to find a good, truly VBAC supportive, OB or midwife. If you know of any others, please leave a comment with the info!

Note that some of the groups are not explicitly about childbirth, however, there is a tremendous amount of overlap between say, those who homeschool and those who VBAC or have homebirths. 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 with no underwear on 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.

I have a list of the questions I find particularly important because the one big thing you want to avoid is the old ‘bait and switch.’ This is when an OB or midwife essentially leads you on. They act all supportive of VBAC in the beginning, but as time goes on, they start to change. They want to do an ultrasound to make sure the baby isn’t ‘to big.’ They start to talk more and more about uterine rupture. They want to schedule that repeat cesarean at 39 or 40 weeks, just in case you don’t go into labor – even though I have yet to meet a woman who was pregnant forever. This happens all the time. All you have to do is join the ICAN email support group to find woman after woman after woman who experienced just this and end up racing around at 37 weeks trying to find a new provider – not an easy task. So grill that provider! Make sure that they are truly supportive and you do this, not by just using your GYN because you like them, but by searching, interviewing, and actively SELECTING your care provider. This is why finding someone through referral is an extra bonus. You can no only get info from the care provider, but since you know someone who has already labored with them, you can get detailed info on how they really act.

Since finding a care provider is one of the critical decisions in working towards a VBAC, I would recommend starting your search before you even become pregnant. That way, you don’t have the crazy emotions of pregnancy pumping through your bloodstream and you can be a little more rational. You also 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 to late. Take the time to find a provider, you won’t regret it!