Friday, January 25, 2013

Dr. Cummings on trusting Birth

Here are my notes from the amazing Tarrant County Birth Network meeting hosting Dr. Fred Cummings OB/GYN in Denton, TX.

Dr. Cummings is one of a select few doctors who wholeheartedly support women's ability to birth naturally and vaginally even in "special situations" meaning VBAC's, vaginal twin delivery, and breech birth.  He has the hands of an OB and the heart of a midwife.

He has three children that he loves dearly. One born vaginally and two by cesarean. None of these comments come from a place to guilt women about their birth experience. Csections have their rightful place in the obstetrical world and if not for them we would have less healthy mothers and babies today. The overuse of surgical birth is a problem though and Dr. Cummings has hard earned wisdom on the subject.

I will type up my notes as-is, but they are from my chicken scratch handwriting done while baby wearing. I'll fill in gaps with my memory. This is from rough notes with paraphrasing and not in the exact order that his talking points progressed in. Please excuse any errors and grammar. And excuse that OB is always referred to as he and nurse always as she, Dr. Cummings himself admits to not being too PC and admittedly its easier that way. Even though I rushed, I thought it was important to get these notes up for the many women around the metroplex who wanted to be there:

I am blessed to help women have their babies. Really I just watch - there is not much to "do". Women tell me 'thank you so much Dr. Cummings" all the time but that is funny I just smile at them, What did I do? They were the ones grunting, moaning, twisting, turning... but then they forget the pain -- there is a disconnect in their minds. Women forget so they will do it again.
Men are not like that. Men work hard not to hurt. Men would not do it again, yet women keep having babies.

I love my books but I don't trust in them...I believe in God. I trust God. I don't think we are flawed. The design is perfect. Babies are made and babies come out.

100 years ago women stopped talking to their daughters about babies and birth and started trusting people who have nothing to do with it.
And it used to be women just fed their babies. No need to ask for permission.

Then he talked about an old obstetrical photo of a man separated from the birthing mother by a screen with cut outs for his arms through which he is trying to help her.

A good doctor talks to you about you having a baby he doesn't tell you about how other people have babies and how you will compare.

It is NOT true that twins means csection. Now if the doctor is not comfortable with a twin vaginal birth then yes his hands are dangerous because he has not been trained properly.

Cesareans are a late phenomenon - when they were first performed you just died. Sometimes they sewed you up sometimes they didn't even do that. You just died. We have perfected the cesarean and made it rather convenient. I can get a baby out in 42 seconds.

Csections are not horrible but our overuse of them is.

I do not do csections to protect a perineum because mom is just scared.

Doctors are afraid of being sued. And it takes very little to convince a woman to have a csection. All that needs to be said is "I don't think things are going well"

If the fear of being sued was gone there would be less csections tomorrow.

Men want to know what labor is like sometimes. I ask them if they've run the 100 yard dash. Its like that running the 100 yard dash flat out with all you got. EVERY FOUR MINUTES for 12 hours.

I believe it is a miracle. What your body is doing is a miracle. I ask these things of mom: Eat well, sleep well, and exercise - and that you will have a miracle.

Don't be afraid of this "you can only have two csections" rule. You want more babies - you can have more csections. Have babies.

If you had a csection. Get your surgery report. Read it. Read it with someone who knows what it means. You will then know ... nothing. They will always make it seem like it was needed.

Do not be opposed to the proper use of forceps. I don't use those vacuum things always popping off the baby's head. No thank you.

Find a midwife or OB who will talk with you, not talk at you.

Do not be frightened - we have statistics that support VBAC.  Find someone to SERVE you.

He told a story of bravely going with a mom's wishes to VBAC during his residency, He said they didn't call it that though and he was called out the next day for letting a woman vaginally deliver after prior cesarean. He  played like he didn't realize it was such a big deal.  So they made him present the case at grand rounds. He prepared for his own barbecue. "I knew they'd put me over the coals and have at my flesh"  I prepared as best I could and they did grill me:

Did you measure her pelvis? Yes.
Did you palpate the baby? yes.
Did you estimate baby's size? yes.

When Dr. Pritchard (He coauthored the 14th edition of Williams Obstetrics with Louis Hellmann in 1971, after which he became its senior author.) in the back addressed him as Dr. Cummings and said "Did you feel this woman presented with the conditions to vaginally birth?" to which he said yes.  And he said well that ends the case. Move on to the next.

"In that moment I knew there were doctors supporting this effort to let women's bodies work"

There is no arbitrary number of csections a woman might have that excludes the chance to VBAC. I had a woman VBAC after five cesareans and one of the largest babies of my career.

It just takes time. Birth takes time. And you have to give it that time.

Now not everyone is successful at VBAC'ing and there is a good reason. Csections are good when the are needed.
(He told the story of his children, one vaginal birth and two needed csections for elevated blood pressure)

He told the story of one uterine rupture presenting with dark blood at 8 centimeters baby was looking good on the monitor. He knew "we should stop" Uterus was open upon abdominal incision - Baby did fine and her uterus did fine.  There are indicators that something is amiss. Do not let them ignore you. Have someone always paying attention to you.  (a doula?)
Mothers really do know when their baby is in trouble. That is how I trust when it is really time to have a csection.

Some dads can't do this. They can't watch their wives hurt. They go crazy. Let them step out. That is when it is good for you to have someone who can stay with you with a level head. Because there will be a point where you won't be sure either. And then you are done. It's when she thinks she can't do it that she is almost done. And then I say sweetie you are there. Yes I say sweetie, sorry I'm not PC.

It is an honor and a privilege to help a woman have a baby. If there are people delivering babies that don't feel that way then it's time for them to stop.
There is nothing more intimate and vulnerable than a woman saying "help me do this"  If you can't back up and go away.

I mean how often is a woman, clothes off saying "lets get this going" laughter ensues... I don't mean in a sexual way, rolls eyes and laughs.. She is trusting me to care for her body.

I have been screamed at, cursed at, if I was a woman I'd have had a mastectomy - a laboring woman will grab anything close she doesn't care if it is attached to you. You learn to lean in with your back arched away. I was even trapped in the clutches of a woman's knees before thinking "I gotta get outta here"

But it is still a sacred inspirational time and 97% of the time it goes off without a hitch.
There is nothing you will do more impressive than give birth to a child. You will do something harder. Raising the kid, that is harder.

The group I am speaking to here. You are the minority. But keep questioning.

When asked about inductions and doctors being pressured to not do them before 39 weeks he said.

You think its the doctors wanting to do them.. but you should walk a mile in my shoes.
37 weeks the moms start talking about wanting to be induced. "Dr. Cummings my back hurts, my feet hurt.. etc"  Yeah well that's normal I say. And they say can't we get the baby out now.
The next appt they bring the husband. And he's sitting in the corner angry that he has to be there and he's putting on the stink eye about get this over with. She says "the baby will be fine." No I don't know that I don't know that your baby will be fine. Next appt she brings her mother. The mother who is wondering why her daughter is uncomfortable and telling you its time to get this going. I ask her "Who told you how to have  a baby? blank stare... No really who told you how? You know what? no one. Your body knows how to have a baby... That shuts her down, she doesn't like me but she's quiet."

Pregnancy is split into three trimesters but the last trimester is split into three mini-mesters:
"this is okay"
'this is a disaster"
"NO REALLY THIS IS A DISASTER. Nothing will ever make you comfortable again."

Don't misunderstand. Doctors are well trained and they know their stuff. I mean us OB's you can't touch us.  But if you make a mistake... You WILL be sued.
Why should they put themselves at risk for you?
If doctors weren't afraid of being sued there would be less csections in the country TOMORROW.
Most doctors don't want to trust the body because its easier to walk the middle of the road and not come out where I am. You need to find someone who will listen to you and be willing to take the risks.

Stay in shape.
Look at what you are eating.
Don't let your kids eat trash.
Think about what you feed your baby, unless it is absolutely impossible, breastfeed your baby. The design is perfect.
I didn't have a hamburger that wasn't made by my mom until I was in college. And I didn't have soda you know why because my mom said "you can't have that stuff"

When asked what influence his grandmother who was a midwife was on him:

I'm not sure really except that she and my family expected your best. You didn't have to be number one or the best around but it had to be YOUR best.

I was going to be a pediatric neurosurgeon but the parents drove me nuts - thought I'd do something that makes me happy and being there when babies are born makes me happy.

On VBAC'ing out of the hospital:
My quirk is that I'd like women to VBAC in a hospital, its just a Dr. Cummings quirk.  But you can go with a skilled midwife, just make sure she has done this, and that you are no more than 15 minutes out from a hospital.

When asked about time after rupture:
How long you have you don't know. After 15 minutes you are on borrowed time. But we had one mom take hours to get to us and they were ok.

The thing is VBACing moms have no interest in putting their babies at risk. And a doctor who is not skilled can use that.  But mothers really do know when their baby is in trouble. That is how I know when it is really time to have a csection.

What to ask a doctor about when wanting a VBAC:
First: Do you believe in VBAC? Their answer to that one question will tell you a lot if you listen carefully.
Then after that:
Does your hospital support VBAC?
Do the nurses support VBAC?
We are only assisting - you are doing it.

On nurses:
Your nurse can determine if you have a csection or not. If you have been mean or your family, or if she doesn't like you then you have a problem because she'll be calling the doctor all day saying she doesn't like the way things look and he will opt for a csection. All she has to say is we have a problem and he doesn't want to be sued.

When asked if there was ever a situation where a mom should be told to have a csection:
He looked up and went hmmmmmm...
Well.. There was this one time:
Mom, back surgery, back fused in three places. scoliosis, skewed pelvis.
(heads around the room nod in understanding of a csection with a collective 'mm-hmm.)
to which he says:
She delivered vaginally just fine.
So I think mom can go for it unless she says "I don't want to do that" or unless you know her vagina is closed or something (rolling his eyes)

When asked about uterine windows (fragile areas of uterus from previous csections.
Well you won't know unless you have to operate. But if I cut you and I gave you a scar is your uterus going to rip open? (with the impression that care with operative skills reduces risks in future VBACs)
The original repair allowed for thinness - repair it properly and she can have more children.

Its like this - a T incision the statistical evidence is rupture in 2.5% of cases. That means with a special scar 97.5% of the time everything is just fine.

When asked why doctors want VBAC moms to deliver before 40 weeks:
There is really no reason.
Now after 42 weeks I get nervous, I'll do it but I get nervous. Midwives have all these herbal things. Utilize those things because they work and they won't hurt anything.

When asked about cord clamping:
I don't see a difference. But you want it to keep pulsing. I don't care. Let it.

When asked about ways to prevent a csection
Come to me... laughter... I hear my name's out there.

But listen birth takes time. If you're waters ruptured and you are only at 1 cm... GO HOME.
Seriously go home.
You will labor all day. You will be tired. Your doctor will be tired. You will have not made much progress and you will have a csection because he is tired.

When asked about gentle csections:
What do you mean gentle? Want me to cut you open 'gently?'
... laughter...
"No like skin to skin immediately after."
Well that's not the csection and yes skin to skin is good.

When asked about adhesions:
You just won't know unless you have to open her up.

Mom from audience on pain:
There is pain.
If you have a natural birth the pain comes before. If you have a csection the pain comes after. I'd always take the natural birth if I could.


Amanda said...

Thank u. Passing this on to my sis in law....who had a c section with her first and very much wants a vbac! i also had a friend just deliver with him last year....she had 3 prior csections!

Ryann said...

Really fascinating Janie!

~Fort Worth Doula said...

Thanks Janie!! One note on Pritchard. He co-authored Williams Obstetrics... He kept saying "He wrote the book!" and that's why it was such an impactful meeting because he looked up to him SO much.
Here is a bio on Pritchard.

~Fort Worth Doula said... Here's a bio on Pritchard. He literally co-authored "William's Obstetrics" and that's why it was such an influential meeting.

Thanks for putting this together!

Nancy Rebarchik said...

Thank you for capturing Dr. C's wisdom from that night, and thanks for sharing it!

Heather said...

Dr. Cummings delivered my three year old son just one day after meeting me for the first time. I met him on a Friday, after seeing my midwife and her confirming my son was, at 34 weeks, breech. He said he would do an external version, but was leaving for Hawaii Monday so it had to be tomorrow. Saturday, he found that I had zero fluid. He kept me on observation that night. The next day he said the baby needed to be born. If I wanted, he would let me try to have him naturally but he didn't think it was the best idea. I agreed a csection ASAP was the best road to take. He saved my son's life. He never pretended like the situation wasn't serious. He was always straight forward, but kind. I felt completely at ease with him as my doctor. If he hadn't agreed to the version, my son most likely would have just been stillborn and no one would have known why. Today, he is a rambunctious three year old and you would never know we almost lost him. Dr. Cummings treated me with kindness and consideration every step of the way even though I wasn't his patient and he didn't know me from Eve.

Unknown said...

Thanks s much for sharing! As his patient, I could hear him saying these things. Wish I could have been there...but this was almost as good!

Unknown said...

I have had three VBAC's without any problems. My second son's birth, in 1984, was the first recorded VBAC at Flow Hospital in Denton, TX. It was a new concept then. I was fortunate to have a doctor who was patient. I was almost 41 weeks when I delivered a 9 pound boy. Anyway, I am a former labor and delivery nurse turned nurse practitioner. I have worked many hours beside Dr Cummings. He's the best, and sincere in every thing he says and does!

Unknown said...

I have had three VBAC's without any problems. My second son's birth, in 1984, was the first recorded VBAC at Flow Hospital in Denton, TX. It was a new concept then. I was fortunate to have a doctor who was patient. I was almost 41 weeks when I delivered a 9 pound boy. Anyway, I am a former labor and delivery nurse turned nurse practitioner. I have worked many hours beside Dr Cummings. He's the best, and sincere in every thing he says and does!