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

May 27th, 2011 by avatar

[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 , , , , ,

Making the Case for VBAC: A Three-Part Interview with Dr. Hélène Vadeboncoeur (2)

May 26th, 2011 by avatar

[Editor’s note:  Today presents Part Two of the three-part interview with childbirth researcher  Hélène Vadeboncoeur, author of the recently released in English book, Birthing Normally After a Cesarean or Two. To read Part One of this interview, go here.]

Science & Sensibility: Help us to understand a woman’s chances of undergoing a VBAC, based on where and with whom she chooses to give birth.

Hélène: Let’s say first that most women can give birth vaginally, and that on average, 3 women out of 4 complete a VBAC after they begin labour. True contraindications to VBAC are rare. Having a ‘classical’ incision (its name is misleading, it’s not done very often), i-e a vertical uterine incision done in the upper part of the uterus, is considered as being a contraindication by most medical associations, as is a previous uterine rupture. ACOG also includes extensive transfundal uterine surgery. Factors related to a woman’s chances of undergoing a VBAC have a lot to do with the ‘environment’ in which it’s prepared and done. Finding a doctor or a midwife who is supportive of their choice, finding a place of birth where people are not scared by VBAC, is important (and if all factors are not there, the woman’s determination and support from a doula is crucial), as is giving birth in a place where the physiology of birth is supported, where it’s considered a multi-dimensional event (familial, social, cultural, and, for some, spiritual event). The presence of a doula can be very important, for a woman that previously gave birth by cesarean, because she may lack confidence in her capacities to give birth (notwithstanding the fact that as shown by multiple studies, the presence of a doula has beneficial effects on labour). Statistics also show that a woman’s chances of completing a VBAC increases if her caregiver is a midwife, for instance (up to 97 %).

Science & Sensibility: You attended the March 2010 National Institutes of Health Conference on VBAC.  Do you feel the recommendations coming from that conference were ultimately helpful, or harmful to women interested in achieving a vaginal birth after cesarean?

Hélène: I have mixed feelings about this conference. While it was very good to review the scientific literature on VBAC and related issues, the group of invited experts did not include women who had cesareans/VBAC nor grassroots organizations like ICAN, for instance. Happily though, the conference was open to the public, so individuals and organizations could comment or question what they heard from the invited experts (either in person at the conference or via the Internet). Another element of the conclusions of the final report was their saying that with regards to VBAC and repeat cesarean “benefit for the woman may come at the price of increased risk for the fetus and vice versa.”  I don’t agree with this point of view. Although risks vary for the women, their babies, in vaginal births and in cesareans, it does not make sense to oppose the interests of the mother and of her baby. And a cesarean presents a higher number of risks than a vaginal birth, as Childbirth Connection showed.

The conference was helpful though in the following ways: by pointing out gaps in research, by saying  that, “given the available evidence, TOL (I don’t like that term, ‘trial-of-labor’) is a reasonable option for many pregnant women with a prior low transverse incision” and that one of their major goals is to support pregnant women… to make informed decisions about TOL versus ERCD. They also urged providers to incorporate an evidence-based approach into the decision-making process.

So I would conclude by saying that this conference was more than necessary (it was the first consensus development conference on VBAC), that it helped look at the situation and understand it, but that it did not position itself unequivocally in favor of  VBAC (the position of the earlier consensus conferences in the 80s on cesarean about VBAC was clearer).

Science & Sensibility:  In Chapter Two of your book, you review the risk assessment of various types of childbirth.  With increasing rates of labor induction occurring in many developed nations, can you help our readers understand the comparative risk of uterine rupture for women undergoing labor induction with synthetic oxytocin, with prostaglandin gels and during a VBAC?

Hélène: In my book, I center on VBAC and cesarean. What the research has shown, is that induction presents increased risks for a uterine rupture during VBAC (separation of the uterine incision), especially the use of prostaglandin gels. It seems that oxytocin use is not as risky, as concluded the NIH VBAC Conference (some studies have shown than its use can increase the risk of uterine rupture and others not). And regarding the use of oxytocin for acceleration of labour, it’s not contraindicated but it should at the least be used with caution.

Science & Sensibility: You mention that 90% of cesareans are prompted by controversial indicators for operative surgery.  What are the top three controversial reasons C-sections are performed?

Hélène: The top ? I don’t know. The more frequent ? Maybe.

Dystocia: is a category frequently mentioned as the reason to do a cesarean (failure to progress, cephalopelvic disproportion). It’s quite a vague category (lots has been put under that name), and often the approach to birth in hospitals leads to malfunctioning of labour–like preventing women to move, having them lay in bed on their back, withholding nourishment, breaking the waters or administering oxytocin which leads to a cascade of interventions (contractions more painful, epidural or Demerol, stimulation of labor, continuous monitoring, etc.). Epidurals can also affect labour.

Fetal distress : EFM readings and interpretations are not always right (mistakes), and cesareans are performed without the baby being necessarily in danger

Breech baby : A cesarean is not necessarily better for all babies that are breech, as research in recent years has shown

[Tomorrow, during Part Three of this interview, Dr. Vadeboncoeur discusses informed consent prior to cesarean delivery, in terms of future VBAC, optimal candidacy for achieving a VBAC and the barriers that make it more difficult, as well as the emotional and psychological aspects of vaginal birth after cesarean and more…]

 

Posted by:  Kimmelin Hull, PA, LCCE

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

Making the Case for VBAC: A Three-Part Interview with Dr. Hélène Vadeboncoeur (1)

May 25th, 2011 by avatar

[Editor’s note:  For the remainder of this week on Science & Sensibility, we will feature an in-depth, three-part interview with childbirth researcher  Hélène Vadeboncoeur, author of the recently released in English book, Birthing Normally After a Cesarean or Two. You will find the dialogue contained in this interview (and the contents of Vadeboncoeur’s book) both informing to childbirth professionals, as well as to the women we serve.]


Science & Sensibility: Tell us about what inspired you to write this book.

Hélène: I wrote this book to let women who had a cesarean know about the possibility that they could give birth themselves, afterwards. In this era of ever-increasing cesarean rates, and of less and less access to VBAC, it’s important that women know about this possibility so they can ask for it, if they wish to have one. I personally had my first child by cesarean, and the second one was born naturally. These experiences changed my whole life, and led me to work for humanization of childbirth and to get a PhD in order to do research in this area.

Science & Sensibility: Based on your research and experience, what are the compelling reasons we can share with our expectant clients as to why a woman should consider VBAC and why clinicians should support them?

Hélène: Because a VBAC is safer for the woman and it helps the baby adapt to extra-uterine life, lessening the risks for him or her to suffer from respiratory distress (some studies point out a smaller risk of death also for the baby).

Because most women can have their baby vaginally.

Because a VBAC facilitates mother-baby contact right after the birth, facilitating bonding.

Because giving birth can be for the woman an empowering, transformative and fulfilling experience that can have a positive impact on her, on her relationship with her baby, and on the rest of her life.

Science & Sensibility: In the Introduction, you mention this book as being for pregnant women who’ve had a cesarean section before, and for their partners.  Are there other people out there who should read this book as well?

Hélène: I have many times realized that caregivers don’t always have a good knowledge of VBAC, which hampers women’s access to it or desire to have one. Often this lack of information on their part can make them say scary things to pregnant women. I had lots of comments by readers (doctors, nurses, midwives), that health care professionals should also read my book!

Science & Sensibility: In your introductory “birth frame,” you describe your own experiences with both a traumatic cesarean section, as well as a vaginal birth after cesarean.  You depict your efforts to find a consultant (obstetrician) who would, in fact, be willing to attend a VBAC as harrowing.  Why does this type of difficulty so often still exist today for most women seeking a VBAC?

Hélène: Since the middle of the 90s, after a climbing rate of VBAC following two consensus conferences on cesarean (in USA and in Canada), VBAC rates started to decline. There are many reasons that could explain why:

  • One is that inductions became more and more common, in general, and medical milieu were not aware of the increased risks of this intervention for VBAC. More uterine ruptures followed. We had to wait until 2001 before a large-scale study warned about the risks of induction, in particular of the use of prostaglandins (Lydon-Rochelle et al, 2001). Caregivers got scared of VBAC uterine ruptures, without realizing the role of induction in it. And even if induction was seen to be the risk factor, the results of this study (and others) were communicated either by editorials in journals (NEJM) or by newspaper journalists in the following way “VBAC is dangerous.”  Medical associations, who had initially been supportive of VBAC, became more and more cautious in their recommendations. However, the basic risk of VBAC (uterine rupture) has not changed : it’s small, being between 0.2 or 0.6 % (NIH says between 0.3 and 0.7 %).
  • Lawsuits happened following VBAC that did not turn out good.
  • Cesarean is becoming so common that it’s considered a ‘normal’ way to have a baby, and its risks are forgotten or not talked about much.
  • The atmosphere of fear that surrounds childbirth in general has also an impact on VBAC. We all live in this culture of fear : the caregivers, the women, their partners, etc. It’s one of the biggest roadblocks to want – and obtain – a VBAC.
  • Cesareans are seen as ‘perfect care’ or as ‘better for the baby’ (neither of this is necessarily true) and women can be considered selfish because they want to have a VBAC for the sake of it, ‘forgetting’ their baby’s well-being.

Science & Sensibility: Many people believe birth options are only a “big deal” to birthing women and yet, you beautifully included your husband Steven’s memories about the births of your children in this book.  Why was this an integral part of your manuscript?

Hélène: Because when I wrote the first edition of my book, in French, I did it as a woman helping other women who were in the situation I found myself in. So it was natural for me to include my birth stories. And since men experience emotions around the birth of their child, it seemed important to include my husband’s views. Having a baby concerns both, the pregnant women and her partner/husband.

Science & Sensibility: Chapter One begins with a depiction of the current situation surrounding VBAC.  Can you give us a primer on what this looks like?

Hélène: VBAC is now only happening for a small minority of women, because lots of hospitals banned access to it, because caregivers became afraid of it, so did women. It’s a lot more convenient for doctors to do a cesarean than to wait until labor starts… And in a private health care system, it also pays more.

Also, as is summarized at the end of the chapter, “our modern view of childbirth is linked to our deep-seated values, particularly in relation to the emphasis on technology, the control of our lives in every aspect, the avoidance of pain and our frenetic lifestyles, etc.”

[Stay tuned:  In Part Two of this interview, Dr. Vadeboncoeur addresses success and risk assessment associated with VBAC, non-evidence-based reasons for moratoriums on VBAC, the March 2010 NIH Conference on Vaginal Birth After Cesarean and top controversial reasons c-sections are performed.]

Posted by:  Kimmelin Hull, PA, LCCE

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

Blog Carnival Round-Up: Stories of Success from the Field

January 28th, 2011 by avatar

It really is a joy and, I believe, imperative to spend time sharing childbirth success stories amongst those of us who dedicate our professional lives to improving childbirth experiences and outcomes for women all around the globe.  This year’s first blog carnival is about just that:  celebrating success while illuminating some ways in which Lamaze’s Six Healthy Birth Practices can and have been implemented in the process of realizing these successes.

Lisa, at Journey Through Lamaze, shared with us a lovely story of one of her recent clients who allowed labor to start on its own, and labored at home long enough before checking into the hospital to find herself fully dilated and ready to begin pushing shortly after admission.  Having begun with Healthy Birth Practice #1, this mama progressed through a non-medicated birth which Lisa describes as, “…the calmest birth I’ve ever been at.”  (Read Lisa’s post to find examples of other Healthy Birth Practices exemplified during this baby’s birth.)

Childbirth Educator, Judith, from Dance While You Cook relates how she incorporates teaching the importance of walking, moving around and changing positions throughout labor (Healthy Birth Practice #2) into her childbirth preparation classes.  Beyond “typical” teaching strategies, Judith shows her students how movement in labor can be effective by demonstration through a labor and birth dramatization. Read her post, and I guarantee you, you will pick up on the renewed energy and empowerment Judith gains each time she conducts this portion of her curriculum.

Many of our carnival contributors wrote about experiencing childbirth from a doula’s point of view.  Wendy from Mom and Little Me wrote about her strong belief in extending Healthy Birth Practice #3 into the prenatal period as much as possible.  It is during the prenatal visits that some of her most effective doula support takes place.  (Follow the link to Wendy’s post to also read about her ambitions for educating “a younger generation on natural childbirth and breastfeeding.”)  Hillary at Infinitely Learning shares with us a lovely anecdote about the birth of one of her doula clients that showed her the importance of holding space and bearing witness to the great journey of another human being, as she describes below:

She was a really independent birther and mostly needed the midwives and me (the doula) there for reassurance during some strong moments, but mostly I just stood Witness. A couple of times I doubted that I was even needed and became self-conscious that I wasn’t doing enough, but when I checked in internally to be guided I heard, “Witness”.

Kate, at Two Bee Birth Services shared the story, as written by the mother, of a successful, un-medicated VBAC.  With a history of multiple medical interventions during previous birth experiences plus some other recent pregnancy-related complications, this mama pursued a vaginal birth in the safest way possible, considering a present and extenuating medical circumstance.  In order to do this, she dedicated herself to avoiding interventions that were not medically necessary (Healthy Birth Practice #4) and succeeded in achieving the VBAC she hoped for.

Providing a fantastic success story that illustrated all six Healthy Birth Practices, in the setting of one birth, “Anthro Doula” Emily at Doula Ambitions simply and beautifully describes the end of one of her first birth experiences as a doula:

Once in the labor and delivery room she crawled up onto the bed on all fours, following her instinct and her urges to push on her own. She changed positions to a squat, leaning against the back of the raised bed, so that she would be able to catch her own baby. (Healthy Birth Practice 5: Avoid giving birth on your back and follow your body’s urges to push!)

This is my favorite part of the story, and my favorite part of any birth so far…
While the baby’s head was crowning, she reached down and felt his head, and she looked up with a face full of wonderment and said, “His head is coming out and then going back in a little!” She was so calm and intrigued, fully experiencing the birth of her first child. Then she pushed out her baby and pulled him up onto her stomach, all the while calm and grinning like mad!

The husband had tears streaming down his face, and the new mother was immensely pleased with herself. Mama and baby stayed together, skin-to-skin, and began to initiate breastfeeding, for the whole first hour.
(Healthy Birth Practice 6: Keep mother and baby together – It’s best for mother, baby and breastfeeding)

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Thank you to all blog carnival contributors for your thoughtful words and illustrative stories which collectively remind us that safe, healthy, fulfilling birth experiences are not an anomaly, but an achievable reality!
**Don’t forget to swing on over to Giving Birth With Confidence to read additional results of this blog carnival!

Posted By:  Kimmelin Hull, PA, LCCE

Blog Carnivals, Doula Care, Healthy Care Practices, Practice Guidelines, Vaginal Birth After Cesarean (VBAC) , , , , , , , , , , , ,