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.

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.

Loyally Devoted to Doctor

I recently read the book The Highly Sensitive Person by Elaine N Aron, Ph.D. In the chapter called Medics, Medication, and Highly Sensitive People, the author states:

“Keep in mind, too, that it is common to feel an attachment to anyone you have been with during an arousing experience, especially if it was a truly painful or emotionally significant ordeal. In the medical realm you hear these sorts of extra feelings when people describe their surgeon or women talk about the person who delivered their child, which is perfectly normal. The solution is simply to know why it happens and compensate for it appropriately.”

In the chapter about relationships, she talks about studies that were done that showed people are far more likely to fall in love under stressful circumstances. She applied this phenomenon to attachment in all relationships, not just romantic relationships. Later when I read the above statement in the medical chapter, so many things started to make sense to me.

Why do women love their maternity care provider, even when they may have done unnecessary procedures on them and not allowed them to make their own choices? Why do many providers use scare tactics? Why do women hold so adamantly to the belief that their provider “saved their life” or “saved their baby” or “was a great doctor” or “really took good care of me”, even when evidence to the contrary is right in front of them? Why do they fail to make important connections, such as that their c-section may have been one of the many unnecessary ones, or that there may not have been a true evidence based need for their induction? Why is childbirth treated like a major emergency with so much fear and anxiety around it? Why aren’t all women who give birth in this system severely traumatized from it, and instead defend and adore their doctors? The answer is simple: the culture of fear that surrounds childbirth actually endears women to their doctors. It cements the relationship between women, their doctors, and the hospitals their doctors practice at. It ensures that the women will keep coming back, and will recommend their providers to all their friends as they speak about them in glowing heroic terms. It is quite brilliant really, providers and hospitals have found the key to running a very successful business, and it has nothing to do with allowing women to make their own choices. They simply have to give the illusion prenatally that the woman can make her own choices for her birth, and then make sure that the actual experience of birth is one filled with fear, anxiety, and of course a healthy baby, and then the narcissistic provider will come out looking like roses to the woman who must endure the “horrors of childbirth”.

Of course, I am not really giving the doctors the benefit of the doubt here. They likely don’t know on a conscious level what they are really doing. They have been trained to act this way, by people who were also trained to act this way, and it is reinforced for them every time a woman profusely thanks her doctor for a job well done, and every time a woman tells her birth horror story where the good doctor makes an appearance as the hero who delivers her baby to her despite all the dangers that presented at the last minute. Both the woman and the doctor seem ignorant of the psychological effects that framing every average birth as a medical emergency creates.

In the statement above, the author states: “it is common to feel an attachment to anyone you have been with during an arousing experience, especially if it was a truly painful or emotionally significant ordeal.” This describes childbirth perfectly. The word “arousing” here is referring to sensory levels. That can mean physically, emotionally, sexually, or any other assault to the senses, good or bad, that can be had. We know childbirth can be described as “arousing” in many ways. It is also inherently “painful” and “emotionally significant”. Even when women use drugs, there is still some level of pain before she took them, and depending on what type of drugs she took, she may still experience pain while she is taking them. So really, all births fit this criteria. Births in a hospital, or at home, or in a birth center all have these same basic elements. It seems women are wired to form an attachment to the people who were with her and helped her through the event. This could be her partner, her doula, her midwife, her doctor, her nurse, or her friend or relative. I think this type of attachment likely had an evolutionary purpose at one time. It would be ideal to attach to an older, wiser woman who assisted with the delivery of babies who would have been there to care for the mom postpartum, and to slowly help her to bond and form an attachment to the baby. This wise woman would then help the mother learn to breastfeed and care for her new infant, while slowly pulling back her own attentions from the situation. This is what we have in homebirth midwives today. How would our ancestors have fared if a man had shown up in the tribe to deliver a baby, and then disappeared immediately afterward? The woman would be left adoring him, yet not having help from him to form an attachment to her infant. Never learning how to breastfeed or other infant care skills. What would have become of humanity? What is becoming of humanity?

Midwives and doulas seem to understand this phenomenon. Doulas usually visit a woman once or twice postpartum and are available if she needs to talk or has questions about the baby, breastfeeding, or the birth. Midwives start seeing a woman more and more as the birth approaches, and then once the baby is born, they start to taper off again, seeing her less and less until she is no longer needed at all. This is a much more natural and appropriate response to caring for a woman during such a pivotal transition in her life. What happens when women see doctors or CNM’s in hospitals though? They are likely seeing a practice, not a specific provider. They will likely not give birth with the same doctor or CNM they saw prenatally. They may never see the same doctor or CNM again after they give birth, or perhaps just once at the six week checkup. How does this affect women emotionally, or in her relationship with her baby, when instead of having a slow winding away from her provider, there is just an abrupt ending to the relationship? Does this interfere with breastfeeding, or affect feelings of trauma related to the birth, or feelings of depression related to her new role as mother? It is ingrained in our psyche to attach to these people who help us through such a major event in our life. How will the people we choose handle this responsibility? Are we choosing someone who will corrupt our experience and force an unnatural attachment to them by creating more anxiety around the experience? Are we choosing someone who will be there for us days, weeks, and months later to answer our questions about the baby or to offer us emotional support? Will the person we choose even be available for the birth, and will we ever see them again afterward?

Now I realize why other women feel the way they do about their provider. I did not attach to my provider, I was instead extremely traumatized by her actions. I still wonder why some women are traumatized, and others fall in love with their providers, given the same set of circumstances. I wonder if it is actually more natural, and thus common, to attach to a provider even when (or perhaps especially when) that provider creates an atmosphere of fear. It makes sense then why so few of us are speaking up about the system and the way women are treated. It makes sense that women are extremely loyal to their providers, even when many aspects of their births were disappointing or upsetting to them. It makes sense that many women are reluctant to accept that there is anything wrong with maternity care. It makes sense why the maternity care system is so hard to change and is met with so much resistance from every side.

What can birth activists do to help women form healthy attachments during this transitional time in her life? It may be tempting to try to convince all women to have a homebirth with a midwife since we know that they are probably the best option for healthy attachments and a healthy weaning away as well, however, if a woman has already formed a strong attachment to a certain provider, it may be more realistic to recommend having a doula. A doula will be there prenatally, for the birth, and postpartum, and therefore can provide much of the physical and emotional support that new moms need and deserve. Some moms may hire a doula, yet keep her same provider that she has formed an attachment to, and others may find that a doula is a stepping stone to having a homebirth the next time. One day I hope that maternity care shifts to being centered around the mother again, and not around the provider and his schedule or routine.

Why Our Women are Afraid of Birth

Deliver Me

It is Tuesday, at 10pm while I settle in after getting my little ones to bed. I flip through the channels and settle on discovery healthy which is a personal favorite of mine, but it really has only recently become a favorite because of shows like I didn’t know I was pregnant. It fascinates me that women could make it though a full term pregnancy and not know they were pregnant, but that is just me, and the experiences that I had with my children is what makes me wonder how the heck women could not know they were pregnant.  But that is completely besides my point today.
So as I watch this show, I am noticing a trend. High risk, high risk, high risk, previous cesarean section, scheduled cesarean section, high risk, healthy first time mother, scheduled cesarean, high risk. Well I mean, that is how it is in Los Angeles right?  You would think so!  But apparently because only these crazy, scary, uncommon births make something called ratings, that is all they are going to feature on TV. Because in reality, no one wants to watch a natural birth or a home birth because no one is running around with a scalpel screaming about the emergency that childbirth is. Nor is the mother screaming for her epidural because she just cant deal with the pain of the 3 hours of labor so far.
But what we should be thinking about most importantly is the message this is sending. What is this teaching first time mothers or even young women that may not be planning on having children soon but will some day?  It is teaching them how scary, dangerous, and medical birth is supposed to be. But is that really how birth is? Of course not. Anyone who has taken the time to read the studies, and just not follow what mainstream society thinks is the right way to handle pregnancy will know that birth is not scary or dangerous or a huge emergency. While it can be in some cases, in most cases it can and will be beautiful when just left alone.

When a woman becomes pregnant today, if they do not already have an Obstetrician they have been seeing for well women care since 16, or whatever age their parent decided it was the right them for them, what is the first thing that they do? They ask around their circle of female friends for the best Doctor out there because isn’t that what we all want? We want the one who is the BMW of pre natal care. Little do women know that they are really going to end up with the 1990 Dodge Dynasty when they take this route because hands off is better.
But because our society has told us this is the way things should be, they run off like lemmings right off the cliff of medical interventions landing in the valley of cesarean sections.

Maybe if the television channels like Discovery health followed a dozen home births or even aired The Business of Being Born they could get a popular, and controversial other side to what they are constantly airing. Maybe it will boost their ratings even more, maybe not?  But what it will do is give the other side of the whole issue. Let’s get Marsden Wagner to do a half hour special on Birth in The United States and see how many women run off to the midwives.  Instead they air these disgustingly inaccurate “Freebirthing” shows. They find the one idiot who is going to make women who choose unassisted birth look like a bunch of uneducated yokels.  Which is exactly what they did with their special on Unassisted birth.

I guess in the end, like anything else the television airs, it is biased and we shouldn’t expect much different.

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.”

The Infamous Cascade Chart

As someone strongly involved in the birth community, this is probably one of my favorite pictures floating around the internet that I run across every once and a while.? One day when I find out the person who actually put these thoughts and cascade of interventions into a physical chart to view, I am going to kiss them!

I have always loved how it starts with induction, because lets face it, so many women today are starting their labors with some kind of artificial labor stimulant. Whether it be pitocin, or the oh so dangerous cytotec. I can personally say I have been the victim of the cascade myself with my first child. Had I seen this before my pregnancy with him, I would have never opted for the induction. Many do not realize that induction in many cases will fail, almost half of the time according to the most recent figures, and when I quote that, I am quoting Robbie Davis Floyd in a 2008 interview, I believe it was in Pregnant in America but my birth/pregnancy movies and interviews all start to blur together when you watch so many of them. These babies are not ready to be born in many cases, especially when we are seeing these inductions before the “due date” or the 40 week gestation mark. Although we know that “due dates” aren’t much to put stock into, many women and providers use them as some type of eviction date, which history has shown to be a pretty bad idea. No one is going to be pregnant forever and many women left alone will go into labor on their own. Now granted, there are cases that induction is medically necessary and for these special cases, I am completely thankful. Without induction these women would be subjected to cesarean sections instead of labor inductions which could in turn be even more hard on their body, and experience over all.
What we do not understand with the induction of labor is, we are creating unnaturally strong contractions in attempt to simulate something similar to natural labor. As someone who has experienced pitocin labor, and natural labor, I would take a million natural contractions over being on the receiving end of pitocin again. The comparison in my opinion is not even in the same ball park. Another issue with these contractions as most know, is the fact that they are more likely to cause fetal distress on the baby because they are not natural contractions or what normal contractions are supposed to be. So in turn we are putting our children under unnecessary stress. Especially if they are not ready to come and join us in “our world” yet. Again something I learned with my first.
Then we have the provider who comes in and looks at the fetal heart monitoring and says, “Oh No! Your baby is in danger!!” So off to the operating room we go for an “emergency” cesarean which in reality was caused by the pitocin to begin with. You would think by this point there would be a bit of common sense in the Obstetric community to say, ya know, I think we are causing these actions instead of blaming the increasing cesarean rate on “patient choice cesareans” which only make up 3% at most of the incredibly high cesarean rate in our country.

But a cesarean is only one path that this induction cascade can lead to. There are still women out there that will have a vaginal delivery when subjected to a labor induction, but in turn these women have greater risks for other procedures including episiotomies which have all in all been proven to really have little to no benefit to women in the long run. While episiotomy rates are starting to decrease, they are still over used in many communities. For example, here in my state of Connecticut, some hospitals have an over 25% episiotomy rate, when science tells us there really shouldn’t be over 10%. Trying to obtain these numbers are like pulling teeth too FYI!

We also have vaccum extraction. I had never really discussed this or spoken with someone who experienced this until I met my Chiropractor in the summer of 2008. He was discussing with me why Chiropractic care in infants is important, and then he described his own daughters birth, they had applied the vaccum to the top of her head, and while “assisting” her out, they pulled so hard the vaccum literally flew right off of her head. My Chiropractor described it so vividly… “I thought her HEAD popped RIGHT OFF! I was horrified to even look!”? My heart broke for him because no parent should have to go through that kind of fright during the birth of their child!

These all often lead to epidurals, which especially if you are going to have a cesarean section, you will either have this or a spinal block. All types of anesthesia that will have a direct impact on the baby. Although I have experienced women told there will be no effects on their baby at all.
I am sure most know about the “breast crawl” and I can say after watching a baby who’s mother did have an epidural, as opposed to a mom who had a natural birth, there is no comparing the instincts of the baby. While I had epidurals with both of my children, I didn’t have the opportunity to breastfeed then until they were a little over an hour old. My first was almost 2 hours. For more information on epidural effects on babies, click this link!

The last thing I want to touch on is the separation of mother and baby after a cesarean section which is very common. It is pretty uncommon for an newborn to be allowed to stay in the OR with mom, although it does happen sometimes. I can really related to the lack of bonding, breastfeeding problems, and reduced bonding because of this because I deeply experienced this with the births of both of my children. While I bonded, it was not that “instant motherly love” I am sure most feel. It hurts me to this day to know that my bonding was an almost learned bonding because I knew as a mother it was something I needed to do in order to protect my babies.? While most women who have had cesarean sections are not quick to admit this, I think by discussing this and acknowledging that this is a true problem it will only help to improve it for others in the long run. I also noticed that mothers who do experience this may be ashamed or fearful to admit this because it make portray them in a less than perfect light, or maybe others may look down on them because of this, but they should not be ashamed. It happens and there is nothing we can do about it but help other women to not go through what we did!

Be empowered by your birth, no matter how you birth!
If it is a bad experience, help to educate others so they do not go through what you did, so they can avoid the pain or heartache you have dealt with!

Why Did I Move During Labor?

I never knew the importance of moving around during labor until I was actually in labor with my second child. With my first I was strapped to a bed, a fetal monitor, and pitocin, so I never really had the option of moving around.

My second time around I realized why it was so important. When I would have a contraction, if I moved, rocked, walked, it would help the pain. Sitting in one spot, tensing up, screaming, or clenching onto something all made the contraction itself a million times worse. As my labor progressed, I realized this. Which helped me to “ride the wave” which is how I looked at getting over my contractions. I pictured them as a giant wave that I must surf over in order to get closer to my baby. As the time went on, and boy what a long labor I had, I realized the more movement the less pain.

The modern form of maternity care, which keeps women in one position, place, or hooked up to machines is what is causing the fear of pain in society today. Because woman’s friends, and family members are routinely going through this kind of system, it is becoming the tell tale so much more.

Until there is a change in how hospitals deal with birth, women are going to continue to think birth is the end of the world because they are not being allowed to move or be active while in labor, when in the end, it does way more good, than it does harm.

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.

Reducing Infant Mortality

Please watch this video and then spread the word about how to reduce infant mortality. Click here to visit the website and get help with writing to your legislator, or sending them this video.

Reducing Infant Mortality from Debby Takikawas on Vimeo.

More Healthcare is Not Better Healthcare - well, duh…

I had to snicker when I saw the headlines that proclaimed that more healthcare was not better healthcare. I mean seriously, birth has been proving that time and time again. ?The more medicalized we’ve made birth the higher the cesarean rate has risen, and the higher the infections, NICU admissions, breathing problems in babies, etc. have risen. ?The more we induce labor, particularly before babies are really ready, the more we see a rise in NICU admissions, cesarean section rates rise, etc. ?Do you see the circle we are going in? ?We’re like a silly puppy dog chasing our own tails. ?

I’d like to suggest that we all just back away from the prenatal care. ?Prenatal care that means invasive tests and inductions of labor when not medically indicated, that is… ?Let’s use the interventions that we have as we really need them - sporadically. ?Just because a new fancy procedure is really cool and works really well to help sick mothers and babies, doesn’t mean it’s good for all mothers and babies.