VBAC - Vaginal Birth After Caesarean

In the state of Victoria, birth centers are "not allowed" to accept women for VBAC, even though birth centers in New South Wales can. So, for women wanting low-tech, midwifery model care as opposed to obstetric care, this greatly reduces their options. Women don't have a problem with it if they know the caesarian was necessary, but there are growing numbers of women who are realizing that their "unnecaesarians" were actually iatrogenic, so they're leery about returning to the same system that contributed to the primary caesarian in the first place. As a result, in Victoria, they have two choices. Go to a hospital - or stay home and hire an independent midwife. As a result, we have quite a few home VBAC waterbirths going on in Victoria, with excellent results.

I like the saying regarding VBAC, "It's just a birth". There are some excellent websites that go fully into the safety & risk factors, the research etc. Keep in mind, "Your scar is strong". The chance of uterine rupture or dehiscence is significantly less than other serious and rare obstetric complications. So, I feel the safest approach to VBAC is to treat it as a birth like any other - not to practice defensive 'what-could-go-wrong" obstetrics. Instead, trust birth and trust the woman. A VBAC woman is no more at risk of developing a serious complication than any of us. It is not fair to strip VBAC women of all the things that ANY woman needs to give birth with the mistaken idea of "making it safer." I think CEFM (continuous electrical fetal monitoring) is ‘cruel and unusual punishment’ for a VBAC birthing woman. I remember reading a comment from a UK midwife, "I would much rather have a midwife observing me, listening to me and in tune with me regarding any possibilities of uterine rupture, than be strapped to a machine that is supposed to detect early signs of uterine rupture, and have the staff watching the machine instead of me."

So, how to dodge CEFM during VBAC? Best way: stay home. Have your own midwife and birth pool. Have a baby. But if you choose to go to hospital for VBAC, be prepared with good research and be willing to be very clear and assertive that you do NOT give your consent to CEFM. I know of one young woman who took off the monitor, removed herself to the toilet and locked the door so that she could have her baby with out the CEFM. I also know of other hospitals where they removed the locks on the toilet doors just so women could not do that! And I know of one woman who managed to have an active labor, and even a bath, while wearing the CEFM belt. (She had a private independent midwife with her, though, to help her negotiate an active labor within the hospital system). In my experience, even with the ‘mobile’ or remote monitors that allow some ambulation, the focus is still on the machine rather than the woman, and her mobility is still curbed.

There is a plethora of evidence showing that CEFM is the kiss of death for ANY normal labor, but our culture is addicted to it and we do not care if c/s rates rise as a result - we just like our toys and our systems and our policies and we tend not to place too much credence on the voice of women: the consumers. Therefore, each individual woman has to take it on herself to research, prepare, become informed, and be clear and assertive about what she wants, what she is going to do and what she will and won't consent to. For women who are used to passively allowing others to wield the authority and make the decisions, this becomes a great learning curve towards maturity - learning responsibility and assertiveness. This maturing makes us better mothers!

For any woman who has had a previous caesarian or caesarians, who is desiring a VBAC, personal research that leads you to a place of confidence where you take responsibility for the well-being of yourself and your baby, will be essential. This goes for any woman and any birth, but particularly in the case of VBAC. Overcoming fear from the events leading to the caesarian, and from the things you were told, and de-briefing from the previous birth or births, will be part of the road to healing and confidence. Finding new knowledge and learning new skills, and choosing new support people, care providers and birth location may well be important steps in the journey.

I love what Gloria Lemay calls VBAC: "Very Beautiful and Courageous". You ARE!

You can read Gloria's blog, a fount of sound knowledge, here.

Resources:
VBAMultipleC from ICAN
A video montage of women who gave birth vaginally after multiple cesareans. There are mothers who'd had 2, 3, and 4 previous surgical deliveries; some went on to deliver in the hospital and others at home.

Question CPD from ICAN
Cephalopelvic Disproportion (CPD) is rare - yet it is vastly over-diagnosed. Here are the stories of a few women who were told their babies were too big for their pelvises by their care providers, but fortunately sought a second opinion and subsequently birthed an even BIGGER baby through that same "too small" pelvis.
VBAC = vaginal birth after cesarean
HBAC = homebirth after cesarean
HBA3C = homebirth after 3 cesareans
UBA2C = unassisted birth after 2 cesareans

International Caesarian Awareness Network
Check out their chapter on VBAC, including many helpful articles, on topics such as:
* VBAC Fact Sheet
* induction of labour
* VBAmulitpleC
* what to do if your hospital does not 'allow' VBAC

Here is a beautiful montage of one couple's VBAC after 3 cesareans. Note that her waters were broken for several days, and she had several days of start-stop labour before 'birth day' came to pass - but with patient, trusting careproviders, she was not rushed or pressured by protocols.



Teresa, the mother in this montage, wrote this to me in an email:

“I think the most important thing for a first time mother to know is:
No one can do this but you.
You are the ONLY one who can do this.
And you CAN do it.
The strength is there, inside of you.
You have everything you need to birth your baby.
And while it will be the hardest work you have ever done, there will be nothing else that will ever come close to being as rewarding when it’s all over.
The work is worth the reward.

That’s what I wish someone had said to me.
I wish someone had just continued to reiterate to me that
I *CAN* do this, there’s no doubt about it …
I was designed to birth my babies.
I don’t need a doctor to save me, or drugs to numb me, or a scalpel to cut me open.
I can birth my baby.
And so can all women.

Instead, the message I got from my care-providers was:
“We are the experts on birth. You are just the mother. We know a lot more about this and about what your baby needs than you do. Just leave it all up to us and don’t question our decisions.”

Sigh.

The worst part it – I bought it.

Understanding this and finding my truth, my strength and my confidence is how, after having three caesarians, I birthed my fourth baby vaginally, normally, at home.”


The VBAC Wars: In the trenches with women planning vaginal birth after caesarean by Cas McCullough, CANA National Spokesperson and VBAC mum. In this challenging and expertly researched article, McCullough asks: "How many women’s attempts at VBAC have been foiled by restrictive and unnecessarily interventionist policies?" and offers this plan for increasing the VBAC rate in Australia above a mere 17%:

* Respect for a woman’s right to choose to VBAC
* Accessible evidence-based information (Childbirth Connection’s booklet a good resource)
* Peer support (Birthtalk, BaBs, NBAC Clinic in WA, Birthrites, CARES-SA)
* Respect for her right to decline routine interventions
* Primary midwifery care
* Time, space and encouragement to give birth normally

Read the complete article here

Now here is some wise advice from Canadian Birth Attendant/Midwife, Gloria Lemay. Her advice about working with your natural bio-rhythms, and having a 'secret sensation time' when labour starts in the wee hours, is apt for any birth - especially first births and VBACs.

Gloria writes:
"Many births begin in the night…. the woman will get up to pee, feel her membranes release and then an hour later begin having sensations fifteen minutes apart. Because we think of birth as a family/couple experience, most women will wake up their husbands to tell them something’s starting and then, probably because we all hope we’ll bethe 1 in 10,000 women who don’t experience much pain, we start getting the birth supplies organized, fill up the water tub, etc.

I have seen so many births that take days and days of prodromal (under 3 cms. dilation) sensations and they usually begin this way. The couple distracts themselves in that early critical time when the pituitary gland is beginning to put out oxytocin to dilate the cervix. Turning on the light, causes inhibition of the oxytocin release. Many couples don’t call their midwives until they’ve got sensations coming 5 minutes apart at 7:00 a.m. but they’ve been up since midnight timing every one of the early sensations. If they had called their midwife at midnight she would have said “Turn off the light and let your husband sleep as much as possible through the night. You, stay dark and quiet. Take a bath with a candle if it helps and call me back when you thinkI should come over.”

That first night can make all the difference and yet so many couples act like it’s a party and don’t realize they are sabotaging their births right at the beginning. Staying up all night in the early part does two things–it throws off the body clock that controls sleep and waking and confuses the brain AND it inhibits the release of the very hormone you need to dilate effectively.When you begin to have sensations, I urge you to ignore it as long as you possibly can. Don’t tell anyone. Have a “secret sensation time” with your unborn baby and get in as dark a space as you can. Minimize what is happening with your husband, family and the birth attendants.

What would you rather have–a big, long dramatic birth story to tell everyone - or a really smooth birth? You do have a say over your hormone activity. Help your pituitary gland secrete oxytocin to open your cervix by being in a dark, quiet room with your eyes closed."
- Gloria Lemay, Vancouver

You can read the complete article by Gloria here

Here is an amazing film by a U.S. mother who had two caesareans and then finally - a VBA2C at home. Watch how a baby is delivered in a cesarean birth and see the dramatic difference of what both the mother and baby experience in a home water birth after cesarean. There is quite graphic footage of the actual caeareans. At the end is a letter she wrote to her Obstetrician - very powerful.


Cesarean vs. VBAC: A Dramatic Difference from Alexandra Orchard on Vimeo.

My Big Ugly VBAC - it wasn't pretty, but it was mine!

I love this blog. It is one of the most raw and honest birth stories I've ever read. This woman really encapsulates the moment when she realised she WOULD have to be "Very Brave and Courageous" to achieve her VBAC ... that she would have to muster up every ounce of her endurance and dig really deep - and do it herself. I think any first time mother, and any woman intending to VBAC, would be inspired and challenged by her story - told with great humour too!
Here's a peek inside:
"You don't understand, I really can't do this" I whined. "Doesn't he GET IT" I scream in my head, "I SUCK AT THIS!" I am caught. The contractions continue to be unbearable and I am fighting them and angry and this is definitely not helping.... I hang off of Brett. My tears are falling on his teeshirt, I grip him, hold him as if his body alone can keep me aloft on the terrible waves. I love him so much. I am so mad at him....
And Meg says "let's do this for one more hour and then we can check again and see". I snarl "HALF AN HOUR! I can't do this for an hour" and I find myself walking back towards my back yard, ending up at the steps to my deck. Pause for hellish contraction.... I stalk to the futon and order Meg to check me. "NOW". Snarling again. I don't care that I'm being rude. Just check me and tell me that nothing has changed so I can screw everything and go to the hospital and start my horrible nightmare that I knew all along was inevitable...
I absolutely did not believe I was going to be able to push the baby out. I would push during a contraction (without an urge) and then in between contractions I would float away into my fantasy of how I was going to end up in a hospital room flat on my back with someone using forceps or vacuum on me. I was imagining what position I would be in in the car while I transported. Probably hanging off of the front seat, facing backwards, kneeling on a towel. Yes, that's it. And I would have horrible tearing but it would all be worth it because at least the baby would have come out of my vagina. Yes, that's the thought process of me during pushing. What a birthing goddess I was, eh?
I was lost in my self-centered world of pain and agony and despair and self-doubt... I'm still caught in the disbelief world... I still am thinking that something is going to happen that will necessitate transfer to the hospital. Time passes. Push. Rest. Fear. Rest.
And then, I can't quite put my finger on it, but something changed. A realization came upon me. And it went something like this.
No one else can push this baby out for you.
I didn't like hearing that. Even if it was only the Voice In My Head saying it.
No one else can push this baby out for you. You have to do it. The only way out is through. You have do it. I have to do it. Me. No one else can do it. It has to be me.
WAAAAIL!!!! *WHY* can't someone else do it for me? PLEASE! That would be sooo nice, can't someone else, why not Brett, he can do it.... not me, I don't want to.
No one else.
No one.
And then I started to really push. Up until then it was mostly fake, "I guess I'll push but I don't really buy into this whole 'baby is coming out' myth that y'all are believing" pushing. It was the pushing of someone who didn't believe it would happen.
I still didn't believe it. But I knew it had to be me. So I pushed. I pushed through that pain. I now understand exactly what that phrase means. I want to go back and read through all those birth stories I read when I was pregnant the first time and jump up and down and point and say YES, YES I know what that MEANS now, I really KNOW! I know what it means to push through the pain of a contraction. I did it. No one else but me."
The other interesting part of the story is that, after mostly being active and upright throughout the labour, and squatting during pushing, a position lying flat on her back was what helped her push effectively, to bring the baby under the pubic bone. There is a big difference between the 'stranded beetle' position being the ONLY position available to you, due to being stuck on a hospital bed with an epidural - and using it intentionally during an active birth when you can still feel everything from the ribs down. It worked!