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Turning a Breech is a Safe Option for Women with a Prior Cesarean

5 Mar

Breech presentation occurs in 3-4% of all term pregnancies and is the third most common reason for performing a cesarean in the U.S. More than 90% of breech babies are delivered by planned cesarean section. External Cephalic Version (ECV), a procedure that helps to turn a fetus from a breech presentation to a cephalic presentation has been shown to decrease the incidence of breech presentation at term for women without a cesarean scar thereby reducing the need for a cesarean section.  However, a study published in the January 2014 issue of  the British Journal of Obstetrics and Gynaecology   suggests it is safe for women with a prior cesarean to have an external cephalic version (ECV) in a medical center. This allows women to labor for a VBAC and reduce exposure to complications from a repeat cesarean.

The researchers in Spain compared a group of 70 low risk women with a prior cesarean with 387 low risk women with a prior vaginal birth who had an external version at or after 37 weeks of gestation.  happy mother with newborn babyAll women were expecting one baby. Physicians were successful in turning a breech in 67.1% of women with a cesarean scar and 66.1% of women with a prior vaginal birth. There were no complications in the group of women with a prior cesarean. Of the women with a prior cesarean 52.8% had a vaginal birth (VBAC). More than half of the women avoided a repeat cesarean section. Of the group of women without a prior cesarean 79.4% had a vaginal birth.

The authors of the study concluded that in addition to the 270 documented cases of uncomplicated ECVs for women with a prior cesarean, their data on 70 additional women that underwent the procedure without a uterine rupture or fetal mortality indicates that ECV is a safe option for women with a prior cesarean who want to labor for a VBAC.

Concern from the medical community for the complications of cesarean section and its impact on mothers and babies is mounting. Recently the American College of Obstetricians and Gynecologists and the Society For Maternal-Fetal Medicine issued Obstetric Care Consensus Statement: Safe Prevention of the Primary Cesarean Delivery which called for physician restraint in performing cesarean sections. The guidelines offered safe directives for preventing the first cesarean including offering a breech version to women to reduce the odds for a cesarean section.

This study on the safety of external cephalic version for women with a prior cesarean adds to the existing evidence and may encourage clinicians to also offer the procedure to women with a prior cesarean who may want to labor for a VBAC.

Resources for Mothers

American Academy of Family Physicians

What Can I Do If My Baby is Breech?

Royal College of Obstetricians and Gynaecologists, U.K.,

Turning A Breech Baby In The Womb

 

 

New Jersey Poised to Increase Access to VBAC

6 Jan

New Jersey has one of the highest cesarean rates in the country. According to U.S. Preliminary data for 2012 New Jersey has the third highest cesarean rate in the nation,  38.7% preceded by Florida (38.1%) and Louisiana (40.2%). In the last two decades repeat cesarean births without labor more than doubled in New Jersey, from 40% to 85%. According to the New Jersey Department of Health currently one in four cesareans are routine repeat operations without serious risk indications. The New Jersey VBAC Task Force wants to change that.

Task Force members agree that VBAC should be available to all low-risk women who choose to labor after a prior cesarean and increasing access to VBAC would improve obstetric care. New Jersey hospital VBAC rates vary widely, from 31.0% at Monmouth Medical Center to 0% for Memorial Hospital and Southern Ocean Medical Center in 2011. The Task Force suggested establishing a network of regional VBAC referral centers who can meet safety requirements for VBAC. The Task Force is a multidisciplinary collaborative group which includes the New Jersey Hospital Association, health insurance payers and malpractice insurers.  20111225_Jess_6619_2000

Hospitals often deny VBAC care by referring to the costly and realistically unattainable ACOG guidelines which recommend a surgical team and anesthesia be “immediately available” when women labor for a VBAC. Having had a prior cesarean adds a level of risk to the subsequent laboring process, however, the risks of laboring for a VBAC are the same as for women giving birth for the first time, yet women giving birth for the first time are not denied medical care, nor are they told that they are at risk because the hospital cannot guarantee that a surgical team and anesthesia will be “immediately” available in case they would need a cesarean section.

The New Jersey VBAC Task Force concluded that ACOG’s definition of “immediate access” has never been defined by ACOG or any other authority and the legal liability of this ambiguous recommendation is “not conducive to frank discussion with patients, resulting in obscure and often misleading counseling.”

Providing safe medical care for women in New Jersey who want to plan a VBAC is not an impossible task. After more than one year of deliberations, the Task Force concluded that many of New Jersey’s hospitals already have the resources that can meet the safety standards recommended to support mothers who want to plan a VBAC. The Hospital Capacity and Regional Accessibility Subcommittee reasoned that being able to provide advanced neonatal care was just as critical for responding to complications that may develop during labor for a VBAC.

New Jersey licenses 20 hospitals as intensive perinatal centers or intermediate/regional perinatal centers. These hospitals are required to have full-time on-site coverage by neonatal and pediatric specialists and consulting arrangements with anesthesiology. Responding to a Task Force survey, 14 of 20  intensive care perinatal centers  reported having 24-hour in-house obstetric coverage for cesarean, availability of anesthesia and operating room teams, and 60% of the intermediate and basic perinatal centers reported 24-hour on-site coverage and the rest the availability of an off-site obstetrician within 30 minutes once the need for a cesarean was established.

Also in response to the Task Force survey, 7 of the intensive perinatal care centers and 6 of the intermediate care centers were in favor of becoming a regional VBAC referral center.

To successfully increase access to VBAC the Task Force made several recommendations:

  • Re-evaluate the risks of laboring for a VBAC by comparing low-risk women with a prior cesarean with New Jersey’s benchmark population, low-risk multiparous women without a previous cesarean for a more realistic evaluation of potential maternal and neonatal complications.
  • Develop a VBAC education program to educate expectant parents about the benefits and risks of laboring after a prior cesarean.
  • Educate providers and hospitals about the benefits and risks of VBAC, adequate staffing and resources, labor progress patterns for VBAC , guidelines for augmentation of labor, signs and symptoms of uterine rupture or dehiscence and practice drills for appropriate response for a uterine rupture.
  • Educate in-hospital staff about VBAC including, risk management, nursing, anesthesiology, neonatology, lab and blood banks to have a more coordinated response in case of complications.
  • Providers should try to shift the focus of their conversation with their patients from “defensive communication and liability strategies toward true shared decision making.”

Tom Westover, MD of Cooper University Hospital in New Jersey and a member of the New Jersey VBAC Task Force will address health professionals and birth advocates about increasing access to VBAC on March 26 at the New Jersey BirthNetwork Symposium at Rutgers University Inn & Conference Center, Supporting NJ’s Birth Plan: Taking the Next Step and Implementing Evidence-Based, Mother-Friendly Maternity Practices in New Jersey.

 Resources

Northern New England Perinatal Quality Improvement Network,  VBAC Project

Childbirth Connection, Maternity Care and Liability: Pressing Problems, Substantive Solutions

Breastfeeding Is Priceless

4 Aug

This week countries all over the world are celebrating World Breastfeeding Week 2013. The World Alliance for Breastfeeding Action and the World Health Organization are among many organization that are providing educational materials and strategies to encourage mothers to breastfeed.

According to the CDC, although continued progress in initiating breastfeeding has been made over the last ten years in the U.S., infants are not breastfed for as long as recommended. More than 3 out of 4 mothers begin breastfeeding, but only 49% of babies are breastfeeding at 6 months and 27% at 12 months.

In an effort to educate maternity care professionals and childbearing families about the value of breastfeeding, the Coalition for Improving Maternity Services published a comprehensive fact sheet showing the evidence to support breastfeeding for mothers and all babies including premature and high-risk infants. The fact sheet shows that breast milk is the ultimate form of nutrition for babies and provides the best strategies for helping mothers initiate and maintain breastfeeding.

BREASTFEEDING IS PRICELESS

There Is No Substitute for Human Milk

A Coalition for Improving Maternity Services Fact Sheet 

The World Health Organization (WHO), health care associations, and government health agencies affirm the scientific evidence of the clear superiority of human milk and of the hazards of artificial milk products. The WHO and the American Academy of Pediatrics recommend that mothers exclusively breastfeed their infants for the first six months, and continue for at least a year and as long thereafter as mother and baby wish.1

Human milk provides optimal benefits for infants, including premature and sick newborns. Human milk is unique. Superior nutrients and beneficial substances found in human milk cannot be duplicated. Breastfeeding provides optimum health, nutritional, immunologic and developmental benefits to newborns as well as protection from postpartum complications and future disease for mothers.

A U.S. Healthy People 2010 goal is to have three-quarters of mothers initiate breastfeeding at birth, with half of them breastfeeding until at least the 5th or 6th month, and one-fourth to breastfeed their babies through the end of the first year.2 In 2007 only four states met all five Healthy People 2010 targets for breastfeeding.3

Maternity Care Practices Greatly Affect Breastfeeding

Labor, birth, and postpartum practices can facilitate or discourage the initiation, establishment, and continuation of breastfeeding.4, 5, 6, 7  According to the U.S. Centers for Disease Control and Prevention (CDC), many birth facilities have policies and practices that are not evidence-based and are known to interfere with breastfeeding in the early postpartum period and after discharge.8 The World Health Organization,9 the American Association of Pediatrics,10 the American Academy of Family Physicians,11 and the Academy of Breastfeeding Medicine12 recommend that maternity health professionals provide birth and postpartum care that is supportive of breastfeeding.

The World Health Organization has identified the following intrapartum mother-friendly childbirth practices as supportive of breastfeeding:

  • minimizing routine procedures that are not supported by scientific evidence;
  • minimizing invasive procedures and medications; providing emotional and physical support in labor;
  • freedom of movement and choice of positions during labor and birth;
  • staff trained in non-drug methods of pain relief and who do not promote the use of analgesics or anesthetic drugs unless required by a medical condition;
  • no unnecessary induction or augmentation of labor, instrumental delivery, and cesarean section.13

The quality of care provided in the first 24 hours after birth is critical to the successful initiation and continuation of breastfeeding. Hospitals and birth centers which encourage and support breastfeeding are more likely to care for mothers and newborns in the following ways:

  • Provide mothers with comprehensive, accurate, and culturally appropriate breastfeeding education and counseling.
  • Encourage skin-to-skin contact for at least thirty minutes between mother and baby within one hour of an uncomplicated vaginal birth or within two hours for an uncomplicated cesarean birth.
  • Give mothers the opportunity to breastfeed within one hour of uncomplicated vaginal birth and two hours of an uncomplicated cesarean birth.
  • Encourage newborns to receive breast milk as their first feeding after both uncomplicated vaginal birth and cesarean birth.
  • Perform routine newborn procedures while keeping mother and baby skin-to-skin.
  • Help mothers with breastfeeding and teach parents how to recognize and respond to their baby’s feeding cues.
  • Encourage rooming in and help the mother to be comfortable with baby care in her own room.
  • Avoid separations of healthy mothers and babies, and encourage continuous skin to skin contact. Promote as much skin to skin contact of sick babies with mothers as possible.
  • Do not give pacifiers to breastfeeding newborns, or any other supplements, formula, water or glucose water to healthy babies.
  • Do not give mothers discharge gift bags with formula samples or formula discount coupons.
  • Provide mothers with breastfeeding support after hospital or birth center discharge. Support may include: a home visit or hospital postpartum visit, referral to local community resources, follow-up telephone contact, a breastfeeding support group, or an outpatient clinic.14

Benefits of Breastfeeding for Children

Enhanced Immune System and Resistance to Infections

The infant’s immune system is not fully mature until about 2 years of age. Human milk contains an abundance of white blood cells that are transferred to the child, acting to fight infections from viruses, bacteria, and intestinal parasites.

Human milk contains factors that enhance the immune response to inoculations against polio, tetanus, diphtheria, and influenza.15

Breastfeeding reduces the incidence and/or severity of several infectious diseases including respiratory tract infections, ear infections, bacterial meningitis, pneumonia, urinary tract infections, and greatly reduces the incidence of infant diarrhea.

After the first month of life, rates of infant mortality in the U.S. are reduced by 21% in breastfed infants.

Breastfed infants are at lower risk for sudden infant death syndrome (SIDS).16

Protection Against Chronic Disease

Exclusive breastfeeding for a minimum of four months decreases the risk of Type I diabetes (insulin-dependent diabetes mellitus) for children with a family history of diabetes, and may reduce the incidence of Type 2 diabetes later in life.

Breastfed children are less likely to suffer from some forms of childhood cancer such as Hodgkin’s disease, and leukemia.

Breastfeeding reduces the risk for obesity, high blood pressure, and high cholesterol levels later in life.17

Human milk contains anti –inflammatory factors that lower the incidence of bowel diseases such as Crohn’s disease and ulcerative colitis.18

The incidence of asthma and eczema are lower for infants who are exclusively breastfed for at least 4 months, especially in families at high risk for allergies.19

Breastfeeding Premature and High-Risk Infants

Breastfeeding and banked human milk are protective and beneficial for preterm infants.

Hospitals and physicians should recommend human milk for premature and other high risk infants.20

Breast milk lowers the premature infant’s risk for gastrointestinal and infectious disease and reduces the incidence of necrotizing enterocolitis (inflammation with possible tissue death and perforation of the small intestines and colon).21

Human milk enhances brainstem maturation. Compared to premature babies who receive formula, preterm infants who receive breast milk score higher on future I.Q. tests.

Breastfeeding the premature infant reduces hospital costs and the length of hospital stay significantly.22

Benefits of Breastfeeding for the Mother

Women who breastfeed benefit from an increased level of oxytocin, a hormone that stimulates uterine contractions lowering the risk for postpartum bleeding. Women recover better with less blood loss at birth.

Exclusive breastfeeding frequently but not always delays the return of a woman’s ovulation and menstruation for a variable 20 to 30 weeks or more. This provides a natural means of child spacing for many.

Breastfeeding may enhance feelings of attachment between mother and baby.

Breastfeeding lowers a mother’s risk for developing ovarian and pre-menopausal breast cancer and heart disease, and may decrease the risk of osteoporosis later in life. The benefits increase the longer she breastfeeds.23

Breastfeeding women without a history of gestational diabetes are less likely to develop Type 2 diabetes later in life.24

The Cost of Not Breastfeeding

Private and government insurers spend a minimum of $3.6 billion dollars a year to treat medical conditions and diseases that are preventable by breastfeeding.25 Since children who are not breastfed have more illnesses, employers incur additional costs for increased health claims, and mothers lose more time from work to care for sick children.26

Coalition for Improving Maternity Services (CIMS) Fact Sheet March, 2009.

References

1. American Academy of Pediatrics, Committee on Breastfeeding, Breastfeeding and the Use of Human Milk, Revised, Pediatrics 115 (2005): 496-506.

2. Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, (2000). Healthy People 2010, Maternal, Infant, and Child Health, 16-30. Washington, D.C. Healthy People, http://www.healthypeople.gov/Document/pdf/Volume2/16MICH.pdf

3. U.S. Centers for Disease Control and Prevention, Breastfeeding-Related Maternity Practices at Hospitals and Birth Centers-United States, 2007. Morbidity and Mortality Weekly Report, (June 13, 2008): 621-625.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5723al.htm

4. U.S. Department of Health and Human Services. Office on Women’s Health, (2000). HHS Blueprint for Action on Breastfeeding. Washington, D.C. Office of Women’s Health

5. American Academy of Pediatrics, 2005.

6. U.S. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report, June 13, 2008

7. World Health Organization (2003). Infant and Young Child Feeding. A Tool for assessing National Practices, Policies and Programs. Geneva: WHO. http://www.who.int/nutrition/publications/infantfeeding/inf_assess_nnpp_eng.pdf

8. U.S. Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, June 13, 2008.

9. World Health Organization, 2003.

10. American Academy of Pediatrics, 2005.

11. American Academy of Family Physicians (2007). Family Physicians Supporting Breastfeeding, Position Paper, http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.printerview.html

12. Academy of Breastfeeding Medicine, ABM Protocols, (2006). Protocol 15: Analgesia and Anesthesia for the Breastfeeding Mother. http://www.bfmed.org/Resources/Protocols.aspx

13. World Health Organization, 2003.

14. U.S. Centers for Disease Control and Prevention. Scoring Explanation for the 2007 CDC Maternity Practices in Infant Nutrition and Care (mPINC) Survey. http://www.cdc.gov/breastfeeding/pdf/mPINC_Scoring_Explanation.pdf

15. U.S. Department of Health and Human Services. Office of Women’s Health, (2000).

16. American Academy of Pediatrics, 2005.

17. American Academy of Pediatrics, 2005.

18. United States Breastfeeding Committee, (2002). Benefits of Breastfeeding. http://www.usbreastfeeding.org/Issue-Papers/Benefits.pdf

19. Greer FR, Sicherer SH, Burks AW, and the Committee on Nutrition and Section on Allergy and Immunology. Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Timing of Introduction of Complementary Foods, and Hydrolyzed Formulas. Pediatrics 2008;121:183-191.

20. American Academy of Pediatrics, 2005.

21. Agency for Healthcare Research and Quality, Evidence Reports and Summaries, 2007.

22. United States Breastfeeding Committee, 2002.

23. United States Breastfeeding Committee, 2002.

24. Agency for Healthcare Research and Quality, Evidence Reports and Summaries, 2007.

25. U.S. Breastfeeding Committee (2002). Economics of Breastfeeding. http://www.usbreastfeeding.org/Issue-Papers/Economics.pdf

26. Washington Business Group on Health (March 2000). Breastfeeding Support At The Workplace, Best Practices to Promote Health and Productivity, Family Health in Brief, Issue No. 2. http://www.businessgrouphealth.org/pdfs/wbgh_breastfeeding_brief.pdf

For more references on breastfeeding, visit:

US Breastfeeding Committee: www.usbreastfeeding.org

Centers for Disease Control: www.cdc.gov/breastfeeding

La Leche League International: www.llli.org

International Lactation Consultant Association: www.ilca.org

This fact sheet was co-authored by Nicette Jukelevics, MA, ICCE, and Ruth Wilf, CNM, PhD.

© 2009 Coalition for Improving Maternity Services. Permission granted to freely reproduce with attribution.

Download a pdf of Breastfeeding is Priceless

A Professor of Psychology and VBAC Mom Explores How Women Make Birth Decisions After a Prior Cesarean and Shares Her Own Birth Stories

19 Jun

Yasmine L. Kalkstein, Ph.D. is Assistant Professor of Psychology at Mount Saint Mary College, in Newburgh, New York. She gave birth to her first child by cesarean. Her second birth was a VBAC. “Making the decision to VBAC was a scary one” the professor said. “I hated the idea of getting my hopes up and being all the more let down. Yet, I also knew that I’d feel an amazing sense of regret if I didn’t try.“  By talking with other mothers, she discovered that many women simply scheduled a repeat cesarean. Some by choice, others because they did not know about another alternative. The psychology professor realized that it was important to understand how women with a prior cesarean make a decision to give birth when they become pregnant again. Last summer Professor Kalkstein conducted the first phase of a research project to better understand this important issue.

On our June 7, 2012 blog post we asked women who wanted to participate in Dr. Kalkstein’s research to take the survey she had designed.  Apparently, the posting encouraged hundreds of women to respond. The data from this first phase of her study is now complete. She is now conducting the second phase of her research project.396871_10150477635423717_1114115397_n Once again she is asking women whose first birth was by cesarean and are currently pregnant if they would like to take the current survey. The research team is especially interested in women whose pregnancy is 25 weeks or less. Doing this survey helps give mothers a voice. The results can also help careproviders better understand the perspective and values of the women they care for.

At our request, Prof. Kalstein was gracious enough to share the results of the first phase of her research study and her own birth stories. If you are a pregnant woman who is considering taking the second BIRTH DECISION SURVEY, please do so before going on to read the results of the first phase of Kalkstein’s research project and her birth stories.

Prof. Kalkstein-My Birth Stories

I gave birth to my first daughter in Minneapolis while a graduate student in Psychology. I remember literally “tuning out” the class on c-sections during my birth preparation class. I nudged my husband and said, “Everything is fine, the baby is in the right position, so I am not likely to have a cesarean.” And I daydreamed through whatever was being said.

My water broke a couple days after my due date. I had never felt a contraction and when my water broke in the middle of the night, I actually thought I wet the bed! My husband called the hospital and they told us to come in right away.I dawdled a little…first I wanted to shower. And to eat something! But my husband was nervous and emphasized that the doctor said we needed to come in immediately.

We called our doula from the car on the way to the hospital. We didn’t want to wake her up earlier than we had to. She said, “Wait, maybe you should stay at home!”  We thought it was best to follow our doctor’s advice. After a few hours had passed with not much progress, they told me we had to start Pitocin. They kept upping the Pitocin and I was in agony, feeling horrible back pain with each contraction which came every 60 seconds. My nurse and doula tried to help me as much as they could, but finally I said, “I have to know how far along I am.” Turns out I was only at 1 centimeter dilation.  At that moment, I realized I couldn’t have an unmedicated natural birth. I could not handle this. They tried to encourage me to wait before taking any medication, but I begged for an epidural. I was so happy when the epidural kicked in and I could just relax.

My doula went to grab a bite and my husband relaxed next to me. Then gradually, I began feeling pain in my back again.  I called for help.  I could barely move to get into any position to relieve the pressure I felt. It took the anesthesiologist nearly an hour to get to me. I was in agony, trying to hold for the doctor to redo the epidural. I only had 45 seconds of relief between contractions. I recall trying to fix my eyes on a beautiful sunset while I felt a sense of panic until the epidural took effect.

I had been experiencing induced labor for 12 hours when the doctor checked me and said I was 10 centimeters. I had just gone through transition without a working epidural. It was time to push. I didn’t feel a thing but tried to push. The nurse was great; the doctor was barely present. I spent three and a half hours of basically seeing the top of the baby’s head, but I couldn’t push the baby out. I started running a fever, my contractions were so weak they could barely tell me when to push, and I was rushed to have an emergency c-section. I threw up when I found out the news, but I was not allowed to drink to wash my mouth out because I was going into surgery.

I began crying. The staff threatened that if I didn’t calm down, they would put me under general anesthesia. When we got to the OR, the doc asked me, “Are you excited to see your baby?” I answered,  “I just want an ice pop” (and at that moment, I really meant it). It had been nearly 22 hours since my labor began and I had been unable to drink or eat anything other than ice chips. My husband had to “sneak” sips of juice when no one was looking, and even then, we were worried we were doing something wrong.

My baby girl thankfully was okay, and I begged to be unstrapped from the operating table so I could touch her. Shortly after, they rushed her off (no nursing) as she had to go on (preventative) antibiotics for 48 hours because I had developed a fever.

I was taken to some post-operative room, where it seemed some of the focus was on “pain control.” I kept asking when I could see my baby. It somehow became clear to me they didn’t want to release me until my pain went down. They asked me to identify the intensity of my pain on a scale of 0-10, 10 being the worst.  I finally said, “What number do you need to hear to let me go see my baby? I’m a 2. Okay? Is that good?”

I nursed my daughter and then I was wheeled down to my suite to thankfully sleep. Or so I thought. I’m not sure what was worse–the labor or the 48 hours afterwards.

My daughter and I were separated by two floors and I was expected to get in a wheelchair and go up to breastfeed her. That was so hard for me and it would take me 45 minutes to get up there and return and then, I would have to go up again. When we were finally together 48 hours later, I was relieved. The recovery was horrible, and I went through some post-traumatic stress, feeling that I was less of a woman, and wondering what I had done wrong. My doctor said that I was probably too small, but told me I could try to VBAC in the future if I wanted.

In the couple of years after my daughter’s birth, I saw a couple of different doctors. One told me that I had a 90% chance of having a repeat cesarean given the way it played out the first time. Another told me 50%. I had moved to New York, and when I got pregnant, I went to see a doctor I had heard was great. It was a male physician with a private practice. I had never seen a male obstetrician before, but I didn’t care…I wanted the best. I told him my story, and cried. He empathized and said he thought I should try for a VBAC. I asked him, “What are my odds?” He said, “I’m not going to give you a number. But, I think you should try.” Then I asked him, “Can I drink during labor?” (I was not going through another labor on ice chips.) He answered, “What? Like vodka?” I realized, as we laughed, that this physician was it.

One week away from delivery, he told me not to come to the hospital until I was “literally crawling.” My doula helped me deal with my fears, telling me over and over that natural labor is not as bad as “Pitocin labor.” My labor was very long, and I called the doctor up and told him, “I just want to get an epidural so I could sleep.” And, “Can I go to the hospital now?” He was very harsh and told me, “If you come, you’ll get an epidural and then possibly a c-section…is that what you want?” I couldn’t understand how my nice doctor could be so mean, but in retrospect, I realize his words kept me out of the hospital a few more hours and he was only trying to help. After more than three days of contractions and nearly 20 hours of labor where I needed support, I finally BEGGED to go to the hospital. My contractions weren’t getting closer together (never closer than 6 min), but I was so exhausted from not sleeping for 2 nights. My husband and doula (who were both amazing) stalled as much as they could, packing my things and offering me food.

Finally we drove to the hospital. When we arrived, I saw my doctor immediately (I was 4 cm) and he did recommend that I get an epidural (he said I was narrow and he thought it might help). We got an “epidural light” when I was at least 5 cm, where unlike the first time, I could feel my body. Unlike with my first birth, I also was served a tray of food and drinks. At 8 cm, they broke my water. When I was fully dilated, this time I knew it was time to push and begged to do so.

While I was pushing the doctor, nurse, and doula at a certain point could see something I couldn’t. They began to say, “It’s going to happen.” The doctor said, “I’m too tired to do a c-section today.”  My doula, who promised me never to say I was going to have a vaginal birth unless she saw the baby crowning  also joined in. “You are going to do it.” I looked at her angrily, “Don’t get my hopes up!” Then I saw my doctor scrub up. I asked, “Are we going to do the c-section here?” In my head, I honestly wasn’t sure this was going to happen. When I saw the surgical tools on the tray and my doctor scrubbed up, I thought I was going to have another cesarean.   However, this time I gave birth on my own. In short, I had a successful VBAC. It was unbelievable to nurse right away and not be separated from my baby immediately after birth. I credit my supportive husband, doula, and doctor for helping me achieve this.

How My Birth Experiences Led To My Research

A week before I gave birth to my second child, I went to a luncheon for mothers and their children. I did not know anyone. In our discussions, I told them I was trying for a VBAC and other moms began to talk about their own births. It seemed that most of them had had cesareans. “I just scheduled a cesarean…I didn’t even think about it,” said one mother and “I wanted it all planned,” said another.   I was shocked at how different my attitude was. I was terrified of having another c-section. I began to wonder what led to our completely different reactions? Was it their doctor and what he/she said about how best to give birth? Was it their memories of their first birth? Was it a personality difference?

I had studied decision-making in the context of my doctoral program in psychology, and I realized this would be a fascinating topic to research. And so for the past eighteen months I have been researching why women choose to try for a VBAC or choose to repeat a cesarean. As a scientist, I am approaching my data analysis without interjecting my own biases. Trying a VBAC was right for me, but it’s not my job or my agenda to tell women what’s right for them. I want to learn how different variables may influence a woman’s choice.

Results of the First Phase of Our Research Study (Pilot Study)

Data we collected last summer revealed some interesting trends. We consider it a pilot study and now are limiting our sample to women who are pregnant (not only planning on being pregnant) and are in the early phase of their pregnancy (where they do not know their baby’s position yet). We are also asking more questions related to personality and gathering more information on what women know about VBAC before making their decision (e.g., odds of uterine rupture).

In our pilot study, we analyzed women who were pregnant (N = 166) or planning on being pregnant (N = 117). 215 were planning to VBAC, 20 were planning an elective repeat cesarean delivery and 48 were undecided. In an online survey, we asked the women questions about perception of risk, previous delivery, locus of control, and sources of influence.

Here are some of our results:

-Not surprisingly, women who plan on having a VBAC perceive VBAC as less risky than a cesarean section whereas women planning on having a repeat cesarean perceive VBAC as more risky than a repeat cesarean.

-Women who are less satisfied with their first birth are more likely to try for a VBAC.

-Women who are trying for a VBAC more strongly endorse these items:

•In my first birth I had no control and my situation determined the outcome.
•I felt like my body had failed in some way.
•I felt like my health providers or hospital staff had failed me in some way.

-Women perceive childbirth differently. Some women believe the doctor/nurse is in control. Others believe they themselves control the success or failure of their birth. Some mothers consider “luck” to play more of a factor. Psychologists call this personality variable “locus of control.”

A scale was developed to measure locus of control for childbirth (Stevens, Hamilton, & Wallston, 2011). We found that women who are choosing a VBAC have a stronger internal locus of control. This means women choosing a VBAC more strongly believe that they have control over their outcomes, and endorse items like, “I am directly responsible for my labor and delivery going well or poorly.” They also have less of a powerful-others locus of control and are less likely to endorse items like, “Following doctor’s orders to the letter is the best way to keep my labor and delivery from going poorly.”

-Women who are choosing to VBAC seem to be obtaining more of their information from and are being influenced by sources other than their healthcare provider.

15% of women choosing a VBAC listed online information as the primary influence on their birth plan.

22% choosing a VBAC listed their healthcare provider as the primary influence vs. 45% of women electing a repeat cesarean.

Why women want to plan a trial of labor after a cesarean (TOLAC): The majority of women who plan a Trial of Labor After a Cesarean (TOLAC) want to experience a vaginal birth, suggesting there is definitely an emotional component to this decision. Beyond that, other common reasons include a shorter hospital stay, avoiding surgery, believing it’s the healthier option, and being able to bond/breastfeed.

What I learned from women’s responses is that many women experience the same feelings I felt and that have been reported in previous studies:

Coping with fear of failure/loss of confidence (McGrath et al., 2010)

Wanting to experience natural childbirth (Kaimal & Kupperman, 2012)

Feeling unsupported by health professionals when they want to have a vaginal birth (Lundgren et al., 2012)

Here are a few comments from the women in our study who were choosing to have a VBAC that reflect some of the above sentiments:

  • “I felt like less of a woman after my c-section. I want to be able to say that I gave birth to my children, I want to endure the pain that is natural… I know this isn’t true but a small part of me believes that natural birth is almost a right of passage to becoming a mom. I know that isn’t the case, but that’s how I feel.”
  • “I am always so jealous of those who have had vaginal births. I really feel like a failure.  If I don’t at least try this second time around, I think I may regret it.”
  • “I’m also becoming afraid of the risks of VBAC as they were presented by one of my doctors.”
  • “ I’m trying to discuss with friends who’ve tried for a VBAC. They seem to be the only people who understand.”
  • “ I feel deeply in my core that my body is capable of delivering this baby vaginally, and I want to have that experience.”
  •  “I had already made my decision long before I became pregnant again, but seeing recent a photo of a college friend who was leaving the hospital after delivering vaginally, smiling broadly while sitting in a wheelchair, with the caption, ‘It’s embarrassing, but they make you go out in a wheelchair,’ made me tear up. When I was leaving the hospital after my c-section, I needed that wheel chair. And the pain and feeling of helplessness at not being able to walk at least sort of normally sticks with me today.”
  • “[I] just want the ‘normal’ experience.”
  •  “I barely remember my daughter’s first day of life. I was in pain for several weeks. I would prefer a day of pain versus several weeks of it. Additionally, I now have a toddler and would like to recover more quickly to try and keep things as normal as possible for her. I think people only see the convenience of the scheduled C-sec and don’t grasp that it is abdominal surgery-which is a big deal!”

Summary

Our results suggest that previous experience, risk perception, personality, and informational sources may influence women to make different decisions. I thank all the mothers who have helped by taking our survey and I look forward to researching this more in the next phase of our study. My research is, without question, personal.  Not only has my own experience led me to be passionate about this line of research, but learning about the issue from an academic point of view has also helped me heal.

Evidence suggests that VBAC is often a safe option, yet so many women aren’t choosing it. We need to understand why this is. Today, we have more of a role in directing our healthcare (patient-centered decision making); thus the exploration of psychological variables on medical decision making is an important area of research.

For additional information about this project, you can contact Dr. Kalkstein  at yasmine.kalkstein@msmc.edu.

 

 

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