Childbirth After Cesarean: Lakeshore Women Have Options

From module 12 of the VBAC Education Project (VEP).

From module 12 of the VBAC Education Project (VEP).

Women in Muskegon and elsewhere along the West Michigan lakeshore have several options for childbirth after cesarean. What are some of these options?

Repeat Cesarean

The majority of women in Muskegon County who have a prior cesarean have a repeat cesarean section (RCS). This may be because they decide this is the safest option for them based on their medical history, while others prefer the certainty and convenience of scheduling their birth. Other times, women don’t realize that they have other options or don’t have the support to access them.

Vaginal Birth After Cesarean (VBAC)

I’ve heard Muskegon birthing people being prepped for surgery be told that they can deliver vaginally in the future, but that they would have to go to a Grand Rapids hospital. That’s only part of the story. While currently, all three of the hospitals in Grand Rapids, Spectrum Health Butterworth, Metro and Mercy Health St. Mary’s, offer VBAC, distance makes this option a challenge for many people. Holland Hospital also offers VBAC as an option.  Others are intimidated by the prospect of receiving prenatal care and delivering with a large practice and facility, which feels impersonal compared to the care they are accustomed to in their community. Despite the challenges, some Muskegon people will travel out-of-county for their VBAC.

Another option that appeals to some families is to deliver in a community hospital that has a VBAC ban, or policies that discourage VBAC, but is known to have supportive providers. Dr. Michele and her colleagues at Spectrum Health Gerber Memorial have an excellent reputation for supporting those who choose to have a VBAC. Others receive their prenatal care locally, put off scheduling a RCS or do not show to appointments, with the plan to show up in labor at their local hospital. Local community hospitals include Mercy Health Hackley in Muskegon and North Ottawa Community Hospital (NOCH) in Grand Haven. I have heard of people having VBACs at Hackley, despite the ban, but not at NOCH.

Free-standing birth centers are an option for women who want to deliver with a midwife in a home-like atmosphere outside of, but close to, a hospital. There is some evidence that choosing midwifery care through a free-standing birth center increases VBAC success rates. Simply Born Birth House is the only free-standing birth center in West Michigan. Sara Badger, a Certified Professional Midwife (CPM) is the provider there. Birth centers have criteria they use to screen women to see if they are good candidates for this type of care. If this is something you are considering, I recommend scheduling a consultation before pregnancy to learn more.

The final option is to plan a home birth after cesarean, or HBAC. In the event of a rare complication, like a uterine rupture, this may not be the safest option, but some people are willing to take the risk to birth on their terms, in the privacy of their own home, with a provider who believes in their body’s ability to birth. As with birth centers, home birth midwives have criteria for screening clients who are candidates for HBAC. You may have to interview several in order to find the right one for you.

As with any birth, there are many decisions to be made. Since providers vary a great deal in their support of VBAC, it isn’t a bad idea to do some research prior to your next pregnancy. A provider may also have good advice to increase your chance of having a successful VBAC, like the amount of time to wait between pregnancies and how to optimize your health.

While those in Muskegon and along the lakeshore may not have all of the options available to birthing people in large, metropolitan areas, they do have possibilities. Knowing what those are is the first step to choosing the course of care best for you and your family.

Waterbirth – What’s the Big Deal?

While attending the American College of Nurse Midwives (ACNM) Michigan Affiliate conference in January of this year, I had the pleasure of hearing Joanne Bailey, PhD, CNM, speak on “Hydrotherapy and Waterbirth: Evidence, Outcomes and Challenges.”

According to Dr. Bailey, the first documented waterbirth occurred in France in 1803. It wasn’t until the 1970’s and 1980’s that waterbirth started to become more popular in Europe and Russia. In 1983, Michel Odent described 100 stories of waterbirth, mostly positive. In 1989, Barbara Harper, who had studied waterbirth in Russia, held the first waterbirth conference in the U.S. She later went on to found Waterbirth International.

Despite such a long, successful history, there are only three options for someone who wishes to have a waterbirth in West Michigan today. The first is to deliver at home. Those choosing a homebirth may rent or purchase a pool that can be set-up in their home and in which they may labor and/or give birth in. The second option is to choose to give birth in a free-standing birth center. The Simply Born Birth House, in Grand Rapids, has deep tubs to labor and birth comfortably in. The third option is for rebels. If a provider is knowledgeable about how to safely manage a waterbirth, the birthing person may refuse to get out of a hospital tub and deliver underwater.

Why is waterbirth so difficult to access within a hospital? Rebecca Dekker of Evidence Based Birth asked herself that same question while delving into the research and case studies that led to the 2014 joint ACOG (American Congress of Obstetricians and Gynecologists) and AAP (American Academy of Pediatrics) statement against waterbirth. Her conclusion was that they based their decision on limited, isolated cases and not on the larger body of evidence suggesting that waterbirth is safe.

While all West Michigan hospitals have policies against waterbirth, this is not the case everywhere. In fact, Dr. Bailey tells the story of how the first waterbirths occurred at University of Michigan Health System in 1996 as the result of a consumer-driven effort. Currently, 16.4% of the births there occur underwater.

How about you? Did you have a waterbirth and if so, how did you achieve it? Please share your story!

Can CNMs attend VBAC deliveries in West Michigan hospitals? The answer is: it depends!

As a birth advocate, supporting the rights of women who plan a vaginal birth after cesarean (VBAC) will likely keep me busy for the duration of my career.  My heart goes out to women who have to navigate their healthcare options for childbirth after a cesarean one facility, practice and provider at a time. At the end of their inquiries, many find that their options are limited by their individual histories, provider decisions, hospital policies, insurance reimbursement and even politics.

Since October, I’ve been working through the West Michigan Better Birth Network, the local chapter of the non-profit, Birth Network National, to address the official VBAC ban at Spectrum Health Gerber Memorial. We have collected stories of women who have had VBACs there in order to stress to administrators that, despite being counseled that the main hospital campus, Spectrum Health Butterworth in Grand Rapids, is the safest place to labor and deliver, they have legitimate reasons for choosing a community hospital setting. [Link to a sample letter from Rebekah Thompson of New Life Doula Services. Link to my own letter from the perspective of a Substance Abuse Prevention Specialist.]

I was recently attending an event at Amanda Holbert’s yoga studio, Renew Mama. While discussing the work of the WMBBN, Amanda brought up the “ban” on CNMs attending VBACs in West Michigan hospitals. Amanda inspired me to look into this restriction further. Why could CNMs attend VBACs in some hospitals, like Borgess in Kalamazoo, but not at Spectrum Health Butterworth (the only hospital in West Michigan that both allows VBACs and has CNMs who deliver there)?

I called Spectrum Health to ask about their policy on CNMs attending VBAC deliveries and was referred to Charmaine Kyle, Clinical Nurse Specialist in Women and Infant Services. Right away, she informed me that the hospital does not have an explicit policy banning CNMs from attending VBAC deliveries. I checked in with Jen Kamel of VBACfacts, an advocate for greater access to VBACs nationwide, who suspected internal politics to be the culprit.

Before hearing back from Charmaine with a definitive answer, I attended the American College of Nurse Midwives (ACNM) Michigan Affiliate conference in Kalamazoo.  There, I met midwives from across the state, most of whom are supported in attending VBACs at the hospitals where they work. Meeting these midwives made me even more determined to find out what is causing the restriction and advocate for overcoming it – West Michigan women deserve all possible options!

This past Wednesday, I received a reply: “a midwife is available through the residency clinic and would be able to establish care with a patient antepartum.  When it comes time for delivery the midwife would partner with an obstetrician and co-manage the care during labor.  The only problem right now is we don’t have enough midwives to provide 24/7 coverage.  Our hospitalist (core faculty) obstetricians would manage the care during the night and on weekends.” In other words, a woman could see a midwife for prenatal care, but could only have one in attendance at her birth if she happens to deliver during normal business hours.

After speaking with a CNM in private practice who delivers at Spectrum Health Butterworth, I learned they are in a similar situation. The hospital’s laborist (salaried staff Ob/Gyn) will not cover them in the event a cesarean becomes necessary, so an obstetrician from their practice has to both be available and willing to stay at the hospital until the mom delivers without being paid to do so. Since they cannot guarantee that this requirement will be met, the midwives who practice at the hospital cannot advertise their ability to take on pregnant women planning VBACs.

Several changes could move West Michigan toward increased access to CNM-attended VBAC births in hospitals. First, Spectrum Health Butterworth could hire more midwives so that those working in their residency clinic could be paid to cover births occurring 24-hours a day. Secondly, the hospital could further find creative solutions to overcome the liability fears of the laborist which lead to the unwillingness to cover the midwives working in private practice. Thirdly, other hospitals that allow VBACs could hire midwives.  Finally, smaller community hospitals who already have midwives delivering there could remove their VBAC bans.

Are CNMs able to attend VBACs in hospitals in your area? What worked to increase access in your community? Do you wish you had this option?  I want to hear from you!

Chani’s Birth Story

I’ve wanted another baby since I had Felipe 16 years ago. At that time, I was living in a squat in the lower East Side of Manhattan with his father, a jealous man who already had two children with a woman he was still legally married to. My parents were here in MI and his parents lived in Puerto Rico. As if that wasn’t isolating enough, he was delusionally convinced that I conceived Felipe when cheating (I hadn’t) and that I lied to him in order to get pregnant (I didn’t). So, for 8 months, I had no affection from a crazy person who screamed at me every day that I needed to get an abortion because I was ruining his life. I otherwise enjoyed being pregnant and thought, “This would be so much better with someone else.” It just took me 16 years to find someone. It was worth the wait.

As far as hospital births go, I had a pretty good one with my son in 1998. After 22 hours of labor, I showed up at the hospital at 8 cm, 100% effaced and delivered him attended by midwives with three pushes about 1 and ½ hours after I arrived. Aside from several things that made getting breastfeeding off to a good start harder than it should have been, I was satisfied with the experience, but felt overall that being there was unnecessary and the staff were just in my way. I decided then that I wanted to have my next one at home.

This time around, making it to term was my goal. Both my parents were extremely premature and my son was a month early, so I didn’t expect to make it to 40 weeks. Still, I kept scheduling activities as though my due date wasn’t real just to keep my sanity. At 38 weeks, I started getting Braxton Hicks contractions daily. I had back labor with Felipe and never felt my uterus contracting, so I really enjoyed the repetition and rhythm of these sensations. At first, we took this as a sign that something was about to happen, but after a few days it got old. After two weeks, I just ignored them so as not to alarm anyone in public and tried to forget I was pregnant.

My due date was on a Saturday. The following Thursday, I had an appointment with my midwife, Susan Wente, at her office in Newaygo. We had already discussed having her strip my membranes and I was all for it. My elderly and bedridden grandmother had come to live with me around 37 weeks and it was getting really hard to take care of her with the big belly. I had help lined up to get me through postpartum recovery, but I felt like the lives of everyone involved were on hold for this baby and I was ready to give birth. Susan has a reputation for being successful in starting labors in this way. In fact, she told me that 60% of her patients go into labor within 72 hours. I knew that I was already 100% effaced and felt like this should work. Having it done was moderately uncomfortable, but it was over quickly.

At about 6 AM the following morning, I was lying in bed when my water broke. The fluid was clear and odorless. I texted Susan and woke up Matt to get me something to put between my legs so that I could get downstairs. I spoke to Susan on the phone. The night before, her dog got in a fight with a porcupine and needed medical attention. I hadn’t had any contractions at that point, so I told her to tend to her dog and I’d keep her posted.

The moment I stood up, I started getting contractions. I had enough time to tend to my grandmother, use the bathroom and call my bestie, Rachelle, to come over before they really started to demand my full attention. Rachelle started timing the contractions, which lasted 45 seconds to 1 minute with no break in between. I kept trying to wrap my head around relentless contractions at the onset of labor. It was the kind of labors people have in movies, but not in real life. I was hoping this was real, but kept thinking it wasn’t because I knew labor wasn’t supposed to be like this. My bestie got in touch with all of the people who were supposed to be there with actual experience: my midwife, my doula (Cindy) and my doula friend (Laurie). Rachelle timed my contractions, looking scared and concerned, while I instructed Matt (my baby’s daddy) in hip squeezes and sacral massages, the only things that were even remotely helpful. I stood up for each contraction, roaring through them. When they were over, I’d get on my knees, thinking I’d get a break, only to jump right up again. I started to doubt myself: there was no way I was going to be able to keep this up for 24 more hours!

I thought I’d try the shower. I stood at the back of the tub with the water on my lower back, but ended up getting out. I was in so much pain and there were no breaks and no relief. At the height of the contractions, I felt like my hips were stretching so far apart that they were going to snap and go flying in opposite directions. I was leaning against the bathroom wall, howling at the top of my lungs, when Janis Flint, the midwife’s assistant, arrived. I told her all of the things that I hear women say at births, but never thought I’d say myself: “I can’t do this! Make it stop!” And she said the simple words that myself and other doulas have said to so many other laboring women: “Of course you can! You are doing it!” What magic there is in positive support at that moment!

Somewhere between running around to find the supplies for the birth I had stored away and supporting me, Janis told me that, due to liability, she couldn’t check me for cervical dilation, but that I should reach down and check myself to see if I could feel the baby coming. Her request made no sense to me. It was as if she was asking me to fly a plane when I had never flown before. I tried to check myself, but didn’t feel a head. How much longer could this go on? Just about then, Susan arrived. I was never so happy to see anyone in my entire life and I’m not exaggerating. Her words of, “You’re fine. Your baby’s fine. Everything is perfectly normal,” was like stardust sprinkled over my head. She wasn’t just calm, she was cheerful.

Susan checked me and I was fully dilated. She asked me where I wanted to deliver. I was naked in my bathroom and my brother, grandmother and son were in the other room. I was in intense pain and wanted to not be in labor anymore as quickly as possible. We weren’t going anywhere. How did I want to push? I tried to get into a supported squat with Matt, but that was just awkward and uncomfortable. I got on my hands and knees on the bathroom floor and, leaning against the bathtub, pushed out my baby in three pushes.

My baby was wrapped in a towel under me while I was trying to recover from that whirlwind labor. I looked down between her legs and saw she was a girl and let Matt know. Felipe came in and cut the cord. Matt took off his shirt and held Chani Alice while I delivered the placenta and got cleaned up. By then, my other support people had arrived. Janis and I measured and weighed Chani. Laurie gave me a leg massage and gave us all a tour of Chani’s heart-shaped placenta before preparing it for a smoothie. Cindy helped me with breastfeeding. Matt contacted family and friends, who started arriving. It was 10:30 PM before everyone left and the house was quiet.

That’s my birth story for my daughter who came into the world one morning in the late summer of 2014, 20 ½ inches and 7# 9 oz.