For Doulas

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 Demands Cesarean Delivery.” In Cesarean Section: Guidelines for Appropriate Utilization. B. L. Flamm and E. J. Quilligan, Eds. Springer-Verlag:New York.

Joseph, G. F. et al. 1991. Vaginal birth after cesarean section:The impact of patient resistance to a trial of labor. American Journal of Obstetrics and Gynecology, 164(6),1441-1444.

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Kline, J. & Arias, F. 1993. Analysis of factors determining the selection of repeated cesarean section or trial of labor in patients with histories of prior cesarean delivery. The Journal of Reproductive Medicine,38(4), 289-295.

Los Angeles Times, February 4, 1998. "Health Chief Criticized for Lawsuits."Home Edition, Section; Metro, Page:B-1.

Madsen, Lynn. 1994. Rebounding from Childbirth: Toward Emotional Recovery. Westport, Connecticut: Bergin & Garvey.

Medical Leadership Council. 1996. Coming to Term: Innovations in Safely Reducing Cesarean Rates. The Advisory Board Company, Washington, DC.

Mutryn, C.S. 1993. Psychosocial impact of cesarean section on the family: A literature review. Social Science and Medicine, 37(1): 1271-1281.

OB-GYN Malpractice Prevention. June 1996. "$98.5 million verdict in missed uterine rupture. 3(6):1.

Sakala, Carol. 1993. Medically unnecessary cesarean section births: Introduction to a symposium, Social Science and Medicine, 37(10):1177-1198.

Shepherd -McClain, C. 1985. Why women choose trial of labor or repeat cesarean section. The Journal of Family Practice, 21(3), 210-216.

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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)