Thursday, October 2, 2008

The VBAC Debate

In response to Sarah's request on VBACs...

I have already started writing this once, but saved it under a c-section title. I am having a hard time writing about VBACs (Vaginal Birth After Cesarean) without writing about the reasons for all the c-sections in the first place.

So many women are having c-sections, as we already know. Some women are requesting them, and some don't care if they have one or not. The majority of doctors are very comfortable with them, so it's become very commonplace. Every now and then, a woman truly feels "ripped off" by not giving birth vaginally. If you have had a c-section, I would recommend getting in touch with the ICAN support group.

I am a member of the International Childbirth Education Association (ICEA), who publishes the International Journal of Childbirth Education. There were some fantastic articles in the journal this month. One woman was commenting on the stress of having a c-section and the after effects (it didn't give a reason for the c-section): "My baby was next to me but I didn't want to touch him or look at him. I was mourning the loss of a child who never came through me. I was unable to give birth. He was stripped from me." There is a strong link between postpartum depression and cesarean birth and also with epidural birth. Typically, women who experience childbirth and breastfeed their babies do not experience depression.

I hear people say this all the time: "Well, at least the baby is healthy," or "It doesn't really matter how the baby got here, as long as it's healthy." Does this mean that if you have an unhealthy baby, you don't want it? Likely, women just want their baby, whether it's healthy or not. And it does matter how they get here. No woman would choose a good birth over a healthy baby. Accusing women of doing so is a way of dismissing their valid requests for good health care and respectful, positive births. Whatever the case, and whatever the reason a c-section was performed, during the next pregnancy, she should find a provider who does VBACs and believes in their safety.

This is what happened: VBACs were on the rise in the 90's, until Cytotec appeared on the scene in the late 1990s. Cytotec is a drug that is FDA approved to treat people with stomach problems, such as ulcers. A side effect is that is causes the uterus to contract. Women were receiving this drug as an induction drug who had previously had a c-section, and as a result, many lives were lost -- both mothers and babies. The makers of Cytotec have requested that it not be used to induce labor, but let me assure you, it is alive and well. In fact, one of my students received it just last week.

Your OBGYN will tell you how dangerous it is to have a VBAC -- that your uterus could rupture. Did you know that you have less than a 1% chance of that actually happening? Did you also know that a woman who has never had a c-section can also have her uterus rupture from the use of induction drugs? I have never heard of a woman being told that when they are scheduling an induction.

I was talking with a woman several months ago and asked her what month (not what day!) her baby was due. She said she was having her baby on such-and-such date. She had scheduled another c-section. She wasn't even sure why she had had the first one! I told her that there were doctors and midwives in this area who would do a VBAC, but she said that she liked her doctor and she was "really nice." This is not a reason to let your doctor surgically remove your baby from your body! This is not good health care! A repeat c-section carries far more risk than a vaginal birth after a c-section! The evidence backs this statement over and over. You need to truly understand why you had the first c-section. What are your chances of having the same "complication"?

So, first of all, if you want to have a VBAC, you will not be induced. You need to seek out a birth attendant who is supportive of VBACs. They should have a VBAC rate of at least 75%. In Albuquerque, when I was doing my Bradley certification, (5 1/2 years ago), I was interviewing a group of midwives at one of the hospitals, and they were very proud of their 92% VBAC rate. ACOG has gotten very strict with the allowance of VBACs now, which is completely absurd. What has changed in womens' bodies to all-of-a-sudden make a VBAC dangerous? It doesn't make any sense.

When you find a birth attendant that does VBACs, they will request your medical records from your previous birth. They will examine the records of the surgery and determine if you are a candidate for a VBAC. It has become popular, because of the recent denial of VBACs by OBs, to perform a single suture instead of a double suture when sewing the uterus back together. They know that you'll be having another c-section with subsequent babies, so why bother securing it for a VBAC? Be sure that you are double-stitched if you have a c-section! Also, if you have a vertical incision (more common in other countries), you will likely not be having a VBAC.

When you introduce any medications or interventions you are more likely to have another c-section. To really understand this concept, you need to understand how the body works in labor and birth. You need to know how medications work and why you are 4 times as likely to have a c-section with an epidural than without one. The bottom line is this: Prepare yourself -- mind and body -- to give birth without drugs.

What I have seen over the years is that women who have had a c-section become so focused on having a vaginal birth, they don't even contemplate not having an epidural (probably because they assume them to be completely safe). I would like to share the 4 factors that research has found to make the greatest contribution to a woman's degree of satisfaction with her birth experience. I thought these could easily be said of a VBAC:  
1) Having good support from caregivers (who support VBACs); 
2) Having a high quality relationship with caregivers (who likewise respect you and your body's abilities to give birth vaginally);
3) Being involved with decision making about care (even if this means another c-section); 
4) Having better than expected experiences (or having high expectations). "The best predictor of a woman's experience of labor pain is her degree of confidence in her ability to cope with labor." Confidence in yourself is everything.

So, this is the bottom line: If you are planning a VBAC, don't make your focus the previous c-section. A few months ago, I was on the phone with a woman in labor, having a VBAC, and everything kept coming back to the c-section. I finally said, "Let's just forget the c-section and that this is a VBAC. It's getting in the way of this labor. You are just a woman having a normal labor." Use the experience to learn and grow from. If you know where things "derailed" last time, do what you can to not have it happen again. Your chances of rupture are about the same as a woman having an induction who has never had a c-section.

You are simply a woman who is going to give birth.


publichealthdoula said...

"No woman would choose a good birth over a healthy baby. Accusing women of doing so is a way of dismissing their valid requests for good health care and respectful, positive births."

I love this statement! Occasionally I take a look at the "Homebirth Debate" blog, and while I think that it is not a terrible thing for homebirth advocates to have to be challenged and respond cogently, I hate the tone that the woman who runs it takes. There is very much this sense that all women who seek compassionate care, or who try to make requests about their birth, are just spoiled, ignorant princesses who don't have a clue what "real" birth is like. I do think she's given some fuel for her fire by the very small number of women who do say they would rather take very serious chances with their birth than accept any intervention, but she likes to paint the picture much more broadly. Essentially, her thinking goes, in labor you should not be an "active patient" - which is what more and more doctors are urging patients to be, particularly in the hospital. You should just walk in and put your care unquestioningly into the hands of the highly trained professionals there. You should not ask questions about whether something is necessary or choose to accept or decline interventions, because that makes you a crazy lady who puts her "birth experience" over her baby. It seems impossible to some of the posters that because their birth experience did not matter to them, it would or should matter to anybody; and that you could prioritize both a positive birth experience and a healthy baby. If a medical provider is truly concerned a woman is doing that, I think the provider needs to look at why their patient doesn't trust their professional assessment, and too often the blame there is laid on having been "brainwashed" by the "natural childbirth nazis".

Kate's mommy said...

Thank you for covering this topic, Donna. I, too, highly recommend ICAN in support of recovering women. I don't think I read any of the chapters on c-sections, just skipped right by. I wish I'd have known how high my risk was of having bonding, breastfeeding, and depression problems. You really covered a lot. I am so going w/ a birth center next time!!

amy said...

hi.. could i please get your email address so i can talk to you directly? thank you .. amy in mansfield.

Donna Ryan said...

Amy, I don't want a bunch of spam, but I'd love to talk to you. My email is simply my name donna ryan at Sorry for the coding! A friend suggested I type it in that way. It probably doesn't matter, but oh well. Talk to you soon.

Sarah said...

Wow. This is a great post (and I'm not even that interested in VBAC!) I was wondering if you'd also do a post linked with this on how to AVOID a c-section in the first place? You mentioned it at the beginning of this post, and I know it is a subject all its own, but I'd love to direct some first-time moms over to your blog to get a good idea of how these things can spiral out of control in no time. I SO miss you teaching Bradley here!