CiC’s March Healthy Birth Workshop: Cesarean Birth and VBAC
CiC would like to give a HUGE thank you to Milon Nagi, a member of our volunteer Program Committee, for writing this week’s blog.
“My midwife walked back into the room on her phone: ‘I’ve got to go, my patient’s about to be sectioned.’” That was how Theresa, deep in labor, learned she was about to have a cesarean section. Theresa shared her story with an audience of expectant second and third time moms, all planning a VBAC (Vaginal Birth After Cesarean), at this month’s Choices in Childbirth Healthy Birth Workshop.
Pregnant with her first child, Theresa had found a midwife and was planning to have her baby at an in-hospital birth center. Just past 41 weeks, however, she was “risked out” of the birth center for being overdue. After laboring at home for a long time she arrived at the hospital already 9cm dilated. However, events took a turn following an epidural, as her labor slowed and her baby’s heart rate showed some decelerations. An OB drew Theresa’s midwife out of the room. They seemed to have a disagreement. When she returned, Theresa learned her baby was to be delivered via surgery.
Shocked and traumatized by her experience and a cesarean section that seemed to have come out of nowhere, Theresa at first had difficulty bonding with and nursing her son. “I just felt like somebody took the baby out of me, I didn’t birth the baby,” she said.
Pregnant with her second child, it took her a while to find a care provider who would allow her to attempt VBAC, partly because her pregnancies were fairly close together. However, across the country, women with prior cesarean sections struggle to find care providers who will allow them a trial of labor rather than an elective repeat c-section – according to ICAN around 30% of hospitals nationwide have an outright ban on VBAC. This is despite ACOG’s official position that most women with a prior cesarean should have the option to try VBAC.
Theresa was fortunate. She educated herself about VBAC and found an OB practice she loved and which was very supportive of her choice. With the support of her doula, her husband and some hypnobirthing CDs, she labored in hospital and even found the strength to refuse the initially tempting offer of a late epidural, remembering the change in direction she felt it had led to in her first labor. She went on to birth her baby girl in four pushes.
Later in the workshop, we heard Mayra’s moving story of her medically indicated planned cesarean section, and were fortunate to have Dr Gae Rodke OB/GYN and midwife Susan Brockman CNM available to answer questions. Much discussion focused on the safety and dos and don’ts around VBAC.
The greatest danger associated with a prior cesarean section is the very low risk – around 1% – of uterine rupture. Dr Rodke mentioned a recent study which put it at 2%, a finding she feels is connected with the increasing prevalence of some surgeons using single rather than double layer suturing after a cesarean, something she personally never does.
VBAC is contraindicated in some situations – in particular, if a woman has a vertical incision (external or internal) from her previous cesarean rather than a low, horizontal incision, this significantly increases the likelihood of rupture and makes VBAC less safe. Similarly, VBAC is not a viable option for women with conditions such as placenta previa (where the placenta lies over the cervix) or whose placenta is growing over the old cesarean scar.
Once in labor, pharmaceutical induction can increase the likelihood of rupture – misoprostol notoriously so – though, says Susan Brockman, the “careful and judicious” use of pitocin is not contraindicated. Lower tech methods of induction such as nipple stimulation, acupuncture and a foley balloon can be used safely if labor does not begin by itself or needs a little encouragement.
Overall, though, preparing for a natural labor with a truly supportive care provider and avoiding interventions as far as possible is the soundest way to achieve a successful VBAC. As Dr Mussali, OB, told us in a previous workshop: “an early epidural is the biggest obstacle to successful VBAC”. Having a doula on your birth team can be invaluable in helping you to achieve the birth you want.
While we can’t control all the circumstances that may arise – and in so many ways birth is about surrender – there are measures we can take to help set ourselves up for success. ICAN has a helpful checklist of things to consider when preparing for a VBAC. Most important, perhaps, is carefully choosing your care provider. Don’t be afraid to ask questions and get to the bottom of a practice’s statistics. How many VBACs do they do – for example, do they have a 100% success rate because they only allow one VBAC a year or carefully “risk out” candidates as they approach their due date? Interview several care providers and do your research to find someone who is truly committed to and supportive of VBAC, with a low cesarean section rate.
“Birth is such a big deal – I’m so in awe that people do it all the time!” Theresa told us, glowing with triumph, her 6 week old daughter in her arms. “I really highly recommend a VBAC”.
References and other VBAC Resources:
The VBAC Companion, By Diana Korte
A Guide to Effective Care in Pregnancy and Childbirth, By Murray Enkin: http://givingbirthwithconfidence.org/2-2/a-womans-guide-to-vbac/
National Institutes of Health, NIH Consensus Development Conference Statement on Vaginal Birth After Cesarean: New Insights(Vol 27, Number 3, March 8-10, 2010 http://consensus.nih.gov/2010/images/vbac/vbac_statement.pdf
Article published on Our Bodies, Ourselves blog: “ACOG Releases Updated VBAC Practice Bulletin, Emphasized Individualized Approach and Maternal Autonomy.”, July 22, 2010 http://www.ourbodiesourblog.org/blog/2010/07/acog-releases-updated-vbac-practice-bulletin-emphasizes-individualized-approach-and-maternal-autonomy
ACOG’s updated VBAC Practice Bulletin: http://www.ourbodiesourblog.org/wp-content/uploads/2010/07/ACOG_guidelines_vbac_2010.pdf
International Cesarean Awareness Network’s blog article: http://blog.ican-online.org/2010/07/21/ican-responds-to-new-acog-guidelines-on-vbac/
The International Cesarean Awareness Network, Inc. (ICAN) is a nonprofit organization that was founded by Esther Booth Zorn and many other motivated women in 1982. ICAN has now grown to over 130 chapters throughout the United States and worldwide.
ICAN offers a variety of educational, support, and advocacy resources online at www.ican-online.org. ICAN empowers consumers to seek evidence-based care through webinars, white papers, forums, and blog, and provides unique support via local Chapters and social networking sites such as Facebook and Twitter.
Article on ICAN website: “Cesarean Rate Nearly Static at 32.8%.” (Nov 23, 2011) The National Center for Health Statistics has reported that the cesarean rate in 2010 has slightly dipped to an overall rate of 32.8 percent, down from 32.9 percent from 2009. The one-tenth percent reduction reflects the first decrease in fourteen years.
A midwife’s blog: article” “VBAC: Making a Mountain out of a Molehill”; Feb 23, 2011 http://midwifethinking.com/2011/02/23/vbac-making-a-mountain-out-of-a-molehill/
Childbirth Connection: www.childbirthconnection.org
“What every pregnant woman needs to know about cesarean section” (free downloadable booklet). This comprehensive booklet provides trustworthy information in more detail than you and your caregiver are likely to be able to cover during busy prenatal visits.
The Thinking Woman’s Guide to a Better Birth, Henci Goer
Optimal Care in Childbirth: The Case for a Physiologic Approach, Henci Goer & Amy Romano
Henci Goer’s Forum on Lamaze.org: http://www.lamaze.org/Default.aspx?tabid=363.
“The best cesarean possible”. http://www.pennysimkin.com/articles.htm
The Truth about c/sections: http://www.youtube.com/watch?v=7zDnigbvPvk