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Aug232009

Considering a VBAC?

I gave out an assignment to my Facebook friends asking what they would say to a woman considering a Vaginal Birth After Cesarean, but who was unsure of which way to go. Below are the responses, but first is mine.

- Where did you hear about VBACs? Did someone bring it up or were you discontent with your cesarean experience. What have you read so far? What do you know about CBACs (Cesarean Birth After Cesarean)? Especially scheduled CBACs.

The discussion of rupture surely has taken center stage and if you aren’t worried about it, your partner most likely is. It really is vital to weigh the risks and benefits of VBAC vs. CBAC. Where do you begin?

I encourage you to start a list, even from the very beginning of research. A column for Risk of CBAC and then another for Benefit of CBAC. Then do the same for VBAC. As you learn, put your thoughts into those columns. I promise, as you read more and hear about more, your risks and benefits might flip flop several times. But, having the columns allows you to keep a somewhat logical head about the impending decision. Of course, the earlier you are in your pregnancy, the more time you have. Plenty of women change their minds from CBAC to VBAC at 36 weeks or later (I’ve had two change at 39 weeks!), so until you are in the operating room, you do have a choice.

This decision does have many emotional components to it and writing or talking about those is vital. I encourage finding someone who isn’t strongly opinionated one way or another, but one who will read the research and books with you and be there as a sounding board as you figure all of this out. It might be your partner, your mother or a therapist. People usually do have an opinion one way or another, though, so sometimes finding someone on each end of the spectrum is what needs to be done. It can be challenging to find someone pro-VBAC and that’s where ICAN comes in. The International Cesarean Awareness Network supports women from around the world as they work to have the birth of their dreams and hopes. And it can be work.

Not all doctors or hospitals support VBACs. This can be an important part of your decision. Do you "love" your OB? Or is s/he not listening to or dismissing your questions about natural birth. Are you in a location where VBACs are even an option in the hospital? Far too many hospitals around the US no longer offer VBAC as an option because insurance companies (who lose money with lawsuits regarding not doing cesareans/repeat cesareans fast enough) don’t allow it. Even if your doctor is VBAC-positive, the hospital s/he works in might not be. It is up to you to learn your options ALL of them.

For some women who have no in-hospital options, they decide to birth at home. Birth centers with CNMs are not an option for VBAC women; the nurse-midwives depend on physician back-up and they and their insurance companies do not allow it. If the idea of homebirth is horrifying to you, you are not alone. Most of us thought homebirth was for the radical hippie, not the middle class soccer mom. That has changed as natural birth has become extinct in hospitals; women still have the urge/need/desire to birth their way, just like in the 70s. Perhaps someday hospitals will have enough consumer pressure to change their highly medicalised way, but we can’t wait that long. Women have taken birth into their own hands.

So, if homebirth seems absurd or completely foreign, keep an open mind for a few minutes and then, with introspection and very real knowledge, you will be better equipped to make a decision. For some, it is the only VBAC option. For others, it becomes the most likely path to VBAC.

All over the Internet, you can find the pros of delivering at home. Read about them and picture yourself in the birthing woman's position. Look at homebirth videos on YouTube and the many sites around the Net on private websites. Google words and phrases such as "homebirth," "homebirth midwife (your city here)," "waterbirth," "natural birth," and "what is a midwife?" The answers to those search words will add to your knowledge base and allow you to get a feel for if this is something you might be able to wrap your head around or whether this is way far-fetched and impossible for you to do.

What if you do decide to have a homebirth, but there aren't midwives in your area? Most women do the best they can by finding the least invasive care provider possible. Ask around at La Leche League (breastfeeding support group) or find a Bradley or Birthing From Within teacher... someone should be able to point you in the right direction. (When you are considering your childbirth classes, another must-explore is Hypnobirthing. I've seen wonderful births that were too similar to be coincidental with Hypnobirthing. But, as a midwife, I highly encourage you to ignore the perineal massage information and homework.

There is the rare woman who chooses to birth completely unassisted instead of facing the known repeat cesarean awaiting them in the hospital. I have very real safety issues surrounding UC (Unassisted Childbirth), but for women with no choice, this can be an option.

I’m not going to outline all the studies that are out there either for or against VBAC because they are easy enough to find (the ICAN site and then medical journals) and I don’t need to even speak about the pros and cons because those lists are out there in spades. I will talk from a homebirth midwifes opinion and experience. For those that don’t know me, I also assist women as they have hospital VBACs, something I enjoy for those women who don’t feel an HBAC (Home Birth After Cesarean) is for them. I try to be balanced in my opinion, but definitely have a bias towards the more natural route.

Women in labor are meant to move around. The baby and mother do a dance with each other, each having their own role in getting the baby into proper position for the birth. While most see the baby’s head and the mother’s pelvis as a solid, they really are more liquid. The head has soft spots (openings in the bones) that allow the head to mold, smoosh together, the bones crossing over each other, making the head smaller going through the pelvis. The mom’s pelvis is not solid, either. It is two pieces joined by cartilage that softens during pregnancy. During labor, as the baby’s head begins its descent into the pelvis, the bones pull apart, ever so slightly, accommodating the head readily. When women are left alone in labor, they stand, rock, sway, do shallow squats and lean over. In all these years, I have rarely seen a woman not do this dance and it tends to be women who feel that the bed will make the pain go away, similar to when we are sick and hunker down inbetween the sheets. But birth is not an illness and lying in the bed does not make the pain less; it actually amplifies it greatly.

Women who have had two types of labor one lying in bed and the other out of the bed- will tell you the mobile labor was infinitely more comfortable. Knowing how the bones (both mothers' and babies') work together to bring the baby down the pelvis to be born, you can visualize why movement would be crucial. When women are in a bed and then let’s add an epidural to that for increased immobilization the pelvis stagnates into one position that doesn’t change unless the mom turns from side to side. Even then, the pelvis ability to shift is quite minimal. When mom doesn’t move around, the head isn’t rocked into position very well, either, and Failure to Progress as a cesarean diagnosis can happen all too often.

As you probably know, having a baby in the hospital requires you to remain in bed. In fact, The Bed takes on an almost exalted status, its being in the center of the room, surrounded by a mass of technology. Trying to have a birth plan that includes staying out of bed is close to impossible to achieve.

Even if you do decide to birth in the hospital, considering staying home for as long as possible in labor might be a good option. While some are comfortable on their own, you might consider hiring a monitrice, a doula with additional skills in monitoring the baby and you as you labor out of the hospital. I have a distinct prejudice for hiring a monitrice over a doula; I feel monitoring is pretty important in labor for a VBAC. Many people are perfectly fine with having a doula that comes to the house for moral/emotional support before going to the hospital. Some doulas will only meet laboring clients once she is in the hospital, so be sure to ask this question of your support person (if having her come to your house is important to you). Because I know how to monitor the mom and baby, I know my viewpoint is different, but when I was a doula who used no clinical skills, I was still pretty comfortable supporting women in their homes. Nowadays, many pregnant women choose to rent dopplers and know how to listen to the baby themselves. A doula cannot diagnose what is happening, but if you all know the normal fetal heart rate (120-160 beats per minute), you can count and make a decision with the information you gather. This is NOT to say you need to have a doppler; it is merely something some women choose to do.

Below, a mom offers some ideas of books to read to help you come to your own best choice for where and how to birth. I cannot recommend Ricki Lake's and Abby Epstein's Your Best Birth enough. The book is the most balanced and informative book on the market. Please, please do yourself a huge favor and throw What to Expect When You're Expecting away and get yourself Your Best Birth. You won't be sorry. Read Birthing From Within helps women work through the fears of the upcoming birth. Even if you aren't pregnant yet or don't know if you are ever going to birth again, Birthing From Within can transform your emotional and spiritual healing from the last birth. Anything by Ina May Gaskin or Sheila Kitzenger are great, too. Search "natural birth books," read the reviews and see if they resonate with you. Check your library first before spending the money if that is an issue (as it is for so many of us), although some libraries are very conservative in the childbirth sections.

If you are definitely leaning towards a CBAC, please listen to this story. I recently heard a surgeon speak and she talked about repeat abdominal surgeries and how dangerous they are for the patient and how challenging they are for the surgeon. She explained that as incisions heal, whether inside or outside the body, they create scar tissue -adhesions- and subsequent surgeries are more difficult, even the second surgery, each one getting more and more complicated. She described scar tissue as "Super Glue" in consistency, the surgeon having to carefully cut through each band lest some vital artery be mistaken for an adhesion, causing quite the complication in the patient. After her talk, I asked about cesareans in particular and she said that each layer that was incised creates its own scar tissue, making the surgery more delicate than standard abdominal surgeries. Of course, there is the baby under all of that Super Glue to think about, too. OBs are loathe to do several repeat cesareans, urging women to not have more than a couple of cesareans. Plenty of doctors highly encourage women to have a tubal ligation with their third or fourth cesarean. Yes, women can (and do) have several cesareans, but it really is important to know what the consequences are if they do. Research CBACs as much as you research VBACs. The information is certainly black & white, but listening to both polar sides of the equation, I firmly believe you can find your own center.

So, here are the pieces of wisdom from my Facebook friends:

- Anna says: Visualize your birth every day.”

- Christie says: “Stay open to all options as well as the way things may unfold.”

- Cristina offers: “VBAC can be an option for many women. It must not be considered lightly. Who is you care provider, & do they really support VBAC? How long ago was your c-sec? WHY did you have your c-sec? How was your c-sec performed & closed? Is your support team (partner) behind your choice to VBAC? What is your emergency back up plan?

- Another friend offers: My short piece of advice is that she might like to sit quietly and connect with her baby.... what occurs to her? Birth choice is highly personal and should, imo, be directed by the whole self not policy, not statistics, not popular opinion. Blessings....”

-And another: I’m not a birth professional but my friends do know me as someone who is passionate about birth, has done a lot of reading etc so I have friends I hope will ask my advice on this topic one day.

(She continues...) My 1st advice would be to look at their medical records from the last birth. Find out why the section was done, have some proof of a double sutured low transverse incision, etc.

Also I’d have them find out what their current Health Care Providers typical protocol is and what her preferred places of delivery usual protocols are for VBAC.

Best case scenario, the section was for something not likely to show up again w/ the next pregnancy, was a double sutured low transverse incision and she’s already with a provider who is open to VBAC and delivers at a location with good VBAC protocols in place.

Even then, I would recommend she do some reading from both sides of the argument. Look up some recent studies, read some of the classics... Silent Knife, etc. and some of the newer ones like Henci Goer; read a few recent books about the birth culture in general Pushed for instance.

Definitely contact ICAN (International Cesarean Awareness Network) and read their white papers and read their forums.

If she wasn’t the reading type, I’d print some summaries out for her and get some magazine articles together.

If she wanted to know what I would do, I'd tell her that for me, a VBAC would be the optimal choice based on everything I’ve read.

I’d go over the stats regarding uterine rupture (seems to be the big thing w/ providers who are against VBAC) and compare those stats to some other commonplace interventions like amniocentesis.

I would give her the name of the OB in town w/ the best/ lowest repeat section rate.

I would pretty much just give her all the info I have and let her make her own decision but I’d offer to doula for her and just support her anyway I could. (Regardless of her decision, I’d be supportive.)

Would I try to talk her into a VBAC over a repeat? Yeah, to a point. The evidence supports VBAC as a safe and probably safer option. I’d absolutely be sure she had evidence-based info. But if she was dead set on a repeat then that would be her decision and once she had made it, I wouldn’t continue to argue with her about it.

- Jen says: The number one thing I would say to a woman seeking VBAC is:

If you have the knowledge, tools, and support, the likelihood that you will successfully VBAC is high. Hire an OB or midwife that is truly supportive, because they will set the tone of your birth. Aim for an unmedicated birth because drugs, most of the time, increase the risk of complications as well as repeat cesarean. Select a birth location that will be encouraging rather than be a source of fear, doubt, and, ultimately, failure. Find women who are planning VBACs or have VBACed and use them as your cheerleaders and sounding board.

(Me again) So, I hope this information offers at least a jumping off point for your VBAC consideration. Feel free to ask questions here or on forums, of doctors, midwives and read, read, read. Make your decision as informed as possible. And may your upcoming birth be everything you wish it to be.

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Reader Comments (18)

Great piece. :) After days wrestling with your call for advice I found I could come up with very little beyond "research both options on your own, and see what works best for you". So many variables kept running through my head, from reasons for her first section to her general birthing philosophy that I was just totally overwhelmed. It's such a personal decision, and I'm so close to it at this point that I don't know how helpful I could be. Lol. Ask me in a few months. :)

August 23, 2009 | Unregistered CommenterStassja

Well written Barb! I would also recommend taking a HypnoBirthing class either in place of a Bradley or Birthing From Within or in addition to either of those classes. HypnoBirthing classes helps VBAC moms release their fears & learn deep relaxation techniques as well as teaches moms-to-be that their bodies didn't fail them & are meant to birth naturally if fear/flight or fight response isn't released in the body.
Carol Yeh-Garner, LCSW, HBCE
www.AWellLivedLife.Net

August 23, 2009 | Unregistered CommenterCarol Yeh-Garner

I added the info, Carol. How I forgot it is beyond me! Thanks for the reminder. :)

August 23, 2009 | Registered CommenterNavelgazing Midwife

I had an absolutely fantastic hospital VBAC with midwives. It was the best choice for me, and the midwives were fantastic. The OB covering them that night was also great, and made me feel very safe. For me, as a NICU nurse, I psychologically could not get the fear of delivering a baby at home after a C-section out of my head. I felt the safest in a hospital, and was lucky enough to deliver in a very pro-VBAC site.
The most important thing I would say to a woman wanting a VBAC is, have confidence in your own body! You can do it. Do not listen to anyone's negativity or horror stories. Be positive!

August 23, 2009 | Unregistered CommenterReality Rounds

Great post! Thanks! I'm going to link to it.

August 23, 2009 | Unregistered CommenterDiana J.

Agree with everything except for a layperson renting a doppler, "counting the number and making a decision" FHR is so much more than just "normal is between 120 and 160" A baby can have a heartrate between 120 and 160 and be actively dying.

But otherwise, agree with everything!

August 23, 2009 | Unregistered CommenterDenise

I have decided on a birthing center (with a hospital as a very very last resort) with a midwife for the following reasons:

a) a water birth would be ideal for me and my home is 99% carpet.

b) my home is 30 minutes away from the hospital but only 15 minutes to the birthing center

c) I live in a third floor condo (not practical for emergency reasons)

d) I have more support for a private birth (If I had a home birth my whole family would weasel their way in! I love them but our home is TINY!)

if I didn't have these issues then I would choose to have a homebirth in a heartbeat.

(I have not had a cesarean in the past but I think I would have the exact same concerns If I had on in the past)

August 23, 2009 | Unregistered CommenterAmy

It is very important for a woman who wants a VBAC to surround herself with others who believe that she can do it, who reaffirm that her body is not broken. The easiest way to get this support is to go to an ICAN meeting in your area. Everyone in that room has had a cesarean or is trying to avoid a cesarean. Everyone feels the same way that you do and it is a safe place to express your emotions and heal from your cesarean. Look up www.ican-online.org for the chapter meeting nearest you. It will be well worth your time and energy and it's FREE!

August 23, 2009 | Unregistered CommenterMary Callender

Great post! Women can learn more about VBAC at:
http://vbacfacts.com/2009/01/15/im-pregnant-and-want-a-vbac-what-do-i-do/ as well as at via "The Truth About VBAC" class offered in Southern California and also as a web seminar:
http://vbacfacts.com/vbac-class.

August 23, 2009 | Unregistered CommenterJen @ VBACFACTS.com

The first, and most pertinent question for anyone considering VBAC is, am I a candidate for VBAC? Far too often, it is overlooked that not every woman CAN safely attempt VBAC.

Good to see you blogging again, Barbara!

August 24, 2009 | Unregistered CommenterAntigonos

Amazing Post!! I am very pro-VBAC, and I hope one day to have an HBAC.

I think the most important thing for a VBAC mom is to have faith in herself and her decision. After that she has to have people around her that support her decision. You can't have someone at your birth that will be talking you into a cesarean all the time. Especially if it is your care provider. Find someone you can trust, and go from there.

August 24, 2009 | Unregistered CommenterKayce

Denise: I'm curious about your comment. Can you point me to more information about this? What are other indications of fetal distress if the fetal heart rate remains in the normal range throughout?

August 26, 2009 | Unregistered CommenterRéka

And I think there is something to be said about the long term consequences of repeat c-sections both maternal health and the baby's health, which were the primary reasons I chose to have a VBAC last time (and worked damn hard to create it).

Barb, something that I think is opaque and perhaps I have written it somewhere - but as a large woman (6', 330lbs - and I look like I weigh 230 so it's not just fat) my hugeness and what damage I could do to furniture and other people is in my head. So laboring in bed has been the best option for me not because I like it, my feet hang off the end of the beds in the L&D I go to, but the nurses come to my shoulders, weigh half of my weight, and the furniture is meant for a small (to me) person - not a giant. I have always worried about crushing the little humans, and their stuff, and it interferes with labor I know.

I think for the next labor (I want two more) I will try to have a little more faith in the little nurses strength.

Anyway, small tangent as I am prone too take, but something I bet you haven't considered.

August 27, 2009 | Unregistered CommenterEthel

I really wanted to let you know how much I enjoyed browsing through your site today. As someone who has had 3 c/s, one by choice, I did attempt to vbac with both my second and third children, I really appreciate when I find people out there who are supportive of vbac. It can be extremely difficult, if not nearly impossible, to find a care provider willing to help you as the birthing woman to acheive your goals. Clearly, I was not successful in my quest. I think that if I had a more supportive birth team things would have been different, but things are as they are.
How much information do you have on vba multiple cs? The hospital system here in IL is pretty abyssmal when it comes down to it, unfortuately. I always wonder what would happen if we had another baby. I wouldn't want to be forced into yet another repeat c/s, but I would not feel at all comfortable with a uc.
Enough of my thinking out loud. I just really wanted to let you know that I truely appreciate that there are people like you out there in the world.

September 9, 2009 | Unregistered CommenterNicole

With my first I had an unesscesarean. I felt devastated, failed, felt like it took me forever to bond with my baby. Had a bout with PPD.

When I found out I was pregnant again, I dropped my OB like a hot rock. Found myself a midwife, began reading and reading and reading. And realized I never should have had my first c-section.

I went on to have a happy VBAC and even a year later when I think about his birth, I still have an emotional high,

September 28, 2009 | Unregistered CommenterJaded

Perineal massage reduces risk of trauma- systematic review in support:

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005123/frame.html

October 7, 2009 | Unregistered CommenterB

Im hoping for a VBaC, had one noraml birth before, keeps me in focus, thanks

October 27, 2009 | Unregistered Commentermeeme

Come to New Zealand, where 80% of women who have had caesareans attempt a VBAC and 70% of those are successful (which is only 5% less than the normal C-section rate at the hospital I'm training at). I find it really interesting reading about these issues as a medical student in NZ because in our training VBAC is the default option and midwives are standard care with ob-gyns saved for complicated pregnancies. Not that NZ's a birthing utopia, but we have different issues!

I'm enjoying reading this blog and I'm sure I'll take these messages with me in my training.

September 8, 2010 | Unregistered CommenterCaitlyn

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