VBAC - A Hot Topic

PHOTO CREDIT - THE UNISON PHOTO CNM
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Correction - ACOG is the American College of Obstetricians and Gynecologists; ICAN is the International Cesarean Awareness Network

What is a VBAC?

A VBAC is a vaginal birth after cesarean.

If a woman has had a cesarean and wants to plan a vaginal birth for her next, it would be considered a VBAC.

Cesarean Surgery

Cesarean section is major abdominal surgery that involves serious potential risks for both a mother and her baby.

When medically necessary, it can be life-saving. I am very grateful for this. And it is still of course a birth to celebrate.

Unfortunately, cesareans have become so routine. I believe women are not given the opportunity to explore all their options and are not offered education and empowerment to have a vaginal delivery after a previous cesarean, other than a repeat cesarean birth, if that is their choice.

Statistically, the United States ranks among the highest in the world among cesarean rates. It’s approximately 30% and rising.

It’s as high as 40-50% in some areas near to where I live, and this is absolutely unacceptable.

Benefits of a VBAC

There are many benefits to a VBAC. These are physical, emotional, mental, and spiritual.

These are only a few important benefits on the long list:

  • No risks from major abdominal surgery. This is huge.  Unfortunately, a cesarean can lead to trauma to the internal organs or reproductive tract, risk of hemorrhage, complications with scar tissue, long term post operative pain, wound infection, blood clots, stroke, and possible respiratory problems for the baby. High rates of cesarean section contribute to high rates ofmorbidity and mortality – and this is occurring in modern countries such as the US, which ranks among the bottom of them in terms of outcome stats.

  • Easier postpartum healing and recovery.

  • Baby receives needed bacteria for optimal health, from mother when passing through the vaginal birth canal.

  • Breastfeeding may be more successful

  • No potential harm to future fertility.

  • Feeling more positive about the birth experience

  • Increased sense of empowerment.

  • More involvement of family and support people.

  • Less risk of postpartum depression and emotional birth trauma.

Image by midwife @lindseymeehleis after mama's triumphant and healing VBAC.

Image by midwife @lindseymeehleis after mama's triumphant and healing VBAC.

Major Health Care Regulators and Advisory Organization Support VBACS

Most major health care regulators and advisory organizations like the World Health Organization encourage VBACS.

“The World Health Organization recommends that the caesarean section rate should not be higher than 10% to 15%. According to the Society of Obstetricians and Gynecologists of Canada (SOGC), vaginal delivery represents the safest route for the fetus and newborn in the first and subsequent pregnancies” – World Health Organization website, http://www.who.int/bulletin/volumes/85/10/06-039289/en/ This is generous, as when cesarean section was originally implemented, it was intended to serve 5% of the birthing population – those with serious complications who really needed surgical intervention.

Also encouraging of VBACS are the American College of Obstetricians and Gynecologists (ACOG) (link to their website: http://www.acog.org/ , The National Guideline Clearinghouse https://www.guideline.gov/  ,  Agency for Healthcare Research and Quality, and the American College of Nurse Midwives

No words can describe this amazing mama's feelings after her VBAC, captured by @skyla_walton

No words can describe this amazing mama's feelings after her VBAC, captured by @skyla_walton

“The AAFP strongly recommends that clinicians inform women who have had a prior vaginal birth, either before or after a prior cesarean birth, that they have a high likelihood of VBAC. Unless there are specific contraindications to a vaginal birth, these women should be encouraged to plan a labor and VBAC and should be offered referral to clinicians and facilities capable of providing this service, if it is not available locally. (Quality of Evidence: High)” – Source: The National Guidelines Clearinghouse website (insert link: https://www.guideline.gov/summaries/summary/49115/clinical-practice-guideline-planning-for-labor-and-vaginal-birth-after-cesarean?q=vbacs

In most cases, a VBAC is a safe option.

I share the opinion of many concerned with improving maternity care and reducing our rising rates of maternal and newborn death and serious health consequences from the interventions in childbirth, that a woman should not be forced to have a major surgery against her will, rather provided research and empowered to make her own decision, considering she is having a healthy pregnancy.

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AAOG removed the previous unreasonable restriction requiring immediate availability of a surgical staff for an emergency cesarean, as most hospitals around the country, let alone free standing birth centers and home settings, do not meet this criteria. Most hospitals are not able to have a surgical staff at all times and cannot perform an emergency cesarean in under 30 minutes.

Despite this, research is showing that far too many obstetricians do not offer VBACS. They routinely recommend repeat cesareans because they may fear law suits, succumb to scheduling pressures, have restrictive hospital or malpractice insurance policies, and/or feel pressured to uphold certain standards among their colleagues who are not supportive of VBAC. The hands of a midwife whose collaborative obstetrician and hospital do not support VBAC can often be unnecessarily tied as well for these reasons. Most repeat cesareans are not actually medically necessary, and are commonly recommended due to various non-medical reasons. This is very concerning.

What also concerns me is that the risks of a VBAC are magnified in conversation with women, while the risks of a repeat cesarean are downplayed, so women may feel forced, afraid and powerless.

I want women to feel like they have a voice.

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Some women who want to VBAC have limited options and local doctors in the area are only offering cesareans. Some feel they have no option other than having an unattended homebirth, or labor alone at home until the last minute without any monitoring, or not be truthful with their providers about their previous cesarean birth – all of which can increase the risks for her and her baby.

A trained and experienced midwife who is continuously with the woman in active labor, can detect concerning signs and symptoms before they can become a crisis, and she be transferred and treated in time to save her and her baby’s life and heath.  A midwife wears many hats, one of which is protecting the space so the natural process of birth can proceed with ease and grace, and another is a lifeguard – to know when and how to intervene to prevent problems or manage emergencies.  There are many wonderful obstetricians supportive of VBAC who have this training and style of practice as well; they are just harder to find.

What are the chances of having a successful VBAC and who is a good candidate for a VBAC?

The stats range that 60-80% of women, who have had previous cesareans, are candidates for a successful VBAC. In actuality, most healthy pregnant women carrying healthy babies are candidates.

The chances of a successful VBAC are higher if a woman is using a midwife, even higher in free standing birthing centers and home settings.

Above photos of rockstar mama's VBAC are by @karinariveraphotographer

Above photos of rockstar mama's VBAC are by @karinariveraphotographer

Going to a hospital and working with an OB/GYN with high cesarean rates, will increase the likelihood that a woman will have another cesarean.

In some hospitals, there are a lot of restrictive procedures, like continuous electronic fetal monitoring, confining a laboring woman to lay in bed, not allowing her to eat or drink, routine IVs and time limits, which increase the risk of a cesarean.

What is the main risk of a VBAC?

The risk of separation of the prior uterine scar is approximately 2 in 1000 VBACs, but often it is a mild superficial dehiscence (slight separation of some layers of the surgical wound) that has no clinical significance and does not impact the health of mom or baby. The risk of severe life-threatening emergency from a partial or complete uterine rupture of all the scar layers is significantly lower – a highly unlikely occurrence, significantly less than 1 %.  The main risk is of a VBAC is this rare catastrophic rupture of the previous uterine incision. This rare total disruption of the uterine scar risks both the mother and her baby, and can lead to catastrophic outcomes. It cannot be ignored and must be monitored for appropriately; but it cannot be exaggerated or make the risk of repeat cesarean less alarming.

Although every decision has risks, a VBAC is a reasonable, appropriate and safe option. If a woman panning a VBAC decides to give birth at home, I highly recommend working with a well trained and experienced midwife and consider the distance to a hospital (30 minutes or less driving time is ideal).

There are risks and benefits to every kind of birth and in every setting. I provide women with evidence based information, encourage each family to dig deep and look at the pros and cons to having a VBAC in a hospital setting, free standing birthing center or home, vs a routine cesarean and have informed consent for her birth.

Are there benefits to a cesarean?

A planned cesarean is in a controlled environment, and some women find great comfort in that knowing. Perhaps a woman has had a previous traumatic, long labor the first time and they just don’t want to go through that experience again. Some women are very anxious about that and they just feel safer knowing they will have another cesarean.

I take that seriously, because she won’t labor well if she doesn’t feel safe.

Like I mentioned before, the serious risks for a VBAC can be often prevented, treated or transferred to surgical care in time, with a skilled midwife or obstetrician who is attending to the laboring women, aware and mindful of the symptoms that lead up to that.

Thankfully some hospitals are now at least allowing more time for baby to get the cord blood from the placenta, skin to skin bonding, and her partner or main support person in the operating room. Some hospitals and providers are performing “gentle cesareans” – cesareans that are family and woman centered, and try to provide the environment of a natural birth as much as possible. This is a wonderful attempt to restore humanity to birthing in the operating room.

Last tips:

If a woman knows she wants to have another baby, I would start with research and education. Ask yourself: “What do I want and why?”

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A woman should get the support she needs. Most women who have had a prior cesarean have issues they need to discuss. There are therapists who specialize in this.  One of my dedications and areas of expertise is creating space so a mom can debrief, process and heal from her previous upsetting or traumatic birth experience, as well as plan for a better one next time around. Schedule a consult with me here. http://homesweethomebirth.com/chat-with-anne/.

I tell mamas to do what they can to educate and empower themselves, and know they do have a voice, build their circle of support, and include in their birth team advocates to speak for them when they are in the heat of labor. I tell them to prepare for a vaginal birth. The mind, body, heart and spirit can prepare for a vaginal birth - and a deeply positive, beautiful and empowering one. This is one of my passions and main focus of my online childbirth course. http://homesweethomebirth.com/onlinecourse/

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PHOTO CREDIT – THE UNISON PHOTO

A woman is more likely to have a vaginal birth if she has a natural birth. Although this is not in all cases, a woman who is educated, empowered and prepared for a natural birth has a greater chance for having one.

Things a woman can do to prepare for a vaginal birth:

  • Take an excellent childbirth course! My online LOVE YOUR BIRTH course is available here. 

  • Check out www.vbacfinder.com to find VBAC rates for local hospitals.

  • Check out ICAN (http://www.ican-online.org) for more information; seek out VBAC groups in your community, on Instagram and on Facebook, to connect with other women who have had successful VBACS.

  • Watch movies of women who have had VBACS… inspiring stories of healing, beauty and empowerment.

  • Create your tribe, in your pregnancy, of like minded women who have gone through what you’re going through.

  • Interview providers, and choose one that aligns with you the most – one that has high rates of VBAC and low rates of repeat cesarean. It is very important to ask them their rates, and if you are planning a hospital birth, research the hospital rates here (link to http://www.cesareanrates.com/2015/01/what-is-my-hospitals-cesarean-rate.html

     Most midwives, especially those who practice out of hospital settings, have the highest rates of VBAC and the lowest rate of repeat cesarean, but plenty of hospital midwives and obstetricians have similar stats – they just may take some work on your part to seek them out.

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I also recommend hiring an awesome doula, as those who have a doula are less likely to have a cesarean.

A doula is amazing because they offer the mothering comfort and support that our ancestors had.  When women would give birth in their tribe or village, and they were surrounded by mothers, aunts, sisters, grandmothers, and the other women of their community, they received that mothering support by women who were comfortable with birth and relaxed around it. Fear has no place in birth, and a doula provides needed calm and loving support.

Lastly, I recommend drawing and journaling , mediation and visualization – which tap more deeply into her intuitive self. A woman can imagine how she’d do it differently or what she wants for herself. And she can face her fears head on, which often lessens them, or she can be with them and plow forward with courage in spite of them.

Remember, In the end it’s not in our control, and we let go and surrender,

If you do all of these things and end up having a cesarean, it’s not a failure. There is no failure in birth. It is a birth, a belly birth, and it’s the birth of your baby and you as a mother. It is the birth of your family and your partner as a parent. Stay present, stay involved and keep a positive mindset. Focus on the blessing, that you did all that you could, and thankful for modern medicine, which saved you and your baby’s life and preserved health. Also, you can ask for a gentle cesarean, which restores humanity to the operating room by doing such things as allowing your support people in with you, enabling baby to emerge from the incision simulating as much as possible a vaginal birth to help baby clear his/her own lungs, enabling you to participate by lowering the drapes so you can see your birth, giving you sterile gloves to receive your baby, delaying the umbilical cord clamping so baby can benefit from the cord blood, encouraging immediate skin to skin bonding and early breastfeeding.  

Image by angiebeehotz

Image by angiebeehotz

Healing can occur afterwards, and may take time and lots of support. But there is no place for shame and negative self judgement here.

Image by Megan Hancock Photography

Image by Megan Hancock Photography

Let Me Help You Create The Happiest Birth Experience Of Your Life...

Whether you're a first time or experienced momma, planning a VBAC

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Regardless if you are intending to birth at home, a hospital, a birth center or need a cesarean section, or if you are taking another childbirth education class…

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  • Speak your truth from your heart in a way that deepens your relationships, sets clear boundaries, and has people listen to you and support you before, during and after pregnancy
  • Trust yourself, connect with your body wisdom andcommunicate with baby in belly
  • Connect with natural time and sync your body and mind up with your unique biological clock for ease from pregnancy to postpartum
  • Reprogram negative patterns, stories, and beliefs that undermine your confidence, strength and self trust so you can rock your birth

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To learn more, visit:  LOVE YOUR BIRTH Online Childbirth Course!

It is based on my years of experience, as a midwife and yoga teacher, helping thousands of women tap into their calm and live and birth from a place of grounded relaxation and joy. 

Some other resources:

In the end, how a woman births is her personal decision and the more informed she is and empowered to play a large role, the greater the likelihood is she will have a positive birth experience.