Belly Tales » VBAC

Empowering Birth in the Trenches

The Midwife — Mon, 05 Sep 2011 12:49:55 +0000

Welcome to the Empowered Birth Week Blog Carnival
This post is part of the Empowered Birth Week Blog Carnival hosted by Child of the Nature Isle and Betsy Dewey. For this special event the carnival participants have shared their perspective on Empowered Birth. Please read to the end to find a list of links to the other carnival participants.

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When we think about empowered birth, we most often think about women going outside the system and choosing homebirths or unassisted births. We think about women who experienced a traumatic birth with a prior pregnancy and are now determined to do it differently. We think of finding the power and strength necessary to avoid interventions in our high-tech low-touch hospitals. We think of choosing to birth free of drugs and medications, and welcoming our babies into this world in the softest and safest ways possible. And certainly, all of this IS empowering, especially since it flies in the face of a birthing industry which has forgotten how to trust both women and birth. However, when we broaden our definition of empowerment, we can suddenly see that strength and joy and beauty can still be found in even in the trenches of the hospital system, and that empowerment can mean very different things to different people.

Cases in point: as a midwife working in an urban hospital with an under-served, medicaid-only population (some of New York City’s most vulnerable women), empowered birth doesn’t come in the usual trappings. By and large, we’re not dealing with women who’ve been doing their research and know exactly the kind of birth experience they’re looking for. The method of delivery, the type of interventions used or not used, the provider attending their birth, the setting, the soul-changing journey that birth can be is often of little importance compared to the much more immediate problems many of these women face: not enough food on the table, abusive partners, unstable housing situations, older children who are uncontrollable, substance abuse, peer pressure, high school (we all know how difficult high school can be!), minimum wage jobs which often involve intense physical labor or oppressive conditions, illegal status…the list goes on and on. As a midwife working in this hospital, birth plans are not something I’m seeing a lot of (although I have seen one or two!).

And of course, this is a hospital, bound by all of the usual, myriad hospital rules and regulations, some official, well-researched and evidence-based, others unofficial and absolutely asinine. There are 18 midwives in our practice at this hospital, but we’re employed not because the demand for midwifery care is so high, but because the hospital finds it more cost-effective to hire midwives instead of doctors (midwifery care saves money, after all). And while it’s a very good thing that our hospital doesn’t have a residency program, the sad truth is that we midwives basically function like residents; we do the majority of the triage, the majority of the admissions, and we’re the ones managing the floor, more or less (in collaboration with our attending physicians, of course, although many of our attending physicians are more than happy to wait in the wings and let us do the bulk of the work, which has its advantages and disadvantages). I’ve written about this type of hospital midwifery many times before in the past, and it certainly does present its own unique set of challenges and compromises. Nevertheless, empowered birth CAN and DOES happen in this setting, all the time; this is what it looks like:

Empowered birth is the woman who decides she doesn’t want an epidural. Sometimes she had decided this in advance, but very often this happens in the spur of the moment, as the woman is listening to her body and riding the labor wave. Sometimes this is decided in the face of (sometimes extreme) family pressure. I have attended births where the father of the baby or the patient’s mother or some other family member will seek me out repeatedly to tell me that the patient wants an epidural. This is most often well-intentioned, since the family member doesn’t want to see the woman in pain, but when I go into the room and actually talk to the woman about it, I hear a different story. She’s working hard, but she’s not ready for the epidural yet. Or, are there any other options besides the epidural? (In which case, we talk about other analgesics, like stadol, or position change–getting into the rocking chair, for example, and off of her back). I have been accused by family members many times before of being unfeeling, cruel, selfish, uncaring, but I’m always quick to point out that they’re not the ones in pain, and it’s not their decision to make. Of course, I’ve also seen this in reverse: a family who’s dead-set on a woman having a natural birth, but a woman deciding that she’s had enough, and would, in fact, like an epidural. And again, the same rules apply. If she’s not coping well with the pain, if she feels like she’s at her limit (whatever that limit might be) and would like some relief, she’s welcome to it, even if her family is telling her that she doesn’t need it. Empowered birth is helping a woman to have what she feels is the best pain coping method for HER birth, and helping to protect her decision, even when no one else in the room agrees with her choices.

Empowered birth is a woman deciding that she would like to have a VBAC, and finding a way achieve this goal come hell or high water. I like to think that our hospital has a pretty successful VBAC rate, and all of our attendings are very supportive of VBAC (though not always the most patient with a VBAC-ing woman, when push comes to shove), but one of the biggest challenges we face is the fact that our hospital requires a copy of the operative report from the woman’s prior cesarean in order to ensure that her uterine scar is low-transverse (i.e. horizontal), as opposed to a classical (vertical) incision, which has a much higher rate of uterine rupture. Many of these primary cesareans were done in foreign countries: Honduras, Haiti, the Dominican Republic, Mexico, Poland, Bangladesh, Egypt etc. etc. Getting a copy of an op report is a laborious process which often takes several months to obtain. First the woman has to contact her existing family members in her country of origin, who then have to trek out to the local hospital and go through the medical archives to find the report (if it can even be found!), and then send it to either the woman, or to our hospital. This requires a great deal of time and explanation during prenatal care devoted solely to finding of the op report. I have had patients go through this finding and obtaining process again and again. One patient brought me a copy of a report (all in Spanish) which detailed her stay at the hospital after her cesarean but said absolutely nothing about her actual uterine scar. After translating the report and going through it with her, I told her that she’d have to ask her family to go back to the hospital again and find the actual notes from her surgery, as written by the doctor who had performed it. Which she did, bringing in the correct report just days before she actually went into labor. Empowered birth is when this woman is so determined to have a VBAC that she’s more than willing to jump through all of these unfortunate hoops, and then empowered birth is watching her successfully deliver her baby vaginally just a few days later.

Empowered birth is watching a fifteen year old (wo)man up to the task at hand and finally do what has to be done to birth her child. Sometimes this comes only after hours and hours of watching her run from the pain, or refuse to push, or throw the equivalent of an adolescent temper-tantrum; sometimes it’s impossible for her to think about anyone or anything else besides herself for most of the labor. And yet, inevitably, there comes a point in the labor when she realizes that she is the only one who can get herself out of her current predicament, that there’s no other way out except to actually hunker down and do the work. Empowered birth happens when she finally realizes she’s the one who has to rise to the occasion, and then watching her do exactly that. And sometimes it comes as a complete surprise—adolescents you’ve cared for during their pregnancies who have been needy, high-maintenance, low-pain-tolerance drama queens can sometimes turn around and completely bowl you over by their grace, maturity and strength during birth. Empowered birth is learning (again and again and yet again) to NEVER underestimate an adolescent, just because she is young, and to always trust her.

Empowered birth happens in our hospital when, after a long, two-day induction for oligohydramnios, a woman decides she’s finally had ENOUGH of the wise-cracks and mean comments and general lack of support from her partner, and insists that he leave the room. Empowered birth is that woman claiming her right in that moment to be surrounded only by people who are helpful and supportive of her. And as the midwife in this situation, this sometimes means calling hospital police to make sure that the unwanted party isn’t allowed back in, or providing hospital police with a copy of a patient’s order of protection to make sure that unwanted “guests” can’t just drop in unexpectedly. Empowered birth happens every time a woman demands nothing but respect and support during her birth.

Empowered birth happens in operating rooms during necessary cesareans when a woman is 100% present while giving birth. It happens when her face lights up at the very first sound of her baby’s cry. It happens when she insists on having her baby close to her immediately, with either the partner or family member or midwife holding her baby up to her face so that they can look each other in the eye for the very first time, despite the disapproving look and pursed lips of the anesthesiologist. Empowered birth even happens afterwards, when she breastfeeds that baby shortly thereafter in the recovery room.

I believe that the act of giving birth is in itself empowering, and that birth is capable of transforming a woman even if there wasn’t a lot of forethought or planning put into the where, why and how of it. When we widen our gaze and look at all the ways that women can be empowered even in situations which don’t, on their surface, look like they are, we see that empowered birth comes in all shapes and sizes, just like women do! Empowered birth happens whenever a woman decides: this is my experience, my birth, my baby, MINE, and I claim it.

The Empowered Birth Blog Carnival was lovingly hosted by Child of the Nature Isle and Betsy Dewey

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We invite you to sit, relax and take time to read the excellent and empowering posts by the other carnival participants:

Empowered Birthing – Amy at Anktangle shares a simple list of things that support an empowered birth experience.

Little Miss Green’s Home, Water Birth Story – Mrs Green at Little Green Blog shares her (home, water) birth story. Even though it happened 10 years ago, the empowering feelings are the same to this day (and yep, it STILL makes her cry!). This post is also a tribute to her husband who was there mind, body and soul throughout.

Save Birth, Change The World – Toni Harman, mum and film-maker talks about the highs and lows of creating the ONE WORLD BIRTH film project dedicated to helping more women around the world have empowered births.

12 Steps to an Empowered Natural Birth – Terri at Child of the Nature Isle wants to talk to all pregnant women and tell them YES they can have an Empowered Birth! This is her personal 12 step guide.

The Blessingway: a sacred blessing for birth – The Blessingway is a sacred ceremonial circle of women gathered with the intention of blessing and preparing a pregnant woman and her child to give birth. Betsy Dewey describes the beauty and the how-to of a modern Blessingway.

Informed Birth is Empowered Birth – Darcel at The Mahogany Way Birth Cafe tells us why it’s important to take control and be responsible for our own births. She says Informed Birth is Empowered Birth.

An Empowered First Birth – Zoie at TouchstoneZ follows the path she took to her first homebirth and finds she may not have started out as the best candidate for an empowered birth.

And this one to be published on Sept 12th :
Empowered Birth: From the Personal to the Universal – Zoie at TouchstoneZ questions the criteria for what makes an empowered birth and finds she has to let them all go.

One World Birth about to launch!

The Midwife — Tue, 30 Aug 2011 17:29:32 +0000

Just stumbled upon this via a friend on Facebook, and watching the welcome video just sent chills down my spine. Two passionate filmmakers are creating an interactive, continuously-updated online TV channel focusing on nothing but birth, and the state of birth in our world right now, by interviewing the world’s leading experts in birth and attempting to fuse birth, birth education and film-making. Their mission is to empower women to believe that they CAN give birth, fully informed of their choices. Now that’s a mission I can get behind! Oneworldbirth.net will launch on September 1st; until then, you can watch the website trailer below:

This video was embedded using the YouTuber plugin by Roy Tanck. Adobe Flash Player is required to view the video.

My one hope is that they don’t just focus on birth in the developed world (although, granted, we’re desperately in need of a birth revolution here in the developed world), but also tackle some of the ongoing issues in the developing world, too. I can’t wait to see what comes next out of this! Viva la revolucion!

The Obstetrician’s Lament

The Midwife — Thu, 19 May 2011 19:44:45 +0000

There is an astounding collection of writing going up on The Unnecesarean regarding the growing rift between obstetricians and the out-of-hospital birth community. All of this is in response to the The Obstetrician’s Lament, written by OB-GYN Anette Fineberg, MD, which came out in the May edition of ACOG’s Green Journal (Obstetrics and Gynecology). I will post the full text of “The Obstetrician’s Lament” here, (courtesy of Navelgazing Midwife) since most readers here will not have a subscription to ACOG:

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!

NIH Consensus updates on VBACs

The Midwife — Fri, 04 Mar 2011 03:35:54 +0000

One of the advantages to being a midwife is being on all kinds of funky mailing lists, which means that all softs of health information, conference invitations, and sometimes even free samples often show up on my doorstep. A few days ago, I got just such a mailing– the NIH Consensus Development Conference Statement on Vaginal Birth After Cesarean: New Insights. Granted, this is from 2010, but nevertheless represents the most current and updated NIH State-of-the-Science statement to date.

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!

Question CPD

The Midwife — Mon, 17 Dec 2007 20:52:27 +0000

I’ve been sick as a dog for the past three days, for the second time this season (I was so sick right before Thanksgiving that I actually lost my voice and had to call in sick to work…something which I NEVER do). Luckily I’ve had the past 3 days off to recover, but I’m due to be back at work again tomorrow, and I’m not sure how my voice will hold up. I keep coughing up icky green stuff, and I feel like this is potentially moving into my lungs. I’m so rarely sick! It must be all of the chronic stress of being a new midwife which has absolutely blitzed my immune system. Joy. At least I’m over the contagious part of it, so that when I’m at work tomorrow I won’t be getting pregnant women ill as well.

In any case, I’m not up for writing much of anything, but I found another amazing video over at Sage Femme’s, and thought I’d share it too. It’s been up at Sage Femme’s for awhile, and I’ve seen it before, but since I only just recently learned how to embed You Tube videos, might as well polish the new skills, w00t! This one is ultimately brought to you by the folks over at International Cesarean Awareness Network. Just goes to show what a bogus diagnosis “cephalo-pelvic disproportion” (CPD) often is, and what a VBAC can accomplish when it’s actually allowed to proceed (which is why the declining VBAC rate is an absolute tragedy). Baby heads are made to mold, and pelvises are made to stretch. Given enough time and patience, I believe that almost all babies, regardless of size, will make their way into the world. And just look at the triumph on these women’s faces. Talk about blowing a raspberry to the entire technocratic fear-based model of birth!

This video was embedded using the YouTuber plugin by Roy Tanck. Adobe Flash Player is required to view the video.

The news from the NAPW summit

The Midwife — Mon, 22 Jan 2007 23:11:32 +0000

National Advocates for Pregnant Women just concluded its 4 day Summit To Ensure the Health and Humanity of Birthing Women in Atlanta, GA, this past weekend. This summit, one of the first of its kind, was organized by NAPW and NAPW’s director, Lynn Paltrow, to explore the grey area where pregnancy, birth and the law intersect. In our increasingly litigious society, the debate about reproductive choice and reproductive freedom is not limited only to the debate over abortion; women are constantly facing difficult decisions, constrictions and legal battles on a daily basis simply to be allowed to give birth where they want, how they want and when they want. It seems like one of the overt aims of this conference was to widen the terms of the discussion and to get the reproductive rights advocates talking with the pregnany and birth rights advocates, demonstrating how these two debates are really just different ends of the same spectrum, and how all womens’ rights are being constricted, whether they choose to have children or whether they choose to have an abortion.

The Summit program covered everything from the overbearing and disempowering birthing machine in this country to our culture’s rampant fear of birth, from the legal restrictions being placed on VBACs, contraception and abortions to the disturbing rise in fetal rights, where mothers with substance abuse problems are prosecuted for “child abuse” on behalf of their unborn fetus, instead of being offered the care and treatment they need….and so much more, more, more. I really wish I could have attended! NAPW even offered several bloggerships to a few of the lucky feminist, birth and reproductive rights bloggers who were able attend. Too bad we didn’t get a longer winter break; school started again on January 9th, alas.

It’s been absolutely fascinating reading the reports and thoughts of many of the bloggers who were able to attend. I’ve linked to a partial list of the blogs on the Summit, so that you can read for yourself. It’s almost as good as being there (although not quite).

Feministing: Semi-live blogging from NAPW Conference

Gymno: Sick Blogging

Gymno: Summit Day 1 (cont.)

Is there no sin in it: NAPW Conference is happening now!

bird in a bottle: More Lynn Paltrow love (and a prelude to Blog for Choice Day)

bird in a bottle: Language and Gender, Part Deux

bird in a bottle: Why I want to be Dorothy Roberts when I grow up

Angry Black Bitch: Thoughts inspired by sessions

Angry Black Bitch: Thoughts inspired by debates, particularly the VBAC v. cesarean delivery debate.

Pandagon: NAPW Summit kicks off

Pandagon: NAPW Summit: end of the 1st Day

Bitch PhD: Join this Organization

Women of Color: The first part of the conference

And even more from brownfemipower here and here and here, and finally: Midwives of Color.
Oh, and this is just too cute not to pass on.

And finally, a word or two from the demi-goddess herself: Lynn Paltrow’s article in the San Francisco Chronicle, On the Anniversary of Roe v. Wade

In the news: cesarean rate rises and VBAC rate declines

The Midwife — Thu, 07 Dec 2006 05:02:55 +0000

Well, huh, this isn’t really news, but better late than never: a very well balanced article from the New York Times examines many of the issues which contribute to the declining rate of VBACs in this country, including doctors’ rising fear of uterine rupture, hospitals’ difficultly in staffing the necessary number of qualified doctors to support and provide VBACS, women who are more than happy to schedule their second, third and fourth (and primary!) cesarean, and women who desire a VBAC and feel betrayed by the lack of options available to them in their area.

Many women are willing to take the risk [of having a VBAC], and the hospitals’ stance has become a charged issue, part of a larger battle over who controls childbirth. Some women say their freedom of choice is being steamrolled by obstetricians who find Caesareans more lucrative and convenient than waiting out the normal course of labor. Doctors say their position is based on concern for patients’ safety.

Meanwhile, a story from yesterday’s New York Daily News charts the rising cesarean rate in hospitals, citing which five hospitals in New York city have the hightest rates: New York-Presbyterian Hospital Columbia (a whopping 39.6%, which still seems monumental even when you factor in that NY Presb handles many of the highest risk births in this city—the method of handling them is obviously cesarean), St. Vincent’s Hospital Staten Island (39.5%), Brooklyn Hospital Center (38.5%), New York Presbyterian Weill Cornell (37.1%) and finally, Flushing Hospital (37%).

Powerful numbers, indeed. If this continues, the Healthy People 2010 goal of a 15% cesarean rate for first time mothers and an increase the VBAC rate to 63% will seem laughable, rather than even remotely attainable.

Closer to the dream

The Midwife — Thu, 30 Nov 2006 18:09:21 +0000

Last week I had an exam in Neonatology, and my teaching project and a presentation in Neonatology all due at the same time, so it was a bit hectic. This week, the only thing on my plate is a few modules and some studying for the upcoming final exams, and a write-up of my teaching presentation, so I’m taking a justified, (albeit brief) break, and blogging for a delicious change.

I was looking back over some of the posts I’d written about hospital birth over the past year and a half, and I feel that the time has come to eat some crow. Not a huge amount of crow—not a grilled crow steak with onions and salad and the works, but maybe a crow kebab or crow pie appetizer. I think I was feeling very burned out this past summer, very very tired of all of the hospital birth BS, and I think a lot of that had to do with how very tired I was of working as a nurse. I was (and am) ready for change, and ready to be working as a midwife, and now that I’m actually more than halfway through my IP clinical rotation, and am finally (FINALLY!!!) catching babies, it’s as if a large piece of the puzzle has fallen into place. Suddenly, everything feels right in the universe, and I’ve been so ridiculously happy lately, now that I am actually doing what I have wanted to do for so long—this glorious, miraculous, beautiful work that has called to me for over 5 years now. So, the burned out feeling is gone, and in it’s place is a refreshing sense of growth, because I am learning so much right now, and heading in such a fantastic direction, and things finally feel like they’re moving. It’s slowly dawning on me that school will in fact be over (probably much sooner than I’m ready for), and that I will indeed be a midwife someday (really, truly!!).

The point being, the hospital where I’m currently doing my clinical rotation flips a lot of the hospital-birth stereotypes on their heads, and maybe this has a lot to do with the fact that midwives are employed by this hospital, and respected by this hospital (and the OB Dept., which says a lot right there), and do a lot of the work of running the labor and delivery floor. I can only write from my experience, and this is what I’ve seen: 3 years of working as an L&D nurse in two seperate hospitals, and I’d say that at least 90% – 95% of all births involved an epidural. A woman without an epidural was either making a huge and difficult point to labor “naturally”, or had simply managed to show up to the hospital fully dilated and unable to recieve one in time before she delivered. I can’t say that the majority of births I’ve seen have had at least a 1st degree laceration, but I do feel that at work, an intact perineum is often a rarity, and a very pleasant surprise. Women, as a rule, are not allowed to eat or drink during labor. The squat bar often sat gathering dust in a corner, the birthing balls were rarely (if ever) used, and getting a woman out of bed was always a very rare and unexpected treat, that often required a lot of fighting for. It was never the norm.

And this is not to say that there are no fights to be fought at the hospital where I am currently doing my clinicals, but I’ve been paging through my delivery book (21 births so far, believe it or not!!!) and noticing that more than halfof the woman I’ve worked with haven’t had any analgesia or anesthesia on board (14 out of 21, to be exact). The majority of them have had intact perineums. I’ve used the squat bar more times in the past 7 weeks than I have used it or seen it used in the past year at the hospital where I’m working. The women on the floor are almost always given clears to drink, which is a much better deal than being NPO (i.e., not allowed to eat or drink anything), and some women are even allowed to eat some lunch in the early part of their labor or induction. And while getting a woman out of bed still causes a lot of eyebrows to be raised, I’ve seen it happen at least 4 times so far, and once we even got the woman out of bed, off the monitor, and into the shower, where she would have remained if only someone could have stayed in the room with her to fend off the anxious nurses trying to get her back on the monitor.

Oh, and VBACs! Did I mention that this hospital does VBACs? And not just attempted VBACS, but actual, squalling-baby-born-vaginally type VBACs?? Very very pleasant surprise. I think I can possibly count on one hand the number of successful VBACs I’ve seen at Tried and True Hospital.

And have I mentioned lately how much I’m enjoying my clinical rotation so far? And these births!! All these beautiful births!! I’ve caught so many babies so far! I feel so blessed, and so lucky, despite the exhaustion and over-worked brain and tired legs and mounds of homework. I stayed late one night and caught three babies in a row, one right after the other—women I’d been laboring with all day, and had been examining all day, and watching as their cervixes changed from 2 cm to 6 cm to fully dilated, and was then lucky enough to be able to catch all of their babies. Afterwards, at around 2:00 in the morning, as I was finally leaving, I stopped by the postpartum room of the first woman I had delivered that night (she was a successful VBAC!!) to say goodbye. She had been wearing a gorgeous woven cloth rosary around her neck throughout her entire pregnancy and birth, and she pulled it off and gave it to me, and I walked down to the lobby with tears in my eyes, cradling the beautiful rosary. It is such an honor, and such a gift, to be able to be with women at the moment of their births, and to be able to catch their babies. Some days I can’t believe my luck and good fortune, because that’s really what it feels like to me. I am such a lucky woman! This really is the best job in the world.

VBACs only slightly less safe than repeat cesarean

The Midwife — Tue, 07 Jun 2005 18:17:39 +0000

Whenever news abour labor and birth hits the mainstream media, I sit up and take notice. The fold-out section on Women’s Health in this sunday’s New York Times certainly caught my attention, and while perusing it, I read the following tidbit in Eric Nagourney’s article about shifting health guidelines for women:

There was a time when women who had already given birth by Caesarean section would never be allowed to have their next child naturally. Doctors considered the practice too dangerous.

That thinking changed about two decades ago. Doctors are now taught that in most cases, vaginal birth after Caesarean – often referred to as VBAC (commonly pronounced VEE-back) – is only slightly less safe than having another Caesarean.

But try getting a hospital to allow it. After years in which the number of VBAC’s went up, many hospitals, concerned about medical complications and legal liability, have begun forbidding the practice.

Part of the concern is that the stresses of labor may put so much pressure on the old incision site that the uterus can rupture, putting baby and mother at serious risk. Even advocates of VBAC say that it should be done in hospitals that are equipped to deal with a problem.

The American College of Obstetricians and Gynecologists counsels that most women who have had what is known as a low-transverse incision Caesarean should be offered a chance to give birth vaginally. (The group advises against it with women who have had a “classical” Caesarean incision.) Epidural anesthesia is fine, the group says, but inducing labor should be discouraged.

According to the preliminary birth data for 2003, the cearean section rate is at an all time high in this country, coming in at a whopping 27.6%. Meanwhile, the report issued by the CDC noted that the VBAC rate has fallen abysmally from it’s high of 31% in 1998, and is now down to 10.6%. What I want to know is: what’s happening here? Why is the VBAC rate falling so precipitously?

The overall risks of a VBAC are low, but there is always the possiblity of uterine rupture, which occurs in approximately 1 out of every 2,000 births, and is pretty serious, of course, since it puts both the mother and baby at risk, depending on the severity of the rupture. However, a repeat cesarean is hardly risk free: not only does it bring with it the usual risks associated with abdominal surgery (risk of infection, anesthesia complications etc.), but the risks of infection and surgical complication are higher with a repeat, and the chance of incorrect placental implantation or placental accreta with future pregnancies is much higher as well. If a woman has one repeat cesarean, she will almost unequivocably be having a cesarean with her third child and fourth child too, and the risks associated with those cesareans will just keep rising each time.

I do wonder how much fear of litigation is affecting this. When a cesarean is viewed as the “safer” option, the consevative approach, the correct course of action and the solid defense that will hold up in court, then of course a nice, clean, quick cesarean would seem much more preferable to a long, drawn out (i.e. normal vaginal birth) VBAC, with its inherent risk of uterine rupture and potential malpractice claim. Even though the chance of uterine rupture is very low, when the cost of defending a malpractice claim is so high, I wonder if a lot of doctors just don’t think it’s worth it anymore?

A very large and comprehensive study of the risks of VBAC versus elective repeat cesarean was published in December, 2004 in the New England Journal of Medicine. This study found that the overall risk in having a VBAC was low, but nevertheless, slightly higher than the risks involved in having an elective repeat cesarean. Hospitals have been limiting the number of VBACs for several years now, and there are several hospitals which flat-out refuse to do VBACs, even if their attending doctors (not to mention the women giving birth) are willing. If a hospital was on the brink, perhaps this study has just offered up the unequivocal proof they were looking for, and tipped them over the edge, into the No VBAC zone.

ACOG still recommends that women with low-transverse incisions and no other obvious risks attempt a VBAC before having a repeat cesarean. The Healthy People 2010 guideline is recommending a 37% percent VBAC rate by 2010, so we’ve got a long ways to go to reach that, in not a lot of time. However, as Eric Nagourney’s article in the New York Times pointed out, guidelines keep changing, and what was seen as sound, incontrovertible medical practice now is often found to be questionable 10 years down the road. VBACs changed the landscape, challenging the old medical idea of “once a cesarean, always a cesarean”, but now perhaps we’re in the middle of a cesarean backlash, as the VBAC rate keeps plummeting. We can only hope that 10 years down the road, VBACs will be on the rise again, and the notion of “once a cesarean, always a cesarean” will be something relegated to history books.