VBAC from a Care Provider’s Perspective

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What is it really like to be a hospital care provider attending VBACs? Janelle from Birth Sense describes it in this post submitted to the ICAN VBAC Blog Carnival.

The whole post provides a very rational, no nonsense description of the actual problems that care providers face without an emotional “WE’RE ALL GOING TO BE SUED AND EVERYONE IS GOING TO DIE AND YOU JUST DON’T UNDERSTAND RISK!” She calls upon providers of modern obstetrics to “speak up on behalf of women who want VBAC and insist that realistic, evidence-based guidelines are instituted.”

Furthermore, Janelle points out something that would probably shock the public about hospitals. The “special” mandate that an OB remain in the hospital during the entire VBAC labor with an operating team standing by is hypocritical. If hospitals are so serious about having a team ready to handle VBAC-related emergencies, why would they not want to have the same safety net available to deal with comparable emergency scenarios in “low-risk” women? When I gave birth in a hospital for the first time, I mistakenly assumed that there was an OB and an operating team on hand for those rare emergencies. Why else would I have been in a hospital?

What is most perplexing to me is the mandate that the provider remain in the hospital during a VBAC labor “just in case”, yet other serious causes of perinatal morbidity and mortality are not considered adequate reason to have a surgeon and operating team standing by.  Some examples are:

1. Cord prolapse, with an incidence of 0.14-0.62 percent.  This can cause permanent fetal injury or death.¹
2. Placental abruption, with an incidence of 0.6 percent.  Again, this complication of labor can cause permanent fetal injury or death, as well as potentially life-threatening blood loss for the mother.²
3. Placenta accreta, and its variations (placenta increta and placenta percreta).  With a reported incidence of as many as 1 in 533 births, this is a serious maternal complication which can cause death.³

If we are serious about being able to take immediate action in the event of uterine rupture (approximately 0.5% incidence in low-risk labors VBAC labors), we should be equally serious about being prepared to immediately manage other perinatal emergencies.   The truth is, VBAC is not much riskier than a normal first birth, provided a few criteria are met:

• One low transverse uterine scar
• Normal onset of labor, no cervical ripening or induction
• No use of pitocin augmentation during labor
• Prior vaginal delivery increases chances of successful VBAC
• At least 18 months since cesarean birth

The risk associated with VBAC that concerns hospitals, insurance companies and care providers isn’t just the potential risk to women and babies. They are naturally concerned about the risk to their financial bottom line associated with a potentially predictable obstetric emergency.

The next time you hear anyone try to tell you that patients or laypeople just don’t understand risk, the question should be “The risk to whom?” I would argue that, given accurate information and percentages, most patients understand risk just fine. When you read between the lines, it’s clear that patients are expected to believe that the risk that lies behind scare tactics and lies about necessity of many cesareans and inductions is based on a certain risk to them or their baby. Unfortunately, it often has little or nothing to do with risk to the patient and everything risk to the care provider or institution.

And that’s the risk that most patients do not understand about how decisions are made about their bodies until it’s too late.

Angie’s List Induction-Turned-Cesarean Commercial

Screen cap of laboring woman being rushed to surgery

Transcript of an actual Angie’s List review:

At my 41 week appointment, my OB decided to induce me, but I guess I took longer than he expected because just as I went into hard labor, he told me he was leaving for an important meeting. On his way out, he said goodbye, dressed in his tennis clothes. One hour later, I was getting a c-section… while he was out practicing his serve.

Restriction of Food and Drink in Labor from a Medical Anthropologist’s Perspective

The recent Cochrane review, Restricting oral fluid and food intake during labour, analyzed five studies and concluded that women should be free to eat and drink in labor at will.

Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labour for women at low risk of complications. No studies looked specifically at women at increased risk of complications, hence there is no evidence to support restrictions in this group of women.

The rationale behind denying laboring women food is that the danger of aspiration and the potentially lethal complication known as Mendelsohn’s syndrome while under general anesthesia is greatly reduced.

Medical anthropologist Robbie Davis-Floyd wrote extensively about the cultural myths about non per os and childbirth in the 1992 book, Birth as an American Rite of Passage. Mendelsohn’s original 1946 article reported several cases of aspiration and subsequent pneumonia, but no deaths. Davis-Floyd cites Baggish’s 1974 study which showed that at most 2 percent of maternal deaths were caused by aspiration under general anesthesia and Scott’s 1978 work that placed the risk of death at 1 in 200,000 women.

So what purpose would denying food and drink to all laboring women serve more than six decades after Mendelsohn’s work and with the great improvements made to regional anesthesia? Davis-Floyd wrote:

According to Feeley-Harnik, “persons undergoing rites of passage are usually prohibited from eating those highly valued foods that would identify them as full members of society” (1981:4). In rites of pregnancy and birth across cultures, food tabus serve the purpose of marking and intensifying the liminal status of the pregnant woman. The pseudo-foods (ice chips and lollipops have no nutritional value) allowed in the hospital are often fed to the laboring woman by her partner as if she herself were the baby, a symbolic process that can heighten her own sense of weakness and dependence.

In a recent article in Birth, Broach and Newton (1988) address the question of why laboring women are still prohibited from eating and drinking in labor in spite of mounting evidence that such prohibitions are medically contraindicated. Pointing out that this custom started in the 1940’s when general anesthesia was widely used for childbirth and the danger from aspiration was therefore higher, they posit that its continuance is the result of “culture lag”—that is, of “culturally patterned behavior that continues to be practiced long after the reasons for doing so have disappeared” (1988:84).

Davis-Floyd views denying food in labor as indicative of the confirmation of a woman’s initiate status as a dependent of the institution.

On the contrary, I would suggest that this custom forms an integral part of the technocratic tapestry of birth in the United States, continuing as routine procedure not because of culture lag but because it serves so well to legitimate and further necessitate the technocratic interventions we investigate here as transformative rituals. To deny a laboring woman access to her own choice of food and drink in the hospital is to confirm her initiatory status and consequent loss of autonomy, to increase the chances that she will require interventions, and to tell her that only the institution can provide the nourishment she needs—a message that is most forcefully conveyed through the “IV.”

Restriction of food and liquids in labor was the subject of many discussions last year following the American Congress of Obstetricians and Gynecologists’ press release that women should be allowed “modest amounts” of water and clear liquids in labor, with physicians defending IV use and telling women to calm down their rhetoric and fight for things that matter.

Quote of the Day: Make Yourself Look Important and Busy

“A doctor must do something. He cannot remain a spectator merely, where there are many witnesses, and where interest in what is going on is too deep to allow of his inaction.”

Walter Channing, 1848
Harvard Medical School professor of obstetrics

Read more about Channing’s career and what the Harvard Medical School’s alumni blog calls the Channings “legacy of compassion” and “commitment to social justice.”

No Intervention Necessary: Woman Has Surprise HBAC

This surprise out-of-hospital birth story focused on the toddler-as-midwife angle. Just as interesting, however, was the fact that this woman avoided surgery. She was scheduled for her fourth cesarean on December 6, 2009.

Congratulations to the family.

Two-year-old Jeremiha Taylor doesn’t have to ask his mother where babies come from — he helped deliver his little brother at the foot of his family’s living room couch.

“He’s my little hero,” Jeremiha’s mom, Bobbye Favazza, 27, of Olive Branch, said Tuesday. “It was like he knew what to do.”

Favazza gave birth to a 7-pound, 4-ounce baby boy, Kamron Taylor, on Friday morning. Firefighters arrived moments later to cut the umbilical cord.

Greg Mynatt, an emergency services supervisor with the city, said the 911 call about Favazza was probably the third this year about a woman in labor, but usually the mother makes it to the hospital before delivery.

Even rarer is a child assisting with delivery. Mynatt did not recall it ever happening here.

“This would probably be the first,” he said.

Jeremiha can count to five, feed himself and go to the potty himself. He communicates in short sentences.

Of course, nothing about his brief childhood had prepared him to assist in delivering a baby, but Favazza said that of her four children, Jeremiha is the bold one, the one who “will try anything.”

Favazza had made proper plans. Baptist Memorial Hospital-DeSoto was expecting her — on Dec. 6, for her fourth caesarian section — not on Friday the 13th.

Looking back, Favazza realized she was in labor all through the night before the birth, but she did not realize it at the time. The discomfort was minor compared to the labor pains she remembered before giving birth to her sons, ages 2 and 3, and daughter, 5.

On Friday morning, Favazza complained to her mother, Leigh Favazza, about the pain, but neither woman believed delivery was imminent.

Leigh Favazza considered taking the day off from her sales job if indeed her daughter was going to give birth, but first she had to get her granddaughter, Keely Taylor, settled at school.

Leigh Favazza left the house to take the 5-year-old to the bus stop at the end of Maury Drive, then she headed for Olive Branch Elementary School to drop off snacks for her granddaughter’s classroom. While en route, Bobbye Favazza called.

“Mom, I’m having the baby,” Bobbye Favazza said.

Leigh Favazza hung up and called 911. It was 8:26 a.m. She was frantic. Her daughter was alone in the house with a 2-year-old, a 3-year-old, a bull mastiff and a poodle and her water had just broken.

Bobbye Favazza’s oldest son, 3-year-old Jamison Taylor, had awakened to discover his mother bleeding and in pain.

“He sat on the couch right here and cried,” Bobbye Favazza said. “He was terrified. He’s my emotional one.”

The 2-year-old was calm.

“I laid on the couch and he went and got a towel,” Bobbye Favazza said. “He grabbed a towel on his own.

“It happened so fast. My water broke and the baby came two to three minutes later. I just pushed and he caught him.”

Bobbye Favazza said she held her baby, still attached to her by the cord, as she walked a few feet to unlock the front door for emergency personnel. They cut the cord.

Jeremiha, quizzed about the birth of his brother, can point to the spot at the end of the couch where Kamron Taylor was born.

“Over there,” he said.

“Sometimes these things happen, especially to mothers who’ve had multiple births,” said Mynatt, the city’s emergency services supervisor. “The time gets less and less with each delivery.”

Mother and son were discharged from Baptist-DeSoto. Neither suffered any complications.

“I’ve had three,” said Leigh Favazza, the proud grandmother, “and I can’t imagine having any of them like this.”

Bring a Loved One, Friend, or Doula for Continuous Support

When discussion of doula care surfaces on the Internet, it is always surprising how many commenters dismiss continuous labor support by a trained professional as unscientific fluff. Couples who hire a doula are sometimes labeled as selfish, out for “the experience” and elitist.

When a person believes that a pregnant woman (who is not planning a cesarean) checks into a hospital in labor to have a medical procedure performed on her, the idea of labor support seems superfluous. You wouldn’t bring a doula to heart surgery, the naysayers grumble. However, hospital birth should be an opportunity to allow a physiological process to take place in a location in which skilled professionals are readily available to intervene immediately if necessary. A primary goal of maternity care should be determining exactly what is optimal in supporting this physiological process, then ensuring that women in institutional settings have access to whatever best supports the normal process of birth.

Until the 1970’s, most American women labored alone, separated from her loved ones. Advocates, vocal consumers, obstetricians like Robert Bradley and childbirth educators fought hard for the right to labor with a partner. In Birth as an American Rite of Passage, Robbie Davis-Floyd wrote, “Hospitals tolerance of fathers’ presence increased as it was discovered that when fathers are educated and prepared for birth, the support they provide the laboring woman enables her to cope with her labor in more socially acceptable ways (breathing instead of screaming, for example), thus helping her and making it easier for hospital personnel to cope with her.”

While the normalization of epidural anesthesia has filled the role of allowing hospital staff to cope with laboring women, often multiple laboring women at one time, many women would still prefer to optimize support of the physiological process of birth and are not given the chance to do so in hospitals or are discouraged from hiring a doula by those who claim that birth is best left to science.

Fortunately, everyone wins with continuous labor support, the efficacy of which is supported by scientific evidence. According to Childbirth Connection, women who received continuous support were less likely than women who did not to:

• have regional analgesia
• have any analgesia/anesthesia
• give birth with vacuum extraction or forceps
• give birth by cesarean
• report dissatisfaction or a negative rating of their experience.

Here are just a handful of links that detail the evidence supporting continuous support of laboring women. And, really, is support of laboring women something that needs scientific evidence to justify its normalization?

Cochrane Review on Effects of Continuous Labor Support (Childbirth Connection)

Best Evidence: Labor Support (Childbirth Connection)

Healthy Birth Practice #3: Bring a Loved One, Friend, or Doula for Continuous Support (Lamaze)

A Doula at Your Birth (VBAC.com)

CAPPA Position Paper: Evidence-based Labor Doula Care (pdf)

OBs denying doula access: Where’s the SCIENCE!!!1!? (Hoyden About Town)

CDC Releases New Report Comparing U.S. and European Infant Mortality Rates

The CDC National Center for Health Statistics (NCHS) released a new report this morning which compares infant mortality rates in the U.S. and Europe.

Authors of Behind International Rankings of Infant Mortality: How the United States Compares with Europe explored what they refer to as the recent stagnation in the U.S. infant mortality rate that has generated widespread concern among researchers, policy makers, health care providers and activists.

Using data from the United States? Linked Birth/Infant Death Data Set and the European Perinatal Health Report, authors Marian F. MacDorman, Ph.D., and T.J. Mathews, M.S. of the CDC National Center for Health Statistics found that the main cause of the United States high infant mortality rate when compared with Europe is the ?very high percentage of preterm births in the United States.?

According to the study, while infant mortality rates for preterm (less than 37 weeks of gestation) infants are lower in the United States than in most European countries, infant mortality rates for infants born at 37 weeks of gestation or more are higher in the United States than in most European countries.

Discussions of the U.S. infant mortality rate are often countered with criticism that the U.S. records data differently than other countries, reporting very premature babies as live births. While this is true for five of the 19 European countries whose data was analyzed, 14 of the 19 European countries require that all live births at any birth weight or gestational age be reported.

The United States remains near the bottom of the rankings.

The report states, ?Reporting differences have little effect on the percentage of preterm births because most preterm births occur well after 22 weeks of gestation. For example, the percentage of preterm births for the United States in 2004 was 12.5% when all births were included and 12.4% when births of less than 22 weeks of gestation were excluded.?

MacDorman and Mathews attribute much of the high infant mortality rate in the United States to the high percentage of preterm births. Using the direct standardization method to apply the U.S. gestational-age specific infant mortality rates to Sweden?s distribution of births by gestational age, the NCHS found evidence that lowering the percentage of preterm births could have a dramatic impact on infant mortality in the United States.

November is also Prematurity Awareness Month.? Considering the risks involved in preterm birth, you may be wondering what you can do as a birth activist or as a parent.? Here are some basic things to consider:

• Let labor begin on its own. Without a valid medical reason, let your baby pick his or her birthday for the safest, easiest birth.
• Choose a practitioner with a low induction rate. If you have a midwife or doctor who rarely sees anyone who goes past their due date, it should be a red flag.? Ask the receptionist for her opinion of how many women go past 40 weeks. The answer might surprise you.
• Know the signs of preterm labor. If you think you’re having any of the signs of preterm labor, call your midwife or doctor immediately.? The sooner you get help, the more likely that premature birth can be delayed or stopped completely.
• Be mindful of the risk factors. Face it, you have responsibility for some of the risk factors.? While there are certainly some risk factors for preterm labor that you don’t control, take charge of the ones you can, including prenatal care, good nutrition, not smoking, etc.

Obstetricians: They are listening

Think no one is listening to what you have to say as a birth activist? Think again.

OBGManagement.com featured an article about the recent Birth Matters Virginia video contest.

A national video contest to encourage minimal medical intervention at birth and inspire women ?to make decisions about their maternity care as carefully as they make other consumer decisions? recently named a winner: ?Prevent cesarean surgery,? a video by Ragan Cohen. The prize was a $1,000 cash award. Obstetricians may find the investment of 5 minutes to watch the video useful for understanding what some of their OB patients are thinking.

The contest was sponsored by Birth Matters Virginia, a nonprofit organization based in Richmond, Virginia, ?as a step toward our goal of educating women about their choices and options during the childbearing years,? according to the organization?s Web site, www.birthmattersva.org.

Sarah Allen-Short, the director of public relations for Birth Matters Virginia was interviewed:

The winning video cites the high cesarean section rate in the United States (roughly 32%), the risk of maternal and neonatal complication with the surgery, and the risk of future problems such as uterine rupture as arguments against medically unnecessary cesarean.

?I think cesarean birth has its place and times when it?s really a gift,? says an unidentified woman in the video, ?and it allows us to bring babies into this world that might not otherwise make it through safely, but if we choose care providers that really have faith in the natural birth process, then they will only do cesarean section if it?s really necessary for the mom and the baby.?

Allen-Short concurs with this viewpoint and points out that her organization seeks, overall, to limit the use of oxytocin, epidural analgesia, and other ?medically unnecessary? interventions.

?The more interventions involved in a labor,? she says, ?the more likely that labor will end in cesarean.?

?I hear anecdotally from doctors that a lot of women want cesareans,? she continues. It?s up to the doctor to educate patients about the risks of cesarean and to remind them that it is major surgery, Allen-Short says. ?It?s not just a teeth cleaning.?

If you’re a doctor who reads this blog, don’t be shy. Leave a comment and share your opinions on the video or childbirth advocacy in general.

Cochrane Review Finds No Evidence for Treating Group B Strep with Antibiotics

The following is the summary of the recently published Cochrane review, Intrapartum antibiotics for known maternal Group B streptococcal colonization, which found that giving antibiotics is not supported by conclusive evidence:

Women, men and children of all ages can be colonized with Group B streptococcus (GBS) bacteria without having any symptoms; bacteria are particularly found in the gastrointestinal tract, vagina and urethra. This is the situation in both developed and developing countries. About one in 2000 newborn babies have Group B streptococcus bacterial infections, usually evident as respiratory disease, general sepsis, or meningitis within the first week. The baby contracts the infection from the mother during labor. Giving the mother an antibiotic directly into a vein during labor causes bacterial counts to fall rapidly, which suggests possible benefits but pregnant women need to be screened. Many countries have guidelines on screening for GBS in pregnancy and treatment with antibiotics. Some risk factors for an affected baby are preterm and low birthweight; prolonged labor; prolonged rupture of the membranes (more than 12 hours); severe changes in fetal heart rate during the first stage of labor; and gestational diabetes. Very few of the women in labor who are GBS positive give birth to babies who are infected with GBS and antibiotics can have harmful effects such as severe maternal allergic reactions, increase in drug-resistant organisms and exposure of newborn infants to resistant bacteria, and postnatal maternal and neonatal yeast infections.

This review finds that giving antibiotics is not supported by conclusive evidence. The review identified four trials involving 852 GBS positive women. Three trials, which were around 20 years old, compared ampicillin or penicillin to no treatment and found no clear differences in newborn deaths although the occurrence of early GBS infection in the newborn was reduced with antibiotics. The antibiotics ampicillin and penicillin were no different from each other in one trial with 352 GBS positive women. All cases of perinatal GBS infections are unlikely to be prevented even if an effective vaccine is developed.

NHS YouTube Video Campaign Teaches Teens that Birth is Humiliating

The Leicester NHS Trust posted an anti-teen pregnancy campaign video on YouTube aimed at teaching school-age girls and young women that sex (or unprotected sex) should be avoided because it can result in pregnancy, which will end with birth, which is excruciating, humiliating and shameful.

From The Sun on May 15, 2009:

The video appears to have been filmed with a mobile phone camera to give an air of authenticity and had more than 1,000 hits before it was removed.

At first it looks like another sad example of happy-slapping featuring a gang of secondary school pupils crowding round in a school playground.

Excited children are seen running towards a crowd with youngsters egging on what seems to be a fight.

A girl in the centre is seen screaming while another has blood on her cheeks.

But as the camera moves in closer one of the teenagers can be seen on the ground in the middle of labour.

In explicit detail it shows the girl giving birth and the baby being delivered by a fellow pupil as other students yell and jeer at her.

The footage was intended as a shock tactic to highlight rocketing teen pregnancies by harnessing the publicity power of the internet.

But Leicester NHS did not anticipate YouTube?s stringent content rules and today their clip was replaced after less than a day online with a message saying ?This video has been removed due to terms of use violation?.

Renee of Womanist Musings has the video linked in her post ?Naughty Girls Give Birth in Public in Great Britain.? Please visit her site to view the video which is no longer available on YouTube and read the rest of her sociological analysis of the video, some of which is excerpted below:

This little video teaches young girls that should they engage in sexual activity, the punishment for their behaviour is a painful labour. It is very reminiscent of the punishment assigned Eve for giving Adam the apple in the garden of Eden. The father is quite typically absent from this scenario mirroring the privileging of masculinity in our social discourse. It is women that are constructed as ?controlling? sex and therefore the abandonment of men of their parental obligations is rarely a subject that receives much discussion. Note that this ad is supposed to serve as a warning against teenage sex and yet it is aimed solely at girls as though she became pregnant by herself.

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This advertisement teaches young girls that pregnancy is a punishment rather than a natural outcome of sex, this further supporting the idea that unless conception occurs inside the patriarchal family it is a sign of lasciviousness whereas; a man is not stigmatized for participating in pre marital sex. Though this ad is projected to teach kids to act responsibly when it comes to sex, it comes across as highly sexist in its determination to make women responsible and produce fear about a natural biological process.

From a birth activist perspective, this campaign?s premise is extremely troubling. Many women experience psychologically and emotionally traumatic births for reasons such as inadequate emotional support, a fearful birth space, a birth space full of strangers or care providers who resort to humiliation or bullying to gain compliance. In other words, the feelings that some women experience in a hospital would mimic the presumed feelings of this teenager giving birth while taunted by schoolmates.

The goal of this video was clearly to show birth as a humiliating, painful and scary consequence to bad behavior, which is one of the reasons that Catherine Skol is suing obstetrician Scott Pierce. Pierce allegedly told a nurse that Skol deserved to feel pain for not calling before coming to the hospital and that sometimes ?pain is the best teacher.?

So where will teenagers see positive birth videos? Unfortunately, they will not see them on YouTube, which routinely censors or removes birth videos or requires that viewers be 18 years of age. One of the many negative consequences of moving birth from a home model to an industrialized hospital model in the last 70 years is that birth is that the birth process has become unfamiliar to most people. This goes for all mammalian births?how many of our parents or grandparents moved away from rural areas where they regularly saw animals give birth?

Internet birth activism and flooding social media outlets with positive and realistic images of normal birth have never been more relevant or necessary.