The Problem with Using Place of Birth
as Proxy for Style of Intrarpartum Management

faith gibson, LM CPM

MANY MEDICAL AND MIDWIFERY PROFESSIONALS, as well as birth activists and consumers, confuse birth setting (hosp. vs. OOH) with intrapartum management style or may use these terms interchangeably, sometimes to mean an actual physical location, and other times to refer to a management style.

In this paradigm, 'home' has become a frequent proxy for non-medical or physiologically-managed care without use of, or access to comprehensive obstetrical services, while hospital has become a proxy for medical management. We generally assume that the hospital-based medical model is universally safer, while planned home birth care is inevitably more risky. This makes two erroneous assumptions simultaneously -- that PHB attendants routinely reject the appropriate and timely use of obstetrical services and that routine medicalization of healthy women is universally positive or at the very least, neutral.

I would never want to live in a place or an era without timely access to comprehensive medical and surgical services (which depend on hospital facilities), so I never see this as an 'us vs. them' issue. I want hospitals to work and work well. But these proxy assumptions make it impossible to get our hands around the very real social and medical problems we face. Instead of stepping stones to progress, these notions become stumbling blocks that keep society from finding innovative solutions and making "best practices" more widely available to more people.

Even in places like Africa, we generally apply these same proxy assumptions. People frequently refer to the high maternal mortality rate in developing countries as a realistic measure of how dangerous childbearing is. However, an exhaustive study of all maternal deaths occurring in one particular region of The Gambia is instructive.

It begins with the information that all but 2 of these maternity patients were in hospital at the time of their death, and one of those died of an infection after returning home after a Cesarean section performed in the hospital. The vast majority of these women either delivered in the hospital or were admitted early enough in the course of a potentially fatal complication to have been successfully treated by current medical standards. It was not location but quality of care that was the critical issue. The most frequently preventable cause of unnecessary MM identified by the study was a tragic lack of simple economic resources (hospitals with no running water, no drugs, no banked blood, no gas to run the hospital generator for electric lights in the OR, no doctor on site who could perform a CS, etc) combined with unresponsive or inappropriate actions (or omissions) by the hospital staff.

As former administrator of a professional liability group from 1998 to 2000 for CNMs and licensed midwives in three states, I was privy to reports of malpractice cases against obstetricians and midwives in both hospital and OOH settings. Unfortunately there were a number of instance in which it was evident (med-mal carrier settled out of court) that a baby died or was neurologically damaged by the elective use (physician preference) of medically unnecessary obstetrical intervention in a healthy mother who did not herself want the intervention (ex., induction or augmentation to speed things up) or the OB was not in the hospital and *did not come* when asked to by the nurses.

There were also a small number of OOH mfry cases with bad outcomes. These fell into two general categories. The first, and luckily the rarer category, was total disregard for well-established, evidence-based practices by either the parents or the midwife. In those instances, it was not location (home), but lack of common sense and good judgement by either one or both. This is also is not a "place of birth" issue. The answer to this problem is better education of the public, more responsive maternity care so that parents do not become pathologically fearful of medical services, and more effective preparation and regulation of midwives in the responsible practice of their profession, irrespective of location.

The more frequent, (but still statistically rare) situation was a genuinely unpredictable adverse event such as prolapsed cord with baby at a +1 station or placental abruption in a normotensive primipara. One certainly could argue that if the mother had been in the hospital 15 feet from a fully staffed OR in a tertiary care institution with 24-7 in-house surgical, anesthesia and perinatal services, the baby could have been rescued, maybe w/o suffering neurological damage, maybe not.

But as a former L&D nurse who often worked in smaller or rural community hospitals, I also know of instances in which the mother was in the hospital but the doctor was at home. Unfortunately, the same critical issues applied, with the same poor outcomes. Thirty-nine minutes from decision to incision can be far too long, no matter if it represents transport time from the parents' home to an awaiting institution or time spent (waisted!) by nurses frantically paging "any doctor in house stat to L&D", while calling the OB at home, then paging him and finally waiting for him to arrive while the nurses prepare the mother for a crash C-section that turned out to be too little too late.

In far too many places, PHB is the only circumstance where true physiological management can be legally and fully employed. This reflects OB department policies and med-mal carrier protocols that require obstetricians to follow a strictly-defined medical model of care. This frequently includes elective induction at 40-41 wks and the preemptive use of IVs, continuous EFM, a medically-defined schedule for progress in labor, and liberal use of operative delivery for any number of minor variations. Any obstetrician who fails to maximumly medicalize each and every patient risks a lawsuit in which plaintiff's attorney's will parade a line of "expert witnesses" happy to testify that physiological management is "substandard" in the context of professional care by an MD trained in the surgical specialty of obstetrics.

This artificially forces us into this proxy state of affairs that appears to pit hospital against PHB. But in a rational evidence-based system, no healthy women should ever have to choose between a midwife and a physician or btw home and hospital in order to receive physiologically based care for a normal birth.

Statistically-speaking, the relative risks for planned place of birth in each location are approximately the same. Since we all know of preventable perinatal deaths and emergency hysterectomies subsequent to care in both places, the logical conclusion is that *both sides* are having bad outcomes that are preventable by today's standards. While occurring for different reasons, the bad outcomes from each side are only canceling each other out and thus do not represent a true measure of relative risk. That means we can stop arguing about place of birth and instead focus on improving all aspects of maternity care by all categories of birth attendants in all locations.

Over the last 100 years, a consensus of scientific research has identified physiologically-based birth services, regardless of location, to be a relatively safe and therefore responsible choice when provided by trained midwives with access to and use of comprehensive obstetrical services to treat complications or if requested by the mother. Every year one or more credible study on physiological management in non-medical settings is added to this growing body of research. However, five particular sources of research data do the best job of identifying the specific information needed to make science-based decisions relative to national maternity care policy for the United States.

The hottest controversy currently is an ideas spawned by ACOG in 2008 that rejects all available research data because the studies are not randomized controlled trials. According to ACOG policy, the status quo -- maximum medicalization of healthy childbearing under a strict obstetrical model -- is the only 'proven' standard for safe and responsible maternity care and must be maintained until such time as randomized controlled trials can be done to address the question of safety. However, its obvious to everyone else that randomized trials under the terms insisted on by ACOG can never and will never be done

Fortunately for the rest of us, that is not the conclusion arrived at by Australian authors Bastia, Keirse, and Lancaster in a paper published in the BMJ in 1998 on perinatal death in PHB. They were able to distinguish the forest from the tress and do a superb job of debunking this idea by identifying (again) that the real issue is not place of birth. When we look across the board at M&M statistics (historical and contemporary) and records of malpractice litigation, its clear that none of the categories of birth attendants have a monopoly on poor judgement, failure to use common sense and/or inappropriate use of resources.

The introduction to this Australian study hits all these high notes and gives us somewhere dependably solid to stand:

"Despite decades of political and academic debate the relative merits of home-versus-hospital birth remain unproved. This is likely to remain so.

Although home and hospital offers different risks and benefits for birth, neither has standard care characteristics. In fact, the range from safe to unsafe may be wider within each location than it is between them. Addressing what constitutes safe birth practice at home and in hospitals may be a more pivotal concern than attempting to quantify the theoretical differences attributable to place of birth. .... In the Netherlands, where 30% of birth are planned to be at home, there is a widely accepted list of criteria for home birth. When home birth is uncommon, opinions and practices can vary more widely."

These authors observed that when high-risk obstetrics is practiced in an OOH setting, the outcomes disfavor PHB (surprise, surprise!). However, when this high-risk group is removed from the calculations-- a category the majority of midwives and physicians agree is generally best served by making physiological care available to them in a hospital setting -- PHB is demonstrated as relatively safe for mothers and babies as compared with hospital-based medical management.

I have grouped the other 4 studies mentioned above together as a set. They include (1) unattended OOH, (2) lay midwife-attended OOH, (3) professional midwife-attended OOH and a meta-analysis of medically-managed hospital births by obstetricians, FP physicians and certified nurse midwives. This configuration of outcome data includes a "control group" of unattended births which allow us to compared 'care' vs 'no care' and then to compare the specific care of the 3 major groups of birth attendants to one another and to "no care".

One must establish a baseline for "no medical or mfry care" in order to determine the innate riskiness of childbearing in an essentially healthy population, to determine if medical and mfry care make an over-all positive contribution (what economists refer to as 'value added") and finally to statistically calculate the manner and magnitude of medicine & midwifery's ability improve maternal-infant outcomes in a cost-effective fashion. Only in this way can we actually distinguish the qualities of maternity care that are essential (safety + cost-effectiveness) from those that represent traditional customs and preferences of professional providers, but do not directly contributed to improved maternal-infant outcomes via cost-effective "best practices".

(1) The control group consists of women with the same general health and demographic characteristics that are seen in the CDC birth registration data. This is predominately healthy, white, middle-class women who had economic access to all categories of maternity care providers and settings, but in this case, purposefully chose unattended births. Data on this group of unattended home births came from Indiana state mortality statistics for a fundamentalist religious group that all rejected medical care under all circumstances – no prior diagnosis or treatment of chronic medical problems, no risk-screening of mothers during pregnancy, no prenatal care, no trained attendant during childbirth and no emergency transfer of mother or baby with ife-threatening complications to a medical facility (a situation similar to rural parts of the developing world).

Out of 344 births, the unattended group had 6 maternal deaths and 21 perinatal losses.The baseline mortality rate for unattended childbirth was one maternal death per 57 mothers or MMR of 872 per 100,000 live birth (92 times higher than Indiana’s MMR for the same period) and one perinatal loss for every 16 births or PNM rate of approximately 45 per 1,000.

(2) Planned Home Birth in an impoverished and medically-indigent population attended by experienced lay midwives. These maternity patients were risk-screened one time by a public health officer prior to be approved for PHB under the care of a lay midwife. However, state laws did not authorized non-nurse midwives to carry oxygen or emergency anti-hemorrhagic drugs (Pitocin) or to suture perineal tears. These county-registered midwives were required to transfer patients with complications to a local hospital in an appropriate and timely manner. The lay midwife-attended group had no maternal deaths and 3 perinatal losses per 1,000.

Note: This study also reported the perinatal mortality rate for medically indigent women in the same rural regions of North Carolina who delivered unattended, often because local hospitals turned away laboring women who did not have the prescribed ‘cash in hand’. These unattended births had a dramatically increased perinatal mortality rate ranging from 30 to 120 stillbirth and neonatal deaths per 1,000, a perinatal mortality rate consistent with 3rd world countries and unattended births among the religious group in Indiana. [Note again that the take-home message the same -- its not the place of birth but the quality of care and the crucial preventive quality is physiologically-based services, not high-end obstetrics]

(3) Planned Home Birth in a general population attended by nationally-certified direct-entry (non-nurse) midwives. All clients were risked-screened and received prenatal care and those with medical or pregnancy complications were referred to medical services. Professional midwives monitored maternal vital signs and fetal heart tones during labor and were authorized to carry emergency supplies such oxytocin (Pitocin + Methergine), IV fluids, oxygen, neonatal resuscitation equipment and to suture perineal lacerations. Twelve percent of PHB patients were transferred to the hospital during labor or after birth, the majority of
 whom were first-time mothers. Cesarean rate was under 4% for PHB women hospitalized during labor.
This group had no maternal deaths and 2.6 perinatal losses per 1,000.

(4) Planned Hospital Birth for low and moderate risk women -- labor attended by a professional nursing staff, routine use of continuous electronic fetal monitoring, IVs and epidurals; birth conducted as a surgical procedure by a physician or certified nurse midwife. Medical intervention rate for this group was 99%; aggregate surgical intervention rate was 70% (episiotomy, forceps, vacuum extraction and Cesarean section). The CS rate was approximately 25% in 2002. This group had no maternal deaths and a neonatal mortality rate of 1.3 per 1,000. 
Studies of obstetrically-managed hospital birth in low-risk women give a range of NNM from a low of
 0.79 to 4.1.

Note: The routine use of prenatal screening in the hospital population in conjunction with termination of affected pregnancies during the pre-viable state results in an artificially lowered rate of PNM due to a reduced rate of babies carried to term with lethal anomalies.

As measured by the outcome statistics of the four groups -- unattended, lay midwife-attended, professional midwife-attended and hospital-based, medically attended -- the most efficacious strategy for preventing 
maternal and perinatal mortality and morbidity consists of three simple aspects 
of maternity care that balance safety and cost-effectiveness and apply regardless of place of birth.

They are:

(1) Access to prenatal care, on-going risk-screening & referral to medical care for evaluation or treatment as indicated

(2) The presence of an experienced birth attendant during labor, birth and immediate postpartum-neonatal period

(3) Access to hospital-based services for complications or if requested by the mother

Of the three birth attendant categories, the physiologically-based (i.e., non-medical) care by lay midwives demonstrated the most extraordinary level of cost-effectiveness and reduction in both maternal and perinatal mortality when compared to unattended birth and NNM rates comparable to professional midwives. This good outcome was achieved by providing childbearing women with access to risk-screening during the prenatal 
period and referring those with serious medical or pregnancy complications to
obstetrical services. The mother and unborn baby were monitored during active labor by capable midwives, who also arranged to transfer patients with complications to obstetrical
 services at the county hospital.

This simple access to prenatal care and physiological management during the intrapartum and postpartum-neonatal period reduced perinatal mortality by 20 to 40
 times as compared to the mortality statistics for unattended women and at a small fraction of the expense, was able to lower
 the maternal mortality rate to levels equal to that of hospital-based
-obstetrical care. Lay birth attendants are not an option within the structured healthcare systems of North American, which serve an educated population who rightfully expect their healthcare providers to be professionally trained, regulated by the state, able to carry emergency drugs and equipment and to repair simply perineal lacerations as a part of their normal scope of practice. However, lay midwives are an eager and reliable group that are able to provide safe care within a cost-effective system that dramatically improves mother-baby safety in developing countries.

When taken together, these five studies offer great certainty about what makes maternity care safe and effective and gives us a solid starting place. We know that childbearing is unnecessarily and unacceptably risky when women are denied (or refuse) the benefits of 20th century biological science and modern healthcare. We know that three simple, cost-effective steps reduce this high background rate to a level equivalent to most developed countries. National health policy must education the public to the very real dangers of 'no care' and then consistently provide circumstances that make such situations extremely rare by supporting this trilogy of skilled prenatal care that includes timely access to medical services during pregnancy, experienced birth attendance during labor, birth, the immediate PP & neonatal period and comprehensive obstetrical services whenever indicated for the treatment of health problems, complications and emergencies.

Again it must be noted that these are NOT place-of-birth dependent, but they do depend on integrating these three distinct categories of birth attendants (professional midwives, family practice physicians, and obstetricians) and both hospital and OOH birth settings. In such a system, the individual management of pregnancy and childbirth would always be determined by the health status of the childbearing woman and her unborn baby, in conjunction with the mother’s stated preferences, rather than the occupational status of the care provider(obstetrician, GP physician, or midwife) or the planned location of care. To do otherwise is illogical.

It is useful to take into account the enormous benefit that physiological management of labor and spontaneous birth in healthy women contributes to safe maternity care. This is the form of care routinely provided by general practice physicians and midwives in those countries with the best maternal-infant outcomes.

Simply put, the physiological principles of normal maternity care should be integrated with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women with normal pregnancies. This integrated standard should apply universally to all categories of birth attendants when providing care to healthy women and be used in all birth settings, with comprehensive obstetric services reserved for those who develop a complication or if requested by the mother.

For essentially healthy women in an intregrated system, physiologically-based childbirth services would be provided by family practice physicians and professionally-trained midwives, with appropriate access to the services of obstetricians, perinatologists and other specialists as necessary. Only this articulated model of maternity care can bringing evidenced-based maternity care into the mainstream of our healthcare system and consistently provide safe and cost-effective services to a healthy population of childbearing women and their unborn and newborn babies.

The most efficacious form of maternity care for an essentially healthy population is always the method that provides “maximal results with minimal interventions”. This is defined as a beneficial ratio of interventions to outcomes for each childbearing woman. It factors in mortality and morbidity rates for mothers and babies both, as well factoring in the immediate, delayed and downstream cost. The ideal maternity care system seeks out the point of balance where the skillful use of physiological management and adroit use of necessary medical interventions provides the best outcome with the fewest number of medical/surgical procedures and least expense to the health care system.

Creating such a rationally-based maternity care system would require a calm and fair-minded coalition of professional groups, willing to learn how to cooperate effectively with one another. The goal (already modeled by the Canadian system) would be a complimentary scope of practice and cooperative style of care among the different categories of birth attendants, a cost-effective model of care that is to the benefit of patients and professional alike.

Lessons for Evidence-based Maternity Care in the 21st Century :

Under those circumstance, place of birth would become what it was always suppose to be -- the right choice for the particular situation for that specific mother & fetus -- with PHB and hospital both seen as equally responsible choices in an integrated, cooperative and 'minimalist' model based on "best practices".

References:

B-1 Maternal Mortality in the Gambia: PhD Thesis by Mamady Cham
B-2 Paper #1 Maternal Mortality in Bansang Hospital, The Gambia - Levels, Causes and Contributing Factors
B-3 Paper # 2 Maternal Mortality in Rural Gambia: What do we need to know to prevent It?
B-4 Q & A: What we can do to prevent maternal deaths

Study #1 Perinatal & maternal mortality in a religious group avoiding obstetric care -- Am Jour Obst Gyne 1984 Dec 1: 150(7):926-31

Study #2: "Home Delivery and Neonatal Mortality in North Carolina", Burnett et al; JAMA, December 19, 1980, Vol. 244, No. 24, p. 2741-2745

Study #3: Outcomes of planned home births with certified professional midwives: large prospective study in North America; Kenneth C Johnson, senior epidemiologist; BMJ 2005;330:1416 (18 June),
doi:10.1136/bmj.330.7505.1416

#4 Meta-analysis - Perinatal MR for planned hospital birth reflects a consensus of scientific literature, CDC birth registration stats and data on obstetrical intervention levels in general population from the "Listening To Mothers" survey, Childbirth Connection; 2002 and 2006

This statement is from the "core measures" of the Joint Commission for hospital accreditation and relate to reducing elective deliveries before 39 completed weeks of pregnancy and Cesarean sections, particularly in first-time mothers.

@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@

VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE
Measure Information Form

Measure Set: Perinatal Care(PC) Cesarean Delivery

Performance Measure Name: Cesarean Section

Description: Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section

The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean section (CS) rates. Some hospitals now have CS rates over 50%. Hospitals with CS rates at 15-20% have infant outcomes that are just as good and better maternal outcomes (Gould et al., 2004).

There are no data that higher rates improve any outcomes, yet the CS rates continue to rise. This measure seeks to focus attention on the most variable portion of the CS epidemic, the term labor CS in nulliparous women. This population segment accounts for the large majority of the variable portion of the CS rate, and is the area most affected by subjectivity.

As compared to other CS measures, what is different about NTSV CS rate (Low-risk Primary CS in first births) is that there are clear cut quality improvement activities that can be done to address the differences. Main et al. (2006) found that over 60% of the variation among hospitals can be attributed to first birth labor induction rates and first birth early labor admission rates. The results showed if labor was forced when the cervix was not ready the outcomes were poorer.

Alfirevic et al. (2004) also showed that labor and delivery guidelines can make a difference in labor outcomes. Many authors have shown that physician factors, rather than patient characteristics or obstetric diagnoses are the major driver for the difference in rates within a hospital (Berkowitz, et al., 1989; Goyert et al., 1989; Luthy et al., 2003).

The dramatic variation in NTSV rates seen in all populations studied is striking according to Menacker (2006). Hospitals within a state (Coonrod et al., 2008; California Office of Statewide Hospital Planning and Development [OSHPD], 2007) and physicians within a hospital (Main, 1999) have rates with a 3-5 fold variation.

Type of Measure: Outcome Improvement Noted As: Decrease in the rate
=====================================================

VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE

Measure Information Form
Measure Set: Perinatal Care(PC) Set Measure ID: PC-0

Performance Measure Name: Elective Delivery

Description: Patients with elective vaginal deliveries or elective cesarean sections at >= 37 and < 39 weeks of gestation completed

Elective Delivery
For almost 3 decades, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have had in place a standard requiring 39 completed weeks gestation prior to ELECTIVE delivery, either vaginal or operative (ACOG, 1996). A survey conducted in 2007 of almost 20,000 births in HCA hospitals throughout the U.S. carried out in conjunction with the March of Dimes at the request of ACOG revealed that almost 1/3 of all babies delivered in the United States are electively delivered with 5% of all deliveries in the U.S. delivered in a manner violating ACOG/AAP guidelines. Most of these are for convenience, and result in significant short term neonatal morbidity (neonatal intensive care unit admission rates of 13- 21%) (Clark et al., 2009).

According to Glantz (2005), compared to spontaneous labor, elective inductions result in more cesarean deliveries and longer maternal length of stay. The American Academy of Family Physicians (2000) also notes that elective induction doubles the cesarean delivery rate. Repeat elective cesarean sections before 39 weeks gestation also result in higher rates of adverse respiratory outcomes, mechanical ventilation, sepsis and hypoglycemia for the newborns (Tita et al., 2009).

Type of Measure: Process

Improvement Noted As: Decrease in the rate

This VBAC story is from Dr Daniels' blog. She is an ob-gyn physician why had an unintended VBAC, which dramatically changed her perspective on the obstetrical profession and the unintentional role it plays in making normal childbirth for healthy women more difficult, less satisfactory, unnecessarily medicalized and unproductively expensive. She had a lot of very insightful things to say about the difference btw medicalized care and physiological management.

Here is one that is a "Pearl of Great Price":

"We should continue to make efforts to reduce medically unnecessary inductions for mom and baby’s well-being, we should attempt to humanize cesareans for moms who need to have them, we should properly evaluate and assess each VBAC individually to decrease risk, and we should place natural labor and birth back into the realm of the norm, with the interventions and surgeries reserved for the truly high-risk."

If you reading time is limited, drop down to read the last few paragraphs.

original source: www.drpoppy.com/wordpress/?p=116

@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@

March 19th, 2010

As I type, I look over at my one-week old baby zonked out in his cradle swing and am in awe at how awesome his arrival was. Instead of having my third c-section as scheduled, I went into labor on my own (first time in 5 tries) and delivered him (precipitously in fact), one hour before I was to arrive at the hospital for my surgery. I find this wonderful and quite ironic in light of the recent NIH VBAC conference in Bethesda, MD; I had just downloaded the consensus statement and was digesting it while awaiting my baby’s arrival (more on that later).

In order to tell the story of how I ended up with a surprise VBAC, I have to start at the beginning of my long and adventurous reproductive journey. My first pregnancy ended in the first trimester with a miscarriage and heavy bleeding requiring a D&C to stop it. I was a OB/Gyn resident at the time and was surrounded by high risk OB patients every day. I trained in downtown Philadelphia where an addicted mom with no prenatal care could deliver on one end of the hall, while a high risk IVFer from the Main Line might be delivering on the other end. Although we worked side by side with midwives, we only became involved if their patients developed complications or needed a C-section. Needless to say, like most OB residents, my experience with normal, low-risk physiological birth was minimal.

Being pregnant in this environment and then losing the baby certainly colored my perspective. Like any mom who loses a first baby, I was troubled with the worry that I wouldn’t be able to have another baby, so that when I did become pregnant again, I embraced the “we have to be very careful and be supervised very closely with this one” approach. I worked up until term, 36 hr shifts, 100 hr work-weeks, having to turn sideways at the operating table at the end, and then it was decided that I should be induced at 39 weeks due to gestational hypertension. There were no signs of pre-eclampsia and the pressures were not sky-high, but at the time, I fell into the “you’re term, what’s the need to take a chance” mentality and was scheduled for an induction.

I went in at night for prostaglandin gel due to an unripe cervix (should have known better) followed by Pitocin the next morning. I labored all day, getting the obligatory epidural that a Pitocin induction necessitates, finally getting to complete around 8 pm. I pushed for 2 1/2 hrs, I used the bar, the sheet, everything the hospital approach has to offer…but the baby was OP and would not rotate with “all” of our maneuvers and so I received a C-section for “arrest of descent.” Happy as I was with my new son, everyone who has labored and then had surgery, knows the pain that you are in for. I wasn’t disappointed in the C-section because at that time, I was still fully entrenched in the “at least I have a healthy baby” mindset.

Despite that experience, I always wanted to have a vaginal birth and since most university hospitals were still doing them regularly (’03), I chose a new doctor whose obstetrical/surgical skills I trusted who would support by desire for VBAC. My pressures started acting up again so I was slated for induction, although this time my cervix was riper and I went right in for Pitocin. They did one of the most inhumane things which was to artifically rupture my membranes on Pitocin in the active phase of labor. Needless to say, an epidural was imperative but I almost couldn’t sit for it due to the pain. This time I pushed for 3 hours, hard pushing, hands and knees at one point (I must have learned something from the midwives), and ended up with a vacuum extraction and a fractured coccyx, from a 7#14oz baby. He had jaundice and a cephalohematoma but hey, I got my VBAC. He today is honored to say, “I broke mom’s butt when I was born.”

Baby number 3 was an easier pregnancy although this time I added on gestational diabetes so that plus the usual spike in blood pressures brought us back to induction. Although he was my smallest baby, 7#, he still was delivered by vacuum although my butt remained intact. With baby number 4, I figured another VBAC was practically guaranteed so I didn’t resist the induction assuming the last birth meant smoother sailing now. This time they decided to start the Pitocin the night before, but instead of staying at a low dose overnight, the nurse kept coming in and increasing the dosage. I knew I wasn’t progressing because I was not in active labor, so I questioned her about the dose, reminding her that I did have a scarred uterus. She responded that everything looked fine but she would stop until morning.

Morning arrived with the usual course of epidural, AROM and increasing Pitocin. When it came time to push, within 20 minutes, I knew something was wrong. Despite the epidural, I could tell he wasn’t coming down with my pushing and by the frazzled looks of everyone in the room, I knew the heart tones were dropping. I looked at my husband and told him we needed to stop. By the time they got down to the uterus in the OR, it became clear that if we wouldn’t have stopped, I would have had a uterine rupture. As it was, I had what is called a uterine window, they were able to see the baby’s hair through a very thin lower uterine segment.

Finally, I made the connection between the induction and the narrow avoidance of catastrophe. So with baby number five, I knew I did not want another induction. Interestingly, this pregnancy was also my healthiest. I had made a concentrated effort before becoming pregnant to address my diet and treat my vitamin deficiencies, so I had no blood sugar or blood pressure problems, kept my weight gain to 15 pounds and did not have any obstetric problems other than being an advanced maternal age grandmultipara with a history of 2 c-sections! Knowing that I had never gone into spontaneous labor, I felt the safest route was to do a scheduled repeat C-section at 40 weeks.

I did put it into God’s hands and had been in prayer that I was open to the baby coming forth in whatever way he was supposed to…and so I went into spontaneous labor at 2 am, the morning of surgery, got to the hospital at 4:30 and was 9 cm dilated. The staff asked me what I wanted to do and I said, “I’m going to have him!” They also offered me an epidural (too late for that) and IV pain meds (I certainly didn’t want a narced up baby), so unmedicated it was, and he was born at 5:13 AM, a beautiful, alert 7#11oz baby boy who latched right on and has been peaceful ever since. Not having to recover from an extensive surgery was a gift for which I continue to be amazed and grateful.

Reflecting back over my journey, I see how much the field of obstetrics has managed to contribute and sometimes outright cause complications, all the while assuming they are just keeping everyone safer. And I see how much fear has overtaken the natural birthing process. I’ve said before that shows like Deliver Me, A Baby Story, and Birth Day should be renamed “Fear Factor” because they play on a woman’s often natural concerns about the birth by portraying the whole process as highly dramatic, with a woman strapped down and hooked up, by a doctor gowned and gloved like an alien visitor and often highlighting very anxious family members. Sure a woman has fear, fear that something is going to happen to her or the baby, fear of pain, fear of failure, that she just won’t be able to “do it.” Add in snarky, cynical nurses and doctors who ridicule anyone who seems to want to be in charge of her birth (after all we’re the experts)…limited labor support or assistance in the form of doulas or labor coaches except in certain areas…restricted mobility, food and drink…and almost endless interventions and you have potential for trouble.

We have cultivated an environment that this is normal, and somehow now some women even find value in being “risky.” My mentor, Dr. Lauren Plante, a maternal-fetal medicine specialist who had two midwife-attended home births, wrote about this in an essay entitled “Mommy, what did you do in the industrial revolution?” Meditations on the rising cesarean rate: “Although the inherent literal meaning of the high-risk pregnancy is one that entails a higher risk of a poor outcome (for mother or baby), the sub-text seems to be that high-risk equals high-value…is it the Disneyfication of a primal human endeavor, longing for the synthetic and dramatized in preference to the authentic?” In other words, do we have more regard for the Main-Liner’s IVF-achieved pregnancy who has an elective c-section over the addicted mother’s unmedicated spontaneous birth?

All of the repeat C-sections and almost extinction of VBAC, have not really prevented poor outcomes as revealed by the NIH VBAC conference. Women who have a trial of labor after a previous cesarean have a lower risk of maternal mortality compared to those who have a repeat cesarean. Although there is a higher risk of uterine rupture with trial of labor, spontaneous labor versus induction has the lowest risk. And there have been no reports of maternal mortality due to uterine rupture (we were constantly told…mother and baby could die with VBAC). Repeat C-sections are also associated with an increased risk of abnormal placental position and growth in subsequent pregnancies, which also increases risk of cesarean hysterectomy. Although there is an increased risk of perinatal mortality with trial of labor, the risk is small and not that different from a laboring woman with her first pregnancy. Issues related to medical liability are a big concern for many practitioners, a fact that could be alleviated or helped by tort reform and hospitals assuming some malpractice costs up front.

In our local hospital, although the hospital allows VBACs, there is at least one doctor who simply doesn’t want to take any risk and personally won’t do VBACs. This approach is unfortunate since the overall finding of the NIH conference is that trial of labor is a safe option for many women and that women should be fully informed so that they may make the best decision for them. ACOG certainly needs to revise its mandate that anesthesia and c-section should be available immediately so that more rural hospitals can still offer VBAC to their patients without feeling they are not within standard of care.

Can you imagine if I had been in a VBAC-banned hospital and been forced to have surgery at 9 cm dilated? Can you imagine how that would have increased my potential for morbidity and even mortality? Should everyone have a VBAC? No, but every woman should still have the opportunity to discuss her personal issues and whether it could be an option for her, and she should be not be forced to have surgery against her will due to a medically-unsubstantiated VBAC ban. We should continue to make efforts to reduce medically unnecessary inductions for mom and baby’s well-being, we should attempt to humanize cesareans for moms who need to have them, we should properly evaluate and assess each VBAC individually to decrease risk, and we should place natural labor and birth back into the realm of the norm, with the interventions and surgeries reserved for the truly high-risk.

Check out Dr Daniel's blog www.drpoppy.com/