Scars in Labor

Every injury leaves a scar. Some fade to invisibility, while others are there for life. Whether accidental or intentional, every deep cut has the potential to heal with adhesions. The role of adhesions in a person’s daily life does not get enough attention. The role adhesions may play in a pregnancy and birth gets even less. There is a dearth of research on the topic. This literature review gives a rundown of what is known and unknown on the topic, and yet the effect of scar tissue on labor and birth is conspicuously absent. While it includes a hypothetical mechanism for adhesion formation, admitting that second and later cesareans often take longer due to scar tissue from previous surgeries, this particular review does not address scar tissue in labor, nor do any of the studies it references. Scar tissue from surgeries is an acknowledged downside, so its absence from labor progress factors seems very out of place.

Dr Neel Shah is among few willing to discuss the adverse effects of c-sections. He took some heat for describing a woman’s tissues at repeat c-section as a melted box of crayons. While it’s laudable that he is taking the issue on, even he did not address what that melted box of crayons might look like in labor. Would it shift the uterus in such a way that the baby takes longer to engage? Would it slow dilation in other ways? Would it have no effect at all? The silence is deafening.

There is a range of how much adhesions impact the individual. Take Dawn Thompson, for instance. Before she was the founder of Improving Birth, she was a mom navigating her birth options. Her VBA2C attempt ended in a third cesarean, complicated by scar tissue from her surgeries. While she went on to have a VBA3C, there is no denying the effect of scar tissue in her case.

Anecdotally, Dawn Thompson is hardly alone. Many a birth has been slowed or stopped by a uterus pulled out of alignment, by pain that may have signaled a uterine rupture but was limited to dense adhesions with an intact uterine scar, or by the pain of adhesions amplifying any labor pain.

Are you doomed if you’ve had abdominal surgery, including cesareans? Of course not. The overall VBAC success rate in the US is over 70%, and is even higher among community births. However, don’t be discouraged by a longer labor than you expected. Even “labor on the installment plan” in the form of prodromal labor is a common response in a VBAC or post-surgery labor. 

What else can you do? Pamela Vireday of ICAN lays it out well.

Nutrition and exercise can have so much positive influence on overall health, and on scar formation to begin with. Good nutrition and exercise promoting mobility will help any scar tissue remain flexible. 

Before pregnancy, Mayan abdominal massage may help.

Before and during pregnancy, physical therapy with a practitioner well versed in women’s health can be an empowering experience and a proactive step toward a healthy pregnancy and birth.

And last but certainly not least, having a birth attendant who is willing to walk with you through whatever your labor brings, in a location where you feel most supported, will help you have the confidence in your body, and that you are doing all you can to prepare for a healthy birth. Knowledge is power.

When Baby Needs Help

Resuscitation. CPR. Heart rate. Breathing.

How do these words sit with you? Are they simply part of standard vocabulary or do they hit hard and create an unsettling image?

During pregnancy, the idea that your baby might need some help to transition can be a scary thought. It may conjure images of other emergencies you’ve experienced, or ones you’ve heard about. It’s not a pleasant thing to think about. And yet, it’s worth knowing some of the basics of neonatal resuscitation.

It is estimated that about 10% of newborns need some amount of resuscitation. Keep in mind, this number includes all babies born, whether term or preterm, with or without congenital anomalies, with out without difficult births. In other words, that 10% is not randomly distributed across all births. It goes up dramatically the earlier the birth, so that 100% of babies born very early need help, and comparatively few healthy full term babies need extra help. 

If you’re familiar with CPR, you may know that it involves so-called rescue breathing and chest compressions. In learning the skill for adults and older children, there is a relative emphasis on the chest compression part. The biggest difference between that and neonatal resuscitation is a shift in focus toward providing breaths for the baby. Remember, until the baby emerges from the womb, the lungs are filled with fluid and have never breathed air. The most important thing to do for a baby who is struggling is help them start breathing, more so than any stimulation or chest compressions. 

You may be familiar with TV or film depictions of rubbing or slapping a baby to “get them started.” The idea was to shock the baby into gasping. However, with increased understanding of physiology, we have some less dramatic methods to facilitate that first breath, and it can be a very gentle process. Try it out if you’d like. Try giving a partner or loved one a breath, and taking turns. It shouldn’t hurt, and it may be just what the baby needs after a difficult birth.

Artificial breaths can be given either directly mouth to mouth or with bag and mask equipment. While any devices can bring up concerned or triggered feelings, again, the process of breathing for someone else should be gentle. Ask to see the bag and mask prior to birth, and test out the strength of the breath it gives. It’s just a little puff to help clear the lungs of fluid and let them begin inflating on their own. Most of the time, this is all a baby might need. But if several breaths have not shown improvement, your birth attendant may move on to the next steps, including calling in extra help. 

One more thing. It is very normal for a baby fresh out of the womb to be a bit dusky in color. That healthful glow we may be used to is after breathing is well established. Your baby’s skin tone will change rapidly in the first minutes after birth, but it is a process. Don’t be alarmed. Your baby is doing miraculous things in the transition from fetal to newborn circulation.

Bias in Research

When you have a question about health, a common response is “What does the research say?” It’s a logical next step. There is research literature on just about any topic. With so much of it out there, it’s useful to know the paradigm some researchers have, and we can see clues within the articles.

One of the best examples I’ve ever seen of a clear paradigm comes from a literature review on antidepressant use for postpartum depression. This article is long and thorough, and provides a readable overview of the available research on this topic. Then we come to this part: 

“The use of placebo in women with postpartum depression poses an ethical dilemma due to the potentially serious consequences of untreated disorder for the woman and her family.”

Suddenly we’re presented with a glaring case of circular logic. Placebo controlled studies are considered the gold standard in pharmaceutical research. After all, how do you determine the risks and benefits of any particular treatment unless your control group is getting nothing by comparison? On the surface, you can see why someone would conclude it’s unethical to allow a suffering person to go without treatment for the sake of research. But let’s look at the assumptions behind that mindset. 

Assumption one is that the treatment is definitely better than placebo. That’s exactly what the study is trying to find out! Have the researchers already concluded their treatment will work when they declare the ethics of placebo? Doesn’t science wait and see what the evidence says? Often enough, placebo groups fare BETTER than treatment groups. In those cases, couldn’t we say it’s unethical to give the unproven and potentially harmful treatment? 

The second assumption is that while these people are enrolled in the trial, researchers will not intervene if their condition worsens. Very often in medical research studies, patients in the control group are switched to the treatment group if they deteriorate. It’s something to be aware of when reading articles. Sample sizes may change from the beginning to the end of the trial, and one of the most common reasons is that the control group gets smaller. 

A third assumption is that the control group represents realistic outcomes. Just being a part of the trial is an intervention in itself compared to people in the real world who truly go without any treatment. Consider what is involved in gathering the data for these trials. The patients enrolled will have regular check ins with researchers to monitor any changes in their condition. In the case of perinatal mood disorders, just having someone to talk to who is interested in how you’re doing can be beneficial, and therefore would not be representative of a person going it alone. 

Dhillion et al expand on this idea in their literature review: “It has been observed that participants in control conditions are often motivated to make their own improvements (McBride 2015). Additionally, Kinser and Robins (2013) found that control group participants ended up making more significant changes than was expected, due to discussions between the groups, social support and participating in other activities which promoted positive behaviour changes. Therefore, it would be useful for future research to explore mediational analyses to further understand this area.”

It’s basically impossible to recreate representative conditions in controlled environments. Research on the topic of mood disorders is very subject to observer effect, where the very act of observing a phenomenon has the potential to change it. In this case, the people in the trial know they are being monitored and will behave differently. How differently? That would be an interesting study.

The final assumption is that the people participating in the study won’t have the wherewithal to give informed consent about their treatment. While it’s admirable to want to spare vulnerable people from potentially harmful situations, these people are still adults capable of making their own decisions. Maybe they want to further the research and are willing to take the chance on being a placebo recipient if it means they can have better treatment in the future. Maybe they are willing to take the risks of an untested treatment if they might personally benefit. Why they enter the trial is up to them. It’s a bit paternalistic to assume they shouldn’t make that choice for themselves, after having given their consent to participate. 

There is an overwhelming amount of information out there on any given topic. The common thought is that peer-reviewed research is the pinnacle of information quality. And yet, even published research is subject to bias. Let the consumer beware.