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/

 

Teaching Tips for VBAC Classes

20 Jul

Maternity care professional organizations are finally beginning to acknowledge the health risks of avoidable cesarean sections and the benefits of supporting women who want a normal vaginal birth after a prior cesarean (VBAC). Medical guidelines currently state that any hospital that cares for birthing mothers can support women who choose to labor for a VBAC.  This is an opportunity to introduce and develop a VBAC awareness, education, and support program for mothers considering that option.

Depending on how much time you have, and the physical space you are teaching in, these suggestions may be helpful to you. You can find many of the resources you need to teach a class from the VBAC Education Project. Select the slides in any of the fourteen Modules that best meet parents’ needs in your community. A companion chapter for each of the Modules can be found in VBAC for Educators: A Teaching Guide. The VBAC Education Project

Teaching Tips

The educational offering can be a monthly presentation to a large group or a series of weekly classes. Depending on how much time you have, and the physical space you are teaching in, these suggestions may be helpful to you.

  1. If you have the names of the parents who will be attending your class, you might want to give them a call before class begins. This will give mothers the opportunity to clarify some of their personal concerns and give you specific information that you may want to add for discussion in your class.
  2. Use a room set-up that encourages participation and interaction, circle or U-shaped set-up instead of classroom style. Given the opportunity, VBAC students learn a lot from each other.
  3. Make your role clear. Present the information in a neutral manner without trying to influence parents to choose one option over another. For many mothers, how to give birth after a cesarean is a complicated and emotional process. They need to arrive at their own conclusions. Refer mothers to their caregivers for individual medical issues, but help them to feel comfortable asking questions to get the answers they need. 
  4. Parents need to feel safe. They need to get to know each other and feel comfortable sharing personal issues. Establish some ground rules. Ask your students what those ground rules might be (e.g. not criticizing each other, respecting each mother’s choice).
  5. Allow time for each mother to share her cesarean experience. Let everyone listen without commenting until she has finished her story. Allow time for fathers/partners to do the same. Often, this is the first time that a partner may have heard how the cesarean affected her and the first time a mother  heard how her cesarean birth impacted her partner. This also gives parents the opportunity to begin processing the cesarean birth in a safe environment.
  6. Invite parents who have planned a VBAC to share their experience with the class, whether their birth was a VBAC or an unexpected repeat cesarean.
  7. Let parents who are planning a hospital VBAC know that providers’ care practices vary widely on issues like when to arrive at the hospital, fetal monitoring, IVs, Heparin locks (capped IVs), and how long a woman can labor before “failure to progress” is determined. Help your students discuss these issues within a physiologic birth framework.
  8. Let parents know that hospital cesarean and VBAC rates matter. Guide them on how to compare VBAC services available in their community.
  9. Avoid substituting opinion for facts and help your students assess the accuracy of what they may have heard or found on the Internet. Refer your students to the Resources for VBAC and Physiologic Birth for evidence-based information.
  10. If a care provider is not supportive of VBAC, refer mothers to another health professional, hospital, or birth center you may know so they can get a second opinion.
  11. Encourage mothers to discover their strengths. Emphasize that the overwhelming majority of births are normal and that VBAC labors tend to have very safe outcomes.
  12. Become aware of the variety of cultural approaches to helping women through childbirth, and remember that each can enrich class content. Ask parents to share their own customs of birth and describe how their culture supports women in labor.
  13. For students who have strong religious beliefs—validate that faith and being part of a religious community can be a powerful source of support for them.
  14. Many women have been told by their caregiver that their “pelvis is not shaped properly,” they are “too small,” or they’ll “never be able to birth their baby without a cesarean.” These comments have a strong impact on a woman’s confidence to give birth. Emphasize how a woman’s body changes during pregnancy to facilitate the process of labor. For example, how softening of connective tissues make the pelvis, cervix, and vagina flexible and freedom of movement in labor facilitates the process of birth.   
  15. Help students to consider other challenges and painful experiences that they may have faced in life. Help them to identify the inner resources they used to cope with those challenges and experiences.
  16. Inform mothers of their legal rights. Their right to be involved in all medical decisions that affect them and their baby, their right to informed consent and refusal, their right to respectful maternity care, and their right to make the final decision about how they want to give birth.
  17. Refer mothers to a cesarean/VBAC support group in your community or online. For many women who have had a cesarean, support groups are an opportunity to meet their emotional needs which may have been ignored by their caregivers, family, and friends. A support group can help women process a prior traumatic birth and restore their confidence in their ability to give birth without surgery.
  18. Keep up-to-date with developing research and other relevant information by signing on to receive updates from the websites in the Resources for VBAC and Physiologic Birth: A Parent’s Guide.

Multiple repeat cesareans put women at significant risk for serious complications and death. Providing evidence-based VBAC information and resources to mothers with a prior cesarean may encourage women to avoid a routine repeat cesarean.

 

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Giving Birth After A Cesarean: It’s Your Decision

10 Jun

Many mothers, pregnant after a prior cesarean birth, feel pressured to schedule a routine repeat cesarean when they prefer to labor for a VBAC.

Care providers have an obligation to share information with you about your care. To present the risks and benefits of planning a VBAC or choosing a routine repeat cesarean. When you have received all the information you need to feel confident to make a decision, the choice is yours.  No provider should frighten or coerce you into having a routine repeat cesarean.The decision to have a repeat cesarean or labor for a VBAC is yours.

Prenatal visits give you the opportunity to have a frank discussion with your caregiver about your concerns and how you will be cared for. It is your right to participate in all decisions regarding your health and the health of your baby.

  • During your pregnancy you should have several discussions about the benefits and risks of VBAC and repeat cesarean.
  • Ask your caregiver about his/her VBAC rate, repeat cesarean rate, and VBAC success rate.
  • Discuss your personal medical condition with regard to VBAC and repeat cesarean. You may need to review your operative record (documentation of the surgery.)
  • Ask what safety measures are in place to respond to an obstetric emergency including a uterine rupture.
  • Try to get the hospital informed consent forms for procedures that you may need (for induction, an epidural, pain medications) during your pregnancy so that you have the time to read and understand them.
  • Make a list of the advantages and disadvantages of planning a VBAC or scheduling a repeat cesarean and discuss them with your partner.
  • Consider having a doula at your birth, a midwife as your primary caregiver, or giving birth in a birth center.

Giving birth is a transformative experience. Your caregivers should make you feel cared for, respected, and supported in your wishes and needs.

For more information about your rights in childbirth see the slides in Module 12 of the VBAC Education Project.