Monday, 30 April 2018

VBAC after VBAC: Decreased Risk


A large new study on VBAC after prior VBAC has just come out, and it affirms what we've seen before, that risk for subsequent labors goes down and success rates go up after a previous VBAC.

Krispin 2018 Study

This is a large retrospective cohort study from Israel. It looked back at all women who attempted a VBAC at a major hospital over a period of 7 years (2007-2014).

The study group (n=1,211) contained the women with at least one prior VBAC. The control group (n=2,045) was comprised of women pursuing their first VBAC.

As we've seen before, a prior VBAC increases the chances of another VBAC. So it was in this study, too. Those with a prior VBAC had a 96% subsequent VBAC rate. (I think that's the highest VBAC rate of any study I've ever seen!)

However, even the women pursuing their first VBAC had a high rate, nearly 85%. This suggests that the Israelis are doing something right when it comes to attending VBACs, because their VBAC rates are much better than those of many U.S. hospitals.

Induction of labor was associated with reduced VBAC rates, cutting the VBAC odds by half, but induction rates were fairly low compared to some practices. This allowed the success rate to stay high overall.

The study confirmed that a prior VBAC greatly lessens the risk for uterine rupture (UR). The uterine rupture rate in those with a prior VBAC was 0.7%, whereas it was 1.6% in the women with their first Trial of Labor (TOL).

The take-home from this study is that when other variables were controlled for, having a prior VBAC cut the odds for uterine rupture in half in subsequent labors. 

Even so, both groups of UR numbers seem a little high, probably because the hospital used prostaglandins (PGE2) to induce their VBACs. Prostaglandins (and especially prostaglandins plus pitocin) have been shown to increase the risk for uterine rupture. Unfortunately, the study did not share the rupture rate in the induced groups vs. the rupture rate in the spontaneous labor groups. That would have been illuminating.

It's also important to point out that the risk for rupture wasn't zero. Even after a VBAC, uterine rupture is still a potential risk and has been known to occur. Neither is prior VBAC a guarantee of subsequent VBAC outcomes; there's always a chance of another cesarean because unpredictable things happen in labor.

But it's good to confirm again that the risk for uterine rupture is substantially lower once you've had a VBAC, and that your chances of having another VBAC are very good indeed.

Other VBAC after VBAC Studies

This is not the first study on successive multiple VBACs. Prior research also shows improved outcomes with previous VBAC. For example, Shimoniwitz (2000) found the risk for uterine rupture "decreased dramatically" once a woman has had a VBAC.

Some women have reported being told that risk for uterine rupture goes back up again after a certain number of VBACs and that therefore only a few VBACs can be allowed before a woman is required to have repeat cesareans again. This claim is not based in research at all and flies in the face of common sense.

The most definitive study on this claim is Mercer (2008), who studied multiple successive VBACs in 19 hospitals in the MFMU network. They found that UR rates dropped after the first VBAC and remained low thereafter:
Among 13,532 women meeting eligibility criteria, VBAC success increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%, and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively (P<.001). The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52% (P=.03). The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter.
The other consideration is that if a woman is not "allowed" to VBAC, she ends up with multiple repeat cesareans, which carry significant risks of complications such as placenta previa, placenta accreta, bladder and bowel injuries, hemorrhage, and hysterectomy (Silver 2006). The risk is dose-dependent, meaning that the risk increases with every successive cesarean a woman has. If a woman is planning a large family, the evidence clearly shows that repeated VBACs are far safer than repeated cesareans.

As Mercer et al. conclude:
Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy. There is no reason to place a limit on the number of VBACs a woman can have.
Summary

Once you've had a VBAC, you have an even better chance than before at another VBAC. It's not a guarantee, of course, but most studies show the VBAC after VBAC rate to be above 90%.

The uterine rupture rate after prior VBAC seems to fall between 0.4% and 0.7%. However, it will vary depending on how much induction is used, what induction methods are used, how aggressive providers are with augmentation, and any other other risk factors present. Whatever the exact number is, studies show that the uterine rupture rate decreases strongly after a prior VBAC but there should always be an awareness of the possibility.

The bottom line is that the risk for poor outcomes goes down with successive VBACs, while the risk for poor outcomes goes up with multiple repeat cesareans. In most cases, VBAC after VBAC offers more advantages and should not be restricted. 


References

J Matern Fetal Neonatal Med. 2018 Apr;31(8):1066-1072. doi: 10.1080/14767058.2017.1306513. Epub 2017 Mar 27. Association between prior vaginal birth after cesarean and subsequent labor outcome. Krispin E, Hiersch L, Wilk Goldsher Y, Wiznitzer A, Yogev Y, Ashwal E. PMID: 28285573
OBJECTIVE: To estimate the effect of prior successful vaginal birth after cesarean (VBAC) on the rate of uterine rupture and delivery outcome in women undergoing labor after cesarean. METHODS: A retrospective cohort study of all women attempting labor after cesarean delivery in a university-affiliated tertiary-hospital (2007-2014) was conducted. Study group included women attempting vaginal delivery with a history of cesarean delivery and at least one prior VBAC. Control group included women attempting first vaginal delivery following cesarean delivery. Primary outcome was defined as the rate of uterine rupture. Secondary outcomes were delivery and maternal outcomes. RESULTS: Of 62,463 deliveries during the study period, 3256 met inclusion criteria. One thousand two hundred and eleven women had VBAC prior to the index labor and 2045 underwent their first labor after cesarean. Women in the study group had a significantly lower rate of uterine rupture 9 (0.7%) in respect to control 33 (1.6%), p = .036, and had a higher rate of successful vaginal birth (96 vs. 84.9%, p < .001). In multivariate analysis, previous VBAC was associated with decreased risk of uterine rupture (OR = 0.46, 95% CI 0.21-0.97, p = .04). CONCLUSIONS: In women attempting labor after cesarean, prior VBAC appears to be associated with lower rate of uterine rupture and higher rate of successful vaginal birth.
Similar Studies on VBAC After VBAC

Mercer BM, Gilbert S, Landon MB. et al. Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstet Gynecol. 2008 Feb;111(2):285-291. PMID: 18238964 You can read the entire study here.
OBJECTIVE: To estimate the success rates and risks of an attempted vaginal birth after cesarean delivery (VBAC) according to the number of prior successful VBACs. METHODS: From a prospective multicenter registry collected at 19 clinical centers from 1999 to 2002, we selected women with one or more prior low transverse cesarean deliveries who attempted a VBAC in the current pregnancy. Outcomes were compared according to the number of prior VBAC attempts subsequent to the last cesarean delivery. RESULTS: Among 13,532 women meeting eligibility criteria, VBAC success increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%, and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively (P<.001). The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52% (P=.03). The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter. CONCLUSION: Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy.
Isr Med Assoc J 2000 Jul;2(7):526-8. Successful first vaginal birth after cesarean section: a predictor of reduced risk for uterine rupture in subsequent deliveries. Shimonovitz S, Botosneano A, Hochner-Celnikier D. PMID: 10979328
...Although a vaginal birth after a cesarean is considered safe in modern obstetrics, it is not known whether repeated VBACs increase the risk of rupture, or whether the first VBAC proves the strength and durability of the scar, predicting further successful and less risky vaginal deliveries. OBJECTIVES: To evaluate the effect of repeated vaginal deliveries on the risk of uterine rupture in women who have previously delivered by cesarean section. METHODS: In this retrospective study, 26 VBAC deliveries complicated by uterine rupture were matched for age, parity, and gravidity with 66 controls who achieved VBAC without rupture... We found that the risk of rupture decreases dramatically in subsequent VBACs. Of the 40 cases of uterine rupture recorded during the 18 year study period, 26 occurred during VBAC deliveries. Of these, 21 were complicated first VBACs. We also found that the use of prostaglandin-estradiol, instrumental deliveries, and oxytocin had been used significantly more often during deliveries complicated with rupture than in VBAC controls. CONCLUSIONS: Once a woman has achieved VBAC the risk of rupture falls dramatically. The use of oxytocin, PGE2 and instrumental deliveries are additional risk factors for rupture, therefore caution should be exerted regarding their application in the presence of a uterine scar, particularly in the first vaginal birth after cesarean.
Risks of Multiple Repeat Cesareans

Obstet Gynecol. 2006 Jun;107(6):1226-32.National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal morbidity associated with multiple repeat cesarean deliveries. Silver RM,  et al.  PMID: 16738145
...METHODS: Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999-2002). RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively. CONCLUSION: Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.


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Saturday, 21 April 2018

Those Pesky Attention Seeking Activists

2017 FAC StickerFive years ago, Disney and Barney’s announced a partnership for the Barney’s holiday window in which they would dramatically alter Minnie Mouse’s body — making her a 5’11, size zero in order to “look good” in a Lanvin dress. There was an uproar, the result of which was that Disney and Barneys changed the campaign, making it a “dream sequence” with Minnie eventually waking up wearing the dress on her actual body.

However, when Disney announced the changes in a press release, they claimed they had planned to do it the whole time and added: “We are saddened that activists have repeatedly tried to distort a lighthearted holiday project in order to draw media attention to themselves.”

They were talking about me. I was one of the attention seeking activists.

I had started a petition against the campaign that garnered over 140,000 signatures (including actors, models, and Walt Disney’s granddaughter) and drew international media attention.

It wasn’t the first time I’d been called an “attention seeking activist” by a person or company I had called out for oppressive behavior. When activists point out the bad behavior of a company, the response is often to attack the activist. One of the most common ways that activists are attacked is by being labeled as “attention seeking.”   Sadly, it can be a successful strategy. Often, people are uncomfortable with change and activism, so they are all too happy to roll their eyes at these rather than engage with the real issues.

Knowing this, I wanted to write an open love letter to any activist who has ever been called “attention seeking.”

To read the letter, just click here!

If you value my work, you can support my ability to do more of it with a one-time contribution or by becoming a member.

Like this blog?  Here’s more cool stuff:

 Wellness for All Bodies ProgramA simple, step-by-step, super efficient guide to setting and reaching your health goals from a weight-neutral perspective.  This program can be used by individuals, or by groups, including as a workplace wellness program!
Price: $25.00 ($10 for DancesWithFat members)
Click here for all the details and to register!

Book and Dance Class Sale!  I’m on a journey to complete an IRONMAN triathlon, and I’m having a sale on all my books, DVDs, and digital downloads to help pay for it. You get books and dance classes, I get spandex clothes and bike parts. Everybody wins! If you want, you can check it out here!

Book Me!  I’d love to speak to your organization. You can get more information here or just e-mail me at ragen at danceswithfat dot org!

I’m training for an IRONMAN! You can follow my journey at www.IronFat.com

If you are uncomfortable with my offering things for sale on this site, you are invited to check out this post.



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Friday, 20 April 2018

Actor Matt McGorry Does Some Serious Ally Work

Matt McGorryIf you’ve watched How To Get Away With Murder or Orange is the New Black, you’ve seen the work of actor Matt McGorry. If you follow him on Facebook you saw him do some serious ally work for Health at Every Size and Size Acceptance, even giving shouts out to people in HAES community:

This one is an important read. “Health At Every Size: The Surprising Truth About Your Weight” by Linda Bacon.
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I wish that all people, and especially health care providers, fitness industry professionals, and nutritionists would read this book.
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Like most people in our society, you’ve probably been on a diet aimed at losing weight. In fact, you’ve probably been on a diet MANY times. And when you inevitably “fall off” of the diet, you most likely blame yourself for not having enough willpower. You hope that next time will be different. But how many times has this happened? And should you really have to make yourself miserable with overly-restrictive eating and exercise plans in order to look a way that can make you feel worthy and valued? How is it that nearly everyone in our society constantly goes through this and yet we have grown to see it as “normal”?
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Health and body fat are not inextricably linked, despite what most of society believes and teaches us. This book breaks it down with studies and shows that the conflation of these 2 things is actually hugely damaging to health (mental and physical). It IS possible to be fat (or soft, or chubby, etc) and be healthy. Everyone deserves to live free of size-based discrimination.
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The more times and the more harshly we diet the more it makes our metabolism efficient at storing body fat as well as causing a host of health issues. Not the least of which is A WORLD WHERE JUST ABOUT EVERYONE IS CONSTANTLY DISSATISFIED WITH THE WAY THEIR BODY LOOKS. Many people hate the way their body looks. And women, of course, face greater pressures here than man due to societal expectations. For women of size, even more so.
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If you’re ready to accept (or at least learn about) how you didn’t fail your New Years resolution, but your New Years resolution (and societal expectations and lessons about weight) has failed YOU…then I highly recommend this book.
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This book and learning from many of the amazing people I follow (specifically women and folks such as @fyeahmfabello & @bodyposipanda who have personally helped me process ) in the Body Positivity movement has set me on my own journey to self acceptance and pursuing a happy and healthier life without obsessive eating and exercise tendencies. Moving from the extraordinarily restrictive behaviors of competitive powerlifting and bodybuilding to the pressures of the film and TV industry, and the current realization that my body is beautiful the way it is. Something that I know intellectually, but am on the continuous journey of working on accepting in my everyday life. It’s time to try something different.
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I have a great deal of privilege in regards to my body. I am a white, heterosexual, able-bodied, cis-gender, and famous man. And even in spite of these privileges that make my body much more accepted than others, I am often compelled to hide the way my body looks. Even if this is the norm… this shit ain’t normal!
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#LindaBacon #HealthAtEverySize
#McGReads

There’s a lot of great work that thin folks can do around HAES and Size Acceptance, and the good news is that a world without fatshaming helps people of all sizes.  If you want more ideas for how to be a thin ally, check out this post!

If you value my work, you can support my ability to do more of it with a one-time contribution or by becoming a member.

Like this blog?  Here’s more cool stuff:

 Wellness for All Bodies ProgramA simple, step-by-step, super efficient guide to setting and reaching your health goals from a weight-neutral perspective.  This program can be used by individuals, or by groups, including as a workplace wellness program!
Price: $25.00 ($10 for DancesWithFat members)
Click here for all the details and to register!

Book and Dance Class Sale!  I’m on a journey to complete an IRONMAN triathlon, and I’m having a sale on all my books, DVDs, and digital downloads to help pay for it. You get books and dance classes, I get spandex clothes and bike parts. Everybody wins! If you want, you can check it out here!

Book Me!  I’d love to speak to your organization. You can get more information here or just e-mail me at ragen at danceswithfat dot org!

I’m training for an IRONMAN! You can follow my journey at www.IronFat.com

If you are uncomfortable with my offering things for sale on this site, you are invited to check out this post.



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Thursday, 19 April 2018

VBAC after Cesarean for Arrest of Descent or Cephalo-Pelvic Disproportion

Your pelvis is NOT defective
A cesarean for "Arrest of Descent" means a cesarean done after a woman has dilated fully and pushed for a while without the baby descending. The amount of pushing time required for the diagnosis varies from source to source but is usually at least 1-3 hours.

When a woman has a cesarean for Arrest of Descent, she is often told something is wrong with her pelvis. She might be told she has:
  • A "flat" sacrum 
  • A "prominent" sacrum
  • A pubic arch that is "too narrow"
  • Ischial spines that are "too prominent" 
  • A pelvis that is "too small"
  • "Too much soft tissue" (fat) lining the vagina/pelvis
  • A pelvis that is the "wrong shape" 
  • A baby that was "too big" for her pelvis 
  • "Cephalo-Pelvic Disproportion" (baby too big and pelvis too small, causing baby to not fit)
Often women who have been told these things are strongly discouraged from trying for a Vaginal Birth After Cesarean (VBAC). There are documented cases where women have been told their pelvis is too flat or too small to have a VBAC, that they have "soft tissue dystocia" (a.k.a. "fat vagina"), that their pelvis is the wrong shape, or that since they couldn't push out a baby before, chances are they never will be able to because CPD is a recurring condition:
Yesterday, at my appt, while speaking with one of the midwives - she asked if I wanted her honest opinion & that if I was unable to push out a 7 and 1/2 pound baby and 2nd babies are normally larger then she didn't think it would be successful. 
The bottom line is that providers that are not truly VBAC-supportive often make women believe that something is wrong with their bodies and that they have little chance of having a vaginal birth, implying it's better just to schedule a repeat cesarean. Then the care providers conveniently have fewer VBAC labors to attend.

However, many women who have been told they have an abnormal pelvis or soft tissue dystocia or who have had a cesarean for Arrest of Descent or CPD have gone on to have VBACs anyhow.

And a new study just out confirms that many women with a prior cesarean for Arrest of Descent do indeed go on to have a VBAC and should not be discouraged from trying.

New Study on VBAC after Arrest of Descent

A recent American study (Fox 2018) shows that VBAC after prior Arrest of Descent is often successful.

In the study, one hundred women who had one prior cesarean for Arrest of Descent had a "Trial Of Labor After Cesarean" (TOLAC or TOL). A whopping 84% ended up having a VBAC. This is an excellent rate and better on average than many VBAC studies.

The authors concluded (my emphasis):
This suggests that arrest of descent is mostly dependent on factors unique to each pregnancy and not due to an inadequate pelvis or recurring conditions. Women with a prior CD [Cesarean Delivery] for arrest of descent should not be discouraged from attempting TOLAC in a subsequent pregnancy due to concerns about the likelihood of success.
The fact that the authors state this so strongly in an obstetrics journal is a big deal because it goes against what is commonly taught to many OBs, so let's reemphasize those points:
  • Arrest of Descent is NOT usually due to an inadequate pelvis
  • "CPD" is not necessarily a recurring condition
  • Women with this history should not be discouraged from trying for a VBAC
Many women can and DO have VBACs after diagnoses of CPD and Arrest of Descent. Yet strong discouragement away from VBAC is exactly what happens to many of these women, even today. 

Other Similar Studies

Was this study just a fluke? What do other studies on Arrest of Descent say?

There are only a couple of studies that specifically use the term "VBAC after Arrest of Descent" so you have widen the search a bit. Other search terms to consider include "CPD + cesarean," "cesareans after full dilation," or "cesareans done during second stage of labor" (pushing), or "prolonged second stage," or similar terms. Carefully vetted, these are essentially Arrest of Descent cesareans too.

If you just look at studies that examine VBAC after a cesarean for CPD, research reviews show that about two-thirds of women will have a VBAC. This rate is lower than for those whose first cesarean was for breech or fetal distress, but is still a very good rate. If all those women had been discouraged from VBAC or pressured into repeat cesareans, two-thirds of them would have had unnecessary cesareans!

There is very little data on women who have had more than one cesarean for CPD. However, one 1989 study did contain some data on women like this. If you crunch the data in the full text of the study, women with 2 prior cesareans for CPD had a 56% VBAC rate. So although we don't have a lot of data on this, what we do have suggests that even among women with more than one cesarean for CPD, more than half will have a VBAC.

The doctors who like to discourage VBAC cite a discouraging 1997 study that found a low VBAC rate (13%) in women who had reached full dilation and pushed in their previous labor. However, the rest of the research is much more encouraging.

In one Californian study from 2015, 54% of women with no prior vaginal birth and a prior cesarean during pushing stage went on to have a VBAC. In other words, they were just as likely to have a VBAC as not.

Similarly, a Danish study found a 59% VBAC rate in women whose cesareans occurred at 9-10 cm of dilation (9 cm often represents a fully dilated woman with a cervical lip, likely due to fetal malposition). Again, more than half had a VBAC and avoided the risks of additional surgery.

But some studies have results even better than that. In a New York study, 74.5% of women with prior pushing-stage cesareans went on to have a VBAC, some of them with forceps help, which suggests that fetal malpositions were an issue for quite a few.

Echoing those numbers is a Canadian study that found a 75% VBAC rate in those with a prior second stage dystocia cesarean. A very small, older Irish study found a 73% VBAC rate in those with a prior cesarean in the second stage.

Similarly, an older Dutch study found an 80% VBAC rate in those with a prior Arrest of Descent cesarean. This echoes our current Fox 2018 study that found an 84% VBAC rate after prior Arrest of Descent.

In summary, the majority of the research clearly supports the idea that women with a prior cesarean that occurred after full dilation and pushing can be offered a "trial of labor after cesarean" and will have a quite reasonable chance for a VBAC.

In the end, the decision whether to go for a VBAC is the mother's, but she should be reassured that she is just as likely to have a VBAC as not, and in many practices, especially with proactive care regarding fetal position, her chances are even better.

The Importance of Fetal Position

So what causes Arrest of Descent? Why does it happen in some births but not others in the same mother? The answer is usually fetal position.

In Arrest of Descent/CPD cesareans, the problem is usually the BABY'S POSITION, not the mother's pelvis.

If the baby is not well-positioned, labor tends to be slow and extra painful. It often slows or stalls between 4-7 cm of dilation. Often the mother eventually dilates fully but there is little or no progress during pushing. Fetal distress may occur.

Some providers become impatient and intervene with procedures (like breaking the waters) which may do more harm than good. Frequently, they are too quick to move to surgery when more patience might see the position resolve or the baby be born just fine in the "less-optimal" position. Recent research suggests that more than three-fourths of women with prolonged pushing stages (more than 3 hours) will deliver vaginally if just given a little more time.

What kind of fetal positions can cause problems? Read here for illustrations and specifics of the different fetal positions. The Spinning Babies website also has many helpful articles and illustrations on fetal position and how to help create maximum room in the pelvis. In the meantime, below is a brief introduction of the most common fetal malpositions.

Keep in mind that Presentation refers to which part of the baby is presenting first, and Position refers to how the baby is oriented in the mother's body in a head-down position. Also keep in mind that when describing fetal position, obstetric texts reference the back of the baby's head (the occiput) and which way the occiput is oriented in relationship to the mother. Most laypeople find it easier to understand by thinking of which way the baby is looking, so I use both in my descriptions.

Both the Spinning Babies website and The Labor Progress Handbook by Penny Simkin et al. have many ideas for various ways to help malpositioned babies resolve their position, and for creating more space in the pelvis. We will discuss this further in future posts.

Occiput Anterior (Easiest for Birth)


Occiput Anterior or OA
The easiest fetal position for labor and birth is usually Occiput Anterior. This is abbreviated OA and means the baby is head-down with the back of the baby's head against the mother's front; in other words, the baby is looking towards the mother's back. This position is considered the norm and the vast majority of babies will be born in this position.

Direct OA is when the baby is looking directly back at the mother's sacrum. LOA is when the baby is mostly facing the mother's back but his back is a bit towards the left side; ROA is the same but a bit towards the right side.

Ideally, the baby's chin is tipped towards its chest so the smallest possible diameter of its head presents. If the baby's head is not well-flexed, the presenting diameter is a bit larger. If the baby's head is tipped to one side or the other, it can be even larger. More on that below.

Occiput Posterior 


Illustration by Gail Tully, Spinning Babies
One of the most common fetal positions that can cause problems during labor is the Occiput Posterior position. This is abbreviated OP; the back of baby's head is against your back and baby is looking at your tummy. If the baby is directly facing your back, that's direct OP; if it's a little to the right or left, then that's ROP or LOP.

Although many babies enter labor in less-ideal positions like OP, only about 5% stay posterior all through labor and deliver that way. Babies that come out in the OP position are sometimes called "Stargazers" or "Sunny Side Up."

By itself, an OP position does not have to mean a cesarean, since most OP babies turn during labor and become OA before birth. The labor may be a little longer and more painful but it often proceeds just fine with a little patience. However, babies that are persistently posterior all the way through labor and birth have a high rate of problems.

Research clearly shows that persistent posterior babies have higher rates of cesareans for CPD or Arrest of Descent. This is because the presenting head diameter of a baby in OP position is larger than the baby in an OA position. In addition, the back of the baby's head is against the mother's back and that makes for a more painful labor, with lots of back labor and a slower dilation. This in turn often means lots of interventions from care providers that may make the situation worse, like breaking the waters, which takes away the cushion for baby to turn more easily and may lead to fetal distress.

However, OP babies do not always end with cesareans. With time and patience, an OP baby with a flexed head (chin to chest) can often be born vaginally. Alternatively, a vaginal birth may be possible if the care provider is patient and allows extra time for the baby's head to mold enough to descend into the pelvis. When it hits the pelvic floor, it often then rotates from OP to OA on the perineum and may be born quickly. Often an OP baby can be helped to rotate to OA through manual rotation, an instrumental delivery, or maternal postural changes like the all-fours position.

But because of the impatience of many providers, the fetal distress that can occur, and the extra-painful, longer labors associated with OP babies, many persistent OP babies end up being born by cesarean.

Deflexed Heads

If a baby's head is deflexed (not chin to chest), this can cause problems as well. A deflexed head makes the baby's presenting head diameter larger. This means the baby may not fit through very well, or the baby needs extra time for its head to mold enough to get through. OA babies with mildly deflexed heads experience longer labors, but with a little patience, are usually able to be born vaginally.

However, significant problems can occur if deflexion is extreme. Extreme examples of deflexed heads include a brow (forehead first) or face (face-first) presentation. Although vaginal births of brow and face presentations have been documented, most often they end in cesarean these days unless the baby's position can be resolved. Fortunately, brow and face presentations are quite rare.

Deflexed babies in an OP position are fairly common and result in many long, difficult labors. OP babies already start out with a larger presenting head diameter; when they also have deflexed heads (known as a "military" position), this makes the head diameter even larger. Big OP babies often have deflexed heads, making their head diameters even larger. These babies often have extremely long and hard labors, and many end in cesareans. Turn the baby around and/or tip its chin towards its chest so that the head is flexed and the baby would likely fit much better; many cesareans could be avoided.

Occiput Transverse/Transverse Arrest

Occiput Transverse, which can result
in Transverse Arrest
When a baby's head is directly sideways, facing the hip, this is called Occiput Transverse or OTOften OT positions are able to resolve to OA, but sometimes they do not and result in a vacuum extraction, forceps delivery, or cesarean.

OT often occurs when the baby was posterior earlier in labor, tries to rotate to anterior, and gets stuck in the process of turning. Sometimes it is iatrogenic (caused by the provider). If labor is slow, the care provider may break the mother's waters in an effort to speed up labor. This removes the buoyant cushion that can make it easier for the baby to finish its turn and the baby may end up "stuck" in this position. This is called "Transverse Arrest." A fair amount of cesareans are caused by transverse arrest.

Compound Presentation

A nuchal hand presenting alongside the head
Babies who have their hands up by their faces (a "nuchal hand" or sometimes a nuchal elbow/arm) can present another challenge.

The baby is basically OA and in a great position for birth, but the hand or arm beside the head causes larger-than-average presenting parts that must fit through at the same time. If the care provider can get the baby to pull back its arm/hand near birth, the baby is likely to then be born quickly. If the arm/hand remains by the baby's head, pushing is likely to be slow, painful, and difficult. Usually babies with nuchal hands can be born vaginally, but there may be quite a bit of tearing and damage to the mother. If the provider is not patient during a slow pushing stage with a nuchal hand/arm, it may result in a cesarean.

Asynclitic Heads

Asynclitic baby in OA position

Similarly, babies who have their heads tipped to the side instead of straight ("asynclitic") also have difficulty fitting. Instead of the top of the head presenting first, their parietal bone (bony side of head) presents first. The tipped head causes a larger than average head diameter that doesn't fit as easily.

Many asynclitic babies will correct the tilt of their heads if the mother's waters are kept intact and she is able to be mobile in labor. Asymmetric birth positions may help correct the tilt. Once the tilt is corrected, the baby is often born fairly quickly.

If the baby is not able to correct the tilt of its head on its own, then the care provider may be able to help through the use of a vacuum extractor or forceps. Sometimes the tilt of the head goes undiscovered or is not able to be resolved during labor; these babies often are born by cesarean.

Summary

Unfortunately, many women with a prior cesarean for CPD or Arrest of Descent are discouraged from even trying to have a VBAC. They may be told they have little chance at a VBAC and they should just schedule a planned repeat cesarean rather than risk another cesarean during labor. One woman was told:
You've already proven you can't get a baby out of your pelvis.
Obviously, that OB believed that the pelvis itself was the issue, not the baby's position, but the recent Arrest of Descent study suggests it is likely not true.

This kind of misleading "guidance" from care providers is not evidence-based. Most women with a prior CPD or Arrest of Descent cesarean who go through with labor actually have a reasonable chance at a VBAC, as this woman found:
The OB that did my c-section told me that my pelvis was small and also tilted and that because of that, a vaginal birth wouldn't be possible. Well, I...went for a VBAC anyway and it's a good thing I did because I had a wonderful amazing and natural VBAC with my next baby. And she came out in about 4 pushes. It was so easy! I had my second VBAC with my son a year ago and it went perfectly as well!
Here is a link to the story of another case where a woman who had a cesarean was told that her pelvis was too small to birth a baby and to forget about a VBAC. She went on to birth a 9 lb. baby ─ with a nuchal hand ─ as a VBAC. The Birth Without Fear blog has an awesome picture of it in their birth stories section.

That's not to say that CPD is never real. Sometimes it is. Although most cases of "CPD" are actually situational (caused by a malposition), sometimes there are rare cases of true CPD. These are usually a result of significant malnourishment in childhood, severe scoliosis, a history of rickets, or a history of a bad fall or accident where the pelvis was damaged. And sometimes, women don't have any of that in their background, really do try everything, and still end up with a cesarean because the baby just didn't fit. It does happen and it's important to acknowledge that.

But far too often, women who have had a cesarean after not being able to push out a baby are told that their pelvises are too small or defective, and they'll never be able to push out a baby. This is not true. Many women with this history can have a vaginal birth, if given an adequate chance to do so. Anecdotally, many women who have been told this benefit from having a good chiropractor evaluate their back and pelvis to help maximize the space in it and get it well-aligned. See my story below.

Women with a history of cesareans for Arrest of Descent or CPD should be offered the chance at a VBAC if they want it. Chances are good they will have one. There are never any guarantees, but research clearly shows that trying for a VBAC is a very reasonable choice in this group and should not be discouraged.

My Story

Again, many women have had cesareans for arrest of descent and yet gone on to have a VBAC. Conventional wisdom is that you need a smaller baby to get a VBAC, but some women do have VBACs with a baby even bigger than their cesarean baby. Again, fetal position is key.

This includes me. I had my first cesarean after a difficult induced labor. I dilated to 10 cm and pushed for two hours in stirrups, but ended up with a very traumatic cesarean. With my second baby, I had a relatively easy spontaneous labor where I did all the "right" things including position changes but still had FIVE HARD HOURS of pushing with little descent of my deflexed OP baby. I ended up with a second cesarean for CPD.

Both of my babies were big. I was told I had a "marginal" pelvis by my first care provider, and unless I had a smaller baby I would probably not have a vaginal birth. After my second birth, a nurse-midwife told me I probably had a pelvic shape predisposed to posterior babies and my babies would likely always be posterior. After two CPD cesareans at full dilation and after hours of pushing, I was told I was extremely unlikely to have a VBAC. The "VBAC Calculator" gave around a 20% chance of having a VBAC if I tried again.

All these declarations were wrong in the end but it was difficult to have faith. In my third pregnancy, I wavered between choosing to labor again or just going straight to a repeat cesarean. The baby was consistently posterior again all through pregnancy and I had no desire to go through a long hard labor only to end up with another cesarean ─ but neither did I want to go through another surgical recovery. I was also worried about the increase the risk of placental issues from another cesarean if I decided to have another baby in the future.

Near the end of my third pregnancy, I found a chiropractor who did a lot of work on my pelvis, including the Webster Technique and releasing the round ligaments that attach to the uterus. She felt my history of car accidents was highly relevant to the malpositions going on. According to her, the significant back and pubic pain I was having indicated "in utero constraint" that was making it hard for my babies to be in the easiest position for labor. The chiropractic adjustments eased a lot of my discomfort and the baby moved pretty quickly into a more optimal OA position for the first time in three pregnancies!

I went on to have a VBAC after 2 cesareans (VBA2C), something many providers would have told me would be extremely unlikely with my history and risk factors (short, old, "morbidly obese," big babies, two prior CPD cesareans, no prior vaginal births). Instead of pushing for 2 hours or for 5 hours as I did with my first two children, I pushed for 12 minutes with that baby. The doctor didn't even make it to the birth.

And it wasn't just a lucky fluke. Several years later, I had another VBA2C, this time with a baby that was a pound larger than either of my cesarean babies. I only pushed for 24 minutes with that baby.

Afterwards I asked my midwife to evaluate my pelvis and tell me honestly if it was truly marginal or not. She examined me and said it absolutely was not. Either the prior evaluation was wrong or chiropractic care really did create more space in my pelvis ─ or maybe a little of both. I do feel that the chiropractic care was integral to my VBACs, given that I never had an anterior baby until I had chiropractic care.

Remember, each labor and birth is unique and previous problems do not necessarily happen again.

Even a history of more than one Arrest of Descent or CPD cesarean does not mean it will continue to happen, especially if the mother is very proactive about fetal position. I had a history of TWO cesareans for Arrest of Descent and still went on to have two VBACs.

I have known women who have had VBACs after 1, 2, and even 3 prior CPD cesareans, including full dilation and pushing for hours each time with no vaginal birth. Yet they still eventually had a VBAC. The International Cesarean Awareness Network (ICAN) has a number of stories of women who have had a prior cesarean (or more) for CPD or Arrest of Descent and yet went on to have a VBAC. You can see some of them in their "Question CPD" video below.

There are never any guarantees, of course, and there are important risks to consider with both VBAC and an Elective Repeat Cesarean. However, if you choose to labor, your VBAC chances are good, anywhere between 50-80% based on the research. Don't let care providers convince you out of trying for a VBAC based on a past history of CPD or Arrest of Descent. In the end, it's your decision.



April is Cesarean Awareness Month. For more information on cesareans and VBACs, see the International Cesarean Awareness Network. 


References

J Matern Fetal Neonatal Med. 2018 Feb 27:1-5. doi: 10.1080/14767058.2018.1443069. [Epub ahead of print] Vaginal birth after a cesarean delivery for arrest of descent. Fox NS, Namath AG, Ali M, Naqvi M, Gupta S, Rebarber A. PMID: 29455594
...This was a retrospective cohort study of all patients delivered by a single MFM practice from 2005 to 2017 with a singleton pregnancy and one prior CD for arrest of descent. We estimated the rate and associated risk factors for successful VBAC. RESULTS: We included 208 patients with one prior CD for arrest of descent, 100 (48.1%) of whom attempted a trial of labor after cesarean (TOLAC) with a VBAC success rate [of] 84/100 (84%, 95% CI 76-90%). Among the women who attempted TOLAC, women with a prior vaginal delivery >24 weeks' had a significantly higher VBAC success rate (91.8% versus 71.8%, p = .01). Maternal age, body mass index, estimated fetal weight, induction of labor, and cervical dilation were not associated with a higher VBAC success rate. CONCLUSIONS: For women with a prior CD for arrest of descent, VBAC success rates are high. This suggests that arrest of descent is mostly dependent on factors unique to each pregnancy and not due to an inadequate pelvis or recurring conditions. Women with a prior CD for arrest of descent should not be discouraged from attempting TOLAC in a subsequent pregnancy due to concerns about the likelihood of success.
J Matern Fetal Neonatal Med. 2017 Feb;30(4):461-465. Epub 2016 May 5. Prolonged second stage in nulliparous with epidurals: a systematic review. Gimovsky AC, Guarente J, Berghella V. PMID: 27050812
...A systematic review of the literature was performed... for case series evaluating the morbidities of prolonged second stage of labor. Search terms used were "prolonged", "second stage", and "labor". Prolonged second stage was defined as three hours or more. Retrospective case series of prolonged second stage in nulliparous women with epidurals were identified. The primary outcome was the incidence of cesarean delivery. RESULTS: Two retrospective series with 5350 nulliparous women with prolonged second stage were identified. 76.3% (4 081/5 350) had an epidural. Of all nulliparous women with an epidural, 11.5% (4 081/35 469) had prolonged second stage. Cesarean Delivery occurred in 19.8% of these cases (782/4 081), while 80.2% had a vaginal delivery. CONCLUSIONS: Over three quarters of nulliparous women with epidural diagnosed with a prolonged second stage deliver vaginally.
VBAC After CPD Diagnosis

J Obstet Gynaecol Can. 2003 Apr;25(4):275-86. Vaginal birth after Caesarean section: review of antenatal predictors of success. Brill Y, Windrim R. PMID: 12679819
"...Even with a history of CPD, two-thirds of women will have successful VBAC, though rates decrease with increasing numbers of prior CS...There are few absolute contraindications to attempted VBAC. Attempted VBAC will be successful in the majority of attempted cases."
Obstetrics and Gynecology. February 1989. 73(2):161-5. Twice A Cesarean, Always a Cesarean? Phelan, JP et al.  PMID: 2911420
[My summary of highlights from the full text] 501 women with 2 or more previous cesareans had a TOL, and 69% had a VBAC overall. Women who had had at least one previous cesarean for CPD had a 64% VBAC rate. Those who had had 2 successive labors both ending in c/s for CPD still had a 56% VBAC rate. In other words, even those women with a previous 'failed' trial of labor had a better chance of a VBAC than another cesarean in labor.
Other Studies on Arrest of Descent or Similar Definitions
  • Am J Obstet Gynecol. 2015 Dec;213(6):861.e1-5. doi: 10.1016/j.ajog.2015.08.064. Epub 2015 Sep 6. Effect of stage of initial labor dystocia on vaginal birth after cesarean success. Lewkowitz AK, Nakagawa S, Thiet MP, Rosenstein MG. PMID: 26348381
  • Acta Obstet Gynecol Scand. 2013 Feb;92(2):193-7. doi: 10.1111/aogs.12023. Epub 2012 Nov 5. Cervical dilation at the time of cesarean section for dystocia -- effect on subsequent trial of labor. Abildgaard H, Ingerslev MD, Nickelsen C, Secher NJ. PMID: 23025257
  • Obstet Gynecol. 2001 Oct;98(4):652-5. Should we allow a trial of labor after a previous cesarean for dystocia in the second stage of labor? Bujold E, Gauthier RJ. PMID: 11576583
  • Obstet Gynecol. 2000 Apr;95(4): S38. https://doi.org/10.1016/S0029-7844(00)00660-8 Obstetrics Prognostic indicators for successful vaginal birth after cesarean delivery. Marshak J, Cooperman BS, Fried WB, Shi, Quihu. Available here.
  • Br J Obstet Gynaecol. 1998 Oct;105(10):1079-81. Vaginal delivery after previous caesarean section for failure of second stage of labour. Jongen VH, Halfwerk MG, Brouwer WK. PMID: 9800930
  • Obstet Gynecol. 1998 Nov;92(5):799-803. First delivery after cesarean delivery for strictly defined cephalopelvic disproportion. Impey L, O'Herlihy C. PMID: 9794672
  • Obstet Gynecol. 1997 Apr;89(4):591-3. Correlation between maximum cervical dilatation at cesarean delivery and subsequent vaginal birth after cesarean delivery. Hoskins IA, Gomez JL. PMID: 9083318


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Drew Barrymore Illustrates Our Issues with Food and Weight

Drew BarrymoreLet’s start with the fact that I’m a fan of Drew Barrymore – I recently went on a kick and watched a bunch of her movies (the song from the end of The Wedding Singer is still in my head.)

I also want to acknowledge that she is not typically “Hollywood thin” and her weight has fluctuated throughout her career, which means that she’s had to deal with all kinds of body shaming nonsense, and that’s total bullshit. Based on a recent People Magazine interview, it seems that she may have bought into diet culture in a way that illustrates the problems that many of us have, or have had that I think are worth acknowledging. Discussing her eating habits around her show Santa Clarita Diet she says:

“Let’s face it, I hate it, I would much rather eat fettuccine alfredo all day long…When I first started the show [Santa Clarita Diet], I was 145 lbs. and my life was kind of falling apart,” she said. “And I said, ‘Victor [Fresco, the show’s executive producer], can I lose 20 lbs. over the course of the show, and change my eyebrows and the height of my shoes and the body language and attitude and go from someone who’s kind of na├»ve and unhappy to someone who’s empowered and alive?’ And he said yes, and so I got to make that transformation.”

We have to let go of this idea that becoming thinner is the same as becoming more empowered and alive. For that matter, we should let go of the ideas that performing femininity in a way that brings us closer to a stereotype of beauty that reinforces things like racism, sizeism, ableism, healthism, cissexism, and heteronormaitivity, is the same thing as being empowered and alive.

She continued:

“When I’m doing the show I’m a vegan and I barely eat anything, and I workout every day, and it’s so healthy,” she said. “It gets to be euphoric, and then it’s like food poisoning, you feel like you’ll never eat again, and then before you know it you’re pigging out with the feed bag strapped to your face. And I’m a foodie, and love food and I travel the world for food, so I get heavy again between the show.”

“I heard Denzel Washington does this and I don’t know because I just want to believe it, I don’t want to know it’s not true. But he just enjoys his life and then pulls himself back together when he’s doing movies and looks amazing,” Barrymore said. “So I’m giving it the full ‘Denzel,’ even if that exists or not, and I let myself go.”

Holy shitballs. I’ve never heard anything that so clearly and accurately described disordered eating. Of course Drew Barrymore is allowed to do whatever she wants with her body, but let’s be clear that any competent healthcare provider would see this as red flag behavior for an eating disorder. This doesn’t have to be what’s normal. We can have a relationship with food that takes into account hunger, satiety, enjoyment, the social aspect of food etc. and does not involve severe restriction of food types and amount. Talented actors should not have to put their bodies through this kind of dangerous starvation cycle just to do their jobs.

If we would stop equating thinness with attractiveness, talent, morality, and being empowered and alive, then we could choose our actors based on their ability to act rather than their ability to approximate an impossible standard of beauty, and the characters they play could be whatever size the actor happens to be (including if they are a zombie on a high protein diet, since there are fat people on high protein diets in real life.)

For now I hope that Drew Barrymore’s disordered eating doesn’t escalate, and I hope that her casual discussion of it doesn’t lead anyone else to try it. And I continue to be a fan of a very talented woman who, it would seem, has been deeply affected by an extremely toxic diet culture.

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Book and Dance Class Sale!  I’m on a journey to complete an IRONMAN triathlon, and I’m having a sale on all my books, DVDs, and digital downloads to help pay for it. You get books and dance classes, I get spandex clothes and bike parts. Everybody wins! If you want, you can check it out here!

Book Me!  I’d love to speak to your organization. You can get more information here or just e-mail me at ragen at danceswithfat dot org!

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Wednesday, 18 April 2018

Eat Your Heart Out!

Life is such a funny beast of a thing! When you think you know yourself, and I feel like I really know myself at this point, things happen or change and suddenly you’re meeting an ex downtown for tea. WHAT?! I know! SO not a Me thing to do. Shit happens, things change, you pivot or bail, whatever! Ha-ha! It’s good to surprise yourself, I guess. And, well, I guess I’m glad that I did it! So…what happened?

So, after I left my husband in 2012, I befriended a man I had met at a terrible BBW club. There was attraction, but it was more than that (always is for me).We didn’t ever actually date. We “hung out” and were “friends” but whenever things felt too serious for him, he’d bail and I wouldn’t hear from him for weeks. *Yawn* Long story short, after a year of chasing after the dumbass, I found some love elsewhere and left him in the dust. He moved away, I had moved one. End of story. Sort of. Really he has continued to text me every few months. Usually simple things like, “Thinking of you” or “I miss hanging out and having tea together.” nothing offensive. I have not responded to him with one exception in 2016 when he called my phone for the first time since he moved away. I was expecting a work call, I was at work, and picked up by mistake not recognizing the number. I was very curt with him, professional even, and ended the call quickly. It was also my birthday and I got drunk with some coworkers and on my train ride home I drunkenly text him demanding to know his intentions for calling and texting me before my phone died. Outside of that one day, I haven’t said a single thing to him.

Sometimes I would forget about him entirely. 6-9 months would go by and he would be the furthest thing from my mind. And then *TextNotificationSound* He’d pop up again. I would roll my eyes and archive the text, not wanting to block him which might inspire other means of communication. I saw in my blog’s stats that he regularly downloads pics of me from my posts, mostly old ones from right before I met him. He doesn’t even read what I write! Psshht! So he wasn’t even aware of my breakup last year or that I’d been with the same person for four years. So, not long ago he started to text me again. I thought nothing of it or him, to be honest. Mild flattery at best, mild annoyance at worst. Then he called my phone again and I didn’t pick up. Why should I? I’m not really into talking on the phone unless I have to for work things. A few days went by after that and I get a random text while in line at CVS one night, “You suck!” and it was all I could do to keep the tears at bay from my laughter!

Something about that “You suck!” text just tickled me! Talk about the long game! Ha-ha! I still didn’t reply, because why?! Fuck that. My life, my terms. Being single and living alone means I am beholden to no man (okay, my puggo and perhaps my landlord? Hahahahah!). Then a few days later a few of us were sitting together to get a project done by the end of the day and were supporting one another through the process. I get another text from him, this one full of regret and apologies, things he’s never said before. I was surprised, but firm in my non-respsonse. Until I read what he said to two of my coworkers. My bff/coworker “A” gave me the “Oh hell no, grrrrl!” look and went right back to work. Another coworker was all, “Maybe I watch too many movies, but you never know, what if he ends up being the love of your life!” and she looked so wistful and sweet that I actually fucking caved and text him back!

He was in town, but leaving in two days, and wanted to see me to apologize for how he treated me in person. I gave him hell, but agreed to meet quickly for tea near my work. I showed up hard as nails, ordered my tea and sat down. He walked in and I won’t ever lie to you here, he looked gorgeous! I kept my cool and insisted he say whatever he needed to and then I would leave. But you know that isn’t how it worked out, right? I’m not afraid of confrontation, and relished the opportunity to put this fool in his proper place, in the past! He gave non-apologies, I rejected each of them. I then called him out for being a homophobic racist and misogynist. He was shocked! He expected, I imagined, that I would be all starry eyed and sweet like I was back when. Ha-ha! Nope! While I had to explain some things to him, I pushed back and insisted he needed to get with the fucking times and read some books before claiming to not be the things I know him to be.

I want to give people the benefit of the doubt. I want to believe that people can change. I have only ever given one person a second chance when it comes to romantic relationships. That didn’t go well. I don’t intend to make that mistake again. And this guy? Oh. Hell. No. That doesn’t mean I couldn’t enjoy the moment or his company again, even if only for the short time at tea. Soon we were talking and catching each other up on life and family things and very naturally he asked if we could walk around the lovely little downtown area we were in. I was game, but I was on guard! We talked about all sorts of random things and then he said, “Sarah, I have been thinking a lot about moving back to the bay area to win you back.” I laughed loudly at this. “You said we were never together!” I nearly shouted before laughing a whole lot more. “Do I have a chance to win your heart back?” he inquired. “You never had it or wanted it until I moved on. You are not up to the challenge of even attempting to properly date me. You’d have to read so many books! Ha-ha! No, no, you couldn’t possibly! Ha-ha!”

We walked around and talked some more and he had asked for a hug at some point and I said no. He was confused but respected that boundary. Shortly after though, whilst laughing about something together, I grabbed him and kissed him. Curiosity got the best of me, what else can I say?! I immediately told him that it meant nothing and was not intended to imply anything at all and that I was just curious. He was in shock and happy af! Ha-ha! Then I gave him shit about his past behavior again. I did kiss him again before saying goodbye, but he understood finally that there was no chance for there to be an “us” now or ever. He’d asked if he could see me before he left town and I said no and explained that I already had plans.

The next day he text to invite me to lunch, but I’d woken up with a terrible headache and said no. He text me later to see if I was feeling better and I honestly was and my plans had been pushed back until later that evening so I text him, “Where are you buying me dinner tonight?” with a sunglasses emoji. He responded a bit later but with the perfect answer and to that I sent him a pic of me looking dramatic and glamorous (bottom-center pic below)! He replied, “Who is this model?!” *Barfs* Ugh! But I went and it was a fantastic meal, and honestly the conversation was enlightening in that I could feel/see the spell I had on him and it felt fantastic to finally not be the one pining away for someone. You’d think that would make me kinder to someone in that position, but no, I treated him as he deserved and he understood and admitted and agreed. He even took me out for gelato after dinner and we hit up this little boutique we used to venture into years ago and he bought me a pin of a pug I wanted. He walked me to my car, I wished him well and agreed that he could text the next time he was in town but that I would make no promises to respond or meet up again. At that we said goodbye and I kissed him one last time. He hasn’t text me since.

I’m not saying it’s right or wrong, my behavior or his. We do things that even we cannot understand why. In the end it felt amazing and powerful and exciting and ridiculous all at once. I’m glad I met up with someone I was once gaga for and confirmed that I have zero feelings for. While in line at the gelato place he said he understood that I had no feelings for him, but asked if I cared about him, even a little. “Well, I wouldn’t want you to get hit by a bus.” was my response and I saw in his eyes how disappointing that was for him to hear. I felt a little bad, but he refused to remember all of the pain he caused me and insisted that I should only remember the good times. He holds onto some fantasy version of a memory of me that never actually existed. He’s still stuck in a time that I was trying to escape from back then. He doesn’t see me as a whole, equal and completely amazing human being. He sees me as a beautiful woman, made for traditional trappings of which I have no interest in. He enjoys my sass, which is abundant, but he is not a worthy mate for me by any measure.

I had never done the running into an ex thing before. I don’t look to my past for lessons in life these days, I keep it behind me. I’m always suspicious of anyone from the past popping up with seemingly good intentions. It’s never what it was and is rarely worth the time or trouble to entertain. I don’t regret meeting up with this ex, I know now for certain that what once was can never be. I feel good about that, actually. I do not care for loose ends. There’s definitely no one else in my past that I would give the time of day to. So, this feels more like a closure that, while it wasn’t needed, it was kind of nice. And damn did I look great! His jaw dropped when I walked into the restaurant…my other “plans” jaw dropped later that night, too!

 

(the dress is from Eshakti.com and I’m in love with it! My glasses are from Coastal.com and the pearls are old but from ShaneCo.com)

Rad Fatty Love to ALL,

<3
S

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Plus This! Talks All Things Fat Positive

Plus This Show CoverLast week I got the chance to be on Plus This! A show created by Eva Tingley and Kathy Deitch, two powerful plus size women in entertainment. Kathy’s credits include the original Broadway casts of Footloose and Wicked, and Eva’s credits include Scandal and Community.

I met Kathy at the Fattitude screening in LA and she invited me to be on the show. They have a lot of seriously famous guests so I was feeling nervous, but of course I agreed.

As we walked into the Universal Broadcasting Network studio, they pointed out that it’s in the same building as Scandal, and How to Get Away With Murder  – which didn’t help me feel any less intimidated, but did make me want to sneak on to the elevator to check things out.

Kathy and Eva are amazing, hilarious, brilliant, talented, and a total joy to be around so that put me at ease right away. Jarvis, the show’s producer was also amazing and incredibly kind despite doing roughly 1,000 things at once. I hung out through the first segment and then we were off to the races. You can check out the show below as well as the pictures I actually remembered to take this time!

 

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 Wellness for All Bodies ProgramA simple, step-by-step, super efficient guide to setting and reaching your health goals from a weight-neutral perspective.  This program can be used by individuals, or by groups, including as a workplace wellness program!
Price: $25.00 ($10 for DancesWithFat members)
Click here for all the details and to register!

Book and Dance Class Sale!  I’m on a journey to complete an IRONMAN triathlon, and I’m having a sale on all my books, DVDs, and digital downloads to help pay for it. You get books and dance classes, I get spandex clothes and bike parts. Everybody wins! If you want, you can check it out here!

Book Me!  I’d love to speak to your organization. You can get more information here or just e-mail me at ragen at danceswithfat dot org!

I’m training for an IRONMAN! You can follow my journey at www.IronFat.com

If you are uncomfortable with my offering things for sale on this site, you are invited to check out this post.



via Dances With Fat https://ift.tt/2qG4UWg