Cesarean vs, VBAC - a dramatic difference

This is such a touching video and eye opening video. Most people do not realize the force needed to get a baby out during a cesarean section - in the second birth, a vacuum is used as well as manual force. It is 16 minutes long, but worth the time.

Cesarean vs. VBAC: A Dramatic Difference from Alexandra Orchard on Vimeo.

For some, life begins at home

Emma Downs
The Journal Gazette

Kat Hickey was nine months pregnant – although anyone who has gone through a pregnancy knows that nine months feels a lot like 19 somehow – and ready … really ready … to deliver.

Sitting in a bathtub inside her Fort Wayne home, Hickey diligently breathed through a series of contractions and waited patiently for her certified nurse midwife to arrive.

OK. Maybe not that patiently.

“My husband asked me if I could hang on just a little longer,” Hickey says. “The midwife was just 10 minutes away.”

And then Hickey felt the crown of her soon-to-be-born daughter’s head touching her hand. So that answered that question.

Ummm … no. Huh-uh. There would be no hanging on for a little longer.

“Knowing it would just take one good push and I would have her in my arms,” Hickey says. “That was the motivation.”

So she pushed. And, with the help of her husband, a few minutes later a beautiful, healthy baby girl was staring at them with that “Whoa. What just happened?” newborn expression.

“It was beautiful. We had the baby the same way we made it,” Hickey says. “Just two idiots, in our own house.”

And as dramatic as this story sounds, this is exactly what Hickey and her husband had planned from the beginning: a home birth involving the whole family.

As with many women who choose to deliver at home, Hickey wanted to avoid what she considered to be the unnecessary medical interventions she’d encountered while delivering her first child at a hospital. For her, this had included Pitocin to speed up or regulate labor, an epidural and narcotics, an IV, a catheter, a constant fetal monitor and, eventually, forceps used to extract the baby from the birth canal.

“When it came to pushing, I could’ve been blowing my nose for all I knew,” she says. “It was a bazaar situation. It seemed like the baby had been ejected from my body. And that left me thinking, ‘Did I do that? Or did they?’ I knew that couldn’t be the best way to do it.”

Growing demand

The process of delivering at home – even in the bathtub – was transformative, Hickey says. And it convinced her to become a doula, a trained labor coach. She began assisting with home births in 2000, shortly after her daughter was born.

“One of the biggest misconceptions is that giving birth at home is not an informed choice,” Hickey says. “A lot of people who do research on birth and the risks of giving birth come to the conclusion that the risks of the medical interventions are higher than the risks of delivering naturally at home.

“And the number of women who encounter an unexpected complication – when no problems existed prenatally – is incredibly small. My husband, for instance, was mostly just worried about our carpet. I knew we could work around that.”

Hickey frequently assists in births with Laura Gilbert, a certified nurse midwife with Homebirth & Women’s Health in Goshen. Gilbert, who assists with births in Fort Wayne, has recently started to turn clients away. The demand for home births is growing for a number of reasons, she says.

“There really is a desire to avoid unnecessary medical interventions,” Gilbert says. “But there is also a drive to have the birth be a family-centered event instead of a medical-centered event.”

Gilbert performs about six deliveries a month and insists that all of her clients be single, low-risk pregnancies. Although the majority of her clients are Old Order Amish, the next largest group are conservative Christians looking to save money, she says.

“The cost is probably less than half of a natural birth in the hospital,” Gilbert says. “But despite the cost, I always tell people who are thinking about home birth to have the baby in the place where they feel most comfortable.

“For me and my clients, that’s at home. For some people, that’s the hospital. There is no right or wrong.”

‘Informed choice’

For local mom Kristin Rahn, the most comfortable place to have her most recent child was standing up next to the living room couch. Gravity, it turns out, helps more than you’d think.

“That’s the big advantage to having a baby at home,” Rahn says. “You’re on your own turf, so your fight-or-flight instinct is less likely to kick in and inhibit your labor.

“And you’re more comfortable listening to your own body. You decide whether to eat or drink, whether to stand up, squat, take a bath, take a shower. You’re not flat on your back, hooked up to an IV and a catheter.”

Rahn and her husband have four children; two born in the hospital, two born at home. And when the couple first made the decision to deliver at home, they didn’t tell all of their relatives.

The midwifery model of care treats birth as a normal occurrence, relying on the idea that biologically a woman is designed to give birth. It was easy for Rahn to trust that her body and the process of giving birth naturally would work.

But not everyone felt the same. Some people she encountered felt a home birth was innately risky, she says.

“There were people who were worried,” she says. “People who frowned and said, ‘We’ll be praying for you.’ And people who thought my decision was based on bravado and not research. And that is a misconception.

“It’s totally evidence based. It’s definitely an informed choice, not second-rate or a last choice. It’s always something consciously chosen.”

Gilbert combats the misconception that home birth is dangerous with a rundown of what’s inside the travel bag she carries with her to every home birth – a dopler to check the fetal heartbeat, injectable Pitocin, oxygen and an IV for any needed antibiotics.

Fewer than 10 percent of Gilbert’s patients end up in the hospital – most of them due to long drawn-out labors when pain relief is needed.

“It’s important for the mother and baby to be low risk,” Gilbert says. “Prenatally, we check for anything out of the norm. And thank goodness hospitals are there. It’s the best of both worlds, really. You can have a home birth, but the hospital is nearby, too.

“If you were living 600 years ago, you wouldn’t have had that choice.”

For Hickey, the birth of her daughter – at home, in the bathtub – is a story worth retelling. Every year on her birthday, Hickey and her husband tell their daughter about the day she was born.

“My husband has this visceral memory of seeing our daughter’s little face, fitting perfectly in the palm of his hand,” she says. “And it’s that – those memories. That’s the beautiful thing about home birth.”

Breech Vaginal Birth is NOT an Emergency

This blog was written by a blogger friend. It was so good, I asked if she would mind me posting it here. Thanks Emily (http://jeremyscorner-grifter.blogspot.com) for letting me share this with my readers!

In my continuing crusade to shoot down OB myths, this week I am tackling breech vaginal birth. This post has taken a lot longer to write than I thought it would. At first I thought I was having trouble with the amount of information available about it, but that isn't the problem. The problem is that I can't really understand why breech vaginal birth is considered an emergency in the first place. Sure, I know that there are risks associated with breech vaginal birth, but I just can't shake the idea that babies are born breech all over the world with little fanfare or issue. Nevertheless, obstetricians continue to look for more and more excuses to avoid the topic entirely by just cutting the babies out. So, in the interest of being thorough, here is some food for thought.

According to this article, "Vaginal breech deliveries were previously the norm until 1959 when it was proposed that all breech presentations should be delivered abdominally to reduce perinatal morbidity and mortality." Typical of obstetric mentality, instead of looking at the cause of morbidity and mortality in the first place, they chose to focus on the correlative factor instead - that many babies who presented breech had a high rate of injury or death. But as far as I know, no one thought to ask if medications, managed, or instrumental delivery could have contributed to those injuries or deaths.

Fast forward to today, and more than 90% of all breech births in the U.S. are delivered by c-section. This has happened largely because of a study that was done in 2000 by Hannah, et al, that shows a higher rate of perinatal morbidity and mortality associated with breech vaginal birth, as compared to planned c-section. Consequently, the American College of Obstetrics and Gynecology (ACOG) has systematically condemned breech vaginal birth, and it is no longer offered as a choice to women today. Henci Goer does a good job here of explaining why the conclusions of that 2000 study are not valid.

However, the ACOG has a history of picking and choosing those studies that support its own position. They also prefer to ignore any studies not done in the United States, as those studies are often contrary to American obstetric practics. For example:

A study out of Sweden in 2003 in the European Journal of Obstetrics & Gynecology and Reproductive Biology showed no difference between elective cesarean vs. planned vaginal birth for term breech deliveries.

Another study actually published with the American Journal of Obstetrics and Gynecology in 2006 examined planned breech delivery in France and Belgium, and found no discernable difference in outcome with more than 8,000 breech patients studied.

A different study from France in 2002 and published in European Journal of Obstetrics & Gynecology and Reproductive Biology looked at more than 500 patients and found no difference in outcome.

The International Journal of Gynecology & Obstetrics published a study in 2004 from the United Emirates which found no clear difference in breech vaginal vs. cesarean, but did find more maternal morbidity associated with cesarean section.

The Malaysian Journal of Medical Sciences, published a study in 2007, which concluded, "Most of the perinatal mortality was due to IUD, congenital abnormality and prematurity and there
were no perinatal death related to mode of delivery or due to birth trauma."

and there have been other studies to support these findings.

Danell Swim writes in her article, A Breech of Trust,

So I ask you, what are the United States hospitals doing wrong for their vaginal breech deliveries?

It is NOT that cesarean section is safer for breech deliveries in this nation, it is that vaginal breech is more dangerous in this country. US hospital policy and procedure are killing more breech babies than their European counterparts.

And to remedy the situation, it’s been recommended that nearly all babies in a breech presentation be delivered via cesarean section. This is despite the study published with the American Journal of Obstetrics and Gynecology that discovered that France and Belgium are able to safely deliver them vaginally, and safely.

So rather than teach our doctors how to safely deliver a breech baby, the ACOG's answer to the breech problem is to simply take them by c-section at term.

This article describes how best to safely deliver a breech baby. Included in the highlighted points are:

• Spontaneous onset anytime after about the 37th week.
• No augmentation if labour is slow or there is poor progress - caesarean section.
• Mother encouraged to assume positions of choice during the first stage.
• Fetal heart listened to frequently with a Pinard stethoscope or a hand held Doppler Sonic aid using ultrasound.
• Food and drink encouraged, but remembering that women in strong progressing labour rarely want to eat.
• Membranes not ruptured artificially.
• Vaginal examinations restricted to avoid accidental rupturing of the membranes.
• If, and when spontaneous rupture occurs conduct a vaginal examination as soon as possible.
• Second stage by maternal propulsion and spontaneous expulsive efforts guided by the attendant if judged appropriate.
• Mother encouraged to be in an all-fours position.
• No routine episiotomy.
• Third stage without chemical or mechanical assistance, usually managed according to woman's wishes.

Of that list, tell me how many of those are likely to occur in a medically managed birth in a US hospital today?

The most dangerous aspect of this trend is that American health care providers are losing, or have completely lost, the art of safely delivering breech babies. While some doctors may envision a 100% c-section rate for breech births, that will never be possible. The World Health Organization (WHO), in this publication about planned c-section for breech says,

It will be impossible to deliver all term breech pregnancies by caesarean section. The systematic review showed that 9% of women with breech presentation still have a vaginal breech delivery because the mother may insist on vaginal delivery, breech labour may be precipitate, or special situations such as the second fetus in twins. It is therefore imperative to continue providing expertise in vaginal breech delivery to all the intrapartum care providers.

This atmosphere of fear and foreboding surrounding breech births is leading women to choose dangerous options to avoid having a breech baby at all costs. The current recommendation is to attempt an external cephalic version (ECV), in which the care provider attempts to turn the baby from the outside into a head-down position. But ECV is not without risks. According to this publication:

The largest review which included 44 studies and 7377 patients found the most common complication of ECV to be transient fetal heart rate abnormalities (5.7%). The risk of placental abruption, emergency cesarean section, vaginal bleeding, and perinatal mortality were less than 1 percent combined. Because of the risk of alloimmunization, Rhogam is recommended for non-sensitised Rh negative women following ECV. There currently is not enough evidence from randomized controlled trials to assess complications of ECV.

In addition, in order to perform an ECV, tocolytics such as terbutaline, and epidural anesthesia are sometimes used. The risks of epidural anesthesia are well-documented. Risks of terbutaline to the baby include fetal tachycardia, hyperinsulinemia, hyperglycemia, myocardial and septal hypertrophy, myocardial ischemia. Terbutaline not only does not have FDA approval but the FDA disapproves of its use as a tocolytic.

ECV is only successful 50-60% of the time (various sources). When ECV is unsuccessful, the only other option is to schedule a planned c-section for some arbitrary date. The problem with this is that breech babies can and do turn, up to, and even during labor. So planning a c-section may be taking a baby even before it is ready to be born, and without giving it a chance to get itself into a favorable position.

It is clear to me that breech birth, while carrying some risk, is not unreasonably dangerous in itself. The danger lies in breech birth in a highly managed hospital setting. For this reason, I would suggest that if a woman plans to birth in the hospital in the U.S, and her baby is breech, she should plan to have c-section. In fact, if a woman is planning a hospital birth and her baby is breech, she probably won't have a choice about it. If she does not want to have a c-section, she should stay home. But she should know a c-section for breech is not necessary! In fact, I don't even believe any undue concern should be attributed to breech presentation, especially if one has a midwife who is experienced and skilled in delivering breech babies.

If you find yourself pregnant, approaching term, and your baby is breech, please try these suggestions for gently encouraging your baby to turn. If you want to avoid unnecessary surgery, start now looking for a midwife who is experienced in breech delivery. Don't schedule a c-section - allow baby all the time it needs to turn itself. You can visit spinningbabies.com to learn how to tell whether your baby is head-down.

Free Natural Birth Stories Book Download

Sheri Minelli, the author of this book, has graciously given the download to her book away in hopes that it will possibly someday replace What to Expect When You Are Expecting. It contains natural birth stories to encourage.

I hope you enjoy. http://www.birthingbusiness.com/Book/InspirationalBirthStories.pdf

Mothers respond more to baby's cry after natural birth

http://www.guardian.co.uk/science/2008/sep/04/medicalresearch

Childcare: Mothers respond more to baby's cry after natural birth, says study
Ian Sample, science correspondent
The Guardian,
Thursday September 4 2008


Mothers who give birth naturally show a greater surge in brain activity when they hear their baby cry than women who have caesarean sections, scientists have found.

The study, the first to use brain scans to investigate mothers' responses to their babies, follows work that suggested women who have a caesarean may have more difficulties bonding with their baby.

The Yale University team behind the study said it could help doctors identify women who may find it harder to form an emotional connection with their baby, which some studies have linked with an increased risk of postnatal depression.

More than 130,000 caesarean sections were carried out by the NHS last year in England alone, accounting for about 24% of all births. "Our results support the theory that variations in delivery conditions, such as with caesarean section, which alters the neurohormonal experiences of childbirth, might decrease the responsiveness of the human maternal brain," said James Swain, who led the study.

In the Journal of Child Psychology and Psychiatry, the researchers describe how they used functional MRI scans to look at 12 women's reactions to 30-second recordings of their babies crying. These were compared with their brain activity while listening to white noise for 30 seconds.

The scans revealed that women who had natural deliveries had heightened activity in a broad range of brain regions, including the amygdala, which plays a role in governing emotional states.

"This study provides an interesting link between the method of birth and the way a mother relates to her new baby," said Belinda Phipps, of the National Childbirth Trust. "Women who have a caesarean section should be encouraged to cuddle their newborn against their skin straight after birth and be offered practical support to help them feed and care for their baby."

"A caesarean section is necessary in some conditions and can save lives. However, surgery can create more problems than it solves."

Twins & Triplets...a new standard of care?