Archive for the ‘Medical Interventions’ Category

Series: Supporting Women When a VBAC Doesn’t Happen – Part Three: Supporting The Mothers

November 12th, 2015 by avatar

By Pamela Vireday

“Remember, no effort that we make to attain something beautiful is ever lost.” – Helen Keller

cbac part 3Today we conclude our three part series on Cesarean Birth after Cesarean, written by Pamela Vireday, who is an occasional contributor to Science & Sensibility.  In this series, Pamela examines the topic of women who experience a Cesarean Birth after a Cesarean. This is when families are planning for a vaginal birth after a prior cesarean, but the birth does not go as planned.  The experiences of women who have a CBAC are often negated and their emotional and physical well-being given short-shrift by both professionals and their social community of friends and family.  The research on this topic is slim and begs for exploration by qualified investigators.  Last week, Pamela discussed the unique grief that CBAC women may experience. Two days ago, Pamela examined the limited research available on CBAC births in part two.  Today, Pamela will provide information on how to support CBAC women in the absence of published research.  There is also great set of resources in the post to share with the families you work with or include in a CBAC Resource packet you provide after birth. You can also read a companion piece of Pamela’s own personal story, “Cesarean Birth after Cesarean, 18 Years Later” on her own website.- Sharon Muza, Community Manager, Science & Sensibility.

In the first post of our series –  Supporting Women When a VBAC Doesn’t Happen – Part One: A Unique Grief, we discussed how women who want and work for a VBAC but end up with a cesarean have a unique grief that is different from a primary cesarean or an elective repeat cesarean. Many women who have experienced a CBAC say they felt unsupported and isolated. They had nowhere to tell their stories, nowhere to process their anger, and got little sympathy from those around them.

In the second post – Supporting Women When a VBAC Doesn’t Happen – Part Two: The Forgotten Mothers, we examined what research there is on CBAC mothers and found limited wisdom to guide us. In the absence of research on how best to help CBAC mothers, we must rely on the words and experiences of CBAC mothers to tell us what they need.

In the final part of our series today, we suggest concrete ways that birth professionals can support CBAC mothers, based on suggestions made by CBAC mothers themselves. Keep in mind that each story and woman is unique, and the needs of one may be different than the needs of another. The best thing to do is to follow the lead of the CBAC mother; she will tell you in word and deed how best to support her.

Create a Safe Space for the Birth Story

One of the most important things that birth professionals can do to help CBAC mothers is to give them a safe space to tell their stories ― their full stories.

CBAC mothers often edit their stories for others, leaving out their disappointment or scary details because people only want to hear the happy parts. When they try to tell the full story, they may hear, “Just get over it already” or “Oh, we’re not going to talk about that again, are we?” CBAC mothers also often self-edit their stories in order not to discourage or scare other expectant mothers. But an untold story is one that weighs heavy on the heart.

Be the safe person to whom the full birth story can be told. Be truly present while listening. Don’t armchair-quarterback her story; suspend your judgment, put aside your own birth agendas, and focus only on supporting this woman, right now, in this situation. Eliminate distractions, use attentive body language, and really focus on the woman so that she truly feels like she is being heard.

Realize that she may need to tell the story multiple times; each time she tells it, she processes it on a new and different level. Ask her, “What do you need from me right now?” so she can tell you if she wants something more than just listening. If possible, check in with the woman’s partner, who may also need help processing or understanding why the mother is still coming to terms with her experience.

“Listen. Listen. And don’t contradict. Just listen. Don’t compare. Just listen. And don’t try to make me feel better. Just listen.”     – Kristina R.

Use Creative Support Techniques

Once the mother is ready to start processing the birth story further, use reflective listening techniques. Listen to what she says, seek to understand what seems most important to her, and paraphrase back to see if you understood her point. Don’t make assumptions about how she is feeling or add judgments. Ask open-ended follow-up questions that invite her to explore her feelings if she is ready. Give her the time and space to come to her own conclusions about her experience.

Many women find that journaling, making art, singing, writing poetry, and participating in rituals is helpful in processing their emotions. This can be particularly helpful for those who get stuck in a negative feedback loop or who need to process significant trauma. Don’t be afraid to refer to a good birth-supportive therapist in your area if needed.

Validate the Mother

CBAC mothers need to have their experiences and feelings validated. Mothers need to be reminded that their hard work and accomplishments during birth are still valid, however the baby was born. Acknowledge the amazing sacrifice she made in giving up her own dreams and bodily integrity for her baby.

“CBAC women need validation. They need encouragement that every birth can be different. Above all, they need to be appreciated for the work they did both before and during the experience, the sacrifices made for their babies, and the special place inside themselves that now carries yet another scar.” – Teresa Stire

“Effort does not always equal outcome. Give yourself credit for that effort, and don’t boil it all down to the moment of birth alone.” -Melek Speros

Encourage Bonding

Bonding can be especially difficult after a physically or emotionally traumatic birth. Others may have stepped in to care for their babies, which can leave some mothers feeling incompetent or disconnected.

Start by encouraging more time with the baby. Promote as much skin-to-skin contact as possible; this helps produce more oxytocin and may help breastfeeding too. Some women find bathing or napping with babies to be very healing.

It can be helpful to compartmentalize grief behind an emotional door so women can focus on their baby’s immediate needs, on their older children, and on their own physical needs. However, it’s important that women schedule time periodically to take out the grief, actively work through it, and then put it away. Otherwise, grief may intrude on the bonding process.

Give the Mother Support Resources

Create a CBAC Resource Packet that you can email or hand out as needed. Include a list of CBAC support sites, CBAC brochures, and names of local postpartum doulas or birth therapists. Edit it to each woman’s unique situation.

The International Cesarean Awareness Network (ICAN) has a new brochure about CBAC, which will be available soon in its store, as well as a website dedicated specifically to CBAC, including an archive of CBAC stories. In addition, there is a closed ICAN support group on Facebook just for CBAC mothers.

Although not all CBAC mothers experience post-traumatic stress symptoms, having birth trauma resources in the CBAC Resource Packet puts the ball in the mother’s court and lets her decide the emotional ramifications of her experience. It also gives her concrete options for reaching out for further support, possibly even long after your working relationship with her is over.

Help Her Connect with Other CBAC Mothers

CBAC moms are their own best mentors. This may be the only place CBAC women find others who truly “get” what they are going through.

The unique feelings around CBACs may mean that birth groups, especially those centering on VBACs, could be uncomfortable for a while. Many CBAC mothers feel intensely jealous when hearing other women’s easy birth stories. They may need to insulate themselves for a bit. Taking a break from birth-related groups for a while can be healthy and self-protective; she can return when she is ready.

Of course, not every support resource is perfect. Encourage CBAC mothers to be careful about whom they seek support from. Many well-meaning people say hurtful things like, “Just be grateful you got a healthy baby,” or “You’re just lucky you didn’t die!” CBAC mothers need to find support that will not inadvertently trigger or hurt them more.

Acknowledge Unique Circumstances

Each CBAC is unique, and each may carry its own particular color of pain.

Some women had CBACs because their providers suddenly withdrew support for VBAC at the end of pregnancy or during labor. Some faced so many interventions and conditions during their labors that a CBAC seemed almost inevitable. Some experienced mistreatment and abuse during their experience.

On the other hand, some women had very supportive providers but still ended with a CBAC. Others felt they had a “prudent CBAC,” a difficult but sensible choice because of fetal distress, poor fetal position, rising blood pressure, or other complications. Some had an “empowered CBAC,” where there was powerful learning and healing to help balance the disappointment.

Some women have multiple CBACs, each with their own emotional resonance. Some have a VBAC and then a CBAC, which has its own particular pain. A few have had the bitter experience of having lasting physical and emotional damage from their CBAC, including uterine rupture, hysterectomy, or loss of their baby.

As always, each person’s experience is different, and each CBAC mother needs their unique experiences honored.

“Try on” a CBAC

“Trying on” a CBAC can help birth professionals have a deeper empathy for the unique grief of a CBAC mother.

Consider what it might feel like to have a CBAC. Let yourself feel what it might be like to hope and dream for a VBAC and then not have one, to have to tell everyone afterwards that you didn’t VBAC after all, to listen to the naysayers who believe your body really is broken and who tell you that you should have just scheduled a cesarean section, to listen to other women’s easy birth stories and feel envious all the time.

Walking in someone else’s shoes for a while gives people a better appreciation for the difficulties and the bittersweet feelings surrounding disappointing life events. More empathy for CBAC mothers is definitely needed in the birth community.

Contact the Mother Periodically to Check In

CBAC is a bit of an emotional rollercoaster and feelings will change over time. The way the mother feels immediately after a CBAC will probably not be the same as a few months or a year later. Check in with her periodically to see how she is feeling about everything and whether there is any way you can support her further. This is especially important for CBAC mothers who have experienced a major trauma.

It’s not unusual for CBAC mothers to experience emotional upset around the six month mark, on the child’s first birthday, or even later. A quick check-in can affirm that someone remembers and cares about what she is going through.

Discuss Future Pregnancies

Another common point of emotional crisis for CBAC mothers is when the mother considers having another child. At that time she revisits her fear and trauma from past births, decides whether to have more children, and if so, may be torn over whether to choose a repeat cesarean or another VBAC trial of labor (TOL).

Although conventional medical wisdom holds that once a woman has had a CBAC, she has shown she cannot birth vaginally, the reality is that a number of CBAC women go on to have a VBAC in future pregnancies, and the American College of Obstetricians and Gynecologists (ACOG) is supportive of VBAC after two cesareans. Women who choose a TOL in this situation may need particularly strong emotional support as they work through their fears and concerns from both a primary cesarean and a CBAC.

However, it’s also important to remember that sometimes a VBAC is truly medically contraindicated, the woman is done having children, or does not wish another TOL. Although VBAC is no longer an option, that doesn’t mean these women are at peace with past or future CBACs. They may still need support too. Little research has been done on how to support this group as they integrate their experiences into their lives. In particular, information is needed on how to support women who experienced significant emotional trauma during birth (Beck and Watson, 2010).

Believe That Healing Can Be Had

Life gives us all disappointments and sometimes these remain bittersweet forever. As with other griefs, you never truly “heal” from a CBAC; the disappointment and loss of that birth is always there, and it never goes away. However, birth professionals need to communicate that – with time and distance – women often come to some sort of peace with the experience.

If given the chance to process their feelings thoroughly, women eventually have enough distance from it to not grieve as sharply, to find lessons or growth in the experience, and to be able to integrate the disappointment of it into their lives.

Some transform the power of the CBAC experience into advocacy, becoming health care workers themselves or advocates in birth-related fields. Others practice micro-advocacy by informally helping birthing women they encounter in their personal lives.

Women don’t have to ever be grateful for their CBACs, but in time they can recognize that good things can spring from difficult things, and that great trauma can lead to great growth. The process is not quick or facile, but it can happen. And birth professionals can be a vitally important part of that process.

“My joy [in my births] has gradually returned. I am learning now to honor my experiences…We are not failures, we are no less brave than the women who accomplish the VBAC goal. I keep reminding myself that I will never climb Mount Everest, either, and will probably not accomplish some of the other things I think I want in my life. Maybe this missed childbirth opportunity is just that ─ another missed opportunity ─ and maybe we can find some other accomplishments/ life experiences to compensate. Maybe.”       -K

“Today, 12.5 years after my first CBAC, I can honestly say how much growing and learning came from it and for that I am grateful.” -Teresa Stire

“My CBAC made me the compassionate advocate I am today.” -Melek Speros

Resources for CBAC Mothers

Here are a few select resources that may be helpful to CBAC mothers. If you know of more, please add them in the comments section.

CBAC Resources

CBAC Support Groups

General Birth Trauma Support Organizations

Articles on CBAC Recovery

Birth Trauma Articles



Beck CT, Watson S. Subsequent childbirth after a previous traumatic birth. Nurs Res 2010 Jul-Aug;59(4):241-9. PMID: 20585221

About Pamela Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Image from Wikimedia Commons.

Pamela Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 20 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.


Cesarean Birth, Childbirth Education, Guest Posts, Maternal Mental Health, Maternity Care, Medical Interventions, PTSD, Series: Supporting Women When a VBAC Doesn't Happen, Vaginal Birth After Cesarean (VBAC) , , , , , , ,

Series: Supporting Women When a VBAC Doesn’t Happen – Part Two: The Forgotten Mothers

November 10th, 2015 by avatar

By Pamela Vireday

“CBAC mothers have powerful lessons to teach, if you are willing and able to hear us.”  — Melek Speros

CBAC part 2We continue our current series on Cesarean Birth after Cesarean, written by Pamela Vireday, who is an occasional contributor to Science & Sensibility.  In this series, Pamela examines the topic of women who experience a Cesarean Birth after a Cesarean. This is when families are planning for a vaginal birth after a prior cesarean, but the birth does not go as planned.  The experiences of women who have a CBAC are often negated and their emotional and physical well-being given short-shrift by both professionals and their social community of friends and family.  The research on this topic is slim and begs for exploration by qualified investigators.  Last week, Pamela discussed the unique grief that CBAC women may experience. Today, Pamela examines the limited research available and part three (on Thursday) will provide information on how to support CBAC women in the absence of published research.  We will also conclude the series with a useful resource list to share with the families you may work with who find themselves in this situation.  You can also read a companion piece of Pamela’s own personal story, “Cesarean Birth after Cesarean, 18 Years Later” on her own website.- Sharon Muza, Community Manager, Science & Sensibility.


In Part One of the series – Supporting Women When a VBAC Doesn’t Happen, we discussed how women who work for a VBAC but end up with a cesarean have a unique grief that is different from that of a mother who has a primary cesarean or who chooses to have a repeat cesarean.

There is a pressing need for better support for CBAC mothers, but often birth professionals and family members have no idea how to go about offering this support. Does research have any insight on improving CBAC support to these women?

CBAC Research

Unfortunately, there has been very little research done on CBACs. Most VBAC-related research deals with VBAC rates, complications, cost-effectiveness, or the woman’s decision-making process. Women who choose VBAC but don’t end up with one are largely ignored in academic studies.

However, there are a few studies with implications for the CBAC mother, including those that address physical recovery and a few that address emotional recovery.

Physical Recovery

Most CBAC research focuses on physical morbidity, which can certainly have an influence on how a woman feels after a CBAC.

Although most CBAC mothers recover just fine, women who have a trial of labor cesarean do have higher rates of infectious morbidity, postpartum hemorrhage, hysterectomy, blood transfusions, and neonatal morbidities (El-Sayed 2007, Hibbard 2001, Durnwald and Mercer 2004).

One study found that 2.1% of women with a trial of labor experienced major maternal morbidity (Scifres 2011). How much more complicated is emotional recovery if the mother is also dealing with the aftermath of a serious infection, a sick baby, surgical injuries to nearby organs, anemia from a major hemorrhage, or heaven forbid, a uterine rupture, hysterectomy, or stillbirth?

The lesson here is that some mothers will be dealing not only with the disappointment of CBAC, but also with significant physical fallout afterwards. This can greatly complicate emotional processing, but sadly, these are often the mothers who receive the least emotional support afterwards. It’s as if their complications have made them toxic to the birth community because their experiences represent the rare worst-case scenarios no one wants to acknowledge.

The first step in helping a CBAC mother is to help her focus on her physical recovery, especially if there have been complications, even as you help her explore her emotions around the CBAC.

Emotional Recovery

There is only a small amount of research available on the emotional impact of CBACs. How do women feel about the CBAC experience? Do they regret having tried for a VBAC? Would they want to try again? What can be done to help women process the experience emotionally?

One study surveyed CBAC mothers.(Chigbu 2007) Not surprisingly, they found CBAC mothers, particularly those with no previous vaginal birth experience, often had feelings of:

  • Dashed expectations
  • Inadequacy as a mother
  • Frustration of experiencing the pain of both labor and surgery

Some women experience long-lasting trauma from birth. Although many people have written about Post-Traumatic Stress in childbirth, it is unclear from the research what the most effective approach is for dealing with PTSD in birth.

Some research indicates that Eye Movement Desensitization and Reprocessing treatment (EMDR) can be helpful (Sandström 2008, Stramrood 2012). However, research trials have been extremely small and limited in the childbirth field.

A recent Cochrane review (Bastos, 2015) concluded that there was little high-quality evidence for or against using debriefing interventions to prevent psychological trauma after childbirth. Still, many women find counseling helpful after a traumatic birth, and EMDR helpful if flashbacks are frequent or intrusive.

From anecdotal evidence, anger is a common theme among some CBAC mothers. They may be furious with care providers who let them down, with the seemingly random nature of birth fortunes, or with their bodies for “not working right”:

It was very important to me that someone recognize and validate my anger. I was SO FREAKING ANGRY!!!!! And I needed to hear, “You have every right to your anger!”    – Jer 

This kind of anger is uncomfortable for birth professionals to hear. We want women to have happy endings and just be enthralled with their babies. But denying anger doesn’t make it go away; it just makes it burrow down more destructively. Helping a mother speak her anger without taking it personally vents it and takes away some of its toxicity so that healing can start to take place.

Many CBAC mothers deal with a strong sense of shame and failure, of feeling broken. Health care providers make this worse when they blame women by telling them their pelvises are “too narrow,” their cervix is “horrible,” or that they have “too much soft tissue” around their vaginas. Health care providers must be careful in issuing judgments such as these because many women told these things have gone on to have vaginal births. More often it’s a case of “this baby, this birth, this time” didn’t work, not that the woman’s body is defective.

Some CBAC mothers obsess over the “what-ifs” of birth decisions or spend a lot of time analyzing what went wrong. This can be a way of asserting a sense of control over what feels uncontrollable. Analysis can sometimes be useful, but it also can lead to a never-ending rabbit hole of self-blame. Sometimes we just don’t know why birth turns out the way it does, and it can help when health care providers and birth professionals share this.

“Pregnancy/childbirth is one of the most unfair endeavors I’ve encountered. Realizing that has set me free in a way. If something as commonplace as childbirth has so many variations even despite what is actively chosen/done, then how can anything else in our lives go the way we want if we just. work. hard. enough. Life isn’t fair. Childbirth, the ease for some, the struggle for others, just isn’t fair. And that’s been liberating for me.”  – L  

Common Recovery Arcs

Recovery from a CBAC can be an emotional roller-coaster. Many women experience ambivalent feelings and these feelings can change considerably over time.

Immediately after a CBAC, some women are so traumatized that they need to process it immediately. Yet the people around them may feel threatened by any negative feelings around the birth; they don’t understand that women can love their babies but still feel upset about how the baby arrived.

Some CBAC women find a place of temporary peace about the experience. They may be reconciled to its necessity, or may simply need to focus first on the baby and put aside any other feelings. It may only be later that more ambivalent feelings rise up and must be dealt with.

Sometimes right after the birth, women wish they had just chosen a planned repeat cesarean. However, with time, this feeling changes for many CBAC women. One study found that, while women were disappointed at not having a VBAC, 92% of CBAC women “were pleased that they had attempted a vaginal birth” (Cleary-Goldman, 2005). The authors concluded that “Although the most satisfied patients were those who succeeded at vaginal birth, most women valued the opportunity to attempt a vaginal birth regardless of outcome.”

This result was also found by Phillips (2009). Indeed, Chigbu (2007) noted, “This survey revealed that most women still would prefer to be delivered vaginally after 2 previous cesarean deliveries.”

What few surveys have been done show the emotional impact a CBAC can have, but the topic is glaringly understudied. More research is urgently needed on the experiences of CBAC mothers and what can be done to help support them.

In the absence of research to guide us, we must trust what CBAC women tell us they need. More on that in Part Three of the series on Thursday.


Bastos MH, Furuta M, Small R, McKenzie-McHarg K, Bick D. Debriefing interventions for the prevention of psychological trauma in women following childbirth. Cochrane Database Syst Rev. 2015 Apr 10;4:CD007194. doi: 10.1002/14651858.CD007194.pub2. PMID: 25858181

Chigbu CO, Enwereji JO, Ikeme AC.  Women’s experiences following failed vaginal birth after cesarean delivery. Int J Gynaecol Obstet 2007 Nov;99(2):113-6.   PMID: 17662288

Cleary-Goldman J, Cornelisse K, Simpson LL, Robinson JN. Previous cesarean delivery: understanding and satisfaction with mode of delivery in a subsequent pregnancy in patients participating in a formal vaginal birth after cesarean counseling program.  Am J Perinatol. 2005 May;22(4):217-21.  PMID:15906216

Durnwald C and Mercer B.  Vaginal birth after Cesarean delivery: predicting success, risks of failure. J Matern Fetal Neonatal Med 2004 Jun;15(6):388-93.  PMID:15280110

El-Sayed YY, Watkins MM, Fix M, Druzin ML, Pullen KKM, Caughey AB.  Perinatal outcomes after successful and failed trials of labor after cesarean delivery. American Journal of Obstetrics and Gynecology 2007 Jun;196(6):583.e1-5; discussion 583.e5.  PMID: 17547905

Hibbard JU, Ismail MA, Wang Y, Te C, Karrison T, Ismail MA. Failed vaginal birth after a cesarean section: how risky is it? I. Maternal morbidity.  American Journal of Obstetrics and Gynecology.  2001 Jun;184(7):1365-71; discussion 1371-3.  PMID: 11408854.

Phillips E, McGrath P, Vaughan G.  ‘I wanted desperately to have a natural birth’: Mothers’ insights on Vaginal Birth After Caesarean (VBAC).  Contemporary Nurse 2009 Dec-2010 Jan:34(1):77-84. PMID: 20230174

Sandström M, Wiberg B, Wikman M, Willman AK, Högberg U. A pilot study of eye movement desensitisation and reprocessing treatment (EMDR) for post-traumatic stress after childbirth. Midwifery. 2008 Mar;24(1):62-73. Epub 2007 Jan 12. PMID: 17223232

Scifres CM, Rohn A, Odibo A, Stamilio D, Macones GA.  Predicting significant maternal morbidity in women attempting vaginal birth after cesarean section.  Am J Perinatol 2011 Mar;28(3):181-6. PMID:  20842616

Stramrood CA, van der Velde J, Doornbos B, Marieke Paarlberg K, Weijmar Schultz WC, van Pampus MG. The patient observer: eye movement  desensitization and reprocessing for the treatment of posttraumaticstress following childbirth. Birth. 2012 Mar;39(1):70-6. doi: 10.1111/j.1523-536X.2011.00517.x. Epub 2011 Dec 19. PMID: 22369608

About Pamela Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Image from Wikimedia Commons.

Pamela Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 20 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.


Cesarean Birth, Childbirth Education, Guest Posts, Maternal Quality Improvement, Maternity Care, Medical Interventions, Research, Series: Supporting Women When a VBAC Doesn't Happen , , , , , , ,

Time for ACOG and ASA to Change Their Guidelines! Eating and Drinking in Labor Should Not Be Restricted

October 27th, 2015 by avatar

“…The problem for anesthesiologists is that our practice guidelines on obstetric anesthesia are strongly worded, and state that women can not eat during labor. We can’t ethically design a large enough study to answer this question, so we will have to wait for expert opinion to change.” – Paloma Toledo, MD

Screenshot 2015-10-26 17.04.39Social media was all abuzz yesterday about information coming out of the American Society of Anesthesiologists (ASA) conference currently being held in San Diego, CA. Headlines everywhere screamed “Eating During Labor May Not Be So Bad, Study Suggests,” “Light Meal During Labor May Be Safe for Most Women,” and “Eating During Labor Is Actually Fine For Most Women.”  People chortled over the good news and bumped virtual fists over the internet celebrating this information.

The ASA released a press release highlighting a poster being presented at the ASA conference by two Memorial University medical students, Christopher Harty and Erin Sprout. Memorial University is located in St. Johns, Newfoundland, Canada. When a professional conference is being held, several press releases are published every day to advise both professionals and the public about news and information related to the conference. This was one of many released yesterday.

The student researchers suggested in their poster presentation that it may be time for a policy change. Their research indicated that, according to the ASA database, there has only been one case of aspiration during labor and delivery in the period between 2005 and 2013. That aspiration situation occurred in a woman with several other obstetrical complications. “…aspiration today is almost nonexistent, especially in healthy patients,” the researchers stated. The research was extensive – examining 385 studies published since 1990. Much of the research available supported the findings in the poster presentation/study.

The current policy of the ASA on oral intake in labor is that laboring women should avoid solid food in labor. You can read the ASA’s most current guidelines, published in 2007: Practice Guidelines for Obstetric Anesthesia An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia.  The American College of Nurse Midwives recommends “that women at low risk for pulmonary aspiration be permitted self-determined intake according to guidelines established by the practice setting.” They also conclude “drinking and eating during labor can provide women with the energy they need and should not be routinely restricted.”  American College of Obstetricians and Gynecologists recommends no solid food for laboring women and refers to the ASA guidelines.

I connected with Paloma Toledo, MD, an obstetrical anesthesiologist who is attending the ASA conference in San Diego to ask her what her thoughts were on this new research. “General anesthesia is becoming increasingly rare, so fewer women are at risk for aspiration, since most women will have neuraxial anesthesia for unplanned cesarean deliveries. The question is, is eating in labor unsafe? They do allow a light meal in the UK, studies have shown that eating does not adversely affect labor outcomes, and in the CEMACE data, despite allowing women to eat in the UK, there have not been deaths related to aspiration. I think a lot of women want to move away from the medicalized childbirth and have a more natural experience. Women want to eat, and I believe the midwife community has been encouraging eating in labor. The problem for anesthesiologists is that our practice guidelines on obstetric anesthesia are strongly worded, and state that women can not eat during labor. We can’t ethically design a large enough study to answer this question, so we will have to wait for expert opinion to change.”

Lamaze International released an infographic in July, 2014 covering this very topic. “No Food, No Drink During Labor? No Way!” and I covered this in a Science & Sensibility post sharing more details.  You can find all the useful infographics available for downloading, sharing and printing here.  Additionally, the fourth Healthy Birth Practice speaks to avoiding routine interventions that are not medically necessary, and it has long been clear that restricting food and drink in labor is certainly an intervention that should not be imposed.

It is important for birth professionals to recognize what the American Society for Anesthesiologists’ press release is and what it is not. We must not overstate the information that they have shared. Please be aware that this is not a policy change.

Hopefully, this will be a call to action by the ASA to examine the contemporary research and determine that that their existing guidelines are outdated and do not serve laboring and birthing people well, nor reflect current research.

Childbirth educators and others can continue to share what the evidence says about the safety and benefit of oral nutrition during labor and encourage families to request best practice from their healthcare providers and if that is not possible, to consider changing to a provider who can support evidence based care.


American College of Nurse-Midwives, (2008). Providing Oral Nutrition to Women in Labor.Journal of Midwifery & Women’s Health53(3), 276-283.

American Society of Anesthesiologists Task Force on Obstetric Anesthesia. (2007). Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia.Anesthesiology106(4), 843.

Committee on Obstetric Practice. (2009). ACOG Committee Opinion No. 441: Oral intake during labor. Obstetrics and gynecology114(3), 714.

Singata M, Tranmer J, Gyte GML. Restricting oral fluid and food intake during labour. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD003930. DOI: 10.1002/14651858.CD003930.pub3.

Childbirth Education, Do No Harm, Evidence Based Medicine, Healthy Birth Practices, Lamaze International, Medical Interventions, Research , , , , , , , ,

The PregSense Monitor: A useful new tool or fear-based marketing

August 18th, 2015 by avatar

By Deena Blumenfeld, ERYT, RPYT, LCCE 

pregsensePart of a parent’s job description is to worry about their children. In doing so, parents can help the child maintain their physical health and their emotional wellbeing. However, when the line is crossed into fear based parenting; they may become overprotective to the point of stifling a child’s natural curiosity and the need to learn by making mistakes. They are then at risk of becoming “helicopter parents”.

This is an issue of control. When parents take full control, of their child’s overall well being, they feel that they are protecting them from all the negative aspects of the world. This is a fallacy.

Advertisers and marketers play into this fear and the need for control, that feeds into the parents’ feelings of limited or lack of control. Companies create and market products that provide the impression of safety and security. These products provide a false sense of control for parents, which furthers the illusion that they are doing something “good” or “right” as they “protect” their baby.

Making the rounds of Facebook, and other social media feeds, was this nifty little video about an at-home, wearable baby monitor. It’s called the PregSense Monitor by Nuvo Group. The general consensus from the online community, both mothers and professionals alike, was “Wow! This is amazing! We’ll save so many babies this way!”

My own reaction was a bit different. I’m a skeptic at heart and like all Lamaze educators; I’m a big fan of evidence based products, treatments, procedures and medications. So, I knew I needed to learn more about the PregSense monitor. What’s the evidence behind it? Would it really meet expectations, and save babies and reduce moms’ anxiety?

I attempted to contact Nuvo Group for an interview, but I have not received a response from them at the time of this writing.

Nuvo Group claims

The Israeli tech firm hopes the device will reassure anxious mothers like Michal, in week 32 of her pregnancy, who require monitoring without having to see her doctor.

Claim:  “(The monitor will) allay mothers’ fears by transmitting data about the health of the mother and fetus.”

  • It appears to monitor all of the mother’s vital signs, not unlike a Fitbit or other activity tracker. But how does having the knowledge about your own vital signs and getting additional information about baby’s activities reduce fear?
  • What if the monitor malfunctions? What does that do to a mother’s level of fear?
    • Can one make the assumption that if the monitor isn’t picking up the baby, the mother will become more worried, rather than less. This might lead to increased health care provider visits and further unnecessary medical testing.
  • Could wearing this monitor increase anxiety and potentially cause mothers to be so focused on the monitor it becomes a bit of an obsession?
    • Mothers may become hypervigilant and reliant on the constant stream of “data” available to be reviewed.
  • How would a mother feel if she was unable to wear the monitor one day? Would that increase her fears, even if those fears were unfounded?
    • Removing access, even for a short time could increase worry and interefere with a mother’s ability to continue her daily activities.
  • When there is a constant stream of data it becomes easy to tune out the information. Wouldn’t that defeat the purpose of this device?
    • The information may become white noise and fade into the background, because it’s a nonstop stream.

Claim: Mothers can connect, see and hear the fetus whenever they want, without needing to consult a doctor.

  • Do mothers need a device to help them connect with their babies?
    • This product is trying to create a consumer need that does not exist.
    • Mothers connect with their babies all the time by feeling their movements; talking to them; touching their growing bellies, etc. Would the device reduce this natural mother/fetus interaction? Would a mother be more likely to turn to her smartphone for results from the monitor instead of paying attention to what her baby is actually doing throughout the rhythm of the day.?
  • Using this device would require a health care provider to be monitoring all of these women, all the time. This doesn’t take into account staffing levels or time to complete the task. 24/7 monitoring would be a massive time commitment and responsibility.
  • What about additional liability for the health care provider for not monitoring a woman properly or correctly identifying a problem?
    • We live in a very litigious society. A care provider might be facing a lawsuit if the data from the monitor is not evaluated regularly and an anomaly was missed.
  • Since there are two monitor types – the clinical monitor and the consumer monitor, this raises additional questions. What if the mother is low-risk and healthy, but chooses to wear the consumer model, without a prescription to “reassure” herself that all is well?
    • Would the physician then be required to monitor this mother, if there is no medical need and was not advised by the physician?
    • What is the physician’s liability in this case?

Claim: “We will be able to analyze this data to predict about events of pregnancy, like preterm labor, like preeclampsia and more and we will be able to intervene in the right time…”

  • Preterm labor may be able to be detected with continuous monitoring. However, the monitor is only identifying contractions. It’s not looking at vaginal discharge, cervical change, flu-like symptoms or downward pressure from the baby.
  • Would the monitor be able to tell the difference between Braxton-Hicks contractions and early labor?
    • The limited information on Nuvo Group’s website and in their press release does not provide enough information to say for sure.
  • What about those women who experience Braxton-Hicks regularly throughout pregnancy but are not in labor? Would the monitor be helpful or harmful for them in identifying mothers in preterm labor? Would they be in and out of their care provider’s offices more frequently, causing disruption to their daily lives?
  • Preeclampsia cannot be prevented at this time. So, at best, the monitor would let the mother and her care provider know that her blood pressure is high. It would not test for protein in her urine, swelling in her face, headaches, vision changes or any of the other symptoms of preeclampsia, so it’s an incomplete test. Would preeclampsia be missed because mother’s blood pressure is borderline and no other tests were administered.

Claim: Regarding monitoring high risk mothers with continuous monitoring in hospital; the monitor will benefit the health care provider by replacing a bulky machine with one that is lightweight and not connected to the wall.

  • We already have telemetry units for Electronic Fetal Monitoring (EFM), in many hospitals. This device is now redundant and may not integrate with the current software used to monitor the EFM units.
  • How much will this cost a hospital to replace all of their current EFM units by purchasing these PregSense clinical monitors? Is the financial outlay for a new convenience worth the expense?
  • Does the new monitor increase safety for mother and baby in comparison to traditional EFM. Is this alternative truly better for mothers and for doctors in an in-patient setting? Where are the studies that compare the two options? Is the data we get any better? Or are we still subject to human interpretation of the data in identifying the appropriate course of action?

Claim: The PregSense monitor is safer than ultrasounds that can cause tissue damage

nuvo-ritmo-beats-pregsenseAt this point in time there is no evidence and no research, to support monitoring mothers at home during pregnancy. All of the literature refers to full time electronic fetal monitoring (EFM) during labor. Therefore my assumptions are based off of that literature.

Consensus among professional and governmental groups is that, based on the evidence, intermittent auscultation is safer to use in healthy women with uncomplicated pregnancies than electronic fetal monitoring (EFM).  (Heelan 2013) These professional groups include ACOG and AWHONN.

The issue with the beneficial claims made by Nuvo Group is they are in opposition to what the research finds for routine continuous EFM. Continuous EFM in low risk mothers provides no benefit for babies and increases the risk of cesarean for mothers. Therefore the whole concept of the PregSense Monitor is based on an erroneous assumption. It is not possible to prevent a problem by monitoring the baby. A problem can only be detected as it is occurring. So, even if a problem is observed while doing at home monitoring, by the time the mother makes it to the hospital it is may be too late to intervene effectively.

There is also the risk of false positive results. The monitor may detect an anomaly that then increases the mother’s fear about her baby’s well being only to be examined to find out that her baby is doing just fine, causing undue stress and panic.

The claims of the manufacturer of this product don’t hold up under current EFM guidelines and are not FDA approved.

Simplifying fetal monitoring for the care provider may not actually be the case when we look at 24/7 monitoring which still needs to be interpreted by a human being and a potentially large financial investment for a hospital that already has an EFM system that is adequate.

The claim that this product is safer than what currently exists with today’s EFM technology and ultrasonography is unsubstantiated. Without proper research, we do not know if it is safer, more harmful or neutral in relation to EFM and ultrasound as they are done today.

Resolving mother’s fears and helping her connect with the baby are at best an assumption regarding the “softer side” of the product’s results. It may be that some women do have greater piece of mind and feel a greater connection with their baby when using the device. Selling a feeling does not provide medical benefit to mother or baby. It is, however, good marketing.

The takeaway for your students is to have them look at all products with a discerning eye. Fear based marketing is insidious and plays to their emotions. They need to be making informed decisions based on accurate and evidence based information, rather than an emotional response to something that hits them in the heart.


 Nuvo Group’s website

Reuters, “Wearable device provides continuous fetal monitoring”

Dekker, Rebecca, Evidence Based Fetal Monitoring, 2012

Dekker, Rebecca, What is the Evidence for Fetal Monitoring on Admission, 2012

FDA, Avoid Fetal “Keepsake” Images, Heartbeat Monitors, 2014

FDA, Ultrasound Imaging

ACOG Practice Bulletin #106, “Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles,”, July 2009

ACOG press release, ACOG Refines Fetal Heart Rate Monitoring Guidelines, 2009

Lisa Heelan, MSN, FNP-BC, Fetal Monitoring: Creating a Culture of Safety With Informed Choice, J Perinat Educ. 2013 Summer; 22(3): 156–165.




ACOG, Babies, Fetal Monitoring, Guest Posts, Medical Interventions, News about Pregnancy , , , ,

Elective Induction at 40 Weeks? “Decision-Based Evidence Making” Strikes Again

July 14th, 2015 by avatar

Today on Science & Sensibility, contributor Henci Goer takes a look at a systematic review released in spring that examined the impact of elective inductions on the cesarean rate.  Sound analysis or a house of cards?  Looking closer at the studies reviewed provides insight into how the conclusions reached by the investigators might need to be examined more closely.  Henci does that in this review.  Have you read this new systematic review?  Did you come to the same conclusions?  I invite you to share your thoughts in our comments section below. – Sharon Muza, Community Manager, Science & Sensibility.

flickr photo by catharticflux http://flickr.com/photos/catharticflux/2710057340  CC licensed.

flickr photo by catharticflux http://flickr.com/photos/catharticflux/2710057340 CC licensed.

Yet another systematic review has surfaced “Induction of labor at full term in uncomplicated singleton gestations: a systematic review and metaanalysis of randomized controlled trials”  in which reviewers claim that electively inducing healthy women, this time at 40, not 41 weeks, offers benefits and doesn’t increase the cesarean surgery rate (Saccone 2015).

Let’s take a closer look.

Reviewers included five trials: three of them conducted in the 1970s (Cole 1975; Martin 1978; Tylleskar 1979), the fourth published in 2005 (Nielsen 2005), and the fifth in 2014 (Miller 2014). Already we have a problem. Induction management in the 1970s is sufficiently different from management today that results are unlikely to apply to contemporary care, but let’s get down to specifics. Two of the 1970s trials were deemed inadequate for inclusion in the Cochrane review of elective induction (Gulmezoglu 2012), and Miller 2014 is published only as an abstract. Quality systematic reviews exclude abstracts because they don’t provide enough information to evaluate the study. For these reasons, these three trials should be taken off the table..

That leaves us with the other two. Nielsen 2005 states in the title “Comparison of elective induction of labor with favorable Bishop scores versus expectant management: a randomized clinical trial” that it is confined to women with favorable Bishop scores. Anyone familiar with elective induction research should know that inducing when the cervix is ready to go won’t increase the cesarean rate compared with spontaneous onset, but inducing with an unripe cervix is a different story even when using cervical ripening agents (Dunne 2009; Jonsson 2013; Le Ray 2007; Macer 1992; Prysak 1998; Thorsell 2011; Vahratian 2005). As you move the induction date earlier and earlier, more and more women will have an unfavorable cervix, so including a trial limited to women with a ripe one will tilt the playing field in favor of induction. Furthermore, half the participants were multiparous women (113/226). Women with prior vaginal births will go on having vaginal births pretty much no matter what you do to them, which raises another point: inducing earlier means a higher percentage of the inductees will be first-time mothers because first time mothers tend to run longer pregnancies (Mittendorf 1990). Nulliparous women are much more vulnerable to anything that pushes them in the direction of a cesarean. That’s not all: The authors tell us that their hospital has a 7% cesarean rate for dystocia in women at term. If a hospital has a cesarean rate much higher than that—and many do—then results can’t be generalized to it, although, frankly, if the doctors are performing cesareans left and right, induction or spontaneous onset may not make much difference. In short, Nielsen (2005) doesn’t make a compelling argument for 40-week elective induction.

flickr photo by Selbe <3 http://flickr.com/photos/stacylynn/11944718954 shared under a Creative Commons (BY-NC-ND) license

flickr photo by Selbe < http://flickr.com/photos/stacylynn/11944718954 shared under a Creative Commons (BY-NC-ND) license

This brings us to the last trial, Cole (1975). Investigators allocated healthy women either to induction at 40 weeks (111 women) or 41 weeks (117 women). As with Nielsen, half the women had prior vaginal births. Despite being healthy, 22 women were induced for “obstetric complications” (undefined) in the 41-week induction group before reaching 41 weeks. If their doctors induced labor because they had concerns, then this would likely put the women at heightened risk for cesarean. Another 32 women were induced for exceeding 41 weeks. This means that overall, nearly half (46%) of the comparison group didn’t begin labor spontaneously, which would mask any association between induction and cesarean. Leaving the induction vs. spontaneous onset issue aside, the U.S. cesarean rate in the early 1970s was around 5%, which means it was a rare woman who would have one regardless of circumstances. Again, not exactly a strong case for inducing at 40 weeks.

What about the benefits? The best reviewers can come up with are a clinically meaningless reduction in mean blood loss (-58 ml); a lower rate of meconium-stained amniotic fluid (4% vs. 14%), not, mind you, a reduction in meconium aspiration, and therefore clinically meaningless as well; and an equally meaningless reduction in mean birth weight of -136 g (5 oz). If they had found something more impressive, surely they would have reported it.

Really? This merited a pre-publication media blast? Because it amounts to a textbook example of “garbage in, garbage out.” I can see only three possibilities to explain it: either 1) the authors and peer reviewers at the American Journal of Obstetrics and Gynecology (AJOG) don’t know as much as they should about what constitutes a quality systematic review, 2) they are so steeped in medical model thinking—“How early can we get the baby out of that treacherous maternal environment?”—that their judgment is compromised, or 3) we have a “pay no attention to what’s behind the curtain” effort to promote elective induction. I don’t know which is the more troubling, but if it’s the last one, the sad thing is that because it’s got the magic words “systematic review,” “meta-analysis,” and “randomized controlled trials” in the title, it’s likely to succeed.


Cole, R. A., Howie, P. W., & Macnaughton, M. C. (1975). Elective induction of labour. A randomised prospective trial. Lancet, 1(7910), 767-770.

Dunne, C., Da Silva, O., Schmidt, G., & Natale, R. (2009). Outcomes of elective labour induction and elective caesarean section in low-risk pregnancies between 37 and 41 weeks’ gestation. J Obstet Gynaecol Can, 31(12), 1124-1130.

Gulmezoglu, A. M., Crowther, C. A., Middleton, P., & Heatley, E. (2012). Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev, 6, CD004945.

Jonsson, M., Cnattingius, S., & Wikstrom, A. K. (2013). Elective induction of labor and the risk of cesarean section in low-risk parous women: a cohort study. Acta Obstet Gynecol Scand, 92(2), 198-203. doi: 10.1111/aogs.12043

Le Ray, C., Carayol, M., Breart, G., & Goffinet, F. (2007). Elective induction of labor: failure to follow guidelines and risk of cesarean delivery. Acta Obstet Gynecol Scand, 86(6), 657-665.

Macer, J. A., Macer, C. L., & Chan, L. S. (1992). Elective induction versus spontaneous labor: a retrospective study of complications and outcome. Am J Obstet Gynecol, 166(6 Pt 1), 1690-1696; discussion 1696-1697.

Martin, D. H., Thompson, W., Pinkerton, J. H., & Watson, J. D. (1978). A randomized controlled trial of selective planned delivery. Br J Obstet Gynaecol, 85(2), 109-113.

Miller, N., Cypher, R., Pates, J., & Nielsen, P. E. (2014). Elective induction of nulliparous labor at 39 weeks of gestation: a randomized clinical trial. Obstet Gynecol,132(Suppl 1):72S.

Mittendorf, R., Williams, M. A., Berkey, C. S., & Cotter, P. F. (1990). The length of uncomplicated human gestation. Obstet Gynecol, 75(6), 929-932.

Nielsen, P. E., Howard, B. C., Hill, C. C., Larson, P. L., Holland, R. H., & Smith, P. N. (2005). Comparison of elective induction of labor with favorable Bishop scores versus expectant management: a randomized clinical trial. J Matern Fetal Neontal Med, 18:59-64.

Prysak, M., & Castronova, F. C. (1998). Elective induction versus spontaneous labor: a case-control analysis of safety and efficacy. Obstet Gynecol, 92(1), 47-52.

Saccone, G., & Berghella, V. (2015). Induction of labor at full term in uncomplicated singleton gestations: a systematic review and metaanalysis of randomized controlled trials. American journal of obstetrics and gynecology.

Thorsell, M., Lyrenas, S., Andolf, E., & Kaijser, M. (2011). Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women. Acta Obstet Gynecol Scand, 90(10), 1094-1099. doi: 10.1111/j.1600-0412.2011.01213.x

Tylleskar, J., Finnstrom, O., Leijon, I, et al. (1979). Spontaneous labor and elective induction – a prospective randomized study. Effects on mother and fetus. Acta Obstet Gynaecol Scand, 58:513-518.

Vahratian, A., Zhang, J., Troendle, J. F., Sciscione, A. C., & Hoffman, M. K. (2005). Labor progression and risk of cesarean delivery in electively induced nulliparas. Obstet Gynecol, 105(4), 698-704.out

About Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.


ACOG, Cesarean Birth, Childbirth Education, Do No Harm, Evidence Based Medicine, Guest Posts, Medical Interventions, New Research, Research , , , , , ,

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