Cesarean Birth

December 8, 2009 by  
Filed under Education

A major operation, each cesarean actually involves a series of separate incisions in the mother. The skin, underlying muscles and abdomen are opened first and then the uterus is opened allowing birth of the newborn.

There are two main types of cesarean operations, each named according to the location and direction of the uterine incision:

  • Cervical–a transverse (horizontal) or vertical incision in the lower uterus, and
  • Classical–a vertical incision in the main body of the uterus.

Today, the low transverse cervical incision is used almost exclusively. It has the lowest incidence of hemorrhage during surgery as well as the least chance of rupturing in later pregnancies. Sometimes, because of fetal size (very large or very small) or position problems ( breech or transverse), a low vertical cesarean may be performed.

In the classical operation, a vertical incision allows a greater opening and is used for fetal size or position problems and in some emergency situations. This approach involves more bleeding in surgery and a higher risk of abdominal infection. Although any uterine incision may rupture during subsequent labor, the classical is more likely to do so and more likely to result in death for the mother and fetus than a cervical incision.

Why Have Cesarean Rates Increased?

Many factors account for rising cesarean birth rates. By the 1960′s, increasing emphasis was being placed on the health of the fetus. With declining birth rates and couples having fewer children, even greater attention was given to improving the outcome of pregnancy, and infant survival in general. The nation’s infant morality rate began to be seen as an international yardstick on the quality of health care.

At the same time, advances in medical care combined to make maternal death from cesarean childbirth a rare occurrence. The safer the procedure became, the easier it was to decide to perform the operation. As a safe alternative to normal delivery, the cesarean became a practical way to try to improve the outcome of difficult pregnancies.

Studies suggesting the benefit of cesarean birth in dealing with various pregnancy complications also led to more cesareans. Obstetricians came to favor surgery in pregnancies with difficult deliveries that formerly would have required the use of forceps. The diagnosis of “dystocia”, a catch-all term meaning difficult labor, was made more frequently and handled more often with the cesarean operation. Fetal distress during labor–a condition often resulting in a cesarean–was more apt to be detected with the introduction of electric fetal monitoring. Increasingly, physicians used the cesarean method to deliver infants in the breech position prior to birth, adding still further to the rising cesarean rate.

Another important contributing factor was the rising number of repeat cesareans. As the number of women having their first cesarean increased, the long-held tenet “once a cesarean, always a cesarean” led to rapid increase in the number of repeat cesarean births.

What Is The Current Medical Thinking About Repeat Cesarean Deliveries?

Having had a prior cesarean delivery is one of the two major reasons women have the operation today. (The other is the diagnosis of dystocia.) The consensus development panel found that the rate of repeat cesareans is likely to increase further if present trends continue. Currently more than 98 percent of women in the U.S. who have had a cesarean undergo a repeat cesarean for subsequent pregnancies.

This practice was begun in the late 1900′s to avoid the risk of uterine scar rupture and hemorrhage during labor. At that time the classical cesarean incision was most widely used and the cesarean birth rate was extremely low.

Physicians now know that the classical, low vertical and “inverted T” incisions have a higher rate of rupture than the low transverse incision now in general use. The low transverse cervical cesarean also has been shown to result in fewer cases of lasting health disorders or death among mothers and infants. Today, many women who had earlier low transverse cesareans safely deliver subsequent children vaginally.

In studying the issue, the consensus panel found that the risk of maternal death in a repeat cesarean is two times that of a vaginal delivery. In addition, the maternal mortality rate for repeat cesareans has not fallen since 1970. The group concluded that the practice of routine repeat cesarean birth is open for question, and that labor and vaginal delivery after previous low transverse cervical cesarean birth are of low risk to the mother and child in properly selected cases.

The panel recommended that:

  • In hospitals with appropriate facilities, services and staff for prompt emergency cesarean birth, some women who have had a previous low transverse cervical cesarean may safely be allowed a trial of labor and vaginal delivery.
  • The present practice of repeat cesareans should continue for patients who have had previous cesareans with classical, inverted T or low vertical incisions, or for whom there is no record or the type of incision.
  • In hospitals without appropriate facilities, services and staff, the risk of labor for women having had a previous cesareans may exceed the risk to mother and infant from a properly timed, elective repeat cesarean birth. To allow patients to make an informed decision, they should be told in advance about the limits of the institutions offering this service.
  • More adequate information should be compiled on the risks and benefits of trying labor in patients with previous low transverse cervical incisions.
  • Institutions offering labor trials following low transverse cesareans should develop guidelines for managing those labors.
  • Patient education on initial and repeat cesarean birth should continue throughout pregnancy as an important part of patient participation in making decisions about the delivery.

What If The Baby Is In The Breech Position Prior To Birth?

There is a continuing trend to use the cesarean method to deliver a “breech baby”–a fetus positioned in the womb to be born in some way other than the normal head first manner. Nationally, the proportion of breech positioned infants delivered by cesarean rose from about 12 percent in 1970 to 60 percent in 1978.

Breech positioning involves higher risks for the mother and child, regardless of whether the delivery is vaginal or cesarean. Cesareans are being selected more often in these cases to try to improve the outcome in the face of the increased risks. But the consensus group found scientific data in this area generally inadequate to make firm conclusions about desirability of one approach over the other.

Most clinical reviews suggest that the cesarean may involve less risk for the premature breech infant, but this may not be true for term breech babies. Several studies indicate vaginal delivery of the uncomplicated term breech infant is preferable because an elective cesarean birth involves risk significant complications for the mother and little or no decrease in the risk of infant death.

Deciding which method of delivery to use in these situations involves considering many factors. These include maternal pelvic size, size of the fetus, the type of breech position and the experience of the physician with vaginal breech delivery.

In general, the consensus panel concluded that the cesarean presents a lower risk to the infant than a vaginal delivery when the breech fetus is 8 pounds or larger, or when a fetus is in complete or footling breech position or when the fetus is breech with marked hyperextension of the head.

The group recommended that vaginal delivery of term breech babies should remain an acceptable choice when the following conditions exist:

  • anticipated fetal weight of less than 8 pounds;
  • normal pelvic dimensions and structure in the mother;
  • frank breech positioning without hyperextended head; and
  • delivery by physician experienced in vaginal breech delivery.

What Is The Single, Most Common Reason For Performing A Cesarean?

Dystocia is a catch-all medical term covering a broad range of problems which can complicate labor. The consensus group found that this diagnosis was the largest contributor to the overall rise in the cesarean rate, accounting for 30 percent of all cesareans.

Included under the dystocia, or difficult labor, diagnosis are the following three basic types of problems which may impede labor:

  • abnormalities of the mother’s birth canal, such as a small pelvis;
  • abnormalities in the position of the fetus, including breech position or large fetal size; and
  • abnormalities in the forces of labor, including infrequent or weak uterine contractions.

The first two categories are well-defined areas. The physician usually recognizes size or position problems early; guidelines for appropriate obstetrical action are available; and the effects of the various approaches for mother and infant are reasonably well known.

The consensus panel agreed that the last category–forces of labor–is most in need of scrutiny and offers an opportunity for moderating the cesarean rate. Generally, this diagnosis occurs with low-risk infants of normal weight and size. Studies have not shown that infants in the group are better off with either cesarean or vaginal deliveries, although the maternal mortality rate for dystocia in 1978 was 41.9 deaths per 100,000 cesarean births compared with 11.1 deaths per 100,000 vaginal births.

The panel concluded that in handling a difficult or slowly progressing labor without fetal distress, a physician should consider various options before performing a cesarean. These include having the patient rest or walk around, sedating the patient or stimulating labor with a drug called oxytocin.

The panel recommended that because the diagnosis of dystocia is poorly defined and so prominent in increasing the cesarean rate, practice review boards in hospitals should include dystocia cases when conducting reviews. The panel also stressed the need for more research on the factors affecting the progress of labor.

Has The Use Of Electronic Fetal Monitoring Led To More Cesareans?

Another diagnosis accounting for the rise in cesarean birth rates is fetal distress. Occurring during labor, this problem can result in various complications, the most serious being fetal brain damage because of oxygen deprivation.

The use of electronic fetal monitoring techniques has led to an increase in the diagnosis of fetal distress but not necessarily to increase in cesarean deliveries, according to the consensus panel.

Because current data are insufficient on the possible risks or benefits of handling this condition with either cesarean or vaginal deliveries, the panel recommended studies to gather information on the outcomes of births involving fetal distress and development of new techniques to improve the accuracy of the diagnosis. These steps, the panel said, may be expected to improve fetal outcome and lower cesarean birth rates.

Are There Other Medical Conditions Which Would Necessitate A Cesarean?

Because of a need for early delivery, certain medical problems in either the mother or fetus can lead to cesarean birth. Examples include maternal diabetes, pregnancy-induced hypertension, vaginal herpes infection, and erythorblastosis fetalis, a blood disease related to the Rh factor in the mother. This entire group, however, contributes only a small part of the cesarean birth rate increases.

The consensus panel said that in some of these situations vaginal birth would be a safe alternative if a more effective method of stimulating labor before term was available. The panel recommended research to develop such methods.

What Are The Benefits Of The Cesarean Method?

There are certain times when conditions in the mother or infant make cesarean delivery the method of first choice. By providing an alternate route of delivery, the procedure offers great benefit in situations when a vaginal delivery carries a high risk of complications and death.

A cesarean is usually used when an expectant mother has diabetes mellitus. Such women have a high risk of having stillborns late in pregnancy. In these cases, a slightly early cesarean helps prevent this occurrence.

The cesarean can also be a lifesaving procedure when the following conditions are present:

  • Placenta previa–when the placenta blocks the infant from being born.
  • Abruptio placentae–when the placenta prematurely separates from the uterine wall and hemorrhage occurs.
  • Obstructed labor–which can occur with a fetus in the shoulder breech, or any other abnormal position.
  • Ruptured uterus.
  • Presence of weak uterine scars from previous surgery or cesarean.
  • Fetus too large for the mother’s birth canal.
  • Rapid toxemia–a condition in which high blood pressure can lead to convulsions in late pregnancy.
  • Vaginal herpes infection–which could infect an infant being born vaginally, and lead to its eventual death.
  • Pelvic tumors–which obstruct the birth canal and weaken the uterine wall.
  • Absence of effective uterine contractions after labor has begun.
  • Prolapse of the umbilical cord–when the cord is pushed out ahead of the infant, compressing the cord and cutting off blood flow.

What Are The Maternal Risks In Cesarean ?

The risks of any medical procedure are determined by examining the related mortality statistics showing death rates and morbidity figures showing complications, injuries or disorders linked to the event. These vary from hospital to hospital and from locale to locale.

Although maternal death during childbirth is extremely uncommon, national figures show cesarean birth carries up to four times the risk of death compared to a vaginal delivery. The maternal mortality rate for vaginal delivery in 1978 was about 10 deaths per 100,000 births. For cesareans, the rate was about 41 deaths per 100,000 births. (In some cases, maternal deaths indicated in these figures were caused by illness rather than the surgery.)

The morbidity rates associated with cesarean births are higher than with vaginal delivery. Because major surgery is involved, the chance of infection and complication is greater. The most common are endometritis (an inflammation of tissue lining the uterus) and urinary tract or incision infections.

Does Cesarean Childbirth Require Special Anesthesia?

The use of anesthesia during childbirth is unique because it requires attention to the infant about to be born as well as the mother. Although rare, anesthesia-related maternal deaths continue to occur. Most, however, are potentially avoidable.

There are three major anesthetic techniques for cesarean birth. Spinal anesthesia is widely used, although the use of lumbar epidural anesthesia is increasing. Both are considered “regional” anesthesia because they deaden pain in only part of the body without putting the patient to sleep. General anesthesia, which renders the patient unconscious, is often used in an emergency situation and with women who object to the spinal or epidural approach.

The consensus panel recommended that the types of anesthesia available should be discussed among the patient, obstetrician and anesthesiologist. Each approach has advantages and disadvantages. If possible, the report recommends, the patient should have the option of receiving regional instead of general anesthesia.

Are There Risks To The Infant?

Infants delivered with elective cesarean surgery, especially if it is performed before the onset of labor, appear to have a greater risk of respiratory distress syndrome (RDS). This condition, in which the infant’s lungs are not fully mature, may result if an error is made in estimating the age of the developing fetus. Under these circumstances, an infant–who otherwise would have been healthy if allowed to develop fully–encounters the problems of prematurity when removed too soon by cesarean. These include RDS and other lung disorders, feeding problems and various complications which is some cases require a long hospital stay.

Measures and techniques to assess the maturity of the fetus and the degree of lung development are readily available in the United States. The consensus report stressed the need for improving physician and patient education about the safe and effective use of these techniques in planning for elective cesarean delivery. Respiratory distress is unlikely to be a problem, regardless of the type of delivery, if the infant is born at or near term.

What Are The Psychological Effects Of Cesarean Childbirth?

Other factors must be taken into consideration when weighing the prospects of cesarean. Although there has been only limited research on the psychological effects on parents following a cesarean birth, it is clear that surgery is an increased psychological and physical burden compared to vaginal delivery. In limited follow-up studies of infants, there has been no evidence of an adverse psychological effect on infants born by cesarean.

In some hospitals, family-centered maternity care has been extended to cesarean deliveries. The presence of the father in the operating room and the closer contact between the mother and newborn in this approach appear to improve the cesarean process.

The consensus panel recommended strengthening the information exchange and education of perspective parents about the overall cesarean experience. They urged hospitals to allow fathers in the operating room when possible and to avoid routinely separating the newborn from its parents immediately following delivery.

Tags: Childbirth, Caesarean birth, Caesarean, Stillbirth, Caesarean section, Presentation, Caesarean delivery on maternal request, Cardiotocography, Breech birth, Obstetrics

Information About Cesarean Birth

December 8, 2009 by  
Filed under Education

In the United States and Canada almost one in four babies is born by an operation called cesarean section. Consumer and medical groups alike have expressed concern over the rising numbers of cesarean sections. Yet many families seem to believe that a cesarean is just another way to have a baby. Are there definite disadvantages to a surgical birth? It’s time to look at some important facts about cesareans.

Why are there so many cesareans?

Researchers have listed many reasons for the high number of cesarean sections. These include a difficult or long labor, fetal distress, a breech presentation (when the baby is not arriving head first), placental problems, and other conditions in the mother such as toxemia, diabetes and severe bleeding, a greater use of technology such as electronic fetal monitoring and one or more previous cesareans. Some reasons are valid; others are not necessarily beneficial for the mother or the baby.

But cesareans save lives, don’t they?

Of course they do, when they are absolutely medically necessary. They also have risks and side effects that can physically affect the mother and her baby right away and can change the relationship among mother, infant and family by adding more and different stresses than those following a normal vaginal birth.

But a cesarean can prevent the pain of labor and birth.

That’s an interesting thought, but cesarean mothers usually have much more pain after their babies are born. After all, a cesarean is major surgery where several layers of body tissue are cut open and then repaired. This certainly makes it difficult to move, walk, urinate, and to hold and feed a newborn for at least several days or even weeks afterward. Mothers often need much medication to cope with the constant pain following a cesarean. Gas pains, which can be severe, and a sensation of one’s insides failing out are also quite common. Other discomforts include an itching or oozing at the incision area and a general feeling of exhaustion.

In addition, cesareans carry all the same risks of major abdominal surgery including:

  • Infections of:
    • the uterus
    • the bladder
    • the wound (incision)
  • Excessive loss of blood
  • Blood clots
  • Adhesions (scar tissue) within the abdominal cavity
  • Injury to nearby organs (bladder, bowel)
  • Blood transfusion complications
  • Pneumonia
  • Death related to surgery
  • Injury to baby

Major complications such as death following a cesarean are rare. Others such as infections are more common. When a cesarean is a possibility, you need to know about these risks. You should also find out about the possibility of even suspected long-term risks such as infertility due to scar tissue. At the very least, recovery from a cesarean section takes longer since mothers are usually in more pain and more tired afterward. Mothers also need more support physically and emotionally than those who give birth vaginally.

Well, then, aren’t cesareans better for babies?

Once again, that is sometimes true, when the risks associated with a cesarean are outweighed by the benefits of having a baby born surgically. Sometimes a cesarean is performed before labor begins. However, even with advanced techniques (ultrasound or amniocentesis), there is a greater risk of respiratory problems even in term infants than when the start of labor determines the baby’s birthday. Truly premature infants are subject to breathing and other physical difficulties of low birth weight, whether they are born surgically or vaginally. In addition, cesarean babies can also have anesthesia complications and may be sluggish and slow to start breathing. They may also suffer from some neurological problems. Such a start can impair relationships with the new baby, including a more difficult beginning to breastfeeding.

I never knew such a simple procedure could have such effects.

Oh, but the point is, as cesareans have become more commonplace, we’ve accepted them as simple procedures. But, although cesarean sections are safer than ever and, when necessary, a true blessing, a cesarean is clearly not a simple procedure. And we haven’t even talked about those other side effects that are harder to measure.

What does that mean?

Well, there is no doubt that the immediate relationship between the cesarean mother and her baby is different from the relationship after a natural birth. The mother may be groggy and unable to hold her baby and baby is often moved out of sight and touch for an examination during the important introductory moments following birth. Infant and parents may be separated for a time while the baby is observed in a central nursery. After a cesarean, mothers often describe a wide range of feelings that include failure, anger, disfigurement, inadequacy and resentment, while at the same time feeling glad that their babies are born. Such opposite feelings can sometimes lead to an uneasy and confusing start for parenting. It’s harder to care for a baby when you need so much care yourself. Fathers and other companions may feel frustrated at having to give so much more physical and emotional support. After all, besides learning to care for her newborn and/or taking care of other children, a cesarean mother is recovering from surgery. The time following a baby’s birth is tiring. As sleep, housekeeping and general life patterns change to meet the needs of the new family, the additional needs of the cesarean mother may increase the typical difficulties of adjusting to the new baby.

If I really don’t need a cesarean, how can I avoid one?

Education is the key word in preventing unnecessary cesareans and having a safe and memorable birth experience. Find out about birth practices in your area. Why and how often do caregivers recommend and perform cesareans? Choose a supportive caregiver and birthplace with the lowest possible rate of cesarean sections. Contact local childbirth educators, midwives and consumer groups such as childbirth education or breastfeeding associations for their information. Even before you become pregnant, look for the many available publications and resources to help you find ways to have a more natural pregnancy, labor and birth. Find out about how you can naturally cope with labor and about trained labor support persons who can help you avoid pain medication and anesthesia. Read Unnecessary Cesareans – Ways to Avoid Them. If you have had a previous difficult birth (whether cesarean or not), you will want to consider what happened and why. Was the difficulty caused by a chain of events that changed the natural process? Unpleasant memories of events and interventions in labor can make it painful to look forward to another birth. It can be helpful to work through such past experiences before you become pregnant again.

Develop a confidence and belief that birth is a safe and natural process that generally succeeds without intervention. Recognize that when a cesarean section is necessary, it can be truly life-saving, but that giving birth naturally is the way it is meant to be.

Copyright 1992 International Educators Association (used with permission)

Common Feelings After Unexpected Cesarean Birth

  • Combination of relief, fear, shock – if labor has been long or difficult, if there has been anxiety for the mother or baby – a sense of not knowing what to expect, or having lost control.
  • Disappointment – especially common when parents have expected and prepared for a more active participation in the birth.
  • Loneliness – being separated at a time when support, closeness, and the need to be together occurs.
  • Failure – feelings of inadequacy because delivery was not vaginally. Support person may feel that she/he let the mother down by not being present for the birth.
  • Anger – “Why” and “why me”, anger at the doctor, nurses, baby’s father, and/or the family.
  • Resentment – towards the baby for the cause of her pain, discomfrot, and trouble. Cesarean mothers often have less energy at first and may resent the demands and responsibilities of child care.
  • Self blame and depression – turning anger inward – “if only I hadn’t gained so much weight, if only I didn’t do this, or had done that.”
  • Self esteem – sometimes suffers because they couldn’t do it “right” and that they are failures as women.
  • Body Image – may suffer. Not only have their bodys not worked “right”, but the scar is an ever present reminder. Some women may feel rejection from their mate due to the scar.
  • Depression – a period of the “blues” may be common after any mothod of childbirth. Cesarean parents may feel that the birth was a “let down”.
  • Mixed feelings of future births – many dread the anxiety and pain of another cesarean. Others may see it as a relief from the labor.
  • Guilt – over having negative feelings at a time when a mother (or parents) is (are) to be happy with their new baby.
Tags: Breech birth, Obstetrics, Elective caesarean section, Midwifery, Caesarean section

Vaginal Birth After Cesarean Birth – VBAC

December 8, 2009 by  
Filed under Education

You’ve had one or more cesareans and you’re looking ahead to your next birth. “Once a cesarean, always a cesarean” is no longer the rule, and for reasons that are uniquely yours, you want to have a vaginal birth this time. Good for you! You are about to join the growing number of women who have planned for a vaginal birth after a cesarean (VBAC).

Why have a VBAC?

Many women want to have a VBAC because of the feeling that they missed out on an important life experience when they had a cesarean. They want to feel a baby move through and out of their bodies and into their arms. Other women and medical professionals know that labor is important for the newborn’s adjustment to life outside mother. They also know that vaginal births are safer for mothers and infants than planned cesareans. Still others want a faster recovery from their births and to go home much sooner than when they had a cesarean. They want to mother and nurture their infants (and other children) without the restrictions that accompany surgical delivery. They want to avoid surgery and its risks and complications.

You may share these reasons or have different ones, but it’s important to remember that any reason to want a VBAC is a good reason.

What do I need to know about my previous cesarean?

It’s helpful to know why you had your cesarean(s). Most reasons for a cesarean don’t necessarily repeat themselves. These include:

  • Fetal distress – baby in trouble;
  • Cephalopelvic disproportion (CPD) – “too-big baby for too-small pelvis;”
  • Failure to progress – labor lasts too long;
  • Breech position – baby comes bottom or feet first;
  • Transverse – baby lies sideways;
  • Abrupted placenta or a placenta previa – location or separation of the placenta causing bleeding and problems with the baby’s supply of oxygen;
  • Prolonged rupture of the membranes – the bag of waters breaks, and either labor does not begin or the baby is not born within a specified amount of time;
  • Previous birth(s) by cesarean – including planned, repeat cesareans.
  • Despite cesareans for the above or other reasons, countless women have successfully and safely had their later babies vaginally.

What about my scar?

It is important to know the type of incision that was used on your uterus. The two most common incisions are the horizontal (low transverse), which is considered the safest, and vertical (classical or low vertical). You should check with your doctor or hospital records to see if your abdominal scar (outside, on your skin) is different from you uterine (inside) scar. It is encouraging to know that some women who did not know their type of uterine incision have been permitted to labor and gave birth vaginally without any problems.

In the past the most common reason for planned, repeat cesareans was a belief that the uterine scar would rupture (or separate) during a vaginal birth. Recent medical findings, however, show that this is extremely rare, particularly in the case of the more common low transverse incision. The risk of uterine rupture is far less than the risk of complications associated with a cesarean.

What about a caregiver?

In many places women planning VBAC can choose between midwives, obstetricians and family physicians. As VBAC becomes more common, it is easier for women to be accepted as VBAC clients by all practitioners.

The way a woman is treated in pregnancy and labor varies from one caregiver to another. Because midwives use fewer medical interventions, women under their care are less likely to have a cesarean section.

What about medical interventions?

Common interventions in pregnancy and labor might include the use of ultrasound, electronic fetal monitoring, drugs to start or speed up labor, breaking the bag of waters, intravenous fluids (IV) and the use of a wide variety of drugs for pain relief. Although advantages may exist for such practices in some instances, routine use of such interventions may interfere with the progress of labor and increase the possibility of another cesarean.

Not all midwives or doctors follow the same guidelines and procedures for VBAC. Some prefer using interventions, whereas others offer care with fewer restrictions and more choices. Recent medical guidelines state that women with one previous low-transverse incision should be treated the same as the woman without a previous cesarean! Professionals now even recommend that women with two or more cesareans can have a VBAC if they wish.

As with any birth, it is important for you to discuss with your caregiver and hospital what options exist for you during labor and birth. If you know your choices, you can negotiate for something different or even change to a caregiver who will respect your preferences and treat you as individually as possible.

How can I guarantee that I will have a VBAC?

No one can guarantee that you will have a VBAC, although current medical information makes it clear that most cesarean mothers can later give birth naturally. But there are some things that VBAC women have found helpful to increase the chances for a vaginal birth.

What can I do before I get pregnant (or in early pregnancy)?

  • Inform yourself and take personal responsibility for your birth experience. Learn as much as you can before you get pregnant and during your pregnancy. There are many excellent books, films, tapes and written materials on VBAC and birth in general. Such information can help you make informed choices and accept the responsibility for your birth.
  • Join a support group. Don’t overlook the value of cesarean or birth support groups that may exist in your area. The information and caring atmosphere in such groups can help promote healing of any past unhappy birth experiences and offer encouragement for upcoming births.
  • Take childbirth classes. Consumer-oriented childbirth classes or special VBAC classes offer a wealth of information and skills. They also give you and your partner an opportunity to consider this new pregnancy and birth as a separate experience from your cesarean(s). Learn and practice the skills you are taught to cope with the reality of labor.
  • Get in touch with yourself. Techniques such as visualization, meditation and affirmation can help you heal and accept feelings inadequacy, grief and failure from past births. Recognizing these feelings, even if they are not totally resolved, will help clear the way for more positive thoughts and more confidence in yourself and the birth process.

My partner is nervous about a VBAC. What can I do?

Talking to each other about past birth(s) will help clarify ways in which you can work together toward VBAC. Involve your partner as you read and research. Reassure your partner that vaginal birth is safe and the best choice for you and your baby – and important to you! Another labor support person can assist both of you during labor. You might also ask your partner to read this booklet.

What about additional companions?

Some women have found it helpful to have one or more additional people with them as they labor and give birth. Such companions, professional or not, should be available to the woman throughout her labor and should know exactly what the pregnant woman wants from her birth.

If you choose to have others at your birth, let them know your desires before labor begins. For example, do you want a birth without medication or are you willing to accept medication under certain circumstances? When are you planning to go to the hospital? And so on…

What can help me in labor?

There are simple measures that can help a woman work with her labor. Many women have found it a good idea to wait until labor is well established before they telephone their caregiver or to go the place where they will give birth. Still others have found that eating and drinking in labor, walking, making noise, taking a warm bath or shower, being upright and/or avoiding interventions and drugs have helped them work better with their bodies. It is also important to know that lying flat on your back in labor is not helpful and can cause complications to your baby.

My friends think I’m crazy to want to labor.

VBAC is a very personal decision, and sometimes a lonely one. If you find that family and friends are not supportive of your goals, it’s probably best to keep your feelings and plans to yourself, or to share them only with those friends who understand your feelings. A local support group can be especially helpful at a time like this and give you any additional information you may need.

Being pregnant and planning a VBAC are not everyday occurrences. You deserve a supportive environment. You probably don’t agree with your friends and family about everything anyway. What you want for you, your baby, and your family is your responsibility.

What if I end up with another cesarean?

This is a difficult question. Certainly if you have planned and worked for a VBAC, having another cesarean can be, at the least, a disappointing or sad experience. You will have physical and emotional reactions common to cesarean mothers – some of which may be familiar to you. However, you will not be a failure, because you have worked at having the best possible birth experience for you and your baby. Sadness and grief over any loss (including the loss of a vaginal birth) is a part of living. As time passes, you will find that you have grown and learned from this experience too. Women who have repeat cesareans after planning vaginal births often say how glad they were to have tried. Many are delighted that labor began on its own and their babies were naturally ready to be born.

Is all this effort to have a VBAC really worth it?

Women who have traveled this road have found new strengths and confidence as a result. They have filled spaces in themselves emptied by previous births and have been pleased with the new discoveries of their abilities as women.

Combination of relief, fear, shock – if labor has been long or difficult, if there has been anxiety for the mother or baby – a sense of not knowing what to expect, or having lost control.

Disappointment – especially common when parents have expected and prepared for a more active participation in the birth.

Loneliness – being separated at a time when support, closeness, and the need to be together occurs.

Failure – feelings of inadequacy because delivery was not vaginally. Support person may feel that she/he let the mother down by not being present for the birth.

Anger – “Why” and “why me”, anger at the doctor, nurses, baby’s father, and/or the family.

Resentment – towards the baby for the cause of her pain, discomfrot, and trouble. Cesarean mothers often have less energy at first and may resent the demands and responsibilities of child care.

Self blame and depression – turning anger inward – “if only I hadn’t gained so much weight, if only I didn’t do this, or had done that.”

Self esteem – sometimes suffers because they couldn’t do it “right” and that they are failures as women.

Body Image – may suffer. Not only have their bodys not worked “right”, but the scar is an ever present reminder. Some women may feel rejection from their mate due to the scar.

Depression – a period of the “blues” may be common after any mothod of childbirth. Cesarean parents may feel that the birth was a “let down”.

Mixed feelings of future births – many dread the anxiety and pain of another cesarean. Others may see it as a relief from the labor.

Guilt – over having negative feelings at a time when a mother (or parents) is/are to be happy with their new baby.

In the United States and Canada almost one in four babies is born by an operation called cesarean section. Consumer and medical groups alike have expressed concern over the rising numbers of cesarean sections. Yet many families seem to believe that a cesarean is just another way to have a baby. Are there definite disadvantages to a surgical birth? It’s time to look at some important facts about cesareans.

Why are there so many cesareans?

Researchers have listed many reasons for the high number of cesarean sections. These include a difficult or long labor, fetal distress, a breech presentation (when the baby is not arriving head first), placental problems, and other conditions in the mother such as toxemia, diabetes and severe bleeding, a greater use of technology such as electronic fetal monitoring and one or more previous cesareans. Some reasons are valid; others are not necessarily beneficial for the mother or the baby.

But cesareans save lives, don’t they?

Of course they do, when they are absolutely medically necessary. They also have risks and side effects that can physically affect the mother and her baby right away and can change the relationship among mother, infant and family by adding more and different stresses than those following a normal vaginal birth.

But a cesarean can prevent the pain of labor and birth.

That’s an interesting thought, but cesarean mothers usually have much more pain after their babies are born. After all, a cesarean is major surgery where several layers of body tissue are cut open and then repaired. This certainly makes it difficult to move, walk, urinate, and to hold and feed a newborn for at least several days or even weeks afterward. Mothers often need much medication to cope with the constant pain following a cesarean. Gas pains, which can be severe, and a sensation of one’s insides failing out are also quite common. Other discomforts include an itching or oozing at the incision area and a general feeling of exhaustion.

Cesareans have all the same risks of major abdominal surgery including:

  • Infections of:
    • the uterus
    • the bladder
    • the wound (incision)
  • Excessive loss of blood
  • Blood clots
  • Adhesions (scar tissue) within the abdominal cavity
  • Injury to nearby organs (bladder, bowel)
  • Blood transfusion complications
  • Pneumonia
  • Death related to surgery
  • Injury to baby

Major complications such as death following a cesarean are rare. Others such as infections are more common. When a cesarean is a possibility, you need to know about these risks. You should also find out about the possibility of even suspected long-term risks such as infertility due to scar tissue. At the very least, recovery from a cesarean section takes longer since mothers are usually in more pain and more tired afterward. Mothers also need more support physically and emotionally than those who give birth vaginally.

Well, then, aren’t cesareans better for babies?

Once again, that is sometimes true, when the risks associated with a cesarean are outweighed by the benefits of having a baby born surgically. Sometimes a cesarean is performed before labor begins. However, even with advanced techniques (ultrasound or amniocentesis), there is a greater risk of respiratory problems even in term infants than when the start of labor determines the baby’s birthday. Truly premature infants are subject to breathing and other physical difficulties of low birth weight, whether they are born surgically or vaginally. In addition, cesarean babies can also have anesthesia complications and may be sluggish and slow to start breathing. They may also suffer from some neurological problems. Such a start can impair relationships with the new baby, including a more difficult beginning to breastfeeding.

I never knew such a simple procedure could have such effects.

Oh, but the point is, as cesareans have become more commonplace, we’ve accepted them as simple procedures. But, although cesarean sections are safer than ever and, when necessary, a true blessing, a cesarean is clearly not a simple procedure. And we haven’t even talked about those other side effects that are harder to measure.

What does that mean?

Well, there is no doubt that the immediate relationship between the cesarean mother and her baby is different from the relationship after a natural birth. The mother may be groggy and unable to hold her baby and baby is often moved out of sight and touch for an examination during the important introductory moments following birth. Infant and parents may be separated for a time while the baby is observed in a central nursery. After a cesarean, mothers often describe a wide range of feelings that include failure, anger, disfigurement, inadequacy and resentment, while at the same time feeling glad that their babies are born. Such opposite feelings can sometimes lead to an uneasy and confusing start for parenting. It’s harder to care for a baby when you need so much care yourself. Fathers and other companions may feel frustrated at having to give so much more physical and emotional support. After all, besides learning to care for her newborn and/or taking care of other children, a cesarean mother is recovering from surgery. The time following a baby’s birth is tiring. As sleep, housekeeping and general life patterns change to meet the needs of the new family, the additional needs of the cesarean mother may increase the typical difficulties of adjusting to the new baby.

If I really don’t need a cesarean, how can I avoid one?

Education is the key word in preventing unnecessary cesareans and having a safe and memorable birth experience. Find out about birth practices in your area. Why and how often do caregivers recommend and perform cesareans? Choose a supportive caregiver and birthplace with the lowest possible rate of cesarean sections. Contact local childbirth educators, midwives and consumer groups such as childbirth education or breastfeeding associations for their information. Even before you become pregnant, look for the many available publications and resources to help you find ways to have a more natural pregnancy, labor and birth. Find out about how you can naturally cope with labor and about trained labor support persons who can help you avoid pain medication and anesthesia. Read Unnecessary Cesareans – Ways to Avoid Them. If you have had a previous difficult birth (whether cesarean or not), you will want to consider what happened and why. Was the difficulty caused by a chain of events that changed the natural process? Unpleasant memories of events and interventions in labor can make it painful to look forward to another birth. It can be helpful to work through such past experiences before you become pregnant again.

Develop a confidence and belief that birth is a safe and natural process that generally succeeds without intervention. Recognize that when a cesarean section is necessary, it can be truly life-saving, but that giving birth naturally is the way it is meant to be.

Tags: Breech birth, Pregnancy, Caesarean section, Midwifery, Uterine rupture, Childbirth, Obstetrics, Vaginal birth after caesarean

Epidural Anesthesia

December 8, 2009 by  
Filed under Education

Epidural anesthesia is one way of taking away the pain of labor and birth. Like most medical treatments it has risks and benefits. It is important that you learn about those risks and benefits before deciding if an epidural is right for you.

What is epidural anesthesia?

Epidural anesthesia uses repeated doses of a local anesthetic in the epidural space of the spinal area. It numbs the nerves from the uterus and birth passage without stopping labor. A successful epidural once administered gives you an almost pain-free awake state throughout the entire labor and birth of your baby.

An epidural is administered by an anesthesiologist, a physician who is a specialist in anesthesia. Your labor is watched carefully before the medication is given. A specially trained nurse or the physician will be near you until the baby is born.

You and your support person should discuss risks and benefits and sign a written consent before the epidural anesthetic is given.

How is it done?

An epidural is not administered until you are in active labor. Before the procedure begins, intravenous (IV) fluids are started and 1-2 liters of fluids are given. The IVs will continue throughout labor and birth. Then you will be asked to position yourself on your left side or in a sitting position with your chin on your chest and you knees close to your abdomen. This position is uncomfortable for most women. The waistline area of your mid back is wiped with an antiseptic solution to reduce the skin bacteria and thus lessen the chance of an infection.

A coin-sized area of skin on your back is numbed with an injectable local anesthetic. Then a larger needle is placed through the numbed area and into the epidural space of your spine. A small tube (catheter is threaded into that needle until the tip reaches the epidural space around the spinal cord. At that time the needle is removed carefully leaving the catheter in place.

A “test dose” of medication is injected into the catheter to confirm the proper placement. If the placement is correct an initial dose is administered. The catheter is then taped to your back so more medication can easily be injected later. Once in place the catheter does not restrict moving side to side in bed and it is not felt in the back. The pain involved during the administration procedure may be a slight pinch or it may be painful for several minutes.

Three to five minutes following the initial dose, the nerves of the uterus begin to numb. After ten minutes you will feel the full effect. As the initial anesthesia begins to wear off, another dose can be given through the catheter before contractions become uncomfortable. This will be done every one to two hours depending on the specific anesthetic drug(s) and the amount and strength of the medication given.

As soon as the baby is born, the catheter is removed. The effect of the anesthesia usually wears off completely in one or two hours. At that time you may experience an uncomfortable burning sensation around the birth canal.

Are epidurals safe?

At this time, epidurals are thought to be safe for both mother and baby. However, there are risks, and limited studies have been done. Epidurals may require other medical procedures (such as forceps) which add to the risk. The most common side effect is a sudden drop in the woman???s blood pressure. This problem occurs 1 to 2 percent of the time and can be dangerous to a woman and baby. When it does occur, the medical staff is there to take quick action. Usually they can correct the problem. Frequent blood pressure monitoring with either a machine or by a staff member is required after each dose of medication. Some women find this comforting while others find the monitoring irritating because it disturbs the interaction with their support people.

When can I have it and Will it affect my labor?

An epidural anesthetic is administered once you are in true labor. Once started, however, it can slow your labor and make the contractions weaker. If this happens you may be given oxytocin, a drug which makes contractions stronger. If oxytocin is used you will be watched closely since oxytocin can over stimulate the uterus, causing contractions that are too severe.

Does it always work?

If the physician cannot easily locate the epidural space, it may not be possible to use epidural pain relief. This seldom happens. Sometimes labor begins so fast that there is not enough time to use an epidural. Some epidurals give “patchy” anesthesia, causing the feeling that some parts of the abdomen are anesthetized and other parts are not.

Can anyone have it?

Most women can have an epidural, although women who have had back surgery, heart or blood disorders and those who have an allergy to “-caine” medications should discuss those problems with their physicians and anesthesiologists.

Must I remain in bed after I receive the epidural?

Yes, you will be allowed to lie on your side with your head elevated 30 degrees. The epidural also anesthetizes your legs somewhat so you cannot bear your weight and stand. This means, of course, that you cannot go to the bathroom or walk about. You must also have continuous intravenous fluids and electronic fetal monitoring. Electronic fetal monitoring involves having two belts around your abdomen or a wire into your vagina which attaches to your baby’s head.

What else will be done?

Because your abdomen is anesthetized you cannot urinate as you wish. If your labor lasts more than a few hours you will probably need a urinary catheterization which requires that a tube be put into your bladder to release your urine. Catheterization increases the risk of urinary infection 1 to 2 percent each time it is done.

Will I be able to push?

Under epidural anesthesia you may not be aware that you are having a contraction. If you are aware, you can cooperate by pushing. If you cannot feel the contractions, you will probably not be able to push. The baby will then be forced down the birth canal by someone pushing down on your abdomen at the top of your uterus and/or forceps will be placed around the baby???s presenting part and pulled. Both methods produce some risks to the baby. Many experts feel that the timing of the re-injections determines whether the woman can feel her contractions.

Will it slow labor?

Some labors are slowed by the use of an epidural. For other labors, an epidural may actually speed labor because the woman is more relaxed.

Will I need forceps?

There is an increased possibility that forceps will be necessary. Forceps usually require an episiotomy which is a cut enlarging the birth opening. The use of forceps makes most episiotomies extend (get larger), requiring even more stitches and potential pain.

Advantages of an epidural

  • Freedom from pain during labor and birth.
  • Unlike some other drugs it does not make the woman drowsy before or after the birth.
  • Little medication reaches the baby.
  • Close monitoring by the hospital staff may give the laboring woman a sense of confidence

Disadvantages of an epidural

  • Labor may be slowed by the woman???s inability to move about and make use of gravity.
  • The woman must remain in bed on her side with her head at the same level throughout labor.The woman must have constant intravenous fluids and electronic fetal monitoring.The woman must have her blood pressure taken frequently.
  • The woman will probably require catheterization which has risks.
  • The baby will probably be delivered by forceps which has risks.
  • The woman will have little control over her body and may not feel the birth process. This can interfere with maternal-infant bonding.
  • The woman must depend totally on nurses and doctors for basic physical needs.
  • Extremely rare but serious medical risks exist about which the woman and her partner must be aware.

What else can be used instead of an epidural for pain relief?

There are other ways of reducing the pain of labor. Many women are helped by techniques learned in childbirth classes – relaxation, massage, positioning, visualization, distraction, focusing and breathing that are done with the support of another person. These non-drug coping skills use your own strengths and place you in control of your own body.

Epidural anesthesia is one method that can give relief from pain and discomfort in labor. It does require that you give some control to the hospital staff. It does involve risks. The final decision is yours. Understanding this procedure can help you decide what is right for you.

Remember to be open and talk with your co-workers about your breast-feeding. Try to gain their support and interest.

Tags: Epidural, Anesthesia, Midwifery, Childbirth, back surgery, Anesthetic, Obstetrics, Catheterization, epidural anesthesia

Is it Baby Blues or Post Partum Depression?

December 8, 2009 by  
Filed under Education

For many women, the days after birth are filled with a lot of mood changes. Some women find they feel weepy without any definite reason. Some women notice a change in their appetites. A few women notice they cannot sleep even when very tired; others may feel like sleeping much more than before. In the first weeks after birth, lots of women speak of feeling overwhelmed with the work of caring for a baby. Some women say they felt their lives would never return to a normal routine.

All of these feelings and changes are normal. They are sometimes called the baby blues. They are part of the first few days and weeks after birth for many new mothers. These feelings can be caused by rapid changes in your body after birth. The “baby blues” also come from seeing the kind of responsibility that a parent has. Even when you have thought a lot about caring for a baby, the reality of what a job that is does not really hit most parents until the first few days at home.

The baby blues may be eased by limiting what you do – giving yourself time to get used to this new job, just taking care of yourself and your baby and getting as much rest as possible. Often, that is easier to say than do. Taking care of a baby is a 24 hour a day job. One new mother said, “On a good day with my baby, I found time to brush my teeth.” That gives you some idea of how full your days will be in the first weeks.

Signs of true depression are different from the baby blues. Women who have true depression can feel sad day after day, often feel overwhelmed by anxiety and may not have the energy to care for themselves or their babies. This kind of depression is a serious problem when not treated. If you notice any of those signs, call your doctor, midwife or a public health nurse. Any of those people will be able to help you work through your feelings or get you in touch with others who have skill in working with mothers experiencing depression.

Be Good To Yourself

Here are some tips on easing your adjustment to your new role:

  • Plan Ahead. Most new parents say that the evening meal time is the most difficult time of the day. While still pregnant, prepare and freeze some meals that will only require heating up. This can make meal times much less hectic in the first couple of weeks.
  • If possible, invite a friend or family member to spend the first week or so at home with you. This person???s job should be to take care of household tasks. That is better for you than letting others take care of your baby while you do household tasks. If you prefer not to have anyone stay, don???t be afraid to ask for occasional help. If friends or family are willing, let them bring over a few meals or do the laundry or shopping.
  • Stay in a robe or nightgown for the first week at home. This reminds you and others in your home that you are giving yourself time to recover. Be good to yourself – let unimportant things wait! Rest whenever your baby does.
  • Take your phone off the hook during rest periods.
  • Limit visitors for at least the first 2 weeks. It is fun to have others admire your baby with your – but it is also tiring for both you and your baby.
  • Fathers can be as good at caring for a baby as mothers, but men need a chance to learn, just as women do. Let dad do things his way – as long as they are safe. New mothers hate having someone watching and giving advice every moment – and so do new fathers.
  • If you find yourself feeling down or getting angry with your baby, look for help. Never pick up your baby when you are angry. Give yourself time . . . count to 20 slowly, wait until you can pick your baby up gently and lovingly. If you are having a very hard time and are afraid you might hurt your baby, call for help. Many communities have crisis counseling that you can call 24 hours a day. Looking for and getting help is so much better than trying to go it alone – and is a sign of what a loving parent you are working to become.
Tags: Infancy, Childbirth, Postpartum depression, Pregnancy, Maternity blues

Physical Comfort During Pregnancy

December 8, 2009 by  
Filed under Education

Physical and hormonal changes are largely responsible for the common discomforts of pregnancy.

During pregnancy, your body???s center of gravity is altered due to increase in weight, and a change in how your weight is distributed. Hormones, particularly one called Relaxin, contribute to the looseness of ligaments that support the pelvic joints and join the uterus to the pelvis and abdominal wall.

It is important to maintain good posture and avoid muscle strain, and stress on joints of your pelvis and spine.

Correct Posture for Standing

  • Keep your feet almost parallel, a few inches apart
  • Knees straight, but not locked
  • Buttocks tucked under
  • Head held high, chin tucked in
  • Abdominal wall pulled up and in
  • Shoulder blades pulled back
  • Arms hanging relaxed by your sides

Don’t wear..

  • High heels and shoes that are too big or too small – you could trip and fall
  • Clothes that are tight, such as girdles, pantyhose and knee-high stockings or socks
  • High platform-type shoes
  • Shoes with slippery or unstable bottoms

Learn the right way to put on support hose if you need to wear them.

Getting out of bed

Lying on your side, bend knees, push with arms and until you can straighten elbows, and as you sit up, slowly swing your legs over side of bed.

Lifting

Never bend from the waist, always bend from your hips and knees, keeping your back straight. Avoid heavy lifting or carrying because your pelvic and spinal joints may be unstable, especially later in your pregnancy.

Squatting

Stand with feet and knees well apart. Keeping head and spine straight, bend your knees and gently lowering your body to a squatting position. Heels may lift off floor. To stand up again, push up with your legs and then straighten knees.

Kneel Squatting

Stand with one foot placed forward in front of the other. Keeping your head and back straight, bend your knees, and lower yourself onto back knee, which rests on the floor. To stand back up, push up from the floor, straightening your legs.

Always hold onto nearby support for extra balance and control while squatting, climbing stairs, and sitting down. Avoid standing for long periods, or sitting with your knees crossed as this adds to poor circulation in the legs and pelvis. When possible sit with your legs elevated to help the blood flow in your feet and legs.

Tags: Pelvis, Keeping head, Press-up, Childbirth, muscle strain, Bodyweight exercise, Sitting, Obstetrics, exercise

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