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Episode 282 What You Need to Know About Assessing Risk

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Nội dung được cung cấp bởi Meagan Heaton. Tất cả nội dung podcast bao gồm các tập, đồ họa và mô tả podcast đều được Meagan Heaton hoặc đối tác nền tảng podcast của họ tải lên và cung cấp trực tiếp. Nếu bạn cho rằng ai đó đang sử dụng tác phẩm có bản quyền của bạn mà không có sự cho phép của bạn, bạn có thể làm theo quy trình được nêu ở đây https://vi.player.fm/legal.

Hearing about risk is hard. Interpreting risk is even harder, but deciding which risks are comfortable for you is an essential part of birth!

Meagan and Julie discuss how to tell the difference between relative and absolute risk, and what kind of conversations to have with your provider to help you better understand what the numbers mean.

They also quote many stats and risk percentages around topics like blood transfusions, uterine rupture, eating during labor, epidurals, Pitocin, AROM, and episiotomies.

And if you don’t feel comfortable with accepting a certain risk, that is OKAY. We support your birthing in the way that feels best to you!

Risk of Uterine Rupture with Vaginal Birth after Cesarean in Twin Gestations

Journal of Perinatal Education Article

What are the chances of being struck by lightning?

Needed Website

How to VBAC: The Ultimate Prep Course for Parents

Full Transcript under Episode Details

02:52 Review of the Week

06:08 Determining acceptable risk for you and your provider

08:00 Absolute versus relative risk

15:21 More conversations need to happen

25:29 Risk of blood transfusion in VBAC, second C-section, and third C-section

30:37 Understanding the meaning of statistical significance

32:05 “The United States is intervention intensive”

36:27 Eating during labor and the risk of aspiration under anesthesia

43:03 Epidurals, Pitocin, AROM, episiotomies, and C-section percentages

44:43 The perspective of birth doulas and birth photographers

Meagan: Hello, hello everybody. Guess who I have today? Julie!

Julie: Hello.

Meagan: Hello. It’s so good to have you on today.

Julie: Of course. It’s always fun to be here.

Meagan: It really is. It’s so fun. When we sit and chat before, it just feels so comfortable like that is the norm still for me even though it has been a while, it just feels so normal and I love it. I miss you and I love you and I am so excited to be here with you today.

You guys, we are going to talk a little bit about risk. We know that in the VBAC world, there’s a lot of risk that comes up. I should say a lot of talk about risk that comes up whether it be is it safe to even have a VBAC? Is it safe to be induced? What are our real risks of uterine rupture? Is it safe to VBAC with an epidural or without an epidural? What about at home out of the hospital? Is that safe? I don’t know. Let’s talk about that today.

Julie: Let’s talk about it.

Meagan: Let’s talk about it. I think it’s really important to note that no matter what— and we’re going to talk about this for sure today, but no matter what, you have to take the risks that you are presented and that is given and still decide what’s best for you. That risk doesn’t mean that is what you have to or can’t do. Right?

So I think while you are listening, be mindful or kind of keep that in the back of your mind of, “Okay, I’m hearing. I’m learning.” Let’s figure out what this really means and then let’s figure out what’s truly best for you and your baby.

02:52 Review of the Week

I do have a Review of the Week so I want to hurry and read that, then Julie and I will dive into risk and assessing.

Julie: Dun dun, we’re ready.

Meagan: We are ready.

Okay, holy cow. This is a really long review, so—

Julie: You can do it.

Meagan: Thank you to Sara R-2019 on Apple Podcasts for leaving this review. I love how Julie was like, “You can do it,” because she knows that I get ahead of what I’m reading in my mind and then I can’t read, so let’s see how many times it takes to read this review.

Julie: You’ve got this.

Meagan: Okay. It says, “A balanced and positive perspective.” It says, “As a physician myself I think it is unusual to find balanced resources for patients that represent the medical facts but also the patient experience and correct for some of the inaccuracies in medicine. This podcast does an amazing job of striking this balance!

“I had an emergency C-section with my daughter 2 years ago. Despite understanding that the CS was medically appropriate and my professional experience, I still found the whole experience to be mildly traumatic and disappointing. This podcast was the main resource I used to help prepare for my second child’s birth and my plan to have a VBAC. I am now holding my new baby in my arms with so much pride, love, self-confidence, and trust because I had a smooth and successful VBAC.

“I am thankful for this podcast which gave me ideas, confidence, strength, and a sense of community in what is otherwise a very isolating experience. I especially appreciate the variety of stories that are shared, including VBAC attempts that result in another C section so that we can all prepare ourselves for the different outcomes. No matter what happens we are strong women and have a welcome spot in this community, even when we may feel alone with our thoughts and fears. Thank you, Julie and Meagan!

Julie: Aw, I love that.

Meagan: Yes, that was phenomenal. Congratulations Sara R-2019. If you are still listening here, congratulations and we are so happy for you and thank you for your amazing review.

06:08 Determining acceptable risk for you and your provider

Meagan: All right, Julie. Are you ready?

Julie: Here we go. Here we go. Can I talk for a minute about something you mentioned before the review? You were talking about risk and how it’s not a one-size-fits-all because we were talking about this before. We all know that the uterine rupture risk is anywhere between .2%-1% or whatever depending on the study and what you look at. The general consensus among the medical community is .5%-1% is kind of where we are sitting, right?

Now, some people might look at that risk and be like, “Heck yeah. That’s awesome. Let’s do this,” especially when you look at a lower risk than that that it’s a catastrophic rupture. Some people might look at those numbers and be like, “This feels safe. Let’s go.” Some people might look at those numbers and be like, “This feels scary. I just want to schedule a C-section.”

Meagan: No, thank you.

Julie: And that’s okay. It is okay. However you approach risk and however you look at it is okay. We’re not here to try and sway anybody. Obviously, we’re The VBAC Link, so we are going to be big advocates for VBAC access, right? But we’re also advocates for having all of the information so you can make the best decision no matter what that looks like. But also, I think another very important part of that is finding a provider whose view of risk is similar to your view of risk so that you guys have a similar way to approach things because if you find a provider who thinks that 1% risk of VBAC is really scary, it’s not going to go good for you if you think a 1% risk for a VBAC is acceptable.

So yeah, I just want to lay that out there in the beginning. Meagan, you touched on it in the beginning, but I feel like provider choice in risk is really important there.

Meagan: It is.

Julie: For sure.

08:00 Absolute versus relative risk

Meagan: It is and also, one of the things we wanted to talk a lot about is absolute risk versus relative. So many times when people, not even just the actual percentage or 1 out of 5 is shared, it’s the way it’s shared. The way the words are rolling off of the tongue and coming out can be shared in a scarier way so when we say 1 out of 5, you’re like, “Okay, that’s a very small number. I could easily be one of those 5’s.” It’s the way these providers sometimes say it.

A lot of the time, that’s based on their own experience because now they are like, “Well, I am sharing this number, but I’m sharing a little extra behind the number because I’ve had the experience that was maybe poor or less ideal.”

Does this make sense?

Julie: Yeah.

Meagan: Sometimes the way we say things makes that number seem even bigger or even worse or scarier.

Julie: Right. It really comes down to absolute risk versus relative risk, right? Relative is your risk in relation to another thing that has risk. Absolute risk is the actual number. It’s like 1 in 10. That is an absolute risk. You have a 1 in 100 chance of uterine rupture. That is an absolute risk. Your chance of uterine rupture doubles after three Cesareans. That’s not true. That’s not true. But that’s a relative risk.

I really like the example that I feel is really common for people to relate to is stillbirth after X amount of weeks. Evidence-Based–

Meagan: That’s a huge one.

Julie: Yeah, it’s a big one that gets thrown around all of the time and it sounds really scary when people say it. I love Evidence Based Birth. They have this whole article about due dates and risks associated with due dates and why due dates should really be adjusted and look at differently. They don’t say that. They just present all of the data, but what I really like about that is they have a section here about stillbirth and they talk about absolute risk versus relative risk. I feel like that would be a great thing to start with.

I’m just going to read it because it’s so well-written. They said, “If someone said that the risk of having a stillbirth at 42 weeks compared to 41 weeks is 94% higher, then that sounds like a lot.” Your risk of stillbirth doubles at 42 weeks than if you were to just get induced at 41 weeks. Your baby is twice as likely to be stillborn if you go to 42 weeks.

Meagan: Terrifying.

Julie: Okay? 94% higher. That’s almost double. That is scary. For me, I’d be like, “Uh, yeah. That is super scary.”

Meagan: Done. Sign me up for induction.

Julie: Right? Sign me up for induction. But when you consider the actual risks or the absolute risks, let’s just talk about those numbers. 1.7 per 1,000 births if they are at 41 weeks. Stillbirth is 1.7 per 1000 births. At 42 weeks, it’s 3.2 per 1000 so it’s a .17% chance versus a .3% chance so you are still looking at really, really, really small numbers there. So yeah, it’s true. 3.2 is almost double of 1.7 if you do the math. Sometimes math is hard so that’s fine. We have to get out the calculator sometimes, but while it’s true to say the risk of stillbirth almost doubles at 42 weeks, it could be kind of misleading if you’re not looking at the actual numbers behind it.

So I think that it’s really important when we’re talking about risks and the numbers and statistics to understand that there are different ways of measuring them and different ways of looking at them and different ways of how they’re even calculated sometimes. So depending on how you look at them, you could even come up with different risks or different rates which can really sway your decision.

We’re not talking about a 5%-10% double which is still true. It’s still double, but it’s just a really small number. Now, I also want to do a plug-in for people who have been in that .3%. It might as well be 100%. I can’t even imagine the trauma of having to have a loss like that. I can’t. I have supported parents through that. I have documented families like that and documented their sweet babies for them. I can’t imagine the pain that goes with that.

But I also think it is very important to look at the actual numbers when you are making a decision. Now, maybe that .32% is too high for you and that’s okay, but maybe it’s not and that is a risk you are willing to accept. I feel like approaching it like that is so much better. If somebody ever says to you, “This risk of that is double” or whatever, I don’t know.

I’m just going to make up some random stuff here like, “If you drive in your car to school, you have a 1 in 10 chance of getting in a car crash but if you drive on a Wednesday, your risk doubles so now you have a 2 in 10 chance or 1 in 5 chance of getting in the car crash,” so maybe you would want to avoid driving to school on Wednesdays, but maybe you wouldn’t. But if you say you’re risk is higher of dying in a car crash if you go to school on Wednesdays, they would be like, “I’m not leaving the house on Wednesdays or ever.” I’m not leaving the house today because it’s so dog-gone cold and I’m warm in my blanket.

I don’t know. I feel like looking at it like that. Actually, 1 in 10 is really high for getting in a car crash, but I don’t know. I just feel like looking at that is really important for providers telling you, “Oh, your risk of uterine rupture doubles if we use Pitocin so I’m not going to use Pitocin.” Okay, we’re looking at a small increase to an already small risk. We know that any type of artificial induction could lead to an increased risk of uterine rupture especially if it’s mismanaged, but what we do know is that it’s not– I don’t want to say that because that might be wrong.

When you are presented with the actual numbers, yes. It might double. I don’t know what the actual numbers are, to be honest off the top of my head. I feel like maybe it doubles, but if you are already looking at a .2% to a .4% or a .5% to a 1% chance, what’s the tradeoff there? What are your risks of just scheduling a repeat C-section instead of doing an induction? Is that worth it to you? What are the risks associated with repeat Cesareans? Are they bigger than that of using Pitocin to induce labor? What is that compared to the other one because there is another that is relative risk? The absolute risk is what the percentage is. I’m not even going to say the number.

But if there’s a risk of rupture using Pitocin relative to the risks that come with repeat Cesareans, those are risks that are relative to each other, so how does that compare? Because when we talk about it in just that singular form or that singular amount of risk without considering the other risks that might be associated with it because of the decisions we made from that risk– am I making sense here? Then you know, I don’t know. I feel like there is just a lot more conversation to have sometimes when we are talking about risk.

15:21 More conversations need to happen

Meagan: Yes. There are. There is a ton more conversation and that is what I feel like we don’t see happening. There’s a quick conversation. Studies show that 7 minutes are spent in our prenatal visits which is not a lot of time to really dive into the depths of risk that we are talking about when we say, “We can’t induce you because Pitocin increases–”. This is another thing I’ve noticed is significantly. You have a serious–. Again, it comes down to the words we are using. Sometimes in these prenatal visits with our providers, we do not have the time to actually break down the numbers and we’re just saying, “Well, you have a significantly higher risk with Pitocin of uterine rupture so we won’t do that.”

When we hear significantly, what do we do? We’re like, “Ahh, that is big.” You know?

Julie: Yeah.

Meagan: We’re just not having the conversation of risk enough and again, it’s kind of being skewed sometimes by words and emotion. We were talking about this before. I remember we made a post– I don’t know, probably a year and a half ago maybe. It seems like a while ago about the risk of complications in a repeat Cesarean meaning you have a C-section and then instead of going for a VBAC, you go for a repeat Cesarean which as you know, if you’ve been with us, is totally fine and respected here from The VBAC Link.

A lot of the time, we don’t talk– and when I say we, I mean the world. We don’t talk about the actual risk of having a repeat Cesarean, right? Don’t you feel like that, Julie? I don’t know. As a doula, I feel like our clients who want to go for VBAC know a little bit more of the risk of having a VBAC, but they have not been discussed at all really with the risk surrounding a repeat Cesarean. We made a post talking about the risks of repeat Cesarean and I very vividly remember a lot of people coming at us with feeling that we were fearmongering.

Julie: Or shaming.

Meagan: Shaming, yep. A lot of people were feeling shamed or disrespected. People would say, “You claim to be CBAC supportive, but here you are making these really, really scary numbers.” Anyway, looking at that post and going into what we’ve talked about, in some of those posts, we did say things like, “You are going to have a 1 out of 10 chance of X, Y, Z,”

Julie: Or twice as likely to need this. Twice as likely to need a blood transfusion or 5x more likely to have major complications. Things like that.

Meagan: Yeah. We would say things like that. I remember specifically in regards to miscarriage. It’s a very, very sensitive topic, but there are risks there. So a lot of people were triggered. In the beginning, we talked about the way providers say things and the way they put them out on paper and the absolute risk versus the relative and way they do that. We’re guilty of that too. Right here at The VBAC Link, we were like, “This is the chance. These are the chances. You are 5x more likely to X, Y, Z.” So know that I don’t want to make it sound like we are shaming anybody else for the different ways that they give the message of risk. Am I making sense?

Julie: Yeah, and you know what? I feel like sometimes it’s just about giving people the benefit of the doubt. We want to give providers the benefit of the doubt just because it’s probably something that they’ve continuously heard and spoken and that’s okay because we do it too sometimes. We go on that thing like, “Oh my gosh, maternal death.” I think the risk of maternal death is 10x higher in a C-section than it is in a VBAC which sounds really scary and makes me never ever want to have a C-section again, but when you look at that, it’s .00001% to .0001% or whatever is 10x more. It is such a small level of risk, but it is higher.

I feel like trying to look at both absolute and relative risk for any given thing together is really, really important. Yeah. Give people the benefit of the doubt. Give us the benefit of the doubt. We are in such an awful cultural climate right now where it’s easy for people, especially on social media to jump on the attack train for anybody when we feel triggered or when we feel like people are being unjust to us or to other people and I hate that so stinking bad.

Whenever I catch myself with those feelings, I try to take a step back and I’ve actually gotten pretty good at that, but it’s so easy for us to get on that bandwagon of just railing against people who present information in certain ways or railing people without getting all of the information about that person.

Before I go off too much on a soapbox in that direction, yeah. I feel like your provider when they are saying those things is probably not trying to coerce you into anything. Our providers, especially our hospital providers are incredibly overworked. They are incredibly stressed. Their time management skills have got to be off the charts because they are so overloaded with everything and they just don’t have time to automatically sit down and explain things.

But you know what I have found? Most of them, when you stop them and ask questions, they are more than happy to answer and explain. Sometimes, they are just repeating things they have heard all the time or that they have learned at some point or another without giving them a second glance.

Do you know what? We all do that too. Me, Meagan, you listening right now. We all do that. We hear things. We regurgitate them. We hear things. We regurgitate them and we don’t even think about questioning or challenging those things until somebody else brings it up to us to question or challenge those things.

So, don’t be afraid to ask your provider for more information or ask them what the real numbers are to those things. I have a really special place in my heart for our CBAC moms because there are lots of things that they are working through, so many emotional things, but I challenge not just people who have had a repeat Cesarean that was unwanted, but people just in all life, when something triggers you online, stop and explore that. Stop and question because that is probably an area of your life that you could use a little healing and work on. It could be a little bit of work. It could be a lot of work, but usually, when something triggers you, it’s a challenge to look into it more because there is something that your body and mind have an unhealthy relationship with that needs to be addressed.

Julie: Anyways, circling it back to risk. Meagan, take it away.

Meagan: I just want to drop a shameless plug on our radical acceptance episodes that we did, so kind of piggybacking off of what she just said. We dive into that a little bit deeper in our radical acceptance episode. It really is so hard and like what she said, our heart goes out to moms that have a scheduled C-section that didn’t want to schedule a C-section or felt like they were in a corner or felt like that was the best option, but not the option they wanted. There are so many feelings, but definitely go listen to radical acceptance part one and part two.

25:29 Risk of blood transfusion in VBAC, second C-section, and third C-section

Meagan: I just want to quickly go down a couple of little risks. Blood transfusion– we have a 1.89% or 1 in 53 chance of a blood transfusion with a VBAC. To me, 1.89% is pretty low, to me, but it might not be to some. I don’t know, Julie. How do you say the other? Okay, then blood transfusion in a repeat Cesarean is 1.65% in the second C-section. It’s lower. So for vaginal birth, it’s higher. I’m not good at math.

Julie: No, vaginal birth, yeah. That’s true. So 1 in 53 for VBAC versus a 1 in 65 for a repeat Cesarean. Yes, right.

Meagan: For a third Cesarean, the chances of a blood transfusion go to 2.26%.

Julie: Yes, so it’s like 50% higher than if you have a VBAC for the third Cesarean, but it’s slightly lower for the second C-section. See? I feel like we could have talked about this before, but I don’t know if we say it often enough. When you are talking about overall risk for VBAC versus C-section, when you are looking at just the second birth, right? So first birth was a C-section, what are you going to do for your second birth? The risks overall are pretty similar for vaginal birth versus Cesarean. The overall total risk is pretty similar as far as your chances of having major complications and things like that.

But when you get into three, four, five, six C-sections and vaginal births, that’s when you really start to see significant changes in those risks. See? I used the word “significant” again, but we’re going to talk about where the more C-sections you have, the higher your chances of having complications you have. The more vaginal births you have, your chances of complications actually go down.

So when you are looking at if you want more than two kids, that might be something that you want to consider. If you are done with two kids, then that might be something that is not as big of a player in your choices. So yeah.

Meagan: Yeah. Then there are things like twins. So when I was talking about it earlier, the word significantly, there was a systematic– I almost said something– systemic.

Julie: Systemic review?

Meagan: Yeah, see? I can’t say it correctly. I can’t. Published– oh, I’m trying to remember when it was published. We will get it in the show notes. It talks about the risk of uterine rupture with twins and it does say. It says “significantly higher in women with twin gestation”. That’s kind of hard, I feel like because again, like we were saying, some reviews and studies and blogs and all of these things wouldn’t say the word significantly. They may share a different one. I’m going to see if I can find the actual– maybe Julie can help me while I’m talking– study.

Okay, it says three out of four studies in a group of zero cases of uterine rupture. Notably, the study with the largest patient population reported cases of uterine rupture in both groups and demonstrated a significantly greater risk of uterine rupture in the VBAC group. Meanwhile, the other three studies found no significant difference between rates of uterine rupture among groups 31-33. Nevertheless, the study shows that electing–”

Okay, so I’m just going to say. It says, “Electing to have a PRCD reduces but does not eliminate the small risk of uterine rupture.” So what I’m reading here is that in some of them, it showed significantly greater, but then in 3 out of 4 reviews, and I don’t even know actually how many people were in each of these reviews, but in 4 reviews, one had a greater risk and three didn’t really show much of a difference, but we see that in the very beginning right here. “Uterine rupture is significantly higher in women with twins.” What do you think? If you are carrying twins and you see that, Julie, significantly higher enters into the vocabulary at all, what do you think?

Julie: Well, I think I would want to schedule a C-section for my twins, probably.

Meagan: Probably.

30:37 Understanding the meaning of statistical significance

Julie: I want to just go off on a little tangent here for a second. I think it’s really important when we are talking about studies that we know what statistically significant means because sometimes if you don’t know much about digging into studies and things like that which I’m not going to go into too much right now–

Meagan: It’s difficult.

Julie: It is difficult. It’s really hard which is why I’m not going to go into it because I feel like we could have a whole hour-long podcast just for that. Statistically significant really just means that the difference or the increase or the change that they are looking into is not likely to be explained by chance or by random numbers which is why when you have a larger study, the results are more likely to be statistically significant because there is less room for error basically.

A .1% increase can be just as statistically significant as a 300% increase because it just comes down to whether they are confident that it is a result that is not related to any chance or external environmental factors. I feel like it’s really important to clarify that just because something is statistically significant doesn’t mean that it’s big, catastrophic, or a lot, it just means that it’s not likely to be due to chance or anything random.

32:05 “The United States is intervention intensive.”

Meagan: Yeah. I love that. Okay. There was one other thing I wanted to share. This was published in the Journal of Perinatal Education and it is a little more dated. It’s been 10 years or so, but I just wanted to read it because it was really interesting to me. It doesn’t even exactly go with risk and things, but it just talks about your chances which I guess, to me– do you know what I”m trying to say?

Julie: They kind of go hand in hand.

Meagan: To me, at least, they do. So when I read this, I was like, “Well, this is interesting.” I just wanted to drop it here and I think it’s more just eye-opening. It says, “Maternity care in the United States is intervention intensive.” Now, if we didn’t know this already, I don’t know where I’ve been in the doula world for the last 10 years. Right? You guys, as doulas, obviously, we’re not medical professionals, but as doulas, we see a lot of intervention and a lot of intervention that is completely unnecessary and a lot of intervention that leads to traumatic birth, unexpected or undesired outcomes and then they lead to other unnecessary interventions. It’s the cascade. We talk about the domino effect or the cascade of interventions, but this is real so for them to type out, “Maternity care in the United States is intervention intensive–”

Julie: You’re like, “Yeah, where have you been?” Not you, but the writer.

Meagan: Yeah, the writer. Yeah. It says, “The most recent national survey–” Now, again keep in mind it is 2024. This has been a minute since this was written.

Julie: About 10+ years.

Meagan: 10-12 years. Just keep that in mind. But it was interesting to me that even 10-12 years ago, this was where we were at because I feel like since I started as a doula, I’ve seen the interventions increase– the inductions, the unnecessary Cesareans increase a lot.

Julie: Some of them, yeah. Yeah, especially inductions and Pitocin.

Meagan: Not all of the time. I cannot tell you that in 10 out of 10 births that I attend, this is the case but through the years of me beginning doula work and what I have witnessed, it’s increased. At least here in Utah, it seems that it has increased.

It says, “The most recent national survey of women’s pregnancy, birth, and postpartum experience reports that for women who gave birth in June 2011-2012,” so a little bit ago, “89% of women experienced electronic fetal monitoring.” Okay.

Julie: That seems actually low to me for hospital births.

Meagan: It does seem low because to me–

Julie: I wonder if there had been a ton of stop and drops or something.

Meagan: I don’t know, but I agree. 89%. I feel like the second you get into the hospital, no matter VBAC or not, they want to monitor your baby.

Julie: Strapped onto the monitor, yeah.

Meagan: It says, “66% continuously.” So out of the 89%, it says 66% were continuously meaning they didn’t do the intermittent every 30 minutes to an hour checking on baby for a quick 15 minutes to get another baseline, they just left that monitor on them which makes me wonder why. Usually, when a client of mine goes in and has that, they’re like, “Oh, your baby had a weird decel so we are going to leave the monitor on longer,” and then they don’t say anything. They just keep it on there. Maybe that’s– I don’t know.

It says, “62% received intravenous fluids.”

Julie: IV fluids.

Meagan: Which to me, is also a lot.

36:27 Eating during labor and the risk of aspiration under anesthesia

Meagan: “79% experienced restrictions on eating.” 79%. You guys, we need to eat. We need to fuel our bodies. We are literally running a marathon times five in labor. We shouldn’t be not eating, but 79% which doesn’t surprise me, and “60% experienced restrictions on drinking in labor.” Why? Why are we being restricted from drinking and eating in labor unless we have other plans for how labor may go?

Julie: That’s exactly what it is. They’re preparing you for an emergency Cesarean. That’s what they’re doing. That’s exactly what restricting non-IV fluids is. It’s not only that, but it is preparing you for the incredibly low risk of you having to go under general anesthesia, and then even people that go under general anesthesia have an incredibly low risk of aspirating and that is what it’s coming down to. Don’t even get me started on all of the flaws in all of the studies that went over aspiration during general anesthesia anyway because they are so significantly flawed that we are basing denying women energy and fuel during labor based on flawed studies that are incredibly outdated and on incredibly low risk during an incredibly already low risk.

I mean, you probably don’t want to down a cheeseburger while you’re having a baby. I don’t know. Maybe me. Just kidding. Even I didn’t want a cheeseburger, but I wanted some little snacks, and some water to keep you hydrated. Yes. Oh my goodness. Let’s please stop this. Sorry. Stepping off the soapbox.

Meagan: You know, there is a provider here. I actually can’t remember her name. It was way back in the beginning of my doula career and actually, it was in an area that is not one of my more common areas to serve. It was outside of my serving area. Anyway, we were at a birth and there was an induction. I remember being in there with her and the provider, an OB, walks in and is like, “Hey, how are you doing?” He was so friendly and kind and asked some questions like, “How are you feeling? What are you thinking about this?”

Then she was getting ready to leave and she turned back and said, “Hey. I just thought about this. Have you eaten anything?” The mom was like, “No.” She was like, “Uh, you need to eat.”

Julie: Yeah!

Meagan: She had an epidural at this point. The mom was like, “Wait, what?” She was like, “You need to eat.” I literally remember my jaw falling, but had to keep my mouth up because I didn’t want to look like I was weird.

Anyway, I said, “That’s something I’ve not usually heard from an OB especially after someone’s had an epidural.” She was like, “Oh, I am very passionate about this.” She was like, “When I was finishing up school and graduating,” she had to write some big thing.

Julie: Her dissertation probably.

Meagan: Time capsule, I don’t even remember what it was called. Some really, really big thing. She was like, “I specifically found passion about the lack of eating and drinking in labor.” She was like, “I did all of this stuff and what I found was you are more likely–” Here comes risk. “You are more likely to be struck in the head twice by lightning–” This is what she said. “Twice by lightning than you are to aspirate in a Cesarean after having an epidural.”

Julie: I love this lady. Who is it?

Meagan: I can’t remember. I will have to text my client.

Julie: Where was it? What hospital?

Meagan: It was up in Davis County.

Julie: Oh, interesting.

Meagan: It was not an area for me. I said, “Whoa, really?” She said, “Yeah. You need to get that girl some food.” I was like, “Done. 100%.”

Julie: More likely to get struck by lightning.

Meagan: More likely to get struck by lightning twice in the head than you are to aspirate in a Cesarean after receiving an epidural. That stuck with me forever. Literally, here we are 10 years later.

Julie: I love that because first of all–

Meagan: I don’t have documentation to prove that. She just said that.

Julie: That is 100% relative risk. Aspirating during a C-section relative to getting struck by lightning twice. So that’s cool. What are the numbers? I know that the numbers are super incredibly low and I feel like when you put in context like that, getting struck by lightning twice, I don’t know anybody that’s been struck by lightning once and who has been alive to tell about it. I know of a friend whose sister got struck by lightning and died when she was very young. I only know one person in my entire life who has been struck by lightning.

Meagan: I just looked it up really quick. I don’t even know if this is credible. I literally just looked it up really quickly. It says that the odds that one will be struck by lightning in the US during one’s lifetime is 1 in 15,300.

Julie: Wow.

Meagan: Okay.

Julie: So twice that is 1 in 30,000. That’s a freaking low risk. Anyway, what I’m saying is that I love that OB first of all. I feel like from what I’ve read about aspiration under general anesthesia during a C-section seems right in line with those numbers and those chances because it’s so rare, it’s almost unheard of especially now with all of the technology that we have.

It’s fine because I’m not going to go on that soapbox. I love that. I love that analogy and that we’re talking about that because 10 years from now or when our daughters are having babies, they’re going to talk about how their poor moms couldn’t eat when they were in labor because of the policies just like we talk about the twilight sleep and how our poor grandmas had to undergo twilight sleep when our moms were being born.

I feel like that’s just going to be one of those things where we will look back and be like, “What were we thinking?”

43:03 Epidurals, Pitocin, AROM, episiotomies, and C-section percentages

Meagan: Okay, I’m going to finish this off. It says, “67% of women who gave birth vaginally had an epidural during labor and 37% were given Pitocin to speed up their labors.” Sorry, but come on. That also may go to show, that we’re going to do an epidural episode as well, that epidural maybe does really slow down labor. Maybe it really does impact the body’s response to continuing labor in a natural way, so 31% of those people had to have help and assistance.

It says, “20% of women had their membranes artificially ruptured,” which means they broke your bag of water artificially with the little whatever, breaking bag water hook thing versus it breaking spontaneously.

Julie: Amniohook. Is it an amniohook?

Meagan: Amniohook, yeah.

“17% of women had an episiotomy.” I don’t know.

Julie: I feel like those numbers are probably lower now.

Meagan: I think that’s changed, yeah. “31% had a Cesarean.”

Julie: That is right in line with the national average.

Meagan: It is, still. “The high use of these interventions reflects a system-wide maternity care philosophy expecting trouble. There is an increasing body of research that suggests that the routine use of these interventions rather than decreasing the risk of trouble in labor and birth actually increases complications for both women and their babies.”

44:43 The perspective of birth doulas and birth photographers

Julie: I believe it. Do you know what? Can I just get on another tangent here because I know that you all love my tangents? I really wish that somebody somewhere would do something and I don’t know what that something is, to get the voices of birth doulas and birth photographers heard because this is why. Doulas and birth photographers– I’ve said this before. We see births in all of the places. We have a really, really unique point of view about birth in the United States because we attend births at home. We attend unassisted births. We attend births at home with unlicensed providers. We attend births at home and births at birth centers with licensed providers. We attend in-hospital births with midwives and we attend in-hospital births with OB/GYNs and some of us are lucky enough to attend out-of-hospital births with OB/GYNs because there are a handful of them floating around.

We see birth in every single variety that it takes in the United States. I really wish that someone somewhere would do something to get those voices lifted and amplified because I feel like yes, a lot of that is going to be anecdotal, but I feel like the stories there have so much value with the state of our system in the relationship between home and hospital birth, how birth transfers happen when births need to be transported to hospitals, the mental health of the people giving birth, the providers and the care, and all of that.

I feel like, like I said, somebody should do something to do something with all of that information that we all carry with us. I think it could provide so much value somewhere, right? I don’t know what yet, but if anybody has an idea, message me. Find me on Instagram at @juliefrancombirth. Find me. Message me if you have any ideas. Maybe write a book or something. I don’t know.

Meagan: I’ve wanted to do an episode and title it “From a Doula’s Perspective”. We could do that from a birth photographer and all that, but it’s crazy. It’s crazy.

Julie: We see it all.

Meagan: There was a birth just the other day with one of our sweet, dear clients where the provider was saying things that seemed scary even though the evidence of what was happening was really not scary, went into a scheduled induction, and the way they were handling it, I felt so guilty as a doula and I was like, “This is going to turn Cesarean. This is not good.” Sure enough, it did and it broke my heart because I was like, “None of that needed to happen,” but again, it goes to us deciding what’s best for us. That mom had to decide what was best for her with the facts that we were giving, what the doctor was giving, and all of these things.

Again, we don’t judge anyone for the way they birth, but it’s sometimes so hard to see people not get the birth they wanted or desired, or to have people literally doubt their ability because someone said something to them.

Julie: Yeah.

Meagan: You know–

Julie: Yeah. I agree. It’s just interesting. Anyways.

Meagan: We are getting off our topic of risk, but risk is a hard conversation to have because there are different numbers. It can be presented differently and like I said, it can also have a tone to it that adds a whole other perspective. So know that if you are given a risk, it’s okay to research that and question it and see if that really is the real risk and if that’s the evidence-based information. We like to provide them here like we were saying earlier. We may be guilty and I hope you guys stick with us if we share some that might be a little jarring on both sides of the VBAC and C-section, but we love you. We’re here for you. We understand risks are scary. They are also hard to break down and understand, but we are here for you.

I love you guys and yeah. Anything else, Julie?

Julie: No. I just want to say be kind to each other. Give each other the benefit of the doubt. Do everything you can to make the best decisions for you. Trust your intuition and find the right support team. We’re all just trying to do our best– us at The VBAC Link, you as parents, providers as providers, and if you feel like you need to make a change, make it.

Meagan: Make it. All right, okay everybody. We’ll talk to you later.

Julie: Bye!

Closing

Would you like to be a guest on the podcast? Tell us about your experience at thevbaclink.com/share. For more information on all things VBAC including online and in-person VBAC classes, The VBAC Link blog, and Meagan’s bio, head over to thevbaclink.com. Congratulations on starting your journey of learning and discovery with The VBAC Link.

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Nội dung được cung cấp bởi Meagan Heaton. Tất cả nội dung podcast bao gồm các tập, đồ họa và mô tả podcast đều được Meagan Heaton hoặc đối tác nền tảng podcast của họ tải lên và cung cấp trực tiếp. Nếu bạn cho rằng ai đó đang sử dụng tác phẩm có bản quyền của bạn mà không có sự cho phép của bạn, bạn có thể làm theo quy trình được nêu ở đây https://vi.player.fm/legal.

Hearing about risk is hard. Interpreting risk is even harder, but deciding which risks are comfortable for you is an essential part of birth!

Meagan and Julie discuss how to tell the difference between relative and absolute risk, and what kind of conversations to have with your provider to help you better understand what the numbers mean.

They also quote many stats and risk percentages around topics like blood transfusions, uterine rupture, eating during labor, epidurals, Pitocin, AROM, and episiotomies.

And if you don’t feel comfortable with accepting a certain risk, that is OKAY. We support your birthing in the way that feels best to you!

Risk of Uterine Rupture with Vaginal Birth after Cesarean in Twin Gestations

Journal of Perinatal Education Article

What are the chances of being struck by lightning?

Needed Website

How to VBAC: The Ultimate Prep Course for Parents

Full Transcript under Episode Details

02:52 Review of the Week

06:08 Determining acceptable risk for you and your provider

08:00 Absolute versus relative risk

15:21 More conversations need to happen

25:29 Risk of blood transfusion in VBAC, second C-section, and third C-section

30:37 Understanding the meaning of statistical significance

32:05 “The United States is intervention intensive”

36:27 Eating during labor and the risk of aspiration under anesthesia

43:03 Epidurals, Pitocin, AROM, episiotomies, and C-section percentages

44:43 The perspective of birth doulas and birth photographers

Meagan: Hello, hello everybody. Guess who I have today? Julie!

Julie: Hello.

Meagan: Hello. It’s so good to have you on today.

Julie: Of course. It’s always fun to be here.

Meagan: It really is. It’s so fun. When we sit and chat before, it just feels so comfortable like that is the norm still for me even though it has been a while, it just feels so normal and I love it. I miss you and I love you and I am so excited to be here with you today.

You guys, we are going to talk a little bit about risk. We know that in the VBAC world, there’s a lot of risk that comes up. I should say a lot of talk about risk that comes up whether it be is it safe to even have a VBAC? Is it safe to be induced? What are our real risks of uterine rupture? Is it safe to VBAC with an epidural or without an epidural? What about at home out of the hospital? Is that safe? I don’t know. Let’s talk about that today.

Julie: Let’s talk about it.

Meagan: Let’s talk about it. I think it’s really important to note that no matter what— and we’re going to talk about this for sure today, but no matter what, you have to take the risks that you are presented and that is given and still decide what’s best for you. That risk doesn’t mean that is what you have to or can’t do. Right?

So I think while you are listening, be mindful or kind of keep that in the back of your mind of, “Okay, I’m hearing. I’m learning.” Let’s figure out what this really means and then let’s figure out what’s truly best for you and your baby.

02:52 Review of the Week

I do have a Review of the Week so I want to hurry and read that, then Julie and I will dive into risk and assessing.

Julie: Dun dun, we’re ready.

Meagan: We are ready.

Okay, holy cow. This is a really long review, so—

Julie: You can do it.

Meagan: Thank you to Sara R-2019 on Apple Podcasts for leaving this review. I love how Julie was like, “You can do it,” because she knows that I get ahead of what I’m reading in my mind and then I can’t read, so let’s see how many times it takes to read this review.

Julie: You’ve got this.

Meagan: Okay. It says, “A balanced and positive perspective.” It says, “As a physician myself I think it is unusual to find balanced resources for patients that represent the medical facts but also the patient experience and correct for some of the inaccuracies in medicine. This podcast does an amazing job of striking this balance!

“I had an emergency C-section with my daughter 2 years ago. Despite understanding that the CS was medically appropriate and my professional experience, I still found the whole experience to be mildly traumatic and disappointing. This podcast was the main resource I used to help prepare for my second child’s birth and my plan to have a VBAC. I am now holding my new baby in my arms with so much pride, love, self-confidence, and trust because I had a smooth and successful VBAC.

“I am thankful for this podcast which gave me ideas, confidence, strength, and a sense of community in what is otherwise a very isolating experience. I especially appreciate the variety of stories that are shared, including VBAC attempts that result in another C section so that we can all prepare ourselves for the different outcomes. No matter what happens we are strong women and have a welcome spot in this community, even when we may feel alone with our thoughts and fears. Thank you, Julie and Meagan!

Julie: Aw, I love that.

Meagan: Yes, that was phenomenal. Congratulations Sara R-2019. If you are still listening here, congratulations and we are so happy for you and thank you for your amazing review.

06:08 Determining acceptable risk for you and your provider

Meagan: All right, Julie. Are you ready?

Julie: Here we go. Here we go. Can I talk for a minute about something you mentioned before the review? You were talking about risk and how it’s not a one-size-fits-all because we were talking about this before. We all know that the uterine rupture risk is anywhere between .2%-1% or whatever depending on the study and what you look at. The general consensus among the medical community is .5%-1% is kind of where we are sitting, right?

Now, some people might look at that risk and be like, “Heck yeah. That’s awesome. Let’s do this,” especially when you look at a lower risk than that that it’s a catastrophic rupture. Some people might look at those numbers and be like, “This feels safe. Let’s go.” Some people might look at those numbers and be like, “This feels scary. I just want to schedule a C-section.”

Meagan: No, thank you.

Julie: And that’s okay. It is okay. However you approach risk and however you look at it is okay. We’re not here to try and sway anybody. Obviously, we’re The VBAC Link, so we are going to be big advocates for VBAC access, right? But we’re also advocates for having all of the information so you can make the best decision no matter what that looks like. But also, I think another very important part of that is finding a provider whose view of risk is similar to your view of risk so that you guys have a similar way to approach things because if you find a provider who thinks that 1% risk of VBAC is really scary, it’s not going to go good for you if you think a 1% risk for a VBAC is acceptable.

So yeah, I just want to lay that out there in the beginning. Meagan, you touched on it in the beginning, but I feel like provider choice in risk is really important there.

Meagan: It is.

Julie: For sure.

08:00 Absolute versus relative risk

Meagan: It is and also, one of the things we wanted to talk a lot about is absolute risk versus relative. So many times when people, not even just the actual percentage or 1 out of 5 is shared, it’s the way it’s shared. The way the words are rolling off of the tongue and coming out can be shared in a scarier way so when we say 1 out of 5, you’re like, “Okay, that’s a very small number. I could easily be one of those 5’s.” It’s the way these providers sometimes say it.

A lot of the time, that’s based on their own experience because now they are like, “Well, I am sharing this number, but I’m sharing a little extra behind the number because I’ve had the experience that was maybe poor or less ideal.”

Does this make sense?

Julie: Yeah.

Meagan: Sometimes the way we say things makes that number seem even bigger or even worse or scarier.

Julie: Right. It really comes down to absolute risk versus relative risk, right? Relative is your risk in relation to another thing that has risk. Absolute risk is the actual number. It’s like 1 in 10. That is an absolute risk. You have a 1 in 100 chance of uterine rupture. That is an absolute risk. Your chance of uterine rupture doubles after three Cesareans. That’s not true. That’s not true. But that’s a relative risk.

I really like the example that I feel is really common for people to relate to is stillbirth after X amount of weeks. Evidence-Based–

Meagan: That’s a huge one.

Julie: Yeah, it’s a big one that gets thrown around all of the time and it sounds really scary when people say it. I love Evidence Based Birth. They have this whole article about due dates and risks associated with due dates and why due dates should really be adjusted and look at differently. They don’t say that. They just present all of the data, but what I really like about that is they have a section here about stillbirth and they talk about absolute risk versus relative risk. I feel like that would be a great thing to start with.

I’m just going to read it because it’s so well-written. They said, “If someone said that the risk of having a stillbirth at 42 weeks compared to 41 weeks is 94% higher, then that sounds like a lot.” Your risk of stillbirth doubles at 42 weeks than if you were to just get induced at 41 weeks. Your baby is twice as likely to be stillborn if you go to 42 weeks.

Meagan: Terrifying.

Julie: Okay? 94% higher. That’s almost double. That is scary. For me, I’d be like, “Uh, yeah. That is super scary.”

Meagan: Done. Sign me up for induction.

Julie: Right? Sign me up for induction. But when you consider the actual risks or the absolute risks, let’s just talk about those numbers. 1.7 per 1,000 births if they are at 41 weeks. Stillbirth is 1.7 per 1000 births. At 42 weeks, it’s 3.2 per 1000 so it’s a .17% chance versus a .3% chance so you are still looking at really, really, really small numbers there. So yeah, it’s true. 3.2 is almost double of 1.7 if you do the math. Sometimes math is hard so that’s fine. We have to get out the calculator sometimes, but while it’s true to say the risk of stillbirth almost doubles at 42 weeks, it could be kind of misleading if you’re not looking at the actual numbers behind it.

So I think that it’s really important when we’re talking about risks and the numbers and statistics to understand that there are different ways of measuring them and different ways of looking at them and different ways of how they’re even calculated sometimes. So depending on how you look at them, you could even come up with different risks or different rates which can really sway your decision.

We’re not talking about a 5%-10% double which is still true. It’s still double, but it’s just a really small number. Now, I also want to do a plug-in for people who have been in that .3%. It might as well be 100%. I can’t even imagine the trauma of having to have a loss like that. I can’t. I have supported parents through that. I have documented families like that and documented their sweet babies for them. I can’t imagine the pain that goes with that.

But I also think it is very important to look at the actual numbers when you are making a decision. Now, maybe that .32% is too high for you and that’s okay, but maybe it’s not and that is a risk you are willing to accept. I feel like approaching it like that is so much better. If somebody ever says to you, “This risk of that is double” or whatever, I don’t know.

I’m just going to make up some random stuff here like, “If you drive in your car to school, you have a 1 in 10 chance of getting in a car crash but if you drive on a Wednesday, your risk doubles so now you have a 2 in 10 chance or 1 in 5 chance of getting in the car crash,” so maybe you would want to avoid driving to school on Wednesdays, but maybe you wouldn’t. But if you say you’re risk is higher of dying in a car crash if you go to school on Wednesdays, they would be like, “I’m not leaving the house on Wednesdays or ever.” I’m not leaving the house today because it’s so dog-gone cold and I’m warm in my blanket.

I don’t know. I feel like looking at it like that. Actually, 1 in 10 is really high for getting in a car crash, but I don’t know. I just feel like looking at that is really important for providers telling you, “Oh, your risk of uterine rupture doubles if we use Pitocin so I’m not going to use Pitocin.” Okay, we’re looking at a small increase to an already small risk. We know that any type of artificial induction could lead to an increased risk of uterine rupture especially if it’s mismanaged, but what we do know is that it’s not– I don’t want to say that because that might be wrong.

When you are presented with the actual numbers, yes. It might double. I don’t know what the actual numbers are, to be honest off the top of my head. I feel like maybe it doubles, but if you are already looking at a .2% to a .4% or a .5% to a 1% chance, what’s the tradeoff there? What are your risks of just scheduling a repeat C-section instead of doing an induction? Is that worth it to you? What are the risks associated with repeat Cesareans? Are they bigger than that of using Pitocin to induce labor? What is that compared to the other one because there is another that is relative risk? The absolute risk is what the percentage is. I’m not even going to say the number.

But if there’s a risk of rupture using Pitocin relative to the risks that come with repeat Cesareans, those are risks that are relative to each other, so how does that compare? Because when we talk about it in just that singular form or that singular amount of risk without considering the other risks that might be associated with it because of the decisions we made from that risk– am I making sense here? Then you know, I don’t know. I feel like there is just a lot more conversation to have sometimes when we are talking about risk.

15:21 More conversations need to happen

Meagan: Yes. There are. There is a ton more conversation and that is what I feel like we don’t see happening. There’s a quick conversation. Studies show that 7 minutes are spent in our prenatal visits which is not a lot of time to really dive into the depths of risk that we are talking about when we say, “We can’t induce you because Pitocin increases–”. This is another thing I’ve noticed is significantly. You have a serious–. Again, it comes down to the words we are using. Sometimes in these prenatal visits with our providers, we do not have the time to actually break down the numbers and we’re just saying, “Well, you have a significantly higher risk with Pitocin of uterine rupture so we won’t do that.”

When we hear significantly, what do we do? We’re like, “Ahh, that is big.” You know?

Julie: Yeah.

Meagan: We’re just not having the conversation of risk enough and again, it’s kind of being skewed sometimes by words and emotion. We were talking about this before. I remember we made a post– I don’t know, probably a year and a half ago maybe. It seems like a while ago about the risk of complications in a repeat Cesarean meaning you have a C-section and then instead of going for a VBAC, you go for a repeat Cesarean which as you know, if you’ve been with us, is totally fine and respected here from The VBAC Link.

A lot of the time, we don’t talk– and when I say we, I mean the world. We don’t talk about the actual risk of having a repeat Cesarean, right? Don’t you feel like that, Julie? I don’t know. As a doula, I feel like our clients who want to go for VBAC know a little bit more of the risk of having a VBAC, but they have not been discussed at all really with the risk surrounding a repeat Cesarean. We made a post talking about the risks of repeat Cesarean and I very vividly remember a lot of people coming at us with feeling that we were fearmongering.

Julie: Or shaming.

Meagan: Shaming, yep. A lot of people were feeling shamed or disrespected. People would say, “You claim to be CBAC supportive, but here you are making these really, really scary numbers.” Anyway, looking at that post and going into what we’ve talked about, in some of those posts, we did say things like, “You are going to have a 1 out of 10 chance of X, Y, Z,”

Julie: Or twice as likely to need this. Twice as likely to need a blood transfusion or 5x more likely to have major complications. Things like that.

Meagan: Yeah. We would say things like that. I remember specifically in regards to miscarriage. It’s a very, very sensitive topic, but there are risks there. So a lot of people were triggered. In the beginning, we talked about the way providers say things and the way they put them out on paper and the absolute risk versus the relative and way they do that. We’re guilty of that too. Right here at The VBAC Link, we were like, “This is the chance. These are the chances. You are 5x more likely to X, Y, Z.” So know that I don’t want to make it sound like we are shaming anybody else for the different ways that they give the message of risk. Am I making sense?

Julie: Yeah, and you know what? I feel like sometimes it’s just about giving people the benefit of the doubt. We want to give providers the benefit of the doubt just because it’s probably something that they’ve continuously heard and spoken and that’s okay because we do it too sometimes. We go on that thing like, “Oh my gosh, maternal death.” I think the risk of maternal death is 10x higher in a C-section than it is in a VBAC which sounds really scary and makes me never ever want to have a C-section again, but when you look at that, it’s .00001% to .0001% or whatever is 10x more. It is such a small level of risk, but it is higher.

I feel like trying to look at both absolute and relative risk for any given thing together is really, really important. Yeah. Give people the benefit of the doubt. Give us the benefit of the doubt. We are in such an awful cultural climate right now where it’s easy for people, especially on social media to jump on the attack train for anybody when we feel triggered or when we feel like people are being unjust to us or to other people and I hate that so stinking bad.

Whenever I catch myself with those feelings, I try to take a step back and I’ve actually gotten pretty good at that, but it’s so easy for us to get on that bandwagon of just railing against people who present information in certain ways or railing people without getting all of the information about that person.

Before I go off too much on a soapbox in that direction, yeah. I feel like your provider when they are saying those things is probably not trying to coerce you into anything. Our providers, especially our hospital providers are incredibly overworked. They are incredibly stressed. Their time management skills have got to be off the charts because they are so overloaded with everything and they just don’t have time to automatically sit down and explain things.

But you know what I have found? Most of them, when you stop them and ask questions, they are more than happy to answer and explain. Sometimes, they are just repeating things they have heard all the time or that they have learned at some point or another without giving them a second glance.

Do you know what? We all do that too. Me, Meagan, you listening right now. We all do that. We hear things. We regurgitate them. We hear things. We regurgitate them and we don’t even think about questioning or challenging those things until somebody else brings it up to us to question or challenge those things.

So, don’t be afraid to ask your provider for more information or ask them what the real numbers are to those things. I have a really special place in my heart for our CBAC moms because there are lots of things that they are working through, so many emotional things, but I challenge not just people who have had a repeat Cesarean that was unwanted, but people just in all life, when something triggers you online, stop and explore that. Stop and question because that is probably an area of your life that you could use a little healing and work on. It could be a little bit of work. It could be a lot of work, but usually, when something triggers you, it’s a challenge to look into it more because there is something that your body and mind have an unhealthy relationship with that needs to be addressed.

Julie: Anyways, circling it back to risk. Meagan, take it away.

Meagan: I just want to drop a shameless plug on our radical acceptance episodes that we did, so kind of piggybacking off of what she just said. We dive into that a little bit deeper in our radical acceptance episode. It really is so hard and like what she said, our heart goes out to moms that have a scheduled C-section that didn’t want to schedule a C-section or felt like they were in a corner or felt like that was the best option, but not the option they wanted. There are so many feelings, but definitely go listen to radical acceptance part one and part two.

25:29 Risk of blood transfusion in VBAC, second C-section, and third C-section

Meagan: I just want to quickly go down a couple of little risks. Blood transfusion– we have a 1.89% or 1 in 53 chance of a blood transfusion with a VBAC. To me, 1.89% is pretty low, to me, but it might not be to some. I don’t know, Julie. How do you say the other? Okay, then blood transfusion in a repeat Cesarean is 1.65% in the second C-section. It’s lower. So for vaginal birth, it’s higher. I’m not good at math.

Julie: No, vaginal birth, yeah. That’s true. So 1 in 53 for VBAC versus a 1 in 65 for a repeat Cesarean. Yes, right.

Meagan: For a third Cesarean, the chances of a blood transfusion go to 2.26%.

Julie: Yes, so it’s like 50% higher than if you have a VBAC for the third Cesarean, but it’s slightly lower for the second C-section. See? I feel like we could have talked about this before, but I don’t know if we say it often enough. When you are talking about overall risk for VBAC versus C-section, when you are looking at just the second birth, right? So first birth was a C-section, what are you going to do for your second birth? The risks overall are pretty similar for vaginal birth versus Cesarean. The overall total risk is pretty similar as far as your chances of having major complications and things like that.

But when you get into three, four, five, six C-sections and vaginal births, that’s when you really start to see significant changes in those risks. See? I used the word “significant” again, but we’re going to talk about where the more C-sections you have, the higher your chances of having complications you have. The more vaginal births you have, your chances of complications actually go down.

So when you are looking at if you want more than two kids, that might be something that you want to consider. If you are done with two kids, then that might be something that is not as big of a player in your choices. So yeah.

Meagan: Yeah. Then there are things like twins. So when I was talking about it earlier, the word significantly, there was a systematic– I almost said something– systemic.

Julie: Systemic review?

Meagan: Yeah, see? I can’t say it correctly. I can’t. Published– oh, I’m trying to remember when it was published. We will get it in the show notes. It talks about the risk of uterine rupture with twins and it does say. It says “significantly higher in women with twin gestation”. That’s kind of hard, I feel like because again, like we were saying, some reviews and studies and blogs and all of these things wouldn’t say the word significantly. They may share a different one. I’m going to see if I can find the actual– maybe Julie can help me while I’m talking– study.

Okay, it says three out of four studies in a group of zero cases of uterine rupture. Notably, the study with the largest patient population reported cases of uterine rupture in both groups and demonstrated a significantly greater risk of uterine rupture in the VBAC group. Meanwhile, the other three studies found no significant difference between rates of uterine rupture among groups 31-33. Nevertheless, the study shows that electing–”

Okay, so I’m just going to say. It says, “Electing to have a PRCD reduces but does not eliminate the small risk of uterine rupture.” So what I’m reading here is that in some of them, it showed significantly greater, but then in 3 out of 4 reviews, and I don’t even know actually how many people were in each of these reviews, but in 4 reviews, one had a greater risk and three didn’t really show much of a difference, but we see that in the very beginning right here. “Uterine rupture is significantly higher in women with twins.” What do you think? If you are carrying twins and you see that, Julie, significantly higher enters into the vocabulary at all, what do you think?

Julie: Well, I think I would want to schedule a C-section for my twins, probably.

Meagan: Probably.

30:37 Understanding the meaning of statistical significance

Julie: I want to just go off on a little tangent here for a second. I think it’s really important when we are talking about studies that we know what statistically significant means because sometimes if you don’t know much about digging into studies and things like that which I’m not going to go into too much right now–

Meagan: It’s difficult.

Julie: It is difficult. It’s really hard which is why I’m not going to go into it because I feel like we could have a whole hour-long podcast just for that. Statistically significant really just means that the difference or the increase or the change that they are looking into is not likely to be explained by chance or by random numbers which is why when you have a larger study, the results are more likely to be statistically significant because there is less room for error basically.

A .1% increase can be just as statistically significant as a 300% increase because it just comes down to whether they are confident that it is a result that is not related to any chance or external environmental factors. I feel like it’s really important to clarify that just because something is statistically significant doesn’t mean that it’s big, catastrophic, or a lot, it just means that it’s not likely to be due to chance or anything random.

32:05 “The United States is intervention intensive.”

Meagan: Yeah. I love that. Okay. There was one other thing I wanted to share. This was published in the Journal of Perinatal Education and it is a little more dated. It’s been 10 years or so, but I just wanted to read it because it was really interesting to me. It doesn’t even exactly go with risk and things, but it just talks about your chances which I guess, to me– do you know what I”m trying to say?

Julie: They kind of go hand in hand.

Meagan: To me, at least, they do. So when I read this, I was like, “Well, this is interesting.” I just wanted to drop it here and I think it’s more just eye-opening. It says, “Maternity care in the United States is intervention intensive.” Now, if we didn’t know this already, I don’t know where I’ve been in the doula world for the last 10 years. Right? You guys, as doulas, obviously, we’re not medical professionals, but as doulas, we see a lot of intervention and a lot of intervention that is completely unnecessary and a lot of intervention that leads to traumatic birth, unexpected or undesired outcomes and then they lead to other unnecessary interventions. It’s the cascade. We talk about the domino effect or the cascade of interventions, but this is real so for them to type out, “Maternity care in the United States is intervention intensive–”

Julie: You’re like, “Yeah, where have you been?” Not you, but the writer.

Meagan: Yeah, the writer. Yeah. It says, “The most recent national survey–” Now, again keep in mind it is 2024. This has been a minute since this was written.

Julie: About 10+ years.

Meagan: 10-12 years. Just keep that in mind. But it was interesting to me that even 10-12 years ago, this was where we were at because I feel like since I started as a doula, I’ve seen the interventions increase– the inductions, the unnecessary Cesareans increase a lot.

Julie: Some of them, yeah. Yeah, especially inductions and Pitocin.

Meagan: Not all of the time. I cannot tell you that in 10 out of 10 births that I attend, this is the case but through the years of me beginning doula work and what I have witnessed, it’s increased. At least here in Utah, it seems that it has increased.

It says, “The most recent national survey of women’s pregnancy, birth, and postpartum experience reports that for women who gave birth in June 2011-2012,” so a little bit ago, “89% of women experienced electronic fetal monitoring.” Okay.

Julie: That seems actually low to me for hospital births.

Meagan: It does seem low because to me–

Julie: I wonder if there had been a ton of stop and drops or something.

Meagan: I don’t know, but I agree. 89%. I feel like the second you get into the hospital, no matter VBAC or not, they want to monitor your baby.

Julie: Strapped onto the monitor, yeah.

Meagan: It says, “66% continuously.” So out of the 89%, it says 66% were continuously meaning they didn’t do the intermittent every 30 minutes to an hour checking on baby for a quick 15 minutes to get another baseline, they just left that monitor on them which makes me wonder why. Usually, when a client of mine goes in and has that, they’re like, “Oh, your baby had a weird decel so we are going to leave the monitor on longer,” and then they don’t say anything. They just keep it on there. Maybe that’s– I don’t know.

It says, “62% received intravenous fluids.”

Julie: IV fluids.

Meagan: Which to me, is also a lot.

36:27 Eating during labor and the risk of aspiration under anesthesia

Meagan: “79% experienced restrictions on eating.” 79%. You guys, we need to eat. We need to fuel our bodies. We are literally running a marathon times five in labor. We shouldn’t be not eating, but 79% which doesn’t surprise me, and “60% experienced restrictions on drinking in labor.” Why? Why are we being restricted from drinking and eating in labor unless we have other plans for how labor may go?

Julie: That’s exactly what it is. They’re preparing you for an emergency Cesarean. That’s what they’re doing. That’s exactly what restricting non-IV fluids is. It’s not only that, but it is preparing you for the incredibly low risk of you having to go under general anesthesia, and then even people that go under general anesthesia have an incredibly low risk of aspirating and that is what it’s coming down to. Don’t even get me started on all of the flaws in all of the studies that went over aspiration during general anesthesia anyway because they are so significantly flawed that we are basing denying women energy and fuel during labor based on flawed studies that are incredibly outdated and on incredibly low risk during an incredibly already low risk.

I mean, you probably don’t want to down a cheeseburger while you’re having a baby. I don’t know. Maybe me. Just kidding. Even I didn’t want a cheeseburger, but I wanted some little snacks, and some water to keep you hydrated. Yes. Oh my goodness. Let’s please stop this. Sorry. Stepping off the soapbox.

Meagan: You know, there is a provider here. I actually can’t remember her name. It was way back in the beginning of my doula career and actually, it was in an area that is not one of my more common areas to serve. It was outside of my serving area. Anyway, we were at a birth and there was an induction. I remember being in there with her and the provider, an OB, walks in and is like, “Hey, how are you doing?” He was so friendly and kind and asked some questions like, “How are you feeling? What are you thinking about this?”

Then she was getting ready to leave and she turned back and said, “Hey. I just thought about this. Have you eaten anything?” The mom was like, “No.” She was like, “Uh, you need to eat.”

Julie: Yeah!

Meagan: She had an epidural at this point. The mom was like, “Wait, what?” She was like, “You need to eat.” I literally remember my jaw falling, but had to keep my mouth up because I didn’t want to look like I was weird.

Anyway, I said, “That’s something I’ve not usually heard from an OB especially after someone’s had an epidural.” She was like, “Oh, I am very passionate about this.” She was like, “When I was finishing up school and graduating,” she had to write some big thing.

Julie: Her dissertation probably.

Meagan: Time capsule, I don’t even remember what it was called. Some really, really big thing. She was like, “I specifically found passion about the lack of eating and drinking in labor.” She was like, “I did all of this stuff and what I found was you are more likely–” Here comes risk. “You are more likely to be struck in the head twice by lightning–” This is what she said. “Twice by lightning than you are to aspirate in a Cesarean after having an epidural.”

Julie: I love this lady. Who is it?

Meagan: I can’t remember. I will have to text my client.

Julie: Where was it? What hospital?

Meagan: It was up in Davis County.

Julie: Oh, interesting.

Meagan: It was not an area for me. I said, “Whoa, really?” She said, “Yeah. You need to get that girl some food.” I was like, “Done. 100%.”

Julie: More likely to get struck by lightning.

Meagan: More likely to get struck by lightning twice in the head than you are to aspirate in a Cesarean after receiving an epidural. That stuck with me forever. Literally, here we are 10 years later.

Julie: I love that because first of all–

Meagan: I don’t have documentation to prove that. She just said that.

Julie: That is 100% relative risk. Aspirating during a C-section relative to getting struck by lightning twice. So that’s cool. What are the numbers? I know that the numbers are super incredibly low and I feel like when you put in context like that, getting struck by lightning twice, I don’t know anybody that’s been struck by lightning once and who has been alive to tell about it. I know of a friend whose sister got struck by lightning and died when she was very young. I only know one person in my entire life who has been struck by lightning.

Meagan: I just looked it up really quick. I don’t even know if this is credible. I literally just looked it up really quickly. It says that the odds that one will be struck by lightning in the US during one’s lifetime is 1 in 15,300.

Julie: Wow.

Meagan: Okay.

Julie: So twice that is 1 in 30,000. That’s a freaking low risk. Anyway, what I’m saying is that I love that OB first of all. I feel like from what I’ve read about aspiration under general anesthesia during a C-section seems right in line with those numbers and those chances because it’s so rare, it’s almost unheard of especially now with all of the technology that we have.

It’s fine because I’m not going to go on that soapbox. I love that. I love that analogy and that we’re talking about that because 10 years from now or when our daughters are having babies, they’re going to talk about how their poor moms couldn’t eat when they were in labor because of the policies just like we talk about the twilight sleep and how our poor grandmas had to undergo twilight sleep when our moms were being born.

I feel like that’s just going to be one of those things where we will look back and be like, “What were we thinking?”

43:03 Epidurals, Pitocin, AROM, episiotomies, and C-section percentages

Meagan: Okay, I’m going to finish this off. It says, “67% of women who gave birth vaginally had an epidural during labor and 37% were given Pitocin to speed up their labors.” Sorry, but come on. That also may go to show, that we’re going to do an epidural episode as well, that epidural maybe does really slow down labor. Maybe it really does impact the body’s response to continuing labor in a natural way, so 31% of those people had to have help and assistance.

It says, “20% of women had their membranes artificially ruptured,” which means they broke your bag of water artificially with the little whatever, breaking bag water hook thing versus it breaking spontaneously.

Julie: Amniohook. Is it an amniohook?

Meagan: Amniohook, yeah.

“17% of women had an episiotomy.” I don’t know.

Julie: I feel like those numbers are probably lower now.

Meagan: I think that’s changed, yeah. “31% had a Cesarean.”

Julie: That is right in line with the national average.

Meagan: It is, still. “The high use of these interventions reflects a system-wide maternity care philosophy expecting trouble. There is an increasing body of research that suggests that the routine use of these interventions rather than decreasing the risk of trouble in labor and birth actually increases complications for both women and their babies.”

44:43 The perspective of birth doulas and birth photographers

Julie: I believe it. Do you know what? Can I just get on another tangent here because I know that you all love my tangents? I really wish that somebody somewhere would do something and I don’t know what that something is, to get the voices of birth doulas and birth photographers heard because this is why. Doulas and birth photographers– I’ve said this before. We see births in all of the places. We have a really, really unique point of view about birth in the United States because we attend births at home. We attend unassisted births. We attend births at home with unlicensed providers. We attend births at home and births at birth centers with licensed providers. We attend in-hospital births with midwives and we attend in-hospital births with OB/GYNs and some of us are lucky enough to attend out-of-hospital births with OB/GYNs because there are a handful of them floating around.

We see birth in every single variety that it takes in the United States. I really wish that someone somewhere would do something to get those voices lifted and amplified because I feel like yes, a lot of that is going to be anecdotal, but I feel like the stories there have so much value with the state of our system in the relationship between home and hospital birth, how birth transfers happen when births need to be transported to hospitals, the mental health of the people giving birth, the providers and the care, and all of that.

I feel like, like I said, somebody should do something to do something with all of that information that we all carry with us. I think it could provide so much value somewhere, right? I don’t know what yet, but if anybody has an idea, message me. Find me on Instagram at @juliefrancombirth. Find me. Message me if you have any ideas. Maybe write a book or something. I don’t know.

Meagan: I’ve wanted to do an episode and title it “From a Doula’s Perspective”. We could do that from a birth photographer and all that, but it’s crazy. It’s crazy.

Julie: We see it all.

Meagan: There was a birth just the other day with one of our sweet, dear clients where the provider was saying things that seemed scary even though the evidence of what was happening was really not scary, went into a scheduled induction, and the way they were handling it, I felt so guilty as a doula and I was like, “This is going to turn Cesarean. This is not good.” Sure enough, it did and it broke my heart because I was like, “None of that needed to happen,” but again, it goes to us deciding what’s best for us. That mom had to decide what was best for her with the facts that we were giving, what the doctor was giving, and all of these things.

Again, we don’t judge anyone for the way they birth, but it’s sometimes so hard to see people not get the birth they wanted or desired, or to have people literally doubt their ability because someone said something to them.

Julie: Yeah.

Meagan: You know–

Julie: Yeah. I agree. It’s just interesting. Anyways.

Meagan: We are getting off our topic of risk, but risk is a hard conversation to have because there are different numbers. It can be presented differently and like I said, it can also have a tone to it that adds a whole other perspective. So know that if you are given a risk, it’s okay to research that and question it and see if that really is the real risk and if that’s the evidence-based information. We like to provide them here like we were saying earlier. We may be guilty and I hope you guys stick with us if we share some that might be a little jarring on both sides of the VBAC and C-section, but we love you. We’re here for you. We understand risks are scary. They are also hard to break down and understand, but we are here for you.

I love you guys and yeah. Anything else, Julie?

Julie: No. I just want to say be kind to each other. Give each other the benefit of the doubt. Do everything you can to make the best decisions for you. Trust your intuition and find the right support team. We’re all just trying to do our best– us at The VBAC Link, you as parents, providers as providers, and if you feel like you need to make a change, make it.

Meagan: Make it. All right, okay everybody. We’ll talk to you later.

Julie: Bye!

Closing

Would you like to be a guest on the podcast? Tell us about your experience at thevbaclink.com/share. For more information on all things VBAC including online and in-person VBAC classes, The VBAC Link blog, and Meagan’s bio, head over to thevbaclink.com. Congratulations on starting your journey of learning and discovery with The VBAC Link.

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