The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
|
The AMA wants to make birth centers illegal, along with homebirths,
even though
Read more about the ACOG 2008 Press Release from The Big Push for Midwives and Childbirth Connections You can also educate yourself week-by-week in your pregnancy with theLamaze Weekly Pregnancy Newsletter for Parents |
See this great You
Tube video about women who had VBACs of babies
bigger than
their CPD babies. What an inspiration!
IMPORTANT! A surgeon performing a cesarean section may choose from among a number of different techniques. If you're planning a cesarean, it makes sense to discuss these choices with your surgeon, and if you're not planning a cesarean, it's even more important to have discussed these issues ahead of time, in case a cesarean becomes medically necessary.
There are two significantly different techniques used to close the internal incisions - single-layer vs. double layer closure. Single-layer closure appears to be more vulnerable to rupture in subsequent pregnancies.
There are two significantly different techniques used to close the external incision - suturing or stapling. Yes, stapling, as in "with a staple gun". Many people feel that the suturing facilitates better healing and leaves a scar that isn't quite so frankenstein-like as the stapled scar.
The fastest way is with a single-layer closure of the internal incisions followed by external stapling.
These are important choices. Educate yourself and talk with your
surgeon beforehand.
This raises a really significant question. If the strength of
the healed uterine scar is dependent on the quality of the suturing, why
is the liability for uterine rupture assigned to the care provider with
the subsequent pregnancy, rather than the original surgeon?
This gentlebirth.org web page is mostly about avoiding Cesareans and planning VBACs, but there are women who cannot or choose not to plan future VBACs. There used to be an online support group for these women called novbac, but it seems to have disappeared. Here was their charter:
"This list's sole purpose is to support women who for whatever reason have been unable to have a VBAC after one or more c-sections. Although we do support VBAC, we feel a need to support the woman that cannot have a VBAC or has attempted a VBAC only to have a repeat c/s. This is a list to promote healing and to support our fellow mothers."The best replacement list I could find is birthingbycesarean at yahoogroups.
"This is a list for women who had a cesarean birth(s), who want to discuss their feelings, thoughts, and/or experiences regarding cesareans, labour, birth, HBAC, VBAC, the impact of a cesarean section on self & spouse/family, or any other topics you wish to discuss. This list is also available to women who have a possible c-section pending and want to discuss any issues that they presently coping with. "I would expect that we'll soon see support groups for women planning elective cesareans, despite the increased risks.
ICAN - International Cesarean
Awareness Network - The organization that is most focused on reducing
the cesarean rate.
You can read through their ICAN
eNews Archive.
Donate to ICAN or join ICAN today to support their work and receive their excellent newsletter.
They maintain a referral service - Professional Subscriber Network for midwives, doulas, CBEs, chiropractors, massage therapists, hypnobirth therapists......
And . . . NEW in the UK . . . ukvbachbac
- A Yahoo! Group - A UK discussion group on vbac and home vbac for interested
mums, mums to be, midwives and anyone else with an interest in avoiding
unnecessary c-sections. Useful information and articles can be found at
caesarean.org.uk
Citizens for Midwifery – the only national consumer-based group promoting the Midwives Model of Care!
Join Citizens for Midwifery
today to support the midwifery model of care and superior outcomes
for mother and babies.
Vaginal Birth
After Cesarean - notes from the American College of Nurse-Midwives
48th Annual Meeting from Medscape Nurses [Medscape registration is free.]
Why
does the national U.S. cesarean section rate keep going up? The page
dispels two myths that continue to arise and identifies interrelated factors
that are leading to record-level cesarean rates year after year.
Soaring
C-Section Rate Troubles Doctors - [Forbes magazine - 7/13/07] - It
includes quotes from Marsden Wagner and discusses the economic pressures
contributing to this trend, the increased risks of cesarean, and an observation
by another obstetrician that the overuse of this surgery runs counter to
the sacred rule in medicine of “First Do No Harm.” At the end, readers
are directed to ICAN for further information.
ANACS nurses endorse the booklet "What Every Pregnant Woman Needs to Know About Cesarean Section". This evidence based material is put out by the Maternity Center Association. Nurses are encouraged to bring this to consumers attention and to help educate women about cesarean sections. Nurses and consumers can download a copy for free!
Publicized by the Association of Nurse
Advocates for Childbirth Solutions (ANACS)
We
don't browbeat women into having caesareans - from the UK
Elective
Cesarean Surgery Versus Planned Vaginal Birth: What Are the Consequences?
and The
Problem with ‘Maternal Request' Cesarean from the Lamaze
Institute for Normal Birth.
NIH
Cesarean Conference: Interpreting Meeting and Media Reports
"Although second stage caesarean section is sometimes appropriate, many
could be prevented by the attendance of a more skilled obstetrician."
Previous
cesarean delivery: understanding and satisfaction with mode of delivery
in a subsequent pregnancy in patients participating in a formal vaginal
birth after cesarean counseling program.
Cleary-Goldman J, Cornelisse K, Simpson LL, Robinson JN.
Am J Perinatol. 2005 May;22(4):217-21.
See also: Significance
for Normal Birth from the Lamaze
Institute for Normal Birth
See also: Microbial Colonization
of Newborn Skin and Gut / Cesarean Effects - Cesarean birth disrupts
this crucial colonization
Many women are mis-led to believe that a cesarean is the "pain-free"
way to give birth. In the landmark study, Listening
to Mothers, the authors write about the "Myth of the Pain-Free Cesarean.
For women who had a cesarean, pain in the area of the surgical incision
was the leading postpartum health concern, with five out of six of these
mothers citing it as a problem in the first two months and one in fourteen
citing it as a problem at least six months after birth."
Great response from an OB/GYN to the "Choosy Mothers Choose..." story.
Dear Editors:
Your writer glamorizes a major surgical procedure that,if performed unnecessarily, can have serious outcomes for the mother and baby. This is not a face-lift,it is major abdominal surgery that has three times the maternal death rate as vaginal birth. Are the women who elect this [usually when prodded by their doctors] made aware of that? Are they also aware that their baby may be born too soon or too small and have long-term educational problems because their brains are not fully developed? Do they understand that,after the first cesarean, the next pregnancy has twice the stillbirth rate and can have life-threatening problems with the placenta because of the uterine scar? Do they know that there is no epidemiologic evidence that cesarean prevents future urinary incontinence and in fact can make future abdominal surgery more difficult due to abdominal adhesions?
My point is that most women with normal pregnancies who agree to elective induction of labor or scheduled cesarean haven’t a clue about some of the very negative consequences of the surgery. Cesarean section is a very important and life-saving intervention in some high risk situations. However there is plenty of evidence that vaginal birth has a toning and protective effect on the baby’s brain and results in babies with less asthma,chronic lung disease, and learning disabilities.
In my opinion,if this unfortunate trend continues, our society may find out in the near future that “It’s not nice to fool Mother Nature.”
Charles Mahan, MD, FACOG
Professor,USF Chiles Center for Healthy Mothers and Babies
Vaginal
birth after caesarean section versus elective repeat caesarean section:
assessment of maternal downstream health outcomes.
Pare E, Quinones JN, Macones GA.
BJOG. 2006 Jan;113(1):75-85.
CONCLUSIONS: These results indicate that long term reproductive consequences
of multiple caesarean sections should be considered when making policy
decisions regarding the risk-benefit ratio of VBAC.
Caesarean birth triples maternal death risk
Postpartum
Maternal Mortality and Cesarean Delivery.
Deneux-Tharaux C, Carmona E, Bouvier-Colle MH, Breart G.
Obstet Gynecol. 2006 Sep;108(3):541-548.
RESULTS: After adjustment for potential confounders, the risk of
postpartum death was 3.6 times higher after cesarean than after vaginal
delivery (odds ratio 3.64 95% confidence interval 2.15-6.19). Both
prepartum and intrapartum cesarean delivery were associated with a significantly
increased risk. Cesarean delivery was associated with a significantly increased
risk of maternal death from complications of anesthesia, puerperal infection,
and venous thromboembolism. The risk of death from postpartum hemorrhage
did not differ significantly between vaginal and cesarean deliveries. CONCLUSION:
Cesarean delivery is associated with an increased risk of postpartum maternal
death. Knowledge of the causes of death associated with this excess risk
informs contemporary discussion about cesarean delivery on request and
should inform preventive strategies. LEVEL OF EVIDENCE: II-2.
Infant outcome worse with planned c-section [1/8/07] Newborns who are delivered via planned cesarean section are more likely to be transferred to the neonatal intensive care unit and to experience lung disorders compared with those delivered via planned vaginal delivery.
Planned
cesarean versus planned vaginal delivery at term: comparison of newborn
infant outcomes.
Kolas T, Saugstad OD, Daltveit AK, Nilsen ST, Oian P.
Am J Obstet Gynecol. 2006 Dec;195(6):1538-43.
CONCLUSION: A planned cesarean delivery doubled both the rate of transfer
to the neonatal intensive care unit and the risk for pulmonary disorders,
compared with a planned vaginal delivery.
Babies born by Caesarean are three times more likely to die in first month
Infant
and Neonatal Mortality for Primary Cesarean and Vaginal Births to Women
with "No Indicated Risk," United States, 1998-2001 Birth Cohorts.
Macdorman MF, Declercq E, Menacker F, Malloy MH.
Birth. 2006 Sep;33(3):175-182.
Results: Neonatal mortality rates were higher among infants delivered
by cesarean section (1.77 per 1,000 live births) than for those delivered
vaginally (0.62).
Mothers
aren't behind a vogue for caesareans - [Boston Globe, 4/3/06]
Cesarean
Delivery on Maternal Request - 2003 Data from the National Vital Statistics
reports, Vol 54, Number 2, (116 pdf pages)
In 2003, the latest year statistics are available, there were 4,089,950
births.
In 2003 there were 51,602 VBACs.
There were 1,119,388 Cesarean surgeries.
The current rate of cesarean section, per the highest rate in the study quoted in the NIH papers, would place up to 103 women at risk of dying from or with or right after their cesarean. According to one study the worst rate of mothers dying due to cesarean deliveries was reported to be 92 per 100,000 such deliveries. ( a rate of 0 was also reported in a different study).
Some of these women had diseases such as eclampsia that killed them.
Many would have died from hemorrhage, stroke, anesthesia complications,
infection or a combination of these. Some of the women who died in relation
to their surgeries, had undergone their Cesarean because there really was
no better choice. Some who die may have elected their section for personal
or quasi-medical reasons.
Look for a terrific rebuttal from Suzanne
Arms at http:
Consumer
Reports Questions Cesarean Frequency [12/30/05]
Risks Associated
With Cesarean Delivery - [Medscape registration is free] If you're
considering an elective cesarean, make sure you know the risks.
The risks associated with cesarean delivery can be divided into those
that are short term, those that are longer term, and those that present
risks to future pregnancies. There are also risks to the newborn that need
to be considered.
As
C-Sections Increase, So Do The Complications
C-section studies
from BirthRites
Neonatal
impact of elective repeat cesarean delivery at term: a comment on patient
choice cesarean delivery.
"RESULTS: Neonates born by elective repeat cesarean are more frequently
admitted to advanced care nurseries than infants born to mothers intending
to deliver vaginally (risk ratio 3.58, 95% confidence interval 3.35-3.58).
CONCLUSION: The decision to undergo scheduled cesarean delivery appears
to negatively impact immediate neonatal outcomes."
Now add to the doubled risk of a NICU stay after a planned c/s the corresponding
increase in the risk of interrupted mother/father/baby attachment, increased
child abuse and/or neglect as a result of interrupted attachment, a significant
reduction in the initiation and duration of b/f, and maternal/paternal
depression/anxiety and the corresponding effects of THAT on infant growth
and development, and you have a long-term ripple which is the stuff of
horror movies. Yikes.
Cesarean Voices, A web site
by, for, and about cesarean born people - explores the implications
of having been born non-labor cesarean, of coming into a human life here
on earth without going through the heretofore universal initiation and
learning experience of the journey down the birth canal.
Researchers describe the "novel clinical entity" of intrapartum elective
cesarean, and find that it is more often proposed by the physician than
the patient.
Intrapartum
elective cesarean delivery: a previously unrecognized clinical entity.
CONCLUSION: This study documents a heretofore unrecognized clinical
entity: intrapartum elective cesarean delivery. Physician characteristics,
as opposed to patient characteristics or intrapartum factors, are a major
determinant of whether laboring patients are being offered cesarean delivery.
API's statement
about the medical ethics of elective caesarean sections
Women's Health
Care Professionals Issue Warning About Cesarean Section on Demand -
Research shows that the risk of maternal death following cesarean section
is five to seven times higher than vaginal birth. Complications during
and after the surgery may include injury to the bladder, uterus and blood
vessels, hemorrhage, anesthesia accidents, blood clots in the legs, pulmonary
embolism, paralyzed bowel and infection. There are serious risks
also in subsequent pregnancies.
I am familiar with at least one fairly recent case (not my case), circa
1992, from rural north central Missouri. Obese female demands general anesthetic
for elective repeat C-section. Physician agreed. Just after induction of
general, patient arrested and expired about 24 hours later in ICU. Husband
was in OR and refused C-section (during cardiopulmonary resuscitation),
C-section not done later, fetal heart tones still present post arrest,
but gone before patient death. Large settlement (about 900,000)--husband's
deposition denied any memory of refusing C-section after cardiac arrest.
I don't know what the indications for the section were. No one is sure
why the patient died. The section was completely elective, patient was
not in labor.
After
the afterbirth: a critical review of postpartum health relative to method
of delivery.
Four million women give birth each year in the United States, yet postpartum
health has gone largely unaddressed by researchers, clinicians, and women
themselves. In light of rising US cesarean birth rates, a critical need
exists to elucidate the ramifications of cesarean birth and assisted vaginal
birth on postpartum health. This literature review explores the current
state of knowledge on postpartum health in general and relative to method
of delivery. Randomized trials and other published reports were selected
from relevant databases and hand searches. The literature indicates that
postpartum morbidity is widespread and affects the majority of women regardless
of method of delivery. Women who have spontaneous vaginal birth experience
less short- and long-term morbidity than women who undergo assisted vaginal
birth or cesarean birth. To maximize postpartum health, providers of obstetric
care need to protect the perineum during vaginal birth and avoid unnecessary
cesarean deliveries. Clinicians must initiate the discussion about postpartum
health antenatally and encourage women to enlist needed support early in
the postpartum period. Flexibility in the schedule of postpartum care is
essential. More research from the United States is warranted.
Risks
of adverse outcomes in the next birth after a first cesarean delivery.
CONCLUSION: Cesarean delivery is associated with increased risks
for adverse obstetric and perinatal outcomes in the subsequent birth. However,
some risks may be due to confounding factors related to the indication
for the first cesarean. LEVEL OF EVIDENCE: II.
Caesarean
delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal
and perinatal health in Latin America
Interpretation - High rates of caesarean delivery do not necessarily
indicate better perinatal care and can be associated with harm.
Fogelson NS, Menard MK, Hulsey T, Ebeling M.
Am J Obstet Gynecol. 2005 May;192(5):1433-6.
Kalish RB, McCullough L, Gupta M, Thaler HT, Chervenak FA.
Obstet Gynecol. 2004 Jun;103(6):1137-41.
Physician Perspective on Elective Cesarean
C/Section on request, whether primary or repeat, in my experience has always
been by someone with fear of labor, due to a bad previous experience, or
mis-information by family or friends. I assure patients I will abide by
their wishes; however, I want them to make a decision based on accurate
information and statistics, not on fear or bad information. We all know
we can present any subject in a light which can move a patient to our view.
On VBAC, if we emphasize uterine rupture, the patient will refuse it. If
we emphasize success rates, no differences for the infant, and better outcome
for the mother if successful, she will accept it. Fernando Arias, M.D.
and Perinatologist who wrote the red book on High Risk Pregnancy, was my
Attending when I was a Chief Resident at Barnes Hospital in St. Louis.
His favorite question on VBAC was "What happens when a lower uterine segment
scar ruptures?". The only answer he would accept from an Intern or Resident
was , "Nothing". I have found when a patient is given accurate information
without scare tactics and is reassured that she is in control and you will
make her comfortable and try to give her a healthy baby and pleasant experience,
she will do what is right.
Risks of Cesareans
Borders N.
J Midwifery Womens Health. 2006 Jul-Aug;51(4):242-8.J Midwifery
Womens Health. 2006 Jul-Aug;51(4):242-8.
Kennare R, Tucker G, Heard A, Chan A.
Obstet Gynecol. 2007 Feb;109(2 Pt 1):270-6.
José Villar a , Eliette Valladares b,
Daniel Wojdyla c, Nelly Zavaleta d, Guillermo Carroli
c, Alejandro Velazco e, Archana Shah a,
Liana Campodónico c, Vicente Bataglia f,
Anibal Faundes g, Ana Langer h, Alberto Narváez
i, Allan Donner j, Mariana Romero k,
Sofia Reynoso l, Karla Simônia de Pádua g,
Daniel Giordano c, Marius Kublickas m and
Arnaldo Acosta n, for the WHO 2005 global survey on maternal
and perinatal health research group
The Lancet 2006; 367:1819-1829
Risk of Placental Abnormalities Rises with History of Multiple Cesareans
Previous
cesarean delivery and risks of placenta previa and placental abruption.
Getahun D, Oyelese Y, Salihu HM, Ananth CV.
Obstet Gynecol. 2006 Apr;107(4):771-8.
CONCLUSION: A cesarean first birth is associated with increased risks of previa and abruption in the second pregnancy. There is a dose-response pattern in the risk of previa, with increasing number of prior cesarean deliveries. A short interpregnancy interval is associated with increased risks of previa and abruption.
The following information is from Volume 3, Issue 3 of Research Summaries for Normal Birth, July 2006, from the Lamaze Institute for Normal Birth:
Summary: This large retrospective cohort study examined the association between history of one or more previous cesarean surgeries and the risk of placental abruption or placenta previa in a subsequent pregnancy. Data were obtained from a Missouri state-wide dataset in which siblings were linked to one another and to their biological mothers. Missouri’s vital statistics recording system has been described as a “gold standard” for its reliability and validity in previous literature.
Risk for previa in the second birth was increased 50% among women with a previous cesarean surgery. Among women with two previous cesareans, there was a two-fold increase in the risk of previa in the third pregnancy. Risk for abruption in the subsequent pregnancy was increased 30% in both the second and third births when the prior birth was by cesarean. A pregnancy occurring within the first year after giving birth by cesarean was associated with further elevations of the risk for both previa and abruption. The researchers controlled for the effects of potential confounding factors such as maternal age, race and smoking status.
Significance for Normal Birth: This study adds to the growing
body of research showing strong evidence of a dose-response relationship
between cesarean surgeries and placental complications in subsequent pregnancies:
the more cesareans, the more complications. The doubling of risk for placenta
previa in women with two previous cesareans is particularly troubling because
previa in the presence of a cesarean scar is associated with placenta accreta,
a complication that results in very high maternal morbidity and mortality.
The long-term reproductive risks of cesarean surgery are only beginning
to be understood. As the evidence of harm accumulates, it becomes ever
clearer that preventing unnecessary primary cesareans is a crucial measure
for protecting the health of both mothers and babies.
ICAN President's Letter to California Medical Board about VBAC - from Tonya Jamois, 4/20/05
Your Right to Refuse - What to do if your hospital has "banned" VBAC.
E-mail ICAN with the name of
the hospital and your city/state.
50 Ways to Protest a VBAC Denial by Barbara Stratton
File a VBAC ban complaint
Dear Friends,
Barbara Stratton has been working hard to find a way to reverse VBAC
bans both in her own state of Maryland as well as nationwide. Please
read her letter below, explaining an action many women can take that may
not only help reverse their local bans, but could also have an impact across
the country.
Barbara writes:
One of the most promising approaches we have to reversing hospital
VBAC bans nationwide is to file complaints through the Medicaid system
and then appeal any denials to the federal level. If successful, all hospitals
nationwide that receive Medicaid funding (most do) would be forced to reverse
their VBAC bans.
So far, I've only known of a single woman to file one of these complaints
and she didn't appeal the initial denial. We need to have these complaints
come in from across the country from women willing to file and then appeal
any denials.
You don't have to receive, or have received Medicaid in the past in
order to file a complaint. The only qualifying factor is that you live
near a VBAC banning hospital and want to see that ban reversed!
Simply call the hospital and verify that they receive Medicaid funding.
Then ask for the contact info for the Chief Compliance Officer for Medicaid.
I can then email you a letter template that just requires you to insert
your info plus the compliance officer's info. Print it out, mail it in
and you are done.
See how easy that is?
Please email me directly if you are interested.
Thanks,
Barbara Stratton
womancareadoula@comcast.net
At least 30% of births in this country are by cesarean section, including
at least 20% of first births. That means there are a large number of women
who would benefit from being able to give their best try at having a VBAC.
Many of us can file the kind of complaint Barbara describes, which could
help so many women and babies have a better birth.
Denied
VBAC? - [from Robin Elise Weiss at pregnancy.about.com] - A vaginal
birth after a cesarean (VBAC) is becoming more and more rare these days
and doctors and lawyers fight over the risks of VBAC. For the women who
have decided that they want a vaginal birth, they may be told no. Here
is what they can do to try to find the birth they want.
Here's the article that was first used as the justification for ACOG's opposition to VBAC:
Risk
of uterine rupture during labor among women with a prior cesarean delivery.
Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP
N Engl J Med 2001 Jul 5;345(1):3-8
Risk/benefit of Delivery Mode After C-Section Should Be Individualized (News)
Vaginal birth after a previous cesarean section (VBAC) may be the wisest
choice for women planning to have two or more pregnancies. However, another
cesarean may be less likely to lead to problems in women who intend to
have no more than one additional pregnancy, according to researchers.
Standing up
to the VBAC-lash: - A critique of the New England Journal of Medicine
VBAC study and implications for the future of the medical model of childbirth
by Jill MacCorkle
BMJ followup Vaginal delivery after caesarean section triples risk of uterine rupture(BMJ 2001;323:68 ( 14 July )
Women respond
to the Britsh Medical Journal about VBAC
Anti-VBAC Study and Refutations
A definite yes! to the suspicions of recent backlash.
I was recently labor coaching for a hospital birth - planned to be the first VBAC after three sections. The OB was known in the community to be very supportive of natural childbirth, but even he was trying to convince my client that a VBAC after three surgeries was taking some huge risk. He asked her to sign some "backlash" forms about how dangerous VBAC is.
Then, when my client arrived at the hospital in labor, she was informed by the hospital staff that they could not support her in her choice to have a vaginal birth. Some tense discussions followed, during which it became clear that the hospital intended to get a court order to force her to delivery surgically if she didn't make that choice. (It's ludicrous to call it a "choice" at this point.)
The perinatologist said that because there were no studies showing the safety of laboring with three uterine scars, they had to assume it was not safe and that it was putting the baby at risk. She told us that there is an increase in risk for laboring with 1 vs. 2 scars, and that they had to assume the possibility that there could be an enormous increase in risk between 2 scars and 3.
She actually told us that their working assumption was that the risk
of catastrophic rupture (in which the baby died) was 5%. Yes, 1 out of
20. My hope for her is that she finds herself in a position to learn more
respect for women's choices in birth.
The first c-sec is the major problem. I can't tell you how many women who had c-secs for their first baby told me it was because the baby was in distress yet it took 1-3 hours for them to go to surgery. When a baby is in true distress they have those ladies in surgery and open within 15 minutes. And mind you, once surgery was decided on no one checks dilation again or monitors any of the contractions.
And another problem is that they use those blasted machines to declare that a woman is in labor. No dilation (or maybe she is dilated 1-2 cms), no effacement but the dang machine says she is in labor so some yahoo comes in after a while and does AROM, because she is not moving along. Then augments. All the while (which by now it could easily be 8 hours) she has been on an IV with no food. These primips now have drugs forcing the labor process and the poor gal just can't handle it anymore. C-sec due to maternal exhaustion or fetal distress.
Best thing is to stop that first c-sec and the only way to lower those
numbers is by having midwives attend them. Our local CNMs have lowered
one hospitals c-sec rate to 14%. The hostile hospital, which abhors
midwives, has a rate of 29%. I applaud those midwives because it
has been a rough row to hoe and one waited for years to get the respect
due her.
Dr. Phelan has definitely changed his colors on VBAC. It is very ironic that his earlier medical research supports the safety of VBAC. In the last few years he has become a VBAC antagonist.
Not too long ago, someone posted an outrageous "VBAC consent" form filled with scare tactics and even inaccuracies. Guess who the author was? Yep- Dr. Phelan. He published this as a recommended consent form for all OB's to present to women during their pregnancies if they are considering VBAC.
He also published an article a couple years ago with a title something
like: Cesarean goal rate for the year 2000: 50%. It also was an outrageous
editorial.
LATimes, Sunday, January 25, 1998, Home Edition; Section: PART A; Page: A-1
Dr. Jeffrey Phelan, a noted obstetrician and fetal medicine specialist who along with Paul of County-USC helped pioneer the idea of vaginal birth for women who have had caesareans, makes no bones about rejecting the ideas he once proposed.
Phelan, co-director of maternal-fetal medicine at Pomona Valley Medical
Center and an attorney, recently called for increasing the caesarean rate
to 50% of all births.
* rocking in a rocking chair
* drinking hot lemon water
* walking
As your intestines begin to function again, you may have gas pains.
To ease your discomfort, eat light foods that are easy to digest (toast,
yogurt, soup). Get out of bed and walk around. Movement helps stimulate
your digestive system. Actually, come to think of it, so does sucking
on something - a lollipop or popsicle would help, or heh, why not ask the
nurses to get you a pacifier to suck on! Seriously, that kind of
sucking is what stimulates babies to move their bowels every time they
nurse. :-)
Some naturopaths are offering a treatment to soften up scars from c-sections.
Apparently they inject saline fluid into the scar area, which causes inflammation,
which helps the scar tissue to heal.
Scar Reducer™ Gel - Reduces the appearance of scar tissue and beautifies skin texture.
Complications
of Cesarean Deliveries [Medscape registration is free]
Excerpt
from Nursing the Caesarean Born, by Michel Odent, MD - Midwifery
Today Issue 69
Feeling pressure from hospital for more c-sections, she leaves By Cheryl Welch, Staff Writer
Dr. Helen Sandland closed her Wilmington practice and is moving to Mississippi
after New Hanover Regional Medical Center asked her to perform more cesarean
sections on her patients.
As VBAC access becomes more limited, some women are going to other countries to avoid a surgical birth or hiring traveling midwives to come to their home from other parts of the country.
Plenitud; embarazo, parto digno y lactancia (Plenitude; pregnancy,
birth with respect and lactation)
We are in Guadalajara, Mexico and offer bilingual (Spanish/English)
care for birth at a local rental home or at the birth center - a little
4 room retreat within the 18 bed hospital Valle de Atemajac. The hospital
houses us but does not dictate our policy. Our primary cesarean rate is
11% and our VBAC/HBAC rate is 85%.
Email contact info is Joni Nichols - joninichols@infosel.net.mx
Phone: 011 52 333 656 82222
The ob/gyn I work with is Dr José Luis Grefnes Sanchez.
In addition to our autonomous four bed water-birthing center within a hospital (part one of the story of how we created it was just published in Midwifery Today #75; Autumn 2005) we also attend VBAC at home. Barbara Harper describes us in the newest edition of Gentle Birth Choices.
We serve families from all over the United States, Canada and Mexico.
Travel to Guadalajara is a straightforward flight from the US! There are
no problems with acquiring US or Canadian passports for the babies born
to families coming from these countries. Both countries have consulates
in Guadalajara. I typically offer one night's stay in my home
to give visiting families a base while they check out their housing alternatives.
We have a terrific bed and breakfast/kitchenette option locally with good
weekly and/or monthly rates and we sometimes know of apartments or homes
available for short term rental.
donna mitchell in alabama will accept VBAC moms who will come here..or
may be able to travel. heartathome@att.net
On a quiet, beautiful and secure country estate, overlooking the central
valley of Costa Rica, Central America, Birth-my-baby
offers two modern homes for expectant mothers to have their babies in peace
and gentleness.
From Sherri Holley in Farmington, NM. "I am in a state where we
can do VBACs OOH. Plus I have a large birth center. I have always taken
last minute ladies, and I don't turn anyone away for finanical reasons.
Have done over 150 VBAC's with only one transport. Everyone else has done
wonderful.". midwife@obii.net
From Jane Gandy in Garland, Texas - As long as someone has been getting
prenatal care somewhere, I'm fine taking them at the end. fruitofthewomb@att.net
From gail hart in Oregon, hdw4@msn.com
I don’t mind taking them at the end. Even if they haven’t had prenatal care!
It might be heresy to say this, but I think prenatal care – or lack of it – is pretty irrelevant if you are meeting a healthy mom with normal Blood pressure, at full term, with an appropriate-sized vertex baby, in good position, with good heart-tones.
I’ve actually met a couple of women for the first time when they are
in early labor.
It’s nice to have some bloodwork on them. Or at least to know their
blood type.
A woman with severe anemia will show it.
An Rh negative mom is probably the only sneaker, but generally it isn’t
a problem with the first pregnancy. And moms will usually know if they
are rh negative if they’ve ever had a baby before.
If they PASS a very thorough prenatal/labor exam – I don’t see lack of prior care to be an impossible hurdle.
I think the biggest issue is to try to convince them to let me use eye
meds for the baby (just in case)
From Suzanne Smith, CPM, in Orem, Utah, suzanne@betterbirth.com
I would accept such a client. Of course, I would prefer for arrangements
to be made early, not have her show up all of a sudden at 37 weeks, but
as long as she has been getting good care and I can look at the other risk
factors and find them acceptable, I have no problem with a transfer in
at 37 weeks.
From Deva Burgess in California - I also have taken ladies as they were
in labor. shstamidwife@finestplanet.com
From Judi Mentzer in California - Mentzer Maternity accepts anyone who comes to our door. Occassionally we have those who we have never seen prior to labor and may or may not have been seen by someone else. jmentzer@pa.net
We have met ladies in labor who have left others' care at the last minute.
I judge each case as it comes and handle those ladies as I handle all ladies.
If they need medical care they will be referred. If not, they deliver.
We have had VBACs come in like that.
From Brenda Capps in southern California: I have and still do take ladies
last minute. If they are sincere I will help them. BCappsmidwife@cs.com
BirthLove.com has a list of VBAC
Friendly Institutions. [The BirthLove site is by subscription only
- it's well worth the subscription fee.]
Ollie Anne Hamilton, Great
Falls, MT, 406 453 4915, E-mail: mwinmt@birthwithlove.com
In practice since 1977, will travel to most anywhere.
Sandi
Blankenship, BA, LM, Jensen Beach, FL, 772-359-1258, E-mail: sandib2@juno.com
In practice since 1997, will travel overseas to attend a birth for
any woman expected to have a normal pregnancy, labor and birth, including
first-time and older mothers.
Lillian Alice Sanpere, LM, CPM
(I go by Alice), Tallahasee, FLorida, 850-681-6969 or 850-509-1540, E-mail:
purplemidwife@yahoo.com
In practice since 1986, will travel to most anywhere, internationally,
will consider suitability for homebirth on an individual basis. Speaks
fluent english, spanish and fairly good french.
Jerry Whiting, Perris,
CAlifornia 92570, 951-657-7734 Home, 909-553-5344 Cell, E-mail: Jerry@homebirth-only.com
will travel anywhere to attend births for VBAC's, Primip's, Twins, Breeches,
The very young. In practice since 1999, 450 home births.
donna mitchell in alabama will accept VBAC moms who will come here..or
may be able to travel. heartathome@att.net
Dismayed at the lack of VBAC-friendly institutions near you? Don't
just get mad - get active! Get involved with ICAN
and your local birth circles or midwifery support groups. If you
don't have any in your area, start one. If you don't do something,
how will things get better for your sisters, daughters and nieces?
birthingbycesarean@yahoogroups.com - This is a list for women who had a cesarean birth(s) or to women who have a possible c-section pending and want to discuss any issues that they presently coping with.
HBAC@yahoogroups.com - This list is for people who are exploring the option of having a vbac at home. For more information.
vbac-hope@yahoogroups.com
- This is a Christian list offering support and hope for those facing all
aspects of Cesarean and VBAC, including HBAC (home birth after cesarean).
For
more information.
Be sure to read their Focus: Sex and the Myth of Cesareans from The
Clarion, Volume 33, February 22, 2006
Cesarean
& VBAC from Mothering Magazine
- Crucial information, to help you understand (and advocate for) your right
to birth safely and without surgery.
Vaginal Birth After One Previous Low-Segment Caesarean Section - clinical practice guideline from the Association of Ontario Midwives [337.4KB 20/11/2006 21:25] - note that they state:
"Recognition that hospital policies perceived by a woman as restrictive
may lead her to choose giving birth at home;"
"Home birth reduces the risk of iatrogenic consequences;"
The Royal College of Obstetricians and Gynaecologists Issues Practice Paper on VBAC
In this practice guideline, issued in February of 2007, the RCOG recommends the following to inform the care of women undergoing either VBAC or elective repeat cesarean section (ECRS):
VBAC Success
CD from HypnoBabies
This is taken from the Winter 2006 - Number 76 issue of Midwifery Today:
"The federal Emergency Treatment and Advanced Labor Act (EMTALA) requires hospitals to admit women in active labor and to abide by their treatment wishes until the baby and placenta are delivered. The act was originally passed to prevent hospitals from "dumping" patients who can't pay, but its since been applied in all sorts of other ways and includes specific provisions that apply to laboring women.
The attorneys we've consulted on the VBAC ban issue have told us that hospitals are much more afraid of being found in violation of EMTALA than they are of malpractice suits because the act is routinely enforced and each violation subjects them to fines between $50,000 and $100,000.
I can't emphasize enough the importance to individuals who may find themselves in this situation of memorizing phrases such as "It's a violation of my rights under EMTALA to force me to undergo a cesarean," or "I'm invoking my right under EMTALA to refuse a, b, c." Whether the hospital in question says it bans VBACs is unimportant; according to EMTALA, you have the right to be admitted to a hospital once you're in active labor and, once admitted, you have the right to refuse any recommended treatment. You can also remind them that VBAC isn't a treatment, it's the natural culmination of a normal physiological process. Cesareans are the treatment.
Also, it's helpful to know that EMTALA begins to apply once you are anywhere within 250 feet of a hospital; you don't have to be in the emergency room. You can be standing in the hospital parking lot, and if they so much as touch you against your express consent, they are in violation of EMTALA. For anyone interested in reading more, we've compiled a legal primer on the rights of pregnant women at http://www.birthpolicy.org
Editor's Note: To learn more about this important subject, go to
Risk
of Uterine Rupture With a Trial of Labor in Women With Multiple and Single
Prior Cesarean Delivery.
CONCLUSION: A history of multiple cesarean deliveries is not associated
with an increased rate of uterine rupture in women attempting vaginal birth
compared with those with a single prior operation. Maternal morbidity is
increased with trial of labor after multiple cesarean deliveries, compared
with elective repeat cesarean delivery, but the absolute risk for complications
is small. Vaginal birth after multiple cesarean deliveries should remain
an option for eligible women.
Elective
Cesarean Surgery Versus Planned Vaginal Birth: What Are the Consequences?
- Elective or "maternal request" cesarean surgeries pose serious and life-threatening
complications for mothers and babies. Despite the risk, the popularity
of elective cesarean surgery continues to rise-from 2001 to 2003, the rate
increased by 36 percent.
For example, following a population of 100,000 healthy, low-risk first-time
mothers, through three pregnancies, comparing outcomes based on whether
they have elective cesarean surgery for the first delivery or plan vaginal
birth.
With elective cesarean surgery:
57 more women will die
Vaginal Delivery
After Prior Cesarean Delivery May Have Low Absolute Risk CME
VBAC info from an HMO! (circa 2001) - This
is a pro-VBAC handout.
Preliminary
Births for 2004: Infant and Maternal Health - The cesarean delivery
rate rose 6 percent in 2004 to 29.1 percent of all births, the highest
rate ever reported in the United States (2). The rate has increased by
over 40 percent since 1996. For 2003–04 the primary cesarean rate rose
8 percent, and the rate of vaginal birth after cesarean delivery (VBAC)
dropped 13 percent. The primary rate has climbed 41 percent and the VBAC
rate has fallen 67 percent since 1996.
Battle
lines drawn over C-sections (USA Today) - For some women, birth has
become the latest battleground for reproductive rights. At a growing number
of hospitals, women are being forced to schedule a repeat cesarean section
just because they already had one. Doctors and hospitals say they fear
lawsuits if they allow a patient to attempt a VBAC and something goes awry.
VBAC.com - A woman-centered, evidence-based
resource
50 Ways to Protest
VBAC Denial - by Barbara Stratton
ICAN of Tacoma offers downloads
of brochures to give to your clients, friends or family who may have
had a cesarean or is trying to avoid one, wants help planning a vaginal
birth after cesarean, or wants to get involved with protesting the VBAC
bans.
Model
predicts risk of emergency after previous cesarean
Consumer
Reports Questions Cesarean Frequency [12/30/05]
The American
Academy of Family Physicians Trial of Labor After Cesarean (TOLAC),
Formerly Trial of Labor Versus Elective Repeat Cesarean Section for the
Woman With a Previous Cesarean Section
The American Academy of Family Physicians (AAFP) recently published
these new recommendations regarding vaginal birth after cesarean (VBAC),
which differ significantly from the current recommendations of the American
College of Obstetricians and Gynecologists (ACOG).
Some of the most notable highlights are:
~ "TOLAC [Trial of Labor After Caesarian] should not be restricted only
to facilities with available surgical teams present throughout labor since
there is no evidence that these additional resources result in improved
outcomes."
~ "Our recommendation significantly differs from current ACOG policy
because we could find no evidence to support a different level of care
for TOLAC patients. Without good-quality evidence, we believe that different
levels of resources cannot be advocated because their potential for unintended
harms cannot be evaluated against their purported benefits."
~ ". the ACOG policy suggests that one rare obstetrical catastrophe
(e.g., uterine rupture) merits a level of resource that has not been recommended
for other rare obstetrical catastrophes (e.g., shoulder dystocia, abruptio
placenta, cord prolapse) that may actually be more common."
~ ". current risk management policies across the United States restricting
a TOL after previous cesarean section appear to be based on malpractice
concerns rather than on available statistical and scientific evidence."
ACOG currently recommends that an OB and an anesthesiologist should
be "immediately available," widely interpreted as being on the premises
throughout the trial of labor. ACOG recommendations were based on "expert
opinion." In contrast, the AAFP recommendations are based on a comprehensive
review of published medical studies, a much higher level of evidence for
such recommendations. The ACOG recommendation of having a surgical team
immediately available has possibly been one of the biggest limiting factors
for hospitals allowing a VBAC, leaving women with limited or no options
for avoiding a repeat cesarean section.
The AAFP guidelines certainly give family practice physicians more incentive
to allow their patients to have a VBAC than the ACOG policy currently gives
an Ob/Gyn. It will be interesting to see how the AAFP recommendations will
factor into the current climate, and how useful they may be for women and
birth advocates working to change hospital policies.
Vaginal Births after C-section are safer
in Birth Centers in certain situations by Judy Slome Cohain,
CNM
Vaginal
birth after c-section safe after due date [Reuters - 10/3/05]
Safety
and Efficacy of Vaginal Birth After Cesarean Attempts at or Beyond 40 Weeks
of Gestation.
CONCLUSION: Women beyond 40 weeks of gestation can safely attempt VBAC,
although the risk of VBAC failure is increased. LEVEL OF EVIDENCE: II-2.
Guidelines
for Vaginal Birth After Previous Caesarean Birth by Ashraf Fouda, MD,
Ob/Gyn Specialist, Egypt - Domiatt General Hospital
This
study by Pauline Dillard, M.S., focused on Post Traumatic Stress Disorder
(PTSD) differences between women who have had cesarean sections versus
those who have had natural childbirth.
Hypnosis
for VBAC - from Maggie
Howell of Natal Hypnotherapy in the UK
Maggie sent me a review copy of this CD, and I was VERY, VERY impressed
with it. I have a background in hypnotherapy and am now a midwife,
so I'm very sensitive to all the issues of hypnosis for VBAC, and I thought
Maggie did an excellent job. The guided relaxation is exquisitely
sensitive to the issues of VBAC, and I would think any woman planning a
VBAC would benefit tremendously from listening to this on a regular basis.
Maggie's website makes it easy to order these CDs from other countries,
so don't hesitate!
Maggie's work is a gift to birthing women everywhere.
Some more resources from Henci Goer:
CIMS: www.motherfriendly.org/resources
(scroll down to the fact sheet on c/sec)
Advice for
Pregnant Women about C-Section, Vaginal Birth and Vaginal Birth After Cesarean
(VBAC) from Maternity
Center Association
3 in 10
U.S. Mothers Gave Birth by C-Section in 2004: Sharp, Continuing Rise Defies
Best Evidence and Best Practice from Maternity
Center Association
my article: "Rebuttal to rationales for denial of VBAC" http:
The Maternity Center Association (MCA) is the oldest organization in
the United States advocating on behalf of mothers and babies. They
have recently developed three new tools to help pregnant women make informed
decisions and meet their goals:
What Should
I Know About Cesarean Section? — a new booklet to help prepare every
pregnant woman to make informed decisions about this important matter
Should
I choose VBAC or repeat c-section?
How can
I prevent pelvic floor problems when giving birth?
Could mode of delivery influence the neonatal immune response? - Cesarean
section may increase the risk of diarrhea and allergy in susceptible babies,
German researchers suggest.
Caesarean
section and gastrointestinal symptoms, atopic dermatitis, and sensitisation
during the first year of life.
CONCLUSION: Caesarean delivery might be a risk factor for diarrhoea
and sensitisation in infants with family history of allergy. Further research
in this area seems warranted as choosing caesarean section becomes increasingly
popular.
Birthing
the Easy Way -Learning the Hard Way - a book written by a woman who
has had 5 VBAC's
My Cesarean Poem by Barbara Stratton
Uterine
rupture is more likely, but not common, after previous caesarean section
"The risk of uterine rupture during labour in women who have had a previous
caesarean section is small. Reviewing 568 articles published since 1980,
Guise and colleagues (p 19) found that, in women delivering vaginally after
a previous surgical delivery, the risk of uterine rupture during labour
was increased by 2.7 per 1000 cases, the additional risk of perinatal death
was 1.4 per 10 000, and the additional risk of hysterectomy was 3.4 per
10 000. It would require 370 elective caesarean sections to avoid one symptomatic
uterine rupture in women who had a previous caesarean section."
Vaginal
Birth After Cesarean Birth --- California, 1996--2000 from the
CDC: "Because cesarean birth is associated with higher maternal morbidity
than routine vaginal birth (2,3), two of the national health objectives
for 2010 are to reduce the cesarean birth rate among women at low risk
to 15% of women who are giving birth for the first time (objective no.
16-9a) and to 63% of women with previous cesarean births (objective
no. 16-9b) (4). A key strategy to reduce the repeat cesarean birth rate
is to promote vaginal birth after cesarean (VBAC) as an alternative
to ERCD."
VBAC
safety: A closer look at the 2002 JAMA study by Henci Goer
The
Assault on Normal Birth: The OB Disinformation Campaign by Henci Goer,
which starts with a focus on the NEJM's July, 2001, VBAC study and accompanying
editorial.
Is
vaginal birth after cesarean risky?
Rebuttal to rationales
for denial of VBAC
Levine, Audrey, 2000 - Midwives as radical educators: preserving informed
choice in the midst of a VBAC-LASH available from Senior
Research Papers at Seattle Midwifery
School. [I'm encouraging them to put these resources online.
You could, too.]
Caesarean Birth:
Making Informed Choice - an online booklet available from Birthrites:
Healing After Caesarean Inc.
Victorious Birth After Cesarean
Cesarean and Traumatic Birth Support ~A site for women who want
to reclaim their birth and truly heal spiritually and emotionally after
a cesarean.
HBAC FAQ - Q&A about Homebirth After Cesarean
- Although this was written by a VBAC mom planning a homebirth, the safety
information should easily qualm fears about VBAC'ing in a hospital!
[Homebirth advocates would say this isn't necessarily true, since many
aspects of homebirth make it safer for a VBAC, but most people who worry
about VBAC won't know that!]
"By their own words shall they be known" - a recent
discussion among obstetricians helps birthing women understand their
view of cesarean, VBAC and birth in general.
Elective
repeat cesarean delivery versus trial of labor: A meta-analysis of the
literature from 1989 to 1999.
Birthrites: Healing After Caesarean
- Great Australian VBAC site (used to be BACUP - Birth After Caesarean
Unlimited Possibilities). This site is amazingly affirmative.
They offer a terrific Suggested
Reading List and a Birth
Visualization Poster that is truly inspired! (The poster can
be ordered from a U.S. distributor, Birth
With Love, either plain
paper or laminated.)
They publish a quarterly journal/newsletter which is very inspiring
and supportive - excellent for those in Australia and also available in
other countries. (Annual subscription $15 for the US.)
They also have a feature - 'Ask an Obstetrician' - a forum set up to
answer your questions; they will be answered by a qualified Obstetrician,
who is very sympathetic to the valid choice of VBAC for most women.
A Butcher’s
Dozen - by Nancy Wainer - an article about 12 labors that could easily
have ended as cesareans under the medical model.
What would you say are the top 5 VBAC books you would recommend someone
to read? [year 2001]
The VBAC Experience by Lynn Baptisti Richards
1- Nancy Cohen's Silent Knife
All five just make you spittin' determined to get your birth as far
away from the sharps as you possibly can. I'd temper them with others
like Birthing From Within, Rahima Baldwin's Special Delivery,
as well as Susan McCutchen's excellent Natural Childbirth, The Bradley
Way for the practical aspects of getting physically ready for natural
childbirth.
Vaginal
birth after cesarean - from National Guideline Clearinghouse, a public
resource for evidence-based clinical practice guidelines.
They have 5
other guidelines related to VBAC and cesarean.
"Research Shows No Evidence to Support Increasing Cesareans" by Henci
Goer, BA, LCCE, printed in GENESIS - The Lamaze Advocate, Summer, 2000.
This is a very good article, similar to the one below but updated for the
2001 ACOG statements supporting a woman's right to choose a cesarean section.
She quotes him, "Every other medical condition we give the patient the
options to deal with it. This is the only area where we deny the
patient the choice. It's not a matter of procedure, it's the principle
of a woman's right to control her body." As Goer astutely observes
later in the article, "Contrary to Harer's statement, the 'right' to a
cesarean is the sole instance where obstetricians have ever championed
a woman's right to determine any aspect of her care other than, perhaps,
her right to refuse an epidural." Indeed, the issue of a woman's
right to choose the circumstances of giving birth seems to disappear when
the issues of VBAC and homebirth are on the table.
Cesareans:
Are they really a safe option? by Henci Goer - If you watched the recent
segment on Good Morning America [June, 2000] addressing the safety of cesareans
and the issue of a woman's right to choose this surgical procedure, you
probably ended up feeling quite confused.
[The BirthLove site is by subscription only - it's well worth the subscription
fee.]
Leilah McCracken, author of The
Revolutionary Passion of Mothering offers a collection of Birth
Love Columns from the weekly Online
Birth Center newsletter. Many of these are about cesarean and
VBAC. In particular:
Midwifery
care and out-of-hospital birth settings: how do they reduce unnecessary
cesarean section births?
Vaginal
birth after cesarean section: the demise of routine repeat abdominal delivery.
Vaginal Birth
After Cesarean Homepage
American College
of Obstetricians and Gynecologists - Vaginal Birth After Cesarean Guidelines
Vaginal Birth
After Cesarean Checklist
Robin Elise
Weiss' Vaginal Birth After Cesarean FAQ
MOTHERLOVE - Childbirth
Services VBAC pages
Faith
Gibson's Homebirth VBAC Consent Form
The
Trials of the Midwife
I have Natural Childbirth After Cesarean by Crawford & Walters and
Birth After Cesarean by Bruce Flamm. These are both excellent books. But
the Vaginal Birth After Cesarean by Elizabeth Kaufman is a depressing book
for women who are planning for a VBAC. This woman's point of view is that
VBAC and vaginal birth are not all they are cracked up to be. It disturbed
me greatly so I returned it to the book store. I got it by mistake when
I was looking for Lynn Baptiste Richards Vaginal Birth After Cesarean Experience.
I still can not find this book anywhere to purchase. I think the positive
VBAC stories described in this book would be revealing and encouraging.
Ken Turkowski's VBAC
Births and Uterine Ruptures - has an extensive
bibliography and there are some useful Suggestions
for VBAC Delivery.
I checked out this bibliography, and it's huge. I am not sure how unbiased
it is. In particular, most of the interpretations of the studies ignore
the many possible problems resulting from Cesarean sections. But it might
be helpful to someone doing research.
No, it can't be unbiased. Read his sad birth story about
Catherine
Grace's Birth (VBAC, induced, epidural rupture, sad) . This is
from his web page on VBAC
Births and Uterine Ruptures.
The extreme poor care of the labor was this: While laboring the woman
gets a constant pain even between contractions, husband and mother are
questioning, hospital staff dismisses. Then husband and mother notice what
seems to the father a bulge of a fetal foot sticking clearly out right
through the uterus and into the abdominal wall, brings it to the staff's
attention but again staff dismisses carelessly saying bulges like that
are not uncommon during labor. Finally a stat cesarean is ordered when
during descent the baby returns too far back into the uterus or actually
abdominal wall at this point.
Ken sent me to this site-some of you may remember that Ken and I struck
up a cyber acquaintance through some message boards that he posted to-
and while the idea of having VBAC research all in one handy reference sounded
nice, it doesn't quite pan out that way. I posted about this site earlier
with the disclaimer that it was a bit biased against what they term "TOL"-trial
of labor. I agree that the conclusions reached in the majority of the studies
seemed to ignore the morbidity from repeat cesarean. I also resented the
intro. To quote directly from the site:
In short, skepticism is healthy[GRIN]
Books and Newsletters about VBACs, Unassisted
Birth and Pleasurable Husband/Wife Childbirth
VBAC Abstract - Miller - Vaginal birth after
cesarean: a 10-year experience
Is Homebirth Appropriate for a VBAC?
Are there studies which demonstrate that cont EFM is superior than intermittent
monitoring in "high-risk" cases ?
Vintzileos AM, Antsaklis A, Varvarigos I, et al. A randomised trial
of intrapartum electronic fetal heart rate monitoring versus intermittent
auscultation. Obstet Gynecol 1993;81:899-907.
This study is an anomaly--the only RCT, as I recall, that finds a better
outcome with EFM. The biggest problem with it is a highly suspect randomization
scheme. They ended up with nearly 3 times (as I recall without looking
at it again) the number of patients in the EFM group as the auscultation
group. The randomization was supposed to be by a coin toss, which is, of
course, an inadequate method. It is all to easy for the physicians to decide
that this patient "needs" EFM, and just repeat the coin toss until he gets
the desired outcome. In a response in Birth somebody calculated
the odds of getting such a lopsided distribution randomly, and it was literally
less than one in a million. There's something rotten in Denmark with this
study.
Getting a stubborn patient to say Yes
- an article written by and for OBs about perception of VBACs and how to
coerce laboring women to agree to routine treatment.
This is the actual practice of the theory expounded in "Patient Choice
and the Maternal-Fetal Relationship".
Excerpt
from: Patient Choice and the Maternal-Fetal Relationship
Look for updates here
or here
or here
These were the ideas that The Farm gave to me regarding encouraging
a successful vbac. Some are new to me, so take what you need and
leave the rest:
Here are some sources I found in the Midwifery
Today newsletter archives.
-Rupture of the unscarred uterus occurs more often and does more harm
than rupture of the scarred uterus (Martin, M et al., Vaginal birth after
cesarean section: the demise of routine repeat abdominal delivery, "Ob
Gyn Clin North Am, Vol 15, No. 4 1988, pp. 719-736).
Dr. Osterhaus in Oregon is doing some work with scar tissue therapy,
injecting water or saline into the scar and massaging it to break up the
scar tissue. This might be helpful for women with painful abdominal
scars.
Cesarean Art - for all the scarred
mothers
I talked with Dr. Flamm (author of numerous VBAC studies and the book
"Birth After Cesarean: The Medical Facts") last night about an article
he's letting the Clarion use. I picked his brain while we were talking
about some of the topics that have recently come up on our line. From Flamm:
Rupture/Pitocin: Although there are times that judicious use of pitocin
have helped some women accomplish VBAC, there is data which suggests that
the risk of rupture does increase slightly with the use of pitocin (From
me: nearly every incident of rupture I've heard of, Pit was used). Pitocin
should only be used when necessary, not routinely.
VBAC with Low Vertical Incision: A large study is in progress right
now, but available data suggests that VBAC is safe and recommended with
a low, vertical.
VBAC after Multiple Cesareans: There isn't a huge amount of data, but
what they have suggests that VBAC is safe with multiple cesareans, with
no particular limit to the number.
VBAC with twins: Flamm's practice does VBAC with twin births as long
as the presenting twin (not both!) is head down.
VBAC consent forms (see my other post) Flamm is sending me a copy of
the consent
form that Dr. Phelan published which is currently the "latest trend"
in the OB offices. We both agreed that it was an unfair approach since
risks of repeat cesarean is not included in the consent form. [Here
is an annotated version
of this consent form from Birthrites:
Healing After Caesarean Inc. ]
It seems that none of the docs in our area "allow" VBAC moms to go past
their due date
She has another option. She can ask her ob to show her the research
that supports performing an elective cesarean if she exceeds her due date,
or, if that is the plan, inducing labor. She would also be wise to find
out if this ob puts any other unreasonable restrictions on her such as
estimated birth weight being over some particular limit or arbitrary time
limits for making progress in labor, and if so, to ask to see the evidence
that supports these. If no evidence can be provided for these restrictions,
she may wish to exercise her right to informed refusal. If she would like
to have the research supporting the safety of VBAC and the harms of both
any individual cesarean and of accumulating cesarean surgeries, it can
be downloaded free at http:
Ultrasonography has a high negative predictive value, meaning that for
the third of women with the thickest lower uterine segments, there is a
very, very low chance of rupture. This may be a helpful technology
to pursue if your OB is using the possibility of rupture as a significant
factor in recommendations about your care. However, it should be
noted that even for the women with the thinnest lower uterine segments,
the risk of catastrophic rupture is still very, very small and can be offset
through vigilant management during labor, i.e. having a labor attendant
actually present in the room with you, instead of relying on the remote
monitoring common in most hospitals.
Ultrasonographic
measurement of lower uterine segment to assess risk of defects of scarred
uterus.
and
Published
erratum appears in J Gynecol Obstet Biol Reprod (Paris) 1997;26(8):839
The research (what little there is) seems to indicate that for a very
small percentage of women, the doctors were able to predict that their
uteruses (uteri?) would be stable throughout labor & delivery. For
all the rest of the women, they were completely unable to make a prediction.
As my doctor put it, "I get no usable information from an ultrasound of
the scar." This same doctor also pointed out that about 50% of ruptures
occur prior to the onset of labor. He said, "This is why I feel comfortable
with a trial of labor - since you've already accepted 50% of the risk."
I just read through the Spring, 2000, edition of Birth
Gazette and wanted to respond to the article, "A New VBAC Concern".
I understand the concerns about an undocumented cesaraean surgery, but
it seems somewhat draconian simply to turn away all mothers in this situation.
There do exist technologies that can help to provide good information
even when an operative report isn't available:
This may help only a third of women, but it seems better than nothing
for those women who would otherwise be denied the opportunity to pursue
a home VBAC.
Is ultrasound sensitive enough to detect a uterine dehiscence at the
site of a Cesarean scar?
Would it be able to detect whether fetal parts had started to come through
the dehiscence?
While I have never actually seen a case of uterine rupture or dehiscence
along a C Section scar, I am sure we could see it, especially if fetal
extremities were protruding. Inspection of the uterine wall is a part of
detailed exams. There is quite a bit of literature demonstrating the Dx
of placental accreta, percreta, etc. So I am confident that sonography
could detect a breach in the uterine wall. However, NONE of the 7 major
and comprehensive textbooks on OB sonography said anything about it.
There are two significantly different techniques used to close the internal
incisions - single-layer
vs. double layer closure. Single-layer closure appears to be
more vulnerable to rupture in subsequent pregnancies.
Single
vs. double layer suture - a white paper by Gretchen Humphries
A longer, better version is in the summer '03 issue of Midwifery Today
Magazine but when I search the MT website it only comes up as an article
that you can purchase (not read for free online).
See also: Uterine Rupture
A small uterine rupture won't even be detectable in most cases.
It is only a problem if the baby starts to come through the opening in
the uterus so that the uterus "thinks" the baby has been born and the placenta
starts to detach from the uterine wall. This movement of the baby
through the opening in the scar is call fetal extrusion.
Fetal extrusion is preventable. If you have dedicated one-on-one
care for the laboring woman, preferably by a midwife trained to look for
the signs of rupture, it is possible to mitigate the results of uterine
rupture by holding the baby inside the uterus while awaiting a surgical
birth. This will prevent the reduction in uterine size that precipitates
placental separation or abruption.
Also, fetal extrusion is not possible as long as the baby's head is
down in the pelvis, which is almost certain with upright positions.
Most cases of catastrophic uterine rupture occur with pitocin and epidural
and with the woman in a reclining position so that the baby's head is not
contained by the pelvic girdle.
Uterine Rupture
by Debbie Miller from Birthrites:
Healing After Caesarean
Uterine
rupture after previous cesarean delivery: maternal and fetal consequences.
This article discusses the sequence of events involved in catastrophic
uterine rupture. It implies that the most serious danger is when
the baby is pushed through the opening in the uterus into the abdominal
cavity, precipitating placental abruption.
Women
get good news about normal delivery after C-section - By Rita Rubin,
USA TODAY [2/8/04]
The risk of complications from vaginal births after C-sections - known
as VBACs - is actually quite small, according to the most definitive study
on the subject. Liability concerns have spurred a growing number of U.S.
doctors and hospitals to ban VBACs. In 2002, only 12.6% of pregnant women
with a prior cesarean section delivered vaginally. That's only one-third
of the government's goal of 37% by 2010. Meanwhile, the overall C-section
rate in the USA has climbed to its highest level ever - 26.1% in 2002.
Interdelivery
Time Affects Uterine Rupture Risk During Trial of Labor After Prior Cesarean
The risk . . . is threefold higher if the interval since the previous
delivery is 18 months or shorter, rather than 19 months or longer.
All evaluations of birth outcomes ignore statistics regarding long-term
outcomes, such as differences in childhood infections and hospitalizations
for breastfed vs. bottlefed babies, and how cesarean rates affect those
differences. They also ignore avenues focused on prevention of uterine
rupture through upright labor positions, early detection of uterine rupture
through dedicated face-to-face care in labor, and mitigation of uterine
rupture through application of pressure over the rupture to prevent fetal
extrusion into the abdomen.
"Dr. Dermot W. McDonald of the National Maternity Hospital in Dublin
Ireland suggested that the medicolegal pressure to perform a cesarean may
abate only when mothers begin suing physicians for assault, alleging that
they were not given fully informed consent...
"'If one went to the extreme of giving the patient the full details
of mortality and morbidity related to cesarean section, most of them would
get up and go out and have their baby under a tree,' [Dr. McDonald] said."
[Neel J. Medicolegal pressure, MDs' lack of patience cited in cesarean
'epidemic.' Ob.Gyn. News Vol 22 No 10]
Irish physician McDonald's remarks accord with the 1990 findings of
British research statistician Marjorie Tew who concluded that the British
maternity system is run by obstetricians who "withhold and pervert knowledge
in order to maintain public ignorance and delusion." [Tew M. Safer childbirth?
A critical history of maternity care. London: Chapman and Hall, 1990.]
VBAC, C-Section, and EFM: How Safe Are They?
by Jennifer L. Griebenow
Relative Risks of Uterine Rupture - Several
gems, including "The risk of cord prolapse is 1 in 37 (2.7%), or nearly
ten times more likely than that of rupture. "
Anne Frye on VBAC and Uterine Rupture
The easiest introduction to the studies is basic introduction.
Uterine
rupture associated with the use of misoprostol in the gravid patient with
a previous cesarean section.
There is a very interesting report on rupture of the uterus from the
largest hospital in Turkey (52,000 births in 3 years -- yikes!). They had
a policy of routine repeat cesarean, but many women did not seek prenatal
care and simply presented themselves during labor. If a woman with a previous
cesarean presented in very late labor, she could avoid a cesarean, but
otherwise once a cesarean, always a cesarean. They had a rupture rate of
1/1457 (0.068%), pretty low unless you remember that most women with previous
scars were sectioned upon presentation to the floor in labor (must be a
really chaotic place with all those deliveries) .
Of the 40 uterine ruptures, 10 were in unscarred uteri, mostly associated
with prolonged labor and pitocin augmentation, with a mean parity of 3.
The 30 ruptures in scarred uteri all occured with low transverse incision,
11 had more than one cesarean. The rate of rupture in >1 cesarean was 4
times that in those with 1 cesarean, but still less than 0.5% (but their
overall rupture rate was really low, compared to other authors).
Rupture
of the uterus.
A little bit closer to home, some authors in LA reported on 10 years
of vbac. There were 17,000 women with at least one prior cesarean, 13,500
with 1 (79%), 3,000 with 2 (17%), and 800 with 3 or more (4%) -- all of
whom underwent a trial of labor. All women with previous cesarean were
considered for trial of labor -- except known classical (unknown scar could
TOL), previous uterine rupture, or contraindication to labor. They did
a routine inspection of the scar after delivery and classified separations
not requiring intervention as dehisences and anything requiring intervention
as a rupture.
80% (11,000 of 13,500) of single previous cesareans underwent a TOL
with an 83% success rate and rupture rate of 0.6% and a rupture-related
perinatal death rate of 0.18 per 1000 trials of labor.
54% (1600 of 3000)of two previous cesarean had a TOL, with a 75% success
rate and a rupture rate of 1.8% and a perinatal death rate of 0.63.
30% (240 of 800)of three or more prior cesareans had a TOL, with a success
rate of 79% and a rupture rate of 1.2% and no rupture related deaths (of
course, the numbers in this group are much smaller -- only n=240 who had
TOL, so a larger group would be needed to really observe the risks-- although
I wonder where you might find a larger group?)
Another interesting factoid is that of the total uterine ruptures in
women with previous cesarean, 23% (n=22) were prior to labor onset or diagnosed
immediately upon admission when fetal distress was noted. All the other
95 uterine ruptures were supposedly discovered at "non-emergency repeat
cesarean". Does this mean that none of the TOLs resulted in obvious uterine
rupture and fetal distress, but that when they decided to throw in the
towel on the TOL, they found 95 ruptured uteruses? There were 3 rupture-related
perinatal deaths in women undergoing TOL, but 5 rupture related perinatal
deaths in the group that was discovered to be ruptured upon admission.
They had one rupture related maternal death.
The authors conclude that a TOL is a reasonable option for 2 or more
previous incisions, but is best reserved for motivated patients who understand
and accept the increased risk of uterine rupture and decreased risk of
success which is pretty much what we have been saying in our discussion.
Vaginal
birth after cesarean: a 10-year experience.
For those of you who are really interested in this subject, Public
Citizen put out a White Paper in 1994 (getting outdated, I know) called
Unneccessary
Cesareans: Curing a National Epidemic. They have an excellent analysis
of the relative risks of TOL, failed VBAC, successful VBAC, planned repeat
cesarean -- for the mother and for the baby. It cost $15 for a single state
report (the national report costs $60, but only has more raw data on individual
hospital cesarean rates and is unlikely to be worth the extra money) and
I have found it to be an in-valuable resource in the vbac or not to vbac
debate.
There is no value in treating VBAC moms with uncomplicated histories
any different than any other mom. ACOG even agrees (sorry no handy references).
50% of the less than 1% of VBAC that have ruptured uteri (with low transverse
scars) happen before labor and even the labor ruptures are unpredictable.
The figure of 1% is probably too high and is in dispute because much of
the data comes from the now out of vogue practice of manually exploring
uteri after VBAC, when you might find a small window or separation that
was of absolutely no consequence.
It is very clear that VBAC with a low transverse scar is very safe.
If I may quote a few juicy statistics from the Public Citizen report on
Cesareans:
I have not seen ANY studies which indicate a higher rate with multiple
cesareans. if he has some, I'd like to see them . I don't believe the stats
he was showing you. The guidelines to doctors from the American College
of Obstetricians and Gynecologists state that doctors should "counsel and
encourage women" with previous cesareans to plan VBAC over repeat cesareans
as the safer choice. The latest edition of the VBAC guidelines also includes
VBAC as safe for women with multiple cesareans.
There have been no reported MATERNAL deaths due to uterine rupture of
a low transverse incision.
Although rare, there have been incidences of fetal death associated
with rupture of low, transverse incision. From Flamm's book:
Abstracts about Pit and Home VBAC
What I find very odd about all this fear about uterine rupture from
VBAC is that they seem to forget that the risk of rupture is unaffected
by laboring. The danger is introduced by the presence of a uterine scar,
which, by the way, came from the previous surgery. In any case, the danger
is very small, and attention to one's body is likely to notice it before
it becomes a life-threatening problem.
If the risk of uterine rupture in subsequent pregnancies was really
so high, wouldn't they be doing more to avoid those first cesareans?
When I did the state stats for the Oregon Midwifery Council a few years
back the rate was as follows:
Once
a Cesarean, Always a Controversy - VBAC article by Dr. Bruce Flamm. MD
I know that we have had threads like this, before, but what is the size
of the biggest baby you've ever caught? i am still reeling from the huge
VBAC baby a few days ago -- 12 pounds 6 ounces. Her first was 9 pounds,
and her second was 10 lb 8 ounces. We don't routinely test for GD, and
this lady didn't want to be tested. We thought she was growing a smaller
baby this time. She was really careful with her diet, really didn't want
a big baby this time. We are usually pretty good at estimating weight.
After the birth, we watched this baby carefully, and she just seemed fat.
No problems whatsoever. I've had several 11 pound babies, now, one recently
that was born effortlessly, and posterior. I am already impressed with
the capacity of the human body to give birth, but this was really amazing.
I want to know the size of the biggest VBAC baby ever delivered. Does anyone
know? This baby has to be in the running----
My largest VBAC was 11-7, spontaneous rotation from OP to OA. Had c/s
for cpd and sepsis of 8-7 the first time around. Actually, she was heading
for OR this time too....5 hrs stuck at 6 or 7 cm, got fever, OR was busy.
By the time OR was free her temp was ok and cx was 8-9 so we proceeded.
NSVD VBAC w/ first degree lac.
I will not work with a care provider who would think of an untried healthy
pelvis as any different in its natural ability to birth its baby than any
other pelvis is. To me also size of baby is a nonissue as I do not believe
that babies grow too big to fit the pelvis of the woman it is growing in.
In addition to this, I have never heard of a breech baby's head not getting
out of a pelvis in a natural non interfered with delivery.
Last month I beautifully homebirthed my 9 lb. 6 oz. baby girl after
two unnecessary scheduled cesarean surgeries for ten and eleven pound babies!
My girl sailed out of me! I know I could have birthed all of my children
as nature intended. I informed myself this pregnancy and baby size became
a nonissue to me.
I want to see the too big baby myth, untried pelvis myth, and breech
baby indication for cesarean surgery myth debunked.
Marriage Problems after Cesarean
The Pain Continues - How A Cesarean Birth Can
Affect a Marriage
C-section, VBAC, HBAC . . . Ecstasy? - "I
believe that our increasingly joyous birth experiences have been
a
With VBAC births it is important for the midwife to work with the dad
prenatally. a vbac father is in a horrible position because, despite
the fact that his wife had an operation and a long recovery, he still got
a live wife and baby at the end of it all. Vbac dads are often "fantasy
bonded" to the medical system and terrified of childbirth in general.
the good thing is that they listen very carefully and really know when
the care is better and more thorough and when the practitioner is authentically
on their team. I find that if the midwife talks to them very honestly,
they can trust and be fully supportive when the birth time arrives.
Primary
mode of delivery and subsequent pregnancy.
CONCLUSIONS: Following an initial delivery by CS, fewer women went on
to have another pregnancy compared with SVD. The incidence of subsequent
pregnancy is similar following instrumental and SVD.
There's some thinking that taking large amounts of Tums may cause the
baby's head to harden so that it doesn't fit into or through the pelvis.
If anyone had a cesarean for a head that wouldn't mold (sometimes called
CPD, but typically showing as a stall at 6 cm),
please
e-mail me with information about your Tums intake during pregnancy, the
official diagnosis, how far dilated you got in labor and whether your baby's
head was molded much, some or not at all. Thanks.
See also Monitoring Fetal Heart Rate/Decels
about unnecessary cesarean for fetal distress
Lack
of progress in labor as a reason for cesarean.
10 positive things I learned from my c/s
VBAC Success - Story and Rates
Jenny's Tale - Saga of a Birth Gone Wrong
Jenny Strikes Back - A Set of Letters and a Meeting
about the Unnecessary Cesarean
Eight Hours of Torture - Horrible Epidural Experience
Ends in Cesarean
Kristi
- Our Miracle Baby - Mom Ignores Medical Advice to Abort A Troubled
Pregnancy and Births a Healthy Baby. Kristi was also one of the first
babies born naturally to a mother with multiple previous cesareans.
[from someone whose wife had an unnecessary cesarean]
Where fetal distress is a diagnosis without a definition, a failure
to progress is a diagnosis without a prognosis: there is no meaningful
link between the length of labor and the outcome although there is a statistical
link between the length of labor and the chances of something else going
amiss. But the two things aren't the same; until something actually goes
wrong which DOES require a surgical delivery there is no reason for surgical
intervention.
FTP is also a completely arbitrary diagnosis. For example, the person
we are suing states in one of her affidavits that a "three minute recovery
from bradycardia is significant when there has been a failure to progress,"
the clear implication being that my wife was suffering from a FT
Landon MB, Spong CY, Thom E, Hauth JC, Bloom SL, Varner MW, Moawad
AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter
M, Peaceman AM, O'sullivan MJ, Sibai BM, Langer O, Thorp JM, Ramin SM,
Mercer BM, Gabbe SG.
Obstet Gynecol. 2006 Jul;108(1):12-20.Obstet Gynecol. 2006 Jul;108(1):12-20.
999 more women will have a hysterectomy
135 more women will have a uterine rupture and 7 babies will die
63 more women will have a cesarean-scar ectopic pregnancy 45,900 more
women will have dense adhesions (adhesions make subsequent pelvic or abdominal
surgery more difficult, increase the likelihood of injuring organs or blood
vessels during surgery, and can cause chronic pain and bowel obstruction)
13,500 more women will experience wound (abdominal vs. perineal) pain
for 6 months or more
378 more babies will die in the womb (antepartum fetal demise)
without explanation after 34 weeks of pregnancy
7,830 more babies will be born preterm (before 37 weeks completed gestation)
1,620 more babies will born weighing in the lowest 5% for their gestational
age
4,244 more babies will have respiratory problems serious enough to
require admission to intensive care
3,240 fewer women will have anal sphincter trauma (This assumes an
anal sphincter injury rate of 1%, a rate achievable with optimal care [Albers
2005].) BUT
630 more women will have bladder injury
10,260 fewer women will have moderate to severe urinary incontinence
BUT
0 fewer women will have later-life urinary incontinence (MCA 2004)
March 2005 A Review of the Evidence and Recommendations by the American
Academy of Family Physicians American
Coassolo KM, Stamilio DM, Pare E, Peipert JF, Stevens E, Nelson DB,
Macones GA.
Obstet Gynecol. 2005 Oct;106(4):700-706.
"Have you had a ceasarean and want a vaginal delivery next time?
The VBAC (vaginal birth after a c-section) is a 2 part CD which helps you
overcome any trauma from your previous c section and the prepares you for
a natural vaginal delivery"
Laubereau B, Filipiak-Pittroff B, von Berg A, Grubl A, Reinhardt D,
Wichmann HE, Koletzko S; GINI Study Group.
Arch Dis Child. 2004 Nov;89(11):993-7.
BMJ 2004;329 (3 July), doi:10.1136/bmj.329.7456.0-a
Mozurkewich EL, Hutton EK
Am J Obstet Gynecol. 2000;183:1187-11
Natural Childbirth after Cesarean by Karis Crawford & Johanna
Walters
Birthing from Within by Pam England and Rob Horowitz
Silent Knife by Nancy Wainer Cohen & Lois Estner
Natural Childbirth the Bradley Way by Susan McCutcheon
2- Nancy Cohen's other book-- Open Season (if not the
above)
3- Gentle Birth Choices by Barbara Harper (AND see the
companion video!!!!)
4- Diana Korte and Roberta Scaer's A Good Birth, a Safe Birth
5- Susanne Arms' Immaculate Deception
For wonderful support during pregnancy, subscribe to her BirthLove newsletter!
Sakala C
Soc Sci Med 1993 Nov;37(10):1233-50
U.S. women beginning labor with midwives and/or in out-of-hospital
settings have attained cesarean section rates that are considerably lower
than similar women using prevailing forms of care--physicians in hospitals.
Martin JN Jr, Morrison JC, Wiser WL
Obstet Gynecol Clin North Am 1988 Dec;15(4):719-36
by Katie Granju - From Minnesota Parent, October 1997
A must-read article for anyone trying to understand why the healthcare
system in the U.S. continues to snub the midwifery model, despite reduced
Cesareans, proven safety, and lower costs.
The problem of VBAC is essentially one of playing the odds.
If a pt chooses TOL and is successful, they win-minimal morbidity, short
stay and low cost. If VBAC is not successful, they lose: repeat CS after
a long labor with increased risk for high morbidity, prolonged stay and
high cost. On the other hand, if they choose repeat CS they play a sure
thing: low morbidity, slightly longer stay and moderate cost. I encourage
counseling patients about VBAC from a perspective of what is good for the
patient rather that what is good for the hospital cesarean section rate.
Low morbidity with an elective repeat cesarean? Oh really? Moderate cost?
What color is the sky where HE lives? What is good for which "patient"?
Baby? Mother? How does he determine this? Worth noting is the fact that
while some of the studies, McMahons in particular, have received valid
criticism for unjustified conclusion and poor methodology, none of the
criticisms have been mentioned. I e-mailed Ken about this today. I feel
that an unbiased source of VBAC information should include these criticisms.
American College of Obstetricians & Gynecologists, Committee Opinion,
No. 214, April 1999
Doula Recommendations for VBAC Client
You might have your client read "Silent Knife" by Nancy Cohen and Lois
Estner as well as "The Vaginal Birth After Cesarean Experience" by Lynn
Baptisti Richards - she says VBAC stands for Very Beautiful And Courageous.
Nice, huh? These books will stimulate some anger, but it will ultimately
help her sort out her feelings. The sooner this is done in preg. the better.
Then she needs (with your encouragement) to focus on herself as capable
and able to have her baby, no different than any other preg. mom, the cesarean
being relevant to her past history only. She probably would have delivered
fine last time, only at 41-42 weeks, (why was she induced at 39 weeks,
anyway?) While the cesarean is relevant history info for you to have, it's
important that you don't regard her as a "VBAC mom," any more than you'd
regard a mom with a hx.of a previous epis. as an "EPISIOTOMY mom." She
will so appreciate your confidence in her ability to give birth! And yes,
VBAC moms are often (not always) very similar to primips in their labor
patterns - if there is such a thing :-)
-The scar that has remained intact up to the threshold of labor is
very likely to remain intact through the birth (Macafee, C, Irish J. of
Med Science, Vol 38, 1958, p. 81).
-The possibility of other unforeseen events occurring which may necessitate
transport such as intrapartum hemorrhage, fetal distress, or cord prolapse
is about 2.7 percent, roughly ten times the rate of rupture during labor
(Enkin, M. et al., "Effective Care During Pregnancy and Birth, New York:
Oxford U. Press, 1989).
-In her literature review, Henci Goer ("Obstetric Myths Versus Research
Realities" p. 42) found reference to only 46 ruptures during 15,154 labors,
a rate of 0.3 percent (benign scar separations are a more common occurrence).
-thanks to Anne Frye and her book, Holistic Midwifery Volume 1, Labrys
Press 1995
VBAC Guidelines (from ICAN President)
Safety of Going Past Due Date with VBAC
Scroll down to Step 6.
Ultrasound to Predict Dehiscence or Uterine Rupture
Rozenberg P, Goffinet F, Phillippe HJ, Nisand I
Lancet 1996 Feb 3;347(8997):281-4
[Echographic measurement of the inferior uterine segment for assessing
the risk of uterine rupture]. [Article in French]
J Gynecol Obstet Biol Reprod (Paris) 1997;26(5):513-9
Ultrasound to Detect Dehiscence or Uterine Rupture
Single-layer Vs. Double-layer Closure
Uterine Rupture and Fetal Extrusion and Mitigation
Leung AS, Leung EK, Paul RH
Am J Obstet Gynecol 1993 Oct;169(4):945-950
VBAC Safety/Rupture Statistics
Plaut MM, Schwartz ML, Lubarsky SL
Am J Obstet Gynecol 1999 Jun;180(6 Pt 1):1535-1542
The uterine rupture rate for patients attempting vaginal birth
after cesarean section was significantly higher in those who received misoprostol,
5.6%, than in those who did not, 0.2% (1/423, P =.0001)
Note that this uterine rupture rate of 0.2% without misoprostol
is significantly lower than the 1.5% commonly quoted!
Saglamtas M, Vicdan K, Yalcin H, Yilmaz Z, Yesilyurt H, Gokmen O
Int J Gynaecol Obstet 1995 Apr;49(1):9-15
Miller DA, Diaz FG, Paul RH
Obstet Gynecol 1994 Aug;84(2):255-8
Maternal Deaths per 100,000 Births
All Vaginal Deliveries
9.8
All Cesarean Sections
40.9
Uncomplicated Vaginal
4.9
Elective repeat Cesarean
18.4
I just opened the report from The Public Citizens health Research Group
and here are some rupture stats: Flamm 1990 5,733 women laboring for VBAC,
10 ruptures (0.17%), Farmer 1991, 7,598 women, 61 ruptures, (0.8%), Meehan
1989; 1,350 women 6 ruptures (0.4%); Nielson 1989 1,008 women, 6 ruptures
(0.6%)
These papers reported on a total of 11,027 women who had attempted
VBAC: 8,693, or 78.8 percent, of these women had successful vaginal births
in spite of their previous cesarean operations.
As far as risks to the baby, there were two fetal deaths per
ten thousand births due to low transverse uterine rupture. Thus, the risk
of a baby dying because of uterine rupture appears to be less than one
in one thousand. To put these numbers in perspective, remember that in
the US, the perinatal mortality rate is around 1.2%. In other words, if
a woman decides to have a natural birth after a previous cesarean section,
she is essentially at no higher risk of losing her baby than any other
woman.
Ceserean rate for total -- 2.8%
ceserean for mulitps -- .08%
for primes 5.8%
for vbac attempt - 11%
Size of VBAC Baby
Marriage and Cesarean Aftermath
real blessing to him and to us as a couple. "
Mollison J, Porter M, Campbell D, Bhattacharya S.
BJOG. 2005 Aug;112(8):1061-5.
Women Who've Had Cesareans Talk About What Happened
Gifford DS, Morton SC, Fiske M, Keesey J, Keeler E, Kahn KL
Obstet Gynecol 2000 Apr;95(4):589-95
Conclusion: Lack of progress in labor is a dominant reason
for cesarean delivery. Many cesareans are done during the latent phase
of labor, and in the second stage of labor when it is not prolonged. These
practices do not conform to published diagnostic criteria for lack of progress.
or Yes, It Can Happen To You