By Lisa Mackell
previously published in Birth Issues Winter 2010
Rarely do you hear of women who want to have a Vaginal Birth After a Cesarean (VBAC). The VBAC rates in Alberta have dropped considerably in the past ten years, and the rates of repeat sections have gone up1. Now why is that? Although the Society of Obstetricians and Gynecologists of Canada (SOGC) recommends a VBAC over a repeat section2, it is usually the caregiver’s preference to perform surgery so that they can have the convenience of a speedy and managed labour over having to ‘babysit’ a vaginal delivery that could potentially go in any direction. Many caregivers do little to support women prenatally when they are informed that their patient would like to have a VBAC. They do not inform them about the VBAC association support groups or literature that may be helpful. Instead they often scare them with the words “high risk” and “uterine rupture” reinforcing that their bodies are broken and further disempowering them. Some caregivers may offer lip-service and say “I am supportive of you having a VBAC,” but once the woman is in the hospital and in labour she will often experience undue pressure to perform (and make her caregivers comfortable). This unfortunate practice is discouraging many women from a VBAC and it is my hope that you will find here the support you need to have one.
The International Cesarean Awareness Network (ICAN) has many recommendations to help women reduce their risks and to increase their success rates in achieving a vaginal birth. One of the many pieces of advice is to hire a Doula3. As a doula I am in a very privileged position to support and educate a woman who has had a previous cesarean and would like to give birth vaginally.
I support women in a variety of ways. First of all I always ask a woman to tell me her birth story. This is an opportunity for her to feel heard and to have a witness to her journey. Aa woman who has had a cesarean needs to share her story and having someone who is new and interested can relieve 50% of the burden that she has been carrying over the years. Be prepared, the story may be long and tears will flow. But the tension release and the bonding will all be worth your while.
Some may argue that it’s not important, but I disagree. This gives the parents a chance to fully understand what happened and to deal with it emotionally so that it does not stall their upcoming delivery. I’ve seen emotional stress halt a labour. Also, a primary cesarean for a breech delivery or a transverse presentation has better odds of having a natural, vaginal delivery. As a doula, this helps me provide information that is tailored to a woman’s personal experience.
From there, I ask “What steps are the parents willing to take to achieve the VBAC birth?” Simply hoping it will happen is not an acceptable step. You have to be willing to educate yourself and to learn how to advocate for yourself. If you have a doctor and you want a VBAC birth, you will have to prepare to fight for it. Arm yourself with the latest research. Do the leg work; don’t rely on your physician to do this for you. You want to make sure that your caregiver is willing to help you achieve your desire for a VBAC. As a doula I can help you formulate questions (e.g. the intervention rate at that doctor’s hospital, if the whole medical practice is supportive of VBAC, etc.). The last thing you need to deal with is a physician who changes his/her mind in the last few weeks leading up to your due date, causing undue stress. You can also ask about your caregiver’s VBAC rates, and if s/he doesn’t provide it to you, I would be hesitant that this physician will truly support your wishes. As your doula, I can point you in the right direction to choosing a physician that will be supportive of your wishes, as I have worked with a few obstetricians who are very VBAC friendly.
Choose your caregiver wisely
Many of us don’t like confrontation in the best of times. When we are pregnant and then in labour, we usually have zero tolerance for it. I often recommend to my clients who are motivated for a VBAC to hire a midwife. If you have a midwife, you have the option of giving birth at home (this removes possible interventions, hospital protocols, and non-supportive staff) and you are guaranteed a certain model of care, where the caregiver is taught to offer a collaborative care model with the woman/client at the center. As a doula I can help you find a midwife, encourage you to get on their waiting list, or perhaps I may know that they have a spot open at the last minute.
Doulas encourage all women to educate themselves. Knowledge is power. Your desire to have a VBAC is actualized when you do your homework. It is especially important to not skip the chapters on cesareans because there is a one in four chance4 that a woman will have a surgical birth. As a doula I can offer you a list of lectures/classes on having your baby vaginally. There are VBAC and ICAN support and meeting groups out there and lecture series provided by ASAC (Association for Safe Alternatives in Childbirth). It can be very encouraging to hear other success stories, and help to bolster your spirits and outlook. I also encourage you to read and read some more. Get your hands on some of the best VBAC books out there, most are available through the Edmonton Public Library and at the ASAC office. They have a huge library of books relating to maternity. As a doula I am also available to answer any questions after one of your prenatal visits or to remind you of research that is available.
Know your rights
A doula not only supports you in educating yourself but also in reminding you of your goals; during pregnancy and throughout labour. Although I cannot be your advocate and cannot speak on your behalf or recommend any procedure, I am there for you continuously 24/7 until you have a baby (and even after!). At any time during your labour, I can reassure you and remind you (and your partner) of your rights. Patients have the legal right to make informed decisions; their decision can be informed consent or informed refusal. Do not let anyone (caregivers, family members, best friends, your fears) intimidate or coerce you into having a procedure you do not want. As a doula I am always there to remind you of the options available to you or even to ask for 5 minutes to catch a breath and allow you to talk things through with your partner.
When I have clients who are planning a hospital birth with a doctor, I encourage them to stay home as long as comfortable. According to my experience an average length of labour will be around 12 hours and the average pushing stage will be 1-2 hours. In most cases then, barring any medical complications (Group B strep, pre-eclampsia, etc) the birth team should allow and encourage a woman to labour at home as long as she is comfortable.
As a doula I can help you stay at home as long as you can and as long as you are coping well. You can sleep, take a bath, move around in different parts of your home, go for a walk, eat your favourite foods, drink, and not ask permission to do anything. It is private, familiar and warm. These are all ingredients that allow you to go into labour land and progress at your own pace. The earlier you arrive at the hospital, the more likely you are to have interventions performed (because of hospital protocols for the management of labour and especially for VBACs) and to be less mobile (continuous fetal heart monitoring, IVs, feeling self-conscious, etc.). This makes your hospital stay long and boring. If you can make it to the hospital in the later stage of active labour (after 5cm of cervical dilation), or even in transition (8-10cm), you are more likely to have a vaginal birth (as there is less time for the staff to “suggest” pain management that you do not want).
Once a client is sure that she really wants a VBAC birth and is prepared to do what it takes to achieve it (and not just the thought of it), then we start working out our plan. Some doctors do not like the thought of a birth plan as it can set up the parents for disappointment in the event that things do not go as planned. When I am with my clients and we are working on the birth plan, I prefer to refer to it as “birth preferences,” being that with all things going smoothly, this is the preference for medications, procedures or lack thereof. It is stated at the beginning of the birth preference sheet, that they are aware that there can be complications that will change the journey of birth, but that they would like to stay on course as much as possible.
During our prenatal home visits, we go over various procedures, pain management and typical hospital policies. For example, most nurses will strongly suggest that a labouring VBAC mother be denied food while she is in active labour. Remember, this is a trial of labour so VBAC moms are prepped for a possible surgery. This is not for the benefit of the client who is in labour, but rather for the remote possibility of protecting a mother that may need general anesthetic (and not a spinal block/epidural) to undergo surgery, and could possibly asphyxiate on the contents of her stomach, which occurs to approximately 1 in 1600 women5 who undergo general anesthesia. My response to that is “Athletes are expected to eat and drink to achieve their marathon, so do labouring women to achieve their birth!” I encourage them to stay home and keep hydrated and to eat lightly. I would avoid the heavy foods. I recommend to my clients to make sure to pack sports drinks for extra energy boost as well.
When selecting your birth team, select those that will support your wishes and surround you with positive energy. Do not listen to birth horror stories, rather read positive and encouraging stories, written by the women who went through a VBAC birth. There are great reads on ICAN’s site and in the Birth Issues magazines. Bring to your birthing suite (whether this be at home or in the hospital) supportive people who will help you realize your goals. A good support person is someone who will advocate for you (e.g. your spouse or your mother) and not put their goals ahead of yours. Some well meaning support people may gently steer you towards pain relief, for example, as they do not like to watch their loved one in such discomfort, and are only wanting to help you. Your support team should allow you to trust the birth process, and be ready to encourage that and remind you of that.
Labour Support Advice
A VBAC mother is typically treated like a first time mother, mostly because her body did not get to finish the vaginal birthing process, or even start, so her labour may resemble that of a first time mom. The only difference being that she has a cesarean scar. This does not make much of a difference for the birth team in early labour.
So what advice could I give a birth team member? First of all, when the labouring woman is having regular steady contractions, remind the mother to eat lightly and drink fluids to keep up her hydration, and alternate periods of activity (walking, climbing stairs) with periods of rest. She may not feel like eating, but encourage her to try to help with her energy. If the labour starts at night, remind her to stay in bed and to keep the lights turned off. She may not sleep much but she needs to conserve energy for the active part of labour. You may want to fill a bath for her, and light some candles, and she can soak and relax and then come back to bed. Again do not turn on the lights in the bathroom as it will wake her up and initiate the production of adrenaline, which at this point she does not need.
You will know the labour is more active when the labouring mom stops talking, breathes heavily during contractions, closes her eyes, and rests in between. You can help her relax by encouraging her to visualize her cervix opening up like a rose and her baby descending. Comfort her as best you can, and listen to what she needs (e.g. a glass of water, a pillow to prop her up, soft music, silence, dimming the lights, or effleurage). There are several non-medical forms of pain relief such as hot compresses, massage, showers, aromatherapy, and changing positions. It is very important that you encourage her to adopt gravity-friendly positions and to change positions regularly (every half an hour or so). This will modify the diameter of her pelvis which will help to get the baby into a better birthing position and put pressure onto the opening of the cervix.
If you are having a hospital birth, make your way there when the contractions are roughly 3 – 5 minutes apart and one minute long (the length is a very important measure). When you are there, a nurse will assess and measure the cervix. If a woman had a cesarean because labour had stalled at 4cm it will be a huge relief to hear that the labouring mother is 5cm or more. This will be very encouraging news. Be her cheerleader. Remind her that her body can give birth vaginally as it is doing what it should be doing. Note that there is more to progress than just the cervical dilation. Ask about effacement (how much the cervix has thinned), ask the position of the cervix (posterior, mid, or anterior) and ask about the station of the baby (-2, -1, 0 or +1). If a mom gets discouraged that she is only 4cms, knowing that these other things are going on can help to diminish that “it isn’t going to happen” feeling she may have. Keep things positive and focus on these. A VBAC mom needs lots of support and encouragement.
If things are going a bit slow, and there is some pressure from hospital staff, make sure you are protecting her cocoon; that she is feeling safe, warm and loved. She needs to know that during her time of need, you are there for her, you are the best version of yourself you could ever be – trusting, positive, and calm. She will need you to be her rock. She will want you to give her non-wavering attention and encouragements. She will want you to remind her that she is doing the right thing. Don’t criticize her or place doubts in her mind. Remind her of her options if she is forgetting her goals. Make sure you take care of your energy too by eating and drinking. Have some aspirin in your wallet, just in case, so that you can be functional and helpful to her. She relies on you. No pressure!
The time has now come. Your labouring mother has reached full dilation and is ready to do what she’s wanted to do, push her baby out into the world. This moment can be an incredible feeling, especially if she never got to push with the first birth. Encourage her and embrace her joy and tell her how proud you are of her. Help her push by supporting her, however she needs it, whether it be with a squatting position, or simply to hold her leg. If a mirror is available and she wants it, have her watch the miracle of her baby’s birth. Have her touch the baby’s head as it emerges if this will also energize her to finish with the final pushes. When the baby is born, and all is well, the baby can be placed onto mom’s chest as soon as possible.
She did it. All can rejoice in this successful VBAC. Hopefully mom will look back on her VBAC birth as one of triumph and joy, and it will help to renew her faith in her body. I know it did for me! You will also have acquired a deeper relationship with her – one where trust never failed. This will serve you for a very long time.
VBAC Support Meetings:
Cesarean and VBAC Parent Support Meetings: Free meetings on the fourth (4th) Thursday of every month from 7:30 – 9:30 pm. Le Soleil Clinic #15, 9353- 50 Street. Please RSVP, Fathers and babies are welcome.
Cesarean Prevention and VBAC Classes: Prenatal Class “ICAN Birth: Cesarean Prevention and VBAC.” Same date and location, earlier time 6:00 – 7:20 pm. Cost: About $25 for the mother and her birth support person. E-mail edmontonVBAC@gmail.com
ASAC Lecture Series: Check out the birthissues.org events calendar in the Fall and Spring!
Lisa Mackell is a stay at home mom to two wonderful boys, Shane (6) and Alexander (3). Her first birth was an emergency c-section, and her second was a successful VBAC. She is a busy birth doula and just obtained her Childbirth Education Diploma. She is fascinated with pregnancy and birth, and believes being a birth doula is her calling.Editorial notes:1. National Institute of Health (2010) Panel Questions “VBAC” Bans, Advocates Expanded Delivery Options for Women. Retrieved Sept 2010 from www.nih.gov/news/health/mar2010/od-10.htm2. SOGC Clinical Practice Guidelines (2005) Guidelines for Vaginal Birth after Previous cesarean Birth. Retrieved Sept 16, 2010 from www.sogc.org/guidelines/public/155E-CPG-February2005.pdf3. Doula Association of Edmonton (2010) Hire a doula. Retrieved Oct 2010 from edmontondoula.org/?page_id=44. Canadian Institute for Health Information (2008) Highlights of 2008 – 2009 Selected Indicators Describing the Birthing Process in Canada.5. Schneck, H.; Scheller, M.; Wagner, R.; von Hundershausen, B.; Kochs, E (January 1999) Anesthesia for Cesarean Section and Acid Aspiration Prophylaxis: A German Survey. 88: 63-65