The old adage ‘once a cesarean always a cesarean’ is no longer holding true for more and more women giving birth in Ireland. Worldwide VBAC births are increasing. (Vaginal Birth After Cesarean) As women become better educated in the birthing process more are opting for a ‘trial of labour’ instead of automatically scheduling a repeat cesarean.
Having a VBAC in Ireland takes work ! Work to find a consultant who will support you....work to get support from family and friends and work to rebuild your confidence in normal birth. There are however ways you can stack the deck in your favour through education and preparation so that you will have the most empowering experience possible even if you don't have a vbac.
Is VBAC safe?
With appropriate care, 70 to 80 percent of women who labour for a VBAC will have an uncomplicated vaginal birth. With a planned VBAC, the risk of uterine rupture with one low transverse scar is 5 per 1,000.
Why chose VBAC?
There are many psychological ramifications of a caesarean birth. These continue on, if this mode of delivery was unexpected and considered undesirable by the mother, during the next pregnancy and birth. The loss of control, and the fear associated with an earlier birth experience, may result in the need to maintain control the next time. The amount of technology involved and the sterile atmosphere may cause a need for a 'natural' labour and a reduction in unnecessary interventions. When women choose a VBAC birth, they tend to be making an extremely informed choice in doing so.
Ellen Porter describes her experience “with my first child I really wanted totally natural i.e. no meds/interventions. Unfortunately labour was progressing too slowly so I ended up with a Pitocin drip and an epidural – it was a long and painful labour, then 2hrs of pushing (on my back) failed forceps attempt and culminating in an emergency c-sec. It’s a birth experience I bear not to even re-tell to my son one day. The scar is a painful reminder that I could not even hold him immediately after he was born.
I knew I had to do it differently the 2nd time around. I changed Obstetricians and hospitals, did my research all over again, got assistance from a doula, and went ahead with the vbac full of quiet confidence. It was so different. I laboured mostly at home, and it was quite bearable. Only when I felt like pushing, did we go to the hospital along with my doula. This time I felt completely in control. When my baby emerged it was such a wonderful feeling to hold this enormous vernix coated bundle in my arms and it was me who found out 1st that she was actually a girl!”
Questions about VBAC
Q: My doctor told me my pelvis is too small to vaginally deliver a baby over eight pounds and I have to have another cesarean. Is this true?
A: No, the pelvis and the baby's head are not fixed bone structures. During labor the pelvis opens, allowing room for the baby, whose head molds to fit. The pelvis will actually open up 33% larger than it's pre-pregnant size with a squatting position. There are several factors that contribute to this. First a hormone called relaxin is released during the latter part of pregnancy, which soften the ligaments and cartilage surrounding the pelvis. Also different positions assumed during labor will change the dimensions of the pelvis such as walking, climbing stairs and squatting. This combined with the flexibility of the baby's head gives ample room for babies to move through the pelvis. The baby's head is made up of five plates that are connected with soft tissues that allow it to mold during the birth process as the baby travels through the pelvis. These bones return to their pre-birth state within hours of birth.
Q: I can't find a doctor willing to support a vaginal birth after cesarean.
A: Finding a doctor to be supportive can be difficult. Take the time to make an appointment and go in a see several doctors. Ask questions and listen to their answers.
Q: Doesn't a vaginal birth cause problems like pelvic floor "damage"?
A: Lead researcher Dr. Alastair MacLennan in an interview with Reuters Health states, "80% of the problems a woman having a vaginal delivery has, also happen to a woman having a Cesarean section." Most often it is the interventions like episiotomies, vacuum and forceps deliveries that contribute to urinary and fecal incontinence, uterine prolapse, and pelvic floor damage rather than the vaginal birth itself. Women who have had cesarean deliveries also experience urinary and fecal incontinence and other concerns due to the surgery or simply as a result of the hormones of pregnancy and/or the drugs used during the delivery.
Q: Wouldn't a cesarean be safer than a vaginal birth after a cesarean?
A: A cesarean section is major abdominal surgery with all that entails. The surgery itself, as opposed to medical problems that might lead to a cesarean increases the risk of maternal death, hysterectomy, hemorrhage, infection, blood clots, damage to blood vessels, urinary bladder and other organs, postpartum depression, post traumatic stress syndrome, and rehospitalization for complications. There are also risks to the baby such as respiratory distress syndrome, prematurity, lower birth weights, jaundice, lower APGAR scores (APGAR is the means of assessing the health status of a newborn), and finally in 1 to 9 percent of cases the baby is injured by the scalpel.
Q: When is a cesarean absolutely necessary?
A:
• Complete placenta previa at term.
• Transverse lie
• Prolapsed cord.
• Abrupted Placenta.
• Eclampsia or severe preeclampsia with failed induction of labor.
• Large uterine tumor which blocks the cervix
• True fetal distress confirmed with a fetal scalp sampling or biophysical profile
• True cephalopelvic disproportion (CPD- baby too large for pelvis). This is extremely rare and only associated with a pelvic deformity (or an incorrectly healed pelvic break).
• Initial outbreak of active herpes at the onset of labor.
• Uterine rupture
Since we know that vaginal deliveries are almost always safer for the mother, and usually as safe for the baby, and that VBAC attempts are successful in about 80% of cases, why do some women still choose to have a repeat cesarean rather than try for a vaginal delivery? In some cases it is fear of pain during labor (although many patients report that the pain from recuperation from a cesarean section is worse than labor pain), in others it is a "fear of the unknown," while for some women there is a convenience in scheduling the exact date of their baby's birth.
Finally, a number of women do not wish to take the risk, no matter how rare, of uterine rupture. No matter what the reason, since there is a small risk with an attempt at vaginal delivery and a risk with repeat cesarean patients should make the best choice for themselves, based on their specific medical history and individual situation.
Resources:
http://www.ican-online.org/
http://www.vbac.com
