Doula Dani On Cesareans And Post-Cesarean Birth Choices

'Don't Be Afraid To Have Those Conversations With Doctors'

What advice would you give to women who are not sure whether to choose a trial of labor after c-section (TOLAC), or a repeat cesarean (RCS)?

It’s important to know who is and who is not a good candidate for TOLAC; RCS is the best option for some women and babies but TOLAC may be the best option for others. There are a lot of factors at play. And that isn’t something I’d be able to answer for anyone. That answer comes from honest conversations with a woman’s care provider about the benefits and risks.

Personalized care means continued assessment throughout pregnancy. That doesn’t mean a care provider should never be questioned. But it also doesn’t mean concern is a "bait and switch". So really, the only advice I can give is to not be afraid to have those conversations with doctors. Don’t be afraid to ask questions. Write them down ahead of time, if need be. Be your own advocate.

'Being "five minutes from a hospital" doesn’t mean transfers are quick and easy'

Do you think a woman should ever attempt to have a HBAC, a homebirth after cesarean section?

When you are looking a TOLAC mortality rate in a hospital setting of 1.30/1000 versus a TOLAC mortality rate in an out-of-hospital setting of 4.75/1000, and knowing that a baby needs to be delivered relatively quickly – less than 30 minutes after rupture – HBAC is just a huge gamble. Being "five minutes from a hospital" doesn’t mean transfers are quick and easy. They take time. Getting a laboring woman out of the house, travel time, hospital assessment, preparing an OR… it’s not a quick process.

Do you believe, after your recent investigation, that it is possible to detect a uterine rupture at home, accurately and in a timely manner? What are the main symptoms for most women? 

To quote the American College of Obstetricians and Gynecologists: "The most common sign associated with uterine rupture is fetal heart rate abnormality, which has been associated with up to 70 percent of cases of uterine ruptures. This supports the recommendation of continuous fetal heart rate monitoring in labor."

To quote the Guise study: "As stated in a prior VBAC evidence report, and echoed in studies contained in this report, there is no single sign for the occurrence of uterine rupture; however, fetal heart tracing abnormalities, particularly fetal bradycardia (reported in 33 to 100 percent of all studies) is the most frequently reported sign of uterine rupture. Other signs reported in uterine rupture studies in descending order are maternal vaginal bleeding, maternal pain, and uterine contraction disturbances."

Continuous electronic fetal monitoring for TOLAC is recommended by the ACOG, American Academy of Family Physicians, SOGC, RCOG and others. Based on these recommendations, it certainly seems wise to have electronic fetal monitoring at least as an option. And at home, it’s not an option. A handheld Doppler or fetoscope is not the same as electronic fetal monitoring.

Again, knowing the limited amount of time a woman has in order to avoid serious morbidity or mortality for her baby, it’s a gamble.

You mentioned that the rate of uterine rupture coincides with the HBAC infant mortality rate as shown by MANA's statistics. Does this mean it is nearly impossible for a baby to survive a uterine rupture that occurs at home? 

We don’t know for certain if those five deaths were due to uterine rupture. We don’t know anything about uterine rupture in the MANA study because the authors didn’t include any information about it. But again, based on the information available for how quickly a cesarean section must be performed when uterine rupture does happen, it’s not a stretch to say that a uterine rupture at home would likely have deadly consequences. What can be done to help a baby in the case of uterine rupture at home? Nothing. There is nothing that can be done to help a baby at all other than get the woman to a hospital in an operating room as quickly as possible. 

'I felt so well-informed and educated' 

Interpreting statistics is really hard for a lay person. Do you have any advice for people struggling to interpret how safe certain birth options truly are?

I am a lay person. I'm not an expert. So I completely understand how challenging it can be. It's part of what had me confused when we were initially planning our home birth. I felt so well-informed and educated on the matter. I didn't realize the sources I trusted were not actually trustworthy.

More than anything, it’s just a matter of having information available and an awareness of the agenda of those interpreting the information. It’s a matter of knowing where to look for objective information. The MANA study authors did not provide any comparison rates for mortality rates.

A home birth mortality rate of 1.62/1000 for babies born to low risk women might not mean much of anything without having something to compare it to. 1.62/1000 just sounds low. However, when you compare it to the 2013 Birth Center study, for example, which has a mortality rate of 0.87/1000 for babies born to comparable risk women, then it makes you wonder why is the MANA study mortality rate twice as high? 

These numbers all seem low, though. But it’s important to remember how many babies are born every year in the USA, specifically how many are born in an out-of-hospital setting. According to the CDC Wonder Database, in 2012 there were 38,997 midwife-attended out-of-hospital births - some in birth centers, some at home. So just for the sake of illustrating a point here, let’s round up to 40,000 births and let’s pretend they are all low risk women. According to the MANA study mortality rate of 1.62/1000, approximately 65 babies would die out of 40,000. According to the Birth Center study mortality rate of 0.87/1000, approximately 35 babies would die. According to the hospital mortality rate of 0.38-0.58/1000, approximately 15-23 babies would die.

See Also: Cesarean Delivery Risk Factor

What is home birth in America doing so wrong that their mortality rates are so much worse than hospitals and CABC-accredited birth centers? 1.62/1000 is the mortality rate for babies born to low risk women. This is not acceptable. Instead of addressing this issue and figuring out ways to make home birth better, safer they instead are spending their time trying to pull the wool over everyone’s eyes. They want people to think that 1.62/1000 is good. But it isn’t.