Neonatal Outcomes Better With VBAC

This is from the June issue of *Obstetrics and Gynecology*!! All of the things WE'VE KNOWN, yet they have been against admitting. Maybe the evidence of harm in ERCS is increasing?

Women need to be educated. That's the first step. They need to stop being so darn scared of the pain of labor, and educate themselves of the dangers of things like inductions, augmentation, epidurals, labor narcotics, artificial rupture of membranes, and delivering in the hospital period.

~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~


Neonatal Outcomes May Be Better With Vaginal Birth After Cesarean Delivery

Laurie Barclay, MD


June 3, 2009 — Neonates born after elective subsequent cesarean delivery have significantly higher rates of respiratory morbidity and neonatal intensive care unit (NICU) admission and longer length of hospital stay vs those with vaginal birth after cesarean (VBAC), according to the results of a retrospective cohort study reported in the June issue of *Obstetrics & Gynecology*.

"Controversy remains on whether a trial of labor or an elective repeat cesarean delivery is preferable for a woman with a history of cesarean delivery," write Beena D. Kamath, MD, MPH, from the University of Colorado
School of Medicine in Denver, and colleagues.

Wait? What?!?!?! Didn't the study prove that outcomes were better with VBAC?

"Historically, concerns regarding the increased risk of uterine rupture and perinatal asphyxia in trial of labor after cesarean compared with planned repeat cesarean have swayed obstetricians away from recommending a trial of labor after cesarean delivery; however, the absolute risk of perinatal asphyxia remains small."

Um - the risk of Uterine Rupture is approximately 0.3-0.7%. And that's not the risk of death with UR. The actual risk of death of baby after a Uterine Rupture is a FRACTION of this less than 1% risk. And the OBs are swayed against recommending it - why?? And historically? Really? Is that why the VBAC rates were HIGHER 10 years ago, and the cesarean rate lower?

The goals of this study were to compare the outcomes of neonates born by elective subsequent cesarean delivery vs VBAC in women with 1 previous cesarean delivery and to compare the cost differences between these
procedures. The study cohort consisted of 672 women with 1 previous cesarean
delivery and a singleton pregnancy at or after 37 weeks of gestation. Participants were categorized based on their intention to have an elective subsequent cesarean delivery or a VBAC, whether successful or failed. The main endpoints of the study were NICU admission and measures of respiratory morbidity.

Compared with the VBAC group, neonates born by cesarean delivery had higher
NICU admission rates (9.3% vs 4.9%; *P* = .025).

:Nods: I lived through the absolute HELL of this.


Rates of oxygen supplementation were also higher in the subsequent cesarean group for delivery room resuscitation (41.5% vs 23.2%; *P *< .01)

:Nods Again: Noah was on CPAP the first 2 days, intubated the following 2 days, and then on a nasal cannula for the remainder of his 9 day stay.

and after NICU admission (5.8% vs 2.4%; *P* < .028).

DOUBLE the risk of NICU stay - did you catch that?!?!

The rates of delivery room resuscitation with oxygen were lowest in neonates born by VBAC and highest in neonates delivered after failed VBAC.

Yep. I can see that. "Failed" VBAC = Another Cesarean Section. Cesareans are harmful for baby. Got it.

Although the costs of elective subsequent cesarean delivery were significantly higher vs VBAC,

And women really believe that their surgeon - Ooops! I mean OB - don't get paid more for elective surgeries? They can schedule it around their personal schedule, and they're in and out in about a total of 2 hours. Hmmmm ...


the highest costs for the total birth experience were for failed VBAC, considering both delivery and NICU use.

I would LOVE to see hospital VBAC success % vs Home VBAC success %. Those of us who know, know that VBACs are more likely to be successful at home, due to a NUMBER of different factors.

"In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay," the study authors write.

And yet, women are still told that VBAC is too dangerous. Really?!

Limitations of this study include relatively short postpartum follow-up of the mothers to determine the additional costs of postsurgical complications and insufficient data to allow estimation of costs other than those for hospital care.


Even if you don't know a whole lot about Cesareans vs. Vaginal Birth, it is a pretty logical conclusion to believe that complications are higher after surgery, correct? This study didn't account for those women who had to go back into surgery because of an infected uterus or incision. It didn't account for those who were sent home with Home Health Care Nurses, because they had to pack their incision for several weeks.

"Given the increasing rates of primary cesarean delivery and the concomitant decrease in VBACs, once a woman has had a primary cesarean delivery, we must consider the risks that this places on her subsequent deliveries and subsequent neonates," the study authors conclude.


Hmm. Okay study authors, are you suggesting that cesarean sections not be recommended for the slightest thing, as they are now? That would require OBs not intervening in normal labor as much as they do. That would mean not breaking a woman's water, not restricting women to the bed, and not recommending inductions or augmentation. Start THERE!


"Indeed, this argues for greater selectivity in performing a cesarean delivery in the first place, and certainly a greater need for counseling before a primary elective cesarean delivery.

The ways that "elective cesarean delivery" are used though, is what needs to be examined as well. My cesarean was labeled "elective" in my surgical notes. Did I ultimately consent? Sure, after having the crap scared out of me by my OB. Do they account for coercion? Abuse of perceived authority?


As investigators continue to search for ways to make cesarean delivery safer,

Wait - WHAT?!?! There *AREN'T* any ways to make cesareans safer. It's MAJOR ABDOMINAL SURGERY! You are literally removing a baby from a woman's body - most of the time before the baby is ready to be born. And has anyone missed how rough a cesarean can be for a baby?

we may be better served by exploring other means for reducing overall cesarean delivery rates and recognizing our own preoccupation with the individual that will be our patient, whether it be mother or neonate."

Not very intelligent or witty, I know - but my only response to this is DUH!

*The study authors have disclosed no relevant financial relationships.*

*Obstet Gynecol*. 2009;113:1231-1238.

Free in Southern Utah - Midwife Open House and Business of Being Born Screening

Meet the Midwife Open House and Film Screening!

Bring your girlfriends, neighbors, pregnant ( or hoping to be ) friends! Hope to see you there!

Christine Fiscer - Traditional Midwife
www.joyfulbirthservices.com
(Please excuse the kinks - still working some out )

I am a new Midwife to Utah, originally from California. I will be hosting an open house on Saturday, August 8th at 6pm. Business of Being Born showing at 7:30pm.


*Watch Ricki Lake's birth documentary - The Business of Being Born
*Free initial consultations
*Q&A about Home Birth, Waterbirth, VBAC, Twins
*Raffle for a handmade Mei Tai Baby Carrier

I am located in Hurricane, just 2 1/2 miles from I15 on State Route 9. Email JoyfulBirthServices@gmail.com, or call 435-216-5411 for additional information and directions. **Please RSVP if you plan on attending.**

In need of some emotional purging ...

I lost my baby two weeks ago this past Friday. And yet? It feels like it was longer, and just yesterday at the same time.

Longer, because in a sense, I have had to stuff my emotions. My husband doesn't understand why I am "still" emotional. He doesn't understand why I have moments of utter depression, or why I can get into a funk quickly. In all fairness, I haven't given him room to simply not understand. Right after I started writing this, he came out and saw me crying, and we talked a bit.

He truly doesn't understand the emotional side of this. Yes, he's sad that we lost a baby, but he doesn't understand what I'm going through - to the depth that a woman feels when she loses a baby she very much wanted. I had to explain that I am coming to terms with how traumatic it was to lose so much blood, and to see how large the clots were that were falling from my body. It was traumatic to sift through the clots, to watch for tissue. It was more traumatic to come home from the ER to a house without my husband, and have to clean up all of the blood.

For the past two weeks, with the exception of a day here and there, I have tried desperately to act as if I am "normal" ( as normal as I can be anyway, lol ) so that I can FEEL normal again. And it's not working. I have been ignoring my husband, I have been lapsing into funks that he doesn't understand and that I don't fully know how to explain. We moved a mere 3 days after I lost the baby. I was pretty much "expected" to be back to normal so that we could get done what needed to get done. And that's not reflective of my husband. He would get thoroughly pissed off at me if I didn't sit down every few minutes, or I lifted a box heavier than I should be. But, I wasn't allowed to wallow and grieve.

I don't feel like I've had a chance to talk through this, and don't want to be the dramatic one who keeps mulling over something already done. I'm sensitive to not being "over emotional" because of how my mom is ( whole 'nother story to it ). So I feel like I have to be OKAY already, and yet I'm not. I don't have anyone in person that I can sit and talk to and cry with who really GETS this. My husband tries. He just doesn't know what to say, so it feels like a one-sided conversation. Which, it would be for the most part anyway. LOL I get that. :sigh: I'm not sure WHAT I'm trying to get across right now.

I'm terrified of not being able to get pregnant again. I'm more terrified of having another miscarriage. I honestly don't know that I could go through this again and get through it whole. I don't feel whole NOW.

And I'm angry. There, I said it. I'm angry. At God, at myself, and with other irrational things. I'm angry. I don't understand why I would be allowed to get excited and then have it yanked so brutally. And then there, right there, I feel guilty for saying it, because I have friends who have had full-term stillbirths. I cannot even FATHOM going through that. I was only 7 weeks. Yet I had already envisioned this baby. Not in the womb, but after birth. I envisioned the birth, and breastfeeding, and cloth diapering this time. For crying out loud, I bought a serger so that I could more easily make the diapers - and I haven't been able to bring myself to try it out yet. I bought it 3 days before I miscarried.

So there you have it. I'm still a mess, even though I feel like I have to pretend to be fine. The world doesn't stop because I'm sad. I get that. I'd just love to be able to crawl into a cave for a while, and be allowed to wallow and feel sorry for myself, and just grieve.

I needed to write some of these things out. Writing for me is cathartic.

Some Sad Updates

As much as I loved and appreciated all of the well-wishes and congratulations from my last post, I need to update what has gone on.

Last Friday morning I woke up to blood. In a blur, I went into the bathroom and as soon as I sat down, a huge clot came out. I was horrified and instantly a wreck. I got myself to fish it out to see what it was, and it was a clot larger than my hand. I call my husband who was already in Utah at that point, and he doesn't answer. I call Laura ( best friend ) and am sobbing. I knew I was losing the baby. I finally got a hold of DH, and he felt helpless from 400 miles away. I went on to pass 3 more clots that were larger than my hand, and soaked through at least 3 pads. It was at this point that I began getting tired, and decided to head to the ER after talking to Laura again. Gramma came and picked up the kids, and I headed to the hospital alone. Thankfully, my very good friend Janna was able to meet me there. I wasn't alone.

They did blood work, started an IV, did a sterile speculum exam to see if cervix was closed or open ( it was closed ), and then finally an ultrasound. Funny, odd, and scary things happened while I was there, just to keep me on my toes. First, I had a male nurse named Hans - no joke. Blond, accent, Hans. I couldn't make this up if I tried. Why he felt the need to tell me that his wife was going to have their first baby on July 1st, while I was there for losing my baby, I'll never know. :-/ Other than that, he was very nice. Second ( and this is the scary part ), I had a female nurse come in to be in the room for the sterile speculum exam. She had the personality of an ice cube. She walked in and asked me if I am pregnant. I wait a beat, and dryly say "I was". Would it be too much to ask to read the chart before asking a question like that? :sigh: Then, she puts on gloves, looks for an outlet for the light for the end of the speculum, moves my bed around, moves the tray around, touches the wall .... and then takes off the sterile package from the speculum ... AND THEN TOUCHES THE END OF THE SPECULUM!!! I did mention that she basically touched everything else in the room first, didn't I? When the doctor came in ( a VERY nice man - I was at least blessed with a mostly wonderful staff ), I apologized for being a pain, and then went on to explain what the nurse did, and asked for a new speculum. She looked a bit irritated, but he was wide-eyed and totally understood. "Good" news was that my cervix was closed, and there wasn't any "product" hanging out of it.

I went in for the ultrasound, and after a few seconds I knew the answer. She couldn't find anything. She did a transvaginal one as well, because she wanted to clearly see my ovaries and tubes, to make sure there wasn't anything eptopic. There wasn't. My lab results came back, and my hcg count was over 5700 still ( about normal for 7 weeks ). He recommended that I get labs done again within the next week to make sure that the levels are going down. I got my rhogam shot, and was discharged after being a patient in the ER for about 6 hours. I went home devastated.

I honestly don't think I've ever grieved anything as deeply. I may only have been 7 weeks along, but I was so excited. I was already looking ahead to the birth, to breastfeeding, to cloth diapering and baby wearing. I was heartbroken, plain and simple. And Jeramy was 400 miles away. I've gone back and forth between being fine, and being a complete mess. We moved to Utah on Monday, just 3 days after the miscarriage. I'm still not feeling 100% back to normal, physically or emotionally. The hard part is, I'm kind of surrounded by pregnant women here. LOL Laura had just found out she was pregnant a few days after I did. I am SO excited for her, but it will definitely be hard to see her go through the stages that I would have been at. Through all of this though, DH and I know beyond a shadow of a doubt that we want another baby. I am going to work on getting healthier, while we TTC for the first time ever. It was never a problem before, it was always PREVENTING actively because I was so fertile. I am just praying, through fear, that I don't have something wrong that makes it impossible for me to carry a baby to term now.

As for moving, we got here at about 11:30 on Monday night, utterly exhausted. We decided to leave the unloading for the morning. Thankfully, we got it done pretty quickly and I am now in the process of unpacking and making this house a home. I broke down today, because the kids are beyond horrible. Change, inconsistent discipline, and a mom who's not 100% "there" are factors I'm certain. But it doesn't make it easier.

It's been a hard week. I'm coping the best I can, and praying that life gets back to "normal" soon.