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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

Series: Birthing Normally After a C/S or Two, Uncategorized , , , , ,

Making the Case for VBAC: A Three-Part Interview with Dr. Hélène Vadeboncoeur (1)

May 25th, 2011 by avatar

[Editor's note:  For the remainder of this week on Science & Sensibility, we will feature an in-depth, three-part interview with childbirth researcher  Hélène Vadeboncoeur, author of the recently released in English book, Birthing Normally After a Cesarean or Two. You will find the dialogue contained in this interview (and the contents of Vadeboncoeur’s book) both informing to childbirth professionals, as well as to the women we serve.]


Science & Sensibility: Tell us about what inspired you to write this book.

Hélène: I wrote this book to let women who had a cesarean know about the possibility that they could give birth themselves, afterwards. In this era of ever-increasing cesarean rates, and of less and less access to VBAC, it’s important that women know about this possibility so they can ask for it, if they wish to have one. I personally had my first child by cesarean, and the second one was born naturally. These experiences changed my whole life, and led me to work for humanization of childbirth and to get a PhD in order to do research in this area.

Science & Sensibility: Based on your research and experience, what are the compelling reasons we can share with our expectant clients as to why a woman should consider VBAC and why clinicians should support them?

Hélène: Because a VBAC is safer for the woman and it helps the baby adapt to extra-uterine life, lessening the risks for him or her to suffer from respiratory distress (some studies point out a smaller risk of death also for the baby).

Because most women can have their baby vaginally.

Because a VBAC facilitates mother-baby contact right after the birth, facilitating bonding.

Because giving birth can be for the woman an empowering, transformative and fulfilling experience that can have a positive impact on her, on her relationship with her baby, and on the rest of her life.

Science & Sensibility: In the Introduction, you mention this book as being for pregnant women who’ve had a cesarean section before, and for their partners.  Are there other people out there who should read this book as well?

Hélène: I have many times realized that caregivers don’t always have a good knowledge of VBAC, which hampers women’s access to it or desire to have one. Often this lack of information on their part can make them say scary things to pregnant women. I had lots of comments by readers (doctors, nurses, midwives), that health care professionals should also read my book!

Science & Sensibility: In your introductory “birth frame,” you describe your own experiences with both a traumatic cesarean section, as well as a vaginal birth after cesarean.  You depict your efforts to find a consultant (obstetrician) who would, in fact, be willing to attend a VBAC as harrowing.  Why does this type of difficulty so often still exist today for most women seeking a VBAC?

Hélène: Since the middle of the 90s, after a climbing rate of VBAC following two consensus conferences on cesarean (in USA and in Canada), VBAC rates started to decline. There are many reasons that could explain why:

  • One is that inductions became more and more common, in general, and medical milieu were not aware of the increased risks of this intervention for VBAC. More uterine ruptures followed. We had to wait until 2001 before a large-scale study warned about the risks of induction, in particular of the use of prostaglandins (Lydon-Rochelle et al, 2001). Caregivers got scared of VBAC uterine ruptures, without realizing the role of induction in it. And even if induction was seen to be the risk factor, the results of this study (and others) were communicated either by editorials in journals (NEJM) or by newspaper journalists in the following way “VBAC is dangerous.”  Medical associations, who had initially been supportive of VBAC, became more and more cautious in their recommendations. However, the basic risk of VBAC (uterine rupture) has not changed : it’s small, being between 0.2 or 0.6 % (NIH says between 0.3 and 0.7 %).
  • Lawsuits happened following VBAC that did not turn out good.
  • Cesarean is becoming so common that it’s considered a ‘normal’ way to have a baby, and its risks are forgotten or not talked about much.
  • The atmosphere of fear that surrounds childbirth in general has also an impact on VBAC. We all live in this culture of fear : the caregivers, the women, their partners, etc. It’s one of the biggest roadblocks to want – and obtain – a VBAC.
  • Cesareans are seen as ‘perfect care’ or as ‘better for the baby’ (neither of this is necessarily true) and women can be considered selfish because they want to have a VBAC for the sake of it, ‘forgetting’ their baby’s well-being.

Science & Sensibility: Many people believe birth options are only a “big deal” to birthing women and yet, you beautifully included your husband Steven’s memories about the births of your children in this book.  Why was this an integral part of your manuscript?

Hélène: Because when I wrote the first edition of my book, in French, I did it as a woman helping other women who were in the situation I found myself in. So it was natural for me to include my birth stories. And since men experience emotions around the birth of their child, it seemed important to include my husband’s views. Having a baby concerns both, the pregnant women and her partner/husband.

Science & Sensibility: Chapter One begins with a depiction of the current situation surrounding VBAC.  Can you give us a primer on what this looks like?

Hélène: VBAC is now only happening for a small minority of women, because lots of hospitals banned access to it, because caregivers became afraid of it, so did women. It’s a lot more convenient for doctors to do a cesarean than to wait until labor starts… And in a private health care system, it also pays more.

Also, as is summarized at the end of the chapter, “our modern view of childbirth is linked to our deep-seated values, particularly in relation to the emphasis on technology, the control of our lives in every aspect, the avoidance of pain and our frenetic lifestyles, etc.”

[Stay tuned:  In Part Two of this interview, Dr. Vadeboncoeur addresses success and risk assessment associated with VBAC, non-evidence-based reasons for moratoriums on VBAC, the March 2010 NIH Conference on Vaginal Birth After Cesarean and top controversial reasons c-sections are performed.]

Posted by:  Kimmelin Hull, PA, LCCE

Series: Birthing Normally After a C/S or Two , , , ,

Is there Such a Thing as a “Natural” Cesarean Section?

May 18th, 2011 by avatar

Introducing….the concept of the “natural” cesarean…
I have struggled with whether or not to post on this YouTube video for some time.  The title, in and of itself, is aggravating.  And I don’t mean from a judgmental standpoint, but simply from a realistic standpoint:  cesarean birth—whether positively, clinically indicated or not—is not “natural.”  It is an alternative method to birth compared to how nature originally designed it.

I have heard many others refer to the practices described in the video as “gentle cesarean.”  This, at least, seems to be a bit more accurate—except for the cutting, pushing, tugging, pulling, suctioning, cauterizing, and externalizing of the uterus that goes on.  (In a former career life, I used to surgically assist on cesareans, so I’m pretty familiar with what the procedure looks like.)

A list serve I’m a member of has recently spent a lot of time debating practices that surround cesarean births: should hospital policy allow for placement of baby skin-to-skin with mother directly following birth?  Should breastfeeding be allowed in the OR while mom is still being sewn up?  Should separation of mom and baby in the minutes and hours be avoided following a C-section in the same way this practice has taken hold in the vaginal birth setting?

Other questions about cesarean birth discussed frequently in my own local birth network include:  Should birth plan elements such as low lighting, quiet music and delayed cord clamping be integrated into the C-section setting?  Should doulas be allowed into the operating room to provide the emotional support the mother/parents hired her for?  (An aside here:  the most common argument against allowing doulas into the OR at my local hospital is that, “the OR is too small to have an extra person in there.”  Every time I hear this I nearly explode:  the OR seems to be large enough to admit medical and nursing students at-will, along with the various OR staff coming and going from the room throughout the procedure.  And yet the presence of a doula sitting quietly and still beside the birthing woman/couple seems to take up WAY too much space!)

The “Natural C-Section” video encourages many of the issues discussed above.  It follows a second-time-mama into the OR for her second cesarean birth and features obstetrician, anesthesiologist and midwife talking heads who all describe this version of a cesarean birth in a universally positive light.  In fact, mood lighting does seem to be implemented.  The sterile drape separating mom’s head and the rest of her body is dropped in time for her to see her baby being pulled from the incision in her belly.  The doctor holds the baby up, legs spread, so mom and partner can “discover” the baby’s sex on their own, as the OB narrates, “…it’s one of them.” Baby is placed right away, vernix, fluid, blood and all, on mom’s chest.  Dad cuts the cord following a delayed cord clamping.  In this video, the midwife’s job following the baby’s birth is explained as being focused on facilitating bonding measures like skin-to-skin contact and early breastfeeding, while also assessing baby’s well-being.

Interestingly, the anesthesiologist included in the video describes the birthing woman as ‘awake and participating in her baby’s birth.’  I have a hard time agreeing with his sentiment.  While it is certainly preferable for the mother to be awake and aware the moment her baby exits the womb, I’m not sure how much ‘participating’ she is doing when strapped down with 2/3 of her body numb and immobile.

For women who must deliver via cesarean—I can definitely see the appeal in this version of a surgical delivery.  It attempts to come up to speed in so many ways.  There is no hour-long separation between mom and baby.  When mom goes to the PACU (Post Anesthesia Care Unit), so does baby.  The midwife in the video even acknowledges the associations between postpartum depression and cesarean rates as well as decreased breastfeeding initiation rates amongst women who have undergone a cesarean birth.  She then goes on to imply that this gentler approach to the C-section might just ameliorate some of this association.

Criticism Against the “Natural Cesarean”
Here is the cause of my hesitation:  does this promotional video of the “Natural C-Section” run the risk of making surgical birth look so enticing that the risks of C-section get pushed under the table?

Dr. Andrew Kotaska, an obstetrician in Yellowknife, NT, Canada describes his concern over the “Gentle Cesarean” this way:

 

“It is admirable to minimize the necessary disruption of normal early maternal- neonatal contact associated with NECESSARY cesarean section. The gentle measures employed will not, however, reduce the maternal risk of amniotic fluid embolism, pulmonary embolism, operative injury, infection, severe hemorrhage, and death – all several times higher with C/S than vaginal birth. They also will not help achieve the neonate’s normal immune system activation during labour, perhaps leaving it more vulnerable to autoimmune disease later in life.

 

“In no way can the “gentle cesarean” be construed as making C/S safer. In the best quality prospective data set on elective C/S, 1/2300 women died. Soft, family-centered window dressing does not change the cold, hard risks; it is important practitioners and women keep this in mind.” (Landon; NEJM 2004)

In the United States, we are struggling against an ever-increasing cesarean rate.  Readers of this blog are well-aware of the ~ 33% C-section rate that doesn’t seem to be decreasing any time soon.  In an age when we should be working to reduce the C-section rate to somewhere at least close to that which the WHO recommends, the promise of a gentler, naturalish surgical birth could threaten the work many maternity care professionals and normal birth advocates, alike, are doing to properly inform women (and some providers) of the true risks associated with cesarean birth.

On the same list serve I mentioned above, another related thread developed:  should we “allow” post-cesarean moms to initiate breastfeeding while still in recovery?  The meat of the debate was whether or not women with anesthesia levels up to the nipple line will suffer nipple damage from incorrect infant latches, if they cannot feel the latch.  Hospitals apparently have policies on this:  when a mother is and is not allowed to nurse her baby, depending on the type of birth they have experienced (and the resultant side effects—such as prolonged numbness).  Since when did it become reasonable for maternity care facilities to dictate when a woman is and is not “allowed” to feed her own child?

This is exactly the type of down-stream effect of surgical birth that 1) likely does not get discussed prior to consenting for a cesarean and 2) is not erased by a gentler approach to the procedure and 3) involves the institution of policies that certainly are not evidence-based.

A Wolf in Sheep’s Clothing
I will never become the person who denies the importance of C-section as an option in a few, particular cases:  umbilical cord prolapse, placenta previa, abruptia or accreta to name a few.  The cesarean method of birth was, after all, developed to be a life-saving measure and, to this day, continues to be just that in a handful of circumstances.   And when a C-section is truly indicated (but not emergent) then, YES, incorporating gentle, respectful, best-practices elements into the cesarean experience should be done.  To me, this should quickly cease to be a point of debate at all. But for the remainder of women who find themselves in the position of contemplating the type of birth they’d like to experience—those who might be considering an elective C-section; those who have had a previous cesarean and are toying with whether or not to go for a VBAC—the promise of a “Natural C-Section” may turn out to be a wolf in sheep’s clothing.

As one participant on the list serve summarized:

“Can we work to make cesareans less common and also kinder–at the same time?”

Click on image below to watch the entire video on YouTube

 

Posted by:  Kimmelin Hull, PA, LCCE

Cesarean Birth, Films about Childbirth, Science & Sensibility, Uncategorized, Vaginal Birth After Cesarean (VBAC) , , , , , , , , , ,

Putting the tools in the hands of women: Two new cesarean resources

September 12th, 2010 by avatar

Whether a woman is having her first baby or has already given birth, whether she is sitting in a prenatal appointment or in the midst of labor, if she is pregnant in the United States, there’s at least a 1 in 3 chance she will find herself hearing some version of the words, “You are going to need a c-section.”

Sometimes those words are spoken and heard with clear knowledge that cesarean is the only reasonable and safe option – a complete placenta previa or severe fetal distress in labor, for instance. But does every woman who hears these words really need a cesarean?  What if it’s a labor that seems to be going nowhere, or a fetal heart rate pattern that is not entirely reassuring, or something in the woman’s medical history that increases her risk slightly?

In these gray area cases, non-medical factors tend to influence decision-making. On the doctor or hospital side, it may be fear of malpractice, financial incentives, protocols, or impatience. On the woman’s side it could be her knowledge and values, her plans for future pregnancies, her own tolerance for risk, and her physical condition and support network that may profoundly affect postoperative recovery.

All “nonmedical factors” are not alike, however. Evidence suggests that factors on the physician and hospital side are exerting a much stronger influence than factors on the woman’s side.

How to correct this imbalance? Enter two new woman-centered tools to assist decision-making around cesareans.  I’m honored to have been involved in the development of both.

C-section Data from California WatchJust launched is a new resource from California Watch, a project of the Center for Investigative Journalism.  California Watch conducted an independent review of birth records from California hospitals and showed for the first time that for-profit hospitals have significantly higher c-section rates than not-for-profit hospitals, even when they are serving similar populations. As a companion to a powerful article that explains the findings, California Watch produced a set of “React and Act” tools that are available on their web site, including an open-access database of hospital c-section rates and related outcomes, an expert Q&A (with yours truly as the featured expert), and downloadable primers in English and Spanish for women to print and bring with them to their care provider’s office, childbirth class, or hospital tour.

vbac-primer-contributorAlso, if you haven’t already heard, Lamaze launched another consumer primer earlier this week.  A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations addresses the most common and pressing questions women face when considering or planning a VBAC and all of the content is derived from the NIH Consensus Conference that was held last spring. It breaks down into understandable language the pros and cons of planned VBAC and planned repeat cesarean, how to make sense of prediction models and candidacy for VBAC, how the risks of VBAC stack up to other obstetric risks, the history of hospital “VBAC bans” and how to challenge them, the critical gaps in the research and how to make choices in spite of them, how to discuss options with a care provider, women’s legal rights and protections, and how to take action to improve VBAC access at the community level. (This resource is web-only for now, but we hope to have printed or print-friendly versions available very soon.)

Please pass these important tools to women and I’d love to hear from readers about how they can be incorporated into childbirth classes.

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Quick Hit x4: Four Papers of Interest to Childbirth Educators

August 14th, 2010 by avatar

The blog has been quiet for longer than usual. I had a great family vacation at the beginning of the month and came back to deadlines. I’ve got a pile of blog posts half-written and some good stuff in the pipeline, but I thought I’d share a few papers of interest to childbirth educators in the meantime. I don’t have the time to give these the full critical treatment, but I knew my CBE readers (and maybe others) would want to know about them.

1. The current issue of the Journal of Obstetric, Gynecologic, and Neonatal Nursing (JOGNN) has several articles on disaster preparedness efforts for childbearing women and newborns. I was happy to see this since I wrote recently that this topic has gotten too little attention. One of the articles, titled Targeting Prenatal Emergency Preparedness Through Childbirth Education, suggests including disaster preparedness in childbirth education offerings,  proposes a topical outline for curriculum development, and reviews relevant literature on disaster planning, evacuation and public sheltering, and the mental health consequences of disasters for childbearing women.

2. In the journal, Medical Decision Making, researchers from the Cochrane Collaboration present the outcomes of qualitative research aimed at improving consumers’ comprehension of “plain language summaries” of Cochrane Systematic Reviews. The results, as presented in the abstract, reveal that consumers have very limited knowledge of what a systematic review is and how to interpret findings, a problem of major importance to perinatal educators who wish to convey evidence from systematic reviews.

Participants preferred results presented as words, supplemented by numbers in a table. There was a lack of understanding regarding the difference between a review and an individual study, that the effect is rarely an exact number, that evidence can be of low or high quality, and that level of quality is a separate issue from intervention effect…Confidence intervals were largely ignored or misunderstood. Our attempts to explain them were only partially successful. Text modifiers (‘probably,’ ‘may’) to convey different levels of quality were only partially understood, whereas symbols with explanations were more helpful. Participants often understood individual information elements about effect size and quality of these results, but did not always actively merge these elements.

As a result of these findings, the Cochrane Collaboration is currently evaluating a new format for Plain Language Summaries.

3. An article in press in the journal Midwifery reports findings from a qualitative study of 11 first-time fathers’ expectations and experiences of being present during labor and birth. Two of the fathers’ partners gave birth by elective cesarean section, two had emergency cesareans, three had  instrumental births and four had a spontaneous vaginal births. All of the couples had taken hospital antenatal classes. Most of the fathers reported in prenatal and postnatal interviews:

  • feeling disconnected from their partners during pregnancy and labor
  • feeling on the periphery of events during labor
  • feeling ill prepared for and alienated from decision-making, and
  • “becoming a father” and reconnecting with the experience and their partners at the moment of birth.

The authors concluded,

Birth is the moment that fathers ascribe as the beginning of fatherhood. However, through their lack of knowledge and perceived control, they struggle to find a role there.

4. And finally, my article, Social Media, Power, and the Future of VBAC, co-authored with Hilary Gerber and Desirre Andrews, is out in the current issue of the Journal of Perinatal Education and it’s FREE! The article reviews the contemporary consumer movement for improved access to VBAC and explores the role of social media in enabling access to evidence-based information and peer support. It’s my contribution to the “Looking Back/Looking Forward” issue of the Journal, which marks and celebrates Lamaze’s 50th anniversary. I hope to feature much more from this important issue of the Journal, but in the meantime members can access the full issue for free.

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