Monday, March 17, 2008

The Cesarean Option

If you have considered cesareans as a favorable option to avoid the pain of childbirth, or if you have thought that c-sections are no big deal, or if you think that the recovery from a cesarean is shorter or easier than a vaginal birth...

...or if you simply want to become more educated on cesareans, what they're like, what happens to the woman's body...

...Take 30 minutes and watch the linked webcast. It is a straightforward, uncomplicated c-section performed in Kansas.

The webcast can be viewed here.

Thursday, March 06, 2008

For first-time pregnant moms

If you are pregnant for the first time, you are either caught up in the magic of pregnancy, the drudgery of daily queasiness and the consequent change in your eating habits, or both. You know that in a few months you will become a parent. You are likely looking at how your baby is developing; when the heart has started beating, when the fingernails are present, how large your baby is, and so on. You are probably also thinking about the lists of things you will need, like clothing, diapers, cribs, mobiles, other furniture, car seats, strollers...It's an exciting time.

Truly, there is nothing like your first pregnancy.

But don't get complacent.

Here are some things that you don't want to overlook during your journey:

1. Learn about birth. Even if you assume you will have an epidural, or you really like your doctor, educate yourself. Find out what will happen. Have a backup plan (in a startling number of women, epidurals don't work! What will you do if that happens to you?). This won't be just another day in your life; what happens to you on the day you give birth will affect you and your relationship with your baby. And if you don't know your options, then your options are limited.

You may want to hire a doula, to make sure you have the birth you want.

At the very least
, take a childbirth education class. When you go into labor, it is too late to prepare for it. All education is valuable, and with birth, there is so much to learn. Find out what kind of birth you want to have and ways you can encourage it to happen.

2. Find out what you want. What works for one person may not be ideal for you. Stop worrying about criticism and take the time to work out what you want and how to go about getting it. There are few things as frequently and openly criticized as pregnancy, birth, and parenting. It requires courage from you to research your preferences, be open to doing things differently, and do what you believe is correct.

The first year, from conception to babyhood, is full of facing your fears. Do you really want to try cloth diapers instead of disposables? Find out about it! Are you nervous about an epidural and are considering an unmedicated birth? Look into it! Are you thinking about having your baby with you in bed instead of in a crib in another room? Read about co-sleeping! In every case, talk to people who have done it. Find out what worked well and what didn't. Remember that you may be different. You may discover that you don't want to pursue something you thought you wanted, and that's good. Now you know for certain.

This process of self-discovery is so important; the alternative is going along with a random opinion you aren't sure you share, one that shapes your relationship with your child and your style of parenting. The truth is that these things are highly individual and varied.

2. Prepare for parenthood. Getting ready for birth is important, but the shock of what taking care of your own baby is actually like, could be detrimental without some real preparation. Don't schedule trips for a long time after the baby is born. Have everything ready in the month before you're due. Stock your freezer with meals you can easily defrost. Get a support network of friends, family, other new moms, and anyone else you can lean on or call if you need help or advice.

Understand that you will need to let go of all ability to schedule your days (and nights) for a time. Your baby will probably not sleep through the night, and you will need your rest; figure out potential sleeping arrangements.

And realize that every mother had to learn this on her own, just as you will. You aren't supposed to know how to do it all; it's a learning process. You, your baby, and your relationship with your baby are all unique. Have the confidence to figure out what works for you.

Wednesday, February 06, 2008

Article on Fear in Childbirth

Help urged on childbirth fears

Woman wanting Caesareans for no medical reason should be offered counselling to help them overcome their fear of childbirth, experts have said.

A study from the Karolinska Institute in Stockholm, Sweden, found that more than 40% of first-time mothers had a clinical fear of giving birth after hearing stories from family and friends who had bad experiences.

These women were least likely to be happy about the delivery and some were afraid their child would die.

Expectant mothers who opt for a Caesarean without medical justification are often dubbed "too posh to push".

The operation is linked to higher risks for the mother and baby, including increased risk of hysterectomy, death, blood clots and infant breathing problems. Almost one in four babies born in England in 2005/06 was delivered by Caesarean.

The study, published in BJOG: An International Journal of Obstetrics and Gynaecology, followed 496 pregnant women until three months after they gave birth.

Comparisons were made between women actively choosing a Caesarean, Caesarean due to a baby's breech position and women acting as controls who wanted a normal vaginal delivery.

The women were asked for their views before delivery and three months after birth. Mothers requesting a Caesarean section had more negative expectations of how a vaginal delivery would be and 43.4% in this group had a "clinically significant" fear of delivery.

The authors said these women - and those still wanting a Caesarean but without a clinical fear - clearly needed more support.

Meanwhile, mothers who were expecting a normal delivery but who needed an emergency Caesarean (14%) or an assisted vaginal delivery (such as with forceps - 16% of the women) had more negative experiences of childbirth.

Friday, January 04, 2008

Preparing for a VBAC

For women who have had a cesarean and wish to give birth vaginally for subsequent deliveries

1. Your Care Provider

The most important factor in your VBAC journey is the support of your care provider.

No matter how much preparation and determination you otherwise have, if your care provider is not comfortable with VBACs, your chances are diminished.

Whether you choose a doctor or a midwife, you must talk openly and specifically about VBACs. You need to gather information as well as find out what your care provider's attitudes towards VBACs are.

Here are some questions to which you will need direct answers:

How many VBACs have you attended? Keep in mind that the number might not be very high. Many women do not have the support or confidence to achieve a VBAC, and in our current medical climate, the numbers are low. Watch for how enthusiastic your care provider is.

How many women attempting VBACs in your practice were successful? This is to find out who simply says "I will support you" but won't, and who is truly capable of supporting women who want VBACs. Some care providers give lip service to VBACs early on while never intending to allow post-cesarean women a fair chance at a vaginal birth.

Do you think I will be able to have a VBAC? This is your chance to discuss your childbirth history. Your reason for a previous cesarean should not matter, but watch for warning signs, such as "I will consent to a VBAC attempt so long as your baby is less than X pounds" or "You can have a VBAC if you go into labor within seven days of your due date" or "VBACs are much riskier than repeat cesareans" or if they put a time limit on labor or use the phrase "trial of labor." These are red flags indicating a care provider who is unwilling to offer the support you will need.

What do you do about a suspected CPD or past due pregnancy? VBACs should not be induced, if it can be at all avoided. Going past your due date, by itself, is not a reason to induce. Doctors are inducing earlier and earlier, often with the reason of "large baby" (macrosomia), but inducing for suspected large baby will often lead to cesarean section, rather than avoiding complications. If you had one or more cesareans for CPD, there is no reason to believe that you will never have a vaginal birth. Many CPD diagnoses are disproved by subsequent vaginal deliveries of larger babies. CPD, FTP (failure to progress), malposition, and the body's unpreparedness for an induced labor, are often one and the same reason. Your care provider should not assume that a previous diagnosis of CPD is accurate and permanent. Ask specifically how long past your due date your care provider believes it is safe to go. Change providers if your time is limited to one week or less.

Who can be in the room with me during labor and birth? If you can bring one, hire a doula. Doulas with VBAC experience will be able to provide invaluable support to you during labor. VBACs can be difficult. You will need as much encouragement, advocacy, and support as you can get.

What are the medical guidelines for women having a VBAC? Find out if you will be required to have constant external fetal monitoring (EFM). Are you required to have an IV or heplock? How about free movement? Will you need to labor in an operating room? Is pitocin routinely given to all women, including VBACs?

Do you personally attend all your patients' deliveries? Some doctors may not be able to control whether they are the physician present at any delivery, while others make a point of being with all their patients' births. Find out if you will be unexpectedly working with another doctor when you go into labor. Talk to that care provider as well to gauge how supportive they are of VBACs.

2. Your Physical Self

To maximize your ability to birth safely and without complication, take excellent care of your health. Eat well, including lots of fresh fruits and vegetables, and exercise. The better care you take of your body, the better it will function. Also, eating well helps your tissues to stretch farther without injury. Do not drink alcohol, caffeine, or smoke. Cut sugar. Do your Kegels. Yoga is wonderful, too, but make sure you are doing the prenatal kind, since you do not want to harm yourself.

3. Your Psychological Self

Do not underestimate the impact your first cesarean has on your outlook. Many women whose dreams of vaginal birth were undermined by their c-section experiences carry a heavy burden of doubt in their birthing capabilities.

All fears will manifest themselves the most strongly when you are in labor. You are best prepared to face them when you deal with them before labor. And keep in mind that all women who have had VBACs began by thinking they may not be able to accomplish it.

One of the most effective means of facing your fears is through hypnosis. Hypnobabies and HypnoBirthing courses are designed for the express purpose of building your confidence, understanding and handling your fears about labor and birth, and nurturing a positive outlook of birth. It also teaches women how to relax during childbirth, which is a fundamental part of preparation for any birth, but will be especially helpful for VBAC women.

The fear of repeating your previous experience(s) is very real and must be confronted if it is to be overcome. Your mind has a tremendous influence over what happens in your body. If you are scared, your body will respond and hold back; if you are confident and unafraid, your body will work more smoothly. Work with a counselor or hypnosis instructor to sort out your fears. Read everything you can. Take charge of your life, of your body, and begin your preparation for your VBAC.

Many women need a good deal of determination to have their VBACs. With supportive doctors and hospitals lined up, the last and greatest obstacle is the mother's belief in herself to give birth. This may be where your personal support team steps in, but you would be best served by working through as much of your fears and doubts as you can before they seem overwhelming.

4. Your Educated Self

I separate this section from the one above because they are truly distinct. Any facts you learn about VBACs and cesareans are likely to have no bearing on what you believe about yourself. Even if you learn that VBACs are safe, you may still harbor extreme doubt about your own ability to birth vaginally at all. Your self-belief is predominant.

However, education is still valuable, and in the case of VBACs, it is solid and startling.

The only reason VBACs are termed 'risky' is because of the chance of uterine rupture. Scar tissue does not generally have as much flexibility as unscarred tissue, and so the incision line along the uterus has a slightly higher chance of separating. Uterine rupture is a serious and life-threatening medical emergency, for both the mother and the baby.

For a woman with a previous cesarean, the chance of uterine rupture is about 0.5%. The chance of the uterus rupturing along the scar line is increased by the following factors: chemical induction (pitocin, prostaglandin, misoprostol), suturing type (previous cesarean incision closed in single-layer suturing rather than double-layer suturing), timing (previous cesarean less than two years before), age (the numbers rise as the woman ages past 30 years), classical incision in previous cesarean, and frequency (two or more previous cesareans).

If the sole risk for VBACs is uterine rupture, and the chances of it happening are so low, why is there so much controversy? Why is it difficult to find doctors supportive of VBACs? Why is the VBAC rate plummeting?

The answer is not in the increase of risk. It is in the expense.

Most hospitals require more staff for VBAC attempts. This means an anesthesiologist, an obstetrician, and increased nursing staff, just in case there is an emergency (read: rupture) and the woman needs immediate surgical attention.

If all goes smoothly and the woman delivers vaginally, it is possible that this staff would have been on call, at the hospital, paid, and not used. The woman is also not billed for their services.

Many hospitals are understaffed, a fact shown most clearly through the nursing crisis. Hospitals want to either save money or make money. With our national cesarean rate rising to an all-time high of one in three births, the number of VBAC candidates has also risen. Repeat cesarean is currently the number one reason for all c-sections. Obviously most hospitals are attempting to make money rather than cut costs, and VBAC is a primary target.

The other reason for the trend is malpractice costs. As lawsuits continue to be the standard response for anything having gone wrong in a hospital birth, malpractice insurance has risen accordingly. Not offering VBACs to women is a way of cutting the cost of malpractice insurance; if you don't offer it, you don't need to cover it. (Case in point: Last year, a local CNM was forced to stop offering VBACs because malpractice insurance to cover them had increased by over $10,000 in a single year). Another example is this quote from the vice president of a hospital, referring to the risk associated with VBACs: "99 out of 100 times it works, but I'm not willing to play those odds."

The alternative is that you, the taxpayer, the insured, are footing the bill for the increase of cesareans.

Cesareans are not without risk. Terming them a 'safe' alternative is both relative and circumstantial.Cesareans cause much higher incidences of infection, hemorrhage, depression, have far longer recovery times, and the risk of unpredictable complications such as accidental severing of nerves or tissues. Babies born vaginally are generally in better condition, with the benefit of catecholamines released during vaginal birth, healthier lungs, higher Apgar scores, earlier contact with their mothers, and better breastfeeding success.

The bottom line: VBACs are safe. They are safer than repeat cesareans. But they are not inexpensive.

5. Resources

Take advantage of the availability of information on the internet and do your homework.

Here are some very helpful resources:

ICAN (International Cesarean Awareness Network) -- Read The White Papers. Find a local ICAN chapter, if one is available to you, and attend regularly.

Childbirth Connection -- A fantastic site for information. Provides evaluations of current studies and medical research.

Pushed -- Informative blog about our current birth culture and a few sections specifically addressing VBACs.

Henci Goer -- The author of The Thinking Woman's Guide to a Better Birth and Obstetric Myths versus Research Realities has several articles on cesareans and VBACs.

Birthrites -- A site devoted to VBACs and healing after cesarean surgery. -- A comprehensive resource for women wanting to know more about and prepare themselves for VBACs.

Hypnobabies and HypnoBirthing -- While similar in both philosophy and practice, the main difference is that Hypnobabies classes can be taken independently (a workbook and CDs may be purchased from their site), while HypnoBirthing requires an instructor and in-person classes.

Wednesday, January 02, 2008

The Myth of CPD

CPD (cephalopelvic disproportion) is a common reason for cesarean section. It means that the pelvis is too small to admit the passage of the baby's head.

It is vastly overdiagnosed. True CPD is a malformation of bones. Unless medical issues such as gestational diabetes exist, babies will not be too large to fit through the mother's pelvis.

Induction for suspected big baby will often lead to cesarean section. The reasons are many: the pelvic bones will not stretch as much when labor is induced, the baby may not be in an ideal birthing position, lying in bed (common when one is receiving pitocin, and often leads to epidurals, which out of necessity restrict movement) does not help but seriously hinders the natural gravitational pull of babies out of the birth canal.

Many women who have been diagnosed with CPD have gone on to vaginally birth much larger babies.

This wonderful clip, put together by ICAN, reveals the myth that is CPD.