February 15, 2006
Volume 8, Issue 4
Midwifery Today E-News
“VBAC/Cesarean Prevention”
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Send submissions, inquiries, and responses to newsletter items to: mtensubmit@midwiferytoday.com.

In This Week’s Issue:


Quote of the Week

"We must work to make the pursuit of birth happiness a feasible option for as many women as possible, in as many ways as possible."

Jennifer Rosenberg


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The Art of Midwifery

To help prevent malpresentations, I advise pregnant women not to cross their legs. Nearly every woman I see crosses her legs when sitting in a chair. When doing so, the pelvis tilts backward as the spine makes a nice sling for the baby and—in many cases—instant posterior presentation! I've attended many easier births since I became aware of this situation and pointed it out to the mums I work with.

Megan, Midwifery Today Forums


ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com.


student specialSubscription Sale for Students!

Special prices on Midwifery Today magazine and The Birthkit newsletter OR BOTH! Act fast! This offer expires March 1, 2006 (postmark or fax by the expiration date).

Passionate Midwifery Education

We are introducing a new regular column in Midwifery Today E-News to help you with your education to become a midwife. I think doulas and educators will also find it helpful. It is aimed mostly at aspiring and student midwives. You are our hope for the future. Of course, since we as midwives are always learning, there will be suggestions for furthering your education even if you have been a midwife for decades. This column is designed to get you started with your education as well as bring up and discuss the many issues we grapple with as midwives. I plan to bring you hints for self-study as well as ideas about formal schooling.

When I became a midwife almost 30 years ago there were very few choices for getting a midwifery education in the United States. We made up our education process as we went along. We were doing births in our small homebirth practice, "The Birth Coop," with women who were determined to have their babies at home—with or without a midwife. Within the cooperative were a few "midwives" who had attended 20–35 homebirths, and the rest of us with passion and enthusiasm. Marion Toepke McLean offered us classes in midwifery skills. I organized various people from the community to teach us the weeks Marion was off. We had an obstetrician, a pediatrician, nutritionists and other specialists teach us various subjects. It was a unique way to get an education, workable for the time. It is still possible to become a Certified Professional Midwife (CPM) completely through apprenticeship. However, there are so many varied education routes, I hope you will consider them all.

It is important that you get the kind of education that will let you practice as you want. Midwifery Today's book Paths to Becoming a Midwife gives a full discussion of routes of entry. The chapters "Getting Started," "Politics and Philosophies," "Direct-Entry Midwifery" and "Certified Nurse-Midwifery" are an excellent resource for aspiring midwives. Elizabeth Davis's book Heart and Hands became our "Midwifery Bible" both for our own education and to give pregnant moms. It has been recently updated. I would suggest you get this book for its wide coverage of the many issues within midwifery as well as its discussion of sound clinical practice.

This column will also be of help to student nurse-midwives and midwives from around the world, especially when feeling bogged down in the medicalization of birth. This column is designed to help us all know more natural ways to handle pregnancy and birth care. It will lead you to other places of inquiry: books, Web sites, and articles on the Midwifery Today site and others. Since we are all life-long students, I hope it will be of service to all. If you know of a great Web site, book, article or tip for education or midwifery practice, please let me know. Midwifery education is so very important because this is where we learn to really care for and love the women we serve. It is vital that we experience good models for caregiving early on so that we know how to treat motherbaby in our own care later on.

love, Jan
Jan Tritten, Mother of Midwifery Today

To read all installments of Jan's column on midwifery education, go to our Better Birth and Babies Blog.


Paths to Becoming a Midwife: Getting an Education can be ordered.

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VBAC/Cesarean Prevention

Why should VBAC work in America? American obstetrics doesn't work! What can you even begin to say about a country with an American College of Obstetricians and Gynecologists (ACOG) conference entitled "Promoting Medically Unnecessary Cesarean Sections"? We rank 24th in the world: 23 other countries have better birth outcomes than we do. And the countries with the best outcomes use midwives and encourage out-of-hospital births.

Many obstetricians didn't understand certain aspects of successful VBAC—excellent nutrition, the absence of fear, the importance of the energy in the birth room, and faith in the birth process. Many of them told women they had to have their babies by 40 weeks, or they would be induced. Since more and more women were having/demanding VBACs, that was where the money was, and doctors began to get more comfortable with the idea. For doctors, VBACs equaled more time with less money, less power and less control. OBs who were attending VBACs were merely "baby catchers"—something any ol' midwife could do; performing surgery was lucrative and awe-inspiring. They could schedule cesareans at a time that was convenient for them, instead of possibly being disturbed in the middle of the night. They couldn't understand what was so important about a vaginal birth, and they oftentimes used scare tactics to get women to…agree to schedule a repeat cesarean. They accused women who wanted normal deliveries of compromising the health and well-being of their babies for their own aggrandizement and at the expense of their babies. Of course nothing could be further from the truth.

…The more comfortable they became with VBAC, the more risks they began to take. Before, no one ever induced a VBAC woman, and certainly no one every used Pitocin, but now, Pitocin was used frequently. There has been an increase in uterine rupture with the advent of induction and Pitocin. I find it incomprehensible and wicked that instead of understanding how obstetrical directives create problems and decrease the safety of VBAC, obstetricians in the United States believe that the danger is inherent within VBAC. In fact, it has come to our attention that instead of taking the time to suture the incised uterus in layers, doctors have been taught a "short cut" technique that uses only one layer. This method compromises the integrity of the scar and predisposes a woman to greater incidence of uterine rupture. So now they can tell you with a straight face that VBAC is dangerous: they are making it so.

…Life has risks. Not everyone who plans a VBAC will have one, and not everyone who has one will have a perfect experience. Some women who desperately want VBACs end up with repeat cesareans. But after almost 30 years of researching, writing, counseling and teaching cesarean prevention and VBAC, I know that most women can have safe, gentle, sacred, delicious VBAC births, and that they are safer than repeat cesareans. It is a travesty that the majority of sections and repeat sections are unnecessary. It is a tremendous sadness when women have been so indoctrinated with fear about birth that they choose numbness and technology to "get the baby out" rather than their own power and efforts.

Nancy Wainer, excerpted from "A Butcher's Dozen," Midwifery Today Issue 57


Factors that Increase the Risk of Uterine Rupture

In several large studies of VBACs, the following factors were seen more frequently with uterine rupture: prostaglandin cervical ripening, Cytotec/misoprostol ripening, induction of labor, use of Pitocin, failure to progress, forceps/vacuum and epidurals. A recent study showed that rates of uterine rupture are 3.0 times higher when the trial of labor is less than 18 months after the cesarean, suggesting that good scar integrity requires adequate time for healing before the next pregnancy. While home VBAC does create time and distance barriers to responding to a crisis, home VBAC does not introduce iatrogenic risk. Home VBAC with rapid access to surgical intervention may be safer than interventionist hospital obstetrics with VBAC, but there are no data that midwives may cite to support that assertion. The ACOG Clinical Management Guidelines and most obstetricians do not acknowledge most of the iatrogenic risks listed above, even though several retrospective studies have shown statistical significance. A recently published study actually looked at rupture rates in VBACS after one previous c-section. They found that the rupture rate was 0.4 percent in spontaneously laboring women, while the rate was 1.0 percent in oxytocin-augmented labors and 2.3 percent in induced labors. A growing body of retrospective studies suggests that meddlesome obstetrics increases the risk for VBACs, which suggests that the midwifery model of care is safer for women seeking VBAC.

Heidi Rinehart, MD, excerpted from "A VBAC Primer: Technical Issues for Midwives," Midwifery Today Issue 57


The answer to the question "How safe is cesarean section [CS]?" depends on who is answering. If a CS is done, the woman and her baby take the risks while if the CS is not done, the doctor takes the risk. This helps explain why documented risks to the woman and her baby are not widely discussed and often not presented by doctors.

The most reliable maternal mortality data come from the UK Confidential Enquiries into Maternal Deaths. While it may have been obstetric politics which promoted the omission of the usual chapter on maternal mortality with CS from the latest report (1998), two scientists calculated the rate from data in the report. An elective CS with no emergency present had a 2.84-fold greater chance of the woman's death than if she had a vaginal birth. Since a randomized controlled trial is not ethically possible, the UK data on 153,929 elective procedures give powerful enough evidence of the increased risk of maternal mortality with women's choice elective CS.

Other risks include the morbidity associated with any major abdominal surgical procedure (anesthesia accidents, damage to blood vessels, accidental extension of the uterine incision, damage to urinary bladder and other organs). Twenty percent of women develop fever after CS, most due to iatrogenic infections. There are also risks due to scarring of the uterus, including decreased fertility, miscarriage, ectopic pregnancy, placenta abruption and placenta previa. Widespread use of the unapproved drug misoprostol for labor induction has created a new risk. Women attempting VBAC who are given misoprostol have a rate of uterine rupture of 5.6 percent compared with a rupture rate of 0.2 percent of women attempting VBAC not given misoprostol. All of these risks affect subsequent pregnancies even if the original CS was not an emergency.

Marsden Wagner, MD, excerpted from "Choosing Cesarean Section," Midwifery Today Issue 57


MIDWIFERY TODAY ISSUE 57 is available for purchase. This issue, which includes 15 articles having to do with cesarean prevention and VBAC, is an important resource for birth practitioners and for pregnant families. Issue 57


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Research to Remember

Kangaroo Care

An Israeli study of kangaroo care (KC), which is postpartum skin-to-skin contact often recommended for premature infants, sought to evaluate its effect on neurobehavioral responses in term infants. Forty-seven mother-infant dyads were randomly assigned to a KC group or no-treatment standard care control group. KC began at 15 to 20 minutes after delivery and continued for one hour. A one-hour observation conducted four hours postpartum of all the infants revealed that the KC infants slept longer, were mostly in a quiet sleep state, showed more flexor movements and postures and less extensor movements when compared with the standard-care infants. The researchers concluded that KC seems to influence body state organization and motor system modulation shortly after delivery.

Pediatrics, Vol. 113, No. 4, April 2004

Bugs for Your Baby

Consider the idea that coming through the birth canal to enter the world exposes a baby to good bacteria necessary for colonizing the digestive tract. As time goes by, we continue to learn many things like this, which we had previously unlearned or discarded as useless. For example, routine epidurals are harmful rather than helpful, babies who are born naturally do better in many ways than those born by c-section, and breastfeeding is better than formula. Jeff Leach shares some more of this kind of knowledge with us in his new pocket guide "Goosebumps, Nipples and Tails: C-sections, Breastfeeding and Bugs for your Baby." Check out this fascinating read, or a shorter article, at: www.gutfeelingcolumn.com/intelligent_nutrition_Pocket_guides.htm


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Midwifery Today Issue 76 Are you passionate about birth? Then you need MIDWIFERY TODAY magazine. This 72-page quarterly print publication will satisfy both your mind and your heart. Open its pages to find in-depth articles, birth stories from around the world, stunning birth photography, news, reviews and more. Give yourself a subscription!


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Forum Talk

I don't understand, that if a woman at 28 weeks shows that her hemoglobin (HGB) dropped by 2 or at all, then that's a good sign and it shows good blood fluid volume, but since she is pathologically anemic she knows to take iron, her HGB would then go up, so how do you really know if she does have good fluid volume? Please explain in depth.

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Question of the Week (Repeated)

Q: What do you do to encourage women to trust birth?

— E-News staff


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message. Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


Think about It: Cesarean Section

While it is symbolic that the only Barbie model that gives birth does so through her abdomen, the escalation of cesarean rates illustrates more than women's self-loathing. It takes two to do this tango. Obstetricians, "relentlessly driven to control the unpredictability of pregnancy and birth," must accept responsibility as the dispensers of cutting-edge technology. Dr. [Germaine] Greer views the rise in cesarean rates as part of the widespread cultural assault on women's bodies and more specifically, a transfer of the ritual mutilation of the vagina (through episiotomy) to the mutilation of the uterus itself. Surely, cesarean rates approaching 25 percent cannot be medically justified. As Dr. Greer points out, "Much of what is done to women in the name of health has no rationale beyond control."

Insult is added to injury when women, who labour but end up delivered by cesarean, are told that their bodies (their pelvis, uterus or cervix) are to blame. The truth is that induction, analgesia, electronic fetal surveillance, an unfamiliar environment and lack of continuous labour support all interfere with the sensitive process of labour and affect the outcome. Dr. Greer reminds us that "blaming the victim for the crime is a pattern of injustice very familiar to feminists."

Karen Robb, excerpted from the article "Thank You, Germaine Greer: A Midwife Comments on Greer's bestseller, The Whole Woman"
Midwifery Today Issue 57


Readers, what do you think? E-mail your thoughts to: E-News at mtensubmit@midwiferytoday.com Enter the words "Think about It" in the Subject line.


Feedback

What a fantastic topic for the newsletter [Prenatal Ultrasound: E-News Issue 8:2]! Perhaps it could be made into a whole issue? Or has it? I let my subscription lapse a few years ago because I am not a midwife and my focus is on, well, simplifying birth rather than on what midwives do. But I see from this newsletter that there are at least a few back issues that I need to have.

Linda Hessel

Editor's Note: Are you missing back issues of Midwifery Today print magazine? You'll find them here.


Only letters sent to the E-News official e-mail address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.


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