For years I have cringed every time I ask a client what books she’s been reading in preparation for childbirth, and she happily chirps, “What to Expect When You’re Expecting!”  When I owned my birth center, I had a lending library.  I received so many questions about that book, that I finally bought a copy and marked it up with comments and post-it notes with rebuttals to erroneous and patronizing information presented inside, just so my clients wouldn’t waste their money buying their own copy!

Because of my long-standing disdain for this book, and my inability to to understand women’s affection for it, I dreamed that someday I would write a parody, with common-sense information for pregnancy that would help women to make informed choices that were best for them.

Recently, Jill at the Unnecesarean posted a blog that so closely reflected my thoughts on that book that I worried my ideas would seem like  plagiarism.  I loved her new title for the book, but wanted a title for my book that would reflect an attitude of NOT worrying about every little thing.  I tried different  ideas:

What To Expect When You’re Expecting

What To Fear When You’re Expecting

What to Obsess About When You’re Expecting

Nothing seemed just right.  Then I had it!  I would call my book:

“What Not To Expect When You’re Expecting”

I would discuss the various topics covered in that book, only from a common-sense approach, rather than a fear-based, “obey your doctor and don’t worry your pretty little head” approach.  I truly believe that if we women can put aside all the fear that has been instilled in us about childbirth, we have a pretty good intuitive sense of when things are going normally and when they’re not, even without that book to warn us about all the things that can, and almost surely will, go wrong.

So this is my introduction to a new series, one that I hope will dispel myths about pregnancy that persist despite evidence to the contrary.  I hope this series will be like a big sigh of relief, helping pregnant women to understand how amazing their bodies are, how seldom things really go wrong, and how often birth turns out right (when we let it).

I’m excited about ICAN’s blog carnival, “Why is VBAC a vital option?”  There are so many reasons that I long for change in the attitude of modern obstetrics toward VBAC, that it is difficult to decide which reasons to write about.  Since I’m sure there will be many bloggers writing about the abundance of good reasons for promoting and supporting VBAC, I’d like to approach the topic from the point of view of the provider.

As a midwife who attends VBAC births, I see a different side of the dilemma.  While women are rightfully angry about the difficulty in finding providers willing to attend VBACs, there are multiple problems facing providers who wish to continue attending VBACs:

1. Insurance issues:  many malpractice insurance companies will not even cover a provider who attends VBACs.  I worked with one female OB who was a strong proponent of VBACs, until her insurance carrier informed her she could no longer attend them, and if she did, her insurance would be dropped.  Without malpractice coverage, a provider cannot contract with Medicaid or most private insurance companies.  In today’s climate of health-care crisis, few providers can survive financially if they are unable to accept Medicaid or private insurance. 
2. Threat of lawsuits.  In my experience, this has actually been a lesser factor for most providers in deciding whether to attend VBACs.  However, it remains a consideration, particularly for women who are at higher risk of uterine rupture during a VBAC.  One lawsuit can render a provider uninsurable for the future.  This painful truth was detailed in midwife Peggy Vincent’s book, Baby Catcher.  Following a lawsuit in which she was named, even though she had only been on the sidelines for the birth, Ms. Vincent’s insurance company dropped her.  This is reality for many providers today, leaving them with the question:  Do I risk my ability to provide evidence-based obstetric care to many women in order to help one woman have the birth she wants?
3. Time contraints.  With the current requirement that the obstetrician/surgeon remain in the hospital during the entire VBAC labor, many providers simply cannot financially afford to offer this option.  Consider a typical scenario:  the obstetrician is called at 7 a.m. to be present for a VBAC labor.  The woman has not given birth vaginally before, and is 1 centimeter dilated.  If her labor progresses in an average fashion, the OB will not leave the hospital until late that night.  He will have to reschedule an entire day’s worth of patients, losing an entire day’s worth of income.  The woman’s insurance company, if they pay anything extra for VBAC (most do not), will only give him $200 more than the regular payment.  If he is one of the few doctors in his community who offer VBAC support, he will be inundated with women wanting VBACs, and can plan on regularly having to be out of the office for long periods of time.  Few obstetricians can survive financially with this sort of scenario, not to mention the personal time commitment it requires away from one’s family.

Unless the restrictions for permitting VBAC labor are revised, I believe we will gradually see the few remaining physicians who offer VBAC cease to offer this option; not because they don’t care, but because hospitals, insurance providers, and ACOG guidelines are making it too stressful, both financially and personally, for VBAC-friendly providers.

What is most perplexing to me is the mandate that the provider remain in the hospital during a VBAC labor “just in case”, yet other serious causes of perinatal morbidity and mortality are not considered adequate reason to have a surgeon and operating tem standing by.  Some examples are:

1. Cord prolapse, with an incidence of 0.14-0.62 percent.  This can cause permanent fetal injury or death.¹
2. Placental abruption, with an incidence of 0.6 percent.  Again, this complication of labor can cause permanent fetal injury or death, as well as potentially life-threatening blood loss for the mother.²
3. Placenta accreta, and its variations (placenta increta and placenta percreta).  With a reported incidence of as many as 1 in 533 births, this is a serious maternal complication which can cause death.³

 If we are serious about being able to take immediate action in the event of uterine rupture (approximately 0.5% incidence in low-risk labors VBAC labors), we should be equally serious about being prepared to immediately manage other perinatal emergencies.   The truth is, VBAC is not much riskier than a normal first birth, provided a few criteria are met:

• One low transverse uterine scar
• Normal onset of labor, no cervical ripening or induction
• No use of pitocin augmentation during labor
• Prior vaginal delivery increases chances of successful VBAC
• At least 18 months since cesarean birth

The Northern New England Perinatal Quality Improvement Project has proposed ranking VBAC risk according to low, moderate, and high-risk factors, and planning the level of provider attendance required based on the risk factors.  A low risk woman would be managed differently than one at high risk of uterine rupture.  Their document, Birth Choices After Cesarean, lays the groundwork for what should become standard procedure in all US hospitals. 

It is imperative that providers of modern obstetrics speak up on behalf of women who want VBAC and insist that realistic, evidence-based guidelines are instituted: guidelines that support freedom of choice in childbirth; guidelines that do not discriminate against VBAC while ignoring equally serious risks of other birth complications; and guidelines which make it financially and personally feasible for providers to offer VBAC.  One consideration might be the laborist, a physician who is in the hospital 24/7, immediately available if surgery is needed, and thus frees the OB provider to manage a VBAC labor just like any other labor.   

Ultimately, it must be realized that women must be offered the freedom to birth the way they want, and receive support to do so.  Providers have a large role to play in speaking up to demand these freedoms for women.

1.   Belogolovkin V, Bush M, Eddleman K.  Umbilical cord prolapse.  give Retrieved 03/03/10 from: http://www.uptodate.com/patients/content/topic.do?topicKey=labordel/2191

2.  Ananth CV, Wilcox AJ.  Placental abruption and perinatal mortality in the United States.  American Journal of Epidemiology Vol. 153, No. 4 : 332-337.  Retrieved 03/03/10 from:   http://www.google.com/#hl=en&source=hp&q=incidence+of+abruptio+placenta&aq=f&aqi=&aql=&oq=&fp=db64f927cfe7b756

3.  Resnick R.  Diagnosis and management of placenta accreta.  Retrieved 03/03/10 from:  http://www.utdol.com/patients/content/topic.do?topicKey=~iuuj5_1.hHBKd1m

Many women in my practice are confused about fetal kick counts.  Some have been told they need to do kick counts every day, as soon as they can feel the baby move.  Others have been told that if they don’t feel a certain number of movements in a two-hour period, to call their provider.  The number of movements varies–I’ve had women tell me they were supposed to feel anywhere from ten movements in a day to ten movements in an hour!  If anything gets a pregnant woman stressed out, it’s worrying about too little fetal movement. 

Many factors can contribute to fetal movement and perception of movement.  Some of these are:

• Position of the placenta.  If it’s toward your stomach, you essentially have a two or three-inch thick “cushion” between you and the baby.  This will delay your perception of fetal movement and may make the movements less noticable.
• Your level of activity.  Very physically active women often do not perceive fetal movement as much as sedentary women.
• Your body mass index (BMI).  If you have a higher BMI, perception of movement may be diminished.
• The baby’s position and size.

 After looking at the value of kick counts in a study of 65,o00 women, Tviet¹ concluded that unexpected fetal losses after 37 weeks of pregnancy were decreased by 33% when women were instructed in a standardized method of fetal kick counts, and a routine response to reports of decreased fetal movement was instituted. 

If a woman reported decreased fetal movement, she was asked to come into the office for a non-stress test (an extended period of observing the fetal heart rate on a fetal monitor) and an ultrasound.  While this method reduced the number of late pregnancy losses, it also increased the number of interventions, and the author admits that a fair percentage of the interventions were probably unnecessary.  It simply is not possible to always know which babies truly need help and which are doing OK, thus we err on the side of caution.

Many women get very stressed about fetal kick counts.  All babies go through periods of time when they are quiet, or sleeping.  Mothers can be concerned during these periods with how to differentiate between a normal sleep cycle, and a baby who is not moving normally.

When a mother calls to tell me she isn’t feeling her baby move normally, I ask her how far along she is.  If she is early enough in her pregnancy that she is just starting to feel fetal movement, it is too soon to worry about kick counts.  So let’s suppose you are 30 weeks pregnant, and you haven’t felt the baby move much today.  What should you do?

• Drink something sugary–juice or a soda.  Low blood sugar can make baby sluggish.
• Lie down on your left side.  It’s OK to gently move the baby to stimulate kicks.
• Get an alarm clock (the old-fashioned kind with the irritating bells is terrific) and place it against your belly, right where you think the baby’s head is.  Let the alarm go off.  One study found that this procedure was just as accurate as a non-stress test in predicting fetal well-being.²  You should feel movement after the alarm goes off.  If you don’t have a loud alarm clock, try a loud radio, or anything else that makes a loud noise.
• If you have tried all these things and have not gotten a response, do call your provider for further investigation.

When and how should regular kick counts be done?  By the time you are 28 weeks, baby is big enough to begin kick counts.  You should also have an idea of baby’s “busy” times throughout the day.  Most women report that the baby is active early in the morning and at bedtime.  Let’s take a common-sense approach to this: if someone was observing you during your time of deepest sleep, would they see much activity?  Of course not.  Your baby is not going to be terribly active during his or her sleepy times.  Count the kicks during baby’s “busy” times.  Some babies are more active than others; as a veteran of seven pregnancies, I can attest to that fact!  Consider whether your baby is moving normally during his/her busy time, as s/he typically does.  If there is a change in what is normal for your baby, talk to your provider. 

1.  Tveit JVH,Saastad E,Stray-Pedersen B, et al. Reduction of late stillbirth with the introduction of fetal movement information and guidelines—a clinical quality improvement. BMC Pregnancy Childbirth. 2009;9:32. 

2.  Brezinka C, Lechner T, Stephan K, Pfeiffer K.  Vibroacoustic stimulation of the fetus using a conventional mechanical alarm clock.  Journal of Maternal Fetal Investigation. 1998 Dec;8(4):172-177.

Preterm contractions are one of the most difficult situations for a pregnant woman to cope with.  First, is the stress of wondering if the contractions are labor contractions, uterine irritability, or just Braxton Hicks contractions.  Second, we know that preterm contractions are overtreated in the United States, yet we don’t have really good tools for determining when treatment is necessary and when it is not.  Third, none of our interventions for preterm contractions–with the exception of steroids to mature the baby’s lungs–has really been proven effective.  It is a frustrating situation for both mother and provider.

Many women will have preterm contractions–also called Braxton Hicks contractions–which can be frequent and regular for periods of time.  Keep in mind that while most preterm contractions do not lead to premature labor and birth, it is unwise to simply ignore them until you know that they are not leading to labor.  This does not mean, however, that you need to rush to the hospital with the first contractions you feel.  Some steps you can take when you experience contractions prior to 37 weeks of pregnancy:

1.  The vast majority of the time, contractions that are causing cervical dilation will be regular, 10 minutes or less apart, and progressively getting stronger and lasting longer.  They may be felt in the back, lower abdomen, or occasionally in the thighs.  While many women will experience regular Braxton-Hicks contractions which may be close together, they do not get progressively stronger and longer, as real labor contractions do.  If you are feeling contractions, change your activity for a half hour and see if the contractions change, too.  If you have been active and on your feet, lie down or take a warm bath.  If you’ve been lying down, get up and move around a little, or sit in a comfortable chair for a while.

2.  Drinking a large glass of water may help if you are dehydrated.

3.  A warm bath or shower can relax contractions.

Real labor contractions are rarely stopped by any of these measures.  So if you think it’s the real thing, what types of intervention might you expect at the hospital?

1.  IV fluids:  these are fairly routine, even though the Cochrane Review states that IV fluids are not beneficial in stopping labor unless the woman is dehydrated.¹

2.  A fetal fibronection test (FFN) and vaginal cultures for bacterial vaginosis and group B strep.  The Cochrane Review did not find the FFN to be beneficial in predicting/preventing  preterm labor², nor did they find treatment of bacterial vaginosis to prevent preterm labor.³  Another review, however, indicated that screening and treatment of lower genital tract infection may be helpful in prevention and preterm labor.4 

3.  Tocolytics will likely be given.  Tocolytics are drugs that relax the muscle of the uterus, calming preterm contractions.  The Cochrane Review states that there is not evidence supporting the benefit of tocolytics beyond the first 48 hours of preterm labor.  The benefit of using them in the first 48 hours is allowing time to administer corticosteroid medication to the mother in order to mature the baby’s lungs, an evidence-based beneficial intervention.5  Tocolytics have all been shown to have potential adverse side effects to both mother and baby, but continue to be routinely used, simply because we don’t have any better treatment at this time. 

4.  The mother will likely be placed on bedrest.  This is not an evidence-based intervention.  Most providers continue to use it in order to “feel like we’re doing everything we can”.  In other words, it’s more of a liability protection, rather than something that will truly benefit mother and baby.  Yes, most women will experience more contractions when they are moving around, but contractions triggered by activity are most often Braxton Hicks contractions.  Bedrest has not been shown to prevent true preterm labor from occuring.

5.  If preterm labor is due to a problem with shortening/dilating of the cervix too soon, a purse-string type of stitch can be placed in the cervix, tying it closed.  This is done under anesthetic and has been shown to be beneficial in preventing preterm labor, but only in cases which were caused by what is termed “incompetent cervix”.  This term refers to a cervix which thins out and then dilates, often painlessly, prematurely.

What then, can be done to preserve the normal process of labor and birth if one is experiencing contractions?  I would recommend the following steps, if you have not experienced a premature birth before:

1.  After following the suggestions above, changing activity, drinking water, etc., if contractions are continuing to be regular and noticeably stronger and lasting longer, call your provider.

2.  At the hospital, there should be no need for IV fluids unless you are dehydrated and unable to drink water.

3.  Before accepting treatment with tocolytics, ask for two cervical exams one to two hours apart, and performed by the same person.  Preterm labor cannot be diagnosed in the absence of cervical change.  If your cervix is not dilating,  you are not in labor, regardless of how many contractions you are feeling.

4.  If you do have cervical change, or if your first cervical exam indicates premature changes, tocolysis for the first 48 hours is evidence based.  A popular tocolytic, Terbutaline, probably has more perceptible side effects for the mother than Nifedipine, which is also used for tocolysis.  If I were in premature labor, I would prefer to take Nifedipine first before using Terbutaline.

5.  Accept two injections of betamethasone, 24 hours apart.  This has been shown to improve outcomes for infants born early. 

6.  Bedrest has not been shown to improve outcomes or halt premature labor.  A reasonable amount of rest is desirable, but you should be able to have light activity.

7.  After 48 hours, consider discontinuing tocolytics, even if you have contractions when you stop them.  Many, many women have taken tocolytics until their 36th week of pregancy, only to go overdue in their pregnancy.  This indicates that many women are taking tocolytics unnecessarily, while running the risk of the side effects that can go with them.  Have your provider monitor your cervix periodically for changes, and as long as your cervix is not changing prematurely, you don’t have to worry about contractions.  A partner may also be taught how to check the cervix in the case of a woman who has lots of contractions.  Cervical exams should not be performed without discretion, however, as they can trigger contractions if not done very gently.

8.  If you do have premature labor and birth, there is no evidence that c-section is better than vaginal delivery for a premature baby.  There is strong evidence that the premature infant is benefited by delayed cord clamping.  Talk with your provider early in the process, requesting this be done for your baby.

9.  While not often practiced in the United States, Kangaroo Mother Care is a marvelous way of humanizing preterm birth and neonatal care.  While most neonatal intensive care units do not allow touching or physical handling of the premature infant, Kangaroo Mother Care has shown benefit from skin-to-skin contact with even micro-premies (the very smallest babies).  I encourage you to visit their website and read their stories and evidence for this practice.  Being aware of this information ahead of time will empower you to be able to advocate for yourself and your baby.

Frequent contractions which are not changing the cervix can be uncomfortable, annoying, and frustrating for the woman experiencing them.  One remedy I have found effective is WishGarden Herbs Welcome Womb, an herbal tincture designed to calm an “irritable” uterus.  In addition to the tincture, resting when you can and keeping a positive attitude are helpful in getting you through those difficult days or weeks.

1.  Intravenous fluids for treatment of preterm labor. Retrieved 02/25/2010 from:  http://www.cochrane.org/reviews/en/ab003096.html

2.  Fetal fibronectin testing for reducing risk of preterm birth.  Retrieved 02/25/2010 from:  http://www.cochrane.org/reviews/en/ab006843.html

3.  Antibiotics for treating bacterial vaginosis in pregnancy.  Retrieved 02/25/2010 from:  http://www.cochrane.org/reviews/en/ab000262.html

4.  Antenatal lower genital tract infection screening and treatment programs for preventing preterm delivery.  Retrieved 02/25/2010 from:  http://www.cochrane.org/reviews/en/ab006178.html

5.  Antenatal corticosteroids for maturing fetal lungs.  Retrieved 02/25/2010 from:  http://www.cochrane.org/reviews/en/ab004454.html

A recent comment on a past post, Are Women Who Choose Home Birth Control Freaks?, got me to thinking.  The reader wrote:

Actually, having met one [a home-birthing control freak] myself, I’d have to say a loud and resounding, YES! Not only that, but selfish as well. For as many women that have had a ’successful’ homebirth, I’ve met just as many who’ve ended up with stillborns or major health complications themselves. Whatever happened to healthy mom AND baby being the desired end? If that means ‘intervention’ or ‘hospital assistance,’ so be it! This is not the place to play out our power trips. Save that for the olympics. This is about LIFE.

My response:

I am interested to learn more about your experiences, because they are very different from mine.  I am not against intervention at all.  It is lifesaving when used appropriately, and potentially life-threatening when used without reason or thought.  In the nearly thirty years I have worked in labor and delivery units, I have observed that it is most often the physician or the nurses who are on the power trip, unwilling to accomodate any request that doesn’t fit into their “routine”.   As a young nurse working in labor and delivery, I became convinced that home birth was the safest and best place for me to birth my precious baby.  It wasn’t about me, it was about keeping my baby safe from many of the things I saw happening in the labor ward, which since that time have been shown by scientific evidence to lack benefit or be actually harmful.  The interventions that were commonly used, and which I felt compelled to avoid, included:

• The “triple-H” enema.  The triple-H part stood for “high, hot, and a hell of a lot”.  The nurse filled a 1 liter bucket with hot, soapy water.  The enema tube was inserted into the rectum of the laboring woman, and the bucket is held high in order to force the fluid to run in rapidly under pressure.  The soap irritates the bowel and causes a laxative effect.  The woman was instructed to “hold” the fluid for at least 15 minutes before she was allowed to go the bathroom and expel it.  The stimulation of the intestines by the hot water and the laxative effect caused intense cramping and increased contractions.
• Routine episiotomy.  Everyone got one, whether they needed it or not.  See my post on routine episiotomy for the story of a horrifying episiotomy I witnessed being performed on a woman after her baby was born.
• Separation of the woman and her partner.  Men could not be present during the birth, because they would either faint or they would be unable to enjoy sex with their wives again after watching her give birth.
• Amnesia-inducing drugs.  The women were not given pain relief, they were given a drug that would make them forget the pain they suffered.
• Forced labor on one’s back.  Women were not allowed to get up and move around during labor. 
• No food or fluids by mouth during labor, and forced IV fluids.
• Routine amniotomy for everyone.
• Patients were required to have their babies in the delivery room, an operating-room style room where the woman would be moved once the baby was crowning.  Even with the baby crowning, she was expected to move from her guerney to the delivery table, where she was positioned flat on her back with feet hanging from high stirrups and hands strapped down to the side of the table.
• Frequent use of forceps, including high-forceps deliveries of babies, which are now known to be extremely risky.
• Mandatory separation of infant from mother for the first 12 hours after birth.  All babies were given sugar water for their first feeding by mouth, before they were permitted to breastfeed.  Babies were not allowed to “room-in”. 

The home birthing women I have met and served have not been selfish; rather they were seeking to protect their babies from the potential harm that is done by unnecessary and mindless interventions.  Although many of the practices noted above are no longer commonly used, other rouine obstetric practices, just as harmful, have taken their place.  

 Your experience sounds very different from mine.  You mention meeting women (plural) who have had stillbirths or maternal complications resulting from home birth.  I would invite you to share your experiences with Birth Sense readers.  What were the circumstances of their adverse outcomes?  Did they have a trained professional assisting at their births? Were they low-risk pregnancies?  How were their labors being monitored, and what were the protocols for transferring to hospital care?  These are the factors that are generally mentioned when discussing home birth safety. 

The bottom line is not what my experiences have been, or your experiences, but what the evidence says.  I believe there is more evidence of home birth safety than home birth risks, when it is undertaken by low-risk women with normal pregnancies.  For a thorough list of the known research on home birth, see the American College of Nurse Midwives Home Birth Bibliography page.