Vaginal Birth After Cesarean (VBAC) Fact Sheet

by Nicette Jukelevics
International Journal of Childbirth Education in November 1994 (Vol. 9, No. 4)

 

Evidence confirming the safety of vaginal birth after cesarean (VBAC) within proper guidelines has been available for more than ten years. However, wide variations in VBAC rates, unjustified by medical factors, still exist between hospitals and physicians. These facts are presented with the hope that more women will be encouraged to avoiding unnecessary cesarean section and supported in their wish to labour and have a VBAC.

  • VBAC with appropriate informed consent is the standard, of care for women with one prior low transverse uterine incision. Studies indicate that overall at least 50% and as many as 90% of women who plan a VBAC can delivery vaginally (ICEA VBAC Review 1990).
  • The rate of reported uterine rupture in planned VBAC with a low transverse scar has ranged from 09% to .22%. This risk is thirty times lower than any other unpredictable childbirth emergency such as acute fetal distress, premature separation of the placenta and prolapsed umbilical cord. A 1994 study based on 5733 planned labours after one or more cesareans reported a rupture rate of .8% with no maternal deaths related to uterine rupture (Guide to Effective Care in Pregnancy and Childbirth 1992; Obstetric Gynecology 1994).
  • Maternal morbidity rates are consistently and substantially lower for women who plan a VBAC - 2%-23% - than for women who have an elective repeat cesarean - 11%-38% (Guide to Effective Care in Pregnancy and Childbirth 1992).
  • Any hospital that provides standard obstetric care can also provide care for women who wish to plan a VBAC. A recent study concluded that family physicians can play a major role in promoting VBAC (American Family Physician 1993).
  • The National Association of Childbearing Centres of the United States (NACC) indicates that birth centres may encourage VBAC clients to tabor and deliver in their facilities provided that emergency care can be initiated within thirty minutes of recognition of a problem (NACC Committee Opinion 1989).
  • In the United States, 22.6% of all births in 1992 were by cesarean section. Thirty-eight percent of all cesareans performed were elective repeat operations. The VBAC rate in 1991 was 24.2%. A national health objective for the year 2000 is a cesarean rate of 15% and a VBAC rate of 35% (Unnecessary Cesarean Sections: Curing a National Epidemic 1994).
  • In 1988-89. the cesarean rate in Canada was 19.5%. Thirty-eight percent of all cesareans were repeat operations. The VBAC rate for this same period was 15.6%, a fivefold increase since 1979-80.
  • In the province of Manitoba, the VBAC rate for women younger than twenty was 55.2% (Canada Health Reports 1991).
  • A review of twenty-five medical reports concluded that women with two prior low transverse uterine scars who wish to plan a VBAC are not at any greater risk for a uterine rupture. The literature indicates that 60% to 75% of women with two or three prior cesareans gave birth vaginally (British Journal of Obstetrics and Gynecology 1991; American Journal of Obstetrics and Gynecology 1988 and 1989; Obstetrics and Gynecology 1990).
  • A low segment vertical uterine incision does not appear to increase the risk of uterine rupture for women who plan a VBAC (American Journal of Obstetrics and Gynecology 1988; Obstetrics and Gynecology 1987 and 1988).
  • VBAC is safe for non-diabetic women who are expected to give birth to infants that weigh more than 4000 grams (Obstetrics and Gynecology 1989; Journal of Reproductive Medicine 1984).
  • A review of forty-two studies concluded that within appropriate e guidelines. VBAC with a breech presentation is a safe and reasonable option (Journal of Reproductive Medicine 1989; Clinical perinatology 1989: American Journal of Obstetrics and Gynecology 1989).
  • External cephalic version (a method of rotating a breech presentation) is a reasonable option for women with a prior low transverse scar who wish to plan a VBAC (American Journal of Obstetrics and Gynecology 1991).
  • Prostaglandin E2 in gel can safely be used for cervical ripening for women who plan a VBAC. Its use can lower the risk of a cesarean for failed induction with oxytocin (Acta Obstetrics and Gynecology of Scandinavia; American Journal of Perinatology 1992).
  • Although uterine rupture in planned labor after cesarean is a rare event, when it does occur, it is often seen as an acute emergency. The most common indicators of uterine rupture are an abnormal fetal heart rate pattern or prolonged declarations with an arrest of progress in labor. Abdominal pain or vaginal bleeding are not reliable indications (American Journal of Obstetrics and Gynecology 1991, 1993 and 1992; Journal of Clinical Anesthesiology 1991).
  • A vertical incision (classical/midline) in the upper segment of the uterus is a contraindication for labor (Canadian Medical Association Journal 1993).
  • A Canadian study of sixteen community hospitals revealed that physicians are more likely to offer a trial of labor-38.2%-if an educationally influential opinion leader initiated practice guideline recommendations. than if the hospital audited charts of women with a prior cesarean, held departmental meetings and discussed the audit results-21.4% (Journal of the American Medical Association 1991).
  • Data from North American studies indicate that 30% to 50% of women who are offered a trial of labor based on the medical benefits versus risks approach choose to have a repeat operation. A significant number of women who elect another cesarean had their initial surgery for non-progressive labor (Culture. Medicine and Psychiatry 1987; Journal of Reproductive Medicine- 1993: Women and Health 1989: American Family Physician 1993).
  • A European study of over 1000 women with a prior cesarean section concluded that routine examination of the prior scar to detect dehiscence after vaginal delivery is of doubtful value (ACTA Obstetrics and Gynecology, of Scandinavia: Enkin, Kerise and Chaimers 1992).
  • X-ray pelvimetry, is an unreliable indicator of the outcome of planned labor after cesarean and should be abandoned (British Journal of Obstetrics and Gynaecology 1993; 1991).
  • A five-year American study concluded that nurse midwives attending women in labor with a prior cesarean had an 83% rate of vaginal delivery (Journal of Nurse Midwifery 1989).
  • Data from a National Birth Center VBAC Study in progress indicate that 8616 of 189 women had a vaginal birth and 93% of these took place in the birth center setting. Forty-nine infants were "macrosomic" - more than 4000 grams: 82% of them were delivered vaginally (NACC 1994).
  • VBAC is a valid option in developing countries. Maternal and fetal outcomes are not compromised when women are attended by midwives in hospitals that do not have the use of electronic fetal monitors and availability of a blood bank. However, an attending physician and a surgical team must be available as needed (International Journal of Gynaecology and Obstetrics 1991: Journal of Reproductive Medicine 1992. Australian and New Zealand Journal of Obstetrics and Gynecology 1988).

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doulala
Dec. 8, 2008 at 12:21 AM

After a Cesarean

Recovering from a C-Section

By Robin Elise Weiss, LCCE, About.com

http://pregnancy.about.com/cs/cesareansection/a/aftercsec.htm

After your cesarean surgery is over you will be wheeled into a post-operative recovery room. Usually there are several beds in one room separated by curtains. You will remain in recovery for a varied amount of time, depending on the anesthesia that you had (general or regional), typically it's about a two to four hour period. If you had an epidural or spinal it's about the time you can wiggle your legs. If you've had general anesthesia you may fall asleep and wake up repeatedly, and possibly feel nauseated.

During this recovery period your vital signs will be monitored carefully and the firmness of your uterus will be periodically checked. As will the flow of blood. You may begin to feel after pains as your uterus contracts down.

The best advice for recovery is to begin to move as quickly as you can. Obviously you will want to start out with simple things like breathing. While breathing sounds like an easy thing, taking a deep breath is not that easy; remember to begin to do this early and frequently.

As you move to your regular room some of your equipment will be coming with you, including your catheter, blood pressure monitors and IVs. The catheter will usually be removed the day after your surgery. The IV will stay until your intestines begin working again, as evidenced by rumbling sounds in the intestines and possible gas pain for mom. Avoid carbonated, hot or cold drinks as they tend to cause gas pain to be worse.

You will feel pain from the surgery and it's important to deal with it early on, because the less pain you feel the more likely you are to be up and moving about, which is key to a speedy recovery. If you've had a regional anesthesia you may have been given Duramorph prior to the removal of the epidural catheter. This provides pain relief for up to 24 hours after surgery, without the use of IV, IM (intra-muscular) or oral drugs. After that period or if you've not had Duramorph, you may request medications for which your doctor has left an order. Some patients will also leave surgery with a special pump on their IV that allows them to dispense their own IV pain medications when it unlocks every so often. These are also used mostly for the initial 24 hour period. While medications will get to breastmilk, some are better than others for nursing mothers, talk to your doctor and the baby's doctor about what is right for you and your baby.

One of the biggest milestones in the hospital will be your first walk. I've been there three times before and it's scary. Here's my advice:

 

  • Splint your incision by holding a pillow over it. Your insides will feel like they are falling out, but they are held in places by several layers of stitches and staples.
  • Avoid the tendency to lean forward, stand up straight.
  • Do not look down, but focus on an object as a goal: the chair, the bathroom, etc.
  • Always begin your walking with help.
  • Walk as frequently, even if only a few steps, as possible.

Your Incision

Don't be afraid to look at your incision, it's actually very important that you do so. The first day it may be covered by gauze, and some women may have special drains to help remove fluids that are collecting on the inside. There are different types of external incision, that may not match the incision on your uterus, make sure to ask the doctor who did your surgery about the uterine incision. The area may look bruised, red, and irritated. You will notice that there are staples or stitches. These will usually be removed within a few days of the surgery or will dissolve on their own like the internal stitches. Looking at the incision now will allow you to be able to report changes that may indicate infection to your doctor at a later date.

One thing that surprised many women including me, was the numbness and itching. This is supposed to go away within a few weeks but doesn't always. It doesn't indicate that there is something wrong.

The best advice that anyone can give you, whether your at home or in the hospital, is to rest. Rest is very important after any birth and particularly true when you add the surgical aspect, even if you did not labor. Ask that visitors wait for awhile, enlist the help of hospital staff at keeping them to a minimum. Be sure to ask for help from your friends and family who offer. And sleep whenever possible.

Your Baby After a Cesarean

Your baby may need special care, particularly if that was the reason for the cesarean. So he or she may spend extra time in the nursery. If this is the case ask that your bed be wheeled to the nursery or a wheelchair as soon as you are able.

If your baby is doing well after the birth and is healthy, you may be able to hold your baby through the entire recovery room period, bringing the baby to your postpartum room with you. Even if you are feeling sleepy or in pain, your family members can help you with the baby while in your room.

Breastfeeding is also still possible after a cesarean, although the positioning may be a bit trickier with your incision. Pain medication can help relieve some of this and there are also great tips on positions to be had from the hospital lactation consultant, breastfeeding educator, or your local La Leche League.

Side lying is a great position to nurse in because it takes so little effort on your part and the baby avoids the incision. The football hold is also great, prop up with a lot of pillows for this one.

Emotions After a Cesarean

Your emotions, as with any new mom, will probably be all over the place for the first few days. In addition to the new mom feelings, you may have certain feelings about the birth.

You may have been afraid when told that you needed a cesarean, that something was wrong with you or your baby. That may have ended with relief as a healthy baby was born, or more fear if your baby had to go to the special care nursery. You may feel disappointed for the way things went or that certain things didn't happen, like a vaginal birth or breastfeeding your baby in the recovery room. It's okay to have these feelings or questions.

The questions can be asked of those who were around, your doctor or midwife, your partner, the nurses. get explanations, which will explain why the surgery was necessary. It's important to realize that these feelings need to be dealt with just as much as the physical healing.

Some women don't feel negatively about their cesareans, and that's one part of the range of normal as well. It's neither right nor wrong to feel either way, but it's important to remember that each side of the fence is valid and that we must be supportive of this mother, no matter how she feels.

Message Friend Invite (Original Poster)

doulala
Dec. 15, 2008 at 9:31 PM

http://www.ican-online.org/.

Each successive cesarean greatly increases the risk of developing placenta previa, placenta accreta and placental abruption in subsequent pregnancies.     Both of these complications pose life-threatening risks to mother and baby. Cesareans also increase the odds of secondary infertility, miscarriage and ectopic pregnancy in subsequent pregnancies.

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doulala
Dec. 18, 2008 at 3:47 AM

Info about Repeat Cesarean risks:

 

childbirth connection

Why is the decision between VBAC (vaginal birth after cesarean) and repeat c-section important?

If you have had one or more cesareans, your decision about whether to plan a VBAC

Unfortunately, a growing number of hospitals and doctors, fearing lawsuits, do not allow you to weigh the facts, consider your preferences and choose for yourself regarding VBAC and planned repeat cesarean. If you wish to use their services, you must accept surgical delivery. Your best approach is to become informed and clarify your goals well in advance and then seek care that is in line with your preferences and birth plan.

("vee-back") or a repeat cesarean section can have far-reaching consequences for you, your baby, and any future pregnancies. You will want to become well-informed about VBAC, understand the trade-offs between VBAC and repeat cesarean, and weigh your own values and concerns so that you can come to a decision that is best for you. Once you reach a decision about VBAC delivery or cesarean delivery, careful planning can help you reach your goals.

Why do I hear conflicting information about VBAC vs repeat c-section?

During much of the last century, a woman who had a cesarean section almost always had a planned repeat c-section and not a VBAC for any births that followed. Doctors were concerned that the scar from the past cut in the uterus could open during labor (uterine rupture), and cause serious complications for mother or infant.

During the last quarter century, however, many health professionals, advocates, pregnant women, policy makers and researchers encouraged vaginal birth after cesarean (VBAC) in light of:

  • change in location of the uterine cut to an area much less likely to open during a VBAC labor
  • growing body of research establishing the safety of VBAC
  • growing recognition of c-section risks.


Now the pendulum is swinging back from vaginal birth after delivery, with new calls for routine repeat c-sections. This reversal leaves many women with cesarean scars struggling to make sense of conflicting, incomplete, and sometimes misleading information about the safety of VBAC vs. repeat c-section and about what birth plan to make this time around.

How can this website help you learn about, decide on and plan for a VBAC or a repeat c-section?

This section of the website provides reliable information and support to help you understand the issues surrounding planned VBAC vs. planned repeat cesarean. In it, you will find:


 

 

plos journal

A Tool to Estimate the Risks of Repeat Cesarean Section

 

 

Citation: (2005) A Tool to Estimate the Risks of Repeat Cesarean Section. PLoS Med 2(9): e325 doi:10.1371/journal.pmed.0020325

Published: September 13, 2005

Copyright: © 2005 Public Library of Science. This is an open-access article distributed under the terms of the Creative Commons Public Domain Declaration, which stipulates that, once placed in the public domain, this work may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose.


Cesarean section can be a life-saving technique for both mother and infant; however, it is a major abdominal operation that poses medical risks to a mother's health, including infections, hemorrhage, need for transfusion, injury to other organs, anesthetic complications, psychological complications, and a maternal mortality two to four times greater than that for a vaginal birth. The World Health Organization (WHO) has said that no country can justify having a cesarean rate greater than 10%–15%. Despite this advice, in the past 20 years, cesarean section rates have risen to nearly 25% in some countries.

To address rising rates of cesarean delivery, health authorities have encouraged women with a previous cesarean to attempt vaginal birth in subsequent pregnancies. However, studies have indicated an increased risk of serious adverse outcome among such women who attempt vaginal birth compared with a planned repeat cesarean delivery. This is due to a greatly increased risk of complications among women who attempt vaginal birth but ultimately are delivered by emergency cesarean section. Consequently, researchers have tried to identify women at low and high risk of failure for an attempted vaginal birth after a prior cesarean, but currently there is no validated antepartum tool to predict the risk of a failed attempt at vaginal birth among women with a prior cesarean delivery.

Now Gordon Smith and colleagues describe the development of a simple, validated model to predict the risk of emergency cesarean section among women attempting vaginal birth after a previous cesarean delivery. They also try to determine whether women at increased risk of cesarean were also at increased risk of uterine rupture, including catastrophic rupture leading to death of the infant.

The team studied 23,286 women with one prior cesarean delivery who attempted vaginal birth at or after 40 weeks of gestation. The population was randomly split into two groups, one on which the model was developed and the second on which it was validated.

The researchers found that the following factors were associated with emergency cesarean section: increased maternal age, lower maternal height, male fetus, no previous vaginal birth, prostaglandin induction of labor, and birth at 41 weeks or 42 weeks gestation compared with 40 weeks. In the validation group, 36% of the women had a low predicted risk of caesarean section and 16.5% of women had a high predicted risk; 10.9% and 47.7% of these women, respectively, were actually delivered by caesarean.

The predicted risk of caesarean was also associated with the risk of uterine rupture in general, and of uterine rupture associated with perinatal death, and women who were at low risk of emergency cesarean section were also at low risk of uterine rupture, including catastrophic rupture leading to perinatal death—one of the principal concerns among women who have had a previous cesarean birth.

Despite the strengths of the present study, including the very large population size, studies using registry-based data have the weakness of inconsistent definitions, admitted the authors. Also the study lacked data on other risk factors for emergency cesarean delivery, such as body mass index, the indication for the previous cesarean section, and whether a previous vaginal birth preceded or followed the previous cesarean section.

Nonetheless, the findings offer a validated model for estimating the risk of emergency cesarean section among women with a prior cesarean delivery who attempt vaginal birth. The true worth of the model will become clear when other researchers test it.

Erratum note: The figure that appeared with this synopsis (Figure DOI:10.1371/journal.pmed.0020325.g001) was incorrect and has been removed from the HTML version of the article. We are unable to remove it from the PDF version. Corrected 10/10/05

 

 

suite101

VBAC or Repeat Cesarean?

Facts to consider when you need to choose between a VBAC and an elective repeat cesarean.

© Brenda Lane

Labor and delivery floor, Jyn Meyer
The decision between VBAC and elective repeat cesarean is a difficult one. Finding the best provider & researching options will help you make the best choice


If you are trying to make the tough decision between having a VBAC and trial of labor versus scheduling an elective cesarean, here are some helpful things to keep in mind:

    1. Elective repeat cesareans carry multiple risks (including minor risks such as UTI's and major ones such as hemorrhage and hysterectomy) which overall may be moreVBAC. likely to occur than the same or other risks from having a
    2. VBAC does have a risk of uterine rupture of about 1% which might be lowered by going into spontaneous labor.
    3. There are at least ten ways women can reduce their risk of having another cesarean.
    4. Putting a positive spin on the stats - women with a previous cesarean and have a trial of labor have a 99% chance of not having a uterine rupture.
    5. If you want a VBAC and find that your provider is not supportive, find one who is. Often providers with a very low intervention rate overall will tend to have a low cesarean rate and also be more supportive of VBAC. One study actually showed that one of the "windows" into the philosophy of the provider was to ask if they cut episiotomies. Those providers that cut episiotomies also tended to intervene medically with a higher level of other interventions. See Questions to Ask Your Provider.
    6. If you decide to have an elective repeat cesarean, the risk of complications, primarily to the mother, grows after each cesarean. Do not make this decision in haste since it can affect how the rest of your children come into this world as well as how many children you should safely have.
    7. Be sure to discuss all of your options for VBAC or repeat cesarean with your provider and entire birth team. New research is occurring every year so be sure you are up-to-date with fact-finding.
    8. Many mothers-to-be find that reading, journaling, lots of discussion and prayer helps them to make the best decision for themselves and their own families.
    9. Research tells us that women who have a trial of labor do not regret it.
    10. Neither choice is pain-free. VBAC brings pain with labor and elective cesarean brings pain during your recovery and during the time when you need to be taking care of the baby.
    11. Many women report that recovery after a VBAC is much easier. See this mother's story on our discussion forum.
    12. If you are considering having a VBAC, be sure you make different choices this time especially with regard to inductions,epidural anesthesia, choosing a supportive birth team, including a doula and planning your birth. It will be very hard to make the same choices and NOT have the same outcome.
    Are you planning a VBAC or elective repeat cesarean? Tell us more.


The copyright of the article VBAC or Repeat Cesarean? in Pregnancy & Childbirth is owned by Brenda Lane. Permission to republish VBAC or Repeat Cesarean? in print or online must be granted by the author in writing.


 

 

american pregnancy association

In what situations would VBAC not be recommended?

  • If you are pregnant with twins
  • If you have diabetes
  • If you have high-blood pressure

Comparing a Repeat Cesarean to a VBAC:

Repeat Cesarean

VBAC

Usual risks of a surgical procedure

Less than 1% chance of uterine rupture. If uterine rupture occurs you have risks of blood loss, hysterectomy, damage to bladder, infection, & blood clots

Hospital stay of approximately 4 days

Hospital stay of approximately 2 days

Development of an infection in the uterus, bladder, or skin incision

Risk of infection doubles if vaginal delivery is attempted but results in cesarean

Injury to the bladder, bowel, or adjacent organs

Possibility of tearing or episiotomy

Development of blood clots in the legs or pelvis after the operation

 

On-going pain & discomfort around incision

Temporary pain and discomfort around vagina

Small chance that the baby will have respiratory problems3

The baby’s lungs will clear as baby passes through birth canal

If you plan for many more children, take into account that the more surgeries a woman has had the greater the risk of surgical complications. A fourth or fifth cesarean has more risk than the first or second.

 



Revolution Health

Risk factors that make a repeat cesarean necessary

Date updated: April 20, 2007
Kathe Gallagher, MSW
Content provided by Healthwise

A trial of labor after a previous cesarean section is not recommended for women who have an increased risk of a previous cesarean scar tearing open (uterine rupture). Regardless of risk factors, no trial of labor is safe without the medical facilities and staff needed for an emergency cesarean.

Some health problems make a trial of labor more risky for you or for your baby. You may know about some of these problems early in your pregnancy or long enough before your due date that you can plan accordingly. Situations that make a vaginal birth after cesarean (VBAC) trial of labor more risky include:

  • A vertical (classical) uterine incision that reaches above the lower uterus.
  • Two or more cesarean scars and no previous vaginal delivery.1
  • A cesarean delivery within the past 2 years.2
  • A single-layer closure, rather than a double-layer closure, of your previous cesarean section.3
  • Previous uterine surgery, such as removal of a uterine growth (fibroid) that has cut deeply into the uterus.
  • A narrow (contracted) pelvis, as determined during your last delivery.
  • Triplets or more during this pregnancy.
  • A medical reason for cesarean in this pregnancy, such as active genital herpes or placenta previa.

Even if you plan a trial of labor, problems that require a repeat cesarean may develop as your due date nears or during labor. You may need a repeat cesarean if:

  • Your labor does not begin spontaneously. One medicine used to start (induce) labor, such as misoprostol (Cytotec) has been linked to a higher risk of uterine rupture during VBAC. (If oxytocin is used sparingly to help a slow labor, it is less likely to increase uterine rupture risk.)1, 4 Some doctors will place a thin tube with a small balloon into the cervix. This can soften the cervix without raising the chance of uterine rupture.
  • Placenta previa or placenta abruptio develops. These problems often require a cesarean delivery. However, if you had your first cesarean because of one of these problems, there is no reason to expect that it will happen again.
  • The baby is in a breech position. For more information, see the topic Breech Position and Breech Birth.
  • You have an active case of genital herpes, which may be transmitted to your infant during a vaginal delivery.
  • Fetal monitoring during labor indicates that the baby may be in distress.

References

Citations

  1. American College of Obstetricians and Gynecologists (2004). Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin No. 54. Obstetrics and Gynecology, 104(1): 203–212.
  2. Bujold E, et al. (2002). Interdelivery interval and uterine rupture. American Journal of Obstetrics and Gynecology, 187(5): 1199–1202.
  3. Bujold E, et al. (2002). The impact of single-layer or double-layer closure on uterine rupture. American Journal of Obstetrics and Gynecology, 186(6): 1326–1330.
  4. Lydon-Rochelle M, et al. (2001). Risk of uterine rupture during labor among women with a prior cesarean delivery. New England Journal of Medicine, 345(1): 3–8.

 

Message Friend Invite (Original Poster)

doulala
Jan. 24, 2009 at 3:40 PM

If a cesarean is UNavoidable:

 

 

  1. Put your feet up. Aching legs and ankles are a common problem in pregnancy, especially in the third trimester, so give yourself regular breaks and take the pressure of your feet. Sit in a comfy chair with your feet on a footstool or propped up on cushions, lie on the sofa or lie on your bed - whatever is comfortable for you. If your ankles are swelling, stack several cushions together to raise your feet up higher, as this helps reduce swelling.

     

  2. Listen to calming music. Take time out from the madness of life and whisk yourself away to a calmer place, with the help of some relaxing music. Choose one of your favourites or treat yourself to a special pregnancy relaxation CD. Sit back, close your eyes and let the music wash over and relax you.

     

  3. Have a massage. Massage is great for easing tension and relaxing the muscles. Rope your partner in to give you a massage or book a treatment with a specialist (many places offer special treatments for pregnant women).

     

  4. Try a reflexology treatment. Reflexology is a natural therapy that believes your feet are in a sense a ‘map of your body.' A reflexologist will clear blockages and ease ailments by putting a small amount of pressure on your feet - it's a bit like a foot massage. It can be very relaxing, can relieve tension and help any pregnancy ailments you're suffering from.

     

  5. Have a go at antenatal yoga. Yoga designed for pregnancy can help tone up your body, but most classes also teach special relaxation tips too. These can help relieve any stress you're experiencing during pregnancy, as well as ease worry about the birth itself. Ask you midwife for antenatal yoga class recommendations.

     

  6. Try meditation or visualisation. Relaxing your mind is just as important as relaxing your body, but it can be hard to do. Meditation or visualisation could help and there are lots of CDs and classes available that teach it especially with pregnancy in mind.

     

  7. Have a laugh. Laughter is a great form of natural - and free - therapy. Meet up with your friends, or watch your favourite comedy or film and have a good laugh. Your baby will pick up on the feel-good factor too.

     

  8. Get some fresh air and sunshine. It's good to get fresh air and sunshine when you can and can be a good pick-me-up if you've been inside all day. Have a stroll around your neighbourhood, walk to the park or even walk around the shops, breathe in the fresh air and relax.

     

  9. Enjoy a night out with your partner. Spend some time unwinding and relaxing together - especially if it's your first baby, as life will change when it arrives. Have a lovely meal, go to the theatre or indulge in your favourite pastime.

     

  10. Enjoy water. Water is another form of natural healer. Swimming is ideal during pregnancy, as the water is supportive, and it's not too exhausting. If you fancy a class, most places offer antenatal swimming sessions, but if a swimming pool isn't your cup of tea, enjoy a nice long soak in the bath instead.

     

And finally, enjoy the course of your pregnancy. The nine months will fly by and a new baby will soon be part of your life.

 

 

 


C-section Relaxation: Preparing for Your Surgery

C-section Relaxation: Preparing for Your Surgery

Author: Elizabeth Mcgee

Moms that deliver babies vaginally are presented with loads of advice for preparation. They're offered pre-natal classes and help through books that they read.  The classes prepare them for relaxing and natural pain relief with various techniques such as breathing, hypnotherapy, neuro-linguistic programming (NLP) and visualization techniques for the labor and for the birth.  



But, what about women that need to have emergency or planned c-sections instead?  They need TLC and relaxation help as well!
 
The Cesaream surgery is a big deal and because you're almost guaranteed to be wide awake during the procedure, it can be stressful! 



Here are some tips to help you whether you're having a planned caesarean or in case you find yourself in an emergency surgery situation.



Take The Classes Anyway!



Most women who don't expect to have a c-section would typically take pre-natal classes to help them prepare for a safe and healthy childbirth. However, if you need to have a planned c-section, you might not think it's worth your trouble to take pre-natal classes, but remember, there are some great techniques taught in those classes that can help you regardless of whether you're in active labor or not.



Depending on where you live there may even be classes that are geared to a planned or elective caesarean. 



Music



There are some awesome relaxation sounds that you can play on an MP3 player or aloud during preparation for the surgery.  Music and other sounds can be very soothing when a situation is otherwise stressful. Slow and deep breathing can be helpful as well in terms of keeping your heart rate and blood pressure at a healthy pace which, by the way, will help with the baby's vital signs as well. 



The relaxation CD or MP3 recordings can also be helpful to you as can relaxation exercises such as deep breathing and visualization.



Knowledge



One of the most important aspects of dealing with a new situation is being prepared with knowledge of what is going on.  If you at least prepare yourself with knowledge about the surgery and what to expect, this can help significantly. 



It can be frightening to think about being cut open and about not knowing what is going on behind the curtain that is up below your waist.  Many women are afraid they'll feel the pain, but also the incision itself and the loss of sensation in your legs after a spinal block can sometimes induce an anxiety attack.  Don't be afraid to ask questions when you go for your hospital registration and research information about preparation and procedures during the surgery.



When a c-section is planned the hospital staff will often talk to you through the procedure because it will be at a more relaxed pace than during an emergency when every moment counts.



Support



Having your spouse or birthing partner in the room during your c-section can be very soothing and reassuring.  The procedure itself doesn't typically take very long but it can feel like it takes a long time when you're not sure what is going on.  A supportive birth partner can make a big difference in how stressful or relaxing the experience is for you.



Planning Ahead



When you plan ahead and you're prepared yourself for a c-section or the potential for an emergency cesarean, you'll be less stressed.  Because recovery time is longer than with a vaginal birth you might prepare by having help around the house and preparing for living as much on one floor of your home as possible.



For the first few weeks you cannot pick up anything heavier than your baby and planning around this possibility will make things easier in those first few weeks after the baby and you are home and getting acquainted with one another.



Statistics have shown that women suffer a much lesser degree of emotional stress and depression from having a c-section if they are prepared for the process, meaning they fully understand why their c-section is needed and take part in the decisions being made.



Relaxation techniques, knowledge, support and a bit of planning can go a long way together in helping your baby's birth experience be as stress-free as possible.

About the Author:

Elizabeth is the creator and author of The Worry Free C-Section , an essential guide to c-section planning, recovery comfort, care & support. Put your c-section fears to rest with this practical yet powerful C-Section Recovery guide.

Article Source: http://www.articlesbase.com/women's-health-articles/csection-relaxation-preparing-for-your-surgery-631313.html

Moms that deliver babies vaginally are presented with loads of advice for preparation. They're offered pre-natal classes and help through books that they read.  The classes prepare them for relaxing and natural pain relief with various techniques such as breathing

, hypnotherapy, neuro-linguistic programming (NLP) and visualization techniques for the labor and for the birth.  

But, what about women that need to have emergency or planned c-sections instead?  They need TLC and relaxation

help as well!
 
The Cesaream surgery is a big deal and because you're almost guaranteed to be wide awake during the procedure, it can be stressful! 

Here are some tips to help you whether you're having a planned caesarean or in case you find yourself in an emergency surgery situation.

Take The Classes Anyway!

Most women who don't expect to have a c-section would typically take pre-natal classes to help them prepare for a safe and healthy childbirth. However, if you need to have a planned c-section, you might not think it's worth your trouble to take pre-natal classes, but remember, there are some great techniques taught in those classes that can help you regardless of whether you're in active labor or not.

Depending on where you live there may even be classes that are geared to a planned or elective caesarean. 

Music

There are some awesome relaxation sounds that you can play on an MP3 player or aloud during preparation for the surgery.  Music and other sounds can be very soothing when a situation is otherwise stressful. Slow and deep breathing can be helpful as well in terms of keeping your heart rate and blood pressure at a healthy pace which, by the way, will help with the baby's vital signs as well. 

The relaxation CD or MP3 recordings can also be helpful to you as can relaxation exercises such as deep breathing and visualization.

Knowledge

One of the most important aspects of dealing with a new situation is being prepared with knowledge of what is going on.  If you at least prepare yourself with knowledge about the surgery and what to expect, this can help significantly. 

It can be frightening to think about being cut open and about not knowing what is going on behind the curtain that is up below your waist.  Many women are afraid they'll feel the pain, but also the incision itself and the loss of sensation in your legs after a spinal block can sometimes induce an anxiety attack.  Don't be afraid to ask questions when you go for your hospital registration and research information about preparation and procedures during the surgery.

When a c-section is planned the hospital staff will often talk to you through the procedure because it will be at a more relaxed pace than during an emergency when every moment counts.

Support

Having your spouse or birthing partner in the room during your c-section can be very soothing and reassuring.  The procedure itself doesn't typically take very long but it can feel like it takes a long time when you're not sure what is going on.  A supportive birth partner can make a big difference in how stressful or relaxing the experience is for you.

Planning Ahead

When you plan ahead and you're prepared yourself for a c-section or the potential for an emergency cesarean, you'll be less stressed.  Because recovery time is longer than with a vaginal birth you might prepare by having help around the house and preparing for living as much on one floor of your home as possible.

For the first few weeks you cannot pick up anything heavier than your baby and planning around this possibility will make things easier in those first few weeks after the baby and you are home and getting acquainted with one another.

Statistics have shown that women suffer a much lesser degree of emotional stress and depression from having a c-section if they are prepared for the process, meaning they fully understand why their c-section is needed and take part in the decisions being made.

Relaxation techniques, knowledge, support and a bit of planning can go a long way together in helping your baby's birth experience be as stress-free as possible.

 

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doulala
Aug. 8, 2009 at 8:31 PM

Take away the incentives for too many c-sections

The state performs 11,000 unneeded caesarean births each year, in part because of insurance incentives. A measure passed by the last Legislature could help change the pattern.

Quick, what’s the most common reason for hospitalization in America? And what’s the most common surgical procedure? If you answered heart attack, appendicitis, cancer, diabetes, car crashes, and any of their associated surgical remedies, you’d be wrong, because the most common cause for hospitalization isn’t a disease or even an injury. It’s childbirth. And the most common surgical procedure is C-section.

C-section rates have been rising rapidly for several decades, a major contributor to the spiraling cost of childbirth in the U.S. Yet maternal and baby outcomes have been stagnating or worsening. The U.S. ranks dead last among industrialized nations for maternal mortality and second to last for infant mortality.

All of which should make childbirth Exhibit A in the Obama administration’s insistence on containing American health care costs while providing better care. It also suggests that an obscure measure buried deep in Washington’s new biennial budget could become an important model for national health reform.

Beginning this month, the state of Washington will pay hospitals the same amount for an uncomplicated C-section as for a complicated vaginal birth when it reimburses them through Medicaid. Almost half of all births in Washington are paid by Medicaid, so this measure will have a significant effect on the economics of birth in the state.

“C-section rates are trending up and there’s no medical necessity for that trend,” says Dr. Jeff Thompson, the state’s chief medical officer for Medicaid. C-section rates vary wildly between hospitals in the state, from as high as 48 percent down to 14 percent (Thompson won’t say which hospitals those are). When the Department of Health studied that variation, it found that it remained even when risks that make it more likely for women to need C-sections — such as maternal age, obesity, and diabetes — were factored out. Your chance of having a C-section depends a lot on what hospital you give birth in and where in the state you live.

Currently, the rate of C-sections in Washington is just under 30 percent. Nationwide, the rate is almost 32 percent, more than double what both the World Health Organization and the Centers for Disease Control say it should be. In many cases, C-sections save mothers’ and babies’ lives. But, like any surgical procedure, C-section causes harm as well as benefit. When the rate at which they’re performed rises above 10 to 15 percent, the WHO and CDC have found, the harm outweighs the benefits to mothers and babies.

It comes down to this: at least half of the approximately 22,000 C-sections performed each year in Washington are not only unnecessary, but harmful.

C-sections are major abdominal surgery, explains Dr. Jane Dimer, a Group Health obstetrician who chairs the regional chapter of the American College of Obstetricians and Gynecologists and co-chairs with Thompson the state’s perinatal advisory committee. C-sections bring with them, for the mother, a longer recovery time and heightened risk of infection and from anesthesia. In a first C-section, these risks are small, she says, but one C-section makes it highly likely a woman will deliver any subsequent babies by C-section. The risks to the mother go up with each surgery, and a woman who has several children by C-section faces heightened danger of placental complications, hemorrhaging, and ruptured uterus.

Babies born by C-section face greater risks of complications, including respiratory issues. “Costs for neonates are really what’s clogging the system,” Dr. Dimer says.

This is one clear example of what Atul Gawande has famously described in a recent article in The New Yorker (which President Obama ordered his aides to read and cited in meetings with members of Congress): “Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse.” Gawande contrasts McAllen County, Texas, which has the nation’s highest per capita health costs, with Rochester, Minnesota, dominated by the Mayo Clinic, with vastly lower health spending and better health.

After ruling out other explanations for the discrepancy, Gawande concludes that the reason for the difference is the profit motive — doctors and hospitals in McAllen County have too many financial incentives to provide more medical care and none for providing better care. At the Mayo Clinic, the incentives push the opposite direction. Its doctors, for example, are salaried, so they have no incentive to perform more tests or procedures, and pay no financial penalty for spending more time with patients. With per-person Medicare spending (a useful proxy for overall health spending) $1,500 below the national average, Washington state is more a Rochester than a McAllen.

There are many reasons for this. The West Coast generally has somewhat lower costs, in part because of the presence of nonprofit HMOs like Kaiser in California and Group Health in Washington. Group Health, with its salaried doctors and a C-section rate near the lowest in the state, is Washington’s version of the Mayo Clinic. Group Health, which delivers 10 percent of the babies in the state, recently was featured in a New York Times article on health care reform, as a model for good yet cheap care. (Full disclosure: I gave birth to my first child at Group Health and remain insured by Group Health.)

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doulala
Aug. 8, 2009 at 8:32 PM

(cont.)

 

(Page 2 of 3)

Washington’s relatively low medical spending may also owe something to earlier efforts Thompson has led to make state health care better and leaner, including creating a medical technology review board and implementing a preferred drug list, which pushes doctors to prescribe the cheapest drug from among equally effective treatments. All of these steps seek to match the practice of medicine with scientific evidence about what works best.

With childbirth, the incentives all go the other way. On average, Medicaid pays $5,000 more for a C-section than for a vaginal birth, and private insurance pays a far greater premium. You don’t have to be a cynic to wonder if that could have something to do with the rise in unnecessary C-sections.

Thompson explains that there’s no good way for the state to pick out which C-sections are unnecessary. “Medicaid won’t pay for an unnecessary C-section, so hospitals have to code every section as necessary,” he says. But equalizing the amount hospitals get paid for vaginal and C-section births eliminates a financial incentive to perform C-sections. That should mean that the only reason for a doctor to perform a C-section will be that it is medically necessary, and in fact doctors and hospitals will have every financial reason to avoid C-sections — letting money sort out the necessary from the unnecessary. Policy wonks call this “realigning incentives.”

“We are choosing to improve quality mostly by using carrots rather than sticks,” says Dr. Dimer.

Dr. Elliott Main, chair of obstetrics at California Pacific Medical Center and principal investigator for the California Maternal Quality Care Collaborative, says childbirth care is a great place to start realigning incentives in medicine. “It’s a pretty good opportunity to put these concepts into action, because it’s circumscribed, not an all-your-life event like diabetes or hypertension,” he explains. “It has a beginning and an end. It’s packageable.”

He considers Washington’s move very promising. The size of the financial incentive is crucial, he says. That’s because there are such powerful incentives pushing for C-sections. Dr. Dimer explains that the incentives for C-section go beyond money. “In nature, labor can go on for hours and is highly unpredictable,” whereas a C-section delivery is highly predictable and far shorter. “In American culture, where time is money, having something that is finite and predictable is highly desirable,” she says.

Dr. Main says that financial incentives for vaginal birth have to be enough to counteract those factors, enough to command attention. He thinks Washington’s cuts in C-section reimbursement may just be that big. The state has slashed Medicaid reimbursement for uncomplicated C-sections from about $3,600 to around $1,000. Hospitals with high C-section rates are in for a rude awakening. Thompson says that since the change in reimbursements took effect he has already received calls from hospitals asking for help revising the protocols they use to decide when a C-section is called for.

Without any powerful lobby pushing for changing the reimbursement rate, it was the state’s fiscal crisis that got the measure into the state budget. The equalization of rates is projected to save the state close to $2 million and the federal government another $2 million. That’s a conservative estimate, which assumes the C-section rate stays flat. If the realignment of incentives works, the C-section rate will fall, saving Washington’s health care system even more in complications avoided.

And, Thompson, is quick to point out, it will make women and babies in Washington healthier. “This is an opportunity for us to take a leadership role to both improve quality of obstetrical service in the community and actually to spend less money,” he says.

 

Washington has a history of bucking the national tide when it comes to childbirth. It has a rate of out-of-hospital birth double the national average, and the state is one of only nine states in the country where Medicaid will cover out-of-hospital birth attended by a licensed midwife. In 2008 the Department of Health funded a cost-benefit analysis of the practice. It found that paying for home birth resulted in good outcomes for mothers and babies and yielded a net savings to the government of about $250,000 per year from the reduced numbers of C-sections. (Licensed midwives have every incentive for their patients not to have C-sections, including the obvious: Licensed midwives don’t do C-sections. They get paid next to nothing when their clients transfer to a hospital and have C-sections.)

Currently, midwives from Washington state are lobbying in the other Washington for legislation to push all states to cover out-of-hospital births with licensed midwives through Medicaid. Amber Ulvenes, a lobbyist for the Midwives Association of Washington State, recently used the state’s cost-benefit analysis to come up with an estimate of how much money this would save nationwide. She says if 1 percent of Medicaid-covered births were attended by certified midwives, at least $71 million would be saved annually.

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doulala
Aug. 8, 2009 at 8:32 PM

(cont.)

 

 

(Page 3 of 3)

If the state’s realignment of C-section incentives were to work and be implemented nationwide, the potential savings would be far bigger. With C-sections accounting for 45 percent of the $86 billion the U.S. spends on childbirth each year, lowering the C-section rate could go a ways toward paying for President Obama’s goal of getting health coverage to everyone in the country. If Washington’s realignment of childbirth incentives works, it will be one piece of evidence that Obama’s rhetoric just might be right: Not only can we afford health care reform, we can’t afford not to do it.

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doulala
Aug. 12, 2009 at 1:06 AM

Several blog visitors have brought up questions about why the cesarean rate is so high now and why attitudes towards VBACs have changed over time.

So let's take a moment to discuss a simplified bit of the history of cesareans and VBACs (Vaginal Birth After Cesarean, pronounced "vee-back") in the USA.

The Days of Low Cesarean Rates

For most of the 20th century, cesareans were a rarely-used procedure, used only in truly life-threatening situations after all other options had been exhausted. The risks from the operation were so significant that doctors were very reluctant to use it without true need.

Doctors in the USA also followed Dr. Edwin Cragin's 1916 dictate of "once a cesarean, always a cesarean." They were very reluctant to do a cesarean on a woman because that usually meant that all her future children would also be born by a similarly risky operation.

They recognized that the decision for cesarean affected a woman's entire reproductive life, and also had other potential life-long consequences (scar tissue, bowel obstructions, damage to other organs, etc.).

For this reason, the cesarean rate hovered between 1 - 5% until about the 1970s.

Cesareans Become Safer

Over time, changes in technique and technology came about that made cesareans safer and easier. This was a good thing.

Antibiotics became common, cutting the risk of infection. Blood transfusions became available. Anesthesia improved greatly, and eventually, the development of regional anesthesia (via epidurals and spinals) decreased the risk of complications over general anesthesia (where the mother is unconscious).

Surgical techniques also improved. Instead of doing "classical" vertical incisions (up-down incisions, from belly button to pubic bone), doctors began using a low-transverse incision (side to side, just above the pubic bone). Low transverse incisions caused less bleeding, were less prone to wound complications, and were less likely to rupture (come apart) in a future pregnancy.

This conversion from vertical to mostly low transverse incisions also made VBAC a safer choice to consider.

The Cesarean Rate Begins To Climb Rapidly

As technology improved and cesareans became safer, doctors started doing more and more of them. As you can see below, the cesarean rate rapidly increases between 1970 and 1988, until it reaches an all-time high (for that time period) of 24.7% in 1988.
  • 1970 - about 5%
  • 1975 - about 10%
  • 1980 - about 16%
  • 1985 - 22.7%
  • 1988 - 24.7%
This was a huge increase in a relatively short period of time, and it set off many alarms in public health officials. By the late 1980s, there was a big push to reduce the cesarean rate, and after 1988 the cesarean does start to go down somewhat again, though it never again dropped below 20%.

Of course, sometimes doing more cesareans was a good thing. For example, instead of risky high forceps deliveries (which often caused injuries to both mother and baby), cesareans became the delivery of choice. Birth injuries related to forceps declined. In that situation, cesareans probably were safer.

However, this also soon meant that even judicious low forceps use (which can help turn a poorly positioned baby and make vaginal birth possible) came into disuse. Vacuum extraction is now used instead of forceps most of the time, but it has its risks too, so many doctors prefer to go straight to surgery instead.

Generally it's a good thing that instrumental delivery has gone down, but along with the loss of this has come a loss of knowledge that mild positional issues can be resolved by any method other than cutting the baby out. For example, studies show that manually repositioning a baby can cut the cesarean rate dramatically, without the risks of instrumental delivery.....but few doctors and hospitals are being taught these skills anymore.

New technology such as External Fetal Monitoring (EFM) also increased the cesarean rate, but without improving fetal outcome in most cases. Despite this, EFM has become "standard of care" and continues to crank up the cesarean rate even today.

In time, more and more doctors saw the cesarean as the "go-to" choice for births they perceived as more risky, either medically or legally. More and more breeches began to be delivered by cesarean, and many babies suspected to be "big" were sectioned out. Mothers with any sort of complication became automatic candidates for a cesarean, even when other choices existed.

Even more influential in the meteoric rise in cesarean rates was the increased use of labor inductions (which strongly increases the risk for cesarean, especially in first-time mothers). Induction of labor allowed doctors to practice "daylight obstetrics" and have more reasonable hours, but the price was more surgery for the mothers and often, more intensive care visits for the babies.

As a result, there was an unprecedented explosion in the cesarean rate. This was quite controversial; many public health officials (including many doctors) decried the strong rise in cesareans and actively looked for ways to reduce the rate.

Others, however, began to be seduced by how convenient cesareans were for scheduling their time and also saw scheduled cesareans as a way out of the increasing risk of malpractice suits.

The debate over the "best" and "most optimal" cesarean rate began to rage and still continues today.

VBAC Becomes More Common

When the cesarean rate was only around 5%, the "once a cesarean, always a cesarean" dictum wasn't a pressing public health issue. But as the cesarean rate went up, that dictum became more of an issue.

If more and more women had primary (first-time) cesareans and all of them had to have repeats for every child, then the cesarean rate had the potential to expand at an unheard-of rate.

VBAC was seen by public health officials as one way to keep the cesarean rate from rising even higher. In addition, more women started questioning whether they had to have a cesarean for every single child. Although still controversial, VBAC became more and more acceptable as an alternative.

In the late 70s and the 80s, concurrent with the rise in the cesarean rate, US doctors finally began really researching VBAC, showing that it was a safe and reasonable choice. Still, there was quite a bit of resistance to VBAC at first, and women had to struggle to find caregivers who would "let" them VBAC.

Many women were told that they would "kill their babies" if they tried to VBAC, yet they heard through the grapevine that VBACs were more common in Europe, and that some U.S. practices were beginning to attend VBACs also. Women began pushing back, trying to make sure VBAC was available universally.

Out of this struggle, a grass-roots women's health movement began, pushing for more choices in childbirth. Women like Nancy Wainer Cohen, Esther Zorn, and Lois Estner pushed to make VBAC a choice for all women, while other pioneers like Suzanne Arms, Penny Simkin, Robbie Davis-Floyd, Sheila Kitzinger and many others pushed for reform of outdated childbirth practices like universal episiotomy, pubic hair shaving, mandatory drugging of the mother, prolonged separation of mother and baby, promotion of formula feeding over breastfeeding, etc.

The International Cesarean Awareness Network (ICAN) was born in 1982 (under a different name at first) and consumers finally had an organized voice demanding the right to choose VBAC. In 1983, Nancy Wainer Cohen and Lois Estner published Silent Knife, a book about VBACs that still remains a classic even now, more than 25 years later.

The power of the consumer to demand change began having an impact, and by the early 90s, VBAC was available in the vast majority of U.S. hospitals.

VBAC Management Began To Change

By the early-to-mid 90s, VBAC became the norm in many places, reaching its peak in 1996.

Research in the 80s had shown that VBAC was an eminently reasonable choice, so more and more hospitals and doctors began offering it. However, they knew from research that in rare cases, the uterine scar could separate in a subsequent pregnancy (uterine rupture), so they were very cautious in how they managed VBAC labors.

VBACs in the 80s were rarely induced, and pitocin augmentation of labor was done very conservatively and with great care.

This began to change in the 90s. As induction of labor became the norm in other labors, so it began to be applied liberally to VBAC moms.

Inducing VBACs became commonplace; many doctors believed that inducing early increased VBAC success (despite studies showing the opposite effect).

In addition, a new induction drug came along called Cytotec (generic name: misoprostol), which was cheaper and more convenient to use than other induction drugs. It was only after a number of years of use and some pretty horrible outcomes that it was "discovered" that Cytotec actually strongly increased the risk for uterine rupture in VBAC moms.

Although researchers still argue about it today, it's become apparent that inducing labor by any means also increases the risk of uterine rupture. Some induction methods increase the risk much more strongly than others, but all methods show some increase of risk over spontaneous labor. This is particularly true if the mother has never had a vaginal birth before, or if multiple induction agents are used. Cytotec in particular raises the risk of rupture strongly.

This routine induction of VBAC was the beginning of a crisis for VBACs.

VBAC-lash Begins

Because VBAC in the early 90s was so mismanaged, by the late 90s a movement against VBAC was starting to take hold. There were several factors in this VBAC-lash.

Because vaginal birth is cheaper than major surgery, promoting VBAC was seen as a way to cut costs for insurance companies. Unfortunately, this meant that VBAC became required in some places, and some women were not given a choice about whether or not to VBAC.

This was the first step on the road to VBAC-lash, because not all women want to VBAC, nor are all women suitable candidates for it.

Some women were required to labor who had contra-indications for labor. Others were forced to labor in crowded hospitals with very inadequate supervision. Conditions in some places were so poor that even when signs of a rupture were obvious, the woman did not receive timely intervention. Other women were induced with dangerous drugs like Cytotec that had a very high rate of rupture.

As a result, some babies were lost, some babies were damaged, and some mothers lost their uteri. This was a tremendous tragedy, and those families were justifiably upset and well within their rights to sue.

Because more and more VBACs were induced, more and more cases of uterine rupture began appearing, more babies died or were harmed, and doctors and hospitals faced some spectacularly big lawsuits. This played a huge role in the VBAC-lash.

But instead of blaming the overuse of induction, mandatory VBACs regardless of suitability, and mismanagement of labor, doctors began saying that it was actually VBAC that was unsafe.

Now mind, research does NOT support this; if you examine the research carefully, the rate of rupture in spontaneous labor VBAC does not change over time. It remains around one-half of one percent on average; some studies show rates as low as 0.2% or even less.

The risk of serious, permanent harm to the baby or mother is even lower. Babies are at far more risk of dying from amniocentesis, a procedure that doctors do not hesitate to recommend.

Yet suddenly, VBAC was considered "too dangerous" because doctors were lumping all VBACs (induced and not, carefully chosen and not) together.

Right or wrong, doctors' perception of VBAC began to change, and they began to see it as tremendously risky.....both in absolute risk to the mother and baby, and in medico-legal risk to themselves. Many doctors decreased the number of VBACs they attended, and some doctors stopped offering VBACs at all.

By the very end of the 90s, there was a distinct downfall in the rate of VBACs, and after 2000 the rate really began dropping off.

The reason for this dropoff is that in 1999, ACOG issued new guidelines for attending VBACs, requiring doctors and anesthesiologists to be "immediately available" during a VBAC labor. This means the OB and the anesthesiologist had to be IN the hospital during a VBAC mother's whole labor. This was financially and logistically impractical, so more doctors quit attending VBACs.

A lot of smaller hospitals instituted official VBAC bans because they could not meet the "immediately available" guidelines. This has had a particularly significant impact on states with lots of rural or small-city hospitals.

Because there had been a few spectacularly high lawsuit awards, many malpractice companies raised rates for or refused to cover doctors who attended VBACs. Therefore, even some doctors who still believed in VBACs and wanted to attend them often felt like they could not afford to continue, or that their hands were tied by hospital and malpractice insurance policy.

Because of malpractice insurance issues, even some large hospitals with 24/7 surgical and anesthesia coverage also began to not "do" VBACs, or began to strongly discourage them.

Now the rate of VBACs in this country has dropped significantly, with many women essentially being forced into repeat cesareans, as documented in the recent TIME magazine article.

Currently, about 92% of women who have a prior cesarean undergo cesareans with all their subsequent children. This is about the same low level of VBACs as in 1986, just as the VBAC movement really started to take off.

We are not quite back to the days of "once a cesarean, always a cesarean" because about 8% of women with prior cesareans still do somehow manage to have VBACs in this country despite all the bans......but basically, we are almost there.

Yet a few voices of sanity still prevail. The authors of an 2006 Irish study on VBAC state:

The North American studies have highlighted correctly the risks of [rupture] in women who labour with a previous caesarean section. We are concerned, however, that obstetricians individually and collectively may have overreacted to their publication and that some have been too quick to revert back to a policy of ‘once a caesarean, always a caesarean’. This simplistic mantra may have been appropriate at the start of the 20th century, but our experience suggests that such a ‘one policy fits all’ approach may not be in the interests of both mother and baby at the start of the 21st century.
Cesarean Rates Soar Again

Combine the anti-VBAC climate in the country with the fact that cesareans make more money for hospitals, more money (hour for hour) for doctors, and make the lives of doctors and hospitals incredibly more convenient, and cesareans in this country have truly become epidemic.

Doctors like to claim that the steep rise in cesarean rates in the USA is because maternal demographics are changing.....mothers are older, fatter, have more multiples, etc. However, careful examination of the research shows that cesarean rates are increasing for ALL women, regardless of risk profiles.

Another argument is that women are requesting all these cesareans and the poor doctors' hands are tied. But there is no convincing research that cesarean on maternal request plays a large part in cesarean rates.

Blaming the explosion of cesarean rates on the mothers just doesn't wash....the truth is it is physician practice patterns that are driving the rates.

Because practice patterns differ between doctors and hospitals, you have a much higher risk for cesarean in some hospitals than in others. For example, in New Jersey, some hospitals still have cesarean rates in the 20-36% range, but many hospitals now have about a 40% cesarean rate. This is becoming more and more common.

Some hospitals in New Jersey, California, and Florida have about a 50% cesarean rate, and there are more and more of these starting to appear. A few even have c-section rates as high as almost 60%......and the high cesarean trend shows no signs of abating.

Summary

Remember when public health officials got all up in arms in the late 80s because the cesarean rate had spiked to around 25%? Well, they did reduce it for a while (it dropped down to 20.8% by 1995), but now it has spiked again, even higher than it was then.

Only this time, almost no one cares.

Now the cesarean rate has soared up to over 30% nationally (the rate was 31.1% in 2006) and is still going up.

(The 2007 figures are due out from the CDC very soon....watch for them. Also watch to see whether the cesarean rate receives much attention in the media afterwards.)

Many consumer groups like ICAN are fighting this spike in cesareans, yet hardly a medical voice is raised against this out-of-control trend.

In some states (like New Jersey and Florida) the c-section rate is almost 40% already.

Now, at the end of the first decade of 2000, about one out of every three women in the USA has her baby surgically extracted, and in some hospitals that becomes ONE OUT OF EVERY TWO....or more.

And if you have that first cesarean, it has become extremely hard to find a hospital that will give you a realistic chance at a VBAC. We are not quite back to the days of "once a cesarean, always a cesarean" but we are getting darn close.

This is the sad and sorry state of birth in America. It can change, but consumers must take the first step and vote with their feet, away from the doctors and hospitals that practice so unsafely and unjustly.

*Graph is of cesarean rates from 1989-2003 only. Source found at: http://www.childbirthconnection.com/article.asp?ck=10554.

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doulala
Aug. 12, 2009 at 1:07 AM

The previous article came from:

A History of VBACs and Cesareans in the USA


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doulala
Aug. 16, 2009 at 12:40 PM

More info if a cesarean is inevitable:

 

 

My latest mission has been to learn what sorts of things can be done ahead of time to prepare one’s house and life for what is essentially the recovery of major abdominal surgery AND a newborn. Phew.

Various doula lists have been incredibly helpful in helping to compile a list, and I figured I’m not the only one out there searching for this information, so here is a compilation (I am fine with people passing this blog post on to others, but please site me - Lea Wolf - and link back as well, thanks!) -

For your home:

*Create a list of friends and family who can help with various tasks, and be sure to communicate with them ahead of time about why you’ll be calling them - making clear that though they are also welcome to ooh and ahh about the babe, they are also getting the call to come help with meals/cleaning/shopping/chores/company/nap-relief/driving.

*Have plenty of food and snacks in the house including but not limited to a freezer-ful of meals that are simple to cook/reheat. Easy to make sandwich fixings, nuts, fruit, snacky veggies (carrots, sugar snap peas, etc), cheese, granola bars, yogurt, and other healthy grab-and-go foods are important too!

*If your community is large enough, ask someone to create a meal-tree for you, so that fresh ready-to-eat meals are delivered every couple of days.

*Do everything you can to make the home-space you will occupy on one-floor (assuming you have more than one floor), on a floor with a bathroom. If this means that you are not on the same floor as your kitchen, figure out a cooler/mini fridge situation so that you have food, water, bathroom — and phone access — on one floor. The point here is obviously no stair climbing. Expect to stay in one place as much as possible to aid in a faster recovery.

*Going along with expecting to stay in one place - plan to lay low. No going for walks, running errands, going out to eat. Come to terms in advance with what it will mean in your life to recover from surgery and plan accordingly. The cesarean rate is so high now that it has become commonplace, and because of that, it is easy to lose sight of the fact that cesareans are major abdominal surgery. And moms need to recover in order to be the best parents they can be.

*Have a basket of necessities that you can take with you if you do need to move room-to-room especially as you begin feeling better. Necessities might include a small water bottle, some non-fridge snacks like nuts, a diaper and wipes, the phone, tissues, etc.

*Hire a post-partum doula to come in to to help with any myriad of tasks - infant soothing, breastfeeding support, caring for infant/siblings so mother can get a shower or rest, support in the process of learning to care for a newborn, light meal prep, light cleaning, and the general support of someone who understands what is “normal” and has a network of referrals to others in the community if needed.

*A total seemingly crazy purchase, but one that could be incredibly helpful is a lifted toilet seat - this prevents the strain on abdominal muscles that happens when sitting and rising from a toilet height. (I’m thinking about getting one of these to lend out to clients who have had cesareans.)

Preparing for the hospital:

*Find out in advance how many support people are allowed in the room during the cesarean and consider advocating for more than one. Partners are usually allowed, but when the babe is out, partners will generally accompany the babe (whether it be across the room or out of the room), and having another support person means that mom will not be left alone. If there is any reason that baby needs to be taken out of the room, partners are able to accompany the baby without worrying that mom is being left alone and that additional support person may be able to relay any information about the baby during a separation.

*Even if you have a scheduled cesarean, if you have hired a doula or considered hiring a doula, their services may still be very useful. Their presence as an extra support person can fulfill the above roles, but with more experience and knowledge available explain each step of the way. They are able to communicate with parents in plain-talk about what might be happening medically, and support parents in advocating for information when there is uncertainty.

*Understand in advance what is going to happen during the cesarean. Find out what happens during prep and what choices you have (ie can you shave yourself, or will the staff do it themselves). Many people do not realize that the baby is birthed within the first few minutes of the surgery - but the rest of the hour-long procedure consists of being stitched up. Making a plan with care providers for how that time is handled is important. Find out what the standard procedure is for mom, support person/people, and baby and what choices you have.

*There is alot of information out there about the importance of skin-to-skin contact for mom and baby for many reasons, including successful breastfeeding - it doesn’t hurt to ask whether it would be possible for mom to have baby on her chest as the stitching happens (with support of course) - there are doctors who allow for this. And if the answer is no, perhaps consider having the partner go skin-to-skin with baby. (And check out this interesting article on “natural cesareans” for some perspective.)

*Find out what policies might be regarding photography - what is okay to take pictures of (ie, baby yes, surgery no, etc). The lovely thing about digital pictures nowadays is that you are able to take photos and it is an easy delete if you’d rather. Converting photos to black and white (also an easy process with digital) can do alot for capturing emotion, while playing down blood/bodily fluids, if that is of concern to you.

*Consider refusing or delaying eye treatment so that baby is clear-eyed and able to see mom after mom is done being stitched up and is able to really explore baby. Antibiotics are used as a prophylactic treatment to prevent the transmission of STDs from the mom to the baby, but if mom has been tested for STDs during pregnancy and is negative, the antibiotics are unnecessary.

*Antibiotic use for the mom prior to and during surgery is also commonplace, so preparing your body in advance so as to best be able to have a successful and fast recovery. Probiotics are all the good stuff in yogurt, but in pill-form, and having as many of these good bacteria present in your body as possible will help combat the more negative affects of antibiotics on mom’s digestive system, and baby’s as well. Good quality probiotics will be in a refrigerated case at natural food stores and natural pharmacies.

Ways to make cesareans less about surgery, and more about birth:

(Thanks to Trish Cremeens for these wonderful suggestions and insight on cesareans.)

*Remember that a babe is (usually) created out of love and closeness. And birth is a culmination of that love and closeness, and having your babe via surgery doesn’t have to take that away. Everything above the drape is not a part of the sterile field. Partners can touch one another, and connect physically; mom’s head, hands, arms, and shoulders can be stroked and massaged. Partners can talk about how their baby is about to be born - avoiding words/phrases like cut, pull and instead using words like birth and born and welcome.

*Mom’s arms are usually strapped down to prevent any interference with the sterile field and because many people become shaky during surgery. However, if you make it clear to your doctor that you understand the concept of the sterile field, one or both arms may be able to be free. This can be helpful in different ways - allowing for normal touch between partners, and also to allow for mom to touch babe after the birth. Even if mom’s hands have to be strapped down, there are ways partners can get that mom-baby touch: babe and mom can nuzzle cheek to cheek, partners can support baby’s weight on mom’s chest (”feel how big that baby is!”), and babe can be kept close to mom, even if she is groggy.

*You can also ask for the staff to talk through what is happening during the surgery, explaining things step-by-step, and you can specify if you want the staff to use or to avoid using medical terminology.

*There are ways to personalize the experience for everyone involved. Prior to the surgery, you can ask everyone in the room to introduce themselves. Listening to music that you chose, and making the decision about what will be talked about during the surgery (assuming all is going well) by the staff and between mom and partner/support staff can also make the experience personal.

*Typical birth practices such as the announcement of the gender (if unknown) and the cutting of the cord are still options during most cesareans. You can also talk with your doctor about dropping the sterile drape as the baby is being born - though you might think that the surgical cut is gory or overly graphic, it may be less so than you’d think. If you’d prefer to not see the birth as surgical, you can ask the staff to show you the babe over the drape (which is typical procedure). Both ways are valid and neither are more “natural” or “right”.

Things to think about and be prepared for with the recovery period:
(Thanks again to Trish!)

*It is not uncommon for there to be breastfeeding issues after a cesarean. Milk takes longer to come in, the incision may make typical nursing positions difficult, the meds used can make baby sleepy or disorganized in their movements. Understand that asking for help is the best thing that you can do - ask for a lactation consultant to assist; most of the nursing staff have knowledge of breastfeeding and have been certified as lactation counselors, but most hospitals have IBCLC certified lactation consultants and these folks specialize in breastfeeding.

*Bonding might be harder as the typical hormonal process is interrupted. Parents should not be too hard on themselves - and just being aware that this might happen makes it easier to understand what is going on. Practices like spending a lot of time skin-to-skin, practicing infant massage, and doing babywearing (when physically capable after the surgery in mom’s case) can all help the bonding experience.

*Parents need to give themselves the space to process. Yes, the ultimate goal is a healthy mom and healthy baby, but that is the goal for ALL births. Finding friends and support people who will allow that process of storytelling over and over will help to integrate the experience into reality - this is necessary for every kind of birth, but in the case of a cesarean it may not be a story full of only happy feelings.

*A seemingly good article - though Australian-based and thus not always entirely appropriate for US cesareans - on cesarean recovery, both physical and emotionally, is here: Caesareans: What to Expect After.

Final thoughts:

*Though scheduled cesareans are convenient for both the medical staff and for families, be well informed the research on “trials of labor” and the ways in which they can help give a baby it’s best start in life - even if it is known that the baby will be born via cesarean. A good article on “Why Labor is Good for Babies” is a good place to start. Waiting for your body to signal that it is time for the baby to be born by waiting for labor to begin ensures that your body has done all that it can to prepare baby for the outside world - their lungs are ready to breath and their systems are ready to operate successfully without help.

*Make sure that all has been done to prevent the cesarean as is possible. This might mean exploring alternatives that your health care provider is not mentioning. If your care provider presents a scheduled cesarean as the only option, remember that it is well within your rights to ask questions and, unless it is an emergency situation, request time to do your own research before the cesarean is scheduled.

In some cases it really may be the best/only option for the health of both mom and baby: placenta previa when the placenta is covering the cervix, placenta abrevia when the placenta detatches from the uterus, severe fetal distress when it seems baby is more than a few minutes away from delivery, baby lying transverse (neither head up or head down) even after all has been done to change baby’s position.

However other common reasons given for scheduled cesareans are not always cut and dry in their necessity: breech, multiples, previous cesarean, mother/baby size; in these cases, be well-informed of all the options (even those your care provider might not be mentioning) so that you can make a decision with all of the information necessary. The Spinning Babies website has a more detailed article entitled “When is a cesarean necessary“.

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Another great article on Having the Best Cesarean Possible was written by Penny Simkin and has lots of great information. This post is getting too long so I’ll just say go read hers as well!!!

 

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