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Guest Post: HBAC Story from CNM's POV

I don't often do Guest Posts (not sure why, exactly), but this new blogger, Dena Moes, CNM, asked if she might share a story here. Dena is a certified nurse midwife in Chico, California, Yale-educated with a history of hospital care, but now a homebirth midwife. Her fledgling blog, The Midwife's Desk, offers an interesting perspective. 

Here's Dena.

This post has been written with permission from the family involved. Names have been changed to protect their privacyMy intent is to inspire others to think through their choices and question the current limits on a woman's freedoms after she has had a cesarean.

Before I share Hannah's journey from a cesarean to a homebirth VBAC (vaginal birth after cesarean), let me discuss the current climate regarding VBACs. When I moved to Chico in 2002 and joined a hospital nurse-midwifery practice, VBACs were being done in all three hospitals in our county. It was understood  that VBACs were safe, as long as the surgical incision was the low, vertical (sic) kind (which most in the US are). These scars are less likely to rupture than the up-and-down kind. I went out on maternity leave, had my baby, left that job, and then started attending homebirths two years later. I began hearing that VBACs were suddenly banned from all three hospitals. As in, NO MORE VBACs were allowed, period.  Even if you had had a previous VBAC, making you a very likely candidate for another successful VBAC, you were told by your care provider "No,  I wish you could have a VBAC, but my hands are tied. I am not allowed to attend VBACs anymore. We must schedule your cesarean." If you said "But wait! I just had a VBAC right here two years ago with no problems. Are you kidding? ", you were told "There is nothing I can do. It is up to the hospital, not me." OUCH. What happened?

What happened has to do with ACOG, the American College of OB/Gyns , a powerful trade group for OB doctors. They are so powerful that their recommendations, which put the interests of the doctors FIRST, become national health policy. American obstetricians have developed this habit of inducing most of their patients. Because using the induction drugs on VBAC women was found to increase the risk of a uterine rupture by a significant amount, they recommended that all sites where VBACs take place have an anesthesiologist in-house and ready, in the event of uterine rupture. Well, smaller hospitals like the ones in my county can't afford to pay for an anesthesiologist to sit around while a woman is in labor. VBACs were banned in hospitals all across America instead. The result of all these inductions, and all these VBAC bans, is that one in three women in America today goes in to have her baby, and comes out having had major abdominal surgery.

Women in Chico who want a VBAC must either have a scheduled cesarean instead, or drive at least 100 miles to a larger urban hospital to have a VBAC. Or, they could find a homebirth midwife. Homebirth midwives put mothers and babies FIRST; not hospital rules, not malpractice insurers' rules, and not convenience for the midwife. (Cesareans are very convenient for the doctor - they last an hour, no one is groaning, grunting, or pooping, and the doctor even gets paid more than for a natural birth.) Hannah came to me about a year ago. She wanted a VBAC, and was considering her options carefully.  Her son had been born in NYC by cesarean after 30 hours of labor, but she felt that with more preparation and better support during labor, she could DO IT this time. Her husband Jason and the rest of her family were not particularly supportive of a homebirth. Hannah wanted me to do her prenatal care, and then she planned drive down to Berkeley, 3.5 hours away, to birth at a hospital where nurse-midwives attend VBACs. As her pregnancy progressed, Hannah became more clear that she actually wanted a homebirth. She educated herself and her family about homebirth, and finally her husband agreed. The Berkeley scenario was dropped, and we began to prepare in earnest.

We delved into the details of Hannah's previous birth. A big difference between hospital-based and home-based prenatal care is the attention homebirth midwives give to the position of the fetus. During the last two months of pregnancy, I pay careful attention to which way the fetus' back is lying, so we can be proactive about helping the baby into the best position for birth. This way, we are not surprised with a longer, more difficult labor due to posterior positioning of the baby. Hannah had started her first labor with her baby in the posterior position, and did not know it. Her doctor had never checked for that. Hannah and Jason had driven across the Brooklyn bridge at rush hour to get to the hospital, a major ordeal. When they got there and were checked, they were told to just go on back home, it was too early to be admitted to the labor floor. Well, Hannah was having the strong, painful contractions of back labor, and was not about to face another two hours of traffic. So she and Jason wandered the hospital, found an empty conference room, and spent the night there laboring away.

When they returned to the labor and delivery floor in the morning, more troubles arose. The "wrong" doctor was on that day, not the doctor Hannah had connected with and wanted. The nurse was kind and helpful, but then the doctor and the nurse "got into it with each other" and the doctor banished the nurse from Hannah's room!   Eventually Hannah pushed for three hours, all alone except for her exhausted husband and mother, with not even her nurse in the room to guide and support her. The doctor came in and out to watch for progress, and then took her in for the cesarean.  Afterwards, the doctor told her that surprise! the baby was posterior! Oh, well.

During her pregnancy I focused on four main areas of preparation.

1. Giving her undivided attention, love, and support so she could build trust in me and my assistants, and know that we will really, truly BE THERE for her. I imagined she would have another 30 hour labor, and mentally prepared myself to hang with that. If she needed to push for four, five, six hours, so be it.  

2. Fetal position! We used chiropractic care, specific exercises, and homeopathic pulsatilla to encourage that baby to rotate forward, not posterior. And she did.  

3. Healing the trauma from her previous birth. She wrote about her first birth and her deepest fears and we used Emotional Freedom Technique to address them. This technique uses the meridians and acupressure points of the Chinese Medicine system, to clear emotional trauma from the nervous system and tissues. Her biggest hidden fear was having to face her family and friends if her home VBAC "failed" and she ended up with another cesarean. She felt they would think "See? You should have just had the repeat cesarean. It would have been easier on everybody." She was so brave to stand up for what she wanted, outside the comfort zone of her intimate circle, while not knowing what the outcome would be.

4. Filling her with positive images, stories, and vibes to promote a sense of well-being and optimism about this birth.

Ten days after her "due date", I got the call at 4:30 am. "Hannah is having very strong, close contractions" Jason told me. I heard her moan in the background. I was on my way. I arrived a little after 5 am. Hannah was on her hands and knees in the kitchen, working with contractions every two minutes. This all had started just an hour ago. She had literally just woken up a hour ago. I could tell things were cooking along and readied my supplies. 45 minutes later, her water broke, and she had a strong urge to push. I checked her and she was completely dilated. We moved her to the rug in the living room where she pushed on her hands and knees for twenty minutes and gave birth to her eight and a half pound girl. She had been awake three hours, and I had been there for little more than an hour!

Well, talk about thrilled, shocked, and delighted! Jason and Hannah snuggled up with their baby and giggled and smooched while she nursed. "That was it?" they kept saying. "Really, that was it????" Her whole labor had lasted three hours and she had barely needed to push. Their eyes were shining with joy. They were both transformed by the experience. Jason was in absolute awe of his wife, so strong and powerful and looking gorgeous lying with their baby in the dawn light. They wouldn't have even made it, driving to Berkeley! It would have been a travesty for her to have had abdominal surgery instead of this experience! As we all ate bagels and eggs, I thought about her two births. Why are one woman's two births so different? Can love, support, and the comfort of one's own home REALLY make such a difference? What do you think?


The Best Response to ACOG Statement Yet

I've kept away from ACOG's Statement Against Homebirth because so many other people have done just fine responding to it.

However, I just came across a piece that is, to me, by far, the best response I have read. On
The Education of Genevieve's blog, she re-posts A Parody of the Recent ACOG Statement by a writer named Tienchinho. I've tried to find the author, but haven't been able to.

Assuming the author would love others to read her work, I re-publish it in its entirety.


A Parody of the Recent ACOG Statement


As a home birth after cesarean mom (HBACM), I reiterate my support of home births. While complications can arise with little or no warning even among women with low-risk pregnancies, childbirth is a normal physiologic process that most women experience without problems. Continuous monitoring of both the woman and the fetus during labor and delivery in a hospital or accredited birthing center has not improved maternal or fetal outcomes.

I acknowledge ACOG’s right not to support programs that advocate for, or individuals who provide, home births, but I do not support a system that denies families the essential information to make informed decisions regarding maternal care. Nor do I support a system that lacks the resources to make VBAC a viable option for all women and ensure the quality of the mother-child dyad immediately after birth.

Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause célèbre. Despite the rosy picture painted by hospital birth advocates, a highly medicalized labor and delivery can physically and emotionally scar both the mother and baby. Attempting a vaginal birth after cesarean (VBAC) at the hospital is especially dangerous because seemingly benign interventions such as epidural anesthesia or Pitocin augmentation can lead to complications with potentially catastrophic consequences for both the mother and baby, including death. Unless a woman is in a supportive birth environment that allows the birth process to unfold on its own schedule, she puts herself and her baby’s health and life at unnecessary risk.

Advocates cite the lack of rigorous scientific studies as one justification for promoting hospital births. Consistent dismissal of existing Level I evidence defining the risks of unnecessary interventions such as episiotomy, epidural anesthesia, and amniotomy has concerned proponents of natural childbirth for the past several decades and we remain committed to changing this. Birth advocates throughout the world use childbirth education, grassroots childbirth networks, and recently, the media to provide mothers and caregivers with the evidence.

Multiple factors are responsible for the persistent exceptions to evidence-based medicine in maternal care, but emerging contributors include a fear-based climate that skews mothers’ decision-making abilities and forces caregivers to follow “standards of care” that ignore the scientific evidence. The availability of a birth attendant to provide continuous labor support and of a midwife to provide expertise and intervention may be life-saving for the mother or newborn and lower the likelihood of a bad outcome.

I believe that the safest setting for labor, childbirth, and the immediate postpartum period is one that respects and trusts the birthing process, that meets the Baby-Friendly and Mother-Friendly standards jointly outlined by the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO), and the Coalition for Improving Maternity Services(CIMS) and is supported by birth advocacy groups.

It should be emphasized that childbirth comes with inherent risks. Implying otherwise is misleading and unjust to a birthing mother and her family. Although able to perform live-saving emergency cesarean deliveries and other surgical and medical procedures, board-certified obstetricians have been cornered into practice styles that perpetuate the need for these same measures.

They have lost skills such as detecting and adjusting a baby in the occiput posterior position. Untreated, this condition can result in prolonged labors mislabeled as “dystocia” and in cesarean sections. They minimize the profound impact of a woman’s birth experience on her future relationship with her children as well as her own view of herself. Since suicide and substance abuse are leading causes of maternal mortality, disregard for a mother’s emotional health can lead to tragic consequences for her and her baby.

I encourage all pregnant women to get prenatal care and to make a birth plan.
Safeguarding the process of giving birth promotes a healthy and safe outcome for
both mother and baby. Every woman should seek balanced information to guide her
decisions throughout pregnancy, childbirth and parenting. For women who despair in the lack of choices, they should look for hope in mothers who have navigated this climate of fear successfully. We are here.

(end post)