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Thread: CPD???? Could I be one of the unlucky ones?

  1. #19
    paradise lost Guest

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    Suse,



    the baby's head moulds in the pelvis, so no, in general a CPD baby would not have a very moulded head, as CPD is when the baby's head is unable to fit into the pelvis. Unless you have had a disease like polio, rickets or an injury to the pelvis where the bones were broken or some other thing to cause a deformity of the bones, it is very very unlikely that your baby would fit into the pelvis but not out of it.

    What positions did you push in for those 3 hours? In general, because the sacral and pubic bone joints are loosened by relaxin during pregnancy, a baby that fitted IN will fit OUT - the looser joints make the whole pelvis like a hinge, if you press on the two highest pelvic arches (top of your hips) it opens the bottom of the pelvis - this is called a "pelvic press" and is a way of unsticking babies who are taking a long long time to mould and seem to have problems fitting through. Did your care providers try this?

    Another sign of a CPD baby is that they remain high - women generally do not have a pushing urge or never have it consistently (every contraction) because the head is not low enough to press on those nerves which drive expulsive pushing. Did you have an urge to push or were you coached to push? I read your birth story and think i remember you had an epidural which they turned down? When you pushed then did you feel you wanted to or did they tell you push when you felt the contraction?

    With posterior babies all bets are off - it is HARD for a posterior bubs of average size to get out - the normal pushing time for a first posterior bubs is 2 or more hours, from that POV although you pushed a long time, it was not abnormally long for that sort of labour (i know a woman who had a brow baby, pushed for SIX hours!). The pelvis/baby combo is the perfect shape for an anterior baby to fit through, and the head of a posterior bub is back to front, the neck has to flex more than it would normally, various little geographic features inside get in the way and make the process longer and harder.

    In addition the kind of pelvic measuring the ob did (either with fingers or scans) is very unreliable - it's about as accurate as sizing the baby with ultrasound - it can be ok but is often WAY off. There is really no way to tell if a baby will fit through except by trying it (have a look at Kel's tiny women birthing big babies to see what i mean) and i suspect until someone is actually able to give birth inside an mri machine the mysteries of the mechanics of the female form will remain mysterious.

    I'm not sure about genetically linked CPD - how would a trait like that have survived the 80,000 years of humanity before c-sections? Were you a c-section baby? Was your mother? Was her mother? These are the sorts of things that would have killed humanity off many many thousands of years ago. The only thing i think is reliably being passed down due to the high diagnosis of conditions like this and c-sections in response is fear. I know several women who had c-sections because their mums had them and they did not BELIEVE the women in their family could birth!

    It sounds from the size/shape of your baby's head that he had definitely begun the arduous task of fitting back to front through the pelvis. Posterior labours can be so hard and painful, the back pain was terible for me until she turned (my bubs was possie for the first part of my first stage, spent ALOT of contractions backwards on chairs, rocking on my knees, crawling about etc. and luckily she turned).

    ETA- ok, i've had a read of your birth story again and i would say that....with a posterior labour the first stage is often slow (days and days) as prelabour is what turns the baby. The fact that they tried to induce things when they were slow meant your bubs was pushed hard down into the pelvis while still posterior. It can take a long time (know a woman on another board who had prelabour (i.e. painful ctx but very little dilation) for 8 days before bubs turned anterior while she was scrubbing her kitchen floor) for the prelabour to turn a possie bub, but if you're well-supported and know which positions will help bubs turn they often will, and then labour follows swiftly and smoothly.

    Once you were under way and had pethidine and the epidural, this is another factor. I had very brief possie labour and believe me, i KNOW how painful just a tiny taster of it is, so i'm not questioning why you went that route, i just want to point out that the route itself has complications. Pethidine passes to the baby, who needs to be alert in order to turn. I did read a study not long ago (on paper unfortunately) that suggested the rate of positional problems is significantly higher in bubs whose mums had pethidine or morphine during labour - maybe one of the other ladies will have a link - babies usually make vigourous efforts to assist their own births, and babies who have had drugs cannot do this so well. In addition the pelvic floor muscles, the deep ones, actually assist in turning the baby and with an epidural this doesn't happen. With the epi it is usually impossible for mum to get her weight off her sacrum entirely. Sitting up can be some help with an anterior labour but with a possie you really need all your weight off your butt and gravity helping you.

    Your baby became distressed, it is very unlikely that by the time that happened there was ANYTHING you could have done to avoid surgery - he was no longer coping with the labour. High forceps delivery is dangerous and usually very damaging to the perineum and vaginal canal, from that POV a c-section would have been the best option for your Ob at that time - possie bubs are hard to extract as well as birth through the vagina!

    However i do think that it's INCREDIBLY likely that you would be able to birth an anterior bubs, when even a possie one had moulded to that extent and fit into your pelvis, and that even with another possie, if you avoided certain elements that featured in this labour your body would be able to either turn the baby or get it out facing the wrong way itself.

    HTH

    Bx

  2. #20

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    Hoobley, what you said is very interresting. Especially the bit about moulded heads. My bub was born with quite a pointy head and I was very surprised considering she was a cs baby. It certainly gave me the impression that she was in the right spot (although my OB said she wasn't at all engaged) her head is still a little pointy nearly 8 months on - although MIL says this is the rusky in her from FIL's side (european head apparently )

    RE; the evolution/natural selection thing - I do remember my Chiro telling me that your back and hip alignments etc are usually worse then the generation before you. Is this true or is he just trying to drum up business?

  3. #21
    paradise lost Guest

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    Engagement can be a funny thing. I used to check DD's engagement daily and more in the last 2 weeks of PG (she was born 11 days past EDD). The MW would check - 2/5ths. I would go home, go for a swim, check myself - completely free. Later on, check again - 1/5th. The next day, again, free while reclining, 3/5ths while stood. That evening, free while stood. Babies with room (i'm 181cm) CAN and DO move up and down. The first time i felt her fully engaged (widest part of head in the pelvis) i had had 5 hours of contractions and my waters had been gone for all that time. Right up to the day she was born she could have appeared too big to fit, but she wasn't at all. Glad i didn't have to get her out posterior though! Any pointiness your DD had that went away in the first week or two after her birth was moulding, if that helps.

    RE; the evolution/natural selection thing - I do remember my Chiro telling me that your back and hip alignments etc are usually worse then the generation before you. Is this true or is he just trying to drum up business?
    Honestly, i think he's probably trying to drum up business, but that there will also be SOME truth in what he is saying.

    The incidence of posterior labour is higher in the west than in the east, because women here sit on sofas or up a desks all the time, whereas there they sit on the ground or squat, both of which do much to help bubs lie anteriorly. We do not (in general, i know some do) exercise our bodies well - women in India and North Africa are hard muscle and bone and little else because their lives are physically very demanding. By contrast western women have weak core muscles (abs/lats) and pelvic floors. Stress incontinence in African girls is almost unheard of and even after a baby (past the first week or two) it is rare, in the west it affects a high enough percentage of women that many rather than seeing the doctor just buy incontinence pads as if it were a normal thing!

    Because the chiro sees a lot of people he probably sees the older generation who had very physically demanding lives and jobs when they were young and growing, who have far better muscle tone and alignment than younger folks who do not do heavy work. But this does not mean that the bodies of the younger generation are defective; anything a chiro can fix is aquired, not genetic. If it was genetic it would be un-fixable - a chiro can fix a functional leg length discrepancy (where the pelvis is tilted on the spine and thus one leg SEEMS shorter) but only invasive and risky surgery can fix a leg which is genetically shorter.

    The problem with all out technology, as wonderfully easy it has made life, is that our body is MEANT to move. Muscles waste if you don't use them. If the first time you need tone in your pelvic floor is when you're lifting 30litres of water onto your 12-year-old head to carry it home then by the time you give birth it's going to be really strong and able to help your baby turn, with a great blood supply to allow an easier birth and post-partum time. If the first time you ever need it to be toned is to push your baby out you might be in trouble.

    If you look at Ina May Gaskin's stats for the farm birthing centre she has run since the 70's which looked at the outcomes of 2028 pregnancies 1970-2000, they show that if you don't interfere at all (they give NO drugs unless you have a PPH, no pain drugs unless you need to be stitched after, nothing during labour), don't prioritise speed as a marker for a "good" labour, and support the woman as fully and as lovingly as you can, around 95% of women will birth vaginally, at home, without major problems. Those who did not either asked to transport to hospital by choice, or had to because of medical emergency. Their c-section rate is 1.4%, forceps is 0.5%, vacuum extraction is 0.05%. They have had 0.5% face presentations, all but one delivered vaginally, 0.4% brow presentations, of which half were born by section, half vaginally. Their VBAC women made up 5.4% of the whole, 108 women attempted VBAC, 106 succeeded. These are every kind of american woman, from hippies to middle class ladies. The only thing they all have in common is the desire to birth their babies in a home-like environment (you get a little birthing house when you go to The Farm) gently and without medical interferance. From when you arrive you are expected to work and help out on the farm every day, pregnant or not. They get your body moving and working so your labour will be easier on you.

    I know it is hard to believe when we are surrounded by and our ears filled with the stories of labours gone wrong, but it really doesn't have to be this way. The human body almost always works if you let it. Every step one takes away from the completely natural route comes at a cost and takes you one step closer to the surgical route. There are always risks to be weighed but more often than not they aren't worth it. And how can a woman ever know until it is too late? So many of us grew up believing birth was hard and labour hurt like hell - in some countries they have a different WORD for the pain of a contraction - the word describes the harmless pain, not the pain of danger and injury. How we think about things, and how much we know about things makes such a big difference.

    Take induction - it is a STANDARD response to a woman dilating slower than 1cm/2hours. But the book's "1cm/hour" is an AVERAGE, some women will take 4 hours to go from 4cm-5cm and then go to 10cm in the next contraction. We do not trust our bodies to labour, we do not think our butt knows how to get the baby out. But the SECOND you intoduce artificial sinctocin you introduce risk - some babies cope fine, many get distressed, some labours progress well, many progress fast towards the point when they can no longer continue because the slow start would have re-positioned bubs slightly had it been allowed to play out, some uteri (plural of uterus anyone?) cope well, others rupture.

    The uterine rupture rate for post-dates induction is the same of that for VBAC, one is done as a matter of course once 10-14 days have passed after the EDD, the other warned against, discouraged, frowned upon.

    Ah, this has been mammoth, it is close to my heart. I have known about The Farm stats for 8 years now, and i look around me at the women in the UK hospital system with their outcomes and i just see that SOMETHING IS WRONG HERE. If you do little but love and support it works 95% of the time without instruments or knives. If you do it "properly" in hospital it doesn't even work 55% of the time. Terrible.

    Bx
    Last edited by paradise lost; May 11th, 2008 at 03:10 AM.

  4. #22

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    Hi

    I can't help you on the CPD issue, though i have learnt alot here from what has been written.

    After the emergency c section I noted that her head was a perfect shape. She had no bruising or shaping suggesting she was even almost there.
    When my niece was born (vaginally), they had 3 goes with the suction cap, and then used forceps to get her out and she still came out with a perfect shaped head with no marks!

    best of luck with your next bub,

    k
    Last edited by HotI; May 11th, 2008 at 11:17 AM.

  5. #23

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    Bec - thank you for such a thorough reply. You truly are amazing, you know that, right? (I only just saw your second "mammoth" post - which is a whole other level of amazing again!). The stats on May Gaskin's birth farm are very interesting indeed!

    What you have written gives me yet more incentive to investigate further into a VBAC, and to find out whether the diagnosis of CPD is accurate. The ob checked from the 'inside' so to speak, it has yet to be confirmed by scan or x-ray. I understand that scans and finger measurements can be highly inaccurate, at the time I wasn't able to ask the nitty gritty of how they check the pelvis during c/s but I assume that it would be visually.

    To answer your questions - pushing occurred post epidural, so it was in a slightly reclined sitting position. (So, no, not a favourable position for posterior birth). We tried all fours, but I didn't have enough sensation in my legs. I don't believe that a pelvic press was done - I don't recall it. I never felt that overwhelming urge to push at any point - I think that things may have been different if I had. So yes, the pushing was coached. The likelihood is that I was subject to the typical cascade of intervention effect, although I was quite aware of the implications of what I had chosen. Prior to the epidural I had been using active birth techniques but with very little progress. Labour had stalled several times in the early stages and whilst I was intellectually aware that this was entirely possible, even probable with a posterior labour, I lost the instinctive sense that my body was doing what it was supposed to. I have no doubt that this smoothed the path towards pain relief, instead of feeling confident that my body was doing what it should I felt only that something was going wrong and sought relief from that. There's no real way of knowing whether my instinct was right (and that things were not going as they should) or whether the subsequent pain relief was what contributed to the failure to progress. Would the result have been different had I made different choices - I don't know. And to be honest - I don't care. What's done is done. If I can make different choices next time and get a different result, then great, but I am not unhappy with the way the birth progressed even though it was the polar opposite to what I had hoped for.

    As for the potential for a genetic predetermination towards pelvic disproportion, no, my mum didn't have a c/s with me, although I was eight weeks premature, whereas my bub was two weeks over and five pounds heavier than I was. And my grandmother has quite a different body shape to my mother and I. I do not know my biological father, so do not know what contribution his family's genes have made to my body shape.

    What I mean when I suggest that pelvic disproportion of a genetic nature is possible is based on the assumption that it works in the same way as any other genetic 'disorder' (I am making an assumptive leap here as I don't know for certain that this is the case - I have not encountered any studies which demonstrate that there is a particular gene marker for pelvic disproportion, but lets assume for the sake of the argument that there is). I suspect that I'm not telling you anything you don't already know here (and probably know better than I) - but statistically, if two parents carry the gene for that disorder, two in four of their children will also be carriers, one in four will not, and one in four will have the disorder itself. In most cases, those with a severe disorder are unable to bear children, they are the evolutionary dead end. But those carrying the carrier gene are what propagates the disorder. Most genetic disorders are extremely rare, in terms of their effect on an entire population. Based on these standard principles of genetic inheritance, I believe that it is feasible that genetic CPD can occur without adverse effect to the species as a whole.

    The other thing that I have considered when forming my belief that genetic CPD is feasible is human evolution itself. Humans have been evolving for a relatively short time compared to many animals and it can be argued that our physical evolution is not yet complete. Evolutionary science suggests that bipedalism creates a birthing trade-off, that due to the re-angling of the pelvis (and subsequent reduction to the size of the pelvic cavity) to enable us to be bipedal, human babies are born at a much lesser stage of development compared to quadrupedal mammals simply so that they will still fit through the pelvic cavity, even factoring our slower rate of development to maturity. Any larger and they would not fit. Any smaller and they would not survive. (As an aside, this in part informs the theory of the Fourth Trimester). It is not impossible that deviation from the norm beyond tolerable limits can occur.

    I'm just throwing ideas around here, they are not informed by concrete data, which is why I would very much like to see a substantive study performed on the actual incidence and causes of CPD. I agree that unnecessary medicalisation and over-diagnosis of what is a very rare condition is not helpful to our understanding (just like the over-diagnosis of ADD and ADHD). I'll personally be seeking more definitive answers in preparation for my next birth!!

    Thanks again!!

    xx suse

  6. #24
    paradise lost Guest

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    Suse, i absolutely APPLAUD your attitude to your birth. I want to be very clear that although the way women are treated and the way birth goes in the western world saddens and angers me, i have no expectation that once in that system the women can actually do much about it.

    It is as you say, you know the implications. But what were you going to do Suse, put your knickers back on, pull your shunt out and walk out of there? Where would you have gone!? What CAN women do? Nothing, once they are in that situation. But you got there where you felt was best and you dealt with things the way they went and here we are, you have a beautiful kid and a birth to look back on which while not what you were expecting was still the day this wonderful little person came into your life. I honestly beleive the ONLY decision i made which saved me from much of the difficulty others have faced was that early on i opted to homebirth, which in the UK is free, or i don't know WHAT i'd have done. I will be honest, it was part romantic ideal, part intellectual wisdom (i had read the stats), part fear (of the hossie), part proving something (many many of my family and friends have homebirthed, it is "how we do it"). But now it isn't. Now i've done it, it is the ONLY way to birth in the UK while the system which hates unpredictability continues to be as unreliable as it is.

    For certain labours (the intervention stats would suggest about 40-50%) the hospital model is ok. Those labours go at the "right" speed, with the baby in the "right" position. They fit well enough into the expected "norm" that those women can pass through the hospital system relatively unscathed. But if you have a less average labour, if the baby is possie, or breech, or if you're having twins, if you're post-dates, or really ANYTHING about you or the baby is outwith the norm, you face oppisition.

    Unpredictability costs money. That's the bottom line. And until the hospital system is willing to not just factor in but CATER TO the unpredictability of labour, some women will continue to suffer from morbidity during their labours and births.

    I don't know how any kind of scan or device or hand can tell, when you are not IN labour, what will fit through your pelvis - do they do the exam/scan/measuring with you on hands and knees - that gives you 20% more space in there - and how can they know to what extent Relaxin will loosen your pelvic joints? Women with SPD (symphsis pubis diastatis) can have as much as a centimetre gap there in PREGNANCY - labour loosens you even more. That's what i mean about scanning a birthing woman, to see what actually happens. I remember seeing the mri of a couple having sex - do you know the penis bends at around a 90degree angle during sex, behind the pubic bone? It looked like a fleshy L. Even the GUY didn't know it until he saw the scan, he was like "wow, that looks way less good than it felt!".

    I think you're very likely to VBAC with resounding success, next time around. Many women i know with similar outcomes to yours found that it was not knowing what not to do that helped, but being in a situation where those choices were not there to make.

    At home no one suggested augmentation - there was none. I was told i was not in labour and the midwife left again - that after 11 hours of contractions. I yelled for an epidural in transition, but the midwife wasn't there and my baby's father told me i was "doing fantastic!" and slapped another wet cloth on my neck and in the next contraction it was forgotten. Would i have taken the epidural if offered it during those contractions....um YES!! I didn't want the gas and air but i sucked on it when they put it in my hand! Next time i'm going to hide the tank! I made the decision not to have pain relief (by staying somewhere where i couldn't have it) when i was still rational and not in unfamiliar and seemingly unending pain. You have no IDEA the amount of women i know who panicked in hossie and in that panic asked for an epidural because they "weren't coping" and seemed not to be "progressing", then as soon as the epi was in they dilated quite fast. They think it was the epidural that made them relax - that panic is TRANSITION! I know MANY MW's who have told me that transition, though often seen at 8cm, is actually more often seen in the hour or so before the 2nd stage. I was 2-3cm about 40 mins before my transition, but transition it was, DD was born, without pushing from me, under 3 hours later. If i'd been in hospital goodness KNOWS what would have become of us.

    I do see what you mean about CPD being a possible genetic trait. I believe the Pink Kit covers differently shaped pelvises and what they may be prone to (i believe there is a pelvis shape more likely to encourage bubs to be possie or breech) but it is the SYSTEM which deems those pelvises unfit to birth through. Those labours make take longer and not look like the "textbook" anterior ceph. labour, but it doesn't mean they don't WORK, it's failure to WAIT that trips up those labours, not failure to progress. If you had been surrounded by people who told you your labour was a totally normal possie one and not to worry and to try to rest and encourage bubs to turn, if when you'd gone to hospital they'd said "ok, bubs is posterior, you're in pain but this could go on for days, it's very normal, so why don't you take these painkillers and come back in tomorrow and we'll see how you're going, this Doula is gonna come home with you and do everything it takes to help you through" you would have kept the faith right? But they don't, they say "HOW many hours? HOW many centimeters? Man, something ain't right..." and then they start strapping things to you and sticking things in you and telling you too much and not enough and then suddenly you're in theatre.

    Of the few homebirth midwives i know, principally in America through another website, those in their 40's and 50's have seen, on average, 3 cases of CPD in their careers. The one in her late 30's has seen 1. The younger homebirth (in their 20's) MW's haven't seen any. The midwives in birth centres see 2 or 3 a year. The hospital midwife sees 4 to 6 a WEEK. Even if the home and birth centre women transport to hospital and are counted into those figures, the numbers just DON'T add up.

    Bx

  7. #25

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    Wow Hoobley, you a such a wealth of knowledge.
    I am so determined to have a VBAC next time. My caesar was under a general (the anaesthetist was unsucessful at getting the epi in) and I cannot bare the thought of missing out on my baby's birth a second time. I truely do not think I have CPD at all and I am also hopeful that I will not get PE again next time.
    Unfortunately, I am a little too chicken to have a HBAC.
    I will be a lot more determined and pro-active with regards to my next birth. With Charli's birth I was naive and thought it was best to go along with my OB's recomendation without really questioning her or looking for alternatives. Next time I will be waiting until my baby is good and ready to come out on his/her own. Even if I have to go to hospital to get daily monitoring of bubs in order to satisfy my OB.

    Thanks again for your enlightening posts here in my thread.

  8. #26
    paradise lost Guest

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    Charli'smumma, don't feel "chicken" about HBAC - i was too "chicken" to go to hospital - it's horses for courses. I don't think every woman should have a homebirth, i think every woman should give birth IN SAFETY, where SHE feels best. For lots of people that will be hossie. For lots that will be home. As i said, horses for courses.

    I bet you VBAC like a pro!

    Bx

  9. #27

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    Thanks Hoobley, I hope so
    I wonder if the length of your mothers and grandmothers labours can be an indication on how your own will go? Seeing as I have not even experienced a single contraction I have no clue on how I would labour but my grandmother had short intense labours. Her longest was 2.5 hours and her shortest was 50 minutes. My mums labour with me was induced (her Ob was going away on holidays) and her labour was 5 hours from start to finish. Her labour with my younger brother was spontaneous and only 2 hours but she said it was extremely painful in comparison to her first. Does this mean I could be likely to have a relatively quick labour myself? If it is quick and intense does this mean I might have a slightly greater risk of uterine rupture then a slower less intense labour? Not that uterine rupture really worries me as I know the risk is small.

  10. #28
    paradise lost Guest

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    In general one's mothers labours indicate little about one's own. My mums labours (she had 6 kids) varied from 4 days (96 hours - her fourth and smallest child, 4 weeks overdue) to 4 hours (her third and aside from me, biggest child, 2 days past EDD - #5 and #6 (my brother and i) were both sections, him for praevia, me because VBAC was not heard of in 1980).

    Expect the unexpected and KEEP THE FAITH. A NORMAL first labour is 12-24 hours. Days of prelabour (painful ctx which seem to intensify and get closer but then drop away again) is normal. Being as much as 14 days post dates is normal. My advice to ANY woman is when labour begins do whatever you would NORMALLY do until it is impossible.

    Sleep if it is sleeping time or if you are tired and would value a wee rest - slow labours and long-prelabours often get properly underway once mum is refreshed with sleep and food...so..

    Eat at the normal times until you REALLY don't want to anymore. If you can't decide try a little something easy (chopped fruit or toast is good). The worse that will happen is that you'll vomit and that helps open your cervix - win/win.

    Walk, clean, launder, MOVE - don't get into an "i'm in labour, better lie in bed". You keep doing whatever you normally do until you can't.

    Talk, laugh, sing. Stay aware and don't close your eyes until you feel you really have to.

    If you can eat or talk during contractions, if you can walk with pauses to contract, if you can have a conversation while you contract (pausing perhaps to contract but keeping the thread of the conversation in between) you are labouring well and still have a ways to go.

    The time will come when all you can do in a contraction is focus and breathe and use your relaxation techniques and all you can do in between is rest because each one is overwhelming. There will be a time when you think you might MAYBE be able to do ONE more ctx, but not 2, and certainly not more. You will be positive you cannot possibly go on. You will have the intellectual idea that the only thing to do is chuck in the towel and go home because all this baby-having is not happening. This despite the fact you can barely open your eyes in between ctx, let alone get up and walk off... When you feel like that you're baby is coming REAL soon.

    Bx

  11. #29

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    Thanks Bec!!

    You know - I am quite lucky really. I don't feel in my case that 'the system' (for want of a better term), failed me in my attempt to have an intervention free, active birth. If anything, they supported it well. I know that this is not the case with many women who present with anything other than textbook, as I did, but I found that my caregivers viewed a posterior birth as just another presentation; it took longer and required different positions but was just as do-able as an anterior presentation. I was given excellent guidance and encouragement to let things take their course, but there were points when I asked for choices. I was given multiple options, told the pros and cons of each one in a realistic, unbiased way, and given time to make my choice.

    I guess what I am saying is that it would be very easy to 'blame' the system for my intervened birth, when I am an intelligent, responsible woman who researched what I wanted from my birth and how to get it, questioned elements of my care that I was unsure of, negotiated alternatives that I was comfortable with (eg: avoiding induction), and understood the limitations of the system that I had chosen to birth in.

    There are women who are mistreated and treated with a lack of respect by the medical profession, and I share your sadness and anger for them, but it would not be fair to say that I was one of them.

    Charli'smumma - thank you for not minding that I have well and truly hijacked your thread - and I really do hope that you get your VBAC. Just as an aside - if you had PE last time, the likelihood of having it in subsequent pregnancies is quite low.

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