Sunday, 12 February 2012

Silent Knife, C/S prevention and VBAC...

So im half way through reading the following book, Silent Knife; Cesarean Prevention and Vaginal Birth After Cesearen...Written by Nancy Wainer Cohen and Lois J. Estner. Its honestly to most amazingly eye opening, honest book ive ever read in my life! Granted it was written and compiled in 1983 but when you read you realise that not much has changed. In fact one of the main things i am getting from this book is the fact that all this VBAC stuff and all the negative stigma surrounding it has been and is soo covered up. It still is. The only difference i see between this book written 30 years ago and todays maternity world are the statistics. In this day and age they are even more STAGGERING and DISGUSTING! (Im constantly left wondering how the authors would be feeling at todays statistics compared with then)! Within the first few pages i found myself laughing, crying, bawling and nodding my head along with EVERYTHING they had written there! I honestly have never felt so right in my opinions, decisions and how i feel. Although it is aimed at women who have had previous C/S, i believe and recommend that EVERY woman, pregnant or not should read this book!! I got my copy from the library but am now planning on buying a copy for myself to keep forever and ever and trust me, i will be reading it well after im finished having babies.

So the rest of this post is an extract from the book that im sure sums up everything beautifully! To go more in depth with everything please please please read the book...For now though, i hope this gets you all wanting more!! 

Let me start by saying.....What lead to your epidural, your induction, your Unnecessary C/S. Heres some ways to avoid another one or to avoid one altogether!

Preventing Unnecessary Caesareans

Reason for C/Sec

  Dystocia, CPD, Failure to progress, Arrest of labor, Uterine inertia, Failed induction, Failed forceps.

Avoidable factors

1.       Lack of patience with normal labor process; misinterpretation of Friedman labor curve. (It’s a mean, not a norm; there is a normal human variation in length and pattern of labor.)

2.       Recumbent position; lack of mobility in the first stage. (When a woman is upright and ambulatory, first stage is shorter, contractions stronger and more efficient, gravity helps, baby enters pelvis at a better angle, mother is more comfortable and feels less pain. Supine position leads to maternal hypotension and reduced uterine flow.)

3.       Exaggerated pushing with prolonged breath-holding in semi reclining or reclining position. (Squatting increases pelvic diameters, can increase available area 20-30%; gravity helps; baby descends at a better angle. Hard, lengthy pushes result in ineffective pushing out-of-sync with uterus’s own bearing-down efforts, as well as maternal exhaustion. Pushing with closed glottis, holding legs up, pushing with heels results in tense, tight legs, buttocks, pelvic floor and vagina, delaying baby’s descent and causing more stress on baby’s head and mother’s soft tissues.)

4.       Too hasty use of pitocin after premature rupture of membranes or after due-date; elective induction; artificial rupture of membranes early in labor. (If cervix is unready for labor, induction will be ineffective or labor prolonged. Pitocin can result in contractions too strong, long, and close together, increasing likelihood of use of analgesics or anaesthesia, and of fetal distress, discussed later in this appendix. Pitocin associated with excessive third-stage bleeding and neonatal jaundice. With precautions, risk of infection after ruptured membranes very small in healthy, well nourished women. Induction solely on the basis of dates runs risk of premature baby if dates wrong; there is a normal variation in length of gestation. Artificial rupture of membranes removes protection for baby's head, can lead to excessive molding; increases likelihood of infection with internal exams, leads to concern over length of labor because of fear of infection.)

5.       Fasting in labor. (Labor is hard physical work and requires lots of calories to burn. Digestion slows down in active labor, but continues slowly. A 5% glucose solution insufficient to supply energy needs. Times when inhalation anaesthesia required are rare; fasting does not eliminate the risk of acid aspiration; effects on maternal and fetal metabolism and uterine functioning of prolonged fasting not clearly known.)

6.       Narcotics in first stage. (Central nervous system depressants can slow uterine functioning, especially if given in the latent phase or if labor is progressing slowly already.) Epidurals in the first or second stage. (Slow first stage by withdrawing blood from uterus and retarding uterine functioning; slow second stage by eliminating urge to push, weakening abdominal muscles; higher incidence of failure of baby’s head to rotate.)


1.       Trust in a woman’s body unless clear clinical signs of fetal or maternal distress; stay at home until at least 5cms; go home if you arrive at the hospital and your less than 5cms.

2.       Stay out of bed and WALK! Avoid semi reclining and reclining positions; no I.V unless indicated for a specific reason, then on mobile stand; monitor by auscultation unless electronic fetal monitoring is specifically indicated, then alternate fetal monitoring with long periods of walking.

3.       Avoid semi reclining and reclining positions for second stage; squat, kneel, stand or sit on toilet, especially if second stage is long or uncomfortable; use these or side lying position to rotate posterior or transverse head. Push only with the body’s own rhythm;  mother avoid holding legs up, pushing with heels, or closing glottis; mother emphasize opening up and tuning into body’s own signals, not technique.

4.       No Pitocin after ruptured membranes unless signs of infection are present; wait at home for labor to start (risk of infection and anxiety both lower there); eat at will and drink lots. No post-dates induction unless signs of placental deterioration. NO elective induction (Banned by FDA). No artificial rupture of membranes except in late labor in a few selected cases.

5.       Eat at will in labor; drink lots!

6.       No narcotics or epidurals. Walking or other positions, relaxation, massage, shower and bath, breathing patterns, loving support and touch, and encouragement instead.

7.       Increase mothers self-confidence by emphasizing birth as a normal physiological function, not only in childbirth classes and during pregnancy, but from childhood; give extra support in labor; stay at home in early labor; improve community options for safe out-of-hospital births and alternative in-hospital births.

Reason for C/Sec

Fetal distress

Avoidable factors

1.       Misinterpretation of electronic fetal monitoring tracings. (Tracings are difficult to interpret, as some variations are normal; electronic monitoring produces many false positives.) Reliance on electronic fetal monitoring for diagnosis. (According to NIH, this is a screening, not a diagnostic tool.)

2.       Reclining position. (Supine position can cause maternal hypotension, reduce blood flow to the uterus; labor less efficient and prolonged.)

3.       Narcotics. (Central nervous system depressants can depress maternal respiration; cross placenta quickly and can depress fetus, especially if already stressed.) Epidurals. (Can lead to maternal hypotension, withdraw blood from uterus, as well as prolong labor.)

4.       Pitocin. (Can cause contractions too long, strong and close together for baby to recover oxygen supply inbetween, especially if already stressed; increases maternal discomfort and anxiety, raises likelihood of the use of narcotics and/or epidurals.)

5.       Exaggerated pushing with prolonged breath-holding (Valsalva maneuver). (Can reduce oxygen to baby by retarding blood return through extreme intrathoracic pressure, and by using up oxygen with mothers own efforts; supine position leads to maternal hypotension and reduced uterine blood flow.)

6.       Hyperventilation. (By several mechanisms, reduces oxygen available to baby.)

7.       Maternal anxiety. (Reduces blood flow to uterus and oxygen available to baby.)


1.       Monitor by auscultation unless electronic monitoring specifically indicated (according to NIH, no benefit of EFM over auscultation demonstrated, except in high-risk cases.) Confirm diagnosis with fetal scalp sampling before intervening.

2.       Stay upright, out of bed, or on side.

3.       No narcotics or epidurals.

4.       Use pitocin rarely and sparingly; turn down once labor established. Stimulate labor by giving the mother a rest, getting her up to walk, helping her to relax, or stimulating nipples, instead of pitocin.

5.       Push physiologically with body’s own rhythms, in upright or side-lying position; hold breath no longer than 6-7 seconds.

6.       Help mother relax upper body, avoid rapid breathing.

7.       Help mother relax; see earlier paragraphs of alternatives.

Reason for C/Sec

Breech presentation.

Avoidable factors

Automatic, blanket rules about how to deliver breech babies.


Prenatal exercise to turn baby; external version; ultrasound at labor onset and trail of labor; skilled, confident midwife or Obstetrician

Reason for C/Sec

Toxaemia, Hypertension, Placental abruption, Placental insufficiency, Premature birth, Low birth weight.

Avoidable factors

Inadequate nutrition during intrauterine life, childhood, adolescence and pregnancy. Use of drugs in pregnancy-prescription, over the counter and recreational, including alcohol, caffeine and especially smoking. Restriction of blood volume and placental size by restricting salt intake or using diuretics.


Education about nutrition and use of drugs in pregnancy, before pregnancy begins, in early pregnancy, and in childbirth classes. Avoid ALL drugs if possible. Avoid use of diuretics, salt to taste; increase protein intake, maintain fluid and salt intake, if fluid retention and high blood pressure become problems.

Reason for C/Sec

Previous Caesarean or previous multiple Caesareans.

Avoidable factors

Automatic, once-a-C/S-always-a-C/S policies. NIH and ACOG have both stated that VBAC is safe in most cases. 2-4 times greater risk of maternal mortality, increased risk of maternal morbidity and neonatal respiratory disease with elective repeat caesarean. Increased maternal-infant separation, stress on attachment process, decreased maternal self-esteem all may follow C/S. Risk of dishence (separation) of lower segment (horizontal) scar about 0.5%, with risk of serious rupture much less. Risk of maternal or fetal death little or no higher than without previous C/S.


Labor and vaginal birth unless new indication for C/S in this pregnancy.

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