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Reasonable Choices for Bringing Back VBAC

September 27th, 2011 by avatar

[Editor’s note:  This article by Amy Romano was originally posted on Childbirth Connection’s Transforming Maternity Care site, September 12, 2011 and is re-purposed with permission.]

 

When I recently updated Childbirth Connection’s VBAC or Repeat C-Section Topic to reflect the findings of a government-sponsored systematic review and national consensus recommendations, I was struck by how few of the facts have changed in the years since the government’s previous VBAC evidence report. While there are more data than before, we already knew that the risks of uterine rupture in labor were about 1 in 200, that accumulating cesareans sharply increases the likelihood of life-threatening complications in future pregnancies, and that there are few situations when planned VBAC is objectively unreasonable. Although the evidence has not abated the precipitous drop in VBACs, perhaps unprecedented national consensus about the importance of prioritizing VBAC services, an increasingly savvy grassroots movement, and urgent calls from obstetric leaders will begin to move the needle.

As we shift the conversation from whether to do VBACs to how to enable more of them, focus on quality and safety in the context of VBAC is long overdue. According to new government statistics (pdf), one in five of the more than 4 million births each year in the United States occur to women who have previously given birth by cesarean. If evidence supports VBAC as a “reasonable option” for most of this population – and indeed the better option for many – it is time to be reasonable about how to make VBAC as safe, accessible, and satisfying as it can possibly be.

In the absence of nationally endorsed quality measures for VBAC, payment reform to provide better incentives to offer and achieve VBAC, and care coordination to help pregnant women navigate the health care system (all urgently needed), we turn to the broader concept of maternity care quality to offer a framework for high-quality VBAC care. We’re interested in hearing what VBAC quality improvement projects exist in your community, and are eager to feature them in our TMC Directory.

A QUALITY FRAMEWORK FOR VBAC

1. Help more women make and implement choices that are informed by the best quality evidence and aligned with their own values and preferences.

Rationale: While much attention has been given to ACOG’s “Level C” recommendation to undertake planned VBAC “in facilities with staff immediately available to provide emergency care,” this recommendation is superseded by their “Level A” recommendation to “counsel women about VBAC and offer [trial of labor]” to appropriate VBAC candidates. In addition, “decision quality,” i.e., the extent to which choices align with a woman’s stated preferences and values and available evidence, is a marker of overall health care quality. Not to mention, honoring people’s informed choices is the legal and ethical standard, acknowledged by all major health care bodies.

Current approach: Few women have a choice at all. According to the VBAC Policy Database, a voluntary monitoring project by the International Cesarean Awareness Network, half of U.S. hospitals either ban VBAC outright or have no providers willing to attend VBACs. In our most recent national Listening to Mothers survey, more than half of women interested in a VBAC were denied the option, usually because of provider refusal or hospital policies. In areas where VBACs are “offered,” women must often meet eligibility criteria that are not supported by high-quality evidence. Informed consent processes typically solicit consent for VBAC but may not provide a special consent process for repeat cesareans, despite the fact that repeat cesareans pose different and in some cases much more serious risks than first cesareans.

Why this is inadequate: Both planned VBAC and planned repeat cesarean section are reasonable choices with important potential benefits and harms but the trade-offs are very different. The current approach, which ostensibly is intended to reduce the already low likelihood of avoidable perinatal death or injury and associated liability, has resulted in significant collateral damage: most notably an increased risk of maternal mortality and a growing prevalence of life-threatening complications for both mothers and babies in future pregnancies. We are also seeing troubling care patterns, including court-ordered repeat cesareans, women laboring in hospital parking lots so they can show up just in time to give birth and avoid the pressure for a cesarean, and a sharp increase in the number of women with prior cesareans choosing to give birth at home, sometimes with no skilled provider present at all. The Agency for Healthcare Research and Quality (AHRQ) team that conducted the 2010 systematic review on VBAC versus routine repeat cesarean referred to the VBAC access issues as “chilling,” an assessment with which we at Childbirth Connection agree.

Another approach: We urgently need evidence-based, field-tested shared decision making tools to communicate the research evidence and help women clarify their preferences and values. We have seen a commitment to this approach in Canada, the United Kingdom, and Australia, but thus far nothing in the U.S. (a situation we hope to change through our Shared Decision Making Maternity Initiative). Although decision support tools can help a woman select the best choice for her, system barriers including payment incentives, liability concerns, and clinician education must be addressed simultaneously to ensure that she can implement her choice. Assessing the potential for shared decision making tools and processes to reduce liability should be a research priority.

2. Maximize the proportion of women planning VBAC who experience uncomplicated vaginal births

Rationale: Morbidity in VBAC labors is concentrated in the subset of women who have unplanned repeat c-sections. These risks include infection, hemorrhage, blood clots and emotional distress. In addition, having a VBAC reduces risks in subsequent pregnancies and virtually ensures that future births will be vaginal, while having a repeat cesarean sharply increases risks in subsequent pregnancies and virtually ensures that future births will be surgical. Finally, repeat cesarean costs payers significantly more than VBAC and has significant downstream economic costs because of these effects in subsequent pregnancies.

Current approach: Clinicians and researchers seem to have responded by focusing on selecting the women most likely to have a vaginal birth. Several researchers have attempted to create prediction tools to select these women, and some clinicians and hospitals have imposed strict eligibility criteria for planned VBAC. Significantly less attention has been given to prenatal and intrapartum interventions and care processes that may enhance a woman’s likelihood of having a safe vaginal birth.

Why this is inadequate: Calculating the likelihood of vaginal birth can provide helpful information to women making an informed choice to plan a VBAC or repeat cesarean. However, even women with a lower-than-average likelihood of vaginal birth usually have a better than 50-50 chance. Moreover, some groups with lower likelihoods of vaginal birth, such as women with high BMI or multiple prior cesareans, also face significantly higher than average likelihood of harm if they end up with a cesarean. The AHRQ systematic review concluded that none of the available prediction tools adequately selected women for successful trial of labor.

Another approach: The AHRQ systematic review researchers emphasized the need to incorporate “non-medical factors” in prediction tools to enhance their usefulness. These factors, which include liability concerns, the nature and extent of informed decision-making, and provider and birth setting characteristics, appear to have a stronger effect on VBAC likelihood than factors intrinsic to the woman. In addition, research is urgently needed to identify labor care strategies to promote safe vaginal birth in women with prior cesareans, in particular the potential contribution of midwives and doulas. A randomized controlled trial examining the impact of doula care on VBAC labors is currently underway in Canada.

3. Provide the best possible response to obstetric emergencies including uterine rupture

Rationale: Uterine rupture occurs in about 4.7 per 1000 VBAC labors and is an obstetric emergency requiring prompt delivery. Although the outcome of uterine rupture is usually favorable for both infants and mothers, morbidity and mortality may be minimized if the team is prepared, communicates well, and responds quickly and in a coordinated fashion.

Current approach: The small chance of a sudden emergency with high risk of serious fetal and maternal harm resulted in ACOG’s recommendation that surgical and anesthesia staff should be “immediately available” for VBAC labors. Although in 2010 ACOG clarified that women should be able to make an informed choice for a VBAC despite this recommendation, or be referred to another facility, the response to the possibility of uterine rupture continues to favor simply prohibiting women from planning VBACs.

Why this is approach is inadequate: The singular focus on availability of a surgical team has created a situation where women in communities without these resources must consent to unwanted and potentially unneeded cesareans in order to access any maternity care at all. It also assumes that availability of surgical resources automatically translates into an optimal outcome, but unprepared or ineffective care teams may not be able to avert preventable poor outcomes despite being “available.” The AHRQ review researchers identified several other obstetric emergencies that occur with similar frequency as uterine rupture and result in similar likelihoods of serious harm but for which the obstetric community does not deem 24/7 cesarean capability to be necessary.  For these obstetric emergencies, rather than forbidding labor, hospitals have begun focusing on proven patient safety strategies like enhancing teamwork, implementing checklists, and conducting drills and simulations.

Another approach: As noted above, obstetric emergencies requiring prompt cesarean delivery can happen in any labor and in any birth setting. The emerging concept of “high reliability obstetrics” provides a framework for preventing adverse events and managing them in a consistent fashion when they occur despite prevention efforts. This requires a multi-disciplinary commitment to preparedness, teamwork, communication, and documentation. Various safety courses teach teamwork and management of emergencies in obstetrics. A systematic review of multi-disciplinary simulation training found that such programs improved knowledge, practical skills, communication, and team performance in acute obstetric situations and were associated with improved neonatal outcome.

BRINGING BACK VBAC

If VBAC is a reasonable option for most women, we need a reasonable approach to ensuring quality and safety in VBAC. Like maternity care generally, transforming VBAC care will take multi-stakeholder commitment to system reform. With so much inertia in the system, consumers and advocates must maintain a strong voice to push for positive change. Our newly updated VBAC or Repeat C-section Topic and the latest data on cesarean and VBAC trends are two resources to help women and their advocates. Our Action Center provides more ideas for engaging in maternity care transformation.

 

Posted by:  Amy Romano, CNM

 

Cesarean Birth, Research, Transforming Maternity Care, Vaginal Birth After Cesarean (VBAC) , , , ,

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 , , , ,

Is there Such a Thing as a “Natural” Cesarean Section?

May 18th, 2011 by avatar

Introducing….the concept of the “natural” cesarean…
I have struggled with whether or not to post on this YouTube video for some time.  The title, in and of itself, is aggravating.  And I don’t mean from a judgmental standpoint, but simply from a realistic standpoint:  cesarean birth—whether positively, clinically indicated or not—is not “natural.”  It is an alternative method to birth compared to how nature originally designed it.

I have heard many others refer to the practices described in the video as “gentle cesarean.”  This, at least, seems to be a bit more accurate—except for the cutting, pushing, tugging, pulling, suctioning, cauterizing, and externalizing of the uterus that goes on.  (In a former career life, I used to surgically assist on cesareans, so I’m pretty familiar with what the procedure looks like.)

A list serve I’m a member of has recently spent a lot of time debating practices that surround cesarean births: should hospital policy allow for placement of baby skin-to-skin with mother directly following birth?  Should breastfeeding be allowed in the OR while mom is still being sewn up?  Should separation of mom and baby in the minutes and hours be avoided following a C-section in the same way this practice has taken hold in the vaginal birth setting?

Other questions about cesarean birth discussed frequently in my own local birth network include:  Should birth plan elements such as low lighting, quiet music and delayed cord clamping be integrated into the C-section setting?  Should doulas be allowed into the operating room to provide the emotional support the mother/parents hired her for?  (An aside here:  the most common argument against allowing doulas into the OR at my local hospital is that, “the OR is too small to have an extra person in there.”  Every time I hear this I nearly explode:  the OR seems to be large enough to admit medical and nursing students at-will, along with the various OR staff coming and going from the room throughout the procedure.  And yet the presence of a doula sitting quietly and still beside the birthing woman/couple seems to take up WAY too much space!)

The “Natural C-Section” video encourages many of the issues discussed above.  It follows a second-time-mama into the OR for her second cesarean birth and features obstetrician, anesthesiologist and midwife talking heads who all describe this version of a cesarean birth in a universally positive light.  In fact, mood lighting does seem to be implemented.  The sterile drape separating mom’s head and the rest of her body is dropped in time for her to see her baby being pulled from the incision in her belly.  The doctor holds the baby up, legs spread, so mom and partner can “discover” the baby’s sex on their own, as the OB narrates, “…it’s one of them.” Baby is placed right away, vernix, fluid, blood and all, on mom’s chest.  Dad cuts the cord following a delayed cord clamping.  In this video, the midwife’s job following the baby’s birth is explained as being focused on facilitating bonding measures like skin-to-skin contact and early breastfeeding, while also assessing baby’s well-being.

Interestingly, the anesthesiologist included in the video describes the birthing woman as ‘awake and participating in her baby’s birth.’  I have a hard time agreeing with his sentiment.  While it is certainly preferable for the mother to be awake and aware the moment her baby exits the womb, I’m not sure how much ‘participating’ she is doing when strapped down with 2/3 of her body numb and immobile.

For women who must deliver via cesarean—I can definitely see the appeal in this version of a surgical delivery.  It attempts to come up to speed in so many ways.  There is no hour-long separation between mom and baby.  When mom goes to the PACU (Post Anesthesia Care Unit), so does baby.  The midwife in the video even acknowledges the associations between postpartum depression and cesarean rates as well as decreased breastfeeding initiation rates amongst women who have undergone a cesarean birth.  She then goes on to imply that this gentler approach to the C-section might just ameliorate some of this association.

Criticism Against the “Natural Cesarean”
Here is the cause of my hesitation:  does this promotional video of the “Natural C-Section” run the risk of making surgical birth look so enticing that the risks of C-section get pushed under the table?

Dr. Andrew Kotaska, an obstetrician in Yellowknife, NT, Canada describes his concern over the “Gentle Cesarean” this way:

 

“It is admirable to minimize the necessary disruption of normal early maternal- neonatal contact associated with NECESSARY cesarean section. The gentle measures employed will not, however, reduce the maternal risk of amniotic fluid embolism, pulmonary embolism, operative injury, infection, severe hemorrhage, and death – all several times higher with C/S than vaginal birth. They also will not help achieve the neonate’s normal immune system activation during labour, perhaps leaving it more vulnerable to autoimmune disease later in life.

 

“In no way can the “gentle cesarean” be construed as making C/S safer. In the best quality prospective data set on elective C/S, 1/2300 women died. Soft, family-centered window dressing does not change the cold, hard risks; it is important practitioners and women keep this in mind.” (Landon; NEJM 2004)

In the United States, we are struggling against an ever-increasing cesarean rate.  Readers of this blog are well-aware of the ~ 33% C-section rate that doesn’t seem to be decreasing any time soon.  In an age when we should be working to reduce the C-section rate to somewhere at least close to that which the WHO recommends, the promise of a gentler, naturalish surgical birth could threaten the work many maternity care professionals and normal birth advocates, alike, are doing to properly inform women (and some providers) of the true risks associated with cesarean birth.

On the same list serve I mentioned above, another related thread developed:  should we “allow” post-cesarean moms to initiate breastfeeding while still in recovery?  The meat of the debate was whether or not women with anesthesia levels up to the nipple line will suffer nipple damage from incorrect infant latches, if they cannot feel the latch.  Hospitals apparently have policies on this:  when a mother is and is not allowed to nurse her baby, depending on the type of birth they have experienced (and the resultant side effects—such as prolonged numbness).  Since when did it become reasonable for maternity care facilities to dictate when a woman is and is not “allowed” to feed her own child?

This is exactly the type of down-stream effect of surgical birth that 1) likely does not get discussed prior to consenting for a cesarean and 2) is not erased by a gentler approach to the procedure and 3) involves the institution of policies that certainly are not evidence-based.

A Wolf in Sheep’s Clothing
I will never become the person who denies the importance of C-section as an option in a few, particular cases:  umbilical cord prolapse, placenta previa, abruptia or accreta to name a few.  The cesarean method of birth was, after all, developed to be a life-saving measure and, to this day, continues to be just that in a handful of circumstances.   And when a C-section is truly indicated (but not emergent) then, YES, incorporating gentle, respectful, best-practices elements into the cesarean experience should be done.  To me, this should quickly cease to be a point of debate at all. But for the remainder of women who find themselves in the position of contemplating the type of birth they’d like to experience—those who might be considering an elective C-section; those who have had a previous cesarean and are toying with whether or not to go for a VBAC—the promise of a “Natural C-Section” may turn out to be a wolf in sheep’s clothing.

As one participant on the list serve summarized:

“Can we work to make cesareans less common and also kinder–at the same time?”

Click on image below to watch the entire video on YouTube

 

Posted by:  Kimmelin Hull, PA, LCCE

Cesarean Birth, Films about Childbirth, Science & Sensibility, Uncategorized, Vaginal Birth After Cesarean (VBAC) , , , , , , , , , ,

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