Thursday, July 9, 2009

"Pit to Distress": Your Ticket to an Emergency Unnecessarean


Jill from Keyboard Revolutionary wrote about a new term that she recently came across— “Pit to distress.”

“Pit to distress.” How have I not heard about this? Apparently it’s quite en vogue in many hospitals these days. Googling the term brings up a number of pages discussing the practice, which entails administering the highest possible dosage of Pitocin in order to deliberately distress the fetus, so a C-section can be performed.

Yes folks, you read that right. All that Pit is not to coerce mom’s body into birthing ASAP so they can turn that moneymaking bed over, but to purposefully squeeze all the oxygen out of her baby so they can put on a concerned face and say, “Oh dear, looks like we’re heading to the OR!”

The term is found in this 2006 article in this Wall Street Journal article:

Oxytocin is a hormone released during labor that causes contractions of the uterus. The most common brand name is Pitocin, which is a synthetic version. It’s often used to speed or jump-start labor, but if the contractions become too strong and frequent, the uterus becomes “hyperstimulated,” which may cause tearing and slow the supply of blood and oxygen to the fetus. Though there are no precise statistics on its use, IHI says reviews of medical-malpractice claims show oxytocin is involved in more than 50 percent of situations leading to birth trauma.

“Pitocin is used like candy in the OB world, and that’s one of the reasons for medical and legal risk,” says Carla Provost, assistant vice president at Baystate, who notes that in many hospitals it is common practice to “pit to distress” — or use the maximum dose of Pitocin to stimulate contractions.

It’s also used on this AllNurses forum:

I agree, and call aggressive pit protocols the “pit to distress, then cut” routine. Docs who have high c/s rates and like doing them, are the same ones that like the rapid fire knock em down/drag em out pit routines.

“Pit to distress” appears on page 182 of the textbook Labor and Delivery Nursing by Michelle Murray and Gayle Huelsmann. In this example, the onus is on the nurse to defend the patient from the doctor if he or she sees the order “pit to distress” by immediately notifying the supervisor or charge nurse.

Jill asks the questions, “OBs, do you still think women are choosing not to birth at your hospitals because Ricki Lake said homebirths are cool? Do you still think we are only out for a “good experience?”

I imagine that all of us who have openly questioned the practices of obstetricians in the U.S. have been hit with the same backlash. We must be selfish, irrational and motivated by our own personal satisfaction. We’ve been indoctrinated into a subculture of natural birth zealots and want to force pain on other women or just feel mighty and superior. We fetishize vaginal birth and attach magical powers to a so-called natural entrance to the world.

Nah. It’s stuff like “pit to distress” that made me run for the nearest freestanding birth center. If I had to do it all over again, I’d stay home.

Great post -

Thursday, May 28, 2009

A Different Kind of Consent Form

The form all of mothers of repeat cesareans should have to sign...

I, the undersigned physician, have, in violation of the Consumer Bill of Rights and Responsibilities, the Emergency Medical Treatment and Active Labor Act, the Patient Self Determination Act, the ethical guidelines of the American Medical Association and the American College of Obstetricians and Gynecologists, Constitutional Law (the right to privacy and self determination protected by the 1st and 14th amendments), international tort law, and case law (of particular interest "In re A.C.", 1987, "In re Fetus Brown, 689 N.E.2d 397, 400 (Ill. App. Ct. 1997)", and "In re Baby Boy Doe, 632 N.E.2d 326 (Ill. App. Ct. 1994)") and the Patient Rights as determined by this institution, deprived my client,________________, of her right to self determination and her right to bodily integrity by ignoring her repeated refusal for delivery by repeat cesarean section. I acknowledge that by refusing to honor my client's denial of consent, I have not only violated the above laws, but I also affirm that I have used unwarranted and unethical pressure including emotional threats to my client's and her unborn child's life and safety, in my attempts to obtain such consent. I further affirm that I have stressed the risks of vaginal birth after cesarean, but neglected to inform my patient of the risks of delivery by repeat cesarean section. I further affirm that I understand, that should I resort to physical force, including but not limited to physical or chemical restraints to compel my client's cooperation, I will be guilty of criminal battery, which is defined as "any form of non-consensual touching or treatment that occurs in a medical setting".

In compensation for the above violations of my client's rights, I hereby guarantee the following:

a healthy baby, born in perfect condition, with no physical, mental or developmental deficits whatsoever, whether arising from surgery or any other cause

no complications for the infant, including but not limited to: persistent pulmonary hypertension, transient tachypnea of the newborn, respiratory distress syndrome, iatrogenic prematurity, lacerations, or hematoma

a speedy, uncomplicated post-operative recovery for my client. Specifically, I guarantee that my client shall not experience nerve damage, organ damage, hemorrhage (whether sufficient to require transfusion or not), disability or disfigurement, intraoperative or postoperative infection of the wound or surrounding skin and tissues, post partum depression and postpartum post traumatic stress disorder (PTSD), and other conditions not listed here.


Great job!!

Saturday, May 9, 2009

The Road to Recovery from Birth Trauma

A person with PTSD (post traumatic stress disorder) does not have to look forward to a life-time of unrelieved suffering and maintenance therapy.

Unlike many mental illnesses, most people can gain permanent, significant, if not substantial relief and freedom from PTSD through a variety of non-chemical options. What follows covers some of these options - how you can help yourself, and what sort of professional help has been found to be of assistance. Even as a scar will seldom completely disappear, neither will the effects of your trauma, however, you can enjoy life again in a meaningful and fulfilling way.

These measures are not an alternative to professional treatment but they will assist with how well you are able to cope before, during and after treatment.

Create your own support network of friends, family and professionals. Use people to help you in the way that they can eg. a family member may not understand your illness but is only too willing to offer babysitting whenever it's needed. Avoid spending time with people who are critical or unsympathetic or those who have a negative outlook on life.

Be aware of your limitations: Don't try to do too much and don't blame yourself for not coping. Accept help when it is offered no matter how small. If you don’t like to ask for help try leaving a list of “jobs” on the fridge that you can refer to when someone asks if there’s anything they can do to help. Prioritize tasks and on bad days stick to only what must happen on the day eg. caring for baby, preparing meals. Leave any non-urgent tasks such as vacuuming the hall or folding the laundry, for your keen volunteers, or for another day.

Take care of yourself.
Tend to your own needs and don’t feel guilty for doing so. Making use of a volunteer to mind a grizzly baby so you can shower in peace or eat a meal while it’s hot can make a huge difference to your day. Make time for some “time-out.” Use aromatherapy, homoeopathy, yoga, exercise, relaxation techniques; anything that works for you to soothe the mind, body and soul. And don’t neglect your spiritual needs either.

Establish some normal routines.
Sometimes, sticking to a routine involves less thought and planning. Along with the routine of feeding and bathing baby in the morning, include time for brushing your teeth, combing your hair, getting dressed and eating a nutritious breakfast. These may seem like obvious and insignificant tasks when we are well but during the bad times they can seem like insurmountable chores to add to an already overloaded day and yet they will help you greatly in your sense of well-being.

Good nutrition is vital.
You need to eat well in order to care for others, especially if you are breastfeeding too. Adjust your shopping list to include healthy, easy snacks like fresh fruit and vegetables, dried fruit, nuts and cheese and simple to prepare meals including tinned and frozen foods. If you cook a dish that can be easily frozen, cook it in bulk and freeze it in meal-size portions for tougher days. Fill a thermos with a hot drink and set it aside with a snack to have in the early hours when you are breastfeeding. Also have a water bottle on hand to keep you hydrated, as breastfeeding is thirsty work.

Eat a well balanced diet.
Eat to maintain your optimum energy, which means keeping your blood sugar levels constant. A low blood sugar level leaves you feeling tired, listless and shaky while a high blood sugar level gives you a short-lived buzz. Avoid simple carbohydrates like sugar and refined white flour which are easily digested and metabolised rapidly, giving an almost immediate energy high, followed later by a significant energy slump. Avoid also caffeine, which is found in tea, coffee, chocolate and some fizzy drinks; also avoid smoking, alcohol and added salt.

B vitamins are essential for effective sugar metabolism and energy release. Alcohol, caffeine, smoking, oral contraceptives and stress can all deplete your body of them. As B vitamins are not stored in the body it will probably be necessary to use a supplement during these times of stress especially vitamins B9 and Bl2. Feelings of depression, irritability and tiredness can be symptoms of a B vitamin deficiency. Fresh fruit and vegetables, wholegrain cereals, wholemeal bread, yeast extract, liver, beans, lentils and tofu are all excellent sources.

An iron deficient diet will also leave you feeling tired. Good sources are cereals, liver, kidneys, dried apricots, eggs, watercress, beef, lamb and wholemeal bread. Vitamin C improves the way your body absorbs iron so combine this in your meals.

Consult your pharmacist, health shop rep, a nutritionist or dietitian, etc. for specific advice concerning your particular nutritional needs.

Allow yourself some simple pleasures.
Try to do at least one thing each day that isn’t a “should”; something that you get some enjoyment from such as reading a magazine in the morning sunshine for 10 undisturbed minutes or going for a leisurely walk around the block while listening to your favorite music. If necessary, plan it into your day but don’t berate yourself if it doesn’t happen. Try not to feel that the minute that you put the baby down for a sleep, you need to race around catching up on all the jobs that need doing. Prioritize and be willing to let some things go.

Be adaptable. New babies invariably mean a lack of sleep and sleep deprivation can make you feel like your going crazy some days. When the going gets tough, accept that it’s not forever and ease up on your expectations of what “needs” to be done each day. Conserve your energy, sleep when and where you can and put off anything that’s not essential.

Be unsociable when you need to be. Don’t feel that you have to always answer the door or the phone. Put a note on the door that says “Mother and baby sleeping, please do not disturb” and put the answer phone on or leave the phone off the hook if the ringing will wake you. Chances are that the minute you get your unsettled baby to sleep and you dive for your pillow, the phone will ring!

Forget trying to keep up to your previous schedule at the gym or worrying about if you are “pushing play” for the required time each day. Simply, a little fresh air, sunshine and gentle exercise, no matter how small will do wonders for your stress levels and to help you to feel connected to the world outside your four walls. Include your exercise as one of your simple pleasures.

Find a trusted person(s) to talk to about the trauma. They need to be empathetic, non-judgmental, and attentive listeners. Your partner may be this person. Be aware, however, that he is likely to be affected by the trauma too and may feel blamed or at fault for things that happened. He may also need to have his feelings heard. Speaking with someone who isn't emotionally involved may be a better option.

The need to debrief. After any highly emotional event, good or bad, there is a strong need to share the experience and to have one's emotions acknowledged. Having a baby is a monumental experience in any woman's life.

Every woman needs to debrief; even after the most normal of births. Those who had a stressful experience will need to talk it through many times. Friends and family may be initially sympathetic but may not understand the continuing need to talk.

Debriefing has been shown to reduce the occurrence of PND. It is also effective in reducing the severity of PTSD.

We believe all women should have the chance to talk over their birth experience in the early postnatal days, preferably with a health professional who was present for the labor and the birth.


Solace for Mothers with Birth Trauma

Birth can be beautiful for some women. And for some women, difficult deliveries bring fear, pain, grief, isolation, anger, and shame for months or even years.

Talking by phone to a trained and sympathetic peer counselor can help a mother to come to terms with the feelings and thoughts she is afraid to say aloud to anyone else. Calls are free and confidential. Monthly in-person facilitated support meetings allow women to come together to cry and to laugh. Call 877-SOLACE4 – sharing, understanding, and healing.

Please browse our web site to learn more about Solace for Mothers. If you work with birthing women, please offer us as a resource. We are please to have launched two online communities where women and those who support them can connect around birth trauma concerns.


Pregnant in America

Very informative movie. Available on netflix for rental

Wednesday, March 18, 2009

CDC Birth Rates for 2007 - 50% increase in the last 10 years!

The preliminary cesarean delivery rate rose 2 percent in 2007, to 31.8 percent of all births, marking the 11th consecutive year of increase and another record high for the United States (Table 8; Figure 3). This rate has climbed by more than 50 percent over the last decade (20.7 percent in 1996). Increases between 2006 and 2007 in the percentage of births delivered by cesarean were reported for most age groups (data not shown), and for the three largest race and Hispanic origin groups: non-Hispanic white (32.0 percent in 2007), non-Hispanic black (33.8 percent) and Hispanic (30.4 percent). The rise in the total cesarean delivery rate in recent years has been shown to result from higher rates of both
first and repeat cesareans (1).

Tuesday, March 17, 2009

VBAC and Scar Integrity

VBAC and scar integrity,
or "Why my uterus isn't going to explode"

Myth: It takes two years or more for uterine scar tissue to heal.
Fact: Your uterus is just like any other cut that is bound with stitches or staples, and does all the healing it's going to in the first few weeks. While a few studies suggest that the risk of rupture (more on what "rupture" is later) is higher if you get pregnant within 18 months, it is still far less than 1%, and while it is often recommended to wait, this does not reflect whether or not a real risk exists following initial healing. Most authorities agree that by the time your fertility returns (2-3+ months), conception happens and the uterus begins to expand (12 weeks), healing is done. The gentle pressure of a slowly expanding uterus is unlikely to cause any damage, and since we don't go into labour immediately following conception it's likely a year or more would have passed since the surgery. Healing can continue even during pregnancy.

(taken from

From BIRTH AFTER CESAREAN by Bruce Flamm: "Rumor has it that its safer to wait several years after a cesearen section before attempting a vaginal birth. There's absolutely no evidence for this belief. Studies on wound healing have shown that tissue regains the majority of its strength within a few weeks of an operation. The tissue that gives a healing wound its strength is called collagen. According to a general surgery textbook, 'Collagen content of the wound tissues rises rapidly between the sixth and the seventeenth days but increase very little after the seventeenth day and none at all after the forty-second day.' Since the uterine scar is almost fully healed within weeks after a cesarean section there is no reason to postpone plans for another baby."

Myth: If you rupture, you and your baby will die.
Fact: Catastrophic ruptures are extremely rare, and much more likely if you have oxytocin induction, cyotec, prostaglandins or lay flat on your back unable to move around. Included in rupture statistics is harmless and asymptomatic dehiscences, which unfairly skews the numbers. When people think of rupture they think of a uterus imploding, they don't think of scar tissue pulling away from where it's gotten stuck, or a small break that heals easily and poses no risk to mother or baby. Dehiscences are the most common type of "rupture", by far. It is usually diagnosed when a second c-section is performed or the doctor physically puts his hand inside a woman's uterus and feels around after birth. Some evidence suggests that many dehiscences actually occur before labour begins.

Catastrophic rupture (the dangerous kind) more often happens due to uterine integrity as a whole (with the vast majority following labour augmentation). The cases of true rupture are not the 1-2% figure we hear all the time, that is for dehiscences. When a true rupture occurs, a cesarean must occur within 30 minutes (ideally 20) to prevent neurological damage to the baby. Death does not occur immediately. Most women attempting a home VBAC are well within 20-30 minutes of a hospital, particularly if 911 is called.

'A Guide to Effective Care in Pregnancy and Childbirth', which is a well-respected summary of evidence-based practice, says that the rate of reported uterine rupture has ranged from 0.09% to 0.8% for women with a single baby, head-down, who planned a vaginal birth after one previous lower-segment cesarean. The authors comment:

"To put these rates into perspective, the probability of requiring an emergency cesarean section for acute other conditions(fetal distress, cord prolapse, or antepartum hemorrhage) in any woman giving birth, is approximately 2.7%, or up to 30 times as high as the risk of uterine rupture with a planned vaginal birth after cesarean"

What does this mean for women who want a VBAC? Up to 99.91% of you will labour normally.
True rupture is not asymptomatic, and the first signs are a steadily falling heart rate (now heavily debated over whether or not this is a true indicator) and/or intense pain that you'll feel even with an epidural. While external fetal monitors, in theory, are meant to catch this kind of thing as it happens - they often do not. External fetal monitoring has not been shown to save any lives, and has only been shown to increase the amount of unnecessary c-sections being performed. It is just as effective, and safer overall, to have a nurse or midwife come in every so often and have a listen with the doppler or fetoscope - particularly during a contraction. This also keeps you off your back, where you are often strictly told to stay if you are hooked up to EFM. This position increases your chances of complications. Move around! Stay hydrated! Stay strong! Avoid drugs! Labour isn't made so you that you can lie back with your feet up.
Home dopplers and fetoscopes are available to rent or buy. Fetoscopes can be purchased online or at any medical supply store for $30 or under, and home dopplers can be rented for as little as $35-$40 a month. Do keep in mind that dopplers, being ultrasound, carry risks. A fetoscope poses no risk to the baby.

Risk of rupture also depends on the type of incision you received. Except in rare cases, modern c-sections are performed by low transverse incision (a horizontal scar just along your pubic bone, usually hidden by a bikini). The risk is highest with a vertical incision over the middle of the stomach. This requires more healing time as well. reads:

Overall, attempted vaginal birth for women with a single previous low transverse cesarean section is associated with a lower risk of complications for both mother and baby than routine repeat cesarean section. The morbidity associated with successful vaginal birth is about one-fifth that of elective cesarean. Failed trials of labor, with subsequent cesarean section, involve almost twice the morbidity of elective section, but the lower morbidity in the 80% of women who successfully give birth vaginally means that overall women who opt for a planned vaginal birth after cesarean suffer only half the morbidity of women who undergo an elective cesarean section.

What does this mean? A repeat c-section is more dangerous than a VBAC. The problem is we don't hear that very often. Some women are only ever offered a repeat c-section by their doctors. If they are truly only ever done in event of "emergencies", how can one justify the risk of denying a woman a VBAC when it is clearly the safest route for both mother and baby?

A 10-year population-based study of uterine rupture.
Obstet Gynecol 2001 Apr;97(4 Suppl 1):S69
Baskett TF, Kieser KE.
Dalhousie University, Halifax, Nova Scotia, Canada
Objective: To review the incidence, associated factors, and morbidity associated with uterine rupture.Methods: A 10-year (1988-1997) population-based review of 114,933 deliveries in one province.

Results: There were 39 ruptures: 16 complete and 23 dehiscence. Thirty-seven cases had undergone a previous cesarean delivery (34 lower transverse, 2 classical, 1 low vertical). Of the 114,933 deliveries, 11,585 (10%) were to women with a previous cesarean delivery. The incidence of uterine rupture in those undergoing a trial for vaginal delivery (4,516) was complete rupture (3/1000) and dehiscence (5/1000). Induction or augmentation of labor with oxytocics was associated with 50% of complete ruptures and 25% of dehiscence. There were no maternal deaths, but 33% of patients with complete ruptures required blood transfusion. There was one neonatal death attributable to uterine rupture.

Conclusion: Induction and augmentation of labor are confirmed as risk factors for uterine rupture. Fetal heart rate abnormality was the most reliable diagnostic aid. Serious maternal and perinatal morbidity was relatively low. PMID: 11275210

Shamelessly stolen from Norwegian_wood's journal:

Here are some statistics to put the risk of rupture in perspective:

* Your risk of rupture from a horizontal LSCS scar is: 1% = 1 in 100 VBAC deliveries (this is the highest statistic)
* Your risk of being diagnosed with dystocia (baby too big) is: 10 - 12% = 10 in 100 vaginal deliveries
* Your risk of a breech baby at full term is: 3 - 7% = 3 in 100 deliveries
* The risk of your baby being diagnosed with fetal distress during labour: 2% = 2 in 100 deliveries
* Your risk of having twins is : 0.4% = 4 in 1000 births
* Your risk of dying from a rupture of the uterus is: 0.0095% = 9.5 in 100 000 VBAC deliveries
* Your risk of dying during any vaginal delivery is: 0.0098% = 9.8 in 100 000 vaginal deliveries

( re-read that one, "Your risk of dying in ANY vaginal delivery is 9.8 in 100,000, compared to a death risk of 9.5 in 100,000 with a VBAC" )

* Your risk of dying during an uncomplicated vaginal delivery is: 0.0049% = 4.9 in 100 000 uncomplicated vaginal delivery.
* Your risk of dying during any ceasarean section is: 0.0409% = 40.0 in 100 000 ceasarean sections
* Your risk of dying during an elective repeat ceasarean section: 0.0184% = 18.4 in 100 000 elective csecs
* The risk of your baby developing cerebal palsy is: 0.25% = 2.5 in 1000 births
* The risk of your baby developing cerebal palsy after fetal distress: 2.84% = 2.8 in 100 fetal distress births
* The risk of your baby dying from a rupture of the uterus is: 0.095% = 9.5 in 10 000 VBAC deliveries
* The risk of your baby dying during any VBAC delivery is : 0.2% = 2 in 1000 VBAC births
* The risk of your baby dying during any type of delivery is: 0.12% = 1.2 in 1000 births

Articles & Links:
Vaginal Birth after 2 or More Cesareans An excellent and informative research-based read analyzing studies, pitocin use and risks of true ruptures versus that of dehiscences. Addresses risks in both VBA1C and VBA2+C.
Twin VBAC not associated with increased risk of rupture
VBAC safe for women with twin pregnancies
Mothering: Fighting VBAC-lash
The Integrity of Caesarean Scars - Originally posted as a reply in a forum, is now an article with a thought-provoking look at the idea that the uterus doesn't heal the same way the rest of the human body does.
Mothering: Cesarean and VBAC index
Birthlove: VBAC is safe!
ICAN: International Cesarean Awareness Network

For those of you convinced that a doctor would only ever have your best interests in mind, I suggest you read articles like this one published in October 2000 entitled, "Getting a Stubborn Patient to Say Yes". This article has since been reposted in many VBAC communities to make women aware of the manipulation tactics that may be used against them.

Don't take your doctor's word for it when he says, "You can't have a VBAC" or, "A VBAC is dangerous". Don't take anyone else's word for it when they say "no one in this town will let you have one". Interview, ask, push and shove - you have the right to the safest birth for your baby. Many midwives will oversee a home, center or hospital VBAC and you can switch to a midwife at any point during your pregnancy, even when your due date is approaching.
Remember, home is safest as far as your risk for dangerous interventions. There's no chance of pitocin induction, epidurals or being kept on your back when you're pacing your own bedroom. Homebirth has been proven to be as safe if not much safer than hospital birth.

Read, educate and inform yourself of the facts so you can be prepared the next time someone tries to scare you out of the best birth for your baby with myths and wives tales. Knowledge is power.

Tuesday, March 10, 2009

2007 Cesarean Rates for MS

34.9 % Cesarean Rate in MS, slight decrease from 2006 data. US rates will be posted when released from CDC

Sunday, March 8, 2009

Homebirth in Mississippi

The good news is that homebirth midwifery is legal in Mississippi and there were 108 homebirths in MS that were reported in 2007. Contact me at if you would like info on homebirth and midwifes in MS.

Tuesday, February 24, 2009

How to Avoid an Unnecessary Cesarean - 1/2 of the cesareans in the US are unnecessary

The Public Citizen Health Research Group in Washington, D.C. has estimated that half of the nearly 1 million cesareans performed every year are medically unnecessary. With more appropriate care during pregnancy, labor, and delivery, half of the cesareans could have been avoided. Clearly, there are times when cesareans are necessary. However, cesareans increase the risk to both mothers and babies. These are suggestions of things you can do to avoid an unnecessary cesarean and can help insure that your birth experience is as healthy and positive as possible.


* Read and educate yourself, attend classes and workshops inside and outside the hospital.

* Research and prepare a birth plan. Discuss your birth plan with your midwife or doctor and submit copies to your hospital or birth center.

* Interview more than one care provider. Ask key questions and see how your probing influences their attitude. Are they defensive or are they pleased by your interest?

* Ask your care provider if there is a set time limit for labor and second stage pushing. See what s/he feels can interfere with the normal process of labor.

* Tour more than one birth facility. Note their differences and ask about their cesarean rate, VBAC protocol, etc.

* Become aware of your rights as a pregnant woman.

* Find a labor support person. Interview more than one. A recent medical journal article showed that labor support can significantly reduce the risk of cesarean.

* Help ensure a healthy baby and mother by eating a well-balanced diet.

* If your baby is breech, ask your care provider about exercises to turn the baby, external version (turning the baby with hands), and vaginal breech delivery. You may want to seek a second opinion.

* If you had a cesarean, seriously consider VBAC. According to the American College of Obstetricians & Gynecologist, VBAC is safer in most cases than a scheduled repeat cesarean and up to 80% of woman with prior cesareans can go on to birth their subsequent babies vaginally.


* Stay at home as long as possible. Walk and change positions frequently. Labor in the position most comfortable for you.

* Continue to eat and drink lightly, especially during early labor, to provide energy.

* Avoid pitocin augmentation for a slow labor. As an alternative, you may want to try nipple stimulation.

* If your bag of water breaks, don’t let anyone do a vaginal examination unless medically indicated for a specific reason. The risk of infection increases with each examination. Discuss with your care provider how to monitor for signs of infection.

* Request intermittent electronic fetal monitoring or the use of a fetoscope. Medical research has shown that continuous electronic fetal monitoring can increase the risk of cesarean without related improvement in outcome for the baby.

* Avoid using an epidural. Medical research has shown that epidurals can slow down labor and cause complications for the mother and baby. If you do have an epidural and have trouble pushing, ask to take a break from pushing until the epidural has worn off some and then resume pushing.

* Do not arrive at the hospital too early. If you are still in the early stages of labor when you get to the hospital, instead of being admitted, walk around the hospital or go home and rest.

* Find out the risks and benefits of routine and emergency procedures before you are faced with them. When faced with any procedure, find out why it is being used in your case, what are the short and long term effects on you and your baby, and what are your other options.

* Remember, nothing is absolute. If you have doubts, trust your instincts. Do not be afraid to assert yourself. Accept responsibility for your requests and decisions.

Cesarean Rates by State - MS is 35.4% - 1 in 3 children enter the world by abdominal surgery

2006 Cesarean Rates by state

United States 31.1

1 NewJersey 37.4
2 Florida 36.1
3 Louisiana 35.4
4 Mississippi 35.4
5 West Virginia 35.2
6 Kentucky 34.5
7 Connecticut 34.1
8 Alabama 33.4
9 Oklahoma 33.3
10 Arkansas 33.2
11 Massachusetts 33.2
12 Texas 33.2
13 South Carolina 32.9
14 New York 32.6
15 Tennessee 32.4
16 Virginia 32.4
17 Nevada 32.3
18 Maryland 32.2
19 California 31.3
20 Georgia 31.3
21 Rhode Island 31.1
22 Delaware 30.7
23 DC 30.6
24 Missouri 30.2
25 Maine 29.9
26 New Hampshire 29.9
27 North Carolina 29.9
28 Michigan 29.8
29 Pennsylvania 29.7
30 Illinois 29.6
31 Kansas 29.3
32 Ohio 29.3
33 Indiana 29
34 Nebraska 28.8
35 Washington 28.4
36 Oregon 28.2
37 Montana 28
38 North Dakota 27.8
39 Iowa 27.7
40 South Dakota 27
41 Wyoming 26.3
42 Vermont 26
43 Arizona 25.6
44 Hawaii 25.6
45 Minnesota 25.4
46 Colorado 25.3
47 Wisconsin 24.6
48 New Mexico 23.3
49 Alaska 23
50 Idaho 22.8
51 Utah 21.5

The Farm Free standing Birthing Center TN - 1.8%

Friday, February 20, 2009

Access to VBAC is Shrinking

Access to VBAC is Shrinking
Feb 19 2009

New Survey Shows Shrinking Options for Women with Prior Cesarean

Bans on Vaginal Birth Force Women into Unnecessary Surgery

For Immediate Release

Redondo Beach, CA, February 20, 2009 – The International Cesarean Awareness Network (ICAN) has released the results of a new survey showing an alarming increase in the number of hospitals banning vaginal birth after cesarean (VBAC). The survey shows an 174% increase from November 2004, when ICAN conducted the first count of hospitals forbidding women from having a VBAC. In 2004, banning hospitals numbered 300. The latest survey, conducted in January 2009, counted 821 hospitals formally banning VBAC and 612 with “de facto” ban.[1] Full results of the research can be seen

The bans essentially coerce women into surgery they do not need. In response to bans, women are either submitting to unnecessary surgery or are traveling long distances to hospitals that do support VBAC. Some women are feeling forced out of hospital care altogether and are having their babies at home in order to avoid coerced surgery.

“There is an alarming disconnect between what medical research says about the safety of VBAC, and the way that hospitals and their doctors are practicing medicine” said Pam Udy, president of ICAN, an all-volunteer patient advocacy organization. “These bans are about business, not about the health and well-being of mothers and babies.”

Research has consistently shown that VBAC is a reasonably safe choice for women with a prior cesarean. According to an analysis of medical research conducted by Childbirth Connection, a well-respected, independent maternity focused non-profit, in the absence of a clear medical need, VBAC is safer for mothers in the current pregnancy, and far safer for mothers and babies in future pregnancies.[2] While VBAC does carry risks associated with the possibility of uterine rupture, cesarean surgery carries life-threatening risks as well. “The choice between VBAC and elective repeat cesareans isn’t between risk versus no risk. It’s a choice between which set of risks you want to take on,” said Udy.

Studies from the National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network, one most recently published in the February 2008 issue of the Journal of Obstetrics and Gynecology, demonstrate that repeated cesareans can actually put mothers and babies at greater clinical risk than repeated VBACs.[3]

Hospitals cite strict guidelines set by the American College of Obstetrics and Gynecology as the driver behind the bans. The ACOG guidelines stipulate that a full surgical team be “immediately available” during a VBAC labor, though the stipulation is a “Level C” recommendation, which means it is based on the organization’s opinion rather than medical evidence.

“If a hospital can’t handle a VBAC emergency, they can’t handle any emergency. VBAC-banning hospitals are claiming to be a safe place of birth for non-cesarean moms, but those mothers are just as likely to have an emergency as a mother with a prior cesarean” says Udy. Placental abruption, cord prolapse, fetal distress are all common emergencies that any mother can experience and require immediate attention.

For physicians, repeat cesareans are often considered more convenient, more lucrative and better insulation from lawsuits. VBACs are inconvenient and costly because they require the physician to be on-site and be available to care for the mother. “ACOG created clinical guidelines that are, in effect, good for business,” said Gretchen Humphries, ICAN’s Advocacy Director, who spearheaded the research. “If physicians think VBAC patients need more attention, then they can simply provide that attention by being in the hospital. But it’s easier to just push women into unnecessary surgery.”

“These bans mean that any mother with a prior cesarean is going to have to be aggressive about seeking out balanced information about the pros and cons of a VBAC versus an elective repeat cesarean, and unfortunately, be prepared for an uphill climb if she chooses to have a VBAC,” said Humphries. For more information about the rights of mothers facing VBAC bans, please visit .

For more information about the clinical risks of VBAC and elective repeat cesarean, please visit:

About the survey: This survey was powered by an all-volunteer team of callers who called, state by state, hospitals across the country. Survey volunteers used publicly available listings of hospitals and made every effort to call every hospital in each state. Surveyors contacted each hospital’s Labor and Delivery (L&D) ward and questioned L&D nurses about the hospital’s practices. Survey questions were designed to elicit information about formal bans, de facto bans, the reasoning behind the bans, and the level of coercion mothers might face if couldn’t find an alternate hospital option. Information from calls were recorded into a central database. A total of 2,850 hospitals were called. Individual records are available for viewing at

About Cesareans: ICAN recognizes that when a cesarean is medically necessary, it can be a lifesaving technique for both mother and baby, and worth the risks involved. Potential risks to babies include: low birth weight, prematurity, respiratory problems, and lacerations. Potential risks to women include: hemorrhage, infection, hysterectomy, surgical mistakes, re-hospitalization, dangerous placental abnormalities in future pregnancies, unexplained stillbirth in future pregnancies and increased percentage of maternal death.

Mission statement: ICAN is a nonprofit organization whose mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery and promoting vaginal birth after cesarean. There are 94 ICAN Chapters across North America, which hold educational and support meetings for people interested in cesarean prevention and recovery.

For Interviews: Contact ICAN President Pam Udy at (801) 458-2190 or ICAN Advocacy Director Gretchen Humphries at (517) 745-7297.

[1] A “de facto” ban means that surveyors were unable to identify any doctors practicing at the hospital who would provide VBAC support.

[2] Best Evidence: VBAC or Repeat C-Section, Childbirth Connection

[3] Mercer et al, Labor Outcome With Repeated Trials of Labor Am J Obstet Gynecol 2008;VOL. 111, NO. 2, PART 1

Silver et al, Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries, Am J Obstet Gynecol 2006; VOL. 107, NO. 6

Thursday, February 19, 2009

The Trouble With Repeat Cesareans from Time Magazine

Time Article 2/19/09 - The Trouble with Repeat Cesareans

The Trouble With Repeat Cesareans

For many pregnant women in America, it is easier today to walk into a hospital and request major abdominal surgery than it is to give birth as nature intended. Jessica Barton knows this all too well. At 33, the curriculum developer in Santa Barbara, Calif., is expecting her second child in June. But since her first child ended up being delivered by cesarean section, she can't find an obstetrician in her county who will let her even try to push this go-round. And she could locate only one doctor in nearby Ventura County who allows the option of vaginal birth after cesarean (VBAC). But what if he's not on call the day she goes into labor? That's why, in order to give birth the old-fashioned way, Barton is planning to go to UCLA Medical Center in Los Angeles. "One of my biggest worries is the 100-mile drive to the hospital," she says. "It can take from 2 to 3 1/2 hours. I know it will be uncomfortable, and I worry about waiting too long and giving birth in the car."

Much ado has been made recently of women who choose to have cesareans, but little attention has been paid to the vast number of moms who are forced to have them. More than 9 out of 10 births following a C-section are now surgical deliveries, proving that "once a cesarean, always a cesarean"--an axiom thought to be outmoded in the 1990s--is alive and kicking. Indeed, the International Cesarean Awareness Network (ICAN), a grass-roots group, recently called 2,850 hospitals that have labor and delivery wards and found that 28% of them don't allow VBACs, up from 10% in its previous survey, in 2004. ICAN's latest findings note that another 21% of hospitals have what it calls "de facto bans," i.e., the hospitals have no official policies against VBAC, but no obstetricians will perform them.

Why the VBAC-lash? Not so long ago, doctors were actually encouraging women to have VBACs, which cost less than cesareans and allow mothers to heal more quickly. The risk of uterine rupture during VBAC is real--and can be fatal to both mom and baby--but rupture occurs in just 0.7% of cases. That's not an insignificant statistic, but the number of catastrophic cases is low; only 1 in 2,000 babies die or suffer brain damage as a result of oxygen deprivation.

After 1980, when the National Institutes of Health (NIH) held a conference on skyrocketing cesarean rates, more women began having VBACs. By 1996, they accounted for 28% of births among C-section veterans, and in 2000, the Federal Government issued its Healthy People 2010 report proposing a target VBAC rate of 37%. Yet as of 2006, only about 8% of births were VBACs, and the numbers continue to fall--even though 73% of women who go this route successfully deliver without needing an emergency cesarean.

So what happened? In 1999, after several high-profile cases in which women undergoing VBAC ruptured their uterus, the American College of Obstetricians and Gynecologists (ACOG) changed its guidelines from stipulating that surgeons and anesthesiologists should be "readily available" during a VBAC to "immediately available." "Our goal wasn't to narrow the scope of patients who would be eligible, but to make it safe," says Dr. Carolyn Zelop, co-author of ACOG's most recent VBAC guidelines.

But many interpreted the revision to mean that surgical staff must be present the entire time a VBAC patient is in labor. While major medical centers and hospitals with residents are staffed to provide this level of round-the-clock care, smaller hospitals typically rely on anesthesiologists on call. Among obstetricians, many solo practitioners are unable to stay for what could end up being a 24-hour delivery; others calculate the loss of unseen patients during that time and instead opt to do hour-long cesareans, which are now the most commonly performed surgeries on women in the U.S.

Some doctors, however, argue that any facility ill equipped for VBACs shouldn't do labor and delivery at all. "How can a hospital say it can handle an emergency C-section due to fetal distress yet not be able to do a VBAC?" asks Dr. Mark Landon, a maternal-fetal-medicine specialist at the Ohio State University Medical Center and lead investigator of the NIH's largest prospective VBAC study. (See 9 kid foods to avoid.)

Part of the answer has to do with malpractice insurance. Following a few major lawsuits stemming from VBAC cases, many insurers started jacking up the price of malpractice coverage for ob-gyns who perform such births. In a 2006 ACOG survey of 10,659 ob-gyns nationwide, 26% said they had given up on VBACs because insurance was unaffordable or unavailable; 33% said they had dropped VBACs out of fear of litigation. "It's a numbers thing," says Dr. Shelley Binkley, an ob-gyn in private practice in Colorado Springs who stopped offering VBACs in 2003. "You don't get sued for doing a C-section. You get sued for not doing a C-section."

Of course, the alternative to a VBAC isn't risk-free either. With each repeat cesarean, a mother's risk of heavy bleeding, infection and infertility, among other complications, goes up. Perhaps most alarming, repeat C-sections increase a woman's chances of developing life-threatening placental abnormalities that can cause hemorrhaging during childbirth. The rate of placenta accreta--in which the placenta attaches abnormally to the uterine wall--has increased thirtyfold in the past 30 years. "The problem is only beginning to mushroom," says ACOG's Zelop.

"The decline in VBACs is driven both by patient preference and by provider preference," says Dr. Hyagriv Simhan, medical director of the maternal-fetal-medicine department of Magee-Womens Hospital of the University of Pittsburgh Medical Center. But while many obstetricians say fewer patients are requesting VBACs, others counter that the medical profession has been too discouraging of them. Dr. Stuart Fischbein, an ob-gyn whose Camarillo, Calif., hospital won't allow the procedure, is concerned that women are getting "skewed" information about the risks of a VBAC "that leads them down the path that the doctor or hospital wants them to follow, as opposed to medical information that helps them make the best decision." According to a nationwide survey by Childbirth Connection, a 91-year-old maternal-care advocacy group based in New York City, 57% of C-section veterans who gave birth in 2005 were interested in a VBAC but were denied the option of having one.

Zelop is among those who worry that "the pendulum has swung too far the other way," but, she says, "I don't know whether we can get back to a higher number of VBACs, because doctors are afraid and hospitals are afraid." So how to reverse the trend? For one thing, patients and doctors need to be as aware of the risks of multiple cesareans as they are of those of VBACs. That is certain to be on the agenda when the NIH holds its first conference on VBACs next year. But Zelop fears that the obstetrical C-change may come too late: "When the problems with multiple C-sections start to mount, we're going to look back and say, 'Oh, does anyone still know how to do VBAC?'"

Sunday, February 15, 2009

The ‘‘Authorities’’ Resolve Against Home Birth Nancy K.

This editorial has been gathering momentum in
my mind since I heard about a resolution introduced
by the American College of Obstetricians
and Gynecologists (ACOG) to the House of Delegates
of the American Medical Association’s (AMA)
annual meeting in June 2008. American College of
Obstetricians and Gynecologists’s resolution #205
was adopted by the AMA and is titled ‘‘Home
Deliveries.’’ So that I cannot be accused of misquoting
the AMA or ACOG, you will find the text
of the adopted resolution at the end of this editorial.
In his ‘‘College News’’ column of ACOGToday (September
2008), ACOG Executive Vice President
Ralph W. Hale reported on his attendance at the
AMA Annual Meeting and wrote, ‘‘Also, there
was model legislation related to home deliveries
supporting the ACOG position against home
births.’’ The point of this resolution is to lobby
against home birth as an option for women and
against providers of home birth services. This type
of resolution by ‘‘authoritative’’ bodies such as
ACOG and AMA will certainly in£uence decisions
made by third-party payers when women request
home birth services and by liability insurance carriers
when providers seek coverage for home birth

Rumor has it, as stated in the Los Angeles Times
on July 9, 2008, that in the original ACOG
resolution, there was another ‘‘whereas’’ that was
deleted before adoption. It read, ‘‘Whereas, there
has been much attention in the media by celebrities
having home deliveries, with recent ‘Today
Show’ headings such as ‘Ricki Lake takes on baby
birthing industry.’’’ You may not be aware that in
2007 producer Ricki Lake and director Abby Epstein
released a documentary film The Business of Being
Born. The film asked the question ‘‘Should most
births be viewed as a natural life process, or should
every delivery be treated as a potentially catastrophic
medical emergency?’’ If you have not seen
this film, I encourage you to do so and to view it with
an openmind, an open intellect, and an open heart.
The DVD can be purchased for a modest price at
Evidently, ACOG felt it necessary to highlight
Ms. Lake’s coverage of this issue as a potential
threat to the safety of mothers and babies. It is
beyond the scope of an editorial to review the international
and national data about maternal
and infant outcomes and the relationship of these
outcomes to location of birth. However, one instructive
example is a prospective cohort study
of maternal and infant outcomes in British Columbia
during the first 2 years after women were
given the choice to plan a home birth with regulated
midwives (Janssen et al., 2002). After controlling
for appropriate confounding variables, the data
showed no increased maternal or neonatal risk
for the 862 planned home births compared
with 1,314 planned hospital births.The overall transfer
rate to hospital care was 21.7% in the home
birth group with 16.5% transferred during labor.
The multivariate analysis showed that the
women who planned to have home births were
significantly less likely to undergo induced or
augmented labor, epidural analgesia, episiotomy,
or cesarean delivery.

I was born in the United States and I am very proud
to be an American, but I am embarrassed that our
country founded on the ideals of individual liberty
and freedom, can also support ‘‘authoritative’’ initiatives
such as these by the ACOG and AMA,
initiatives that are founded on neither science nor
an understanding of the physiologic and psychosocial
needs of mothers and babies. What is most
risky about home birth in the United States is that
for most women who desire it there is a scarcity of
qualified providers of home birth services. There is
no system of care that provides the needed
safety net if transfer to a different type of care is required
during labor. Rather, women who desire to
birth at home sometimes chose providers unwisely,
and those who require transfer are often treated
with disdain and disregard as though their decision
to give birth outside the hospital system is irresponsible,
reckless, and perhaps immoral. There is
nothing more inhumane or uninformed than this attitude
toward women who desire to birth at home
and the qualified providers who are willing to attend

When will we remember that pregnancy, childbirth,
and lactation are normal healthy physiological processes
that are a continuum and do not require
medical intervention unless there is a medical problem?
A woman’s body and the physiology of
pregnancy, labor, birth, and lactation are designed
to promote the well-being of the fetus and newborn.
When will we establish optimal outcomes as the
goal of health care during the childbearing cycle,
rather than attempting to reduce by small increments
the incidence of morbidity and mortality that
is compounded by the very interventions we use to
attempt to avoid such problems? We all know that
in our current health care milieu for childbearing
women, the protection of normal is not valued or
supported, except in a very few locales. Those who
support normalcy are usually swimming upstream
against a system that treats every laboring woman
as a surgical case. The idea that a normal spontaneous
birth is by design the best outcome for a
healthy woman and her infant is neither believed
nor entertained as a basic concept. Most U.S.-
trained physicians and sadly most U.S.-trained
nurses have minimal experience with normal labor
and birth. Without fetal monitors, intravenous lines,
infusion pumps, epidurals, pitocin, endless charting,
and rules theses individuals are helpless and
unskilled to provide the kind of informed human
support and wise guidance that a laboring woman
needs while the normal process of labor and birth

In fact, knowledgeable women often must fight to
defend the normalcy of the process and their desire
to labor and birth spontaneously without medical
technology or intervention.
In many ways it is reminiscent
of the 1960s when many of us who were
young women at the time fought for our right to natural
childbirth without general anesthesia and to
have our husbands accompany us into the delivery
room. Breastfeeding was not the norm and was not
supported by hospital care. During my 5-day postpartum
stay after a vaginal delivery in 1969, I had to
repeatedly insist that my newborn son be brought
to me during the night for breastfeeding because
as I was told by the nurses, ‘‘Dr. X’s patients are to
sleep at night.’’ How audacious authority can be.
Amazingly, a few years later a headline in the science
section of the Chicago Tribune declared,
‘‘Science finds Breast is Best.’’ Since that time the
accumulation of scientific evidence has overwhelmingly
validated that physiologically obvious
statement, and the system, including its ‘‘authorities,’’
¢nally caught up to actively support
breastfeeding.Will it take a similar declaration: ‘‘Science
finds spontaneous labor and normal vaginal
birth is best’’ to change the course that we are currently
on and to change the rhetoric of the

Why do 1% to 2% of U.S. women even want
to birth at home? For most it is simply because
they sincerely believe that the process is normal
and healthy and does not require the environment
of an ‘‘illness’’ system to support it. For these
women, birth has a unique, earthy, and frequently
spiritual component that they want to experience
fully under their own terms. They want to
actively labor and birth, rather than to have labor
happen to them, give over control to a system
and people with their own rules, and be delivered
of their babies. Some desire home birth because of
the subculture of their religious communities,
while others are overtly afraid of what may happen
to them in the hospital. They may be ‘‘on the
edge’’ of the allopathic medical system and be very
resistant to interventions that the system thinks
are in their best interest. Does this make them
wrong? No, it simply means that the system is not
meeting their needs for holistic care that supports

The point is that we have no system of maternity
care in the United States that provides a healthy woman
the choice of giving birth at home and if she
needs to transfer to a different type of care during
labor, the transfer is easy. We do not have a system
in which this woman is treated with respect
and kindness, and her provider either maintains responsibility
for her care or professionally and
respectfully is able to transfer responsibility to another
Interestingly, while ACOG and AMA
have declared that hospital grounds are the only
safe place to give birth in the United States, the
National Perinatal Association (NPA) adopted a
position paper in July 2008 titled, ‘‘Choice of Birth
Setting.’’ The paper supports a woman’s right to
home birth services and concludes that, ‘‘The National
Perinatal Association (NPA) believes that
planned home birth should be attended by a quali-
¢ed practitioner within a system that provides a
smooth and rapid transition to hospital if necessary.
Safety for all births must be evaluated through an
objective risk assessment, especially for non-hospital
births. NPA supports and respects families’
right to an informed choice of their birth setting’’
(available at Further,
in Canada following the model of British Columbia,
the province of Alberta has recently expanded its
health care system to include women’s access to
midwifery services ‘‘in a variety of locations including
hospitals, community birthing centers, or in their
homes’’ (

Some of you who are reading this know me personally,
most do not. I am a nurse-midwife committed
to the midwifery philosophy of care, however, I have
never attended a home birth. I gave birth to my
own children in hospital, and my daughter is a
board certified obstetrician-gynecologist. I am part
of the U.S. system.Yet the very core of my being, my
scientifically trained brain, and four decades experience
in the business of mothers and babies tell me
it is our system that is not serving mothers and babies
well. There is not some inherent danger lurking
for healthy American women who desire to give
birth at home. The primary danger is that the ‘‘system’’
does not support this choice. To pretend that
a normal healthy woman cannot give birth safely
without the trappings of a U.S. hospital is not only
audacious but also uninformed. Perhaps it is time
for a new woman’s movement, one that embraces
the normalcy of childbirth and puts mothers and
babies back on the center stage rather than the
system’s need to defend the interventionist subculture
it has developed and that it must financially
support. This system has not improved outcomes
for mothers or babies while the cost of care has
continued to escalate keeping pace with unnecessary
intervention. The recent initiatives of our
medical colleagues, the ‘‘authorities,’’ simply highlight
the painful reality that the ‘‘Emperor has no

American Medical Association (AMA). (2008). Resolutions. Retrieved
November 1, 2008, from

Block, J. (2008, July 9). Big medicine’s blowback on home births. Los
Angeles Times. Retrieved October 29, 2008, from

Hale, R. A. (2008, September). ACOG’s positions advocated at AMA meeting.
ACOG Today, p. 2.
Janssen, P. A., Lee, S. K., Ryan, E. M., Etches, D. J., Farqukarson, D. F., Peacock,
D., et al. (2002). Outcomes of planned home births versus
planned hospital birth after regulation of midwifery in British Columbia.
Canadian Medical Association Journal, 166, 315-323.
National Perinatal Association (NPA). (2008). Position paper: Choice of
birth setting. Retrieved October 16, 2008, from http://nationalperi

Saturday, February 14, 2009

Juice Plus Vitamins- Reducing Preeclampsia and Cesarean Section

A retrospective chart review was performed on 356 pregnancies at delivery at the University of Mississippi, USA. Half of the expectant mothers had chosen to add Juice Plus+® to their prenatal diet, including prenatal vitamins. A comparison was made of recorded obstetric complications made by medical staff at the time of delivery. The women who added Juice Plus+® had fewer documented complications, including fewer cesarean deliveries, no delivery before 37 weeks gestation and no diagnosis of preeclampsia. These findings suggest addition of Juice Plus+® to standard prenatal care may be beneficial. A prospective randomized, double blind, placebo controlled investigation is currently underway to confirm these observations. (Odom et al. "Phytonutrients May Decrease Obstetric Complications: A Retrospective Study." Journal of the American Nutraceutical Association, Vol. 9, No. 1, 2006).

Saturday, January 10, 2009

C-Section Too Early Risks Baby's Health
Babies Born by Surgical Delivery Before 39 Weeks May Suffer Health Problems

When 37-year-old Alicia Cooney of Cleveland was pregnant with her first child in October 2007, her doctor expressed no concern about scheduling her Caesarian delivery, or C-section, just 38 weeks into the pregnancy.

But when Cooney became pregnant with her second child last April, her doctor was singing a different tune about when to schedule a C-section.

"I did notice a change within the hospital that they really wanted to make sure my C-section wasn't before 39 weeks," Cooney explained.

Cooney said that her doctor expressed concern about the increased risk of wet lung -- or an accumulation of fluid in the newborn's lungs -- in babies delivered by C-section before 39 weeks of gestation.

Cooney's doctor may not be alone in changing his practice in the face of these risks. On Wednesday, a new study published in the New England Journal of Medicine found that C-section delivery before 39 weeks of gestation is, indeed, linked to increased health problems for babies.

According to the National Institutes of Health, a pregnancy of normal gestation lasts about 40 weeks, with "normal" pregnancies ranging from 38 to 42 weeks.

A team of researchers lead by Dr. Alan Tita from the department of obstetrics and gynecology at the University of Alabama at Birmingham examined the results of 13,258 women who had a scheduled, repeat C-section that was planned for no other medical reason than the fact that the woman had previously had a C-section.

The researchers found that, compared to babies delivered by C-section at 39 weeks of gestation, those born at 37 or 38 weeks had a higher rate of breathing problems, blood sugar problems and serious infections. Moreover, those babies were more likely to be admitted to the neonatal intensive care unit.

"Early elected delivery is associated with adverse outcomes for the baby," Tita explained. "And the earlier you deliver, the higher it increases the risk."

These findings are in line with current recommendations by the American College of Obstetricians and Gynecologists (ACOG).

Yet despite the long list of potential complications associated with C-section delivery before 39 weeks, the study also found that a large number of the women studied -- 36 percent -- chose to schedule a C-section delivery before 39 weeks anyway.

"I have seen women induced or have a scheduled C-section because they have family scheduled to be in town, because they want the baby to be born on an anniversary or someone else's birthday, because they want the baby born prior to Jan. 1 for tax purposes, or because they are simply sick and tired of being pregnant," said Dr. Elaine St. John, associate professor of pediatrics in the Division of Neonatology at the University of Alabama at Birmingham.

Other experts say that the increase in C-sections before 39 weeks is due to a lack of understanding of the dangers associated with elective late pre-term birth.
"Most women think the risks to their babies are the same whether the babies are delivered four, three, two or one week before the baby is due," explained Dr. Sessions Cole, director of the Division of Newborn Medicine at the St. Louis Children's Hospital. "This study should help mothers understand that there are significant risks to their babies associated with elective late preterm
Patient Pressure Figures Big

Approximately 30 percent of all babies born in the United States are delivered by C-section. A study published in April 2005 in the journal Obstetrics and Gynecology found that elective C-sections accounted for about 28 percent of all C-sections performed in the U.S. in 2001.

However, many experts report a growing trend toward encouraging women not to schedule an elective C-section before 39 weeks at hospitals all over the country.

"The recommendations for years have been to avoid elective delivery of any kind until after 39 weeks," said Dr. Lisa Jones, a gynecologist at the New Bedford Community Health Center in New Bedford, Mass. "So all this study really does is reinforce what we already knew."

Still, some experts say that the power of maternal insistence in scheduling an early C-section is enough to convince many doctors to go along with their patient's wishes.

"I think the practice of early [C-section delivery] will only end if hospitals ban the practice," Holzman said. "There is little reason for [obstetricians] to stop since they are often pressured by patients."

The study also outlines some of the risks women must consider when opting to deliver by C-section after 39 weeks.

According to Tita, one such risk is having an unexplained stillbirth while waiting for the 39-week-mark to deliver. This risk is very small, but Tita said that it is still best for women to follow ACOG recommendations by waiting the full 39 weeks before delivering by C-section.
Early Surgical Delivery Sometimes Appropriate

There are, however, certain instances in which an early delivery is appropriate.

"If there [are] firm medical indications of risk to the mother's or fetus's ... health [such as] worsening maternal high blood pressure [or] lack of fetal responsiveness ... then delivery is indicated," Cole explained. "However, the risks of these conditions should be weighed against the risks described by this study."

Moreover, Holzman said, "For most of these [conditions], the risks to the fetus in delaying [delivery] are well known and predictable."

Many experts ultimately hope that this study will prove to the public that the risks of early C-section delivery greatly outweigh the benefits in most cases.

"Hopefully articles like this will help educate the general public and fewer babies will be placed at risk in the future," said Dr. Patricia Chess, associate professor of pediatrics at the University of Rochester Medical Center.

Wednesday, January 7, 2009

Early Maternity leave linked fewer C-sections and increased breastfeeding

Studies link maternity leave with fewer C-sections and increased breastfeeding

Berkeley -- Two new studies led by researchers at the University of California, Berkeley, suggest that taking maternity leave before and after the birth of a baby is a good investment in terms of health benefits for both mothers and newborns.

One study found that women who started their leave in the last month of pregnancy were less likely to have cesarean deliveries, while another found that new mothers were more likely to establish breastfeeding the longer they delayed their return to work.

Both papers were part of the Juggling Work and Life During Pregnancy study, funded by the Maternal and Child Health Bureau of the U.S. Health Resources and Services Administration and led by Sylvia Guendelman, professor of maternal and child health at UC Berkeley's School of Public Health. The research takes a rare look into whether taking maternity leave can affect health outcomes in the United States.

"In the public health field, we'd like to decrease the rate of C-sections (cesarean deliveries) and increase the rate of breastfeeding," said Guendelman. "C-sections are really a costly procedure, leading to extended hospital stays and increased risks of complications from surgery, as well as longer recovery times for the mother. For babies, it is known that breastfeeding protects them from infection and may decrease the risk of SIDS (Sudden Infant Death Syndrome), allergies and obesity. What we're trying to say here is that taking maternity leave may make good health sense, as well as good economic sense."

The study on the use of antenatal leave - time off before delivery with the expectation of returning to the employer after giving birth - and the rate of C-sections is the first examination of birth outcomes in U.S. working women, the researchers said. It will appear in the January/February print edition of the journal Women's Health Issues.

The researchers analyzed data from 447 women who worked full-time in the Southern California counties of Imperial, Orange and San Diego, comparing those who took leave after the 35th week of pregnancy with those who worked throughout the pregnancy to delivery. Only women who gave birth to single babies with no congenital abnormalities were included in the analysis. They adjusted for sociodemographic factors such as income, age and type of occupation, as well as for various health measures such as high blood pressure, body mass index, amount of self-reported stress and average number of hours of sleep at night.

Using a combination of post-delivery telephone interviews and prenatal and birth records, the researchers found that women who took leave before they gave birth were almost four times less likely to have a primary C-section as women who worked through to delivery.

The study authors pointed out that the United States falls behind most industrialized countries in its support for job-protected paid maternity leave. The federal Family and Medical Leave Act provides for only unpaid leave of up to 12 weeks surrounding the birth or adoption of a child.

The bulk of studies on leave-taking and health outcomes from other countries suggest that taking leave prior to birth can be beneficial. The authors point to a macroanalysis of 17 countries in Europe that linked failure to take such leave with low birthweight and infant mortality. Rates of pre-term delivery were lower among female factory workers in France if the women took antenatal leave, and a study conducted in several industrialized countries found that paid leave, but not unpaid leave, significantly decreased low birthweight rates.

According to the U.S. Census, among working women who had their first birth between 2001 and 2003, only 28 percent took leave from their jobs before giving birth while an additional 22 percent quit their jobs. Twenty-six percent of women took no leave before birth.

"We don't have a culture in the United States of taking rest before the birth of a child because there is an assumption that the real work comes after the baby is born," said Guendelman. "People forget that mothers need restoration before delivery. In other cultures, including Latino and Asian societies, women are really expected to rest in preparation for this major life event."

The authors added that financial need may also deter women from taking leave in the last month of pregnancy. Only five states - California, Hawaii, New Jersey, New York, Rhode Island - and the territory of Puerto Rico offer some form of paid pregnancy leave, and none offer full replacement of the woman's salary.

The study on maternity leave and breastfeeding is in the January issue of the journal Pediatrics. Using data from 770 full-time working mothers in Southern California, researchers assessed whether maternity leave predicted breastfeeding establishment, defined in this study as breastfeeding for at least 30 days after delivery. Phone interviews were conducted 4.5 months, on average, after delivery.

In this study, women who had returned to work by the time of the interview took on average 10.3 weeks of maternity leave. Overall, 82 percent of mothers established breastfeeding within the first month after their babies were born. Among women who established breastfeeding, 65 percent were still breastfeeding at the time of the interview.

Researchers found that women who took less than six weeks of maternity leave had a four-fold greater risk of failure to establish breastfeeding compared with women who were still on maternity leave at the time of the interview. Women who took six to 12 weeks of maternity leave had a two-fold greater risk of failing to establish breastfeeding.

Having a managerial position or a job with autonomy and a flexible work schedule was linked with longer breastfeeding duration in the study. After 30 days, managers had a 40 percent lower chance of stopping breastfeeding, while those with an inflexible work schedule had a 50 percent higher chance of stopping.

Overall, the study found that returning to work within 12 weeks of delivery had a greater impact on breastfeeding establishment for women in non-managerial positions, with inflexible jobs or who reported high psychosocial distress, including serious arguments with a spouse or partner and unusual money problems.

"The findings suggest that if a woman postpones her return to work, she'll increase her chances of breastfeeding success, especially if she's got a job where she's on the clock and has less discretion with her time," said Guendelman. "Also, women who are in jobs where they have more authority may feel more empowered with how they use their time."

The American Academy of Pediatrics (AAP) recommends that babies be breastfed for at least the first year of life, and exclusively so for the first four to six months.

According to the AAP, increased breastfeeding has the potential for decreasing annual health costs in the U.S. by $3.6 billion and decreasing parental employee absenteeism, the environmental burden for disposal of formula cans and bottles, and energy demands for production and transport of formula.

The study authors noted that just having maternity leave benefits offered by an employer was not helpful in breastfeeding establishment unless the leave was actually used, indicating the importance of encouraging the use of maternity leave and making it economically feasible to take it.

"These new studies suggest that making it feasible for more working mothers to take maternity leave both before and after birth is a smart investment," said Guendelman.


Other co-authors of the paper in Women's Health Issues are Michelle Pearl and Steve Graham, senior research scientists at the Sequoia Foundation, a California-based non-profit organization focused on public health research; Alan Hubbard, UC Berkeley assistant professor of biostatistics; Dr. Nap Hosang, lecturer at UC Berkeley's Maternal and Child Health program and a practicing obstetrician; and Martin Kharrazi, research scientist supervisor in the California Department of Public Health Genetic Disease Screening Program.

In addition to Guendelman, Pearl, Graham and Kharrazi, the Pediatrics paper was co-authored by Jessica Lang Kosa, research associate, and Julia Goodman, former graduate student, both at UC Berkeley's School of Public Health.

The study published in Women's Health Issues received additional funding from the Center for Health Research at UC Berkeley. The paper in Pediatrics also received support from the UC Labor and Employment Research Fund and the UC Berkeley Institute for Research on Labor and Employment.


103 out of 115 delivered VBAC after 2 Cesareans - How awesome if given the chance!

Author: Chattopadhyay-S-K. Sherbeeni-M-M. Anokute-C-C.
Title: Planned vaginal delivery after two previous caesarean sections
[see comments]
Source: Br-J-Obstet-Gynaecol. 1994 Jun. 101(6). P498-500. Comment:
Comment in: Br-J-Obstet-Gynaecol. 1995 Mar.102(3). P 262-3. Journal


OBJECTIVE: To determine the outcome of trial of labour after two
caesarean sections.
DESIGN: Prospective observational study.
SETTING: Maternity and Children's Hospital, Riyadh,Saudi Arabia.
SUBJECTS:Women with two previous caesarean sections considered
suitable for atrial of vaginal delivery.
MAIN OUTCOME MEASURES: The rates of vaginal delivery, scar
dehiscence, uterine rupture and associated complications among 115
women with two previous sections who underwent trial of labour were
compared with 1006 women with two previous sections who did not have
a trial of labour.
RESULTS: Trial of vaginal delivery was requested by 230 out of 1136
women (20%) who had two previous caesarean sections. Of the 115 women
accepted for the trial, 103 (89%)were delivered vaginally
. Labour
started spontaneously in 78 (68%)of the 115 women and was induced
with prostaglandin (PGE2) in the remaining 37. Augmentation of labour
with oxytocin was required in 32(28%) of the trial labour group.
There were no scar dehiscences among the women delivered vaginally.
There was one scar dehiscence and one woman required hysterectomy
after failed trial of labour, a frequency comparable to the
occurrence of these complications in women who did not have a trial
of labour.
CONCLUSION: A trial of labour in selected patients with two previous
caesarean sections appears a reasonable option.