Birth Matters

If you read anything at all about me or that I’ve written, you know that I had both my daughters at home attended by a Certified Professional Midwife.  So why didn’t I have my VBACs in the hospital?  Lots of women do, right?  Well, not exactly and rarely in a way that seemed safe or respectful for me or my baby.  Not to mention what the pregnancy would be like for me, fending off scads of tests designed to perfect the practice of defensive medicine.   I did interview an OB who’d been a friend’s attendant when she had her first VBAC and I did talk to my Family Practitioner about attending me.  For lots of reasons which I’m sure I’ll write about some day soon, I chose a homebirth. But do I support a woman when she wants to plan a VBAC in the hospital?  I’d say that I do, but often that support looks different than she expects.

The majority of the women I’ve known who planned or are planning a VBAC (or birth of any sort – homebirths represent only about 1% of all births in the U.S.) intend to go to the hospital – yes women who birth at home after a cesarean tend to talk a lot about it and how wonderful it is but that doesn’t mean there isn’t something for the hospital birther too.  The facts and info that are collectively contained in the experiences and knowledge of women who’ve had hospital births (either cesarean or vaginal) are probably more useful to a woman planning a hospital birth, to be honest, not the woman who’s already decided to plan a homebirth - at least as far as looking at the sorts of things that put you on the fast track to another c/s (or a rupture, or other bad outcome).

Many of the more active women I know in my online community speak from experiences that led them to homebirth, some don't have actual experience in negotiating a hospital VBAC (like me) – what we do have is lots of theoretical stuff, lots of second hand stuff from women we knew who did have hospital VBACs (or at least planned one), and lots of info from women who do doula work in hospital VBACs.

Uterine rupture (UR) tends to be the one complication that most women planning a VBAC are most worried about.  It tends to be the risk that OBs emphasize.  How it relates to a decision as to where to birth, looking at what it is, how to lower the risks, all of that discussion is a recurring theme in my community.  We don’t pretend that it’s an impossibility if you plan a homebirth or that all will be well if you are in the hospital.  We don’t shy away from the fact that while it’s rare, it can be devastating if it does happen to you.  I know several women who had uterine ruptures, some during a VBAC, some not, some at home, some in the hospital.  Some lost their babies, some lost their fertility, some came through it relatively intact.  It is valuable to hear these stories, as sad as they are. It is only fair to be realistic about it, along with all the other things that could happen during birth.

Many will detect a note of frustration and cynicism from some of us when there's talk of "taking charge" during a hospital birth. That's because of the scenarios we've seen played out over and over and over - women who did everything right - did all the reading, all the studying, all the emotional work, got a good doula, interviewed and got the right OB or even CNM (or sometimes even the right DEM, at home), took the right classes - did everything that could possibly be done to be that woman who was going to claim her birth as her own - and it all fell apart when she got to the hospital, and she comes home with another scar and another questionable c/s. For any number of reasons, most of the time, it just doesn't work the way anyone expected or planned once you are in the hospital - on "their" territory, so to speak.

I've seen it myself in doing labor support for a friend - not a VBAC, but it was her first birth, which is becoming just about as difficult to do vaginally these days. She was fairly well-prepared and she had me there to remind her and be her advocate (I'm no pushover when it comes to medpros - I am one, so I don't suffer from "doctor-worship”) - and she missed a cesarean by the grace of God alone, in my opinion. Now, things are very different in the hospital, as a VBAC, than they were prior to the 1999 ACOG Practice Bulletin on VBAC, which changed the recommendations for how to manage VBAC.  In 2001, a paper published in the NEJM made conditions even worse. Women who had easy hospital VBACs 8 years ago are now being told they have to have an “elective” repeat cesarean (just how its elective if its your only “choice” is not clear to me), in spite of having had a VBAC (or often, more than one) already – its hard to take charge of your birth and stay in the system when that's the standard policy in many hospitals.

If a woman is planning a hospital birth, she needs to do so with her eyes wide open. Some women are really resistant to opening their eyes - we are deeply indoctrinated to not question the perceived "experts" when it comes to birth. Some are not, but believe they can beat the system, or trust that their support team will be enough.   They believe that they can just say no.  I think it's a disservice to tell women that if they plan well enough, they can take charge of their birth, in the hospital.  I think it is wrong to not remind women that it is very difficult to just say no when you are in labor and the nurses and the resident and your OB are telling you that your baby might die, even if you know things aren’t as bad as they say.  I believe it is negligent to not inform women that most of the time, hospital staff are well-trained in how to “get consent”, even from women who came in wanting something completely different (you might want to read an article called “Getting a Stubborn Patient to Say Yes”.  Women need to remember how tired, how big, and how ready they are to just be done being pregnant when they hit that 40^th week.

If you are planning a hospital birth, all the preparation in the world isn't going to prevent events like PROM (premature rupture of membranes- "waters breaking" at home) at term, and no contractions within 12 hours (or less), or gestation past some arbitrary date (I'd say 42 weeks, but its getting phenomenally rare for any pregnancy to be "allowed" to go that "long" anymore), or your attendant believing you are having a "big baby" (these days, anything over about 8#4oz is considered big).   All of these things automatically increase the pressure you are going to be under to get that baby out now, preferably with a cesarean.  Preparation might help you fight off EFM (external fetal monitoring), or routine augmentation or AROM (artificial rupture of the membranes- waters broken with a hook) or mandatory starvation or an IV drip. But fighting typically isn't conducive to effective laboring - and then you really are in a bind – you’ve taken control of the intervention but lost what you need to labor effectively.

I'm all for preparing women for a hospital birth. But I'm for telling it ALL - not just "get a doula and make sure you stay mobile while you labor" or "have your OB and all the other OBs in the practice sign off on your birth plan by your 36 week appointment" or "don't consent to routine induction". Those are all good things - but ultimately, women really have to understand what the hospital itself means.

Women must understand that hospital birth in the U.S. is a business, a system, a revenue source and really doesn't care about them or their babies as individuals.  If they did, no one would be inducing anyone with Cytotec, a drug designed to treat stomach ulcers which also happens to make the uterus contract violently - Cytotec is used because it is incredibly efficient and incredibly cheap -- not because it is a better or safer way to induce women and babies - and it's cheap enough that its still cost effective even when they have to pay off a family every now and again due to a Cytotec induced rupture/death. It's extremely hard to assert yourself as an individual in a system that doesn't see you that way.

Many women still need the safety net that the hospital represents. If they understand the tradeoffs, the risks and benefits to that decision, then they've chosen out of informed consent, which is inherently more powerful that blindly agreeing to someone else’s agenda. Then some women, when they start to see all the stuff that goes with that hospital safety net, decide that the safety net of the hospital has some pretty big holes as far as they are concerned.

If a woman has a body and baby that "cooperate" and fall within the increasingly narrow definition of obstetrically normal, and if "taking charge" for her doesn't involve challenging many of the routine procedures in a typical hospital birth, then she is going to be pretty happy with her hospital VBAC. And I'm more than thrilled for her. If a woman believes that taking charge means being responsible for more than just showing up and laboring as expected, she will probably find it harder and harder to actually take charge - because the windmill she's tilting at is getting bigger and bigger and bigger, the more she expects to be allowed to be personally responsible.

I’ve been on many VBAC lists, most with women who aren't as "militant" as I am -- with a lot fewer women who plan homebirths. And those lists have a lot more repeat c/s. So yeah, I'm pretty militant about being blunt about what the hospital is. And of course, that comes out sounding like I'm a homebirth advocate. But then again, I am a homebirth advocate. I'm even more an advocate of having your eyes opened all the way and honestly appraising how much power you really have, not pretending that you will have as much power as you desire, just because you want it.  That's the essence of informed consent, something sadly lacking in the hospital environment.  The simple truth is if you don’t have informed consent, then you can not have power.

Revised June 2, 2006