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.

DVD: “Birth with Gloria Lemay”

This is the kind of delightful feedback I receive about the DVD. Gloria

From Donna Reicks:
“Gloria, I just have to tell you…..I loaned out your DVD “Birth with Gloria Lemay” as I do to any “English” ladies I serve. These are 1st time parents (after 7 years of trying!) and she loved your DVD and commented her favorite part was the extra features on circumcision!! They were on the fence if they had a boy. Now, their decision is made. Thanks Gloria!! Keep up the good work! Much love to you!”

From Gloria Lemay: “When I made the DVD, it was easy to add a few “extras” besides the footage of 9 home water births. One of the “extras” is a Director’s Cut-type film with me explaining what is going on in the film. The strange thing for me is how many women say, “After watching the version with you explaining what’s going on, my husband is now comfortable with the idea of birthing at home and he feels confident.” The conclusion I’ve come to is that I must have been talking to the back of the sound technician (a man) and that’s why the words seem to affect men. Completely inadvertent but I like it.

Then, there were 2 really good videos that really taught me a lot about the importance of the male foreskin so I requested the use of them from the owners. They were both thrilled to give me their material. Again, so much of the feedback that I get is that those two features have such an impact on people. Both of those intact penis features are available for anyone to watch online but, it seems, a couple sitting on their couch watching a DVD will keep going right to the end of the DVD and THAT has put the information in a lot of people’s hands. It’s so gratifying to know that those DVDs are all over the world. If you have one, don’t leave it on your shelf—get it out and show it or lend it to pregnant families!”

“Birth with Gloria Lemay”

To order the DVD, send $35 via Paypal or Interac to birthdvd(at)gmail.com

Facebook favourite Updates

I’ve been on Facebook for five years, apparently. These are the most popular updates that I’ve posted there:

They are not “unvaccinated”. . . they have a natural immune system. Women are not “unmastectomized” . . .they have their breasts. Boys are not “uncircumcised”, they are intact. Every word creates a hallucination. When we hallucinate wholeness, wholeness will show up as normal.

Gloria Lemay

October 2013 393 likes

What do I want for my birthday? I want everyone who reads this to take 30 seconds to get up, walk through your place and turn off any lights or appliances that don’t need to be on, OFF. We make the difference in having our Mother Earth work. Thank you.

Gloria Lemay

October 2012 270 likes

If you’re hiring a doula to “enforce your birth plan”, “keep you home as long as possible”, and “protect you”, wake up and plan a home birth with an attendant you trust.

Gloria Lemay

July 2012 359 likes

I don’t know who wrote this but I found it very funny 🙂

If you love something, set it free. If it comes back, it will always be yours. If it doesn’t come back, it was never yours to begin with. But, if it just sits in your living room, messes up your stuff, eats your food, uses your telephone, takes your money, and doesn’t appear to realize that you had set it free……. you either married it or gave birth to it.

July 2011 213 likes

www.pinterest.com

Courage

According to the Merriam-Webster dictionary, courage is a noun meaning ‘ability to overcome fear or despair” The fear has to be present in order for courage to exist. The English word “courage” is derived from the French word for the heart, “cour”. When someone finds the heart to continue on doing the right thing in the face of great fear, everyone around her is inspired to become a nobler human being. This is the source of courage for many midwives. In ourwork, we see women and men facing their fears in birth, we ask them to have faith in the face of no evidence, we demand that they be bigger than the circumstances and, when they conquer, we get a renewed vision of how life can look when our fears don’t stop us.

The paths of parenting and midwifery push me up against my fears and despairing attitude on a daily basis. Luckily, I have found teachers and teachings that have inspired me to keep going despite a rapidly beating hummingbird heart. When my daughters were very young and I was juggling my heart’s desire to be a good parent and make a difference in childbirth, one of my friends told me to use the affirmation “My vulnerability is my strength.” I thought she was insane and argued that if I lived by that slogan my children would surely perish. I was pretty sure that my strength was my strength—and by strength I meant my ability to force and push life to suit my will. I now know that true strength is an elusive quality of being able to strengthen others. At that time, I trusted my friend and, on faith in her alone, began toying with sharing my vulnerability. I tiptoed into revealing my fears and apprehensions to a few “safe” people and slowly began to realize that what my friend had given me as an affirmation worked a lot better than my stoic, stubborn, brave warrior act.

After a few harsh lessons, I began to realize that it wasn’t up to me to conceal information that was worrying me at a birth from the parents. In fact, if I am afraid at a birth, the best thing I can do is name the fear boldly and even ask everyone else present to say what his or her fears are. One of my dear clients released her membranes at 36 weeks in her second pregnancy. Her first birth had been a beautiful, straightforward home birth and I was deeply invested in her second birth being just as great. After four days of leaking, she began having regular, intense birthing sensations and we drove to the hospital for the birth. I drove and the parents were in the back seat of my car. As we approached the hospital, my hands on the wheel were clutched into white knuckles and a ball of fear formed in my gut. I started picturing the cord being whacked off immediately and the baby being taken away from Mom. I looked in the rear view mirror and saw the father with his eyes looking terrified. I said to him “What’s your biggest fear right now, Brian?” He replied, “I am afraid we’re going to have a Cesarean.” I never imagined this would be his fear. A cesarean was not even a possibility, I explained, “Your wife is in strong birthing, she has already had one vaginal birth, the baby is small—for sure it will be born vaginally”. He asked me, then, “What are you afraid of?” I told him honestly “ I’m afraid that the baby’s cord will be cut too quickly and the baby will be taken away from Karen.” This had not occurred to him but he knew that my experience was a better barometer of things to come. He asked me what we could do to prevent this. I was able to tell him that it was very important to take the doctor aside out in the hall and tell him “It means everything to my wife and I that the cord be left to pulse and that the baby be placed on her skin until the placenta comes out.” We did a couple of “dress rehearsals” of what had to be said and then went in. The staff at the hospital respected the parents’ wishes to have the cord left intact. The birth went beautifully. I would have wished that the baby didn’t have as heavy doses of antibiotics as he was given (with resulting colic for months) but having a birth that involved no induction or anesthetics was a big accomplishment in these circumstances.

Nancy Wainer, author, midwife

Nancy Wainer, author, midwife


There was a period in my career when I was unable to divest myself of fear and dread. I wanted to have a breakthrough and so I decided to “import” some courage into my city. I thought about my heroes in the midwifery movement and asked myself “Whose the bravest person I know?” The answer was, of course, Nancy Wainer Cohen. Her book “Silent Knife” had kept my feet in the room at VBAC births where every cell in my body had been screaming “What the h— are you doing here?!!” I was pretty sure that if Nancy came and lived at my house for a few days, I could get some courage. My husband picked Nancy up at the airport and she came into my house and hugged me wracking with sobs. She cried her way through several boxes of Kleenex at the workshop she taught for my students. Her visit was four days of snot, tears and intense passion for healing birth. I learned so much about the vulnerability and strength connection. Nancy is still my hero in the courage department and she continues to live her life with her heart pinned right on her sleeve.

The sharing other midwives have done about their fears has strengthened me to face my fears of birth One midwife wrote in Midwifery Today that “the drive to the birth with all the “what ifs” running through my head is the hard part, when I walk through the door and see the woman, all that disappears”. Another midwife told me “The scariest thing for me is the first prenatal class of a series. Meeting new people who have so much riding on my teaching is enough to give me an ulcer.” An acronym for fear is:

F= false
E= evidence
A= appearing
R= real

When I am most afraid, it is because I have forgotten the truth about how loved and blessed I am. The fear can dominate and stop me or it can be used to alert me to something to which I am deeply committed. Using a journal to write out fears in the morning helps to clear the mind. Once the fears are on paper, somehow they seem less foreboding. Being in action is another antidote to the paralysis that accompanies fear. Any action—cleaning your desk, organizing a drawer, making a phone call—will bring a new perspective and lessen the dread.

My favorite philosopher about fear and courage is the Wizard of Oz speaking to the cowardly lion “Courage is doing what’s right even though you’re afraid.” I have learned courage from birthing women and other midwives. We are there to inspire and raise the bar for each other on what’s possible in the domain of courageous action.
This article by Gloria Lemay was written in 2003 and first published in Midwifery Today, Issue 67, Autumn 2003

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