Pregnancy

Placenta accreta – a risk of cesarean section

Posted on August 3, 2009. Filed under: Cesarean, Placenta accreta, Pregnancy, uterine rupture, vbac | Tags: , , , , , , , , , , , , |

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

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Brewer’s Pregnancy Diet for Overweight Mothers

Posted on July 15, 2009. Filed under: Pre eclampsia, Pregnancy, Pregnancy Brewer Diet | Tags: , , , , , |

Overweight mothers often times are told to restrict their calories and to only gain a small amount of weight or even none at all. I have read so many stories of care providers giving over weight moms a really hard time. The Well Rounded Mama talks about this here and shares stories from other women.  The scare tactics used against overweight moms range from ‘you will have a large baby and have a stroke while trying to push it out’ to ‘you will develop blood clots’ to ‘you will not be able to sustain a pregnancy.’ It’s really a shame and instead of berating these mothers for being overweight, it would be so nice if mainstream medical care would help them to be healthier and have the healthiest pregnancies possible by focusing on exercise and proper nutrition throughout pregnancy rather than numbers on a scale. Like I have said before, contrary to popular belief, you can not grow a baby with the extra fat on your hips!

In thinking about this topic, I decided to ask Joy Jones what her thoughts were. Joy is an RN and has been working with pregnant women and the Brewer’s Diet for more than thirty years.  She has  so much knowledge and insight on this that I asked her if I could repost our emails to each other here on my blog. THIS is the information women need. This is what they need to see when they are googling “pregnancy and obesity” and “weight gain recommendation for overweight moms” and ” diet for overweight pregnancy.” So here goes…

Hi Joy, 

I wanted to ask what your experience is with Brewer's and the overweight mother.
I would like to be able to advise an overweight client as I am not sure how she will
be treated by the doctors and what kind of dietary guidance and weight restrictions they will give her.
She walks daily and hired a personal trainer a few months ago and she said that as long she walks
regularly, her borderline high bp stays in the normal range. 

What are your thoughts?

Thanks,

Amy
Dear Amy,

Dr. Brewer's most basic response to this kind of question was......

1)  The kind of food eaten during pregnancy is more important than the number of pounds 
gained—both weekly and overall.

http://home.mindspring.com/~djsnjones/id11.html

2)  Each pregnancy grows a new placenta which needs an expanded blood volume in order to 
function  properly.All pregnancies have this need, regardless of the mother's beginning 
weight.

3)  In order to service the placenta adequately, the mother's blood volume needs to increase
 by 60% by the end of the second trimester, and then it needs to be maintained at that level
for the rest of the pregnancy.

4)  In order for that blood volume to expand by that much by the 24th week, and stay expanded
throughout the third trimester, the mother needs to eat according to a plan that includes a 
certain level of calories PLUS salt PLUS protein (it's not just about protein, and without 
all three components,this plan is not likely to work as it's designed to do).

5)  The mother's body can expand the blood volume only from the food that she eats.  It 
CANNOT create what she needs for expanding the blood volume, or for creating baby cells, or for creating 
new uterine  cells, by breaking down her extra body fat.

6)  There are many different reasons for a woman to become overweight.  But if part of the 
reason for a specific individual woman to be overweight includes too many carbohydrates or 
fats and too little exercise, then she may actually lose weight on the Brewer Diet, simply 
because she is changing her lifestyle to a more healthy way of eating.  But weight loss should
not be her goal, only a consequence of eating in a better way.

7)  If a mother adds extra exercise to her lifestyle, she needs to be careful to add enough 
calories to the Basic Plan of the Brewer Diet to compensate for that extra exercise.  
Otherwise, she may be at risk of burning up some of her precious protein intake for energy, 
thus risking having her blood volume drop and triggering the pre-eclampsia process.

http://home.mindspring.com/~djsnjones/id95.html

8)  A healthy eating style for a healthy pregnancy needs to also include a good level of 
healthy kinds of fats and a good level of healthy kinds of carbohydrates.  The Basic Plan 
of the Brewer Diet includes both of those food groups, and you can see how many servings 
of each (and examples of good  sources) at this page...

http://home.mindspring.com/~djsnjones/id96.html

If you haven't done it already, I also suggest that you check out the "Obesity" page on my 
website....

http://home.mindspring.com/~djsnjones/id69.html

PART II

Dear Amy,

I was answering in a hurry earlier because I was thinking that the laptop was going to walk 
off again  with my husband,but he is using something else today, so I can add a few things 
to my previous response.

"I wanted to ask what your experience is with Brewer's and the overweight mother."

I don't remember any specific overweight mothers from my experience, although I am sure that 
there  were some, since I've been working with pregnant mothers for almost 32 yrs, and probably 
about 500-700 mothers.  Whenever I worked with natural-oriented midwives, we tried to focus 
more on what the mother was eating between prenatal visits, more than on the number of pounds 
she was gaining during those times.  The mothers who stand out in my mind are the one who was 
apparently eating so  poorly that when I showed up to help with the birth, her bones were 
sticking out of her body, like those on an anorexic woman (I was not included in the teaching 
or monitoring of her diet during  the prenatal care)....or the mother who ate little more 
than cocoa puffs, no matter how hard we tried,  and ended up with PUPP syndrome and nursing 
problems.....or the 2-3 mothers who had 10 lb babies with no problems pushing them out 
(and the one who had to work harder at it)....or the mothers who got advised to cut back on 
salt or calories or to exercise a little extra and ended up with elevated BPs and 
pre-eclampsia symptoms and hospitalization and premature births as a result.....or 
the mothers  who were able to hold back their creeping BPs with hourly doses of protein and 
calories and sodium....and the mother who weaned her baby at 4 weeks so that she could go 
on a cruise with her extended family (leaving the baby at home)....and the ESL mother who
insisted on bottle-feeding her baby for the first 3 days because colostrom is obviously not
breast milk or adequate for feeding a baby. I also remember a few pregnant women who had lost 
a lot of weight before the pregnancy, who had to stand with their backs to the number display
on the scales, at every prenatal visit, so that they could eat well and not be anxious about 
the number of pounds that they were gaining. For those women  we also had to put many notes 
on the outside and inside of their charts to caution all the people caring for them to NOT 
tell them what their weight gain was.

I don't consider age or being slightly overweight or having recently lost a lot of weight 
as being risk factors on their own.  I think that the groups of women with those factors 
in their lives may have higher rates of pre-eclampsia (and the other complications associated
with low blood volume),simply because when those women go to mainstream care-givers they are 
labeled "high risk" and put on inadequate diets, which then creates the very complications 
which they are trying to prevent.

In addition,  on the subject of age, depending on lifestyle, you might have a 40 yr old woman 
who  is healthier than a 25 yr old--aside from the issue of increased difficulty in conceiving.

"I want to advise her as I am not sure how she will be treated by the doctors and what kind 
of dietary  guidance they will give her."

I can almost guarantee you that most doctors will treat her as "high risk" and try to control 
her  pregnancy and birth to pieces.  I think that the only way that she will have a chance 
at a normal  pregnancy and birth is to go to a very good midwife.  Homebirth would be her 
best bet.  But if she  is not comfortable with that option, she should not even 
attempt it, because if she does not believe  in her gut that homebirth is her safest option, 
she will most likely just get transported to a hospital  mid-labor, for lack of progress.  
Her cervix simply will not open if she is not laboring and giving birth in a place that feels 
safe to her, and with care-givers who feel safe to her.  Her next best  option would be a 
birth with a midwife in a free-standing birth center.  Her next best option would
be a hospital birth with a midwife--preferably a non-mainstream type of midwife (many midwives
are just  as medically-minded as OBs are, or almost as much).

For that last category, she should look for midwives who do not share an office with their 
back-up  doctors, but work in a practice which is independent from that of their back-up 
doctors.  She can  also interview midwives and see which ones insist on all the tests 
possible, and which ones make at least some of the various prenatal tests optional 
(the latter being the more natural-birth oriented  ones, in my opinion).She can also check 
various homebirth websites for suggested lists of questions  to ask midwives to see if they
are the kind of midwife that is more natural-birth oriented. She can also use the questions 
that I have listed on my first "Registry" page....

http://home.mindspring.com/~djsnjones/id97.html

I also suggest that she go to her local public library and check out "The Pregnancy After 30
Workbook",  by Gail Brewer (or she can get it through inter-library loan, through her local 
public library, if they don't have it).  The following is Dr. Brewer's chapter in that book....

http://home.mindspring.com/~djsnjones/id72.html

At the very least, I suggest that she hire a very, very good, very experienced, very well 
certified doula (and preferably one who has extensive experience in both home and birth center 
and hospital births), from the FIRST DAY that she knows that she is pregnant.  This doula 
can help her work her  way through finding out what are the best options for prenatal care 
in her area, help her to choose a more natural-birth oriented care-giver who also fits her 
unique comfort level and needs, and help  her through every step of the way as her 
care-giver offers (or insists on) various tests, procedures,  or life-style changes, helping 
her to see how much broader her choice of options is than her care-giver  might be giving her. 
A doula might charge a little more for this all-pregnancy kind of care than she  would for 
third-trimester/labor kind of care, but I suspect that she will be able to find a doula
willing to do this, especially if she explains why she needs this kind of help, and that she 
might be  willing to pay a little more for this kind of care.

She might also be interested in the article about how a woman with pre-existing hypertension 
was able to go off of her anti-hypertension drugs when she got pregnant, just by adding more 
salt to her diet....

http://home.mindspring.com/~djsnjones/id70.html

She might also be interested in the recent study which cautions women against doing too much 
exercise  when they are pregnant because it can increase their risk of developing pre-eclampsia – 
which I think underlines the Brewer caution to be very sure to add enough calories and salt to
the diet  when a pregnant woman has extra exercise in their lives (exercise of daily living 
as well as recreational exercise).  You can scroll down to the bottom of the page to where 
the paragraph in red lettering is.  I don't remember precisely, but I think that this study 
suggests that more than 15-20 min of moderate recreational exercise a day is too much for a
pregnant woman.

http://home.mindspring.com/~djsnjones/id95.html

Again, I hope that this helps.

Best wishes,
Joy
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Breech Pregnancy and Birth Survey

Posted on July 7, 2009. Filed under: Birth, breech, Cesarean, Pregnancy, vbac | Tags: , , |

All North American women who have had breech pregnancies or births are invited participate in an essay-response survey, which takes approximately 15-30 minutes to complete. We are interested in participants who had breech pregnancies (breech babies who turned head-down before birth). We would also like to hear from women who have given birth to breech babies, whether vaginally or by cesarean section; with midwives, physicians, or unassisted; at home, in a birth center or in a hospital. We welcome input from both singleton and multiple (twin, triplet, etc) breech pregnancies and births.

How to Participate:
To take the survey, please visit the Breech Pregnancy and Birth Survey

.

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Maybe This Will Be America’s Children Someday

Posted on July 2, 2009. Filed under: Birth, Breastfeeding, Cesarean, Pregnancy |

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Every Mama Needs A Doula!

Posted on July 1, 2009. Filed under: Birth, Breastfeeding, Cesarean, doula, Pregnancy, vbac | Tags: , , , , , , , |

I just realized that I am a doula and I write a blog about birth and I have never done a post on doulas!

A doula (doo-la) is a Greek word that means ‘woman who serves.’ A doula is a professionally trained woman who provides information, physical and emotional support before, during and immediately following birth. Women have attended birthing women for centuries in all cultures. Ancient hieroglyphics show women birthing with other women supporting them. It is only in modern times that we have begun to stray from this support with the medicalization of birth. The need for one on one support in labor is so crucial to the birthing woman’s perception of the birth experience and ability cope with birth. Women supported by a doula frequently report a significant decrease in the length of labor, the perception of pain and the need for anesthesia or analgesia as well as fewer cesarean sections.

I said this about doulas in a previous post

I am a doula, I think every woman should have a doula. It’s not because I am trying to justify the profession or the cost or to promote myself, but I really believe that no woman should have to birth without someone who is trained to support a laboring woman. There is a big difference between a doula and a loving partner, a doula and a best friend who has had five kids and a doula and the grandma. While a doula does form a relationship with her clients, she doesn’t have that intimate relationship these other people do and can help the laboring woman without the emotions that are often involved with these family members. Doulas are also trained professionals who study birth and labor and ways to make labor easier and more comfortable with different positions and massage and other techniques that even someone who has had a few kids of their own may not know. Doctors, midwives and nurses often times have several patients at once and cannot stay with the laboring woman.

The research has shown that the presence of one-on-one support such as that of a doula a less likely to have:

have a cesarean section;
give birth with vacuum or forceps;
have regional analgesia (e.g., an epidural)
have any analgesia (pain medication)
report negative feelings about their childbirth experience

With a doula you can have up to*

• 50% reduction in the cesarean rate
• 25% shorter labor
• 60% reduction in epidural requests
• 40% reduction in oxytocin use
• 30% reduction in analgesia use
• 40% reduction in forceps delivery

*Information was obtained from Mothering the Mother: How a Doula Can Help You Have a Shorter Easier and Healthier Birth, Klaus, Kennell, and Klaus (1993).nc

Doulas can also help incorporate the partner into the labor experience. Often times partners are very inexperienced in childbirth and they are nervous and worried and are scared of labor pains. They are often scared and unsure of how to help their partner even though they very much want to. I have found that they are relieved to have the help of a doula, especially once labor kicks in to high gear and they do feel more of a part of the labor process when they are shown ways to help the mother. It gives them a greater sense of importance and usefulness that they very much appreciate. I love working with the partners as much as the moms because they are so willing and grateful by the end. Even the strongest, most loving and supportive dads benefit from having a doula around.

With every birth I attend, I believe more and more that no woman should birth without a doula and that every woman has the ability and probably should birth without drugs. I have not had a client get an epidural yet but I would completely support a woman if she chose to.

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C Section With an Inverted T Incision and Face Presentation

Posted on July 1, 2009. Filed under: Birth, Cesarean, Face First/Mentum Presentation, inverted t incision, Pregnancy, vbac | Tags: , , , , , , , , |

I have procrastinated writing this post. It is the post that I most wanted to write from the moment I my cyber friend Pam dreamed up the idea of writing a blog. I have put it off because I needed to organize my thoughts and my statistics and references and people. Well, really not MY people but the people who are out there that are dealing with having an inverted t incision scar. I feel the pull to get it all down and typed out and saved somewhere that is easily accessible on the internet though so it’s time to stop procrastinating. I just want to make sure that if there is a woman out there googling ‘inverted t incision’ she finds the answers to some of her questions because there is not a lot of information out there. I feel that if I can at least put everything I know in one place maybe someone else will have an easier time than I did when I was trying to learn everything I could.

My quest for inverted t incision knowledge began with my own birth story. In short, we ended up with a cesarean after a very long natural labor that resulted in an inverted t incision because of my son’s face first presentation. So there is no confusion about what the face first presentation is as some people confuse it for ‘face up’ or OP (occiput posterior), I have included some pictures below.The first picture shows what a normal vertex occiput anterior baby looks like in utero. The second picture shows how the baby hyper extends it’s neck when presenting face first. The third shows the different ways the baby can present. My son was Left Mentum Transverse (LMT).

Optimal Fetal Position Occiput Anterior

Optimal Fetal Position Occiput Anterior

Example of face first in utero, shows hyperextended neck

Example of face first in utero, shows hyper extended neck

Diagram of fetal positions, my son was LMT

Diagram of fetal positions, my son was LMT

Here is an article written by a woman who delivered a face first presentation. I added it into my article because I am scared that one day the link will not work. The link is HERE. Below is the article…

Face Presentation is a relatively uncommon labor presentation (only about .4 percent of births) when the baby is head down but has its neck extended, as if looking down the birth canal, rather than with its chin tucked into it’s chest.  The chin or the nose presents first (very rarely the brow), not the top of the head.

Presentation refers to the part of the baby first entering the pelvic structure on it’s way out the vagina.  A vertex birth (head first) happens approximately 95 percent of the time.  The options (in order of occurance) are: Vertex, Breech, Shoulder, Face, Brow

Attitude is the relationship of the baby’s extremities -arms, legs and head – to his main body.  A fully flexed baby is compact and compared to poorly flexed or extended.   A fully flexed vertex presentation makes for the smallest diameter of the baby’s head exiting at all times.  If the baby’s head is only partly flexed, a larger diamer will have to come through the birth canal, making for a longer labor and more difficult exit.  (Trust me on this!)  If the baby’s head is Fully Extended, the baby is Presenting by Face.  This sounds very scary when described, as the head is bent backwards till it is resting on the back shoulders.  It appears like the baby is going to break it’s neck coming out!

Labor: The top of the baby’s head will be resting (uncomfortably!) on the mother’s backbone.  Labor will likely be slower since the face is not an ideal canidate to dilate the cervix.  Mom is probably going to be in a bit of extra pain.    In my case, once I past transition I had no urge to push since the head was not hitting the proper nerves.  (I don’t know if this is always the case or not)   I found this very disconserting since I knew from past experience I should be wanting to push.  The diamater of the head as it presents is about the same as a vertex birth (abt 9.5 cm).  However, while the presenting parts may be equal, for the face presenting baby – the full width of the head is to follow!    When a baby is vertex, the head bones actually mold together and overlap, making the head easier to push through and out of the birth canal.   Face presentations have no such luck.

Having an angel-faced baby is akin in size to a breech birth!!  However, as long as the baby is face up – chin facing the mom’s bellybutton – there is no danger.   With a breech birth, the danger is the head getting suck in the birth canal after the body has sucussfully exited, possibly with the cord pinched.  With a face first baby, the head comes out first – so there is no danger of asphyxiation.

Please note that angel-faced baby’s are routinely C-sectioned in hospitals.  Any baby that is sunny-side up “fits the requirement for a c-section”.   Moreover, since labor will be longer and mom will appear to be ‘hung up’ at stages – some will say there is a faliure to progress.  (Again, this is simply because the nose does a poor job of dilating the cervix.)  Please give labor a try – these babies can and do fit!  It’s worth the extra effort.

The Prognosis: Since Angel babies are born sunny-side up (face and throat facing upwards toward the ceiling) the baby needs to be suctioned at once, so no amnioatic fluid is asperiated into the lungs.  Since the baby is born with his neck pushing against the mother’s pubic bone, there is sometimes a fear that the child will suffer from breathing difficulties (edema around the throat), but this rarely happens.  Although the baby is terribly bruised during the labor (imagine using YOUR nose to force through the birth canal!) the prognosis for mommy and baby (assuming they have a caring provider that allows them to birth vaginally) is fine.  The face will be swollen for a day or so.  90 percent of angel-faced baby’s deliver vaginally!!!   Mine did!  At over 9 1/2 pounds too!  With a big ole face like a dinner plate!

If the chin is facing the Mom’s tailbone:  (Posterior)  Then the prognosis is not so good.  Even midwives agree that if you have a face presenting baby with a “mentum posterior”, vaginal delivery is almost impossible.   Often the chin will get hooked on the tailbone, and the baby is wedged in the no-mans land of the birth canal.   Happily of all face presentations, only about 30 percent are posterior and many of them rotate before they get stuck.

Vaginal Delivery: Remember, 90 percent of all face presentation babiess deliver vaginally!!  The reason for this is most face babies aren’t diagonosed until very late in the labor when it is already apparent that baby is coming down that birth canal, doctor training or no!  Be aware that if a hospital rountinly uses sonograms during labor, or if your doctor is doing frequent vaginal exams, they will discover your baby is facing the heavens and may request a preemptive c-section (because of the small danger a baby may asphyxiate on it’s own amniotic fluid.)  You need to decide what you feel the risks of this are.  I had my angel baby vaginally, natrually, and at home.  And it’s a decision I feel blessed I made.

Material gathered from:  Spiritual Midwifery, by Ina May Gaskin & Gentlebirth

Also some cool midwife books that I don’t own but that my midwife brought over the day after Stealth Baby’s birth to show head position, rotation and generally talk about what happened the night before while I was in labor land.

Most face first presentations are delivered vaginally as they aren’t diagnosed until the baby is descending. In order for a baby to deliver face first, it would need to be mentum (chin) anterior. Face first labors tend to be much more painful for the mom and much slower since faces don’t dilated the cervix very well. Only 0.4% of babies will present face first. In my situation, the doctor didn’t catch that my son was face first and she even tickled his head to stimulate his heart. She must have felt his cheek or forehead. Often times doctors will realize the presentation when they check and the baby sucks their finger. Sometimes the mouth is mistaken for the anus and the baby is misdiagnosed as being breech. The causes of face first presentations can be a weak abdominal wall and the pelvic shape. Other times it’s an OP (occiput posterior) baby who just happens to stick their face in the pelvis at some point during labor.

It has been said that the problem with the face first presentation isn’t really the face but what follows. In our case, my son had a 14.5 inch head that had the face engaged the pelvis would have had to pass through the pelvis unmolded. I am sure that wouldn’t have happened. I do not really believe that women can grow babies they can’t birth but in a situation where a rather large head must birth unmolded, it makes me wonder. Regardless, because his face presented transversely, he was unable to engage past a -3 station anyway. This article discusses face first presentations in more depth.

My face first presentation was diagnosed once the c section began. He was wedged in such a way that he couldn’t go forward and pulling him back out was very difficult as well. This resulted in the additional vertical cut into  the contractile portion of the uterus. Interestingly enough, as only 0.4% of babies present face first, only 0.4% of cesareans are inverted t incisions. They are typically saved as a last resort in emergency situations are extremely difficult deliveries that require more room to maneuver within the uterus.

When a cesarean delivery starts out with a horizontal bikini cut as mine did and then is given the additional vertical cut, usually the cut is small and stays in the lower segment of the uterus. These kind of scars are generally considered safe to VBAC although finding a provider may be difficult. My operative report does not indicate how long the vertical cut was, sometimes the doctor does include that information. Mine only says that it was cut into the contractile portion of the uterus. Sometimes the t extension does go into the fundus or the top of the uterus. This is more representative of  a classical incision and is considered riskier.

Because of the increased amount of scar tissue and a scar in the contractile muscles, the recommendation from ACOG is that women with inverted t incisions should not TOL (trial of labor) in future pregnancies. My doctor also told me that I should deliver at 36 weeks after an amniocentesis to check for lung maturity. While the third trimester risks of amniocentesis are low
, I have a big problem with purposefully delivering a preterm baby by elective cesarean. My son was born at 41 weeks and 1 day. He was 8lbs and 5 oz. He was healthy other than the birth trauma and breathing issues related to our cesarean. He obviously needed to gestate that long. At 36 weeks, he would have been 5 weeks and a day early. He definitely would not have been ready to be born.

This early delivery recommendation stems from the increased risk of uterine rupture. There is an increased risk but it may not be as high as some doctors make it out to be. The rupture rate for a low horizontal cut (bikini) is about .5% and I have heard doctors say there is a 15% chance of rupture for an inverted t incision (offering no info to back up that claim and not responding when I challenged it). I have read online where doctors say 4-9% but with no references or studies proving that range.

Ann Frye says “.As far as the type of incision goes, the mother who has a low transverse uterine incision is at the lowest risk for scar-related problems such as dehiscence and rupture. Those with classical or T-shaped incisions are at more risk for rupture, which tends to be more traumatic than the usually benign scar disruptions which occur in women with low transverse incisions. While some types of incisions pose more risk, the highest risk is still probably around 5% (some scars are more rare and limited data is available. From looking at the existing data, 5% seems to me a generous estimate of risk for all types of Cesarean scars, with the order of risk as follows: low transverse [0.5% Haq, 1988; to 2% Clark, 1988], low vertical [1.3% Enkin, 1989], classical and inverted T [probably about the same for both: 2.2% to 4%, depending on the study], upright T and J-incision [probably somewhat higher, but no specific data is available].). Women with an upright T, J-shaped, or classical incision or those who have experienced previous uterine rupture may want to birth in the hospital, although finding a practitioner that will assist them to have a VBAC will be more difficult. However, in these cases scar disruption is **most likely** [emphasis the author's] to occur during pregnancy with accompanying fetal distress and possible death, or not at all. ” The references are vague here as well.

The Landon Study (2004) found that the rate of rupture for inverted t incisions is 1.9%. I tend to trust this study more than anything a doctor tells me or any other study. The reason is because it seems to be the largest one I can find. Most women with inverted t’s do have repeat cesareans so there are not many large studies. This particular study included a total of 17,898 women who had TOL after cesarean. Of these, 14,483 had a prior low transverse incision (bikini cut) and the rupture rate was 0.07%. Of the total 17,898 women who had TOL, 105 had inverted t incisions, j or classical incisions. Two of these women ruptured equaling a 1.9% rupture rate for inverted t, j and classical incisions combined. All of them either showed up late in labor or simply refused repeat cesareans. The outcomes for these two women and their babies were not included in the study.

For me personally,I am comfortable with TOL after inverted t in a supportive environment with fetal monitoring. If I have a successful VBAC, I am comfortable home birthing the next one. I have found a doctor that will TOL with me. His only requirements are venous access (hep lock but I don’t have to have the IV if I don’t want it) and continual electronic fetal monitoring. I can live with both under the circumstances. I will have no time constraints on my labor, limited staff interruption, the use of a tub and wireless portable monitoring, a doula, my Bradley Method trained husband and the comfort of knowing if my uterus blows that my doctor is there waiting in the hallway. There is a 0.095% chance of the baby dying in the event of a uterine rupture. Outcomes are greatly improved when the cesarean can be performed within 20 minutes of the suspected rupture. For me, I can VBAC comfortable knowing these percentages. I think that the option to VBAC for moms with inverted t incisions should be based on the mothers comfort level and knowledge. I hope that this post can help moms make a more educated decision. I will add new information as I learn it.

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New Movie: Reducing Infant Mortality and Improving the Health of Babies

Posted on June 27, 2009. Filed under: Birth, Breastfeeding, Cesarean, Pregnancy, vbac | Tags: , |

This is a very important topic. As many people as possible need to see this film.

From The Unneccesarian

Reducing Infant Mortality, a free online film, will be released this summer as a tool for drawing attention to infant mortality and health issues as national health care policy is debated on Capitol Hill.

According to the film’s web site, the U.S. health care system is failing babies and families before, during and after birth as evidenced by the country’s worldwide infant mortality ranking of 42nd, with more than double the infant deaths compared to the top 10 countries of the world.

The filmmakers report that they are seizing the opportunity to make a 10-12 minute video to point out the flaws in the way we care for babies and families and to identify the keys to improved care at a time when the U.S. government is working to reform health care.

Of particular concern to the creators of Reducing Infant Mortality is the “astronomically high” African American infant mortality rate of 16 deaths per 1,000, which is similar to countries such as Malaysia and the West Bank. Their hope is for legislators and public policy makers to rethink the current health care system and incorporate the midwifery model of care to save taxpayers millions of dollars each year and promote a new measure of success for the infant’s first year of life—thriving, not just surviving.

The extensive list of experts interviewed for the film includes Michel Odent, Thomas Verny, Marshall Klaus, Phyllis Klaus, Marsdsen Wagner, David Chamberlain, Karen Strange, Robbie Davis-Floyd, Jennie Joseph, Sarah Buckley, Bruce Smith, Yeshi Neumann, Paul Fleiss, Maria Iorillo, Stuart Fischbein, Debra Bonaro-Pascali and Judith Prager.

The Santa Barbara Graduate Institute, a 501 (c) (3) non profit organization, is the fiscal sponsor of the Reducing Infant Mortality film project. Tax deductible donations to support the film can be made by check or electronically via the website. The film’s creators are looking for networking partners to help promote the film and provide a contact e-mail on the site’s home page for those interested in helping.”

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More Info on the Brewer Diet

Posted on June 26, 2009. Filed under: Birth, Pre eclampsia, Pregnancy, Pregnancy Brewer Diet | Tags: , , , , , |

This website is very informative and explains how the Brewer Pregnancy Diet works in great detail. The author if the site is Joy Jones. She is an RN and childbirth educator with extensive knowledge of the Brewer diet and nutrition in pregnancy.

The Brewer Diet, as I discussed in a previous post, focuses on protein, salt and calories. Joy goes into depth on the benefits of the diet and how nutrition can affect:

Premature Labor
Swelling
Blood Pressure
Pre-eclampsia
HELLP/Hemorrhage
Mistaken Diagnoses
IUGR
Underweight Babies
Obesity
Anemias
Gestational Diabetes
Abruption

As I have said before, diet cannot necessarily cure every pregnancy issue but it can affect many aspects of pregnancy and it is something that we can and should control. Please be sure to read about the Brewer diet if you are pregnant and pass this on to anyone you know that is pregnant.

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The Six Care Practices that Support Normal Birth (Part Two)

Posted on June 25, 2009. Filed under: Birth, Cesarean, Pregnancy | Tags: , , , , , , , , , , , |

As I said in Part One of this article, there are six care practices that support normal birth. Lamaze International says “The six care practices below are supported by research studies that examine the benefits and risks of maternity care practices. Therefore, they represent “evidence-based care,” which is the gold standard for maternity care worldwide. Evidence-based care means “using the best research about the effects of specific procedures, drugs, tests, and treatments, to help guide decision-making.”

Unfortunately, in the U.S., the trend is not towards normal birth and adhering to the six care practices that support normal birth. Maternity care in the U.S. has a “prominent position, large expenditures and troubling performance” according to the Milbank report Evidence-Based Maternity Care: What It Is and What It Can Achieve released in October of 2008. This report discusses the issues with the U.S. maternity systems, the overuse of routine interventions and the harm they cause and closing the gap between them and the normal birth practices for healthier moms and babies. I will talk about this report in depth in another post as it has some great information that every pregnant woman should know.

Care Practice #1: Labor Begins on its Own

This seems so obvious but women are being induced more and more and for more and more reasons that really are not means for induction. In my Truth About Pitocin post, I discussed the difference between medical inductions and elective inductions. The medical reasons for induction are:

* your water has broken and labor has not begun.
* your pregnancy is postterm (more than 42 weeks).
* you have high blood pressure caused by your pregnancy.
* you have health problems such as diabetes that could affect your baby.
* you have an infection in the uterus.
* your baby is growing too slowly.

Suspected big baby is not reason for induction and ACOG doesn’t recommend it either but it is commonly a reason for induction. Also common to that is the birth of an 8lb baby after the induction failed and a cesarean had to be performed when if given time, the mother would have spontaneously began labor on her own when both she and the baby were ready.

Also important to note is that a pregnancy is not considered post term until AFTER 42 weeks. Only after 42 weeks should the pregnancy be induced if all else is normal.

Labor induction is not without risk. Research has shown there is a significant increase in

* vacuum or forceps-assisted vaginal birth;
* vacuum or forceps-assisted vaginal birth;
* cesarean surgery;
* problems during labor such as fever, fetal heart rate changes, and shoulder dystocia
* babies born with low birth weight;
* admission to the NICU;
* jaundice (yellow skin caused by the breaking down of red blood cells) that required treatment; and
* increased length of hospital stay.

In addition, the chance of cesarean is nearly doubled when induced and there is a higher risk of prematurity as due dates are only estimates. There are also psychological effects as it makes us think that there is something wrong with us for not going into labor on our on. I have had clients ask me if I thought a friend was capable of going into labor or if someones water can break on it’s on. These are pretty valid questions, especially for a first time mom who has seen most of her friends get induced for one reason or another and every one of them had artificial rupture of membranes (water broken for them). The thing is, our bodies will not stay pregnant forever. We are meant to birth the babies that we grow. We are just forgetting that in this day in age where most women are given pitocin and think that they just HAD to have it or they couldn’t have birthed their baby. It’s really sad that we have come to this. We do not HAVE to have pitocin to give birth.

Care Practice #2: Freedom of Movement During Labor

This one is pretty simple but too often women are told to get in the bed and stay there. Usually this happens because they are on some medication (pitocin, cytotec, anesthesia) that requires continual fetal monitoring and IV lines. All of this is counterproductive to what the body and the baby are trying to do. The uterus works better when a woman moves around. It’s a muscle and movement increases circulation. The pelvis not stationary. It moves and flexes and bends and as it does the baby is able to moved and wiggle down into it with the help of gravity. Being on the back in bed prohibits this movement and closes the pelvis up making a smaller exit for the baby to move in to.

The research has shown that movement causes:

shorter labors,
more efficient contractions
greater comfort
less need for pain medicine in labor

Even if there is a medical reason to have continual electronic fetal monitoring, there is enough slack in the line to get out of bed and sit in a chair or a birth ball or to sway with your partner.

Care Practice #3: Continuous Labor Support

I am a doula, I think every woman should have a doula. It’s not because I am trying to justify the profession or the cost or to promote myself, but I really believe that no woman should have to birth without someone who is trained to support a laboring woman. There is a big difference between a doula and a loving partner, a doula and a best friend who has had five kids and a doula and the grandma. While a doula does form a relationship with her clients, she doesn’t have that intimate relationship these other people do and can help the laboring woman without the emotions that are often involved with these family members. Doulas are also trained professionals who study birth and labor and ways to make labor easier and more comfortable with different positions and massage and other techniques that even someone who has had a few kids of their own may not know. Doctors, midwives and nurses often times have several patients at once and cannot stay with the laboring woman.

The research has shown that the presence of one-on-one support such as that of a doula a less likely to have:

have a cesarean section;
give birth with vacuum or forceps;
have regional analgesia (e.g., an epidural)
have any analgesia (pain medication)
report negative feelings about their childbirth experience

Doulas can also help incorporate the partner into the labor experience. Often times partners are very inexperienced in childbirth and they are nervous and worried and are scared of labor pains. They are often scared and unsure of how to help their partner even though they very much want to. I have found that they are relieved to have the help of a doula, especially once labor kicks in to high gear and they do feel more of a part of the labor process when they are shown ways to help the mother. It gives them a greater sense of importance and usefulness that they very much appreciate. I love working with the partners as much as the moms because they are so willing and grateful by the end. Even the strongest, most loving and supportive dads benefit from having a doula around.

There are three more care practices supporting normal birth. I will discuss them in Part Three.

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Reporting Cytotec Induction to the FDA

Posted on June 23, 2009. Filed under: Birth, Cesarean, cytotec, Pregnancy, vbac | Tags: , , , , |

I wrote a post on the dangers of Cytotec last week and sitrred up some conversation on this topic on a mommy board that I have been a part of since I was pregnant with Graham. One of the moms, Margaret, was induced with Cytotec and didn’t know anything about it at the time and had a pretty terrifying delivery as a result of it. Both mom and baby were fine but in the months after her daughter’s birth, she began to learn more about Cytotec and the dangers of it and she was understandably outraged by what she found. She sent me this link . It is the FDA’s MedWatch Online Voluntary Reporting Form. If you were induced with Cytotec, you can report the information here and hopefully raise the awareness of it’s dangers by demanding action from the FDA. To read more about it, please go to The Tatia Oden French Memorial Foundation. Tatia and her baby Zorah died as a result of an amniotic embolism caused by an overstimulated uterus induced with Cytotec. It’s a sad story but one that needs to be told so that more women become of aware of the dangers of this drug. Please pass this information on to anyone you know that was induced with Cytotec or to any women you know that are pregnant.

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