What you need to know to “Just Say No”

What you need to know to “Just Say No” to medically unnecessary cesareans:

Ten important documents to have when planning a VBAC.

1. ACOG’s Statement on Maternal Decision Making, Ethics and the Law can be downloaded here. Now, why is the Committee on Ethics Opinion Statement from the American Congress (formerly College) of Obstetricians and Gynecologists (ACOG) from 2005 important in a world where women are regularly denied informed consent?  It’s more ammunition to fight back against care providers who are behaving UNethically.  While the entire document is worth reading to know where and how the committee came to its opinions, the opening abstract hits on the most important parts:

“ABSTRACT:  Recent legal actions and policies aimed at protecting the fetus as an entity separate from the woman have challenged the rights of pregnant women to make decisions about medical interventions and have criminalized maternal behavior that is believed to be associated with fetal harm or adverse perinatal outcomes.  This opinion summarizes recent, notable legal cases; reviews the underlying, established ethical principles relevant to the highlighted issues; and considers six objections to punitive and coercive legal approaches to maternal decision making.  These approaches 1) fail to recognize that pregnant women are entitled to informed consent and bodily integrity, 2) fail to recognize that medical knowledge and predictions of outcomes in obstetrics have limitations, 3) treat addiction and psychiatric illness as if they were moral failings, 4) threaten to dissuade women from prenatal care, 5) unjustly single out the most vulnerable women, and 6) create the potential for criminalization of otherwise legal maternal behavior.  Efforts to use the legal system to protect the fetus by constraining pregnant women’s decision making or punishing them erode a woman’s basic rights to privacy and bodily integrity and are not justified.” – ACOG Committee Opinion, November 2005.

While ACOG does not expect us to use this document against them, the reality is that in and of itself, ACOG expects its member providers to live within the bounds of these types of opinions.  If a provider follows the “immediately available” standard which is NOT law in any state, then it reasonably follows that you can show them this committee opinion and ask them to hold themselves to the same standard.  VBAC is not a procedure and this document would also apply to any hospital offering obstetric care and refusing to allow a woman to vaginally birth (VBAC) within their hospital.

2. The National Institutes of Health (NIH) Consensus Development Conference Statement and their recommendations regarding VBAC can be downloaded here.  This document is most useful for pointing out the research that backs up VBAC as a safe and reasonable choice for mothers to make and has comparative risks to a primipara (first-time) mother.  There is a problem with these documents being only recommendations, without force of law and/or protocol on obstetricians but it’s still a re-affirmation of the same information that we knew thirty years ago with the force of thirty more years of research to back it up.  If you don’t want to print the abstracts, then you can print only the conclusion.  Watching the actual consensus development process is worthwhile to understand the science that the panel was hearing and to further understand the true underlying causes of cesarean.

3. Federal Emergency Medical Treatment and Labor Act (EMTALA)

A good link to what is entailed in EMTALA is http://emtala.com/law/index.html.

Does EMTALA work to allow VBACs in hospitals that claim to have vbac bans? There is some dispute as to whether or not EMTALA would work in the case of a woman presenting in labor who wants a VBAC.  It’s a valuable document to have considering that a woman who is far enough along in labor does reserve the right to refuse treatment (cesarean) and right to refuse transfer if her birth is imminent but the hospital is still required to provide appropriate care under this law.

There is one section of a current recommendation that exists that may be somewhat helpful despite any debate over EMTALA’s total usefulness for VBAC moms:

“Individuals who present at these locations and request examination or treatment for a medical condition or have such a request made on their behalf must be screened under EMTALA and, if an emergency medical condition is determined to exist, provided necessary stabilizing treatment, because these locations are dedicated emergency departments.”

In the language of a normal mom, this could mean that a woman in labor with imminent delivery is expected to be treated with only stabilizing treatment and therefore, has the right to refuse a cesarean despite the hospital’s objections and without being told she must leave and find another care center.

4. ACOG’s Statement on VBAC (2010) which emphasizes that VBAC or Trial of Labor (TOL) is a reasonable choice for women who have had a cesarean under certain conditions. It should be noted, however, that these are simply guidelines by the obstetrical trade union and do not necessarily apply to other providers and/or their organizations. Many providers find that with informed consent, very FEW restrictions should be placed on VBAC and those reasons would almost all overlap with requirements for cesarean birth overall, such as a complete placenta previa.

5. Your state’s Patient’s Bill of Rights or Pregnant Patient’s Bill of Rights.

While not every state has one, if your state does, this could be a legal statute that binds providers to act ethically despite their personal wishes for care.  In some states, this document reiterates a woman’s right to informed consent and refusal, giving grounds to refuse the procedure of a non-medically indicated cesarean.  Check out our State By State page to see if your state has one listed.

6. A VBACFacts.com calling card or Quick Facts Sheet. These handy little cards describe your risks or non-risks in a quick, easy to produce form.  They are ideal for recalling what the studies break down to and include citations for those studies as well.  Not to mention, if you share…you will be helping other women break the cycle of myths about VBAC.

7. The “Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery” Study (Landon, et al NEJM 2004). If you are a mom who has had multiple cesareans, a copy of Landon’s study is a must.  This landmark study is the best ammunition for mothers of unknown/unusual scar types or multiple cesareans.  The study reaches conclusions about the relative safety or risk of uterine rupture that shows that even after multiple cesareans, VBAC is not an unreasonable choice for mothers.  The wording on this study is actually very medically inclined but for those who want to understand the real risks of cesarean and how it affects every labor thereafter (Uterine rupture is NOT a risk of vaginal birth, it’s a risk of prior cesarean.  VBAC is not to blame, the first cesarean is, which is why prevention is VITAL) should check out this study’s conclusion, excerpted here:

“Among 17,898 trials of labor and 124 ruptures, we found two neonatal deaths, for an overall rate of rupture-related perinatal death of 0.11 per 1000 trials of labor.  A recent review of 880 maternal uterine ruptures during a 20-year period showed 40 perinatal deaths in 91,039 trials of labor, for a rate of 0.4 per 1000.

8. The American Association of Family Physicians’ (AAFP) Statement on VBAC.  This particular document is interesting because it does not agree with the ACOG recommendations for VBAC.  Several family physicians went even further with editorials regarding the controversies here and another, additional document under the AAFP also shows that maternal and infant outcomes do not improve under ACOGs “immediately available” guideline.

9. The Northern New England Perinatal Quality Improvement Network document set.  This includes a sample consent form, VBAC guidelines and a patient education document.  While this document set does not clear all women with prior cesarean for VBAC, the guidelines are just that, they provide a framework for understanding relative risk and factors that may contribute to risk and to help a mother and provider choose appropriate care.  A favorite quote is the last paragraph:

“If our goal were to prevent all cases of fetal injury due to uterine rupture, approximately 7.5 million dollars would be spent for each case of fetal injury from rupture that was prevented.  This is based on a general risk of uterine rupture of 0.5%, a 10% incidence of significant fetal injury when rupture occurs, and the cost of cesarean delivery listed above.  In addition to the economic costs, substantially more children would be require intensive care services due to respiratory complications at birth, some of them severe.  The price of discontinuing VBAC services is thus substantial.”

10. The March of Dimes statement on “Why the Last Weeks of Pregnancy Count” (2009).  This page emphasizes NOT doing cesareans before 39 weeks unless absolutely necessary (in the case of a medically indicated cesarean) due to the increased morbidity (harm) and mortality (death) in these infants.  Another page on the March of Dimes site that is important is “Cesarean Birth By Request”.

I truly wish that any and/or all of these documents could protect women from an OB/GYN or hospital facility violating her rights to bodily integrity by trying to force her into a cesarean.  The only way this will truly be overcome is by women filing complaints, going to newspapers and other media outlets and presenting our cases to our state attorneys offices in the hope they will take up the case or filing private lawsuits.

In the case of Florida, the state attorney and the state insurance commissioner both stated, “We simply don’t get enough formal complaints about these subjects.”  And they don’t.  Many women are either still pregnant and search out other providers or simply cave to the planned cesarean or they are new mothers caring for an infant and a healing wound and possibly, other children at home.

Filing complaints is something BirthAction is trying to make easier on our State By State and Advocacy pages.  There are also templates on the site for approaching insurance companies or other interested parties.  If you are confronted by an unfriendly provider who refuses to allow VBAC or who refuses to acknowledge your right to refuse a cesarean, we suggest you do something about it.  We do not have to remain victims of this system, we can learn and grow and fight back for our births and our babies.  Birth IS Action.  Arm yourself.

Making Decisions: Bring your Brain to Work

Women and childbirth educators often talk about how to make decisions while under the influence of care providers or while standing in their offices. We all know it’s intimidating to sit there, half-naked in a paper sheet. Often, we need a non-confrontational way to think about the choices in front of us. Here’s some helpful standard acronyms for making good choices:

BRAND:

  • B – benefits
  • R – risks
  • A – alternatives
  • N – what happens if we do nothing
  • D – decision/delay/decide later (What if we wait? Respect your intuition! Ask for a few minutes to evaluate.)

BRAIN:

  • B = benefits
  • R = Risks
  • A = Alternatives
  • N = do Nothing (What happens if we decide to do nothing?)
  • D = Decision

Or

  • I = Intuition
  • N = Now What?

Or you can download this pdf from Lucina Birth Services.

Types of Care Providers for VBAC Moms

Choices in Birth Care Providers for VBAC Mothers

A mother who has had a prior cesarean does not always have an easy time finding someone to attend her birth, either in the professional care provider role or even for as something as simple as support.  Many times, mothers find avenues closed to them when they say they want a vaginal birth after cesarean (VBAC).  Since choices are often limited, BirthAction wants to outline what choices a mother does have when giving birth after cesarean and looking for care.

Obstetrician (OB) –

Obviously, the most mainstream and common of choices, some OBs do still attend VBAC births in hospitals around the country.  This usually takes a fair amount of research to find one locally and they may have qualifying protocols which a mother needs to be careful to ask questions about and use her best judgment.  There are also concerns about whether or not an OB truly supports VBAC mothers or is simply giving lip service until the mom gets so far along in her pregnancy.  There are some OBs that give all the rest a fantastic name and not only support VBAC but also do VBAC with twins and breeches or VBAmC (vaginal birth after multiple cesareans) based on a mother’s individual risks, knowledge and care.

Certified Nurse Midwife (CNM) –

Second to the OB in the number of VBACs done, CNMs are also a more common choice, often practicing within an OB practice or birth center.  While CNMs typically have some obvious drawbacks in being more medically-minded or using protocols that are required by law to be approved by OBs, CNMs are still a choice that many women make in trying to compromise between having a less-interventive but still vaginal birth and an elective cesarean.

Other Midwives (DEM, LM, CPM, “lay”) –

While often thought to be the same thing, different types of midwives also have different types of training while having one thing in common in helping women to have homebirths.  VBACs are frequently done at home in many states in the US, often due both to the decline in availability in hospital providers of VBAC but also in concerns for the safety of the mother and baby and prevention of a repeat surgery due to interventions from the care providers that practice in-hospital.  Women should be careful to do research about their midwife, her training and her philosophies about births, including handling an emergency situation.  While concerns are often raised about the immediate available of cesarean in case of uterine rupture, homebirth has not been shown to dramatically increase the rate of rupture or of catastrophic outcomes.  There is some question of the legality of midwifery in some states but many women choose to birth at home with a midwifery attendant anyway due to the same concerns of safety and realistic support of VBAC.  “Traveling midwives” would fall under this category as well.

Unassisted –

Some mothers also choose to have an unassisted or unattended birth.  This does not usually mean the mother is birthing alone, without a support person, but it does usually mean that she does so without a medically-trained provider.  The reasons for this are numerous, from religious and privacy concerns to an inability to find a supportive provider.  Unassisted mothers are typically very educated women who research and trust in the birthing process being normal.

When Lightning Strikes

This is a re-release of an article I wrote several years ago.  The majority of the information still applies to all interactive support groups on the web.  When leaders from the ACOG community stand in front of a panel like the recent NIH VBAC Consensus Hearing and claim to be saving that “one baby” through repeat cesareans and setting an impossible standard that cannot be met for VBACs, this is what goes through my mind.  The personal loss and horrible tragedy that touches all of those families that experienced cesareans without medical indication which caused more pain and agony than can ever be replaced or healed through unreasonable protocols and restrictions of women’s choices for healthy birth.

On the ICAN-online Yahoo Group we are often accused of ignoring the risks in order to achieve an experience.  The reality is, we are all too aware of the risks we take.  In our world, they have names.  They are women we have lost or babies who have passed too quickly on.  We mourn for our sisters and when the risks are named, we picture “uterine rupture” not as a medical condition but as the face of our losses and cold, still black and white photos of those we yearn to hold one more time.
This issue is dedicated to unnecessary cesareans and the reason for this article is to count the cost of when lightning strikes.  The risks say, “.5% unless that uterine rupture happens to you, then the risk is 100%.”   This sounds terrifying and so incredibly personal and we try to wipe it away with the glib idea that if we had to bet on getting run over by a bus, we would take the 99.5% every time.  So the risk is placed on us and we live in fear of the risk, even as a background noise through a healthy pregnancy and delivery.  We remember our sisters and fear somewhere in small recesses that it could happen to us.
And yet, lightning strikes are not without the storm.  The lightning that struck Amanda and left her without her son would most likely not have happened without the failed induction that left her uterus damaged with a cesarean scar.  This was not the random event one would like to think in order to have peace and it was not caused by the attempt at VBAC.  The original damage was done by a cesarean she did not need.  The face of medicine today reflects that we are often blaming the mother for her attempt at a ‘dangerous’ VBAC and yet we rarely see the medical providers rail at an unnecessary first cesarean that falls out of a failed induction or a big baby scare.  We don’t see them out at the first sign of the storm, telling us to avoid the clouds and the severe weather.  We only see them when they stand over us in the aftermath, asking us why we didn’t see the lightning coming.
Placental abruption, uterine rupture, hysterectomy.  This lightning isn’t without cause.  The studies show us that for every cesarean, the stillbirth rates double.  We lose twice as many babies with the first cut, and four times as many with the second.  What happens when we have mothers having three and four cesareans?  We start taking them earlier at 39 weeks, raising their risks of early infant death in order to hopefully prevent those stillbirths.  And not knowing where lightning will strike, VBAC plans and trial of labor is severely discouraged in order to protect the mother and this baby, without regard to the next.  The storm continues building.  Is sectioning every mother with a suspected big baby or early induction worth this?  If the cesarean rate continues to grow beyond 50%, what does this say for the future safety of women or their babies?  Can we then expect to return back to the days of expecting more losses than living children?  Right now, we stand on the cusp.  We see the maternal mortality rates rising and see ourselves losing multiple women in our communities such as New Jersey for the same medical emergencies arising from their cesareans and managed births.  The doctors try to convince us that these are random strikes.  That no one knows and they did the most they could do to get a healthy mother and healthy baby.  One has to wonder if they are reading the same research or if they are simply trying to avoid taking responsibility for starting the cascade that continues to escalate and rob us of those things most precious to us.
This is dedicated to the ones we have lost…to Marcia and Logan, to Kimberly, to Deb and Fiona and to all the numerous others who blend into facelessness and pain simply because we fail to reduce the cesarean rate and stop the lightning from striking.

Originally printed in The Clarion, Summer 2008.

Surviving the First Birthday After a Cesarean

“Once a Cesarean, Always a Cesarean” never rings more true than when referring to a child’s birth. Even though a mother may later go on to have a vaginal birth or future healthy pregnancies, there is no way to step back into our footsteps in the snow and change that day in surgery. Sometimes, coping lasts a lifetime but there are critical moments in recovery in the first year that moms have to weave through and often, they are alone and unsupported. Most of the time, those close to them don’t even realize the impact of their words or actions, thinking they are sharing the moments with the new mother. On baby’s first birthday, many well-intentioned friends and family fail to see what is in front of them: a mother in mourning being forced into celebration.

A mom may ask herself if she’s even normal, because she feels so despondent or unwilling to plan birthday parties. She may throw herself into planning the biggest celebration possible, hoping it will drown all the pain out. The reality is, she often sees this is as the first anniversary of trauma. While not all cesarean moms view it this way, it’s important to understand how a mom could wind up in this emotional dilemma of baby’s birth vs mother’s birth experience.

Research shows that women remember their birth experiences for the rest of their lives. These stories impact not just today but the rest of their lives. A mother goes into labor and gives birth, remembering much of it while wrapped in the heightened sensations of labor.  She remembers specific smells, looks, people’s faces and attitudes and words. As she goes into labor or is induced, she is often afraid of the unknown or even the known if this is not her first labor. She walks into the hospital and deals with strangers she is forced to trust at the most vulnerable time of her life. In some cases, she doesn’t really like her care provider or her nurses. Then, as labor continues, something changes and she labors longer and harder and suddenly, a cesarean. This isn’t what she prepared for, this is surgery. She is drugged, she is strapped down, and she is often throwing up. Sometimes, she is not even conscious, depending on the circumstances. Unable to help herself, she watches the ceiling as her body is cut open and her baby is taken away. Often, the obstetricians and nurses discuss their day or other clients or even football games. This event that was hers and personal becomes distracted and impersonal. Her baby is born and she gets a glimpse before having the baby removed, wrapped, and only a face and then gone to the nursery. There is no physical contact to solidify this bond between mother and child. There is no orgasm of love and completion in each other’s arms that is so tactile and important for every being. She is left alone with the staff, cleaned up and moved to recovery.

At this point, her husband or partner goes with the baby. They share joy, “Look at his hair! His fingers, his toes!” They call family and tell of joy in the new little person. His size, his weight, his features. They take cell phone pictures and post on Facebook or blogs. They are building a vision of love.

A year later, they share this vision. They talk over and over about the day he was born or the first moments they saw her. They are overwhelmed by the joy of that moment and they relish in it. “I was the first person to hold her!” a grandmother remembers. As they share these moments, the mother remembers, “Everyone held her but me. And when I finally got to hold her, it hurt so badly, I could barely move. “ They pass around pictures of baby’s first few moments, none of which include the mom except one, with an upside down baby’s face, wrapped tightly in a blanket, next to her head while she feebly smiles. She thinks to herself that even in that moment, she didn’t get to hold her baby or touch, skin to skin and feel the baby newness.

This is the reality of the first birthday. These flashbacks and moments where only the mother , and she alone, remembers and recovers her own experience. So how can someone help a mother in this situation? How can you, help yourself? Here are some tips on recovering at that first birthday:

Listen.

The new mother needs you to hear her side of the story.

Talk.

If you are the new mom, talk about the birth. Find someone you can share this with and just talk. Many women turn to online support at this time just to be able to get it out and share with other moms who get it.

Accept.

It’s not only ok but normal to wonder things like, “Is this baby really mine?” or “I don’t feel like her mom, I didn’t give birth.” Many moms have asked themselves these questions. Accept for yourself that your child and you have moved past that day, even if you were not unaffected by it. The feelings surrounding the birth do not have to stop you from loving your child, bonding with them and helping you both to grow.

Feel.

You have every right to feel however you want to feel. You do NOT have to dwell on feeling grateful that your child is alive or that your birth occurred the way it did. You have the right to feel questioning of the outcome and ungrateful for the way things happened.

Express.

Talk, paint, feel, write letters to the providers about your care. Write out your birth story in the way you wanted it to occur. Cry if you need to. Have a day for yourself, treating yourself well and celebrating your motherhood while allowing yourself the freedom to see the day as a multitude of different occasions that happened to different people at the same time.

Ignore.

You can ignore a child’s first birthday. The subtle way to do this is simple: Move the date. Make the party on a day that has nothing to do with the actual birth. Celebrate a half-birthday instead. You can still use a 1 candle at 1.5! You can have a small thing at home with just a cake and you and baby, celebrating together and being special in a way you were denied the first time.

All in all, treat this as if it were YOUR day. This is not simply a birthday, deserving of a Blue’s Clues cake smooshed by a happy baby. It is also the anniversary of a transition in your life that you deserve to memorialize in whatever way best suits your personal needs.

Would you like to share your story or ideas for surviving the first birthday? Send your emails to director @ birthaction.org .