KC Birth Network conference: Birthing naturally in the hospital

This is the fourth in a series of posts on what I learned at the Kansas City Birth Network conference on Apr. 23-24.

Dr. Tami J. Michele, DO, OB/GYN, formerly practiced in Kansas City. Now she lives and practices in a small city in Michigan. She has been a part of the Michigan Health and Hospital Association Keystone Project.

I’ll post my notes from her talk without trying very hard to organize them.

Preparation for natural birth in a hospital
Dr. Michele recommends:
— classes with unbiased information
— doula
— natural-birth-sympathetic healthcare provider (midwife or natural-based doctor)
— eat well, avoid excess sugar
— practice squatting and flexibility
— create a birth plan, and talk about it early with your doctor

Labor
— avoid induction of labor unless necessary
— stay at home till active labor
— eat/drink as desired
— intermittent monitoring unless high-risk
— ambulatory monitor if monitoring is needed
— place IV site if antibiotics or other medication is needed
— comfort measures for pain control
— avoid an epidural unless absolutely necessary
— change positions often

Pushing
— wait till urge is strong; follow instincts
— woman chooses position; out of bed, standing, squatting are fine
— quiet encouragement
— oil with massage to perineum
— don’t use stirrups or break down bed
— warm perineal compresses for pain

More about second stage (pushing)
Recommends delaying pushing until mom has the urge, up to 2 hrs. for first-time mom/1 hr. for multipara mom
Fetal heart rate should look the same through pushes as between contractions

Pitocin induction/augmentation
Tachysystole — when there are consistently 5 contractions within 10 minutes over a 30-min. EFM strip; this is “the first thing you see when pit use goes bad.”
New protocol calls for starting at 1 mL/hr, increased by 1 mL/hr every 30 min. Results with these new guidelines show women usually don’t need any more than 6 mL/hr. altogether. (Disclaimer: I’m wrestling with understanding the units/proportions here; any nurses or doctors reading my blog, feel free to explain further or correct me if I’m wrong. This is on my list of stuff to learn.)
Old protocol — some doctors start at 6 mL/hr and increase regularly by 6 mL/hr.
Pitocin is the #1 thing looked at in medical malpractice suits.

Dr. Michele attended the NIH VBAC consensus conference.

Notes on VBAC

VBAC success rate is 60-80% (same as vaginal birth rate for first-time moms).
Success factors: baby < 4,000 g; lower gestational age; good Bishop score @ start of labor; spontaneous labor; previous vaginal delivery.

Short-term benefits of trial of labor (TOL)
— maternal mortality is increasing with c-sections: 3.8 per 100,000 in TOL; 13.4 per 100,000 in repeat c-section
— hysterectomy: 157 per 100,000 in TOL; 280 per 100,000 in repeat c-section. Risk increases with each c-section.

Short-term harm of TOL
Uterine rupture: 0.2% for term baby with c-section; 0.7% for term baby with TOL; 1.5% for term baby with induced TOL; 3.2% if baby > 40 wks. with induced TOL
Point: avoid induction!
Risk does not appear to be increased with pitocin augmentation of spontaneous labor.
— 5.6% risk of uterine rupture if there are 2 or more previous c-sections.
Every time a mother has a VBAC, her risk of uterine rupture goes down.

Other factors that may increase risk of uterine rupture (insufficient data for these): unfavorable cervix upon admission; obesity; interpregnancy interval of 18 mos. or less; single-layer closure of previous incision; infant > 4,000 g; giving birth in a low-volume hospital.

Consequences of uterine rupture
— no maternal deaths
— 14-33% of women need hysterectomy
— 6% of uterine ruptures will result in perinatal death, but less than 3% if baby is full-term

Criteria for TOL
— 1 prior c-section
— at least 18 mos. apart from time of c-section to time of conception
— no induction
— low transverse scar

Long-term benefits of TOL
— avoid abnormal placenta in future pregnancies
— 0.9% have placenta previa after 1 c-section
— 1.7% have placenta previa after 2 c-sections
— 3.0% have placenta previa after 3 or more c-sections
— 0.3% have placenta accreta/increta/percreta after 1 c-section
Complications in future surgery: adhesions, perioperative complications at time of repeat c-section, bowel or ureteral injuries, complications if hysterectomy occurs.

NIH evidence does not support cesarean to avoid vaginal prolapse or pelvic-floor incontinence.

Outcomes for baby with VBAC
— TOL outcomes in VBAC comparable to any laboring nulliparous woman (first-time mother)
— neonatal mortality after TOL is 0.1%; after repeat c-section, 0.05%
— hypoxic ischemic encephalopathy (perinatal asphyxia) study in 35,000 women — 12 in TOL; 0 in repeat c-section

My thoughts:
The things Dr. Michele recommends as enabling you to have a natural birth in the hospital ring true with my experience as a doula. I have a lot of clients who are hoping for a “natural birth” (I realize this term is not very specific; different women define it differently). If you really want a “natural birth” in the hospital, these are the things you really have to DO. You have to prepare for it, not just hope it will happen.
Regarding VBAC, this is the kind of evidence women should have in order to make informed decisions about a repeat cesarean vs. a VBAC.

What do you think?

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