Evansville Birthnetwork

If a mom has had a cesarean and is planning another birth, she has two options.  She can have a repeat cesarean or a vaginal birth after cesarean (VBAC).  There are risks and benefits of both options.  The main risk of having a VBAC is uterine rupture.  Uterine rupture happens about .8% of the time during a VBAC.  Most uterine rupures are not dangerous- many aren't even noticed until a cesarean or other abdominal surgery is done.  But occasionally, a rupture can cause serious consequences- the death of the baby or mother. 

On the other hand, having multiple cesareans poses risks too.  Cesareans increase the risk of placenta problems in future pregnancies such as placenta previa and placenta accreta.  The chances of these occuring increase with each cesarean.  These conditions are serious and can be life threatening.  Cesareans also increase risks such as breathing problems for the baby and NICU admissions.

In 2010, the National Institutes of Health held a conference on VBACs.  You can read their Consensus Statement, which includes information on the risks and benefits of VBACs and repeat cesareans. 

Another helpful resource is A Woman's Guide to VBAC, which explains the NIH Statement. 

The Internation Cesarean Awareness Network (ICAN) has lots of great resources about cesareans and VBACs.  The website includes information to help moms make the decision between repeat cesarean and VBAC, webinars, forums, and a listing of hospitals' VBAC policies. 

You can also watch vol. 4 of More Business of Being Born:  The VBAC Delimma.  The video is available on demand for $4.  The video includes information about risks, benefits, issues that keep many doctors and hospitals from offering VBAC, and stories of moms who have VBACs. 

If you are a mom considering VBAC, please contact us at evansvillebirthnetwork@gmail.com.  We can provide information on local options for VBAC and give you tips for having a VBAC.  Several moms in the Birthnetwork have had VBACs and are willing to talk about their experiences.  EBN also has a yahoo group where you can post questions and get input from other local moms. 

In most births, the baby's umbilical cord is clamped within seconds of being born.  Recently, this practice has been called into question.  There have been several studies that show benefits to waiting  even just a minute before clamping the cord.  More moms are beginning to ask for delayed cord clamping, and sometimes their doctors are not familiar with the benefits of it.

Nicholas Fogelson, an OB/GYN, has this blog post which summarizes the research on delayed cord clamping.   Much of the research he looks at focuses on preterm babies.  Some of the benefits seen in preterm babies include fewer cases of intraventricular hemorrhage and late-onset sepsis, higher red blood cell volumes and hematocrits and less need for mechanical ventilation and surfactant.  In term babies, there were higher iron stores at 6 months.

There is this study in the Journal of the American Medical Association which Dr. Fogelson doesn't discuss that looks at term babies:

Late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials.  Hutton EK, Hassan ES.  Source: Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario.

In that study, babies had better iron status and less anemia. 

Dr. Folgelson also has this video of a Grand Rounds presentation he did looking at delayed cord clamping.  The video is 50 minutes long and divided into four parts.  In the video, he compares immediate cord clamping to robbing the baby of 40% of its normal blood volume.

Some local moms have talked to their doctors about delayed cord clamping.  One objection the doctors have had is that they believe if they put the baby on the mother's belly after birth and do not clamp the cord, the baby's blood will drain back into the placenta, or the blood in the placenta will not be able to get to the baby.  Dr. Fogelson addresses that issue in Part 2 of the video, starting around minute 6:30.  He discusses a study that says that babys who are placed on their mother's stomachs after birth get the same amount of blood from the placenta as babies held even with the birth canal or as babies held slightly lower than the birth canal. 

So if you are interested in having delayed cord clamping at your birth, look at these resources and share them with your doctor or midwife.  We would love to hear from you about your experience of asking for and receiving or not receiving delayed cord clamping.  Feel free to post a comment below or email evansvillebirthnetwork@gmail.com.

Interested in knowing your hospital's cesarean rate?

The Indiana State Department of Health publishes yearly hospital discharge data.  The reports include information on each hospital stay for all kinds of conditions.  Although the reports are made public, they are in no way user friendly for the average person.  I have gone through the data using Microsoft Access and calculated cesarean rates for each hospital in the state for 2010.  I have listed the cesarean rates in an Excel file here-

Indiana Hospital Cesarean Rates 2010

Some highlights:

• The cesarean rate for Indiana was 31.4%.  There were 81,380 births in Indiana in 2010.

• The hospital with the highest cesarean rate was Scott Memorial Hospital, with a rate of 57.8%.
• The hospital with the lowest cesarean rate was St. Elizabeth Medical Center with a rate of 14.3%.
• 5 hospitals had cesarean rates lower than 20%.
• 2 hospitals had rates higher than 50%.*

• Local hospitals-
• St. Mary's Medical Center's cesarean rate was 39.6%.
• The Women's Hospital's cesarean rate was 35.9%.
• Good Samaritan Hospital in Vincennes had a 25.5% cesarean rate.
• Memorial Hospital in Jasper had a 34.9% cesarean rate.
• Daviess Community Hospital in Washington had a 24.0% cesarean rate.
  

*I am not including information for hospitals that had less than 5 births.

Want to lower your chance of having a cesarean?  Read 10 Tips for Avoiding a First-Time Cesarean.

The Kentucky Cabinet for Health and Family Services makes information on hospitals' quality indicators and rates of utilization of certain procedures on its website.  This information includes number of cesareans performed, cesarean rates, VBAC rates, and cesarean rates for first time mothers.  To see the information on their website, go here:

Kentucky 2010 Quality Indicators: Childbirth 

It can be difficult to sift through all the data available on that website.  It includes information on all types of condtions and procedures.  So I have gathered some of the info parents and birth advocates may be interested in.  I have taken the information for risk-adjusted cesarean rates, risk-adjusted VBAC rates and risk-adjusted cesarean rates for first time mothers and put them into an Excel spreadsheet.  I also took the information from that website on the number of cesarean performed at each hospital and divided it by the number of births at each hospital (found here on page 61) to calculate the actual cesarean rate.  I was curious how the actual rates and the risk-adjusted rates compared.  For most hospitals, the risk-adjusted rates were 1-3% lower than the actual rates.

Kentucky Hospital Cesarean Rates 2010 (Excel Spreadsheet)

Some highlights from the data-

• Kentucky's cesarean rate in 2010 was 36.2%. 

• The hospital with the highest cesarean rate is Paul B. Hall Regional Medical Center with a 71.0% cesarean rate.  The hospital's VBAC rate was 0%.

• The hospital with the second highest rate is Three Rivers Medical Center with a 66.3% rate.
• 
  
• The Vaginal Birth After Cesarean (VBAC) rate for Kentucky is 4.3%.  In other words, 95.7% of women who have a cesarean and then have another birth have a repeat cesarean.  The University of Louisville Hospital has the highest VBAC rate at 11.6%.
• 20.6% of first time moms gave birth by cesarean in Kentucky.

• Hospitals in our area-
• Methodist Hospital in Henderson had a 43.4% cesarean rate and a 1.3% VBAC rate.  21.7% of first time moms gave birth by cesarean
• Owensboro Medical Health System Inc. had a 42.6% cesarean rate and a 1.5% VBAC rate.  23% of first time moms gave birth by cesarean.
• Regional Medical Center in Madisonville had a 40.8% cesarean rate and a 8.9% VBAC rate.  25.9% of first time moms gave birth by cesarean.

For information on lowering your risk of having a cesarean or on Vaginal Birth After Cesarean (VBAC), visit our Cesarean Awareness page.

Eating and drinking during labor can give a mother energy and keep her hydrated.  It also helps her avoid feelings of hunger and thirst, which keeps her more comfortable.  Many birth locations restrict moms from having anything more than ice chips.  But are these restrictions necessary?

Not allowing moms anything to eat or drink started in the days when most moms gave birth while unconscious- under twilight sleep.  When someone is unconscious, they can vomit and the contents of their stomach can enter their lungs, causing a serious and sometimes fatal condition called aspiration pneumonia.  Today, it is rare for moms to give birth under general anesthesia.  And even when it happens, precautions are taken to help prevent aspiration.  A breathing tube is inserted into the mom's trachea to help prevent stomach contents from entering the lungs.  An antacid is given to help neutralize the acid in the mother's stomach. 

In 2010, the Cochrane Collaboration looked at policies restricting moms from eating and drinking in labor.  They found that, for low risk mothers, policies that restrict eating and drinking are not justified.  The review is available here-

Singata M, Tranmer J, Gyte GML. Restricting oral fluid and food intake during labour. Cochrane Database of Systematic Reviews 2010, Issue1. Art. No.: CD003930. DOI: 10.1002/14651858.CD003930.pub2

Available at: http://www2.cochrane.org/reviews/en/ab003930.html

The American College of Obstetricians and Gynecologists has this to say about drinking in labor:

“According to ACOG, women with a normal, uncomplicated labor may drink modest amounts of clear liquids such as water, fruit juice without pulp, carbonated beverages, clear tea, black coffee, and sports drinks. Fluids with solid particles, such as soup, should be avoided, however. Women who have uncomplicated pregnancies and are scheduled for a cesarean delivery may also drink these clear liquids upto two hours before anesthesia is administered.”          - from the ACOG press release “Recommendations Relax on Liquid Intake during Labor.” Available at http://www.acog.org/from_home/publications/press_releases/nr08-21-09-2.cfm

The American Society of Anesthesiologists has this statement:

“The oral intake of modest amounts of clear liquids may be allowed for uncomplicated laboring patients. The uncomplicated patient undergoing elective cesarean delivery may have modest amounts of clear liquids up to 2 h before induction of anesthesia. Examples of clear liquids include, but are not limited to, water,fruit juices without pulp, carbonated beverages, clear tea, black coffee, and sports drinks.”   - from the statement Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia available at: http://www.guideline.gov/content.aspx?id=10807

And the American College of Nurse Midwives has this to say:

 “The newest Clinical Bulletinfrom the American College of Nurse-Midwives reviews evidence relevant to providing oral nutrition to women in labor and concludes that drinking and eating during labor can provide women with the energy they need and should notbe routinely restricted.”  -from an ACNM press release “AMERICAN COLLEGE OF NURSE-MIDWIVES PUBLISHES CLINICAL GUIDELINES FOR ORALNUTRITION DURING LABOR” available at http://www.midwife.org/siteFiles/news/ACNM_Clinical_Guidelines_on_Nutrition_in_Labor.pdf

So if your doctor, midwife or hospital routinely restricts moms from eating and drinking in labor, you can ask if those restrictions are justified, or consider switching to a different provider or birth location.

April is Cesarean Awareness Month.  In honor of that, we are posting one of the Mother's Advocate's videos, Let Labor Begin on its Own.  Induction can double your chance of having a cesarean, so unless there is a medical reason to induce, it makes sense to wait until your body goes into labor on its own.  You can go to the Mother's Advocate website to view all six of Lamaze's Steps for a Safer Birth.  Each video is 2-3 minutes.

The Leapfrog Group, a non-profit organization that compares hospitals on national standards of safety and quality, released a Call to Action this week: Protect Mothers and Babies from Unnecessary Harm.  From the press release:

The employer-driven hospital quality watchdog, The Leapfrog Group, issued a Call to Action in response to its new data finding that thousands of babies are electively scheduled for delivery too early, resulting in a higher likelihood of death, being admitted to a Neonatal Intensive Care Unit (NICU), and life-long health problems.

The group asked hospitals across the country to voluntarily report their rates of early elective births- inductions or cesareans without a medical indication happening before 39 weeks gestation.  The rates are out of births occurring between 37-39 weeks.   Some hospitals had a rate of zero, showing that it is possible to avoid early elective births all together.  Other hospitals had rates of 50% or higher.

The March of Dimes lists these possible complications for babies born too soon:

• the baby's organs might not be fully developed
• the baby can develop vision and hearing problems that last throughout life
• the baby can have a low birthweight, which leads to problems staying warm
  
• the baby may have problems eating and breathing at the same time, which makes it difficult to gain weight

The Leapfrog Group released this list of hospitals and their rates of early elective births.  You are encouraged to use the information when deciding where to give birth.  If your hospital chose not to respond, consider writing them a letter and telling them the public needs access to this information. 

From Leapfrog's press release:

“Hospitals, health plans, providers, and communities need to do more to protect women and babies from this harmful practice,” said Leapfrog CEO Leah Binder. “And women need to protect themselves by refusing to schedule their deliveries before 39 weeks without a sound medical reason, and by knowing the facts about the hospitals they plan to deliver in.” She noted that currently only hospitals that report to Leapfrog’s annual hospital survey are making their rates of early elective deliveries public. “Every hospital should publicly report on their rate and actively prevent the practice, and every woman planning to give birth should demand the information,” Binder added.

So, you just found out you're pregnant and now you're deciding who you should pick as your care provider during pregnancy and birth.  Do you go with the OB/GYN you've been seeing for several years?  Do you choose a midwife?  Do you pick someone based on the recommendation of a friend?  If you are hoping for a low intervention birth, who you choose to be your care provider is one of the most important factors in whether or not that happens. 

Providers have different styles.  Some are quick to use interventions.  With this style of provider, most mothers will be induced or augmented.  This type of provider probably has a high cesarean rate.  This type of provider may see birth as an accident waiting to happen and will do all sorts of things trying to control the process.

A different type of provider sees birth as a normal process.  This type of provider uses "watchful waiting-" keeping an eye out for potential problems, but not assuming problems will happen.  Interventions are used less often and only when the potential benefit outweighs the potential risks. 

If you want a low intervention birth and you choose a high intervention provider, chances are things aren't going to go the way you hope.  So how do you choose someone? 

First, ask around.  People are usually willing to share their impressions of who they go to.  Just remember what is important to them might not be what's important to you.  If a friend tells you she loves her OB because he loves to induce and she wanted an induction- that might not be the provider for you.  (That's still good information to know, though!)

Second, go to www.TheBirthSurvey.com to view feedback on doctors & midwives (and also hospitals and birth centers).  Soon, you will be able to read comments as well as ratings in different categories.

Third, plan on asking plenty of questions when choosing a provider.  Here is a good list of questions to ask a potential midwife or doctor.  These questions help you determine the midwife or doctor's practice style, and whether their style is a good fit with your philosophy of pregnancy and birth.  Here is another set of questions listed on Birth Sense.

It may seem like a lot of work, but it's worth it to take your time when choosing a provider. 

This post is dedicated to the person who found our site by searching for "Do you need informed consent for labor induction?"

Please watch this great video from Lamaze-

And the answer is Yes, you are supposed to have informed consent before being induced.  Unfortunately, it doesn't always work like that.  If you feel like your doctor or midwife is not allowing you to have informed consent, see this handout from Mother's Advocate-

Changing Your Care Provider

Many women experience problems with their pelvic floor- leaking urine and, occasionally, feces.  In the past, some people have blamed having a vaginal birth for pelvic floor problems.  Childbirth Connection has a resource separating fact from fiction- what causes pelvic floor problems and what can be done to help prevent them. 

Vaginal birth has been blamed, and some suggest that enlarging the opening of the vagina by cutting it at the time of birth (episiotomy) or even having a surgical birth when there is no medical complication (elective c-section)will prevent weakened pelvic floor muscles and injury. Unfortunately,there is a lot of false, unproven, and incomplete information on this topic.

A few women plan a cesarean section in hopes of avoiding pelvic floor problems.  But will a cesarean prevent those problems?

Planning cesarean surgery simply to avoid the possibility of pelvic floor problems is unlikely to be in your self-interest. Cesarean surgery involves numerous extra risks to you and your baby. By contrast, the likelihood of continuing to experience bothersome symptoms after the postpartum recovery period with a vaginal birth is small. Moreover,some women with continuing problems can obtain relief or cure and avoid a corrective operation by an intensive regimen of pelvic floor exercises (kegels). It makes much better sense to avoid the procedures and practices that are known to cause problems in the first place.

Some of the interventions that may cause pelvic floor problems include: lying on the back, episiotomy, vacumm and forceps, directed pushing and fundal pressure.  Epidurals increase the chance of needing a vacuum or forceps delivery and the risk of having a tear into the anal muscle.  Those two things, in turn, increase the risk of pelvic floor problems.  Many of these interventions are overused in maternity care.  By choosing a caregiver that supports normal birth, you may be able to avoid having interventions that increase your risk of pelvic floor problems.