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Making the Case for VBAC: A Three-Part Interview with Dr. Hélène Vadeboncoeur (3)

[Editor's note:  This is Part Three of our in-depth interview with childbirth researcher  Hélène Vadeboncoeur, author of the recently released in English book, Birthing Normally After a Cesarean or Two. To read Parts One and Two, of this interview, go here.]

Science & Sensibility: How much does the issue of VBAC get discussed when a woman is facing a C-section during her present pregnancy/birth?

Hélène: Our society (and several care providers) is biased towards repeat cesareans, which sure has an impact on how it’s talked about. Risks of cesareans are not necessarily talked about as much as the lesser risks of VBACs. Women are asked to sign an informed consent for VBAC, without having the same information about cesareans. And there is a lot of false information circulating, like if the baby is presumably ‘too big’ you can’t have a VBAC, or if you had a cesarean for cephalopelvic disproportion, or for ‘failure to progress’, you can’t either, or if you are expecting twins, if you’re ‘too old’, etc.

Science & Sensibility: Based on your research, can you describe for us the picture of an optimally favorable candidate for VBAC?  Considering this picture of favorability, what barriers is this woman still likely to face in achieving a vaginal birth?

Hélène: It’s possible to estimate the level of risks that individual women wanting a VBAC entails. Research has shown that these factors are the most favorable, from the ‘risk’ point of view:

  • Having had one cesarean (as opposed to 2 or more)
  • An interval of at least 18 to 24 months (ideally 24 months and more) between the moment  the cesarean was done and the VBAC due date
  • Double layer sutures, for the uterine incision
  • Labour starts spontaneously
  • Having already given birth vaginally (before the cesarean)
  • And maybe a uterine scar of at least 2.3 to 2.5 mm in width (research results are contradictory at the moment)

Regarding the chances of completing the VBAC, these factors are most favorable :

  • Being younger than 30 or 35 years old (older women end up having more cesareans)
  • Having had  a cesarean for breech, fetal distress, i-e a reason that has nothing to do with the ‘functioning’ of the uterus
  • Being healthy (some studies show that being diabetic (Type 1), asthmatic, having high blood pressure, being obese*, for instance, lessen the likelihood of completing the VBAC.)
  • Expecting a baby whose estimated weight is under 4 kg.
  • Entering in labour before 41 completed weeks
  • Giving birth with a midwife

There are other factors, listed in Chapter 3 of my book. The barriers even these women are likely to face:

  • Not finding a caregiver that will accept to support her choice of a VBAC, or a hospital.
  • Not being supported by her entourage, because of the atmosphere of fear that surrounds birth in general, and VBAC in particular
  • Her own lack of confidence in her ability to give birth, linked with the increasing and quite generalized lack of confidence that women feel in our society towards their capacity to give birth.

Science & Sensibility: In Chapters 4 and 5 of Birthing Normally after a Cesarean or Two you spend a lot of time discussing the emotional and psychological aspects of planning/achieving a VBAC.  Why is this element so important?

Hélène:

  • Because women’s suffering around having had a cesarean needs to be addressed
  • Because it can be helpful for a woman to advance in the ‘healing’ of her cesarean experience (if need be) before preparing for a VBAC
  • Because a woman that had a cesarean often lacks confidence in her ability to give birth, so the psychological aspects (and mental aspects) of preparing for a VBAC needs to be addressed
  • Because achieving a VBAC can have quite a positive impact on the psychological well-being and self-esteem of a woman, as can have a vaginal birth per se.

Science & Sensibility: The end of each chapter concludes with several “Birth frames”—personal depictions of birth stories that do (and sometimes don’t) include successful VBACs.  Why spend so much time in your book offering these anecdotal experiences?

Hélène:

  • First because I’ve had lots of comments by women on how they love reading birth stories
  • Second because it helps women realize that it’s possible, that other women achieved it
  • Because it’s a form of sharing between women and they learn from each other
  • Because it can validate women’s feelings about their cesarean (reading how others experienced it)
  • Since some quote men (new fathers), it can also help some men realize that it’s possible
  • Because if offers qualitative data, instead of mainly quantitative information
  • Because it helps to balance out the more scientific parts of the book, giving it a more ‘human’ side

Science & Sensibility: Given the history and present circumstances pertaining to VBAC, where do we go from here?  More specifically, what do you envision happening in the coming decade in terms of women achieving vaginal births after cesareans?

Hélène:

  • I hope that the trend we’re in will change, because right now it’s not very encouraging. One woman at a time, let’s hope more and more women will be tempted to have a VBAC, and especially will be supported by caregivers and institutions in preparing for it and in doing it. What is encouraging for me, as a researcher, is that more and more attention has been given in recent years to birth as a normal event, that has many more dimensions than the biomedical one : there is more research on normal birth,  there are more conferences, more research centers in different parts of the world. There is now an Initiative that completes the Baby-Friendly Initiative : the International MotherBaby Childbirth Initiative, centered on the respect of women’s rights during labour and birth, on the physiology of labour and birth, on  evidence-based care, on the importance of non-separation of the mother and her baby, etc.  So this recent focus on the importance of normal birth and on the mother-baby unit adds weight to the importance of VBAC.

Science & Sensibility: What else would you like to share with our readers, not already discussed here?

Hélène:

  • First I would like to point out that for a woman, wanting to give birth herself is something totally valid, and that a woman choosing to have a VBAC is not endangering her baby. It should be an informed choice. It’s, as the NIH VBAC consensus development conference underlines it in its final report, a reasonable option. Giving birth is not only something that can be very empowering and deeply transforming for the woman, it’s something, as science increasingly shows, that benefits the baby too (going through labour prepares him or her to have an easier transition to life outside  of the uterus).
  • Then I would add that giving birth to a baby and being in total and close contact with him or her right from the first seconds after the birth helps the mother and the baby bond together. Increasingly, research also shows the benefits of this first contact that no woman ever forgets. Mother and baby belong together, and what’s happening during labour and birth has an impact on how things are afterwards. Take for instance breastfeeding and bottle-feeding : we now know that although babies can develop normally if bottle-fed, breastfeeding is not the same, and brings to both mother and baby something that bottle-feeding will never be able to give them, including protection against some diseases. For me, the same idea applies to giving birth oneself as opposed to having a cesarean. There is something in the act of giving birth, especially if the environment is supportive, that you can’t experience if you have a cesarean. We’re starting to understand it with the help of science (how hormones are at play during a birth and how they work), and research is beginning to show the possible impact of giving birth on personal growth.

[Thank you to Dr. Hélène Vadeboncoeur for the time she took out of her busy schedule to give us an excellent representation of the ground she covers in her book, Birthing Normally After a Cesarean or Two.  Go here to access the original, French version of the book.]

*Next month, Science & Sensibility will take a close look at the topic of obesity during pregnancy, including an assessment of the studies associating maternal overweight with cesarean delivery and the controversy that surrounds them.

Posted by:  Kimmelin Hull, PA, LCCE

Series: Birthing Normally After a C/S or Two, Uncategorized , , , , ,

  1. May 27th, 2011 at 11:54 | #1

    At a recent conference (wish I could remember the details of what, where, and who!) someone presented latest research that said that number of suture layers wasn’t particularly important. What did matter was the type of suture material used.

  2. May 27th, 2011 at 17:38 | #2

    I would disagree. I’ve just completed the VBAC chapter for the new edition of Obstetric Myths Versus Research Realities. New, and in agreement with other studies finding an association between single-layer suturing and scar rupture, is a study of factors associated with 96 cases of scar rupture during VBAC labor after one prior cesarean (cases)compared with 288 similar women with no scar rupture (controls). Single-layer suturing was an independent risk factor after adjusting for birth weight, interdelivery interval, induction with an unfavorable cervix, oxytocin use for induction or augmentation, and gestational age of 41 w or more http://www.ncbi.nlm.nih.gov/pubmed/20567166?dopt=Citation. Suture material (chromic catgut vs. Vicryl or Polysorb) was not associated. (I should add, though, that we still don’t know whether suturing technique plays a role.) Furthermore, a new problem with single-layer suturing has surfaced: An analysis of adhesion formation in 127 women at first repeat cesarean reported 7 times the odds of bladder adhesions (24% vs. 7%) with single-layer suturing but no relationship with adhesions at other sites http://www.ncbi.nlm.nih.gov/pubmed/20236104?dopt=Citation. Investigators theorize that double-layer closure reduces raw surgical surfaces and that traumatized surfaces generate scar tissue.

  3. May 28th, 2011 at 14:28 | #3

    @Henci Goer
    Thanks Henci. That’s very helpful. The conference had left me rather confused about how to talk about this when I’m teaching classes. One realization I’ll stick to though: birth plans/birth conversations may be more effective if they emphasize the goal (successful VBAC) more than micromanaging surgical technique.

  4. May 30th, 2011 at 14:31 | #4

    From favorable factors: labor starts spontaneously.

    I have a couple anecdotal stories. My sister was in her third pregnancy. The prior two births were by cesarean section (twin pregnancy and repeat cesarean). She went into labor at full term and the hospital was experiencing a strike (nurses I think). Staffing was very thin so she continued in labor. It was a difficult birth–long pushing phase, but my nephew was born healthy. My sister went on to have another vaginal birth after that. She avoided being induced for the 4th and went into labor on her own.

    As a labor and delivery nurse we received a patient via ambulance who was a prior c-section. She was completely dilated. We encouraged her to push while she protested that she was suppose to have a c-section. To her stunned amazement she gave birth vaginally to a healthy baby.

  5. May 31st, 2011 at 10:35 | #5

    Thank you for sharing these anecdotes, Carol!

  6. June 5th, 2011 at 09:29 | #6

    Great series! I’d have appreciated getting a taste of her perspective on VBA2C since it’s part of her title.

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