Think there’s no difference between a C-section and a vaginal birth?

This video begs to differ.


The Safe Motherhood Quilt Project

From the Safe Motherhood website:

The Safe Motherhood Quilt Project is a national effort developed to draw public attention to the current maternal death rates, as well as to the gross underreporting of maternal deaths in the United States, and to honor those women who have died of pregnancy-related causes since 1982.

This is a wonderful visual adjunct to my previous post on maternal mortality, with additional statistics. This project is the vision of Ina May Gaskin, who nearly single-handedly brought back midwifery, home birth, and normal birth in the 70s. She also wrote an article about this, “Masking Maternal Mortality,” in the current issue of Mothering magazine. I think it is an important reminder of how much further we have to go. Please visit this site, and if you know of someone who died of pregnancy-related causes within 1 year of the end of her pregnancy (whether miscarriage, abortion, or birth), you may there find out how to add a quilt block in her memory.

Maternal Mortality

First the facts: WHO/UNICEF/UNFPA Estimates of maternal mortality for 2005 lists the U.S. maternal mortality rate as being 11/100,000; but more recent figures show it to be 13/100,000. On the opening page of the National Center for Health Statistics “Maternal Mortality and Related Concepts” Feb. 2007 report (p. 6 of the pdf), it says that “35 percent more maternal deaths are identified through surveillance efforts than solely by the death certificate.” This discrepancy is caused by numerous factors, including different ways of assessing and coding death. If this is correct, then the current U.S. maternal mortality rate should be more like 17-18/100,000. Here are a few countries’ maternal mortality rates (but the information for all countries is there on that link; most of the countries’ numbers are estimates, due to poor or absent record-keeping in these places): Australia is 4; Belgium is 8; Brazil is 110; Burundi is 1100; Ethiopia is 720; Japan is 6; North Korea is 370, and South Korea is 14. Sierra Leone is the worst, with 2100/100,000. At the bottom of the page, it groups countries by level of development, and shows the average maternal mortality rate:

8/100,000 for industrialized countries

450/100,000 for developing countries

870/100,000 for least developed countries

So, the United States is worse than average for industrialized countries. I’m not going to engage in post-hoc arguments, but just point out some facts–the U.S. has the highest rate of obstetrician-attended birth in the world, and among the highest rates of hospital birth and C-section (if not the highest). We are the richest country in the world by just about anyone’s estimation, yet our maternal mortality rate is worse than Australia, Austria, Belgium, Bosnia, Canada, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Kuwait, Latvia, Malta, Netherlands, New Zealand, Norway, Poland, Slovakia, Slovenia, Spain, Sweden, Switzerland, and the former Yugoslav Republic of Macedonia. We are tied with Bulgaria, Lithuania and Portugal, and just barely edge out Luxembourg and Qatar. Why?

One factor that I have heard blamed for the U.S.’s poor standing compared to the world is the much-higher rate of maternal mortality for black women. The NCHS document I referenced above shows that in 2003 (the latest figures in the document), white maternal mortality was 8.7 while black maternal mortality was 30.5. But looking at only white births (and of course, European nations are going to be almost entirely white), the U.S. MMR is still only “average”–and we’re the richest country in the world! We have everything high-tech available, and the Emergency Medical Transport and Labor Act requires that hospitals give care to women who present to them in active labor, regardless of whether the woman can afford her care or not.

Some people blame the lack of socialized medicine, and I’m sure that lack of prenatal care does adversely affect some women; yet women who are in the lower socioeconomic brackets can get government assistance while pregnant (I worked at a pharmacy for over 5 years, and saw numerous women who did not need to be on Medicaid receiving these benefits just because they could). Some undoubtedly fall through the cracks; but there are also undoubtedly many women who simply don’t care enough about themselves or their babies to take measures–through better nutrition, getting off of drugs, etc. The higher black MMR has been blamed by some on their being more likely to be in lower socioeconomic brackets. While I do not disagree with the fact that poor people tend to be in worse health than those who are better off, I think this highlights the bias that exists against women who are poorer or who are on government assistance. It is sad that health-care providers can ignore signs and symptoms of problems in minorities or poor women that they will pick up on in white and/or well-off women. And those in the obstetric community who would say, “We can’t have the low MMR that European countries have, because we have a higher percentage of black women, and they have almost 4 times the death rate of white women.” That is simply “blaming the victim”! It is also fatalism, because this attitude suggests that this rate cannot be changed. But if this be the case, then that starts sounding like black women must somehow be genetically weaker or inferior to white women. [As an aside, I would like to know if there have been any studies of infant or maternal mortality that have had women of the same socioeconomic class, and divided by race. Are the statistics that much worse for wealthy black women, versus wealthy white women; or middle class, or lower class? Is the disparity more due to racism or "classism" by care providers against the poor or minorities, or is it simply a health or genetic thing? If it's racism, then shame on those who perpetrate it! If it's the poor health of these women, then care providers should first educate their clients on the importance of nutrition, and try to raise their clients' health in that way. I don't believe it's genetics.]

Others blame obstetric interventions that are overused, used too frequently, or used without a specific need or benefit. Routine use introduces risks without the corresponding benefit; when used specifically, interventions have a higher presumed benefit than known risk. [You can check out my posts entitled "safe motherhood" for more information on this topic.]

Even accepting the racial disparity as an unalterable fact for the moment, looking just at the white MMR, the U.S. 2003 death rate was 8.7, which puts it equal to or worse than all but about 3 of the countries mentioned above. This is unacceptable for the richest and best nation in the world!

Update — at this blog is a world map showing different maternal mortality rankings by different colors.

Doctors trying to figure out what midwives have known for millenia

I save a lot of stories and websites on my computer bookmarks or “favorites,” and just the other day, I came across this link to an article in a British newspaper entitled, “Cramp blamed for Caesarean boom.” It says that doctors have found higher-than-normal levels of lactic acid in the wombs of women who have had a C-section. Interesting. In doing some more research on lactic acid, I’ve discovered that there are conflicting theories. The old idea (which this newspaper and/or doctor hold to) is that lactic acid is a waste by-product of muscles working too hard with not enough oxygen–this stemming from experiments a scientist did about a century ago and just handed down as unassailable truth. Newer theories and newer research does not back up the idea that lactic acid causes muscle cramps, although it is noted that high levels of lactic acid are indicative of muscle cramps and fatigue. But whether it’s a “cause and effect” question, or that excess lactic acid is simply a marker of muscle fatigue is unknown. More research is needed, but what is known is that intense activity causes lactic acid to accumulate.

In the article, it mentioned that lactic acid build-up is well-known among athletes, so I dug further and found this article on Muscle Cramps/Spasms: Nutritional Causes, Prevention, and Therapies. Again, very interesting. Although it deals primarily with athletes, and training for things like long-distance running and biking, as well as weight-lifting, it made me wonder if some of the things could apply to labor. Since labor typically takes many hours, perhaps even more than 24 hours in some cases (I’ve even heard of labors taking several days), it would definitely qualify as an athletic event. This article makes me wonder how much of the pain of labor, and the length of labor, and labor dysfunction and dystocia, can actually be traced to nutritional deficiency (since it implicates low calcium or vitamin E intake in some causes of cramps and lactic acid build-up).

This article was also interesting in that it says that lactic acid is made by breaking down glucose, and is used as fuel by the muscles; and when athletes train in brief intense spurts before their competitions, they increase their ability to burn lactic acid as fuel. Braxton Hicks contractions, anyone?

And then there is this article, which has the following quote:

Lactic acid does not cause that dreaded burning sensation during intense exercise. Lactic acid is formed from the breakdown of glucose, our body’s main source of carbohydrate. When made, it’s split into a lactate ion (lactate) and a hydrogen ion. The hydrogen ion is the bad guy–the acid in lactic acid that interferes with electrical signals in nerve and muscle tissue. When the rate of lactic acid entry into the blood exceeds our ability to control it effectively, then those pesky hydrogen ions begin to lower the pH of muscle. This invariably interferes with how the muscles contract and thus our ability to perform. [emphasis added]

So this makes me think that glucose is burned as the first muscle fuel, and lactic acid is secondary. The more efficient your muscles are at burning lactic acid the better, because if too much lactic acid builds up then it lowers the pH of muscle, and causes problems with contractions. Or perhaps this hypothesis is wrong, and that high levels of lactic acid simply indicate that your muscles can’t use it quickly enough, so it’s running out of fuel. Your uterus is a muscle, and it needs to be able to efficiently contract in order for your cervix to dilate, and then to push your baby out.

This leads me to an article in the current Runner’s World magazine (March 2008), about world-record holder Paula Radcliffe. This article talks about her pregnancy, baby and birth as part of a larger discussion of the British runner’s life and running career. As a birth junkie, the birth part is what I’m most interested in. She was induced because she was more than a week overdueno reason other than she went past a magic date on a calendar. Although she ended up having a vaginal birth, inductions are much more likely to fail (and then necessitate a C-section) in first-time moms. She did, however, have an extremely long and painful labor, which is also pretty typical of inducing a first-time mom–in her case, 24 hours of Pitocin-induced contractions, which most women will say is harder than normal labor. Here is a quote from the magazine article:

There were the 14 hours sitting immobile and cross-legged, under orders not to get up; there was the raging thirst she wasn’t permitted to quench because they told her she might eventually need a cesarean and therefore could have nil by mouth, as doctors say. (‘They said, “Imagine that this is a marathon and so you can’t have anything to drink!” I said, “Actually, in a marathon you can start drinking at five kilometers.” They said, “You can wet a flannel, and we’ll squeeze it into your mouth.”‘)

[As an aside, just from the scanty information provided in this article, the following things in Ms. Radcliffe’s labor went against the World Health Organization’s “Safe Motherhood” guidelines: Of “Practices which are Demonstrably Useful and Should be Encouraged,” she did not have #4. Offering oral fluids during labour and delivery, or #15. Freedom in position and movement throughout labour; of “Practices for which Insufficient Evidence Exists to Support a Clear Recommendation and which Should be Used with Caution while Further Research Clarifies the Issue,” she had #3. Fundal pressure during labour; of “Practices which are Frequently Used Inappropriately,” she had #1.Restriction of food and fluids during labour, #3. Pain control by epidural analgesia, #7. Oxytocin augmentation, and #12. Operative delivery (vacuum assistance). While I do not blame her for getting an epidural (after many, many long hours of Pitocin-induced contractions, without being able to move from the bed), that probably made vacuum assistance necessary. “[T]hings culminated in a wild finale with two nurses pushing on her belly and a suction device on Isla’s head and the doctor bracing one foot against the delivery table in order to yank full strength.”]

In Henci Goer’s book, The Thinking Woman’s Guide to a Better Birth, she discusses IVs in labor (usually a glucose solution) being used instead of the woman being allowed to eat and drink as she wishes. On page 77 she says, “IVs are problematic by nature. Hunger and thirst and our natural responses to them invoke complex balances in both mother and unborn child. These balances are disrupted when they are bypassed by dumping huge amounts of fluids, often over a short period of time, directly into the bloodstream.” Then on page 79 is this, “Dehydration and starvation are associated with longer labors, increased use of oxytocin (trade name: Pitocin or “Pit”) to stimulate stronger contractions, and instrumental delivery. In addition, during pregnancy, starvation causes a faster, sharper drop-off in blood sugar levels and an earlier switch to metabolizing body fat. Vigorous exercise–in this case, labor–accelerates this process.” Then on page 80 is the following, “Glucose-containing IV fluids, also called ‘dextrose’ IVs, can raise maternal and fetal blood glucose levels to diabetic levels (hyperglycemia). Hyperglycemia in the baby increases the production of lactic acid, a metabolic by-product when there is insufficient oxygen.”

So how does this all work together? Here is my summary: Lactic acid is indicative of muscle fatigue (even if it’s not a cause or effect). To analogize, glucose is cash in your pocket that your muscles “spend” in order to work; lactic acid is “money in the bank.” Your body automatically converts glucose to lactic acid, so dumping too much glucose in your system at once (such as with an IV) can be counter-productive because the glucose is too-quickly converted into lactic acid (the “cash” is automatically deposited into your “savings account”); while the body’s normal digestive system allows you to take in a large amount of food and slowly converts it into “cash.” If you run out of glucose (easily expendable cash), then you must do the harder work of getting energy from lactic acid (taking a trip to the bank, waiting in line….). If you run out of cash at the grocery store, it doesn’t matter if you have a million bucks in a money market account–you still can’t buy your groceries because you have no cash in your pocket. Your body can increase the efficiency at which it burns lactic acid, but this takes time and training, neither of which is available in labor. (It’s possible that Braxton Hicks contractions leading up to labor are making the muscle of the uterus become more efficient at burning lactic acid–but this is just my hypothesis.) If your body is not very efficient at “spending” lactic acid, then the overload of lactic acid may make your uterus contract less efficiently–either due to the overload itself, or the fact that your muscles can’t efficiently “spend” the lactic acid, so you’re standing in line at the bank too long, trying to “liquidate your assets,” as it were. Marathon runners (or any athletes, for that matter) speak of hitting “the wall” when they simply can’t go any further. One of the articles I read says that the body has only so much possible reserves of calories to spend, and loading up on carbs before the event can help you overcome “the wall”; but food and drink during competition are necessary, too. As the world-record holder Paula Radcliffe said, “You get to drink at the 5-K mark!” Expert runners can complete a marathon in a few hours, average runners take several hours to complete. Volunteers line the race path with food and drink for the runners to have if they need it. This “quick energy” is enough to keep them going. When women are forbidden to eat or drink during labor, it seems like there is a time when the uterus hits “the wall” and simply can’t keep working under such adverse conditions. (Could you walk, run, or bike for hours without anything to eat or drink? Would that even be considered healthy? Is fasting a good thing for your baby?) Glucose IVs can help, but they can be “too much of a good thing” in a lot of ways, including the too-quick conversion of glucose (which your body is best at burning) into lactic acid (which your uterus is not as used to using). Artificial stimulation of the uterus through Pitocin can force it to contract and may prevent a C-section from being necessary, but this is not always the case.

A better way to avoid uterus fatigue is what midwives have always known and what women have always done (prior to about a century ago, when they started going into hospitals)–eat if you’re hungry, and drink if you’re thirsty.

“Pardon the Mess”

It’s interesting to see what the search terms people use to find your website or blog. The latest was, “does blood come out when you give birth?” Short answer: yes.

As always, this is not medical advice; and any bleeding should be discussed with a healthcare professional.

Leading up to labor, many women have a tinge of pink discharge occasionally. This is usually from the dilation or possibly effacement of the cervix. Occasionally it may be from other causes–a friend had this due to a yeast infection that irritated a spot on her cervix. She was of course concerned that she was spotting, but it ended up being not a concern. Any bright-red bleeding is a cause for concern.

When the baby is born, there will likely be some blood on the baby. If the woman has an episiotomy (a cut at the vaginal opening), then she will definitely bleed. Most women do not need an episiotomy, although some will tear. Most tears will be smaller and less damaging than an episiotomy, and most tears extending into the rectum are caused by an episiotomy. How much blood is on the baby depends on how much the woman bleeds when she gives birth.

My first birth was in the water, so the baby had his first bath at his birth, and he didn’t have any blood on him, although I did tear. My second birth was “on land” and there was minimal blood on the baby. The tears were minor “skid marks” not requiring any stitches at all.

After the baby is born, the placenta sheers away from the wall of the uterus, and the blood vessels that supplied the placenta begin to bleed (my second midwife called “the placental gush”). The uterus begins to contract, clamping down on the site where the placenta attached, minimizing the blood flow. If the uterus doesn’t contract enough, the woman may bleed too much and hemorrhage. While postpartum hemorrhage is a major cause of maternal death in the developing world, this is rarely a problem in the U.S.

Anything over 200-250 ml of blood loss (about 2 cups) is considered a maternal hemorrhage for a vaginal birth; the average blood loss for a C-section is about 500 ml. When women are pregnant, their blood volume increases by half, so a large amount of blood loss is not as traumatic as might otherwise be. Most midwives carry Pitocin to home-births, which when administered after the baby is born can stop a hemorrhage. Occasionally, a woman must transfer to the hospital for help, including potential transfusions (extremely rare). It is standard procedures in many hospitals to give a shot of Pitocin to the mom as soon as the baby’s shoulders are born, but according to the WHO guidelines for Safe Motherhood, this can increase the possibility of retained placenta, and have other adverse maternal reactions, so they do not recommend it as a matter of course.

With my first birth, I had postpartum hemorrhage, and my midwife gave me a shot of Pitocin in the thigh. I was quite weak afterwards (a few days later, I couldn’t walk more than a few blocks at a time). I’ve had problems with anemia, and try to remember to take iron fairly regularly. When I have tried to give blood, I was denied one time for low iron, and another time just barely made the cut. This latter time, I couldn’t do anything after giving blood because I was so tired. When I was pregnant with my second baby, I was more diligent to keep my iron intake up, as well as eating foods high in vitamin K (a natural blood-clotting substance). Anecdotally, I will say that these things helped me avoid excess blood loss in my second birth.

After the birth, the uterus begins shedding its very rich lining that sustained the pregnancy (this occurs regardless of whether you had a vaginal birth or a C-section). While the amount of time varies, it usually takes a couple of weeks to lose the lochia (as it is called). At first, it is red and heavy, like the blood of a period, and gradually lightens up until it is gone. Any recurrence of heavier bleeding or redder color indicate that you have probably done too much, and need to rest more.

Cytotec (ge. misoprostol, a.k.a. “miso”)

The obstetric community at large loves this drug. Some doctors refuse to use it at all, and some use it rarely. It’s a little white pill that as one person put it, “turns the cervix into absolute MUSHIE.” That’s the good side. But you know there has to be a bad side. First of all, notice the little picture of the pregnant woman with the big red slash over it. That obviously means it should not be given to pregnant women. The red rectangle on the side is a verbal description of why.

As a pharmacy tech for over 5 years, I’m well acquainted with drugs, their intended effects, and their side effects. All drugs have side effects. Sometimes this effect is so slight that people don’t even notice it; other times it’s overwhelming, or even deadly. Even something as innocuous as Tylenol (acetaminophen) can be deadly. Years ago, I read a story of a college student who accidentally overdosed on acetaminophen and required an emergency liver transplant, because she took several cold medicines and didn’t realize that all of them had acetaminophen in them.

Here is the package insert for Cytotec, taken from the FDA’s website. You should first know what this drug is–it’s to treat ulcers. They found out that it causes uterine contractions, which is why it’s contraindicated for pregnant women. I’ve heard of women inducing their own abortions by getting this medication and taking a few of them. The package insert says that after the 8th week of pregnancy, this drug can cause uterine rupture, but some abortion clinics’ websites I found said they use this drug in 2nd-trimester abortions.

But, after doctors found out that it can ripen an unfavorable cervix, it began to be used popularly in hospitals. I’ve heard more than one report that women are being given this without their knowledge, and/or without informed consent. One of my fellow childbirth educators was the first to tell an OB-resident of the potential dangers of this drug. He had never heard of the risks. Many women are just told that they’ll be given a pill (usually vaginally) to ripen their cervix. They are not told that this drug is contraindicated in pregnant women; nor are they told that it is an off-label use of the drug. What the doctors are doing is completely legal, but I consider it to be unethical not to give these women the full information.

Here is the information from the package insert about labor and delivery:

Cytotec can induce or augment uterine contractions. Vaginal administration of Cytotec, outside of its approved indication, has been used as a cervical ripening agent, for the induction of labor and for treatment of serious postpartum hemorrhage in the presence of uterine atony. A major adverse effect of the obstetrical use of Cytotec is hyperstimulation of the uterus which may progress to uterine tetany with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy), or amniotic fluid embolism. Pelvic pain, retained placenta, severe genital bleeding, shock, fetal bradycardia, and fetal and maternal death have been reported.

There may be an increased risk of uterine tachysystole, uterine rupture, meconium passage, meconium staining of amniotic fluid, and Cesarean delivery due to uterine hyperstimulation with the use of higher doses of Cytotec; including the manufactured 100 mcg tablet. The risk of uterine rupture increases with advancing gestational ages and with prior uterine surgery, including Cesarean delivery. Grand multiparity also appears to be a risk factor for uterine rupture.

In the year 2000, Searle (this drug’s manufacturer, since taken over by Pfizer) issued a letter of warning to health care providers who might consider using this drug to induce labor or cause an abortion. (My thanks to “americanmum” for reminding me of this!) It says in part:

“Serious adverse events reported following off-label use of Cytotec in pregnant women include maternal or fetal death; uterine hyperstimulation, rupture or perforation requiring uterine surgical repair, hysterectomy or salpingo-oophorectomy; amniotic fluid embolism; severe vaginal bleeding, retained placenta, shock, fetal bradycardia and pelvic pain.

Searle has not conducted research concerning the use of Cytotec for cervical ripening prior to termination of pregnancy or for induction of labor, nor does Searle intend to study or support these uses.”

You may be wondering why anybody uses it at all. This drug can ripen the cervix and/or induce labor. In the case of a medically indicated induction, many women have an unfavorable cervix, and the induction is likely to fail, thus necessitating a C-section. If Cytotec is used, and the cervix dilates and effaces, then the woman can have a vaginal birth and be spared a C-section. That’s a good thing. But at what cost?

Some doctors and even some midwives consider this benefit to be so good, and the risk of a ruptured uterus to be so slight, that they will use it. But isn’t that a choice for the patient to make? And shouldn’t the patient be given all of the information? That’s the simple idea behind “informed consent.” I will grant that most women do not have a problem with this drug. I will allow that most babies will survive with few negative sequelae after a Cytotec induction. But these are choices that the mother must make, weighing all the risks and benefits.

Here is a link to Ina May Gaskin’s website, where she has compiled a summary of articles about Cytotec’s use in labor. It has been quite some time since I’ve read it, but I remember that at least one trial was stopped because of the high rate of uterine ruptures in women who had had a C-section. I hope that if you’ve had a C-section, that your doctor will not use this drug on you, but he is legally allowed to use the drug any way he sees fit. The contraindication warning of this drug to pregnant women does not make it illegal to induce a woman with this drug.

In addition to the above article, here are some more true stories of women who have had negative outcomes from the use of this drug. No drug is 100% safe–not even Tylenol. When the benefit outweighs the risk, it makes sense to use it. But it is up to the person who takes the drug to decide the benefit-risk level.

This woman was induced for her 6th birth, and ended up nearly dying from a uterine rupture.

Here is a link to an investigative report that aired in Nashville, about the potential dangers of Cytotec.

Here is a link to a story that aired on CBS news a few years ago.

There are many other stories I could share, but I will let you conduct your own internet searches. The known disastrous side effects are rare but extremely serious. If you believe that Cytotec/misoprostol/miso should not be used on you, then you should discuss this with your doctor or midwife and have that in writing. Some of the doctors and nurses who have talked about this drug have such cavalier attitudes toward it that they may give it to you without even telling you what they’re doing, or giving you an option. But it’s your body, your baby, and should be your choice.

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Trendy Birth: An Odd Dichotomy

I haven’t posted on my blog about this topic (ACOG’s support of elective C-section, but opposition to home-birth), although I did post something to the Independent Childbirth Educators’ blog. But I came across this short article written by Amy Haas which expresses so well and succinctly the problem, that I asked her permission to post it on my blog. In addition to the well-written post, she provides a plethora of studies so that others can look up and verify what she says. I have noticed a trend among doctors (especially obstetricians) to have an attitude of “trust me, I know what’s best.” This is what I like about being a childbirth educator–finding out the facts for sure, and not just relying on anyone’s opinion. I’ve found that sometimes there is a great difference between what people say and what the research actually shows. Enjoy!

From Amy V. Haas, BCCE:

Trendy Birth: An Odd Dichotomy

Recently the American College of Obstetricians and Gynecologists (ACOG) released a statement against homebirth, calling it, among other things, a dangerous popular trend in modern times. Oddly enough the latest trend in birth truly isn’t homebirth (an occurrence that has existed since the beginning of time) but elective cesareans, or Too Posh to Push, as the media has dubbed it. A few years ago ACOG released a statement about elective cesareans, acknowledging the serious risks to choosing major abdominal surgery for birth, but stated that it was a choice that should be left up to the doctor and his patient.

When I started looking into existing research on both issues I was quite fascinated to note that, contrary to ACOG’s opinion, there was quite a bit of good research showing the safety of homebirth. In fact the one study used as the reason to restrict homebirth was actually flawed to the point of uselessness, due to, among other things, poor controls. Other than that one flawed study, used as the basis for ACOG’s opinion, I could find no other studies that showed homebirth to be riskier than hospital birth for low risk women. In addition to the latest large study on homebirth published in the British Medical Journal in 2005, I also found over ten years worth pervious studies that showed the safety of homebirth for low risk women attended by Midwives.

Conversely one of the sad benefits of the latest trend toward elective cesareans is that we now have enough of a population to determine the pros and cons of an extreme choice like elective cesarean. The results show some very extreme negative risks that are punctuated by increases in maternal and infant mortality.

So why, if there is this laundry list of serious risks to elective cesarean, but no real studies showing serious risks for low risk moms having homebirth, is ACOG coming out full force against homebirth, but not against elective cesarean? Very strange, and very scary.

Amy V. Haas, BA, BCCE
Community Resource Coordinator
Rochester Birth Network
Certified Childbirth Educator

(References available upon request)


American College of Obstetricians and Gynecologists, News Release, February 6, 2008, ACOG statement on homebirths; Office of communications, 201-484-3321.

American College of Obstetricians and Gynecologists (ACOG). (2000). Planning your pregnancy and birth. Washington , DC : ACOG.

Bernstein, P. S.; “Elective Cesarean Section: An Acceptable Alternative to Vaginal Delivery?” Field Notes in Obstetrics and Maternal-Fetal Medicine
Medscape Ob/Gyn & Women’s Health 7(2), 2002

Citizens for Midwifery; “Out-Of- Hospital Midwifery care: Much Lower Rates of Cesarean sections for Low Risk Women”.;

Johnson, KC; Daviss, BA; “Outcomes of planned homebirths with certified professional midwives: large prospective study in North America ”; British Medical Journal,; 330:1416; 2005.

Johanson R, et al; “Has the medicalization of childbirth gone too far?” British Medical Journal 324:892-895 (April 2002)

Kolas, T. , et. al, , “Neonatal Outcomes Worse With Planned Cesarean Than Planned Vaginal Deliveries” Innlandet Hospital Trust, Lillehammer , Norway, Am J Obstet Gynecol 2006;195:1538-1543

MacDorman MF, et al; “Infant and neonatal mortality for primary cesarean and vaginal births to women with “no indicated risk,” United States, 1998-2001 birth cohorts, Division of Vital Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland 20782, USA. PMID: 16948717

Martin J., et al ; , “Births: Final Data for 2004”; National Vital Statistics Report; Center for Disease Control Volume 55 # 1, September 29th, 2006,…5/ nvsr55_01.pdf

Pang, JWY, et al; “Outcomes of Planned Home Births in Washington State ” Obstetrics and Gynecology Volume100:#2;253-259 (August 2002)

Schlenska, P F; “Safety of Alternative Approaches To Childbirth” Doctoral Dissertation; Stanford University , California ,

Weaver, J. J., Statham, H., & Richards, M. (2007). ” Are there “unnecessary” cesarean sections? Perceptions of women and obstetricians about cesarean sections for nonclinical indications.” Birth, 34(1), 32-41.

Weigers, TA, et al; “Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in Netherlands ” British Medical Journal 313: 1309-1313 ( November 1996)

“For Low-Risk Women, Risk of Death May Be Higher for Babies Delivered by Cesarean”, Birth: Issues in Perinatal Care. Black Well Publishing, August 29, 2006;

Amy V. Haas©2008

“I agree completely with the excellent article by Amy Haas on the ACOG position on home birth and on elective C section. The simple explanation for both these ACOG positions is the same—MONEY. ACOG is against home birth because it takes clients away from them and they are in favor of elective C section because they get more money with C section than with a vaginal birth “ Marsden Wagner , MD (Former head of the committee on maternal child health for the World Health Organization) 2/14/08


Once your cervix is fully dilated, you may or may not feel the urge to push. Often, once your cervix is dilated, you will be directed to push whether you feel the urge or not. According to the WHO guidelines for safe motherhood, this is “a practice which is frequently used inappropriately.” It mentioned that women are typically checked for full dilation once they feel the urge to push, but it is not known how long they were fully dilated (which means that they could have had a long “latent” period in which they were fully dilated but not yet pushing). This means that when women are checked and found to be fully dilated and told to start pushing, they may also be in this “latent” period. I consider this to be nature’s way of giving women a break. The contractions slow down or are less intense than transition contractions, and allow women to rest and regroup before the work of pushing the baby out.

In the hospital, the typical pushing is “directed pushing” or “Valsalva maneuver” or “purple pushing.” This is what you see in all of those awful birthing shows in which a team of people surround a poor woman on her back, and count to ten telling her not to take a breath. The WHO guidelines (see my post here) says that this practice is “clearly harmful or ineffective and should be eliminated.”

The alternative to directed pushing is spontaneous pushing. When women are allowed to push naturally, they will usually bear down for 5-6 seconds and do this several times a contraction. A small study of 39 first-time moms showed “women who used spontaneous pushing were more likely to have intact perineums postpartum and less likely to have episiotomies, and second or third degree lacerations.” When women hold their breath for 10 seconds, taking only a couple of quick breaths in between pushing, they are more likely to feel faint and weak, or need oxygen. (You can try this yourself–just hold your breath for 10 seconds, take a quick breath, hold your breath for 10 more seconds, take another quick breath, and then hold your breath for 10 more seconds–and see how you feel.)

This link to cites many studies that show the multiple benefits to spontaneous pushing, and the risks of “purple pushing.” When you follow the link, you can see all the studies they cite, in the footnotes. The only benefit of directed pushing was a slightly shorter second stage (13 minutes–discussed more fully below), but this did not have any improved maternal or fetal/neonatal benefit. In fact, sustained pushing was associated with a higher incidence of pelvic floor trauma (leading to greater urinary and fecal incontinence), and reduced fetal oxygenation. This only makes sense–if you’re feeling light-headed from lack of oxygen, your baby is also being deprived of oxygen.

This study reached the following conclusion: “These studies indicate that the only apparent advantage of Valsalva pushing is a shorter second stage, which, on occasion, may be desirable. However, expediting delivery by forceful, directed pushing is achieved at the expense of three negative outcomes: reduced oxygenation of the fetus, more frequent trauma to the birth canal, and potential injury to future pelvic floor function.”

The study that determined a shorter second stage of 13 minutes when using directed pushing looked only at women who had an epidural. Typically, women are directed to start pushing once they reach full dilation, whether they feel the urge or not. Since women who have had an epidural sometimes don’t feel an urge to push because of the medication, they are much more likely to be subjected to directed pushing than non-drugged women. The two groups this study divided women into immediate pushing once full dilation was determined, or delayed pushing of an hour or until they got the urge to push, whichever came first. Another study (this one appearing in ACOG’s Green Journal) had the following results: “When a period of rest was used before pushing, we found a longer second stage, decreased pushing time, fewer decelerations, and, in primiparous women, less fatigue compared with control patients. Apgar scores, arterial cord pH values, rates of perineal injury, instrument delivery, and endometritis were similar in both groups.” It concluded, “Delayed pushing was not associated with demonstrable adverse outcome, despite second-stage length of up to 4.9 hours. In select patients, such delay may be of benefit.” While the authors stressed the need for close monitoring of the women to make sure that the labors were not obstructed (in other words, that the delay in pushing was not due to a problem, but was indeed normal), they said, “Our data suggest that in appropriately selected and managed women, extension of these time periods is safe, and may be beneficial for mother and fetus using a policy of rest and descend.”

This research demonstrates that it is reasonable to delay pushing until you feel the urge, and to push spontaneously instead of to a count of ten. While there are certain circumstances in which this may not be best for your baby, in the absence of these occasional problems, there is no reason to put your perineum or the baby’s oxygen at risk.

Updated to add this link with a discussion (and citations) of “purple pushing” and this link on waiting until there is an urge to push.

Oh, wow, what a birth story!

Just read it.

Pain in Pregnancy

Most women take pain and discomfort in pregnancy as being normal. Even when pain is bad, and women complain to the obstetricians about it, most doctors dismiss it as the “normal” aches and pains of pregnancy. I did this too. After all, gaining 40 pounds with my first pregnancy (and losing it all), then gaining 50 pounds with my second (working on losing it now), I wasn’t exactly shocked when my lower back started hurting. It doesn’t take a rocket scientist to figure out that a watermelon on your belly is going to throw your back out of whack. One thing I probably would do differently, though, is to see a chiropractor. I would also have eaten healthier so I wouldn’t have gained as much weight (or lost weight prior to getting pregnant). In one way, I still accept some aches and pains as being normal. I might be wrong.

When my late-pregnancy symptoms that I had conveniently forgotten from my first pregnancy started in my second pregnancy, I was unpleasantly surprised. Not only did they start earlier, but they were worse. It was one thing to have a month or so of poor sleep before giving birth, but almost three months was a whole ‘nother story! I just couldn’t get comfortable, but attributed it to my greater weight gain. Finally, I mentioned it on a birth-y list I was on (a group of probably 10 or so women, all due about the same time, which was a cool coincidence), and one of them gave me this link, because of the specific symptoms I was having. I didn’t have all of the symptoms, but I had enough to agree with the “diagnosis.” Here is a summary of symptoms of “Symphysis Pubis Dysfunction” (and I strongly suggest that you click on the above link and read the entire page, and don’t just take, “Well, of course you’re uncomfortable, dearie–you’re pregnant!” as an answer):

  • pubic pain
  • pubic tenderness to the touch; having the fundal height measured may be uncomfortable
  • lower back pain, especially in the sacro-iliac area
  • difficulty/pain rolling over in bed
  • difficulty/pain with stairs, getting in and out of cars, sitting down or getting up, putting on clothes, bending, lifting, standing on one foot, lifting heavy objects, etc.
  • sciatica (pain in buttocks and down the leg)
  • “clicking” in the pelvis when walking
  • waddling gait
  • difficulty getting started walking, especially after sleep
  • feeling like hip is out of place or has to pop into place before walking
  • bladder dysfunction (temporary incontinence at change in position)
  • knee pain or pain in other areas can sometimes also be a side-effect of pelvis problems
  • some chiropractors feel that round ligament pain (sharp tearing or pulling sensations in the abdomen) can be related to SPD

The rest of the webpage has tips for coping, as well as what can be done to resolve the problem (chiropractic–but not every chiropractor will have heard of this or know how to treat it, so do some research first). You don’t have to suffer. Even after reading this page, I didn’t seek chiropractic care, because I assumed it would be too expensive and I didn’t think I had enough time (I was just a couple of weeks away from my estimated due date)–I thought all chiropractic adjustments took three visits a week for a month before you got “fixed.” After giving birth, I mentioned that on that same email list, and regrettably found out that it usually clears up after one visit.

But you might not have to seek chiropractic help! From Dr. Jennifer Padrta, a chiropractor who is on another email list that I’m on is the following:

This is excruciating….and I’ve seen it so much in pregnant moms – usually 1 -3 adjustments clear it up completely….but here’s what she can do at home to help it….
Have mom lie on her back on the floor with her feet on the floor and her knees up. Keep the feet touching and have dad put his hands between her knees. Mom needs to pull together while dad “wishbones” her legs….GENTLY. She may get a “pop” or a crunch sound or no sound at all – all of which is perfectly normal. She may even feel it in her sacroiliac (SI) joints. This is classic for pregnant moms. He keeps doing this until they strengthen up and he can’t pull them apart. If they don’t strengthen within a few days of doing this, then, she may need to go see a chiropractor and get her SI joints checked. Often, the pubic bone won’t release unless I’ve adjusted the SI joints and vice versa….since it’s all connected.
Ligaplex I from Standard Process works well during the beginning of the pregnancy. Usually 4 each day suffice until the 36th week of pregnancy, when I have moms stop it, so the ligaments can relax….but until then, it helps hold adjustments and joints together, which makes life a LOT more comfortable.

My friend complained to me about her pelvic pain, so I sent the above to her, and she said that one time of doing this exercise helped her tremendously. Don’t suffer needlessly. There is an answer.


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