Pissed! but Accepting?

Wednesday was a banner shite day.  My midwife had been encouraging me to maintain a relationship with an OB, and I knew this necessitated a change.  Friends and L&D nurses urged me to try this one doc, Dr. A (we shall call him), stating that if anyone was going to give me a chance at VBA2C, it would be him.

So, I naively went to my 9:50am interview/appointment with Dr. A.  I was nervous – didn’t really sleep the night before – but hopeful.  The staff was very nice; the nurse was nice.  (I had previously talked with her.)  I had previously met this doc, so at least I wasn’t worried about that.

He was interested to know why I was there since obviously I had been seeing another OB for the 1st three-quarters of my pregnancy.  I told him I had 4 reasons:

  1. I am very motivated for a VBA2C

He interrupts . . . “Don’t do it.”  Shaking head.  Patronizing tone.

I cry.

The rest of the appointment was him trying to scare me out of it, and by the time I told him I’d been diagnosed with a thin lower uterine segment (LUS) during the RCS, he was certain that I am a nut.  Actually, he recognized that I had done a lot of thinking and researching, but he didn’t think I had given enough thought to permanent damage to the baby and permanent damage to me.  (Like, DUH!  What else have I been thinking about the past 7 months.  FFS!!!!!!!)

What was scary is that he’s familiar with the same research I’ve studied.  He mentioned the Cochrane library.  He refuted the opinion of the NIH VBAC Consensus Panel (because most of them don’t deliver babies).  The research doesn’t point to maternal death from uterine rupture but he’s seen it.  Fetal demise begins within 8 minutes of the onset of bradycardia associated with rupture which is too short a time to get a cesarean performed.  Yada yada.

Terrifying.  And I’ve done my research.  I’ve been researching this since 2007.  I have a PhD.  I have fantastic research and analytical skills.  And I was still terrified.  And I still doubted myself, my support system, everything.  And I resented my baby.

And I freaked the hell out.  Couldn’t go to work. 

So, you probably see the “pissed” part.

Here’s the “accepting” part.

Of course he’s going to do “his job” and dissuade me from VBA2C.  In his experience, it’s too  risky to justify.  He’s not going to understand why I disagree.  I’ll never be able to “educate” him here either.  When I don’t rupture and have this baby at home without incident, he’ll assume I got lucky.  I accept that he views birth with a completely different lense.

However, he’s agreed to take me and said he won’t drop me either even if I go forward with the VBAC.  He’d rather babysit me through this poor choice than turn me away.  I’ll have to sign an AMA (against medical advice) waiver just to cover his butt.  Fine; whatever.  So, for now . . . I’m planning to continue my concurrent care with him.  If it becomes a regular thing for him to try and terrorize me, then I’ll drop him.

Although he really shook me to the core on Wednesday, thanks to the amazing support of ICAN and Birth After Cesarean, I’m back on track and actually feeling more solid about my birth plans.  I just don’t “see” the hospital figuring into this experience.  Perhaps God or my baby or some 6th sense will change things, but for now, I’m back to planning a peaceful birth at home.

Impactful Tweets (pt 3) ICAN 2011 Conference

I tried to catch as much of the Henci Goer chatter on twitter as I could tonight.  We have a full house tonight (our 3 plus 2 neighbor kids spending the night, oy!) so I’m playing with less than a full deck.  Ha!

Disclaimer: Since I read these tweets on a public hashtag channel, I’m not asking permission to repost.  If anyone wants their tweet removed or wants to clarify a tweet, please let me know.

anderzoid #ICAN2011 henci goer: how much we have over medicalized birth? IV drip- not allowed to eat or drink – induction- cord clamping- etc
I assume this was a slide of the topics used to justify the point that birth is over medicalized.  My previous research leads me to concur that these are some of the ‘biggies.’

poderyparto Ineffective & harmful practices: sonograms to estimate fetal weight, planned cesarean for breech,not supported by research. #ICAN2011
Ultrasound is such a poor diagnostic tool for assessing fetal weight in the 3rd trimester.  I can’t recall exactly ‘when’ ultrasound is more accurate for predicting due ‘dates,’ but it’s very early on – I’m thinking 8-12 weeks gestation, but don’t quote me on that.  Only one mom out of the many I know personally that were told they were going to have a big baby actually did have a big baby.  Friends and family members who have had 3rd trimester estimates done with specialists have birthed babies 2 pounds lighter than predicted!!!!  Regarding the no-questions-asked cesarean for breech – a flawed Canadian study is what dictates current US practice.  Thank goodness Canada is taking the lead to restore breech as a version of normal.

bbybirthingmama Scheduling a section for breech, twins, “big baby” and slow labor are not supported by research! #ICAN2011
I was sad to discover that 75% of twins in Montana are born by cesarean.  I imagine all breeches are born by cesarean except for the rare surprise breech or unattended breech births.  Many docs aren’t ‘allowed’ by their insurance companies to deliver breeches naturally – how convenient for them.  Slow labor – yeah!  Most women just DON’T dilate 1cm/hr.  I REPEAT – MOST WOMEN AREN’T GONNA DILATE ACCORDING TO FRIEDMAN’S CURVE.

tconsciousdoula The way to get a VBAC? Tell the Dr you are planning on having 10 children! #ican2011
Now that’s a good one.  I’ll have to add that one to my list!

babydickey: Perinatal death from csec scar uterine rupture is 6 in 10,000. But did you know pregnancy loss from amniocentesis is 60 in 10,000? #ICAN2011 AND Unnecesarean 6% of scar ruptures—> perinatal death (3 per 10,000). Compare to excess risk of pregnancy loss from amniocentesis… 60 per 10,000. #ICAN2011
Here’s what was stated in the NIH VBAC Report: “Approximately 6 percent of uterine ruptures will result in perinatal death. This is an overall risk of intrapartum fetal death of 20 per 100,000 women undergoing trial of labor. For term pregnancies, the reported risk of fetal death with uterine rupture is less than 3 percent.”

tconsciousdoula planned VBAC should be the norm (87%) actual rate is 9% (2007) #ican2011
Add this information to your notebooks in case you need to make the case for VBAC to a doctor, a nurse, a hospital administrator, or a friend.

tiffrobyn A 41 week pregnancy is not only normal, it is AVERAGE! #ICAN2011
Like . . . duh.  Why have care providers forgotten that?  Well, statistically that may not be the exact average for all childbearing groups (i.e. primip vs. multip), but it’s absolutely ridiculous to pressure a woman into inducing at 41 weeks.  Some providers will start pressuring you at 39 weeks, especially if you let them anywhere near your cervix!

bbybirthingmama WHO Recommends no more than 10% induction rate. I didn’t know that. #ICAN2011 BUT poderyparto US induction rate 2005: 47% (babydickey tweeted 41%) of women planning vaginal birth! #ICAN2011 #CAM2011

shedenka So hospitals and docs tell ALL women “you can’t eat/drink” during labor. Total CYA: aspiration risk is 3.2 women out of 10 million #ICAN2011

nashvillebirth Henci Goer makes my head hurt in a good way. She always melts my face off. #ICAN2011
*Giggle*  This really made me smile.  I love having my brain hurt in a good way.  It’s invigorating!!

bbybirthingmama Early Cord Clamping can take up to 40% of newborns blood volume! #ICAN2011
I had no idea!  All of my babies have had their cords clamped immediately.  I will definitely add this to my notebook – I had decided a while back that I wanted delayed cord clamping.  I know it’s not really a strange thing to ask of a CPM but may be strange for an OB.

anderzoid Henci Goer still on ineffective & HARMFUL practices: Care by an OB for LOW-risk & MODERATE-risk women #ican2011
This point was made by a NYC OB in “The Business of Being Born.”  It’s overkill, and generally speaking, normal birth just isn’t exciting enough for them.  Plus, most of them have never seen a normal birth – especially the younger OBs.

anderzoid: #ICAN2011 #ppdchat Henci Goer: it’s hard to get #PTSD on radar bc TRAUMA is centered in Institution. DEPRESSION is centered in women.
This is a very interesting statement and one that I’d like to have fleshed out for me.  I can almost grasp it but not quite.  I will say that people seem to be aware of PPD and acknowledge it but are less able to grasp PTSD as it relates to childbirth (or pregnancy loss).

Want to read more conference hi-lights?  Here is part 2 and part 1 of my Impactful Tweets “coverage.”

DH & I have a big to do list for the weekend, so I don’t know how thorough future posts will be.  Enjoy the weekend!

EDITED to add “Birthing Beautiful Ideas’s” wrap-up of the day’s presentations at the ICAN 2011 Conference.  Have a look!

Hindsight Quarterbacking a hospital VBAC

I recently joined My Best Birth, a network on NING.  Today I noticed that a woman posted a link to her VBAC story, so of course I had to go read.

My goodness what she encountered:

  • Urge to push at 2cm dilation
  • Pressure to have a cesarean
  • Early epidural
  • More pressure to have a cesarean
  • Stalled labor
  • More pressure…
  • Slow dilation
  • More pressure…
  • Scare tactics
  • Multiple birth attendants
  • Fear
  • Swollen cervix
  • Presented with “limit of liability” and cesarean consent forms
  • DH had to go fight off the OB
  • A lovely doula
  • Wonderful calm-inducing friends
  • Finally ready to push
  • Pushed in stirrups
  • BABY!!!!
  • Doc pulling on the placenta
  • Contraction finally finished birth
  • SUCCESS!!!!!

My goodness me!!

I was intrigued by a back and forth in the comments between the Feminist Breeder and At Your Cervix.  At Your Cervix was saying that pitocin augmentation might have helped speed things along for this woman.  Feminist Breeder stated that pitocin augmentation was contraindicated for VBAC… which is certainly what I thought as well.  So, I had to look.  I googled VBAC “pitocin augmentation” and one of the first things that came up was a page from Dr. Wagner’s Born In the USA (table 6) with a chart which estimated uterine rupture rates:

1 in 33,000 – woman with unscarred uterus
1 in 200 – VBAC without augmentation or induction
1 in 100 – VBAC with oxytocin augmentation
1 in 43 – oxytocin induction
1 in 20 – Cytotec induction [ref]
Have a look also at Homebirth.org’s information on “Induction or Acceleration of Labour in VBAC Candidates.”  All of this makes me understand the wide variety of rates that I’ve heard doctors cite.  Of course they never admit a .5% rupture rate probably because a large number of them induce and augment labor.  (Maybe that’s an unfair assumption, I don’t know; the fact remains that I’ve never heard a doctor actually use that rate.)  A CNM I talked to this past year used the 2% rate.  I’ve heard 1%.  I’ve even heard 5%.

I read an interesting discussion – “How high is too high for pitocin” at All Nurses Dot Com.  Definitely something to keep in mind.  I should write down some of this . . . and ask our hospital staff about their policies.

Another related resource that I highly recommend can be found at VBAC Facts, one of my favorite sites – “Two doctors respond to the Hastings Indian Medical CenterVBAC Ban . . .”  Specifically, pay attention to the charts and suggested protocols in the Leeman/Espey response.

A Note to My Friend

This morning I received an encouraging e-mail from a friend.  She has been through infertility and recurrent losses, but it looks like she finally has a keeper!  Luckily she has found medical providers who were able to come up with a good treatment protocol for her situation.  She has weaned off of the progesterone shots (daily shots of progesterone in oil – owie!) but is still on heparin, I believe, for the duration of her pregnancy.  She is finally in the second trimester!

She mentioned that her fear of childbirth is abating.  Some of that is because she has experienced natural miscarriage, and she has been told that it is like mini labor.  I wanted to share (most) of my response to her.  Of course I could have said much much more, but I really don’t want to be “that crazy friend” who can’t shut up about natural childbirth.

Just remember that the OB is just a person, not a god.  And what YOU want DOES matter.  Ask about birth plans and how the hospital honors them.  I would hire a doula, someone who will be able to advocate for your needs and your desires.  Seriously, that’s the biggest mistake I made – I thought that having a CNM would “save” me from unnecessary intervention, but it didn’t.  The rest is history.


I thought the childbirth education classes at [name removed] were just fabulous.  My only criticism is that I somehow didn’t understand how life altering the cesarean was going to be.  I’m not trying to scare you – the cesarean was a piece of cake for me, and it didn’t mess with breast feeding at all (in my case).  It’s just that I was so shocked when I went in for my 6-week post-partum appointment with the OB who did my surgery and was told about uterine rupture.^  And then last July-August when I was preparing for baby #2 I learned so much about the failings of our maternal health care system, and that’s when I really “cracked.”  I was just so pissed and became somewhat disappointed in [name removed] for not having been more forceful.*

Regarding labor – I didn’t even know I was in labor.  Granted I had a violent stomach flu . . . but I was surprised that I showed up at the hospital 9cm dilated!  Probably one of the most painful things I have gone through was my second miscarriage.  Supposedly subchorionic hematoma miscarriages are pretty bad, and this one was no exception.  And during my last miscarriage I kept nearly fainting from the blood loss.  Labor?  Piece of cake.  You’ll be brilliant!  Remember that the pain is good – it’s there for a reason.  It helps get your baby out and into your arms.

I am just so excited for you.  I am so glad that you’re out of the first trimester!!  And hopefully you’ll really start feeling great, and pretty soon you’ll start feeling your “lemon” move.  That will bring you much comfort and joy.

^ For the record, every laboring women has a small risk of uterine rupture.  Most uterine ruptures in VBACs were historically caused by labor augmentation and induction tactics.  A “window” or a dehiscence (separate terms in my mind) is not the same as a true uterine rupture.

* One thing I forgot to mention to her is that my husband seems to remember our childbirth educators talking about uterine rupture.  Maybe they mentioned it, but again, it didn’t leave the impression that it should have.  I only pushed for 2 hours and then gave in to the cesarean.  I thought it made sense.  Had I known – really known – what a cloud the cesarean would cast over the rest of my childbearing years, I’d have resisted that cesarean.  My baby would have tolerated it – when she was delivered, her APGAR scores were 9 & 9.  Nearly perfect.  Not a baby in distress as I had been told.

Perhaps what childbirth educators could add into their series is a session on how doctors perceive cesarean scars.  Why the medico-legal culture dominates obstetric practices.  Why certain risks (cesarean surgery, amniocentesis, etc.) are acceptable and others (natural birth, especially after a cesarean) seem foolish.

Too Late for Natural Birth?

In my google alerts today, one headline stuck out: “Too late to reverse rise in c-sections?” from the Boston Globe.  It is a letter to the editor from Lois Shaevel, co-author of “Silent Knife.

Shaevel states:

For eons we females had been capable of giving birth with very little medical intervention. Then childbirth went into the hospital, and the process became a medical and increasingly surgical event.

It’s sad really.  I’m not saying that all women don’t need a hospital and that all births can be achieved non-medically, but what makes me sad is the shift in how pregnancy and childbirth are viewed by our society.  Pregnancy and birth used to be normal and expected events in a woman’s life.  Now when you tell someone that you are pregnant they ask you if you have a first trimester ultrasound scheduled yet.  When you respond by saying that you don’t plan to utilize ultrasound technology unless it becomes medically necessary, they cock their heads, look at you funny, and respond with a suspicious “huh!”

Shaevel continues: 

When Nancy Wainer and I wrote “Silent Knife” in 1983, we hoped our work would reverse the trend and give women confidence in their bodies’ innate ability to birth their babies. If this trend of surgical intervention in the natural process of childbirth continues, the only women who will birth their babies naturally 50 years from now will be those who don’t make it to the hospital in time for their caesareans.

Some women are finding ways to become more confident in their bodies.  I joined the International Cesarean Awareness Network (ICAN) which greatly increased my confidence and understanding that a repeat cesarean would likely be unnecessary.  However, the doctors will always find a way to rob us of our confidence.  One ICAN list member was told early on in her pregnancy that s/he was supportive of her choice to VBAC.  Now at 36 weeks she’s been told to schedule a repeat cesarean.  This is not an uncommon story.

Here are my thoughts on how/why this keeps happening to women who desire vaginal birth after a cesarean (VBAC).  Perhaps the doctor just wants the business and thinks s/he will be able to change the patient’s mind along the way?  Perhaps the doctor believes in a woman’s choice but loses confidence along the way?  Perhaps in losing confidence in the mother along the way, the doctor is thinking about the legal consequences of not performing an elective repeat cesarean?  Perhaps the doctor, losing confidence along the way or thinking s/he can coerce the patient into surgery, also has the $$ in his/her eyes since surgical birth costs so much more than vaginal birth?  Perhaps the doctor knows that VBAC labor can take longer, and since s/he will have to be more readily accessible thanks to ACOG directives, s/he pushes for the quicker solution – major abdominal surgery?  Perhaps the doctor is more afraid of the uncertainty of normal (as in natural) birth because s/he is not familiar with it versus that which s/he is trained to do – perform surgery?

Shaevel’s letter was formed in response to this recent Boston Globe article.  Here are a couple of important points to consider from the article:

“It’s important for us to step back and say, ‘Why is this happening, and is it in the best interest of the public?’ ” said [the state's secretary of health and human services, Dr. JudyAnn] Bigby, whose research before entering state government had focused on women’s health issues at Brigham and Women’s Hospital. “This is not a minor surgical procedure; it’s a big deal. We need to understand why this trend continues.” [emphasis mine]

She is “sufficiently alarmed” that her state’s cesarean rate now eclipses the national average of 31.1%.

Obstetricians’ fears of lawsuits may also fuel some of the increase.

“There’s no doubt about the medical-legal burden; the litigious nature of society has an impact on this,” said Dr. Fred Frigoletto, chief of obstetrics at Massachusetts General Hospital. “Very few obstetricians have been litigated because they did a C-section. But they’re always litigated because they didn’t do one.”

Fear of litigation is NEVER an appropriate motivator for medicalized childbirth.  Interventive practices are only appropriate when there is sound evidence of need.  Basing medical opinion, advice, and practices on a fear of litigation is unethical and violates the oath and creed to “first do no harm” that all doctors agree to when they become registered practitioners.

It once was popular to deliver subsequent babies [following a cesarean] by vaginal birth, but by the late 1990s the practice began to fall out of favor because of potential risks.

Potential risks – yes, it is possible that a woman’s uterus may rupture during labor.  The risk of rupture may be as low as .5%, and any doctor who puts forward a rate of greater than 1% should be asked for the research to support such a statistic.  Avoiding induction and augmentation of labor and having continuous labor support (an experienced doula and/or midwife) will help VBAC moms achieve their goals.

Anyone who doubts the importance of natural childbirth for both mother and child should register for the “What Would Mammals Do” webinar through Conscious Woman

I am the decider

I hate to quote our current president, but it makes for a catchy title.

I AM THE DECIDER!

You can tell the OB that:

  1. I can’t be cut against my will.  (In other words, VBAC bans are bogus.)
  2. I don’t have to have a heplock or IV upon entrance to the hospital.
  3. I don’t have to show up for a scheduled cesarean that I did not request.
  4. My baby doesn’t need continuous fetal monitoring.  (Continuous fetal monitoring does not improve outcomes.)
  5. Sometimes babies take longer than mothers, fathers, family members, friends, and doctors would like.  That’s life.  Deal with it – you can eat, sleep, and play golf later.
  6. Women don’t necessarily need to birth babies in hospitals.  (There are other options!)
  7. Most women could safely birth their babies at home (and escape unnecessary medical intervention).
  8. That the immediate availability of an obstetrician or anesthesiologist does not improve the outcomes for the overwhelming majority of mothers and babies.
  9. That hospitals without 24-hour surgical staff aren’t safe for anyone.
  10. That the risk of rupture in VBAC is equal to or less than the risk of complications from cesarean “delivery”.

Want to learn more about positive mother-child-centered birth?  Visit the International Cesarean Awareness Network (ICAN) or the links posted on this site.

Scar Integrity

Cesarean scar integrity in future trials of labor is a big topic in birth circles.  Someone on my ICAN list found a great entry on scar integrity, and the link is recirculating on that list as I write.

I appreciate and sympathize with her regarding the reason for such a journal entry:

People keep approaching me with “honest concern” regarding risk of rupture in a VBAC. Unfortunately, not a single one of these people has told me something that is true. There are many myths about c-sections and VBACs, most of which are perpetuated by caregivers forced to only offer repeat c-sections for liability and VBAC bans.

I especially like what she has to say with regard to healing time.  I’ve heard this myth circulated even in the homebirth community.  Shame on them!

Babyslime reference a post found at Joyous Birth.  I particularly adore this paragraph:

If your old surgeon questions the integrity of your healing, then he or she is expressing a complete lack of confidence in his/her work. Point that out. They need to think about this. If your new OB or midwife is questioning the integrity of your womb, then they need to be confronted about doubting the surgical skill of your previous surgeon. If they doubt his or her skill that seriously, perhaps they need to express their concern to the medical board.

I hope you’ll read both posts and then do your own research with regard to uterine rupture and scar integrity.  A couple of sites I usually send people to right away include: