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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.

 

 

TRIAL OF LABOR, A New Film About Four Mothers and Their Determination To Give Birth Naturally After A Prior Cesarean

22 Jul

Two fathers, Robert Humphreys, an independent, award winning film maker and Dr. Elliot Berlin, a Chiropractor specializing in alternative prenatal care, set out to make a documentary film about the VBAC Ban in U.S. hospitals and its impact on the physical and psychological health of women who want to birth naturally after a prior cesarean. TRIAL OF LABOR, a documentary initially conceived as an educational film about the medicalization of birth in the U.S. and the pros and cons of VBAC and repeat cesarean, evolved into a powerful and inspiring personal journey of four mothers who had a prior cesarean and who were determined to find caregivers who would support their choice for a VBAC. The children of both Humphreys and Berlin were born at home. As men and fathers, they witnessed how powerful and validating birth can be.

With a healthy pregnancy, and a low horizontal scar on the uterus, women who go into labor on their own at term have about a 70% to 75% chance that they will have a safe VBAC. Avoiding a routine repeat cesarean protects women from complications of major abdominal surgery as well as potential complications in a subsequent pregnancy.

However, current controversial ACOG guidelines (Practice Bulletin #115) requiring that trial of labor (TOLAC) should take place in hospitals where resources for emergency cesarean are “immediately available” make it very difficult for expectant mothers to find VBAC supportive careproviders.

The National Institutes of Health (NIH) found that this “immediately available” recommendation was based on consensus and expert opinion rather than strong support from high-quality evidence.  The NIH also found that this recommendation had influenced about one-third of hospitals and one-half of physicians to no longer provide care for women who want a VBAC.

Told from the mothers’ own point of view, TRIAL OF LABOR is a sensitive and insightful look at four strong and courageous mothers who challenge an irrational and un-affirming medical care system to escape from a routine repeat operation-initially, the only option they thought they had.

Their journey to VBAC forces them to look back at their unexpected and unwanted cesarean birth. Face conflicting emotions about their ability to give birth and examine carefully the benefits and downside of both a natural birth and another operation.

“It was the most surreal Kafkaesk experience,” said one mother about her cesarean. “When I reflect about it,” says another, “I get visibly angry. That I didn’t inform myself enough.”

The mothers’ decision to give birth vaginally, where and with whom , did not come easy. “It’s very difficult to step away from the medical establishment,” expressed one expectant mother and yet,  chose to have a VBAC at home, her last resort, despite the lack of published evidence about its safety. Each mother decided for herself how she can best give birth this time.

The U.S. saw an increase in VBACs from the 1980s through the mid 1990s, but the VBAC rates have consistently declined since. One in four women had a VBAC in 1996 compared to 1 in 100 today.

Filmmaker, Robert Humphreys said, “Women have the power and wisdom to give birth. They have been doing it for thousands of years. We men need to step back and respect their strength and ability to give birth on their own.“

The producers of TRIAL OF LABOR have received an encouraging response to their request for  funding to complete the film and meet their post-production costs. They also plan to produce DVDs of the film. Humphreys and Berlin have launched a Kickstarter campaign to raise the funds and are asking the birthing community and the public at large to view the trailer and spread the news about this important and much needed film.

To view the trailer and find out more about the film visit, TRIAL OF LABOR.

A New Edition of a VBAC Book That Mothers Would Really Appreciate

12 Aug

Hélène Vadeboncoeur’s book, Birthing Normally After a Cesarean or Two, is written with the compassion, sensitivity and personal guidance of a mother who has herself experienced a traumatic first birth by cesarean and a second empowering and healthy normal birth. It is also written with the credibility of evidence-based research. Vadeboncoeur does not pass judgment on women’s choices and chooses to use the word “normal” simply as a substitute for vaginal birth. Written specifically for mothers, this comprehensive, well-researched and well thought-out book can also be a valuable resource for midwives, nurses, childbirth educators and doulas. Vadeboncoeur’s book was originally published in French.

Dr. Vadeboncoeur searched long and hard through her personal journey to better understand what led to the cesarean birth of her first child and why that experience impacted her life so profoundly. Her pursuit of a Ph.D. after the birth of her children was in great part a means to conduct research into the maternity care system and the high rate of cesareans .  Although it was challenging for her to find a care provider to support her wish for a normal birth in her second pregnancy, she found that experience to be transformational. That is why she wants women to know that it’s possible for them to avoid a routine repeat cesarean and have a safe normal birth.

The book begins with an assessment of the historical and current perspective on cesarean and VBAC. How the beliefs of the day regarding the safety and indications for cesareans have changed in the last three decades and how widespread non-medical indications for cesarean have increased the cesarean rate. Cesarean section, the most common major operation in the world is examined within the current climate of fear of childbirth, the undervalued process of normal birth and the highly charged medico-legal climate in the United States.

The author believes that birthing decisions  should be made by women and their partners and writes in her Introduction, “We women need to have our say because we’re the people most immediately affected by birth.” Vadeboncoeur’s respect for women’s autonomy and empathy for each woman’s  personal journey towards making a decision about how she wants to give birth is reflected throughout the book.

She presents factual information and her personal point of view without judgement. Her guide offers women a balanced view of the benefits and risks of repeat cesarean and VBAC. Even women who decide that a repeat cesarean is best for them can benefit from the advice given about how to have a satisfying cesarean birth.

Mothers considering a VBAC will get an honest estimate of the level of risk  that they are likely to face and how likely they are to give birth on their own.  The author also covers a wide range of issues that are likely to affect a VBAC – having had one or more cesareans, the time interval between the current pregnancy and the prior cesarean, whether or not labor is induced, having had a vaginal birth and if single or double layer sutures were used to close the cesarean incision.

Dr. Vadeboncoeur makes a convincing case  for why it’s worth the effort to consider a normal birth after a prior cesarean. Overall, VBAC is safer for women than major abdominal surgery especially if they are considering having several children. Normal birth makes it easier for babies to adapt to extra-uterine life, breath on their own and begin breastfeeding. Mother-infant attachment is more likely to be successful.  Emerging research is also helping us to understand the complex science of hormones and the significant part they play for mothers and babies during the process of normal birth.

Throughout the book Vadeboncoeur shares with women that giving birth normally can be an empowering, transformative and fulfilling experience when they work together with their care provider to plan the birth experience they want. Women considering a VBAC will find useful and realistic information about how best to prepare for a VBAC- before and during pregnancy as well as during labor and birth.

Given how difficult it is in North America today to have access to caregivers and hospitals who support vaginal birth after cesarean the author also provides her readers with advice about how to increase their odds of finding a supportive provider and how to reassess the need for medical interventions proven to reduce their chances of having a normal birth.

Birth is a powerful emotional and psychological experience that impacts women’s well being, their self-confidence and self-esteem and their capacity for early parenting. To help women explore and understand how their cesarean  may have impacted them and to help them heal from a traumatic birth Vadeboncouer writes  with compassion and wisdom about the value of revisiting their experience so as to better prepare for a normal birth. “It is possible that some of this book will shock you,” she writes. “That emotions about your previous cesarean(s) will resurface for the first time, or that they will re-emerge, even if you think you’ve put those feelings behind you. Don’t let that stop you. As you will see when you read the birth stories in this book…this is perfectly normal.”

The book is enriched by many  birth stories of women who have had a wide range of birth experiences. Personal accounts of women who began searching for a VBAC-friendly provider soon after their first cesarean as well as of women who, reluctant at first eventually did labor for a  VBAC. We also read about the women who labored for a VBAC but ended up needing a cesarean. Vadeboncoeur’s own personal birth experience and the stories that are weaved throughout the book give an honest account of what women experience when seeking providers, a safe place for birth, and support for labor.  Above all, the stories are testimony to what women can accomplish despite the many obstacles they find in a health care system that stacks the odds against them.

Fathers as well as mothers will also find Vadeboncoeur’s partner’s honest account of his experience of the birth of his two children very valuable. Although both children are now adults, it is revealing to find out how birth is also vividly remembered by fathers. Although Steve was a constant companion throughout both of  Hélène’s pregnancies and births he admits that during the first long birth that ended with a cesarean under general anesthesia he at times felt “a sense of impotence.”  When finally the couple found a supportive provider that would “allow” laboring for a VBAC  the conditions at the hospital were not quite as expected. The staff reflected anxiety and fear. “We did not experience this VBAC in peace and harmony,” Steve writes. “It was almost as if we felt that having a VBAC was a sin.”

This valuable book is available in both an American and a British edition. My only reservation is that having read Vadeboncoeur’s book in French, as originally published in Canada, occasionally I found myself, while reading the American translation, occasionally stumbling over a sentence or two that lacks the natural flow and cadence of the English language.  Overall, this comprehensive, well-researched and sensitively written book is a real find.

To find out more about Hélène Vadeboncoeur’s book and her  perspective on normal birth and cesareans, read her Three-Part Interview on Lamaze International’s Science & Sensibility blog.


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