My first baby was born by cesarean and I had been told by many medical staff that this meant I had to have a cesarean birth every time. However I had been involved in the natural birthing community for some time and I personally knew quite a few women who had natural births after having one or even two cesarean births. I was confident that my body knew how to give birth, and if people could have heart transplants and other organ transplants and still function normally, then with a healed incision, my uterus could still function normally. In the medical community many obstetricians believe that a cesarean birth is safer for the mother, but there are also many who disagree and feel that a natural/vaginal birth is safer. They disagree with each other, so I knew that I had to make a confident stand, or I would be railroaded by a hospital system designed for efficiency, rather than the good of the mother and child.
First, for those new to this, VBAC is vaginal birth after cesarean, this is the usual term used in the natural birthing community.
Many women are having cesareans these days due to a cascade of interventions, rather than a real medical need. The normal length of labour is not considered to be normal in our hospital system, therefore there are lots of medicines designed to speed things up. So when a woman in early labour goes into hospital, and labour progresses slowly due to her body’s natural objection to being in a strange place, if she is not well prepared for the labour she can be railroaded into some of these interventions. Some of the interventions seem like they are for the woman’s good, such as epidural and other pain dulling drugs. However, the side effects of epidural can be a slower labour which needs to be “managed” with synthetic hormones to speed it up.
Childbirth, for most women, is a natural process which should not need to be “managed” with drugs to induce, speed it up or even to dull pain. The body is designed perfectly to manage it all on its own. When anything is done to force these things it puts the body’s perfectly designed system out of balance. Many of the medicines and drugs used for augmenting contractions or dulling pain have side effects which can include life threatening complications . When you are in labour is not the time to make decisions about taking a drug. You should research well ahead of time in order to know exactly what you will be taking, and what the possible side-effects are before putting yourself in a position where a cesarean birth may be the only option to save your life or your baby’s from the complications arising from the drugs.
My own experience was not due to a cascade of intervention, however, so I have a personal understanding that cesarean births sometimes need to happen.
My first baby was born when I was 19 in a hospital in a small town in Italy.
When I went into labour, I thought I was prepared. I had been involved in the natural birthing community, and I knew natural was the route I would go. My own mother had heroically birthed 8 babies, starting with my own birth at home, and including a couple of quite large babies, without medical intervention.
My husband and I felt ready for the birth.
It started out normally and everything seemed to be right. My last check up had shown the baby head down and facing backwards(anterior), so all seemed good for a wonderful natural birth.
I had 12 hours of fairly light contractions, so the experienced mother who I was consulting with said I should go to the hospital, which was 1 hour away. I felt really good until I got there and was told after some monitoring that my contractions weren’t strong enough and I was only 1 cm dilated. As you can imagine this was very discouraging, but I was determined to soldier on. I didn’t want to go home, even though they advised me to, because we lived so far away. Basically what happened was that contractions got harder to deal with, but the discomfort was all in my back. By this time I had been there for another 12 hours and the waters had broken, but I was only 3cms dilated. The doctor decided that they would augment the labour to help get me going as I was in excruciating back pain and the only comfortable position was on my feet swaying and leaning over the bed. I later discovered, through my research and doula training that the reason my contractions weren’t regular or strong and I felt so much back pain was because of the baby’s position which had changed since the last doctor’s visit.
To make a very long story much shorter, after 12 more hours I was fully dilated and pushing without any success. They said that something was wrong because after 2 hours of pushing the baby’s head was not descending. The midwife reached up to see if she could feel his head but she felt a shoulder instead. The baby was very distressed so they recommended a cesarean. I quickly agreed. I would have agreed to anything by this point, I couldn’t concentrate as they read me all of the side effects of the anesthesia. After almost 2 days of labour, I just wanted it to be over. During the delivery it became clear that the reason why he hadn’t descended was that the umbilical cord was wrapped around his neck several times and he was obviously trying to move away from the pressure.
Fast-forward to next baby, 1 year later. My local hospital refused to agree to anything but another cesarean, but I knew that with the bikini cut that wasn’t necessary. So I shopped around for another hospital that would let me have what they called a “trial of labour”. I finally found a training hospital near Bergamo (another Italian hospital) where they agree to my demands ( going into labour naturally, being allowed to be active in labour and birthing vaginally)by this time I was in a fighting mood as I had looked at 3 other hospitals. I had been seeing an obstetrician privately and it turned out that he worked at this hospital. They had me sign waivers to say I was taking responsibility for my decision to labour and birth vaginally. They also asked if they could have students there to observe. I said that was fine as long as they didn’t get in my way. My pregnancy went to 42 weeks and the last week was touch and go whether they would let me continue with my birth plan. I went into the hospital every second morning so they could check the waters for clarity(to make sure she wasn’t distressed and hadn’t pooped in the water).
I went into labour on the morning of the 42nd week.
I had mastitis and was in bed that day and was supposed to go in to the hospital for another check up, but I called and said I was in labour and would come in when I was ready. I laboured at home, and I could immediately tell the difference between this one and the last one. This time I could feel the contractions low down in my abdomen instead of all in my back. The waves steadily got stronger and stronger and as each one got stronger, I felt myself feel more and more relieved. My body was working and doing what it was supposed to. My positive attitude was a real boost to helping me through the labour, even though the baby was in a posterior position, facing the front.
I went to the hospital in the morning, and laboured for about 6 hours in the hospital till I was ready to push. I went to the delivery room and climbed up on the delivery table (it was a very old fashioned hospital) and grabbed onto the handle to pull myself up and push. They told me the baby was face up(posterior) and they gave me an episiotomy, which I wouldn’t have needed in an upright position. I pushed and as I was pushing, the doctor pushed down on my stomach and the baby popped out. I was ecstatic. I had given birth naturally and the baby was fine and I hadn’t had a cesarean. She fed properly and we had a wonderful breastfeeding relationship, I then went on to have 4 more babies naturally as well.
My research over the years into Vaginal Birth After Cesarean has led me to some helpful information which I hope is of help to anyone in a similar position.
More than 80% of women will be able to have a VBAC. According to “Midwifery Today”(Winter, No 36, Page 47) the American College of Gynecologists recently updated their opinion on VBAC and stated,”VBAC is safer than repeat cesarean and VBAC with more than one previous cesarean does not pose any increased risk.”
Why would I want a vaginal birth?
If you have only experienced a cesarean birth, either elective or in an emergency situation, you may be wondering why you would want to go through the bother of trying for a natural vaginal birth.
There are many reasons that you may want a vaginal birth after a cesarean. Some reasons may be medical and some may be emotional, others might be financial or in order to have a quicker recovery. Here are some benefits to the mother and baby of a vaginal birth.
Mother:
l Prevention of lesser complications of surgery
l Prevention of blood loss as a result of surgery
l Prevention of surgery related infection
l Prevention of injury (bowel, bladder etc.)
l Prevention of blood clots in the legs
l Prevention of feelings of guilt or inadequacy that can often result from a surgical birth
l Breastfeeding is generally easier after a vaginal birth
l The cost of a vaginal birth is a lot less, especially if you live in a place where you will have to pay for medical care
l Emotional satisfaction from birthing your own baby yourself
The hormone of love, oxytocin, is present in high levels in the bloodstream after labouring naturally with no intervention. This makes bonding and breastfeeding a natural, instinctive process, rather than a forced one.
Baby:
l Prevention of iatrogenic prematurity (when cesarean is performed too early after an error in guessing a due date)
l Prevention of persistent pulmonary hypertension(breathing and heart problems due to surgical birth)
l Labour prepares the baby for life outside the womb by clearing the lungs in preparation for breathing and by stimulating the brain.
l Prevention of surgery related fetal injuries
l VBAC results in fewer fetal deaths than elective repeat cesareans
Babies born vaginally after a natural labour have the bonding hormone oxytocin in their bloodstream, which kickstarts their instincts including the instinct to breastfeed.
Evidence for the Safety of VBAC
Uterine rupture:
A common fear among women who have had a previous cesarean is that they will have a ruptured uterus in labour. Most of this fear dates back to when the common incision was the high vertical or classical incision. These were more prone to rupture. Nowadays most incisions are the low transverse type, also known as the bikini cut.
There are two types of uterine rupture: complete and incomplete. Complete rupture usually happens spontaneously not necessarily during labour, and can happen to women with no prior history of cesarean.
Complete uterine rupture is very unlikely today for a variety of reasons. One reason is that when a labour is augmented using Syntocinon (synthetic oxytocin) the amount is regulated and controlled according to how strong the contractions are. In the past it was put into the IV and allowed to flow freely. Other obstetric practices of the past which caused rupture of the uterus, have also been abandoned, such as
high forceps, internal version etc.
A true complete rupture occurs in less than 1% of women attempting a VBAC. Incomplete rupture occurs in 1-2% of women attempting a VBAC. However usually these women are asymptomatic (meaning that there are no symptoms of a rupture) and neither mother nor baby require any medical assistance because of the partial rupture.
Golan published a study in 1980, where there were 93 ruptures of the uterus.
61 of these occurred in women who had no history of cesarean section.
32 of the women had a history of an incision.
There were 9 deaths from the rupture, but they were all from the group who had no previous experience of cesarean.
This means that rupture is something that can happen to any pregnant woman, not just those with a history of cesarean.
Another fear is that your body will get “stuck” at a certain amount of dilatation because that’s what happened last time. You may fear that your body can’t do the job. This fear needs to be addressed. It is very unusual for a woman whose contractions have worked up till 4 centimetres or more to not be able to go on and finish the labour. It’s quite common for a woman to have what is called “false labour” which means that she has contractions for a few hours and then stops then continues the next day, often at a similar time of day. Sometimes a woman will even go into hospital and be told to go home until labour becomes established (contractions coming every 5 minutes and lasting at least 60 seconds). The main important thing to remember is that your body is made to labour and birth your baby. Unfortunately you can work against your body by putting yourself into a stressful situation such as going to hospital too early, or by having a fearful attitude. Fear and stress produce adrenalin which prepares us for “fight or flight”. Adrenalin sends the message to our bodies that we need more blood in the large muscles such as our legs, meaning that we begin to have blood diverted from the uterus to other places. It can slow down and even stop labour.(see “The Labour Cocktail” for more details). Educating yourself about the process of labour and practising techniques for coping with labour can be a great help in reducing and preventing adrenalin producing emotions.
Should I attempt a VBAC?
Before making a decision to attempt a VBAC, you should ask yourself, “am I willing to take time to prepare for a VBAC?” If the answer is yes, then you should begin right away. It’s never too early to prepare.
The main areas which need preparation are:
l Mentally
l Physically
l Emotionally
Mentally: You will need to resolve to make the decision and stick with it as there will be some opposition. You may need to interview several caregivers to find someone who is sympathetic and willing to support you in VBAC. You may have friends or family who don’t really understand your need to attempt VBAC.
Physically, it’s important to be in shape in preparation for any birth. A woman who is well nourished and exercises and stretches her muscles with yoga for pregnancy or a similar type of exercise will have more endurance for labour and will more easily find comfortable positions for labour and birth. For a VBAC you may also need to research positions to help with turning a breech or posterior baby, or birth positions that open your pelvis more to give more room for the baby to come through.
Emotionally, attempting a VBAC will bring back memories of your previous labour and with this may come fear. It is important to work through these feelings ahead of time so that when you come to labour you have already faced your feelings about the last time. If your partner was there, they may also have suffered emotional trauma from the event. If they don’t find a way to talk about their feelings on this it may come out in the next labour, or they may not be able to support you because their feelings are getting in the way. For both you and your partner it’s a good idea to debrief your previous experience before you attempt a VBAC. This can be done on your own or with a counselor or a doula. Talk about what happened and your feelings about what happened. It can also help to read lots of positive stories from other women who have experienced VBAC. Your experience will be unique, but reading about other’s experience can be reassuring and help you to build up your confidence.
Reasons for Cesarean.
When the situation is life threatening to either the mother or the baby a cesarean section can be used to save lives.
Some of these reasons may be:
Placenta Previa
This is a condition where the placenta is attached to the lower portion of the uterus either covering or partially covering the cervix. It can only be properly diagnosed in the third trimester as the position of the placenta may not be clear in the beginning of the pregnancy. Treatment usually involves bedrest and frequent monitoring. If a complete or partial placental previa has been diagnosed, a cesarean is usually necessary. If it is a marginal placental previa, (when the placenta is attached to the lower portion of the uterus but is not attached to the cervix or covering any portion of it), a vaginal delivery is usually an option.
Placental Abruption
This is when part of the placenta starts to separate from the uterine lining. It can interfere with the baby’s supply of oxygen and proper nourishment. Approximately 1% of women will experience partial placental abruption, with symptoms including bleeding and pain in the area of the abruption. Depending on the severity of the separation an emergency cesarean may be performed.
Uterine Rupture
See above.
Breech or Transverse Position
Depending on the circumstances, a breech baby may be delivered vaginally, unless the baby is in distress or there is cord prolapse. A baby who is in a transverse lie may only be delivered by cesarean.
Cord Prolapse
A cord prolapse is when the umbilical cord slips through the cervix and protrudes through the vaginal opening before the baby is born. When the uterus contracts it can cause pressure on the cord which diminishes the flow of blood to the baby. A cesarean is usually performed in this case.
Fetal Distress
True fetal distress is rare because the baby is usually delivered before it gets to that stage. Quite often a fetal scalp blood sample is taken to determine if the baby’s acid level is at a level which shows distress or borderline distress and this is used as a yardstick to show whether a cesarean is needed.
Complications from Gestational Diabetes
There are many complications of gestational diabetes which can increase the risk that you may need a cesarean birth. These should be discussed with your doctor.
Preeclampsia
Preeclampsia is a condition of high blood pressure during pregnancy. This condition can prevent the placenta from getting the proper amount of blood flow needed and decrease oxygen flow to the baby. Delivery is sometimes recommended as a treatment for this condition. Only with severe preeclampsia is a cesarean performed.
Birth Defects
If a baby has been diagnosed with a birth defect, cesarean may be performed if it is deemed that a vaginal birth may risk the life of the baby.
Multiple Births
Many twins can be delivered vaginally. This is less likely with three or more multiple births, depending on the position of the babies, their estimated weight and gestational age.
Unfortunately many cesarean sections are performed for less clear cut reasons.
Let’s examine what some of those reasons might be:
Your pelvis was too small (cephalopelvic disproportion)
It is very rare for a woman to truly have a pelvis that is too small to birth a baby, unless she has a previous history of polio or has suffered a bad pelvic fracture or she is very young..
Many women who have been given this reason for a cesarean have gone on to have a VBAC and delivered an even bigger baby next time.
What if the baby is large?
The pelvis and a baby’s head are not rigid structures. The four main bones of the baby’s head are joined together with cartilage and connective tissue before birth. There are “soft spots” on the crown of the head and the top of the head close to the forehead. The baby’s head molds to the shape of the vaginal canal as it descends. The pelvis is also made up of several bones that are joined together by connective tissue at the pubic area and the hips and lower back. The connective tissue becomes softer than usual during pregnancy as your body produces hormones which soften the tissue in preparation for birth. As the baby’s body passes through the pelvis the bones move apart to allow the birth. You can facilitate this by practising birth positions which widen the pelvis, such as squatting which opens the pelvic outlet by about 10%. (see “Active Birth”)
What if I have had herpes?
In years past many women were advised to have a cesarean to prevent passing genital herpes to their baby. Doctors did cultures in the last few weeks to determine whether the infection was active. It is now recommended that, unless there is a visible lesion at the time of labour, vaginal birth is acceptable. The best way to prevent a lesion is to keep in good health, as well as avoiding foods rich in arginine. Take lysine(a natural enemy of the herpes virus) on a daily basis as labour approaches to prevent an outbreak.
What if I have had more than one cesarean?
Research shows that there is no more risk for a mother trying for a VBAC after a history of multiple cesareans than there is after just one. There is no reason to do anything differently if you have had more than one cesarean.
What if the other cesarean was for fetal distress?
True fetal distress is rare, and only a handful of cesareans are done for fetal distress. One study(Finley, Gibbs) indicates that fetal distress only occurs in 1.5% of VBAC attempts. Another(Paul, Phelan, Yeh) showed that of women whose primary cesarean was for fetal distress only 3% of those attempting VBAC had fetal distress.
This brings us to fetal monitoring. In a normal low-risk pregnancy, fetal monitoring has not been shown to improve maternal and fetal outcomes, rather it only serves to increase the cesarean rates. Some care providers insist on continuous electronic fetal monitoring for any woman attempting a VBAC. This is something you need to research beforehand and decide if it’s something you want and can live with.
Pregnancy after cesarean section?
You may be feeling anxious about being pregnant again after a cesarean and you may be wondering what you can do to increase your chances of a successful VBAC.
Pregnancy doesn’t need to be a problem, just be sensible about eating right, getting regular gentle exercise and avoiding heavy lifting. Check out the section on “Preparing for a VBAC”.
Your birth choices for VBAC.
Can I use a midwife?
You certainly can. As we have discussed before, with a few exceptions, VBAC is actually safer than repeat cesarean. Midwives are trained to detect problems and can refer you to their back up obstetrician if necessary.
Can I give birth at a birth centre?
This is something that you need to discuss with your health care provider. Most birth centres in Australia are part of larger hospitals and are near facilities should emergency intervention be required.
Can I have a home birth?
This is also something that should be discussed with your care provider. Most practitioners of home birth don’t see any reason why you cannot have a home birth VBAC.
What about pain relief in labour?
Before deciding to have pain relief in labour there are some things that should be considered. There is evidence that using epidural can increase that chance of having a cesarean, so if you are trying for a VBAC you may want to consider delaying the use of medical pain relief and use non-medical pain relief options as long as possible. There is some evidence that the rate of cesareans drops dramatically if woman waits till after she is 5 centimetres dilated to have an epidural.
Narcotics(pethidine, entonox gas) are also sometimes used in labour. Although narcotics do not have a direct effect on your chances of cesarean, they do have an effect on your mobility and your ability to focus in labour. Narcotics do not get rid of pain completely, they only reduce it slightly but they can give you a feeling of drunkenness. Narcotic use can also cause a cascade of other interventions such as fetal monitoring, epidural and augmentation. It can lead to a cesarean if the other interventions cause side affects which interfere with the labour.
Preparing for VBAC.
Information: Get as much of it as you can. Research the internet, read books, talk to other women who have had good experiences, find support groups.
Obtain a copy of the medical records from your previous births for yourself. Ask your current care provider to explain anything that you don’t understand.
Physical Preparation: You need to prepare your body for labour and birth. Being in good physical condition by being properly nourished and getting regular exercise will help you to have a much better experience of labour and birth. Yoga for the pregnant woman is especially helpful, such as the exercises in “Active Birth”.
Mental Preparation: Preparing for any labour requires mental preparation. If you have had a previous cesarean, both emergency or elective you will have issues that need to be dealt with before trying for a vaginal birth. You’ll need to resolve any feelings that you may have about the previous birth(s). You will need to persuade your mind that it is possible for you to birth vaginally. You need to trust yourself and your body before you go into labour. Talking to other women who have had a good experience with VBAC will help with this. It is also helpful to go over mental exercises which help you to focus on a goal, such as looking at a picture of an arch such as a rainbow or the Sydney Harbour Bridge, and imagining that the low end of the arch is the beginning of a contraction. Time 30 seconds to get to the top and 30 seconds to get down the other side. This is one way to focus on getting through each contraction. Other suggestions can be found in “Practical Skills for Labour and Birth”.
Your Birth Team: The number one important member of your support team is your partner. They will need to read information about VBAC and be as persuaded as you are that you can do it. Their emotions will transfer to you and affect you when you are in labour, so it is very important that they are onside and emotionally supportive. Next it is very important that your medical care provider is very sympathetic to what you want to do. Different hospitals will have different policies regarding VBAC, so you may need to call and talk to people at different hospitals and inquire about what their policies are. If you are going for a private obstetrician or midwife, interview lots of different ones to find the one who will be most sympathetic and believe in you.
Another vital and important member of a birth support team is a doula. A doula is trained in birth support, and some specialise in VBAC. A doula is not a medical person, but they can help you to understand the medical terminology, as well as giving you someone to bounce your questions off of. Your medical care provider is usually limited in the time they can spend with you, but a doula is more available and flexible in the time they can spend with you. If they specialise in VBAC, they have probably also experienced it, so that can be the source of a wealth of knowledge and support for you. A doula is there for you and is there to support what you want so they are an advocate for your wishes, although they won’t speak to your medical carers for you, except in dire circumstances.
If you are going to have anyone else at your birth such as a mother, friend or relative, it’s very important that they read your birth plan and discuss with you what exactly you want them to do to help you during labour. Don’t let anyone pressure you into allowing them to be there. It’s very important that you trust and feel comfortable with every member of your birth support team, otherwise they can have an adverse effect on your labour.
Patient Rights.
By communicating openly with your medical caregiver, together you can make choices that best meet your needs. Every woman has the right to fully participate in any decision to do with the health and well being of herself and her unborn child. This legal doctrine is called the right to informed consent. The World Health Organisation and the Australian Medical Association and many other oragnisations worldwide support the right of women to have an active part in their own health care decisions in consultation with their medical caregivers. Doctors must disclose to their patient information about the risks and benefits associated with any recommended treatment, test or procedure, so that the woman can make an informed decision. When a doctor has clearly explained the benefits and risks, a woman has the right to choose between the options available to her or to refuse treatment altogether. Patients are entitled to what is called an ”informed refusal”.
Labour and Birth:
As a mother-to-be you have the responsibility of obtaining early prenatal care, living a healthy lifestyle, and finding out as much as you can about the process of labour and birth. You have the right to say:
-Can you explain this to me?
-Where can I get more information?
-Can you write this down? Draw me a picture?
-I want to think about this before I make a decision.
-I don’t feel comfortable with this recommendation. What are my options?
-Is there anything else I can do or try?
Tests and Procedures:
Your caregiver will give you information and advice. You will probably feel better about making decisions if you ask your caregiver a few questions:
-How is this helpful to me or my baby?
-Are there any risks involved?
-Can you recommend a safe alternative?
-How will this affect my labour, my baby?
-Do I have time to think about this and give my answer later?
-If I choose not to go ahead with this recommendation what will be the consequences for me and my baby?
-How do you feel about me getting a second opinion?
Consenting to treatment:
When you are in a hospital or birth centre you are asked to sign a consent form before being treated. Your signature gives staff permission to treat you and your baby.
A separate consent is usually required for epidural or cesarean.
You can change your mind at any time by letting you wishes be made known. If you choose not to go ahead with a treatment or procedure, you may be asked to sign a waiver of liability acknowledging that you are taking responsibility for your decisions.
You also have the right to a copy of your own medical records. You should be able to obtain them directly from the hospital or birth centre, sometimes for a small fee. Otherwise your caregiver can obtain them.
Caregivers may disagree about what is best for pregnancy and childbirth. By becoming actively involved in your care, you are likely to be more satisfied with your decisions.