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If I Plan a VBAC, What Are the Odds that I’ll Have a Normal Birth?

7 Sep

There is research that tells us which women are more likely to have a VBAC than others, but we also know that having a normal birth depends greatly on a woman’s state of mind and how she is cared for during pregnancy, labor and birth.

Goer and Romano tell us that mothers and babies have healthier outcomes if their careproviders respect the natural (physiologic) process of labor. Introducing interventions only when medically necessary.

We know that mothers and babies have healthier outcomes when mothers are full participants in making decisions about how they want to give birth and when all careproviders work together to make sure that mothers and babies receive optimal care. The care that is best for them, not care that is beneficial or convenient for the careproviders or hospitals.

Simkin and Ancheta teach us that a woman’s psycho-emotional state can facilitate or complicate the progress of her labor. “ Labor is facilitated when a woman feels safe, respected, and cared for by the experts who are responsible for her clinical safety, when she can remain active and upright, and when her pain is adequately and safely managed.”

Here Is What ACOG Tells Us About the Odds of Having a VBAC

Women who labor after a cesarean have a 60−80% chance for a vaginal birth. A mother is more likely to have a vaginal birth if:

She had a prior vaginal birth before her cesarean

She has a healthy pregnancy weight

Her prior cesarean was for malpresentation (for example a breech)

She goes into labor at or near term

Her cervix has started to dilate or her bag of water had already spontaneously ruptured when she is admitted to the labor and delivery unit at the hospital

Her VBAC labor is not induced or augmented, and if

She does not have a medical complication such as preeclampsia

Other Significant Factors That Can Increase the Odds for a VBAC

Each labor and birth is unique but the way a woman is cared for can make birth easier, safer and more satisfying for mothers.

A mother is more likely to have a vaginal birth if she has freedom of movement for labor and birth. Pregnat Woman in Hosptail Using Exercise BallIf she is free to walk, change positions during labor and if she doesn’t give birth on her back. Many tried and true labor positions can help make labor easier and less painful. Hospital-based careproviders can safely monitor a VBAC labor by using a hand-held Doppler or ambulatory telemetry monitors to provide fetal monitoring so the mother can move about and benefit from comfort measures.

If a mother can avoid an epidural in early labor she is less likely to end up with a cesarean. An epidural can slow down labor and make it necessary to use Pitocin to get labor going again. It can interfere with the baby’s ability to move through the pelvis and rotate to an anterior position for birth (easiest way for the baby to be born). An epidural can lower a mother’s blood pressure to a dangerous level and affect the baby’s heart rate. We now know that with an epidural, a mother can take up to two additional hours to give birth.

With the help of labor support from a doula (continuous emotional and physical support during labor and birth), careproviders that practice evidence-based care, and maternity care nurses who are trained in a variety of non-drug options for pain relief mothers are much more likely to have a normal birth. Evidence shows that with a midwife women have more prenatal education and counseling time, fewer labor interventions, fewer complications of birth, fewer cesareans and more VBACs.

Mothers can have safer and healthier births if their caregivers support Mother-Friendly care. The Ten Steps of Mother-Friendly Care was developed by The Coalition for Improving Maternity Services (CIMS). It is evidence-based, collaborative care that supports optimal, physiologic care for mothers, babies, and families. Mother-Friendly care has been shown to improve the odds for a VBAC, reduce complications, and improve health outcomes and satisfaction among mothers and their families. Mother-friendly care is the safest and most satisfying for mothers and families.

CIMS has published a brochure for parents to help them find a mother-friendly caregiver. It’s called, Having a Baby? Ten Questions to Ask.

To Increase Your Odds for a VBAC Look for a Supportive Maternity Care Team

How do your caregivers view VBAC? With confidence or fear?

Are they giving you enough information to help you make decisions about your birth?

Are your careproviders taking the time to answer your questions? To discuss the benefits and risks of treatments, procedures,  and drugs?

What are their VBAC rates? Repeat cesarean rates? Routine intervention rates?

Are they treating you with respect?

Are they supportive of your wishes?

Do they make you feel safe?

Do they view labor and birth as a normal process?

Do they encourage doulas, family members or partners to help you when you give birth?

Are they offering you community resources that may be helpful to you?

What are your caregiver’s hesitations about VBAC? Can you discuss them so that you can labor with confidence?

If they are not comfortable with VBAC, are they giving you referrals to other providers, birth centers or hospitals that support VBAC?

If you don’t feel that your caregiver can give you full support to labor for a VBAC, are you willing to consider making a change?

Look for a Supportive Environment in which to Give Birth

žDo you have the space to walk? Sit? Kneel?

žDo you have furniture, pillows, a bed or rails to lean on?

žDo you have a squat bar, birth stool, rocking chair or birth ball?

žDo you have access to a bath or shower?

žDo you have access to light foods and drink?

žCan the light be dimmed? Can noise be eliminated?

žCan you listen to the music of your choice?

žDo you have privacy?

It may take much more time and effort than you anticipated to find the right caregiver and birth place to have your VBAC. But, it will probably be the most important work you would have done to help you have a safe and normal birth.

Resources

Pain Relief During Labour

Short Videos on Labor and Birth Positions,Birth Pool, Birth Ball

Preparing for Vaginal Birth: Pushing Past a Previous Cesarean,a webinar

Healthy Birth Your Way: Six Steps to a Safer Birth

Rebecca Dekker, Friedman’s Curve and Failure to Progress: A Leading Cause of Unplanned C-sections

Laboring for a VBAC: Why the Discrimination in U.S. Hospitals?

22 Apr

Childbirth

Childbearing women have a fundamental right to choose how, where and with whom they want to give birth, but in the United States  women who choose to labor for a VBAC (known as TOLAC, trial of labor after cesarean) in a hospital are often being denied that right. Effectively giving thousands of women no choice but to concede to  major abdominal surgery that put women and babies at risk for complications and mothers with multiple cesareans at risk for placental problems.

According to the National Institutes of Health (NIH), since 1996 about one third of hospitals and one-half of physicians have stopped providing care for VBAC. In 1996 the VBAC rate in the U.S. was 28%. Today it’s less than 10%. A report on the trends of  home vaginal birth after a cesarean indicates that denial of access to care for VBAC has prompted an increasing number of women to labor for a VBAC at home.                                                                                             Childbirth

Three out of four women who labor for a cesarean do give birth vaginally and the risks of major complications from laboring for a VBAC are less than 1%. The reason given by physicians and institutions to deny medical care for these expectant mothers have no foundation in science. Denying care for VBAC  also presents a clear conflict of interest for providers and institutions who want to protect themselves from a potential medical malpractice suit, a frequent explanation given to deny care.

Physicians who do want to support these mothers are forced to pay additional malpractice insurance premiums and are often discouraged to support women who want to labor for a VBAC by their hospital’s administration.

Here is what the National Institutes of Health say about laboring for a VBAC:

Given the available evidence, trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision.

Women who have a trial of labor, regardless of ultimate mode of delivery, are at decreased risk of maternal mortality compared to elective repeat cesarean delivery.

žComparing mothers (pregnancy with all gestational ages) with a uterine scar who labored for a VBAC with mothers who had a scheduled repeat cesarean the NIH found:

Maternal Mortality at Delivery Per 100,000 live births
Women who labored for a VBAC

3.8

Women who had a planned repeat cesarean

13

For low-risk women, the risks of laboring for a VBAC are the same as for any other woman giving birth for the first time.

According to the NIH, these are the odds of a uterine rupture in low-risk women laboring for a VBAC compared to other unpredictable complications that also require an emergency cesarean.

Per 1,000 women who labor Risk for Complications
Uterine rupture (separation of uterine scar)

7-8

Shoulder Dystocia ( baby’s shoulders are too wide to fit through the pelvis)

6-14

Placental Abruption ( placenta separates from the uterus before the baby is born)

11-13

Umbilical Cord Prolapse (umbilical cord precedes the baby’s head through the cervix)

14-62

 

The risk of laboring for a VBAC is the possibility of a uterine rupture, the separation of the uterine scar from the previous cesarean. It is a serious medical emergency that occurs in less than 1% of  VBAC labors and requires an immediate cesarean. Hospitals who deny women the option to labor after a cesarean say they cannot provide an “immediate” emergency cesarean as recommended in the American College of Obstetricians and Gynecologists (ACOG) guidelines for VBAC (Practice Bulletin #115) .

But, the National Institutes of Health concluded that there is no evidence to support ACOG’s selective safety recommendations for VBAC.  The “immediately available” recommendation was based on consensus and expert opinion rather than strong support from high-quality evidence. Dozens of maternity care organizations and individuals also objected to the restrictive guidelines.

Women giving birth for the first time are also at risk for unpredictable complications that require an emergency cesarean. However, they are not denied medical care nor are they told that the hospital cannot provide an emergency cesarean, should they need one.

The NIH encouraged leaders in maternity care and insurance companies to work together to change the status quo and give more women access to medical care for those who want to labor for a VBAC.

ACOG and the Society of Maternal-Fetal Medicine recently admitted in their Safe Prevention of the Primary Cesarean guidelines that too many cesareans are being performed exposing mothers and babies to avoidable harms without improved outcomes. Providing low-risk women medical care to labor for a VBAC can reduce their exposure to the harms of a cesarean section.

Denial of Informed Consent and Informed Refusal

Physicians have an obligation to provide women with a prior cesarean with information about the benefits and risks for both repeat cesarean and for a VBAC. Women have the right to an informed consent or informed refusal of either options based on the accurate information provided.

ACOG’s Committee Opinion on Ethics (#439) states:

Seeking informed consent expresses respect for the patient as a person; it particularly respects a patient’s moral right to bodily integrity, to self-determination regarding sexuality and reproductive capacities, and to support of the patient’s freedom to make decisions within caring relationships.  

Refusing to provide medical care for women who want to labor for a VBAC and forcing them to “consent” to a repeat surgery denies their right to bodily integrity, self-determination and the freedom to make their own healthcare decisions. It also questions the integrity of that “caring relationship.”

Physicians have an ethical obligation to provide the best care possible for their patients including the primary ethical obligation, First Do No Harm.

Many hospitals and providers have found a way to safely support women who want to labor after a cesarean. All it takes is the will to make that happen.

Resources for Informed Decision Making and Childbearing Women’s Rights

ACOG

Affordable Care Act

Childbirth Connection

Human Rights in Childbirth

Informed Medical Decisions Foundation

Turning a Breech is a Safe Option for Women with a Prior Cesarean

5 Mar

Breech presentation occurs in 3-4% of all term pregnancies and is the third most common reason for performing a cesarean in the U.S. More than 90% of breech babies are delivered by planned cesarean section. External Cephalic Version (ECV), a procedure that helps to turn a fetus from a breech presentation to a cephalic presentation has been shown to decrease the incidence of breech presentation at term for women without a cesarean scar thereby reducing the need for a cesarean section.  However, a study published in the January 2014 issue of  the British Journal of Obstetrics and Gynaecology   suggests it is safe for women with a prior cesarean to have an external cephalic version (ECV) in a medical center. This allows women to labor for a VBAC and reduce exposure to complications from a repeat cesarean.

The researchers in Spain compared a group of 70 low risk women with a prior cesarean with 387 low risk women with a prior vaginal birth who had an external version at or after 37 weeks of gestation.  happy mother with newborn babyAll women were expecting one baby. Physicians were successful in turning a breech in 67.1% of women with a cesarean scar and 66.1% of women with a prior vaginal birth. There were no complications in the group of women with a prior cesarean. Of the women with a prior cesarean 52.8% had a vaginal birth (VBAC). More than half of the women avoided a repeat cesarean section. Of the group of women without a prior cesarean 79.4% had a vaginal birth.

The authors of the study concluded that in addition to the 270 documented cases of uncomplicated ECVs for women with a prior cesarean, their data on 70 additional women that underwent the procedure without a uterine rupture or fetal mortality indicates that ECV is a safe option for women with a prior cesarean who want to labor for a VBAC.

Concern from the medical community for the complications of cesarean section and its impact on mothers and babies is mounting. Recently the American College of Obstetricians and Gynecologists and the Society For Maternal-Fetal Medicine issued Obstetric Care Consensus Statement: Safe Prevention of the Primary Cesarean Delivery which called for physician restraint in performing cesarean sections. The guidelines offered safe directives for preventing the first cesarean including offering a breech version to women to reduce the odds for a cesarean section.

This study on the safety of external cephalic version for women with a prior cesarean adds to the existing evidence and may encourage clinicians to also offer the procedure to women with a prior cesarean who may want to labor for a VBAC.

Resources for Mothers

American Academy of Family Physicians

What Can I Do If My Baby is Breech?

Royal College of Obstetricians and Gynaecologists, U.K.,

Turning A Breech Baby In The Womb

 

 

New Jersey Poised to Increase Access to VBAC

6 Jan

New Jersey has one of the highest cesarean rates in the country. According to U.S. Preliminary data for 2012 New Jersey has the third highest cesarean rate in the nation,  38.7% preceded by Florida (38.1%) and Louisiana (40.2%). In the last two decades repeat cesarean births without labor more than doubled in New Jersey, from 40% to 85%. According to the New Jersey Department of Health currently one in four cesareans are routine repeat operations without serious risk indications. The New Jersey VBAC Task Force wants to change that.

Task Force members agree that VBAC should be available to all low-risk women who choose to labor after a prior cesarean and increasing access to VBAC would improve obstetric care. New Jersey hospital VBAC rates vary widely, from 31.0% at Monmouth Medical Center to 0% for Memorial Hospital and Southern Ocean Medical Center in 2011. The Task Force suggested establishing a network of regional VBAC referral centers who can meet safety requirements for VBAC. The Task Force is a multidisciplinary collaborative group which includes the New Jersey Hospital Association, health insurance payers and malpractice insurers.  20111225_Jess_6619_2000

Hospitals often deny VBAC care by referring to the costly and realistically unattainable ACOG guidelines which recommend a surgical team and anesthesia be “immediately available” when women labor for a VBAC. Having had a prior cesarean adds a level of risk to the subsequent laboring process, however, the risks of laboring for a VBAC are the same as for women giving birth for the first time, yet women giving birth for the first time are not denied medical care, nor are they told that they are at risk because the hospital cannot guarantee that a surgical team and anesthesia will be “immediately” available in case they would need a cesarean section.

The New Jersey VBAC Task Force concluded that ACOG’s definition of “immediate access” has never been defined by ACOG or any other authority and the legal liability of this ambiguous recommendation is “not conducive to frank discussion with patients, resulting in obscure and often misleading counseling.”

Providing safe medical care for women in New Jersey who want to plan a VBAC is not an impossible task. After more than one year of deliberations, the Task Force concluded that many of New Jersey’s hospitals already have the resources that can meet the safety standards recommended to support mothers who want to plan a VBAC. The Hospital Capacity and Regional Accessibility Subcommittee reasoned that being able to provide advanced neonatal care was just as critical for responding to complications that may develop during labor for a VBAC.

New Jersey licenses 20 hospitals as intensive perinatal centers or intermediate/regional perinatal centers. These hospitals are required to have full-time on-site coverage by neonatal and pediatric specialists and consulting arrangements with anesthesiology. Responding to a Task Force survey, 14 of 20  intensive care perinatal centers  reported having 24-hour in-house obstetric coverage for cesarean, availability of anesthesia and operating room teams, and 60% of the intermediate and basic perinatal centers reported 24-hour on-site coverage and the rest the availability of an off-site obstetrician within 30 minutes once the need for a cesarean was established.

Also in response to the Task Force survey, 7 of the intensive perinatal care centers and 6 of the intermediate care centers were in favor of becoming a regional VBAC referral center.

To successfully increase access to VBAC the Task Force made several recommendations:

  • Re-evaluate the risks of laboring for a VBAC by comparing low-risk women with a prior cesarean with New Jersey’s benchmark population, low-risk multiparous women without a previous cesarean for a more realistic evaluation of potential maternal and neonatal complications.
  • Develop a VBAC education program to educate expectant parents about the benefits and risks of laboring after a prior cesarean.
  • Educate providers and hospitals about the benefits and risks of VBAC, adequate staffing and resources, labor progress patterns for VBAC , guidelines for augmentation of labor, signs and symptoms of uterine rupture or dehiscence and practice drills for appropriate response for a uterine rupture.
  • Educate in-hospital staff about VBAC including, risk management, nursing, anesthesiology, neonatology, lab and blood banks to have a more coordinated response in case of complications.
  • Providers should try to shift the focus of their conversation with their patients from “defensive communication and liability strategies toward true shared decision making.”

Tom Westover, MD of Cooper University Hospital in New Jersey and a member of the New Jersey VBAC Task Force will address health professionals and birth advocates about increasing access to VBAC on March 26 at the New Jersey BirthNetwork Symposium at Rutgers University Inn & Conference Center, Supporting NJ’s Birth Plan: Taking the Next Step and Implementing Evidence-Based, Mother-Friendly Maternity Practices in New Jersey.

 Resources

Northern New England Perinatal Quality Improvement Network,  VBAC Project

Childbirth Connection, Maternity Care and Liability: Pressing Problems, Substantive Solutions

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