Breech Presentation...What? Why? How?

A baby in "breech" position is basically considered an automatic cesarean, at least in the United States. Many doctors are no longer trained in breech deliveries, and so the immediate conclusion that they come to is that mom will need major abdominal surgery due to their lack of training. It is what it is, right?

Wrong.


What is Breech?

• Frank Breech, which tends to be the most favorable. This is when baby’s bottom presents first and feet are by the head.
• Footling Breech is when baby has one or both feet presenting first.
• Complete Breech is when your baby is comfy sitting cross legged.

Why won’t my doctor do a vaginal breech birth?
This could be due to a variety of reasons:

• They may not have a lot of experience attending vaginal breech births.
• May not feel comfortable attending vaginal breech births.
  
• May have had a bad experience in the past.
  
• There may not be suitable back-up at the hospital where they practice (on call anesthetists, pediatricians, experienced midwives, 24 hour operating room staff).
  
• They may not believe in vaginal breech birth.
  
• Defensive practice in current childbirth culture means that doctors are more likely to err on the side of intervention (cesarean section) rather than non-intervention (vaginal birth).
  
• It is easier for a doctor to perform a cesarean section than a skilled vaginal breech birth.
  
• Cesarean is an accepted birth method in today’s culture.

How should I approach my child's breech position?
*Do nothing.
Depending how many weeks pregnant you are, you may decide just to wait for your baby to turn. The majority of babies turn spontaneously pre-term.

*Non-medical turning
Alternatively, there are various non-medical turning techniques you can try.  You can read more on Spinning Babies. 
 
*Look for a care-provider who will support you in whatever option you choose
Many maternity care-providers do not support vaginal breech birth and will advise a planned cesarean section at 38 or 39 weeks if your baby does not turn.  This is partly because most obstetricians and midwives do not possess skills in vaginal breech birth and so they are unable to offer this option safely. However, depending on various maternal and fetal factors, vaginal breech birth is not necessarily any riskier than cesarean section, particularly with the support of an experienced attendant. 

Before 37 weeks of pregnancy, breech presentation is much more common - about 20% of babies at 28 weeks are breech, and 15% at 32 weeks. Before term, which is defined as 37 weeks, it doesn't matter if the baby is breech, as there is always a good chance that she will turn spontaneously. Some babies do turn by themselves after this time, but it is much less likely, and some preparations should be made to decide how delivery is going to take place. About 10% to 15% of breech babies are discovered for the first time late in labor!


Very soon, I will post two guest birth stories. One of these stories is from Felicia, who had a cookie-cutter, non-complicated pregnancy but was forced into cesarean delivery solely due to a breech presentation. The second is from Kristel, whose daughter came out booty-first at home in the water. These ladies are examples of how having supportive care providers can make the difference between the birth experience you want and the experience that is forced upon you.

Further Reading:
Spinning Babies 
The Webster Technique
Breech Decision Making Sheet

UPDATE: Please click HERE for the Breech Babies tab, so you can read the birth stories mentioned above and any other resources on this site regarding breech babies.



Sources: 1, 2, 3, 4

Factors for VBAC success, Part 1/2

In this post, I will discuss why each of the following factors are important in VBAC success:

*reasons for previous c-sections
*arriving at the hospital as late into labor as possible
*not having continuous fetal monitoring
*epidural as late as possible into the labor, if at all
*no induction or acceleration
*previous vaginal birth

*Reasons for previous cesareans
If previous cesareans happened because of something unlikely to reoccur, like the baby being breech (which is a whole other topic, and I will be featuring both facts on breech babies and a couple of guest post on the topic next month), you have a pretty good chance of a successful VBAC. Something like CPD (a medical condition where one's pelvis is actually too small to allow a baby to pass) can make a VBAC more difficult, but it is still not impossible. According to The VBAC Handbook, as many as 2/3 of women with CPD that attempt VBACs are successful!

*Arriving at the hospital as late into labor as possible
The reason for this is simple. The longer you labor at home, the less opportunity the hospital/doctors/nurses have to "help" you with a cascade of interventions that could just lead to a RCS.

*Not having continuous fetal monitoring
Continuous monitoring restricts your mobility, which is a huge problem because being able to move around in labor is a necessity to help labor progress. You might also experience more pain/discomfort constantly laying on your back because you're stuck in bed, hooked up to a monitor. 15 minutes an hour is more than sufficient to give care providers an idea of how baby is doing, and then momma can focus the other 45 minutes of the hour on LABORING how she's most comfortable. Another reason to avoid monitoring if you can help it is that results are often misread, which leads to more cesareans unnecessarily.

*Epidural as late as possible into the labor, if at all
Epidurals usually require continuous fetal monitoring so that the laboring moms lowered blood pressure (a side effect of the epidural) can be checked regularly, along with it's effect on the baby. Because you don't want CFM (see above), you should wait as late as you can to get the epidural, if you get one at all. Epidurals have also been shown to stall labor.

*No induction or acceleration
Any sort of induction or acceleration of labor, including artificial rupture of membranes (AROM, or having your water broken) can raise the risk of the previous cesarean scar "unzipping". Some doctors might want to administer pitocin once a labor really gets going to speed things up, but be aware of the risks before you consent to ANY sort of augmentation!!!

*Previous vaginal birth
If you have had a vaginal birth before your cesarean, you are likelier to have a successful VBAC. You are also likelier to have a successful VBAC if you've already had a VBAC! Crazy, huh? ;) Not much help for mommas like me, that had an unnecesarean right out of the gate, but perhaps good news for other mommas out there!


The next post will finish up the list of factors and the reasons behind them. I'd love to hear your thoughts on the list so far!

"Once a C-section, ALWAYS a C-section"

Is there any truth to this common misconception about labor and delivery?

In short, no. And here's why:

Routine "Repeat Cesarean Section" (RCS) came into practice in the early 1900s because back then. cesareans were done in a vertical cut. This cut is much more prone to rupture, so cesareans became the norm for every mother who had already previously delivered by cesarean in order to prevent rupture during labor.

Today, most c-sections are done with a "bikini-cut", which is a low, horizontal cut on or along the bikini line. It is much less vulnerable to rupture or "unsealing" during labor. The World Health Organization actually declared over 20 years ago that "there is no evidence that cesareans are required after a previous transverse low segment c-section cut".

So what is your option after a cesarean, if not another? Certainly, there is a time and place for RCS, but usually, a safer alternative is VBAC, or Vaginal Birth after Cesarean.

Success of VBAC depends upon:
*reasons for previous c-sections
*arriving at the hospital as late into labor as possible
*not having continuous fetal monitoring
*epidural as late as possible into the labor, if at all
*no induction or acceleration
*previous vaginal birth
*being able to eat, drink and move in labor
*no time restraints
*good relationship with your care providers
and
*the use of midwives



In the next two posts, I will go deeper into the success factors listed above so there is a better understanding of each and why they are important for the success of a VBAC.

Vaccinations...

Something to consider...there's "on schedule", "delayed schedule" and "non vax" parents, but everyone has to do their research and follow their instincts when it comes to vaccinating their children.

It's a hot topic, which is way I try (and I mean try, though I think it's usually obvious where I lean personally) to encourage parents to really research ingredients, possible side effects, etc before taking a course of action. The most important thing though is of you're not 100% certain where you stand, WAIT. You can always start vaccinating later but you can't take it back if you do it and then decide its not the best choice for your family.

I leave you with this graphic from the Facebook group "Educate before you Vaccinate"...believe it or don't, but hopefully it at least piques your curiosity enough to look into it for yourself :)

Gestational Diabetes - What is it? (1/3)

This will be one of a three part series I'm doing on gestational diabetes. It seems to a be a topic that has been coming up a lot lately in the forums/groups I belong to, and what I'm finding is that a lot of women are being told they have it or being threatened that they will develop it, but no one is really receiving proper information regarding what it is, how it's diagnosed or how to treat it.

What is Gestational Diabetes?

According to the American Diabetes Association: "Pregnant women who have never had diabetes before but who have high blood glucose (sugar) levels during pregnancy are said to have gestational diabetes. Based on recently announced diagnostic criteria for gestational diabetes, it is estimated that gestational diabetes affects 18% of pregnancies."

Basically, your growing baby needs glucose to grow. Your body errs on the side of "too much" rather than "too little" so the baby doesn't go without. As the placenta grows, the hormones it creates may interfere with your body's processing of all that glucose. This is why testing tends to be done later in the pregnancy (if no other risk factors exist) because the placenta is larger as the pregnancy progresses.

Non-Caucasian women, and women that are overweight pre-pregnancy, are likelier to develop Gestational Diabetes.You are also likelier to develop it if there is a history of diabetes, gestational or otherwise, in your family. Granted, it's not to say you WILL develop GD if you fall into any (or all) of these categories, your chances are simply greater.

Some of the risks of having Gestational Diabetes are macrosomia (baby growing too large), which could mean a broken clavicle or collarbone upon vaginal delivery, among other complications. This is why doctors are quick to induce as early as 39 weeks when the diagnosis for GD is present, or even elective c-section.

AGAIN, let me be clear...the doctor will be quick to suggest (or even insist) upon these interventions, but they may not be necessary. Also, ultrasounds are not, have never been, and are not meant for measuring your baby, and they are usually off by 1-2 pounds either way, so don't be alarmed if the doctor decides your baby weighs 10 pounds solely based on ultrasound...but that's another topic for another post.

Women that have had GD are likelier to develop Type 2 Diabetes later in life, but many of these cases are because the women studied may have had undiagnosed Type 2 Diabetes before pregnancy, and GD may not have been a factor.

Most of the time, GD can be kept under control by diet and exercise, and only in extreme cases will an insulin regimen be needed...so please, do not worry right off the bat that you will need to inject yourself several times a day until you've spoken to a specialist about the severity of your case! Stressing about it will do no one any good, though I know that is easier said than done.


On the next post, I will write about information, evidence and resources surrounding testing for Gestational Diabetes and how it is diagnosed. The last post in the series will be about treatment options. I'll also talk about my own borderline GD diagnosis during my pregnancy and what I went through as far as testing and treatment. If anyone would like to share their GD experience, whether just the testing or actual treatment if you were diagnosed, please email or comment. Also, please let me know if you have any specific questions and I will try to answer them in an upcoming post or at least point you to resources that can help.

Circumcision: opinions, facts, and a rebuttal.

I just ran across this article today, and I have to say it really fired me up. Every person is entitled to their opinion and every parent of a son has a choice to make regarding their foreskin. I firmly believe that like religion and all sorts of other things, there are certain choices that should be my son's and his alone, and I would be doing him a disservice by taking such choices away from him.

That being said, I feel that because a lot of controversy swirls around circumcision, so do a lot of misconceptions. So I wanted to break down the reasoning the author uses in her article FOR circumcision, and offer some alternative views. The original authors views are in italics.

"First and foremost, we knew we wanted it done for hygiene reasons. It's so much harder to keep that area clean if the procedure isn't performed -- and we believed it would leave him more prone to infection if he was not circumcised."

"In babies, the foreskin is completely fused to the head of the penis. The infant foreskin is perfectly designed to protect the head of the penis and keep feces out.  All you have to do is wipe the outside of the penis like a finger.  It is harder to keep circumcised baby's penis clean because you have to carefully clean around the wound, make sure no feces got into the wound, and apply ointment." - Psychology Today.

The foreskin retracts on its own throughout childhood, at which point the child should be taught to pull the skin back and wash like any other part of his body with water and mild soap.


"Second, and I really don't care how stupid or cliche this sounds, we didn't want him to get teased in the high school locker room because he was the only boy who hadn't been circumcised.......And there was no way I was going to let my kid be the dude with the weird looking penis."

 I think this is the part of the article that most burned me. Firstly, you're putting your child through a potentially dangerous procedure for the sake of fitting in. Secondly, at the rate circumcision is dropping in the country, it's a possibility that a circumcised male may be in the minority by the time the authors son is in high school. Lastly, and I feel most importantly, the last sentence in the paragraph is the kind of thinking that leads to bullying. The fact that she's even throwing out there that someone may have a "weird looking penis" and that it's reason to be potentially made fun of only teaches that "we should make fun of whoever looks different to us". Not the parenting style I personally adhere to.


"Lastly, we worried about how being uncircumcised might affect his sex life down the road......I know I'd want to hop out of bed and run if I saw all that extra skin staring back at me."

Once again, she closes the paragraph with a really judgmental-based-on-looks sentiment that really irks me and only perpetuates stigmatizing intact genitalia. Also, here's something to consider about your circumcised son's future sex life: a study in Belgium found that there is less sexual satisfaction and sensation in circumcised penises (so intact men have better sex, according to the study).  Yet another study shows, quote "circumcised men have more difficulties reaching orgasm, and their female partners experience more vaginal pains and an inferior sex life".  And lastly, here's a big one: "Researchers surveyed 300 men and found that circumcised fellas had a 4.5 times greater chance of suffering from ED than noncircumcised guys." That's Erectile Dysfunction, if you weren't sure.



So, again, every parent has to make their own choice regarding the topic of circumcision, but in case any of these misconceptions were your "deal breaker", maybe it's time to do some more researching and soul searching before committing to something permanent and irreversible for your child. I can see how it may not be an easy choice and there's definitely a lot to consider. I just couldn't believe the stuff the original author was throwing out as fact, so I felt like I NEEDED to do something showing that actually, all the reasons she used to make her choice were misconceptions at best, and that if any of those three things are something that weigh on your choice, that there's actually evidence to the contrary. Some people may still choose to do it for religious purposes, or so baby looks like Daddy, etc. I say as long as you really research extensively and you can come to a decision that sits well in your heart, then you've done your best as a parent and no one can ask more of you than that.

Thoughts on why you did or didn't choose to circumcise your son(s)?

VBAC vs RCS risks

VBAC vs Repeat CS Risks as presented by iCAN

VBAC or Repeat Cesarean
What is safe? What are my options?
If you have had a cesarean delivery and are planning another birth you have to make a decision to have a Vaginal Birth after Cesarean (VBAC) or a Repeat Cesarean Section (RCS).  This can be a hard decision with all the misleading information out there on both topics.  Lets look at some of the facts.
VBAC (Vaginal Birth after Cesarean)
The biggest concern with VBAC among women is uterine rupture. Permitting labor to begin naturally with a low transverse scar ("bikini cut") VBAC after one previous cesarean carries a risk 0.4% of uterine rupture with an increase in an augmented or induced labor. (Landon, 2004)  Successful VBAC's have lower complication rates than planned RCS which have lower complications than a "failed" VBAC. (Landon, 2004)
VBAC is a safe and appropriate choice for most women with one prior cesarean and for some women with two prior cesareans according to ACOG, 2010.
"the chance that a VBAC candidate will require emergency surgery, is for all practical purposes, no higher than that of any other pregnant woman" and "the risk of VBAC is not substantially greater than the risk of any type of childbirth" (Bruce Flamm, MD, Birth after Cesarean)
VBAMC (Vaginal Birth after Multiple Cesareans)
Here is a link to a study done in 2006 by Landon, Risks of Uterine Rupture with a Trial of Labor in Women with Multiple and Single Prior Cesarean Delivery.
The study of 975 women with multiple previous cesareans found a rupture rate of 0.9%. They also showed VBA2C within two years of a previous cesarean delivery to have a 1.1% rupture rate. Not nearly as high as many doctors tell you. Those risks are still lower than those risks of a 3rd cesarean.
Landon concludes, Vaginal birth after multiple cesarean deliveries should remain an option for eligible women.
Overall trial-of-labor success rates were 73%Single prior cesarean delivery success rate of 74%Multiple prior cesarean deliveries success rate of 66%Two prior cesarean deliveries success rate of 67%Three prior cesarean deliveries success rate of 55%
Cesarean
When a cesarean is necessary it can be a life saving procedure for mother and baby.10 true reasons for a Cesarean
Cesarean Risks include placenta accreta, hysterectomy, blood transfusion, ICU admission, which increases with each surgery and uterine rupture. Whereas with successful VBAC uterine rupture and other labor related complications decrease significantly.
The risks associated with RCS increase with each cesarean performed.
Maternal death is very low with each option: 0.02% with VBAC and 0.04% with RCS. (Landon, 2004)

Make an informed choice about the risks of Repeat Cesareans vs. VBAC's
1st C-section Risk of hysterectomy: 0.65%Risk of blood transfusion: 4.05%Risk of placenta accreta: 0.24%
2nd C-section 1st VBAC Risk of major complications: 4.3% Chance of successful VBAC: 63.3% Risk of placenta accreta: 0.31% Risk of uterine rupture: 0.87% Risk of hysterectomy: 0.42% Risk of hysterectomy: 0.23% Risk of blood transfusion: 1.53% Risk of blood transfusion: 1.89% Risk of dense adhesions: 21.6%
3rd C-section 2nd VBAC Risk of major complications: 7.5% Chance of successful VBAC: 87.6% Risk of placenta accreta: 0.57% Risk of uterine rupture: 0.45% Risk of hysterectomy: 0.9% Risk of hysterectomy: 0.17% Risk of blood transfusion: 2.26% Risk of blood transfusion: 1.24% Risk of dense adhesion's: 32.2%
4th C-section 3rd VBAC Risk of major complications: 12.5% Chance of successful VBAC: 90.9% Risk of placenta accreta: 2.13% Risk of uterine rupture: 0.38% Risk of hysterectomy: 2.41% Risk of hysterectomy: 0.06% Risk of blood transfusion: 3.65% Risk of blood transfusion: 0.99% Risk of dense adhesion's: 42.2% NOTE: "Major complications" include one or more of the following: uterine rupture, hysterectomy, additional surgery due to hemorrhage, injury to the bladder or bowel, thromboembolism, and/or excessive blood loss.
All VBAC stats for this chart are taken from the Mercer and Gilbert study, 2008 which includes induced and augmented labors. Additional studies have shown lower uterine rupture rates (especially with spontaneous labors) and higher VBAC success rates with non augmented or induced labors.

According to the World Health Organization (WHO) Countries with some of the lowest perinatal mortality rates in the world have cesarean rates of less than 10%. There is no justification for any region to have a higher rate than 10-15%.
In all 50 states VBAC is legal and in some states it is legal for a midwife to attend an OOH (out-of-hospital) VBAC. However of the women interested in VBAC 57% are unable to find a supportive care provider or hospital.
With the new AGOC (2010) guidelines in place we hope to see VBAC's increase and have more women find supportive care providers!You CAN birth!!

The VBAC Dilemma

The VBAC Dilemma - More Business of Being Born 

In case you can't see the video above, you can see it directly on YouTube here. 

thoughts?