Natural Birth for Normal Women: December 2009

Thursday, December 31, 2009

VBAC Resources

Tuesday, December 29, 2009

There are lies, damn lies, and...

I frequently use statistics when I talk to women about their birthing options. I say things like "up to 50% of first-time moms who are induced end up with c-sections" and "when you choose VBAC your risk of uterine rupture is only 0.4%!" I bring up statistics to highlight the risks and benefits of various birth options, and because I think many many doctors do not take the time to provide truly informed consent to their patients.

Over the past few months, I have been reading quite a bit about management of "postdate" pregnancies, and whether it is best to wait for spontaneous labor or induce. The study that stuck with me showed that, counterintuitively, at 41 weeks' gestation there were fewer cesarean deliveries in the induced group. (http://www.bio-medicine.org/medicine-news-1/Induced-Labor-May-Prevent-Need-for-Cesarean-Section-54811-1/) Fewer cesareans!!!! To understand why this is so earth-shattering for me, you need to know that I was induced a day past 41 weeks with my first child. After a long and miserable labor I "failed to dilate" at 9 cm and had an unplanned cesarean delivery. I spent over a year struggling with feelings of inadequacy and failure. I failed to go into labor, failed to give birth to my child, and missed out on what I consider a major rite of passage for a woman: BIRTH! Part of processing my cesarean was considering whether I had failed, or whether I had been failed by modern obstetrics.

For years I have believed that my cesarean was "necessary" by the time it was performed, but it was almost certainly avoidable had I not been induced and subjected to what so many in the birth community call the "cascade of interventions." I have progressed from blaming myself for my cesarean to blaming my induction- and I have found no small amount of triumph in pointing out that 2 of my 3 very successful vaginal deliveries occurred spontaneously well past 41 weeks. I truly believed I had gotten past the questioning stage and had reached a point where I accepted all that led up to my first delivery. And now this study.

If it is true that induction at 41 weeks leads to fewer cesarean deliveries, then maybe my ire has been misplaced. Perhaps I did experience a "failed induction" as I've always believed- but if a spontaneous labor would have carried an even greater risk of cesarean, perhaps the induction was still the best choice. The right choice. It is hard for me to even type those words, difficult for me to consider that no matter what I might have ended up with a c-section to deliver my son. It is difficult for me to think that I wasn't able to birth him and yet I was able to birth my other 3 with no problems at all. Was it his size? Was he in a strange position? Was it the calcification on my placenta? Was it because I was unsure of my last menstrual period and I was actually much further along that we thought?

If I had not had my cesarean delivery, I doubt I would ever have found my passion for birth. In that respect I am almost happy for having had it, and I most certainly do not think I would love my son any better than I do if he'd taken a different exit from my body. But I thought I was well beyond playing "what-if" when I think of his delivery, and I am surprised at how deeply reading this study has affected me.

Monday, December 28, 2009

It Only Hurts if You're Doing it Wrong

I just read a woman's birth story. She had planned and hoped for a natural birth- not just in the baby-coming-out-her-vagina sense, but in the unmedicated sense as well. She'd taken classes, hired a fabulous doula, practiced, visualized, done everything she could to prepare. Then she had a very long, incredibly painful labor, and chose to get an epidural when she was about 4 centimeters dilated. She went on to decline pitocin and other intervention that is typically "required" once you have an epidural, and she triumphantly pushed out her perfect baby later that day. She is truly happy with her birth and doesn't feel like she failed by opting for an epidural even though she still believes natural childbirth is the best way to plan to deliver.

What suprised me was not the birth story itself, becuase certainly many women who carefully plan an unmedicated birth do end up opting for epidurals and don't feel like they've failed (I count myself among them), but other women's responses to the story were shocking! One woman in particular told the mother that she must have unrealized fears related to childbirth. If she had truly been at peace with the process and had trusted her body's innate ability to birth, her labor would have been manageable without drugs, and it would not have taken her so long to completely dilate.

I almost fell out of my chair!!! I was astonished that anyone would imply that this mother had to have done something wrong to experience her labor the way she did. Why is it so difficult to accept that everyone- and every labor- is different? I have to admit to having some bias of my own this way; before I had my third child my labor experiences were limited to a failed induction turned c-section, and a very fast and easy spontaneous vaginal delivery. Sure, spontaneous labor hurt but it wasn't the same kind of excruciating, uncontrolled-vomiting, holding onto the siderails and begging for it to be over, kind of thing my induction had been. Right?

Not so fast! When I had my third child my labor was weird from the start. Contractions didn't regulate the way they had with my second, and wow did they hurt right from the beginning. After about 6 hours of not walking or talking through them, we headed to the hospital only to find out I wasn't dilating. It was the worst news ever! I was barely coping with prodromal labor? How in the world was that possible when I'd had a completely unmedicated delivery the last time? I knew what to expect! This was decidedly not what labor was like! Except it was, and it continued that way for hours on end, until I finally got an epidural and started dilating. Progress continued to be excruciatingly slow- and like the mom whose story I opened with, I declined pitocin and other interventions- but I did eventually, triumphantly, deliver my baby vaginally.

That experience forever changed how I read other women's birth stories. I no longer had preconceived notions about how much pain is involved in labor, or whether or not any particular woman was "justified" in getting an epidural early, or late, or at all. I realized that my own experiences in birthing my babies are just that: my own. In that respect I am grateful for the long and painful labor I had that time. It not only made me appreciate the (dare I say it?) easy labor I had with my fourth child, but also gave me the insight I needed to understand that saying "Every labor is different" is more than just a cliche. And sometimes it hurts even when you do everything right.

Your Body Is Not Broken

On another forum there was a journal entry written by a woman who was bothered when others offered support by telling her she would be able to give birth to her baby- that her body is not broken. I had to respond because I do frequently tell women they are not broken, and my response ended up one of my better ones so I wanted to copy it here. If I have ever annoyed anyone with my insistence that birth works, my apologies:

I am guilty of this. To so many women at the end of their pregnancies, I say "Relax, your body knows what to do, your baby knows when to be born. Birth works if we let it. Have faith in yourself and your innate ability to deliver your child. You can do it!"And it never in a million years dawned on me that it was offensive or unsupportive or unhelpful.I had my own cesarean following a 27 hour labor ending in failure to dilate at 9 cm. I struggled with feelings of failure, feelings of inadequacy, worry that my VBAC would fail after another day or more of labor because maybe my body really was broken. People told me I needed to have faith, I needed to believe my body was not broken, I needed to believe it was the modern maternity system that failed me. And it was hard! Every day at the end when I didn't have a single contraction, my baby didn't drop, I didn't dilate, I left my OB appointments crying... every day, it was hard. But I had to find my center again, I had to believe that VBAC was not only possible, but probable, I had to truly believe that my body could- and would- work.

Birthing a baby isn't something we need to learn, any more than we "learn" to breathe or digest or eliminate.Are there risks? Of course. Are there situations where modern medicine is lifesaving and provides better outcomes? Of course!!! But that doesn't negate the hundreds of thousands of years before me, filled with women who gave birth to their babies, eventually coming down to the one woman who gave birth to me. Birth works. If it didn't, humanity would not exist.

And women in developing countries? What about their outcomes? Why do so many of them (and their babies) die? Is it because birth is inherently flawed? Or is it because they conceive immediately following the onset of menstruation, they are malnourished, they have no prenatal care, they have no support during labor, they lack even the most basic medical care? At the turn of the century in the US, maternal mortality was just under 1%, with half those fatalities caused by infection. The majority of the rest were caused by hemorrhage or unidentified toxemia. Sanitation and availability of blood transfusions and antibiotics were the biggest factors in reducing maternal mortality. Not c-sections, not inductions, not continuous monitoring. Basics.

So many of the things we think of as complications in labor are really just variations of normal. Western medicine wants us all to fit in a neat little box, and we (in general) want to have a quick and pleasant birth. We don't want to be the woman who labors for 3 days and ends up with a 4th degree tear for her trouble. We don't want to be the woman who doesn't agree to an induction 12 hours after her water breaks and ends up with an infection. We don't want to be the woman who refuses any given intervention and has a poor outcome, so we accept it all- and right along with that we accept the implication that birth is broken. Birth doesn't work. We need all this technological help to get our babies out safely, and if we don't accept it we are deluding ourselves and ignoring the risks of birth. But are we? Are we really?

In closing I will tell you this: Having faith in something you have never experienced is difficult. Believing you can do it when you have "failed" before is even harder. It is normal to have doubts and it is normal to question yourself and wonder if it is birth that doesn't work, or if it is you. Perhaps there is comfort in thinking birth is inherently flawed, there is safety in modern medicine because intervention means it is no longer just you and your baby involved in the process. But perhaps there is some truth to the other side of it as well, and planning your birth with hope and just a little faith that it really can work- perhaps there's something to that, too.

I will never tell you your body is broken, or birth does not work, or you are destined to fail. If telling you the opposite is somehow offensive then I really don't know what to say or how to offer you support. No matter what happens, no matter what your birth choices, I do wish you a beautiful birth.

Natural Birth for Normal Women