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#1 of 37 Old 09-08-2008, 11:21 AM - Thread Starter
 
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I just had my first visit with the midwife. She said that since I'm a vbac I'm required to have continuous fetal monitoring and iv access throughout labor and delivery. Any thoughts on this?
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#2 of 37 Old 09-08-2008, 12:20 PM
 
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Did you ask her why? I know there are midwives and OBs that will VBAC without those two things but it seems harder to find, particularly if you're having a hospital birth. My midwife did require them but talking to her about why and what it would mean really helped me.

The IV was a hospital rule -- something she didn't support but couldn't change (as long as I was having a hospital birth).

She was in favor of CFM for VBACs because sustained low heartbeat is an early indicator of uterine rupture. We talked about what she was using it for, what she meant by sustained, etc. It helped me to be comfortable that we weren't going to head for the operating room the first time the heart rate dipped. We also talk about how we could minimize the impact of CFM on my labor - ability to move around, etc. An honestly, the CFM didn't bother me a bit - which may have had something to do with arriving at the hospital in transition and not really wanting to pace the halls anyway.

I wasn't happy about either of these things, but talking about it with her made me more comfortable that they weren't going to push me into an unnecessary c-section. And I had my all-natural VBAC, 9lb 4 oz baby.
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#3 of 37 Old 09-08-2008, 03:03 PM
 
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Its the same situation with me: a Hep Lock is required and "continous monitoring" as required by the hospital. She did state that they have to allow me to use the rest room as often as I need to go...
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#4 of 37 Old 09-08-2008, 03:26 PM
 
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The cool thing about being the Mama is that *you* get to decide what is required and what isn't. They can tell you their policies and you have every legal right to decline them. Some will lie and tell you that you cannot decline them but they are absolutely wrong. Of course, this early in the game, they can drop you as a patient but then, that would probably be a blessing in disguise.

Personally, I would not consent to either.

CFM has not been shown to have better outcomes (check out Henci Goer's book "OB Myths v. Research Realities). Yes, monitoring a VBAC is important as it is the best indicator of a UR but it does not have to be continuous to be effective.

When you have an IV...you are tied...literally...to that IV. Plus, it gives CP easy access to give you a drug w/o your permission (sounds paranoid but I've read TONS of stories of this happening...especially w/ Pitocin).

Either way....whether you want these things are not....the choice is ultimately yours and your alone.

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#5 of 37 Old 09-08-2008, 11:17 PM
 
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yeah, these are common hospital protocols. I'm a "pick your battles" type, and I would try approaching it this way:

IV - ask if you can have a heplock instead. This means you'll have a port and a short tube hanging off which is tied off. If you are a bad stick, this is a very good idea, because it means you can arrange for one of the experienced nurses to do it and not worry about taking pot luck in an emergency. It's not as comfortable as not having an IV at all, but you have a lot more mobility than if you're attached to a bag and pole.

EFM: The trials looking at intermittent ascultation (handheld doppler) vs cEFM (CTG) were based on low risk women. I don't know if any studies have been done specifically applying it to VBAC. Your MW/hospital may be very uneasy using IA because there is no recorded strip for them to refer to. (A lot of lawsuits have hinged on those strips.) What you could do is discuss a schedule of EFM with your MW, so your "continuous" EFM isn't truly continuous. Your other possibilities are telemetry monitoring, which is offered by a few hospitals and means improved mobility, and internal monitoring. This would require ROM, and I personally would not have AROM for IFM unless I were having real problems with the EFM (there are times when EFM is unreliable, and a better reading can be obtained with IFM; in these cases, IFM can prevent a CS). But if you've had ROM and are already on the clock, and EFM is getting uncomfortable, it might be something to consider.

I had a really awful experience with EFM with my first baby; I was tied to it for hours, and the minute I moved the midwives lost the signal. (It was not routine monitoring; I was in hospital with preeclampsia.) So I am VERY sympathetic to not wanting EFM. But, I think it helps to have some flexibility if you're planning a hospital VBAC.

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#6 of 37 Old 09-08-2008, 11:19 PM
 
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With my daughter I used an OB in our area that was ok with doing vbac's... It is the rule that you have to have monitoring, we agreed to do every 20 min... Also, I agreed to a hep lock just to appease them... What ended up happening was I waited to go to the hospital until totally necessary and when we got there it was in the middle of the night, I was going really heavy then so we asked them to read our birth plan and they left us alone... I got out of there with only being monitored once for 15 min, and no IV, no hep lock... I was amazed I got away with it... What worked for me I think was having the balls to say what I wanted and not being bossy or bitchy about it... Like with the first nurse we had she was rather rude, so I was prepared to ask for someone else, I was not a patient I was a participating birthing momma... it was my birth....

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#7 of 37 Old 09-09-2008, 12:24 AM
 
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I LOVE LOVE LOVE the EFM that we use at the hospital I work at! Cordless, waterproof things that are worth 10x their weight in gold! : Seriously, they are awesome!

Want to go in the labor tub? No problem! Shower? Sure! Walk the hall (small hospital, just the one hall on our unit, lol!)? Go for it! Sit on the toilet? Okay!

Check out your local hospitals and find out what type of equipment they have. You might be pleasantly surprised at what "continuous EFM" can look like. Oh! Here's a link to them!

Um, not to say that EFM has been proven to be predictive of fetal outcomes or anything.

"IV access" to me sounds like a saline lock, which is indeed standard at most hospitals. But it doesn't mean an IV pole to drag around necessarily.

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#8 of 37 Old 09-09-2008, 01:23 AM
 
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Yep, that looks like the telemetry monitoring I mentioned earlier. It's great, but not all hospitals have it. Also, they need to be able to get a tight fit. When I had EFM, i could not move AT ALL because the belts shifted and they'd lose the trace. Really, I tried sitting up a little more to read (I wasn't having contractions ) and they made me stop because that tiny movement made the belts slip. : If you have that problem it doesn't matter whether the EFM is wireless or not; you're stuck there.

With standard "wired" EFM you can shift position to some extent, but the cable is pretty short, so you can't walk around. That's why I recommend asking for a schedule so you get breaks and can stretch and get more comfortable.

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#9 of 37 Old 09-09-2008, 02:19 AM
 
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Originally Posted by AlexisT View Post
Yep, that looks like the telemetry monitoring I mentioned earlier. It's great, but not all hospitals have it. Also, they need to be able to get a tight fit. When I had EFM, i could not move AT ALL because the belts shifted and they'd lose the trace. Really, I tried sitting up a little more to read (I wasn't having contractions ) and they made me stop because that tiny movement made the belts slip. : If you have that problem it doesn't matter whether the EFM is wireless or not; you're stuck there.

With standard "wired" EFM you can shift position to some extent, but the cable is pretty short, so you can't walk around. That's why I recommend asking for a schedule so you get breaks and can stretch and get more comfortable.
Your experience hasn't been my experience with these EFMs- I actually don't find that they are any different from the wired ones as far as how well they pick up or how tight the belts need to be- one of the reasons I love them so much! It is always a bit of a "chase the baby" thing when mamas are moving around a lot, but I always tell them to go ahead and move and I adjust the monitor (and adjust and adjust and adjust... lol). I find that I more often have problems tracing contractions than I do with keeping the FHR.

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#10 of 37 Old 09-09-2008, 09:40 AM
 
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No, I'm not saying they're different in that respect--I'm saying that if you have problems with the belts, as I did, then the telemetry units won't really be an improvement over a wired one.

Gah, re-read and I wasn't clear at all! It does read as if I was saying that a tight fit was more important generally. What I meant to say, and should have said, was that if you want to take advantage of the increased mobility, you need to get a good fit so it doesn't slip straight away. My experience was that the belts slipped, and so I couldn't move at all; being wireless wouldn't have improved that problem. I was on standard EFM, not telemetry.

DD 01/2007, DS 09/2011

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#11 of 37 Old 09-09-2008, 10:01 AM
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I had a vbac (which ended in a c) and a vba2c which was a vag birth. I was at a great mw practice in a hospital. They did require continuous monitoring, which I also wanted. They put in a hep lock with my first vbac attempt ,in case they needed to do an emergency c. I did, however, LOVE the internal fetal monitor. They tried the telemetry belt, and it kept slipping, so when the IFM was attached, I could forget about everything and turn inward and labor as I felt, with more freedom of movement than you'd imagine.

With my first vbac attempt, my labor was so long, that it was actually helpful to have extra fluids via the IV, in addition to anything I wanted by mouth - which wasn't much, actually since labor was hard, tiring, and at times nauseating. the IV fluids kept me a bit more hydrated.

With my second vba2c, I arrived at 10cm and +3, so I just started pushing the minute I arrived, and no time to even do a hep lock. In fact, I was admitted after the birth! I felt fine and drank as I needed. The IFM was once again, incredibly reassuring. The sensations of a 'first timer actually pushing the baby out' were beyond anything I could imagine, so knowing that everything was going well was very reassuring.

Weather or not to even have these two things is an important decision to make. I've read stories about moms having to go under general when an emergency c arose, and that breaks my heart, so having a hep lock ready can be a nice thing. It doesn't mean you're willing to give up by any means. It just means you're smart enough to make decisions along the way as new scenarios arise.

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#12 of 37 Old 09-09-2008, 10:10 AM
 
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Seems to be par for the course. IMHO this seems a legit medical reason for CFM b/c it can be an early indicator of UR (lots of literature on this). IV access doesn't mean you need an IV in place, just a hep-lock. Lots of earlier discussions on this board about that and you can decide for yourself whether you want to fight either one of these, but I had both during my VBAC and had a fabulous birth. They never needed to use my hep-lock but I figured that if it made them happy and they left me alone, fine. I would check to see if they have a telemetered CFM system, since that will allow you mobility during labor. Even without that, you aren't stuck in bed. I labored most of the time on a birth ball next to the bed, and that worked well for me.

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#13 of 37 Old 09-11-2008, 03:38 PM
 
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My hospital requires both too. I agreed to the Heparin Lock as a precaution for emergency, and also agreed to "monitoring as long as it did not interfere with my ability to manage my labor pain." If they are distracting me at the hospital, I will just remove the unit and let them howl. My husband knows this and knows that his job is to referee this for me.

You can sign the AMA forms if you want and opt out entirely, but I hate to throw out the good with the bad. Getting a quick IV in an emergency is a good thing, and a hep lock won't affect you at all. Monitoring can indicate rupture, but won't necessarily show that. So it is a crap shoot.

Funny note: I arrived for my last vbac at 10cm +2, and the nurses are required to get 30 minutes of continuous monitoring before they can "allow" me to birth my baby. Well, their unit was either broken or they just couldn't get it to work right, and they were telling me to stop pushing because they weren't ready! One nurse actually told my doula that my baby's heart had stopped, but not to tell me! I would have laughed, but I was kinda busy at the time! I mean, my baby was almost crowning. They were just going to have to wait a minute, then they could tell me if he was pink or blue! It's not like they could do anything for my baby at that point, except deliver him!

He came out nice and pink, by the way!
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#14 of 37 Old 09-11-2008, 04:15 PM
 
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a hep lock won't affect you at all.
Not necessarily. My hand and wrist hurt for *months* after having a heplock. Everything has the possibility of affecting gyou somehow.

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#15 of 37 Old 09-11-2008, 05:12 PM
 
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The later you show up to the hospital, the better! LEss time for intervention. My VBAC was a superfast labor - I (unintentionally) showed up at 10cm. There wasn't time for ANYTHING except to birth the baby!
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#16 of 37 Old 09-11-2008, 06:57 PM - Thread Starter
 
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Thanks for all your input! I just switched MW to attempt my first HBAC!!
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#17 of 37 Old 09-12-2008, 01:58 AM
 
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Originally Posted by MomtoXane View Post
I just had my first visit with the midwife. She said that since I'm a vbac I'm required to have continuous fetal monitoring and iv access throughout labor and delivery. Any thoughts on this?
If you really want a successful VBAC, it would be in your better interests to plan a homebirth. If you needed to transfer, so be it. But if the CNM is already talking CFM and IV access(even a heplock) then the next thing you know is pit and a time frame impossible to keep up with. And immobility, and epidurals, and, and, and....

have a Homebirth, most successful VBACs are that way...
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#18 of 37 Old 09-12-2008, 03:52 AM
 
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I actually just had a rupture and neither the iv nor the heart monitor made a lick of difference. We were laboring close to the hospital just in case and were monitoring with a doppler just fine. Her heart rate never dropped even 2 beats per minute the entire time from the time we left the hotel to the time I was hooked up momentarily at the hospital to the time I had an emergency cs. I wouldn't have known I ruptured at all except for the pain that lasted through and between the contractions and that I was passing a lot of blood. We got to the hospital around 4am and I had a cs at 4:23. The iv happened faster than the anesthesiologist could decide which type of anesthesia to use (within 45 sec). The thing about a rupture is that it is not that likely to happen. Yes it is bad when it happens but it isn't likely. If you labor with all of that apprehension, you might stall out- I did a couple of times. Set yourself up for a normal delivery and just keep the other things in mind- in your midwife's and husband's minds. You don't have to have an iv if you don't want to and you don't have to have cfm. If you are worried about your baby or your progress, take a minute to assess while you're laboring. If pressured, you can play the yes game, yes I agree only not right now. At any time you can get a heart rate and iv if they make you more comfortable. It is all about you. You know what is safe for you and your baby. I appreciate the hospital being there for me when I did rupture and as much as they were angry with me they did a great cs. It actually took me a few minutes to convince them to move faster- they started to hook me up to the normal machines for normal protocol, even though we had called ahead to warn them I was having major issues. As soon as I mentioned how many previous cs I'd had, I was in surgery about 10 min later and baby was born 13min after that. A rupture is an emergency and they throw their own protocol in high gear and scrap what isn't necessary. You'll be fine at home or at the hospital but it is your show.
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#19 of 37 Old 09-12-2008, 10:20 PM
 
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have a Homebirth, most successful VBACs are that way...
Really? Do you have numbers on that? Because our success rate in the hospital is 70%, 85% for women with a nonrepeating reason for the section. In a hospital. With monitoring and IV access even. So I'd be impressed to see a higher success rate at home!

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#20 of 37 Old 09-12-2008, 10:39 PM
 
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Really? Do you have numbers on that? Because our success rate in the hospital is 70%, 85% for women with a nonrepeating reason for the section. In a hospital. With monitoring and IV access even. So I'd be impressed to see a higher success rate at home!
Wow, yeah, that's a pretty horrible rate, IMO. Maybe better than some but still pretty bad.

Every MW I've ever heard from had MUCH better rates. Granted, I doubt there are any scientific studies out there to back that up as orgs like the ACOG and the like push MWs underground and fight tooth and nail to take away our right as Mamas (VBAC especially) to birth w/ the MW of our choice. Therefore, it's really impossible to come up with a stat. The question is, therefore, disingenuous.

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#21 of 37 Old 09-12-2008, 10:40 PM
 
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Thanks for all your input! I just switched MW to attempt my first HBAC!!
: YAY!!!! Go, Mama! You CAN do this!!!

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#22 of 37 Old 09-12-2008, 10:53 PM
 
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Wow, yeah, that's a pretty horrible rate, IMO. Maybe better than some but still pretty bad.
actually, that's an excellent rate. the NHS in England (where you have the right to VBAC, though some consultants hate it) has a VBAC rate of 32% (I can't find stats on TOLAC, so can't compute a success rate of attempts). (I was shocked to see how low it was, frankly. The hospital where i gave birth has a VBAC rate of only 19%, lower than the US hospital where I plan to deliver next time!)

MWs will almost always have higher success rates than hospitals because they risk out quicker. OBs have a higher risk caseload.

ETA: The Albany Practice, a famous London midwifery group doing hospital and home birth (57% at home, mixed caseload, but the most high risk cases would have been referred to consultant, and they wouldn't be handling ERCS cases) had 76% standard vaginal births, 19% CS, 5% forceps/ventouse.

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I understand what you are saying and, as I said in my post, I agree that it's better than others. However, a horrendously low bar does not make a better stat "good" IYKWIM.

Not every "high risk" Mama is denied care w/ a HB MW which is yet another reason that a true stat just isn't possible right now.

I remember reading about the study you speak of. IIRC, there were just to many unknown variables to really pull anything concrete from it w/ regard to what we are talking about here.

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#24 of 37 Old 09-12-2008, 11:21 PM
 
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Wow, yeah, that's a pretty horrible rate, IMO. Maybe better than some but still pretty bad.

Every MW I've ever heard from had MUCH better rates. Granted, I doubt there are any scientific studies out there to back that up as orgs like the ACOG and the like push MWs underground and fight tooth and nail to take away our right as Mamas (VBAC especially) to birth w/ the MW of our choice. Therefore, it's really impossible to come up with a stat. The question is, therefore, disingenuous.
No, actually a 15% section rate is pretty close to the WHO recommended section rate. And remember, we can't pick and choose our clients.

I do hope you would have some information for me about HBA2C success rates, especially with a J incision. Because I just can't seem to find any anywhere!

I'm glad to know you take your midwife's word on her success rates without verifying them. What kind of law is it that you practice again?

mama to Max (2/02) and Sophie (10/06); wife to my fabulous girl
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#25 of 37 Old 09-12-2008, 11:37 PM
 
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I remember reading about the study you speak of. IIRC, there were just to many unknown variables to really pull anything concrete from it w/ regard to what we are talking about here.
Which study? I'm not quoting from any study; these are basic statistics collected by the National Health Service. They're of interest because the NHS lacks the particular medico-legal context that has made VBAC such a minefield in the US. (Notably, OBs/MWs do not carry individual insurance and are employees of the health service; their individual level of exposure is much lower.)

And while not every "high risk mama" is denied care by a HB MW (though most are, since the very definition of midwifery is expertise in normal birth and low risk women), the NHS is a different animal. There are set criteria for risking a woman upwards to OB care. It's an entirely different system. (I gave birth to my daughter in the UK, so I speak from personal experience here.)

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#26 of 37 Old 09-13-2008, 12:13 AM
 
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Wow, yeah, that's a pretty horrible rate, IMO. Maybe better than some but still pretty bad.

Every MW I've ever heard from had MUCH better rates. Granted, I doubt there are any scientific studies out there to back that up as orgs like the ACOG and the like push MWs underground and fight tooth and nail to take away our right as Mamas (VBAC especially) to birth w/ the MW of our choice. Therefore, it's really impossible to come up with a stat. The question is, therefore, disingenuous.
actually, that is a pretty great rate for VBAC success.

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MWs will almost always have higher success rates than hospitals because they risk out quicker. OBs have a higher risk caseload.

ETA: The Albany Practice, a famous London midwifery group doing hospital and home birth (57% at home, mixed caseload, but the most high risk cases would have been referred to consultant, and they wouldn't be handling ERCS cases) had 76% standard vaginal births, 19% CS, 5% forceps/ventouse.
exactly! i'm not saying that i am against HBAC (because i am not!), but i think VBACs in the hospital with good care providers can be very successful. you just have to be choosy about your HCP/hospital, just like you should be choosy about your HB/BC midwife!

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#28 of 37 Old 09-13-2008, 12:17 AM
 
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I understand what you are saying and, as I said in my post, I agree that it's better than others. However, a horrendously low bar does not make a better stat "good" IYKWIM.
(sorry for the serial posting! )

what is a good rate for VBAC success, would you say?

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#29 of 37 Old 09-13-2008, 12:35 AM
 
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No, actually a 15% section rate is pretty close to the WHO recommended section rate.
For those Mamas that fell into the difference of "close", I would say "close" isn't good enough.

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I do hope you would have some information for me about HBA2C success rates, especially with a J incision. Because I just can't seem to find any anywhere!
Curious, why would I have those particular stats if the stats for basic HBACs don't exst?

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I'm glad to know you take your midwife's word on her success rates without verifying them.
Really? You know this even though I never mentioned whether or not I've verified them...or that I even have a MW for this birth? I'm impressed!

AlexisT - Yikes...sorry. Too many windows/discussions going on at once on my computer. The comment regarding a study was meant for a different person.

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the very definition of midwifery is expertise in normal birth and low risk women
I disagree. I've never heard of such a restrictive definition. For example...here...and here. As I understand it, the pure definition of midwife is simply "with woman".

- Kim
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#30 of 37 Old 09-13-2008, 12:42 AM
 
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"Expert in normal birth" is something I've heard straight from the mouths of midwives here on MDC.

DD 01/2007, DS 09/2011

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