Expert / 25 April, 2021 / Nicette Jukelevics
Nicette Jukelevics is a certified childbirth educator, author, and speaker on cesarean prevention and VBAC and in this in-depth and exclusive interview, she talks us through the all-important question: to VBAC, or not to VBAC?
Some mothers who have had a cesarean know that next time they want to plan a VBAC. Other mothers are sure they want a repeat operation. Sometimes the decision is hard to make. Each woman is different and has the right to decide for herself how she wants to give birth. Based on the best evidence, her prior birth experience, and what medical care and support is available to her, she will choose the birth option that feels best for her and her family.
By choosing to labour for a VBAC rather than scheduling a medical unnecessary cesarean, you have a chance to avoid the complications of surgery. With each additional cesarean, a mother is at risk for hemorrhage, infection, adhesions, and developing a blood clot in the legs or lungs. Multiple cesareans also increase the risk for serious placental problems (placenta previa and placenta accreta). By labouring for a VBAC with one or two prior cesareans with a low horizontal uterine scar, 1 out of 200 mothers is at risk for a uterine rupture.
I’m in a dilemma. I’m 27 weeks pregnant and my consultant has advised that there is no reason my next baby can’t be born vaginally if my pregnancy continues to progress well. My first child, a daughter, now 19 months, was born via planned C-section due to an excruciating perianal hematoma. My daughter has suffered from dairy intolerances and gut issues since birth and while I realise these things can happen to babies born ‘normally’, it is a more likely outcome of a C-section baby. So, I need to weigh my options and decide how I want to give birth if my pregnancy continues to be a healthy one. I have many reservations about a VBAC, and some nitty gritty questions I’d like answered…
It’s good to know that your care provider is supportive of VBAC. The overwhelming majority of women (3 out of 4) who labour after a prior cesarean have a safe, normal birth and avoid the complications of a routine repeat cesarean. The risk for the separation of a uterine scar with one prior horizontal uterine incision is about 1 in 200 women who labour for a VBAC. The risk is not higher than any other unforeseen complication that can occur with a first birth such as fetal distress, maternal haemorrhage from a premature separation of the placenta or a prolapsed umbilical cord.
Labouring for a VBAC between 18 and 24 months after a prior cesarean reduces the risk for the separation of a uterine scar. The risk is also reduced if the prior cesarean incision was closed with two layers of sutures (double-layer closure) as opposed to a single-layer of sutures (single-layer closure), often done in recent years to shorten the time in the operating room.
Here is a secret about labour that most people don’t know. The same woman labouring for a VBAC can have a safe and normal birth or end up with a repeat cesarean depending on how she is cared for in labour and birth. We know that the VBAC rate is higher with midwives. Midwives avoid complications that may lead to a cesarean by not routinely breaking the bag of waters, or inserting an IV. Midwives encourage women to move and use a variety of positions during labour and birth.
Midwives also encourage non-drug methods of pain relief such as immersion in warm water, use of showers, relaxation techniques, and massage. This approach helps labour to progress and allows mothers to be more in control of their birth. They are more likely to feel more confident, be more alert, and more responsive. Using drugs for pain relief affects the baby’s heart rate and may cause fetal distress (non-reassuring fetal heart rate). Midwives look to maximise health outcomes using a minimum number of medical interventions. They also address the emotional, psychological, and cultural concerns of women in their childbearing year.
The definition of “term” birth has recently changed. Today, it is acknowledged that an expectant mother can carry her baby till the end of her 41st week of pregnancy before having to induce labour. This includes mothers with a prior cesarean. So, unless there is a medical problem, mothers need not be induced early.
Baby must not be too “big” and its position in the pelvis has to be correct:
Estimating the birth weight of a baby to decide whether or not a mother can birth vaginally or by cesarean section is an outdated practice. Evidence has shown that this practice is fallible and should not be a reason for a mother not to labour for a VBAC or to be induced before term. In fact, many women who have had a scheduled cesarean for a “big” baby do have a VBAC with a larger baby. Most guidelines agree that even if a baby is anticipated to weigh 4000 grams (8.82 lbs) at birth, mothers can choose to labour for a VBAC after being informed of the benefits and risks and their odds of having a vaginal birth.
If the baby’s head is down when it enters the mother’s pelvis there is no reason not to labour for a VBAC. The most favoured position for birth is OA (occiput anterior) when the baby faces the mother’s back and its back is towards the front of its mother’s belly. This position allows the baby to rotate and move more easily through the pelvis. Sometimes the baby is in the OP (occiput-posterior) position, facing its mother’s belly, which makes it more difficult for the baby to move through the pelvis. However, with the right positioning the baby can usually rotate to an OA position during labor.
Evidence shows that induction of labour increases the odds for a cesarean section. Because inducing labor with Pitocin is not widely regulated, the dosage and length of time the induction continues varies by the practice style of the provider, and so does its effects.
It is the induction agent and method used that makes a difference regarding the risk for the separation of the uterine scar when labouring for a VBAC.
A few years ago, ripening the cervix and inducing labour with a specific prostaglandin, misoprostol (Cytotec), was common. This agent is known to hyper stimulate contractions. For mothers labouring for a VBAC, this led to many more separations of the uterine scar and led caregivers to believe that all inductions for women labouring for a VBAC should be avoided. Also, many maternity care providers were not aware of the signs of a potential uterine rupture and were not cautious in monitoring labor. Cytotec has been banned for use in women who labour for a VBAC.
A mother has a higher chance of having a VBAC if her labour begins on its own rather than if she is induced. Some caregivers aim for avoiding an induction if possible and using a judicious dose of Pitocin if needed.
With a first labour after one or two prior scheduled cesareans expect your labour pattern to progress like a first birth. That does not mean that labour will be long or drawn out. As mentioned before there are many ways of helping labour to progress and easing the pushing stage. Using upright positions, a birth ball and/or peanut ball during labour as needed can help you feel more comfortable and help labour progress. What is likely to complicate or slow down labour progress is not being allowed to move around and change positions in labour, labouring on your back, using drugs for labour pain, or restricting your activity with an induction or an epidural. To help you have a vaginal birth when using an epidural, it’s important to shift positions during labour. Your nurse, midwife, or doula can suggest what positions are likely to be more favourable.
You may also want to try “labouring down.” That is, after full dilation, waiting for the baby to be low down in the pelvis before beginning to push. The uterus will continue to contract without your efforts and this gives you a chance to rest.
Having a positive frame of mind and feeling confident about labouring for a VBAC is very important. To get there, it’s helpful to find out as much as you can about VBAC, what does the evidence say? It’s normal to be anxious or fearful about labouring after a cesarean since it will be an unknown experience for you. How will you deal with the pain? What if you have complications? What if you labour, but still end up with a cesarean? Speak to mothers who had that experience. Bring together a birth team that will support you. Your partner, caregiver, doula, friend, or family member.
Monitoring the pattern of your contractions and the baby’s heart rate is important because it can register signs of a potential uterine rupture. But monitoring need not restrict your movements. Many mothers can still move around, sit in a chair, kneel forward, labour on hands and knees, use a birth ball, and squat for birth with electronic fetal monitoring. Some caregivers use a fetal Doppler to monitor labor intermittently. With a Doppler you are free to move around as you wish, even labour in water.
The chance that your scar will open while you labor is 1 in 200. If these odds sound too high for you, you may want to schedule a repeat cesarean.
Every woman has the right to choose how she wants to give birth. Some women fear the pain of labour or being out of control. Scheduling a cesarean when you know who your caregivers will be may feel safer. It’s important to find out the benefits and risks of both options for birth after a cesarean so you can make the decision that is best for you.
There has been a turn around by the medical community since the 90’s about scheduling medically unnecessary cesareans. Years of increasing cesarean rates have shown that multiple cesareans can cause harm for both mothers and babies. Each additional cesarean increases the risk for complications. The World Health Organisation is urging caregivers to avoid performing medically unnecessary cesareans. The Lancet also recently published a series of articles on the risks of cesarean section and how caregivers and hospitals can change their practices to avoid unnecessary cesareans.
Here again, it depends on how a woman perceives the risks and benefits of having a repeat cesarean or labouring for a VBAC. Evidence suggests that when women who fear labour are educated about VBAC and can count on the support of their care providers they tend to labour rather than schedule a cesarean.
The odds that a woman would have an uncomplicated “normal birth” is more likely dependent on her caregiver’s style of practice rather than on her medical condition. Avoiding unnecessary medical interventions in labour is likely to reduce complications.
It is important to find out the facts about labouring for a VBAC and not rely on anecdotal information.
There is not much difference between labouring after a cesarean and labouring without a uterine scar. All mothers should be free to move as they deem comfortable, use upright positions for labour and birth. With a VBAC the difference is that it’s important to monitor labour contractions and the baby’s heart rate very closely since fetal monitoring can predict the likelihood of a uterine scar and help caregivers to respond to this situation as quickly as possible.
To date there is no evidence to show that labouring for VBAC in a tub is less safe than labouring in a bed. There are fetal Dopplers that are water-proof for women who want to spend part of their labour in a tub.
The theory of vaginal seeding is to colonise the fetal gut with the mother’s microbiome and reduce the risk for disease like asthma, allergies, and diabetes shown to be associated with a cesarean birth. Although the concept of vaginal seeding has increased in popularity there are many questions left answered. How much of the vaginal fluids is necessary? Is it beneficial only for term births? What about premature babies? What about the potential for harm for the baby from undiagnosed diseases like chlamydia, GBS (Group B Streptococcus), HPV (human papilloma virus), HSV (herpes simplex virus)? Can exposure to these pathogens harm the baby? Some studies suggest that a cesarean born baby can benefit from exclusive breastfeeding for at least six months to increase exposure to these beneficial microbes. With time breastfeeding increases the beneficial microbiomes in the baby’s gut. The American College of Obstetricians and Gynecologists recommends that vaginal seeding should not be done outside of research protocols.
In this case, encouraging VBAC rather than a routine repeat cesarean is not only cost effective, but it also happens to be best practice. Three out of four women with a low-horizontal uterine scar can avoid the complications of routine repeat cesareans if they labour for a VBAC. Babies are more likely to be breastfed and less likely to suffer from breathing problems and the need to be transferred to a NICU.
Planning for a VBAC may be time consuming, but mothers who give it serious thought usually have a safe, empowering, and satisfying birth. Take the time to understand how your body is designed to give birth. Knowing how your body changes during pregnancy and how your own hormones prepare you for labour and birth will give you the confidence you need to work with the powerful forces of childbirth.
Consider taking a childbirth class. Most women learn about childbirth from watching TV or from seeking information on the internet. Unfortunately, they may only see a skewed view of birth and miss out on learning many ways to help them cope with labour. Take a class that empowers you and helps you to discover your inner strengths. The right class can prepare you realistically for birth and help you work with the intensity of labour. It should also include information about your rights and the options available to you.
Work through any psychological issues, fears, or trauma from your prior cesarean that may still be unresolved. This will help you to focus on this labour rather than think about what may have gone wrong with your last birth and what if the situation repeats itself.
Talk to other mothers who planned a VBAC. There are many support and discussion groups online that may give you confidence to go ahead and labor for a VBAC.
Consider having a birth doula. A birth doula is a person trained and experienced in childbirth who provides continuous physical, emotional and informational support to the mother before, during and just after childbirth. Evidence shows that doulas have the skills to help your labour progress. With a doula mothers have lower cesarean rates, are less likely to need an instrumental delivery (vacuum or forceps) and less likely to need an epidural for pain relief. With a doula mothers and babies are healthier and mothers are more likely to breastfeed and to be satisfied with their birth.
Develop your own birth guide. Think about how you and your baby would like to be cared for during and after birth. Discuss your preferences and concerns during your prenatal visits and when your labour begins. Your caregivers should try to work with you and respect your choices while still providing safe care.
Try to keep a balanced, open-minded attitude, and remember that most births turn out safely, no matter how a baby is born. Recent medical guidelines have recognised the need to avoid the serious complications of repeat cesareans for both the mother and her baby.
To that end medical societies are now supporting the normal process of birth. They are encouraging caregivers to avoid non-medically necessary cesareans and to promote normal birth. They are rethinking outdated rules such as restricting the time that women are “allowed” to labour or push during the second stage. This perspective of childbirth should make it easier for women to access medical care for VBAC.
Copyright: Nicette Jukelevics, January 21, 2019