Here is the radio interview I did with Debbie Hull of the Whole Mother Radio show.  We talked about the current percentage of cesareans, VBAC availability, where to obtain support, ways to prevent an unnecessary cesarean and much more!

http://archive.kpft.org/mp3/090803_063001wholemother.MP3

Today the cesarean rate is an alarming 31.8% (CDC 2007 preliminary data).  Only a maximum of 15%  of birthing women should be having cesarean deliveries in order to keep mortality (death) and morbidity (poor outcomes) to the healthiest levels according to the World Health Organization. With the staggering discrepancy in what should be and what is, you NEED to care about this topic.  You could have a questionable cesarean like so many others.

It is important that you the childbearing woman understand how to have the healthiest birth for you and your baby which is most often a no-to-low intervention vaginal birth.

When a cesarean occurs for a truly medical and/or life saving reason it is necessary and the benefits far outweigh the consequences for mom and baby.  The cesareans that occur for other than truly medical and/or life saving reasons are often not necessary or became necessary due to external influence that skewed the labor and delivery outcome (routine induction, epidural,  impatience by provider, mal-position of baby, staying in bed during labor, routine continuous monitoring, pushing in one position, lack of food and water during labor, routine augmentation of labor, lack of support, etc.)

Below is a list of ways to promote having a vaginal birth even if you have already had a baby this information needs to be known.

• Take the ICAN webinar on cesarean prevention.
• Interview before choosing your care provider – you are doing the hiring! Know his or her statistics.  If you do not get a clear answer, that is a RED flag.  You need individualized care. ou and your baby deserve no less.
• Interview both midwives and OB’s.
• Research your chosen birth location well.  There are other options outside of the hospital – home and birth center.
• Hire a doula who shares your philosophy and is comfortable with the type of birth you desire. Some searchable places for a doula are: www.cappa.net, www.dona.org, and www.alldoulas.com.
• Without medical reason standing in the way, labor at home into active labor if traveling to a hospital or birth center.  Well established labor upon arrival to the hospital or birth center decreases the opportunity for interventions, medications, and cesareans.
• Get educated! Take a childbirth class that promotes confidence, consumer awareness (knowing rights and responsibilities), and evidence-based practices. A “good patient” class is not what you want to take.  READ books that share positive stories and good information.  A few of the searchable sites are: www.cappa.net, www.independentchildbirth.com, www.lamaze.org, and www.ican-online.org.
• Turn off your TV – stop watching the dramatic birth shows.  They are not real.
• Use mobility in labor.
• Drink and snack in labor.
• Say NO to routine interventions – meaning interventions or medications without a true medical reason. These can include, IV with fluid running, artificial rupture of membranes, continuous monitoring, wearing of hospital gown, and vaginal exams.
• Say no the the epidural completely or at the earliest at 6 cm’s dilated.
• Push and deliver in positions other than the reclined or “C” position unless that feels good and baby is coming well that way.
• Only have those around you who will support what you need and desire in labor and birth. When you close your eyes who is there with you in your labor “cave”? Who doesn’t fit well there?
• Study yourself for what comforts, assures, and adds to your feeling of safety.
• Eat healthy and exercise during pregnancy.
• Read What Every Woman Needs to Know About Cesarean Section – http://www.childbirthconnection.org/article.asp?ck=10164
• For more information on Cesarean recovery and support, VBAC education and support, and Cesarean prevention go to www.ican-online.org.
• Bottom line – take your money and walk if you are not being listened to and treated as a partner in your care.

This is a  slight re-do from a popular blog post from early 2008. The information is vital and pertinent to the near 1.5 million women (based on previous CDC data) who will have a cesarean surgery this year.

Having a cesarean section will almost always  get you a baby.  Generally there is much more to it and anyone could bargain for or anticipate even in the best of recoveries.

Let me count the ways in no particular order:

• A scar that in no way makes a bikini look better. Sometimes described as a shelf or a pouch.
• The feeling of failure, guilt or less than deserving of motherhood.
• The struggle of living with the huge dichotomy of loving your baby and perhaps hating the birth.
• Higher probability of losing your ability to have more children either through physiologic secondary infertility, pregnancy complications, self-induced secondary infertility, hysterectomy or lack of sexual intimacy in relationship.
• Higher probability of difficulty in breastfeeding.
• Postpartum depression or PTSD, especially in an unwanted cesarean.
• The feeling of failure as a wife or partner.
• Having others discount your feelings and needs. After all you “just” had a baby. Really you just had MAJOR surgery, perhaps by coercion, a true medical indication, or completely from interventions and medications.
• Living with the idea that you failed to pass induction, you failed to push out your baby, you failed because _________ (fill in the blank).
• Obtaining your records to find what you were told and what was written are different. Could your trusted care provider have lied and cheated you?
• Simply finding out that no one told you and you didn’t think it would happen to you. That being induced, getting the epidural, allowing AROM, not getting out of bed, etc. is why you had the cesarean. Is maternal ignorance and fear enough to quell what you feel and make it okay?
• How can you trust yourself as a mother when you ignored your maternal intuition and kept saying yes, because the nurse, midwife or doctor told you to?
• The way your marriage or partnership takes a turn toward hell or in the least a divided place.
• Living with dread when a hungry hand sweeps over your scar. Being sexual can be extremely difficult physically and emotionally.
• Having great fear of becoming pregnant again.
• Having great fear of going for a VBAC and ending up in the OR at the end.
• Not being understood and having others say to your face how lucky you are that you got to take the easy way out.
• Pain.
• Difficulty moving, walking, getting up, rolling over, coughing, laughing, tending to personal cleaning…. You get the idea. It is surgery.

Though not every woman will experience what is on the list, many do.  For all of these – there a stories layered and interwoven for too many women.

Every thirty seconds a woman is surgically having her baby delivered. Light her a candle. Offer her a meal. Let her speak. Listen to her intently. Don’t judge her. Send her to ICAN. http://www.ican-online.org/.

Putting effort into the initial postpartum period is in my opinion equally as important as preparing for pregnancy and birth.  Sometimes it is even more important due to circumstance or birth outcome.  Too many focus solely on the labor, delivery and perhaps the “stuff” that goes with having a baby while completely forgetting to look at all incredible change that occurs with having a new baby 24 hours a day, 7 days per week.

Below is a listing of important information to think about, investigate, understand and/or plan for.  Make a note of people in your immediate life that can be a resource as you go through the list.

Look carefully at class descriptions you may take in your local area, some are very thorough and others do not go into information you need in detail.

Here’s to postpartum preparedness!

Common Physical Changes for the Mother

Uterine Change and Bleeding

Breast Expectations and Breastfeeding Norms

Hormones and Symptoms

Recovery Requiring Attention

Vaginal Tearing, Episiotomy, Cesarean, Extreme Soreness or Swelling, Hemorrhoids

Nutrition

Common Psychological Changes

Mother and Father/Partner Changes

Processing the Birth Experience

Processing Becoming a Family

Postpartum Mood Disorders

Peer and Professional Support Resources

Understanding Your New Baby

Babymoon

How Baby’s Feed

Attachment

Infant Development

New Family Dynamic

Coping with Sleep Deprivation and Exhaustion

Managing Stress

Grieving the Changes

Siblings and Pets

Knowing How to Get the Right Support

Postpartum Doulas and Practical Support

Making Your Best Decisions

Defining Parental Roles – Financial, Baby Care, Changing the Status Quo

Choosing a Health Care Provider for your Baby

Early Infant Health Care Decisions – Vaccinations, Circumcision, etc.

Parenting Philosophies

Developing Your Parenting Style

Where Baby Will Sleep

Boundaries with Family and Friends

When to Seek Professional Help

Relationship Care

Realistic Expectations

Sexual Intimacy

Practicalities of Life

“Dating”

Priorities

Single Parenting

Arranging Practical Support

Making a Community

Parenting Needs

Unexpected Outcomes

Processing a Difficult Birth

Babies with Medical Needs, Coping and Advocating

Dealing with Loss, Grief, and Trauma

I offer a Postpartum Strategies class privately in the Colorado Springs area that goes into more detail on many of these topics.  My Bookstore lists several helpful books as well.

I have been invited to share with you an intimate and challenging (and graphic) journey of a mother from an unexpected primary cesarean, physician decided repeat cesarean and a home water birth after those two cesareans.

Before you watch it, take a deep breath and have an open mind. A box of tissues may be in order as well.

Cesarean vs. VBAC: A Dramatic Difference from Alexandra Orchard on Vimeo.

Watch how a baby is delivered in a cesarean birth and see the dramatic difference of what both the mother and baby experience in a home water birth after cesarean.

---

Thank you Alex for allowing me to share your story!  Many blessings to you and yours.

For more information on cesarean recovery, support, prevention and VBAC information go to www.ican-online.org.

ACOG recently updated guidelines for fetal monitoring in labor.  They call it a refinement.  Very interesting.

Directly from the press release “Since 1980, the use of EFM has grown dramatically, from being used on 45% of pregnant women in labor to 85% in 2002,” says George A. Macones, MD, who headed the development of the ACOG document. “Although EFM is the most common obstetric procedure today, unfortunately it hasn’t reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions.” That is an increase in use by 89% with what benefit to mothers and babies? More cesarean?  More interventions and managed labors? Perinatal mortality hasn’t decreased.  Shocking really.   So for the needs and most likely benefit of the truly high-risk moms and babies all women have been subjected to more and more electronic monitoring in labor resulting in more morbidity for mothers and babies.

Apparently a big issue is that there are huge discrepancies in interpretation when assessing the FHT strips by physicians. There was a group of 4 physicians who initially assessed 50 FHT tracings and only agreed 22% of the time. Then two months later the same 4 physicians were asked to re-assess the same 50 tracings and their own evaluations varied nearly 1 in 5.   I have heard this over and over anecdotally from labor and delivery nurses through the years.  That no one can agree.  That the variance is so great.  Better to treat just in case whether by interventions or a cesarean.  I have been told that even a 40 hour course on FHT assessment leaves one without any clear advancement of skill or knowledge. The training actually left one individual less inclined to trust assessment.  So how does this comfort the expecting woman? Knowing that the machine that rules so much of labor and delivery in combination with the human element is so fallible.  Now that is non-reassuring in real life application.

So what can be done?  Unless there is a real high-risk situation that needs to be addressed, ask for intermittent auscultation with a handheld doppler or even better with a fetascope.  When a nurse, midwife or doctor actually listens personally to a baby with a fetascope there is no machine interpreting sound. It is with their own ear and skill assessing your baby.

The other thing to remember is keeping away from routine use of  induction, narcotic use, and epidural use in labor can greatly improve the opportunity to remain low-risk and healthy.  Thus not requiring continuous fetal monitoring.

I only touched on a few aspects of the new guidelines.  For a more complete breakdown of the refined guidelines, the NY Times did a nice piece.

ACOG released a press release today regarding a new practice bulletin revising labor induction guidelines.  Though the practice bulletin is not available on the ACOG site, a detailed review is available by Medpage today.  I hope to soon have the full copy to share.

Some high points I found in the explanation and review of the revision:

• Misoprostol (Cytotec) should not be used to induce any woman with a previous uterine surgery or cesarean due to the increased risk of uterine rupture.
• The Foley catheter is a reasonable and effective alternative for cervical ripening and inducing labor (as stated in my blog earlier this week).
• The recommendation for fetal demise is for induction rather than cesarean unless unusual circumstances present as it is associated with maternal morbidity without fetal benefit.
• ACOG also states that the assessment of “gestational age and consideration of any potential risks to the mother or fetus are of paramount importance for appropriate evaluation and counseling before initiating cervical ripening or labor induction.”
• Admitting to this fact – At the same time, there have been a number of reports linking the induction of labor with increased risk of adverse events including uterine rupture and meconium-stained amniotic fluid.
• “A physician capable of performing a cesarean should be readily available any time induction is used in the event that the induction isn’t successful in producing a vaginal delivery,” notes Dr. Ramin. Although rare, there are potential complications with some methods of labor induction. (perhaps less inductions that are for lack of medical reason will be done if a physician must induction sit?)
• Post cervical ripening whether by medication or mechanical once the cervix is dilated, labor can be induced with oxytocin, membrane stripping, rupture of the amniotic membrane, or nipple stimulation. (using an alternative like nipple stim interesting)

Some low points I found in the explanation and review in the revision:

• The new guidelines include seven recommendations based on “good and consistent scientific evidence” — considered the highest evidence level — including one that sanctions 25 mcg of misoprostol as “the initial dose for cervical ripening and labor induction.” The recommended frequency is “not more than every 3-6 hours.” (I want to see these studies)
• ACOG said that the data on the safety of high-dose misoprostol (50 mcg every six hours) were “limited or inconsistent,” making its recommendation on high-dose misoprostol an evidence level “B” recommendation. (again studies please)
• The practice of inducing labor has become more common. More than 22% of pregnant women undergo labor induction, ACOG says, and the overall rate doubled from 1999 to 2006. (once again – only 22% – this one I need to research)
• Rapid delivery or lack of access to good care at home as a potential reason to induce labor in rural areas.

More possible low points:

• Some examples in which labor induction is indicated include (but are not limited to) gestational or chronic hypertension, preeclampsia, eclampsia, diabetes, premature rupture of membranes, severe fetal growth restriction, and postterm pregnancy.(need more information on how these are defined)
• Low- or high-dose oxytocin regimens are appropriate for women in whom induction of labor is indicated. (Pit to distress with high doses?)

So even ACOG says that induction needs to be taken seriously as there are risks and consequences associated.  Definitely I am in agreement with that. It IS a very big deal and the risks to not having your baby immediately must outweigh the benefits of baby staying put a little longer.

It has been reported that Molly Ringwald naturally birthed her twins (son Roman and daughter Adele) on July 10th, 2009.  Her babies arrived within minutes of each other.  No other details were given.

She had previously spoken publicly in a Fit Pregnancy interview about her desire for a vaginal birth.  Also that she would not schedule a cesarean due to expecting twins alone.  This is no small feat in today’s maternity world.  Women today nearly always deliver twins and other multiples via planned cesarean without labor (unless both babies are head down and the mother agrees to a tethered labor).

Something else stands out to me.  She appears to have bucked the trend of advanced maternal age obstetrics based on this study ama study.  You see Molly Ringwald is a gorgeous, healthy 41 year old!

Though Molly Ringwald is a celebrity, she is like all the rest of us, a  childbearing woman.   If she can do it, so can you!

Congratulations to Molly and her family.

In recent days there has been much chatter in the birth and consumer worlds about the use or rather misuse of the synthetic oxytocin drug Pitocin (ICAN, unnecesarean, nursingbirth, daytondailynews).

Pitocin is used very commonly in the United States before labor to induce, during labor to augment the process and post birth for the purpose of eliminating or preventing  hemorrhage. Women are told that it is just like the oxytocin she produces, it is a way to mimic natural labor, it is no big deal, etc.  Clearly that is not the case.  Unfortunately women are rarely if at all informed of the manufacturer’s protocol’s for use or the documented risks and  consequences to her and her baby as seen here – pitocinKingPharmPamphlet.

For a drug this powerful to be used routinely for  non-medically indicated induction and unnecessary labor augmentation is frankly terrifying and unethical.  How many complications go unreported or under reported that are directly attributed to such liberal Pitocin use? The thought is staggering.  My heart aches and sobs as there are thousands of women and babies suffering needlessly every minute, every hour, every day and every year.  The advocate in me raises a fist and grabs a bullhorn. Please spread the truth.

The many women who come out of birth terrified and traumatized.  They say how painful, how out of control, how trapped in bed, how unable to cope without pain medication, how they fear for another labor, how they don’t ever want to go through that again and so on.  Next time you hear that ask her if she was induced or augmented with Pitocin.  I think you will be astounded by how many will say yes and how many will give an account of the cascade of interventions that came with it.

Women I believe overall say yes to induction and augmentation because they have no idea of the true risk involved, and of the deep held ideal that no care provider or staff would recommend or allow any procedure (yes it is a procedure) that could harm a woman and a baby unless the benefit greatly outweighed the risk.  I do not believe that a care provider or staff member is trying to do harm, but more the realistic function that there is another medication to fix it, a protocol to manage it or the go to cesarean option to handle the pit-to-distress syndrome.

Every pregnant woman must find out how her care provider uses Pitocin with his or her patients.  She needs to inquire with the birth facility as to normal protocols surrounding this medication.

Be aware.  Be informed.  A decision only can be made well when the playing field is leveled.

Having a cesarean section will likely get you a baby, but generally much more than you bargained for.

Let me count the ways in no particular order:

• A scar that in no way makes a bikini look better. Sometimes described as a shelf or a pouch.
• The feeling of failure, guilt or less than deserving of motherhood.
• The struggle of living with the huge dichotomy of loving your baby and hating the birth.
• Higher probability of losing your ability to have more children either through physiologic secondary infertility, pregnancy complications, self-induced secondary infertility, hysterectomy or lack of sexual intimacy in relationship.
• Higher probability of difficulty in breastfeeding.
• Postpartum depression or PTSD, especially in an unwanted cesarean.
• The feeling of failure as a wife or partner.
• Having others discount your feelings and needs. After all you “just” had a baby. Really you just had MAJOR surgery, perhaps by coercion, or completely from interventions and medications.
• Living with the idea that you failed to pass induction, you failed to push out your baby, you failed because _________ (fill in the blank).
• Obtaining your records to find what you were told and what was written are different. Could your trusted care provider have lied and cheated you?
• Simply finding out that no one told you and you didn’t do the research, that being induced, getting the epidural, allowing AROM, not getting out of bed, etc. is why you had the cesarean. Is maternal ignorance and fear enough to quell what you feel and make it ok?
• How can you trust yourself as a mother when you ignored your maternal intuition and kept saying yes, because the nurse, midwife or doctor told you to?
• The way your marriage or partnership takes a turn toward hell.
• Living with dread when a hungry hand sweeps over your scar. Being sexual can be extremely difficult physically and emotionally.

For all of these – there a stories layered and interwoven for too many women. Every thirty seconds a woman is surgically having her baby delivered. Light her a candle. Offer her a meal. Let her speak. Listen to her intently. Send her to ICAN. http://www.ican-online.org/.