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Almost two decades ago some women were willing
to travel hundreds of miles and spend almost unlimited amounts
of money in search of a care provider supportive of VBAC.
Women intent on avoiding an unnecessary repeat cesarean labored
and proved to the skeptics that VBAC was safe, both for the
mother and her baby.
Today, many physicians are trying to convince
women with prior cesareans to plan a VBAC, but surprisingly
they find it a tough sell. Many women need not be convinced
that VBAC is a safe option; they are self-motivated, focused,
and determined not to have a repeat operation. However, several
studies show that when women are offered a choice between
a repeat cesarean and a planned labor up to 50% of the women
choose a repeat operation. The majority of these women had
a prior cesarean for "failure to progress". Although
60-80% of women who plan a VBAC give birth vaginally, in the
United States, only 26.3% of women with a prior cesarean delivery
had a VBAC in 1997.
Factors That May Discourage Women from Planning
a VBAC
Prior Birth Experience
Research shows that presenting VBAC to women
as a safer medical option may not be the best approach to
get them to say "yes" to labor. The experience of
giving birth cannot be evaluated solely in terms of benefits
and risks, successful VBAC or failed trial of labor. Giving
birth affects a woman physically, psychologically, socially,
economically, and spiritually.
Women choose to plan a VBAC or schedule
an elective repeat operation based on their prior birth experiences,
their personal and cultural beliefs about childbearing, and
the level of trust they have in their care providers. Also
significant is the extent of control they perceive to have
over their anticipated birth and the emotional support available
to them.
Although many women who had unexpected cesarean
births eventually heal physically and emotionally from their
birth experience, many do not. Evidence is gathering about
the devastating psychological effects that unanticipated cesarean
births may have on some women. Depression is a known side
effect of any major surgery, but it is often unacknowledged
when it comes to women who have given birth by cesarean.
It is not a contradiction in terms for a
mother who had a cesarean delivery to be appreciative of her
healthy baby, but still feel overwhelmed, sad, confused, or
angry, with regards to her operation. Women who have not had
the opportunity to process these feelings may not be psychologically
ready to risk laboring again.
Some women, convinced they are not "dilators"
or believing that they "failed" at birth because
they were 'too small" will be reluctant to repeat an
unpredictable labor they experienced as oppressive. Mothers
convinced that the "'cascade of medical interventions"
eventually led to their cesarean birth will not feel emotionally
safe in a medical environment in which they fear they will
have little "control" over their birth.
Mistrust of Healthcare System
Today, many women belong to prepaid health
plans (HMOs) and are locked into a group of care providers
and birthing facility. An expectant mother who feels she has
few options, may labor reluctantly or without much confidence
unless she feels a strong sense of support from her care providers.
Expectant parents are sometimes skeptical
of care providers who are marketing VBAC as the norm. The
risk for uterine rupture is still perceived to be greater
than it really is and some consumers suspect VBAC to be one
of the many cost-cutting strategies insurers are employing
today. The mythical dangers of VBAC still find their way in
major newspapers across the country and fear of a malpractice
suit for bad VBAC outcomes is a daily reality of care providers.
Cultural Attitudes
Birth by cesarean is, in some cultures,
valued as an "upper class" procedure. A way of preempting
the pain and suffering of labor and protecting the disfiguration
of the vagina. A cesarean is sometimes used as a method of
birth control. A mother who wishes not to have any more children
can have her tubes tied during a cesarean section. In countries
where birth control is illegal or not funded by the national
healthcare system, multiparas will often choose to have a
cesarean when giving birth to their last child.
Socio-economic Issues
Women who have invested much time and energy
in developing a career sometimes prefer to schedule a repeat
cesarean so that their work schedules are minimally interrupted.
If an expectant mother can rely on the anticipated postpartum
help from a close relative who lives far away, she may also
prefer to schedule a cesarean to facilitate her postpartum
stay. However, her health insurance may not reimburse her
for an elective repeat cesarean and she may find herself reluctantly
having to labor.
VBAC Consent Forms
Some malpractice insurers now require that
women sign a VBAC consent form during a prenatal visit. The
risks of VBAC as stated in these forms may be exaggerated
and the risks of a repeat cesarean underplayed. Although one
sample form admits that VBAC carries a lower risk to the mother
than a cesarean delivery, it also states, that "VBAC
is associated with a higher risk of harm to my baby than to
me." It also warns that,"If my uterus ruptures during
my VBAC, I understand there may not be sufficient time to
operate and prevent death or permanent brain injury to my
baby." (CAP 1997)Consent forms such as these are likely
to undermine the confidence of many mothers. In fact Dr. Bruce
Flamm, author of Birth After Cesarean, stated
that the author of one consent form believed "no sane
woman will sign" them.
Increasing the Odds for VBAC
If you choose to support an expectant mother
who plans a VBAC you can help her and her partner to prepare
wisely for the coming birth. Know your facts about the safety
and risks of VBAC.
Before Labor Begins
When you have established a comfortable
relationship, ask the parents to talk about their prior cesarean
birth. Try to listen with an open mind first without imposing
your views or personal beliefs. Find out which aspect of the
birth disturbed them most, what they feel they would have
changed, what they didn't feel prepared for. What did they
feel good about?
Often the mother's perceptions and feelings
will be very different from her partner. Sometimes a father
will state that he is ready to do whatever she wants, but
may in fact prefer the perceived safety, predictability and
control of a surgical birth.
Orient the parents to the protocols of their
care providers and the birth facility they will be going to.
Let them know that sometimes the on-call physician or midwife
will be attending their birth rather than the provider they
have become familiar with during prenatal visits. Know what
VBAC protocols the facility may have in place, such as time
limits for labor, mandatory fetal monitoring, a triage lounge
for pre-labor, etc. Going over this information can help parents
anticipate and plan a strategy they can feel comfortable with.
If the mother had a cesarean for failure
to progress or big baby/small pelvis, go over the physiology
of labor with the parents, explaining the flexibility and
suppleness of the pelvic joints, key positions that can facilitate
labor or help turn a posterior baby. Spend some time before
labor going over these positions.
To help parents make an informed decision
if a cesarean is recommended, discuss with them their right
to informed consent. Help them to clarify whether the mother's
or the baby's health is at immediate risk, or whether
the cesarean can be delayed or possibly avoided altogether.
For example, when labor has gone on "too long" but
the mother's and baby's vital signs are stable there may be
time to ask questions, consider the options, and reevaluate
the situation at a later time.
During Labor
Sometimes, during labor, a mother will have
"flashbacks" of her prior birth that ended in a
cesarean. Sounds, smells, or words spoken by the staff may
trigger anxiety and tension. She may fear a repeat scenario
of the last "failed labor" and lose confidence in
herself. She may feel a sense of panic without really knowing
why. Transient fetal decelerations may trigger the fear of
fetal distress and another crash cesarean.
A mother will labor more confidently if
she feels she can be in control of her birth this time. That
may mean having an epidural to deal with her pain, or avoiding
one at all costs. She may need to bring everything but the
kitchen sink with her to the hospital to feel comfortable
and safe: a bean bag chair, a CD player for music, room scents,
extra pillows, multiple copies of her birth plan, etc.
As a doula you can best help the VBAC mother
by listening, understanding, watching, waiting for her queues
and then doing what you do best: provide the emotional support,
physical comfort, encouragement and inspiration that will
help to guide her towards a natural birth.
If it is a Cesarean Birth
If her birth does end up being a cesarean,
give her the opportunity to express her feelings and process
the events. Reach out to her during postpartum. Ask about
her physical and emotional recovery. Give her names of cesarean/VBAC
support groups in the community she may want to call or other
VBAC mothers with whom you have worked. Let her know she can
call on you whenever she needs to talk.
There is nothing quite like sharing
the feelings of elation, accomplishment, joy, and empowerment
that fill the room when a mother who wanted a VBAC realizes
she has just given birth to her child all by herself. The
challenges that come with supporting a VBAC mother may be
greater than what you had anticipated, but the rewards will
surpass them by far.
This article was first published in The International
Doula. For information about training and certification
see Doulas of
North America.
References
Abitbol, M. et al. 1993. Vaginal birth after
cesarean section: The patient's point of view. American
Family Physician, 47(1), 129-134.
ACOG (American College of Obstetricians
and Gynecologists) August, 1995. Practice Patterns: Vaginal
Delivery After Previous Cesarean Birth. Number 1. American
College of Obstetricians and Gynecologist, Washington, DC.
Curtin, S.C. et al. 2000. U.S.cesarean and
VBAC rates stalled in the mid-1990's. Birth: Issues
in Perinatal Care, 27(1), 129-134.
Flamm, B. L.1995. “The Patient Who
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for Appropriate Utilization. B. L. Flamm and E. J. Quilligan,
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Shepherd -McClain, C. 1985. Why women choose
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This article was first published in the
International Doula, Vol.6, No.2, Summer 1998, a quarterly
publication of Doulas of North America (DONA)
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