VBAC scare tactics (6): CPD or FTP = no VBAC

Many women who want to have a vaginal birth after cesarean (or VBAC, pronounced “vee-back”) in the U.S. have faced some sort of opposition from their care providers when they have expressed their desire to VBAC.  Oftentimes, this opposition comes in the form of ” VBAC scare tactics.”

The (outrageous) statements are often misleading, exaggerated efforts by OBs (and yes, even midwives) to discourage women from VBAC and to encourage them to “choose” a repeat cesarean.  (Of course, it’s not really a choice if your provider won’t even “let” you VBAC, is it?)

And if you find yourself up against a barrage of scare tactics–as I once did–it can be exceedingly difficult to stake your claim and argue against the doctor (again, or midwife) who may or may not have your and your baby’s health prioritized higher than medico-legal concerns and who may or may not be hurling phrases like “catastrophic uterine rupture” and “dead baby” your way.

If you do find yourself facing such scare tactics, and if you do want to have a VBAC, there are some questions that your care provider should be able to answer when s/he hurls those scary and/or outrageous comments and standards your way.  And if s/he refuses to or even cannot answer these questions, then you might want to consider finding an alternative care provider–one who is making medical decisions based on research, evidence, and even respect for your patient autonomy and not on fear, willful ignorance, or even convenience.

I encourage all mothers who read this post (and others in my “VBAC Scare Tactics Series”) to  take the information contained herein as a springboard from which they can 1) continue their research on VBAC, 2) maintain a communicative relationship with their care providers, and 3) find a care provider who best supports the mother’s interests and plans for the birth of her child.

(To read my disclaimers about “why I am not anti-OB” and “why I take the gravity of uterine rupture seriously,” please see my posts on VBAC scare tactics (1) and (2).)

 

Scare tactic #6: Here in your chart, it says that your cesarean was for failure to progress.  Oh, and there’s also a note here about cephalopelvic disproportion.  You’re not really an ideal VBAC candidate since your cesarean wasn’t for fetal distress or breech presentation, so we need to schedule a repeat cesarean.

 

Questions to ask your care provider:

• Does this mean that you will not support my VBAC attempt if I refuse a repeat cesarean?
• Do either of those “diagnoses” make a VBAC attempt riskier than it would be for a mother who had a c-section for fetal distress or breech presentation?
• What is the VBAC success rate for women whose cesareans were for cephalopelvic disproportion (CPD) or failure to progress (FTP)?
• Were there any contributing factors–such as induction, fetal malpositioning, maternal immobility, labor time limits, or ruptured membranes–that could have inhibited my labor progression and led to a cesarean for CPD or FTP?
• How was the diagnosis of CPD or FTP made?

 

A more nuanced analysis:

Firstly, you can find an excellent resource on CPD and VBAC on ICAN’s White Papers.  I strongly recommend this resource to anyone who is questioning their care provider about a CPD or FTP diagnosis or wanting to attempt a VBAC after one or both diagnoses.

Secondly, it is my position that a previous CPD or FTP should not disqualify a mom from attempting VBAC, that there can be other preventable factors that contribute to these diagnoses, and that women should question their care providers about these diagnoses, especially if they are facing opposition to their desires to have a VBAC.  And yes, these diagnoses may be wrong and/or simply illustrative of a care provider’s impatience.

So what exactly is CPD?

CPD itself refers to a disproportion between the baby’s head and the mother’s pelvis.  In other words, it suggests that the baby’s head (or at least the presentation of the baby’s head) is too large to pass through mother’s pelvis.

A CPD diagnosis can be made before labor, often when a care provider decides that, based on an ultrasound estimation of the baby’s weight and/or a measurement of the mother’s pelvis, the baby is too big to fit through the mother’s pelvis.  It is worth noting, however, that near-term estimates of fetal weight and size can be “off” by a pound or more in either direction.  So a baby who is estimated to be 8 lbs. may actually less than 7 lbs. or more than 9 lbs.  What’s more, unless a mother has uncontrolled gestational diabetes or has suffered a severe pelvic injury or has experienced malnutrition, there is little evidence–especially pre-labor–that even a “big” baby cannot fit through her pelvis.

In addition, the  hormone Relaxin is released in increasing amounts in the mother’s body during pregnancy (particularly during the last few weeks of pregnancy), and this hormone helps to loosen the joints in  her pelvis for the delivery of the baby.  Accordingly, the increased “looseness” of her pelvis might not be accounted for in pelvic measurements taken by the mother’s care provider.

CPD is also (and often) diagnosed during labor.  This generally occurs when a mother’s labor is not progressing “adequately”  (a term I use lightly) and the use of synthetic oxytocin (or pitocin) is not successful in aiding this progression.  It is thus implied that the “poor progress” is a result of a disproportion between the baby’s head and the mother’s pelvis.

Many practicioners and researchers distinguish between “absolute” and “relative” CPD.  (Please see ICAN’s White Papers on CPD for a further elaboration of–and potential problems with–this distinction.)  Truly absolute CPD is very rare and generally occurs when a mother has sustained a permanent pelvic injury and/or extreme malnutrition at some point in her life.  (I emphasize “truly” since many women who have been diagnosed with “absolute” CPD have gone on to have vaginal births, thus proving that the CPD was not so absolute after all!)  In cases of truly absolute CPD, vaginal birth, while not impossible, may be improbable. 

Relative CPD, however, is often diagnosed when there are other factors contributing to the baby’s supposed inability to pass through the mother’s pelvis.  As pointed out on the ICAN resource for CPD, these contributing factors include:

Position of the baby’s head – The baby may have his head straight or tilted back instead of flexed with chin to chest. The baby’s head may also be asynclitic (tilted to the side).

Nuchal arm or hand – The baby may have her hand(s) or arm(s) raised to her head.

Posterior position – Baby is facing mother’s front instead of back.

Other malposition of the baby’s head – The back of the baby’s head may be facing sideways and has arrested in that position (transverse arrest). Occasionally, this happens as the baby tries to turn during labor into a more favorable position. Also brow or face presentations, where other parts of the baby’s head present first instead of its crown, may cause the baby to not be able to descend.

Misalignment of the pelvis – The mother’s pelvis could be misaligned due to many factors (mild pelvic jarring due to falls, sports injuries, or car accidents). Many women report this to be generally well-treated with chiropractic care.

Restriction of movement – Limitations on mother’s mobility in labor are very common due to hospital policy, epidural anesthesia, and/or continuous fetal monitoring.

Rupture of membranes – The breaking of the mother’s waters, either naturally or artificially by her care provider, can cause the baby to drop into the pelvis in an unfavorable position. An arbitrary and artificial time limit being placed on labor may not allow the laboring woman’s body enough time to birth.

 

I would also add to this list that induction–especially with combined with one or more of the above-mentioned situations–can contribute to a CPD and/or FTP diagnosis.  Particularly when a mother’s cervix is unfavorable for an induction, her body (let alone her baby) may simply not be ready to go into labor.  Thus, an “inadequately” progressing labor may have nothing to do with a failure to progress or a disproportion between her baby’s head and her pelvis–it may be the result of a failed induction.  It is a failure of technology–not of a mother’s body.

And some, if not many, diagnoses of CPD and/or FTP, with or without induction, may also be the result of a failure to wait (given the absence of maternal and/or fetal distress) on the part of the care provider.  And this is why the concept of “adequate labor progression” can be such a tenuous concept, for not every woman’s labor will progress according to a subjectively-determined timeframe.

Notably, while some studies have found that moms with a prior CPD or FTP diagnosis have a lower VBAC success rate than moms who had cesareans for other reasons (such as breech presentation or fetal distress), none of these studies suggest that a CPD or FTP diagnosis contributes to a higher risk of uterine rupture.  So in this respect, VBAC itself is not riskier for moms with these diagnoses. 

There is also no guarantee that CPD or FTP will repeat themselves in subsequent labors, especially if one can attempt to prevent the interventions or situations that can contribute to CPD or FTP.  (And sometimes this just means choosing a different care provider!)

This is particularly worth noting since the reason that some care providers will deny a VBAC to a mom who had a cesarean for CPD or FTP yet “allow” a VBAC for a mom whose cesarean was for breech presentation or fetal distress is that they think that CPD and FTP (unlike breech presentation of fetal distress) are likely to re-occur in subsequent labors.  One of the many problems with this reason comes down to a matter of how these care providers define “likely,” especially since a majority of women with prior CPD or FTP diagnoses can go on to have successful VBACs.

In fact, a study in the 1987 issue of the American Journal of Public Health found that the VBAC success rate for moms with a previous CPD diagnosis to be approximately 65%.  Another study published in a 1998 issue of Obstetrics and Gynecology found a 68% VBAC success rate for moms with a previous CPD diagnosis (Obstet. Gynecol., 92(5): 799-803. Nov 1998.).  There are even other studies (referenced in the ICAN resource) which report an 80% VBAC success rate for women with a previous CPD diagnosis, and a 56% VBAC success rate for women who underwent two cesareans for supposed CPD.

Accordingly, a CPD diagnosis certainly does not mean that VBAC success is impossible–or even improbable!  Nor does it mean that CPD is necessarily a permanent diagnosis.  You have options.  And in this respect, ICAN gives the following recommendations to help lower your risk of a CPD diagnosis:

Some women report that chiropractic care throughout and between pregnancies is helpful in avoiding CPD. Look for a chiropractor who has experience working with childbearing women and utilizes in-utero constraint techniques.

If you want to be mobile in labor, listen to your body. Don’t remain strapped to the bed; insist on getting up and moving around.

Learn labor positions that aid in opening your pelvis.  Consider reading & using The Pink Kit, a childbirth education tool useful for any woman planning a VBAC. It can help a woman find the best birth positions for her particular pelvic shape and size.

Learn the position of your baby and how to encourage your baby to be in the optimal position. Read the material at Spinning Babies website.

Have a doula. Research shows that a birthing woman with continuous labor support is more likely to have a shorter labor and a spontaneous vaginal birth.

And then, once you’ve asked all your questions and researched your options and determined your goals and plans for your next birth, watch this video:

It will inspire and astound and encourage you.  (And probably make you cry.)

*Note: the soundtrack for the video was disabled because of copyright issues.  But if you have it available, you can play The Stone Roses’ “She Bangs the Drums”–or another favorite, empowering song of yours–in the background while you’re watching it.