MAYD to Birth: At Your Doorstep

Promoting gentle, empowering mother journies…

Press Conference in Jackson, MS, on Monday!

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Read all about it here — it’s the final countdown! The bill will die in committee, if it’s not acted on by Tuesday.

A Mother’s Beauty

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I often hear women talking about themselves, especially mothers, and saying the words “fat”, “gut”, “muffin top”.  It makes me so sad. One thing that has drawn me to helping women is how beautiful they are.  Short, tall, big, small.  They are all just so gorgeous. And the women I love more than anything are [...]

VBAC: making a mountain out of a molehill

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VBAC (vaginal birth after caesarean) is big. A google search for ‘vbac’ results in ‘about 1,390,000′ results. Reviews, guidelines, policies and statements are being produced by every organisation with an interest in birth. Support groups and networks are growing. I am not going to add to this wealth of information. Others are doing a fantastic job and I will provide some links at the bottom of this post. This post is really aimed at putting VBAC into perspective risk-wise and discussing how we can best support women planning a vaginal birth after caesarean. I haven’t personally experienced the VBAC journey and would welcome some input from mothers who have via comments, suggestions and links. This is written from my perspective as a midwife…

With a c-section rate of around 1 in 3 (Australia) a significant proportion of women approach their subsequent birth with a scarred uterus. Of those women, 83% will have another caesarean. I can’t find the stats re. how many of these repeat c-sections are planned vs emergency. But, considering the 50-90% ‘success’ rate for VBACs, I am assuming that most repeat c-sections are planned. I wonder if more women would choose to experience a vaginal birth if they had adequate information and support from care providers who believed in them?

Guidelines suggest that women should be counselled about the risks of VBAC, and they should have additional monitoring and intervention during labour. The big concern is uterine rupture and this is what I am going to focus on. By the way – unless I provide a reference/link you can assume I am getting my numbers from the NIH Consensus Statement (US) or Having a Baby in Queensland (Aus). Both of these resources are based on the current research evidence. So, if you need the original research sources check out their reference lists.

What happens during a uterine rupture?

Considering this is the risk associated with VBAC is worth briefly describing what is involved. Uterine rupture can happen at any birth, even when no scar is present (particularly if syntocinon is used). There are two types of uterine rupture associated with VBAC (Pairman et al. 2010):

  1. Catastrophic (symptomatic) – the old scar separates long its length, the amniotic sac ruptures and the baby is pushed into the abdominal cavity. This results in significant bleeding, shock and the baby is in grave danger.
  2. Asymptomatic – the scar separates partway along its length, the amniotic sac stays intact and the baby remains in the uterus. Bleeding and shock is minimal and the baby usually survives. This is the most common type.

Here is a youtube clip of what happens during a catastrophic uterine rupture:

For more information about uterine rupture (including symptoms) check out this article on BellyBelly.

Risk by numbers

Risk is a difficult concept. You can have odds of 1 in a million, but if you are the 1 it is 100% for you. It is also impossible to eliminate all risk from life (or birth) and every option has risks attached. All women can do is choose the risk that feels right for them – there is no risk-free choice. There are many ways of presenting risk and some ways may mean more than others for individuals. For example, if we look at the overall risk of uterine rupture for a woman who has had 1 previous c-section. By overall, I mean without adding or subtracting factors which increase or decrease an individual’s risk (eg. syntocinon during labour, transverse scar). The risk can be presented like this:

  • 50 out of 10,000 will rupture
  • 9,950 out of 10,000 will not rupture
  • 1 in 200 will rupture
  • 199 out of 200 will not rupture
  • 0.5% will rupture
  • 99.5% will not rupture

Which of these versions would help you conceptualise risk? I know when I look at the picture versions of risk I assume I’m the ‘red person’. Personally I like the 99.5% intact uterus odds.

As stated above these figures are the taken from the NIH Consensus Statement (US) or Having a Baby in Queensland (Aus). A more recent UK study (Fitzpatrick et al. 2012) found an even lower overall risk of rupture – 0.2%.

The risk of rupture may be even lower in labours that are not induced or augmented (the stats above are a mixture of all labours). An Australian study (Dekker et al. 2010) found that the risk of uterine rupture during VBAC was 0.15% in spontaneous labour, 1.91% in augmented labour and 0.88% in labour induced using prostin and oxytocin. Fitzpatrick et al. (2012) also round an increase in rupture with induction and augmentation. In contrast a US study (Ouzouian et al. 2011) found no different in rupture rates between spontaneous and induced labours – but found a significantly greater vaginal birth rate following spontaneous labour. Another study (Harper et al. 2011) found an increased chance of rupture during induction when the woman has an ‘unfavourable’ cervix. There are also other risks associated with induction which need to be considered before heading down that pathway.

For women who have had multiple c-sections: Landon et al. (2006) suggest the risk of rupture rises to 0.9%. Fitzpatrick et al. (2012) also found a slight increase in risk for women how had had 2 or more previous c-sections. However Cahill et al. (2010) found that: “Women with three or more prior caesareans who attempt VBAC have similar rates of success and risk for maternal morbidity as those with one prior caesarean, and as those delivered by elective repeat caesarean.”

The story looks a little different again when you look at the mortality and morbidity caused by uterine rupture.  Guise et al (2004) conducted a systematic review of research relating to VBAC and uterine rupture. They found that uterine rupture resulted in: 0 maternal deaths; 5% perinatal deaths (baby); and 13% hysterectomy. They conclude that: ‘Although the literature on uterine rupture is imprecise and inconsistent, existing studies indicate that 370 (213 to 1370) elective caesarean deliveries would need to be performed to prevent one symptomatic uterine rupture.’

So, out of the small number of women who experience uterine rupture, an even smaller proportion will lose their baby or uterus because of it. When the uterus ruptures 94% of babies survive.

VBAC vs planned c-section: uterine rupture

Most resources and guidelines compare the risk of a VBAC with the risks of a repeat c-section. This can be a brain-twister because of the multiple and complex risks associated with c-section. Childbirth Connection cover them well, so I won’t. Having a Baby in Queensland directly compares VBAC with planned repeat c-section for a number of complications. I’m trying to stick to the risk of uterine rupture (the ‘big’ one). So, planned c-section wins with a 2:10,000 uterine rupture rate compared to 50:10,000 for a VBAC. That’s if you are happy to take all the (more frequently occurring) risks associated with c-section in exchange.

Uterine rupture vs other potential birth emergencies

A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations compares uterine rupture with other potential complications. You are more likely to experience a placental abruption, a cord prolapse or a shoulder dystocia (not associated with previous c-section) during your vbac than a uterine rupture. Your baby is also more likely to die from the placental abruption or cord prolapse than from a uterine rupture.

Anecdotes

Anecdotes hold as much power as numbers. I can guarantee that I will get a comment telling me about a poor outcome associated with a VBAC. They do happen (see the stats above). Unfortunately when care providers have been involved in a traumatic situation, it can be hard not to let that experience colour their perspective and approach. The memory of one uterine rupture will be stronger than all of the VBACs they have seen. Obstetricians in particular have to deal with the fall out of major complications because this is their area of expertise. They also miss out on seeing physiological normal births which end well because this is the realm of the midwife (I know this is different in the US/private sector). This can lead to fear-based counselling and practice, and a general fear of normal birth. Interesting that a poor outcome associated with a c-section does not seem to elicit quite the same response – ie. fear of c-section.

When parents find themselves the 1 in how ever many, it is even more devastating. their stories are powerful and need to be heard. However, it can be difficult for other parents to contextualise the story without also hearing stories with good outcomes.

The real risks of VBAC (according to me)

I am a bit confused about why such a huge deal is made about the risk of uterine rupture during VBAC. Why are these women subjected to serious (and often biased) discussions with fearful obstetricians about the dangers of attempting birth? Why are they categorised as ‘high risk’, limiting their care options and imposing additional monitoring and intervention during their labour? If we agree that this is the right approach, then we also need to treat all women like this because the risk of placental abruption or a cord prolapse is greater than the risk of a uterine rupture during a VBAC.

To be honest, as a midwife uterine rupture is the least of my worries when caring for a woman having a VBAC. I actually think the mountain that has been built out of the risk-molehill requires more energy and attention. These women do need special treatment, but not in the form of disempowering fear-based counselling or practice. They have often had a previous traumatic birth experience and are dealing with fear from family, friends, and the medical system, in addition to their own worries. They have been labelled ‘high risk’ and are constantly reminded of the potential disaster waiting to occur. They also risk ‘failing’ if they encounter any complications or end up having a repeat c-section. This impacts on their ability to trust their body, follow their intuition and allow the physiology of birth to unfold. Often these women need more nurturing, reassurance and support from their care givers.

Suggestions

During pregnancy

It is important to not only help women to prepare but also their partners and/or other close family members who may be at the birth. Often the partner was present at the previous birth which may have been traumatic to witness. For a partner their priority is the safety of the woman they love – not a particular birth experience. Winning them over may be difficult. In some cases the decision the mother makes may be that the partner should not be present. OK – some suggestions:

  • Find out the details of her previous birth experience. If she needs debriefing help her do so, or refer to someone who can. Knowing about her previous experince and her fears can help you know what she needs during her labour.
  • Offer to discuss ‘risk’ and present the statistics in a number of ways. Find out what they (mother and partner) find most useful and empowering. I could say ‘don’t mention risk’ but to be honest unless she is living in a cave she will already be aware that VBAC is ‘risky’ and will need to explore this.
  • Make sure she is aware that she has a 50-90% chance of having a vaginal birth – greater than a first time mother. She can increase this chance by choosing supportive care providers (and setting) and not having her labour induced or augmented.
  • Talk about the possibility of the pregnancy going beyond the prescribed ‘due date’. This is often a feature of VBAC pregnancy. Some hospitals or midwives consider this to be a risk factor because the chance of a repeat c-section is about 9% greater (Coassolo et al. 2005). However, the risk of uterine rupture is no greater.
  • Make sure she knows that having a c-section after labour has started holds more health benefits than a planned c-section. Her baby will have had a chance to initiate labour and make the physiological changes needed for life outside the uterus. They will be less likely to suffer respiratory distress and end up in special care. In addition both mother and baby will have the important cocktail of hormones that assist with bonding. Even if she chooses a repeat c-section she can insist on going into labour first.
  • Talk to her and her partner about what actually happens if the uterus ruptures. They may be imagining all kinds of horrific scenes such as the baby bursting out of the woman’s abdomen.
  • If she is worried about ‘failure’ reassure her that she doesn’t need to tell anyone she is planning a VBAC. She can say she’s not sure and will decide in labour. Some mothers planning a homebirth after c-section book into the hospital and pretend they are planning a hospital birth. Then if they transfer in they don’t have to deal with the ‘failed home VBAC’ situation. She needs to do whatever takes the pressure off even if that’s lying.
  • If she is planning to birth in hospital she needs to know what the hospital policies are and decide what she will or won’t go along with. This means talking about the risks of the usual interventions such as CTG monitoring. A very clear birth statement can help the staff to support her wishes.
  • Encourage her to talk to other women about their experiences of VBAC, read positive birth stories and watch beautiful VBAC birth movies.
  • Do not use disempowering language such a ‘trial of scar’ or constantly refer to her birth as a VBAC. She is a woman having a baby, not a disaster waiting to happen.

During labour

The physical care of a woman having a VBAC should be no different (although I know it is in hospital). Yes, I’m watching for signs of a uterine rupture: unusual pain, fetal heart rate abnormalities, unusual bleeding, a change in maternal observations etc. But, those symptoms in any birthing woman would be concerning, so this is not different care. In addition if a woman is unmedicated and connected to her body/baby she will be the first to notice a problem. I have found that women having a VBAC may have additional psychological needs. For example, they may request vaginal examinations, particularly if their c-section was for ‘failure to progress’ (aka failure to wait). Even with information about how poor VEs are at indicating progress they may want that dilation number – some non-VBAC women do too. They may also want more frequent fetal heart rate auscultation and need you to reassure them the baby is well. In general these women, and even more so their partners need reassurance and a care giver who believes in them. Of course some women don’t need any of this and choose freebirth.

Personally I love attending VBACs. These births are usually immensely healing and empowering for a woman and her partner. I wonder whether this aspect of birth is discussed at the ‘risk consultations’ along with the numbers.

You can read a birth story and watch the film here. I may be biased but this is the most beautifully filmed/edited birth film ever: Madeleine’s birth

Here is another couple’s VBAC journey (have a tissue handy). This is the most likely outcome of a VBAC – particularly a homebirth:

Further Reading/Resources

Drawn To Birth

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I haven’t posted on here in a long time.  No posts I write feel right, so they sit in my drafts.  I just haven’t been very inspired lately. Since August, I have wondered why I do the work I do.  I am surrounded by pregnant women, by births that seem very unlikely I will ever [...]

Ivan

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Nakita, 24
November 19 is my dad’s birthday. All throughout my pregnancy my dad said he’d love for the baby to be born on his birthday. I thought, “Oh gosh I better have had him before then.” Well November 19 rolled around and I was still pregnant so I thought “Ok, please let me have him today!!” We went down to Provo in the afternoon to hang out with my family and do birthday stuff. I felt crampy and was having Braxton-Hicks as always, but no more than normal. All day I was waiting for that first contraction but alas, nothing. We headed home after the birthday festivities were over. I was slightly depressed since I hadn’t gone into labor like I’d hoped. At about quarter to 11 I decided I’d go to bed since I wasn’t in a great mood and was quite tired. While lying in bed I flipped over to my other side and heard a little pop, water started leaking out. I though “Ok, so did I just wet the bed or did my water break?” I stood up and a whole lot more water came draining out, I then knew it was my water that had broken! I was ecstatic! That was how I was hoping it’d happen because labor almost always starts within 24 hours of your water breaking. I told Eric the good news and then called my midwife.
My midwife, Angela, is an apprentice midwife and so she told me that she needed to call the main midwife to update her on my status and would call me back but told me to try to get some sleep in the meantime before contractions started. She wanted me to again call her once contractions started or call in the morning (if nothing had started) and they’d have me come into the office and try to get things moving along. About 15 minutes later, Angela called me back to tell me that the midwife agreed with what she told me, to get some sleep, but contractions had already started, so I updated her on that. After I got off the phone Eric gave me a blessing through which I received a lot of comfort and reassurance. I knew I wasn’t alone in doing this and that everything would go as it should.
At about 11:30 contractions were about a minute long and coming every 5 minutes. I let that go on for an hour and then called Angela. She asked me some questions:
- Can you walk or talk through contractions? No, I have to lie down or lean on my birthing ball and it takes all my concentration to try to relax through them so I can’t talk.
- Where is the pressure located? Throughout my pelvis and a lot in my back.
She told me that it sounded like I needed to come into the birthing center. I got our bags and stuff together and we headed to Provo to drop my daughter Reese off at my parents. I had heard that many times contractions will stop while traveling because of the anxiety but mine just kept coming. By the time we got to my parents’ house contractions were every 3 minutes, lasting closer to 80 seconds. Things were going a lot faster than I had expected. I tried to tune out everything around me during contractions. I would fasten my chin to my right shoulder and concentrate on letting the pressure do the work of dilating my cervix and try not to fight against it.
After dropping Reese off at my parents we got to the birthing center. This was around probably 2:30 or 3, I don’t remember. After getting things situated and having my vitals taken, the midwives (Angela, the apprentice, and Trinette, the main midwife) asked if I wanted to be checked for dilation now or later. I told them I’d wait a little while because I was afraid that I’d be checked and that no dilation would be found and I’d be discouraged. I was now having contractions every 2 ½ minutes. At 3:40 I asked if they’d check me because I wasn’t going to want them checking me once contractions were any closer together. I was at a 6. Whew! The contractions WERE working!
I labored in the bed for another 15 minutes or so and then asked if I could get in the tub. They filled the tub, I got into my swim suit, and hopped on in. In all reality, it didn’t do for me what I thought it would. I had heard that it was a natural “epidural” but no pain was lessened by getting in the tub. The advantages were:
- When the water was running the noise would help me relax a little (now that I think back I maybe should’ve turned on the jets to keep the relaxing noise.)
- I was able to twist and turn my body in the water in ways I wouldn’t have had I been in bed or walking around.
I studied the Bradley Method, which is husband coached childbirth, but when it came down to it I just wanted Eric nearby. I didn’t want him talking to me, touching me, or anything else. I just wanted to be left to my thoughts of concentrating on feeling the “pressure” of each contraction come and go and making my muscles relax and allow my body to do the work it was supposed to be doing. Eric did remind me a few times as I was moaning through the pain that it was just pressure, not pain. That helped me try to focus on it being a good thing I was feeling – just doing the work needed to get my little man here.
By probably 4:20 my contractions were so close together and so strong that I almost didn’t feel any kind of break between each one. I couldn’t keep my legs still during the contractions. This is where I was thankful to be in water. I would keel over on to my right side and move my legs in a bicycle motion, still trying to relax but not knowing if I could. I prayed and prayed that I could do this. I knew I could, and that I really had no choice, but I just needed the constant reassurance. For the next few minutes I felt slight urges to push during contractions. It felt so much better to push through the contraction than to try and relax through them. By 4:30 I couldn’t help but push. It was weird how automatic and natural of a response it was. The only thing I can really compare it to is throwing up. You know when you throw up how your stomach wretches automatically, you don’t have to do anything to make it do that? Well same idea.
I pushed through a few contractions in the tub before they had me re-situate so I’d have some bars to hold onto and a straight back to sit against. I told them I wasn’t planning on a water birth but didn’t know if I could get out of the tub because the contractions were on top of each other. I pushed for a while longer in the tub, such a weird sensation having a little head right down there in the way of where you are trying to sit. After a couple more minutes the midwives helped me out of the tub and onto a birthing stool where I continued to push. After some pushes in that position my legs were super wobbly and tired. They had me get onto my hands and knees to finish off the job. This helped because having my weight on my knees and hands helped me keep my body stable and keep from shaking.
As the baby was crowning my body responded in ways I would’ve never expected. I am NOT a screamer, I’m pretty good at controlling the noises my body makes when in pain but it was involuntary. Through the last 2 or 3 pushes I couldn’t help but scream. I was slightly embarrassed, but seriously had no control over it. I was hoping I’d be able to be one of those women who claimed their unmedicated childbirth was painless but I can’t claim such. This crowning burned like CRAZY. It was everything I could do to make myself push through the pain. I knew I had to, there was no other choice, and I couldn’t and didn’t want to keep him in there. Thankfully I can handle pain, so handle I did.
As his head emerged I felt a great decrease in burning. I knew at least part of him was out. I asked and they told me that his head was out so I just needed to push with all I had to get the rest of him out. So I did as they said and out he came. They immediately brought him to my arms where I got to cuddle him to me. Skin on skin, just like I wanted! It wasn’t a stressful rush to get him cleaned and his cord cut, as was my experience in the hospital. They just allowed us to enjoy each other while I rubbed his body getting him to breathe well. After a while they asked us if it was okay if we cut the cord. They clamped and Eric cut. It was cool how we weren’t being bossed around but rather were the ones to make the calls for the most part. It was nice feeling in charge of the experience. It really was so beautiful, and so invigorating.
Ivan John was born at 4:49 am on November 20, 2010. 21.5 inches long and weighing in at a whopping 8 lbs 9 oz . Big compared to my little Reese.
I ended up tearing a minor amount, and sadly only because when I had Reese I had 4th degree tears from the episiotomy and forceps and then had been stitched up too tight, so I tore a little around the scar tissue. It was very minor though and only took 3 stitches in one place and 1 stitch in another. I spent the first hour on the floor in the bathroom – not ideal. I thought I could walk over to the bed right after giving birth but passed out. Luckily the midwives did a great job catching me before I hit the floor. I did get to nurse Ivan right away, though it was slightly awkward positioning laying flat on the floor and all. It is so fantastic nursing an unmedicated newborn. He was totally alert and latched right on and nursed for a solid 40 minutes. After I was all stitched up Eric and the midwives carried me to bed where I drank and drank and drank! So much juice! Ivan was alert for another hour or so and then finally dozed off into a deep slumber between me and Eric.
Once my bleeding was normal we were given 4 hours until we needed to check out. Our check out time was 11 am. We napped and enjoyed our little guy. My sisters came for a quick visit and then a little before 11 we packed up and headed to my parents so Reese could meet her new little brother. It was all just completely ideal for what we were hoping the experience would be.
Turns out November 20th had more pull than November 19th. The 20th is my Great Grandpa Messick’s birthday, Eric sister Amber’s birthday, and my Grandparents’ Anniversary.
1. When did you decide you wanted to deliver your baby naturally?
- I had my first baby in the hospital with pitocin, an epidural, and Dr. breaking my water. I had a reaction to the epidural called Horner’s Syndrome where it appears that you have a stroke. At the time the Dr. didn’t know what was wrong with me so assumed a stroke and wouldn’t let me push my baby out. He used forceps and I had 4th degree tears from a combination of episiotomy and forceps. It was all terrorizing and then I got sent off for tests (heart, brain, etc.) to see what was wrong. I didn’t even get to spend much time with my baby until a couple hours after the birth. I decided I needed to find a better alternative for my next birth, because I recognized that all the problems with my first birth experience were because of the medical interventions which were used on me.
2. What reasons or factors went into your decision?
- I wanted a good memory of childbirth, not one that was completely terrifying. I recognized that medical intervention (speeding up childbirth) only causes stress for both mom and baby and contributes to most problems that come up during labor/delivery. I was also looking for a less expensive alternative. My 1st would’ve cost $17K had we not had insurance, and with this baby our deductible was quite high so that was also a pulling factor in my decision to go natural at a birthing center with a midwife.
3. What did you do to prepare for natural childbirth? (midwife, classes, methods, books, etc.)
- I read a lot about natural childbirth and home births. I talked to people who I knew were advocates of natural childbirth about their experiences and things they’d recommend. I studied the Bradley Method and tried to learn how to make my body relax regardless of pain I may be experiencing. The most helpful thing for me was learning about the female body and the anatomy and physiology of the uterus/cervix/birth canal. This helped me put a picture to what I was feeling during childbirth.
4. What was the hardest part of your experience – before, during, or after childbirth?
- Four days after. I began to have horrible abdominal pain. I knew it wasn’t normal pain to be having. I ended up having an infection in my uterus from retained afterbirth. The pain was much worse than laboring because it was continuous and was a pain I knew I shouldn’t be feeling.
5. What was most helpful to you during labor to help make pain from contractions manageable?
- Picturing what my body was doing when I felt what I was feeling. If I could remember that my uterus is a big bag of muscles contracting like any other muscle and that my cervix needed to stretch, I was better able to make myself relax to allow my body to do the work it needed to. I kept reminding myself that if I didn’t allow my body to relax and do its work, than things wouldn’t progress as quickly.
6. What do you wish you would have known going into delivery?
- That although pushing is very rewarding, it was, in my case, also quite painful in the perineal area. For some reason I just hadn’t thought about having pain while the baby was crowning. I had heard that the perineum goes numb because of the lack of circulation from the baby’s head crowning, but I didn’t experience the numbness.
7. Is there anything you would have done differently?
- Not get so anxious on the days leading up to childbirth. A week or so before my due date people were trying to convince me that my body just might not go into labor so maybe I should just go to the hospital to get induced or to at least ask my midwife to strip my membranes. Although I knew I wanted to go natural and prove that a body really can go into labor on its own, I still kept fretting that maybe my body wouldn’t know what to do. After talking to my midwife I found out that it is pretty much impossible to stay pregnant. As long as everything is normal and healthy, your body WILL go into labor when you and baby are ready.
8. What did you feel were the positive benefits to your natural childbirth – were the benefits what you expected?
- Easy breastfeeding/latching on with an alert baby. Quick attachment, immediate skin to skin contact, feeling totally empowered and amazed with my body’s ability to birth a baby without medical help. In the birthing center I was able to do things my way. I loved being left alone while laboring. Of course there was some “interruption” when they’d check the baby’s heartbeat, but other than that everything was up to me.
9. Is natural childbirth something you recommend to other mothers, or something you’d do again?
- As long as my pregnancies are low risk, it is the only way I want to go. I would definitely recommend it to other mothers.
10. What advice do you have for other mothers interested in natural childbirth?
- Educate yourself on advantages of natural childbirth and a woman’s body’s ability to birth a baby so that you can be confident in your decision and your body’s ability even if people close to you are trying to discourage you.