VBAC's, Repeat Cesarean and Cesarean Surgery

What is a VBAC?
VBAC comes in many forms. At its most basic, VBAC is simply the vaginal birth of a child after a previous cesarean. For some mothers, this is listed as a "procedure" and for others it takes the form of HBAC (Home Birth After Cesarean), WBAC (Water Birth After Cesarean) and VBAmC (Vaginal Birth after Multiple Cesarean) and on and on. And for some mothers, their planned VBAC will become a CBAC.

Why VBAC are's safe
Simply put they do not carry the dozens of risks a cesarean does. They are safe!

Can I have a VBAC after 2 cesareans or more?
Yes!  A VBAMC (vaginal birth after multiple cesarean)  is almost always safer than a repeat c-section.
http://www.plus-size-pregnancy.org/CSANDVBAC/vbac_after_2_cs.htm
http://www.ican-online.org/vbac/vaginal-birth-after-multiple-cesareans 

How to have a successful VBAC
Vaginal Birth after Cesarean Checklist

Read good pregnancy and Vaginal Birth After Cesarean books. Two suggestions are: "The VBAC Companion" by Diana Korte and "Open Season" by Nancy Wainer Cohen.  

Focus on good nutrition and exercise. Make a daily checklist to ensure you are getting essential nutrients. Engage in daily exercise such as swim, walk, yoga, prenatal fitness class- whatever feels good. For information on diet throughout pregnancy, we recommend reading, "What Every Pregnant Woman Should Know" by Dr. Tom Brewer and Gail Sforza Brewer or The Brewer Diet.  

Register for VBAC, refresher or another quality, independent prenatal program. Even though you may have taken classes in a previous pregnancy, an evening out together with your partner will help to prepare you both, promoting discussion, giving you ideas on coping with labor and bringing a focus to this baby and its birth.  

Enlist the encouragement of a supportive care provider. Find a caregiver/hospital who ALREADY provide the options you want. Find someone who believes in VBACs, has a VBAC success rate over 75% and a cesarean rate that is lower than the community average. Consider having a midwife as your primary caregiver. Midwives have a very low rate of cesarean birth. If you are unsure about anything, get a second opinion. Trust your inner strength and knowledge.  

Hire a doula/labor assistant/support person. It is worth every penny to be reassured during labor by someone who believes birth is a natural function. This person will have supportive non-medical skills to help you through labor for the birth you want. This person will assist you from your first contractions at home right through postpartum. A labor assistant, or doula, takes the pressure off fathers and family members so that the whole family can be supported.  

Throughout pregnancy practice relaxation and visualization with exercises, tapes, massage, affirmations and touch. Use affirmations such as "Each contraction strengthens my baby and me." Or "I will birth my baby vaginally, naturally, and joyfully."  

Write a birth plan. Discuss everything that is important to you with your care provider, putting it all into your birth plan. Make extra copies to be put in your chart. Know your hospital's VBAC policies and negotiate well before the birth for anything different.  

Things to consider when writing your birth plan are: 

•·Establish a safe, supportive birth environment to encourage labor.

•·Try a variety of positions. Instead of lying down, try standing or walking. Squatting to push can be most effective. Try the birth ball. Try walking the halls. Try ‘dancing' with your partner.

•·Continue your calorie and fluid intake. Labor is work and takes energy. Far from eliminating the risk of aspiration with general anesthesia, total fasting (NPO) may increase the risk by raising the acidity of the stomach contents.

•·Avoid medical intervention whenever possible. Continuous electronic fetal monitoring may restrict your movement. Ask for noninvasive options. Ask what will be done with the results.

•·Artificial induction should be avoided, if possible. Medical induction is linked with high rupture rates and many interventions.

•·Ask for time to try non-medical methods to stimulate labor if your labor is not progressing. These include change of position, walking, nipple stimulation, aromatherapy, acupressure. Every labor is different. Unless you dilated to five or six centimeters during a previous labor, consider this one your first labor.

•·Avoiding an epidural may increase your chance for a vaginal birth. An epidural interferes with the baby being optimally lined up and will reduce your ability to push effectively. Try natural pain relief measures, such as: hot/cold compresses, bath/shower (once labor is established), tenns unit, massage, relaxation, guided imagery, birth ball. If you start to think you really need an epidural, give yourself a few more contractions, or request that you be checked one more time. You may be moving quickly into transition without realizing it.  

Having a birth plan cannot guarantee that your wishes will be followed. Working with a careprovider who believes in birth is easier than fighting one who does not. No amount of demanding or asking nicely will get you the birth you want. 

Many cesareans are done due to posterior or asynclitic presentation. Avoiding reclining positions prenatally. Read Val el Halta's "Posterior Presentation - A Pain in the Back" article and "Understanding and Teaching Optimal Fetal Positioning" by Jean Sutton and Pauline Scott.  

Believe in yourself and the process of birth. Repeat affirmations to yourself constantly. Encourage yourself to believe that you are capable of delivering your baby vaginally. Get in touch with your inner self; your resources and abilities. Forget about your scar and focus on the positive aspects of your pregnancy.  

Work on leftover negative emotions (guilt, disappointment, anger) from previous cesarean birth(s). Two wonderful books for this are Lynn Madsen's "Rebounding From Childbirth", and "Ended Beginnings" by Claudia Panuthos. 

Learn to trust, cooperate with and listen to your body and baby. Listen to your own unique labor pattern.  

Feel good about yourself and your relationship as a couple and keep a positive outlook.  

Enlist the support of family and friends. Remember that according to medical studies VBAC is usually safer for both you and your baby than a repeat cesarean. Don't be afraid to let your family know how much you need their unconditional emotional support.  

Attend VBAC support meetings and join national organizations. Through meetings and newsletters, you will hear from others who have been there, sharing their VBAC experiences. Read "The VBAC Experience" by Lynn Baptisti Richards, a collection of VBAC stories.  

Having a VBAC is worth it! You can do it. Not everything is within our control - however, it is within all of us to prepare ourselves as best we can to maximize the chance of VBAC.
http://ican-online.org/vbac/vaginal-birth-after-cesarean-checklist

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Comments:

cali4...
Nov. 9, 2010 at 9:46 AM

My Hospital/OB won't "let" me have a VBAC - help!
My hospital is currently not allowing VBAC and forcing me to have a cesarean; what are my options  

•·Contact ICAN with the name and city/state of the denying hospital, along with the name and contact information of the Nurse-Manager of Labor & Delivery/Birthing unit that is forcing you to have surgery against your will.   

•·You may choose to present a signed VBAC Consent Form as proof of your understanding of the benefits and risks involved in childbirth.   

•·According to the Patient Care Partnership of the American Hospital Association, you have the right to refuse recommended treatment, including a cesarean section. If you refuse a recommendation, alternative treatment should be provided.  In this case, a VBAC.   

•·State you require more time to consider your decision. Ask to postpone the surgery until you have been given adequate time to research your decision thoroughly.   

•·When labor begins spontaneously, some mothers feel more comfortable laboring in the comfort of their own homes for as long as possible. It may be possible to find a doula or monitrice for labor support.   

•·It is never too late to change caregivers or birth location. Begin seeking another caregiver or birth location immediately. Even a physician's slightest counter to VBAC may ultimately become a forced cesarean.   

··Write a letter to your local television station and/or the editor of your local newspaper, telling them you are being forced to have a cesarean against your will.

Also see
Your Right to Refuse: What to Do if Your Hospital Has "Banned" VBAC 
50 Ways to Protest a VBAC Denial
http://vbac.com/hottopic/deniedvbac.html  

What questions should I ask my provider if I want a vbac?
What is your vbac attempted rate? Of those, how many are successful?
Do you ever induce a vbac?
Do you put gestational limits on vbacs?
Do you require me to do anything to have a vbac? (I.E some hospitals/Obs demand an IV, CEFM, and signing a waiver)
Do you handle the 3rd stage(delivery of placenta) differently when attending vbacs?
What are your concerns, if any, about vbacs?   
   

What about uterine rupture?
The risk for uterine rupture is approximately 0.3% to 0.7% for women laboring for a VBAC compared to 0.022% to 0.026% for women who have an elective repeat cesarean. 

Uterine ruptures have also been known to occur in some women who have never had a cesarean. This type of rupture can be caused by weak uterine muscles after several pregnancies, excessive use of labor inducing agents, a prior surgical procedure on the uterus, or mid-pelvic use of forceps.

For more info:
http://vbac.com/uterine.html
http://www.ican-online.org/vbac/uterine-rupture-a-10-year-population-based-study-uterine-rupture
http://vbacfacts.com/category/vbac/uterine-rupture/    

Why should I hire a doula for my vbac?
Doula" refers to a supportive companion who is professionally trained to provide labor support. There is also a postpartum doula, who provides support during the postpartum period. We will be talking mostly about labor doulas.

First time moms, VBAC moms, moms having cesareans, moms wanting a natural birth, all these moms and their partners could benefit from having a doula. As a first time mom, it is helpful to have someone there who knows what's happening. A VBAC mom can benefit greatly from the reassurance a doula continuously gives. A mom having a cesarean can be comforted by her doula. Moms wanting less intervention can be greatly increase their chances of a beautiful birth by having a doula as part of their birth team. A mom with
special needs is strengthened by her doula.    

Numerous clinical studies have found that a doula's presence at birth:

Tends to result in shorter labors with fewer complications
Reduces negative feelings about one's childbirth experience
Reduces the need for pitocin, forceps or vaccum extraction and cesareans
Reduces the mother's request for pain medication and/or epidurals 

Research shows parents who receive support can: 
Feel more secure and cared for
Are more successful in adapting to new family dynamics
Have greater success with breastfeeding
Have greater self-confidence
Have less postpartum depression
Have lower incidence of abuse
  

Doula Statistics:
50% reduction in the cesarean rate
25% shorter labor
60% reduction in epidural requests
40% reduction in oxytocin use
30% reduction in analgesia use
40% reduction in forceps delivery
   

More info about Doulas and VBACS 
http://www.ican-online.org/pregnancy/professional-labor-support 
http://www.glorialemay.com/blog/?p=41
http://vbac.com/doulaatyourbirth.html

 

http://ican-online.org/vbac/My-Hospital-Is-Currently-Not-Allowing-VBAC  

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cali4...
Nov. 9, 2010 at 9:48 AM

When is a cesarean necessary?

Cesarean section is only indicated in the following situations: 

··Complete  placenta previa at term 

•Vaginal Birth After Cesarean (VBAC) is safer for both mother and infant, in most cases, than is routine repeat cesarean, which is major surgery.     

•The risk to your infant from the very low incidence of uterine rupture (less than 1%) is much less than the risk to your infant from respiratory distress as a result of a scheduled cesarean.    

• One-half of all cesarean women suffer complications, and the maternal mortality rate is at least two to four times that of women with vaginal births. Approximately 180 women die annually in the United States from elective repeat cesareans.     

•Many indications for cesarean can and should be questioned, including cephalopelvic disproporton (CPD or baby too big, pelvis too small), dystocia, failure to progress, breech, etc.    

··According to the World Health Organization, "Countries with some of the lowest perinatal mortality rates in the world have cesarean rates of less than 10%. There is no justification for any region to have a rate higher than 10-15%."
Also See

Don't be afraid to ask for help. Physical recovery means just that. You need rest, fluids, good food and only light physical activity. If someone comes over to visit, let them know what you need done around the house like laundry or dishes. Your job is to relax with your new baby, not entertain company.     

Moms aren't the only ones who need recovery time after cesareans. Often, the process of being born can result in sore muscles for baby. Many moms find cranial-sacral therapy or chiropractic helpful for their infants, but even just taking a bath with mom or lying in bed skin to skin is relaxing and helps the two of you to form important bonds. If your baby came early due to the cesarean, it can sometimes take a week or two to really get the hang of breastfeeding for the baby as well. Try not to become discouraged and reach out to your local breastfeeding support or lactation consultant.    

Cesareans can raise the risks of postpartum depression and some women develop PTSD (Post Traumatic Stress Disorder) and should seek further help from a therapist who is skilled in dealing with birth trauma. These therapists should not be dismissive of your needs or concerns and realize that there is more to birth than a "healthy baby" and that even the healthiest of babies can come through a traumatic event to the mother. You have the right to mourn your birth and your trauma while celebrating your child. These are two different events in your life, even if they are happening simultaneously.  

Also see Recovering from a Cesarean: Tips on Healing

http://vbacfacts.com/vbac/ 

Cesarean Recovery
Recovering from a cesarean can be a short-term process for some moms and for others, it takes much longer. Cesareans have an impact on us socially, emotionally, mentally, spiritually and physically. They also impact our babies. Here are a few suggestions for recovery:      ··Transverse lie at complete dilation 
··Prolapsed cord 
··Abrupted placenta 
··Eclampsia or HELLP with failed induction of labor
··Large uterine tumor that blocks the cervix at complete dilation (Most fibroids will move pwards as the cervix opens, moving it out of baby's path.) 
··True fetal distress confirmed with a fetal scalp sampling or biophysical profile 
··True absolute cephalopelvic disproportion or CPD (baby too large for pelvis). This is extremely rare  (1 in 300 women)  and only associated with a pelvic deformity (or an incorrectly healed pelvic break). Fetal positioning during labour and maternal positioning during second stage, most notably when women are in a semi-sitting position, cause most CPD diagnosed in current obstetrics.5 
·· Initial outbreak of active herpes at the onset of labor 
·· Uterine rupture 

Cesarean Surgery Risks
When a cesarean is necessary, it can be a life-saving technique for both mother and infant.   

•One in four births is a cesarean, with some hospitals reporting as high as one in two. This represents a 400% increase in less than 15 years. This cesarean rate increase has not led to an improvement in the infant mortality and morbidity rates but instead has put mothers and babies at greater risk. Rates began to fall in the mid-1990s, but are rising again in the new millennium.     

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cali4...
Nov. 9, 2010 at 9:49 AM

Repeat Cesarean Risks   

•·         A cesarean poses documented medical risks to the mother's health. These risks include infection,19 blood loss and hemorrhage,20 hysterectomy,21,22 transfusions,23 bladder and bowel injury,24,25 incisional endometriosis,26,27 heart and lung complications,28 blood clots in the legs,29 anesthesia complications,30 and rehospitalization due to surgical complications,31 rate of establishment and ongoing breastfeeding is reduced,32 and psychological well-being compromised and increased rate emotional trauma.33 Potential chronic complications from scar tissue adhesions include pelvic pain, bowel problems, and pain during sexual intercourse.34 Scar tissue makes subsequent cesareans more difficult to perform, increasing the risk of injury to other organs and the risk of chronic problems from adhesions.35 One-half of all women who have undergone a cesarean section suffer complications, and the mortality rate is at least two to four times that of women with vaginal births. Approximately 180 women die annually in the United States from elective repeat cesareans alone. 

•·         Each successive cesarean greatly increases the risk of developing placenta previa, placenta accreta and placental abruption in subsequent pregnancies.36,37,38 Both of these complications pose life-threatening risks to mother and baby. Cesareans also increase the odds of secondary infertility, miscarriage and ectopic pregnancy in subsequent pregnancies.39,40

•·         A cesarean poses documented medical risks to the baby's health.41 These risks include respiratory distress syndrome (RDS),42,43,44,45 iatrogenic prematurity (when surgery is performed because of an error in determining the due date), 46,47 persistent pulmonary hypertension (PPH),48 and surgery-related fetal injuries such as lacerations.49,50 Preliminary studies also have found cesarean delivery significantly alters the capability of cord blood mononuclear cells (CBMC) to produce cytokines.51 An elective cesarean section significantly increases the risk to the infant of premature birth and respiratory distress syndrome, both of which are associated with multiple complications, intensive care and burdensome financial cost. Even with mature babies, the absence of labor increases the risk of breathing problems and other complications. Far from doing better, even premature and at risk babies born by cesarean fare worse than those born vaginally.

•·         Cesareans can delay the opportunity for early mother-newborn interaction, breastfeeding, and the establishment of family bonds.52,53,54

•·         Cesarean rates are influenced by nonmedical factors. These include: individual philosophy and training, convenience of doctor or patient, the patient's socioeconomic status, peer pressure, fear of litigation, and financial gain.55,56,57

•·         In the United States, obstetricians offer defensive medicine as an excuse for the astronomical and sharply rising U.S. cesarean rate. Deliberately performing unnecessary surgery in the belief it avoids lawsuits is indefensible. That many obstetricians seem oblivious to the profound violation of ethical principles is shocking.58,59

•·         Vaginal Birth After Cesarean (VBAC) is safer for both mother and infant, in most cases, than is routine elective cesarean, which is major surgery.60,61,62,63,64,65,66 Learn More in our VBAC Section.

•·         The risk to your infant from the very low incidence of uterine rupture (less than 1%) after a prior cesarean is much less than the risk to your infant from respiratory distress as a result of a scheduled cesarean.67,68,69,70 

How to have a "family-centered" Cesarean.
Read article HERE

What Books and Websites do you recommend?
Mothering - VBAC and Cesarean
ICAN (International Cesarean Awareness Network)
VBAC Facts.com
VBAC.com
TheUnnecesarean.com

The Silent Knife by Nancy Wainer
Ina May's Guide to Childbirth by
Ina May Gaskin
The Thinking Woman's Guide to a Better Birth by Henci Goer
A Good Birth, A Safe Birth by Diana Korte
Born in the USA by Marsden Wagner
PUSHED by Jennifer Block
Obstetric Myths Vs. Research Realities by Henci Goer
Birth as an American Rite of Passage by Robbie Davis Floyd
Pursuing the Birth Machine by Marsden Wagner

What articles should I read?
VBAC and Choice: Many Questions and a Few Answers
A Butchers Dozen
A VBAC Primer
Vaginal Births After C-section Are Not Necessarily Riskier in a Birth Center than in the Hospital
Cesarean Birth in a Culture of Fear
Once a Cesarean, Always a Cesarean: The Sorry State of Birth Choices in America
Nonhospital VBAC and the Risk of Uterine Rupture


Where do I find support? 

ICAN Local Chapters
Online VBAC Support Groups
Trust Birth Meetings
CafeMom VBAC Moms Group

 

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catho...
Nov. 9, 2010 at 8:57 PM

Thanks for the info!

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