Journey With Us
I hope that you have heard of Ina May Gaskin. She is an amazing woman who became a midwife on a commune in Tennessee. This TEDx talk just scratches the surface of her passion and work. I encourage you to check out anything she has written or videos about her work and life.
On her website can you more information about the books she has written. inamay.com
Enjoy and let me know what you think about Ms. Gaskin!
During pregnancy you may be tested to see if you are anemic. The blood count level your provider is most often looking at is your hematocrit/hemoglobin levels. The criteria for anemia changes during pregnancy, as your blood volume changes.
The American College of Obstetrics and Gynecology recommends that women who are anemic during pregnancy have further work-up to determine the source. If you are borderline anemic or have struggled with anemia in the past, you may want to attempt to increase your iron stores if a work-up isn’t indicated.
When looking up ways to increase your iron intake, you may have heard that calcium interferes with the absorption of iron. However, it actually seems like the evidence is unclear. In the immediate sense, calcium does block the absorption of iron, but the long-term effect does not seem to have a strong negative impact. On the flip side, Vitamin C (ascorbic acid) has been shown to increase the iron absorption. It is easy enough to find a list of high iron foods, but where do you go from there.
Because the evidence is unclear, moving from information to intake can be a little perplexing. Adding extra iron to your diet might be enough without changing your calcium/Vitamin C intake if you are looking to make a slight bump in your numbers. But what if you want to go a step further? It would seem reasonable to consider adding in one or two high meals or snacks that maximize the absorption. Here are a few suggestions to potentially increase the amount of absorption:
Leafy green salad: Skip the cheese and dress with lemon juice and oil. Top with chickpeas, pumpkin seeds, and broccoli, perhaps raisins for a touch of sweetness. Making this for dinner, and top with steak.
Chili: Find a ground beef recipe that is heavy on the beans. Again skip the cheese and consider avocado as a topping. If you can’t live without the creaminess, use sour cream instead of cheese. If you stick with the two tablespoon serving suggestion, the amount shouldn’t change the iron absorption.
Hummus: Made from chickpeas, hummus is rich in iron. Squeeze a little extra lemon juice on your serving. Not feeling the hummus, try eating the beans whole as a snack.
Simple switches:
Soup for lunch? Consider lentil, black bean, or a broth based one that includes beans.
Cereal for breakfast? Check out the labels on your favorites. Go for the one that has the highest iron content.
Craving a little sweet? While I wouldn’t use the iron content as an excuse to indulge, if you are going there anyway consider dark chocolate. Real black licorice candy also contain a small amount of iron.
Apparently spices such as thyme, parsley, and cumin can also add to your iron intake.
In general, babies take what they need from mom, so unless she is severely anemic the baby will still be able to build enough iron stores for after delivery. However, if mom’s levels are already low, it could mean that mom is the one left in need. Making small diet changes can help increase mom’s iron stores, letting her feel less depleted.
Any woman planning a VBAC knows the support for her decision is of utmost importance. Ideally this support would be found in her family and care provider. However, this might not be the case for each woman planning a VBAC or she would simply like to connect with someone making the same decision.
There is little to no research about the supportive environment affecting the rate of VBAC, but for those who have been through the experience, support is one of the key factors of successful VBAC.
In the day and age of social media, many women are turning to online communities to find the support they desire while planning a VBAC. In a recent article from the Journal of Perinatal Education, a childbirth educator describes the online support she saw for a woman who attempted a VBAC and ultimately ended up with a tertiary cesarean section. Strangers followed this woman’s story, and hundreds commented on her posts during labor.
Another journal article analyzed a VBAC forum and pregnancy forum on babycenter.com. The VBAC forum appeared more personal and supportive than the pregnancy forum based on their scoring criteria.
You may want to consider the following when joining an online group:
1. Size. Are you looking for a more intimate group where members know each other well or a larger group that might have more activity.
2. Moderation level. Some groups may have a monitor that deletes inappropriate comments or off topic threads.
3. Privacy. Is it a closed group or open to the public? How are members approved?
4. Types of questions asked. This will probably be mixed in all groups, but overall are members looking for support, medical advice, or general information.
5. Usefulness in your own life. Does the group bring you the support you are looking for, positiveness to your situation, or just a fun distraction?
There are no right or wrong answers to the considerations above. It is all based on personal preference and determination of value in your own life. If you are looking for extra support when pursuing a VBAC or want to hear from someone else going through the same situation, an online group may be a viable option.
Have you heard about the Listening to Mother's surveys? In 2013 the third report was published, where over 1000 women in the United States were interviewed about their childbirth experience. This report gives a snapshot of the state of maternity care in the United States.
Some of the results are mind blowing! One of the most startling results was about women being told their baby would be "big" at the end of their pregnancy. In the shared decision making section, 32% of women reported they were told their baby may be big. The majority of these mother's said their practitioner brought up an induction (62%) and 44% reported a discussion about cesarean. In the end, the average size of the baby's actual birth weight was 7lbs 13oz.
Another startling response was that 47% of first time moms reported being induced. Almost half!
In teaching childbirth classes, there is often this disconnect where you sometimes feel like you are teaching women to fight for their rights. Many elements in this report underscore the importance of women learning to be advocates for their care. But is that fair? Should a woman in labor or at the end of her pregnancy be expected to stand her ground when it comes to unnecessary interventions, or rather should it be expected that she will be offered good quality care based on evidence and putting her first?
I encourage you to check out the results and consider the state of maternity care in the US.
With each of my pregnancies I have gained the majority of my weight in the second trimester. As many women gain their highest amount in the third trimester or at least maintain a steady weight gain, this had myself and my providers nervous in the past.
The first time around, I was the nervous one. However, if memory serves me correctly, I didn’t gain any weight after 32 weeks and found myself delivering at the low end of my pre-pregnancy weight gain recommendation*. The second time around, it was my providers who were a little nervous. At 26 weeks I had gained 19 lbs, and was on track to gain about 35 lbs if the momentum stayed the same throughout my pregnancy. Somehow I found myself at the exact same weight gain as my first when delivering my second.
This time around I am on a similar weight gain pattern, and if history serves me well, the weight gain should start to slow down soon. But with my first VBAC pregnancy, I had to ask myself, why does my provider care so much if I gain 35 lbs? At the time I did a literature search and found gaining weight above the Institute of Medicine’s recommendation was negatively associated with successful VBAC. I was curious to see if any new literature had surfaced since that time. Here is what I found.
This article studied women considered high-risk during pregnancy, classified by hypertension, diabetes, and/or obesity. The researchers found women who gained more than the weight gain recommendations were less likely to have a VBAC. The abstract states the weight of 30lbs, but I did not find this specification in the article, just the description of exceeding recommended weight gain based on pre-pregnancy BMI. The study did not seem to consider pre-pregnancy BMI and weight gain separate from the other high-risk factors, though the majority (63%) in the study were obese. What I mean by this is, was the weight gain more impactful if the woman was already obese?
This article looked at pre-pregnancy BMI and weight gain. Both obesity and excessive weight gain, 40lbs in this article, were negatively associated with VBAC. The abstract spells out the different rates.
I found this article a little bit difficult to follow. In the abstract the authors state a BMI >25 is significantly associated with a decreased success rate. While, it never states when the BMI was measured, I can only assume that it is the labor admission BMI, as all of the other variables measured were upon labor admission (gestational age, cervical dilation, etc.). Essentially, only 20% of those in the successful VBAC group had a BMI >25, while 58% of those in the failed VBAC group had a BMI >25. The amount of weight gain that this would relate to varies, depending on a woman’s starting BMI.
Lastly, this article discussed weight gain between the first and second pregnancy. An increasing BMI between pregnancies was associated with a decreased success rate, and a decreasing BMI in women who were overweight or obese before their first pregnancy was associated with a higher success rate. If you aren’t already pregnant, and are planning a VBAC with your next pregnancy, you may want to pay attention to your inter-pregnancy weight.
To be clear, none of the authors stated that a high weight gain or BMI at the time of delivery was an indication to have a planned repeat cesarean. They were only exploring factors associated with a successful VBAC. That said, it may be prudent to only gain within the IOM’s recommendations for pregnancy weight gain while planning a VBAC.
*every woman's weight gain pattern varies during pregnancy. My own story is not an example of how it should/should not be done.
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If you are planning a vaginal birth after cesarean (VBAC), you may have come across a VBAC Calculator. The VBAC calculator attempts to take variables* into account and predict the likelihood of vaginal delivery after a cesarean.
Before you break down in tears, especially if you have never had a previous vaginal delivery, lets consider a few things. A recent Letter to the Editor in Birth: Issues in Perinatal Care critiqued the use of this calculator.
An interesting point to consider is that the risk of perinatal death or hypoxic-ischemic encephalopathy in the newborn is 1 in 2000 for a woman attempting a VBAC. Even if a women’s likelihood of successful vaginal delivery is low, her risk of poor outcomes for her baby is extremely low if she does not have a VBAC in the end. Additionally, the authors pointed out that we don’t use a calculator to determine if a woman with no prior deliveries will have a successful vaginal delivery, though there are certainly factors that influence this.
Multiple studies show that the actual success rate of a VBAC is somewhere around 74%, and this increases to 94% if the woman has had a prior vaginal delivery. VBAC calculators are more accurate the closer to delivery used, rather than the start of a pregnancy. There is a second calculator that takes into account hospital admission factors, gestational age, cervical exam, etc. I was unable to find a link to a public website containing this calculator, but will update this page if I do.
I think the VBAC calculator fails to take into account a variable that I personally believe has a huge impact, the support of your provider. While some providers may initially promise the backing for a VBAC, their support may wane over the course of your pregnancy. A gestational age or predicted estimated fetal weight cut-off, strict monitoring in early labor or an epidural “just in case” may be signs your provider isn’t as supportive as they may say. Similar, a hospital setting that is not supportive of VBAC can also deter a woman’s outcome of VBAC. A woman in a supportive environment with a low prediction of vaginal delivery might just be more successful than another in an unsupportive environment with a higher prediction of vaginal delivery. Wouldn’t it be interesting if the provider’s and hospital’s VBAC rate was added to the calculator!
When I use the VBAC calculator to predict my VBAC a few years ago, I received a likelihood of 65% and without the patience of my providers it probably would have been 0%. This time the calculator predicts 91%, slightly less than what research shows. But with the same supportive providers, barring an emergency, I think the likelihood is much higher. Only time will tell!
Curious if anyone else received a low likelihood of success and went on to have a vaginal delivery. What did you find to be the biggest impact on your outcome?
* BMI is the pre-pregnancy BMI, not current. The second hospital admission calculator takes into account the current BMI
On a personal note, I had a cesarean section with my first child. Two and a half years later I had a vaginal birth after cesarean, commonly shortened to VBAC. During that time I searched the Internet tirelessly looking for resources, stories, anything that would lead me to remain hopeful or perhaps increase my chances of success.
While there were a few solid resources, I wanted more! My hunger for information could not be satisfied. Now two years later, I was curious to see what was still out there and if there was anything new.
Here is my round up:
This website has become a wealth of knowledge. I haven’t even scratched the surface of her new resources. As far as I can tell, it all looks free. I look forward to reviewing her new The VBAC Education Project.
I was hoping this website would be a little easier to navigate after a few years, but while it has been updated, I am not in love with the format. There still seems to be a great deal of information on the website, just a little buried. Jen Kamel (the creator) has workshops around the country, and they look well worth cost/time.
American College of Obstetrics and Gynecology (ACOG)
ACOG has practice bulletins, which should guide obstetricians practicing in the United States. They are in support of VBAC, and their guidelines are far less restrictive than how most obstetricians practice.
Another position paper in support of VBAC
Overall, this is a solid website that focuses on evidence based care. There is a good deal of information about VBAC and repeat cesarean. While I do think the information is good, I want to point out that the last time this section was updated was 2012.
International Cesarean Awareness Network
A website dedicated to providing resources to women who have had a prior cesarean. They also have local chapters where women who have had a cesarean can meet together.
This is a documentary that explores a women’s journey to VBAC. Definitely worth the watch.
This book is not specific to VBAC, but there are a few stories about VBAC in it. The most important part of this book is the normalization of childbirth. Ina May Gaskin is an amazing birth advocate, this is a must read.
The Official Lamaze Guide: Giving Birth with Confidence
Another good read that normalizes birth.
Many websites have a page or two dedicated to VBAC, but these resources dig deeper, fully aware that knowledge is power when pursuing or deciding about a VBAC. Is there anything I missed, a resource you found particularly valuable to your journey?
In the obstetric world, the word failure is often used when the norm is not met or an intervention (regardless of its appropriateness) does not work. Some terms you may recognize include:
· Failure to progress
· Failure to descend
· Failure to dilate
· Failed induction of labor
· Failed trial of labor
· Failed attempted vaginal birth after a previous cesarean
· Failed lactogenesis (not able to make breast milk)
The terms failed or failure are harsh, to say the least. They are deeply personal to those who are the recipients of the diagnosis. But when breastfeeding fails, is it the mother’s fault?
In a recent issue of The Lancet breastfeeding has been highlighted as a health topic that needs more support, investment, and commitment. The health benefits of breastfeeding are staggering, for both mom and baby. In the response to overall low breastfeeding rates, the authors of Why invest, and what it will take to improve breastfeeding practices?*, suggests 6 points to improve breastfeeding rates around the world. Guess how many of these points directly involve the mother? None! The call for support looks more broadly to the system, if the system is improved the breastfeeding rates should follow.
In brief, here are their suggested interventions to improve breastfeeding rates.
1. Disseminate the evidence of exclusive breastfeeding
2. Foster positive societal attitudes towards breastfeeding
3. Show political support
4. Regulate formula companies
5. Monitor trends and interventions in breastfeeding practices
6. Political institutions to exercise their authority and remove structural and societal barriers to breastfeeding.
What do you think, will a systems approach improve breastfeeding rates? What do you think was the biggest influence on your breastfeeding experience?
*The summary of the article is found here
During pregnancy and breastfeeding when the hunger hits there is little time to spare. The nausea, anger, or extreme tiredness is sure to follow. Having a few snacks on hand or at least easy to put together are key in overcoming these desperate moments.
In general, I think sticking with a limited number of snack ideas, for at least a week, is a good idea. It makes grocery planning/shopping easier, and additionally there will probably be less waste. Nothing is worse than throwing out expensive groceries that have passed their prime before you could get to them.
The other key to good snacking is having a balance of carbohydrates and protein. If your snacks are carbohydrate heavy, you are at risk for feeling hungry soon after.
So put down the candy and take a look at the following list of ideas.
· Trail mix, ideally separated into snack size bags. Don’t feel like making your own? Trader’s Joes carries individual sized trail mix bags.
· Hard boiled eggs
· Banana or Apple with peanut butter. Have a desk at work? Store a jar of your favorite nut butter in a drawer
· Handful of nuts
· Popcorn and nuts
· Carrots and hummus
· Crackers with cheese. Pre-slice cheese and keep in an airtight container or try some of the individually packaged cheese
· Celery and peanut butter
· Cottage cheese or yogurt with fruit
· Roasted chickpeas
· ½ peanut butter and jelly sandwich on whole grain bread
Have any go to snacks? Would love to hear what you turn to when the hunger strikes!
Episiotomy use in the United States has decreased dramatically in the last few decades. In the year 2000, about 30% of women still underwent an episiotomy during delivery. Currently the recommendation is that episiotomy should not exceed 5-8% of use during vaginal deliveries.
So what is an episiotomy? Essentially it is a cut made is the delivering woman’s vaginal opening while she is pushing out the baby. Historically, there were thought to be multiple benefits to this procedure. Most, if not all, have not been supported by research. In fact, woman who have an episiotomy tend to have more pain after delivery (and during the procedure!), further risk of tearing, and increased risk of pelvic floor dysfunction to name a few disadvantages to the procedure.
In 2006, yes 10 years ago, the American College of Obstetrics and Gynecology recommended against the routine use of episiotomies. However, what we in the obstetric world know is this varies greatly by physician practice. In fact, some research has found that private practitioners (as opposed to residents or hospital based physicians) have the highest rates of use.
There are very few acceptable reasons for an episiotomy and even those aren’t always concrete. I think most practitioners would agree that if a baby is in distress and the episiotomy will expedite the delivery, then yes an episiotomy is appropriate. However, another reason often considered acceptable, is to prevent severe maternal perineal tearing. This benefit would be difficult to prove. How does the physician know how severely the woman will tear? I haven’t heard or read a good prediction of tearing yet.
It is important to ask your practitioner what their episiotomy rate is. They should know the answer to this question. And if they claim they don’t, ask “50%? 33%? Less than 10%?” Then I think the next question is, when would you do an episiotomy? They should speak to expediting delivery when the baby is in trouble. If you hear, “easier to repair, protect the pelvic floor, or every first time mom needs one” this should raise some red flags.
Feel like you need more information about episiotomies? This is a summary of the ACOG recommendation.
Choices in Childbirth has more information about the procedure itself and how to potentially avoid the procedure.
