5 posts from February 2008

Contrast this study with the one below.

In short, mothers with multiple VBACs have increasingly lower levels of complications while mothers with multiple elective Cesareans with no labor have increasingly higher levels of complications.

Obstetrics & Gynecology (2006;107:1226-1232)

OBJECTIVE: To estimate the magnitude of increased maternal morbidity associated with increasing number of cesarean deliveries.

METHODS: Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999–2002).

RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively.

CONCLUSION: Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.

Straight from the horse's mouth!

Obstetrics & Gynecology (February 2008;111:285-291).

OBJECTIVE: To estimate the success rates and risks of an attempted vaginal birth after cesarean delivery (VBAC) according to the number of prior successful VBACs.

METHODS: From a prospective multicenter registry collected at 19 clinical centers from 1999 to 2002, we selected women with one or more prior low transverse cesarean deliveries who attempted a VBAC in the current pregnancy. Outcomes were compared according to the number of prior VBAC attempts subsequent to the last cesarean delivery.

RESULTS: Among 13,532 women meeting eligibility criteria, VBAC success increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%, and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively (P<.001). The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52% (P=.03). The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter.

CONCLUSION: Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy.

I feel it important to note that this study does not say that VBACs are always safer than C-sections. It simply reports that once a woman has had a successful VBAC, the likelihood of she having future successful VBACs increases.

Ok, people. Prepare to be shocked. And awed. Great Britain's equivalent to the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynecologists (RCOG), issued a joint statement with the Royal College of Midwives explaining their position on home births.

Their position couldn't be any different from ACOG's.

Here's the full statement. The summary alone will blow your socks off.

Ahem. They issued a joint statement with midwives. See ACOG? Midwives are NOT the enemy.

RCOG and RCM then discuss not only the physical benefits to home birthing (due to lower levels of significant interventions like induction, augmentation, perineal trauma and surgical delivery), but acknowledge that the process of birth -- and its resulting emotional and psychological effects -- are quite important and should be considered when studying childbirth, whether in a hospital or at home.

They honestly state the risks and complications of birthing at home (all of which could also occur in a hospital). They conclude that transfer to a nearby hospital should be a backup plan, if serious complications with the mother or baby occur. They also recognize that some mothers choose to transfer for non-critical reasons, such as epidural anesthesia.

When discussing how to achieve best practices for childbirth, they state: "Both the RCM and the RCOG believe that to achieve best practice within home birth services it is necessary that organisations’ systems and structures are built to fully support this service. These will include developing a shared philosophy, fostering a service culture of reciprocal valuing of all birth environments. Comprehensive involvement by local multidisciplinary teams and users to underpin home birth practices within a clinical governance framework results in a quality service which demonstrates commitment to supporting women in their choices." (Emphasis added by me.)

They further flesh this out by placing birthing decisions into the hands of mothers and encourage care providers to give women unbiased information on the risks and benefits of home birth. They also encourage fathers to be involved in the decision-making and childbirth processes!

This next quote made me blink. Then I read it again to make sure I had read it correctly the first time: "It is acknowledged that there are no known risk assessment tools which have an effective predictive value concerning outcomes in the antenatal period and labour." Hallelujah! Finally, doctors who admit they have no way of predicting the future, especially the future of a woman's pregnancy and birth experience. When was the last time you heard ACOG admit it didn't know something?

RCOG and RCM conclude with recommendations about continuity of care, the importance of communication during the antenatal period, and the necessary service structures that should be in place to handle unexpected emergencies. They encourage employers and government entities to be supportive of home births and warn that discriminatory practices based on place of birth are harmful to both women's health and children's development.

Their conclusion? That while home births may not be suitable for every woman or preferred by most women, they are perfectly acceptable and safe for women at low risk of complications.

My only quibble with this? They don't explain what "low risk of complications" means. That simple phrase leaves an open door for unscrupulous care providers to provide biased information on the risks and benefits of both home and hospital births or to coerce a mother into a model of care she may not be comfortable with.

For shame, ACOG. For shame.

The American College of Obstetricians and Gynecologists' Statement on Home Births

I find their statement offensive in many ways. I'll briefly address two points, then let you read more from the links below. First, their opinion is just plain insulting to midwives. They imply that monitoring of the mother and baby do not occur at home births (not true), and then state that the only midwives who have any business delivering babies are CNMs. Direct-entry and other "lay" midwives are simply slapped in the face and called unqualified to attend births. All the CNMs I know don't believe this about their non-CNM counterparts.

Second, they insult women by implying that they are not capable to make an intelligent decision regarding the birth of their baby. ACOG says it respects a woman's right to make her own decision, but then tells women that deciding on a homebirth could kill her baby. Frankly, I'm more scared of giving birth in a hospital than I am at home. Hospitals with obstetric surgeons are fantastic for emegencies, but are by no means necessary for the majority of births. ACOG also insults women by stating that the rising C-section rate is due to the increase in old, fat women becoming pregnant. While maternal age, obesity and diabetes are important factors to consider, I argue that a greater cause for the rising rate of C-sections are doctors who continually insist on inducing, augmenting and interfering with a woman's labor process.

I could write an entire book replying to this, but so many eloquent women have already responded. I'll list a few below.

Mommy Blawg responds to several points, and ends her post with a challenge to ACOG.

True Birth analyzes ACOG's statements, then disproves many of them with ACOG's own papers, statistical facts and just plain common sense.

The True Face of Birth responds with what could be her own position paper. Good points here! She also provides an extensive list of other responses to ACOG's statement.

Pushed Birth pushes back and shames ACOG for playing dirty, and attempting to manipulate mothers while discrediting midwifery in general.

ICAN (International Cesarean Awareness Network) responds, encouraging women to make their own informed decision based on facts and evidence-based research.

While I agree with all these women's statements on home births, VBACs and natural childbirth, I do not necessarily agree with everything else posted on their blogs. You've been warned.

No, we're not pregnant.

No, we're not trying, either.

I just wanted someplace to start stockpiling all the VBAC info I'm hoarding in bookmarks, e-mails and my mind. Stuff like statistics, research studies, risks/benefits, and VBAC birth stories. Since Timmy was ripped from my womb, I vowed to myself and my future children, NEVER AGAIN. (Unless a life or death scenario presents itself, which is unlikely).

I'll also be looking into homebirths. John and I had discussed having future children in the comfort of our own home, but that was before the Timster flipped breech and the resulting C-section occurred. I bounce back and forth between a homebirth and a midwife-attended hospital birth when I think about future pregnancies. It depends on the day, and usually comes down to: How worried am I about a uterine rupture? Considering that several things occurred during my pregnancy with Timmy that had frequency rates of 5 percent or less, I've got this bug in my brain that sometimes convinces me that all those "very small percentage" risks will automatically apply to me, since several did during my first and only pregnancy so far (breech at term, anterior placenta, battledore cord insertion, bilobed placenta). While none of these are life-threatening by themselves or even grouped together as a whole, the odds of having all that in one pregnancy was something like 1 in 10,000, according to the midwives and OB I was seeing. See why I don't like statistics?