New VBAC recommendations from ACOG

In July 2004 the American College of Obstetricians and Gynecologists issued practice bulletin #54 - which changed the status quo for treatment of women with a history of prior cesarean.  The big change was that ACOG recommended that women attempting a vaginal birth after cesarean (VBAC) should labor with a "physician immediately available throughout active labor capable of monitoring labor and performing an emergency cesarean delivery."

The big word there was "immediately".  It appears exactly once in the practice bulletin but it is an important word.  It caused a string of practice changes for obstetricians, policy changes for hospitals and health outcome changes for pregnant women.  In short, the VBAC rate plummeted and hospitals demanded that women submit to surgery.

Yesterday, ACOG issued a new practice bulletin, #115, that they intend to replace the infamous bulletin #54.  This bulletin doesn't seem to remove the damning word (though I just read the press release, it costs $ to order the active bulletins).

This time the press release opens with, "Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans"


But it also uses the word "immediately" three times.  And while ACOG acknowledges that women should not be forced to submit to surgery in hospitals that do not have "immediately available" staff, they are rather vague about what an acceptable plan for these facilities would be for women undergoing a trial of labor after cesarean.  


I appreciate the more nuanced understanding that ACOG has demonstrated with this new practice bulletin.  Maybe they are beginning to recognize the serious impact these statements have on the care women receive across our country.  I certainly hope so.


However, this is not a situation in which the organization can simply say "Our bad" and undo all the damage that has been done by bulletin #54.  It would be nice if we could just "withdraw from circulation" (see here) the fear and ingrained policies and the lack of access that #54 has visited upon American women.  


We know that women who have given birth by cesarean are less likely to choose or achieve another pregnancy and that their subsequent pregnancies are subject to greater risks.  We know that the more cesareans a woman has, the more dangerous it is.  We know that #54 increased the number of cesareans that were performed on women.  We know that #54 was a mistake, and now ACOG has admitted it.


But admitting a mistake and even rectifying that mistake with a nuanced and understanding new practice bulletin doesn't undo the damage of that mistake.  #115 isn't going to be able to undo all the havoc #54 has wrecked upon American maternity care.


 We need a comprehensive approach to cesarean reduction, we need consumer education, targeted interventions for women with prior cesarean, policy reviews at hospitals, practice standards for physicians (set by the physicians themselves, I'm not trying to tell anyone how to practice medicine) and we need public access to cesarean data so that consumers can make truly informed decisions.  


#115 is a nice start, but it doesn't have the chops to undo what #54 has brought down upon us.  So thanks, ACOG, for a great start.  What else have you got for us?

Extreme morning sickness

This article came across my screen this evening as I'm re-adjusting to life at home.  It tells the story of a woman who had such severe morning sickness during her pregnancies that she decided to terminate her second pregnancy because of the health and personal problems it was creating.

What she had was not your usual morning sickness.  Hyperemesis Gravidarum is a condition that is more than inconvenient or uncomfortable.  It is a serious disruption to a woman's health and life.

In my experience with clients diagnosed with HG, the nausea can be debilitating and have a serious impact on a woman's health and life.  Women who experience HG in one pregnancy often have the condition again in subsequent pregnancies and sometimes it gets worse with each pregnancy.

One of the key factors in successful treatment of HG is early, agressive intervention.  Treatment with acceptable anti-nausea drugs, maintaining hydration and vitamin/electrolyte balances through IV if necessary and bedrest and hospitalization at the earliest appropriate time can keep HG from becoming so debilitating that a woman's health is at risk.

Whether or not these measures were available to Mrs. Harrison is unclear in this brief article.  For a public health doula, the article is a poignant story about one woman's suffering that leaves many questions unasked about how terminating her pregnancy became the necessary step.  What does the public health care system in the UK do to screen early pregnancies?  What knowledge of treatments did the doctors have?  Was Mrs. Harrison advised of the importance of early intervention with her subsequent pregnancy?  Were she and her husband and daughter supported at all with family leave and child care options while she dealt with a debilitating medical condition during pregnancy?

Anti-nausea medications are expensive, maybe they weren't covered by her health care.  I know that has been an issue for my clients in the past.  I have absolutely no doubts about Mr. and Mrs. Harrison's ability to decide for themselves to terminate the second pregnancy.  I just think it would be a shame if something could have been done for her health before it became so compromised that the best solution was to terminate the pregnancy.  And I applaud Mrs. Harrison for speaking up and sharing her experience.  The more women give voice to their experiences with pregnancy and abortion, the less shame and shadow we have surrounding these parts of our lives.  She's right when she suspects that other women have terminated for the same reason but have kept silent because of the taboo.

I've only just returned from a 9 day vacation with my family.  The experience was fantastic, and has left me re-energized and ready to hop back into my work life.  It won't be another 3 months before I post again, I promise!

Re-certified

I just finished my recertification paperwork for my Lamaze Childbirth Educator and DONA International Birth Doula certifications.  This is the 3rd time I've recertified as a DONA doula and my first official re-cert with Lamaze.  I was pleased with how easy it was to do online continuing educaiton through the Lamaze member center.  I took two ethics courses worth one CEU hour each and they actually took me less than an hour to complete while being interesting, educating and thought provoking.

Here's to another 3 years as a birth junkie.

Internal Consistency

Today I was had a wide-ranging and interesting conversation with a woman who runs a local emerging non-profit organization.  Though the conversation was organizational development-this and capacity building-that, I realized that my explanations of how I could help the board grow the organization sounded a lot like my conversations with expectant couples and how I can help them be strong advocates and educated consumers of health care.

Internal consistency, in statistics and research tools, is the ability of a tool to measure or demonstrate a value consistently throughout.  It means that if someone answers a question one way in one question, they will answer a later question in a way that supports their previous position.  

I don't advocate for people, I teach them to and support them in advocating for themselves.  I can't take the burden of labor away from a woman but I can support her in finding her own strength to labor as she will.  Similarly, when working with an emerging organization, I don't tell them how to grow and develop their missions and programs, I help them articulate their collective passion and vision.

I realized today, happily, that though my work as a doula, public health professional, and even as a temporarily home-schooling parent, looks fragmented and random, it is actually very internally consistent with who I am, what I enjoy and what I'm good at doing.

What a lovely way to start a day.

Retired military leaders and public health officials have something in common.

News today from Mission: Readiness, 75% of American youth are too out of shape [read: obese] to serve in the military.

From their press release:

"Declaring that escalating rates of child obesity pose a serious threat to national security, retired military leaders joined Sen. Richard Lugar (R-IN) and U.S. Secretary of Agriculture Tom Vilsack today in support of new child nutrition legislation to help reduce the obesity epidemic and expand the pool of healthy young adults available for military service."

I agree.  Our nation needs soldiers fit to defend our borders and our interests.  We also need a healthy enough population that we will be able to compete in the global marketplace, create art, serve on juries, and raise families.

If what speaks to policy makers and the average American is that we need better food policy in order to get better soldiers, then I am all over it.  Because they aren't wrong and the policies and cultural changes necessary to create healthier 17-24 year olds will also create healthier <17 and >24 year olds too.

Prepared foods need to be healthier, we need to be able to eat fast and convenient food without getting 300% the RDI of sodium.  Poor communities need access to fresh food.  School lunches need to be healthier.  Fast food joints should put calorie counts up with the prices.  We need physical education in schools and bike paths in cities.

These things will make more American's fit to serve in our armed forces (shout out to my little brother the vet!).  And if we are fit enough to serve in the military, then we'll be fit enough to stand up for ourselves in democracy as well.

Wow, has it really been almost a month since I posted last?  Spring breaks were tough on my professional productivity and things are just starting to creep back into controlled chaos.  Plus, I need to stop thinking that I need to write novels and term papers for my blog.  I'm a blogger who doesn't know how to whip out a post, which makes me either a lousy blogger or a very green one.  Time will tell...

Pseudo-live Blogging - Maternal morbidity elevator speech

What is the one thing I'd say to a woman on an elevator about her risks from cesarean delivery?

"Try really hard not to have a cesarean.  It can be very dangerous to your health."

A longer version - I'm really impressed with the data that are available about the risks of adverse outcomes for women after their first cesarean.  It is also shocking how much strong evidence there is about how dangerous the 2nd and 3rd and upward cesareans are.

Given what we know from these data, it seems clear that the lack of VBAC availability is not driven by concern for women's health outcomes.

A lot of the reasearch for this conference was compiled by OHSU's evidence-based practice center.  Go Oregon!

On with the webcast...

Pseudo-live Blogging - Cringe

I remember at the last NIH conference how hard it was for me to listen to my non-scientific birthing community colleagues rail at the deaf (or at least hard of hearing) ears of the researchers who had planned and were running the conference.  I'm cringing again while I watch the first participant comment opportunity.

It isn't that the researchers are bad guys (there that is again) it is just that they are dealing with the issues of VBAC in such a different way from the birthing community that they barely speak the same language, are barely talking about the same subject.

I wish there were more public health doulas & folks like my friend Judith (she was on the VBAC conference planning committee) who could advocate for women's rights in ways the researchers and scientists can understand.

Maybe after my kids go to college, I'll take that one on too.