Outlining VBAC Pros, Cons, Risks and Choices.I would like to begin by saying that I'm not a childbirth professional or an expert. I'm here to speak as a mother, and more especially, as a VBAC mother who is concerned about the availability of VBAC and woman-centred birth as choices for women in childbirth. I will tell you a little of my own childbirth history and involvement in Birthrites so that you have a better idea of where I'm coming from. I have three sons. My first was born fifteen years ago and was posterior at birth and born by forceps delivery. Two and half years later, I had my second, who was undiagnosed breech and was born by emergency caesarean after a drug free natural labour which had reached full blown second stage. Both of these deliveries seemed to happen around me, and with both, I didn't feel like I'd had a baby, it was more like I'd had a nasty operation. During both labours and deliveries I was bullied, belittled, spoken about rather than to, and generally treated like the container that held the goodies, rather than something precious in itself. Recovery times with both were long and painful, although I recovered far more quickly after my caesarean than the forceps delivery. In the case of my forceps delivery I experienced difficulty bonding with my baby, it took quite some days to register that he was really mine, and I believe that the only reason I finally did bond with him was due to the fact that I was determined to breastfeed him and was able to redevelop a sense of ownership over both my body and my child. In both instances, though, I was left with a strong sense that I had been violated, and that things had been completely out of my control. In contrast, my third baby, born eighteen months ago at home, came into the world quietly and calmly, with my partner and my midwife looking on. During this labour I moved about as I liked and birthed in a position that was comfortable for me. I was treated with an attitude of love and respect at all times, and my needs and wants were also respected. Apart from wobbly legs, my recovery was almost instant. In fact, it was difficult to rest over the following days because I felt so well. It's not difficult to tell which experience was the more positive for me! I don't tell you all this to bore you with my own horror stories, but to make the point that many women have these same stories to tell. This really is, in a lot of cases, a kind of shared history, and one that is often only ever voiced among groups of women. Over the years after my first two children were born, I harboured a lot of anger and pain about the way they came into the world, and the way I was treated. I had wanted a natural birth with both of my big boys, but natural birth seemed to be something I would only ever read about others doing. The way I saw it, my forceps delivery happened the way it did because of an over managed labour, and my caesarean happened because of my history - that I'd had a difficult first birth, that I wasn't able to spontaneously deliver, and that I didn't carry my babies properly so they didn't get into the right position for delivery. When I discovered that I was pregnant again, eleven years after my last baby was born, I decided that I would like to try again to have a natural birth, and after finding out that my previous caesarean would be an issue, I found the Birthrites website on the internet and contacted Jackie, who was wonderful in sharing her vast knowledge of VBAC and providing me with books and other information which eventually made it possible. I became more involved because I believe that the work that is done by this very small group of women around healing and birthing is so valuable for women and their families. To explain further, we are a support group which was set up to help women like I was, who aren't happy with their caesarean sections, or who question the need for it to have happened, are therefore experiencing some difficulties moving on from it, and who want to do all that they can to avoid it happening again with subsequent births. At Birthrites, we aim to support such women in educating themselves about their choices in childbirth so that the outcome might be both a healthy baby and a healthy and happy mother, whatever the mode of delivery. We are not anti-caesarean, we have all had babies who were born by caesarean, but we do believe that it has become overused, under explained and has contributed to the fact that childbirth itself has become shrouded in fear and mystery. We are about restoring a higher level of choice for women in relation to childbirth. We believe that it's possible for a woman to have an empowered birth, whether naturally or by caesarean section. At Birthrites, we don't subscribe to the 'success/failure' logic that is so often applied to the VBAC mother. Every birth is a success when mothers are well informed and have a voice that is clearly heard by caregivers. Earlier this year, Birthrites carried out a survey on women who've had unplanned or unhappy caesarean sections. From the results of this survey, one point that stood out was that for some women, there is a lack of balanced information coming from health service providers about VBAC. As health consumers, women want and need to be informed about all of their choices in childbirth, and they need that information to be balanced so that they can work out for themselves the best options for them. Of course, women can do the research for themselves, but all institutions and practices in the business of childbirth should be able to provide this kind of information, and all women who've had a previous caesarean have the right to make decisions for themselves about their bodies and their babies, with the guidance of their doctor or midwife, and given the right information. Instead, what we sometimes see happening is that information given is either heavily laden with fear and foreboding, or incorrect information is given and women are left with the feeling that their doctors won't 'let them' try for a VBAC. For many potential VBAC women, their pregnancy becomes a race against time to find supportive caregivers, even though it's now generally accepted that VBAC is safe and should be considered in most cases after taking into account the reason for the first caesarean. To this end, health service providers must have to hand the latest information to help the woman in making a good decision. For example, CPD is often cited as a reason for a first caesarean, and many doctors insist on their patients undergoing an X-ray examination towards the end of pregnancy to try to ascertain the size of the baby's head in relation to the size of the mother's pelvis. Apart from the obvious safety issues for the unborn foetus, it has been found that this procedure is unnecessary in most cases, that it increases the caesarean rate and is not a good way to predict the outcome of labour. Anecdotally, this is self-evident. We hear so many stories about women who've had a first caesarean because of CPD, and have then gone on to have considerably larger babies vaginally. In women's own birthing circles the term CPD has become something meaningless, because it is so often proven to be an incorrect diagnosis by womenÕs own experiences, which is alarming when you consider that in some cases it must be the correct diagnosis. Women are becoming increasingly immune to the power of the doctor/patient relationship, and are questioning more and more. It has never been so important for health service providers to get the information right. It is an unfortunate fact that many women report disappointing responses from doctors in relation to VBAC. To refer back my own experience, during my last pregnancy, when I asked my then doctor about the possibility of having my baby at the birthing centre at KEMH, I was told it wasn't possible because of my history. Although disappointed, I accepted that these were the rules of the birthing centre. Ironically, it was because of that history that I wasn't comfortable with having my baby in a hospital, or confident that if I did go to hospital I'd end up with the outcome I desired. I felt that the hospital system had failed me in the past, so I then asked about the possibility of birthing at home. I was met with what is, sadly, a response that many many women have heard and especially potential VBAC women. And the question we're so often asked is, "do you want your baby to die?" It seems ridiculous to have to state that of course none of us want our babies to die. The question leaves us feeling either shocked and angry, or shocked and afraid, but always shocked! In fact, it seems to be a question which is asked with no other aim than disempowerment for the woman by forcing her to question her own values, choices, and rights, to make her feel that she's putting her own needs and desires above those of her unborn baby. It is a question designed to exert control. Being faced with this question is a demeaning experience. No, we donÕt want our babies to die. What we do want is the right to choose the safest, most gentle and healthy birth experience for both our babies and ourselves. We want to be taken seriously, and it goes without saying that we want to keep our babies safe. It is difficult, as a pregnant woman, to separate where you end and your baby begins, and wanting to be safe and comfortable for yourself doesn't exclude the baby growing inside of you. Women have a unique intuition when pregnant, which shouldn't be trivialised, and what feels best for us is usually best for our babies. For some of us, that sense of safety is found in the hospital, but others do feel safer in a less medical environment, either at a birthing centre or at home. This is obviously not for all women, but there has to be that choice for those of us for whom it is, and that choice shouldn't carry any added burden of guilt or fear. Childbirth itself is stressful enough! Overstating the risks limits choices and this is a violation of our rights as women. Given that the reasons for the initial caesarean indicate that a VBAC is possible, the fear that then seems most prevalent for both mothers and their service providers is uterine rupture. The statistics available on uterine rupture during an attempted VBAC labour show figures that are comparatively low, with ruptures occurring in less than 1% of labours. Obviously, if it's your own uterus that is rupturing, that figure is high enough, but something that is hardly ever explained to women is that even an unscarred uterus can spontaneously rupture during labour, depending upon whether or not the labour is 'managed', and how this is done. It is generally accepted as fact that uterine rupture is linked to the use of both prostaglandin to induce labour and artificial oxytocin during labour, which brings me to my next point. A major problem that women perceive in relation to the medical model of birthing is the amount of unnecessary interventions that can happen when the mother is labouring in hospital. This is double edged, and more so for the VBAC mother. Not only do medical interventions interrupt or rush the natural rhythm of childbirth, but they also diminish the mother's trust in her own body, undermining a uniquely female and natural function. Women, and especially VBAC women, need to REALLY KNOW with their hearts and souls that their bodies can and will give birth unaided in the vast majority of cases. Unfortunately in hospital, the labouring mother is often treated like a child, and all the responsibility for birthing is taken away from her by medical staff who are focussed on removing the pain, and expediting the birth, in an effort to 'help' the mother. Perhaps watching someone in that kind of pain is difficult for people whose training is almost exclusively geared toward creating comfort and easing pain, but for those women who welcome the pain of childbirth as a sign that everythingÕs working as it should, these interventions at best hinder their labour and at worst, will interrupt it altogether. Once an initial intervention is implemented, it seems likely to result in what has been termed a 'cascade' of further interventions. In these cases, medical care goes into a kind of overkill that often leads to caesarean section. And, of course, another less obvious cascade is then set into motion, with the mother being unfairly discriminated against when she decides to have another baby and is told that she's unable to use the birthing centre, unable to have a homebirth, and unlikely to have a natural birth in hospital, because of the interventions that are deemed necessary for someone with her history. Too many women believe that their birthing bodies don't work, simply because of one unnecessary initial intervention. It's important to note, also, that mothers who've had a previous caesarean have not two, but three choices open to them. That is, to try for a VBAC, to schedule a repeat caesarean, or to go into labour spontaneously before their elective caesarean to ensure that their baby is being born at the right time, and is ready to live outside the womb. On a different note, a disappointing trend that has emerged both here and in the United States has to do with the numbers of women having caesarean sections in relation to their socio-economic situation, and also to whether or not they have health insurance. Women of higher socio-economic levels, who have private health insurance are much more likely to end up with a first caesarean section, and then with an elective caesarean with subsequent pregnancies. This is a direct result of the commercial aspect of the medical institution as part of a wider consumer culture, and ultimately is at the cost of natural and unmedicalised birth. Of course, again, not all women want a natural birth, and the choice should be there for them, but the trend is such that medicalised birth is becoming normalised, and natural birth is then seen as left-wing, or something that hippies do. Again, it is ultimately women's choices that are at risk here. When those women have already experienced one caesarean section, their choices are severely limited for future births, although all the figures show, and it is generally accepted by most of the medical profession, that VBAC is a safe option in most cases. I would like to see a birthing environment where it is possible for women themselves to assume responsibility for their outcomes. Where women and their health service providers work together in finding the best options available, and where the risks of natural childbirth are weighted more realistically and appropriately against the risks involved with medicalised childbirth and caesarean section. There is a two-fold benefit, in that parents feel more a part of this precious event, and also, that the medico-legal aspects associated with medicalised birth take on a more appropriate position for doctors and their patients. It doesn't serve anyone well for doctors, midwives and hospitals to have to operate within a system of fear and blame. The mother's support person during labour is most important here - whether that be the father or another person. For some women in labour, there are times when it isnÕt easy to make a quick decision, and a support person can take over if or when this happens. This person must know exactly what the woman wants of her birthing experience, and must be completely trusted to make decisions on her behalf if need be. Ideally this person will have spent lots of time with the woman during her pregnancy, so that they can form a relationship based upon mutual trust and respect. Women need advocates in the current birthing environment, and unfortunately we haven't always found them amongst the hospital staff and medical professionals who are around us during labour and birth. Too often, women report the feeling that decisions in the birthing suite have been made based upon professional convenience, and the mother's own birthing preferences are forgotten. It is so important that medical service providers remember that what is for them a part of their workaday routine, is for the mother a once in a lifetime experience and one that should be supported with the utmost care and respect to make it calm, joyful and loving, whatever the mode of delivery. I'd like to finish with a short excerpt from Women's Bodies Women's Wisdom, by Dr. Christiane Northrup, about birth and creation. It has a message for us all.
Gail Hancock is Vice-Convenor of Birthrites: Healing After Caesarean Inc. She is is passionate about womenÕs rights to education about their bodies, and access to correct information which would enable them to choose what happens to their bodies and their babies during childbirth. Her presentation, as well as all the others over the whole day of the conference, will soon be available on video to purchase singly, or as a set. |