A Spectrum of Pregnancy, Birth & Parenting Services to Meet Your Needs

After working with San Luis Obispo families for over 20 years I am more strongly committed than ever to helping families find what feels right to them for pregnancy, birth and parenting. I have a broad perspective and a depth of knowledge which is grounded in the work I have done with families making a wide variety of choices. As a doula I have been blessed to be part of over 100 births. Working beside doctors and midwives I have witnessed inspiring births both in and out of the hospital. As a birth educator I have impacted the births of several hundred babies and through my work with the Birth & Baby Resource Network, La Leche League, and the International Cesarean Awareness Network I have touched the lives of countless families in our community and beyond.

I offer a variety of support/education options to match your unique needs. Our journey together may start at any point along the spectrum. Please feel free to mix and match and make the exact support and education package that meets your needs. All classes are offered both as group or private experiences with flexible schedules.


Before You are Pregnant

Private consultations over tea: learn about options & resources in our community or review and process a past birth and discuss possible effects on future births. We can meet in the privacy of your home or at a coffee shop.                              

 

Early in Your Pregnancy

Classes: learn how to nurture your body, your baby and your relationships in my Healthy Beginnings/Healthy Choices classes.

                                                        

Preparing for Your Birth

Classes: My small group classes held, in the privacy of a home, foster a sense of belonging as we eat, laugh, learn and share together this amazing adventure. My Heart, Mind & Body series empowers and inspires you to create the birth you want.

For each class group I create a private on-line community for extended sharing of ideas, inspiration, connection and support which continues until your baby is sleeping blissfully in your arms.

Labor Land Practice: My Birth Connection Date Nights are serene spaces where all learning is experiential through relaxation, guided imagery and touch. The focus is encouraging oxytocin, the “love hormone”, to flow between you, your partner and your baby, and to teach you how to move through labor land together. These “practice” sessions are ideal for experienced birthers, homebirthers, or as an expansion of more intellectual birth classes.

Private Classes in Your Home: Every family has different needs; bed resting moms, changing schedules, or simply a desire for privacy. I try to be as flexible as possible to let you create your unique education package. Let my Class Outline be your guide. I am happy to create a series just for you!



Doula Service: I am happy to join your birth team no matter where you are planning to birth; home, birth center or hospital. We start building a trust relationship with prenatal visits in your home. Through listening I learn what you need and want to feel confident about your coming birth. I facilitate thinking and dialogue between partners to help clarify and prioritize what is important to them and help craft a birth plan which reflects these values while being well received by your care provider and staff.

I am available via phone, email or Facebook to answer questions and lend support throughout the pregnancy.

                    Once labor begins. . .

 I will stay continuously by your side
 where ever you are laboring until. . .

your baby has arrived. . .

and is blissfully breastfeeding for the first time!

I will visit your home a few days after your birth to ensure breastfeeding is going well, check on your postpartum recovery, and help you process your experience with tears, talking and laughter. I will answer questions, clarify and enlighten you on issues you may not have understood. I want you to have a thorough grasp of what happened, why, and how necessary it was, to empower you for future births.

After Your Birth

Private consultations over tea: When women suffer after a difficult birth experience it is very helpful to share your story to a listening heart who is knowledgeable enough to review your birth, answer your questions, and help you move forward in your process. I can connect you to resources for your recovery and discuss things you will need to think about for future births.

Private Postpartum Visits: I believe new mamas need to rest and adjust to motherhood in the comfort of their home. I am happy to travel to you. The first days and weeks of parenthood many new families need some additional guidance. A little hands-on help from an experienced mother/doula can give a new mama just the boost of confidence she needs.

Welcome to the parenting community!

Classes: My Fourth Trimester Parenting Support group meets every Tuesday from 10:30-12. I provide this free to the community because I believe deeply that women need support during this important transition in their lives to grow fully into confident motherhood.




Support Group: I lead a La Leche League Mothers’ Meeting once a month in the South County which is free and open to all mothers for breastfeeding advice and support.

 

Loving Guidance Workshops: These periodic workshops cover my Five Steps to Creating a Healthy, Happy, Whole Family empowering parents to move through the normal ups and downs of parenthood, take control of their own learning, and make their own decisions on how they wish to parent.

Support Group: I created “Whole”istic Mamas and Papas to provide community for families choosing to parent from an alternative point of view; attachment parenting, co-sleeping, extended nursing, baby wearing, individual vaccination choices, homeschooling, etc. It is a safe space; both in our face-to-face play day meet ups and private on-line group for asking questions, gathering information, sharing and learning from each other.













Parenting is much more fun when we share and play with others!

Let's connect! I am happy to answer questions and get you started on just the right path for you.            Call: 805.459.8145
jenniferstoverdoula@gmail.com

What a VBAC Calculator Shows

This morning I noticed this intriguing post in our local ICAN group's Facebook page:

I know this isn't an active group, but this is the only one of my groups where it seems appropriate to post this. Does anyone know where I can find info about the VBAC rates for home births and hospital births? I found this cool VBAC calculator, but it doesn't account for birth setting.https://mfmu.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbirth.html

A Vaginal Birth After Cesarean calculator? Really? So I decided to try it.

It is always important to know who you are playing with so I investigated who created this calculator. OK it says it is based on data collected from an article "Development of a nomogram for prediction of vaginal birth after cesarean". A nomogram? Huh? That is just a geometric way of looking at multiple variables. The data set came from the Maternal-Fetal Medicine Unit Network. Here is their mission statement: "The MFMU Network conducts clinical studies to improve maternal, fetal and neonatal health emphasizing randomized-controlled trials. The aims of the Network are to reduce maternal, fetal and infant morbidity related to preterm birth, fetal growth abnormalities and maternal complications and to provide the rationale for evidence-based, cost-effective, obstetric practice." They are a network of university based hospitals. These teaching hospitals are where the births happened that form the statistics to base this calculator upon.

First the questions they ask to help them calculate are telling. They want your age and body mass index. Don't know your BMI? Don't worry they'll calculate it for you. They want to know if you have a "proven pelvis". What's that? It is a woman who has either had a vaginal birth before or after a cesarean. In other words at some point a baby "fit" through. They want to know if your cesarean was for lack of progress dilating, lack of progress moving the baby through your pelvis or some other reason. Other reasons could be twins, breech, high blood pressure, fetal distress, maternal fever, etc. They just lump all the other reasons into one category. Most distressing to me are their questions about race. They break it down by African-American, Hispanic and all others lumped together. What the hell? What on earth should race have to do with it?

So here is what I found when I did some calculations.  I kept all other factors the same except the one I was looking at. Trying to compare apples to apples. Let's look at age first.

Age 
They obviously feel age matters. I changed the age from 18 to 30 to 35. 
I had between 7% to 10% less chance of successfully VBACing at 30 than at 18 years old. The low end reflects women who progressed on their predetermined schedule. The top end reflects women who fell off the time chart plus were heavier. At 35 it drops again. Now I have 10% to 15% less chance depending on the other factors. Ugh! Obviously age is NOT something you can do something about or can you? How many 35 year-olds do you know? I have worked with many and some have the physical health of a 40 year old while others could pass for being in their twenties.

Weight
By adding 70 pounds to a white woman with no previous vaginal births and allowable progress during labor/pushing she has lowered her chances of VBAC success by 12%. If she had a "failed" labor the numbers move down to 16% because of the additional pounds alone. This may make some sense because weight can cause confounding health issues, such as high blood pressure.So if you want to VBAC stack the decks in your favor by starting at a healthy weight. Oh wait! If you want to avoid that first section be a healthy weight before you get pregnant and then work with someone who knows about pregnancy nutrition to stay on track.

Arrest of Labor
This is defined as absence of progress. So of course one must FIRST note that progress is a very subjective animal. The good news is this calculator says if you had a surgical birth for arrest or "failure" either during dilation or pushing your chances are only 9% to 12% less than the woman who didn't. As a doula I know it is critically important to look at WHY you stopped progressing or weren't progressing fast enough. Was the baby in a poor position? Was this a failed induction? Why were you induced? Too long past due date? How far was too long? Baby "suspected" of being too large? How large was he or she really? Induced for other health concerns, blood pressure, diabetes, etc.? Perhaps your water broke and labor didn't start quickly enough so you were given labor initiating drugs. Did you have an epidural? At what point in the labor? I can't stress how important it is to obtain ALL your records and to go over them with an experienced doula or midwife. Perhaps your "failure" to progress was actually THEIR failure. 

Race
Here is where they doubly fail women. Be prepared to get angry.
I went back and changed only race as a factor. So let's look back at the age issue WITH race added in. If I am a 30 year old woman of color I had a 10 to 16% less chance than an 18 year old. While a white 30 year old has a 7% to10% less chance.  And at 35 I as a white woman would have 10% to 15% worse odds but as a woman of color it plummets to a 21% less chance of success. Excuse me? What about race with weight? If I am a 30 year old white woman with healthy weight, no vaginal births and no "failure" the calculator predicts I have a 80% success rate in their hospitals. That same woman of color? 67.2%! That is a difference of about 13%. If  I am 70 pounds heavier I have a 16% worse chance of success than my white sister. 

So now I compared the best case scenario; 18 years old, healthy weight, no arrested labor c-section, vaginal birth before and after surgical birth, White to Black or Hispanic. Shockingly the numbers say a woman of color automatically gets 4% worse chance of birthing vaginally. That my friends is systemic racism in its most insidious form. It is in how they are treated from the moment they are in their doctor's offices until the moment they are discharged from the hospital. I have witnessed this unequal treatment. Every time it has angered me. Usually it appears to anger me more than the woman trapped in it. Perhaps because she has only her own experience to compare, whereas I can compare her to the white women I have supported. But here the numbers are; in black and white for all to see. A disgrace.

I did not intend for this to be a post about race. I started in thinking I was going to check out this calculator and compare hospital stats with homebirth stats. But the numbers took me a different direction. Here are two links for those of you who wish to compare homebirth and hospital birth numbers. They were posted by Terri Woods of SLO Doula Connection  in response to the ICAN query. She rightly warns that homebirth midwives automatically risk out a variety of complications and so it isn't exactly apples to apples. Still it is worth noting that out of 1,354 VBAC women 87% were successful. There is no way for me to do a straight comparison because I don't know anything about age, weight, reasons for prior sections or if they have had a vaginal birth either before or after their surgical birth. 

Science and Sensibility looks at the MANA homebirth study 

Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009

Planning to VBAC? Hire a doula. Plan a home birth. Hire a midwife. Get healthy and stay healthy. Finally question, question, question; especially if you are a Black or Hispanic woman. 

Consumer Reports: Cesarean Births

“How you deliver your baby should be determined by the safest delivery method, not which hospital you choose.” 

I couldn't agree more with this statement. Consumer Reports is beginning to tackle the issue of our disproportionate cesarean rate. The World Health Organization has determined that NO region, area or country should have a higher rate than 15% rate. Currently the US has a rate twice that and California's is even higher. The rate is "up 500 percent since 1970. All those C-sections have not translated into substantially better outcomes for mothers and babies. The infant death rate in the U.S. is higher than that of most other industrialized nations. And the maternal death rate actually increased slightly from 1990 to 2013, according to an analysis published May 2, 2014, online in The Lancet medical journal."

So What? 
Why should we be concerned? C-sections are safe right? Usually when they are done it is because they are safer for mom, baby or both, than a vaginal delivery right?
"A C-section—the second most commonly performed surgical procedure in the country, requiring a 6-inch incision in the abdomen and a second through the uterus—is major surgery, and thus takes longer to recover from than a vaginal delivery and also carries additional risks." 

Consumer Reports is also concerned that hospitals within a few miles of each other with similar populations can have such drastically different rates of surgical births. "And unfortunately, it’s usually much easier to find a hospital with a high C-section rate than a low one." 

Our Local Hospitals
To earn top marks a hospital had to have a c-section rate of between 5-9.5%. None of our local hospitals earned this ranking. Twin Cities comes in at the next best level between 9.5 and 11.5%. French is in the average zone at 11.5-15%. Both Marian and Sierra show up in the next to lowest ranking with between 15-21%.

Hey That's Not Fair 
You may be thinking Sierra Vista should have a higher rate because they have the high risk mothers. Consumer Reports tried to correct for this. "To level the playing field, the measure controls for some things that affect C-section rates, such as not including multiple gestations and breech births. However, this measure does not account for all differences in patient characteristics (such as chronic illness) that might affect the C-section rates of an individual hospital." So yes their rate should be higher because the high risk moms with chronic illness appropriately deliver there. The question is how much higher? Both Sierra and Marian are just a few percentage points away from being given the worst rating.

“We think it’s time those hidden numbers are brought to light,” said John Santa, M.D., medical director of Consumer Reports Health. 

Well said! Pregnant consumers and their families deserve this information in order to make true informed choices about their births.

Quotes were taken from the following 3 articles by Consumer Reports.

What Hospitals Don't Want You to Know About C-Sections:
Very good in-depth article with an excellent section on things to do to avoid a surgical birth.

Hospital Ratings; Avoiding C-sections: 
Their statistics

Safety Scores:
Finding your hospital's score.

More Research and Reading

What to Reject When You are Expecting
Good list of prenatal and during labor procedures to avoid

My Birth Statistics
Comparing my stats with our local hospitals

Some Truth about the Strength of Women

I recently ran into the quote on Facebook. I liked it so much I chose to use it as a cover on my Labor of Love Facebook page. Then I went searching to learn about Laura Harm. I immediately ran into this article; "Why Some Birth Quotes May Be Damaging to Women" on the Midwife International web site.  After carefully reading their post and the comments left by others I was drawn to leave this comment.

I have been a doula in San Luis Obispo for many years supporting women in the hospital and at home through medicated, un-medicated and cesarean births. I recently saw this quote and chose to put it on my doula facebook page. For most women birth IS painful. For most women it requires them to surrender in some form. Surrendering to your process where ever that process may lead, even into an operating room, IS the strength I see in this quote. Women ARE strong.The strength it takes to endure a surgery at the end of a long labor, the strength it takes to hold yourself together for the sake of your baby during an emergency cesarean, the strength it takes to surrender to the power of the process of dilation, the strength it takes to push a baby out of our bodies and into the world. This strength inspires me each time I am lucky enough to witness a birth, any birth. I make no distinction in my respect for birthing women, medicated, un-medicated, vaginal or surgical. ALL women are strong and need strength no matter how their baby arrives. I wish women could stop dividing themselves into groups. I wish women could stop feeling they are being judged and stop judging themselves. Filtered through our own souls this quote, like art, will mean something different to each of us. I am sorry it is painful for you. I wish you could see the beauty in this quote that I see. The acknowledgement that ALL women no matter how they birth are strong. You were strong.

I would like to know how YOU feel about this quote. I encourage you to read their article. Look deep into your soul. How does this quote make you feel? Who have you been judging?
Please post your comments here or on my Facebook page.

My Birth Statistics: 2010 through 2012

Statistics are an interesting animal. You can shape them or skew them various ways. They are used by many people to prove points or to motivate or even manipulate people into taking an action they desire. When asked about statistics on issues such as risks associated with a possible course of action doctors often answer with non-answers. Many times I have heard doctors say, "if it is your baby that dies the risk was 100% not worth taking" or "I only recommend this or do this procedure when it is necessary." They rarely give couples what percentage of their clients do they deem it necessary to do the procedure on, or how that compares to a local, national or global average. They certainly don't offer the parents what studies have proven the statistic should be based on best outcomes for mothers and babies. Those studies weigh the risks of both doing and not doing any given procedure.

Cesareans

For cesarean section the World Health Organization took a global look. Because they are a world-wide organization they looked at poor countries with low access to cesareans and wealthy countries with lots of access to cesareans. Their studies say a cesarean rate of between 5 to 10% of births is ideal and further when you get beyond 15% you are now doing more harm than good to mothers and babies. My total rate has increased from 15% to 17%. My rate in the last 3 years alone, when calculated as I believe WHO intended: total number of births and number of cesareans for any reason, is a depressing 22%. My numbers prove to me what my gut had been sadly telling me for a while; it has gotten harder to keep women out of the operating room. When looking at my statistics is important to remember how few births I attend; 27 since 2009. An individual birth has the ability to shift my rates wildly. But let's put my numbers into context.

Here is the national trend.

Here is the state trend.

But as I said numbers can be shaped many ways. Let's compare my section rate not using WHO's way of compiling statistics. Instead let's use the way California compiles their stats. They choose to not include breech babies, twins, premies and abnormal presentation. Abnormal presentation seems so vague to me it could include posterior babies (facing the wrong way), babies with a hand coming beside their faces (compound presentation) and babies that don't get their heads lined up just right (acenclytic). I have had all of these over the years and most but not all of them came through their mama's pelvis just fine. Using this system of exclusion my rate for the last 3 years plummets to 7% while California's is shocking.

OK now I'm not feeling so bad and a lot less frustrated. But wait! Maybe this doesn't reflect me at all. Maybe we just have really great providers and hospitals? Using identical parameters of exclusion in the statistics here are our local hospitals 2011 rates:

 French 21%

Sierra Vista 32%

Twin Cities 22%

Marian 30%

Now I'm definitely feeling better about my 7%! Let's not forget that I have done births at all of these hospitals in the last 3 years interacting with the staff and working within their individual medical establishment cultures. Don't forget to factor in that my clients use a variety of care providers, 15 in the last 3 years; from the ones who never saw an intervention they didn't like to the most
hands-off low-tech midwives. I've supported high risk moms and teen moms. I've had women hire me 1 week before their birth, 1 day before their birth and 2 this year during their births! Fifty-six percent of my moms were having their first babies and only one of them ended up having a section because of failure to progress.

Now let's compare my primary (first time) cesarean section rate to our hospitals rates. Using their compilation methods I have a 4% rate. The local hospitals 2011 rates:

French 12% 

Sierra Vista 18%

Twin Cities 10%

Marian 16%

Because I go to whichever hospital my client's choose for a birth place, 41% of my births took place in the 2 hospitals with the highest surgical birth rates.

But numbers are just a snap shot. They certainly don't tell the whole story. Let's look back at my true total of 17%. Ten percent of those aren't included in the numbers above. What are their stories? Some moms had a herpes outbreak and felt it was safest for their baby to be born via surgery. A small number were failed v-bacs. About 1% were failed inductions for one reason or another. In the last 3 years I had 2 un-diagnosed breech babies. Both moms labored great but when their baby's position was discovered a cesarean was performed. I had a high risk mom go into labor with her premie baby the day after we first met. Another was a mom trying for a vaginal birth after her first child was a cesarean baby. After laboring at  home and in the hospital for a long time she ultimately had a second section. This time I was able to explain to her exactly what was going on inside her pelvis which made her babies need to come through an incision in her belly.

This last mom called me because her doctor had said her baby was too large and scheduled her for a section for the next day. She was in a panic. We both worked very hard for a week trying to find a care provider willing to take her and let her try for a vaginal birth whom her insurance would cover. We couldn't find one and after an exhausting week of discussions with her doctor she ultimately chose to have a scheduled cesarean. I was with her as much as Marian Hospital would allow and helped her become one of the first moms to latch her baby on in the recovery room immediately after her surgery. 

But women have lots of worries about more than just cesareans. Here are my statistics which speak to those issues; the dreaded pitocin, its connection with induction and the need for pain medications!

Pitocin

Since 2010 I have had 22% of my mamas use pitocin at some point during their birth process; either to induce labor (7%) or to move a labor along (15%). This represents a significant increase from my past 14% rate. On closer inspection I see the change has come in my use of pitocin to augment or move a labor forward. 

Induction  

My induction rate has held steady since 1993; 7%. The only reason for induction in the last 3 years has been because their water had broken and we couldn't get labor rolling with natural methods. All of these women were able to labor without resorting to pain medication and birthed vaginally. 

Augmentation

Between 1993 and 2009 7% of my clients opted to use pitocin to augment their labors. But in the last 3 years 15% utilized pitocin to try to make progress during a stalled labor. Half of the stalled labors, or 7.4%, were transferred into the hospital after a planned out-of-hospital birth. Fifty percent of those transfers ended with a vaginal birth. 

Pitocin plus Pain Medication

The other 7.4% who augmented their labor with pitocin had chosen to take pain medication and then their labor stalled. Ultimately all of these women birthed vaginally. My hat is off to the 33% of my moms who labored on pitocin without pain medication. I am in awe.

This amazing mama successfully navigated a high risk pregnancy, a pitocin induction for broken waters and a vaginal birth in the operating room; all without pain medication!

Pain Medication 

Speaking of pain medication... let's see what my numbers say about the issue. Since 2010 I have had 19% of my moms choose to use pain medication of some sort during their labor. This is up from my 1993-2009 rate of 11%. Not what I had hoped for but to put it into perspective I looked up the official epidural rate in California in 2012. Turns out it was 42%. It is hard for me to believe this is an accurate number considering how ubiquitous epidural use has become in our culture. Digging into it further I see that in 100% of the cases my moms chose pain meds, pitocin was involved; either before or after. It turns out 10% of my moms opted for pain medication and then ended up on pitocin and 10% of my moms needed pitocin and then chose an epidural to  help them cope or as part of an over-all strategy to make forward progress during their birth. I don't know how that compares with the rates for California or our individual hospitals. They don't break their rates down this way.   

Speaking of progress...as a doula I am always pushing the boundaries of the places and providers that my clients have chosen. This usually involves giving moms the information they need to confidently say no to routine policies that are not based in evidence-based practices, such as the 40 week automatic induction or rigid guidelines on fetal heart monitoring. One of the areas my clients and I have been pushing is gravity enhanced non-traditional pushing positions, i.e. birthing on hands and knees, in a squat and standing. I have felt that I wasn't getting anywhere with this issue but the numbers tell a different story. I am happy to say 15% of my moms in the last 3 years have birthed within a traditional setting using a non-traditional position. This is a testament to the strength of will and confidence of those mamas. If I was at all instrumental in creating that to happen I am satisfied.    

This beautiful 9 pound 4 ounce baby boy was born quickly and easily as his mother stood beside her hospital bed.

By the Numbers
2009-2012
27 births
55% first time mothers 

Total Vaginal Birth Rate: 78%

Adjusted Vaginal Birth Rate: 93%

        (See above story for explanation of adjustment)

Adjusted Vaginal Birth Rate First Babies: 96%

Spontaneous Start of Labor: 93%

Total without Pain Medication: 81%

Pain Medication after Pitocin: 10%

Labor without Pitocin Augmentation: 85%

Labor without any Pitocin: 78%

Successful VBAC Rate: 50%

Looking at it another way...

Total C-section Rate: 22%

Adjusted C-section Rate: 7%

    (See above story for explanation of adjustment)

Adjusted Vaginal Birth Rate First Babies: 4%

Total Pitocin Rate: 22%

Pitocin Induction Rate: 7%

Pitocin Augmentation Rate: 15%

Total Pain Medication Rate: 19%

A Positive Cesarean Birth

Approximately 10% of women will truly need to give birth to their babies via surgery. For most of the women in this country this is far from a positive experience. Their babies are born behind a screen and then are moved to a plastic box, called an isolette, far enough away the mothers can't really see them. Once they are checked over and determined to be breathing ok, they are wrapped up so only their tiny faces are visible and given to their dads sitting next to the mothers' heads. The mothers who are lying flat desperately want to at least see their babies' faces. The dads try to find a way to accomplish this with their floppy newborns. Mothers crane their necks trying to catch a glimpse of their babies' gaze. They are biologically driven to look deep into their babies' eyes and connect. In just a few minutes dads and babies are whisked away to a nursery. All the other normal biologic functions which kick into gear as soon as the mothers have given birth are disrupted. These are called claiming behaviors. We are meant to smell our babies, kiss our babies, touch our babies. We are meant to look them over from head to toe and to count each tiny finger. And of course to put the baby to our breast and begin the breastfeeding relationship. Our senses and our babies are heightened at the moment of birth. We are both exquisitely aware of each other. We are meant to connect on a deep emotional, biological, chemical level; a connection which will last a life time. But for most mothers around the world having cesarean babies they get none of these. By the time they get to really see their babies they have been washed and dressed and are deeply asleep; too sleepy to breastfeed for  hours.

For a different perspective on the cesarean birth experience please watch this video. Then talk to your doctor, your midwife, your doula, your husband, and your hospital. You and your baby have a right to the most natural positive birth possible. You can make this happen!

A Woman’s Guide to VBAC

Wow!!! Great new site full of just the right info for women considering trying to go for a vaginal birth after a cesarean! Thanks to Megan Bochum, a local student midwife and member of our local ICAN, for posting this link on facebook.

A Woman’s Guide to VBAC

Weighing the Pros and Cons of Planned Vaginal Birth after Cesarean and Repeat Cesarean Section

VBAC Success Rates and Prediction Models: Understanding Your Chances of Important Outcomes

Putting Uterine Rupture into Perspective

Are You an “Ideal” Candidate for VBAC? What Are Your Choices If Not?

The “Immediately Available” Standard: Where It Came from, What It Means, and How to Move Forward with New Evidence and Guidelines

What We Don’t Know: Critical Gaps in Evidence and How to Make Informed Choices In Spite of Them

Discussing Your Options with Your Care Provider

Legal Rights and Protections for VBAC: Issues from the NIH Consensus Conference

Take Action!

The Pendulum Swings

Can you feel it? The pendulum is beginning to swing the other way again. Last February I witnessed a doctor emotionally manipulating a woman, who was courageously working on pushing her baby out, into agreeing to a cesarean. I didn't know then that in that hospital room we were standing at the apogee of the pendulum's arc.

Apogee (Merriam Webster) Definition: 1. Farthest point on an orbit 2. final climactic stage, standing at the culmination

I only knew that in the past few years it had become a greater and greater struggle to keep my hospital doula clients out of the operating room. I didn't know that this was the final climatic stage in a hailstorm of surgeries.

Here is a simple physics lesson:
When a pendulum reaches it's apogee it holds its maximum potential energy. This energy is released as it begins to swing back the other way.

Can you feel it? In the past few months there has been a huge release of energy on a national and international scale against cesarean sections. On Tuesday I opened our local paper and saw more evidence of this phenomena; an article reprinted from the Los Angeles Times titled Study Finds Patience May Lower C-section Rates. That's right patience, not patients.

Here is a simple vocabulary lesson:
**Patient as a noun.
(Merriam Webster) Definition: 1.an individual awaiting or under medical care and treatment 2. one that is acted upon
**Patient as an adjective
(Merriam Webster) Definition: Patient 1.manifesting forbearance under provocation or strain 2. not hasty or impetuous 3. steadfast despite opposition, difficulty or adversity
**Patience is a singular noun
(Merriam Webster) Definition: the fact of being patient

Here is what this latest study done by the Eunice Kennedy Shriver National Institute of Child Health and Human Development said:

If doctors and their patients (women under their medical care) would have patience (forbearance under the strain of waiting out those last difficult weeks of pregnancy) and not go with an induction they have a much greater chance of not having a surgical birth. Of course for the woman remaining patient (steadfast) to the idea of waiting for spontaneous labor in spite of her doctors threats of placental disintegration, baby too large or blood pressure rising (opposition) can be a daunting (a great strain). In my experience getting a mom through these last prenatal visits is very difficult but well worth the effort. My own doula statistics bear this out with a 1% section rate for my first time moms who wait for labor to begin on its own.

If doctors would be patient (not hasty or impetuous) about the progress of their patients (women who they are acting upon) labors there could be many fewer c-sections. The authors of the study say doctors aren't acknowledging that labor takes time and doesn't follow a predictable pattern, especially in first time mothers. A high proportion of the surgical births reviewed were done after the patient (one who is acted upon) had been in active labor for only 2 to 3 hours! OMG!!! These women are being labeled as suffering from "failure to progress" which leaves them feeling defective the rest of their lives which leaves them much more open to being manipulated into repeat elective cesareans for all future babies. Most of the women I attend at births are in active labor for waaaaaaayyyy longer than that. I guide them, support them and explain that this is normal, babies take time and they are doing just fine. My cesarean rate even for mom's who agreed to an induction; 1%. The study showed that a major reason for having a cesarean was having had a cesarean. But my total cesarean rate with spontaneous labor, inductions and v-bac attempts is only 7%. There is no great mystery here. I am no wonder woman. Doulas and midwives support women whom they do not see as patients but instaed as healthy people in the process of a healthy physiologic act; like breathing or sex. Doulas and midwives having an abundance of patience is the key to good, safe, healthy births.

One final thought: Years ago I met the women who were spearheading our local International Cesarean Awareness Network at the time. One of them said, "There is no such thing as a 'failure to progress' only a 'failure to wait'. I have been calling it that ever since and now we are beginning to have the studies to prove who failed and what that failure has meant to women in america.

Can you feel it?

National Institute of Health panel strongly urges that steps be taken to reverse repeat cesarean sections.

Study in Journal of Obstetrics and Gynecology says v-bac is a reasonable and safe choice because the outcomes for repeat elective surgery and v-bac were basically the same.

New Guidelines from American College of Obstetricians and Gynecologists on repeat sections.

Study Finds Patience May Lower C-section Rates.

You Don't Know How Lucky You Are

I don't believe the birthing women of San Luis Obispo have a clue how lucky they are. Even many of the women working in our birth community don't know how lucky we are. We are so busy being in the here and now of our little corner of the world we assume this is how it has always been, this is how it is everywhere. Those of us working in the "alternative" birth community often see only the negatives. Guess what? Your perception is wrong. There are so many positives going on every day in our community. There is constant movement toward making births better for all women and their babies.

This was brought home to me in a very powerful and personal way the first time I attended a birth outside of our community. Being with my sister-in-law as she birthed at a hospital in Berkeley was an eye opening experience. A few years later attending another sister-in-law in Nevada taught me to treasure our hospitals and the people working in them. I can't tell you how grateful I am to be working as a doula in SLO.

So let's focus on the positives please! Here is a list:

Twenty years ago when I had my son if your baby was born in need of serious medical attention he was flown by helicopter to Stanford. Moms, dads and babies were separated until the mom was recovered enough from the birth to drive up to the Bay Area. Then the staff at Sierra Vista got together and created our local NICU. This was a huge project which now benefits women, babies and families in our community every day. Now if you are a high risk mom or have a high risk baby you have a place to go close to home and the support of family and friends.

When it became clear to everyone that General Hospital was probably going to no longer be funded by the county French Hospital stepped up to fill the gap. General had always been the low-tech family friendly hospital. French Hospital with it's small size and supportive staff is an excellent hospital for women going for a less medicalized birth approach.

Not too many years ago the best we could do for using water as a pain relief method was a shower. Now we have labor tubs at all three county hospitals where women can seek pain relief without the use of narcotics and needles. Want to birth in water? You can rent a tub and birth at home with one of our skilled homebirth midwives.

Fifteen years ago when a friend needed a specialized ultrasound done to check out the chambers of her baby's heart she had to travel to the Bay Area. Now for women who need specialized monitoring of their pregnancy we have qualified perinatologists with ultrasound capabilities far beyond what we once had.

We have lots of OB doctors with lots of different personalities and philosophies and styles to choose from. If you want to use a midwife instead we have an ever growing choice. There is something for every woman on the menu. Want to birth in the hospital but with a midwife? Guess what? We currently have two different certified midwifery groups working with two different doctors. Don't want to go to the hospital? We have two different licensed midwives to choose from and by this time next year we should have several new midwives joining their ranks.

Don't feel comfortable either birthing at home or in the hospital? Guess what? We have an out-of-hospital birth center currently under construction. It is due to be open for women with December due dates. Watch their progress on facebook.

I remember when your only choice for birth education was to take Lamaze at the hospital or Bradley outside the hospital. Now you can choose from these as well as Informed Birth & Parenting, Hypnobirthing, Birth Works or Birthing from Within. There is something for everyone from over the grade to the south county.

We have many other support groups and professionals for new parents in our area. Need free breastfeeding help? Call the Warm Line at 541-BABY. Want a breastfeeding support group? Try our local La Leche League meetings. Speaking of breastfeeding; we have excellent lactation consultants working in and out of our hospitals. Need postpartum support and counseling? Call the Postpartum Hot line at 549-7786. Need a shoulder to cry on about a negative birth experience? Go to one of our ICAN meetings. We have mommy support networks both on line and in person such as SLO County Mommies. We have parenting classes through Parent Participation throughout the county or Andrea Herron's Growing with Baby.

Considering using a doula at your birth? Go to the resource guide at the Birth & Baby Resource Network: wwwbbrn.org. We have a whole list of doulas working in the community and new ones getting trained all the time. The perfect match to your personality and belief system is just waiting for you.

As a doula these last items are the most important to me.

When the American College of Obstetricians and Gynecologists created new rules which required anesthesiologists standing by for a woman to be "allowed" to go for a vaginal birth after a previous c-section Sierra Vista stepped up and did what was necessary to make that happen for our community. Guess what? We have the only hospital for hundreds of miles that will do v-bacs. I recently had a client who moved back here from Santa Barbara just to be able to successfully v-bac!

Need a c-section? Our hospitals are actively working to create them to be as family friendly as possible given their staffing and geography restraints. They are trying to keep moms, dads, and babies together as much as possible. And guess what? Usually your doula, as well as your husband, can be with you during the entire process.

Last I would like to speak about the relationships with the hospital staff and doulas in our community. It has been many years since I was introduced at a birth as a doula and felt open hostility from the nurses. Now the staff has grown in their understanding and acceptance of the value of doulas within the hospital setting so much that I have even been paired with new nurses so they could be part of a "natural" birth. I would like to also say that anytime I have had doula clients with special needs or situations in preparing for their births both Marie Chaney, Maternal Child Assistant Director, at Sierra Vista and Charley Ault, OB Nurse Manager, at French took the time to speak with them and did their best to accommodate their needs and desires.

So within SLO town the picture looks pretty rosy but step outside this box and the picture gets ugly fast. There are hospitals that won't "allow" doulas to be present at births. They also don't "allow" birth plans or want couples who have taken classes which encourage natural unmedicated births. As a doula I have run into open hostility, been excluded from c-sections, had my client's pre-arranged wishes for their births ignored and witnessed verbal disrespect bordering on abuse of a mom preparing for a cesarean birth.

So thank you to all the women over the years who have tried to make this community more mother/baby friendly. A mountain of sand can be moved one grain at a time.


To read more about life outside our bubble go to A Sign on the Door.

New Guidelines Aim to Reduce Repeated C-Sections

Great reporting on an important birth issue by someone in the mainstream media! This reporter does an excellent job of thoroughly explaining the complexities of the issues surrounding giving women back the right to make their own choice to try for a vaginal birth after a previous cesarean or to go with a repeat surgical birth.

But before you read it let's put it into historical, local, political, and a doula's context.

When I was in my twenties the cesarean rate was rising. Like my sister-in-law most of these women were being sectioned the first time for something called cephalopelvic disproportion. This means the baby's head (cephalo) is too big (disproportion) to fit through mom's passageway (pelvic). How did they figure this out? Two ways. One was a labor that wasn't progressing at the rate of speed the medical community agreed was normal at that time. I say "at that time" because I have worked with plenty of local doctors who no longer practice with this older time frame model in mind. Or before she ever began labor they might xray the mom , take measurements and make a determination without even a trial of labor. Of course this practice has now been abandoned. Xraying moms; it sounds crazy doesn't it? Guess what! We still routinely ultrasound moms who have gone past their due date and one of the things the doctor does is make a recommendation to your OB or midwife about the possible size of your baby and whether you should be sectioned for...wait for it...here it comes...cephalopelvic disproportion or possible shoulder dystocia (shoulders to big to fit) before you even try!

The second reason women were being operated on to give birth was the fact that they had been operated on to give birth. This was the era of "once a cesarean, always a cesarean". The surgical technique of the time was to cut the mom vertically from below the ribs to the pubic bone. This classical cut was associated with a high rate of rupture during future labors. The ghost of this fear based on the rupture rate of classical incisions is still with us today in the doctor's office when women discuss their "options" for future births. It is still in women's hearts too, passed down to them from their mother's birth era.

When I was in my thirties things were changing. The medical community had realized the cesarean rate was sky rocketing and they needed to do something about it. Surgical technique for incisions and suturing had changed; the "bikini cut" had come into vogue, and the risk of rupture had been significantly reduced. Also consumers had put pressure on the medical establishment by taking matters into their own hands; either birthing out of hospitals all together to achieve their V-BAC, or going into the hospital late in labor and refusing to undergo a repeat surgery. Doulas were being asked to labor sit at home with these moms and try to bring them to the hospital at the last moment. These brave pioneers proved women could safely and successfully labor and birth vaginally after a previous surgical birth. They proved V-BAC was a viable option for many women. I remember Dr. Clutter and Dr. Lickness being our first local doctors to support women in this choice.

When I was in my late thirties it was the norm to at least go through a "trial of labor" before deciding to section a woman again. Some of our doctors were much more liberal in their "trials" than other local doctors. As a doula I often felt I had to match wits with some of our more scalpel ready doctors to keep my clients out of the operating room. Another positive change was our local certified nurse midwives being allowed by their supervising doctors to V-BAC women in all our hospitals. Sandy Rodriguez and JoAnne Tarkington caught many, many a successful V-BAC baby.

By my forties the pendulum was swinging back. The fear of uterine rupture was again haunting doctors' offices and labor rooms. A study came out showing that V-BAC women had a greater chance of rupturing than nonV-BAC women. This study lumped all women together without taking into account if the mom went into labor on her own or if she was induced. It also didn't make any distinction as to the method used for induction. (Remember that wonderful induction drug Cytotec? This is the era it is becoming more popular among the medical community. Don't know about Cytotec? Read my piece, Let's Talk about Off Label Use, Cytotec and You.) In reponse to the study the American College of Obstetricians and Gynecologists (ACOG) came out with guidelines requiring hospitals to have anesthesiologists waiting in the hospital the entire time a V-BAC mom labored. Most hospitals found this a financial, practical, legal and bureaucratic impossibility. For a brief time all V-BACs were shut down at our hospitals. Luckily for us Sierra Vista took the bold step of contracting with our local anesthesiologists for enough coverage to allow Sierra Vista to offer the V-BAC option to women in our community. But it is the only hospital within hundreds of miles to do so! I recently had a client who moved back from Santa Barbara to Atascadero just so she could successfully V-BAC at Sierra. ACOGs guidelines also required OBs to be standing by throughout potentially long labors. For many doctors' practices this was a practical, geographic, and financial impossibility. So if your OB's office was located physically close enough to Sierra Vista you could V-BAC, if not you could not. And of course our wonderful nurse midwives were no longer "skilled" enough to catch V-BAC babies. I will never forget the last V-BAC I was at with Sandy and JoAnn. My client had been told she could V-BAC with them but when she was in labor in the hospital she was told the supervising doctors could no longer advise she go for a vaginal birth because she was past her due date. My client decided to refuse to say yes to another surgery. Sandy supported her decision and JoAnn did a great job catching a beautiful healthy baby girl. I have never been more proud of three women in my life. Meanwhile women continue to safely V-BAC with our licensed midwives at home and with doctors at Sierra Vista every day.

When I was fifty I was hired as a doula by a woman who was trying to find some way to not end up with a second operative birth. She was caught in a terrible bind. Her due date fell at a time when one of our homebirth midwives was not practicing and the other was already over committed trying to service all the local women who wanted to birth at home. Her MediCal doctor had deemed her too great a risk for V-BAC and wanted her to have a repeat operation. He put her under extreme pressure to agree to a surgical birth, even sending her a certified letter saying he had explained the risks to her of not agreeing to a surgical birth and requiring her to get a notarized signature. Although the nurse midwives wer supportive of her desire they could not help her. It was suggested to her that she labor at home with me for as long as possible, then come to the hospital and refuse the surgery. You tell me how it can possibly be a good choice to labor at home without a skilled medical attendant, with a woman who has more risk of things going wrong, without anyone who can take the baby's heart tones or has any emergency equipment or training? This is an impossible position to put doulas in. My client called me late into her labor and when I arrived at her home it was quickly obvious to me she would be pushing soon. I told her we needed to go to the hospital and she begged me to stay with her at home and catch her baby. She told me she trusted me. I told her I couldn't do it, I had no equipment and no experience. I convinced her to go to the hospital and she ended up with another c-section. An outcome that will weigh on both our hearts forever.

In the last few months I have seen another change on the horizon. I believe we are witnessing a new V-BAC era being born. There have been a flurry of studies, articles and announcements about the concern over the rise in our national cesarean rate, balancing risks of repeat c-sections versus v-bac and a woman's right to choose. The National Institute of Health came out with their finding which has pushed ACOG to review it's guidelines and make their own announcement. Read Neergaard's great article to see where we are headed.

By LAURAN NEERGAARD
AP Medical Writer

Most women who've had a C-section, and many who've had two, should be allowed to try labor with their next baby, say new guidelines - a step toward reversing the "once a cesarean, always a cesarean" policies taking root in many hospitals.

Wednesday's announcement by the American College of Obstetricians and Gynecologists eases restrictions on who might avoid a repeat C-section, rewriting an old policy that critics have said is partly to blame for many pregnant women being denied the chance.
Fifteen years ago, nearly 3 in 10 women who'd had a prior C-section gave birth vaginally the next time. Today, fewer than 1 in 10 do.

Last spring, a National Institutes of Health panel strongly urged steps to reverse that trend, saying a third of hospitals and half of doctors ban women from attempting what's called VBAC, for "vaginal birth after cesarean."

The new guidelines declare VBAC a safe and appropriate option for most women - now including those carrying twins or who've had two C-sections - and urge that they be given an unbiased look at the pros and cons so they can decide whether to try.

Women's choice is "what we want to come through loud and clear," said Dr. William Grobman of Northwestern University, co-author of the guidelines. "There are few times where there is an absolute wrong or an absolute right, but there is the importance of shared decision-making."

Overall, nearly a third of U.S. births are by cesarean, an all-time high. Cesareans can be lifesaving but they come with certain risks - and the more C-sections a woman has, the greater the risk in a next pregnancy of problems, some of them life-threatening, like placenta abnormalities or hemorrhage.

The main debate with VBAC: That the rigors of labor could cause the scar from the earlier surgery to rupture. There's less than a 1 percent chance of that happening, the ACOG guidelines say. Also, with most recently performed C-sections, that scar is located on a lower part of the uterus that's less stressed by contractions.

Of those who attempt VBAC, between 60 percent and 80 percent will deliver vaginally, the guidelines note. The rest will need a C-section after all, because of stalled labor or other factors. Success if more likely in women who go into labor naturally - although induction doesn't rule out an attempt - and less likely in women who are obese or are carrying large babies, they say.
Thus the balancing act that women and their doctors weigh: A successful VBAC is safer than a planned repeat C-section, especially for women who want additional children - but an emergency C-section can be riskier than a planned one.

Because of those rare uterine ruptures, the obstetricians' group has long recommended that only hospitals equipped for immediate emergency C-sections attempt VBACs. Many smaller or rural hospitals can't do that, and that recommendation plus high-dollar lawsuits have been blamed for some hospital VBAC bans.

"Restricting access was not the intention," the new guidelines say. They say hospitals ill-equipped for immediate surgery should help women find care elsewhere, have a plan to manage uterine ruptures anyway, and not coerce a woman into a repeat C-section.

Educating women about their options early enough in pregnancy for them to make an informed choice is key, said Dr. F. Gary Cunningham of the University of Texas Southwestern Medical Center, who chaired the NIH panel on repeat C-sections.

It requires a fair portrayal of risks and benefits that can differ by patient, added Dr. Howard Minkoff of Maimonides Medical Center in Brooklyn, N.Y., which has women sign a special VBAC consent after counseling yet has a higher-than-average VBAC rate of 30 percent.

"There's no doubt that how things get framed influences how people act," he said.

While the guidelines cannot force hospital policy changes, some women's groups welcomed them.
"I feel like ACOG has really listened to how their previous policies have impacted women," said Barbara Stratton of the International Cesarean Awareness Network's Baltimore chapter, adding that she'll advise women seeking a VBAC to hand a copy of the guidelines to caregivers who balk.
But she called for reducing overuse of first-time C-sections, too, so that repeats become less of an issue.
Read more: http://www.sanluisobispo.com/2010/07/21/1223164/new-guidelines-aim-to-reduce-repeated.html#ixzz0uQm4tHXf