I am very glad to see that the American College of Obstetricians and Gynecologists has revised their guidelines for women who have had a prior cesarean. There are several positive changes listed in this .pdf file that I know many women will be very happy to be aware of. One of them is that a woman who desires to have a VBAC should not be forced to have a cesarean or denied care. Read the rest of the report here.

Courtney’s due date was September 1, 1999. Overall I had had a good experience with my doctor and hospital with Matthew’s birth, so I didn’t really think about any other options for my birth this time around. My pregnancy went well, although it was a little harder being pregnant while taking care of a toddler! I had more morning sickness with Courtney too, so I remember lots of mornings of lying on the couch while playing videos for Matthew. His favorite one was Winnie the Pooh and he watched it every day!

I very much wanted to have Courtney before her due date, and I had convinced myself that she was going to come early. My goal was to have her on August 16th, which was my father-in-law’s birthday. I searched the internet and did all of the home induction methods I could think of, including eating pineapple every day and several other things. So on Friday, August 14th, when I started having regular Braxton Hicks contractions every 3-5 minutes, I got excited. I called the nurse helpline, and she told me I was probably in early labor, even though my contractions didn’t hurt, because they had been going on for over an hour. So I called my sister-in-law who lived next door, and she drove me to the doctor’s office. The doctor said I wasn’t making any progress yet, but she expected me to have the baby that weekend sometime. So I went home and got ready, and started waiting. And waiting…

Obviously Courtney wasn’t ready to come out yet, and I fought my discouragement and disappointment when August 16th came and went. I kept waiting, and not much happened until the morning of September 1st, my due date. I slept well all night (not counting the bathroom trips), and woke up to my water breaking at 7:30 AM. This was the same way that Matthew’s labor had started! I woke Nelson up, he was about ready to get up and go to work anyway. Then we called my sister-in-law to come over and babysit Matthew for us. I remember having my husband take a picture of my pregnant belly before we left for the hospital because we hadn’t taken one in awhile.

The doctor’s office wanted me to come and be checked to make sure I was in labor, so we drove there first. When we got to the office, I was already having contractions enough so that I wanted to stop and sit down during them. We sat down a couple of times between the car and the office, and then again sat down in the waiting room. I remember looking around at the other pregnant women thinking that they didn’t know that I was in labor right then. When I got back into the exam room, my doctor checked me and I was 4 cm dilated, and sure enough, my water had indeed broken. They said there was meconium in the fluid, but weren’t concerned about it at the time. She smiled and told me we would be having a baby soon, and that I needed to get dressed again and go over to the hospital. Then she left the room, and I just laid there for a little bit. The last thing I wanted to do at that moment was get up! I even asked my husband (half joking) if we could just stay there and have the baby right there. But eventually of course, I got up and got dressed, and we slowly made our way back out to the car for the very short trip to the hospital which was right next door to the office.

Once we got to the hospital, my husband dropped me off at the door and went to park the car. I walked in, and the lady at the desk immediately asked me if I wanted a wheelchair. I guess she could tell that I wasn’t feeling very well… I said yes, and they wheeled me over to the elevator and up to the Labor and Delivery area. They checked me into a room, and I laid down on the bed and looked at the clock. It was 10:00 AM. At that time I was 5 cm dilated.

The nurses left me alone for awhile, and I thought to myself that I wanted to rest for a bit before getting up and moving around some more. I was determined to be more active during this labor, unlike my first one where I spent several hours in bed throughout the night. But I laid on the hospital bed for awhile, with the monitors strapped to my belly. I breathed through the contractions and had my husband play some worship music that I had brought along.

At 11:00 AM the nurse shift changed, and the new nurse came in to introduce herself to me. Right at that moment, I felt an urge to push during a contraction. She said that she would check me, and found that I was 7 cm dilated. She said that it would not be too much longer, and left the room again. I continued to have the urge to push, and contractions right on top of each other. I started screaming, and then a lot of people started coming and going, trying to get the warmer and all of the birth supplies ready very quickly. I heard one nurse tell someone to go and call my doctor, but by that time I was really screaming and having an uncontrollable urge to push. Several nurses gathered around my face, talking to me and telling me not to push. I remember one nurse with her face right in my face, telling me not to push, and my response was (screaming) “But it hurts!”

All this time, no one was paying any attention to my lower half, they were too busy trying to get me not to push. Even my husband was caught up in their antics, and was trying to talk to me as well. But nothing was going to stop my body from pushing this baby out, and in one big push/scream, she was born right onto the bed  at 11:15 AM with no one catching her! It was a good thing that no one had dismantled the bed yet, or Courtney would have fallen onto the floor! The doctor wasn’t there yet, and later she said that she was asking the nurse if she could finish examining a woman, and then heard me screaming in the background and said “I guess I can’t wait!”

Once Courtney was born, they did not put her directly onto my belly like they had with Matthew, because they wanted a doctor to examine her for signs of distress due to the meconium in my amniotic fluid. They took her over to the warmer right away, and suctioned her very well and listened to her breathing. I could see her the whole time, but I wanted to hold my baby! Finally they brought her back to me, and I got to meet my 1st daughter. She was beautiful!

Courtney breastfed very well right away, and I got a couple of stitches for a minor tear. I spent one night in the hospital, my husband didn’t stay with me this time because he wanted to go home and get some sleep in a bed rather than in a chair. We went home the next day and were so happy to have our new baby girl!

Click here to read more from this author – a mom of 3 boys and birth doula in California.

As an educator, I am pretty easy-going.  My main goal is to offer accurate, evidence-based information and trust the expectant family to make the decisions they feel are right for their situation.  I don’t give a lot of “you should do this” kind of advice — it’s just not my style, and I don’t think it lends well to a woman learning to trust her inner wisdom.

One place where I throw this out the window, though, is when it comes to “rules” a partner absolutely must follow.  These rules are not covered in a particular class, rather they come up according to what topics we happen to be discussing.  In class last week we happened to touch upon quite a few of these rules, and I told my families, “I should write these down.”  Enter, the blog!

These are for partners, so the “you” in the sentence is not the woman who is pregnant, but her direct support person…I think you know who you are.

1.  You are not allowed to have bad breath.  Her breath will probably be less-than-optimal — she is working hard, breathing through her mouth, it could have been hours since she last brushed her teeth, or she may have thrown up her last snack.  None of this matters.  She needs support, often in a very close, in-your-personal-space kind of way.  If her breath causes you to recoil, you can muster up your strength and remind yourself of the awesome events unfolding within her body.  If your breath causes her to recoil, she may, very bluntly, tell you so, or maybe she will just involuntarily vomit in your lap.  You have been warned.  No chili cheese fries with extra garlic for you, partner.  Breath mints, gum, and mouthwash are your friends.

2.  You are not allowed to comment about anything else that might come out of her that is NOT a baby.  It is very common for a woman to have a bowel movement during the second stage of birth — it is actually a good thing — not only does it provide extra space for a baby, it also shows she knows how to push.  If a woman asks later, “Did I poop?” be careful, this question can be as loaded as, “Do I look fat?”  My best answers to this question:  “Hmm, I don’t remember,” or a solid, “No.”  One situation, kids, where honesty doesn’t pay.

3.  You are not allowed to try and have a conversation with her during a contraction.  Commonly, partners pick this one up pretty quickly, so it is kind of a freebie.  But, there is a second part:  While this seems like a simple idea to you, others coming and going may not remember to “respect the contraction.”  Your job is to run interference so the laboring woman can focus — remember her contractions are her body’s little bursts of working energy, and her concentration is needed.  If a nurse or friend tries to talk to her at this point, not only can it be a source of irritation to her, it can actually impede her body’s ability to unroll the red carpet that is the birth process.  “Let’s wait and ask her when the contraction is over.”

4.  You are not allowed to suffer in silence if there are people in the room that your partner is obviously not comfortable with.  This includes friends and family as well as hospital staff.  If the person(s) happen to be friends or family, and they just won’t listen to your kind requests of removal, enlist help from your doula or nurse or practitioner.  Get one of these fine folks alone in the hall and let her know your company has gotten out of control, and to save yourself the potential grudge at the 4th of July party and forever, could she please help you out?  These professionals have mouths like magic wands and they can easily clear a room with smiles on their faces and official-ness in their voices.  Your guests will never know what was at the root of their departure, and you have helped protect your partner and the space she needs to un-focus for birth.

If the unwanted guest happens to be working at the hospital, it is perfectly acceptable to ask for a replacement or a removal.  If you feel there is a bad connection with your nurse, you can talk to her about it, talk to the nurse manager about it, or talk to your practitioner about it, and see if the situation can be changed for the better, either with improved communication, or with a new nurse who better fits your philosophy and birthing plans.  If a nurse walks in with a group of students and your birthing partner does not want to be on the observation deck, this is a situation where you can ask for removal, in a nice way, of course.  “My-partner-the-laboring-woman and I discussed this beforehand, and she is not comfortable having students present.”

5.  You are not allowed to get upset if you catch the brunt of some unseemly comments.  When a woman is having a baby, some odd things happen in her brain and she may not be in the “polite” part of her mind – that filter of sorts – that “nice-izes” the things we say.  Imagine this:  your eyes are closed and you are listening to something you know is very important, but it is lightly garbled and it runs together.  Your job is to pick out the words and phrases and construct some logical instructions out of it.  The words are being whispered, and you are concentrating hard, trying to understand them.  At the same time, you are aware of a fly buzzing around your face.  You don’t know how long the fly has been there, but suddenly it seems like forever, and in a nanosecond, the idea of that fly just consumes you, and you pop open your eyes and start flailing your arms around like crazy, surprised by how you went from zero to medieval in no time flat.  That’s kind of what it’s like in your head when you are absorbed in having a baby.

6.  You are not allowed to complain about being tired, hungry, sick, or sore.  That just kind of goes without saying.  If you feel you might need someone to help you help your partner if one of these four physical conditions should arise, consider hiring a doula.  Not only does she help the laboring mother, she also ensures the birth partner is doing well, gets to eat, gets to rest, gets a shoulder rub, etc.

To sum up:  Labor and birth are intense times.  There is so much going on that it can be hard to know how to help.  A woman must go through this process herself – no one can do it for her.  But that doesn’t mean she has to be alone while she is doing it.  The most important rule a partner should remember is to be with her and remind her of the wonderful job she and her baby are doing together, and that she has your support, your heart, and your presence during the process.

Author: Stacie Bingham. Printed with permission.

If the mother is to be conscious, an anesthesiologist will inject spinal or epidural anesthesia (usually fentanyl, a derivative from the opium family; and bupivicane, a derivative from the cocaine family) into the mother’s back or epidural space (between the vertebra) via a thin catheter. Vomiting and/or dry heaves may occur as a reaction from the narcotics, as may uncontrollable shivering. A catheter is inserted into her urethra to allow urine to be eliminated.

In a sterile operating room, with a surgical team in “scrubs”, masks, hair net, and gloves, preparation continues with strapping the mother’s arms, crucifix-style, to an operating table. A nurse starts an IV with fluid and/or narcotics (usually demerol or stadol, a derivative of the morphine family), and an anesthesiologist applies oxygen and/or general anesthesia. A curtain is hung between the mother and her lower body to prevent her from seeing the surgery. Her belly is laid bare and she is completely naked, save for a hospital gown that is now pulled up to her neck or just below her breasts. Her belly and pubic area are rubbed with a 10% Povidone-Iodine solution (a.k.a. “Betadine”) and her pubic hair is shaved. A sticky plastic drape is laid over her belly to stabilize her skin.

A horizontal incision is made with a scalpel, just above the pubic bone where the pubic hair begins, slicing through five layers of skin, tissue, and muscle: 1) the derma, or outer layer of skin and 2) fat; 3) the fascia, the tough, thin layer that supports the muscle; 4) the rectus muscle, which is manually separated with the fingers down to the pubic bone; and 5) the peritoneum, the shiny layer that encases the entire abdominal cavity. Suction is applied to absorb excess blood. A metal “spatula” known as a bladder blade is inserted to pull back and protect the bladder. Another “spatula” known as a retractor is inserted at the top of the incision and/or on the sides, and are pulled back tightly to enlarge the incision, usually by two surgical assistants. Another incision is made into a sixth layer, the uterine lining, taking care not to cut the bladder, causing infection. Suction is again applied. Sponges and gauze are used to blot blood and fluid pooling in the abdominal cavity.

The mother may feel intense pulling and tugging to dislodge the baby’s head from the pelvis. If vertex, the baby is pulled by the neck backwards out of the pelvis and then by the head through the incision in the uterus. The baby’s nose and mouth are then suctioned to remove any amniotic fluid, mucous and/or meconium from the airway. The remainder of the baby’s body is pulled from the mother’s uterus through the abdominal incision, taking care not to tear the uterine or abdominal incision wider.

The umbilicus is clamped and cut immediately and the child may be held up over the curtain for the mother to see before being taken to a warm table to be suctioned further, toweled off, footprinted, weighed, measured, tagged and wrapped in a blanket and hat. Pitocin and/or methergine is immediately injected into the mother’s IV to begin contractions of the uterus to aid in the removal of the placenta. The remaining umbilicus is then pulled and the placenta is scraped off the uterine wall by hand to tear away the placenta from the uterine wall. The placenta is removed and examined to ensure all pieces are intact. The uterus is then removed from the mother’s body and placed on her stomach for the incision repair. One set of stitches is made in the wall of the uterus, then a second layer of stitches in the outer lining. The uterus is then pushed back through the abdominal incision and into the mother’s body. Sponges and gauze are counted to ensure none are left in the surgical cavity. The abdominal cavity is irrigated with water to flush out bacteria (to prevent infection) and check for bleeding.

Approximately 1000cc of blood is lost during the procedure. A layer of absorbable stitches are made in the rectus muscle, another layer of sutures are made in the fascia. The plastic drape is pulled away from around the abdominal incision and another set of absorbable sutures or staples may be used for the outer layer, usually removed three to five days later by a nurse. A second dose of demerol may be injected into the mother’s IV to aid in relaxation as she is wheeled into recovery to hold her child when the physician allows it. Again, the mother may experience dry heaves and/or uncontrollable shivering and chills.

Within 24 hours, the urine catheter is removed and she is allowed to stand and perhaps walk to the bathroom or shower. Within three to five days she is discharged and permitted to return home, with a check of her incision in two weeks. If infection or seeping occurs, antibiotics may be prescribed. Incision pain may occur constantly or intermittently for up to a year. Feeling may be regained on the incision site, or nerve damage may result in permanent lack of sensation. Her ability to birth normally in the future may be called into question.

For video of a cesarean section, contact The Learning Channel at (800) 544-1717 and request a copy of the video, “The Operation: Cesarean Section.”

This may be copied and distributed with retained copyright.
© International Cesarean Awareness Network, Inc. All Rights Reserved.

Induction of Labor

The International Cesarean Awareness Network strongly advises women and health care practitioners to avoid induction of labor unless a true medical indication exists. Induction of labor frequently leads to further intervention in birth including the need for fetal monitoring, epidural anesthesia, instrumental delivery and cesarean section. Each of these interventions increases risks to babies and mothers.

First time mothers are especially vulnerable: Induction itself doubles a first-time mother’s risk of having a cesarean section.1,2

A cesarean puts a woman’s entire reproductive life, including subsequent pregnancies, at higher risk.

For all women, induction of labor increases the use of forceps and vacuum extraction as well as rates of shoulder dystocia.2,3

Women with a prior cesarean who are induced have a 33-75% risk of having another cesarean.4,5

Induction of labor has been shown to increase the risk of uterine rupture for women with a prior cesarean scar.6-9

Babies whose births are induced more often experience resuscitation, admission to the intensive care unit, and phototherapy to treat jaundice, which generally require separation from the mother. 10

References:
1. Maslow AS, Sweeny AL. Elective induction of labor as a risk factor for cesarean delivery among low-risk women at term. Obstet Gynecol 2000 Jun;95(6 Pt 1):917-2.
2. Dublin S, Lydon-Rochelle M, Kaplan RC, Watts DH, Critchlow CW. Maternal and neonatal outcomes after induction of labor without an identified indication. Am J Obstet Gynecol 2000 Oct;183(4):986-94
3. Nesbitt TS, Gilbert WM, Herrchen B. Shoulder dystocia and associated risk factors with macrosomic infants born in California. Am J Obstet Gynecol 1998 Aug;179(2):476-80
4. Learman LA, Evertson LR, Shiboski S. Predictors of repeat cesarean delivery after trial of labor: do any exist? J Am Coll Surg. 1996 Mar;182(3):257-62.
5. Sims EJ, Newman RB, Hulsey TC. Vaginal birth after cesarean: to induce or not to induce. Am J Obstet Gynecol 2001 May;184(6):1122- 4.
6. Blanchette H, Blanchette M, McCabe J, Vincent S. Is vaginal birth after cesarean safe? Experience at a community hospital. Am J Obstet Gynecol 2001 Jun;184(7):1478-84; discussion 1484-7.
7. Baskett TF, Kieser KE. A 10-year population-based study of uterine rupture. Obstet Gynecol 2001 Apr;97(4 Suppl 1):S69.
8. Shimonovitz S, Botosneano A, Hochner-Celnikier D. Successful first vaginal birth after cesarean section: a predictor of reduced risk for uterine rupture in subsequent deliveries. Isr Med Assoc J 2000 Jul;2(7):526-8.
9. Ravasia DJ, Wood SL, Pollard JK. Uterine rupture during induced trial of labor among women with previous cesarean delivery. Am J Obstet Gynecol 2000 Nov;183(5):1176-9.
10. Boulvain M, Marcoux S, Bureau M, Fortier M, Fraser W. Risks of induction of labour in uncomplicated term pregnancies. Paediatr Perinat Epidemiol. 2001 Apr;15(2):131-8.

This material may be copied and distributed with retained copyright.

Click here to visit the ICAN Website.

State of American Childbirth

Pregnancy and childbirth are normal, healthy processes for the majority of women and babies.

SCOPE AND SCALE OF MATERNITY CARE — EACH YEAR IN THE UNITED STATES:

1. Over 4 million Births
2. 99% in Hospitals
3. Over 90% Attended by Surgeons
4. Second Most Common Reason for Hospitalization
5. Most Common Reason for the Hospitalization of Women
6. Care for Mothers and Babies combined Rank 4th in Hospital Expenses
7. Over 6.8 million Obstetric Procedures Performed – 2nd Most Common Category of Surgical Procedures
8. Three of the Four Most Common Surgical Procedures Performed in the United States are Obstetric

Nearly all women giving birth in hospitals are subjected to some level of technological or medical intervention.
THE MOST COMMON INTERVENTIONS ARE:

1. Over 31% (1.3 million) Cesarean Surgeries – Has risen over 50% since 1996, HIGHEST EVER
2. Vaginal Birth after Cesarean (VBAC) rate has fallen over 50% since 1996, ACCESS DISAPPEARING
3. 34% (1.4 million) of Labors Medically Induced
4. 41% (1.66 million) Need Vaginal Stitching (episiotomy, tears, vacuum extraction, forceps)
5. 47% (1.88 million) of Labors Artificially Stimulated
6. 60% (2.4 million) of Women Denied Fluids
7. 76% (3.04 million) of Women Restrained In Bed
8. 85% (3.4 million) of Women Denied Food
9. 86% (3.44 million) Given Drugs For Pain Relief
10. Over 90% (3.68 million) of Women Attached To Electronic Fetal Monitors

What do we have to show for all this intervention?

OUTCOMES IN THE UNITED STATES:

1. High Infant Mortality Rate – Stayed Flat over the last 6 years, 29th in the world – Twice as High for African American Babies
2. Maternal Mortality Rate – Not Improved in 20 years, 25th in the world – Four times as High for African American Mothers
3. 12.8% (over 546,000) of Babies Born Preterm – has Risen 21% since 1990
4. Over 8.3% (over 354,000) of Babies Born Low Birth Weight – has Risen 19% since 1990
5. 44% (1.76 million) of Mothers have Emotional Or Physical Impairment after Birth Interfering with Ability to Care for their Babies
6. Over 25% (1 million) of Mothers have New Health Problems after Birth
7. 63% (2.52 million) of Mothers have some symptoms of Postpartum Depression
8. 18% (720,000) of Mothers show symptoms of Post Traumatic Stress with 9% showing all signs of PTSD.

With all the money we spend, why aren’t our outcomes better? Countries with lower costs and better outcomes for mothers and babies rely on midwives to attend most births – and many support out-of-hospital births.

The Midwives Model of Care & The Mother-Friendly Childbirth Initiative
www.cfmidwifery.org/mmoc www.motherfriendly.org
Promote Wellness, Education, and Individualized, Motherbaby-Centered Care.
Midwives are Key to Effective, Affordable Mother-Friendly Childbirth

Reprinted with Permission from Citizens for Midwifery

Click here for this article along with references.

“Two of the most over-utilized and most commonly performed surgeries in America are cesarean sections and hysterectomies. When a doctor and a hospital get involved in the natural process of childbirth, time is money. “Spontaneous deliveries,” as they are often referred to (where there is no surgical intervention), are time-consuming for doctors.”

To read the rest of this article, click here.

Your Right to Refuse: What to Do if Your Hospital Has “Banned” VBAC Q & A