ACOG’s 2017 VBAC GUIDELINES: WHAT MOTHERS NEED TO KNOW

3 Dec

Most mothers in the United States who want to labor for a VBAC still face resistance from their physician or hospital despite clear evidence that VBAC is a reasonable choice for women with a prior cesarean birth.

The American College of Obstetricians and Gynecologists (ACOG) has published and revised several VBAC clinical practice guidelines, the last time in 2010. Although the 2017 revisions seem to be the most supportive of VBAC to date, unfortunately the guidelines are not enforceable. Physicians and hospitals who support VBAC choose to do so voluntarily. It is important for mothers to become familiar with ACOG’s guidelines so that they can start a conversation with their provider during pregnancy and make an informed decision about how and where they want to give birth. Care providers are required to educate mothers about the benefits and risks of VBAC and elective repeat cesarean. Mothers have the right to accept or refuse the physician’s recommendations.

Many mothers today are still told they can’t labor for a VBAC if they are past-due, if their baby is “too big,” or if they have had two prior cesareans. However, ACOG’s guidelines support VBAC in those situations. The College recommends that “…individual circumstances must be considered in all cases.” Ultimately, it is the mother’s choice.

The following are highlights of ACOG’s Practice Bulletin, Number 184, Vaginal Birth After Cesarean Delivery.

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Can I Plan a VBAC After a Cesarean for a “Big” Baby?

19 Oct

Many mothers have given birth to heavier babies vaginally after a cesarean for a “big” baby. How you are cared for during pregnancy, labor and birth can make a big difference.

Estimated Fetal Weight in Pregnancy is Often Inaccurate

Care providers are concerned about vaginal birth for a potential “big” baby (fetal macrosomia) because as fetal birth weight increases so do the risks for shoulder dystocia, vaginal tears, and permanent nerve injury to the newborn. Macrosomia is defined as a suspected birth weight of 8lbs. 13 oz. or more. The problem is that estimating the size of the baby during pregnancy has been shown to be inaccurate. In the U.S. one out of ten babies are big at birth, but a national survey found that one in three women were told during pregnancy that their baby was too big for a vaginal birth.

Ultrasound estimates of fetal weight are not always accurate. ACOG discourages care providers from recommending an ultrasound in the third trimester to estimate the size of the baby or recommending a cesarean because the baby is “too big.”  The Royal College of Obstetricians and Gynaecologists in Britain  suggests that the majority of “big” babies do not develop shoulder dystocia and 48% of newborns who develop shoulder dystocia weigh less that 9lbs. 14 oz. The Society of  Obstetricians and Gynaecologists of Canada state that suspected microsomia is not a reason to discourage mothers from planning a VBAC. 

Helpful Positions for Labor and Birth

Having the freedom to walk around, staying upright during labor and using comfort measures can make a difference.

A woman’s body changes to prepare her for pregnancy and birth. Connective tissues soften in the joints. The pelvis, cervix, and vaginal tissues expand to accommodate the baby. The baby’s head molds as it moves through the mother’s body. Knowing how to move your body and change positions during labor and birth can reduce your pain and help labor progress. Specific positions such as squatting for birth can widen the pelvic diameters and allow a “big”  baby to move through the pelvis with ease.

  • Walk, move about, and stay upright during labor.

 

  • Change positions to make yourself more comfortable.

 

  • Use pillows to support every part of your body.

 

  • Avoid an epidural in early labor which can make it more difficult for your baby to move through your pelvis and turn into a favorable position for birth.

 

  • Give yourself enough time to reach full dilation . Current evidence shows that women are not considered to be in the active phase of labor until the cervix widens to 6cm and the membranes have ruptured. 

 

  • Push your baby down when you feel the urge rather than immediately after reaching 10cm (laboring down). Mothers who have had a vaginal birth can take up to 2 hours and with a prior cesarean without labor, 3 hours to give birth. All mothers need an additional hour if an epidural is still effective.

 

  • Ask your childbirth educator about movements and positions for labor and birth that can help to widen your pelvis. You can download the Optimal Positions Labor Guide from BirthTools.org for examples of helpful positions for laboring with a “big” baby. 

 

  • Consider hiring a doula to support and guide you. Doulas are familiar with comfort measures and non-drug options for pain relief. Women who are supported by doulas have fewer cesareans.

 

  • Consider having a midwife as your primary caregiver. With midwifery care, women have fewer cesareans.

 

Resources

Evidence-Based Birth: The Evidence for Induction or Cesarean Section for a Big Baby

VBAC Education Project: Download Module 5 of  Deciding if a VBAC Is Right for You: A Parent’s Guide and Educational Handouts for Parents: A Parent’s Guide  for additional guidance on planning a VBAC.

 

 

What Are the Odds of Having a VBAC? A Guide for Birth Educators

12 Sep

These guidelines are based on the content of the VBAC Education Project. 

Planning a VBAC presents different challenges for different women. Some are ready to face labor head on without any drugs for pain relief choosing instead a variety of comfort measures, doula care for emotional and physical support, and a midwife as their primary care provider. Others, who may have had a long, difficult, and painful labor before having a cesarean may feel they can only go through another labor if they have dependable pain relief (an epidural), the safety of electronic fetal monitoring, and the reassurance of an “immediately available” physician and operating room staff in case of complications. Every mother’s choice should be respected. There are many ways to support women who labor for a VBAC within their self-selected birth choices.

ACOG’s guidelines for VBAC suggest there are factors that are likely to increase women’s odds for completing a VBAC:

  • A prior vaginal birth;
  • A healthy pregnancy weight;
  • The prior cesarean was for malpresentation (baby in a non-vertex position);
  • Going into labor at or near term;
  • Labor that is not induced or augmented;
  • The bag of waters having ruptured on its own or the cervix having started to dilate before admission to the hospital labor and delivery unit;
  • No complications in the current pregnancy such as preeclampsia.

However, there are other important factors that can make a difference in whether or not a mother will complete a VBAC.

Evidence is mounting and validating what many maternity care professionals have always known, that health outcomes are better when the process of labor is allowed to unfold on its own (physiologic birth) without routine medical interventions and when mothers are full participants in their care. Women are more likely to get the support they need and the care that is best for them when care providers collaborate to bring about healthy outcomes for mothers and babies (Goer & Romano, 2012).

Simkin and Ancheta (2011) have demonstrated that women can have an easier and safer birth when they feel safe and respected by their caregivers and when their values and preferences are taken into consideration. When they have freedom of movement and can stay in upright positions as long as they feel comfortable.

Routine Interventions and Electronic Fetal Monitoring

žAvoiding routine interventions helps labor progress, but with a VBAC, monitoring the baby’s heart rate is important. žThe baby’s heart rate pattern frequently changes when the uterine scar separates.ž Up to 70% of the time electronic fetal monitoring (EFM) has detected an abnormal heart rate pattern, suggesting a separation of the uterine scar (ACOG, 2010).

žSome care providers recommend continuous EFM in active labor. Even with continuous monitoring for a hospital VBAC it’s possible to change positions, rock in a chair, stand and move side to side, lean over the back of the bed or a birth ball and use an upright position for birth. A telemetry unit (portable fetal monitor), or a waterproof hand-held Doppler allows mothers to walk, change positions or use the birth tub while monitoring the baby (Simkin & Ancheta, 2011).

Implications for Educators 

The concept of physiologic birth, allowing birth to proceed without interventions unless medically necessary, moving around in labor, and avoiding an epidural in the early stage of labor will probably be new for most of your students. In U.S. hospitals the majority of women experience multiple interventions, two out of three women have an epidural for pain relief in labor, only four out of ten have freedom of movement once labor begins and more than six out of ten are on their back for the second stage of labor (Declercq, Sakala, Corry, et al., 2013) . 

To help women clarify what options are available to them and how they prefer to give birth use the list of suggested questions in the Educational Handouts For Parents for Module 4 to begin the conversation so that they have the time and opportunity during pregnancy to get the answers they need.

The questions are designed to encourage parents to feel comfortable asking questions of their caregivers and to find out more about their provider’s approach and philosophy of birth. The discussion will also help partners themselves to find out if their views about having a “safe” VBAC are similar or different. Partners may decide they can both benefit from the expertise and support of a doula.

Mothers have their own unique preferences for how they want to give birth and what they need to labor safely for a VBAC. Educators have the tools and knowledge to support them and give them the confidence they need.

 

Second Chance: A Mother’s Quest For A Natural Birth After a Cesarean- A Memoir by Thais Nye Derich

1 Aug

Thais Nye Derich’ book is a beautifully written, restorative journey of self-discovery, empowerment, and spiritual growth. It is also a testament to a maternity care system that has inadvertently failed many women. Managing the natural process of childbirth with routine protocols and multiple interventions geared more to an intensive care patient than a healthy woman giving birth. Multiple interventions used on a healthy woman often lead to an avoidable cesarean section.

The mother of two boys, Luke, born by cesarean and Mikko, born naturally at home with midwifery care, Thais tells us that she wrote this book to heal from the trauma of her unexpected cesarean and unresolved past trauma, untreated and buried. Her mother had abandoned her family when Thais was four. After Luke’s cesarean birth assisted by a vacuum extractor, her goal was to find a way to talk about Luke’s birth without crying.

This book is not a general guide to a VBAC, but a personal narrative that reflects the deep disappointment and disconnect that many mothers feel after an unexpected cesarean. It is also an example of the strength and resilience of mothers who take the difficult but rewarding journey to resolve their conflicted feelings about a cesarean birth they experienced as traumatic.

Thais’  cesarean was performed many hours after having been in labor with a typical “cascade of interventions.” A Pitocin augmentation, an IV, continuous fetal monitoring, restricted movement, fentanyl to mitigate the pain of the relentless contractions, and finally an epidural and a bladder catheter.

“ I am in a panic now,” she writes. “I have no idea how to handle my contractions. I am about to have a baby while hallucinating.” When she begins to push, still numb from the epidural, she writes, “My body isn’t with me, or I am not with it…My instincts are hidden from me…This is like swimming with a backpack full of rocks.”

Unable to make progress in the pushing phase within the expected time frame for a first birth, her physician was called in because she lived far from the hospital and it was nearing midnight. Neither Thais or her baby were at risk, but after examining her the physician said, “It’s time to get that baby out.” She wanted to “grab” the available OR before someone else did. Although Thais was treated kindly and agreed to the interventions, neither her physician nor her nurse took the time to explain her options nor the risks of a cesarean section on future pregnancies. Her physician made the recommendation and waited on Thais’ bed with a consent-for-surgery form that needed to be signed although Thais had no time to read it nor the mindset to understand it at the time.

Like many mothers who have had a cesarean, Thais struggled for years to understand what happened that led her to have a cesarean and why her psychological pain was so visceral. She looked for someone to listen to the story of Luke’s birth without thinking like she was “crazy.”

When she became pregnant with her second child, her search to find a caregiver she could trust and a safe place to give birth to her second child was not easy. Her path led her to a spiritual healing center, chiropractic care, yoga, visualization, meditation, an improved diet, a Blessing Way, and a woman’s circle where she found the reassurance and emotional support she needed.

Like many women who are focused on  laboring for a VBAC, the author’s decision alienated her from her partner at times. “ I realize that Jake and I are living two separate lives. He sees my struggle, but he doesn’t understand it. He doesn’t get me anymore.”

Laboring for a VBAC at home for a mother who has not had a prior vaginal birth has increased risks. But, Thais researched all she could on VBAC and made her decision with her eyes wide open. “…there is something about taking full responsibility for the birth of my child that leads me to the very real possibility of death. The glory of a beautiful and peaceful birth in my own home doesn’t come for free…Birth is not a fairy tale.”

When her midwife gave her the consent-for-treatment forms to sign, she did not mince words about the risks of a homebirth VBAC. “This form says you understand that there is an increased risk of maternal or neonatal death at home because there is not an operating room down the hall….in reality we could be dealing with some very hard scenarios at home that require guts and grit and trust in one another.”

Thais’ midwife had an agreement in place with a hospital four minutes away to care for her client in case of a home-birth transfer.  The collaborating physicians on staff did not support home birth,  but did respect  a woman’s ethical and legal right to make her own informed decisions. If Thais needed to be transferred to the hospital she would go directly to the labor and delivery unit and her medical record would be accessible to any member of the staff that needed to care for her. Her midwife had the right to accompany Thais, but not provide any medical care.

This book reveals to us that birth is a transformational experience. It is also about compassion, dignity, autonomy, trust, emotional support, and empowerment.

As Maria Iorillo, LM, CPM, former Vice President of the Midwives Alliance of North America and Chairwoman of the California Association of Midwives writes in the Forward, “How we as a family and community care for women in this fragile state (of giving birth) can mean the difference between suffering and empowerment.”

Every mother who begins the difficult journey to resolve her feelings about her unexpected cesarean will find her own safe way to give birth in her subsequent pregnancy. This safe place may be a birth center. Or the hospital with an OR down the hall, but with caregivers who respect her wishes for non-drug pain relief, freedom of movement, and doula care. Failing to find supportive caregivers, a good birth may also be an elective “gentle” repeat cesarean. Second Chance is inspiring for any mother making this journey.

Derich’s memoir is also  an important contribution to the current international debate about human rights in childbirth and  the critical role of respectful maternity care. In today’s world it is no longer acceptable to move ahead with or simply recommend a procedure or a course of care. It is women themselves who get to decide what they are willing to consent to and what to refuse.

Without respect for autonomy and women’s ability to make their own informed decisions about how they want to give birth it will be difficult for caregivers to gain the trust of the women they serve.

For more information about Thais Derich, see http://www.thaisderich.com/