Birth politics, breech, VBAC, and doula'ing--oh my!

I'm still over the moon about doula'ing my nephew's home waterbirth 5 days ago, but eagerly anticipating the three other births I'm on call for. Lord willing that I can make it to all three births, they should be very different experiences, and I'm so thankful for the (potential) opportunities to support my friends to have the best possible births for their situations.

One friend is low-risk and planning a homebirth with midwives. She had a hospital birth with her first child and didn't feel supported by the staff. She felt pushed (for the staff's convenience) into interventions that she didn't want or need, and she did not feel that she truly gave INFORMED consent. How is it possible, when the interventions were presented in a way that gave the impression that they were 1. necessary, 2. urgent, and 3. the only possible option? Sometimes interventions meet one, two, or all three of the criteria I just listed, but in her case they were not.

She hopes to have a healing birth this time, one where she is supported and encouraged, rather than coerced or made to feel fearful or pressured. I'm excited to attend another homebirth; it's what I love. However, homebirth is also what I know best. I'm coming to realize that I have the potential to learn and grow far more from the births I will attend that are far outside my realm of familiarity and experience.

I am also on call for the hospital birth of a mom who has been high-risk for all three of her pregnancies. She has a rare blood-clotting disorder which necessitates certain interventions for her safety and for baby's. Her first birth was cesarean; her second was hospital VBAC. She is preparing for another hospital VBAC, even though her heart yearns for a peaceful homebirth. Her circumstance is one of those for which I am thankful for the specialized skills of obstetricians. Midwives are experts in normal birth and a number of variations, whereas OBs are highly trained surgeons. Going to an OB for a normal, low-risk pregnancy is like going to a periodontist or oromaxillofacial surgeon for checkups instead of going to your regular dentist for checkups and maintenance. Your dentist is trained in normal oral health and care, and can perform a number of necessary procedures in his/her office. If a specialist is necessary, a dentist is trained to recognize the situation and refer the patient to the appropriate specialist. It's much the same with midwifery.

I digress. So, this friend of mine really needs an OB in a hospital because of various risks associated with her rare disorder. I'm trying to help her prepare for the best possible birth for her, including her preferences for Plan A (no interventions or as few as possible), Plan B (in the event that an induction becomes medically necessary--special considerations for VBAC), and Plan C (a family centered cesarean--no, that's not an oxymoron). In fact, I try to encourage all my clients to draft 3 plans that way. It's always better to be prepared. Murphy's Law and all that.

Anyway, this birth (provided that I make it on time--her last birth was very short!) will give me experience observing several categories of birth that are totally new to me: VBAC, high risk, and interventive hospital birth.

I'm so excited about the other birth I'm awaiting that I'm nearly ready to pee myself. Are you ready for this? I'M INVITED TO ATTEND A VAGINAL BREECH BIRTH!!!!!!!!!!! Do you realize that vaginal breech births are almost unheard of nowadays? Not because they're unsafe (they can be safe), but because care providers are no longer trained on how to attend breech births.

This momma has done EVERYTHING UNDER THE SUN to get baby to flip head-down, yet he remains firmly frank breech. (Yes, we're aware that he may still flip vertex up until or even during labor.) She and her husband are not comfortable with a homebirth due to an issue that came up during their last two (hospital) births, so even though they found a homebirth midwife who volunteered to attend a vaginal breech homebirth for them, they really preferred to find a way to get support for their wishes in a hospital setting.

The couple discussed it with their OB, who agreed that she is the perfect candidate for a vaginal breech delivery! He was very supportive and encouraging, and told her she shouldn't worry, it wouldn't be likely to be any more difficult than a standard vertex (head-down) delivery. She's beside herself with joy, and I'm so happy that it looks as though she can have exactly what she feels is safest and most positive. I cannot WAIT to see how this story unfolds.

I'm beginning to think that this particular OB could possibly be WV's "Dr. Wonderful." Time will tell. I'm afraid to get my hopes up, but I've heard great things about this OB so far. He is rumored to be VBAC supportive as well as supportive of normal, physiological birth in general. He told this particular mom that she can absolutely attain her goal of a delivery without an epidural, and he reassured her that there is no reason for her to be stuck in bed in labor (that was one of her concerns; she wants to be mobile for comfort, for pain relief, and to allow gravity to assist in bringing her baby down). It sounds as though a normal physiological birth *can* possibly occur in a WV hospital, without a fight, after all!

This really is a basic issue of human rights and a woman's legal right to choose what is best for her circumstance. Recently, ACOG recanted their prior position of denying women the right to hospital VBACs, not out of acknowledgment of safety (the data have been there for years) nor out of compassion, but as always, for political and monetary reasons. They now admit what the birthing community has known for years: "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."

What does this say for the women who have been denied the opportunity to VBAC over the years? Shouldn't it be up to the expectant mother to make the decision what is best for her and her child? Consider this: if there is no allowance for informed refusal, then you may be assured that there is no such thing as true informed consent.

If you ask me, the same thing can be said for a mother's right to attempt a vaginal breech delivery, if she is a good candidate for it. It saddens me that so many women are denied the option. They are not even told they have choices. Many are not even told that there are more than a dozen methods to try to get a breech baby flipped head down, let alone that they may be able to successfully deliver a breech baby vaginally. Most are forced into scheduling a cesarean, denied even the option of attempting a trial of labor or of at least waiting until the labor begins on its own to perform the cesarean so that the baby receives the fullest benefits of labor (chemically, hormonally, etc.). When I say that mothers are "forced" into such a cesarean, I don't mean that they are handcuffed or that the doctor literally holds the woman's hand to the paper to sign the liability waivers for major abdominal surgery. No, it's more subtle than that. They're told that no good mother would risk her baby's life for the vaginal birth "experience." The risks of the cesarean are downplayed or ignored entirely.

It all comes down to true informed consent. If a mother is given all the most current information on breech vaginal birth or VBAC or whatever the situation is, including risks and benefits of doing nothing, interventions, C-section, or whatever, and still opts for the C-section, I can respect that. That's a personal decision, and only the mother and her partner can decide what is best for them. My beef is that many women are bullied or belittled and denied options.

I'm excited that so many of my friends are becoming educated about birth, learning their options, and claiming back the responsibility for their health and joint decision making. They are researching to find out which care providers (whether it's OBs or midwives) practice truly evidence-based care, and which are fearmongers and bullies. They come to their appointments having read up on their options so that they can ask intelligent questions. They want to be active participants in their birth experience, as opposed to having the entire delivery experience "done" to them.

I realize that I have such an incredible learning opportunity before me, in so many ways. I have the honor of being invited into the sacred and intimate space of a woman's birth (in fact, several!). I can learn how to better serve and care for a laboring woman and her birth partner. I have the privilege of supporting my friends in a vulnerable and memorable time. And what an amazing chance to see a wide range of birth experiences, and to become a better childbirth educator.