Tuesday, December 22, 2015

April's Birth Story (respectful natural hospital birth)

April's Adorable Baby
Because there are many egregious examples of bias in the maternity care of women of size, sometimes it can sound like no women of size receive respectful care during birth, but of course that's not true. There are some WONDERFUL care providers out there who really do give appropriate and respectful care to women of size during pregnancy and birth. Periodically it's important to share those stories too. That sounds like a wonderful and upbeat Christmas week post to me!

Here is the story of a "supersized" woman who gave birth recently in South Dakota. Many care providers would have predicted gloomy things based on her size (over 300 lbs.) and age (35). Yet she had a healthy pregnancy and baby, as well as an easy and completely natural birth in the hospital with a very caring OB and supportive nurses.

Remember, while there is a higher risk of some complications in "obese" women (especially as size increases), many high BMI women have completely normal and healthy pregnancies and births, especially when they take good care of themselves and are able to labor spontaneously with excellent support. 

The value of truly supportive care providers cannot be underestimated. So let me stop and speak to the care providers among my readers for a moment.
Providers, the most powerful intervention you can provide to women of size is to treat them with dignity and respect at all times. Some women of size have been so shamed and mistreated that they avoid care providers whenever possible. Regardless of what the scale says, all women deserve gentle and respectful care, but far too often they do not experience it. Respectful care can be a transformative experience for women of size who have had mostly negative contacts with health care before. Help heal that relationship; go out of your way to be as respectful and gentle as possible. 
Today, we women of size send a big shout-out to all the providers who DO provide respectful, excellent care to women of size. Thank you for all that you do.

We thank you for your gentle care and for your advocacy on our behalf. We know it's not always easy to do so in the weight-biased environment of many hospitals, but it is SO important that care like this be available to women of all sizes. Thank you for your efforts on our behalf.

And now as a holiday treat, here is April's birth story, an example of respectful care for a woman of size giving birth in the hospital.

I'm from South Dakota and I got my pregnancy care and gave birth at Sanford Hospital in Sioux Falls.  
On my first visit with my obstetrician, she did make a point of talking with us about the increased risks due to my weight (340-ish at the time) and my age (35). She said that I needed to be cautious about gaining too much weight and that I shouldn't be alarmed if I lost weight but also that I shouldn't TRY to lose weight. She also made a point of saying that even though the risks were increased, they were still quite low - especially since I am healthy with no major medical problems.  
I ended up losing about 20 pounds over the next couple of months and then my weight just stayed the same until my last month when I gained back about 5 pounds. Neither she nor any of the nurses that weighed me every visit ever commented on my weight except once when the nurse asked if I was deliberately trying not to gain weight. I told her now, that I ate when I was hungry and she was good with that, she didn't want me dieting.
I did have several ultrasounds over the course of the pregnancy but that was because she didn't like to sit still and the tech had trouble seeing the bits of her anatomy that they wanted to see. Everything went very well with the pregnancy. 
I went into active labor 2 days before my due date though I had been contracting for a couple days before that - just very far apart. I said I wanted a natural birth and they had a copy of a birth plan (checkboxes) that my obstetrician had given me months before. I also brought a simple birth plan I had typed up myself - one page with simple goals and requests. I also requested a nurse familiar with natural birth if possible.   
My nurse was wonderful. They assign each woman her own nurse so she was by my side the whole time. She was super supportive - kept saying how wonderful I was doing and helped keep my confidence up.  I didn't have an IV - they were okay with a heplock and only intermittent handheld monitoring so I had complete freedom of movement. Also, I had a jacuzzi and a shower.  
I labored from early morning until about 4pm I was 7cm dilated. Contractions came constantly after that and I got the urge to push. They checked me and I was 8cm so they said not to push. I couldn't really not push, though I tried and the midwife tried to help. 10 minutes of that and they checked me again and I was 9 1/2 and could push. FINALLY!  
I was half on my side hanging on to the bars on the side of the bed and the nurses (not the midwife) tried to get me to roll onto my back. I refused and said the doctor had said I could push in any position, even upside down (which she had said). So they let me be. 
The doc came in and it was my obstetrician since she just happened to be on call that day. She confirmed I didn't need to move and my daughter practically flew out she came so fast!  The doc almost didn't make it to the room in time - they were seeing hair! 
I believe because of this [being in a side position], the birth went very quickly and I didn't tear at all. All the nurses were very surprised and I feel that they will be more supportive of alternative positions in the future.The nurses were amazed that she came so easily and that I didn't tear even though it was pretty fast. My little girl was 7 lbs 6 oz and in perfect health. 
So, even though there was a lot of pain (though I don't really remember the worst of it now) I'm glad things went as they did and I hope you all can have as wonderful an experience as I did. 
Key thing is ask lots of questions to find out what your doc/nurse is okay with and don't be afraid to speak up for yourself, though keep it civil - if you are confrontational it will just hurt you in the end. You need to radiate calm, confidence, and that you are sure you know what you want. Also remember that we have the right to give birth in the position we choose. 
I found the book "Natural Hospital Birth" by Cynthia Gabriel very helpful also. I highly recommend anyone wanting natural birth in a hospital setting to read it - it is full of tips on how to stay in control even in the hospital. 
Also, I'd like to mention that I'm donating my extra milk to the Mother's Milk Bank of Iowa and I'd like to encourage anyone who has extra breast milk to donate to their local bank. It is so important for the little sick babies in the NICU to have breast milk.  

Tuesday, December 15, 2015

The Healing Effect of Health At Every Size College Courses

When I went to college I was truly shocked by the amount of eating-disordered behavior I saw there.

In time I discovered I knew several people with true bulimic issues, some with binge-eating, and some with anorexic tendencies. Many others simply had a lot of neuroses around food and major guilt about "being bad."

What shocked me most was that most of these eating-disordered behaviors were in people who were "normal" weight or just a bit "overweight" by societal standards.

I didn't usually see these behaviors in the fat women I knew, and I didn't see these behaviors in myself. Instead, I saw them in the people that others expected to have healthy eating behaviors compared to me.


That really shocked and surprised me. It made me start to rethink many of the things I had been taught in Weight Watchers and elsewhere. For years, I had believed that all fat people had eating problems (or they wouldn't be fat, right?) and that nearly all average-sized people did not have eating problems. I knew a few had anorexia and I'd heard about binge-eating and bulimia, but I expected most eating disorders to be in people with body size extremes.

Yet really, most of the people I met with eating disorders looked "normal." They were basically of average size, and because of that fact, they were able to hide their eating disorders very well indeed. No one would believe that they had an eating disorder just by looking at them, whereas many believed it of me based on my looks...but it wasn't true.

Now, I have to qualify that a little. After years of dieting, I had started to develop some eating-disordered behavior, but it was pretty mild. It certainly hadn't developed even remotely to the level of binge eating, anorexia, or bulimia. I was never an emotional eater, I didn't binge, nor did I have the kind of neurotic fixation on food that I saw in many of my peers. Once I realized how screwed up some people's behaviors around eating were, I realized that I was better off than I thought. I didn't have an actual eating disorder, and I realized that simply being fat certainly didn't guarantee one. And once I eventually left the dieting lifestyle, any leftover neurotic eating behaviors disappeared altogether.

College campuses are rife with eating-disordered behaviors. The good news is that some colleges are recognizing this, organizing support for those who need it, and offering coursework surrounding these issues. This is a huge step in the right direction.

I hope that college courses like the one below can help blunt some of this angst and help heal people's body issues. College is a powerful time to heal body image and eating disorder issues, so I hope more colleges will make courses like this available.

Wouldn't it be great to see something like this in medical schools too? I certainly have read about a lot of eating-disordered behavior (including compulsive exercise behavior) in medical students over the years. A Health At Every Size® course like this in medical school be incredibly valuable in influencing a more compassionate and healing approach towards body size and eating issues in future care providers.

Colleges and medical schools, are you listening?


J Nutr Educ Behav. 2015 Mar 10. pii: S1499-4046(15)00011-1. doi: 10.1016/j.jneb.2015.01.008. [Epub ahead of print] Health at Every Size College Course Reduces Dieting Behaviors and Improves Intuitive Eating, Body Esteem, and Anti-Fat Attitudes. Humphrey L1, Clifford D2, Morris MN1. PMID: 25769516
OBJECTIVE: To investigate the effects of a Health at Every Size general education course on intuitive eating, body esteem (BES), cognitive behavioral dieting scores, and anti-fat attitudes of college students. METHODS: Quasi-experimental design with 149 students in intervention (45), comparison (66), or control (46) groups. Analysis of variance and post hoc Tukey adjusted tests were used. RESULTS: Mean scores for total general education course on intuitive eating (P < .001), unconditional permission to eat (P < .001), reliance on hunger (P < .001), cognitive behavioral dieting scores (P < .001), BES appearance (P = .006), BES weight (P < .001), and anti-fat attitudes (P < .001) significantly improved from pre to post in the intervention group compared with control and comparison groups. CONCLUSION AND IMPLICATIONS: Students in the Health at Every Size class improved intuitive eating, body esteem, and anti-fat attitudes and reduced dieting behaviors compared with students in the control and comparison groups.

Wednesday, December 9, 2015

2015 studies on d-chiro-inositol

Here are a few recent (though small) studies on d-chiro-inositol (DCI) for Polycystic Ovarian Syndrome (PCOS). They had promising results. This is good news.

However, this little taste of research on DCI only points out the gaps that still exist and sure leaves me wanting more. So here's my Christmas wish list for PCOS research.

  • I would like to see some gold-standard randomized controlled studies with larger study groups. What's with all these little studies? It doesn't mean that much until it's been done with large study groups and replicated several times
  • I'd like to see more research from the USA and other countries; why are the Italians the only ones really pursuing this so closely?
  • I'd like to see more research done on how DCI affects metabolism, not just menstrual regularity, and whether it slows or prevents progression to Type II diabetes. It's really the metabolic implications that could have the most potential impact on people's health
  • I want to know if there is any interaction between metformin and DCI
  • I want to make sure DCI is safe in pregnancy and breastfeeding
  • I'd like to see DCI studied in post-menopausal women too; that is a vastly understudied group for DCI. Does it impact the incidence of diabetes, heart disease, or stroke?
  • I'd like to see DCI studied in close male relatives of women with PCOS. If PCOS women have a secondary messenger insulin signaling defect, wouldn't you think that our male relatives probably have it too? And that DCI might benefit them too?
  • I'd like to see this question about which protocol is best (DCI vs. myo-inositol vs. both) settled with better quality research

Okay, I'm cranky and demanding, but with a PCOS medication that shows this much promise, isn't it about time we had larger, more complete, and more qualitative trials?

Come on, PCOS research community, get on the stick. Stop putting out these tiny little fluff studies and start cranking out some meaningful inositol research that starts answering the most critical questions.


Gynecol Endocrinol. 2015 Jan;31(1):52-6. doi: 10.3109/09513590.2014.964201. Epub 2014 Sep 30. The menstrual cycle regularization following D-chiro-inositol treatment in PCOS women: a retrospective study. La Marca A1, Grisendi V, Dondi G, Sighinolfi G, Cianci A. PMID: 25268566
Polycystic ovary syndrome is characterized by irregular cycles, hyperandrogenism, polycystic ovary at ultrasound and insulin resistance. The effectiveness of D-chiro-inositol (DCI) treatment in improving insulin resistance in PCOS patients has been confirmed in several reports. The objective of this study was to retrospectively analyze the effect of DCI on menstrual cycle regularity in PCOS women. This was a retrospective study of patients with irregular cycles who were treated with DCI. Of all PCOS women admitted to our centre, 47 were treated with DCI and had complete medical charts. The percentage of women reporting regular menstrual cycles significantly increased with increasing duration of DCI treatment (24% and 51.6% at a mean of 6 and 15 months of treatment, respectively). Serum AMH levels and indexes of insulin resistance significantly decreased during the treatment. Low AMH levels, high HOMA index, and the presence of oligomenorrhea at the first visit were the independent predictors of obtaining regular menstrual cycle with DCI. In conclusion, the use of DCI is associated to clinical benefits for many women affected by PCOS including the improvement in insulin resistance and menstrual cycle regularity. Responders to the treatment may be identified on the basis of menstrual irregularity and hormonal or metabolic markers.
Minerva Ginecol. 2015 Aug;67(4):321-5. Epub 2015 Feb 11. Myo-inositol vs. D-chiro inositol in PCOS treatment. Formuso C1, Stracquadanio M, Ciotta L. PMID: 25670222
AIM: Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women in fertile age. It is an endocrine and metabolic disorder characterized by oligo-anovulation, hyperandrogenism and insulin-resistance. Various therapeutic approaches have been attempted in PCOS, including diet and the use of pharmacological agents such as oral contraceptives (OCs) or anti-androgens. Recently, the introduction of inositol in the treatment plan has proved to be as reasonable as useful in countering the endocrine-metabolic disorders of this syndrome. METHODS: The aim of our study was to compare the clinical, endocrine and metabolic response after 6 months of therapy in 137 PCOS women characterized by oligomenorrhea and/or acne and/or mild hirsutism and insulin-resistance. The patients were treated with myo-inositol or with D-chiro-inositol or with placebo. RESULTS: Our study showed that both myo-inositol (MI-PG) and D-chiro inositol (DCI-PG) treatments are able to significantly improve the regularity of the menstrual cycle, the Acne Score, the endocrine and metabolic parameters and the insulin-resistence in young, overweight, PCOS patients. CONCLUSION: Definitely, we assumed that both treatments with myo-inositol and with D-chiro inositol could be proposed as a potential valid therapeutic approach for the treatment of patients with PCOS. Additionally, further examination and for a longer period of treatment are needed.
Arch Gynecol Obstet. 2015 May;291(5):1181-6. doi: 10.1007/s00404-014-3552-6. Epub 2014 Nov 22. Evaluation of ovarian function and metabolic factors in women affected by polycystic ovary syndrome after treatment with D-Chiro-Inositol. Laganà AS1, Barbaro L, Pizzo A. PMID: 25416201
PURPOSE: To evaluate the effects of D-Chiro-Inositol in women affected by polycystic ovary syndrome (PCOS). METHODS: We enrolled 48 patients, with homogeneous bio-physical characteristics, affected by PCOS and menstrual irregularities. These patients underwent treatment with 1 gr of D-Chiro-Inositol/die plus 400 mcg of Folic Acid/die orally for 6 months. We analyzed pre-treatment and post-treatment BMI, Systolic and Diastolic blood pressure, Ferriman-Gallwey score, Cremoncini score, serum LH, LH/FSH ratio, total and free testosterone, DHEA-S, Δ-4-androstenedione, SHBG, prolactin, glucose/IRI ratio, HOMA index, and resumption of regular menstrual cycles. RESULTS: We evidenced a statistically significant reduction of systolic blood pressure, Ferriman-Gallwey score, LH, LH/FSH ratio, total Testosterone, free Testosterone, ∆-4-Androstenedione, Prolactin, and HOMA Index; in the same patients, we noticed a statistically significant increase of SHBG and Glycemia/IRI ratio. Moreover, we observed statistically significant (62.5%; p < 0.05) post-treatment menstrual cycle regularization. CONCLUSIONS: D-Chiro-Inositol is effective in improving ovarian function and metabolism of patients affected by PCOS.

Tuesday, December 1, 2015

Physical Recovery After CBAC

Artwork by Molly Remer, from Brigid's Grove Etsy Shop
Recently, we have been talking about Cesarean Birth After Cesarean, or CBAC (some people prefer Cesarean Surgery After Cesarean, or CSAC). This is when someone wants and works for a VBAC but doesn't have one. Usually it means that she labored but ended up with a repeat cesarean, but sometimes it can involve an unwanted planned repeat cesarean that was done for medical indications or because of unsupportive providers. It is the unwanted aspect of it that is most important.

As we have discussed, everyone celebrates a VBAC but many CBAC mothers feel alone and unsupported, both in their physical and emotional recovery. This needs to change.

As part of our CBAC emphasis this past month, I shared my CBAC story a few weeks ago, as well as the CBAC support website I created to discuss the many feelings that a CBAC can involve and some ideas for working through them. I also wrote a 3-part series for the Science and Sensibility blog that discusses how birth professionals can better support people who have had a CBAC:
  • Part One - CBAC: A Unique Grief
  • Part Two - CBAC: The Forgotten Mothers
  • Part Three - CBAC: Supporting Women When VBAC Doesn't Happen
For the International Cesarean Awareness Network (ICAN), I wrote a brochure on CBAC so birth professionals have something to give the CBAC mother immediately afterwards to help support her emotional journey. And I will be recording several webinars for ICAN about CBAC as well.

For my last posts in this series here on this blog, I'd like to focus on physical healing after a CBAC, what you might be feeling after a CBAC, and some things you might do to help in  your emotional healing as well. As always, take what works for you and leave the rest behind.

Physical Recovery

Having a CBAC is hard. Usually it involves recovering from both the rigors of labor and major surgery, and of course recovery can be harder after multiple cesareans. In addition, CBAC mothers have a higher incidence of complications like infections and bleeding, and about 2% experience significant morbidity.

It is hard to process emotions when your body is struggling to heal. Many women find it is helpful to focus first on physical recovery after a CBAC. Here are some ideas to help promote physical recovery.
  • Rest as much as you can. The most potent tool for physical healing is rest. If you are doing too much, your body must divert energy from its recovery. It can be hard to get enough rest with a new baby, but with the support of others, you can prioritize as much rest as circumstances allow
  • Ask for help. Don't be afraid to enlist help from friends, family, your partner, or a post-partum doula. Others should be doing the cooking, cleaning, shopping, and caring for other children; your priority is to feed the baby and sleep as much as possible at first 
  • Take pain meds when needed - Don't neglect pain medication post-partum; you've had surgery. Take them a little bit early, before the pain gets ahead of you. Taper them off over time, but don't be afraid to take them for as long as you need them
  • Set up your home to make recovery easier. Have all the supplies you need right at hand, including a water bottle, the phone, extra diapers and burp cloths, healthy snacks, a footstool, and extra pillows to make positioning more comfortable. Include some entertainment for yourself (a book, the TV remote, music) for those moments when baby just won't let you get up
  • Eat healthy. Your body needs help to repair tissue and replace lost fluids. Get plenty of iron-rich and vitamin C foods and stay well-hydrated to replenish your blood supply. Adequate protein plus vitamins A and E are important in helping to rebuild tissue. Let others feed you, but keep around plenty of easy snack foods like string cheese, nuts, fresh and dried fruit, and pre-sliced vegetables to make grabbing a bite easier while caring for the baby
  • Don't go back to your regular schedule too quickly - Many women go back to a normal schedule too soon after a baby is born, and their body lets them know it's too soon with increased bleeding and pain. Respect what your body is telling you. Take it easy for as long as you can once you get home from the hospital
None of these hints is a magic pill that will wipe away all pain and difficulty. You still will have a surgical recovery, with all the pain and fatigue that entails. Although CBACs are usually harder than primary cesareans, not all are hard. Some have an easy recovery. Others have more difficult recoveries, and a few have very complicated recoveries. Let's talk more about these. 

Dealing with Complications

Although major injuries are quite unusual after CBAC, they do sometimes occur. Women who have experienced major physical trauma (like severe bleeding, significant infection, severe scar tissue, surgical injury to nearby organs, uterine rupture, or hysterectomy) will need significant support as they recover.

If you have experienced complications, it is important to take recovery slowly, since set-backs can easily occur. Get as much rest as possible and seek out complementary therapies like acupuncture, chiropractic, Maya Abdominal Massage, physical therapy, or nutritional counseling to help support your recovery.


One study found that about 35% of CBAC women experienced significant bleeding, while other studies have found much lower rates. Differing thresholds for defining hemorrhage explains many of these differences, but blood loss is a real risk to be aware of.

If you experienced significant bleeding during your labor or cesarean, have your provider check you for anemia. Being anemic can make healing more difficult, impair milk supply, and prolong fatigue, yet many providers are not proactive about monitoring for this. Taking extra iron, eating iron-rich foods, and taking supplements like Floradix can help your iron levels recover. Women with hypothyroidism may have more trouble with anemia and should probably be extra proactive about this and have additional tests.

If you experienced a major hemorrhage, you should be watched for Sheehan's Syndrome. This is when part of the pituitary gland dies due to a relative lack of blood supply to the area if a hemorrhage happens during childbirth. This can impact milk supply negatively and eventually lead to secondary thyroid dysfunction and many other distressing symptoms. Sheehan's Syndrome often doesn't present fully until years later, sometimes not fully triggered until a successive health crisis (surgery, infection) causes an adrenal crisis. If you experienced a major hemorrhage during your birth, be aware of the symptoms of Sheehan's Syndrome and be ready to advocate for testing if needed.


Women who have a cesarean after a VBAC trial of labor have increased rates of infectious morbidity. One study found that 25% of CBAC women experienced chorioamnionitis afterwards, although other studies have found lower rates.

If you experienced a major infection after your CBAC, this can involve a long hard healing process. If you are still in the hospital (or are readmitted later), ask about IV antibiotics instead of oral ones, and ask for a consult with a wound or infection specialist.

Some women have had better healing on an infected cesarean wound using a wound vacuum (Negative Pressure Wound Therapy, NPWT), while others have found it painful and not very useful. Basically it sucks out fluids and infection and draws more blood to the area to improve healing. Bandages are changed about 3x/week, which some women find quite painful; be sure to take your pain meds at least an hour ahead of time. Some people report that using alcohol between the skin and the bandage ahead of time can help remove adhesive tape more easily, and infusing saline first into the sponge inside the wound can ease its removal considerably.

Medical-grade honey is another option (FDA-approved) that has shown some promise in limited studies. It is rarely utilized for cesarean wound issues in first-world countries, but can be another option to consider if you do not want the wound vacuum or find it too painful. You might have to strongly advocate for it since it is used more often in non-obstetric wounds and most OBs won't be familiar with it.

If you are heavy, ask about using weight-based dosing for your antibiotics. Not all antibiotics need weight-based dosing but many do, yet the research shows that the majority of doctors tend to under-dose patients of size, especially those with a very high BMI. Research also shows that "obese" people benefit significantly from longer courses of antibiotics, IV antibiotics instead of just oral ones, and more frequent dosing regimens, so ask your care provider to consider these options too.

Scar Tissue and Nerve Damage

Some women develop significant internal scar tissue (adhesions); the more cesareans you have, the more at risk for adhesions you are. One study found that 46% of women with three or more cesareans had developed "dense" adhesions. These types of adhesions can lead to significant pelvic pain, difficult menstruation, and even bowel obstructions.

Severe cases of adhesions may require additional surgery to break them up. Although this has the risk of creating more adhesions, some women find significant relief with it. Other women are able to address pelvic pain from adhesions through physical therapy, massage, yoga, acupuncture, and Maya Abdominal Massage techniques, which can help loosen and break up the scar tissue.

Some women experience long-term numbness after their cesarean from nerve damage. Although this has little medical significance, it can have significant emotional significance to the woman involved, who may mourn loss of sensation in the area. Sometimes an "itching" feeling can be felt from the inside, even though scratching on the outside does not help. The loss of sensation in the area around the scar is often cited by cesarean mothers as one of the more distressing results of their cesareans. Again, the techniques above may help loosen scar tissue and restore some degree of nerve function.

Injuries to Nearby Organs

Because the uterus is located in the abdomen, one of the risks of surgical birth is injury to nearby organs like the bladder and bowels. This is not a big risk, but if it happens to you it is a big deal.

One study found an incidence of 0.86% of bladder injuries in women who had a CBAC after a trial of labor. Although this risk is low, it does increase in the face of prior cesareans, especially if dense adhesions are present. It is also increased in the face of induction and augmentation.

Sometimes these injuries occur for other reasons. One CSAC mother I know shares her story of recovery after a severe surgical injury by a doctor who was angry with her for laboring "so long":
My bladder was severely damaged through a surgical error during my CSAC. The surgical error was made in an O.R. environment of carelessness and anger that I had fought against CSAC and labored for so long (~60 hours).
Things that helped me recover were: Time, innate stubbornness, acupuncture to help my bladder relearn how to contract after surgical reconstruction, EMDR therapy for PTSD, and antidepressants. My recovery was long and so hard and 7 years later I can finally see the progress I've made.
Uterine Rupture

Uterine rupture is rare but it does happen occasionally. When it happens, it can be absolutely devastating, emotionally and physically. Although usually the rupture is able to be dealt with in a way that preserves both the uterus and the baby, in worst case scenarios the uterus, the baby, or both may be lost. The mother can be left with tremendous physical and emotional trauma.

Obviously, the mother will need to watch for many of the complications listed above. Sheehan's syndrome in particular should be monitored for. Once the initial healing is over, the mother may feel better physically with some of the complementary therapies listed above.

There are groups that specialize in support for women who have had a uterine rupture. You can find more information about these groups here and here. Please also look into the resource groups listed below that help women deal with birth trauma.


Women who have a CBAC are at increased risk for hysterectomy, although the absolute risk for this is also low. In one study, about 1% of CBAC women had a hysterectomy during labor.

Of course, if you are among that 1%, it feels like a very personal risk. To lose your uterus and all future childbearing potential is a tremendous grief. Even though the hysterectomy may have been necessary, it still can be traumatic to recover from physically. Hormonal changes due to the hysterectomy may intensify both the physical and emotional recovery. Find a sympathetic care provider to help ease you through these changes. A naturopath or a doctor with a more "alternative" mindset may be your best bet. Acupuncture may also help ease these changes.

Unfortunately, there are not a lot of resources available specifically for women who experience hysterectomy after a trial of labor. There are groups that offer support after hysterectomies in general; these groups can be found here and here. If you search on these sites for "hysterectomy during childbirth" you will find other women who have had similar experiences. Here is a link to an article on coping with unexpected hysterectomies.

Women who lose their uterus during childbirth may develop symptoms of Post-Traumatic Stress Disorder (PTSD). There are a number of organizations out there who can help women dealing with PTSD after childbirth, including Solace for Mothers and others listed below.


The good news is that research shows that the rate of significant complications after a CBAC is quite low. Medically speaking, most CBAC mothers will experience a pretty unremarkable recovery.

However, recovering from a cesarean is always a challenge, especially when you already have older children to take care of. Many mothers try to do too much too soon and end up delaying their recovery and exhausting themselves. It's important to remember that you've had major surgery and to let others take care of you as much as possible.

If you experienced a complication after a CBAC, that can make your recovery, both physical and emotional, harder. Even more difficult are the rare but very serious complications like injuries to adjacent organs, uterine rupture, or hysterectomy. If this has happened to you, please be sure to get extra support for your physical healing and personal support for your emotional healing.

Although most women benefit from focusing first on their immediate physical recovery, sometimes the emotions of a CBAC are so overwhelming that they need to be addressed right away in conjunction with the physical healing.

If you feel overwhelmed emotionally, find a way to debrief the birth as soon as you can. This can be with your providers (if they are supportive), with a doula, with a birth-friendly therapist, or with your partner. The important thing is to find someone who is truly supportive and emotionally safe to speak to, not someone who will downplay your emotions or tell you to "just get over it."

Finding a support group of like-minded women who have been through a similar experience is also vital in dealing with birth trauma. See the resources below for links to birth trauma resources and support groups.

More on emotional recovery in the next post in the CBAC series.


Emotional Support for CBAC Mothers:
Emotional Support After a Difficult Birth:

*Note: The medical community uses the term "failed" in the following abstracts. Do not let their terminology bring you down. We are NOT failures and we did not fail. 

Scifres CM, Rohn A, Odibo A, Stamilio D, Macones GA. Predicting significant maternal morbidity in women attempting vaginal birth after cesarean section. Am J Perinatol 2011 Mar;28(3):181-6. PMID: 20842616
...We set out to identify factors that are predictive of major morbidity in women who attempt VBAC. A nested case-control study was performed within a large retrospective cohort study of women with a history of at least one cesarean. Women who attempted VBAC were identified and those who experienced at least one complication of a composite adverse outcome consisting of uterine rupture, bladder injury, and bowel injury (cases) were compared with those who did not experience one of these adverse outcomes (controls)...Of 25,005 women with a history of previous cesarean, 13,706 (54.9%) attempted VBAC. The composite outcome occurred in 300 (2.1%) women attempting VBAC. Using logistic regression analysis, prior abdominal surgery (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.2 to 2.1), augmented labor (OR 1.78, 95% CI 1.29 to 2.46), and induction of labor (OR 2.03, 95% CI 1.48 to 2.76) were associated with an increased risk of the composite outcome. Prior vaginal delivery (OR 0.39, 95% CI 0.29 to 0.54) was associated with decreased risk for the composite outcome...Women attempting VBAC with a history of abdominal surgery or those who undergo augmentation or induction of labor are at an increased risk for major maternal morbidity, and women with a prior vaginal delivery have a decreased risk of major morbidity. The multivariable model developed cannot accurately predict major maternal morbidity.
Obstet Gynecol. 2006 Jul;108(1):21-6. Maternal complications associated with multiple cesarean deliveries. Nisenblat V1, Barak S, Griness OB, Degani S, Ohel G, Gonen R. PMID: 16816051
...The records of women who underwent two or more planned cesarean deliveries between 2000 and 2005 were reviewed. We compared maternal complications occurring in 277 women after three or more cesarean deliveries (multiple-cesarean group) with those occurring in 491 women after second cesarean delivery (second-cesarean group). RESULTS: Excessive blood loss (7.9% versus 3.3%; P < .005), difficult delivery of the neonate (5.1% versus 0.2%; P < .001), and dense adhesions (46.1% versus 25.6%; P < .001) were significantly more common in the multiple-cesarean group. Placenta accreta (1.4%) and hysterectomy (1.1%) were more common, but not significantly so, in the multiple-cesarean group. The proportion of women having any major complication was higher in the multiple-cesarean group, 8.7% versus 4.3% (P = .013), and increased with the delivery index number: 4.3%, 7.5%, and 12.5% for second, third, and fourth or more cesarean delivery, respectively (P for trend = .004). CONCLUSION: Multiple cesarean deliveries are associated with more difficult surgery and increased blood loss compared with a second planned cesarean delivery. The risk of major complications increases with cesarean delivery number.
Am J Obstet Gynecol. 2007 Jun;196(6):583.e1-5; discussion 583.e5. Perinatal outcomes after successful and failed trials of labor after cesarean delivery. El-Sayed YY1, Watkins MM, Fix M, Druzin ML, Pullen KM, Caughey AB. PMID: 17547905
...Matched maternal and neonatal data from 1993-1999 in women with singleton term pregnancies with prior cesarean undergoing trial of labor were reviewed. Women with uterine rupture were excluded. Maternal and neonatal outcomes were analyzed for successful and failed trials. Predictors of success and failure were examined. RESULTS: 1284 women and their neonates were available for analysis. 1094 (85.2%) had a vaginal birth and 190 (14.8%) underwent repeat cesarean. Failed trials of labor were associated with higher incidence of choriamnionitis (25.8% vs. 5.5%, P<.001), postpartum hemorrhage (35.8% vs. 15.8%, P<.001), hysterectomy (1% vs. 0%, P=.022), neonatal jaundice (17.4% vs.10.2%, P=.004) and composite major neonatal morbidities (6.3% vs. 2.8%, P=.014). CONCLUSION: Failed trial of labor in women at term with prior cesarean is associated with increased maternal and neonatal morbidities.