ACOG’s newest VBAC guideline changes

In a long overdue updated Practice Guidelines, the American College of Obstetricians and Gynecologists (ACOG) released new guidelines on July 21, 2010 for vaginal birth after cesarean (VBAC).  This will hopefully bring some balance to a growing problem for women’s birth choices and changes on the local level.

For many years, VBACs were offered as standard procedure in most American hospitals.  The former ACOG guidelines recommended that a trial of labor be offered women who fit the criteria as long as a surgical team could be made ‘readily available’.  This generally meant within 30 minutes of determining the need for surgery.  Later, the guideline wording was changed to ‘immediately available’ which would have required that any time a woman was attempting a trial of labor for a VBAC, the surgery team had to be on the premises and ready to perform surgery right away.  There were apparently no supportive studies to justify the wording change, but it quickly became the standard of care and with those two words came many years of women being forced to submit to repeat surgical birth because of the lack of resources to attempt a VBAC.  The new requirement was not practical from the financial or time constraints of the medical facility and physician personnel.  It had nothing to do with the safety issues, but was strictly a financial, time, malpractice and legal issue.

The National Institutes of Health met in March 2010 on the topic of cesarean birth and VBAC and made some recommendations because of the concern over the growing number of cesarean births conducted in our country.  Recent statistics place cesarean birth at around 31% of all births, but many local facilities’ statistics are much higher.  In 1970 the cesarean rate was about 5%.  While a cesarean birth is a life-saving surgery if truly necessary, most experts (including the World Health Organization) agree that the legitimate use of cesarean should be between 10-15% of the birthing population, not the high numbers we are now seeing.  The overuse of induction, medications (including pitocin and epidurals), subjective interpretation of electronic fetal monitors, confinement of laboring women to bed and lack of trust in a woman’s body to birth normally have led to the use of cesarean section in epidemic proportions.  Then because of the lack of VBAC options, women were forced to continue to have repeat cesareans.

The newest guidelines condemn VBAC bans and encourage VBAC as a “safe and reasonable option for most women, including some women with multiple previous cesareans, twins and unknown uterine scars”.  It also states that respect for patient autonomy requires that even if an institution does not offer a trial of labor after cesarean, a cesarean cannot be forced nor can care be denied if a woman declines a repeat cesarean during labor.   The new guidelines also encourage women and their physicians to make a plan for a trial of labor after cesarean (TOLAC) even in institutions where surgical teams may not be ‘immediately available’.  The risk of rupture during a TOLAC is very low, between 0.5% and 0.9%, though circumstances may develop during labor that may require a repeat cesarean delivery.

Women should take the time to educate themselves on their options, discuss and encourage their local care providers and facilities to come into alignment with these newest practice guidelines, and avoid interventions that may lead to a primary cesarean birth unnecessarily. Continued consumer pressure may be the only way real changes in maternity care will occur. For more information, consult International Cesarean Awareness Network at:



Teaching video on how to do a proper prenatal exam using Leopold’s manuevers.

Breast Crawl

This little video is one I show to all my childbirth classes.  It shows babies in two groups-medicated and separated from their mothers for cleaning and weighing and non-medicated, non-separated babies.  Illustrates beautifully the ‘stepping relex’ in newborns as their method of propelling themselves up the mother to reach their source of food.

An excellent video about homebirth safety and birth with midwives

This is an excellent video featuring many birth experts discussing the safety of homebirth with a midwife.

October is Breast Cancer Awareness Month

Think Before You Pink website has this featured video, which will hopefully make you think about the doublemindedness of pharmaceutical companies.

Milking Cancer from Breast Cancer Action on Vimeo.

Did you know that if you give birth twice and breastfeed each child for 12 months each for a total of 24 months of breastfeeding, you reduce your potential risk for breast cancer IN HALF?

Did you know that by breastfeeding, you reduce your offspring’s breast cancer risk?

Reducing Infant Morality in the U.S.

Please take 15 minutes to view this most important short film on reducing infant mortality in the U.S.

Reducing Infant Mortality from Debby Takikawa on Vimeo.

Pit to Distress- disturbing trend

Copied from The Unnecesarean Blog:

Jill from Keyboard Revolutionary wrote about a new term that she recently came across— “Pit to distress.”

“Pit to distress.” How have I not heard about this? Apparently it’s quite en vogue in many hospitals these days. Googling the term brings up a number of pages discussing the practice, which entails administering the highest possible dosage of in order to deliberately distress the fetus, so a C-section can be performed.

Yes folks, you read that right. All that Pit is not to coerce mom’s body into birthing ASAP so they can turn that moneymaking bed over, but to purposefully squeeze all the oxygen out of her baby so they can put on a concerned face and say, “Oh dear, looks like we’re heading to the OR!”

The term is found in this 2006 article in this Wall Street Journal article:

Oxytocin is a hormone released during labor that causes contractions of the uterus. The most common brand name is Pitocin, which is a synthetic version. It’s often used to speed or jump-start labor, but if the contractions become too strong and frequent, the uterus becomes “hyperstimulated,” which may cause tearing and slow the supply of blood and oxygen to the fetus. Though there are no precise statistics on its use, IHI says reviews of medical-malpractice claims show oxytocin is involved in more than 50 percent of situations leading to birth trauma.

“Pitocin is used like candy in the OB world, and that’s one of the reasons for medical and legal risk,” says Carla Provost, assistant vice president at Baystate, who notes that in many hospitals it is common practice to “pit to distress” — or use the maximum dose of Pitocin to stimulate contractions.

It’s also used on this AllNurses forum:

I agree, and call aggressive pit protocols the “pit to distress, then cut” routine. Docs who have high c/s rates and like doing them, are the same ones that like the rapid fire knock em down/drag em out pit routines.

“Pit to distress” appears on page 182 of the textbook Labor and Delivery Nursing by Michelle Murray and Gayle Huelsmann. In this example, the onus is on the nurse to defend the patient from the doctor if he or she sees the order “pit to distress” by immediately notifying the supervisor or charge nurse.

Jill asks the questions, “OBs, do you still think women are choosing not to birth at your hospitals because Ricki Lake said homebirths are cool? Do you still think we are only out for a “good experience?”

I imagine that all of us who have openly questioned the practices of obstetricians in the U.S. have been hit with the same backlash. We must be selfish, irrational and motivated by our own personal satisfaction. We’ve been indoctrinated into a subculture of natural birth zealots and want to force pain on other women or just feel mighty and superior. We fetishize vaginal birth and attach magical powers to a so-called natural entrance to the world.

Nah. It’s stuff like “pit to distress” that made me run for the nearest freestanding birth center. If I had to do it all over again, I’d stay home.

Have you heard this term before? What is your experience with “Pit to distress?”

Before you comment here, please go applaud Jill from Keyboard Revolutionary for blogging about this term and enjoy her brilliant and honest commentary.

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Update on Tuesday, July 7, 2009 at 4:35AM by Jill–Unnecesarean

More discussion of “Pit to distress” on the Internet:

The then labor and delivery nurse who blogs at At Your Cervix wrote this in April of 2007:

I see the wide use of cytotec (misoprostil) for inductions. I see what it does to a woman’s uterus and to her baby. Not to mention – it’s not FDA approved for use as a labor induction agent in pregnant women! I see many, many women being induced with a “hospital made” form of prostaglandin gel to induce labor. I also see a HUGE number of pitocin inductions/augmentations, where pitocin is titrated at such high doses, so quickly, that it’s like we’re trying to blow the baby out of the woman’s uterus.

Many of the obsetricians that I work with are eager to “get her delivered” as quickly as possible. There is also the “pit to distress” or “make the baby prove itself” – in other words, keep cranking that pitocin up until the baby crumps into fetal distress and the obstetrician does a stat c-section —- all so the doctor can be done, and get out of the hospital. Why wait 12-14 hours for a natural labor, when you can be done in less than an hour?

Our induction rates are through the roof. The nurses are rarely told the unit statistics, and when we are given them, they seem grossly understated. The L&D nurses know how many patients are induced or augmented, day after day, because we are the ones there, admitting the patient, and running their pitocin. We see them in massive amounts of pain from what is a very unnatural process designed to speed up the labor process, thus leading to increased epidural rates due to the higher levels of pain from synthetic oxytocin versus natural oxytocin.

The term was discussed in this Alexian Brothers Medical Center Employee Newsletter

Back in 2006, our tradition, like most maternity units, was to induce mothers when the fetus reached term gestation which was 37-40 weeks gestation. The medication, oxytocin (Pitocin), was administered to high dose levels to affect delivery. At times, the over-zealous use of oxytocin led to uterine hyperstimulation (terminology changed in September, 2008 to tachysystole), where the contractions were occurring too close together to allow the fetus sufficient time to recover before the next contraction would begin. The notion of “Pit to distress” was commonplace back then.

It was mentioned in this Mothering message board thread about Cytotec:

With a reactive baby (either by NST or auscultation) 25 mcg cytotec can be placed in the back of the vagina for cervical ripening 24 hrs prior to hospital induction and the mom sent home to wait, after observing her and baby for an hour. The vast majority (like 90%) will go into spontaneous labor before coming in for their “scheduled” induction. My biggest problem with cytotec is that we just hit moms with it over and over again, and then , surprise,when it does kick in, there’s too much on board, sorta like “pit to distress”.

Pit to distress was mentioned in the comments of the post My Rant on Pitocin on Knitted in the Womb after the blog’s author, a former chemist and doula, was scolded by an anonymous OB nurse for not understanding the difference between microunits and milliliters when it came to dosing Pitocin.

I’m a trained chemist. I hold a bachelors degree in biochemistry, did some course work towards a masters in chemistry, and worked for 6 years in an R&D lab in the specialty chemicals industry. I probably know WAY more about different units of measure than you do. I used “microunits” and “milliliters” in my discussion appropriately.

I’m not sure why I have to resuscitate a newborn to have “been there,” but since it seems to be very important to you, I’ll talk about it. 90% of the time labor should go just fine, with no need for resuscitation—this according to the World Health Organization. Of the other 10%, not all of them would require newborn resuscitation. If you’ve found that a large percentage of the births you’ve been at have required resuscitation, perhaps you should look at the medical interventions that might be causing that. From my end, the only clients I’ve had who had babies who required resuscitation were cases where there had been “Pit to distress.”

The news just broke yesterday of the largest jury award for a medical malpractice case in Ohio history. Miami Valley Hospital was found liable for $31 million in damages, but the parties agreed to settle, according to this Dayton Daily News blog post.

VBAC is safe. VBAC with induction is not, let alone VBAC with Pit to distress.

The lawsuit also identified Dr. Kedrin E. Van Steenwyk and Contemporary Obstetrics and Gynecology as defendants, but the jury found that neither was liable for what happened to the boy.

The boy’s mother, Renetha, was a VBAC patient, meaning she would deliver the boy vaginally, though she had previously had a Caesarian section. That meant she was at a higher risk for a ruptured uterus during labor, which occurred, Lawrence said.

At that point, the mother’s body stopped providing oxygen through the placenta, though the boy was still inside her. He probably went 18 to 20 minutes without oxygen, Lawrence said.

The hospital staff, which knew Renetha Stanziano was a high-risk patient, erred by failing to monitor the labor properly, by failing to diagnosis the hyper-stimulation of her uterus, by inappropriately using the drug Pitocin and by not telling the attending physician of her “inappropriate contraction pattern,” according to the complaint.

The nurses continued to give her Pitocin, even as her contractions escalated to unsafe levels, and “they blew the uterus apart,” Lawrence said.

The boy, called “Leo,” has severe cerebral palsey [sic]. He uses a feeding tube. He cannot speak, is not ambulatory and has trouble holding anything in his hands,” Lawrence said. Though Leo is badly disabled, he is alert and can recognize family members. When he needs something, he communicates by kicking, Lawrence said.

Leo will never be able to work, and Renetha and her husband Douglas are now “24-7 health-care givers,” Lawrence said. After Leo’s birth, Renetha stopped attending college and quit her job at Wright-Patterson Air Force Base to take care of the boy, Lawrence said.