A Tale of Two VBACs

I had the pleasure of attending 2 different VBACs (vaginal birth after cesarean) this month. Both of these ladies had been my doula clients for their first birth and both ended in cesarean, for different reasons. This month was the month for redemption it seems in that both of them achieved their VBAC, though I have to say they were both very different.

My first client, we'll call her Sarah, had a cesarean for her first birth after hours and hours of labor with a posterior baby, an epidural that didn't work, and a diagnosis of Failure to Progress, suspected Cephalo-pelvic Disproportion which is a big word that basically means the baby didn't fit into the pelvis. She was told at the time that she might have a pelvic problem that led to the cesarean, leaving her feeling inadequate and broken. This lead to many months of depression and many, many conversations between her and I about why the labor didn't progress. It took a long time for her to come to peace with her first birth, and I am sure she would say she still is not there.

My second client, we'll call her Katie, never went into labor with her first birth. At 36 weeks, her breech baby had very low fluid levels and it was determined that an immediate cesarean was necessary. After seperation from her baby for hours after the birth, she went on to have numerous breastfeeding problems. The sad part of this story is that her poor 2 week old baby caught a near fatal case of bacterial meningitis necessitating a long NICU stay and a lot of worrying.

Both of these women came to me this time desiring a VBAC. After so many hours of discussion about her first labor and a lot of soul searching, Sarah decided to have a HBAC or homebirth after cesarean. There were many reasons for this decision but mostly it was an understanding of the hormones of labor. We, as mammals, are not meant to move locations during labor. If you move an animal during labor, the labor stops until the animal feels they are in a safe location. Babies are not born to people or to animals if they do not feel that their location is safe, unless we use drugs to push them out for us. Sarah got this. She recognized that her beautiful active labor pattern immediately disipated upon arrival at the hospital. She knew that her previously well positioned baby turned posterior as soon as she set foot in that hospital. She noticed her body changing with the fear of being in a new location. She also noticed how on edge she felt when yet another stranger popped their head into her room. She eventually came to realize that her cesarean was probably caused by the location she chose for her birth, not a problem with her body.

Katie contemplated a repeated cesarean but, not wanting all the breastfeeding and seperation issues she'd had with her first led her to decide on a VBAC. She and her husband contemplated a home or birth center birth but ultimately decided that, due to their first baby's brush with death with menigitis, they felt the hospital was safer. I honestly felt powerless but really wished I could have shared with them my opinion that their baby got bacterial meningitis from having no immune system left after wide-spectrum antibiotics given during the cesarean. I do believe that women should give birth where they feel safest. I just wish that more women would realize that birthing in the hospital carries inherent dangers that homebirth does not.

For Sarah, labor began late one evening near her due date. She called me to say she was having them every so often and wondered if this was it. I quickly determined that I thought she was indeed in labor, given the fact that she had to breathe deeply for the minute long surges her body was giving her. She packed her first "baby" off to visit the grandparents and labor got stronger once she was alone. I had wondered if she would be a worrier during labor. We in the birth industry always say that a woman labors the way she is and Sarah is a worrier. It took a lot of conversations between us to get her to truly trust her body and her abilities and I hoped there would be no more doubt. There was only one time she seemed to worry. Her husband called me near midnight to say she was worried the baby was posterior, like her first one had been. I asked why she was thinking that and he said, according to her, the surges were piggy-backing, which can be a sign of a mal-positioned baby. I asked whether they were truly piggy-backing or whether they were just close together. He said they were very close together and had increased in intensity in the past few minutes. I told him to tell her to stop worrying and believe in her body. He also shared that he didn't feel like anything was wrong and off he went to offer words of encouragement.

Now, during their first birth, Sarah's husband by his own words felt shoved to the side, unable to do anything to help her through her difficult labor. In pictures of that birth, the uncomfortability in the room is palpable. Her husband is a very caring and loving man but in the hospital he felt helpless. He was her biggest supporter of doing the homebirth. He too recognized that it was not what it could have been and that, at home, he wouldn't have to feel like the protector. He knew at home he would feel empowered to help her, and love her.

After I hung up the phone with him late that night, I knew I'd be getting a call back soon. Finally around 4:30am, he called again to say she was ready for me to come. When I arrived around 5, I could see that she was in transition. Just one more worry was voiced by her when she declined to be checked saying "I just can't know. I might not be very far along." I offered reassurance that what I was seeing was advanced labor, not someone at 3cm. I mostly sat back and watched with awe as her husband and her worked together beautifully. Her husband who, in their previous birth, had been so uncomfortable, helpless, and even angry (at the staff for their constant interruptions), gently cradled his wife, stroking her and whispering words of encouragement only the 2 of them could hear. I realized this birth was a birth of redemption for BOTH of them!

About an hour later I noticed the tell-tale sign of a woman who has completed dilation, a thin dark line extending from her butt up the back. I decided not to share this information with her and wait for spontaneous pushing to begin. About 45 minutes later she pushed during a surge and got a look of surprise on her face as if to say "Am I pushing?? Already??" And thus began her physiological pushing phase, the one she had hoped she would get to feel. Less that an hour later, her baby was born into her own hands. The look on her husband's face as he touched his baby's head for the first time as he emerged was priceless! The joy in that room was astounding! That joy grew to disbelief and eventually chest-bursting pride when we weighed him and discovered that this baby weighed exactly 2 lbs more than her first baby. And she had been told her pelvis was too small to birth her 7 1/2lb baby...Now she cuddled a beautiful, healthy infant who weighed over 9lbs after only 12 hours of labor.

Katie's labor began with her waterbreaking in a huge gush at 5am. She called me shortly after to let me know and asked if they should go ahead and go to hospital. I encouraged them to stay home until contractions began and were regular. Try as I might, I can never seem to convince anyone as to why it is a good idea to remain home as long as possible before going to the hospital. 4 hours after her water had broken, they drove to the hospital with contractions 4-5 minutes apart and 1 minute long. In childbirth classes, this is the point you are encouraged to head to the hospital though I have found even that is too early for a lot of people. Of course one of the immediate side-effects of arriving at the hospital was the immediate slowing on contractions to every 15 minutes.

Upon arrival, Katie encountered another pitfall of hospital birth, lack of trust that you know what is going on in your own body. You can't blame the hospital, they don't know their patients afterall. She was immediately sent to the triage unit to "determine" if her water really had broken. Silly me, but I always trust that when a woman says "There was a huge gush of cloudy water and I am still leaking every time I move" that she knows exactly what happened to her. Then, because she is a VBAC, an ultrasound is ordered to make sure the baby is not "too big." One might wonder what they would have said is Sarah had gotten an ultrasound at this point, or if she would have been able to birth had they said her baby was too big for her.

Then comes the part of hospital birth that no one ever talks about. Antibiotics. Her water had been broken for 5 hours at this point and antibiotics were immediately ordered to "prevent infection." How does a woman get an infection, you might ask? Very, very few women get infections unless something is inserted into their vagina, like say a hand to check for dilation. Despite the fact that she was barely contracting and her water had been broken and we had unknown number of hours to go, they decided to go ahead and check her. Afterall, we have antibiotics on-board so why worry about infection? 1cm and many many hours to go.

What is the problem with antibiotics? First of all, I believe it is to counteract a couple of problems with birthing at the hospital in the first place. The first of which is having a woman enter into an environment that is full of unfamilar bacteria and virus, all of which have had the incubation necessary to make them into superbugs. The second of which is the incessant need of the staff to know exactly how far a woman is along at all times. You might also be surprised to know that getting antibiotics does not prevent infection. In fact, antibiotics or not, every time you have a vaginal exam after your water breaks, even with a sterile glove, your risk of infection goes up by 20%. That means, whether you have antibiotics on board or not, after 5 exams, you have a 100% chance of getting an infection.

An undesired side-effect of Katie getting the antibiotics was an allergic reaction. Although for reasons unknown to me, the staff claimed it was not an allergic reaction. It manifested in flushing red, rash, and intense itchiness and they "cured" it by giving her a large dose of benedryl. Unfortunately the benedryl effectively stopped her labor completely.

Over the next several hours they conversed with me by phone. Every time it was the same story. They wanted to avoid using pitocin as pitocin increases the risk of uterine rupture in a VBAC mom by 25%. So they walked, she took a bath, she bounced on the ball, she did nipple stimulation, all of which worked until 45 minutes later they were told she needed to lie down in bed to be monitored for another 30 minutes. 30 minutes later they would start the process over again, contractions would get going only to stall out again while being monitored. It was like the hospital was effectively preventing her from getting labor started without the use of medications. Eventually they felt they had no choice but to cave in and allow the pitocin to be used. I might add that the reasoning for this, given by the midwife, was that she was concerned about infection, the very reason they had been talked into getting antibiotics for a few hours earlier, and a condition they obviously do not care to prevent in any other way considering their frequent vaginal exams.

Finally, I could tell they were at the end of their rope. I really should have gone earlier. If I had, I would have discovered hours earlier that their baby was posterior, just as Sarah's first baby had been. I asked if the staff had ever mentioned this to them and they said during the ultrasound they had heard them mention it but only to each other, they never disclosed this information to her. So hours of suffering later and only 3cm, she was asking for an epidural when I got there. I asked her to let me work with her to see if I could get the baby to turn. She agreed. We did several things and lo and behold, he did rotate but 2 hours after the first request she admitted to wanting an epidural and I knew she was at the end of her energy. She needed sleep. At home, if you need to sleep, you sleep. In between surges if necessary or we use herbs to help space out the surges so you can sleep more. In the hospital, sleeping in not allowed, unless of course you have an epidural in place. She received her epidural, along with another dose of antibiotics piggy-backed with Benedryl and she fell asleep immediately.

Several hours later, Katie's husband calls me at home (I had gone home while they were sleeping to catch some shut-eye myself). He says she is 10cm and they will have her start pushing in about an hour. This is at 6am. I knew, as Murphey's Law predicts, that she would want and need to start pushing right at the shift change which would get in the way of getting things started. I was right. When 7 rolled around there was no chance of pushing starting but Katie was still fine to labor her baby down. The baby begins having head compressions at every contraction, a sign that he is low enough to temporarily cut off his oxygen at the peak of every contraction and low her heart rate. An hour later, still no pushing. An hour after that, the midwife is still too busy to even come introduce herself. Finally 4 hours after being declared complete dilation, she is "allowed" to begin pushing. By that point I was feeling very sorry for that baby, who was patiently sitting in his mother's vagina while his oxygen is cut off every 3 minutes.

I found it funny that the nurse explained to the student nurse that the valsalva maneuver is a pushing technique where we have the woman hold her breath for 10 seconds while pushing and that holding the breath for that long lowers the oxygen to the baby. Then, just as though she didn't just say that, she turns to Katie and instructs her to hold her breath for 10 seconds "Don't let your air out at all until I say 10 OK, Hun?" And on a side note, this student nurse was wonderful and ecstatic to be there. It was her first vaginal birth, she had only seen cesareans before this one. So that's how they start them out? Cesareans first, then vaginals...

2 contractions later and the nurse calls the midwife in, saying that she is pushing very well. The midwife rushes in, doesn't even make eye contact, puts her hands in Katie's vagina and says "Give it all you've got with your next one." Well, Katie must have heard her because the very next push, the baby crowned and was born. Bing, bang, boom. The midwife immediately clamps the cord and asks dad if he wants to cut it. He says "Oh we wanted to wait for it to stop pulsing before we cut." to which the midwife says "Oh it already did and I already clamped. No going back now." I was thinking as I see her filling capillary tubes with blood that is literally spurting out from the cord, there is no freakin' way that cord had even come close to stopping pulsating.

Then, immediately after the birth, literally not more than 1 minute later, the midwife introduces herself first (little late!) and tells her she has a tear that needs to be sewn up and thus stitching begins. Forget about enjoying the moment, we've got to get your vagina back in order RIGHT NOW! In a homebirth, we definitely wouldn't do that unless we needed to stop some bleeding. I always wait at least an hour. What's the rush anyway?

The baby nurse come in to wrap the baby up 17 ways to Sunday and put a diaper on his less than 5 minute old bottom. Katie and her husband watch from across the room as their new baby cries in fear from being taken away from his mama. Ask Sarah if her baby ever left her skin and she will tell you emphatically NO! Then another nurse comes in to announce to these new parents that, because her water was broken for "so long" (24 hours) she will need to take the baby to do a full septic work up and CBC. And they will not be leaving the hospital for at least the next 48 hours. Sarah's older son came home later that day to his new baby brother and never spent a night without his mom and dad. Katie's daughter will have to stay with grandma for at least 2 more days, on top of the 24 hours she had already spent away from them.

So what was different about these 2 experiences?

Katie was ecstatically happy with her VBAC but Sarah...Sarah found a new sense of self. She joyfully tells anyone who will listen that she birthed her baby into her own hands. She was empowered, absolutely empowered by her birth.

Sarah never had a vaginal exam, not even one. Her water did not break until a few minutes before her baby was born and if it had, she would never have been subjected to procedures that increased her risk of infection. She would have been in the comfort and safety of her own home that contains bacteria, viruses, and other flora that her body is used to. She never had an IV. Her baby was monitored intermittantly by doppler, which studies show is every bit as safe as intermittant or continuous monitoring by an external monitor. She never encountered anyone at her birth she did not know well. She was allowed and encouraged to be in whatever position was right for her. When I listened to her baby, I found a way to get there without asking her to move for my convinence. When she began pushing, I trusted that her body knew what it was doing and I didn't feel the need to check her to be sure. I knew she was complete because her body knew it was time. Her baby didn't sit in her vagina waiting, nay begging, to be pushed out. He came when he needed to. When he was born, the first 2 people who touched him were his parents. He never once left his parents' side. We didn't weigh him or do any sort of exams until he had breastfed and was happy and satisfied. When we examined him, we did so with his mom and dad lying next to him and we did so with respect. Babies don't have to cry during this portion. They should be respected. And Sarah's feelings about her birth were beyond what any hospital experience could top. She said she now feels like announcing to everyone she passes "I birthed a 9 1/2lb baby into my own hands!" How awesome would that be if she did! I think her husband summed it all up when he spoke about their first birth. He called it a giant clusterf*&k and said the only thing they did right at the hospital was not killing Sarah or their baby. The empowerment in his voice when he talked about feeling his son emerge said everything.

I wonder what Katie will think about her birth in retrospect. She is now just basking in the glory of having a vaginal birth. I feel sorry that she doesn't know how different it could have been. She may have birthed through her vagina but she doesn't have the redemption of "My body isn't broken" that Sarah has. Katie will undoubtedly still feel like her body couldn't have done it without all the assistance. I know that all the "assistance" was needed because of a fundamental problem, not her body, but the hospital. Immediately upon admission, things need to be done to counteract the very situation of being in the hospital. I sincerely hope that she does not come out with the attitude that so many people do. "Thank GOD we were at the hospital!" people say. "What if we hadn't been there??" To that I say, if you hadn't been there, you probably wouldn't have needed any of those things that you feel were such an integral part of your safe birthing. You would have had your birth, you way, and your body would have been allowed to do what it already knows how to do perfectly. You would have been ecstatic.

To Circ or Not to Circ

It was announced this week that the circumcision rate fell from 56% in 2006 to 33% in 2009. There could be several reasons for this, one of them that several states withdrew Medicaid payment for the procedure, siting that it is elective and unnecessary. In fact the American Academy of Pediatrics has gone back and forth over this but for the past few years has remained steady in it's statement that there is no medical reason for circumcision. There have been only a few studies that have shown any sort of benefit and to be honest, when you read the studies, even a lay-person could see that they are seriously flawed.

A friend of mine said recently that she was happy the circ rates are down by so much but that she wonders what will eventually be said to bring these rates back up again. These are money-making procedures afterall and the people who make money off of them are not going to sit idly by and allow profit to just go away. It is so sad to me that things like surgery on a newborn are profit-makers. And before you question it, YES it is surgery!

I have had a few clients who choose to circumcise but many more who do not. I think the initial inclination is to make their boy like his dad but once they learn everything involved, many choose not to. So what is involved? First of all pain medication. Not that I would ever, ever want a baby to not have pain meds on board for a procedure like this but so many people go through hard labors without pain meds because they want to avoid to negative side-effects for their babies. Then 24 hours after birth they are signing the consent form to pump their baby full of medication to alleviate the pain of a completely unnecessary procedure.

Aside from the pain medication, many people do not realize that their precious, long-awaited baby boy will be strapped to a board with arms and legs tied down for the duration of the procedure. I bet all I would have to do is show parents pictures of a circumcision procedure that are in some of my textbooks and they would say "No way in heck am I putting my baby through that."

One of my moms, after a beautiful homebirth, decided she wanted her son to be circumcised. She sat in my office crying a few days later at the horror she witnessed when she insisted on being in the room during to procedure. She said they roughly strapped her screaming son to the board, injected the pain medication and the doctor began to cut before the medication even had a chance to take effect. She said after the procedure, her son was "gun shy" for days. Every time he was picked up, he jumped. Her previously peaceful baby became cranky and, probably most distressful to her, he no longer trusted that his parents would keep him safe.

So knowing all of this, what are some of the reasons parents choose to circ?

• Wanting their son to look like his dad: This is honestly the most common reason I hear. Most moms and dads who say this want to know how they are supposed to explain to their son why his penis looks different than his dads. My answer to that is to tell him the truth. What child wouldn't to hear that his parents spared him an unnecessary procedure?



• Fear that their son will choose to have the procedure later in life and will be in great pain because of it: To this I say that the procedure is the same no matter when it is performed. Will their child have an actual memory of the procedure if it is done at 24 hours? No. But there is a memory of it somewhere in the subconscious. Plus, what is wrong with allowing your child to make their own decision about this major procedure? I know several men who have told me they wouldn't have chosen to be circumcised but this decision was made for them. The decision is irreversible once you have circumcised.



• Not wanting their child to be subjected to ridicule in the locker room: In this day and age, at least 1/2 of all boys are intact making this argument null and void.



• Fear that an intact penis is unclean or may be subject to disease/irritation, etc: As with any part of the body, boys need to be taught how to clean themselves. Obviously it is there for a reason and, just as we trust in our body's ability to birth, we need to trust that the foreskin has a purpose. Once the foreskin can be retracted, at about 2 years of age, it is as simple as teaching them to pull the foreskin back and clean underneath. Several moms I know that have intact boys have told me there is no need to actually teach this because they just naturally do it.

Other things to think about:

• No form of female circumcision is considered OK in the US. In fact it is called female genital mutilation. It would never be considered acceptable to remove all or part of the clitoral hood, which is the female equivalent to foreskin. Why are boys any different?



• A boy loses over 10,000 nerve endings when the foreskin is removed. Yes the feeling is fine without, as I have been told by many circumcised males, but removing 10,000 delicate nerve endings from a very sensitive part of the body has implications which we may not yet understand.



• There can be an interruption in breastfeeding if the procedure is done too early in life. At 24 hours of life (when many circs are done) the baby has not yet learned to use the breast for comfort and thus may not breastfeed because of continued pain. Waiting a few days changes this risk but also changes the number of circs that take place. Why? Because parents become fully bonded to their boys and are less likely to subject them to an unnecessary procedure.



• The uncircumcised male often takes on a look more like a circumcised male at puberty. The foreskin can actually retract over the head of the penis, giving the boy a circumcised look once the penis grows larger.



• There are risks to the procedure that no one seems to ever talk about. There is a risk of infection. There is a risk of hemorrhage. There is a risk of undesirable cosmetic appearance. Did you know there is even a risk of losing the penis all together??? It is a very small risk but how could you live with yourself if you chose for your son to have a procedure that ended in the loss of his penis? How could this be explained?

These are all things that I wish people would think about before they decide to have a circumcision. I find that when people can rationally think about these issues, they almost always choose not to circumcise. Need more info? http://www.nocirc.org/

Mentoring the Mentor

I've been reading this book called Sacred Contracts by Caroline Myss and it has totally changed how I think of myself, my place in this world, and who my tribe is. The book is all about how each of us has several archetypes which influence our personality and our actions. We can live in the shadow aspect of these archetypes or in the light of them. Through this reading I have found that one of my archetypes is that of the mentor. I can remember "mentoring" other kids as far back as elementary school. In first grade, I took a so-called "troubled" boy (really I think he was just a normal, kid who couldn't sit for 6 hours straight) under my wing and mentored him. All I did was talk to him and told him something along the lines that I knew he wasn't a bad kid and I knew he could do better. And lo and behold, he did! I was 7 years old.

There have been many more people on my path that I have mentored in one way or another and honestly, I thrive in it. There is nothing better than giving a few words of encouragement, sending intention, and hearing later that those very words and support changed someone's life for the positive. It's not the thank you that I need. What I need is the knowledge that a few words of encouragement can spur someone into self introspection and that they themselves do the work that is necessary to change for the positive.

But I do believe that one cannot go about only being a mentor. A mentor needs a mentor, or probably more accurately, several mentors. I have myself had several over the years and this weekend I met another one.

I've read several things written by Dr. Michel Odent and was surprised that I agreed with nearly everything he said regarding natural birth, even though I came to my conclusions based on my own experience. It is always cathardic when someone else observes the same thing and comes to the same conclusions. I was very interested when I learned that Dr. Odent was going to be speaking at the DONA conference, especially when I read that his topic was about re-evaluating midwifery practices.

There were so many things that spoke to me in his talks but most of all was his reminder to me that midwifery is fundamentally supposed to be about selective care, not routine care. We should treat each woman as an individual, because she is! As soon as we start making arbitrary rules about what the supposed line of health is, we weaken midwifery a little more. Right now the rules say you are only within normal limits if you go into labor sometime between 37 and 42 weeks, if your baby is head down, if you only have 1 baby, if you are not "infected" with GBS, if you do not have gestational diabetes, if you hemoglobin/hematocrit levels are within the proper range, if, if, if. What happens when we, as Dr. Odent suggests, use these limits as a sign to increase vigilance. We use watchful waiting. We give positive emotional support and make sure the woman does not feel that there is something wrong with her body. What if we teach her how to check in with herself and her baby, something many women don't know how to do and something that could arguably help her long beyond pregnancy.

Dr. Odent spent great length answering my question regarding care for women when they approach 42 weeks. It is never my choice to push an induction, even if it is a "natural" one. Mostly this comes from the fact that I myself went beyond the 42 weeks mark, albiet by just 1 day. I knew there was nothing wrong, that it was normal for my body and my baby, and mostly I knew that my baby was healthy and knew the right time to be born. It is interesting to me how few people truly believed that as I was going through it. Of course few people actually spoke to me directly about it but I heard the whisperings of "How late is she going to go? Can you go past 42 weeks? Do you think she's really OK?" I know that there was pretty much no way that I was going to do anything to "augment" my labor, even if it was supposedly natural. So I have a very hard time telling someone else that they should.

After spending such time in answering my question, I felt that tingling of what I know others feel when I speak to them as a mentor. I can see it in their face that I am saying something that is hitting them on a very deep level. I can see the change starting to happen, the wheels beginning to turn. I wonder if he saw that in me.

After the workshop, I was sitting at a table of friends eating my lunch when I hear from behind me "Ahem, pardon me, is anyone sitting here?" and who do I see but Dr. Odent himself plopping down in the seat next to me. We discussed a few more things but the change had already happened for me. Don't get me wrong, I was honored! But, I didn't need any more from him. I already got the tell-tale changing phrase that started the wheels cranking in my head. Thank you Dr. Odent for mentoring the mentor!