5 a.m., one Friday morning, 3 years ago.
Water splashes on my thighs as I adjust myself—one leg kneeling, the other perpendicular to the floor, open, stretching. I feel the immense pressure of my baby’s head pressing into the world, but he’s not quite there yet.
A few minutes more and I’m barrelling over the edge of the bath. I squat and push harder than I’ve ever pushed in my life. My eyes are bulging and every vein in my face is ballooning as my body draws strength from the sudden surge of adrenalin. I reach down to feel what seems like a furry artichoke but is in fact my baby’s head, half out of my body. The final wave hits and with all my might I push my baby boy out into my midwife’s waiting hands, all in one go.
In my haste to meet my baby, I move to draw him near, but in doing so, nearly pull the cord tight around his neck—not the start I wanted. We unfurl him. His cord was wrapped around him four times and it was nearly a metre long, but he’s just fine. I notice he has my feet and we just gaze at each other. I am in shock, euphoric disbelief. ‘I did it!’ I say to my midwife who is smiling from ear to ear. ‘I finally did it!’ I can’t seem to say anything else, as coherent speech evades me, but I feel fantastic.
When I think about Adam’s birth now, what strikes me is how normal it was. I laboured. I met, challenged, and conquered my inner demons. I pushed my body further than I ever thought it could go and I pushed a baby out into the world—all in a day’s work. Only, the thing is, to get to that point took a battle of epic proportions, and the sad reality is that many who walk the same path, get trodden on in the process.
VBAC in Australia
According to the most recent Australian Institute of Health and Welfare report, Australia’s Mothers and Babies, 2005, 83.2 percent of women who have a previous caesarean have another one. Women who’ve had a previous caesarean account for approximately half of all caesareans in Australia (about 15 percent of 30.9 percent nationally). These figures seem to indicate that demand for repeat caesareans is high, but what factors are at play in pushing the repeat caesarean section rate up?
Media reports that women are driving the increase in caesarean section rates are poorly supported by evidence, especially when it comes to birth after caesarean. Recent research in the UK (Moffat et al) revealed that women in the study didn’t know what to do after a first caesarean birth and looked to their care providers for advice on subsequent births. Other research from Australia and the US has shown less than one percent of women request a caesarean without a medical reason (Gamble et al., 2007; Childbirth Connection).
The reality is that many practitioners recommend and even insist upon repeat caesarean surgery. The landmark US survey Listening to Mothers and Babies II showed that only 12 percent of women in the survey had a vaginal birth after caesarean (VBAC) despite 45 percent of the survey participants being interested in having a VBAC. Of these, about half were denied the option of VBAC due to hospital or practitioner recommendations and policies.
However, this denial of their options is not supported by current best evidence, and in fact, is in direct opposition to the recommendations by the world’s foremost source of evidence-based medical and health information, the Cochrane Review database (Dodd et al.).
Fear of the mother and/or baby dying from a catastrophic uterine scar rupture casts a huge shadow over VBAC. It is argued that the uterine scar is put under immense stress from labour and that can cause it to burst open, causing massive bleeding and the protrusion of the baby’s body from the uterus. However, a rare catastrophic rupture is 30 time less likely than any other rare adverse event that may happen to any pregnant woman regardless of her risk factors (Enkin et al, 2000). In fact, A Guide to Effective Care in Pregnancy and Childbirth, based on a systematic review of the literature on childbirth, states that care of the VBAC woman should be ‘little different from that of any woman in labour’ (Enkin et al 2000).
Queensland’s (Australia) Sunshine Coast obstetrician, Kirsten Small, supports a woman’s right to choose VBAC. ‘As an intelligent educated woman, I want to be able to choose how to give birth, so how could I not offer this to the women who seek me out for care?’ she says. ‘I sometimes hear women say that their doctor “let them”’ or “didn’t let them” do something or other. It is a woman’s right to choose a VBAC, and she doesn’t need and shouldn’t ask for permission to do so. If she does, she runs the risk of having that permission withdrawn, when it wasn’t ever supposed to be in question.’
Perhaps one of the issues not addressed adequately in the debate about VBAC risks is the systemic lack of support for practitioners (obstetricians and midwives). Small believes that lack of support is a key problem in terms of its impact on access to VBAC or normal birth for any woman classified as ‘high-risk.’
When bad outcomes occur in any birthing situation, and obstetricians are faced with the loss of a baby or even the mother, there is ‘very little support as they deal with their grief,’ she says, pointing out that they are expected to get back to work straight away and meet the needs of the next mother before them. ‘There is even less support from the legal system,’ she says.
Small admits obstetricians know intellectually that serious complications such as uterine rupture and stillbirth are rare, but says, ‘When you have all those horror stories rattling around in your attic, you know, and often have lived through, how badly wrong things can get.’
Perhaps what is needed is some perspective. Our culture promotes the myth that medical technology can be relied upon to save lives in the event that something bad should happen to us. But the reality is that bad things happen to normal people everyday and medical technology cannot guarantee survival. In fact, recent evidence shows quite clearly that when caesarean surgery is performed for no medical reason it is riskier to both mother and baby than vaginal birth (McDorman 2006 & 2008; Villar et al, 2006 & 2007; Yang).
I could get in my car tomorrow and the difference between leaving at 7am or leaving at 7.05am could be all it takes to snuff out my lights. Similarly the death of a baby to SIDS would be devastating, especially if a parent does ‘all the right things.’ The incidence of these is far greater than the incidence of a uterine rupture and yet still doctors drive cars, do not prevent families from getting into their cars with babies, and don’t have a policy of routine continuous monitoring of all babies in case they die from SIDS.
So for the women who decide to work toward VBAC, a battle ensues. My battle began when I became pregnant for the second time. I had had a traumatic emergency caesarean birth with my first son and told the first obstetrician I saw that I wanted a vaginal birth because my caesarean was so traumatic. It didn’t take long for her to start the process of coercion. At my 16-week visit she said that if I wanted a VBAC I was risking a dead baby and a hysterectomy. I never went back.
Small says, ‘Obstetricians can, of course, behave like petulant toddlers when they don’t get their own way and bully, badger, and pester women into agreeing to a certain course of action. This behaviour was taught to me during my training—how to do the “your baby might die” lecture. There is a very fine line between informed consent and mis-informed consent! Women’s best defence against this is to be well-educated and be able to question everything that they are told.’
Most practitioners, who do support VBAC, do so with stringent conditions attached to the deal. Accepted practice or standard practice for VBAC labours includes: continuous electronic foetal monitoring, cannulation ‘just in case something goes wrong,’ no food or drink in case the woman needs surgery, time-limits on pregnancy length, strict time-limits on first and second stages of labour, theatre staff on ‘stand by’ in case of emergency, and denial of access to continuity of carer and use of water immersion in labour. Few, if any, of these interventions is supported by robust evidence and can possibly undermine the opportunity for an uncomplicated birth.
The consensus from evidence-based birth advocates is that with these kinds of restrictions, VBAC women receiving standard care don’t stand much of a chance. And research on VBAC reflects this. Almost all research on VBAC occurs in tertiary settings with women subjected to the above interventions. In addition, many of these women are subjected to induction and augmentation of labour despite the fact that use of chemical induction agents have been shown to increase the rates of uterine rupture in any woman, let alone one who has a uterine scar.
Systematic reviews (see sidebar below) show that induction and augmentation of labour in women with a uterine scar doubles the risk of uterine rupture. The risk of uterine rupture in a VBAC labour, with no induction or augmentation of labour, is less than the risk of uterine rupture in women who have no uterine scar but who are induced or have augmented labours. Considering the increase in risks, it seems contradictory that practitioners edgy about supporting VBAC would even consider chemical induction or augmentation. But they do, because overall, the risk of uterine rupture is extremely rare and herein lies the point. If the push to curtail women’s birth choices and expose them to all the additional risks of uterine surgery is based on clinician fear associated with rare and adverse outcomes, then it seems a matter of urgency that this problem is addressed through appropriate education and support. Practitioners need to be enabled to process traumatic events and move on if they are to adequately support the hundreds of women who do not experience adverse outcomes.
A system which fails to support the needs of practitioners and consumers to process trauma has created a culture where the use of precautionary measures in birthcare has become more and more commonplace. In the process, the assumption that current management of VBAC produces the best outcomes has never been challenged. There has been no research to test whether or not a different model of care and a less interventive approach (but more attentive approach) could produce the same or superior outcomes.
While a team at the University of Adelaide is finalising results from a controversial, and arguably unethical, prospective study on VBAC with standard practice routinely enforced on each participant, Maralyn Foureur, a professor of midwifery at the University of Technology in Sydney has set about to take on the status quo of VBAC research. Foureur is heading up a group of obstetrical and midwifery researchers to undertake a study that looks at best practice care for VBAC women. The BACI (birth after caesarean interventions) study aims to investigate what interventions actually improve outcomes for women (including information and education about VBAC as well as counselling and peer-support for women who’ve had difficult or traumatic caesarean births) and they plan to provide women in the study with continuity of care (where a woman has primary care by a known midwife throughout pregnancy, labour & birth and up to six weeks postnatally) to compare outcomes with women who do not have continuity of care, because a growing body of evidence supports the fact that continuity of care improves outcomes for women and babies.
The role of education
As part of the BACI study, researchers will also assess the role of education, preparation, and motivation to VBAC in improving outcomes. At present, practitioners do not routinely suggest that women wanting to VBAC prepare for birth any differently to any other pregnant woman. However, given the incidence of trauma and distress following difficult births and obstetric interventions, the emotional baggage women may carry with them to their next pregnancy needs to be explored and acknowledged (Creedy et al.; Gamble et al., 2005).
The popularity of online pregnancy and birth forums is testament to the fact that women seek advice and validation from their peers, despite that much of the information shared is neither evidence-based nor reliable. A few women seek independent information in addition to this but according to midwife and childbirth educator Debby Gould, many women don’t know where to start.
Gould is the support contact for Caesarean Awareness Network Australia and runs a popular support and education group called Birthtalk. Based in Brisbane, Gould and her sister-in-law, mum Melissa Bruijn, run an antenatal education programme including Australia’s only long VBAC course, an eight-session course that covers information specific to those planning VBAC as well as a range of topics: from their ‘Path to a Better Birth Course,’ including the benefits of natural birth to both mother and baby (and future babies); ‘Supporting Your Support People,’ where women learn to communicate their needs to their support team and ‘Birth Unplugged,’ where women hear good stories about birth. They also run monthly ‘Healing from Birth’ sessions free-of-charge for women who have questions about their previous births, or who may be disappointed, distressed, or traumatised by their experiences. Gould firmly believes that women who are enabled to process their previous births, and who are empowered with evidence-based information in preparation for birth after caesarean, have better physical and mental health outcomes.
And perhaps this is where the future of VBAC lies. Gould says, ‘Only when women’s fears are addressed, their understanding of VBAC risks put in perspective, and their knowledge of empowering birth enhanced, will they have the understanding and tools to start demanding care that meets their individual needs.’
Gould explains, ‘This is our focus at Birthtalk: acknowledge where women ‘are’, keep the challenges facing them in perspective, and take them, through education and support, to a place where the need for a positive birth experience is not only desired, but completely within their grasp.’
6.30 pm, in a hospital committee meeting with hospital administration, one month ago.
I sift the pages of my evidence on caesareans and VBAC and prepare for the worst. The health service administrator looks at me with apprehension. It seems, every time I open my mouth in that room the tension rockets… Oh here we go again. They think I’m naïve, and perhaps a bit self-indulgent. But I know I just represent all the other women out there like me. I talk about the woman at a rural hospital who was told she was not ‘allowed’ to VBAC after two caesareans and state that I want to know that women attending any hospital in the district will be supported to VBAC if they so choose. I have the research evidence to support this as a reasonable option, plus I’ve had my own VBAC after two caesareans and I know the challenges these women face in our system.
The GP in the room starts to wax eloquently about how these women need access to blood transfusions and tertiary obstetric care. But the evidence in front of me does not concur with what she is saying, which tells me she is basing her decision-making on fear. The administrator makes no apology for denying a woman her right to give birth naturally and instead goes on to tell me how they have a right to use child safety laws to intervene if they feel the woman is making a bad choice. Yet I know most women don’t get anywhere near the information and support they need to make an informed choice to begin with. I lose this round but live in hope that if more women speak up and start to demand the care they need, change will happen. It’s already happening elsewhere, in hospitals where VBAC is supported and so the battle continues.
Note: see Caroline McCullough’s related article: Time to Give Mother-Guild a Hersterectomy
Childbirth Connection (2006). Listening to Mothers Survey II. www.childbirthconnection.org
Creedy D, Shochet I, & Horsfall J. (2000) Childbirth and the development of acute trauma symptoms. Birth 27 (2):104-111.
Dodd JM, Crowther CA, Huertas E, Guise JM, Horey D. (2004) Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth. The
Cochrane Database of Systematic Reviews Issue 4. Art. No. CD004224, DOI: 10.1002/14651858.CD004224.pub2.
Enkin, M., Keirse, M., Neilson et al. (2000). A Guide to Effective Care in Pregnancy and Childbirth. Oxford University Press, London. Available online free of charge via www.childbirthconnection.org.
Gamble J, Creedy D, Moyle W. (2005) Effectiveness of a counselling intervention after a traumatic childbirth: A randomized controlled trial. Birth 32(1):11-19.
Gamble J, Creedy D, McCourt C, Weaver J, Beake S. (2007). A critique of the literature on women’s request for caesarean section. Birth 34(4), 339-347.
Laws P, Abeywardana S, Walker, & Sullivan EA. (2007). Australia’s Mothers and Babies 2005. Perinatal statistics series no. 20. Cat. No. PER 40. Sydney: AIHW Perinatal Statistics Unit. Available online at www.npsu.unsw.edu.au/NPSUweb.nsf/page/ps20.
Moffat MA, Bell JS et al. (2007). Decision-making about mode of delivery among pregnant women who have previously had a caesarean section: A qualitative study. BJOG: An International Journal of Obstetrics & Gynaecology E.(1): 86-93.
MacDorman MF, Declercq E, Menacker F, Malloy MH. (2006). Infant and neonatal mortality for primary cesarean and vaginal births to women with ‘‘no indicated risk. United States, 1998–2001 Birth Cohorts. Birth 33:3.
MacDorman MF, Declercq E et al. (2008). Neonatal mortality for primary cesarean and vaginal births to low-risk women: application of an ‘intention-to-treat’ model. Birth E.(1): 3-8.
Royal College of Obstetricians and Gynaecologists, “Evidence-based Guidelines for Delivery after Previous Caesarean Birth” compiled by Professor G C S Smith MRCOG, Dr R Varma MRCOG, and Dr J K Gupta FRCOG. 2007
Villar J, Valladares E, et al. (2006). Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet 367(9525):1819-29.
Villar J, Carroli G, et al. (2007). Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. 335(7628):1025.
Yang Q, Wen SW, et al. (2007). Association of caesarean delivery for first birth with placenta praevia and placental abruption in second pregnancy. BJOG: An International Journal of Obstetrics & Gynaecology 114(5): 609-13.
 High-risk is a loose term used to indicate pregnancies that require obstetrical consultation and intervention. However, as this article demonstrates, the term is often applied to pregnancies that do not require this level of care because of the current medico-legal climate.
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