Regular contributor, Jacqueline Levine, shares her experiences teaching Lamaze classes and ponders the responses to the question "Why have you come to this class?" The responses motivate her to continue to teach evidence based information and provide families with the resources they need to have a safe and healthy birth. - Sharon Muza, Science & Sensibility Community Manager.

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I teach Lamaze classes to the maternity clients at a Planned Parenthood Center. Planned Parenthood supports women in all facets of their reproductive lives, including supporting a healthy pregnancy and birth. As part of the informal protocol of the first session, I ask each woman why she's come to the class. Most of the time, the answers are pretty predictable; "My sister (friend, mother, partner) said I should come", or "How does this baby come OUT?" or sometimes "I want to have a natural birth with no medication." There is always a recognizable and comfortable rhythm to these answers. Sometimes there's humor, but there's always the feeling of community; mothers-to-be will meet each other's glance and smile. At times, partners roll their eyes ceiling-ward, but the answers I hear do not discomfit, and they do not surprise. Everyone understands that we are together under the sheltering umbrella of learning about birth, about who we are in this room, at this moment and in this context; we are preparing to learn together.

I recently heard another reason for coming to class that in years past would have had me shaking my head in disbelief. "I'm here because I want to have a vaginal birth." I've tried to imagine the look on my face when I first heard those words, and I know that the class read my expression; immediately I was knocked from a comfortable and familiar path, and the lighthearted air that normally suffused the room was neutralized in an instant.

At this writing, five women in four different class series separated from each other by months, were bound together by the fear of having a cesarean. They had each come to class in order to find some sort of powerful knowledge that would stand as a barrier between themselves and cesarean birth. They were asking me (and by proxy, Lamaze) to give them an impenetrable defense, some kind of fortress of information. They were hoping for some special power or status in the world of birth, a talisman or access to some magical knowledge to stay the knife and keep it at bay. They had come to a childbirth education class for information that, in essence, would teach them how to succeed in challenging the childbirth system.

What background and history did these women bring, that they came to class with that simple but remarkable request; "I want to have a vaginal birth." When I inquired further, the answers were all about the same, each a slight variation on "Every one of my friends had a cesarean section, and I saw what happened to them, and I don't want that to happen to me."

I was sure that these women were sounding an alpenhorn blast, a call to us who support natural physiologic birth, that we have to give the women we teach an effective and powerful defense. I was handed a very real challenge.

Throughout the life of the Lamaze International, there has always been the vital re-examination and re-articulation of what Lamaze stands for. Might there be something else we need to do to prepare our clients for the general medicalization of birth. Do we need to do some refinement or expansion of or addition to our syllabi? Might there be a mini- parallel to the early days of Lamaze and other birth organizations, when there was a grassroots movement of women who wanted to be "awake and aware" during birth. Will more women begin showing up to our classes determined to avoid cesarean sections?

Inspiration for meeting this challenge from my classes resides in some of the very words on the Lamaze website describing the Healthy Birth Practices, stating that the birth practices area "supported by research studies that examine the benefits and risks of maternity care practices. Therefore, they represent 'evidence-based care,' which is the gold standard for maternity care worldwide. Evidence-based care means using the best research about the effects of specific procedures, drugs, tests, and treatments, to help guide decision-making." Keeping up with the latest best-evidence information for our clients is what childbirth educators do; we go to conferences to stay current, we spend our time and our money to make sure that we are ultra-informed. We feel that we owe it to those we teach.

In my Science & Sensibility post in May 2011 about best-evidence care and childbirth education, I described something I was doing in classes that seemed to give mothers-to-be an extra lift to their confidence. For every facet of birth covered in class, I would hand out one or more best-evidence studies, with the important parts highlighted. No one had to read the whole thing unless they wanted to, but the conclusions were glowing in yellow for all to see and everyone understood what the doctors said as they spoke to each other through the literature. It was clear that what the doctors were saying to each other was not always what they were saying to the women who were in my class.

An example; we may teach that continuous fetal monitoring doesn't change/improve outcomes for babies, but does raise the cesarean section rate. When we share the actual ACOG practice bulletin to that effect, it just makes sense that the very words in that bulletin confer a new power on our clients. It is doctors telling doctors that continuous EFM isn't effective and may cause harm. How many doctors tell women outright that CEFM is, at the very least, unnecessary for low risk moms? Authority is speaking and those are the voices that our clients must confront when they are laboring in the hospital. Now mothers-to-be can know what is said behind the scenes. They feel supported by the truths the studies tell; this first-time access to those words expands their sense of choice and control.

Does this approach work? I'm sure that it does but my proof is only anecdotal. I observe numerous Planned Parenthood Center clients and those in my private practice have births that unfold without interference. They feel empowered to "request and protest" in whatever measures are appropriate.

When the women in my class who stated they simply wanted vaginal births first announced their aim to me, I was hoping that documentation of the harms of routine intervention, liberal application of the Six Healthy Birth Practices, lots of role-play and comfort-measures practice would provide these women with the tools to confront hospital policies and routine interventions. But cesarean birth is the ultimate intervention at times.

Happily, there is much energy devoted to the avoidance of unnecessary cesarean sections from organizations like the International Cesarean Awareness Network supporting vaginal birth and bringing powerful voices to this struggle, but it's still a one-on-one moment for birthing women. They will meet that moment face-to-face with a health care provider who may push them to choose a cesarean section for any number of reasons. At the moment a doctor says "You haven't made much progress for the last two hours, there's no guarantee that your baby can tolerate labor much longer and I can have your baby out in 20 minutes," the pressure can become overwhelming for any woman.

What can we give women so that at that moment they can push back against that pressure? Is it enough to feel confident in your body? Is it enough to know the cons of unnecessary, capricious cesarean section, its dangers and possible sequelae for mother and baby that make life difficult for both when they go home? All women are entitled to know that ACOG itself does not recommend cesarean unless it is for a medical reason. While a long labor may not be convenient, labor length is not a medical reason for performing a cesarean section. Every woman should know that long labors are not, in and of themselves dangerous. ( Cheng, 2010.) To quote Penny Simkin; "Time is an ally, not an enemy. With time, many problems in labor progress are resolved." (Simkin, 2011.)

But finding the ultimate tool to give women so that they may avoid this ultimate intervention is a complicated matter. Obstetricians admit that concerns about their own possible jeopardy takes precedence over the real health status of the mother. This Medscape Medical News headline proclaims "ACOG 2009: Liability Fears May Be Linked to Rise in Cesarean Rates". The article about these fears was presented at the American College of Obstetricians and Gynecologists (ACOG) 57th Annual Clinical Meeting in May 2009. The article casts the doctor as the victim: "So don't just blame the doctor for doing a C-section, recognize that there's probably a reason that [he or she is] doing it. And that fear of litigation is the reason," concluded Dr. Barnhart. (ACOG 2009)

It's been widely reported that, according to a CDC finding in 2011, the cesarean section rate dropped for the first time in a dozen years, and it's been more recently reported that the rate has stabilized; however, it has stabilized at a at a whopping 31%. One of every three birthing women will have a cesarean surgery. (Osterman, 2013.)

Will the 2010 ACOG guidelines on VBAC have any effect on the cesarean section rate? The rate of cesareans on first-time mothers is still not declining. (Osterman, 2013.) The effect of new guidelines will be equivocal if not minimal. It's guidelines for first-time mothers that has to change, because both the hardened medical atmosphere surrounding normal, physiologic labor, and the ever-accruing protocols that lead to that primary cesarean will not be subject to new guidelines anytime soon. If women who are past their 40th week of gestation, those thought to be having babies bigger than 8lbs, plus all the women who are older than 35 are now thought to be among the acceptable candidates for VBAC, how can OBs still push for primary sections for those self-same criteria on first-time mothers?

Finding a way to inform each and every woman of the range of choices she has for her birth and supporting those choices is our ongoing mission. A hopeful sign is ACOG's call "for evidenced-based practice and greater cooperation between obstetrician-gynecologists and certified nurse-midwives/certified midwives." (Waldman, 2011) ACOG is "recognizing the importance of options and preferences of women in their healthcare"and the recommendation by ACOG that Obstetricans actively include women in the "planning of health services to reduce risk and improve outcomes" with "shared medical decision-making" (ACOG 2011.)

Yet in the labor room, day-after-day, even the most well-informed, well-prepared, experienced and determined mother may, in the last moment, have her perineum snipped by a health care provider who states "Oh, and I gave you an episiotomy because you were starting to tear..." Or there could be the doctor who shares with a mother, "I was getting nervous about the baby getting too many red blood cells" and clamps the cord a few seconds after birth, despite the parent's wishes for delayed cord clamping.

I cannot say that I will have an answer for the women who come in the future seeking answers on how to avoid a cesarean birth. I believe that these women can feel more positive when they read what Dr. Richard N. Waldman, former President of ACOG), said in his August 2010 online letter to his organization:

"...The US maternal mortality ratio has doubled in the past 20 years, reversing years of progress. Increasing cesarean deliveries, obesity, increasing maternal age, and changing population demographics each contribute to the trend. In 2008, the cesarean delivery rate reached another record high - 32.3% of all births. There is a community not far from my home in which 45% of the newborns are delivered via an abdominal incision. Let me be very honest. This increase in cesarean delivery rate grieves me because it seems as if we are changing the culture of birth. While it is certainly true that a physician has a contract with an individual patient, our specialty has a covenant with our society..."

As a childbirth educator, I am committed to teaching evidence based information, providing resources and support and helping women to have the best birth possible. Won't you join me in that goal?

References:

Cheng, Y. W., Shaffer, B. L., Bryant, A. S., & Caughey, A. B. (2010). Length of the first stage of labor and associated perinatal outcomes in nulliparous women. Obstetrics & Gynecology, 116(5), 1127-1135.

Monitoring, I. F. H. R. (2009). nomenclature, interpretation, and general management principles. ACOG Practice Bulletin No. 106. American College of Obstetricians and Gynecologists. Obstet Gynecol, 114, 192-202.

Osterman MJK, Martin JA. Changes in cesarean delivery rates by gestational age: United States, 1996-2011. NCHS data brief, no 124. Hyattsville, MD: National Center for Health Statistics. 2013.

Partnering with patients to improve safety. Committee Opinion No. 490. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:1247-9.

Simkin, P., & Ancheta, R. (2011). The labor progress handbook: early interventions to prevent and treat dystocia. John Wiley & Sons.

Vaginal birth after previous cesarean delivery. Practice Bulletin No. 115. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:450-63.

Waldman, R. N., & Kennedy, H. P. (2011). Collaborative practice between obstetricians and midwives. Obstetrics & Gynecology, 118(3), 503-504.

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