MIDWIFERY CARE FOR THE VBAC WOMAN

Midwifery Care for the VBAC Woman
by Gloria Lemay
© 2001 Midwifery Today, Inc. All rights reserved.
[This article first appeared in Midwifery Today Issue 57, Spring 2001.]

Someone asked me recently what things are done differently with vaginal births after cesarean (VBAC) as opposed to a first baby. Midwives usually reply to this question with a reassuring, “Oh, we treat you normally,” but there are differences in the two situations that can be distinguished in midwifery practice.

Prenatal Preparation

The full history of the events leading to the cesarean is very important. With a VBAC client, ask her to get her operative record, nurse’s notes, anesthetist’s report, pediatric report—get all the records and go over them thoroughly. Often the couple did not get full or accurate information about what was going on. Sometimes there’s a little “clue” as to what went wrong that could help to prevent a cesarean from recurring. Sometimes there is a big chunk of information that didn’t get communicated. I saw one set of records where the only indication for the cesarean was the note from the obstetrician that “this woman is a natural childbirth fanatic.” Another set of cesarean records had no indicator whatsoever of why the woman received abdominal surgery when she had given birth at l9 years old. When she told her parents that the midwife was perplexed and could see no reason for the surgery, her father admitted to her that he had stayed in the visitor’s lounge all day and had been verbally threatening to the doctor: “If anything happens to my daughter, I’ll sue you!” This helped the daughter to understand what had happened to her and also helped her to be firm with her father that he was to be nowhere near her VBAC birth.

With VBAC births it is important for the midwife to work with the dad prenatally. A VBAC father is in a horrible position because, despite the fact that his wife had an operation and a long recovery, he still got a live wife and baby at the end of it all. VBAC dads are often “fantasy bonded” to the medical system and terrified of childbirth in general.

The good thing is that they listen very carefully and really know when the care is better and more thorough and when the practitioner is authentically on their team. I find that if the midwife talks to them very honestly, they can trust and be fully supportive when the birth time arrives.

If the woman has dilated past five centimeters in the first birth, I plan for it to be fairly fast—like any second baby. If the woman has not gone into the birth process or not dilated past five the first time, that’s all right, she’ll still give birth vaginally, but we have extra midwives on call to bring fresh energy if the others get discouraged or tired. We plan for it to be like going to two births in a row. The point that the woman reached in her first birth is often a psychological hurdle for her. If she dilated to six centimeters the first time, the news that she is seven or eight will be a relief and a breakthrough. One of our clients, a minister’s wife, said over and over again in her pregnancy: “I just want to feel what pushing is. If I only get to push, I’ll be happy. I just want to know what other women mean when they say they had to push.” She’d had a Bandl’s ring in the first birth process and the cesarean was done at five centimeters. We were praying that the complication wouldn’t repeat. She dilated smoothly and began to push. With each push she would exclaim “Thank you Jesus, thank you Jesus!” What a wonder it was to watch her push out the baby, a girl whom she named Faith.

All humans have a certain propensity to self-sabotage, and the VBAC woman must be on guard against her own defeating patterns. The midwife must be bold in pointing out ways that the woman is repeating dumb moves—there’s no place for us being “nice” if it will mean another cesarean. An example of this: If the woman had a cesarean with five support people, she will be cautioned to keep her VBAC private.
Privacy and quiet are a must, and we will be very forceful about setting up logistics before the birth so that the woman can birth in peace. In short, the VBAC is high priority because this woman’s whole obstetrical future rides on its success.

Keeping a VBAC normal

Keeping a VBAC normal

We show the couple lots of videos of beautiful VBAC births because one video is worth a thousand words. If you don’t have your own, purchase a copy of my dvd “Birth with Gloria Lemay” which shows a beautiful VBAC waterbirth. Art therapy is helpful in creating the environment before the birth day. I place a big sheet of drawing paper in front of the father and mother with lots of colored pencils and instruct them to, “Draw your birth cave” or, “Color your birth.” When they are finished, I write the date on the two drawings and put them away in my files. After the birth, we take them out and are amazed at the details that were drawn weeks before and later manifested in the actual birth.

I schedule longer appointments with VBAC women because they seem to need to obsess. I don’t have solutions to many of their fears but it seems to help to just be able to talk to someone who cares and understands. I usually also ask them to, “Tell me how you know that this time you’re going to have a vaginal birth?” The answers always amaze me. One woman said, “Because this time I’m not depending on my doctor or my midwives—me and my husband are going to have this baby.” I suggested that she give up depending on her husband, too. She looked terrified at that idea but I could see that she understood; she looked me in the eye and said, “Right!” That was the moment I knew she would do it. She’s had three water homebirth VBACs since then, and after each birth her first words were, “I did it.”

VBAC women are so grateful for the opportunity to birth normally that they are often shy to ask for the extra things that make a birth beautiful, such as a Blessingway ceremony or a waterbirth. The midwife must remember to offer and encourage the mother to think “really beautiful birth” rather than “bare minimum birth.” I find it helpful to ask, “This is the only second baby you will ever have—what would make it really special?”

The Day of the Birth

In my practice, no one gets induced in any way or gets pain medication. This policy is very important for all women but especially for VBAC women. If there is a small chance of uterine rupture, we must have everything on our side to prevent it (the rate of VBAC uterine rupture without induction is 0.4 percent or less than one in 200*). It is beyond my comprehension how anyone could give a VBAC woman misoprostol (Cytotec), oxytocin or castor oil or strip the membranes or use any other form of induction when that would triple her chance of having a uterine rupture.

I believe that VBAC women have longer, gentler births because Nature is compensating for the scar. There is no hurrying. I would be terrified to induce a VBAC woman but feel safe to attend her at home if her body is pacing itself naturally. We keep it in the back of our heads that the signs of rupture are stabbing pain, unusual bleeding, decels of the baby’s heart, or a peculiar shape of the abdomen but we don’t look for problems if they don’t exist.

We are especially careful with the birth of the placenta in a VBAC because there is a slightly increased chance that the placenta might be adhered to the scar, and we do not want to have a uterine prolapse caused by pulling.

Postpartum Differences

After the birth, VBAC women need to be told that they can walk upright. They can’t believe that they can straighten at the waist right after giving birth. Then, they can’t believe it when we ask them to do sit-ups and leg raises on day one. Usually by day three when we go to visit, their husbands say, “Oh, she’s gone to the gym.” With VBAC women, the complaints are very few in the postpartum period because they are comparing to post-surgery pain and any minor scrapes and bruises seem like nothing.

In the years following the birth, these women and men send us more clients than anyone else, and if we’re in legal trouble, they’ll be at all the rallies, raise money, stamp the envelopes, write letters to legislators, and be our true friends for life. A VBAC is an amazing experience for the birth attendants as well as the family. Very Beautiful And Courageous (VBAC).

    Q & A: VBAC

Two Types of Pelvises
by Gloria Lemay

Q: From a midwife: A great many Asian women are very small and small-footed, yet I hear that many of them birth vaginally. Would you comment on pelvic size?

A: When I get a VBAC client and she is endlessly self-psychoanalyzing and beating herself up for having a c-section, I usually say, “Look you made two big mistakes! First you were born in the wrong country, and second you were born in the wrong century—if you’d been born and raised l00 years ago in France, for instance, you would have given birth vaginally.” When I teach my workshops, I tell the students there are two types of pelvises in allopathic medicine: l) contracted, and 2) adequate. In midwifery, there are two types of pelvises as well: l) roomy, ample, and 2) you could get a pony through there!

Gloria Lemay is a Private Birth Attendant in Vancouver, British Columbia, Canada and a frequent contributor to Midwifery Today and The Birthkit.

The "Slow Birth" Movement

Somehow, we all got hooked into thinking that “quick was better” when it came to birth. When women tell their birth stories, it seems to be a point of pride to be able to say “I gave birth in 5 hours”, “I barely made it to the hospital”, “even with my first, it was so fast”. We hear these stories and may envy the women thinking that they performed in a fast, efficient manner and we view them as having a coveted talent.

I’ve been observing women giving birth for thirty years and I have given birth three times. From my experience, I don’t think that quick is necessarily a good thing when having a baby. Often fast births afford the woman no time to get her breath and regain her strength. Some women describe their fast births as feeling like they have been whipped around in a blender. In a rapid birth, the woman’s body sometimes displays the symptoms of transition after the birth of the baby (shaking, feeling hot/cold, vomiting). When a baby comes slower, there’s a building up of the intensity of the sensations so that the woman can adjust herself to the process that’s happening and, even though most women would like to shave a few hours off the whole thing, nevertheless, they know they can cope and that they will get to the finish line of birth. When the baby comes slower, the woman often dozes between her pushing sensations and seems to derive a great deal of energy from those short snatches of sleep even though they are interrupted often. The hormones of birth seem to allow the woman to operate in a different domain of sleep, energy and strength. I’m fond of telling women who are tired and discouraged at transition “You’re going to get a big burst of energy when you get the reflex to push” or “you’ll get an energy rush when you feel the baby’s head at your perineum”.

This trust in the process and knowledge that energy can ebb but then be regained in the birth process seems to be greatly lacking in today’s Western obstetrics. Slowing down or taking a long time to dilate is simply viewed as a problem and it’s a problem to be fixed by hurrying the woman’s body along. There’s no such thing as a resting phase, going in and out of the process, or simply a looooonnnnngggggg, slow birth process. This is not allowed and it’s viewed as pathological.
It hasn’t always been that way.

Waiting for the baby

Waiting for the baby

In his book “The Farmer and the Obstetrician”, Michel Odent does a comparison of big agri-business to modern hospital obstetrics. When we see the environmental disaster that large scale agri-corporations have produced and we know that the hospital obstetric system has produced a North America wide cesarean rate of 30% and rising, it’s clear there’s been a severe skewing of priorities and principles. We have to re-order our thinking about farming in order to survive: local organic farms, 100 mile diet, moratoriums on genetically modified crops, co-op gardens, raw diets—all these things have grown in the past few years as the few who knew they were important have held onto the knowledge (and the seeds) for the ones of us who were slow to catch on to the urgency.

Instead of talking about “fast food” that seemed so sensible a while back, we’re talking about slow food. Food that takes time, patience, work and integrity to grow, sow and cook. Some are even talking about “slow money” to fund “slow food”, the kind of financing that doesn’t look for a quick return and a scheme but rather looks to the quality of neighborhoods, children, the air we breathe and the long term future.

For those of us who know there’s something terribly wrong with the state of obstetrics in North America, we must call for a return to SLOW BIRTHING. Birth which understands that some women will wait for several days after releasing their membranes and have no pathology. Slow birth means returning to a time when induction of birth was reserved for very seriously ill women and undertaken with great trepidation. Midwifery would be patient beyond all known limits . . . practitioners only steering the birth process in the most rare cases. We would return to a time when practitioners used to say such expressions as:

“Every birth is different, every woman is different and every baby is different.”
“Don’t let the sun set twice on a woman who is in active labor (past 4 centimeters dilation).”
“Don’t practice “meddlesome midwifery”.”
“A good obstetrician does not pick unripe fruit.”
“A good practitioner has two good hands and knows how to sit on them.”

These are all things I heard when I first started attending births 30 years ago and, now, I never hear them. We must get back to those times when the cesarean rate was below 15% or we will perish. As a society, we cannot withstand the damage that is being done to large numbers of women, babies and their extended families. The idea that we can “turn hospital beds” in order to make maximum use of the dollar cost of that bed is insane when it comes to giving birth.
The notion that a woman can be induced with all the pursuant cascade of interventions simply for the convenience of scheduling staff or room availability is a crime. We must wake up and recognize that giving birth to a baby is one of the most powerful transformative events in a woman’s life. This process is so important to the family and the rest of society that all efforts must be made to have it flow normally. Our priority must be the well being of the newborn baby and the conditions that are favorable to a long, satisfying breastfeeding experience. What we are doing right now with inductions, surgeries and the mass use of narcotics in childbirth is as harmful to the planet as fish farms and DDT. The small band of people who have kept the notion of SLOW BIRTH alive so that society at large can get back to what we know is the holistic way to treat new mothers and babies must be listened to and appropriate action taken. Childbirth is not a frill, it’s not an expendable experience, it’s a fundamental lynch pin in forming the family and, without it, we are doomed to being a sick society.

A Proven Method for Lowering the Cesarean Rate

Another article in my local newspaper last week bemoaned the fact that the cesarean rate keeps rising and physicians are concerned not only about the high rate of surgery but also the future complications that increase after cesarean surgery.  It’s a well-documented fact that a cesarean can adversely affect a woman’s health for the rest of her life and can lead to catastrophic complications in future births.  That’s one reason why, 40 years ago, doctors did everything in their power to prevent that first cesarean from being done.

What if there was a tried method of reducing the cesarean rate within hospitals?  What if it involved some truly innovative thinking?  What if it had a proven track record and had resulted in a significant drop in the rate of surgeries for first-time mothers?  What if it saved money, recovery time for the patient, and better health for the babies?  Would you think that method would be adopted all over North America right away?  Yes, that would be a reasonable assumption.  Unfortunately, this project was undertaken at B.C. Women’s Hospital, it was a success, and it was dropped once the project was complete with a resulting re-increase of the cesarean rate.  No reason for discontinuing the project has ever been given but i will speculate at the end of this post.

A cesarean is major abdominal surgery

A cesarean is major abdominal surgery


The results were published: Grzybowski S, Harris S, Buchinski B, Pope S, Swenerton J, Peter E, et al. First Births Project manual: a continuous quality improvement project. Vol 1. Vancouver: British Columbia’s Women’s Hospital and Health Centre; 1998.

It was the first phase of a Continuous Quality Improvement project with the aim of “Lowering the Caesarean Section Rate“. Start date was January of 1996. The target objective was to lower the caesarean section rate by 25% for nulliparous women, while maintaining maternal and infant outcomes, within 6 months of implementing solutions. 

Staff from all departments of the hospital were brought together in a brainstorming session to share hypotheses on what was causing the high rate of cesareans.  Many of the ideas thrown out were not under the control of the hospital but, in the end, four practices were identified as possibly contributing to the high rate of surgical births.

1. Women were being admitted to hospital too early (before reaching 4 cms dilation, active labour).

2. fetal surveillance by electronic fetal monitoring (continuous electronic fetal monitoring has been proven to increase the cesarean rate with no improvement to the health of the baby)

3. too early use of epidurals (women who get an epidural before 8 cms dilation are at increased risk of surgery)

4. inappropriate induction (inducing birth before 41 weeks gestational age with no medical indication).

Teams of nurses were assigned to do an audit of hospital records to see if these hypothetical practices were, in fact, as widespread as some of the staff thought.  The audit confirmed that these 4 areas were ones that needed attention.  Task forces were created in each area to use the best evidence and existing guidelines, as well as solutions from other hospitals to improve care at BC Women’s Hospital. Guidelines and other strategies in all four target areas were implemented in the spring of 1997.
 

WHAT HAPPENED?
 
According to published results from the hospital:
After six periods, BC Women’s had admitted and delivered 1369 nulliparous women (first time mothers) with singleton, cephalic, term presentations. The Cesarean section
rate was reduced by 21% compared to the 12 periods prior to implementation. The number of epidurals initiated at 3 3 cms was 64% lower, continuous fetal monitoring was used 14% less, the induction rate had dropped 22% and admission at less than 3 cms cervical dilation had dropped 21%. All changes were statistically significant. Newborn outcomes were unchanged post implementation.”

WHAT’S HAPPENING TODAY (2009)?

It’s back to business as usual at this hospital.  Women are induced, monitored, epidural’ed, and admitted early.  The cesarean rate is 30% and the head of obstetrics is concerned but has no action plan.  Why on earth would this be?  I assert that it is because it is an “up at dawn” battle with the physicians to change their ways.  The gossip that I hear from nurses is that the doctors did everything they could to undermine this project.  For example, a doctor would examine his patient and state “She’s 8 cms dilated, get the anaesthetist.”  Then, later, when the woman had her epidural, someone else would examine the same woman and find her to be only 6 cms.  The doctor would smile and shrug his shoulders, “whoops”.  The same thing happened around the issue of monitoring, induction and admitting. . . trickery to subvert the project and return to their old ways of doing things.

It’s a low tech, novel, innovative approach that had excellent results.  I’d love to see it copied everywhere in North America but it’s a bit like dieting. . . everyone knows how to lose weight (eat less, exercise more) but only a few get into action.  We DO know how to lower the cesarean rate, committed action is needed.

UPDATE: July 2017

A hospital in the USA brings their cesarean rate way down: http://www.stltoday.com/lifestyles/health-med-fit/health/st-mary-s-hospital-has-second-lowest-c-section-rate/article_38258dbb-a906-5e38-9c61-e321c16d6369.html