Tuesday, June 15, 2010

NIH VBAC conference

In March, the National Institute of Health had a conference to assess the research in regards to VBAC and then made recommendations based on that assessment.

An AAMI student, Jessica, has separated the video that the NIH made available into easily watchable segments for anyone who might be interested:
VBAC New Insights Conference

I watched the entire conference. The presentations that I found most illuminating were Day 1 (#4) Overview of the Topic by Caroline Signore, MD and Day 1 (#12) Delivery after Previous Cesarean: Long- Term Maternal Outcomes by Dr. Cathy Spong.

NIH VBAC Conf, Day 1, #04 - Overview of Topic from Jessica, BirthAction Webmistress on Vimeo.

For those who may be unfamiliar with the issues surrounding VBAC- it is becoming increasingly difficult to find a care provider and/or institution that are willing to attend VBAC labors. Women are being forced to schedule repeat cesareans without being "allowed" a trial of labor. There are several reasons for this, the most cited is because of ACOG's recommendation that anesthesia be "immediately available" in case uterine rupture occurs. Many hospitals have instituted VBAC bans because of this policy, indicating it would be unsafe to attend VBACs because they didn't have anesthesia immediately available should something go awry.

There is no doubt that uterine rupture can be an obstetrical emergency. If it is caught too late, death or HIE can result. But, it is not the most common obstetrical emergency. Let's look at some numbers from Dr. Signore's presentation:

fetal/neonatal death following UR during TOL: 0.011-0.04%
HIE following UR during TOL: 0.046%
fetal death following midtrimester amniocentesis: 0.06- 0.5%
fetal death from cord prolapse: 0.01-0.06%
perinatal mortality from placental abruption: 0.7%

These other obstetrical risks are as high or higher than the risks involved in having a VBAC. And yet, there are not prohibitions against amnios. And there are no prohibitively stringent anesthesia policies for labors which are at risk of abruption or cord prolapse, which is to say, all labors. Hospitals tout themselves as the safest place to give birth, all the while saying they don't have adequate resources to deal with VBAC labors . If they aren't safe for VBAC, they aren't safe for any other labor in which an obstetrical emergency might occur.

The second presentation I mentioned, by Dr. Cathy Sprong, addressed the long term maternal outcomes of the various modes of delivery after a previous cesarean. The simplified version is this: the more cesareans you have, the higher the risk. For those women who are planning larger families, this is extremely important information. Too long the maternal risks of repeat cesareans (or multiple repeat cesareans) have been downplayed. It also makes a good case as to why the primary cesarean is a big deal and should not be taken lightly. The segment is 20 minutes long but it is so important.

NIH VBAC Conf, Day 1, #12 - Dr. Cathy Spong from Jessica, BirthAction Webmistress on Vimeo.

Thursday, July 24, 2008

Vaginal Exams (Part II)

We have discussed how a vaginal exam is performed and what it measures, along with the pros and cons of vaginal exams prenatally. In this post, I want to discuss vaginal exams during labor and birth and their impact on the birth process.

What is the point of a vaginal exam during labor? In a typical hospital birth, labor is "supposed to" follow a pattern, called Friedman's Curve. Here is a chart depicting what is expected of a laboring woman's cervix:


This typically equates to the cervix opening about 1cm an hour. And so, dilation is usually checked about every hour, to make sure a woman is following the curve. If they are not, their labor is labeled "dyfunctional" and often, pitocin is used to augment labor. If that doesn't work after a few hours, this is where the diagnosis "failure to progress" comes in and a cesarean is performed.

The problems with this? There are many. The most glaring being that Friedman's curve is based on averages. What do we know about averages? That they are the mean, that there are normal labors that are shorter and there are normal labors that are longer. It is ridiculous to put a time limit on a physiological process, as long as mother and baby are doing well. It is based on the idea that Birthing Woman are Machines.... if the Machine doesn't dilate X number of cm in X amount of time, the Machine is dysfunctional and we try to "fix" it. If the Machine won't be fixed with pitocin, it must be broken, so let's open it up and do a baby extraction.

So many things are involved in birth, the position of the baby, the strength of the contractions, the mother's comfort and mental readiness for birth. Because the medical establishment likes to believe that the mind and body are separate, it completely discounts that if a woman is uncomfortable in her surroundings, her labor will not progress smoothly. But we are mammals. Most mammals make their nest and need darkness, privacy and quiet to birth. If they are disturbed, labor stalls. Humans are the only mammal that make their nest and then leave it to give birth. It is no wonder labor often slows down once a woman gets to the hospital (or when the midwife arrives at the home in some cases), the mammal part of her says, "New environment, people poking me and asking me questions, not a safe place/time to birth"

The physical aspect of it is that it can be, and often is, very painful. During a time when a woman's body is trying to open up and push down and out a baby, fingers up into the vagina are invasive and counterproductive. In addition, the more vaginal exams, they higher the incidence of infection, especially if the water is broken. If the bag of waters breaks before labor starts, one of the most harmful things a care provider can do is a vaginal exam. As long as things stay out of the vagina, the risk of infection is minimal, but as soon as anything foreign is introduced (sterile gloves included), the risk goes up.

The psychological aspect of vaginal exams during labor is that they can be extremely discouraging if things are not progressing "normally" The language used during vaginal exams is often negative... only 3, just 7, not quite 10 cm. And let's go back to the fundamental truth about vaginal exams that we discussed last post: They only tell what the cervix is doing at that moment. There is no accurate predictor of how long the rest of labor will take. It is entirely possible to go from 4 or 5 cm to complete and pushing in a matter of minutes. In the absence of an actual problem (and a long labor is not a problem) it is a completely pointless procedure.

Wednesday, July 16, 2008

Vaginal Exams: Helpful or Harmful? (Part I)

For our purposes, let's break this into two categories: vaginal exams during pregnancy and vaginal exams during labor/birth.

And what is a vaginal exam? A woman's care provider inserts his or her two fingers into the vagina in order to ascertain the following information:
Ripeness: The cervix goes from being firm (like the tip of the nose) to soft (like the lips)
Dilation: How far the cervix has opened. It starts closed and opens to 10 cm
Effacement: The thickness or thinness of the cervix.

Station: How far the baby is engaged in the pelvis. Measured in relation to the ishchial spines in the mother's pelvis. 0 station is engaged. Negative numbers means the baby is not engaged in the pelvis and postive numbers means the baby is past the ischial spines. +4 is on the perineum.

Postion of baby: If the woman is far enough dilated, the baby's position can be ascertained by feeling for the fontanels (soft spots)
Position of cervix: The cervix moves from posterior to anterior

Now that we have a good idea of what exactly a VE is, let's look at vaginal exams during pregnancy. Care providers that practice within the medical model of care often start doing vaginal exams at 36-37 weeks of gestation. This can be a helpful practice, but is largely harmful. Let's look at the positive aspect of it. A woman may feel heartened to hear that her cervix is changing in preparation for birth. Especially if there is progress over the weeks leading up to birth. And encouragement is a great thing in those last, trying weeks of pregnancy.

Why is it harmful? From a physical standpoint, anytime anything foreign is inserted in the vagina, you run the risk of infection. There is an increased chance of rupture of membranes. But what I think is even more detrimental is the havoc it can wreak on a pregnant woman's emotions. It is not an accurate predicter of when labor will begin. The only thing a vaginal exam tells you is what is going on in your body at that moment. Many a woman has been largely discourged because she was 3 cm dilated at 37 weeks and is still 3 cm dialated at 40 weeks. Conversely, a woman's cervix can be closed and firm and she can have a baby a day later. And vaginal exams are often painful.

In the absence of a suspected problem, vaginal exams during pregnancy do more harm than good. If the goal is to satisfy curiosity, it is possible for a pregnant woman to check her own cervix. It is less risky this way, since we are accustomed to our own germs And it can be empowering for some woman. Why go to a doctor or midwife for information you could obtain for yourself?

I'll continue this post soon. Part II is Vaginal Exams during labor and birth

Thursday, December 13, 2007

Question CPD

There is a large number of cesareans being performed with the diagnosis being CPD (cephalopelvic disproportion). This is when the baby's head is too large to pass through the mother's pelvis.

And in most cases it is a completely bogus diagnosis. Sometimes this diagnosis is made without the woman even laboring! In the absence of a pelvic deformity there is no way to know whether a woman can birth vaginally until she has labored and pushed in positions of her choosing with a baby that is presenting correctly.

The diagnosis is made during labor sometimes because of a care providers failure to wait or a malpositioned baby.

This video shows women who had their first cesareans for "CPD" and then went on to birth vaginally, often giving birth to babies that were larger than the one that was supposedly too large to pass through their pelvis.

Very rarely does a woman's body grow a baby too large for her to birth.