It is virtually impossible for anyone who was raised in a white colonialist country – like the United States – to come into adulthood without racism in their heart and mind. This is where implicit bias comes from. So if you have heard people say things like, “All white people are racist,” that’s what they are referring to. It’s not using the N-word or going to a KKK rally. It’s not listening to Black women when they report pain in the hospital and missing a potentially deadly complication as a result. That is one way implicit bias presents. So what can white birth professionals do about it? How can they identify and face the implicit bias in their own heart, and systemic racism within the health care system, so racial disparities can improve?
An advocate claims that the American College of Obstetricians & Gynecologists (ACOG) said VBAC after more than one prior cesarean (VBAMC) doesn’t pose an increased risk. A reader contacted me asking if this was correct. It is not. ACOG does not say that because it’s not true.
VBAC calculators have been embraced with open arms by some providers, whereas others reject them altogether. Who’s right? Trying to predict who will have a VBAC is tricky. We know some individual factors, such as having a prior vaginal delivery, are associated with higher or lower VBAC rates. By combining various factors, VBAC calculators generate a percentage that represents the best guess for an individual’s odds of having a vaginal birth after cesarean. But VBAC calculators, also called VBAC success calculators, are not always accurate and can create emotional baggage.
In 2011 a woman with two prior cesareans named Rinat Dray was forced to have a cesarean at Staten Island University Hospital in New York. She sued the hospital and two physicians for ‘improperly substituting their judgement for that of the mother’ and ‘pressuring and threatening her.’ During the course of her lawsuit, it was revealed that this hospital had a secret forced cesarean policy. When I learned about this policy, I was shocked. Yes, forced cesareans happen. They are woven into the culture of some hospitals as are other forms of obstetric violence. But to have a formal, written policy saying that it was OK?
We often think of the physical risks and benefits when talking about VBAC versus repeat cesarean section, but what about the toll on mental health? The stress of having a complication like placenta accreta is often not addressed and parents are left on their own trying to figure out how to cope with this serious diagnosis. So I was thrilled to come across a study finally addressing this issue and to include it in our monthly Grand Rounds for VBAC Facts Professional Members. Join me for this Grand Rounds excerpt where we review Tol 2019, a study looking at the connection between abnormally invasive placenta and post traumatic stress disorder.
In an attempt to validate parents, some perinatal professionals tell parents who have had a cesarean, “It’s still a birth.” And I get where they are coming from. Their desire to affirm to the parent that they still birthed a baby and that this is a happy moment. Here’s the rub and where unintended consequences come into play: As a cesarean parent, I did not feel like my cesarean was a birth and having someone tell me, “No really, it is,” would have felt really dismissive and invalidating despite the good intentions at play.
Having a prior uterine surgery increases the risk of uterine rupture. The relative risk is still low, but it’s there. Other factors can push that risk higher (such as induction.) But sometimes there is no “reason” for a uterine rupture other than a prior cesarean. Uterine rupture stories illustrate that even though the risk is ~ 0.4% (among those with one prior low transverse cesarean in a spontaneously laboring VBAC), that small number impacts real parents & babies.
A VBAC study out of Canada reported, “Absolute rates of severe maternal morbidity and mortality were low but significantly higher after attempted vaginal birth after cesarean delivery compared with elective repeat cesarean delivery.” After reading the abstract, and full text, I could quickly see how this study will be misinterpreted by many, so let me walk you through it.
I came across this story from a nurse and I wanted to share with you. First because it’s an amazing story illustrating how nurses can help birthing parents avoid a primary cesarean. And second, because we can all use some good news.
“I need to ask a favor from anyone who 1) had a vaginal breech birth in the hospital, 2) had one at home because that was your only option, or 3) was pressured into a cesarean because it was not an option due to hospital policy or lack of experience of attendant. I am getting a lot of pressure to stop attending breech and despite my best efforts to get privileges at a tertiary care hospital with neonatology, it is not happening. Please send your impassioned pleas and experiences to Sutter Davis Hospital 2000 Sutter Pl Davis CA 95616 Thanks!”
Last week, I shared the eleven things that I love about ACOG’s latest VBAC guidelines. And with good reason. There’s some excellent new language as well as reiterations of positions that they presented back in 2010. But there are a few places where ACOG misses the mark and these are the three areas that gave me the most concern.
When I found out that ACOG released their new guidelines yesterday, I couldn’t wait to devour them. This morning, I had an opportunity to cuddle up with the new recommendations and I’m quite pleased. As always, there are things to like and areas where I think ACOG missed the mark. But here are the eleven good things about ACOG’s 2017 VBAC guidelines.