As an example, very recently for me I had a baby who needed full-on resuscitation after the delivery, and I was absolutely shocked and baffled by it.  It was a full term baby, we’d been continuously monitoring the heart the entire time she was pushing and everything was looking good (up to the last few minutes when the baby slipped under the pubic bone and it become incredibly hard to pick up the fetal heart rate…and granted, a few minutes can make a big difference if the baby’s heart rate was decelerated during those minutes, but overall the tracing had been very reassuring).  She wasn’t even pushing for that long, you would expect everything to turn out well, or at least expect the baby to pick up very quickly after some drying and stimulating….and yet, shockingly, the baby came out blue and needed not just positive pressure ventilation with a bag and mask, but chest compressions as well (which you only have to do if the fetal heart is less than 60 and isn’t picking up, and which most babies rarely ever, EVER need; prior to this delivery, I had seen chest compressions done only two other times in my 8 year career as a Labor & Delivery nurse and now midwife).  The Apgars for this baby were 1 at one minute of life (which means the baby had a pulse, and that was it), 4 at five minutes, and 7 at 10 minutes (which is certainly a decent enough score, if not absolutely perfect).   It was a full three minutes before the Peds team arrived on the scene; I was ventilating the baby while the nurse did chest compressions.  And thankfully, in the end everything turned out well; we resuscitated the baby, the baby recovered nicely and went home two days later perfectly normal, but nevertheless, it was absolutely terrifying.  Afterwards, as we were recovering and debriefing and waiting for our own heart rates to return to normal, the only issue we could see was that the mother had had chorioamnionitis (an infection of the amniotic cavity), and one of the attendings pointed out that he has sometimes seen chorio do that to a baby before.  It wasn’t something I had ever seen before, and chorio had never been something I had routinely called pediatricians to a delivery for in the past, but now it gave me pause.  And the next time I had a woman pushing with chorio (only about a week later), you can be damn sure I called Peds to the delivery, well before the baby actually came out.  With that birth, everything was fine, the baby was pink and vigorous with Apgars of 9/9, and the pediatricians were  wondering why I had called them for something as routine as chorio.  I called because personal experience had made me cautious, and has temporarily changed the way I practice.  The next time I am pushing with a woman who has chorio, I may decide to call Peds again, or maybe I will decide to wait and see.  I suspect that gradually over time it will become less scary again, and become more integrated into my overall practice, but I will always and forever add chorio to my mental check-list of reasons why we may need Peds at a delivery, and will probably make the call based on several factors, like 1) how long has she had chorio, 2) how long has she been pushing, 3) how has the tracing been overall, 4) how high has her fever been etc. etc.   And a full-on resuscitation is now always going to be one of the possibilities I consider with a woman who has chorio (although technically it’s something we’re supposed to always consider with every delivery, and it can and does happen out of the blue sometimes for no apparent reason at all); always, always, from here on out.

But personal experience isn’t always negative, or built upon bad outcomes and our responses to them.  I was writing to a friend the other day about how my practice as a midwife has changed now that I’ve given birth myself, and I also find this very interesting to stop and reflect on a bit.  The most obvious change I can think of is how I handle women in early labor/ prodromal labor. This comes from my own experience of an endless early labor which lasted for nearly 2 days.  I think in the past I was a bit more terse with women coming in to the hospital in early labor, only to be sent home again because they were only 1 or 2 centimeters dilated.  They weren’t in active labor yet, and that was that.  Which isn’t to say I wasn’t sympathetic and sweet about it, but I didn’t spend nearly as much time talking with and encouraging these women as I do now.  Now my heart goes out to them so completely because I can so well remember what that’s like.  It’s not like my contractions were irregular and mild—they were strong and regular and painful to me, at the time.  Albeit they were nothing compared to the contractions that were yet to come, but since it was my first time laboring, I had no idea of what was yet to come, and in the beginning, the early labor contractions were PAINFUL.  I spend so much more time with these women than I ever did before in triage, going through what’s normal and what’s not, reassuring them, talking about what (limited, because nothing really helps that much) comfort techniques they have at their disposal.  I’m even more patient with them, and even more understanding.  In this regard, I think empathy is quite valuable–which isn’t to say that you can’t be a good provider if you haven’t gone through it yourself—but I do think it adds another layer to my care which wasn’t there before.

Strangely enough, though, if I’ve become much more patient with women in early labor, I’ve become much more practical and maybe even a bit tougher when it comes to second stage.  In the past, having never pushed a baby out before, and having no idea what that actually felt like, I was incredibly sympathetic to the agonies of pushing.  I would allow women to say things like “I can’t” again and again during pushing while I calmly and unflaggingly told them again and again and again that they could.  For me, this was the epitome of midwifery care—this spoke to the very root of my calling, helping women to find their own strength in the moments when they were convinced that they had no strength left, helping women to climb the mountain that they thought they couldn’t climb.  However, having now pushed out a baby myself, I feel like I cut to the chase much more quickly during the pushing phase than I ever used to in the past.  I can remember just how excruciating the pushing was, and I know all too well that there’s no cure for the pain except to GET THE KID OUT, and I no longer hesitate to use tough love to help women buck up and PUSH, or hunker down and PUSH, or get to work and PUSH, if it seems like that is appropriate and will be effective.  It’s become another tool in my arsenal.

Granted, there is a time and place for everything, and there are certainly some women who will always need a softer touch, and as a midwife you are always acting like a chameleon; in a way, that’s the hallmark of what good midwifery care is.  Because women are so different and because labors are so different, what works in one situation doesn’t work in another situation. There is no cross-the-board answer.  I can get away with saying something with one woman which I would never dream of uttering with another woman,  based on my personal relationship with that woman, and on who she is and on what is needed minute by minute.  And often the situation itself dictates the tone; sometimes the energy in the room is very high, and you can joke around and be loud and loving and teasing, other times the mood is very subdued and quiet and she is working hard and inwardly focused, and what is needed is a soft touch or a single word.  You have to know how to surf the different energies at different times.  But now, thanks to my own personal experience of birth, I try to get women through second stage as efficiently as possible, to try to keep the pain from being drawn out longer than it needs to be.  Because man oh man is it painful!

Experience can be both a blessing and a curse, but it’s all of these little moments strung together which makes you a better provider.  This is the reason you seek out providers who’ve been doing this for awhile, who’ve seen the good, the bad and the messy, and have learned how to integrate it into their larger view.  For all my midwife sisters out there, how has your personal experience changed you?

This meta-analysis (Maternal and newborn outcomes in planned home birth v. planned hospital birth: a metaanalysis) by Wax et. al. (also known simply as the ‘Wax study”) is not new.  It came out last September in the American Journal of Obstetrics and Gynecology (AJOG), but the reverberations of this controversial study are still being felt in the birthing community today.  As mentioned above, the flaws in this study have been discussed on numerous blogs and in numerous articles, so there’s no need to re-hash the entire argument here. (For further reading on this, though, check out the following links: Science and Sensibility, Our Bodies Our Blog, Science Based Medicine, Nature, ACNM’s response, Midwifery Today’s response).  To sum it all up, though, I quote from Michal et. al., Planned Homebirth v. Hospital Birth: A Meta-analysis Gone Wrong:

The statistical analysis upon which [the Wax meta-analysis'] conclusion was based was deeply flawed, containing many numerical errors, improper inclusion and exclusion of studies, mischaracterization of cited works, and logical impossibilities. In addition, the software tool used for nearly two thirds of the meta-analysis calculations contains serious errors that can dramatically underestimate confidence intervals (CIs), and this resulted in at least 1 spuriously statistically significant result. Despite the publication of statements and commentaries querying the reliability of the findings, this faulty study now forms the evidentiary basis for an American College of Obstetricians and Gynecologists Committee Opinion, meaning that its results are being presented to expectant parents as the state-of-the-art in home birth safety research.

And that’s really the crux of the issue right there: ACOG has based their most recent home birth committee opinion paper on the Wax findings, despite the fact that the Wax study is so controversial, and has been so loudly contested.  ACOG seems to take the Wax study as gospel truth: “Published medical evidence shows [home birth] does carry a two- to three-fold increase in the risk of newborn death compared with planned hospital births.” (i.e. the Wax findings).  But as you can see above, the Wax findings are anything but conclusive. Couple this with the fact that a recent study in the current issue of Obstetrics & Gynecology (ACOG’s very own publication, aka the Green Journal) found that two-thirds of all of ACOG’s practice guidelines have no basis in science, and we have a very serious cause for alarm.  As one of the letters to the Editor at AJOG pointed out in regards to the Wax Study,  this is the dangerous practice of communicating bad science to the public.  To quote liberally from this letter to the Editor:

These practices are unethical, causing harm through unfounded confusion and fear, and misleading policymakers and the public. The Singapore statement on research integrity represents the first international effort to unify policies, guidelines, and codes of conduct for researchers worldwide.⁴   Accordingly, the AJOG publication would fail on 2 counts: (1) poor quality of the study; and (2) author recommendations made beyond what the data support and outside of their professional expertise. Obstetricians are not the leading professional group in home birth and midwifery-led care, and should not reach policy conclusions in isolation. It is essential to use appropriate subject peer reviewers: in this case midwife and epidemiology experts in studies examining midwifery care and birth setting.

Obstetricians have never been the experts on home birth.  In my own personal experience, I cannot think of a single obstetrician who has even seen a home birth.  Nevertheless, as Melissa Cheyney writes in the  Huffington Post (Why Home Births Are Worth Considering), the Wax study is only serving to fan the flames between the obstetrical/ medical community and the home birth community (I purposely refrain from saying the homebirth/ midwifery community, because I feel like midwives can and do and SHOULD straddle the gap between the home birth community and medicine, offering high-touch, low-tech intervention as we do, and advocating for all women, everywhere, regardless of their birth choices or location of birth).  When home birth is seen as more dangerous than hospital birth by obstetrical “experts”, what then happens to the women and families who still choose to have a home birth?  Are they considered crackpots and lunatics endangering the lives of their babies?  What happens if they need to transfer to a hospital?  What happens if they need to transfer to a hospital but the midwife is reluctant to make the transfer based on the stigma and ostracizing treatment she and the family will receive in the hospital setting?  Will the barriers to midwives choosing to attend home births continue to rise so high that ultimately they can no longer provide this service? And if that happens, where does that leave the women who will still choose to have a home birth anyway, without any medical provider available to attend them?

So long as ACOG’s opinion on home birth continues to be based on poor science, we’ll continue to move further and further away from what this country truly needs: an integrated model of care, where women who choose home births and the midwives who serve those women are backed up by obstetricians and the medical model of care, allowing for safe transfers when needed without stigma, judgement or blame.

I caught three babies on Friday.  The first woman was already 6 cm dilated when I got onto the floor.  She had just arrived, and had already been brought into a birthing room, knowing that it was her third baby and that things were moving fast.  She was groaning and sweating when I entered the room.  She was by herself; her husband was at work and her sister was at home watching her other two children.  My heart instantly buckled at the thought of being alone during birth.  There is NO WAY I could have made it through my own birth alone.  I sat on the edge of her bed and didn’t want to leave her side (and thankfully, things were progressing fast enough that there was no time for me to be pulled in any other directions).  The sights and sounds of labor instantly took me back to my own very recent birth.  It was almost visceral.  I could almost feel it in my body like a phantom pain.  She looked at me with the slightly panicky eyes of transition, and I could instantly remember my own transition, vomiting over the edge of the birth tub, sweating and shivering at the same time.  For a moment I wasn’t sure how to even help her; I felt like any comforting words are so inadequate compared to that pain.  But she wanted me to do something, so we talked briefly about what her options were.  Pain medicine, or just getting the labor over as quickly as possible.  She just wanted to be done with it, so I broke her water.  We barely had enough time to get the birth kit open before the baby’s head was visible on her perineum.  Three good pushes and the baby was out at 8:38 am, a 7 lb healthy little girl with a strong cry and a head full of hair.  The mother hadn’t known the sex of the baby in advance, and she wanted the father to help her pick out the name.  She cradled her baby but unfortunately couldn’t breastfeed her immediately because we didn’t know her HIV status (somehow this test had been missed during her prenatal care!) and per hospital policy she wasn’t allowed to breastfeed until the results came back.  I left the two of them bonding and stepped back out onto the craziness of the floor.

The second delivery happened at 3:48 pm.  This mother was a thirteen year old girl who looked as if she were 21.  Her half-sister and mother were in the room with her, and had been with her for nearly 24 hours.  She had come in the day before with sky-rocketing blood pressures, and was currently being induced for preeclampsia.  She was on magnesium, and had been making very slow progress.  When I first examined her in the morning (shortly after delivering the first baby), she felt to be about 5 cm dilated, which was exactly like her last exam four hours ago.  This wasn’t the kind of situation where we could tolerate a slow and meandering induction; the cure to preeclampsia is birth, and we needed her to deliver sooner rather than later because her blood pressure was a bit scary: 160s over 110s (so high that we actually administered 5 mg of hydralazine at the start of the shift to try to stabilize her somewhat).  The attending suggested that we break her water to try to get her labor going, but I thought pitocin might be a better option.  Yes, a midwife pushing pitocin!  However, with a slow, drawn-out induction, I felt like breaking her water at only 5 cm was an invitation for an infection, and that there were other ways to encourage her progress without taking that route.  In my limited experience to date, I feel like breaking the water in a multiparous woman who’s clearly progressing quickly is a sure-fire way to speed things up, but in an adolescent primip, there was no guarantee that breaking her water would do anything.  I argued my case and the attending agreed.  We began pitocin and left her water intact.  She didn’t want an epidural, but she took some stadol twice to help her cope with the pain, and around 1:00 pm when I reexamined her she was 7-8 cm dilated, and the baby’s head had moved down considerably.  I broke her water at that point, and she began to feel like she needed to push around 2 pm.  I checked her again, and hallelujah, she was anterior lip.  We tried some different position changes to try to encourage the lip to recede (including hands and knees–the beauty of no epidural!), and around 3:00 she felt like she had to go to the bathroom (music to a midwife’s ears) and wasn’t able to stop herself from pushing.  She began to push, and almost immediately you could see the baby’s head.  We pushed for about 40 min, and she truly was a superstar, giving birth to a healthy 7 lb 4 oz baby boy!  I kept forgetting that she was only 13 years old, such was her maturity and resilience.

The third delivery happened at 7:31 pm.  This was a woman whom I had been taking care of all day, but I wasn’t sure I would be the one to deliver her.  Her water had broken the night before, and she was contracting on her own when I first arrived onto the floor in the morning.  I only checked her twice during the day.  Once around 10:00 am (she was 3-4 cm dilated at that point) and again at around 4:00 pm when she decided she wanted an epidural (she was 5-6 cm at that point).  Shortly after the epidural, while I was up to my neck in triage, her nurse called me because she was having an excruciating headache.  I couldn’t figure out what could be causing such sudden and extreme head pain aside from the very recent epidural (and I did call the anesthesiologist to have him come evaluate her, since a spinal headache is a known complication with epidurals).  She had asked her family to darken the room, and when I walked in she had a washcloth over her eyes.  Her blood pressures were also rising, so I asked her nurse to draw some preeclamptic lab-work on her just to make sure it wasn’t that (photosensitivity and headaches are some of the toxic symptoms of preeclampsia).   While we were waiting for the anesthesiologist to show up to assess the headache, she began to feel like she needed to push.  I didn’t want to examine her again (with prolonged rupture of membranes, the fewer exams the better), but it was pretty obvious that something had changed and the labor was going much more quickly all of a sudden.  She felt like she needed to vomit, so we quickly got a bucket under her; her family fed her ice chips and fanned her face.  This was getting on towards the end of the shift, and by that point our triage room was overflowing, with pregnant women pacing the hallways and filling chairs in the waiting room.  I left her to return to triage, only to be called back by her nurse again about 10 minutes later.  When I walked into the room, the nurse was hastily opening up the birth kit, and the head was visible on the perineum (so much for checking her again….clearly she was fully dilated!).  It was one of those deliveries where I barely had enough time to get my gloves on before another healthy little boy joined us earthside, all 9 lbs and 7 ounces of him!

The rest of this woman’s delivery proceeded normally; the placenta came out without any fuss, and I repaired the tiny 1st degree laceration that she had.  Amazingly, her terrible headache also seemed to miraculously disappear as soon as the baby was out, which was a big relief, since spinal headaches are miserable (and preeclampsia isn’t much fun, either; we sent her bloodwork anyway, just to be on the safe side). However, there was a thin but steady trickle of uterine blood which wasn’t stopping, despite the usual postpartum pitocin in the IV bag.  We emptied her bladder with a straight catheter (sadly, when there is an epidural on board, most women have a really hard time urinating on their own), and by compressing her fundus, I was able to extract another 300 cc of clots.  I thought this would do the trick, but the slow trickle of blood would not let up.  This was around 8 pm (shift-change time).  I was exhausted, my own breasts were sore and in desperate need of being pumped (I had only had a chance to pump once, at 10 am, such was the business of my first day back!), and I hadn’t had a bite to eat or drink since noon.  We gave her 1000 mcg of cytotec to try to stem the bleeding, and while her fundus firmed up nicely with this medication, it was still very high in her abdomen (well above her belly-button) which made me suspect that there were still lots of clots inside which needed to be removed before her uterus could contract down like normal and stop trickling.  At this point I called the attending, and thankfully one of the fresh night-shift midwives stepped into the room to help out.   I gave report to the oncoming midwife, who gowned up and put on a pair of sterile gloves, and thankfully took over.  I *hate* to leave a delivery unfinished like this, but it was already 8:30 pm, I felt like my breasts were about to explode, and with my husband away for the weekend, there was no one to relieve our son’s babysitter except for me, so I had to get home asap (as it was, I was an hour late).  When I stepped out of the room, the attending and new midwife were beginning to explore their options in terms of stopping the trickle.  Later that night I received a text from the midwife who had taken over, and in the end, it did indeed turn out to be a bunch of clots which needed extracting.  Apparently, everything had turned out well once those pesky clots were out of the way.

I came home sore, exhausted, exhilarated and desperate to see my little baby boy (who was sound asleep by the time I got home)!  I had never been apart from him for longer than 4 hours since he was born.  Being away from him for a solid 14 hours was a real shock to the system!!!  In a way, I am very grateful that it had been such a busy, crazy day, because it didn’t give me much time to dwell on how much I was missing him, and our babysitter thankfully sent me text pictures and updates throughout the day, which eased the pain of separation somewhat.  I crept downstairs into our bedroom and spent at least 10 minutes staring at him in silence while he slept, just soaking up his sweet, peaceful face.  Then I tip-toed back upstairs to pump.  I nearly fell asleep while pumping.  It’s been awhile since I had had such a hectic day.   Overall, though, it felt really good to be back to work again, and I felt so honored to be attending births once more.  This will definitely take some getting used to, though–a new routine, as both a midwife and a mother.

A few weeks ago, during a prenatal visit, a woman pregnant with twins told me she would love to have a home birth, but did not have the $4,000 cash required upfront to do so. She was afraid of potential interventions in the hospital. After a discussion of her fears as well as potential complications that can abruptly occur in a twin birth, she admitted she would prefer a hospital birth if she could maintain some control over the situation. This is not a woman who cares more about the birth experience than the baby, but she was tempted, and in some ways I can understand her concerns. My cousin’s wife had her twin induction halted at 4 cm because the new obstetrician on call did not do breech extractions for second twins. Her only option became cesarean delivery.

I recently received a phone call from a woman 2 hours away who had planned a home birth for her second baby after having an easy first birth. When the fetus, which was anticipated to be a little smaller, was found to be a breech, the midwife sent the woman to the local obstetricians. They would only deliver the fetus by cesarean delivery. The midwife offered the woman a home breech birth, but admitted she had only delivered one breech (stillbirth) in her career. The woman appropriately questioned the safety of this, and was referred to us. She met the criteria for our vaginal breech protocol, and had an easy vaginal breech birth in our hospital. Unfortunately, this is becoming a rarity. A colleague of mine in another state watched the residents she was supervising emotionally bully a young woman and her mother into a cesarean delivery. The young woman had a rapidly progressing active labor with a normal-sized frank breech fetus. Had the residents been open to the idea, my colleague easily could have taught them how to deliver a vaginal breech.

The running joke in our community is that the only way to get a vaginal birth after cesarean delivery (VBAC) is to have the birth at home. Unfortunately, this is a reality rather than a joke. Our small community hospital, owing to regional liability insurance constraints, stopped allowing VBACs in 2002 after many years of  successfully offering them. This has led many women to risk home birth rather than travel to a tertiary care center to attempt VBAC. I recently counseled a woman against having a cesarean delivery who had a BMI of 52 and who arrived in active labor at over 35 weeks of gestation with two previous successful VBACs. I spent the following months defending that recommendation, despite her considerable operative risks and high likelihood of success.

Recent news and media excitement about the benefits and increased safety of home birth over hospital birth have made the former seem like a very attractive alternative. A growing notion among women in our region, and perhaps across the country, is that hospitals and obstetricians are a more risky option than lay-home midwives for birth. Although my initial reaction is disbelief, perhaps we should look at how we, the  obstetricians, contribute to this trend.

Each of these women deserves an honest discussion about the fetal and maternal risks of each birthing option. However, our lack of experience as obstetricians colored by our fear of liability is narrowing women’s choices, and sometimes motivating them to ignore fetal and maternal safety in an effort not to be coerced into unnecessary interventions. I sense a mounting tension, because many obstetricians do not have the willingness, time, or skills to provide maternal choices.

I believe we are at a crossroad in maternity care in this country, and I am saddened that obstetricians are considered the culprits. Our contracting skill set as obstetric providers, as well as the prevailing risk-adverse culture among physicians and hospitals, have given support to home birth. We can all agree that VBAC, twins, and breech should not be managed at home, yet we frequently demand complete control of the situation and eliminate some appropriate choices in the hospital. I understand that it can be very unnerving to be ultimately responsible for the outcome, as we are, and yet pushed into situations outside of our comfort zones. However, our unwillingness to budge in these situations is causing us to lose the battle regarding what is really important to most obstetricians: safety for mothers and babies.

Certainly, we can be proud of the dramatic decrease in maternal mortality in the last century. But, despite the highest per capita expenditure of health care in the world, infant and maternal mortality rates in the United States are higher than in all of western Europe. We have the third-highest cesarean delivery rate in the world.

According to a recent study, nearly half of all primigravidas attempting vaginal delivery are induced, and half of cesarean deliveries for dystocia are done before 6 cm of dilation, presumably before active labor. It is amazing how many women begging for elective induction change their minds when told it doubles their cesarean  delivery risk.

We need to draw lines around patient safety, but must they be so rigid? Most midwives know from experience that Friedman’s curve is too strict. A recent study validates that knowledge. I sincerely hope it is taken seriously. Expectant management of ruptured membranes at term has been declared unsafe and of no benefit. The study that settled the question did not account for the number of vaginal examinations women received, and group B strep was not treated, both important variables. Most women do go into labor in 24 to 72 hours. The Cochrane systematic review concludes that, because the differences in outcome are not substantial, women need to be given the appropriate information to make a decision. This very rarely occurs in the hospital setting. The Term Breech Study closed the door on vaginal breech delivery even for the lowest-risk women in most obstetricians’ minds (including the residents I mentioned above). This, despite the opinion of the College that it may be appropriate in carefully selected situations. In any case, vaginal breech delivery is not completely avoidable, and should not be relegated to the history books with vaginal delivery for previa and high forceps.

Our mission has become more difficult in the last 20 years as mothers have become older, heavier, and of lower parity. Many women, admittedly, do have unrealistic expectations. Although I am eternally grateful for the obstetric skills I learned in residency, I have been amazed in my 14 years of practice to see much of the dogma I also absorbed disproven with experience and patience (both my own, my colleagues’, and the midwives I have worked with in the hospital setting). Collaborative practice with midwives is a good start, but in order for obstetricians to be more than providers of cesarean deliveries (a thankless and, in most cases, technically simple procedure) we need to have conversations with our patients that are not one sided and allow for true informed consent. Many of the obstetric disasters we have all seen and which color our  perspective (which David Grimes has called “numerators in search of denominators”) are at least in some part iatrogenic if examined deeply enough. That failed induction for convenience with early artificial rupture of  membranes and chorioamnionitis. The first cesarean delivery done at age 15 after 2 hours of pushing with an epidural that then leads to the fifth cesarean years later, and then accreta and life-threatening hemorrhage, are both typical examples. We need to recognize and own those aspects of obstetric management that are driving our skyrocketing cesarean delivery rate but having no positive effect on maternal or infant morbidity and mortality.

Admitting what is truly evidence based versus what is tradition and culture is a good start. It is essential that we offer real choices to our patients. We need to recover and disseminate the skills that make obstetrics an art and a privilege. Seek out mentors skilled in forceps, vaginal breeches, and breech extractions before it is too late. Then learn to be patient, so that you very rarely need to use them

I find this letter to be very brave and commendable, and while this may sound strange, I am actually really proud of ACOG for publishing it in the first place.  Kudos to Dr. Fineberg for writing this, especially given that she may very well experience a backlash from her colleagues for even suggesting that VBACs, vaginal breech deliveries and vaginal twin deliveries (with breech extraction for the second twin) are things which OBs should be offering their clients, let alone her suggestion that OBs may be partially responsible for driving women with complications to seek homebirth in the first place.

Even more fascinating to me, though, are the commentaries which are going up on The Unnecesarean right now, all written by a collection of different obstetricians who are willing to step forth and give their unvarnished opinion on the true state of things (and huge kudos to them, as well!).  Here are links to their articles:

Lamenting the System, by Dr. Jill Arnold

Lament in Stereo, by Dr. Lauren A. Plante

A Comeback for VBAC?, by Dr. Poppy Daniels

Another Obstetrician’s Lament, by Dr. Gustavo San Roman

An Obstetrician’s Hope, by Dr. David Hayes

The VBAC comments I found particularly compelling, given the sorry state of VBACs in this country right now (see my post below on the new NIH Consensus Guidelines).  The sad truth is, VBACs are no longer being offered as a viable option simply because of politics and a growing culture of fear (aided by our culture of litigation) which states that just because uterine rupture is (occasionally, super rarely) possible, there needs to be 24-hour on-call anesthesia, and an obstetrician on-call ready to brandish a knife at the drop of a hat…and because of this (occasional, super rare) risk, it’s better to not offer VBACs if you don’t have these emergency measures in place.  Nevermind the increasing risks associated with repeat cesareans, the growing rate of cesarean complications, placenta percreta/ acreta etc. etc.  But Dr. Poppy Daniels has addressed this on The Unecessarean more eloquently than I have time to right now, so I’ll let you follow the links.

Besides, I have much more exciting news to share! Stay tuned for a very personal birth story, coming up next!

A consensus panel of 15 non-advocate representatives (i.e. not lobbyists) from different disciplines (obstetrics, gynecology, pediatrics, maternal and fetal medicine, midwifery, clinical pharmacology, medical ethics, nursing, anesthesiology, risk management etc. etc.) got together and performed a thorough literature review and listened to presentations by experts, and then drafted the consensus report, posted above.  Pretty nifty, given the amount of information they had to wade through, and the fact that not all of the research available is good research.  I really liked the fact that the statement divides all of its research up into “High Grade of Evidence”, “Moderate Grade of Evidence”, “Low Grade of Evidence” and “Insufficient Evidence”.  My only complaint is that there isn’t actually a reference list at the back of the statement, and none of the research papers they are discussing are actually cited, so it makes it much harder to find and look at the research yourself.

And what does it say?  Basically, that the VBAC rate is still plummeting, and more research is needed.  Big surprise there.  The VBAC rate has been plummeting for decades, ever since its record high in 1996 of 28.3%.  It also seemed to suggest that ACOG could play a much bigger role in encouraging the practice of VBACs again, but maybe that was just my wishful thinking.

The statement begins by systematically reviewing the evidence behind the short-term and long-term benefits and harms of trial of labor v. repeat cesarean from the perspective of both mothers and babies.   Some of the benefits of trial of labor for mothers includes a decreased risk of maternal mortality when compared to repeat cesarean (high grade of evidence).  There is also a lower risk of hysterectomy (moderate grade of evidence), lower incidence of placental complications with future pregnancies, such as placenta previa, and placenta accreta/ increta/ percreta, (moderate grade of evidence), and shorter hospital-stays, with possible decreased risks of DVT (low grade of evidence).  Among the risks of trial of labor for mothers includes incidence of uterine rupture (moderate grade evidence), which is increased if there is a classical incision, i.e. a vertical uterine scar (however, there was only low-grade evidence to support this).  It’s also interesting to note that there was insufficient evidence to support the claim that repeat cesareans help avoid future pelvic floor dysfunction.

From the babies perspective, the perinatal mortality rate and neonatal mortality rate were observed to be lower in babies receiving repeat cesareans as opposed to trial of labor (moderate grade of evidence), and slightly higher rates of hypoxic eschemic encephalopathy in babies receiving a trial of labor (low grade of evidence).

To my way of thinking, though, the more important part of this statement is the fact that it also looked into many of the non-medical factors that are influencing the declining VBAC rate, such as professional association practice guidelines (ACOG’s 1999 Practice Guideline on VBAC being a big one), hospital and health-insurance policies, and professional liability concerns among physicians and hospitals.  I have heard my OB colleagues joke among themselves that the only bad cesarean is the one that isn’t done.  The general outlook that I have observed seems to be that doing a cesarean is always the right way to go from a medical-legal perspective; cesareans are perceived as being safer, by doctors and patients, no matter what the situation, and if in doubt, it’s better to err on the side of doing a cesarean than not.  This attitude can be found all over the place.  To quote a comment made by an obstetrician on KevinMD.com: “You never get sued for doing a cesarean section, you get sued for not doing one. So given the scenario with a questionable fetal heart rate tracing where any “expert witness” can find fault with, (even if there is none) I would rather perform a cesarean section than not. It comes down to a matter of staying in practice and making a living.”

The last Practice Guideline that ACOG has issued on the subject came out in 1999, and reversed its prior encouragement of VBACs, instead saying that women should be “offered” (rather than “encouraged” to have) a trial of labor if there are no contraindications, but basically asserting that it’s a personal decision, and can be decided on between doctor and patient on a case-by-case basis.  The 1999 Practice Guideline also stated that trials of labor should only be done in hospitals ready to respond to emergencies with on-call physicians always available to perform an emergency cesarean, as well as 24-hour on-call anesthesiology coverage (a standard which many rural and smaller hospitals find very difficult to comply with).   It’s important to note that this recommendation was rated as a Level C in the ACOG Guideline (i.e. based on consensus expert opinion, with no hard evidence to support it).  Nevertheless, many hospitals and providers have cited the lack of these emergency provisions as the reason that they no longer offer women trials of labor.

In it’s conclusion, the NIH consensus report directly addresses this issue:

Given the low level of evidence for the requirement of “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement with specific reference to other obstetric complications of comparable risk, risk stratification, and in light of limited physician and nursing resources.

We now know so much more about the causes of uterine rupture and the safety of VBACs than we did 20 years ago when the practice was first encouraged.  We know that the use of prostoglandin induction agents such as cytotec and cervadil were a chief cause of uterine rupture, and that women with low-transverse uterine incisions actually have a pretty low rate of uterine rupture.  With this in mind, it’s probably time for ACOG to finally issue a new Practice Guideline on VBACs.

A last comment about the NIH report: they left a laundry list of critical gaps missing from the research, highlighting the places where more information is desperately needed, which was nice to see.  They also issued a few choice words about the “cesearean as best defense” mentality:

We are concerned that medical-legal considerations add to, and in many instances exacerbate, these barriers to trial of labor.  Policymakers, providers, and other stakeholders must collaborate in developing and implementing appropriate strategies to mitigate the chilling effect the medical-legal environment has on access to care.

I couldn’t agree more!  Thank you, NIH, for a well-written and informative report.  Maybe this will help swing the momentum back in favor of VBACs again!

Even so, 25 weeks is extremely premature, right on the cusp of viability.  She was moved to L&D this morning because she had begun to contract regularly again, and was feeling increased pressure.  We were able to hold her off for most of the day, but one of the doctors did a sterile speculum exam towards evening in order to visually assess the cervix (vaginal exams are avoided as much as possible when a woman has broken her water, since they tend to increase the risk of infection), and all the doctor saw was a head of hair, without any cervix covering it at all.  A vaginal exam afterwards quickly confirmed what she had suspected: the patient was nearly fully dilated, and the first twin had moved far down into the pelvis, to nearly +1 station.  Initially we thought she might need a cesarean, but a sonogram quickly confirmed the first twin was vertex (obviously…this was the twin that was presenting) and that the second twin was very nearly vertex (more transverse, but with the head still sloping downward).  After consulting with the MFM and attending pediatricians, the decision was made to attempt a vaginal delivery, since one of the risks of extreme prematurity is cerebral hemorrhage in the fetus, and pushing a tiny, head-first twin back up through the bony pelvis in order to deliver through the abdomen was sure to cause more damage, rather than less.  Nevertheless, she was taken to the OR for the delivery just in case a cesarean was needed after all.

All hands were on deck, and the OR was packed.  The attending OB physician was there, the back-up attending was also there, and I was there. We were the delivery team.  Two attending pediatricians, 3 pediatrician residents, and 2 neonatal nurses were also there, divided into two groups–one for each tiny twin.  We had two warmers ready for the twins, two isolettes, two laryngoscopes, two sets of everything.  The anesthesiologist was present and on standby in case we needed to put the patient under general anesthesia for an emergency cesarean.  There were also 3 L&D nurses on hand; one scrubbed and ready to assist in a stat cesarean, and the other two as runners/ circulating nurses.  And a medical student, who was observing (with the patient’s permission)–and holding her hand, and feeding her ice chips.

She was nervous, naturally.  This was her first pregnancy, she’d never pushed before, and she still wasn’t feeling the contractions very strongly (one of the hallmarks of preterm contractions is that they tend to be painless).  We set the sonogram machine next to the patient, and the back-up attending used it throughout the birth to help assess the position of the second twin (twin B), as well as the fetal hearts of both twins throughout the pushing.  We gave her reassurance, helped hold her legs, got her into a good position, and then asked her to push.  Amazingly (well, not really, given how small these babies are, and how low in the pelvis the first twin already was), it took only a few strong pushes before the tiny little head was starting to crown in the vagina.  Before we knew it, the first tiny twin was out, a red little girl weighing only 1 lb 6 oz.  I helped deliver the head and quickly clamped and cut the cord; the attending OB handed the tiny baby to the waiting peds team, and they instantly got to work, intubating and ventilating her tiny little lungs.  She never cried, but she was nice and pink, and waving her little arms and legs around.  Within minutes she was intubated and stabilized, and the team quickly moved her to the NICU.  Meanwhile, we were concentrating on twin B.

The back-up physician was applying steady fundal pressure on the uterus, helping to hold twin B in a vertex position and guide her into the pelvis.  After a few more contractions, the uterus began to close around twin B and push her down into the pelvis.  Once she was engaged, the OB attending broke the second amniotic sac, and we asked the mom to begin to push again, which she did with renewed energy (having gotten a brief rest after the delivery of twin A).  About 10 minutes later, twin B was also crowning, and again, we quickly delivered the baby, clamped and cut the cord, and handed the twin to the second peds team.  She as another tiny little girl, this time 1 lb 8 oz, and again, doing as well as could possibly be hoped for at only 25 weeks gestation.  Once she as stable, she too was moved to the NICU, and the OR began to clear out a bit.

It’s quite an amazing sight, to see two umbilical cords presenting.  We waited for awhile, and slowly the cords began to lengthen as the placenta separated from the uterus.  About 15 minutes after the delivery of Twin B the placenta came out–much larger than a singleton placenta, with two cords and two separate amniotic sacs (di-chorionic/ di-amniotic).  Once the placenta was out, we all breathed a sigh of relief.  A quick exam showed that the woman was intact (not surprising, given how tiny the babies were).  We cleaned her up, took out the foley catheter we had put in just in case she needed a cesarean, and transferred her to the recovery room, where her family was waiting. And there you have it: a remarkably straightforward vaginal twin delivery at 25 weeks gestation.  Not exactly something your average midwife gets to see everyday, but certainly something I felt very lucky to have been able to experience.

Last night I was working (at the HHC public hospital in Brooklyn where I spend a good deal of my time) and I received a phone call from a sister midwife who works with me at the same hospital.  She had just been contacted by a mutual midwife friend who had been contacted by a homebirth midwife who was in the middle of attending a difficult delivery last night and was considering a transfer to a hospital.  While I don’t know all of the details of the birth, I do know that the woman had been fully dilated for several hours already, and had been pushing without much success, and it was getting to the point where the homebirth midwife was beginning to think that a vacuum-assisted delivery might be necessary, hence the need to transfer to a hospital/ MD care.   What the homebirth midwife was most concerned about was the possibility of an MD at a hospital turning her in to the authorities for practicing without an official back-up physician/ written practice agreement.  Nevertheless, any woman in labor coming to any hospital is entitled to immediate emergency care, and cannot be turned away, thanks to EMTALA laws.  The problem is that if the midwife attending her does not have admitting privileges and/or a WPA at the hospital where they transfer to, she has limited authority and cannot necessarily continue to manage the patient.  In other words, the midwife would have to act as a monitrice (midwife at  home, doula in the hospital), which is disappointing and frustrating, to say the least, especially for the woman in labor who was relying on her midwife’s judgment and management.  It pretty much destroys the continuity of care between midwife and client if a transfer to a hospital is required.

And then, of course, there’s the relationship to consider between the midwife and the hospital she’s transferring to.  If the relationship has not been established in advance, the midwife is walking into a situation where she may not know or be familiar with the attending on call, may not have any say or influence in the continued management of the patient, and may actually be judged and excoriated (at the best) and potentially turned into the authorities (at the worst).  The hospital outlook towards women attempting homebirth, and the midwives who attend them, can be outright cruel.  I have heard MDs muttering under their breath before about how “criminal” and “dangerous” it is to give birth at home.  It doesn’t help, of course, that the women who transfer to a hospital are only transferring because something went wrong, or because they need something.  It means that the only type of homebirth that hospital providers see is a failed homebirth, which naturally colors their opinions on the success of the process.  They never see the beautiful, peaceful, uneventful, successful homebirths.  Instead, they can sometimes feel like they are being asked to “clean up the mess” made by homebirth midwives’ mismanagement, and the crazy people who are stupid enough to attempt birth at home.  The attitude of the staff at the hospital and the way they act towards the incoming transfer is crucial.  Either they can be respectful and positive, or judgmental and negative.

So, at the moment, we have plenty of people in New York city attempting homebirth with no back-up hospital to go to.  We have midwives who don’t know where or to whom to bring their patients if they need assistance.  We have couples trying to give birth who face potential castigation at the hospitals they may end up at.

I’m not really sure what happened to the couple last night.  I got a text from my sister midwife whom I work with who told me that the homebirth midwife and her clients would be heading our way, but they never actually showed up.  I was concerned because last night was actually really busy, and we didn’t have any extra beds to accommodate them.  I actually ended up delivering a beautiful 9 lbs. 6 oz baby in triage last night, and the other midwife I was working with had to do a delivery in the recovery room–both of these on stretchers and not actual beds, which is never ideal.  I know for a fact that we would have been kind and welcoming to any incoming homebirthers (we meaning the midwives…I can’t vouch for what the attitude of the doctors and nurses we worked with last night might have been, although I’d like to think that they would be pretty open and respectful, given that so many midwives work at our hospital).  In any case, the couple never showed up.  I can only hope that either they were able to successfully push the baby out at home without needing a vacuum, or else they chose to go to a different hospital than ours.

I can only hope that the homebirth midwives of New York City will be able to find back-up physicians at other hospitals and sign new WPAs/ get new admitting privileges soon, so a situation like this where a homebirth midwife is faced with such a difficult challenge doesn’t occur again any time soon.

And speaking of updates: Choices in Childbirth has just posted a follow-up to their initial action (Action Alert: Part Two), so we can continue to call and harass our legislators about how important this issue is.  Please call or write or sign the Midwifery Modernization Act petition now!  You can read the full text of the proposed Midwifery Modernization Act HERE.

South Dakota’s Measure 11 was soundly defeated: “South Dakotans have affirmed by their votes tonight that no vague law can account for every individual circumstance. And that is precisely why women and families, not the government, should make these personal healthcare decisions,” said Sarah Stoesz, President and CEO of Planned Parenthood Minnesota, North Dakota, South Dakota.

The New York Times, in the midst of all the election craziness, published an article on new links between depression and premature delivery which have been recently reported in the Journal of Human Reproduction. The study interviewed 791 women and ultimately gave them scores based on how many depressive symtoms they exhibited–the higher the score, the worse the depression. The study found that the higher the score, the greater the risk of preterm delivery, even after controlling for prior preterm deliveries, miscarriage, socioeconomic status, education and other variables. This is particularly fascinating considering that so little is known about how depression affects pregnancy, and vitally important since depression during pregnancy (and the mental health of women during pregnancy in general) are so often overlooked in prenatal care.

The New Space for Women’s Health (formerly Friends of the Birth Center) is having a fundraiser on November 18th at Babeland called Women Come First. The event, which is co-sponsored by Ricki Lake and The Business of Being Born, offers an opportunity to not only raise money for the new free-standing women’s health and birth center in New York City but an exclusive cocktail party and shopping opportunity. Sounds like a lot of fun! I’d be there if I wasn’t already working that day…

Finally, I’m sure this is going the rounds on the internet, but I think everyone, everyone, needs to watch Keith Olbermann’s special comment on Proposition 8:

There were two deliveries. One was a grand multip (G6P5005) who came in 9 centimeters dilated with a bulging bag of waters. The other midwife ruptured her membranes at 3:40 am and she delivered at 3:41 am. I love deliveries like that! It’s always amazing to me how QUICKLY a baby can actually exit the human body, when all the conditions are right. It’s as if they’re on a greased slide, and they just whizz on out. If only all births were so quick and easy.

The woman I delivered was 16 years old, having her first baby. She was newly immigrated, and the father of the baby was back in Santo Domingo. She had her mother and grandmother with her, though, and they were a tremendous support team for her as the contractions were picking up, fanning her face and feeding her ice chips. She progressed remarkably fast for a first baby. We forget, sometimes, that teenager’s bodies are meant to give birth, and probably more so at this age than at any other time in their lives. Even though they might not be emotionally ready, their bodies are, and they often open up through labor as if it were the easiest and most natural thing in the world. This girl was having a labor like that.

When I came on at the start of the night she was 4 centimeters dilated and in a lot of pain. We discussed her pain options, but she didn’t think she needed anything just yet, and carried on with the support from her family. Two hours later, she was ready for something for the pain, and was thinking that she wanted an epidural. However, when I checked her, she was a whopping 8 centimeters dilated, and the head had moved down to zero station. I told her she was a superstar, she was doing amazing work and the birth would be really, really soon. I told her that she could have an epidural if she really wanted one, but that by the time she got it she would probably be fully dilated and ready to push, and that an epidural would just slow down the birth in the long run. She didn’t believe me (I can’t really blame her….the contractions were pretty intense at this point), but her mother and grandmother exchanged a look, and both of them rolled up their sleeves. We coaxed her into a sitting position, and her grandmother went behind her, rubbing her back, while her mother continued to fan her face. Less than half an hour later, she was fully dilated (there is a Russian doctor at our hospital who likes to call this moment “fully delighted”), and was pushing beautifully.

The baby came down quickly and was delivered 11 minutes after she was fully: a beautiful little girl with a really tight nuchal cord which had to ultimately be clamped and cut in order to allow for the birth, and a compound right hand that extended as the baby delivered and unfortunately tore the girl’s left labia, leaving a tender, open gash. The pediatricians were there to check on the baby due to the moderate meconium which had been in her amniotic fluid, but the tracing had been overall reassuring (we’re calling this Category II now…has anyone else moved onto the new NICHD guidelines? Our hospital has finally made the switch officially, despite the fact that these guidelines have been around and endorsed by nearly everyone [ACOG, AMA, ACNM etc. etc.] since 1997, but I must admit, I’m still finding it a bit strange) and the baby came out vigorous and screaming, waving her little pink arms around. An altogether beautiful and uneventful labor and birth, which took less than 5 hours in total. You couldn’t have asked for a nicer first birth than that.

The eventful part came next, unfortunately. Everything was looking good. I was checking her perineum (intact! the only tear was the labial laceration) and waiting for the placenta when there was suddenly a pretty forceful gush of blood. I figured it was a sign that the placenta was starting to seperate, so I gave a gentle tug on the cord, and the placenta quickly began to descend. Instead of coming out with the shiny, fetal-side showing first (Shultz presentation) it came out maternal-side first (Duncan presentation) and I immediately noticed that the membranes had been completely sheared off on one side. There was a thick tendril of trailing membranes which were still firmly attached somewhere up in the uterus, and were taut and unmoving when I tried to gently tease them out by spinning the placenta a bit. Rather than tearing the membranes and losing them, I cut the placenta away and put a ring forceps on the trailing end of the membranes, so that at least we had them. I quickly inspected the placenta and saw that there were hardly any membranes present, only the cotelydons of the placenta, and the cord. Which meant that most of her membranes were still inside, either retained or trailing, I wasn’t sure which yet. And all the while she was gushing blood.

We moved pretty quickly. I called the attending doctor, we asked the family to step out a moment, and started the IV pitocin running. I gave fundal massage and felt absolutely no fundus! I couldn’t find it anywhere (later on, the attending pointed out that that is exactly what an atonic uterus feels like…as if there’s nothing there). The attending began to remove the rest of the membranes by traction, gently teasing and working them down. We administered methergine, then hemabate, and finally 1000 mcg of cytotec rectally. We started a second IV line and used a catheter to help quickly drain her bladder. I was doing firm fundal massage all this time, and finally, after what seemed like quite some time, but was really about 8 minutes, I began to feel a hard, firm fundus balling up under my hand, and the bleeding had slowed down to a trickle. The doctor had managed to extract what looked like the rest of the membranes, and his sonogram later confirmed that the uterus was empty. And then, just as quickly as it had started, the bleeding stopped. The total loss was estimated to be between 800 – 1000 cc. But once the trailing membranes were finally out, and the fundus was finally firm, she was absolutely fine. I repaired the labial laceration, cleaned her up, and helped her breastfeed her beautiful girl.

Her hemoglobin and hematocrit dropped pretty precitously when we checked her CBC four hours later, but it was still in the range of normal (10.0/ 30%), so in the end she didn’t need any kind of blood transfusion. In fact, I’m still kind of astounded by the entire thing. It’s as if a huge emergency had been averted, and yet, at the same time, it felt really routine. We drill our hemorrhage protocol pretty regularly on our unit. It was really nice to see that when push came to shove, we were able to go down the steps of the protocol one by one, and amazingly (or perhaps not), they worked just the way they were supposed to, and lo and behold, the bleeding stopped! Nobody panicked, the nurses were prepared, the doctor was calm. Everyone knew what they were supposed to do, and we just did it.

Afterwards I was waiting for the shaky post-adrenaline terror feeling that often comes after emergencies, but it never came. It made me think about how far I’ve come in my first year as a new midwife. A year ago, this would have probably left me crying or near tears, shaking in the chart room, totally freaked out. Instead, I finished the paperwork, checked her bleeding again (it was fine) and carried on with the rest of the non-stop night. I guess this is what midwives do. They don’t panick, and they stop the bleeding, and that’s that. It was just a hemorrhage kind of night.

Cesarean births are not “safer”. Numerous studies have demonstrated, again and again, that cesarean births carry more risks than vaginal delivery, and these risks multiply with each cesarean birth. Sure, the woman in this article had a “safe” and uncomplicated primary cesarean, but no attention is given to what happens when this same woman comes back for her second or third repeat cesarean—how difficult it is to perform surgery on the same site, to cut through scar tissue, how the risks for abnormal placentation such as placenta previa or placenta acreta increase exponentially with each cesarean, how the risk of hemorrhage increases dramatically. There’s also no discussion about how painful recovery from a cesarean is compared to recovery from a vaginal delivery, and how statistics have shown that this poorly affects bonding and breastfeeding rates in women who’ve given birth by cesarean. (Not to mention the fact that the motivation for elective cesareans for many women is a fear of pain, and in fact, the entire process is often much more painful, for a much longer period of time, post cesarean).

Vaginal delivery can, for example, lead to future incontinence and pelvic damage, while babies born by C-section may suffer from respiratory problems because of not being exposed to certain hormones during the birthing process.

Where is the author, Alice Park, getting this information from? How come there are no articles or references cited? I thought we were well beyond the argument that cesareans prevent pelvic floor damage. While injury to the pelvic floor can and does occur during vaginal delivery, it’s often caused by practices such as episiotomy, vacuum-extraction, forceful pushing and lithotomy position during deliveyr, all of which can be (and are being) minimized during vaginal birth. Routine episiotomy, for example, is now by and large a thing of the past. Furthermore, there is no conclusive evidence which demonstrates that cesarean section prevents pelvic floor damage. To quote from What Every Pregnant Woman Needs to Know About Cesarean Section (2006), published by the Maternity Center Association:

Is vaginal birth in and of itself harmful? It is common to hear that “vaginal birth” causes pelvic floor problems. Of hundreds of studies examined, however, not one attempted to avoid or limit the use of practices that can injure a woman’s pelvic floor to try to determine whetehr vaginal birth itself plays a role. It is wrong to conclude at this time t hat the cause of pelvic floor problems is giving birth through the vagina….

Is “vaginal birth” the culprit in the high levels of incontinence that women experience later in life? Studies that take a longer view find that new problems with urinary incontinence that appear after birth lessen over time. These problems tend to completely disappear by the time of menopause. Older women experience high rates of incontinence, but this appears to be due to other factors. For example, excess weight and smoking play a role.

Does cesarean section prevent incontinence? Routine cesarean section would only prevent continuing symptoms of incontinence in a small portion of birthing women. For most women, it would pose numerous risks without benefit. And it would offer no protection against experience incontinence in later years. As no research has found that vaginal birth itself causes incontinence, there are more sensible ways to prevent these problemss: 1) avoid when possible the use of birth interventions that can injure the pelvice floor, and 2) focus on keeping a healthy weight, avoid smoking and other risk factors.

(Still not convinced? Check out the following studies:

[1] Shorten, A, Donsante, J. & Shorten, B. (2002) Birth position, accoucheur and perineual outcomes: Informing women about choices for vaginal birth. Birth, 29(1), 19-27.

[2] Terry, R, Westcott, J, O’Shea, L., & Kelly, F. (2006). Postpartum outcomes in supine delivery by physicians versus nonsupine delivery by midwives. The Journal of the American Osteopathic Association, 106(4), 199-202.

[3] Soong, B., & Barnes, M. (2005) Maternal position at midwife attended birth and perineuam trauma: Is there an association? Birth, 32(3), 164-169.)

The point being, I can’t believe such a mainstream publication could write such an imbalanced, one-sided and poorly researched article. I think I feel a letter to the editor coming on!