Birthrites: Healing After Caesarean.

VBAC Information.

VAGINAL BIRTH AFTER CAESAREAN (VBAC).

Birth by caesarean section.

Caesarean section is a surgical operation to deliver a baby through an incision in the uterus. It is a major operation with great potential benefit, but also with substantial risks for both mother and baby. (Enkin et. al.) In Australia the caesarean section rate is approximately 18%. In some places it is much higher. For example, in the major public hospital in the ACT it has varied between 20 and 25% in the last few years. Approximately half of these births are elective caesareans (ie. planned caesareans performed before labour commences. A caesarean performed during labour is an emergency caesarean). The World Health Organisation recommends a caesarean rate of no more than 10-15 %. Available data suggest that there is minimal improvement in outcomes with a rate above 7%.

Reasons for caesarean section.

Caesareans are performed for a number of reasons. Some of these reasons, such as placenta praevia (where the placenta is attached across the cervix), prolapsed cord or transverse lie during labour, are potentially lifesaving. However, many caesareans are performed for failure to progress in labour (at the rate decreed by the attending doctor), cephalo-pelvic disproportion (CPD, baby perceived too big for pelvis) and possible fetal distress. These indications are very difficult to diagnose and it is often unclear later whether the caesarean was really necessary. On the basis of available evidence, having had one or more previous caesareans is not, by itself, an indication for an elective caesarean. The large variations in the percentage of births by caesarean section in the practices of different maternal health care providers indicates that there is no clear agreement on what conditions necessitate a caesarean. Enkin, et. al. state that it suggests that other factors, such as socio-economic status of the woman, the influence of malpractice litigation, women's expectations, financial considerations, and convenience, may sometimes be more important than obstetrical factors in determining the decision to operate.

Effect of caesarean section.

A caesarean section is major surgery with all the attendant risks. It is not safe. The maternal death rate associated with (but not necessarily attributable to) caesarean section is 4 times greater than in relation to all types of vaginal birth. Mother and baby morbidity is significantly higher. There are risks of anaesthetic accident, operative injury, infection, effects on subsequent fertility and psychological morbidity. The rate of respiratory distress syndrome in babies after caesareans is about 4-6 times higher than for vaginal births. This could be due to the caesarean birth itself or prematurity caused by miscalculation of dates. A woman's psychological well being is often seriously affected after a caesarean, causing, in particular, higher incidence of post natal depression (up to 6 times) and lower breastfeeding rates. Anger, disappointment, grief over lost experiences and feelings of failure and violation are common reactions. Family and sexual relationships can be seriously affected. The post-operative pain and the high incidence of wound infections means a longer recovery period with physical mobility affected for months afterwards. And in addition to all that, caesareans cost the community significantly more than vaginal births. Caesarean section is not a preferable way to have a baby for most women. For some, the desire to give birth vaginally is so strong that a caesarean section causes grief that may take years to resolve. The possibility of a vaginal birth in the future may be a lifeline at a time of deep emotional turmoil.

Why plan a VBAC?

Planning a vaginal birth after a previous caesarean (VBAC) has many benefits. A vaginal birth will result in 86% of planned VBACs (Flamm, p64). Some studies show an even higher rate of vaginal births. (90% ICEA Review, p5) A vaginal birth avoids the risks of surgery and anaesthesia and improves the health outcomes for the woman and her baby. It is well documented that babies benefit from the stimulation of labour and birth, particularly with regard to breathing and alertness at birth. A woman may wish to give birth without intervention. If the caesarean experience was particularly distressing it may be very important to avoid a repetition. It is much less likely that a mother will be separated from her newborn after a vaginal birth and her partner, support person or other children can be present for the birth. During a caesarean a support person can only be present if the woman has regional anaesthesia. With a vaginal birth a woman is more likely to feel in control and as if she and her baby are the most important people present. This is empowering and creates a sense of achievement. A vaginal birth can be a healing process for a woman who has had a previous caesarean.

Why not?

In contrast to these positive benefits, the reasons most commonly cited for choosing an elective repeat caesarean rather than a VBAC, are the possibility of uterine rupture, problems in previous labours, 2 or more previous caesareans, convenience, avoiding the discomforts of labour, avoiding the perceived risk of emergency caesarean after a long labour, and current indications such as breech or transverse position, placenta praevia or 2 or more babies.

Uterine rupture.

This is an extremely remote possibility. The risk is between 0.09% and 0.22% in women with a low transverse uterine scar. (Enkin et. al., p291). The probability of requiring a caesarean section for emergency situations such as acute fetal distress, cord prolapse or ante partum haemorrhage is about 30 times higher. In fact about 75% of the reported cases of uterine rupture occur in women who have not had previous uterine surgery. Of the women who do have a scarred uterus and suffer a uterine rupture up to one third do not rupture along the scar line. In addition the literature often does not distinguish between a scar rupture and dehiscence. The latter is a partial separation of the uterine wall with little or no symptoms and minimal (if any) maternal or fetal morbidity. The risk of uterine rupture is not significant enough to warrant choosing elective repeat caesareans. Previous obstetric history including 2 or more previous caesareans A history of caesarean birth for CPD, slow labour, being overdue, fetal distress, placenta praevia, position of the fetus or multiple birth is not a reason for elective repeat caesarean. Nor is a history of 2 or more caesareans. There is little or no difference in the morbidity figures for VBACs after 2 or more caesareans and the vaginal delivery rate is almost the same as for women with only one previous caesarean. the available evidence does not suggest that a woman who has had more than one previous caesarean section should be treated any differently from the woman who has had only one caesarean section. (Enkin et. al. p288).

Cephalo-pelvic disproportion (CPD).

This indication has been shown repeatedly to be inaccurate as a predictor of the possibility of future vaginal births. Up to 77% of women with a previous caesarean for CPD have a later vaginal birth. One third of them with larger babies. (ICEA Review). X-rays are notoriously inaccurate as a means of diagnosing CPD. The movement of a woman's pelvis during labour and the position of the baby are so significant that an x-ray prior to, or during, pregnancy cannot reliably indicate the likelihood of vaginal birth.

Breech.

Breech presentation occurs in about 3-4% of all singleton births. It should always be remembered that a baby can change position at any time up until the start of labour. So a caesarean performed for breech position before labour commences may be an unnecessary caesarean, even if you consider that a breech position warrants a caesarean. There are many things that a woman can do to help her baby turn, including postural exercises, homeopathics, visualisations and external version (turning the baby manually through the uterine wall. Some practitioners do not recommend this practice). Even if the baby does not turn, breech VBAC is still an option with an experienced practitioner.

Twins.

There are many issues to be examined by a woman expecting twins (or triplets, etc.). Generally however a multiple birth is not automatically a reason for caesarean section. The pregnant woman should have access to accurate information to enable her to make the best choice in her particular circumstances.

Safety.

Enkin et. al. considered a wide range of factors including all the risks and benefits of each option outlined above to determine the optimal birth choice after a caesarean. They came to the conclusion that planned labour proved to be the safer choice.(p287)

Conclusion.

Most women do not voluntarily submit themselves and their babies to the risks of caesarean section. They need as much care and love as any new mother and baby. And a woman planning a VBAC may need extra support and understanding as she rebuilds her belief in herself in preparation for another birth. It is to be hoped that every woman who is planning a birth after one or more previous caesarean sections is encouraged and supported to plan a vaginal birth.

References.

A Guide to Effective Care in Pregnancy and Childbirth, Enkin, Keirse, Renfrew and Neilson, 1995 (2nd Edn)
Birth after Caesarean: The Medical Facts, Dr Bruce L Flamm, 1990 (USA)
Childbirth Choices, Bennett, Etherington and Hewson, 1993 (Aust)
Silent Knife, Nancy Wainer Cohen & Lois J Estner, 1983
So You're Thinking About VBAC.., (pamphlet) ICEA ICEA Review (VBAC), (pamphlet) ICEA, 1990 (USA)
Vaginal Birth After Caesarean, (pamphlet) M. Brorup Weston, P Simkin and K Keolker, 1987 (USA)