Twins and Triplets Born Vaginally

Twins have to be born by c-section, right?

Thank again.

Pay close attention to the sizes of the babies.  Many of the multiples shown were full term and bigger babies.

VBAC With Inverted T Incision

Last year I blogged about an emergency cesarean for face presentation, which resulted with an inverted T-incision.  Even after such an intense experience, the mother was determined not to let her cesarean scar keep her from giving birth vaginally in the future.  She went on to have a successful VBAC (vaginal birth after cesarean) with a planned home birth and a support team that spanned the globe.  You can read her two amazing birth stories here:

Doula Momma: My Birth Stories: C-Section and VBAC

Why So Many C-sections?

Often when I talk with people about the dangers of c-sections they ask me:


"If c-sections are so bad, then why are they so common?"


My response is simple:


If something goes wrong with a vaginal birth and it goes to court, the doctor will be asked "Why didn't you do a c-section?"


If something goes wrong with a cesarean birth, the doctor can say to the court "We did everything we medically could."


It's called liability, and often referred to as "Defensive Medicine".

ACOG Issues Less Restrictive VBAC Guidelines

This has just been released by ACOG this week. It's far from perfect, but definitely a step in the right direction!

This is huge. Very important information for women and their care givers regarding vaginal birth after cesarean. Due to copyright issues I'm not including any direct quotes from the article. Please read the article here:

Ob-Gyns Issue Less Restrictive VBAC Guidelines

For information on the impact of the new guidelines, click here.

Hospital Bans Early Elective Births, Resulting in Fewer Surgeries and Healthier Babies

Hospital cuts C-section rate, leading to healthier babies

As published on fiercehealth.com

June 16 might seem like a great day to give birth, but planning a C-section, or being talked into it for convenience (of either the patient or the physician) may be bad for the baby. Tallahassee Memorial Hospital has decreased the number of preterm births--and thus admissions to neonatal intensive care units and infants with health problems--by cutting elective induction and C-sections over the last three years.

The hospital saw early delivery rates go from 44 percent to less than 37 percent. The statewide rate is 38 percent and has gone up yearly for the last few years; the national rate is 32 percent. The hospital has also reduced first time delivery C-sections from 22 to 15 percent--compared to 25 percent for Florida as a whole. A rate under 20 percent is considered good by childbirth advocates.

Many obstetricians think that deliveries in the 37th or 38th weeks are fine since they don't usually involve serious complications for the infants. They allow both patient and physician more control over their schedules, and inductions can allow physicians to see more patients in a day. But emerging research indicates that any birth before 39 weeks involves potential problems, including respiratory distress. The later the delivery, the fewer admissions of newborns to intensive care, and there is no increase in mortality by waiting until 39 weeks to induce or schedule a C-section.

The Tallahassee Memorial program was the brainchild of a neonatologist who saw a relationship between the sick babies he cared for and how many were delivered by elective inductions or C-sections. Now, physicians can't schedule deliveries before 39 weeks without a medical reason.

The hospital also recommends that physicians not induce until a woman's Bishop's scale score--related to fetal position and cervical dilation--indicates she's ready. Noncompliant physicians get reminders, and the hospital has few outliers among their obstetricians.

Other hospitals should take note: In April, The Joint Commission asked hospitals to start collecting data on prenatal care, including the numbers of near-term deliveries and first-time C-sections in mothers at low risk. It will soon set target rates for hospitals based on their data.

This is a great example of what a huge impact hospital policy can have on the health of its mothers and babies. It's important to ask questions and find out what the policies are at your hospital of choice.

The Dangers of C-section and Benefits of VBAC

I've recently come across quite a few articles and blog posts about c-sections and VBAC's, and I want to share them with you.

Dangerous delivery shows peril of multiple C-sections - This article may be a bit shocking, but I appreciate the candor about the risks of multiple c-sections. The old adage that "once a c-section, always a c-section" is not necessarily true, although many doctors and women still act like it is. The truth is that the more c-sections a woman has the more dangerous it is for her, and vaginal birth after a cesarean can be a viable option.

"The case points out a fundamental truth about surgical delivery: a first cesarean for most women leads to a cesarean with every pregnancy. And while a first section is quick, easy to perform, and rarely complicated, each repeat surgery carries greater risk."

Does Electronic Fetal Monitoring Increase the Rate of Unnecessary Cesareans? - This blog post on The Unnecesarean outlines something that I've read about in other books and articles: Electronic Fetal Monitoring is unreliable and leads to unnecessary c-sections. You know those belts and monitors that are strapped on a laboring woman in the hospital? One of those is the EFM monitor, and that's the culprit we're talking about. If you haven't heard about this risk before please, PLEASE read this post.

"There are numerous reasons that one of three U.S. births now is by cesarean, but Dr. Alex Friedman blames some on an imprecise monitor strapped to laboring women. Too often, he has sliced open a mother’s abdomen fearing the worst, only to pull out a pink, screaming bundle."

"'Everyone knows it’s a bad test,' said Friedman of the Hospital of the University of Pennsylvania. 'You haven’t done the patient a big service by doing an unnecessary surgery.'”

A Doula’s Journey to Vaginal Birth after Three C-Sections - This is a really cool post written by a doula who had a successful VBAC (Vaginal Birth After Cesarean) after 3 prior c-sections. She tells her story, her journey, and how she came to experience what she has supported other women in experiencing in her years as a doula. It's a really beautiful story

Dr. Poppy Daniels Surprise VBAC - Dr. Poppy Daniels had scheduled her third c-section and ended up with a surprise VBAC on the same day her surgery was scheduled to happen! I love her perspective as a doctor who is supportive and trusting of women's bodies to birth babies without intervention. She also explains her journey and how she came to have a beautiful surprise vaginal birth.

International Cesarean Awareness Network - For more than just anecdotal evidence, go here for VBAC information and support. ICAN has local support groups everywhere to help women meet and support each other.

Skin to Skin Contact in the OR: Speaking Up and Making it Happen

I've found more really good information on this subject:

Skin to Skin Minutes After C/S in the OR… Speaking Up and Making it Happen

This blog post by a Labor and Delivery nurse gives some excellent advice on how to speak up and ask for skin to skin contact immediately after a cesarean birth. This can be done while the mother's incision is still being closed, and it provides an important bonding time between mom and baby to establish breastfeeding and a healthier, happier newborn.

Here is a wonderful video that shows an example of skin to skin in the operating room:

Breastfeeding and Skin to Skin in the Operating Room

"With a Cesarean birth the baby can be brought to mom's chest and feed even as the incision is being closed."

Skin to Skin in the OR

The routine is generally to whisk the baby away for weighing, drying, and doing newborn checks while the doctors close the incision and the mother lies on the operating table. As long as the newborn is in stable condition, it can be brought to the mother and held skin to skin just as many would after a vaginal birth.

There are other things that can be done differently to make a cesarean section birth more meaningful. A friend of mine had a positive experience with her cesarean birth. Her midwife gave some really good suggestions to them before going in for surgery. One of those suggestions was for the father to hold the baby and not let the nurses have him back. When the nurses wanted to put the baby in the bassinet to take him to the nursery, the father gently refused and told them he would hold his son. Even after they told him he wasn't allowed to do that, he held tight to his newborn and insisted on carrying him to the nursery himself. He stayed with the baby when the mother couldn't be there.

There are options other than the normal routine, but you must ask for them. You need to know your rights and how to ensure you get them. Do you have any suggestions for expectant parents on what they can do in the event of a cesarean section?

VBAC Articles

Enjoy Birth blog shared these great articles about VBAC, and I thought I'd pass them along.

Rebirth of the Midwife

A Change of Delivery

Enjoy!

Avoiding The First C-Section

This entry was posted by The Midwife on Monday, 12 April, 2010

In honor of Cesarean Awareness Month, featured in the Courtroom Mama blog, I am continuing the topic of avoiding the first c-section. Why is it so important to avoid the first one?

• It’s major abdominal surgery, and carries increased risks for mother and baby
• It often puts the mother in the position of having repeat c-sections, because she cannot find support for vaginal delivery after a cesarean
• It increases the risk of abnormal implantation of the placenta, which can lead to hemorrhaging or need for hysterectomy
• It increases the risk of unexplained stillbirth in a subsequent child.

No one will argue that c-sections can be lifesaving under certain circumstances. Placental separation, placenta previa, cord prolapse, and certain abnormal presentations of the baby might cause injury or death to mother and child if it were not for the ability to deliver a baby by cesarean. I am thankful we have the ability to perform this surgery in a very safe manner. However, the majority of c-sections are not done for emergent, life-saving reasons. It’s those c-sections I want to focus on preventing.

Since most women having a primary (first-time) c-section are also having their first baby, I have five simple precautions that have been invaluable in my practice in helping women to avoid a c-section. I am writing from the perspective of hospital birth, knowing that the majority of women will not choose home birth, although I believe this is the number one way to avoid a c-section:

1. Stay at home in labor as long as possible, and consider giving birth at home. Why?

• Consider an animal in labor. If you’ve ever observed a cat or dog preparing to give birth, you may have noticed that they seek solitude. If they are disturbed during labor, they ahve a natural “fight or flight” reflex that slows or halts labor, allowing them to move to a safer location. While we as human women can intellectually understand the reasons for moving to another location (the hospital) to give birth, our bodies may still respond with a slowing of the labor process.
• It is understood that pain relieving medications can have a slowing effect on the process of labor. Epidurals are associated with a higher rate of vacuum, forceps and cesarean births in some studies. Yet it is difficult for a woman in hard labor to resist the offering of total relief of her pain. When you are at home, you know the pain medication is not available, and so the mind does not focus on it. It is easier to work with the contractions when you aren’t constantly thinking of the epidural available to you in only minutes.
• Staying home in the earlier stages of labor helps you to avoid the urge that hospital staff will feel to “speed things along” if your first part of labor takes many hours. It is common for dilation from zero to four or five centimeters to take many hours, and sometimes more than one day. If you are in the hospital and you are not yet dilated to four centimeters and having contractions three or four minutes apart, you are not in active labor. This part of labor is best spent at home.

2. Hire a doula if you can possibly afford it. If not, seek out an older woman who has had several children naturally herself, or has been present at several natural births, to be with you at home until you decide to go to the hospital.

• A woman who is familiar with the process of a normal birth will be invaluable to you in helping you know when it is time to got to the hospital. She can reassure you that what you are feeling is normal, that you can do it, and that you are stronger than you think.
• Many women are afraid to stay home in labor. A doula or experienced woman will be aware of the normal process of labor and be able to help you feel calm about laboring at home.

3. Find a practitioner who does not put arbitrary time limits on how long you can be in labor. If you are feeling strong, the baby is doing well, and you want to keep going, there should be nor reason to rush to a c-section simply because the labor is taking longer than average.

4. Carry on your usual activities as long as possible. Far too many first-timers make the mistake of doing everything they can to speed labor along. All too often, their efforts succeed at nothing but making them miserable and exhausted. Allow labor to unfold in its own time. Ignore the contractions until you are physically incapable of doing anything else during a contraction as well as in between contractions. This is where many women take their labor too seriously. They think because they have to breathe with a contraction, they are in hard labor. The actions of the mother between contractions are more indicative of the stage of labor. During the latter stages of dilation, the woman is usually quiet, tired, and may even fall asleep between contractions. She does not feel like talking much, or doing anything but resting before the next contraction. If your labor starts in the day, do what you normally would have been doing if you’d not started labor. If your labor starts at night, stay in bed and try to sleep, at least between contractions. If you cannot sleep, at least rest until your normal getting-up time.

5. Stay off the fetal monitor! The American Congress of Obstetricians and Gynecologists has published guidelines for intermittent auscultation of the baby, stating that it is just as safe for low-risk pregnancies as continual monitoring. It has the added benefit of having a lower c-section rate. This suggests that many c-sections are done for “fetal distress” seen on the monitor tracing, when the baby is actually fine. Once you allow someone to connect you to the continual monitor, you most likely won’t be off of it for the rest of your labor. What is intermittent auscultation? It is not being connected tot he monitor for 20 minutes out of every hour, as many hospitals’ protocols require. Rather, it is listening to the baby’s heart rate with a hand-held doppler before, during, and after a couple of contractions every 15-30 minutes during the first stage of labor. A skilled practitioner can determine if the criteria indicating fetal well-being are present, even with a hand-held doppler.

There you have it–my top five precautions to avoid the first c-section. I’d love to hear your ideas for other ways to avoid an unnecessary cesarean.

WHO: "Elective Cesarean Sections Are Too Risky"

"Despite medical advances and increasing access to improved obstetric care across the globe, surgical childbirths are still more risky for both mother and baby, according to an ongoing international survey by the World Health Organization (WHO).

"A new report from the survey... found that in Asia—in both developed and developing nations—cesarean section births only reduced risks of major complications for mother and child if they were medically recommended. Elected surgical deliveries, on the other hand, put both at greater risk.

"'Cesarean section should be done only when there is a medical indication to improve the outcome for the mother or the baby,' the authors of the report concluded. Common reasons for a recommendation for cesarean delivery included a previous cesarean section, cephalopelvic disproportion (when the baby's head cannot fit through the mother's pelvic opening) and fetal distress."

Click here for the full article in Scientific American Observations

2007 US C-Section Rates by State

1 New Jersey 38.3

2 Florida 37.2

3 Mississippi 36.2

4 Louisiana 35.9

5 West Virginia 35.2

6 Arkansas 34.8

7 Connecticut* 34.6

8 Kentucky* 34.6

9 Alabama 33.8

10 New York* 33.7

11 Texas* 33.7

12 Oklahoma 33.6

13 Massachusetts* 33.5

14 Virginia* 33.5

15 South Carolina 33.4

16 Tennessee 33.3

17 Maryland* 33.1

18 Nevada* 33.1

19 Rhode Island 32.2

20 California* 32.1

21 Delaware* 32.1

22 Georgia 32

23 Nebraska 30.9

24 New Hampshire 30.8

25 North Carolina 30.7

26 Michigan 30.4

27 Illinois* 30.3

28 Missouri* 30.3

29 Pennsylvania 30.1

30 Maine 30

31 Kansas* 29.8

32 Ohio* 29.8

33 Indiana* 29.4

34 Iowa* 29.4

35 Montana* 29.4

36 Washington 29

37 North Dakota 28.4

38 Oregon 28.2

39 Wyoming 26.9

40 Vermont 26.8

41 South Dakota 26.6

42 Hawaii 26.4

43 Arizona* 26.2

44 Minnesota* 26.2

45 Colorado 25.8

46 Wisconsin 25

47 Idaho 24

48 New Mexico 23.3

49 Alaska 22.6

50 Utah 22.2

* Tie

SOURCE: National Vital Statistics System, National Vital Statistics Reports, Vol. 57, No. 12.

Click here for Canada C-Section rates and map.

Thinking Out Loud Re: Breech Babies

This topic has become very important to me since giving birth to a breech baby last year, and I'd like to share some of my thoughts on the subject with anyone who cares to read.

Laws in many states require that mothers whose babies are in a breech or transverse position be under the care of a physician and give birth in the hospital. In cases in which the mother is planning a vaginal birth, this usually means a change in plans and a scheduled c-section. If the mother is planning a home birth with a midwife, this means changing her care to an OB and planning a hospital birth (again, most likely a cesarean section).

Why?

This blog post explains in detail about breech babies: Breech Presentation: Risks and Options.

There are ways to try to turn a breech baby into a favorable position before birth. My blog post above describes some of these, and there is also an excellent online resource called Spinning Babies that gives great information about breech babies and how to attempt to encourage a fetus to turn into a vertex (head-down) position. Sometimes the baby moves on its own or with help and the mother is able to plan a normal vaginal birth. Sometimes however, the baby stays breech, and the mother must seriously consider her birthing options at that point.

A recent study was done which found that the risks of c-section outweigh the risks of vaginal breech delivery: C-Section Not Best For Breech Birth. The study states that vaginal breech delivery is the preferable option of birthing breech babies, and that doctors should be trained to support women in this option.

The sad truth is that doctors are no longer trained in vaginal breech delivery. With cesarean section becoming more widely used, it has become the common method of delivering a breech baby. Unless you have an older doctor who has had experience with vaginal breech births, your doctor is likely unqualified to support you in birthing your breech baby if you want a vaginal birth. With many midwives, however, the skill of vaginal breech birth is still being taught and passed down.

The laws however, do not support the evidence. Automatic transfer of care of breech babies, in my opinion, should NOT be required. I feel the laws should allow for the care provider and the expectant parents to make an informed choice in how to birth their baby.

As explained in my blog post above, there are different types of breech presentation and some are more risky than others. For example, a full-term baby in frank breech position is the best candidate for a vaginal breech birth, and a woman with a baby in this position should be given the option of vaginal birth with a provider who is skilled to support her. This could be a midwife or a doctor, as long as he or she has the proper training, and depending on the woman's preferences and choice of birth place. If the baby is a stargazer (looking upward) there is a great risk to the spinal cord if a vaginal delivery is attempted, and experts agree that a c-section is warranted. These are just two examples of breech presentations.

Transfer of care should be a case-by-case decision based on the precise presentation of the baby. A woman should be informed of her options of attempting to turn the baby, as well as the risks and options associated with her infant's presentation and all proposed methods of birth.

This may not be a realistic expectation with current trends, but I hope that in time changes can be made. If doctors are not trained in their regular curriculum about breech birth, then perhaps additional training should be made available to those who are interested in learning and offering the service to their patients. This training should be evidence-based and consistent, and available to midwives as well. Perhaps a certificate could be given, such as with CPR and NRP (neonatal resuscitation) training. Ideally, it would be a requirement for all birth care providers, as basic as any other training they receive.

Does Elective Cesarean Surgery Improve Newborn Outcomes in Ultra-Low-Risk First-Time Moms?

"Henci Goer is an award winning medical writer and speaker. She has published two books: The Thinking Woman’s Guide to a Better Birth and Obstetric Myths Versus Research Realities (a new edition of which is in press)"

Guest Blog – Henci Goer: Does Elective Cesarean Surgery Improve Newborn Outcomes in Ultra-Low-Risk First-Time Moms?

In her guest blog post on the International Cesarean Awareness Network blog, Henci Goer scrutinizes a medical study that supports elective cesarean section.

I've read her book "The Thinking Woman's Guide to a Better Birth", and I've been very impressed with her intelligent evaluation of the modern medical maternity system. She provides sound perspective amid the confusing debates surrounding pregnancy and birth.