Archive for the ‘Vaginal Birth After Cesarean (VBAC)’ Category

Series: Supporting Women When a VBAC Doesn’t Happen – Part Three: Supporting The Mothers

November 12th, 2015 by avatar

By Pamela Vireday

“Remember, no effort that we make to attain something beautiful is ever lost.” – Helen Keller

cbac part 3Today we conclude our three part series on Cesarean Birth after Cesarean, written by Pamela Vireday, who is an occasional contributor to Science & Sensibility.  In this series, Pamela examines the topic of women who experience a Cesarean Birth after a Cesarean. This is when families are planning for a vaginal birth after a prior cesarean, but the birth does not go as planned.  The experiences of women who have a CBAC are often negated and their emotional and physical well-being given short-shrift by both professionals and their social community of friends and family.  The research on this topic is slim and begs for exploration by qualified investigators.  Last week, Pamela discussed the unique grief that CBAC women may experience. Two days ago, Pamela examined the limited research available on CBAC births in part two.  Today, Pamela will provide information on how to support CBAC women in the absence of published research.  There is also great set of resources in the post to share with the families you work with or include in a CBAC Resource packet you provide after birth. You can also read a companion piece of Pamela’s own personal story, “Cesarean Birth after Cesarean, 18 Years Later” on her own website.- Sharon Muza, Community Manager, Science & Sensibility.

In the first post of our series –  Supporting Women When a VBAC Doesn’t Happen – Part One: A Unique Grief, we discussed how women who want and work for a VBAC but end up with a cesarean have a unique grief that is different from a primary cesarean or an elective repeat cesarean. Many women who have experienced a CBAC say they felt unsupported and isolated. They had nowhere to tell their stories, nowhere to process their anger, and got little sympathy from those around them.

In the second post – Supporting Women When a VBAC Doesn’t Happen – Part Two: The Forgotten Mothers, we examined what research there is on CBAC mothers and found limited wisdom to guide us. In the absence of research on how best to help CBAC mothers, we must rely on the words and experiences of CBAC mothers to tell us what they need.

In the final part of our series today, we suggest concrete ways that birth professionals can support CBAC mothers, based on suggestions made by CBAC mothers themselves. Keep in mind that each story and woman is unique, and the needs of one may be different than the needs of another. The best thing to do is to follow the lead of the CBAC mother; she will tell you in word and deed how best to support her.

Create a Safe Space for the Birth Story

One of the most important things that birth professionals can do to help CBAC mothers is to give them a safe space to tell their stories ― their full stories.

CBAC mothers often edit their stories for others, leaving out their disappointment or scary details because people only want to hear the happy parts. When they try to tell the full story, they may hear, “Just get over it already” or “Oh, we’re not going to talk about that again, are we?” CBAC mothers also often self-edit their stories in order not to discourage or scare other expectant mothers. But an untold story is one that weighs heavy on the heart.

Be the safe person to whom the full birth story can be told. Be truly present while listening. Don’t armchair-quarterback her story; suspend your judgment, put aside your own birth agendas, and focus only on supporting this woman, right now, in this situation. Eliminate distractions, use attentive body language, and really focus on the woman so that she truly feels like she is being heard.

Realize that she may need to tell the story multiple times; each time she tells it, she processes it on a new and different level. Ask her, “What do you need from me right now?” so she can tell you if she wants something more than just listening. If possible, check in with the woman’s partner, who may also need help processing or understanding why the mother is still coming to terms with her experience.

“Listen. Listen. And don’t contradict. Just listen. Don’t compare. Just listen. And don’t try to make me feel better. Just listen.”     – Kristina R.

Use Creative Support Techniques

Once the mother is ready to start processing the birth story further, use reflective listening techniques. Listen to what she says, seek to understand what seems most important to her, and paraphrase back to see if you understood her point. Don’t make assumptions about how she is feeling or add judgments. Ask open-ended follow-up questions that invite her to explore her feelings if she is ready. Give her the time and space to come to her own conclusions about her experience.

Many women find that journaling, making art, singing, writing poetry, and participating in rituals is helpful in processing their emotions. This can be particularly helpful for those who get stuck in a negative feedback loop or who need to process significant trauma. Don’t be afraid to refer to a good birth-supportive therapist in your area if needed.

Validate the Mother

CBAC mothers need to have their experiences and feelings validated. Mothers need to be reminded that their hard work and accomplishments during birth are still valid, however the baby was born. Acknowledge the amazing sacrifice she made in giving up her own dreams and bodily integrity for her baby.

“CBAC women need validation. They need encouragement that every birth can be different. Above all, they need to be appreciated for the work they did both before and during the experience, the sacrifices made for their babies, and the special place inside themselves that now carries yet another scar.” – Teresa Stire

“Effort does not always equal outcome. Give yourself credit for that effort, and don’t boil it all down to the moment of birth alone.” -Melek Speros

Encourage Bonding

Bonding can be especially difficult after a physically or emotionally traumatic birth. Others may have stepped in to care for their babies, which can leave some mothers feeling incompetent or disconnected.

Start by encouraging more time with the baby. Promote as much skin-to-skin contact as possible; this helps produce more oxytocin and may help breastfeeding too. Some women find bathing or napping with babies to be very healing.

It can be helpful to compartmentalize grief behind an emotional door so women can focus on their baby’s immediate needs, on their older children, and on their own physical needs. However, it’s important that women schedule time periodically to take out the grief, actively work through it, and then put it away. Otherwise, grief may intrude on the bonding process.

Give the Mother Support Resources

Create a CBAC Resource Packet that you can email or hand out as needed. Include a list of CBAC support sites, CBAC brochures, and names of local postpartum doulas or birth therapists. Edit it to each woman’s unique situation.

The International Cesarean Awareness Network (ICAN) has a new brochure about CBAC, which will be available soon in its store, as well as a website dedicated specifically to CBAC, including an archive of CBAC stories. In addition, there is a closed ICAN support group on Facebook just for CBAC mothers.

Although not all CBAC mothers experience post-traumatic stress symptoms, having birth trauma resources in the CBAC Resource Packet puts the ball in the mother’s court and lets her decide the emotional ramifications of her experience. It also gives her concrete options for reaching out for further support, possibly even long after your working relationship with her is over.

Help Her Connect with Other CBAC Mothers

CBAC moms are their own best mentors. This may be the only place CBAC women find others who truly “get” what they are going through.

The unique feelings around CBACs may mean that birth groups, especially those centering on VBACs, could be uncomfortable for a while. Many CBAC mothers feel intensely jealous when hearing other women’s easy birth stories. They may need to insulate themselves for a bit. Taking a break from birth-related groups for a while can be healthy and self-protective; she can return when she is ready.

Of course, not every support resource is perfect. Encourage CBAC mothers to be careful about whom they seek support from. Many well-meaning people say hurtful things like, “Just be grateful you got a healthy baby,” or “You’re just lucky you didn’t die!” CBAC mothers need to find support that will not inadvertently trigger or hurt them more.

Acknowledge Unique Circumstances

Each CBAC is unique, and each may carry its own particular color of pain.

Some women had CBACs because their providers suddenly withdrew support for VBAC at the end of pregnancy or during labor. Some faced so many interventions and conditions during their labors that a CBAC seemed almost inevitable. Some experienced mistreatment and abuse during their experience.

On the other hand, some women had very supportive providers but still ended with a CBAC. Others felt they had a “prudent CBAC,” a difficult but sensible choice because of fetal distress, poor fetal position, rising blood pressure, or other complications. Some had an “empowered CBAC,” where there was powerful learning and healing to help balance the disappointment.

Some women have multiple CBACs, each with their own emotional resonance. Some have a VBAC and then a CBAC, which has its own particular pain. A few have had the bitter experience of having lasting physical and emotional damage from their CBAC, including uterine rupture, hysterectomy, or loss of their baby.

As always, each person’s experience is different, and each CBAC mother needs their unique experiences honored.

“Try on” a CBAC

“Trying on” a CBAC can help birth professionals have a deeper empathy for the unique grief of a CBAC mother.

Consider what it might feel like to have a CBAC. Let yourself feel what it might be like to hope and dream for a VBAC and then not have one, to have to tell everyone afterwards that you didn’t VBAC after all, to listen to the naysayers who believe your body really is broken and who tell you that you should have just scheduled a cesarean section, to listen to other women’s easy birth stories and feel envious all the time.

Walking in someone else’s shoes for a while gives people a better appreciation for the difficulties and the bittersweet feelings surrounding disappointing life events. More empathy for CBAC mothers is definitely needed in the birth community.

Contact the Mother Periodically to Check In

CBAC is a bit of an emotional rollercoaster and feelings will change over time. The way the mother feels immediately after a CBAC will probably not be the same as a few months or a year later. Check in with her periodically to see how she is feeling about everything and whether there is any way you can support her further. This is especially important for CBAC mothers who have experienced a major trauma.

It’s not unusual for CBAC mothers to experience emotional upset around the six month mark, on the child’s first birthday, or even later. A quick check-in can affirm that someone remembers and cares about what she is going through.

Discuss Future Pregnancies

Another common point of emotional crisis for CBAC mothers is when the mother considers having another child. At that time she revisits her fear and trauma from past births, decides whether to have more children, and if so, may be torn over whether to choose a repeat cesarean or another VBAC trial of labor (TOL).

Although conventional medical wisdom holds that once a woman has had a CBAC, she has shown she cannot birth vaginally, the reality is that a number of CBAC women go on to have a VBAC in future pregnancies, and the American College of Obstetricians and Gynecologists (ACOG) is supportive of VBAC after two cesareans. Women who choose a TOL in this situation may need particularly strong emotional support as they work through their fears and concerns from both a primary cesarean and a CBAC.

However, it’s also important to remember that sometimes a VBAC is truly medically contraindicated, the woman is done having children, or does not wish another TOL. Although VBAC is no longer an option, that doesn’t mean these women are at peace with past or future CBACs. They may still need support too. Little research has been done on how to support this group as they integrate their experiences into their lives. In particular, information is needed on how to support women who experienced significant emotional trauma during birth (Beck and Watson, 2010).

Believe That Healing Can Be Had

Life gives us all disappointments and sometimes these remain bittersweet forever. As with other griefs, you never truly “heal” from a CBAC; the disappointment and loss of that birth is always there, and it never goes away. However, birth professionals need to communicate that – with time and distance – women often come to some sort of peace with the experience.

If given the chance to process their feelings thoroughly, women eventually have enough distance from it to not grieve as sharply, to find lessons or growth in the experience, and to be able to integrate the disappointment of it into their lives.

Some transform the power of the CBAC experience into advocacy, becoming health care workers themselves or advocates in birth-related fields. Others practice micro-advocacy by informally helping birthing women they encounter in their personal lives.

Women don’t have to ever be grateful for their CBACs, but in time they can recognize that good things can spring from difficult things, and that great trauma can lead to great growth. The process is not quick or facile, but it can happen. And birth professionals can be a vitally important part of that process.

“My joy [in my births] has gradually returned. I am learning now to honor my experiences…We are not failures, we are no less brave than the women who accomplish the VBAC goal. I keep reminding myself that I will never climb Mount Everest, either, and will probably not accomplish some of the other things I think I want in my life. Maybe this missed childbirth opportunity is just that ─ another missed opportunity ─ and maybe we can find some other accomplishments/ life experiences to compensate. Maybe.”       -K

“Today, 12.5 years after my first CBAC, I can honestly say how much growing and learning came from it and for that I am grateful.” -Teresa Stire

“My CBAC made me the compassionate advocate I am today.” -Melek Speros

Resources for CBAC Mothers

Here are a few select resources that may be helpful to CBAC mothers. If you know of more, please add them in the comments section.

CBAC Resources

CBAC Support Groups

General Birth Trauma Support Organizations

Articles on CBAC Recovery

Birth Trauma Articles



Beck CT, Watson S. Subsequent childbirth after a previous traumatic birth. Nurs Res 2010 Jul-Aug;59(4):241-9. PMID: 20585221

About Pamela Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Image from Wikimedia Commons.

Pamela Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 20 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.


Cesarean Birth, Childbirth Education, Guest Posts, Maternal Mental Health, Maternity Care, Medical Interventions, PTSD, Series: Supporting Women When a VBAC Doesn't Happen, Vaginal Birth After Cesarean (VBAC) , , , , , , ,

Series: Supporting Women When a VBAC Doesn’t Happen – Part One: A Unique Grief

November 5th, 2015 by avatar

By Pamela Vireday 

“Although the world is full of suffering, it is also full of the overcoming of it.”  –Helen Keller

CBAC part 1I am delighted to share with you a three part series that begins today, written by Pamela Vireday, who is an occasional contributor to Science & Sensibility.  In this series, Pamela examines the topic of women who experience a Cesarean Birth after a Cesarean. This is when families are planning for a vaginal birth after a prior cesarean, but the birth does not go as planned.  The experiences of women who have a CBAC are often negated and their emotional and physical well-being given short-shrift by both professionals and their social community of friends and family.  The research on this topic is slim and begs for exploration by qualified investigators.  Today, Pamela discusses the unique grief that CBAC women may experience.  Part two will examine the limited research available and part three will provide information on how to support CBAC women in the absence of published research.  We will also conclude the series with a useful resource list to share with the families you may work with  who find themselves in this situation.  You can also read a companion piece of Pamela’s own personal story, “Cesarean Birth after Cesarean, 18 Years Later” on her own website.- Sharon Muza, Community Manager, Science & Sensibility.

It is a hard truth that not all women who want a VBAC will have one.

In a typical high-intervention hospital setting, about 60-80% of women who attempt a VBAC will have one. (Grobman 2010) That’s a terrific, strong reason to support VBACs.

The underappreciated flip side of this statistic, however, is that about 20-40% of women who attempt a VBAC will have another cesarean instead, often after a long, hard labor. Yet little attention has been paid to these women and their families. How do they feel about their experience? How is their emotional journey different than after a primary cesarean or an elective repeat cesarean? What do these women need to integrate this experience into their lives?

Anecdotally, many women report that they did not feel supported after a VBAC attempt  (referred to as TOLAC – Trial of Labor after Cesarean) that ended in another cesarean. Some even felt judged or deserted by their care providers and friends. Research shows that the physical recovery is often harder, too. Yet little attention has been paid in the research to the needs of these women, and few resources exist that directly address their experiences.

Where is the support for women who have an undesired, unplanned second cesarean? Where is the acknowledgement of all the work they put in towards a VBAC, the hours of labor, the pain, the worry? Does all that preparation and work not count if one does not end up with a VBAC?

How can we in the birth field better support the women who do not have a VBAC? How can we help all mothers feel supported, regardless of outcome?


The first thing that we can do is to be mindful of our terminology.

Obstetric research typically uses the terms “Failed VBAC” or “Failed Trial of Labor After Cesarean” (Failed TOLAC). Many women feel that this terminology is judgmental and insensitive, adding to their emotional wounds at a time when they feel most vulnerable. Women who did not get a VBAC are not failures. The reality of birth is much grayer than a black-or-white, success-or-failure binary equation.

The term, “trial of labor cesarean,” is a better alternative than “failed VBAC.” However, it is cumbersome and perpetuates the mentality of being “on trial.”

Members of the International Cesarean Awareness Network (ICAN) created the more-neutral term “Cesarean Birth After Cesarean” (CBAC) as an alternative. It helps distinguish between a repeat cesarean that was gladly chosen and one that occurred when a mother planned and worked for a VBAC but didn’t get one.

Most of the time, CBAC refers to a woman who labored and then had a repeat cesarean. However, sometimes CBAC can also refer to an unwanted repeat cesarean performed before labor for legitimate medical reasons, because the mother was coerced or scared into a repeat cesarean, or because she was unable to find a supportive provider. The point is that an undesired cesarean is going to have a different emotional resonance than one which was wanted.

Some women prefer “CSAC” (Cesarean Surgery After Cesarean). We will use “CBAC” here because its meaning is intuitive and it is a logical companion term to “VBAC” but women should choose the term that feels right for their experience.

Women’s Stories

Women who have had CBACs often report that they did not receive adequate emotional support from birth professionals, friends, or family after the birth.

“When it comes to support, I had tons when PLANNING the VBAC but once it turned into a CBAC? Everyone disappeared. No one was willing to talk to me about it. No one really had information to GIVE me about a ‘failed VBAC.’ “Sarah Vincent

“I remember after my failed [VBAC] attempt how much I needed to share my story, talk about my disappointment and sadness, and process what went wrong. But it seemed as though nobody wanted to hear it. It was almost as if my CBAC might be contagious so I should refrain from talking much about it.” Teresa Stire

Personally, I had a CBAC after 5 hours pushing with no progress. My doula made me feel like I had given up too soon. She left soon after the cesarean and I never saw or heard from her again, despite the fact that she was supposed to do a postpartum visit. Her abandonment spoke volumes. Sadly, her judgment was only the first of many from the birth world.

CBAC mothers often feel their decisions are second-guessed like this. Well-meaning people will go through a CBAC mother’s birth story, looking for “wrong” decisions that caused the CBAC. Sometimes CBAC stories are used as cautionary tales to other hopeful VBAC mothers. Even when there are things a CBAC mother might have changed about her decisions, being held up as an example of “what not to do” is incredibly hurtful.

Furthermore, the grief around a CBAC is different in some ways than that around a primary cesarean; women tend to feel more “broken” after a CBAC, as if their bodies had truly failed them, and many feel isolated and unsupported. Yet the birth community treats CBACs as if they are no different from primary cesareans. CBAC mothers have shared:

“I personally felt screwed by careproviders after my 1st CS, but after my 2nd I felt screwed by my body― I truly was broken.” Elaine Mills

“The isolation of CBAC is another aspect that may be relatively unknown. I felt very isolated ― from vaginal birth moms, from Elective Repeat Cesarean moms (ERCS) moms, and very much from VBAC moms. This has been very toxic for me.”   Rebecca H.

“Validating the…compounding nature of that loss (as opposed to a primary c/s) ― the nail in the coffin feeling ─ is so important.” Caroline Kelley

A CBAC is not experienced in the same way as a primary cesarean or an elective repeat cesarean. The grief resonates differently, even if the CBAC was prudent or necessary. Yet seldom is the unique nature of this loss acknowledged. How can we, as birth professionals, recognize these differences and support these women through this emotional journey? More on this in the Part Two of the series on Tuesday.


Grobman, W. A. (2010, August). Rates and prediction of successful vaginal birth after cesarean. In Seminars in perinatology (Vol. 34, No. 4, pp. 244-248). WB Saunders.

About Pamela Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Image from Wikimedia Commons.

Pamela Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 20 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.


Cesarean Birth, Childbirth Education, Guest Posts, Series: Supporting Women When a VBAC Doesn't Happen, Vaginal Birth After Cesarean (VBAC) , , , , , , , , , , ,

Planned Home VBAC in the United States, 2004–2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making – Interview with Study Author Melissa Cheyney, PhD, CPM, LDM

September 15th, 2015 by avatar


“Planned Home VBAC in the United States, 2004–2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making” came out on August 26th as an e-pub ahead of print in the journal Birth: Issues in Perinatal Care. It provides a much-needed analysis of VBACs in the home setting in the United States. To help the birth professional community better communicate the findings with students, clients and others considering home birth after cesarean (HBAC), Jeanette McCulloch of BirthSwell interviewed Melissa “Missy” Cheyney, PhD, CPM, LDM, one of the paper’s authors. The abstract of the paper, lead-authored by Kim Cox, CNM, PhD and co-authored by Marit Bovbjerg PhD, MS and Lawrence M. Leeman MD, MPH, can be found in an online-only version here. Additional insights specifically for midwives can be found at the MANA blog. – Sharon Muza, Community Manager, Science & Sensibility

Jeanette McCulloch: Tell me about the new study looking at outcomes for families planning a trial of labor after cesarean (TOLAC) at home.

Melissa Cheyney: This study is significant because it is the largest study to date on outcomes for women and babies who attempt a TOLAC at home in the United States. We were able to create two subsamples from the MANA Stats 2.0 data set: 12,092 multiparous women without a prior cesarean and 1,052 women with a prior cesarean. This enabled us to compare outcomes for women who went into labor intending to deliver at home and had a previously scarred uterus with those who did not. Our goal was to provide whatever information we could (given our sample size) about the potential risks and benefits of attempting a VBAC at home.

JMc: The actual number of people who are planning TOLACs is relatively small. Why did you think this research was important?

MC: We know that as long as the primary cesarean section rate in the US remains above 20% (it’s currently 21.5%), and as long as many women continue to desire more than one baby, families will be faced with important decisions about what to do in subsequent deliveries. Because there are well-known risks to repeat cesareans as well as to a trial of labor after cesarean, we wanted to make sure that we could provide women who are considering a VBAC (and especially a VBAC outside of the hospital) with as much information as possible to support shared decision making.

JMc: What were the top findings of the study?

MC: First off, we found relatively high success rates. Overall, women with a prior cesarean had a VBAC success rate of 87%. Most of these were HBACs. While some women who who transferred to the hospital during labor went on to have a VBAC in the hospital, most had cesareans for “failure to progress.” Women who had also had a previous vaginal birth had a success rate of 90.2%, and those who had a previous VBAC had an even higher rate of success at 95.6%. These rates are among the highest reported in the literature across places of delivery and provider types.

We also found that women who had a previous cesarean were more likely to need to transfer care to the hospital in the intrapartum period than were women without a previous cesarean. So the transfer rate for women who were attempting a VBAC at home was 21.7% compared to 8.5% for multiparous women who did not have a previously scarred uterus.

We also found that, for those women who transferred, the most common reason that they transferred was a slow, non-progressive labor and not a uterine rupture or anything emergent. We also were able to calculate a combined intrapartum and neonatal mortality rate in the group that had a prior cesarean, and that was 4.75 out of 1000 compared with a rate of 1.24 out of 1000 in multiparous women without a history of cesarean. This is a highly statistically significant difference, and means that we know there is some elevated risk for women who’ve had a prior cesarean relative to a woman who’s already had a baby and who has no scarring of the uterus.

JMc: You had some interesting findings that suggest that not all TOLACs have the same outcomes. Tell us about that.

MC: We also performed some sub-group analyses where we compared women who were having a trial of labor after cesarean with other groups. We compared them to first-time mothers and to women who had a previous vaginal birth and a cesarean and were now attempting a VBAC after a cesarean. We were able to get pretty nuanced findings about relative risk within the TOLAC group.

In other words, we found that there is variation in risk within the TOLAC subsamples. So, just to say that VBAC is dangerous or that TOLAC at home has a high success rate doesn’t really give the full picture. You can break down this group, look at it much more closely, and get a better sense of how to talk with clients about the risks of TOLAC at home under their specific circumstances. Just as success rates vary by obstetric history, so do risks associated with VBAC. Our study is certainly the first study to do that for a large sample of planned HBACs

JMc: What advice do you give to families that may be considering HBAC in your practice?



MC: I say that it’s important to look at success rates, but that it is also important to think about the likelihood of an intrapartum transfer, distance from the hospital, and a variety of other factors that are unique to each person. I actually think that looking at the cases that did not have good outcomes can be very informative. They help us to see who might be a reasonable candidate for an HBAC and who might not be. For example, in our dataset there were five deaths overall—three during labor or in what we call the intrapartum period, one that was early neonatal (or the first 7 days of life), and one that was late neonatal (out to 28 days after birth). Those all occurred in the TOLAC group, yielding death rates of 2.85 for intrapartum, .95 for early neonatal, and .95 for late neonatal. So for the combined intrapartum and neonatal mortality rate, the total is 4.75 out of 1000.

When we look at these cases more closely, we see that two of the cases were very likely uterine ruptures, based on the heart tone patterns that the midwife was able to distinguish at home. The three other ones were deaths that were totally unrelated to the TOLAC status of the mother. One involved known risk factors related to giving birth to a twin, the second one was a surprise breech with an entrapped head, and the third one was a cord prolapse. So three of the five deaths likely had nothing to do with the fact that the mother had had a previous cesarean.

JMc: It’s surprising to see mothers with this kind of risk profile delivering at home. Can you help us understand why you think a mother, for instance, one that is attempting a twin VBAC birth at home, might choose that?

MC: In these kinds of cases, you have to ask this: if you have someone who has a cesarean for her first birth and she gets pregnant subsequently, what happens to her if she has twins in her second pregnancy? Who is going to offer her a TOLAC? What if she happens to be breech at term in the pregnancy following an unplanned and often unwanted cesarean? These women, who have a compounding of risk, have no chance, very likely, of finding a provider in the hospital who’s going to support these births. So, it might seem odd that out of only 1000 VBACs, you’d have this scenario. But it does make sense, if you think about the fact that these women might be the most likely to be excluded from a trial of labor in the hospital. This actually kind of fits with something else we found.

Regions of the US that have low rates of VBAC access in the hospital, the southeast, for example, have a higher percentage of the total births contributed to MANA Stats that are VBACs. When you look on the west coast, in states like Oregon, Washington, and California, where VBACs are more readily available in the hospital, even though there are more contributors and more data coming from the west coast, the total proportion of births that are VBACs is significantly lower in our data set. We take that to mean that when women have the option to try VBAC in the hospital, there is less pressure to attend those women at home. In a state where you have very limited access to hospital VBAC, those midwives are more commonly approached by women who are feeling forced to explore the option of a home birth for a VBAC because they can’t acquire one in their local hospital. That is both concerning and a reminder that even though we often discuss the US maternity care system as less well integrated than, say, the Netherlands, nonetheless, the various models and options for birthing care in this country do impact each other. We should all be working together to make birth safer for all women.

JMc: How do you think these findings should influence families that are considering a trial of labor after cesarean at home? What advice do you have for them?

MC: I think these findings have ramifications for everyone who’s considering a home birth, not just women who are considering a home birth after a cesarean, because one of the most interesting things that we’ve found is that that risk within our sample varies considerably by obstetric history and parity. What I mean by that is that a woman who does not have a previously scarred uterus, and she’s already had a baby vaginally, her risk is incredibly low. It is difficult to find a negative outcome in that group.

The next safest group to be delivering at home is actually women who have had a cesarean, but have also had a vaginal birth. They are less risky than first time mothers as a group. Then the highest risk, along the VBAC status and parity continuum, is a woman who has never had a vaginal birth, but has had a cesarean.

So, the range of risk goes from the lowest risk: a multiparous woman (multip); to a multip with a cesarean and a previous vaginal birth; to a nulliparous woman: and then to a woman who has never had a vaginal birth but has had a previous cesarean. Both deaths from suspected uterine rupture occurred in this later group. Each mother had had only one prior cesarean. That’s a really important thing to keep in mind, and I think that’s where our policy implications lie as well. States that want to restrict all HBACs need to be looking much more closely at the research, especially if some of this work is replicable with larger samples, because there is a nuancing of risk within subgroup. It may not make sense, for example, to allow nulliparous births at home but restrict all VBAC mothers with any prior cesarean history, regardless of the fact that they may have had a previous vaginal birth or a prior VBAC. These women who live within an appropriate distance to a hospital, have well documented placenta positions and adequate time between births may actually be lower risk than a first time mother.

JMc: What advice do you have for policy makers who might be considering HBAC regulations in their state?

MC: Over the course of my career, I’ve seen the data on home and birth center safety, patient selection, ethics, the benefits of normal physiologic birth — so multiple components of midwifery care and birth outside of the hospital — grow so quickly. I recommend setting the scope of practice for midwives in rule (sometimes called regulations or administrative laws) rather than statute. In many states, it is very difficult to get a statute changed, whereas it is often much easier to open your rules or regulations over a period of every few years, for example, to examine new research and make sure that you are writing rules/regulations that support evidence-based practice for midwives. It is an exciting time to be working on some of these questions. Data from registries like MANA Stats and the American Association of Birth Centers’ Perinatal Data Registry should enable us to engage in critical, ongoing quality assurance and quality improvement at national, state and individual practice levels. I think we need to find ways of regulating home birth that stay open, flexible and responsive to the data, to the needs of the families we serve, and to the guidance of medical ethicists who are equipped to help us sort through difficult questions related to choice, individual autonomy and relative risk.

About Melissa Cheyney and Jeanette McCulloch

Melissa Cheyney head shot 2015Melissa Cheyney, PhD CPM LDM is Associate Professor of Clinical Medical Anthropology at Oregon State University (OSU) with additional appointments in Public Health and Women’s Studies. She is also a Certified Professional Midwife in active practice, and the Chair of the Division of Research for the Midwives Alliance of North America where she directs the MANA Statistics Project. She is the author of an ethnography entitled Born at Home (2010, Wadsworth Press) along with several, peer-reviewed articles that examine the cultural beliefs and clinical outcomes associated with midwife-led birth at home. Dr. Cheyney is an award-winning teacher and was recently given Oregon State University’s prestigious Scholarship Impact Award for her work in the International Reproductive Health Laboratory and with the MANA Statistics Project. She is the mother of a daughter born at home on International Day of the Midwife in 2009.

Jeanette McCulloch head shot 2015Jeanette McCulloch, BA, IBCLC has been combining strategic communications and women’s health advocacy for more than 20 years.  Jeanette is a co-founder of BirthSwell, helping birth and breastfeeding organizations, professionals, and advocates use digital tools and social media strategy to improve infant and maternal health. She provides strategic communications consulting for state, national, and international birth and breastfeeding organizations. A board member of Citizens for Midwifery, she is passionate about consumers being actively involved in health care policy.


Babies, Cesarean Birth, Guest Posts, Home Birth, informed Consent, Maternity Care, Midwifery, New Research, Newborns, Research, Vaginal Birth After Cesarean (VBAC) , , , , , , , , , , ,

Too Bad We Can’t Just “Ban” Accreta – The Downstream Consequences of VBAC Bans

April 2nd, 2015 by avatar

By Jen Kamel

April is Cesarean Awareness Month (CAM), and throughout the month, Science & Sensibility will be covering issues that are directly related to the number of cesareans (1,284,339 in 2013) performed every year in the United States.  To start our CAM series off, Jen Kamel, founder of VBACFacts.com, shares important information about placenta accreta.  Tomorrow, April 3rd, is the Hope for Accreta Awareness National Blood Drive, as part of the 30 Day Hope for Accreta Challenge sponsored by the Hope for Accreta nonprofit that provides consumer information and offers support to families affected by placenta accreta. – Sharon Muza, Community Manager, Science & Sensibility

cam lamaze 2015Even though the American College of Obstetricians and Gynecologists (ACOG) and the National Institutes of Health (NIH) have described vaginal birth after cesarean (VBAC) as a safe, reasonable, and appropriate option for most women, VBAC bans (hospital or practice wide mandates that requires repeat cesareans for all women with a prior cesarean) remain in force in almost half of American hospitals. It’s true that scheduled repeat cesareans almost always successfully circumvent the most publicized risk of VBAC (uterine rupture) by virtually eliminating its incidence and for this reason, many people celebrate and credit the repeat cesarean section for resulting in a good outcome for mother and baby. But what most people do not consider is that VBAC bans translate into mandatory repeat cesareans, and those surgeries expose women and babies to a condition far more life-threatening and difficult to treat than uterine rupture: placenta accreta.

Photo Credit: http://fetalsono.com/teachfiles/PlacAcc.lasso

Photo Credit: http://fetalsono.com/teachfiles/PlacAcc.lasso

Placenta accreta occurs when a placenta abnormally attaches to (accreta), in (increta), or through (percreta) the uterine wall. No one knows exactly why some women develop accreta other than there is some abnormality in the area where the fertilized egg implants (Heller, 2013). Anyone who has had a prior surgery on her uterus is at a substantially increased risk of accreta and, as it happens, cesarean section is the most common surgery in the United States (Guise, 2010). In fact, the rate of accreta has grown along with the rate of cesarean surgery: from 1 in 4,027 pregnancies in the 1970s, to 1 in 2,510 pregnancies in the 1980s, to 1 in 533 from 1982-2002 (American College of Obstetricians and Gynecologists [ACOG], 2012). That rate escalates to 1 in 323 among women with a prior uterine surgery and the risk rises at a statistically significant rate with each additional cesarean section (Silver, Landon, Rouse, & Leveno, 2006).

Up to seven percent of women with accreta will die from it (ACOG, 2012). After the baby is born, the placenta does not detach normally, causing bleeding, which can’t be stopped before the doctors are able to either surgically remove the placenta or perform an emergency cesarean hysterectomy. Babies die from accreta due to the very high rate of preterm delivery associated with accreta. In fact, 43% of accreta babies weigh less than 5.5 lbs (2,500 gm.) upon delivery (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013). Accreta is not a routine complication. Accreta is serious.

As Silver (2006) points out, the risk of accreta after two cesareans (0.57%) is greater than the risk of uterine rupture after one prior low transverse cesarean during a non-induced/augmented planned VBAC (0.4%) (Landon, Hauth, & Leveno, 2004). In other words, women are literally exchanging the risk of uterine rupture in a current pregnancy for the more serious risk of accreta in future pregnancies. This poses a striking public health issue when you combine what the CDC (2012) has reported for numbers of unintended pregnancies–49%–and the lack of access to vaginal birth after cesarean: over half a million repeat cesareans every year, resulting in higher rates of accreta.

Yet due to the nonmedical factors that inhibit access to VBAC and influence how the risks and benefits of post-cesarean birth options are communicated to the public, women are rarely informed of these risks in a transparent and straightforward way. Additionally, it can be very difficult for the woman to obtain social support when confusion and fear about giving birth after cesarean remains the norm.

Given all this, providers are ethically obligated to inform patients of the future implications of their current mode of delivery. However, it can be especially difficult for providers working within the political climate of a hospital where VBAC is banned to frankly inform their patients of this reality. How can providers clearly explain to women the risks and benefits of their options, with VBAC as a viable option, when they do not offer that option at the facility? Such a situation could even result in professional ramifications for the provider, like revocation of hospital privileges. Additionally, some providers do not offer VBAC, “not because of an explicit hospital policy against it, but because [they] were unwilling to stay in the hospital with a woman attempting [a planned VBAC]” (Barger, Dunn, Bearman, DeLain, & Gates, 2013).

It is for this reason that some argue that VBAC bans create a conflict of interest among providers (ACOG, 2011; Charles, 2012). On one hand, they are bound by ethical obligations to the patient’s well-being, respect for patient autonomy, and support of an informed decision-making process. But these obligations are threatened by financial and professional ties to the hospital.

ACOG stresses throughout their guidelines and committee opinions that informed consent and patient autonomy are paramount (ACOG, 2011). They share how obstetrics should be moving from a paternalistic system to a more collaborative model (ACOG, 2013). They acknowledge that women should be allowed to accept increased levels of risk (ACOG, 2010). They assert how there is no “right” or “wrong” answer, only what is right or wrong for a specific woman (ACOG, 2010). And they are clear that restrictive VBAC policies cannot be used to force women to have a repeat cesarean or to deny a woman care during active labor (ACOG, 2010).

Yet, with 48% of women interested in the option of VBAC, 46% of them cannot find a provider or facility to attend their VBAC (Declercq, Sakala, Corry, Applebaum, & Herrlick, 2013). Only 10% of U.S. women have a vaginal birth after cesarean, as opposed to another cesarean (National Center for Health Statistics, 2013). Barriers to VBAC remain firm.

Those barriers often include one-sided counseling to women of the risk of uterine rupture in a VBAC. Rarely are they told of the complication rates of accreta, which are higher across several measures. This is true when we look at maternal mortality (7% vs. 0%) (ACOG, 2012; Guise, et al., 2010), blood transfusion (54% vs. 12%) (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013; Barger, et al., 2012), cesarean hysterectomy (20-70% vs. 6%) (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013; Barger, et al., 2012), and maternal ventilation (14% vs. 3%) (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013; Barger, et al., 2012). Further, 5.8% of accreta babies will die within the first week of life (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013) in comparison to 2.8 – 6.2% of uterine rupture babies (Guise, et al., 2010).

Accreta results in higher rates of mortality and morbidity because it requires a complex response which most hospitals are not equipped to provide. A 2012 study advises, “Treatment of placenta accreta is best accomplished in centers that have the expertise to handle the management, which involves multiple disciplines, including blood bank, interventional radiology, anesthesia, and surgical expertise, gynecologic oncology, urology, or obstetric subspecialty expertise” (Heller, 2013).

It ís worth noting that uterine rupture does not require this level of response in order to generate a good outcome. As Aaron Caughey, OB-GYN and Chairman of the Department of Obstetrics and Gynecology at Oregon Health & Science University in Portland explains, “From an obstetrician standpoint, there are no particular special skills to managing a VBAC. Even in an emergency situation, we all have the surgical skills to deal with it” (Reddy, 2014).

Because some hospitals are not equipped to manage an accreta, some women who are diagnosed prenatally find themselves traveling hundreds of miles away from their family in order to deliver with accreta specialists.

At 19 weeks pregnant, Dawn was diagnosed with percreta, the most severe form of accreta where the placenta goes through the uterine wall and attaches to other structures in the abdominal cavity. She had nine prior pregnancies. Dawn was among the 93% of women who were never informed of the risks of accreta when she was pregnant after her first, second, or third cesarean (Kamel, 2014). All she heard were the dangers of VBAC. Thus, she had three cesareans.

Mother after cesarean hysterectomy in ICU. © Dawn Johnson-Baranski

When she got pregnant again, she heard the word accreta for the first time upon her diagnosis as is the case in 59% of women diagnosed with accreta (Kamel, 2014). Dawn ultimately traveled from her home in rural Virginia to Houston, Texas, at 27 weeks pregnant, to the Fox-Texas Children’s Pavilion for Women, an accreta specialty center. Due to complications related to her precreta, her son was delivered by cesarean hysterectomy at 33 weeks. Her son spent 19 days in the NICU before they could return back home to Virginia (personal communication, March 30, 2014).

It’s because accreta is so dangerous, complex to treat, and unknown to the general public, that professionals and researchers are sounding the alarm about the risk exchange that happens when repeat cesarean is chosen (or forced) over VBAC. As Dr. Elliot Main, Medical Director of the California Maternal Quality Care Collaborative, cautions, “In California, we are seeing a lot of hysterectomies, accretas, and significant blood loss due to multiple prior cesareans. Probably the biggest risk of the first cesarean is the repeat cesarean” (Main, 2013). (The state of California has a 9% VBAC rate, just a point below the national rate) (State of California Office of Statewide Health Planning and Development, 2013). A 2009 study from the Netherlands advises, “Ultimately, the best prevention [of uterine rupture] is primary prevention, i.e. reducing the primary caesarean delivery rate. The obstetrician who decides to perform a caesarean has a joint responsibility for the late consequences of that decision, including uterine rupture” (Zwart, et al., 2009). And a 2012 study warns, “Because cesarean delivery now accounts for about one-third of all deliveries in the United States, rates of abnormal placentation and subsequent hysterectomy will likely continue to rise” (Bateman, Mhyre, Callaghan, & Kuklina, 2012). By reducing the primary cesarean rate and increasing access to VBAC, we could also reduce the incidence of accreta, cesarean hysterectomy, and hemorrhage.

Following multiple uterine rupture lawsuits in the 1990s, some hospitals crafted their restrictive VBAC policies around litigation fears. However, the concern over lawsuits resulting from “VBAC gone wrong” may soon be overshadowed by the worry of being sued when women or babies die from accreta, after failing to adequately respond to this dangerous condition and/or denying access to VBAC (Associated Press, 2013; Children to sue hospital over death of mother, n.d.). This will certainly become the case as the public becomes more aware of the connection between VBAC bans, cesareans, and accreta.

It could also become a public relations nightmare as Americans begin to realize that litigation fears–not patient safety, drive hospital policy. This becomes more likely as more women are diagnosed with accreta.

As mothers are the ones who carry the risk of either uterine rupture or accreta, shouldn’t they be the ones deciding which set of risks are tolerable to them? As ACOG (2010) says, “the ultimate decision to undergo [planned VBAC] or a repeat cesarean delivery should be made by the patient in consultation with her health care provider” –  not by hospital administrators, malpractice insurance companies, or providers who simply don’t want to deal with VBAC.

As Dr. Howard Minkoff (2010) shared at the 2010 NIH VBAC Conference, “We should be starting with a sense of what’s the best interest of the mother. Unfortunately, the decision here is not always who are better equipped, it’s more like who are willing. There are a lot of hospitals that are quite capable of providing VBACs but exercise an option not to do it particularly if there’s someone nearby that will take that on for them.”

Hospitals around the country, and particularly those that are located in areas where VBAC bans mean that all women have repeat cesareans, are seeing and will continue to see increasing numbers of accreta. They have no choice but to manage it – which can be especially problematic for smaller facilities in rural areas that don’t offer the sophisticated response accreta requires.

But motivation remains the driving factor in hospital VBAC policy even in rural hospitals. Take the five small community hospitals in New Mexico that serve the Navajo Nation. As Dr. Jean Howe (2010), their Chief Clinical Consultant for Obstetrics, shared at the 2010 NIH Conference, these rural facilities collectively deliver 3,000 babies each year and maintain a 15% cesarean rate and a 38% VBAC rate. Numbers like that just don’t happen. They are the result of motivated administrators, providers, and patients who want VBAC to be an option at their facility.

The bottom line is, VBAC bans simply delay risk. The sooner hospital administrators and the American public realize this, the sooner we can mobilize–reducing future risks of accreta by making VBAC a viable option in more hospitals. It is one thing for a woman to knowingly plan a repeat cesarean understanding this risk. That is her choice as both VBAC and repeat cesarean come with risk. However, it is unconscionable when a woman is not presented with her options and she develops accreta in a subsequent pregnancy.

As the American public becomes more aware of the serious risks associated with repeat cesarean, will more providers and facilities be sued as a result of accreta-related complications and death? Will it have to come to fear of litigation, again, in order for hospitals to throw aside their current VBAC bans, listen to what the NIH, ACOG, and the medical research has to say; to create an environment that is supportive of VBAC, respect a mother’s right to make her own medical decisions, and prepare accreta-response protocols?

Women are entitled to understand what that first cesarean means in terms of their future birth options and their long term health. Consumers and providers should work with hospital administration to reverse VBAC bans, review current VBAC policies to insure they are aligned with national guidelines and evidence, and improve response times for obstetrical emergencies through team training and drills (Cornthwaite, Edwards, & Siassakos, 2013). Providers should have frank conversations with patients about the immediate and long-term risks and benefits of their options within the context of intended family size, acknowledging that sometimes the stork delivers when you’re not expecting it. This is about administrators, providers, professionals, and consumers working together for better processes and healthier outcomes. Let’s get to work.


American College of Obstetricians and Gynecologists. (2010, August). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics & Gynecology, 116(2), 450-463. Retrieved from http://dhmh.maryland.gov/midwives/Documents/ACOG%20VBAC.pdf

American College of Obstetricians and Gynecologists. (2011). Code of Professional Ethics. Retrieved May 16, 2013, from ACOG: http://www.acog.org/About_ACOG/~/media/Departments/National%20Officer%20Nominations%20Process/ACOGcode.pdf

American College of Obstetricians and Gynecologists. (2012, July). ACOG Committee Opinion No. 529: Placenta accreta. Obstetrics & Gynecology, 201-11. Retrieved from http://www.acog.org/Resources%20And%20Publications/Committee%20Opinions/Committee%20on%20Obstetric%20Practice/Placenta%20Accreta.aspx

American College of Obstetricians and Gynecologists. (2013). Elective surgery and patient choice. Committee Opinion No. 578. Obstetrics & Gynecology, 122, 1134-8. Retrieved from http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Ethics/Elective_Surgery_and_Patient_Choice

Associated Press. (2013, Nov 25). $15 million awarded in Illinois childbirth death lawsuit. Retrieved from Insurance Journal: http://www.insurancejournal.com/news/midwest/2013/11/25/312169.htm

Barger, M. K., Dunn, T. J., Bearman, S., DeLain, M., & Gates, E. (2013). A survey of access to trial of labor in California hospitals in 2012. BMC Pregnancy and Childbirth. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636061/pdf/1471-2393-13-83.pdf

Barger, M. K., Nannini, A., Weiss, J., Declercq, E. R., Stubblefield, P., Werler, M., & Ringer, S. (2012, November). Severe maternal and perinatal outcomes from uterine rupture among women at term with a trial of labor. Journal of Perinatology, 32, 837-843. Retrieved from http://www.nature.com/jp/journal/v32/n11/full/jp20122a.html

Bateman, M. T., Mhyre, J. M., Callaghan, W. M., & Kuklina, E. V. (2012). Peripartum hysterectomy in the United States: nationwide 14 year experience. American Journal of Obstetrics & Gynecology, 206(63), e1-8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21982025

Charles, S. (2012, Jul-Aug). The Ethics of Vaginal Birth After Cesarean. The Hastings Center Report, 42(4), 24-27. Retrieved from Medscape: http://onlinelibrary.wiley.com/doi/10.1002/hast.52/abstract

Cornthwaite, K., Edwards, S., & Siassakos, D. (2013). Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies. Best Practice & Research Clinical Obstetrics and Gynaecology, 27, 571-581. Retrieved from http://www.bestpracticeobgyn.com/article/S1521-6934(13)00051-5/abstract

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlick, A. (2013). Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection. Retrieved from http://www.childbirthconnection.org/article.asp?ck=10450

Eshkoli, T., Weintraub, A., Sergienko, R., & Sheiner, E. (2013). Placenta accreta: risk factors, perinatal outcomes, and consequences for subsequent births. American Journal of Obstetrics & Gynecology, 208, 219.e1-7. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23313722

Guise, J.-M., Eden, K., Emeis, C., Denman, M., Marshall, N., Fu, R., . . . McDonagh, M. (2010). Vaginal Birth After Cesarean: New Insights. Rockville (MD): Agency for Healthcare Research and Quality (US). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK44571/

Hale, B. (n.d.). Children to sue hospital over death of mother. Retrieved from Daily Mail: http://www.dailymail.co.uk/health/article-129801/Children-sue-hospital-death-mother.html

Heller, D. S. (2013). Placenta accreta and percreta. Surgical Pathology, 6, 181-197. Retrieved from http://www.surgpath.theclinics.com/article/S1875-9181(12)00183-3/abstract

Howe, J. (2010). National Institutes of Health VBAC Conference, Day 2, #04: Public Comments. 14:45-17:08. Retrieved from Vimeo: http://vimeo.com/10898005

Kamel, J. (2014, Dec 14). Online poll of 227 women with prior cesareans.

Landon, M. B., Hauth, J. C., & Leveno, K. J. (2004). Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery. The New England Journal of Medicine, 351, 2581-2589. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMoa040405

Main, E. (2013). HQI Regional Quality Leader Network December Meeting. San Diego.

Minkoff, H. (2010). National Institutes of Health VBAC Conference, Day 2, #04: Public Comments. 11:16. Retrieved from Vimeo: http://vimeo.com/10898005

National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. (2012, Apr 4). Unintended Pregnancy Prevention. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/index.htm

National Center for Health Statistics. (2013). User Guide to the 2012 Natality Public Use File. Hyattsville, Maryland: National Center for Health Statistics. Retrieved from ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2012.pdf

Reddy, S. (2014, Dec 8). A type of childbirth some women will fight for. Retrieved from Wall Street Journal: http://www.wsj.com/articles/a-type-of-childbirth-some-women-will-fight-for-1418081344

Silver, R. M., Landon, M. B., Rouse, D. J., & Leveno, K. J. (2006). Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries. Obstetrics & Gynecology, 107(6), pp. 1226-1232. Retrieved from http://journals.lww.com/greenjournal/fulltext/2006/06000/maternal_morbidity_associated_with_multiple_repeat.4.aspx

State of California Office of Statewide Health Planning and Development. (2013, December 17). Utilization Rates for Selected Medical Procedures in California Hospitals, 2012. Retrieved from http://www.oshpd.ca.gov/HID/Products/PatDischargeData/ResearchReports/Hospipqualind/vol-util_indicatorsrpt/

Zwart, J. J., Richters, J. M., Ory, F., de Vries, J., Bloemenkamp, K., & van Roosmalen, J. (2009, July). Uterine rupture in the Netherlands: a nationwide population-based cohort study. BJOG: An International Journal of Obstetrics and Gynaecology, 116(8), pp. 1069-1080. Retrieved January 15, 2012, from http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02136.x/full

About Jen Kamel

Jen kamel head shot 2015Jen Kamel is a consumer advocate and a leading national speaker on the medical facts and political, historical climate surrounding vaginal birth after cesarean.  She is the founder of VBACFacts.com and has brought her workshop “The Truth about VBAC: Politics, History and Stats” to over 900 people around the country, giving accurate, current information about post-cesarean birth options directly to families, practitioners, and professionals.

Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Maternal Mortality, Maternal Quality Improvement, Pregnancy Complications, Vaginal Birth After Cesarean (VBAC) , , , , , , ,

The Childbirth Educator’s Role in The Cesarean Epidemic: 10 Steps You Can Take Now!

April 29th, 2014 by avatar

As Cesarean Awareness Month (April 2014) comes to a close, I wanted to share ten things that childbirth educators can do in their childbirth classes to support families to avoid unneeded cesareans, help families to have a cesarean birth that is respectful and family centered and support families who give birth by cesarean, (planned or unplanned) both during the birth, in the postpartum period and when planning future births.

1. Birth plan exercises

Have your birth planning/birth choices activity include preferences for a cesarean birth.  Allow parents the option to select items such as delayed cord clamping, skin to skin in the operating room, delaying newborn weights and measurements, and more.  While these may not be available options in all areas, encouraging discussion amongst families and their health care providers is a good place to start.  Additionally, consider role playing a cesarean section in class and discuss ways to make the procedure family friendly.  Remember to suggest ways that the partner and other support people can best support mother and baby during the surgery. Consider sharing “The natural caesarean: a woman-centred technique” video so families can explore options for a family friendly cesarean birth.

2. Access teaching resources on the Lamaze International website

Lamaze International offers some great teaching resources on cesareans for educators on their website and for families on the Lamaze International parent site.  There are two infographics that cover the topic of cesarean sections; “Avoiding the First Cesarean” and “What’s the Deal with Cesareans.”  You might consider showing the brand new infographic video to your families in class. At only 3 minutes long, it does a great interactive job of highlighting important information. In addition to using these materials in class, encourage families to explore them more thoroughly at home.

3.  Provide current statistics

Access and share statistics about national and provincial or state cesarean rates and VBAC rates, along with local rates for facilities and providers if available.  Help your families to understand the difference between overall cesarean rates and primary cesarean rates and why facilities caring for high risk mothers or babies might have higher rates.  Make sure that you are providing the most current information available, and update your figures when new numbers are released. Encourage discussion in class with families who are considering changing birth location or providers if they feel so inclined.

4. Encourage the use of birth doulas

The addition of trained labor support has been shown to reduce common interventions and cesareans. (Hodnett, 2012)  Take some time during class to share how doulas can help support both the laboring woman and her partner and team.  Provide resources for families to locate doulas (DONA.org and DoulaMatch.net are two such lists that come to mind) and briefly share information on questions to ask a doula during an interview, so the families are prepared.

cam two ribbon5.   Share current best practice information

Be sure that the information in your classes is current, accurate and based on best practices and evidence.  Know the sources of the information you cover.  Make sure it is up to date and verifiable.  Have a short list of favorite online resources to share with families, including Lamaze International’s Giving Birth with Confidence blog- written specifically for parents.  Utilize the references that make up the Six Healthy Birth Practices, there is a citation sheet for all six of the birth practices.

6. Support the midwifery model of care

Share information in your classes about the midwifery model of care, which has been shown to be an appropriate choice for healthy, low risk women.  Let your class families know how to find a midwife by using the search functions on the American College of Nurse-Midwives website and information on finding a midwife on the Citizens for Midwifery website.

7. Have meaningful class reunions

If your childbirth class includes a reunion, create a space for all the families to share their stories, both the vaginal births and the cesarean births.  Honor the work that the families did to birth their babies and celebrate their intention and teamwork.  Highlight their shining moments and let them know that you recognize how hard they worked.  Model excellent listening skills and support all the families as they share their birth stories.

8. Provide support group information

Make sure that all families that leave your class have been given resources for a support group for women who birth by cesarean section.  Access the International Cesarean Awareness Network (ICAN) to find the nearest local ICAN chapter website or Facebook group. Or refer the families to the main ICAN Facebook page.  VBACFacts.com also has a large peer to peer support network active on Facebook as well.

9.  Share postpartum resources

Families that birth by cesarean section might find themselves needing additional support from professionals during the postpartum period.  Be sure that they have resources to find lactation consultants, mental health counselors, postpartum doulas, physical therapists and other professionals that might be useful for healing emotionally and physically from a cesarean section.  In the throes of postpartum hormones, exhaustion, sleep deprivation and physical recovery, having to hunt down appropriate professionals can be a daunting task for any new families, never mind a mother recovering from surgery with a newborn.

10.  Offer a cesarean only class

Some families know they will be needing a cesarean for maternal or infant health circumstances and are hesitant about taking the standard childbirth class, feeling like they won’t fit in.  While they may not be needing the coping skills or comfort techniques and pushing positions that you cover in the typical childbirth class, they do need information about the cesarean procedure, pain medication options, recovery, breastfeeding and newborn care/procedures and informed consent and refusal information, among other things.  Having a class designed with their needs in mind can help them to make choices that feel good to them and participate in the community building that is such an important part of childbirth classes.

Don’t underestimate the role of the childbirth educator (you!) to offer evidence based information, appropriate resources, respectful dialogue along with skills and techniques to help women to have the best birth possible, avoid a cesarean that is not needed and recover and heal  while feeling supported with options for future births.  Thank you for all you do to help women to avoid cesareans or if needed, have the best cesarean possible.


Hodnett, E. D., S. Gates, et al. (2012). “Continuous support for women during childbirth.” Cochrane database of systematic reviews: CD003766.

Cesarean Birth, Childbirth Education, Giving Birth with Confidence, Healthy Birth Practices, Lamaze International, Maternal Quality Improvement, Maternity Care, Medical Interventions, Midwifery, Practice Guidelines, Vaginal Birth After Cesarean (VBAC) , , , , , , ,

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