September 14, 2005
Volume 7, Issue 19
Midwifery Today E-News
“VBAC - Vaginal Birth after Cesarean”
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HOLISTIC MIDWIFERY VOL. II: Care from Onset of Labor through the First Hours after Birth, by Anne Frye

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In This Week’s Issue:


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Quote of the Week

"Birth became something that was performed on women rather than something that women performed."

Colleen Bak


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The Art of Midwifery

It's a good idea to talk to the family before the birth about the importance of having "only mom" hold the baby for the first four hours after the birth. When there are many siblings jockeying for the first chance to hold the new brother or sister, the mother might be tempted to start passing her baby around and not receive the "hormonal cocktail" that prevents bleeding.

Holding the newborn on the skin is most important. If you want to avoid doing vitals after the birth look for: 1) Is the mother holding her baby on her skin? 2) Is her face glowing? If you note these two things, you know the mother's well-being is fine. If she asks someone else to hold the baby for her, that's a red flag that she doesn't feel well and you must find out what's going on immediately. The noises the baby makes also stimulate oxytocin production, and this continues all through the breastfeeding relationship.

Gloria Lemay


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.

Research to Remember

Study Finds Planned Homebirth a Safe Option

A recent study published in the British Medical Journal showed what midwives, moms and other advocates for homebirth have known all along—homebirths attended by certified midwives are safer than hospital births. Rates of medical intervention, such as epidural, forceps and caesarean section, were lower for planned homebirths than for low-risk hospital births. Planned homebirths also had a low mortality rate during labor and delivery, similar to that in most studies of low-risk hospital births in North America. The study also showed a high satisfaction rate by mothers. In 87% of the cases, no transfer to a hospital was required. The results support the American Public Health Association's (APHA) recommendation to increase access to out of hospital maternity care services with direct entry midwives in the United States.

BMJ, 2005 June 18, 330(7507): 1416–19


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VBAC—Vaginal Birth after Cesarean

For a number of years in the early 1990s Cytotec was in widespread use before there was any sound scientific evidence. No one even knew what the proper dose should be and everyone was experimenting with dosage and protocol. Thousands of women were given Cytotec without knowing that it was off-label and experimental, thus giving them no opportunity for informed consent. Proof of the danger of such nonevidence-based practice came in 1999, when there was enough evidence showing the danger of Cytotec use in VBAC that even ACOG came out against it. How many women with VBAC were given Cytotec induction between 1990 and 1999? Almost certainly thousands. How many ruptured uteri? Almost certainly hundreds. How many babies died? Almost certainly dozens. How many women died? We know there were at least several.

In the section [of the New England Journal of Medicine article by A.B. Goldberg, et al.] titled "Induction of Labor in Women with Previous Cesarean Section," the authors review the research showing the huge increase in risk of uterine rupture in VBAC if Cytotec induction is used and correctly conclude that it should not be used in this way. They never mention that the paper showing the risk of uterine rupture with Cytotec induction in VBAC was published in 1999, a decade after Cytotec induction had been used on large numbers of VBAC women.

I have been unable to find any research which looks at the contribution that Cytotec induction makes to the increased risk of uterine rupture in VBAC. We know that the incidence of uterine rupture has increased overall, but we do not know how Cytotec specifically factors in to this increase. The risk of uterine rupture after VBAC is one in 200 births, while the risk of uterine rupture with VBAC using Cytotec induction is one in 20 births—a tenfold increase.

In fact, because the number of cases of uterine rupture being reported was on the increase in the 1990s, ACOG responded with a recommendation that VBAC be done only in the hospital with an obstetrician and anesthesiologist at the ready. ACOG, instead of recommending stopping Cytotec induction, recommended surrounding women having VBAC with experts to deal with the rupture when it happens.

Marsden Wagner, MD, excerpted from "Cytotec Induction and Off-Label Use," Midwifery Today Issue 67

Read this entire article! MIDWIFERY TODAY ISSUE 67 is available in our online store.


Until now researchers have not tried to find out if the risks of rupture are higher or lower after a non-labour caesarean. That is why, during my visit to the Suleymaniye Maternity Hospital in Istanbul, I was highly interested in the work of Dr. Yazilioglu and Dr. Sonmez. They use a technique of ultrasound imaging to evaluate the quality of the uterine scar. They found that the quality of the scar is much better if the caesarean had been performed when the cervix had already reached a certain degree of dilation.

Michel Odent, The Caesarean, Free Association Books (London), 2004

THE CAESAREAN, by Michel Odent, is available in our online store.


Looking at the risks of elective repeat cesarean, we have the following:

  • more respoiratory distress in babies from iatrogenic prematurity and wet lung syndrome
  • accidental laceration of the baby (two to six percent of cesareans in some studies)
  • higher infection and injury for mothers
  • higher risk if maternal death (two to four times that of vaginal birth)
  • more complications in future pregnancies, including placenta previa (seven times the risk after just one cesarean), placental abruption (three times the risk), various degrees of placenta accrete (25 times the risk) and ectopic pregnancy.

Given the above risks, I continue to recommend VBAC to most women who have had a previous cesarean. In my own practice, my partners and I do not attend home or birth center VBACs in the following cases:

  1. women who have had more than two prior cesareans (unless they have already had VBAC without rupture after the last cesarean)
  2. women whose placenta is overlying the previous cesarean scar
  3. women with a prior uterine incision closed with one layer instead of two.

Ina May Gaskin, Spiritual Midwifery, 4th ed., 2002
Book Publishing Company, PO Box 99, Summertown, TN 39483


Recommendations to Midwives Doing Home VBACs

  1. Learn about the physical and psychological differences in a woman with a previous cesarean.
  2. Define the comfort zone of the practitioner about attending VBACs.
  3. Develop a VBAC practice protocol that reflects the midwife's knowledge/comfort and access to emergency/surgical services in labor.
  4. Engage in detailed informed consent with the client.
  5. Perform an ultrasound early in the third trimester to rule out a placenta that is overlying the previous scar.
  6. Know the transport time to the nearest hospital with emergency c-section capabilities and the time for that hospital to initiate emergency surgery (range from less than 10 minutes to 60 minutes depending on the size and resources of the particular institution and its responsiveness to the midwife's call ahead). A regional trauma center often will have the most rapid response after entering the emergency room door.
  7. Decide in advance if your VBAC protocol is negotiable or not.

Heidi Rinehart, MD, excerpted from "A VBAC Primer: Technical Issues for Midwives," Midwifery Today Issue 57

MIDWIFERY TODAY Issue 57, whose theme is Cesarean Prevention/VBAC, can be ordered.


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Web Site Update

Read these articles from the newest issue of Midwifery Today now online:

  • "Bringing Good Birth to the Light"—editorial by Jan Tritten
    "We are in a profession that can give the greatest joy humankind has known—birth. In Spanish, birth is termed a more poetic 'dar a luz,' bring to the light...."
  • "Arriba la Revolución [Midwifery Revolution]"—by Marina Lembo
    This article about midwifery in Argentina is now online in Spanish. The author recounts the development of a community of midwives who have put together a birthing center where they can treat birth as a natural event. Let your Spanish-speaking friends know! If you're studying Spanish, read it alongside the English version which appears in print in Midwifery Today Issue 75.

Forum Talk

Does anyone know if and how the odds of a successful VBAC change as the number of previous cesarean sections increases? What is the most anyone has had experience with?

Marlene Waechter


Go to our forums to share your thoughts and experience.


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Question of the Week

Q: I have used (alone and in a five-week preparation) blue cohosh in six of my ten births. Some of the babies were "in distress," but only one had meconium and all had good Apgar scores. I have read some bad press lately about blue cohosh as a "stressor" and possible heart compromiser. Has alternative medicine backed away from the use of this herb or is it still considered a good herb to use for preparation and in labor/delivery? My daughter is 21 weeks pregnant and would like to use the same five-week preparation that I used in my last birth, but she is hearing some pretty scary stories from my sister (also pregnant).

— Shawn Stokes


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.


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Question of the Week Responses

Q: I have a client who is 32 weeks pregnant and has developed mild choleostasis. She now has it under control with the help of herbs, B vitamins (choline), Sam-e and improved nutrition. Most studies regarding the relationship of stillbirth and fetal distress to this condition seem vague. Has anyone worked with choleostasis, and if so, what have the outcomes been?

— H.M.

A: From what I know, the liver gets clogged and cannot excrete all the poisons it normally filters out. This poison builds up in the system and comes out as an itching, mostly on the hands and feet—which at night is totally maddening. The liver enzymes are elevated, and as the pregnancy progresses, it affects the mother's blood clotting. It usually happens in late pregnancy. I understand there is as much as a 50% mortality rate.

I have had experience with this situation. The mother was diagnosed with this severe problem with baby number four. I delivered the next three babies with the situation becoming more and more problematic with each concurrent pregnancy. The first pregnancy ended with the baby okay and a major postpartum hemorrhage (PPH). She was on herbs and was somewhat itchy at term, but it was not really bad. She did a liver cleanse and was on yellow dock and totally bare-bones diet—meaning *no* sugar and *no* refined food, nothing white. The next baby was late...oh my (don't let that happen), had tachycardia, and mom had another PPH. He pinked up nicely and had good Apgars. The next baby was early because she was itching terribly and the liver enzymes were beginning to get bad. We went ahead and started labor and delivered the baby. Again, she had PPH, and the baby was very tachy. Everyone did okay, but this gal sure makes birth exciting.

— D.C.

A: I was a labor and delivery nurse and had choleostasis with my first pregnancy. The IHC was found late in my pregnancy (36 weeks) although I had been itchy since about 30 weeks. I was not treated with any medications.

I had midwifery care throughout my pregnancy and wanted a normal, unmedicated birth. I was advised by a consulting MFM physician that I should be induced at 36 weeks. We decided to wait until the bilirubin salt level returned. When it was extremely elevated, we went ahead with the induction. I was induced by AROM and delivered six hours later. My midwives managed my labor beautifully. I was able to move about and had noncontinuous monitoring. Without midwives, I'm sure the outcome would have been different. Instead, I had a safe, normal birth and a very healthy baby.

I found the Web site www.itchymoms.com a great help. It is comprehensive and written for the consumer.

— Katy Maistros, Cleveland, Ohio


Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


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Think about It: Avoiding Cesarean Outcomes

When I am asked about the effectiveness of true natural childbirth classes, one of the hallmarks I always point to is the cesarean rate difference. Honest information about interventions and the nature of labor pain invariably helps normalize operative birth statistics.

While we cannot and should not dwell on topics such as pain, transition, terror, etc., deep in our hearts we know that's why a lot of moms are in our childbirth classes. They've been terrorized by tales from inadequately educated moms who have had difficult labors and indescribable pain. The media does its share to add to the general hysteria surrounding birth. I recently taught a young dad-to-be who grew up convinced that it was better to be a male and face getting killed in war than to be female and have to experience birth!

If we don't deal with nitty gritty details such as vomiting, shakes, jackhammer legs and so on, we have abandoned the women to whom these things happen. Couples shown only sanitized birth videos are in trouble when the mom reaches the "I can't take it anymore" stage, especially if she's only at 4–6 cm dilation.

If they've seen a balanced approach created by a light sprinkling of scenes and sounds of women feeling, fighting and flowing with the full, immense, nameless force of Creation's power, they will know that such moments can be survived. This exposure can help empower our couples. If they instead reach those moments of truth without knowing they exist and without having seen a visual depiction with a positive outcome for themselves, how are mothers and their innocent but loving partners to know it's okay?

Sue LaLeike, Midwifery Today Issue 23


Feedback

Editor's Note: Thanks to Missy Thomas for preparing the following post:

The American Academy of Family Physicians (AAFP) recently published new recommendations regarding vaginal birth after cesarean (VBAC) that differ significantly from the current recommendations of the American College of Obstetricians and Gynecologists (ACOG).

The full text of the AAFP policy document can be found at http://www.annfammed.org/cgi/data/3/4/378/DC1/1

Some of the most notable highlights are:

  • "TOLAC [Trial of Labor After Caesarean] should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes."
  • "Our recommendation significantly differs from current ACOG policy because we could find no evidence to support a different level of care for TOLAC patients. Without good quality evidence, we believe that different levels of resources cannot be advocated because their potential for unintended harms cannot be evaluated against their purported benefits."
  • "…the ACOG policy suggests that one rare obstetrical catastrophe (e.g., uterine rupture) merits a level of resource that has not been recommended for other rare obstetrical catastrophes (e.g., shoulder dystocia, abruptio placenta, cord prolapse) that may actually be more common."
  • "…current risk management policies across the United States restricting a TOLAC appear to be based on malpractice concerns rather than on available statistical and scientific evidence."

ACOG currently recommends that an OB and an anesthesiologist should be "immediately available," widely interpreted as being on the premises throughout the trial of labor. ACOG recommendations were based on "expert opinion." In contrast, the AAFP recommendations are based on a comprehensive review of published medical studies, a much higher level of evidence for such recommendations. The ACOG recommendation of having a surgical team immediately available has possibly been one of the biggest limiting factors for hospitals allowing a VBAC, leaving women with limited or no options for avoiding a repeat cesarean section.

The AAFP guidelines certainly give family practice physicians more incentive to allow their patients to have a VBAC than the ACOG policy currently gives an Ob/Gyn. It will be interesting to see how the AAFP recommendations will factor into the current climate, and how useful they may be for women and birth advocates working to change hospital policies.

Susan Hodges, "gatekeeper"


Does anyone know where I can buy elbow-length (or higher) surgical disposable gloves, preferably sterile, for use in waterbirth? I used to buy them from Cascade—they were called X-tenda gloves, made by Ansell-Perry. The company is no longer manufacturing them. Any alternatives out there? I've searched the Internet but can't find anything. I'll appreciate any help or leads.

Ilana Shemesh, shemesha@zahav.net.il


Thank you for the very useful and inspiring information about doulas on your Web site.

I am 17 weeks pregnant and live in Switzerland, near Zurich. Could readers please tell me how I can go about finding a doula to help me in Switzerland? I speak a little German and would if possible prefer an English-speaking doula.

Perhaps there is a registry or association I could contact?

Charlotte Reynolds


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.


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