Archive for the ‘Vaginal Birth After Cesarean (VBAC)’ Category

The Complete Illustrated Birthing Companion: A Book Review

September 10th, 2013 by avatar

I recently had the opportunity to review a book published in January, 2013, written for birthing families. The Complete Illustrated Birthing Companion; A Step-by-Step Guide to Creating the Best Birthing Plan for a Safe, Less Painful, and Successful Delivery for You and Your Baby.  This book is authored by a diverse team of experts, Amanda French, M.D., an OB/Gyn, Susan Thomforde, CNM, Jeanne Faulkner, RN and Dana Rousmaniere, author of pregnancy and birth topics. I wanted to share my review with Science & Sensibility readers so you can consider if you want to add this book to your recommended reading list for expecting families. The book is available on Amazon for 14.29 and a Kindle version is available as well.

This book is marketed as a large 8 1/2 by 11 inch paperback with an attractive cover.  Inside is easy to read print, a pleasant amount of white space on semi-glossy paper, along with full color photographs and illustrations.  There are some beautiful photographs in there, clearly taken by talented photographers, but some of the photos seemed too unnatural, women posed in the perfect position, wearing make-up with hair just so.  The pictures are all completely modest, with the exception of just one woman in a birth tub, which surprised me in a book about birth.  In my experience, birth is a bit more “gritty” than represented by the pictures chosen for this book.  I really appreciated the diversity of images of the women and their families, women of color and their families are well represented throughout. I also appreciated the choice of language, women have partners and those partners can be men or women.

Who is this book for?

This book for is for women who are still deciding on a birth along the spectrum of options, from a home birth to a planned cesarean. It also makes sense for women who are not quite sure what type of birth they want; they can read about all the choices as they settle on what feels good to themselves and their families.  The book is written in easy to understand language, and when medical vocabulary is introduced, a definition is provided so that readers can be clearly understand what is being discussed.  The book is best used for determining what type of birth a woman is interested in having.  If the mother has already determined where and how she would like to birth,  then this book, which is in large part a comparison of the different options, would be less useful.

Jeanne Faulkner, RN

What will families find inside?

The book starts off by asking women to imagine their perfect birth, encouraging them to hold this in their minds, but to also remember that birth requires flexibility as things can change during a pregnancy or labor that will require a deviation from what a mother was planning.  A brief but accurate overview of provider types (and a good list of questions to ask providers to determine who is right for each mother) and childbirth education options are covered, and states Lamaze includes a “good, comprehensive overview of childbirth.”  The chapters are then divided into options by birth location as well as pain medication choices, and then goes on to cover induction, planned and unplanned cesarean. Natural coping techniques and pharmacological pain medication options are covered in a chapter toward the end, along with a guideline for writing a birth plan.

“Unmedicated Vaginal Birth at Home” or “Epidural, Vaginal Birth in the Hospital” are some of the chapter titles and for each section the authors take the time to explain what this option is, why it may or may not be right for any particular woman (in the case of home birth, why a woman  might risk out of this option prenatally or in labor), the pros and cons of each option and how to best prepare if this is the choice a woman has made.  Throughout the book, the authors take care to state that women should be flexible and things may change. Desiring an epidural but not having time for one is a possibility that women need to consider.  I really appreciate this gentle reminder throughout the book, as I too believe that being flexible and being able to deviate from what a woman originally planned will help as the labor unfolds.

For each type of birth, women are given suggestions to help them achieve the birth they want and are encouraged to have a variety of coping techniques lined up for dealing with labor pain if they are choosing to go unmedicated.  Realistic and useful advice is given, even when the birth is highly managed, so that the mother and her partner can have a positive experience.

Amanda French, M.D.

What families won’t find inside?

This is not a book about pregnancy, breastfeeding, postpartum care or newborn care and it doesn’t claim to be.  This is a book about birth and the choices surrounding birth.  Families who want to read about prenatal testing, or learn about breastfeeding techniques will want to have other books in their collection that cover those topics.  While this book does a nice job covering the different options, birth locations and provider choices available to them,  it does so in a very matter of fact way.  There is not a lot of “rah-rah you can do it” language or encouragement for women to stretch for a low intervention option.  On one hand, it is nice to have the facts. On the other hand, evidence shows that for normal, low risk women, the less interventions the better for both mother and baby.  I am not sure that parents will walk away with that message after reading this book.

Would I recommend this book?

While providing a nice general overview of birth choices, I felt like there were several times that the authors wrote that women should trust their care provider’s expert recommendations versus becoming more informed and discussing all options, including the right to informed refusal.

For example, in the small section on episiotomy, it reads “How do I decide whether I want an episiotomy or a tear?  The short answer is this: You don’t make that decision, your provider does…If your provider decides an episiotomy is absolutely necessary, for example, to get the baby out more quickly, then so be it.  Your provider makes that decision based on the medical situation at hand.”  No mention of informing the woman, seeking consent or alternatives to cutting, for example changing position or waiting.

One of the authors, Dr. Amanda French also states several times that she stands with ACOG’s statement on homebirth (which is that birth should occur in a hospital or birth center attached to a hospital) and does not believe that having a baby at home is safe. She does acknowledge a woman’s right to make the decision on birth location for herself.  In reading the chapter on home birth, this bias does come through.

Dana Rousmaniere

In my opinion, the book is written through the health care provider’s lens.  Doulas are promoted- but readers are warned to watch out for those doulas who may have a “strong personal agenda” and parents are encouraged to work with experienced doulas, instead of doulas-in-training or those just starting out.  Birthing women are asked to let the anesthesiologist attempt two epidural placements, (if the first one does not work due to the mother having a “challenging back” or “not being in the ideal position”) before asking for another doctor to try.  Women are told to follow the recommendations of health staff in several places in the book.  Families are told that their newborn will have antibiotic eye ointment and hepatitis B vaccines administered.

In the chapter on VBACs, women are told that a con of VBAC-ing is that ”Vaginal delivery can result in tears in the vagina, which can be repaired immediately after delivery but may result in pain for several weeks after birth.”  Isn’t this a risk of any vaginal delivery?  For the families that I work with, I try to have mothers (and their partners) view themselves as a more equal partner in the decisions that are being made during labor and birth.

In summary

Overall, this book does a fair job of representing what to expect in eight different labor and birth scenarios, who might be a good candidate for each option and how best to be prepared.  Women can read and get assistance in choosing what might be the best option for them. Information on coping techniques and even pictures of good labor positions to try are well organized for easy reference.  For a woman who is undecided about where she wants to birth, this book will help her to understand the differences and the pros and cons of each location and type of birth, along with who attends births in each location.  For women who are have more clarity on what type of birth they want, I might make a different birth book recommendation.

Have you read this book?  Can you share your thoughts and opinion in our comments section?


Book Reviews, Epidural Analgesia, Home Birth, informed Consent, Maternity Care, Medical Interventions, Midwifery, Pain Management, Vaginal Birth After Cesarean (VBAC) , , , , , , , , , , , ,

April is Cesarean Awareness Month! Resources for You and Your Classes

April 4th, 2013 by avatar

April is Cesarean Awareness Month (CAM) and that presents a wonderful opportunity to share resources for cesarean prevention and recovery as well as Vaginal Birth after Cesarean (VBAC) support.

I am a co-leader of the Seattle chapter of the International Cesarean Awareness Network (ICAN) and teach classes in Seattle on both VBAC and Cesarean birth. (I call them VBAC YOUR Way and Cesarean YOUR Way)  I thought I might share my favorite resources on this topic and ask you to share with readers what you prefer to share with your students, patients and clients on this topic.

ACOG Committee Opinion on Cesarean Delivery on Maternal Request

ACOG Practice Bulletin on Vaginal Birth after Cesarean Delivery

Birthing Beautiful Ideas; VBAC Scare Tactics – Kristen Oganowski has a great series on scare tactics that women hoping to VBAC might face.  Good balance of heart and science.

Birthing Normally after A Cesarean or Two – Science & Sensibility three part interview with author and childbirth researcher Hélène Vadeboncoeur, done by Kimmelin Hull, former Science & Sensibility Community Manager

Cesareanrates.com - organized by Jill Arnold (of The Unnecessarean), provides a comprehensive breakdown of cesarean rates by state and hospital for the USA.

Childbirth Connection – Vaginal Birth or Repeat C Section: What You Need to Know

Evidence Based Birth – Rebecca Dekker is a Science & Sensibility contributor and writes a great fact based blog.  She frequently writes on the topic of cesareans.

Giving Birth With Confidence’s A Woman’s Guide to VBAC: Navigating the NIH VBAC Recommendations - Lamaze International’s parent blog hosts this wonderful resource written by Amy Romano and Kristen Oganowski

International Cesarean Awareness Network – international organization that works to prevent unneeded cesareans, promote cesarean recover and help women striving for a VBAC. Offers both online support as well as local chapter meetings.

A Natural Cesarean – A Woman Centered Technique. This video demonstrates and discusses ways that health care providers can make the cesarean more mother-baby centric, offering techniques that provide a great degree of satisfaction to the birthing woman.

NIH VBAC Consensus Statement – In 2010,  the National Institute of Health, a US government agency convened experts on VBAC and Cesareans and took testimony and heard discussions about best practice.  They summarized the results of this groundbreaking forum in this document.

The Truth about Cesareans – by Eugene Declercq.  Short 6 minute video on why the cesarean rate might be so high.


VBACFacts.com – A blog run by Jen Kamel, this website is a wealth of information and analysis on current studies and data as it relates to cesareans and VBAC birth.  Jen also runs a fabulous VBAC webinar that is available online.

The Well-Rounded Mama – blog run by occasional Science & Sensibility contributor Pamela Vireday, provides frequent information on VBACs, cesareans and large sized women, but the insight is valuable for all.

I am also aware of a free webinar, for birth professionals and providers as well as parents, “Family Centered Cesarean Birth” that you may want to consider signing up for.  Click here for more information. The webinar is presented live on Thursday, April 11th and then available after the presentation to watch as a recording.

What are your favorite go to resources to share with expectant parents?  Do you have a particular film clip that you like to show?  A book recommendation?  Do you have an effective method of presenting information on Cesareans and VBACs in your classes and with your clients and patients.  Let’s have a discussion in the comments section.  I welcome your thoughts.



ACOG, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Maternal Quality Improvement, Maternity Care, Vaginal Birth After Cesarean (VBAC) , , , , , , ,

Parents’ Singing to Fetus and Newborn Enhances Their Well-being, Parent-Infant Attachment, & Soothability: Part One

February 19th, 2013 by avatar

Regular contributor Penny Simkin shares her experiences with parents who sing to their baby in utero and then continue after birth and looks at what the research says about this practice in this two part blog piece.  Part two can be found here. Join me in reading about some unique situations that Penny shares as she explores this opportunity for parents to bond with their unborn child.  - Sharon Muza, Science & Sensibility Community Manager.


People have sung to their babies forever. Every culture has lullabies and children’s songs that are passed down through the generations. New ones are written and shared and the custom goes on –a rich part of the fabric of human civilization. These songs are designed to relax babies, calm their fears, or entertain and amuse them throughout childhood. As we have learned more about the life and capabilities of the fetus, we have realized that the fetus can hear clearly for months before birth, and also can discriminate sounds and develop preferences for some sounds over others. Furthermore, at birth, newborns respond to familiar sounds by becoming calm and orienting toward the source of the sound, and even indicate their preferences for familiar voices and words over the unfamiliar.

Newborn babies prefer their parents’ and other familiar voices over those of strangers (1), and they prefer hearing a story that their mother had read frequently in utero rather than an unfamiliar story or the familiar one read by someone other than their mother (2).  Fetuses hear, remember, have preferences, respond to, and discriminate among differences — in sounds, music, voices.

These exciting findings have inspired educators to advocate prenatal learning through recordings played through a mother’s abdomen (of languages, music, and other things). They have inspired birth activists and baby advocates to provide a safe enriching environment for the fetus. Advocates of prenatal bonding emphasize communication between parent and unborn child as a powerful way to strengthen the bond.

I’d like to offer my take on this phenomenon and urge everyone who works with expectant parents to tell them about some unique and heart-warming benefits of singing or reciting rhymes to their unborn babies.

I think my interest in parents singing to their babies prenatally began in the 1980s when I first read Michel Odent’s book, “Birth Reborn”(3). Odent is a French physician who has always been ahead of his time. He had a unique and original maternity care program at his hospital in Pithiviers, France. His book had a great influence on my understanding of normal birth, and the book is still worth reading today, along with all his subsequent ones. One lovely aspect of his program is particularly relevant to the topic of this blog post. The program included a weekly singing group at the hospital, attended by pregnant women, their partners, families with young babies, the midwives, and Odent himself. The group was led by an opera singer who believed singing to be important for fetuses, babies and those who care for them. Odent’s account inspired me to invite Jamie Shilling, a folk singer who had recently taken my birth class, to bring her guitar and her baby to my classes a half hour early each week and sing with the expectant parents. That went on very successfully for several class series, then the groups decided to combine and carry on in a monthly sing- along for expectant parents and new families, in a private home –Although the groups  eventually disbanded, they provided many parents with opportunities to sing together and connect with their babies and each other in relaxing and peaceful surroundings. A high point during that time was when Michel Odent came to Seattle to give a conference and he agreed to come to one of our sing-alongs. See the photo of Jamie leading the group of expectant and new parents, with Michel Odent and myself participating. He taught us the song, “Little Black Cat” in French.

© Penny Simkin

I couldn’t help but think during those times, how the unborn and new babies must love hearing their parents singing. Seeing the parents caressing the mother’s belly as they sang was heartwarming. That happened  in the mid- 1980s, when much research on the capabilities of the unborn and newborn baby was beginning to be published. Recalling those special gatherings, I have always suggested to my students in childbirth class that they sing to their unborn babies, or play their favorite recorded music, with the thought that the baby will remember it and be soothed by it after birth.

But it was one couple, whom I served as a birth doula, who took my suggestion to another level, and showed me much more about the value of singing to the unborn baby. They were having their second child, hoping for a VBAC. When they discovered that they were having a boy, they decided to give their baby the song, “Here Comes the Sun” and sang it to him often during pregnancy. The VBAC was not possible, and as the cesarean was underway, and the baby boy, crying lustily, was raised for the parents to see, the father began belting out the baby’s song. Though the mother didn’t have a strong voice under the circumstances, she also sang. The baby turned his head, turned his face right toward his father and calmed down while his father sang. Time stopped. As I looked around the operating room, I saw tears appear on the surgical masks.

It’s a moment I’ll never forget, and it was that event that taught me the value, not only of singing prenatally, but also, singing the same song every day. Not only does the baby hear his or her parents’ voices, not only does he or she hear music, but the baby also gets to know one song very well. Familiarity adds another feature to this concept, because we know that fetuses have memory and prefer the familiar. Think for a moment about what this might have meant to our cesarean-born baby –suddenly being removed from the warmth, wetness, and dimness of the womb with its mother’s reassuring heartbeat, into the cold bright noisy operating room. The baby’s transition to extrauterine life is hectic and full of new sensations. He cries reflexively, but perhaps also out of shock and discomfort. Then he hears something familiar – voices and music and the sounds of words that he has heard many times before – something he likes. He calms down, and seeks the source of this familiar song. Everyone present is moved by this gift to the baby from his parents.

I’ve become passionate about this idea as a way to enhance bonding between parents and babies, but also as a unique and very practical measure for soothing a fussing baby or a sick baby who can’t be held or breastfed. Please join me on Thursday, for Part Two on this topic when I will continue the discussion including research evidence that supports this concept: practical suggetions for childbirth professionals to share with expectant parents; and some very endearing film clips of families singing to their babies.


1. Brazelton B. Cramer B. (1991)The Earliest Relationship: Parents, Infants, and The Drama Of Early Attachment . Da Capo Press Cambridge, MA.

2. De Casper A. 1974, as described in Klaus M, Klaus P, Kennell J. 2000. Your Amazing Newborn. Da Capo Press, Cambridge, MA.

3. Odent M. 1984, Birth Reborn. Pantheon Books: New York 

Cesarean Birth, Childbirth Education, Doula Care, Guest Posts, Infant Attachment, Newborns, Parenting an Infant, Vaginal Birth After Cesarean (VBAC) , , , , , ,

ICAN, VBAC Friendly Hospitals, Midwives, Childbirth Educators: Speaking with Elaine Diegman, CNM, Ph.D

April 30th, 2012 by avatar

We wrap up Cesarean Awareness Month and acknowledge the week of International Midwifery Day with a post about an initiative to  create a VBAC Friendly Hospital, led by midwives.

ln honor of Cesarean Awareness Month, Lakeisha Dennis, the Chapter Leader of International Cesarean Awareness Network (ICAN) of Greater Essex County, New Jersey, invited Elaine Diegman, CNM, Ph.D, to speak about Worst to First, a talk about how to modify New Jersey’s high cesarean rate. Professor Diegman is head of the University of Medicine and Dentistry of New Jersey’s (UMDNJ) School of Nursing’s Midwifery Program.

Nationwide, the cesarean section rate is about 33%; in other words, one in three women in the United States give birth by surgical cesarean section. The cesarean section rate has risen about 50% in 15 years. According to the World Health Organization, a cesarean section rate of about 5 – 10% is the target for overall optimal maternal – baby outcome.

The state of New Jersey has a cesarean section rate of about 39%. New Jersey consistently places in the top two states for the highest cesarean section rate, sharing this distinction at the moment with the state of Louisiana.

Despite the National Institute of Health’s recommendation about vaginal brith after cesarean (VBAC) being safe under certain circumstances, there is a ourtright ban on vaginal birth after cesarean (VBAC) in many hospitals across the nation and the birth educators and doulas at this meeting said they noticed some ob-gyn practices have a quiet bait and switch tactic in place around this issue.

Professor Diegman has a long and distinguished career. She started out by telling us she’s actually the oldest practicing midwife in New Jersey (and maybe in the American College of Nurse Midwives). She gave us some history about the profession of midwifery. She reminded us midwifery is mentioned in the Bible and all the past royal houses of Europe used midwives for their births. She added she attended so many births in her career, she stopped counting after 3000.

Professor Diegman wanted to talk to us about pro-active change regarding lowering the cesarean section rate. UMDNJK has spearheaded a new initiative at Newark Beth Israel Hospital. UMDNJ has worked to become an official Vaginal Birth After Cesarean (VBAC) Center, keeping with the guidelines developed by the National Institutes of Health and the New Jersey Hospital Association. Dr. Diegman and Mary Markowsky, CNM, who heads the midwifery area of Newark Beth Israel, were instrumental in helping the hospital gain this distinction.

The empowering role of the childbirth educator

Professor Diegman stressed it is crucial we educate women about the normalcy of birth. She is passionate about the midwifery model of birthing. She wants to spread the word about how pain in childbirth is not like pain in illness, and emphasizes women do have the ability to rise to the experience of childbirth.

She emphasized the crucial role of education in preserving a woman-baby-centered birth culture. Professor Diegman said healthcare providers don’t normalize birth for women and don’t introduce women to nonpharmacological techniques to manage their birth.

Women only learn these techniques in independent childbirth education classes. So, the role of the childbirth educator is crucial in helping women understand what birth really can be and in getting our women back. The childbirth educator has a unique role to educate and empower women.

Dr. Diegman said the media and our constant exposure to technology has eroded women’s confidence in their ability to give birth. She wants to bring our women back. When Oprah, a powerful media presence, comes out positively about epidurals, that hugely influences our society’s views of birth. Dr. Diegman went on to say Oprah’s not the only one; there’s a constant flow of negative media stereotypes about birth. In addition, she said our constant reliance on technology has eroded our confidence in our bodies. She said “We need to be warriors and get our women back!”

Sonora Davis, community doula with the Hudson Perinatal Consortium, says “….women don’t seem to be taking the time to acknowledge their pregnancy or bond with their babies in utero.” She said she’s noticed this leads to a lack of focus on the birth. The other doulas, childbirth educators and midwives in the room echoed this concern, saying the disconnect during pregnancy sets up a disconnect to the experience in the birth room.

Childbirth educators play a crucial role in helping women know what their options are for birth, showing them what normal physiological birth looks like, and helping them focus on their pregnancy and the miracle of becoming a mother.

It is indeed good news that there appears to be a small upswing in one corner of the world back to women-baby-centered birth. As childbirth educators we can help women learn their options for women-baby-centered birth.

We need to keep asking, as Beverly Chalmers did in her editorial in Birth (2002):

How Often Must We Ask for Sensitive Care Before We Get It? 


Chalmers, B. (2002).How often must we ask for sensitive care before we get it? Birth, 29(2), 79-82.

 I wish to acknowledge Jill Wodnick, MS, in helping collate the information in this article.

Cesarean Birth, Childbirth Education, Uncategorized, Vaginal Birth After Cesarean (VBAC) , ,

A Teamwork Approach to Maternity Care in Nelson, BC

October 6th, 2011 by avatar

All pregnant women deserve to have access to compassionate, evidence-based maternity care which inherently supports the normalcy of labor and birth—and remains poised to effectively handle the occasional circumstance when birth strays from normal.  They deserve to be cared for by well-trained midwives, family physicians or obstetricians–depending on their particular situation and which type of care is most warranted–who work together seamlessly as a congruent maternity care team.  They deserve to be cared for by maternity care professionals who trust each others’ skills and resist the urge to question each others’ motives.  Expectant families deserve to remain center stage throughout their pregnancies, labors and births—avoiding being lost in the cacophony of politics that so often suffocates the system and obscures the practice of pure, evidence-based care.

Last weekend, Dr. Brian Goldman introduced his CBC Radio audience to this very scenario, during his show, White Coat, Black Art.  During the show “Dr. Brian,” who is both an emergency department physician in Toronto, and a medical journalist, takes listeners to Nelson, B.C., Canada, where he follows obstetrician Shiraz “Raz” Moola and registered midwife Ilene Bell who both work at Kootenay Lake Hospital.

Only minutes into the radio show, it becomes clear: expectant families delivering at Kootenay Lake Hospital are the beneficiaries of a truly integrated maternity care team where family physicians and midwives handle the majority of deliveries, leaving the complicated scenarios to obstetricians.  This is despite Canada’s fee for service medical system in which, “an obstetrician uses the fees he or she earns from doing easy deliveries to offset or subsidize the more time-consuming and more stressful deliveries that require additional skill and experience.”

During the course of the radio show, scenarios in which obstetricians are called in for deliveries are described.   Despite what sometimes feels like a disbelief in the humanity of obstetricians that some normal birth advocates imply, this radio show does an excellent job of pictorializing  the “why” behind the impetus to medicalize labor and birth.  During the interview, Dr. Moola describes a scenario in which he could palpate a fetus inside it’s mothers abdominal cavity—but outside the womb—following a cesarean scar rupture during an attempted VBAC.  Carrying around past experiences like this can prompt a level of caution—even if not evidence-based caution—as the human side of a physician hopes to avoid dealing with such a circumstance in the future.  And yet, the maternity care providers interviewed in Dr. Goldman’s story don’t seem to allow those past experiences—as few or frequent as they may be—to prompt a technocratic approach to their maternity care services.

“Our training is to promote the normal,”  says Ilene Bell.  “We want to normalize.”

In fact, the radio show audibly follows the progress of a VBAC candidate through parts of her labor and successful delivery, attended by  Bell.

“At one level, we all think we can do it the best,” says Dr. Moola.  But he goes on to describe how the “best” (maternity care provider) is most often a midwife or family physician, and only sometimes an obstetrician.

I highly recommend listening to the whole radio show, and forwarding the link onto your colleagues.  After listening, please come back here and answer the following questions:


  1.  What elements of the maternity care partnership described in this show does my local birth community already harbor?
  2. What elements of the maternity care partnership described in this show can my local birth community/hospital learn from?
  3. What are three steps I can take in my community to encourage this type of partnership approach to maternity care?



Posted by:  Kimmelin Hull, PA, LCCE, FACCE

Evidence Based Medicine, Science & Sensibility, Uncategorized, Vaginal Birth After Cesarean (VBAC) , , , , , , , , ,