Maternity Care - International Cesarean Awareness Network

Have Cesareans Driven Evolution Toward Bigger Babies?

February 7, 2017 by Vice President

“The great tragedy of Science: the slaying of a beautiful hypothesis by an ugly fact.”
Thomas Huxley

Reverberating through the internet is an article by a group of scientists theorizing that cesarean availability has altered the course of human evolution, resulting in an epidemic of babies with heads too big to pass through their mother’s pelvises. The article presents a complex argument with formulas, calculations, and graphs showing the tension between maximizing fetal size and the limits of a pelvis designed for walking upright on two legs, a balance, they conclude, disrupted by the option of surgical delivery. It’s all very impressive, and it’s hogwash.

For one thing, the underlying assumptions are false. The authors assume that the dimensions of the mother’s pelvis and the fetal skull are fixed. They’re not. Thanks to the openings in the fetal skull (fontanelles) and the unsealed joints between its bony plates, the fetal skull can mold to the mother’s pelvis. Furthermore, pregnancy softens maternal ligaments, enabling the pelvis to flex open. They also assume that birthweight relates strongly to skull circumference, but mostly, increasing birthweight just means plumper, not bigger headed. And they assume that maternal-fetal dimensions are the sole factors determining ability to pass through the pelvis, but unfavorable fetal positioning—head facing the mother’s belly (occiput posterior) or to the side (occiput transverse) or not chin on the chest (deflexed) or tipped to one side (asynclitic)—all play as big or bigger role by presenting a wider diameter to the pelvic inlet.

For another, the facts contradict their theory. Women having vaginal births after cesarean (VBACs) not infrequently deliver babies as big or bigger than the baby they were supposedly too small to deliver the first time. What’s more, the rise in cesareans for progress delay can’t be due to a surge in big babies because according to “Myth & Reality Concerning Cesarean Section in the U.S.,” there hasn’t been one. The proportion of babies weighing 8 lb 13 oz (4000 g) or more, the usual definition for macrosomia, has fallen from 10% to 8% since 1991 while the cesarean rate for babies of every birthweight soared.

So, let’s turn the spotlight on the real reasons behind the high cesarean rate for progress delay: obstetric practices and beliefs.

FACT: When obstetricians believe a woman won’t be able to birth her baby, it affects their decision-making in ways that tend to make it a self-fulfilling prophecy. For example, studies consistently show that if the doctor suspects a big baby, the woman is far more likely to have a cesarean than when the baby actually weighs in the macrosomic range, but the doctor didn’t suspect it.^{1,2,3,4,5,6,7}

FACT: The cesarean rate for macrosomic babies has skyrocketed over time. It was 3% in 1958 in Great Britain.⁸By the 1990s, obstetricians might perform cesareans on as many as half of women with babies of this size.^2,6Unless you’re prepared to argue that women’s pelvises have been shrinking over the decades, this means cesarean rates for big babies must be due to changes in their doctors’ thinking, not them.

FACT: Conventional obstetric management handicaps women, depriving them of an edge that might make a difference, especially if the baby is bigger. To name a few common practices that tilt the playing field toward cesarean:^9,10

Inducing labor when the cervix isn’t ready;¹¹
Admitting women to the hospital in early labor;^12,13
Promoting universal use of epidurals;¹⁴
Keeping women in bed;¹⁵
Imposing overly restrictive time limits for making progress in early labor,^16,17 during pushing,^16,17 and when oxytocin is being given to strengthen contractions;^18,19
Having women push on their backs.²⁰

The enormous variation in cesarean rates in similar women makes clear that whatever is going on, again, it isn’t about women.²¹

Certainly, some women would be unable to birth their babies vaginally no matter what their care or how much time they were given. For these women, cesareans may be a lifesaver, but as one obstetrician summed it up:²²

I can’t believe that evolution is pushing us into the operating room. I think we’re pushing ourselves into the operating room . . . it’s almost like the perfect storm. You’re going to pay me more, I get to worry less, you’re not going to sue me, and I’ll be done in an hour.

So, please, let’s stop blaming the victims for what is essentially the fault of their care providers.

Reblogged with permission from Henci Goer, a member of ICAN’s Advisory Committee, from her website Childbirth U.com. Childbirth U offers narrated slide lectures at modest cost to help pregnant women make informed decisions and obtain optimal care for themselves and their babies.

Blackwell SC, Refuerzo J, Chadha R, et al. Overestimation of fetal weight by ultrasound: does it influence the likelihood of cesarean delivery for labor arrest? Am J Obstet Gynecol 2009;200(3):340 e1-3.
Levine AB, Lockwood CJ, Brown B, et al. Sonographic diagnosis of the large for gestational age fetus at term: does it make a difference? Obstet Gynecol 1992;79(1):55-8.
Melamed N, Yogev Y, Meizner I, et al. Sonographic prediction of fetal macrosomia: the consequences of false diagnosis. J Ultrasound Med 2010;29(2):225-30.
Parry S, Severs CP, Sehdev HM, et al. Ultrasonographic prediction of fetal macrosomia. Association with cesarean delivery. J Reprod Med 2000;45(1):17-22.
Sadeh-Mestechkin D, Walfisch A, Shachar R, et al. Suspected macrosomia? Better not tell. Arch Gynecol Obstet 2008;278(3):225-30.
Weeks JW, Major CA, de Veciana M, et al. Gestational diabetes: does the presence of risk factors influence perinatal outcome? Am J Obstet Gynecol 1994;171(4):1003-7.
Weiner Z, Ben-Shlomo I, Beck-Fruchter R, et al. Clinical and ultrasonographic weight estimation in large for gestational age fetus. Eur J Obstet Gynecol Reprod Biol 2002;105(1):20-4.
Francome C, Savage W. Caesarean section in Britain and the United States 12% or 24%: is either the right rate? Soc Sci Med 1993;37(10):1199-218.
Boyle A, Reddy UM, Landy HJ, et al. Primary cesarean delivery in the United States. Obstet Gynecol 2013;122(1):33-40.
Declercq E, Sakala C, Corry MP, et al. Listening to Mothers III. Pregnancy and Birth. New York: Childbirth Connection; 2013.
Teixeira C, Lunet N, Rodrigues T, et al. The Bishop Score as a determinant of labour induction success: a systematic review and meta-analysis. Arch Gynecol Obstet 2012;286(3):739-53.
Kauffman E, Souter VL, Katon JG, et al. Cervical Dilation on Admission in Term Spontaneous Labor and Maternal and Newborn Outcomes. Obstet Gynecol 2016;127(3):481-8.
Tilden EL, Lee VR, Allen AJ, et al. Cost-Effectiveness Analysis of Latent versus Active Labor Hospital Admission for Medically Low-Risk, Term Women. Birth 2015;42(3):219-26.
Bannister-Tyrrell M, Ford JB, Morris JM, et al. Epidural analgesia in labour and risk of caesarean delivery. Paediatr Perinat Epidemiol 2014;28(5):400-11.
Lawrence A, Lewis L, Hofmeyr GJ, et al. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev 2013;10:CD003934.
American College of Obstetricians & Gynecologists, Society for Maternal-Fetal M, Caughey AB, et al. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014;210(3):179-93.
California Maternal Quality Care Collaborative. Smith H, Peterson N, Lagrew D, et al. Toolkit to Support Vaginal Birth and Reduce Primary Cesareans: A Quality Improvement Toolkit. Stanford, CA: California Maternal Quality Care Collaborative; 2016.
Rouse DJ, Owen J, Hauth JC. Active-phase labor arrest: oxytocin augmentation for at least 4 hours. Obstet Gynecol 1999;93(3):323-8.
Rouse DJ, Owen J, Savage KG, et al. Active phase labor arrest: revisiting the 2-hour minimum. Obstet Gynecol 2001;98(4):550-4.
Reitter A, Daviss BA, Bisits A, et al. Does pregnancy and/or shifting positions create more room in a woman’s pelvis? Am J Obstet Gynecol 2014;211(6):662 e1-9.
Kozhimannil KB, Arcaya MC, Subramanian SV. Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: analyses of a National US Hospital Discharge Database. PLoS Med 2014;11(10):e1001745.
Kennedy HP, Doig E, Tillman S, et al. Perspectives on Promoting Hospital Primary Vaginal Birth: A Qualitative Study. Birth 2016;43(4):336-45.

Should a Woman’s Ethnicity Decrease Her Access to Birth Mode Options?

January 12, 2017 by Vice President

If you have ever wondered what the leadership of your local ICAN chapter does, the following is a good example of our work to promote ICAN’s mission of improving maternal-child health by reducing unnecessary cesareans through education, providing support for cesarean recovery, and advocating for vaginal birth after cesarean (VBAC).

Recently, in September 2016, an ICAN of Huntsville co-leader was made aware of a situation where a local office had interpreted ACOG’s Practice Bulletin 115 in such a way that did not favor offering a trial of labor after cesarean(s) to women of Non-White ethnicity. The table labeled “Selected Clinical Factors Associated With Trial of Labor after Previous Cesarean Delivery Success”, from ACOG’s Practice Bulletin 115, was cited as the source for the office’s decision. After several days of research, our team discovered many studies citing unknown sources for the decreased chance of VBAC success associated with being of Non-White ethnicity, and even some that cited possible “Physician Bias” as the source. Since we could not get definitive answers through published peer-reviewed research, the aforementioned co-leader contacted ACOG directly, in order to gain clarification on the intended use of the table titled “Selected Clinical Factors Associated With Trial of Labor after Previous Cesarean Delivery Success”. We would like to share their response with you, in order to ensure maternity care consumers are fully informed about Practice Bulletin 115.

The question our co-leader submitted to ACOG on September 7, 2016, is provided below:

Dear ACOG Medical Library,

My name is . . . , and I spoke with one of the Medical Librarians this afternoon. This email is in regards to an ICAN of Huntsville chapter member who is . . . pregnant and was told she would not be “allowed” a trial of labor at this practice because of her race and having two prior cesareans. Due to her situation, and that of one of the ICAN co-leaders of our chapter, the practice has created a new policy stating all . . . doctors MUST sign off on a trial of labor after two cesareans, before a mother is “allowed” to have a trial of labor with the assistance of a doctor from that practice. We are writing to get clarification on Practice Bulletin 115, since it was used as the reason for denying this woman access to a TOLA2C. This office has some form of “check-list” that is being used to determine ideal candidates for VBAC and VBA2C. Two of the items on this list are 1. Number of prior cesareans, and 2. Non-white ethnicity.

Were the tables showing decreased success rates for certain subsets meant to reduce access to TOLAC or TOLA2C to those subsets of women?

This paragraph lists factors that negatively impact likelihood of VBAC, but does not list “non-white ethnicity”.

“Most published series of women attempting TOLAC have demonstrated a probability of VBAC of 60–80% (4, 5, 12–14, 22, 23). However, the chance of VBAC for an individual varies based on demographic and obstetric characteristics (see box). For example, women whose first cesarean delivery was performed for an arrest of labor disorder are less likely than those whose first cesarean delivery was for a nonrecurring indication (eg, breech presentation) to succeed in their attempt at VBAC (37–43). Similarly, there is consistent evidence that women who undergo labor induction or augmentation are less likely to have VBAC when compared with those at the same gestational age with spontaneous labor without augmentation (44–47). Other factors that negatively influence the likelihood of VBAC include increasing maternal age, high body mass index, high birth weight, and advanced gestational age at delivery (44, 48–54). A shorter interdelivery interval and the presence of preeclampsia at the time of delivery also have been associated with a reduced chance of achieving VBAC (55, 56). Conversely, women who have had a prior vaginal delivery are more likely than those who have not to succeed in their TOLAC (44, 57).”

But, the box labeled “Selected Clinical Factors Associated With Trial of Labor after Previous Cesarean Delivery Success” DOES list “non-white ethnicity” as a factor leading to a decreased probability of VBAC success. What evidence led you to add “non-white ethnicity” to that list, and why was it not mentioned in the text? Were these meant to be items to counsel women on so they know their risks vs benefits, or were they meant to be exclusionary items used to decline access to TOLAC and TOLA2C?

If a woman seeking a TOLAC or TOLA2C is not an “ideal candidate” based on information in the above paragraph from PB115, should she still receive full counseling on risks and benefits of both VBAC or VBA2C, and also ERC (elective repeat cesarean), and then be allowed to give her informed consent or refusal, regardless of physician recommendation?

On September 27, 2016, ACOG replied with the following:

Hello,

The Practice Bulletin described clinical and other characteristics associated with a vaginal birth among those undergoing a trial of labor so that patients and providers can have an informed and shared conversation about plans. The list, in general, and non-white race, specifically, was not intended to be used at a facility level to decide if trials of labor would be supported. In this regard, the document does not suggest a specific chance for vaginal delivery above or below which a trial of labor should be planned or prevented. While studies have associated non-white race with a decreased chance of vaginal delivery among women undertaking a trial of labor, ACOG does not support using race to exclude any women from the option of a trial of labor.

We continue to monitor VBAC and TOLAC studies and literature. If there are any changes to ACOG guidance, it will be published in the Green Journal. Please reach out anytime you have any questions- happy to move it through our experts.

Have a great day!

American College of Obstetricians and Gynecologists

Thankfully, ACOG was quick to respond with their intended interpretation of Practice Bulletin 115, in order to end any confusion that may have occurred. We are so grateful for ACOG’s willingness to respond to our questions and are hopeful it will help the women in this country have greater access to evidence-based care.

Sincerely,

ICAN of Huntsville Leadership Team

* For privacy reasons, names, personal information have been removed. ACOG has reviewed and approved of this blog post.

Please follow these links for more information from ACOG on VBAC:

You can contact ACOG at Practice@ACOG.org if you have any questions or concerns regarding a trial of labor after cesarean.

Why is our VBAC Rate So Dismal?

December 19, 2016 by blog

vbacpost_

Improving VBAC Success Through the VBAC Evaluation

Katie Gaither had her first cesarean in 2004 for breech presentation. She got pregnant again shortly after that birth. She was told she had a high chance of uterine rupture and that she wouldn’t find a provider who would agree to a trial of labor after cesarean (TOLAC). Just 13 months later, she had her second cesarean. Fast forward 10 years, and Katie was pregnant again and she found she was still having trouble finding a doctor who would support her desire for vaginal birth after cesarean (VBAC).

In June of this year, the CDC published the National Vital Statistics Report entitled, “Births: Preliminary Data for 2015.” The report indicated a national cesarean delivery (CD) rate of 32.0% in 2015, a drop from a peak of 32.9% in 2009 and the lowest level since 2007. While this slight decline is considered good news by those who are actively addressing the US Cesarean “epidemic,” the fact remains that over 1 in 3 women will give birth surgically. The majority of women who have a CD and have more children afterward will go on to have a repeat CD. A 2008 report by the CDC reported that 92% of women have a repeat cesarean, for a VBAC rate of a dismal 8%. There are many provider, hospital and regional variations in cesarean and VBAC rates, with Mississippi having a cesarean rate of 37.7% and Alabama having a VBAC rate of just 4%.

Many professional organizations have expressed concern about the escalating cesarean rate, including the Society for Maternal-Fetal Medicine and the American Congress of Obstetricians and Gynecologists (ACOG), who released a joint statement in 2014 acknowledging that while CD can be life-saving, “the rapid increase in cesarean birth rates from 1996 to 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused.” A patient approach to normal labor, especially in nulliparous women, and avoiding elective induction were recommendations of ways to prevent a primary CD. Margaret Willbanks’ doctor induced her first labor just two days after her due date. Her membranes were ruptured when she was 1 cm dilated and Pitocin was started. Her labor never progressed and she was taken for a cesarean. Afterward, she was left wondering why her body failed her and the suspicion that her provider’s upcoming vacation caused her to be rushed along when her body wasn’t ready. With Margaret’s next pregnancy she noticed that every time she brought up VBAC, she was told it was unlikely that she would have one. Knowing through her own research that she had no specific risk factors, she switched providers twice before finding someone willing to support her desire to give birth vaginally. Margaret regretted that she didn’t know anything about her doctor’s personal cesarean rate during her prenatal care.

While preventing the first cesarean delivery is of great importance, many public health experts, providers and patient advocates agree that supporting VBAC in women who are suitable candidates is an equally important goal. In 2010, the NIH convened a Development Conference on the subject of VBAC and generated a Consensus Statement that reviewed much of the data regarding elective repeat cesarean delivery (ERCD) and TOLAC. The Consensus Statement recommended that women undergo extensive counseling regarding the risks and benefits of ERCD & TOLAC, suggested that trial of labor was a reasonable option for many pregnant women with a history of a prior CD, and expressed concern about barriers by clinicians and facilities that such women face. The NIH Conference was followed on its heels by a revised ACOG Practice Bulletin on VBAC which stated that most women with a prior low transverse CD “are candidates for and should be counseled about VBAC and offered TOLAC.” The Bulletin went on to say that women with two prior CDs could also be counseled regarding VBAC in light of their individual risk factors. ACOG also acknowledged that its own prior guidelines had in many cases made TOLAC prohibitive for many facilities and patients and reiterated that women could not be forced to have a CD against their will even if a provider or facility were unwilling to offer VBAC (a VBAC “ban”).

Unfortunately, this evidence-based support for VBAC has not translated into clinical practice in an appreciable way. Many women are still being given one-sided counseling with an emphasis on the risk of uterine rupture with a TOLAC and little, if any, acknowledgment of the risks of surgical delivery, especially in women who want a larger family. According to a recent journal article in the Lancet, the US maternal mortality rate (MMR) has risen from around 8 of 100,000 live births in 1987 to 18.5 in 2013. While older or sicker women becoming pregnant is often the reason given for this change, the risks of surgical delivery such as venous thromboembolism and increased risk for obstetric hemorrhage have contributed to the rising MMR. Abnormal placentation such as placenta previa or accreta in a subsequent pregnancy after prior CD is also on the rise. Placenta accreta, where the placenta embeds in the uterus in the location of the previous cesarean scar, has risen from 1 in 4000 pregnant women in 1970 to 1 in 533. Placenta accreta is a potentially catastrophic complication that can result in hemorrhage, hysterectomy and even death. Each CD increases the risk of this scary complication, and in the presence of placenta previa (placenta covering the cervix), the risk of accreta can be 40% or higher with three or more cesareans. Even so, many women undergoing ERCDs are never counseled regarding these risks or asked questions about potential family size in the planning for route of delivery. While the implication given to many women is that VBAC is more risky due to the chance of uterine rupture (less than 1% with spontaneous labor and one prior LTCD), the reality is that each route of delivery has its own risks and benefits. Women would be better served to be given information about the different risks for each clinical situation, in the context of her own individual maternal health and obstetric risk factors. Jessica Yancy had two prior cesareans: one for breech, and the second was “automatically scheduled” because her doctor implied that VBAC was illegal in Oklahoma, her home at the time. When she became pregnant with her third, her research led her to learn the risks of multiple cesareans and she began looking for a VBAC-supportive provider.

To help women navigate often complicated and conflicting information, Lamaze International published “A Woman’s Guide to VBAC” on their blog, Giving Birth With Confidence, which aimed to provide women with a side-by-side informational comparison guide between VBAC and ERCD. Other websites like www.VBAC.com and www.VBACfacts.com are helpful resources for women who are considering pursuing a trial of labor. Pregnant women are sought-after healthcare consumers and just as they might research buying a car, can find out about their state or hospital’s cesarean rate by visiting www.cesareanrates.com and www.leapfroggroup.org/patients/c-section. Women can also ask about their provider’s own cesarean rate.

The International Cesarean Awareness Network (ICAN) is an educational support group which advocates for informed birth choices for women who have undergone cesareans. In 2011, I was honored to present a lecture at ICAN’s “Gateway to a Better Birth” conference in St. Louis, entitled “The 3 P’s of VBAC, Pregnant Woman, Provider, Proviso: Navigating the Waters.” This talk outlined the importance of evaluating every woman interested in VBAC on a case-by-case basis of risk factor assessment by way of a thorough “VBAC evaluation,” and encouraging women to have the option of pursuing VBAC-friendly providers and facilities including OB hospitalists, midwives, and doulas. Optimizing maternal health before and during pregnancy is essential and well as providing quality prenatal care, support and education with the final goal of reducing unnecessary interventions in labor.

The keynote to the ICAN conference was given by Dr. George Macones, MFM and Chair of the OB/Gyn Dept at Washington University and author of multiple journal articles in the VBAC literature. His keynote was called “Talk with Your Feet” where he encouraged women to pursue the chance to VBAC by changing providers or hospitals if necessary. Five years later, I’m excited to report that due to the implementation of the VBAC evaluation model in conjunction with VBAC-supportive OB hospitalists, Katie, Margaret, and Jessica all went on to have successful VBACs. Several more women in my practice have had successful VBACs and 5 out of 6 women who attempted VBA2Cs were successful. Actually, one woman has now had two vaginal births since her two cesareans. The woman who did not achieve VBAC was at peace with the outcome (uncomplicated cesarean) because she knew she had taken the opportunity to try. In spite of these successes, the statistics show that we have so much more work to do to reduce the cesarean rate and encourage VBAC in those women who want it. Let’s help providers and hospitals become aware of the evidence-based support for VBAC so that many more women than currently are can explore this important option.

*All names and medical information are shared with the patients’ permission.

Poppy Daniels, MD is an obstetrician-gynecologist in private practice in Ozark, MO. You can follow her @drpoppyBHRT on Twitter. She also had successful VBACs after two cesareans. You can read her birth story here.

FREE Viewing of the Film ‘Trial of Labor’ for ICAN Members!

March 9, 2015 by info

Beginning on March 20, 2015, ICAN will be providing its members with a FREE viewing of the film Trial of Labor, directed and produced by Rob Humphreys and Dr. Elliot Berlin, until March 30th.

ICAN will also be hosting a number of screenings for the general public in select cities beginning in April.

Look out for details on public screenings coming soon.

Not a member of ICAN? Become a member before March 17th to access your free viewing! https://www.ican-online.org/join/

‘Trial of Labor’ follows a small group of pregnant women and their journeys back to trusting themselves and their bodies after previous births ended in unplanned surgery. Each woman has chosen to plan a vaginal birth after cesarean, and the uncertainty of their imminent births evokes in each a personal reckoning: finding a path through unresolved feelings and difficult decisions to the ultimate, unpredictable event of childbirth.

—Thank you for your generous support!—

Your membership will help us to fulfill our mission of improving maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery, and promoting Vaginal Birth After Cesarean (VBAC).

View the trailer below!