April 2, 2003
Volume 5, Issue 7
Midwifery Today E-News
“VBAC”
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THIS WEEK’S ISSUE

Quote of the Week

“The thing that helps more than anything [at a birth] is that the person who's helping you loves you. It can make the difference between heavy complications and having a nice time.”

Ina May Gaskin, 1979


The Art of Midwifery

Remedies to help strengthen postcesarean uterine scar tissue:

  • Vitamin C with bioflavinoids, and eating oranges with the soft, white inner lining (contains rutin and bioflavinoids). These help form collagen, which will add strength to any scar tissue.
  • Vitamin E, but only 400 IUs a day. Large doses may cause the placenta to adhere to the uterine wall.
  • Rosehips—add to any tonic tea.
  • Comfrey is outstanding for strengthening tissues. Unfortunately during the past decade it has been put in the "hot spot" by various food and drug administrators. I choose to ignore this information, and I have had fantastic results from using comfrey. You'll have to decide for yourself.
  • Red raspberry leaf is one of the best uterine tonics ever.
  • Stinging nettles helps build a good blood supply and helps raspberry leaf work.

Raven
Midwifery Today Forums


ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com


News Flashes

A University of California study that included 250 pregnant women showed that an infant's birth weight may be affected by the amount of social support the mother receives during pregnancy. The women were asked if the baby's father would help them financially and otherwise with the baby, if their parents would be there for them, and if they had friends to turn to for support and assistance. The study found that women with several types of support from various sources during pregnancy had higher birth weight infants.

The relationship between social support and birth weight held even after the researchers took into account other factors often associated with low birth weight, including premature delivery, a history of stillbirth or spontaneous abortion, and medical conditions such as hypertension or epilepsy. The researchers speculated that social support may alter responses of the nervous system to stress and improve fetal growth. Social support may also inspire healthier behaviors and lifestyles among pregnant women and discourage high-risk behaviors such as smoking, substance use, and poor nutritional intake. Pregnant women with more social support may also be more likely to receive treatment for diseases associated with low infant birth weight.

Psychosomatic Medicine, Sept./Oct. 2000

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VBAC

“Risk of Uterine Rupture During Labor Among Women With a Prior Cesarean Delivery”
Lyndon-Rochelle M, Holt VL, Easterling TR, Martin DP NEJM Vol. 345, 3-8 July 5, 2001.

20,095 women, each with 1 prior cesarean.

Uterine rupture:

  • Elective repeat cesarean (ERC) with no labor: 0.16% (11 of 6980)
  • Spontaneous onset of labor (SOOL): 0.52% (56 of 10,789)
  • Induction of labor without prostaglandin: 0.77% (15 of 1960)
  • Induction of labor with prostaglandin: 2.45% (9 of 366)
  • Overall risk of uterine rupture in all TOL groups: 0.6% (80 of 13115)

Fetal deaths:

Five fetal deaths in the women who had uterine ruptures (91 total ruptures) and 100 fetal deaths in the women who did not have uterine ruptures (20,004 total).

If all of the uterine rupture associated deaths occurred in the groups of women who labored, then the risk of the baby dying as a result of a uterine rupture associated with TOL is 0.04% (5 of 13115), over 10 times less than the risk of the baby dying for any other reason (0.5% or 100 of 20,004).

No published studies look specifically at complication rates in completely unmedicated, “natural” VBACs vs. ERC or a medically managed VBAC. No published studies look at complication rates in out of hospital VBACs.

Click here to read about this and three more studies about VBAC safety.


International Cesarean Awareness Network (ICAN) response to the above-cited study:

The study confirmed what ICAN has known for many years: Induction of labor in women planning VBAC increases the rate of uterine rupture significantly.

Babies delivered by elective cesarean section are cut during surgery 2-6% of the time, have a 9% chance of being born prematurely, and risk a 0.4% chance of developing respiratory distress syndrome, a potentially fatal complication. They spend more time in neonatal intensive care units and have more breastfeeding difficulties than babies born vaginally. Elective cesarean section increases a woman's risk of hysterectomy in both the current and future pregnancies, and doubles her risk of death compared to vaginal birth.

Cesareans also increase the risks to both mother and baby in subsequent pregnancies. Incidences of life-threatening placental abnormalities increase with each cesarean. When all short- and long-term consequences are considered, VBAC has been shown to be less risky for both mother and baby than elective repeat cesarean section.

Given that it is the previous cesarean that introduces the risk of uterine rupture into a woman's reproductive life, not VBAC, healthcare providers must heed the call to lower the primary cesarean rate while continuing to support women who choose VBAC.

Cesarean section, which can be a life-saving operation when necessary, carries immediate significant risks for both mother and baby and increases the risk of complications in subsequent pregnancies. Risks to the mother include excessive blood loss and transfusions, scarring, adhesions, injury to internal organs, infection, anesthesia complications, blood clots, decreased bowel function, and postpartum depression. Elective cesarean section increases a woman's risk of hysterectomy in both the current and future pregnancies, and doubles her risk of death compared to vaginal birth.

Thanks to ICAN: pregnancy.about.com/library/blicanresponse.htm


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CONFERENCE AUDIOTAPES FOR THIS WEEK'S THEME

Working with VBAC Women:
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Preventing Cesarean Section


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Forum Talk

Q: How long do sutures take to dissolve? A range you have seen would be great information.

— Adrienne


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Question of the Week

Q: What do you consider to be the true beginning of first stage? Why?


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line.


Question of the Week Responses

Q: I am interested in information about VBACs and getting over the emotional hurdle with a subsequent baby after a traumatic hospital birth, especially those ending in c-section. I had an unnecessary c-section with my first and only baby, and will never go to an OB again. I hope to have a VBAC with a midwife if I can overcome my fears. I am interested in how midwives handle VBAC women.

— Anon.

A: Read books, talk with people who have had homebirths, and begin looking for a midwife before you get pregnant. It is very difficult to overcome the medical-model thinking and begin thinking in a more positive way. The medical model sees us as broken and only they can fix it. We know we are born to birth and that our bodies work! {Do you get up in the morning and wonder if the rest of your body will work?) The book Obstetric Myths Versus Research Realities by Henci Goer is a good place to begin to get some validation and hope for your desired VBAC. Don't be talked out of your quest until you research and can make an informed decision about your next birth.

— Anon.

A: A very empowering book about VBAC is Silent Knife: Cesarean Prevention and VBAC by Nancy Wainer Cohen and Lois J. Estner—midwives who specialize in VBAC. The book not only has a wealth of information about c-section prevention and how to have a successful VBAC, but it also has a section on healing emotionally from previous cesareans. No matter who you choose to attend your next birth, you must believe in your ability to birth and begin to heal and let go of the fear.

— Anon.

A: I remember how much emotional distress I was in while making the decision to switch from the medical establishment to midwives. It seemed making that choice was essentially deciding the outcome for the birth, and I was so afraid that something would go wrong and I would feel responsible. However, the more reading I did ("The VBAC Companion" and "Silent Knife," among others) convinced me that the midwife approach to trusting in your ability to have a baby, even as a VBAC, without interventions, was a very sensible choice.

— Kim Kelleher

A: I am not a midwife, but a childbirth educator and writer who had two cesareans and then a VBAC. In my journey toward VBAC, I found a lot of resources that were valuable in helping people work through their fears and concerns about future births. One of the best resources is the International Cesarean Awareness Network, www.ican-online.org. An e-mail support group is available through the Web site, and there are many local chapters in the country where you can go for group support and help.

I have several FAQs on my Web site www.plus-size-pregnancy.org/CSANDVBAC/vbacresources.htm for women on their journey toward VBAC. The "Great VBAC Resources" FAQ lists books, Web sites, tapes, and videos that may be helpful to women as they work through their prior births and prepare for future ones. The "Emotional Recovery After Cesarean" FAQ discusses why people have differing reactions to cesareans, hints on dealing with friends and relatives after a difficult birth, ideas for emotionally processing your prior birth, and suggestions for healing and planning for future births.

— Pamela Vireday

A: After having a scheduled section for a breech with hydrocephalus, I was desperately seeking a 100% natural VBAC. My CNM wasn't as sure of herself as I would have liked, and the OB was pressuring her a lot. I ended up being talked into an artificial rupture of membranes at 42 wks (LMP dates) and Pitocin was withheld per OB request even after I begged so I wouldn't have to have another section. I ended up with another section. My advice is that if you really want a VBAC, look for a good midwife/OB who totally supports you. My OB backup really tried to scare me out of a VBAC.

— Melissa

A: Choose a competent midwife who is not only trained to deal with complications of labor and birth, but one whom you feel comfortable with and you can deeply connect with. Search for the right midwife before you decide on a practitioner. Learn more about birth's normal processes. Trust your body and the wisdom birth unlocks within you. Surround yourself with positive women, positive energy, and positive birth stories. Love yourself for your last experience and let go of your anger. It is a huge letdown to be c-sectioned, but it is your story and your child's birth. Grow from the experience.

Most of all, love yourself and trust the process. I am now on the midwifery path and have seen the tremendous love and attention VBAC women need. They need to be counseled and be heard. They need empowerment and acceptance. Birth is sometimes longer for the previous etched experiences to dissolve and for the women to be able to progress past certain points along her labor. Longer labors seem to be more common, but not always. It is just the process of facilitating her healing and not pushing her until she has overcome her personal "stuff" she carried with her into this new experience. Prenatal care is crucial, and counseling is nice for releasing and letting go and coming to understanding. Just loving her and her process is all a midwife can really do. Peace.

— Anon.


Re: Polyhydramnios [Issue 5:05]:

A: A client had an uneventful but unsatisfying vaginal birth in the hospital with her first child, a c-section for postdates, polyhydramnios and poor score on a biophysical profile sonogram under midwifery care for the second child, an easy VBAC at a birth center with her direct-entry midwife, and another easy VBAC at home with her direct-entry midwife.

She developed polyhydramnios with the third pregnancy and was advised to discontinue drinking sweet tea, of which she had been consuming what seemed gallons daily. She switched to water, and her AFI decreased to completely normal within two weeks and stayed normal until birth. With the fourth pregnancy she never got started on sweet drinks, drank mostly plain water, and never had polyhydramnios.

The advice to discontinue sweet drinks came from another midwife originally and was an experiment for her midwife. It seems to have worked.

— Molly Germash, CPM
Grand Prairie, TX


Re: Vaginal septum [Issue 5:05]:

A: I have had two clients with a vaginal septum. In both cases the septum was not directly midline, and I tried to direct it to one side of the baby's head during the second stage of labor. In both cases the septum did not stretch adequately and ended up torn in two. Both repairs were sufficiently complex that I had to call a doctor. But the good news is that there was not a great deal of bleeding in either situation. In one case it appeared that the severe stretching had actually interrupted the blood supply to the septum, and there was virtually no blood at all. Of course it would be prudent to be ready to tie off a lacerated septum that was actively bleeding.

— Anita Jaynes, CNM


EDITOR'S NOTE: Responses to any Question of the Week may be sent to mtensubmit@midwiferytoday.com at any time. Please indicate the topic of discussion in the subject line or in the message.


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Feedback

I live in Arizona where midwives are not licensed to do VBACs, twin births, etc. Does anyone have suggestions on how to legally get around this?

Anon.

I would like to hear from someone in Australia who knows about the bachelor of midwifery course or is doing it. I would like to know more about it and what is involved.

Lorelle
Melbourne, Australia

I am an Israeli nurse midwife with a homebirth practice and a member of our newly created Homebirth Midwives of Israel organization. We are currently discussing protocols and even negotiating with the appointed committee of the Ministry of Health that was recently formed to investigate homebirth and protocols. Currently there is no routine screening for Group B strep (GBS) in Israel, but we realize that this will soon come to be. Could you please tell me what is common practice in your country for homebirth regarding women who test positive for GBS? Do you give them antibiotics IV as indicated by the CDC in the USA and done in the hospitals here? I personally have given prophylactic IV antibiotics at homebirths. Some of the midwives fear anaphylactic shock and worry that we need a doctor's prescription for this. Do you need a doctor's prescription to give antibiotic IV at home? What do you do if a woman had one positive culture and then a negative one at 36 weeks? Do you automatically risk out from homebirth women who are GBS positive? Is there an effective alternative to IV antibiotics? Do you routinely screen all women for GBS? What is your policy if there is PROM in a GBS-positive woman? I am especially interested in the Dutch guidelines because homebirth is so popular in the Netherlands. What are the policies in the UK for homebirth and GBS?

Praying for world peace,
Ilana Shemesh

My nephew was born last July and has since been diagnosed with ponto cerabellar hypoplasia. I am finding it quite difficult to find information on this condition. Is anyone familiar with it?

Lisa Cane

I am 28 and dedicated to serving women in gaining power so that we may all have control over our reproductive health and births. I must go the CPM-LM route rather than the university system for my midwifery studies. I had considered a PhD program involving research and then decided to look intently into my well-being as a woman and what I truly needed to do for the well-being of other women. I need to be a homebirth or birth center midwife, not in an academic institution, until later when I would like to teach what women need to the university system. I can learn all the medical information outside of the university (I am beginning a route that will lead to RN—possibly NP), but there is no way I can receive the midwifery education I would receive apprenticing. Observing and practicing in an OB ward instead of a woman's own nest or birth center is not the education I am looking for. Funding remains the issue, for nongovernmental direct-entry programs. If anyone has recommendations, please send to gkcharlotte@hotmail.com.

Charlotte C.

I am pregnant with my sixth child. We have recently moved to a province where midwifery is funded, but midwives are not available in our area. My second child was induced, and I almost lost her. At my fourth birth the doctor yanked the placenta out, and I bled excessively. I had retained placenta after my fifth birth, which left me with an infection.

I am determined not to allow medical manipulation this time. This small town has only one doctor accepting new patients, so I don't have real choice. They won't let me go past my due date because of the weight of my fourth child. I said I would not be induced and I want the placenta to be delivered naturally. The doctor said he would like me hooked up to an IV "just in case" there are bleeding problems.

Does the IV oxytocin I.V. interfere with normal labor? What are some of the hazards?

Berncie Hiebert

I was in a car wreck at 28 weeks pregnant. I immediately started having contractions, and I delivered at 35 weeks. The contractions grew in intensity until delivery day. When I delivered my 3 lb 10 oz girl, a tear was discovered on my placenta. What are the chances that the tear was caused by the accident? And how about the contractions? I had no complications with pregnancy until the car wreck. How easy is it to get a placental tear, and how can or does a tear affect the unborn fetus?

Elizabeth Mendenhall

I am an apprentice-in-waiting and want to educate myself as much as I can until an opportunity for apprenticeship comes along. Do readers have ideas for books, courses, magazines, etc. that would be helpful?

Anon.


EDITOR'S NOTE: Only letters sent to the E-News official e-mail address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.


Classified

INSTRUCTORS NEEDED IN OREGON. The International School Of Traditional Midwifery is hiring two part-time instructors to start in September, 2003. Could include foreign clinical opportunities. E-mail sudy@holisticmidwifery.com before April 15th.


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