Tag: Cesarean

After a Cesarean Birth

CBAC, HBAC, or VBAC?

April is Cesarean & VBAC Awareness month, and we know exactly how important it is to recognize both of these ways of giving birth. We know that nationally, around 1 in 3 births happen via cesarean section, and locally that holds fairly true according to the latest available data. While we don’t know the full extent as to WHY the planned hospital birth cesarean rate is so high, “It seems increasingly clear that anxiety and easy access to many medical procedures at hospital may lead to increased levels of intervention, which in turn may lead to further interventions and finally to unnecessary complications (Olsen & Clausen 2023).” All of that is big picture stuff though, and this post is really seeking to speak to the patient side of things. We celebrate ALL births, no matter how they happen. Let’s talk about 3 big areas where doulas can help after a cesarean birth.

Postpartum

The first 6 weeks after cesarean surgery can be challenging. Your body really needs to rest, but you have a newborn to take care of too. Maybe you’re still dealing with pain when you get home and timing medications, or your other kids really want to cuddle but you’re worried they might bust your incision. Lifting restrictions make moving baby, other kids, laundry baskets, etc challenging after a cesarean birth too. Hiring a postpartum doula, even when you didn’t plan to, can be a huge help to your family and your health in those first 6 weeks. Whether you get a doula or not, delegating should definitely be in your wheelhouse, because your body needs TIME to recover properly in this postpartum period at home.

Recovery

Physical recovery is what most people think about after a cesarean birth, and yes that is really important. After that initial 6 weeks, you may want to talk to your provider about physical therapy to work on scar mobilization and pelvic floor therapy too. Yes, even after having cesarean surgery your pelvic floor might need some work. Honestly, I don’t know why pelvic floor PT isn’t a standard referral after having a baby, but that is a blog for another day.

Mental recovery after a cesarean birth is something that we need to talk about more. I often find myself processing with my clients who’ve had cesarean surgery to talk about how things went, even if I wasn’t there for that birth. People react very differently to having cesarean surgery, and we truly believe all feelings are 100% valid. Mental recovery can be very easy for some and others struggle with it for a long time. Processing with a birth professional like a doula or with a therapist trained in birth trauma can be really validating and helpful for some people. This is a service we offer for clients all the time!

Next time

The big question that many people have after a cesarean birth is often, what should they do next time. Should you try for a VBAC (vaginal birth after cesarean), maybe an HBAC (home birth after cesarean), or maybe a planned CBAC (cesarean birth after cesarean) is for you. There is no one right answer that will work for everyone in this situation, and there are many many factors that go into making that decision. As doulas, we tend to nudge people to think about 4 things when they’re discussing what to do for their next birth:

  1. What were the factors that lead to your cesarean surgery?
  2. How do you feel about giving birth again?
  3. Is there information or other support that would be helpful for you to know when making this decision?
  4. How will you feel about your choice in 10 years?

Everyone answers those questions differently, and honestly there is no one right answer that will work for everyone. One thing we can say with the utmost certainty is that no matter what your choices are, our doulas will be there to support you 100% of the way. We’re working to try to help hospitals understand the value of having your doula in the operating room to support you during your surgical birth too, and will keep pushing for this here locally!

We’re very grateful that cesarean surgery exists, as we’ve seen it save lives. At the same time, we know that it is often over used. We LOVE that VBAC is a truly viable option here locally with many providers, and have seen some amazing HBAC births too. Birth is honestly just amazing in all the different ways it happens. If you’ve had a cesarean birth and want support in any of the above ways, don’t hesitate to reach out to us!

Our 2021 Local Statistics

Every year hospitals submit specific measurements to Leapfrog Group to see how the they are doing, and this year’s aren’t looking great. We like to check in on our local statistics to see how we are doing, and you can read last year’s local statistics if you’d like. In this table, the numbers in bold are from 2021 & those in parenthesis are from 2018.

Hospital NSTV Cesarean RateEarly Elective DeliveriesEpisiotomies
The Women’s Hospital
Newburgh, IN		27% (22.9%) 5.2% (1.7%)11.9% (14.8%)
Ascension St. Vincent Evansville23.5% (27.2%)0% (.8%)5.6%(6.8%)
Owensboro Health declined to respond (29.7%) declined to respond (1.4%) declined to respond (12.7% )
Memorial Hospital & Healthcare Center Jasper, IN17.5% (12.8%)4.5% (0.0%)7.4% (9.8%)
Daviess Community Hospital Washington, IN15.7% (15.2%)2.9% (1.9%)6.9% (13.1%)
Good Samaritan Hospital Vincennes, IN24.2% [20.7%]*3.8% [4.0%]*5.2% [14.2%]*
Deaconess Henderson Hospital27.6% (26.1%)2.5% (2.4%)2.6% (2.4%)
*numbers are from 2020, as we did not record the data for Good Samaritan Hospital in 2o18

Let’s take a moment to congratulate Ascension St. Vincent’s in Evansville for their success in reducing their overall NSTV cesarean section rate. Yes, there is room for improvement, but they are also the only local hospital that reported data and reduced their cesarean rate, as well as early elective deliveries AND episiotomies. Way to go StV!

Why does it matter?

The NSTV rate tells us the likelihood of a 1st time parent walking into a hospital with one head-down baby at 38+weeks gestation and walking out after having had major abdominal surgery to deliver that baby. This statistic doesn’t count surgical births for breech delivery or repeat cesareans or even first cesarean surgeries for your 3rd baby. From a population standpoint, we should be aiming to get that rate to between 10-15%, and huzzah Davies Community hospital is hovering right on top of that target. These reported NSTV local statistics have all gone in the wrong direction, and that matters for birthing families.

It matters because having one cesarean section increases the risks to you with each subsequent pregnancy. Is VBAC an option for you? Maybe, but only around 20% of people who have had a previous cesarean section will even attempt a Vaginal Birth After Cesarean, and then only if they can find a provider who is actually supportive. After a cesarean, your risk of things like placental accreta, increta, and percreta increase too. Surgical birth carries risk, and according to the evidence, we are doing surgery too often.

How can we change?

Hold OBs to their own standards. Yes, I mean us as consumers, but also hospitals and insurance companies too. ACOG gave some great ideas here, California has some ideas we could bring to the Midwest here & Dr. Neel Shah has been a leader in the call to figure out how to reduce cesareans. I have also read about hospitals publishing their own data publicly and privately nudging physicians to change by keeping them informed of their own professional statistics. I promise you that physicians have access to their personal statistics, whether they access them or choose to share them publicly (or even with patients) is another story all together. There has to be that push and pull if we are going to create true lasting change.

How can you reduce your own risk?

  1. Choose a place to give birth with a lower NSTV cesarean section rate. I know that insurance plays a huge factor in this, so that isn’t always an option for everyone. We do know that your greatest risk of needing cesarean surgery is the location of your delivery.
  2. Inform yourself! Know your options & be ready for what is to come for labor and delivery. You can’t prepare for all of it, but you can at least know what to expect and how the system can sometimes set you up to fail. Know what to watch for!
  3. Hire a doula! Having a doula on your team reduces the likelihood of needing cesarean surgery to birth your child. No, we can’t prevent all cesareans, especially because some of them are very necessary and honestly can be beautiful and healing too. We can promise that having a doula on your team will help you ask great questions of your care team and hopefully feel like the most important person in the room with all the decision-making power. (Because really, you are!)

5 Induction Truths

An induction is discussed with every pregnant person at some point, & these are 5 truths you may not hear anywhere else.

1. Sometimes Induction is Necessary.

High blood pressure, blood sugar control issues, protein in your urine, health concerns for the baby, and more can make it healthier for your baby to be better on the outside than on the inside. These are very valid medical reasons to be induced. Some providers prefer inductions to take place because of suspected big babies, low fluid, getting close or passing your due date, and other reasons. As we know from the evidence, these are NOT medical indications for induction.

2. You CAN Say No.

If everything is fine with you and the baby, then it is perfectly ok to say no to an induction. Even if you are in the hospital for an induction, you are STILL allowed to say no to anything that they offer, and you should be having a true informed consent and refusal discussion for each and every procedure. This includes breaking your water, starting medications, cervical exams, internal monitoring, the type of cervical ripening medication, and ANY TIME someone wants to touch you! Signing up for an induction does not mean you leave your autonomy at the front door. You’re still the boss applesauce!

3. Induction Increases Your Risk of Needing Cesarean Surgery.

Yes, there was ONE study that found that inducing everyone at 39 weeks reduces the cesarean rate, which actually was really problematic. I have discussed this previously along with a BUNCH of other scholars, however there is far more research that says the opposite. I really appreciate Dr. Sara Wickham’s resources on induction for help making informed decisions. This is something that needs to be discussed before you agree to any induction, no matter why it is being advised.

4. Induction Affects More Than Just When the Baby is Born.

Induction is forcing your baby and body to do something before they are ready to do it on their own. Most due dates are an estimate, and none are expiration dates, as babies keep developing even after they are born. Induction interrupts the hormonal physiology of birth, as Dr. Sarah Buckley has published on extensively. Interventions also affect breastfeeding, which can make feeding your baby more challenging after an induction. This needs to be part of the discussion when you are weighing the risks and benefits of whether to choose an induction.

5. Induction Can Take a LONG Time.

Especially for first time parents, induction can take a really long time. Locally most inductions start overnight with a cervical ripening medication and then proceed the next day. Will you be allowed to eat and/or drink during that time? Will you be allowed to take a shower? Will you be on the monitors the entire time? When are you allowed to get an epidural if you want one? Will your provider be there the whole time? What kind of time limits will they put on your progress? Will there be breaks? Can you bring your Fire Stick to keep watching your current favorite binge-worthy show? Ask questions to help yourself make the most informed decisions regarding your care!

The bottom line is this: If your provider is recommending induction, have an open and honest conversation with them using the BRAIN acronym:

  • Benefits–what are the benefits to this?
  • Risks–are there any?
  • Alternatives–what else could we try?
  • Intuition–what does your gut say?
  • Nothing–what happens if we wait?

Only YOU get to decide what is the right choice, and we want to make sure everyone goes into birth and parenting with their eyes wide open from the beginning. Want to do some more digging before making a decision about an induction? Asking for TIME can be the most empowering way to step away from what can be a high pressure feeling power imbalanced situation when you are sitting there with your pants off talking to your provider. We talk to clients about this all the time, so feel free to give us a call for a consult if you want a little help!

Ask Questions!

As humans, we like to ask questions. As patients, we are often not encouraged to do so. That is a problem. You are in charge of your body. You are in charge of what happens to it. That means that nobody gets to do things to you without you saying yes; that’s bodily autonomy. You deserve to be given true information to make the best decision possible for you and your family. As a doula, I encourage my clients to inform themselves as best they can and find a provider that they trust to be able to have open and honest conversations about your care.

Misinformation can spread like wildfire, and you have to be mindful about who you are getting your information from, even when you might trust the source for other things. Just because your mother gave birth 25 years ago does not mean that she is up on all the latest evidence regarding birth practices. Just because your neighbor had a fantastic planned cesarean does not mean that committing to major surgery is what is right for you or guarantee that you will have similarly easy outcomes. The point is this: question the source and motives of anyone giving you information!

This is a short list of things I often hear about that are NOT TRUE:

  • Once a cesarean, always a cesarean. (VBAC is an option!)
  • Everyone should be induced at 39 weeks. (Nope)
  • If they think your baby is big, you have to schedule an induction or cesarean surgery. (Nope)
  • Induction is no big deal. (Not always)
  • Laying flat on your back is the best pushing position. (Not according to the evidence)
  • You are in “active labor” at 4cms. (Not since 2010)
  • There are no risks to getting an epidural. (Not true)
  • Doulas are judge-y jerks who only help people who want to go without medication! (not me) I could honestly write a whole post about ideas about doulas that are wrong, but that is for a different day.
  • Home birth is not a safe option. (There is plenty of evidence to say it is.)

The truth is that everyone you ask for their advice is informed by their own knowledge and experience. Your great-grandma may have LOVED being asleep for the birth of her children, but that just isn’t how most people choose to birth anymore. Your doctor may have had a string of 3 traumatic deliveries that they attended in the week before your appointment. Your sister may have had a medical condition that necessitated her induction. You need to make sure to temper any opinions you get with unbiased information too, and then figure out what you would like to do using the BRAIN method:

  • Benefits–Why are you suggesting this intervention?
  • Risks–Is there anything negative that could happen?
  • Alternatives–Are there other options available?
  • Intuition–What is your gut saying you should do?
  • Nothing–What happens if you do nothing?

That last one is REALLY important to remember. If nobody is in danger, it is perfectly prudent to ask for more TIME! Sometimes doing nothing is a perfectly reasonable option, and you are well within your rights to say no to interventions being offered in a non-emergent situation. Even when a non-emergent intervention such as a cesarean needs to be done, it is also perfectly ok to ask for a few moments to gather your thoughts and prepare your mind for what is to come. Though some do, not all necessary cesareans need to RUN to the operating room, and a massive shift in plans can be a bit easier to stomach if you have a moment to wrap your head around it before it happens.

The Rights of Childbearing Women is a great place to start when thinking about what you might want to question. You are not a bad patient for asking questions! Some people prefer to have a provider who tells them what to do, and that is ok too by the way, but if you prefer to have a provider who is open to communicating with you and explaining their reasoning for recommendations, I HIGHLY recommend checking out your options and knowing that you may have the option of switching providers for any reason and at ANY time. Providers all have different styles, and finding one who fits with your style is a GOOD thing. Not all providers are created equal, and sadly there are providers who are less than honest in their recommendations. Trust your gut! Don’t be afraid to speak up, ask questions, and switch if you feel like your provider is trying to push you into something you are uncomfortable with and isn’t necessary, including using coercive techniques to persuade you.

If you want to do research, here are some trusted sources for good information that I send to my clients:

If you are a childbirth professional and you want to learn more about your clients’ rights in childbirth, you can check out Birth Monopoly’s Know Your Rights course designed specifically for us in mind.

Cesarean Awareness Month

I took that picture above at Indiana University many years after I graduated and I was walking around campus with my family, and I saw the statue with new eyes–with my doula eyes. I had never seen the low-transverse incision mark on her abdomen before that day. It made me smile in admiration and wonder if it was intentional. I’ll probably never know for sure, but I like to think that it is.

April is Cesarean Awareness Month. This was started by
ICAN (International Cesarean Awareness Network) to direct attention to the fact that the cesarean rate in the United States is too high.
32% of American babies in 2017 were born via cesarean section according to the CDC. That number actually hides quite a bit though. That is the number for TOTAL cesarean births, as Jill Arnold explains on cesareanrates.org, and looking at the low risk first time cesarean data gives us a more accurate picture of what we should be targeting to change, especially given the lack of access to and support of VBAC in many places in the country. There are some amazing people working to try to reduce that first cesarean, including the American College of Obstetricians and Gynecologists with this statement originally published in 2014, and Neel Shah and his team at Ariadne Labs who are working to reduce medically unnecessary cesarean surgeries. Shah says that as many as HALF of all cesareans may actually medically unnecessary, and he is not the only one working to reduce that number!

Sometimes cesarean surgery IS necessary. Sometimes surgery saves lives. NOBODY is suggesting that there should be ZERO cesarean surgeries! I join the chorus of people saying that perhaps we should question the efficacy and long-term health consequences for individuals all the way up to the population level.

I’ve never had a cesarean section surgery personally, but I have been in the operating room as a doula for some. Cesarean surgery can be scary, especially if you don’t know what to expect and your support person doesn’t either. Many times you weren’t expecting to be in that operating room, or are questioning whether you should be there right then. Learning about what to expect before you go into the operating room is one of the things I talk about in my childbirth classes. In my first prenatal visit with my clients, we talk about birth preferences, and I always make sure to talk about cesarean birth preferences with every single client no matter what their plans are. Plans sometimes go awry, and knowing what your options are if everything else is going sideways is a great way to mitigate fear as well.

Cesarean birth IS birth, and great medical staff can make a world of difference. There are even some hospitals that will allow a doula into the operating room as a second support person, which can be extremely beneficial for parents who can often feel like strangers in a strange surgery land. I know I have learned so much each time I have been in the operating room, including how best to support a person undergoing surgery, what is normal and expected, what exactly happens in that surgery, which staff is in charge of what action, where to stand, what not to say, and soo much more.

I sincerely hope that more doulas will be allowed in the operating room as a second support person for people undergoing cesarean surgery! I hope that it becomes just one more way that doulas can support the rest of the 32% of births in this country!


Photo by Chris Ensey on Unsplash

Birth is amazing, no matter how it happens. I seriously believe that! The bravery of having your body literally sliced open to bring a child into this world is not lost on me at all. I honor and respect all cesarean parents, and know the sacrifice you have made for those tiny humans.