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Come on, raise your hand if you’ve heard this one…

“The hospital wont allow VBAC after 41 weeks.”

“We can’t have you going past 40 weeks.”

“We wouldn’t want that baby getting too big, so let’s just schedule a backup cesarean for 4o weeks… ”

“We’ll induce at 40wks… don’t worry, of course you can try for your VBAC!”

I’m guessing everyone has their hand up, maybe even two hands and a foot.  If the range of normal gestation is 38-42 weeks, why the obsession with 40 weeks?  Is an “over-baked baby” incompatible with a successful VBAC?  What do the studies actually say?

Let’s take a look.  And do feel free to share these citations with the next care provider that mentions a 40week cut off.  You may not be able to change hospital policy but you’ll never know till you try.

Right off the bat, open up PubMed.  This is a huge database that makes all sorts of medical research data available (free of charge) to the public.  These studies represent your taxes at work (if a research group gets federal funding they’re required to share their results via PubMed) so check this database early and often. 

Let’s see… here we go…

Safety and efficacy of vaginal birth after cesarean attempts at or beyond 40 weeks of gestation. Obstet Gynecol 2005;106:700–6.

Women past 40 weeks of gestation were more likely to have a failed VBAC. After controlling for confounders, the increased risk of a failed VBAC beyond 40 weeks remained significant (31.3% compared with 22.2%, odds ratio 1.36, 95% confidence interval 1.24-1.50). The risk of uterine rupture (1.1% compared with 1.0%) or overall morbidity (2.7% compared with 2.1%) was not significantly increased in the women attempting VBAC beyond the EDD.

The MFMU Cesarean Registry: factors affecting the success of trial of labor after previous cesarean delivery.  Am J Obstet Gynecol. 2005;193(3 Pt 2):1016-1023.

Favorable intrapartum factors included greater cervical dilation at admission for delivery (OR, 2.6; 95% CI, 2.4-2.8, when dilated ?4 cm), spontaneous labor without need for augmentation or induction (OR, 1.6; 95% CI, 1.5-1.8), and gestational age less than 41 weeks (OR, 1.6; 95% CI, 1.5-1.8)

Predicting the Likelihood of Successful Vaginal Birth After Cesarean Delivery  Am Fam Physician. 2007 Oct 15;76(8):1192-1194.

The review also identified factors that decreased the likelihood of vaginal birth (i.e., more than one previous cesarean delivery; induction of labor; birth weight greater than 4,000 g [8 lb, 13 oz]; and gestational age greater than 40 weeks).

Vaginal birth after Caesarean section: revie of antenatal predictors of success. J Obstet Gynaecol Can. 2003 Apr;25(4):275-86.

A nonrecurrent indication for previous Caesarean section (CS), such as breech presentation or fetal distress, is associated with a much higher successful VBAC rate than recurrent indications, such as cephalopelvic disproportion (CPD). Even with a history of CPD, two-thirds of women will have successful VBAC, though rates decrease with increasing numbers of prior CS. Prior vaginal deliveries are excellent prognostic indicators of successful VBAC, especially if the vaginal delivery follows the prior CS. A low vertical uterine incision does not seem to adversely affect VBAC success rates as compared to a low transverse incision. Maternal obesity and diabetes mellitus adversely affect VBAC outcomes. Fetal macrosomia does not appear to be a contraindication to VBAC, as success rates exceeding 50% are achieved and uterine rupture rates are not increased. Twin gestation does not preclude VBAC. Post-dates pregnancies may deliver successfully by VBAC in greater than two-thirds of cases. bolding mine

So… what does all that mean? 

Well, your chance of VBAC success does go down after 40 weeks.  But it’s not like stepping off a cliff… even after 40 weeks you have a pretty darn good chance of a successful VBAC.  Certainly better than 50/50 even in the gloomiest study (keeping in mind that your chance of a c/s is 100% if you schedule).  And those gloomy studies didn’t find that risks increased much (if at all) after 40 weeks. 

Given the known benefits of VBAC and the known risks of repeat c/s… why this obsession with 40 weeks?  Threatening a pregnant woman with a 40 week “or else” statement is sure to cause stress and we know stress causes compliactions in pregnancy/birth.  What medical benefit does a 40 week or else limit provide that would outweigh this negative impact? 

Maybe you could ask the next care provider who uses that line to give these articles a read and get back to us all on that one…

October is Pregnancy and Infant Loss Awareness Month.  Not a subject that anyone wants to think about, but like so many of us know, just “not thinking about” something doesn’t prevent that something from touching our families.

If you or someone you know has faced the pain caused by the loss of a pregnancy or newborn, you may want to attend the Memorial Service being hosted at Arnot Ogden Medical Center in Elmira (one of the few local hospitals that support VBAC, and the only local hospital with midwife attended VBAC).

From the Arnot Ogden Medical Center website:

The Perinatal Bereavement Program at Arnot Ogden Medical Center will host a memorial gathering, “Grief Shared is Grief Diminished,” at 2 p.m. Sunday October 17 in the Petrie Conference Room on the ground floor of the Medical Center.

This interfaith memorial gathering is being held for family, friends and caretakers of persons who have experienced a loss of pregnancy or infant death. This gathering allows families to reaffirm that their babies have not been forgotten.  By coming together and remembering the lost loved one, the pain of grief will diminish. Interested individuals are invited to register and/or get more information by calling Health on Demand at 607-737-4499. Child care is available, and a reception will be held immediately following the ceremony.

Postpartum depression is serious, it hurts, and until now there has been little support available in Ithaca.  Every month someone asks ICAN of ITHACA for suggestions… who to see, where to go, how to get help for PPD.  Until now we’ve had to provide “out of town” options.  SOLACE for Mothers, the PPD forum at MotheringDotCommunity, the ICAN forums, and Postpartum Support International are all winderful resources but they’re not local.  They can’t offer a hug, a touch, a warm meal, a friend to sit with.

But Ithaca now has it’s own, much needed, PPD support group.

From Postpartum Depression to Joy
(in countless baby-steps)

Call it the baby blues, hormonal imbalance, or fatigue- induced self-loathing, postpartum depression is too common to be ignored, and too awful to be facing alone. Please join us for a FREE support group: a safe space for sharing, sisterhood, and coping skills.

Who: Depressed moms, overwhelmed moms, sad moms, scared moms, anxious moms, incredibly sleep-deprived moms, I’m-supposed-to-be-happy so-why-am-I-miserable moms, and those concerned for such moms.
(Mothers are welcome to bring their babies)

Leader: Yael Saar (mother of two) draws from her experience with PPD and the extensive toolbox of coping skills she collected in order to disarm it.

When: 11:45am to 1:00pm.  First and third Tuesday of each month.  October: 5th, 19th, November: 2nd, 16th

Where: The community room at Jillian’s Drawers 171 East State Street, at the Center Ithaca Building on the Commons.

Spread the word:  Postpartum depression is very common and under-diagnosed. With proper care and support most moms get better, but when things go terribly wrong it can be lethal. Many mothers who suffer from PPD don’t know enough about it to seek treatment, and go through this torture blaming themselves for being weak or bad. Too often it is the guilt and the shame that cause most of the pain, and this is why support and sisterhood are very helpful.

More info: www.ppdtojoy.wordpress.com
Questions? email  ppdtojoy@gmail.com

How cool is that?  Our next meeting is on October 10th, 2010… so 10/10/10.  Come and join us for a perfect ten of support, information, and companionship.

ICAN of ITHACA OCTOBER MEETING

October 10, 3pm-5pm, Jillians Drawers, the starting topic will be the NIH/ACOG best-practice guidelines and local providers but of course there will be plenty of time (and tissues) for birth stories and processing.

Jillian’s Drawers is located on the Ithaca Commons (there are directions provided in the above link) so there is plenty for partners and older children to do if you’re coming into Ithaca from a distance and want to “make an afternoon” of it. 

And if you’re wondering if you should come… please do!  ICAN is for everyone touched by the cesarean birth epidemic.  Mothers, partners, doulas, midwives, parents, educators.  Come and share your experience in an open and supportive environment.

Hope to see you next Sunday!

The Healing Spiral is here, and worth the wait.

In the current birth climate many of us have experienced a traumatic birth.  Whether it was in the form of unexpected surgery or overwhelming experiences during vaginal birth, many mothers have been left with emotional scars that need time and attention to heal fully.

When healing from trauma it can feel as though we are “just” visiting the same memories over and over, and yet with each visit to a particular event we are reaching deeper into the spiral of healing, getting closer to the point of integration and acceptance.

The International Cesarean Awareness Network (ICAN) of Ithaca will host a Healing Spiral for Traumatic Birth on Saturday, June 26, at the Foundation of Light on Turkey Hill Rd near Ithaca .  It will be from 9am to 3pm, including a pot luck lunch.  The day will include introspection through art, sharing, support, and guided visualization, as well as information on how to continue healing.

There is a fee of $15 to cover the cost of the location and supplies, and preregistration will be required by June 21 so that we know how many supplies are needed.   Join us and make it a special event for us all

To preregister, please contact Michelle Adelewitz by June 21.

Please pass information about this event on to friends/family who may have experienced traumatic birth.

Thank you!

Hosts:
Kate Dimpfl, Birth Counselor and Childbirth Educator
917-613-7854
katedimpfl@gmail.com

Michelle Adelewitz, Chapter Leader, ICAN of Ithaca
michelle.adelewitz@gmail.com
319-0915

Erin Shafto, Chapter Leader, ICAN of Ithaca
342-2723
erinshafto@gmail.com

ICAN of Syracuse made the news!  Check out the link to watch video of the interview, and follow the links from the Channel 9 news page to read the interviews done earlier. (the woman covering the story is a VBAC mama too!)

Although it’s sad to think that offering vaginal birth options, or avoiding unnecessary surgery is “news”, it’s nice to see the topic being brought to the public!  Leave a comment letting them know you appreciate what they’re doing…

Although you may not agree with every cause they champion, the Public Citizen team has handed a wonderful resource to the women of New York State.  A detailed guide to preventing unnecessary cesareans and finding VBAC support in New York State.

Guide to Avoiding Unnecessary Cesarean Sections in New York State, compiled by Sidney Wolfe, M.D.
Public Citizen Health Research Group

This isn’t a guick read.  The guide is packed with personal stories as well as statistics, detailed information broken down by county and hospital, media reports, medical journal articles, patient and provider perspectives, legal  rights and responsibilities, and more.  Get a cup of coffee or tea, give yourself an hour, and walk away with a realistic picture of birth in New York State.

Then visit your local ICAN group (that’s us! second sunday of each month!), write a letter to your local paper or state representative, have your children help you draw pictures to make “thank you’ cards for birth friendly providers and “why wont you let birth be” cards for providers who don’t offer the care women need to birth normally.  Share your feelings (and the hard numbers from the guide) on your blog, through facebook and twitter, at a playgroup or doctor visit, with fellow mothers and women planning their birth.

A great article in today’s Philadelphia Inqiurer takes a look at the electronic fetal monitor, the “fetal strip”, and it’s roll in the soaring cesarean rate.  Check out   Test leads to needless C-sections  by Alex Friedman, a fellow in Maternal-Fetal Medicine at the Hospital of the University of Pennsylvania.  The link is a bit iffy, so keep trying if you can’t get through first try.  And while you wait, check out these quotes:

The odds of my patient’s baby suffering from dangerous lack of oxygen were slim. A study in the New England Journal of Medicine found that only 1 of 500 babies with a bad strip had cerebral palsy. Moreover, it remained unclear if the condition had developed before labor, in which case cesarean couldn’t prevent it.

and

A 2006 analysis by the British Cochrane Collaboration, evaluating all available research, found that fetal heart monitoring failed to reduce perinatal mortality – the risk of a baby’s dying late in pregnancy, during birth, or shortly after birth – and increased cesarean section rates and forceps deliveries, compared with listening to a baby’s heart rate intermittently.

and later in the article

Steven Clark and Gary Hankins, two prominent obstetricians, voiced my frustration. “A test leading to an unnecessary major abdominal operation in more than 99.5 percent of cases should be regarded by the medical community as absurd at best,” they wrote in the American Journal of Obstetrics and Gynecology. “Electronic fetal heart rate monitoring has probably done more harm than good.”

If you’d like to check out the original, scholarly, or medical community publications (and avoid getting your medical advice from the public papers), click on through to:

Uncertain Value of Electronic Fetal Monitoring in Predicting Cerebral Palsy

Efficacy and safety of intrapartum electronic fetal monitoring: an update.

A variety of Midwives and OBs commenting on EFM.  A Midwifery Today review.

Or check out books and articles written by Dr Sears, Dr Marden Wagner, Henci Goer (check out her response to EFM in VBAC on the LLL ask an expert forum), Shiela Kitzinger, Peggy O’Mara, Ina May Gaskin, and Penny Simkin.

…might be in order for pregnant women.

According to a recent study published in the Journal of Clinical Endocrinology & Metabolism, Vitamin D may be vitally important to vaginal birth. (Association between Vitamin D Deficiency and Primary Cesarean Section  Vol. 94, No. 3 940-945 available online here)

Way back when, vitamin d deficieny contributed to rickets… and rickets contributed to a deformation of the pelvis… and that led to an honest-to-gods “baby wont fit” moment that needed cesarean delivery to prevent maternal or fetal complications.  But women in the US today eat milk and various foods enriched with vitamin D, they don’t get rickets, and all is right with the world!  Right?  Maybe not.

Now, it’s not a huge study, and there are variables they didn’t consider.  But whatever the reason, they did find that women with vitamin d deficiency were more likely to have a primary cesarean section.  The more deficient, the higher the chance of cesarean.  The most deficient women were FOUR TIMES more likely to have a primary cesarean, even after controlling for factors like race, age, education level, insurance status, and alcohol use (alcohol use impacted vitamin d levels, in case you were wondering why that factor made the list).  Four times more likely to have a primary cesarean if your vitamin D levels was below 37.5 nmol/liter than if it was above that cutoff?

I’m not giving up my sunscreen and floppy hat just yet, but I’m going to be following this research closely, and spending those 10-15 minutes a day catching some rays.  Just in case.