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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.

 

 

Documentary Film Maker and VBAC Mom Pushes for Increased Awareness About Midwife/Doctor Collaboration

2 Jun

Bridgid Maher is a tenured, associate professor of Film and Media Arts Division in the School of Communication at American University. She gave birth to her first son by cesarean and wanted to have a VBAC when she was pregnant again. Maher chose a midwifery practice with privileges at a Washington D.C. hospital and gave birth naturally to a 9 pound 10 ounce daughter.Sherpaslogo

As Maher shared her VBAC story, she realized that many women did not know about the benefits of midwifery care or that certified nurse-midwives (CNMs) and Certified Midwives (CMs) can attend their clients’ births in a hospital.

Maher wanted to let women with a prior cesarean know about the benefits of midwife/physician collaborative care and decided to direct and produce The Mama Sherpas. Evidence shows that collaborative care reduces interventions, lowers cesarean rates and improves health outcomes. A Sherpa refers to a member of a Tibetan people living on the high southern slopes of the Himalayas in Eastern Nepal known for providing support for foreign trekkers and mountain climbers.

This last year Maher has been filming three collaborative practices: in Alexandria, Virginia; Springfield, Massachusetts;  and Davis, California. The documentary film-maker is looking for financial support to cover production expenses for an additional year to complete the project. Maher hopes to raise $30,000 by July 8th through an indiegogo campaign. Maher and the production team can keep any funds that have been raised by the deadline.

Birth advocates and mothers who want to increase awareness about birth options after a cesarean can support the film-maker by making a donation to the campaign.

Birth Practices that Lead to Optimal Maternal and Newborn Outcomes

10 Apr

April is Cesarean Awareness Month. An opportunity to showcase a model of care that lowers the odds for cesarean section for healthy women and leads to optimal health outcomes for mothers and babies.

Research shows that the following birth practices lead to optimal maternal and newborn outcomes:

  • Provide women with evidence-based information regarding benefits and risks of tests and procedures so they can make informed decisions about their care.
  • Encourage continuous support (doula care) for labor and birth.
  • Provide care that respects women’s cultural, social and religious preference.
  • Allow women to walk freely and choose positions of their choice for labor and birth.
  • Allow women to eat and drink during labor.
  • Do not use the following interventions routinely, and if needed their use should be evidence-based:
  • Amniotomy (breaking the bag of waters)
  • Continuous electronic fetal monitoring
  • Use of I.V.s
  • Encourage mothers to touch, hold and breastfeed their newborns at birth.
  • Encourage skin-to-skin contact for all mothers as soon as medically safe.
  • Strive to achieve a 5% induction rate, a 10% or less cesarean rate in community hospitals and 15% or less in tertiary hospitals, a VBAC rate of 60% or more and a 5% or less episiotomy rate.

These are the recommendations of the Mother-Friendly Childbirth Initiative (MFCI) an evidence-based mother-, baby-, and family-friendly model of care which focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs.

In California maternal and newborn health professionals have formed the Mother-Friendly Childbirth Initiative Consortium of Los Angeles and are using the MFCI as a practice and policy tool to improve outcomes in their communities. You can download powerpoint presentations on the MFCI from the website.

 Resource:

Scientific evidence that supports the Ten Steps of the Mother-Friendly Childbirth Initiative can be downloaded at no cost from the Journal of Perinatal Education: Promoting Normal Birth, Winter 2007 Issue, Supplement, Coalition for Improving Maternity Services: Evidence Basis for the Ten Steps of Mother-Friendly Care.

Cesareans Are Increasingly Being Questioned

14 Mar

In a video address to the Coalition for Improving Maternity Services (CIMS) Forum participants on March 1, Michael C. Lu, MD, MS, MPH, Director of the U.S. Maternal and Child Bureau, stated, “Cesarean has its place, but given the real risks associated with cesarean it should not be performed without clear maternal, fetal or obstetrical indication…Cesarean delivery increases the risk of placenta accreta which intern increases the risk of postpartum hemorrhage and cesarean hysterectomy.“

Michael C. Lu, MD, MS, MPH, Director U.S. Maternal and Child Health Bureau

Michael C. Lu, MD, MS, MPH, Director U.S. Maternal and Child Health Bureau

In an interview with Rebecca Dekker, Ph.D., RN, of evidencebasedbirth.com, Celeste G. Milton, MPH, BSN, of the Joint Commission expressed her concern about preventable cesareans,  “When medications are used to force labor, a first-time mom doubles her chance of having an unplanned C-section…A substantial number of unplanned C-sections are due to physicians mislabeling a woman’s labor as ‘failure to progress’- a term that research says is more aptly named ‘failure to wait.’“ The Joint Commission which accredits and certifies health care organizations wants hospitals to perform fewer early elective cesarean deliveries (before 39 weeks) and fewer cesareans on low-risk first-time mothers.

Milton stated that “physician and hospital practice patterns-not pregnant women’s conditions or their diagnoses- are the major reason for differences in C-section rates among hospitals.”  The Joint Commission has made it mandatory, as of January 2014, for hospitals with more than 1,100 births a year to publicly report on their elective cesarean rates and rates for low-risk first-time mothers.

In a recently published White Paper on cesarean section in the U.S. the California Maternal Quality Care Collaborative recently concluded:

Cesarean delivery has come to be regarded as the safer option, when in fact it has greater risks and complications than vaginal birth. Higher cesarean delivery rates have brought higher economic costs and greater health complications for mother and baby, with little demonstrable benefit for the large majority of cases. With the marked decline in vaginal births after cesarean, cesarean deliveries have become self-perpetuating; and every subsequent cesarean brings even higher risks…

Some women prefer cesarean birth, or view it as a positive experience. However, there is growing evidence that for the majority of women, having a cesarean (compared with giving birth vaginally) is associated with greater psychological distress and illness, including postpartum anxiety, depression, and post-traumatic stress disorder. Cesarean deliveries can have an adverse influence on maternal-infant contact at birth, women’s satisfaction with and feelings about the birth, their babies’ experiences, and their success with breastfeeding.

In its recent systematic review comparing harms of cesarean with vaginal birth, Childbirth Connection cautioned, “Overuse of cesarean delivery in low-risk women exposes more women and babies to potential harms of cesarean with minimal likelihood of benefit. Of particular consequence are downstream effects including childhood chronic illness and placental complications in any subsequent pregnancies. These include life-threatening complications that occur more frequently with accumulating surgeries.”

In Dr. Michael C. Lu’s video address he also emphasized that “…no woman should be subjected to unnecessary interventions and… every woman should be cared for in a system that respects her autonomy and upholds the principles of Empowerment, Do No Harm, and Responsibility (principles of the Mother-Friendly Childbirth Initiative) and be given the choice of mother-friendly maternity services…”

Caring for childbearing women according to the recommendations of the evidence-based Ten Steps of the Mother-Friendly Childbirth Initiative can effectively reduce exposure to unnecessary interventions that can lead to avoidable cesareans.

 

 

 

 

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