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

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

Breech Pregnancy and Birth Survey

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

.

EXCELLENT video on how to prevent cesareans!!!

Do You Know What You are Signing? Elective Cesarean

Below is a copy and pasted version of a real elective cesarean consent form provided by an L&D nurse on her blog. Often times women sign these when they schedule their cesarean but they sign them without reading it or if they do read it they do not understand exactly what they are reading. Yes, they may see the words on the page but they do not realize that the risks outlined on that page are so very real. I have made some additional notes within the content of the form. My notes are in italics.

Consent for Elective Cesarean Section

A cesarean section (c-section) is the surgical delivery of a baby through an incision in the abdomen and uterus. An incision is made on the abdomen just above the pubic area. The second incision is made in the wall of the uterus. The physician can then open the amniotic sac and remove the baby. The patient may feel tugging, pulling, and pressure. The physician detaches and removes the placenta; incisions in the uterus and abdomen are then closed.

I authorize and direct _______________________________, M.D. with associates or assistants of his/her choice, to perform an elective cesarean section on _______________________________.

(Print Patient Name)

Patient’s Initials

_____ I have informed the doctor of all my known allergies.

_____ The details of the procedure have been explained to me in terms I understand.

_____ Alternative methods and their benefits and disadvantages have been explained to me. How many times are the benefits of VBAC explained? Does the patient understand that with a successful VBAC the risk of uterine rupture (which is initially 0.05%) decreases and that the risk of rupture (before labor and during) increases with each cesarean?

_____ I understand and accept the possible risks and complications of a cesarean section, which include but are not limited to:

* Pain or discomfort

* Wound infection; and/or infection of the bladder or uterus. Bladder infections are very common after cesareans because of the catheter. It is not uncommon to be re-catheterized after cesarean because of the inability to urinate independently. This increases the risk of bladder infection immensely. Obviously the uterus is at risk for infection as it has been cut open.

* Blood clots in my legs or lungs You are four times more likely to develop a clot after a cesarean than a vaginal birth. This may not seem like a big deal to most people but as a person with a hereditary blood clotting disorder and a mother with chronic DVT, and a sister who had a hysterectomy at 23 years old because of a blood clot in her ovary, I can tell you first hand that this is real and it is serious.

* Injury to the baby Babies born by c section 50% more likely to have lower APGAR scores than those born vaginally. About 2% of babies born via cesarean are cut by the scalpel. After my own cesarean my OB told me about a friend that she went to school with that cut a baby on her face so badly that she required plastic surgery. What a nice welcome to the world.

* Decreased bowel function (ileus)

* Injury to the urinary tract of GI tract I have ready many stories of the bladder being cut by the scalpel. If you are not aware, the bladder sits on the uterus and is connected by a layer of tissue that must be separated so that the bladder can be moved out of the way and the uterine incision made.

* Increased blood loss (2x that of a vaginal delivery)

* Risk of additional surgeries

* Post surgical adhesions causing pain/complications with future surgeries Adhesions make subsequent cesareans more difficult and longer to perform. They do not interfere with vaginal deliveries.

* Increased risk of temporary breathing problems with the baby that could result in prolonged hospitalization We were in the hospital six days total as a result of this very thing.

_____ I understand and accept the less common complications, including the risk of death or serious disability that exists with any surgical procedure.

_____ I understand in a future pregnancy that I have an increased risk of complications including, but not limited to: These aspects of cesarean are so very important and so often omitted from the discussion. Risks are increased with every cesarean.

* Placenta previa, where the placenta covers the cervix.

* Placenta accreta, where the placenta grows into the muscle of the uterus.

* This may lead to a hysterectomy and excessive blood loss at the time of the cesarean section.

* An increased risk of uterine rupture (with or without labor) and that this risk increases with each subsequent cesarean section. Uterine rupture can lead to the death of the baby or myself.

_____ I have been informed of what to expect post-operatively, including but not limited to:

* Estimated recovery time, anticipated activity level, and the possibility of additional procedures.

_____ The doctor has answered all of my questions regarding this procedure.

_____ I am aware and accept that no guarantees about the results of the procedure have been made.

I certify that I have read and understand the above and that all blanks were filled in prior to my signature.

________________________________ Patient Signature/Date

________________________________ Witness Signature/Date

I certify that I have explained the nature, purpose, benefits, and alternatives to the proposed treatment and the risks and consequences of not proceeding, have offered to answer any questions and have fully answered all such questions. I believe that the patient fully understands what I have explained.

________________________________

Physician Signature/Date

________copy given to patient ________copy placed in office chart

(Initial) (Initial)

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

What is not included on the consent form is the psychological effects on both mom and baby when a cesarean is done. The interference with the normal hormonal processes that both the mom and baby go through do have an affect on bonding and breastfeeding. I have talked to some people who say that they had no bonding issues at all and that breastfeeding was easily established after a c section and that is wonderful. However, MANY times this is not the case. Many mothers and babies do have problems. The rate of postpartum depression is higher as well.

Because the c section rate in the US is so high (31% for 2008) many people just assume that it’s routine and simple and safe. So many women are not taking time to fully understand the consequences of a c section. There are medical reasons for them but that is the small minority. Most c sections are unnecessary. Most primary c sections should have never happened to begin with. The data is there, these are not my opinions. I believe that if women were truly informed and educated on the risks and benefits involved in current obstetrical practices that they would take a more active role in their births. For this to happen, we have to start questioning procedures and asking the questions. We have to have a level of awareness and believe in our bodies abilities to birth.

ICAN’s (International Cesarean Awareness Network) Patient Choice Cesarean Position Statement says:

“The International Cesarean Awareness Network opposes the use of cesarean section where there is no medical need. Birth is a normal, physiological process. Cesarean section is major abdominal surgery which exposes the mother to all the risks of major surgery, including a higher maternal mortality rate, infection, hemorrhage, complications of anesthesia, damage to internal organs, scar tissue, increased incidence of secondary infertility, longer recovery periods, increase in clinical postpartum depression, and complications in maternal-infant bonding and breastfeeding, as well as risks to the infant of respiratory distress, prematurity and injuries from the surgery.

All physicians take an oath to “Do no harm”. This means choosing the path of least risk to patients. Medically unnecessary elective cesareans increase risk to birthing women. It is unethical and inappropriate for obstetricians to perform unnecessary surgery on a healthy woman with a normal pregnancy.”

Food for thought…

Great Post About Big Babies

This blog post is about suspected macrosomia or ‘big baby.’ Very well said…

Every Mama Needs A Doula!

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.

C Section With an Inverted T Incision and Face Presentation

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

Example of face first in utero, shows hyper extended neck

Diagram of fetal positions, my son was LMT

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 fundus, 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, sometimes the cut is only a little bit 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. Usually though, when a the vertical cut is done, they do tend to cut into the fundus. 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.

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. Two of these women ruptured equaling a 1.9% rupture rate for inverted t incisions. 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.

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

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.”