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On Our Radar…Tocophobia and its Consequences

September 26th, 2011 by avatar

The Research
Several interesting studies have recently been published in the Scandinavian journal, Acta Obstetricia et Gynecologica Scandinavica (some of which I will cover in a subsequent post)The greatest one of interest, which has garnered much media attention lately is the study about fear of childbirth which, according to researchers, has a drastic affect on increasing instrumental deliveries (51%), labor inductions (17%), and requests for elective cesarean deliveries (30%) when compared to women not suffering from this intense form of childbirth-based fear termed “tocophobia.”

The results of this relatively small study (cases=353, controls =579) out of  University Hospital in Linköping, Central Sweden, are not necessarily surprising to many of us, but reiterate what many having been talking about for decades: fear has a very real affect on the process of labor and birth.  In fact,  in the most extreme cases, tocophobia may result in avoidance of pregnancy all together.  But for our purposes, as childbirth professionals, we need to be thinking about how we approach the topic of fear pertaining to birth in our interactions with our students/patients/clients.

Take the cascade of interventions, for example: For the woman who is increasingly anxious about what will happen during labor and birth–who asks for an elective labor induction to “just get it over with,” some of the difficulties she may be most afraid of, become a self-fulfilling prophecy when her labor is complicated by the effects of labor induction (increased pain, intensity and frequency of contractions…potential negative effects of epidural analgesia when assistance with her intense pain is requested…fetal heart rate concerns…maternal blood pressure concerns…potential advancement to cesarean surgery).

Application for Childbirth Educators
Carefully and sensitively bringing up the topic of fear related to childbirth is imperative for childbirth educators:  it gives our students the opportunity to express concerns which they might otherwise keep to themselves–thinking they are “the only ones” harboring such anxiety.   It is not about inducing or encouraging fear, rather it is about presenting the opportunity and encouraging dialogue on this topic–offering positive perspectives and coping strategies that the woman/couple may not have come up with on their own.

Don’t be Afraid to Refer
In the event we find ourselves interacting with a woman whose fear pertaining to pregnancy and/or birth is deeper than that which we feel poised to handle in class (or in clinic), referring the woman locally to a trained professional adept at counseling her through this challenge becomes a must.  Tocophobia is a very real phenomena.  This study published in Clinical Obstetrics and Gynecology, 2004 (47:3) describes tocophobia as occurring in 20% of pregnancies with disabling fear occurring in 6%.

As childbirth educators and maternity care professionals, we may not have the training or skill set to appropriately handle and solve every challenge that faces an expectant woman.  And when we don’t immediately posses those skill sets, we must invite the assistance of other professionals trained to do so.  In the mean time, proactively delivering evidence-based information that empowers (rather than frightens or degrades) expectant women can go a long way toward building confidence and reducing fear.

 

 

Posted by:  Kimmelin Hull, PA, LCCE, FACCE

New Research, News about Pregnancy, Preconception Care, Research , , , , , , , ,

Making the Case for VBAC: A Three-Part Interview with Dr. Hélène Vadeboncoeur (2)

May 26th, 2011 by avatar

[Editor’s note:  Today presents Part Two of the three-part interview with childbirth researcher  Hélène Vadeboncoeur, author of the recently released in English book, Birthing Normally After a Cesarean or Two. To read Part One of this interview, go here.]

Science & Sensibility: Help us to understand a woman’s chances of undergoing a VBAC, based on where and with whom she chooses to give birth.

Hélène: Let’s say first that most women can give birth vaginally, and that on average, 3 women out of 4 complete a VBAC after they begin labour. True contraindications to VBAC are rare. Having a ‘classical’ incision (its name is misleading, it’s not done very often), i-e a vertical uterine incision done in the upper part of the uterus, is considered as being a contraindication by most medical associations, as is a previous uterine rupture. ACOG also includes extensive transfundal uterine surgery. Factors related to a woman’s chances of undergoing a VBAC have a lot to do with the ‘environment’ in which it’s prepared and done. Finding a doctor or a midwife who is supportive of their choice, finding a place of birth where people are not scared by VBAC, is important (and if all factors are not there, the woman’s determination and support from a doula is crucial), as is giving birth in a place where the physiology of birth is supported, where it’s considered a multi-dimensional event (familial, social, cultural, and, for some, spiritual event). The presence of a doula can be very important, for a woman that previously gave birth by cesarean, because she may lack confidence in her capacities to give birth (notwithstanding the fact that as shown by multiple studies, the presence of a doula has beneficial effects on labour). Statistics also show that a woman’s chances of completing a VBAC increases if her caregiver is a midwife, for instance (up to 97 %).

Science & Sensibility: You attended the March 2010 National Institutes of Health Conference on VBAC.  Do you feel the recommendations coming from that conference were ultimately helpful, or harmful to women interested in achieving a vaginal birth after cesarean?

Hélène: I have mixed feelings about this conference. While it was very good to review the scientific literature on VBAC and related issues, the group of invited experts did not include women who had cesareans/VBAC nor grassroots organizations like ICAN, for instance. Happily though, the conference was open to the public, so individuals and organizations could comment or question what they heard from the invited experts (either in person at the conference or via the Internet). Another element of the conclusions of the final report was their saying that with regards to VBAC and repeat cesarean “benefit for the woman may come at the price of increased risk for the fetus and vice versa.”  I don’t agree with this point of view. Although risks vary for the women, their babies, in vaginal births and in cesareans, it does not make sense to oppose the interests of the mother and of her baby. And a cesarean presents a higher number of risks than a vaginal birth, as Childbirth Connection showed.

The conference was helpful though in the following ways: by pointing out gaps in research, by saying  that, “given the available evidence, TOL (I don’t like that term, ‘trial-of-labor’) is a reasonable option for many pregnant women with a prior low transverse incision” and that one of their major goals is to support pregnant women… to make informed decisions about TOL versus ERCD. They also urged providers to incorporate an evidence-based approach into the decision-making process.

So I would conclude by saying that this conference was more than necessary (it was the first consensus development conference on VBAC), that it helped look at the situation and understand it, but that it did not position itself unequivocally in favor of  VBAC (the position of the earlier consensus conferences in the 80s on cesarean about VBAC was clearer).

Science & Sensibility:  In Chapter Two of your book, you review the risk assessment of various types of childbirth.  With increasing rates of labor induction occurring in many developed nations, can you help our readers understand the comparative risk of uterine rupture for women undergoing labor induction with synthetic oxytocin, with prostaglandin gels and during a VBAC?

Hélène: In my book, I center on VBAC and cesarean. What the research has shown, is that induction presents increased risks for a uterine rupture during VBAC (separation of the uterine incision), especially the use of prostaglandin gels. It seems that oxytocin use is not as risky, as concluded the NIH VBAC Conference (some studies have shown than its use can increase the risk of uterine rupture and others not). And regarding the use of oxytocin for acceleration of labour, it’s not contraindicated but it should at the least be used with caution.

Science & Sensibility: You mention that 90% of cesareans are prompted by controversial indicators for operative surgery.  What are the top three controversial reasons C-sections are performed?

Hélène: The top ? I don’t know. The more frequent ? Maybe.

Dystocia: is a category frequently mentioned as the reason to do a cesarean (failure to progress, cephalopelvic disproportion). It’s quite a vague category (lots has been put under that name), and often the approach to birth in hospitals leads to malfunctioning of labour–like preventing women to move, having them lay in bed on their back, withholding nourishment, breaking the waters or administering oxytocin which leads to a cascade of interventions (contractions more painful, epidural or Demerol, stimulation of labor, continuous monitoring, etc.). Epidurals can also affect labour.

Fetal distress : EFM readings and interpretations are not always right (mistakes), and cesareans are performed without the baby being necessarily in danger

Breech baby : A cesarean is not necessarily better for all babies that are breech, as research in recent years has shown

[Tomorrow, during Part Three of this interview, Dr. Vadeboncoeur discusses informed consent prior to cesarean delivery, in terms of future VBAC, optimal candidacy for achieving a VBAC and the barriers that make it more difficult, as well as the emotional and psychological aspects of vaginal birth after cesarean and more...]

 

Posted by:  Kimmelin Hull, PA, LCCE

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