The back story to the Times article

Pamela Paul, author of the Times article The Trouble With Repeat Cesareans, wrote another article in The Huffington Post: Childbirth Without Choice. This piece gives the back story of the Times article, including her own fight to have a VBAC in a supposedly "pro-VBAC" hospital.

She writes:

I wrote an article in this week's issue of Time magazine called "The Trouble With Repeat Cesareans" on the subject of women's diminishing patient's rights. I won't repeat the story here, since you can link to it here, but will give some of the back story for those who want more:

This was a story I've been wanting to write for a long time. The short version is, doctors and hospitals are no longer allowing many women to have a vaginal birth after cesarean (or VBAC, pronounced "vee-back") because the "medicolegal" costs are too high. Or, as one ob-gyn put it when I asked why she and other doctors no longer allow VBACs, ""It's a numbers thing. It is financially unsustainable for doctors, hospitals and insurers to engage in a practice when the cost of doing business way exceeds the payback. You don't get sued for doing a C-section; you get sued for not doing a C-section."

Read the rest of the article here.

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Share your VBAC stories here!

In light of the recent Time article on the difficulty of obtaining a VBAC, I'd love for my blog readers to share their VBAC stories (including those who wanted a VBAC but were unable to attain one for whatever reason, or those who are currently planning a VBAC). How hard was it to find a hospital and/or provider who would attend a VBAC? Were there certain conditions you had to meet, such as going into labor on or before a certain gestational age, continuous EFM, or having to have the baby during daytime hours? How far did you have to travel to find a VBAC-friendly provider? What were your biggest challenges in planning for a VBAC? What were some of the supportive or not-so-supportive things you heard from your providers about VBACs? If you were ultimately unable to have a VBAC, what happened?

Please share your stories!

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Time article on VBAC and Forced Repeat Cesareans

I am excited to announce that Time magazine just released an article about VBAC and forced repeat cesareans, called The Trouble With Repeat Cesareans. It will hit newsstands tomorrow morning. I was privileged to play a (very small) part in helping the International Cesarean Awareness Network (ICAN) phone hospitals all across the US to determine whether or not VBACs were allowed in their facilities.

With a few exceptions, ICAN has contacted every American hospital that has a maternity ward. As you'll see in the article, 28% of U.S. hospitals have an outright ban on VBACs, and another 21% have a "de facto" ban: while VBACs are technically allowed at the hospital, no doctor will attend them. To find out the VBAC policies in your local hospitals, visit ICAN's VBAC policy database (it might not be up and running until tomorrow).

I feel that access to VBAC is one of the most pressing maternity care issues in this country, along with the disturbingly high cesarean rate (31.1% as of 2006). Please advertise this article widely, making sure to link to the original article on Time's website. The more traffic it gets, the longer it will remain online.

From the article:

For many pregnant women in America, it is easier today to walk into a hospital and request major abdominal surgery than it is to give birth as nature intended. Jessica Barton knows this all too well. At 33, the curriculum developer in Santa Barbara, Calif., is expecting her second child in June. But since her first child ended up being delivered by cesarean section, she can't find an obstetrician in her county who will let her even try to push this go-round. And she could locate only one doctor in nearby Ventura County who allows the option of vaginal birth after cesarean (VBAC). But what if he's not on call the day she goes into labor? That's why, in order to give birth the old-fashioned way, Barton is planning to go to UCLA Medical Center in Los Angeles. "One of my biggest worries is the 100-mile drive to the hospital," she says. "It can take from 2 to 3 1/2 hours. I know it will be uncomfortable, and I worry about waiting too long and giving birth in the car."

Much ado has been made recently of women who choose to have cesareans, but little attention has been paid to the vast number of moms who are forced to have them. More than 9 out of 10 births following a C-section are now surgical deliveries, proving that "once a cesarean, always a cesarean"--an axiom thought to be outmoded in the 1990s--is alive and kicking. Indeed, the International Cesarean Awareness Network (ICAN), a grass-roots group, recently called 2,850 hospitals that have labor and delivery wards and found that 28% of them don't allow VBACs, up from 10% in its previous survey, in 2004. ICAN's latest findings note that another 21% of hospitals have what it calls "de facto bans," i.e., the hospitals have no official policies against VBAC, but no obstetricians will perform them.

Read the rest of the article here.

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Wednesday wrap-up

I might start doing a weekly wrap-up of miscellaneous news & articles that I find interesting. If I wait much longer than week, they start piling up rather quickly:

Speaking of upright/vertical birth...

• This midwife-designed stainless steel mirror is designed especially for women adopting upright birthing positions
• Mom's Tinfoil Hat had some thoughts about Standing up for birth

Home birth

• The "Authorities" Resolve Against Home Birth: a recent editorial by Nancy K. Lowe, editor of the Journal of Obstetric, Gynecologic, & Neonatal Nursing ( Volume 38, Issue 1, Pages 1-3). Click on the article title for the full text. An excerpt from her editorial: "The point is that we have no system of maternity care in the United States that provides a healthy woman the choice of giving birth at home and if she needs to transfer to a different type of care during labor, the transfer is easy. We do not have a system in which this woman is treated with respect and kindness, and her provider either maintains responsibility for her care or professionally and respectfully is able to transfer responsibility to another provider. Interestingly, while ACOG and AMA have declared that hospital grounds are the only safe place to give birth in the United States, the National Perinatal Association (NPA) adopted a position paper in July 2008 titled, 'Choice of Birth Setting.' The paper supports a woman's right to home birth services....Further, in Canada following the model of British Columbia, the province of Alberta has recently expanded its health care system to include women's access to midwifery services 'in a variety of locations including hospitals, community birthing centers, or in their homes.' "
• Two Charleston Gazette articles: Midwife delivers babies in mothers' homes and Home delivery: After three hospital births, fourth-time mom was determined to deliver the old-fashioned way
• A Herald Tribune (FL) article narrates how a home birth unfolds in Home Delivery
• An article featuring Womancare Midwives of North Idaho
• Tribute to Maude Callen, a nurse-midwife serving rural South Carolina for over 70 years. Make sure you click on the Life photo archive for lots of fantastic pictures!
  
• Adventures in (Crunchy) Parenting wishes to move beyond binary views of safety
  
• Future Search Conference on Home Birth currently being planned. From the description:
• It will be a multi-disciplinary consensus conference of key stakeholders around the provision of home birth services in the United States, to be convened by the University of California San Francisco and various organizations, including the American College of Obstetrics and Gynecology the American Academy of Pediatrics, the Association of Certified Nurse Midwives, Mothers and Midwives Associated, Lamaze International, Association of Women Hospital Obstetric and Neonatal Nurses, and the International Center for Traditional Childbirth. Further, it is hoped that public health practitioners and students, insurers, government agencies, health economists, medical anthropologists, state and national legislators, and women who have given birth will be among the eventual participants. The purpose of the conference is to start to bridge the "divide" between the medical and midwife communities over out-of-hospital births in the United States. Safety of birth in any setting is of utmost priority. Rights to choice and self-determination and culturally appropriate healing are also core values in American discourse that influence this issue. The purpose of this multidisciplinary conference of key stakeholders will be to craft a consensus policy and strategy on provision of home birth services. The project may also inform regulatory discourse, alternative funding structures, and the required modifications of curricula to prepare physicians and midwives in urban, rural and remote settings to provide maternity services across birth settings.

Research studies & articles

• Evidence-based labor and delivery management. Berghella V, Baxter JK, and Chauhan SP. Am J Obstet Gynecol. 2008 Nov;199(5):441-2. From the abstract: "Evidence-based good quality data favor hospital births, delayed admission, support by doula, training birth assistants in developing countries, and upright position in the second stage. Home-like births, enema, shaving, routine vaginal irrigation, early amniotomy, "hands-on" method, fundal pressure, and episiotomy can be associated with complications without sufficient benefits and should probably be avoided." (Email me for full text).
  
• Born in the USA: Exceptionalism in Maternity Care Organisation Among High-Income Countries by Edwin van Teijlingen, Sirpa Wrede, Cecilia Benoit, Jane Sandall and Raymond DeVries. Sociological Research Online, Volume 14, Issue 1. From the abstract: "In lay terms, childbirth is regarded as a purely biological event: what is more natural than birth and death? On the other hand, social scientists have long understood that 'natural' events are socially structured. In the case of birth, sociologists have examined the social and cultural shaping of its timing, outcome, and the organization of care throughout the perinatal period. Continuing in this tradition, we examine the peculiar social design of birth in the United States of America, contrasting this design with the ways birth is organised in Europe."
• Postnatal quality of life in women after normal vaginal delivery and caesarean section. Behnaz Torkan, Sousan Parsay, Minoor Lamyian, Anoshirvan Kazemnejad, and Ali Montazeri. BMC Pregnancy Childbirth 2009; 9: 4. From the conclusion: "Although the study did not show a clear cut benefit in favor of either methods of delivery that are normal vaginal delivery or caesarean section, the findings suggest that normal vaginal delivery might lead to a better quality of life especially resulting in a superior physical health. Indeed in the absence of medical indications normal vaginal delivery might be better to be considered as the first priority in term pregnancy." (full text available by clicking on article title).
• Health Care Reform in the U.S. Organisation for Economic Co-operation and Development Working Paper #665, Feb. 6. 2009 by David Carey, Bradley Herring and Patrick Lenain. From the abstract: "In spite of improvements, on various measures of health outcomes the United States appears to rank relatively poorly among OECD countries. Health expenditures, in contrast, are significantly higher than in any other OECD country. While there are factors beyond the health-care system itself that contribute to this gap in performance, there is also likely to be scope to improve the health of Americans while reducing, or at least not increasing spending. This paper focuses on two factors that contribute to this discrepancy between health outcomes and health expenditures in the United States: inequitable access to medical services and subsidized private insurance policies; and inefficiencies in public health insurance." Full text PDF available by clicking on the article title.

VBAC & Cesarean Section

• List of abstracts on VBACs with twin gestations
• Some NHS trusts will no longer offer primary elective cesareans because of cost and safety issues. Read more in Caesarean births rationed by hospitals in order to cut costs
• A midwife-led initiative in Southampton has lowered cesarean rates and boosted VBAC rates

Birth Centers
For Expectant Moms, a Happy Medium Between Hospital and Home Births: profiles the struggles of one birth center to obtain permission to open

Breastfeeding
Pedialyte Alternative recipe (not necessary for breastfeeding babies, but great for older children & adults)

Gardening
25 plants you should consider growing

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Marvelous makeup giveaway

If you're feeling a bit pale and washed out after the long winter, you might enjoy this Marvelous Makeup Giveaway. You will receive:

• CoverGirl Aqua Smoothers Tinted Moisture SPF 15 in #805 "fair to light"
• CoverGirl Aqua Smoothers Pressed Powder in #710 "translucent light"
• Revlon Age Defying Spa Foundation SPF 18 in #003 "light"
• Revlon Matte lipstick in #001 "nude attitude"
• Revlon Creme Gloss lipgloss in #080 "mischievous mocha"
• Sally Hansen Maximum Growth Plus nail polish in #07 "profound pink"

Giveaway rules:
1) For 1 entry, leave a comment.
2) For 2 entries, do #1 and link to this giveaway on your blog, Facebook, website, etc. Paste the link in your comment.
3) For 3 entries, do #1-2 and subscribe to my RSS feed, letting me know you've done so in your comment.
4) Lower 48 US residents only
5) Giveaway ends Friday, February 20th at 5 pm EST

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Belly shot: 29 weeks pregnant

29.2 weeks from LMP. Fundal height is right around 30 cms, FHTs usually in the mid-140s, lots of movement as usual. I think I'm getting close to the "ack! this baby is really coming soon" stage of pregnancy. I have all these things I want to get done before the baby arrives: sending my book proposal to publishers, doing a belly cast, having a Mother Blessing ceremony, making a silk painting to hang in my birthing room, painting the dining room...

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Teleseminar tonight with Dr. Sarah J. Buckley

You're invited to attend a free teleseminar (via phone or webcast) tonight featuring Dr. Sarah J. Buckley, an Australian physician with specialization in GP obstetrics. Dr. Buckley gave birth to all four of her babies at home, the last unassisted and a surprise breech. Visit MyBabyBelly blog for more details. Dr. Buckley just released a new edition of her 2005 book Gentle Birth, Gentle Mothering. It's one of my favorites as it combines scientific research into the hormones of birth and mothering with her personal experiences of pregnancy, birth, and breastfeeding. I am excited to read the new edition, which contains several new chapters and updated medical evidence.

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Eduador's vertical maternity ward

In an effort to lower maternal and infant mortality rates, one Ecuadorian hospital has implemented a "vertical maternity ward" in which traditional practices--including upright or "vertical" birth, medicinal teas, bathing & massage during labor, and indigenous spiritual rites--are encouraged. Read more about it in the article 'Gravity Birth' Pulls Women to Ecuador Hospital. Some excerpts from the article:

Gravity is the invisible midwife in indigenous birthing rituals, says Rosa Colta, a traditional midwife and intercultural health promoter in Otavalo, a town in the Andean highlands of Ecuador.

For that reason a maternity ward in the dimly lit hospital of San Luis de Otavalo calls to mind a small yoga or ballet studio.

Six horizontal bars covered in colorful rope hang on the back wall, forming a gradient, or "chakana," in Kichwa, the dialect of the Quechua language spoken here.

In a room right around the corner from the hospital's emergency room, laboring women move down the chakana's rungs during delivery, transitioning from almost standing before contractions, to kneeling with their palms on the lowest rung, back curled like a cat, posterior high and ready for birth.

The practitioners believe the downward abdominal pressure as a woman moves down the steps or switches from standing to squatting helps push the child out and speeds up dilation of her cervix.

Part of a model effort to lower maternal and infant mortality and attract more women to hospital deliveries, San Luis de Otavalo is the first public hospital in Ecuador to provide a so-called vertical maternity ward that connects indigenous birthing practices with access to modern medicine. The ward opened in April 2008.

"It was a hard fight for us to get into the hospital and care for women with our ancestral wisdom and practices, with our teas and waters, our sacred cleansing rites," says Colta. "Everyone has bad energy. But we shoo it out at birth."

I particularly enjoyed this gynecologist's commentary about vertical versus horizontal birth:

Pedro Luna, the chief gynecologist at the ward, attributes the speed of ... vertical deliveries to the use of a natural position. "Vertical birth-delivery, adapted by the Kichwa tradition, is a natural and instinctive process that makes physiological sense," says Luna. "Horizontal birth is an occidental practice brought by the conquistadors with zero medical logic."

First chosen mostly by indigenous women, vertical births are becoming more common among mestizas as well. Vertical births have also lowered the hospital's cesarean rate from 18% to 8%.

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Used Hypnobabies Home Study Course

Update--set has been sold.

I have a nearly-new Hypnobabies Home Study course (5th edition) for sale. The set is complete except for the sample-sized Luna Bar, which I ate. (It was good!) The set includes:

1) 170 page Hypnobabies Workbook
2) Birth Partner's Guide Booklet
3) Quick Reference Booklet for Labor
4) 12 Advanced Hypnosis for Childbirth Scripts on CD
5) Prenatal Perineal Massage booklet
6) Various handouts
- Positions for laboring out of bed
- Various signs/handouts for hospital staff
- Midwives Model of Care
- The Rights of Childbearing Women
- Instructions for ipod users
- Introductory letter
- List of other Hypnobabies products
- Bumper sticker
- Pen

Price is $90. Shipping to U.S. or Canada included. Email me if you're interested or have any more questions.

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Heads or tails?

Still trying to figure out how/where this baby is lying. For the past month or two I've been feeling intense activity around and sometimes right on my cervix, which can be REALLY annoying after a while. I suspect the baby was heads up and tails down, based on how strong the movements were down there compared to the gentle flutters and swishes near the top of my fundus. So last week I decided to encourage this little one to move. I gently lifted the baby up away from my cervix with one hand and kind of nudged whatever was on top off to the side with the other. I've been having a hard time making heads or tails (ha!) when I am palpating since the baby is small enough that the landmarks aren't familiar to me yet. But I think it did the trick. I've been feeling lots of big kicks and stretches in my upper fundus, nice polite little punches and waves around my lower abdomen right above the pubic bone, and really nothing at all right on my cervix. Ahhhhh, much nicer. Thanks baby!

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Zari pictures

A few pictures from the past couple of weeks...

Horsing around in the mei tai, which I haven't used for a while. I was trying to get pictures of us using the Mamaponcho but I couldn't get any good ones by myself.

She asked me to take a picture of Baby Bear.

Snuggling with her menagerie.

Ready to get wet in swim gear that my mom sent

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Belly shot: 28 weeks pregnant

28.3 weeks from LMP. I've noticed a lot of breast changes over the past few weeks: they're fuller, the areolas are getting darker (which didn't really happen my first pregnancy), and I've been able to express colostrum recently.

I got some very sexy (not!) thigh-high compression hose for the varicose veins that have been popping up all over my legs. My midwife was quite impressed with how extensive they were. Another thing that didn't really happen the first time around. I wish I'd had the compression hose during all of our Christmas road trips. They feel quite good once I wrestle them onto my legs.

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Arrived, resting

We got off to a soggy start this morning. The Amtrak station and waiting area were submerged under several inches of water. We had to decide between waiting outside in the pouring rain or going inside the (underwater) waiting area. We chose the latter, parking all of our bags on the chairs and standing up on the seats until the train came. Zari enjoyed the train ride, although after the first two hours she started asking to "get off train" and "go to mama and papa's house." We made it to Chicago with only one brief crying episode (involving her wanting to bring her baby doll to the bathroom and I didn't know that at first). Our room wasn't ready when we arrived at the hotel, so we left our bags at the front desk and ate lunch.

Zari's napping now--thank goodness, because I really needed her to take a nap for my own sanity. She was totally wired and crazy from exhaustion. We're going to the Field Museum after she wakes up. It's a free day today--woohoo! Then we'll look for a good pizza place for dinner. There's a Giordano's only a few blocks away, so we might try that out.

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Going to Chicago!

We'll be in Chicago this Wednesday through Saturday. We're going to take the train up there--much easier than trying to drive through the nightmare of Chicago traffic. Anyone have suggestions for fun things for Zari and me to do while Eric is attending his conference?

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TENS and cesarean recovery

I checked out physical therapist Elizabeth Noble's Essential Exercises for the Childbearing Year last month. She wrote about using TENS for post-cesarean pain relief (p. 203):

TENS (Transcutaenous Electrical Nerve Stimulation)
This physical therapy modality works on the same principle as scratching an itch. Another message gets to your brain before the pain, traveling over nerves with faster transmission speed. Electrodes are taped above and below your incision. These electrodes are then connected to a hand-held unit with adjustable controls. You can choose the type and speed of electrical current to meet your needs. Patients who use TENS after any kind of abdominal surgery require less or no pain medication, an important advantage to breastfeeding mothers. The stimulation also reduces the incidence of paralytic ileus (intestinal distention and symptoms of obstruction). I also believe it helps to prevent the formation of a dead zone around the scar. A dead zone occurs from pain, disuse, and the mother’s reluctance to examine or palpate this area. The tissues are like dough, many women feel “cut off” from that part of the body, and nerves to the skin may indeed be injured and take many months to recover.

Another (older) book also mentioned TENS for post-cesarean recovery and pain relief. In Adrienne B. Lieberman's Easing Labor Pain, she wrote:

Transcutaneous electrical nerve stimulation (TENS), occasionally used to alleviate labor pain, also offers many benefits to the woman who is recovering from a cesarean delivery. Russsel Foley, TENS expert, comments, “Taking patients’ pain away with TENS gives them better mobility, and that’s important because the most traumatic thing to the body after an operation is immobilization. The longer a person is immobilized, the harder it is to recover.”

Using TENS can mean you’ll need fewer narcotic painkillers after your surgery. Indeed, a study published in Physical Therapy in 1986 showed that women who used TENS following cesarean birth used significantly less Demerol for pain relief. Narcotics such as Demerol, says Russel Foley, “suppress gastrointestinal motility, change respiration, and alter heart rate. If you remove the need for medication by using TENS, you can also remove the side effects of medications.”

If you use TENS for your post-cesarean recovery, the electrodes can be positioned immediately after suturing, and taped to your abdomen under the dressing. You’ll be taught to use the monitor in order to control the amount of electrical stimulation you receive. The monitor can be detached so that you can shower normally. TENS is usually used just for the first two post-cesarean days. (237)

A quick search about TENS and cesarean recovery led me to this small but promising study done last year in Iran: The Analgesic Effect of Transcutaneous Electrical Nerve Stimulation (TENS) on Caesarean Under Spinal Anaesthesia. The authors concluded that "TENS may be used as an effective, non invasive and non pharmacological approach for reducing post caesarian section pain with reduced use of analgesics. This might lead to better outcomes in pain control and facilitating development of bonding between mother and baby."

If you are planning to give birth in a hospital (or even if you aren't, in the event that you end up transferring), you might want to inquire beforehand about the availability of a TENS unit for either laboring or post-cesarean recovery. Ask the staff if they have ever used TENS for post-cesarean pain relief and if they would be willing to try it if you have a surgical birth.

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Public breastfeeding: why more is better

So often in discussions about nursing in public, breastfeeding advocates tend to frame their replies in one of the following ways:

• breasts aren't inherently sexual; they're for feeding a baby
• nursing in public is actually fairly discreet most of the time; often you can't even tell the baby is nursing unless you look closely

Both of those types of responses imply that nursing in public shouldn't really be noticed, either because it is just a baby eating or because it's really not that obvious anyway. But on the other hand, perhaps nursing in public needs to be noticed more. One of the biggest challenges of modern-day breastfeeding is that women usually have to reinvent the wheel by themselves, in isolation, only with some books or websites to help out. Public nursing can play a vital educational role, but only if women actually have the opportunity to see it in action.

Last month, TopHat related her experience with someone wanting to look over her shoulder to figure out how to nurse correctly:

A lady at church yesterday came up to me and apologized for watching me breastfeed...she was afraid that her watching made me uncomfortable. I don't even remember this, so that'll tell you how uncomfortable I was. :) She had been struggling with breastfeeding and was at the end of her ropes and going to switch to formula that day or the next. She wanted to see a good latch and watch someone who has done it. She did go to a lactation consultant the next day (or soon after that) and her baby is now 100% breastfed. Yay for her!

I think this exemplifies a lot of the problems we have in our culture with breasts and breastfeeding. We just never see breastfeeding--we don't know what it looks like and we don't know how to do it. We really have to go out of our way to see it. I went to 5 months of LLL meetings while pregnant to learn what a good latch is--and I'll even admit to trying to see a latch over someone's shoulder. I remember even contemplating, "Should I just ask her if I can watch her latch the baby on?" about a woman in our playgroup.

It doesn't help that, with our overly sexualized culture, videos of women latching babies on--such as one that I posted on Youtube when Zari was a few weeks old--are removed for their supposed "pornography or sexually explicit content." This particular video showed a real-life attempt at getting a newborn to latch on: it included a demostration of a cross-cradle hold while my other hand supported my breast, little hands that kept waving around and poking in her mouth and getting in the way, and multiple attempts at getting her mouth to open and her hands out of the way before the magic opportunity presented itself. These are things you can't see or understand from reading a book. You need to see them in action.

Jack Newman, a leading expert in breastfeeding, is fond of saying "Babies learn to breastfeed by breastfeeding. Mothers learn to breastfeed by breastfeeding." I suggest that we add: "Mothers learn to breastfeed by watching other mothers breastfeeding."

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Dr. Wonderful is "out" and needs your help!

Remember Dr. Wonderful that Navelgazing Midwife has written about? If you don't, visit these posts:

• Beautiful Birth with Dr. Wonderful
• VBAC (with a whiff of pit)
• Welcome to my new house
• I'm Offensive
• Dr. Wonderful attempts a version
• Dr. Wonderful talks about breech babies
• Letters of thanks to Dr. Wonderful
• Face presentation birth
• Thanking Dr. Wonderful
• A birth unfolds in photos & words
• Garden Laboring
• Some nurses...

Well, his "secret identity" is now made public! So who is this mystery man, this fabulous OB that we all wish we had in our community? He is Dr. Robert M. Biter of San Diego! Read NGM's post about how he's out of the closet and see some lovely photos taken of him and babies he's caught recently.

And Dr. Wonderful needs your help! NGM wrote:

For reasons I cannot disclose at the moment, I am looking for other Dr. Wonderfuls around the United States....If you know of progressive OBs (they have to be obstetricians or family practice docs, the higher on the rung the better), please email me asap. NavelgazingMidwife@gmail.com

If you know, have worked with, or are another "Dr. Wonderful" please get in touch with her ASAP.

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Breastfeeding (sabotage) kit

Enfamil is generously offering, out of the goodness of their hearts, a Breastfeeding Kit. It's everything a new breastfeeding mom needs to get off to a successful start (at formula feeding, that is).

• A sample of Expecta® LIPIL® DHA Supplement for pregnant and nursing moms. Because the first step to supplementing with formula is to undermine the mom's confidence that her breastmilk alone is sufficient for the baby. If you can't persuade her to supplement her baby, then start by getting her to take your magical supplements!

• An excerpt from The Nursing Mother's Companion, a useful guide with tips and suggestions. Because the entire book would be too expensive and would probably give the mother enough information and confidence that she wouldn't need your magical formulas or supplements. I am guessing the excerpts are all the parts that would undermine breastfeeding: probably stuff about how to supplement with formula, etc.

• A sample of Enfamil LIPIL®, our closest formula to breast milk, should you choose to supplement. Because, you know, it's all about choice. Never mind that the "choice" to supplement is often a one-way road to formula feeding, or that once a mom "chooses" formula, she cannot simply choose to go back to breastfeeding.

Does anyone else find this creepy and condescending? Well, at least one other person does: Mama-Is (formerly known as Hathor the Cowgoddess). She made a comic about it.

What would be in your ideal breastfeeding kit? Mine would have:

• At least two breastfeeding books: one solid, informational, problem-solving one like Jack Newman's Ultimate Breastfeeding Book of Answers, and one funny/inspiring one.
• A sling for hands-free nursing. I'm partial to Second Womb Slings...
  
• A stainless steel water bottle: no worries about chemicals leaching out of plastic bottles, good for the environment, helps mama stay hydrated.
• A DVD of helpful breastfeeding videos, such as the ones found on Jack Newman's site.
• A collection of fun music and DVDs so mama can relax and enjoy herself while the baby is nursing.
• A basketful of fruit, nuts, and other delicious snacks for those "holy cow! I need to eat something NOW I am so hungry" breastfeeding moments.
• Breast comfort aids: Lanolin cream, ice packs for engorgement, gel pads for sore nipples, etc
  
• Breastfeeding pillow & cover
• Phone numbers to the local La Leche League and IBCLCs
• Samples of Mother's Milk Tea
• Nursing necklace for mom (for baby to play with when it gets older)
  

Any other things you'd suggest for Rixa's Ultimate Breastfeeding Kit?

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Cesarean section and uterine rupture

Two recent studies--one still in press--that I find quite fascinating relating to uterine rupture. I have the full text of the first one, and hope to access the second one* as soon as it is officially published. As always, email me if you'd like to take a look at the full text.

A few comments/questions/observations:

• I hope that the evidence from the first study won't be used to risk out women who never went into labor before their cesarean section. Instead, I hope it will simply be used to give extra confidence and reassurance to women who did experience labor before they had a cesarean.
• In the second study, note the correlation between oxytocics (i.e., Pitocin) and uterine rupture in both scarred and unscarred uteri. 21 of the 41 uterine true ruptures occurred in connection with oxytocics--9 among women with previous cesarean sections and 12 among women with unscarred uteri. This, of course, doesn't mean that using Pitocin = uterine rupture, but certainly it suggests the need for prudence and caution when administering Pitocin during labor--not just among women having a VBAC, but also among women with no previous cesarean section.
  

1) Laboring before a primary C/S reduces the risk of uterine rupture in a subsequent intended VBAC
C.S. Algert et al. "Labor before a primary cesarean delivery: reduced risk of uterine rupture in a subsequent trial of labor for vaginal birth after cesarean." Obstet Gynecol. 2008 Nov;112(5):1061-6.

OBJECTIVE: To estimate the effect of the onset of labor before a primary cesarean delivery on the risk of uterine rupture if vaginal birth after cesarean (VBAC) is attempted in the next pregnancy.
METHODS: Longitudinally linked birth records were used to follow women from a primary cesarean delivery to a trial of labor at term for their next birth. The effects of characteristics of both the trial of labor and primary cesarean deliveries on the risk of uterine rupture were examined.
RESULTS: Of 10,160 women who had a trial of labor, 39 (0.38%) had a uterine rupture. Women who were induced or augmented for their trial of labor had a greater relative risk (RR) of uterine rupture (crude RR 4.24, 95% confidence interval [CI] 2.23-8.07). Women whose primary cesarean delivery was planned or followed induction of labor also had an increased risk of uterine rupture (crude RR 2.61, 95% CI 1.24-5.49), and this risk remained after adjustment for other factors. Women with a history of either spontaneous labor or vaginal birth had one uterine rupture for every 460 deliveries; women without this history who required induction or augmentation to proceed with a VBAC attempt had one uterine rupture for every 95 deliveries.
CONCLUSION: Labor before the primary cesarean delivery can decrease the risk of uterine rupture in a subsequent trial of labor. A history of primary cesarean delivery preceded by spontaneous labor is favorable for VBAC.
LEVEL OF EVIDENCE: II.

2) Half of all true uterine ruptures are not associated with prior cesarean section
Porreco RP, Clark SL, Belfort MA, Dildy GA, Meyers JA. The changing specter of uterine rupture. Am J Obstet Gynecol. 2009 Jan 9. [Epub ahead of print] Presbyterian/St. Luke's Medical Center, Denver, CO.

OBJECTIVE: The objective of the study was to review all patient records discharged with codes for uterine rupture in 2006 in Hospital Corporation of America hospitals. STUDY DESIGN: All patient charts were distributed to a committee of perinatologists and general obstetricians. Case report forms were analyzed for variables of interest to determine validity of coding and quality of care.
RESULTS: Of 69 cases identified, only 41 were true ruptures. Twenty patients had previous cesareans, and in 9 of these patients, concurrent use of oxytocics was documented. Among the 21 patients without previous cesareans, 7 had previous uterine surgery, and oxytocics were documented in 12 of the remaining 14 patients. Standard of care violations were identified in 10 of 41 true rupture cases.
CONCLUSION: Epidemiological data on uterine rupture based on hospital discharge codes without concurrent chart review may be invalid. Patients with previous cesareans represent only half of true uterine ruptures in contemporary practice.

* thanks to Jill for this one!

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Midwife-turned-med student blog

I recently started reading Mom's Tinfoil Hat, a blog by a self-described "hippiefreak idealist mom" who is currently training to become an OB/GYN. Here's a brief bio she wrote several months ago:

I trained as a midwife for two years, and had both of my children with a midwife. One in a hospital, on in a freestanding birth center. I have attended births in hospitals, including cesareans, in birth centers and at homes. I am training to be an Ob/Gyn, however, so you can take anything I say with whatever flavor grain of salt you like.

And here's a bit about her views on birth-related issues:

I support home birth in the full spectrum of reproductive choice and informed consent. I am afraid that obstetrics, the field I love and plan to practice, is in a very confused state in the United States. Interventionist practices are not based on evidence of improved outcomes. I just spoke to an attending at the closest Ob/Gyn residency who was appalled by the practices she saw when she started at that well renowned research and teaching hospital. What was the most appalling to her, and to me, is not simply that these are medical interventions. We are all in support of life saving technology. But, when these interventions have been shown in easily accessible peer reviewed research to lead to negative perinatal outcomes, why have they become standard of care in normal pregnancy instead of in the rare cases that they are indicated?

She recently commented on Jennifer Block's piece Can We Please Stop Blaming Women for C-Sections? This inspired a longer post on VBAC, in which she explores her experiences with VBACs and doctor-persuaded cesareans.

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