You CAN VBAC

Trust Birth, Trust your Body

In 2008, Vernon's Cesarean rate was 30%. This is a large increase from 2000, where it was 20.9%. (B.C Selected Vital Statistics Annual Report 2000 and 2007).  The World Health Organizations recommendations  indicate the best outcomes for mothers and babies appear to occur when cesarean section rates are 5% to 10%. Rates above 15% seem to do more harm than good (The Lancet, Althabe and Belizan 2006). 

What is a vbac?  

VBAC stands for Vaginal Birth after Cesarean. It is a vaginal birth after on or more cesareans. Research consistently shows VBAC is a reasonable safe choice for most women with a prior cesarean. In a study examining 1776 women undergoing a trial of labor (TOL) after cesarean, the over all success rate was 74%. In another study the success rates were as great as 80%


What are my risks with having a VBAC trial of labor?

The most common fear among women who have had a previous cesarean is uterine rupture. The Lydon-Rochelle et al study showed that the uterine rupture rate among 10,789 women with a single previous cesarean delivery who labored spontaneously during a subsequent singleton pregnancy was 0.52%. This is a slightly increased risk than women with a single cesarean delivery scar who underwent scheduled repeat cesarean delivery without a TOL (trial of labor) was 0.16% a study out of 6980 women who chose elective repeat cesarean.

If you are planning more than two children it is very important to consider VBAC as your risks increase with each cesarean and your risks decrease with each successful VBAC. Shimonovitz et al. found the risk of uterine rupture after 0, 1, 2, and 3 VBAC deliveries to be 1.6%, 0.3%, 0.2%, and 0.35%, respectively, indicating that the risk of uterine rupture decreases after the first successful VBAC.

 

What are my risks with a cesarean compared to a vaginal birth?

Risks increase with each cesarean section compared with a successful VBAC your risk decrease after each one.

Potential Harms to the Mother

-Compared with vaginal birth, women who have a cesarean are more likely to experience:

·     Accidental surgical cuts to internal organs.

·         Major infection.

·         Emergency hysterectomy (because of uncontrollable bleeding).

·         Complications from anesthesia.

·         Deep venous clots that can travel to the lungs (pulmonary embolism) and brain (stroke)

·         Admission to intensive care.

·         Readmission to the hospital for complications related to the surgery.

·         Pain that may last six months or longer after the delivery. More women report problems with pain from the cesarean incision than report pain in the genital area after vaginal birth.

·         Adhesions, thick internal scar tissue that may cause future chronic pain, in rare cases a twisted bowel, and can complicate future abdominal or pelvic surgeries.

·         Endometriosis (cells from the uterine lining that grow outside of the womb) causing pain, bleeding, or both severe enough to require major surgery to remove the abnormal cells.27

·         Appendicitis, stroke, or gallstones in the ensuing year. Gall bladder problems and stroke may be because high-weight women and women with high blood pressure are more likely to have cesareans.

·         Negative psychological consequences with unplanned cesarean. These include:

o    Poor birth experience, overall impaired mental health, and/or self-esteem.

o    Feelings of being overwhelmed, frightened, or helpless during the birth.

o    A sense of loss, grief, personal failure , acute trauma symptoms, posttraumatic stress,and clinical depression.

·         Death.

Potential Harms to the Baby

Compared with vaginal birth, babies born by cesarean section are more likely to experience:

·         Accidental surgical cuts, sometimes severe enough to require suturing.1,28

·         Being born late-preterm (34 to 36 weeks of pregnancy) as a result of scheduled surgery.6

·         Complications from prematurity, including difficulties with respiration, digestion, liver function, jaundice, dehydration, infection, feeding, and regulating blood sugar levels and body temperature. Late-preterm babies also have more immature brains and they are more likely to have learning and behavior problems at school age.

·         Respiratory complications, sometimes severe enough to require admission to a special care nursery, even in infants born at early term (37 to 39 weeks of pregnancy). Scheduling surgery after 39 completed weeks minimizes, but does not eliminate, the risk.

·         Readmission to the hospital.

·         Childhood development of asthma,sensitivity to allergens,or Type 1 diabetes.

·         Death in the first 28 days after birth.

 

Potential Harms to Maternal Attachment and Breastfeeding

Failure to breastfeed has adverse health consequences for mothers and babies. Breastfeeding helps protect mothers against postpartum depression, Type 2 diabetes, high blood pressure, heart disease, ovarian and pre-menopausal breast cancer, and osteoporosis later in life.36,71 Breastfeeding helps protect babies against ear infections, stomach infections, severe respiratory infections, allergies, asthma, obesity, Type 1 and Type 2 diabetes, childhood leukemia, sudden infant death syndrome (SIDS), and necrotizing enterocolitis (a severe, life-threatening intestinal infection).15,36

·         Women who have unplanned cesareans are more likely to have difficulties forming an attachment to their babies.

·         Women who have cesareans are less likely to have their infants with them skin-to-skin (cradled naked against their bare chest) after the delivery. Babies who have skin-to-skin contact interact more with their mothers, stay warmer, and cry less. When skin-to-skin, babies are more likely to be breastfed early and well, and to be breastfed for longer. They may also be more likely to have a good early relationship with their mothers, but the evidence for this is not as strong.

·         Women are less likely to breastfeed.

 

Potential Harms to Future Pregnancies

With prior cesarean, women and their babies are more likely to experience serious complications during subsequent pregnancy and birth regardless of whether they plan repeat cesarean or vaginal birth. The likelihood of serious complications increases with each additional operation. Compared with prior vaginal birth, prior cesarean puts women at increased risk of:

·         Uterine scar rupture. Planning repeat cesarean reduces the excess risk, but it is not completely protective.

·         Infertility, either voluntary (doesn’t want more children) or involuntary (can’t have more children).

·         Cesarean scar ectopic pregnancy (implantation within the cesarean scar), a condition that is life threatening to the mother and always fatal for the embryo.

·         Placenta previa (placenta covers the cervix, the opening to the womb), placental abruption (placenta detaches partially or completely before the birth), and placenta accreta, (placenta grows into the uterine muscle and sometimes through the uterus, invading other organs), all of which increase the risk for severe hemorrhage and are potentially life-threatening complications for mother and baby.

·         Emergency hysterectomy.

·         Preterm birth and low birth weight.

·         A baby with congenital malformation or central nervous system injury due to a poorly functioning placenta.

·         Stillbirth

(Coalition for Improving Maternity Services (CIMS) Fact Sheet February 2010. The risks of cesarean section © 2010 Coalition for Improving Maternity

When is a cesarean is absolutely necessary?

When there is:

  • Complete placenta previa at term

  • Transverse lie

  • Prolapsed cord

  • Abrupted placenta

  • Eclampsia or severe preclampsia 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 associated with a pelvic deformity or an incorrectly healed pelvic break.
  • Initial outbreak of active herpes at the onset of labor.
  • Uterine rupture

When a cesarean is necessary, it can be a lifesaving technique for both mother and baby, and worth the risks involved. Contact ICAN of North Okanagan if you believe that you are facing an impending cesarean, or if you have already had one. We are here to support you, and our chapter is a safe place to discuss and share your feelings.

 

What if I had two or more cesareans?

VBAC in most cases is still a viable option. In the largest study, Miller et al. showed a VBAC success rate of 75.3% out of 1827 women with 2 or more previous low transverse Caesarean deliveries, with a uterine rupture rate of 1.7% versus 0.6% in women with only one low transverse Cesarean.

 

What kind of question you can ask a care provider to get a feel if they are VBAC friendly:

  • Do they and attend VBACs and what is there success rate?

  • Do they have any standard VBAC protocols that differ from a non-VBAC mom?

  • Under what circumstances would they induce a VBAC?

  • If so, what methods do they use on VBAC Moms?

  • What is their philosophy on going past 40 weeks? (SOGC states postdatism is when a pregnancy goes until 42 weeks and it is not a contradiction to VBAC trial of labor)

  • What is their philosophy on "big babies?" Do they attend vaginal breech births?

  • How many uterine ruptures have they witnessed?

  • What kind of monitoring do they require?

  • What is their CS rate?

  • Do they perform an automatic CS if waters have been broken for more than 24 hours, even if there is no evidence of infection and mom and baby are fine? Do they have a time-limit on how long your labor can be before they c-section you?

  • Do they require epidurals for VBAC?

  • Do they require an IV or heplock?

  • Are you permitted to move and deliver in whatever position you want?

You may want to interview several providers until you find one who is truly supportive of VBAC. During your OB consult, if you are told you are not a good candidate for VBAC and you feel different you can seek a second or even third opinion. If you do find a supportive provider, refer everyone you know to this provider so that they can reap the benefit of someone who supports non-intervening birth! If we want to see a decrease in the cesarean rate or intervention rate we all need to support OBs, midwives, and hospitals that support non invasive child birth.

 

What about a homebirth after cesarean (HBAC)?

Homebirth is still an option for many women who have had a previous cesarean.

The B.C College of Midwives VBAC guidelines on Choice of Birth place say: Many women with a history of previous cesarean section with no contraindications to VBAC will be comfortable having a subsequent vaginal birth in hospital with midwifery care. Hospital birth in a facility with cesarean  section capability will likely offer the most timely access to emergency cesarean section in the even to uterine rupture. However, some VBAC women will come to midwives requesting homebirth. Clients with the following conditions may be candidates for vaginal birth in hospital, but should be advised that they are NOT suitable candidates for a home birth: (College of Midwives of British Columbia, Clinical Practice guidelines, Vaginal Birth After Cesarean)

  • History of cesarean section at or before 26 weeks

  • History of Single layer closure

  • History of infection or impaired uterine scar healing

  • Inter-pregnancy interval of less than 24 months

  • Ballotable head in active labor in current pregnancy

  • Prolonged active phase of labour in current pregnancy

 

How to increase your chances of VBAC:    

  • Choose a VBAC supportive care provider

  •  Consider Midwife

  • Consider Homebirth

  •  Avoid inductions

  • Avoid drugs

  • Hire a doula

  • Take a prenatal class in natural childbirth

  •  Read books, Watch videos on natural childbirth, Educate yourself

 

STRATEGIES to HELP PREVENT a FIRST CESAREAN

 

·         Avoid routine ultrasound to determine size of the baby after 36 weeks

·         Avoid a routine induction for term spontaneous rupture of membranes

·         Avoid an elective (convenience) induction

·         Avoid routine cesarean for history of herpes with no active lesions

·         Avoid routine cesarean for “big” baby over 4000 grams (8lb. 13 oz)

·         Avoid routine cesarean for twins (vertex/vertex, vertex/breech)

·         Ask about external version for breech baby at 37 weeks

·         Look for midwifery model of care (non-pharmacological options for pain relief, one-to-one labor support, positioning, hydrotherapy

·         Ask if the hospital has protocols in place to reduce cesarean rates

·         Avoid being formally admitted to labor and delivery unit before active labor (ruptured membranes/ and or bleeding, 100%, 4cm dilation, painful contractions every 5 minutes lasting at least 30 sec.

·         In early labor, do light activities in day time

·         In early labor, rest at night or sleep (with medication if necessary)

·         Ask about intermittent fetal monitoring or auscultation rather than continuous EFM

·         No strict time limit

·         It’s usually not failure to progress before active labor.

 

 
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