My Journey to VBAC

I had a c section with Graham because he was left mentum transverse. This means he put his face into my pelvis first, sideways, with his chin on my left hip and his forehead on the right hip. This is considered a vaginally impossible delivery. I can pretty much attest to that as I had 52 hours of contractions without pain medication of any kind. I was upright and active the entire labor. I didn’t even go to the hospital until my water broke with particulate and thick meonium and even then I was 7cm. Because of all of this, it as very difficult to deliver him once the docs were inside so my uterus was cut a second time. The first cut was the standard bikini incision on the lower segment of the uterus and the second cut was perpendicular to that. It was a vertical cut extended into the contractile portion of the uterus. The result is an inverted T incision style scar on my uterus. This type of cut is reserved for emergency or very difficult deliveries. Only about .4% of c section end in this type cut.

American OBs quote the rate of rupture during a trial of labor in a subsequent pregnancy as 10%, 15% or even higher. It was originally recommended that any future babies were delivered by c section at 36 weeks after an amniocentesis to check for lung maturity. This was very disturbing to me on so many levels. First, I would be purposefully delivering a preterm baby. Graham gestated until 41 weeks and 1 day. By that reasoning, he would have been 5 weeks  early.  It was also concerning because if the rate of rupture was truly that high then was it even  sensible to carry another baby at all?

I started digging around and what I found was the most alarming thing of all. The true rupture rate found by the biggest study ever done on VBACs found a rupture rate of only 1.9%. How could it really be that low? How could I be told something so different previously? Where did the doctors that told me 10 and 15% get their info? I have no clue, I have never been able to find any reference  or study reporting that high of a rupture rate. It kind of made me mad and when I get mad I get determined.  I started reading everything I could find on this type of scar, why the cut is used, what doctors recommend and then I found that women did VBAC with this scar and they did it under the supervision of doctors and midwives that actually supported the idea.  I knew I had to find out all of my options before I could consider getting pregnant again.

I learned through ICAN of Atlanta that there is a doctor in Atlanta that would be VBAC supportive after an inverted t incision. He also support VBAC after multiple cesareans, VBAC after classical incisions, twin VBAC, and does breech vaginal.  His name is Dr. Tate.  I emailed him and talked to him months ago and he was on board when the time came. He was willing to take me as a patient, meet me at the hospital at the onset of labor, only require a saline lock and fetal monitoring and he would stay as long as it took with no pressure how long it took. He was willing to let my body work and do it’s thing without interference. He, like me, believes that the body is capable of birthing without intervention and time constraints and in a higher risk VBAC it is safer to be as hands off as possible.  The level of commitment that he was making touched me and motivated me and  I knew that was the answer. I could go back to the States in my third trimester and live at Ft. Benning and go to Dr. Tate in Atlanta. I finally had some peace of mind.

Then I found out I was pregnant on November 4th.

Yep, that’s right for  all of you that have been guessing, I am pregnant! Due July 15th. It is still very early, I am only 6 weeks along and I didn’t imagine announcing it so soon but I decided that I wanted to blog this experience and I was anxious to get started in case anyone else was going through something similar. So there it is

Once I found out I was pregnant my brain went in overdrive. I was already planning the move to Georgia in my mind and thinking of all the logistical aspects. I was bummed to have to separate my family for such a long period of time but willing to do it. I had decided that I would pretty much do whatever it took to make this trial of labor, my chance to VBAC happen. For me it is that important. I want my next baby to have a gentle peaceful birth. I want my body to experience labor and delivery the way it was meant to. I want to labor. I want to feel my contractions and my body work and my baby work in sync with it. I know it can do it. I am not afraid of labor, I had a very long labor with Graham,  I know that I can labor. I am not afraid to birth. I am surrounded by birth, I attend births, I know that my body can birth. I want that moment of realization that I birthed my baby myself. I want to hold my baby the instant it’s born, preferable pulling it out myself. I have had 19 months to process Graham’s birth but I will always hurt that he didn’t get to be with me for the first three hours of his life. How terrifying and confusing it must have been for him to go to the arms of strangers and bright lights and to be force fed formula rather than nurse. I want to give this baby a  more gentle entrance, it deserves that. I deserve that.

All that said, I am no fool. I know that I may have to have another c section. If the safety of my baby or my life is compromised, I get that. I have a lot of perspective and knowledge going into this next birth and I know that if we have another c section it is because it was truly necessary and I can live with that.

As all of this was coming out, my friend Karen, suggested that I talk to Dr. Chung. He is a Korean OB that has a solo practice and as the Korean’s say it he has gone the “natural way.” Women seek him out specifically for natural birth. Korea has a 45-50% c section rate and a 90%+ epidural rate for vaginal births. The “natural way” is small population in Korea. Dr. Chung also attends homebirths and has even attended homebirths on post at Yongsan Army Base. This is how Karen and I knew of him. It never occurred to me to ask him but I wasn’t aware that he attended VBACs. Once Karen told me this, I immediately emailed him. He got back in a couple days and said to come see him as soon as possible that he thought he could  help me.

OH MY GOODNESS!!! I couldn’t believe it. I may have the option to stay in Korea and do this! I had a question list a mile long. Everything had to be on my terms and my way. I want to do this but  it has to be as  safely as possible.  Here is the list of questions I used…

Approximately how many VBACs have you attended?

Of those patients in your practice who wanted a VBAC, how many were successful?

What do you think my chances are of a VBAC success, given my childbirth history?

What is your rate of cesarean sections and under what circumstances do you usually advise them?

Who is your back-up? Is he/she VBAC friendly? Would he/she support my birth plan?

What hospital(s) do you have privileges at? (Which would you recommend for a VBAC?) (Natural birth?)

What prenatal tests/procedures do you usually require? Recommend?

What do you think of Birth Plans/ Preferences?

How do you usually manage a postdate pregnancy? Or a suspected Cephalopelvic Disproportion (CPD)?

Do you have a vacation scheduled near my estimated due date?Labor & Delivery

What’s a reasonable length of time for a VBAC labor if I’m healthy and my baby appears to be healthy?

Do you know any kind of restriction I should expect from the hospital on a VBAC? (Who do I need to have policy exceptions approved through?)

How many people can I have with me during the labor and birth?

How do you feel about doulas?

What is your usual recommendation for IVs? Pitocin? Confinement to bed?

What’s your approach if the bag of waters has broken at full term but the mothers feels no contractions?

In what percentage of your patients do you induce labor?

Approximately how many of your patients have un-medicated births?

If my baby is breech will you still consider me for a VBAC? ECV?

At what point do you arrive at the hospital during labor/delivery?

What labor positions do you recommend to your patients? Do you encourage movement during labor?

I do not intend to push on my back. I may stand, kneel, squat or get on my hands and knees. How do you feel about this?

I would like to push spontaneously and without coaching or counting. I would like help breathing my baby out to reduce tears. Will you do this?

Do you require continual fetal monitoring for VBAC?

Do you allow light eating/ drinking during labor?

Are you OK with No IV – but a Saline Lock?

I would like a for my labor room to be quiet and undisturbed unless medically necessary. How do you feel about this and can you advocate for me to the hospital staff?

In the event that I need a c section and there is time, will I be able to have spinal anesthesia rather than general?

The conversation went even further than this list of questions.  I spent well over an hour with Dr. Chung yesterday. I was very pleased to learn that he would be willing to show up at the hospital with me at the onset of labor and stay until about two hours after the birth. NO MATTER HOW LONG IT TAKES. There will be no time restrictions. He said that he envisioned his job in my labor and birth as a back up. He said that he felt like he should be there with  me and if I need him he will be there. I will be laboring unmedicated so that I can feel any changes to my scar if there are any, and he can respond quickly because he will be in the room with me. He said that he understood the need to labor undisturbed and peacefully so he would be sure to keep staff out of the room unless medically necessary and that he would be an unobtrusive and quiet observer unless medically necessary. He has attended Hypnobirthing training and could certify as a Hypnobirthing practitioner if he wanted and that really got me excited. I am going to be using Hypnobabies and while the programs are different they are similar enough in that the laboring women requires peace and quiet and he totally gets that and is on board. He also said that his job was to let the staff know that my case is a special situation and while we do want little interruption that everyone should be on guard to respond to an emergency at any time. I will be doing this at a very large university hospital in Seoul that is also the most natural birth friendly hospital in the city. There will be pediatrics, NICU, anesthesiology, adequate nursing staff and a back up OB in case I get into trouble.  I am also A+ which is great because that blood type is abundant in Korea.

I cannot think of a more perfect scenario given my circumstances.

I would normally be very wary of going to the hospital at the onset of labor and laboring with my doctor present the entire labor but I truly believe that Dr. Chung is going to give me adequate  space and time. I don’t believe that his presence will pressure me. I think it will reassure me. Because I know that he isn’t going to put time restraints on me and he will not augment labor in any way, that I can relax. For me, because I have never had a vaginal birth, I need that security of immediate response and there are not many doctors in the world that commit to a patient the way he is committing to me.  I know that if I have another c section it will be because it was necessary. I know that he believes that my body can do this and that my body can birth but that if there is trouble he is prepared to repsond accordingly. With that kind of support, I know that I can labor quietly and peacefully and without worry.

So, like my friend Karen said yesterday, I have all the pieces in place, now it is time to switch gears to “I CAN birth my baby” and leave behind the “what if something happens.” She is right. I am ready. I can trust that I am in good hands and in the best case scenario possible for a trial of labor.

For me and my family, this is the best decision and one that I have been working on for a long time.  After Dr. Chung and I finished talking yesterday he did an ultrasound and I saw the little tadpole. It finally hit me that I was rally pregnant and not just planning any more

OP (Sunny Side Up), Cervical Swelling and Slow Dilation

OP (Sunny Side Up), Cervical Swelling and Slow Dilation…These are a few of the issues my last client had. With her permission, I want to talk about her birth. It’s actually a pretty amazing story. In addition to what I mentioned, she also had a 9lb baby with a very large head and managed to get out with only a 2nd degree tear.

So this client had been complaining of back pain for a couple of weeks. She works at a desk so I was worried that her posturing may have aided in her baby positioning himself OP (occiput posterior) or what some people call sunny side up or face up. When a baby is OP, the back of the head, which is the largest and hardest part of the head, digs into the moms back in utero. This sometimes causes chronic back pain. Some moms never feel any back pain at all when their baby is OP. I had talked with her about this and suggested that she do pelvic rocks daily and spend as much time as possible in the open knee chest position. Open knee chest is when mom puts her head and breasts on the floor and sticks her butt up in the air with her knees about hip width apart. Sounds easy but when you are very pregnant it is quite difficult.  I also suggested that she sit on a birth ball that was inflated enough so that her thighs where parallel to the floor in the hopes of relaxing her pelvic floor and encouraging baby to turn. She is quite tall and I don’t think she found the ball very comfortable. I also told her no reclining on the couch.  I feel as if I should have done more to encourage her to encourage the baby to turn but her back pain came and went and she didn’t feel fluttering indicating hands in the pelvic area and I couldn’t see her tummy (She was two hours away from me) to see if she had the dip in the stomach that OP babies often make.  I guess I didn’t want to freak her out with all the optimal fetal positioning techniques when in reality babies that are OP before labor almost always turn before labor or in labor.

This is a baby that is occiput anterior, the optimal fetal position for easier birth…

This is a picture of  an occiput posterior baby. Notice how the back of the head is in the mother’s back…

This woman, who we will call Alyssa,  began her labor at 4am the morning that she was 41 weeks and 3 days pregnant. At around 5am or so she began to have leaking that she believed was her water.  I joined her at 9:30am. The time line for her birth m my arrival goes as follows…

9:30am: I arrive
Contractions about five minutes apart, less than one minute long
You were breathing through them very well
10:00-10:30am: We walked, contractions started getting longer and more intense
10:30-11:30am: Complaining of back pain, we do pelvic tilts and open knee chest, I worry baby is OP
Breathing well through contractions but growing more intense with each one
You rest in bed for a few contractions
11:30am: Contractions are very intense. Still around 4-5 minutes apart, a minute long.
You are ready to go to the hospital
12:00pm: We arrive at hospital. Staff is busy. We walk for half an hour and take it one contraction at a time. Back pain is  intensifying and you are feeling a lot of pelvic pressure
1:00pm: You are admitted. You are 4cm and 100 effaced and your water is leaking. Baby is at a +1 station. You are monitored for half an hour and the baby looks great. You continue working through each contraction one at a time.
1:45pm: You are taken off the monitor and get into your labor room. Labor is very intense and you labor standing while leaning on the bed for an hour.
3:00pm: Labor is so intense and contractions are coming every three minutes for about a minute and a half. You have a lot of  pelvic and rectal pressure. You are a bit shaky and very hot. We put ice cold towels on you.
Because labor is so intense, the nurse figures you must be very progressed and asks if you want to be checked.
You are 8cm dilated. You are having urges to push.
4:30pm: Contractions continue at 3 minutes apart and about 2 minutes long. Your back pain is much worse as is the rectal  pressure. We try many positions to help complete your cervix. A check shows that you are stlil 8cm. Midwife breaks  your water and your cervix closes to a 5 or 6 and the baby retreats back to a zero station. We talk about the baby possibly being OP but she cannot confirm with exam. We spend the next hour trying to get the baby to turn.
5:30pm: The nurse checks and says you are 9cm with a lip. We spend half an hour getting you in positions to aid dilation.
6:00pm: Labor has become unbearable and you are having urges to push, your back pain is very intense. Midwife checks you and you are 6cm and your cervix is swollen. She again is almost certain the baby is OP. She offers and epidural and you accept. You also have a shot of Nubain to  hold you over until the epidural is placed.
7:00pm: Epidural is in place. You feel pain on one side for an hour or so.
8:30ishpm: You are 10cm
9:30ishpm: You begin pushing. The baby is at a +2/3 station when you being. After an hour is becomes clear that the baby is OP. It is also clear that he has a very large head. You push for another hour holding the squat bar and/or sheet tied to it  while his head molds.
11:30pm: Baby is coming down but getting hung up on the pelvic bone. You push flat on your back with your knees pulled far  back and   apart. He is able to descend past the pubic bone and begins to crown. The doctor uses baby shampoo as  lube and supports your perineum as you push the final few pushes before he is born.
just before
12:00am. Baby is born!!!! He comes out crying and looking around and after being checked out for a
few minutes is brought to you for skin to skin contact. You try to nurse immediately but he was interested just yet.
12:20am: Less than half an hour after being born, your baby is successfully nursing!!!
12:30am: The doctor is finished tending to you and leaves. You and dad bond with your baby.
1:30am: I leave

So the time line is a synopsis and not the birth story with all the details. What I’d like to include in that is that as her back pain intensified and the midwife agreed with me that the baby was probably OP, we began to get Alyssa into every position we could to get the baby to turn. The bed was broken down with the squat bar attached because when she was 8cm we tried to get her to sit on the bed with her legs on the lower portion with her upper body on the bar in a semi squat position in order to put pressure on the cervix to complete it. She didn’t like it because she had so much rectal pressure, so we took the bar off but left the bed broken down. Once the OP presentation because very obvious, we had her lower body on the bottom part of the bed with her upper body on the middle so that she was basically on her hands and knees.  We tried to apply counter pressure but Alyssa didn’t like it. She had not wanted very much massage or touch so we didn’t not try to relieve her back pain that way. She mostly responded to cold on her lower back.

Another point I’d like to talk about is that she was at 8cm for more than two hours before the midwife broke her water.  She had been in active labor for about 13 hours at that point and was ready for things to move along. By this point her labor had become all but unbearable.  I believe that the baby’s OP presentation was making labor much much more painful. She was already beginning to lose control during and even between contractions and I think that even though AROM (artificial rupture of membranes)  was not part of her birth plan, it really did sound like the best idea at the time.  Of course, once it was done and the midwife  felt her cervix close and the baby retract, she had this “OH SH!T” look on her face. And also of course, once it was done the contractions became even more intense.

I am not sure if the midwife breaking the water at 8cm is what caused the  chain of events that followed. If it would have broken on it’s own, the same thing could have happen. I had it happen with another OP baby client. Her bag ruptured spontaneously at 8cm and her cervix went back down to 7cm and the baby retracted from +1 to -1/0 station. I also think that after having been at 8cm for two hours with transition strength contractions after having labored all day, that Alyssa was running out of both steam and motivation, understandably.

The former OP client I mentioned who went from 8cm to 7cm took SIX FULL HOURS to get from 8cm to complete.  She had no option for an epidural as she was in a Korean hospital that did not offer them outside of business hours. The doctor was also performing c section so she didn’t have anyone offering to end the labor for her and her cervix wasn’t swelling either.  She managed and made it through it but it was incredibly difficult. I have no doubt that in that scenario that Alyssa could have continued her labor without an epidural.

What made Alyssa’s labor even more difficult was to spend two hours at 8cm with pushing urges, eventually get told she was 9cm and still have pushing urges and then learn that she was 6cm with a swollen cervix. I think that hearing this was incredibly difficult for her.  Maybe there were too many vaginal exams, maybe she didn’t have to know all of that was going on with her cervix but the fact is, she was pushing involuntarily even at only 6cm.

I have read that premature pushing does not always make a cervix swell and that her swelling was probably more the result of fetal positioning. It could also be a combination of the two, it’s hard to say. At any rate, with the intensity of pain she was feeling the midwife thought it best that Alyssa get an epidural to relax enough to be able to dilate. I was incredibly worried about this because it would be hard to get the baby to rotate with the epidural but I really do believe that at this point it was necessary. Her cervix wasn’t going to get a break and she was in too much pain to be able to invert her with open knee chest to pack the baby out of the pelvis some.

The midwife was right, the epidural helped and she dilated quickly. As the time line mentions, she pushed for nearly two and a half hours. The head was large and had a lot of molding at birth. He did get hung up under the pubic bone but the McRoberts maneuver, flat on back, knees far apart and up as possible dislodged him and within a few pushes he was out.

The most amazing part of this birth is that mom had only a second degree tear. OP babies are often associated with a higher incident of third and forth degree perineal tears and considering the size of this baby as well, I think this mom was incredibly lucky. I think that the fact that Alyssa had a successful vaginal delivery is a little bit of a miracle. We had THE BEST nurse on staff that day who helped me encourage Alyssa to move through her labor before she got the epidural. We had her doing a lot of things she didn’t want to do but she trusted us and we helped her and she did it.  All of these things helped, I really believe this. They helped her baby move down so that when she did get the epidural, labor continued to progress.  The support continued after the epidural in that we continued to help her move to help the baby move down.   The woman used a squat bar to push with an epidural, THAT is a feat in and of itself.  It took three of us (nurse, dad, me) to support her through it but she totally did it.

Here are some facts that I found regarding OP babies…

• The incidence of persistent occiput posterior babies at delivery is about 5.5% overall

• With a persistent posterior, both first and second stages are prolonged (Ponkey et al). However, longer second stages do not in themselves cause worse maternal or neonatal outcomes; in one study, as long as the fetus was stable, the second stage could continue without harm to mother or baby (Kuo et al).

• The likelihood of cesarean section or instrumental delivery (forceps or vacuum extractor) is greater when there is a persistent posterior position; in fact, the 5.5% of persistent posteriors account for 12% of all cesarean deliveries performed for dystocia (Fitzpatrick et al).

• Persistent posterior positions are associated with an increased incidence of premature rupture of the membranes, oxytocin induction and augmentation, epidural analgesia, chorioamnionitis, , episiotomies, severe perineal lacerations, vaginal lacerations, excessive blood loss, and postpartum infection (Pearl et al, Ponkey et al).

• Worse, there is a sevenfold increase in the incidence of anal sphincter injury, that is, third- or fourth-degree perineal lacerations (Fitzpatrick et al). Babies delivered from the posterior position were more likely to have Erb’s Palsy and facial nerve palsy than those delivered from the anterior position (Pearl et al)

• Occiput posterior babies often times cause a premature urge to push (pushing before 10 cm dilated)

• Occiput posterior babies can cause cervical swelling due to the hardest part of the head bearing down unevenly on the cervix. Cervical swelling can cause a stall in dilation or not allow the baby to descend enough to be pushed out despite the mother’s best efforts.

This study also explains the implications of epidurals with OP babies…

Epidural Analgesia Linked to Increased Risk of Occiput- Posterior Babies
Lieberman, E., Davidson, K., Lee-Parritz, A., & Shearer, E. (2005). Changes in fetal position during labor and their association with epidural analgesia. Obstetrics & Gynecology, 105 (5, Part 1), 974-982. [Abstract]
Summary: This prospective cohort study used periodic ultrasound examinations during labor to evaluate changes in fetal position and their relationship with epidural analgesia. The researchers sought to determine whether epidural analgesia is responsible for higher rates of fetal malposition (occiput-posterior (OP) or occiput transverse (OT)) or whether women experiencing labor with a malpositioned baby have more painful labors and are therefore more likely to request epidural pain relief. A total of 1562 nulliparous, low-risk pregnant women were enrolled in the study.The researchers found that the position of the baby (occiput anterior (OA), OP or OT) at the time of enrollment (in the early part of active labor) predicted position at birth poorly. For instance, of the women with an OP baby at birth, only 31% had a baby in the OP position at the initial ultrasound scan. Similarly, sonograms done later in labor were also poor predictors of position at birth. The data demonstrated that changes in fetal position were common during labor, with 36% of participants having an OP baby at the time of at least one scan. More than one-half of the women who gave birth to a baby in the OP position never had an OP baby at any ultrasound assessment in labor. Overall, 79.8% of babies were born in the OA position, 8.1% were OT, and 12.2% were OP at birth.

Epidural analgesia was strongly associated with delivery from the OP position: 12.9% of women with epidurals gave birth to babies in the OP position versus 3.3% of women without epidurals (relative risk 4.0, 95% CI 1.5-10.5). Transverse position was not related to epidural use. In a statistical model that controlled for various medical and obstetric factors that could affect outcomes, epidural use was still associated with a 4-fold increase in the risk of OP birth.

The data suggest that the association between epidurals and OP babies is not because women in labor with an OP baby are more likely to request an epidural. Women who received epidurals were no more likely to have OP babies at prior to or at the time that the epidural was administered. Furthermore, women with OP babies in labor or at birth reported the same degree of pain as those with OA or OT babies and were no more likely to report “back labor,” which is commonly thought to be related to the OP position. Finally, women with OP or OT babies at birth were much more likely that those with babies in the OA position to give birth by cesarean section, with 6.3% of OA babies born by c-section versus 64.7% of OP and 73.8% of OT babies (p<.001).
Significance for Normal Birth: Epidural use increases the risk of instrumental (forceps or vacuum) delivery in first-time mothers. Experts have proposed various reasons for this association, including diminished urge to push and changes in the tone of the pelvic floor muscles that inhibit proper rotation of the fetal head. Letting the epidural “wear off” has been thought to increase the likelihood of unassisted vaginal birth, however, this systematic review calls into question that common practice.
In normal birth, there are complex hormonal shifts that help labor progress and facilitate delivery. The laboring woman produces natural endorphins that help her manage the pain of labor. Her ability to move freely and assume a variety of positions while pushing work in concert with these hormonal changes. Epidural analgesia numbs the sensations of birth, and the production of natural endorphins ceases as a result of the disruption of the hormonal feedback system. When the epidural is discontinued, the woman’s pain returns but her natural endorphins may remain diminished and therefore her pain may be greater than if the epidural had not been given in the first place. Furthermore, when an epidural is administered, the woman is usually confined to bed and attached to fetal monitors and an intravenous line. The woman and provider may become accustomed to laboring in the bed attached to machines. When the epidural is discontinued the restrictions! on her movement may persist. Under these conditions, it is likely that the impact of an epidural on normal birth may outlast the epidural itself.

Ann Tumblin also sent me this regarding OP (face up) babies. It was done by Penny Simkin who is basically the mother of all doulas. It is very informative so if you have ever had an OP baby and are nervous about it a second time, I highly recommend you taking a look at it.

I believe that Alyssa’s birth outcome was the combination of her determination and trust that we were supporting her in every way we could and we were. I was sore the next morning which isn’t saying much compared to how she felt but more of a testament to the work I was doing. We were incredibly lucky to have the staff that we had and  I also believe that if any piece of the puzzle had of been missing that her birth story would be very different. I think the point that I want to make about her birth is that if a mother is supported completely and if epidurals are not done too early that even very difficult births can have a great outcome. Mom is satisfied with her experience which is, other than healthy baby and mom, the best thing.

If you had an OP baby, please share your experience with us.

The Benefit of Breastfeeding Toddlers

I am still nursing my almost 17 month old. He generally nurses twice a day, sometimes only once  and sometimes three times but average twice. He HAS to have his morning nursing to start his day. It’s his morning coffee. During the day he may ask to nurse once or twice more depending on how busy we are and he if he thinks about it or not. He sleeps through the night and hasn’t had a night feeding since he turned one with the exception of a few nights where he was teething or not feeling well. I have no intention of weaning him until he is at least two and hope that he doesn’t self wean before then as he has a lactose sensitivity and I have no intention of giving him cows milk, especially while we are in Korea because the organic kind isn’t always available and I refuse to use the other kind plus I generally believe cow’s milk was intended for calves and not my toddler.  If he chooses to drink a little milk here and there later on (if he outgrows the lactose sensitivity), I won’t mind, but I certainly am not going to get into this whole idea of requiring or forcing him to drink a preset number of ounces of it daily. I feel confident in our very veggie heavy, very low processed food diet that he will get the proper nutrition and healthy fats without supplementing with cow’s milk.

People are often times surprised to learn that I am still nursing. The response ranges from ‘oh wow’ (as in ‘that’s cool!’) to ‘ooooh wow’ (as in ‘you freak!’). I have learned that the more shocked one is the less likely it is that they ever breastfed or they breastfed only a few short months. I am surrounded by mostly mainstream moms so it is not surprising to me and I actually enjoy telling them  because I hope that I am planting seeds in their minds for their own babies.  That said, I do enjoy sharing the information with them on the benefits of breastfeeding and extended breastfeeding.

Because my toddler nurses about 2 times a day off both sides for a total of about 15 minutes, I am estimating that he gets about 12-15 ounces of milk. I am not really sure as my breasts do not leak or get engorged and haven’t in months. I haven’t pumped in over a year so I probably couldn’t use that as a reliable way to tell what kind of supply I have either, I am pretty sure that I wouldn’t get much out if I tried. But just based off every thing I know about breastfeeding, I think I have a pretty fair estimate.  Below is a breakdown of what the nutritional value is of that amount of milk.

• In the second year (12-23 months), 448 mL (15 ounces) of breastmilk provides:
  • 29% of energy requirements (calories)
  • 43% of protein requirements
  • 36% of calcium requirements
  • 75% of vitamin A requirements
  • 76% of folate requirements
  • 94% of vitamin B₁₂ requirements
  • 60% of vitamin C requirements

  — Dewey KG. (2001) Nutrition, Growth and Complementary Feeding of the Breast-fed infant. Pediatric Clinic of North America

These are amazing numbers, especially considering how tough it can be to get a toddler to eat sometimes! This is also way better than an artificially made vitamin as the vitamins from the breast milk are better assimilated by the body and the mother would never have to worry about vitamin toxicity. It’s perfectly made and balanced.

In addition to dietary benefits, there are many other health benefits.  Nursing toddlers have fewer allergies and  are sick less often.

• The American Academy of Family Physicians notes that children weaned before two years of age are at increased risk of illness (AAFP 2001).

• Nursing toddlers between the ages of 16 and 30 months have been found to have fewer illnesses and illnesses of shorter duration than their non-nursing peers (Gulick 1986).

• “Antibodies are abundant in human milk throughout lactation” (Nutrition During Lactation 1991; p. 134). In fact, some of the immune factors in breastmilk increase in concentration during the second year and also during the weaning process. (Goldman 1983, Goldman & Goldblum 1983, Institute of Medicine 1991).

Some people think that nursing a toddler will create a clingy child. I completely disagree. My little guy is so independent that it drive me insane sometimes (like in the parking lot when he won’t hold my hand!). La Leche League’s statement for this is:

Breastfeeding a toddler helps with the child’s ability to mature. Although some experts say a toddler who is not weaned will have difficulty becoming independent, it’s usually the fearful, clingy children that have been pushed into situations requiring too much independence too soon. A breastfeeding toddler is having his dependency needs met. The closeness and availability of the mother through breastfeeding is one of the best ways to help toddlers grow emotionally.

Breastfeeding can help a toddler understand discipline as well. Discipline is teaching a child about what is right and good, not punishment for normal toddler behavior. To help a toddler with discipline, he needs to feel good about himself and his world. Breastfeeding helps a toddler feel good about himself, because his needs are being met.

The research is out there and the data proves it true: extended breastfeeding is healthy and beneficial. The American Academy of Pediatrics currently recommends that “Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child..”  The World Health Organization and UNICEF recommend that babies be breastfed for at least two years.

I think it’s important to have maternal instinct validated at times. I would nurse to at least two or beyond anyway but it is nice to know that the facts and data are on my side.

Reducing Infant Mortality (Video)

I can’t add certain types of video here but I am providing the link to this very well done video. It explains how our health care system is failing babies and mothers and what we can do about it. The video focuses on the issue of prematurity that we have in the US, the high rate of infant mortality and the difference in the midwifery model of care versus the obstetric model of care. Please watch and send to as many people as possible. Now would be the time to forward this to legislators as health care reform is a hot topic in the US today.

Go HERE to watch the video.

Avoiding a Tear After a Prior Episiotomy

This is an email response to the question:

If I had an episiotomy during my first delivery, will it increase the risk of tearing next time? Does perineal massage help?

First, here is some statistical information on tears…

How common are tears/episiotomies?

Most women who have a vaginal birth have either a tear or a cut. A few women have both.

We don’t know exactly how many women have a tear in the perineum during childbirth. Doctors and midwives don’t always record small tears. Experts think that at least a third of women in the United States have a tear large enough to need stitches.

In one study from the United Kingdom, more than 8 in 10 women had a tear or cut during a vaginal birth.

And about 7 in 10 needed stitches.

Bad tears, which go all the way from the vagina to the anal opening (third-degree or fourth-degree tears), happen less often. But we don’t know exactly how many women in the United States have a bad tear. In one study from Canada, about 7 in 100 women who give birth had a bad tear.

Your chance of having a cut (episiotomy) depends on where you live. In the United States, about a quarter of women have a cut. In some eastern European countries, nearly all women have a cut during delivery.

Sources for the information on this page:

1. Graves EJ, Kozak LJ.National hospital discharge survey: annual summary, 1996.Vital Health Statistics. 1999; 13: i-iv, 1-46.
2. Audit Commission.First class delivery: improving maternity services in England and Wales.London: Audit Commission Publications, 1997.
3. McCandlish R, Bowler U, van Asten H, et al.A randomised controlled trial of care of the perineum during second stage of normal labour.British Journal of Obstetrics and Gynaecology. 1998; 105: 1262-1272.
4. Sultan AH, Kamm MA, Hudson CN.Anal sphincter disruption during vaginal delivery.New England Journal of Medicine. 1993; 329: 1905-1911.
5. Wagner M.Pursuing the birth machine: the search for appropriate technology.In: Wagner M. Pursuing the birth machine: the search for appropriate technology. Ace Graphics, Camperdown, Australia; 1994.
6. DeFrances CJ, Hall MJ, Podgornik MN2003 National Hospital Discharge Survey. Advance Data from Vital and Health statistics No 359Advance Data from Vital and Health Statistics 2005.

This information was last updated on Nov 07, 2008

I have had this question a few times because most of my doula clients are second timers. While I have not found any hard studies on this topic (I am sure there have been some but I can’t find any), it has been suggested that up to 50% of women with an episiotomy scar will have a 2nd degree tear in subsequent births. That’s a big number but there is a lot of explanation that needs to go with that.

It is also important to understand that a vaginal tear is generally better than having an episiotomy. Tears typically do not tear as deep and far as a cut will and episiotomies actually increase the risk for a third or fourth degree tear. This is because once the cut is done the head emerging can cause the cut to tear farther back and deeper into the muscle. Tears will usually heal faster too.  (this was not in the original email).

The scar tissue is a weakened area so it is more likely to give way but there is no guarantee that it will tear in a subsequent delivery. It’s not that the scar prevents vaginal stretching, it’s that the scar itself is weak and not as pliable as vaginal tissue. I had a client who had a huge episiotomy her first birth, it require 50 stitches and took months to heal. She had a surface tear her second birth and only needed 3 stitches. Many docs and mw’s wouldn’t have even stitched what she had. She said that within three days she felt completely normal and fine.

Also, 2nd degree tears are really not that bad. They will usually heal on their own without stitches but most OBs and hospital MW will stitch them. Homebirthers tend to opt out of 2nd degree stitching (because it is invasive and interferes with bonding) and they do fine. A 2nd degree tear doesn’t tear into the perineal muscle, it’s more is a skin tear. Of my 3 clients that had 2nd degree tears, two felt fine in less than a week and one was fine after less than two weeks. My point to all of that is that you would much rather tear a 2nd degree tear than to have an episiotomy so don’t let that scare you. Another thing worth mentioning is that none of them felt the tear as it happened and none of them had any kind of drugs during labor.

When you crown unmedicated, you feel the ring of fire for a few minutes, then the area goes numb because the nerves have so much pressure from the baby’s head. It’s natures own anesthetic and it’s also natures way of helping you not to tear. When a woman is left to push as her body tells her (rather than a nurse or doc coaching her) then she will instinctively not bear down when crowning because it burns. This allows the vaginal tissue to stretch as opposed to being push on as hard as possible and forcing the baby’s head out to quickly. This is why it is so very important to instinctively push rather than have cheering leading and counting pushing. Of course, it’s pretty much necessary when you have an epidural because you can’t really feel what your body is doing but when you are unmedicated you know exactly what’s happening. It’s also hard to get staff to let mom push instinctively. Most are so used to coaching epiduralized moms that they do not even realize that an unmedicated mom in an upright position needs absolutely no help.

This is also why it’s so important not to push on your back in the bed because then you aren’t giving the staff free access to everything. In addition to keeping people off your vagina, horizontal pushing also helps you stretch better because of gravity (increased blood flow to the area helps stretching plus it brings baby down with less effort). A squat position (like using a squat bar on the bed) also helps you to stretch better just by way of positioning. It just opens everything up. This is REALLY hard to achieve in a hospital birth most of the time. You will have to be firm and aggressive to make it happen and you will also have to be strong enough to initiate it during labor. Really you should hire a doula but you knew I would say that before you even emailed me;)

That said, there are a few women who require an episiotomy and I say require very lightly, I don’t really think there is any reason to give one other than a SERIOUS decel in the fetal heart tones that requires immediate delivery but that is very rare. It unfortunately is way over used as a reason. There is a difference in a decel and a very serious decel . When this happens to an unmedicated mom, a pressure episiotomy is done but can only be done that way after the ring of fire is no longer felt, meaning the nerves are numb and mom won’t feel pain from the cut. It sounds horrifying and it is but like I said, there is no cutting pain. If the nerves are not numb then a local anesthetic can be given if there is time. Again, these are very rare circumstances and there are ways to prevent this from happening.

The debate is out on perineal massage. Some people swear by it others say it doesn’t work. Don’t allow anyone to do it during pushing though, as it does increase the risk of tearing. If you think about it, it makes sense, someone else is touching you and they cannot feel what they are doing, only you can. You would touch more gently or firmly because you know what is happening. The best thing anyone else can do is to use warm compresses and perineal support which is still easily done if mom is upright. I recommend that moms support their own perineum because again, you are the one that is feeling what is happening and know how much or little pressure you need.

As for perineal massage during pregnancy, even if there is no solid evidence that it works, it can’t hurt and if nothing else it teaches you to relax your bottom. If your partner can do it for you it will teach you how to let the muscles go. For instance, he would use a finger on each side at the bottom of your vagina (while you are sitting up against the headboard or wall, oh and use lube). Then he would gently sweep the fingers out in opposite directions and kind of down and while he is doing that you just completely relax and concentrate on letting the muscles loose. Here is a link

http://www.bestdoulas.com/perineal.pdf

But if your partner were doing it he would use his index fingers instead of thumbs.

I definitely would not use the same care provider that did your episiotomy the first time even if you like them. The thing is that even if you tell them you do not want it under any circumstance and that you would rather tear, those that use it, almost always use it and if they say “we only do it if it’s necessary” then you can count on having one. If you truly want to avoid another one and you truly want to reduce the risk of tearing, then you will need a provider that is more hands off and who will encourage you to get off your back and who is pro-natural birth. Most of them will SAY they are though so that’s the tricky part. This again is where I say hire a doula because doulas usually know the scoop on the different providers in the area. They see these docs and mws in action and know how they really are.

I am not trying to freak you out or be anti doc or negative it’s just that I have seen it happen. I have seen docs tell clients they are pro VBAC and want them to have the birth they want then threaten them with statistics that are not true or try to force a repeat c section on them. I have seen them tell clients that they support upright non coached pushing but in labor force them on their backs and start counting to 10. I think a lot of times they just tell mom what ever she wants to hear to get her to be quiet then when it comes down to the birth, they do whatever they want. Yes they do know best when there is a real emergency and either mom or baby is in trouble. hand down. But when it comes to unmedicated birth and leaving the body to do what it is supposed to do, they are not because the majority of American women get epidurals and that changes things. I would suggest finding that provider who supports your wishes and believes in your body so that you do not have to fight for what you are entitled to. If you are set on keeping the provider (if it’s the same one) then definitely hire a doula so you don’t have to fight alone. (sorry for the little speech:)

SO in short, you do have a risks but you have lots of options and you can set yourself up for the least risk of tearing.
EDIT: I am adding THIS LINK for more information on the history of episiotomies and their use today. This is a great read. Here is the intro…

The following piece was submitted by Rita Ledbetter, CNM ~ she is my midwife and works in the Medical Arts office in Moline.  I asked her if she’d be willing to share her knowledge on the subject of episiotomy ~ to cut or not to cut when delivering.  I am very appreciative that she took the time to write and submit this article so that expectant mothers can be more informed when developing their birth plans!

Hi -this is Abby’s midwife Rita.  She asked me to write a little about episiotomy – the cut made at the opening of the vagina (perineum) when a baby is being born.  Routine episiotomy is no longer recommended but still occasionally is needed.

History:
Birthing babies is not new and tearing or lacerations of the opening of the vagina have always been part of the process of birth.  Some women had tears, some did not.  In olden times it was common to allow as many cobwebs as possible to grow in the home as a woman prepared for childbirth.  If a tear happened during childbirth the sticky cobwebs were packed into the tear and the woman was kept in bed for 10 days or so with her legs closed to allow her bottom to heal…..Go HERE to read more

Follow Up to Business of Being Born, looking for VBAC video

I am on the email list for My Best Birth.  The Business of Being Born did a really good job of bringing about a level of awareness of the crisis in US obstetrics and I think that it is fantastic that the follow up will be focusing on VBAC. I hope that they shed some light on VBACs for the mainstream community.

I received this email today…

A message from Ricki Lake & Abby Epstein to all members of VBAC Moms on My Best Birth!

As many of you know we have been working on a follow up film to The Business of Being Born, to be released this fall.

We are deep into the editing now and are hoping some of you might help us out by sharing 

your personal birth footage and photos. Specifically, we are looking for:

1. Homebirth video footage
2. Birth video footage from anyone who had a VBAC.
3. Video of a sonogram
4. Photos of women recovering post-birth, looking especially unhappy or suffering.
5. Video footage of a free-standing birth center (exterior & interior)
If you have any of the below materials and would be willing to let us use them in the film, please fill out and sign the release form posted under forum discussions and mail us your footage by August 15, 2009 on DVD, mini DV, DVCam or any format you have, to the address below. Please do not send us your only copy as we will not be able to return the copy you send us. If you have photos (for item #4) or any questions you can email us at info@mybestbirth.com.

Mail footage with a brief description and the release form to:

Amy Slotnick
Business of Birth
15 W 11th St #3A
NY, NY 10011

Please note we will blur out faces of any doctors, birth attendants or people in the footage from whom we do not have approval.

Thanks for your help!

Warmly, Ricki & Abby

Placenta accreta – a risk of cesarean section

This is a very good article from vbacfacts.com.

“There is this idea that if you don’t VBAC and you schedule a repeat cesarean, that you will be safe from complications.  This is because during a “VBAC counsel,” women are often told of the risks of VBAC, namely uterine rupture, but they are rarely told the risks of repeat cesareans in their current and future pregnancies.

Abnormal placental implantation is one risk of cesareans that only present themselves when you get pregnant again.

Women who expect to only have two children, and thus opt for a repeat cesarean, might think that not VBACing is the safer, and more controlled choice, for them.

But what happens if you get pregnant again?  Now you have had two cesareans, your risk of placenta accreta (where the placenta grows through the uterus), placenta previa (where the placenta grows over the cerivx), and placental abruption (where the placenta prematurely separates from the uterine wall) all go up.  And here women think they are making the SAFER choice by having a repeat cesarean.

This news article from Canada illustrates this point.

I’ve underlined parts for those who like to skim.”

Complications worry MDs

Surgery carries risks, doctors say

By Sharon Kirkey, Canwest News Service August 1, 2009

Dr. Jan Christilaw was in the operating room the day a routine incision was made into a young mother’s abdomen to deliver her baby.

What happened next, Christilaw says, “is something we never want to see.”

Normally, the placenta separates from the wall of the uterus after birth. It’s lacy almost, and not like solid tissue. “You can take your hands and sort of scoop it up, it’s like breaking cobwebs as you go,” says Christilaw, an obstetrician and president of B.C. Women’s Hospital and Health Centre in Vancouver.

But the placenta had eroded through the wall of the uterus, a condition known as placenta accreta. As soon as they stretched the opening of the uterus to deliver the baby, “the placenta started bleeding everywhere,” Christilaw says.

They couldn’t get the bleeding to stop. The woman was losing two cups of blood every 30 seconds.

The only way to stop the bleeding was an emergency hysterectomy.  The woman was in the operating room for eight hours and lost 15 litres of blood.

It used to be that obstetricians might only ever see one or two cases of placenta accreta in their lifetime. Although still rare, obstetricians across Canada say one of the most feared complications of pregnancy is increasing as a direct consequence of the nation’s rising cesarean section rate.

Virtually all placenta accretas occur in women who have had a previous C-section, and the risk increases with each additional surgical delivery. The placenta attaches to the old C-section scar. Scars don’t have a proper blood supply to feed a placenta, so it keeps burrowing into the uterus until it finds one, sometimes pushing through the uterus completely and into the bladder or other organs.

The condition can be detected by ultrasound, but not always. “You almost never see it in a woman who has not had a C-section,” Christilaw says.

Today, about 28 per cent of babies born in Canada are delivered by caesarean. In 1969, Canada’s rate was five per cent.

More than 78,000 caesarean sections were performed in Canada last year, making it the single most frequently performed surgery on Canadian women.

“We don’t know what the ideal rate is,” says Dr. Mark Walker, a high-risk
obstetrician at the Ottawa Hospital and senior scientist with the Ottawa
Hospital Research Institute. “I think it’s fair to assume it’s lower than
where we are now.”

Walker says changing demographics — older first-time mothers, more multiple births from fertility treatments, more mothers with hypertension, diabetes, obesity and other health problems — are not enough to explain an almost doubling in the C-section rate since the early 1990s.

Neither is there evidence to support the idea that women are seeking
C-sections on demand. Studies from Ontario suggest less than one per cent of caesareans are for “maternal request.”

The Society of Obstetricians and Gynaecologists of Canada says the vast
majority of caesareans are done for medically valid reasons. But there are concerns that too many are being ordered because labour isn’t progressing quickly enough, and that thousands of “routine” interventions are now being done that increase the odds of a woman needing a surgical birth.

What’s more, the number of women who give birth vaginally after a previous C-section is dropping dramatically, meaning more and more women are having repeat C-sections.

Dr. Michael Klein calls it the industrialization of childbirth, where, in
today’s risk-averse society, women in labour are being treated “as an
accident waiting to happen” and where doing something is always better than doing nothing.

“Physicians and society have helped women basically believe that childbirth is no longer a natural phenomenon, but an opportunity for things to go wrong,” says Klein, emeritus professor in the departments of family practice and pediatrics at the University of British Columbia.

“But the fundamental issue is, we aren’t improving outcomes by doing more C-sections. For the first time in Canada, we are seeing the key indicators for mothers and babies going in the wrong direction.”

Risks to babies range from accidental lacerations when the surgeon cuts into the uterus, to neonatal respiratory distress. Research suggests two times as many babies born via C-section will end up in an incubator with water on their lungs, or with serious respiratory problems compared to babies delivered vaginally, because a C-section interferes with the normal hormonal and physiological changes associated with labour that prepare a baby to take its first breath.

Risks to women include higher risks of hemorrhage requiring a hysterectomy, major infections including blood infections, wound infections and bladder infections, and blood clots in the lungs — and every C-section increases the risk for another.

“If you have a caesarean section for the first birth, the probability of
having one the second time around is huge, because of the difficulty women have in getting a doctor to look after them once they have a uterine scar,” Klein says.

The worry is that the scar will pull apart during labour, causing a uterine
rupture.

“If you have a catastrophic rupture, you can get into big trouble,”
Christilaw says. “You can have a negative outcome for mom or baby. In severe situations, the baby can die or become damaged — but that’s a very rare outcome.”

Her hospital is encouraging more VBACs — vaginal births after caesarean — in carefully selected women. “In those women who attempt a VBAC, our success rate is well over 80 per cent.”

But less than one in five women in Canada with a previous C-section
delivered vaginally in 2007-08. Eighty-two per cent had a subsequent
C-section.

Christilaw says the only thing preventing Canada from seeing “horrific”
complication rates from C-sections is the fact women are not having as many babies as they once did.

“A C-section can be a life-saving manoeuvre for a mother or baby. Nobody is saying differently,” she says. “What we’re trying to say to people is, a C-section is not a benign thing. If you need one, that’s different. But you should not be doing this unless you absolutely have to.”

C-sections are frequently the end result of a cascade of interventions that
often starts with inductions.

Tens of thousands of women in Canada have their labours artificially induced every year, often via intravenous infusion of artificial oxytocin. Oxytocin is naturally produced by the human body. It’s what creates contractions in labour. Today in Canada, one in five women who gives birth in hospital is induced.

What doctors fear are stillbirths. But alarmed by the rising rates of
inductions, the Society of Obstetricians and Gynecologists of Canada
recently urged doctors not to consider an induction until a woman is at
least one week past her due date.

Claudia Villeneuve says that women are getting induced “if they’re two,
three, four days overdue.”

“Inductions are rampant,” says Villeneuve, president of the International
Cesarean Awareness Network of Canada. “You have a perfectly normal mom who comes in with a perfectly normal baby, and now you put these powerful drugs into her system to force labour to start.”

The “humane” thing is to offer an epidural, she says. With an epidural, a
woman can’t feel pain in the lower half of her body. But epidurals slow
labour, sometimes so much that labour stops. “Now you have to get this baby out,” Villeneuve says. Two-thirds of first-time C-sections are done for “failure to progress.”

Klein says epidurals are too often given before active labour is
established.

“The majority of women today get their epidurals in the parking lot.”

Kayla Soares had been in mild labour at home for 24 hours when her
contractions suddenly stopped. Doctors told the Edmonton mother she would have to be induced. She was three centimetres dilated when they started the oxytocin drip.

“It was the worst pain I’ve ever felt in the world,” she remembers. “I
wasn’t having contractions at all and then they put me on the oxytocin and every half-hour they would boost it up, so the contractions were coming every minute, pretty much. It was like going from nothing to being in crazy, absolute labour, and in so much pain.” Eleven hours later, she was still just three centimetres dilated. “That’s when they said it was enough, and they were doing a C-section.

“I didn’t want to do it. I was asking, could we just have more time?”

Three weeks later, she still couldn’t get out of bed without help. Her
incision had become infected. “It felt like I was ripping apart every time I
moved. It was a pretty brutal recovery.”

Soares had her second baby in June. “I was dead set on having a VBAC,” a vaginal delivery after cesarean. “It was a fight, an uphill battle the  whole time with doctors.” One obstetrician asked her her shoe size. “She said that because I was a size five and smaller framed that I definitely was going to have another caesarean and that a VBAC wouldn’t happen. She said that because I was a ‘failure to progress’ the first time I’ll be a ‘failure to progress again.’”

Two weeks before her daughter was born, Soares started going in and out of labour. “They had me convinced it was causing stress to the baby even though the tests said everything was fine. They had me convinced it was enough, because I was overdue and they said my incision was going to rupture,” she says.

“They just kind of scared me into having another C-section.”

© Copyright (c) The Windsor Star

Rebirth After Birth Trauma: My Story

This post could be upsetting to someone who is currently pregnant. If you decide to read this and you are pregnant, please remember that many of the birth injuries mentioned are rare. You can also help prevent some of these injuries by preparing your body and your mind for an unmedicated birth as the use of forceps and vacuum extractions are reduced when unmedicated. Also, pushing in an upright or squatting position can help prevent the need for these interventions.

Birth trauma comes in many forms and can occur during vaginal deliveries and cesarean deliveries.  Trauma can be caused by:

fetal positioning
an irregular shaped pelvis
pushing in a supine (on the back) position
a very long or very fast labor
very large fetal head
fetal anomolies
sometimes there are unknown reasons

Trauma can range from mild to severe and can include:

Bruising and Forceps Marks – Sometimes a baby will have bruising on the face or head simply from passing though the birth canal, and from associated contact with the mother’s pelvic bones and tissues. If forceps are used during delivery, they may leave temporary marks or bruises on the baby’s head. Vacuum extraction can also cause bruising to the head, and may cause a scalp laceration. In extreme cases, forceps use can cause depressed skull fractures, which may require surgical elevation.

Subconjunctival Hemorrhage – This common birth injury results in bright red band around the iris of one or both of the baby’s eyes. This does not cause damage to the eyes, and usually disappears completely within a week to ten days.

Caput Succedaneum – This is a severe swelling of the baby’s scalp, and is more likely to occur as a result of vacuum extraction. The swelling will ordinarily disappear within a few days.

Facial Paralysis – Pressure on the baby’s face during labor or birth, or the use of forceps during childbirth, may cause injury to a baby’s facial nerves. If a nerve is merely bruised, the paralysis will ordinarily clear up within a few weeks. With more severe nerve damage, it may be necessary to surgically repair the damaged facial nerves.

More severe injuries include Brachial Palsy Injuries, broken bones and brain damage. These are all very rare. Fetal birth injury accounts for less than 2% of fetal death.

When a newborn has birth trauma it often times causes breastfeeding and bonding problems. I learned this first hand in the birth of my own son. He was in a mentum (face first) presentation and I labored for 52 hours before having a c section.  I discuss both mentum presentations and my birth story in separate posts if you would like to read them.

Because of my sons positioning, his face took the force of 52 hours of contractions. His birth by cesarean was violent.  His face was so wedged into my pelvis that he could not move forward and the doctors could  not pull him back out. The OB tried to pull his head out my pelvis with six failed vacuum extraction attempts. It eventually took three different people pulling on his little body at once to get him out. He was swollen to the point that he could not open his eyes, had bruising and abrasions all over his face,  a hematoma, and what we initially thought was a broken nose.  Luckily and thankfully his nose wasn’t broken and he had no long term damage. Today he still had a little bit of a ‘birth mark’ where some of the bruising was (he is 16 months old) and I personally think it was from his birth trauma.

Once he was born he had deep suctioning because we had thick black meconium and of course he was poked and prodded and force fed formula until he puked. He had also had the cord around his neck twice and because of the way his neck was hyperextended with his face first positioning it was very tight. He remembered it and my husband said that when he was in the nursery while I was being put back together, he kept reaching for his neck.

This was a very rough start for my little guy and for the  first two days he was very very sleepy. We had to undress him to make him wake up to eat. He had so many drugs in his system. After that two days, the crying began and he cried so much. I think he was shell shocked. I was shell shocked myself so I totally understood how he felt but I just didn’t really know how to make him feel better. He had complete breast refusal and even though we had no separation, we were not bonding. My body was also in a state of shock and hardly producing any colostrum to make him interested. I didn’t get milk until six days postpartum. By day three after he was born and of not being able to express any colostrum or having any luck getting the baby to quit screaming at the breast long enough to try to latch, we began finger feeding him formula. I refused to give him a bottle because I knew my milk would eventually come in and I didn’t want for him to have nipple confusion. In the mean time, I pumped as frequently as I could with the hospital grade pump.

My milk came in six days postpartum, the day we left the hospital. Because of how difficult our birth was, we stayed twice as long as most other c section birth stay at the Army hospital in Seoul. I guess I just needed to be home and able to relax a little bit but once it came it in I had a big full supply. For the three days that we had been finger feeding the baby I had continued to try to latch him at the breast and he continued to scream. Once we were home and I had my own milk to give him I decided to take a day off from latching him because quite frankly, I was a wreck about it. I felt that at least I could give him my own milk and not formula and for then that would be ok. The next day, my husband borrowed two breastfeeding videos from the nurse that taught the breastfeeding class at the hospital. At that time there was no lactation consultant, so I was own my own in fixing this breast refusal problem.

About halfway through the video, which by the way was Australian and I have no idea what it was called now, a woman with inverted nipples started telling her breastfeeding story. She talked about how difficult it had been and how her baby had been OP (face up) and that she pushed for over two hours and he came out screaming and wouldn’t latch. He developed breast rejection because of her inverted nipples but she didn’t give up. She said that she and her husband decided to perform a ‘rebirth’ and recreate the birth experience that they wanted for their baby. I was fascinated and willing to try anything so when I told my husband that we were doing it that night.

The idea of rebirth is to recreate the birthing experience for the baby so that he can be born in a gentle and peaceful way. We had a garden tub and filled it with warm water and lit candles and warmed the bathroom up. I got in and my husband passed the baby to me. He was seven days old at this time.  As soon as he was naked he was screaming but I put him in the warm water and held him close and he calmed down a little, just to a cry rather than a scream. After a few minutes I put him in the water, floating him around with only his face out of the water. He fought it a little at first but after a few minutes he completely gave in. His entire body went limp. We were completely amazed at this point. We had successfully recreated the womb and he remembered it! This was the most relaxed this baby had been since he was born.

In following the idea of infant rebirth, I slowing began to lift him out of the water. The idea is that the change in temperature and the removal of water from his environment will trigger the hormonal response that is similar to that of what a baby experiences in a peaceful vaginal delivery. I took him completely out and put him to my chest, just as I would have wanted had our birth gone the way we wanted. He didn’t cry or fight it, he just went limp against me. I let him lay quietly for a bit then decided it was time to try latching on again. I used the nipple shield because I wanted it to be as easy as possible for him. I had tried it before but he screamed at the breast regardless. Not this time, he latched right on. He latched and nursed for almost an hour. I was in awe and shock and disbelief.

We continued using the nipple shield until he was six months old. I tried to get him to nurse without it for months but he refused. I didn’t care, he was breastfeeding and I had a great supply. I knew we would eventually get rid of it and we did when he was six months old. As of 16 months old he is still nursing. Our bonding really began that day. I know that you can bond with your baby if you do not breastfeed but we had so much anxiety between the two of us that we needed that moment to begin healing from our traumatic birth.

I would recommend rebirth to anyone who has birth trauma. As soon as you get home from the hospital, get in the water. Get skin to skin. Recreate what you wanted for you and for your baby. Even if the baby didn’t have a birth trauma or injury of any kind, but you did, do it. If your milk is taking a while to come in, do it. It will help your body to relax and produce the hormones necessary for milk production. I truly believe in this process and it’s healing powers and hope that more moms can learn about the benefits of rebirth after birth trauma.

When Your Water Breaks Before Labor Begins

It is NOT an emergency!!! It does not mean the baby is about to slide out onto the floor in the middle of Target or that you have to call an ambulance so you can get to the hospital ASAP. This is Hollywood and cultural fear of birth and you are actually putting yourself at higher risk for infection by running straight to the hospital.

When the water breaks before the onset of labor this is called premature rupture of membranes (PROM). PROM occurs in 8-10% of term (37 weeks+) pregnancies. Of those, 90% will begin labor within 48 hours.  Unless you or your baby is in some kind of danger or you are showing signs of infection, there is no reason to speed up this process.  Many mainstream pregnancy books and most OB’s  will tell you to go straight to the hospital and what we see in movies confirms that but you actually increase your risk of infection by doing that because the first thing that happens when you arrive is usually a vaginal exam. Interestingly enough, the recommendations are to avoid digital (finger) vaginal exams but anyone who has had a hospital birth knows that this is the first thing that happens  upon admission.

Vaginal exams push bacteria up past the cervix. Fluids in the vagina flow downstream and the only way they will back track is if they are pushed back. In a hospital setting it is not uncommon to have a vaginal check hourly or even more frequently and by several different people. Every time a vaginal exam is performed the infection risk is increased.  It simply is not a beneficial procedure contrary to popular belief in our society. Even with clean hands and sterile gloves, bacteria on the external of the vagina are introduced internally. This is especially an issue for GBS+ women.  When it really comes down to it, vaginal exams tell us nothing because dilation and effacement of the cervix really are not a good indicator of when a baby will be born. I had a client who has two centimeters and 50% effaced the morning of  40 weeks and 5 days. She was not in labor that morning.  She had her baby that night. Labor can progress quickly and examining the cervix is a rough estimate at best.

Another problem with going straight to the hospital when the water breaks is that hospital policy often puts time limits on the labor. Because of the increased risk of infection due to multiple vaginal exams, many hospitals will either being speeding up labor  immediately with pitocin. Some hospitals will give the mom 12 hours for labor to spontaneously begin and a few will give the mom 24 hours.  Some doctors even begin the c section scare tactics immediately. The problem with this is that creates performance pressure and if the mom is unable  to relax, often times labor will not begin or it will stall.  Once these interventions begin, the risk of infection increases and the risk of c section increases dramatically.

There is also the myth of ‘dry birth’ that is simply  not true because the body continues to make amniotic fluid which in turn will continue to leak but by no means leaves the amniotic sac and baby dry.  Because of this ‘dry birth’ myth, women are often times told that they must lay in bed and not move around so that fluid doesn’t continue to leak out. This is counterproductive as gravity is necessary to help the baby rotate and move into the pelvis and movement helps facilitate labor.

So, what do you do if your water breaks and you are not having contractions? First, check the color. If it is clear it is normal. If it is yellowish to dark brown or green, it could be meconium and you may want to call your care provider. Otherwise,  wait.  Like I said previously, 90% will begin labor in 48 hours.  Don’t put anything into the vagina, don’t check your own cervix, don’t have sex. Try to stimulate labor. There are many things you can do to help the process along. Take a walk. Cuddle with your partner as getting touchy feely releases oxytocin, the hormone responsible for causing contractions. This is also the reason that nipple stimulation works. Nipple stimulation triggers oxytocin.Also, the use of acupressure can trigger labor. There are two pressure points on the body that help stimulate contractions.

When using pressure points, search for the area indicated in the pictures. They will feel like a bruise when pressed. Apply steady pressure to these areas for 30 second to a minute. Alternate between the pressure points. Pay attention as these pressure points can actually hyperstimulate the uterus.

Here is a video that helps clarify how to to use acupressure for labor induction but also comfort techniques for late stage pregnancy…

Lastly, while waiting, relax. Take a warm bath, it is ok to do even if the water has broken. Get a massage. The ability to relax can help labor to begin naturally. If you are worried about infection, monitor yourself. Take your temperature and watch for foul smelling discharge from the vagina.

There have been studies done on PROM and infection risk and Henci Goer, author of  The Thinking Woman’s Guide to a Better Birth, has written an article that discusses these studies and the flaws involved. I am including this study below:

When Research is Flawed: Should Labor Be Induced Immediately with Term Prelabor Rupture of Membranes? by Henci Goer Commentary on: Hannah, M. E., Ohlsson, A., Farine, D., Hewson, S. A., Hodnett, E. D., Myhr, T. L., et al. (1996). Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TermPROM study group. N Engl J Med, 334(16), 1005-1010. [Abstract] Study design and results: multicenter, multinational randomized controlled trial in developed countries of 5041 women with confirmed PROM at ≥ 37 completed weeks of gestation. Women were not in active labor, had a singleton fetus in cephalic presentation, and had no contraindication to trial participation. Investigators randomly allocated trial participants to one of four groups: (1) immediate induction with oxytocin, (2) expectant management for 4 days before oxytocin induction or until an indication for induction developed, (3) immediate induction with prostaglandin E2 (PGE2) followed by oxytocin if necessary, or (4) expectant management for 4 days before PGE2 induction or until an indication for induction developed. Selected background information [Note: These represent ranges in rates reported among the 4 study groups. No significant differences across groups were detected for any of the following:] vaginal exam at trial admission: 35-39% digital, 64-67% speculum number of digital vaginal exams: 49-63% had ≥ 4 Group B strep (GBS) status: 9-12% tested positive for GBS median time to active labor in expectant groups: 16-17 h Selected maternal outcomes: cesarean rate: rates ranged among the 4 groups from 10-11% overall, 14-15% nulliparous women, 4-5% multiparous women any sign of chorioamnionitis: 4.0% induction/oxytocin vs. 8.6 % expectant/oxytocin, p < 0.001 [Absolute difference: 4.6%. Absolute difference for diagnosis based on criteria other than intrapartum fever (fever before labor, elevated white blood cell count, or foul-smelling amniotic fluid): 2.3%.] 6.2% induction/prostaglandin vs. 7.8% expectant/prostaglandin. Difference did not achieve statistical significance, meaning it was likely to be due to chance. Neonatal outcomes: neonatal infection: rates ranged from 2-3% and were not significantly different across the 4 groups stay in neonatal intensive care unit > 24 h: 7% induction/oxytocin vs. 12% expectant/oxytocin, p < 0.001. 9% induction/prostaglandin vs. 10% expectant/prostaglandin. Difference did not achieve statistical significance antibiotics: 8% induction/oxytocin vs. 14% expectant/oxytocin, p < 0.001. 11% induction/prostaglandin vs. 12% expectant/prostaglandin, p = 0.003. All other neonatal outcomes were similar, including, fetal distress, meconium-stained amniotic fluid, Apgar score < 7 at 1 or 5 min, cord blood pH < 7.1, need for oxygen resuscitation, jitteriness or irritability, seizures, hypotonia, abnormal level of consciousness, apnea, abnormal feeding at 48 h or more, and ventilation after resuscitation. Problems include but are not limited to the following: Failure to consider the effect of epidural analgesia on intrapartum fever confounds chorioamnionitis results. Most diagnoses of chorioamnionitis were made on the basis of intrapartum fever. At the time of the trial, the association between epidural analgesia and intrapartum fever was not widely known, and no adjustment was made for this factor. Had this been done, an excess probably would remain in the expectant group, but infection rates might have been lower in all groups. Women who were colonized with GBS were not treated in labor. A secondary analysis looked at the effect of GBS status, based on vaginal swabs obtained at trial entry, on outcomes (Hannah, 1997). Calculations using that study’s data reveal that one-third of neonatal infections were in women testing positive for GBS. GBS also caused one of the four deaths in the expectant group in babies without lethal anomalies. Current standard practice—screening for GBS at the end of pregnancy and providing antibiotics in labor to those who are colonized—would have reduced, and might have eliminated neonatal infections in GBS + women, thus reducing infection rates overall, and it might have prevented the death. It is also possible that GBS status would not have been a factor or would have been less of a factor in neonatal infections were it not for women having vaginal exams at trial entry and multiple exams before delivery. (See next bullet points.) Chorioamnionitis rates and possibly neonatal infection rates were confounded by multiple digital vaginal exams. Leaving aside epidural analgesia as a confounding factor in diagnosing chorioamnionitis, yet another secondary analysis reported that chorioamnionitis increased steadily with number of digital vaginal exams independent of other factors (Seaward, 1997). Compared with less than three, the odds ratio climbed from a 2-fold increase for 3 to 4 exams to a 5-fold increase with more than 8. Seaward (1998) reported in their evaluation of risk factors for neonatal infection that chorioamnionitis had the strongest independent association. The rate among infants of women with chorioamnionitis was 16%, a six-fold increase over those not experiencing chorioamnionitis. Neonatal infection rates were confounded by vaginal exams at trial entry. A secondary analysis of trial data found that having a vaginal exam at trial entry increased the risk of neonatal infection by 250%, even after taking into account GBS status (Hannah, 1997). This difference is likely to be greater than appears because the analysis authors chose to combine digital and speculum exams, although only digital exams are believed to increase the risk of infection. Neonatal infection rates were confounded by multiple digital vaginal exams during labor. According to another secondary analysis, the percentage of infections trended upward with the number of vaginal exams independent of other factors, including time from rupture of membranes to labor onset and length of active labor (Seaward, 1998). It rose from 2% in women with 3 to 4 exams to 5% in women with more than 8. The odds roughly doubled compared with women having fewer than 3 vaginal exams, although the difference only achieved statistical significance when 7 to 8 exams were compared with fewer than 3. Comment: Based solely on the TermPROM trial, the American College of Obstetricians and Gynecologists (ACOG) recommends immediate induction, generally with oxytocin, for women with term PROM on the grounds that inducing labor will reduce chorioamnionitis, febrile morbidity, and neonatal antibiotic treatments without increasing cesarean rates (ACOG, 2007). The primary argument for immediate induction has always been reducing neonatal infections, which ACOG acknowledges it does not do, and, as can be seen in this deconstruction, with optimal care other benefits are likely to be smaller than currently appear. By contrast, a Cochrane systematic review published in 2006 also evaluates term PROM management (Dare, 2006). Despite being heavily dependent on the TermPROM trial—three-quarters of the 6800 participants among the 12 trials in total come from the TermPROM trial—the reviewers reach a more tempered conclusion: “Since differences in outcomes between planned and expectant management may not be substantial, women need to be able to access the appropriate information to make an informed choice (p. 12).” In summary, in the absence of signs of infection, expectant management remains a viable option. Nonetheless, the secondary analyses have given us a more nuanced picture. While the original trial report found no difference in neonatal infection rates between immediate induction and expectant management overall, the secondary analyses make clear that length of time between rupture and delivery matters. They also found that modifiable factors affected infection rates, which means we do not know what they would have been with optimal care. For those choosing expectant management, the question arises of how long to wait before inducing labor if one prefers to set a limit. Consider the following: Seaward (1998) reported that time from membrane rupture to labor onset of 24-48 hours versus less than 12 hours was an independent predictor of neonatal infection. Infection rates with 24 hours or more to onset of labor were 4% versus the background 2% rate. Hannah (1996) reported that the median time to active labor, not labor onset, after membrane rupture was 16-17 hours. It therefore seems reasonable to wait about 18 hours before inducing labor. Half the group of women will have achieved active labor by this time, and, if induced, the remaining half are likely to have started labor by the 24-hour cut point. Women with PROM at term who are GBS + constitute a special subset. The Centers for Disease Control (2002) guidelines for management of GBS + women say nothing about inducing women with ruptured membranes at term, which suggests that awaiting spontaneous labor is acceptable provided that antibiotic therapy is initiated. And given that it takes time to instill the recommended dose of antibiotics, common sense dictates that women who prefer not to wait for labor should delay induction until they have an adequate dose of antibiotics on board. In any case, regardless of GBS status or decisions around whether or when to induce, to minimize the risk of infection, women should avoid digital vaginal exams until established in labor, and their use should be minimized during labor. Data also suggest that oxytocin is the induction agent of choice. It appears to reduce infection rates compared with PGE2 without any offsetting disadvantages. References: ACOG. (2007). Premature rupture of membranes. Practice Bulletin No. 80. Centers for Disease Control and Prevention. (2002) Prevention of perinatal group B streptococcal disease. MMWR;51(No.RR-11). Dare, M. R., Middleton, P., Crowther, C. A., Flenady, V. J., & Varatharaju, B. (2006). Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database Syst Rev(1), CD005302. Hannah, M. E., Ohlsson, A., Farine, D., Hewson, S. A., Hodnett, E. D., Myhr, T. L., et al. (1996). Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TermPROM study group. N Engl J Med, 334(16), 1005-1010. Hannah, M. E., Ohlsson, A., Wang, E. E., Matlow, A., Foster, G. A., Willan, A. R., et al. (1997). Maternal colonization with group b streptococcus and prelabor rupture of membranes at term: The role of induction of labor. TermPROM study group. Am J Obstet Gynecol, 177(4), 780-785. Seaward, P. G., Hannah, M. E., Myhr, T. L., Farine, D., Ohlsson, A., Wang, E. E., et al. (1997). International multicentre term prelabor rupture of membranes study: Evaluation of predictors of clinical chorioamnionitis and postpartum fever in patients with prelabor rupture of membranes at term. Am J Obstet Gynecol, 177(5), 1024-1029. Seaward, P. G., Hannah, M. E., Myhr, T. L., Farine, D., Ohlsson, A., Wang, E. E., et al. (1998). International multicenter term prom study: Evaluation of predictors of neonatal infection in infants born to patients with premature rupture of membranes at term. Premature rupture of the membranes. Am J Obstet Gynecol, 179(3 Pt 1), 635-639.

Getting Upright in Labor: InJoy and Lamaze Push Vertical Pushing

I am doing a series on the Lamaze Six Care Practices that Support Normal Birth. Here are Part 1, Part 2 and Part 3. In Part 4 I will be discussing the 5th Care Practice, which is Spontaneous Pushing in Upright or Gravity-Neutral Positions. In the mean time, below is a link to a very informative article and video on vertical pushing.

Great article and video on vertical pushing HERE.

Most women in hospitals do end up pushing on their backs. The Army hospital in Seoul, always wants the mom on her back and does not encourage any other position, in my experience. I have seen nurses lean the back of the bed back so that  mom is closer to flat on her back saying ‘let’s help baby out.’ The hospital here does have a squat bar but last time my client wanted it the nurse said she had to go find it and never did. After the birth she told my client that ‘oops, it was in the bathroom the whole time.’ You may have to insist on not pushing on your back. You may have to demand that the nurse find the bar but it should be your voice that the staff hears. A doula can help you by asking and reminding but ultimately the mom needs to be heard when she is in an ‘on your back’ environment.