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MIDWIFERY CARE FOR THE VBAC WOMAN

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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.

“An Unnecessary Cut”, 20 min video on Hospital VBAC

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This video is timely and a valuable resource for birth workers. It’s a good length (20 mins) and it addresses that large number of women who are not ready for a home birth for a VBAC. It’s also a very good promotion for hiring a doula. Chileshe Nkonde-Price, a cardiologist at the University of Pennsylvania, wants to avoid an unnecessary Cesarean. This is the last week of her pregnancy. Enjoy and tell me what you think of it. Gloria

An Unnecessary Cut? How the C-section Became America’s Most Common Major Surgery – The New Yorker

Producer: Sky Dylan-Robbins

Courage

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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

Insider’s Tip on How to Have a Great VBAC

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The following is a post I sent to the ICAN (International Cesarean Awareness
Network) list. It is very, very important information for ALL birthing women
and can make all the difference in a VBAC birth. Read it carefully, copy it,
send it to your clients. One of the ICAN women replies to my post at the
end:

Subject: ICAN: Tip for birth

I wanted to write to those of you who are pregnant to tell you something
that has been running through my mind all day about how you can be
successful with your VBAC births. Many births begin in the night…. woman
will get up to pee, feel her membranes release and then an hour later begin
having sensations fifteen minutes apart. Because we think of birth as a
family/couple experience, most women will wake up their husbands to tell
them something’s starting and then, probably because we all hope we’ll be
the 1 in 10,000 women who don’t experience any pain, we start getting the
birth supplies organized, fill up the water tub, etc. I have seen so many
births that take days and days of prodromal (under 3 cms. dilation)
sensations and they usually begin this way. The couple distracts themselves
in that early critical time when the pituitary gland is beginning to put out
oxytocin to dilate the cervix. Turning on the light, causes inhibition of
the oxytocin release. Many couples don’t call their midwives until they have
sensations coming 5 minutes apart at 7:00 a.m. but they’ve been up since
midnight timing every one of the early sensations. If they had called their
midwife at midnight she would have said “Turn off the light and let your
husband sleep as much as possible through the night. You, stay dark and
quiet. Take a bath with a candle if it helps and call me back when you think
I should come over.”

Secret beginning of birth

Secret beginning of birth

That first night can make all the difference and yet so many couples act
like it’s a party and don’t realize they are sabotaging their births right
at the beginning. Staying up all night in the early part does two things–it
throws off the body clock that controls sleep and waking and confuses the
brain AND it inhibits the release of the very hormone you need to dilate
effectively. You know that it can take days to recover after a night of
partying or after working a graveyard shift. Don’t start your birth with
that kind of stress on your hormone system.

When you begin to have sensations, I urge you to ignore it as long as you
possibly can. Don’t tell anyone. Have a “secret sensation time” with your
unborn baby and get in as dark a space as you can. Minimize what is
happening with your husband, family and the birth attendants. What would you
rather have–a big, long dramatic birth story to tell everyone or a really
smooth birth? You do have a say over your hormone activity. Help your
pituitary gland secrete oxytocin to open your cervix by being in a dark,
quiet room with your eyes closed. Gloria Lemay, Vancouver

Pam wrote:

“I really loved what Gloria had to say here. For me, it’s all about what
went wrong at my first birth (stayed up all night timing
contractions…stupid, stupid, stupid, and was totally wiped out by morning),
and could have been improved at the second, when I lacked a place to stay
dark and quiet. I printed it out for my husband to read, and am putting it in my
file of important things to remember when labor starts, within the next
couple of weeks.”

Marjorie Tew author of “Safer Childbirth?”

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One of my heroes in the childbirth movement is Prof Marjorie Tew of Glasgow, Scotland. I’d love to meet her and give her a hug. She came to be a supporter of homebirth even though she gave birth in hospital herself and even though she was highly sceptical when her evidence showed homebirth to be safer than hospital. This is the kind of science that I love—when the scientist holds the opposite belief but can still trust her/his method enough to change beliefs. This book review of her 3rd Ed. of “Safer Childbirth” will give you an idea of what she has done for women.Book

Safer childbirth: a critical history of maternity care. Third edition.
Gavin Young
GP in rural Cumbria and member of the UK government’s Expert Maternity Group, which produced the report “Changing Childbirth”

Marjorie Tew. (442 pages, £15.95.) Free Association Books Ltd, 1998. ISBN 1-85343-426-4.

This book is exciting and makes humbling reading for doctors. Its relevance extends beyond maternity care. Marjorie Tew tells a tale of the abuse of professional power, the use of misinformation and the blindness and bigotry of those who should have known better. Even the very best, like Dugald Baird in Aberdeen, could lose their scientific footing in the headlong rush for doctors to take over and hospitalize childbirth: “if it is accepted that confinement in hospital is safer for certain types of patient, where the risks are high, it must also be safer for cases where the risks are less”.

The shift to hospital birth has been one of the great sociological changes in the industrialized world in the past 50 years. Yet this change took place with almost no evidence to support it. It ought to be a source of shame to those who promoted the shift through the 1950s, 60s and 70s that controlled trials were not considered necessary. Only a few brave voices cried in the wilderness, Archie Cochrane notably and Marjorie Tew.

Mrs Tew was teaching statistics to medical students and whilst using the results of the 1970 Birth Surveys found that the conclusions reached by government (through its specialist advisers) were not supported by the evidence. Despite her unbiased stance and clear presentation of the evidence, British medical journals disgracefully refused to publish her paper until the Journal of the Royal College of General Practitioners finally did so in 1985.1

Tew presents a sad litany of errors which doctors inflicted on childbearing women including: enforced recumbency in labour, induction rates at over 50% and X-rays. “It has been frequently asked if there is any danger to the life of the child by the passage of X-rays through it; it can be said at once that there is none if the examination is carried out by a competent radiologist” (Radiologist, 1937). I would personally add electronic fetal monitoring to this list. It is not Tew but a paediatrician who wrote in 1987 “the recent history of perinatal medicine abounds with instances in which belated controlled trials eventually revealed that the apparent benefits of some widely acclaimed treatment had merely disguised the real extent of its tragic consequences”. Most of this stemmed from a belief that biomedicine would solve all the problems of childbirth, ignoring social and psychological factors. Tew has a lovely example from the Rhondda of 1936, where Ovaltine not obstetricians may have reduced maternal mortality.

We should be grateful for Marjorie Tew for her courage and determination in the face of sometimes vicious opposition. She is in the end I believe too critical of the benefits of specialist care. There may be more balanced views, but Tew’s account is lively and impassioned. Readers ought to buy a copy and pass it on to an obstetric colleague, but don’t expect any thanks.

Reference

1 Tew M. Place of birth and perinatal mortality. J R Coll Gen Pract 1985; 35: 390–394

    Added October 2013

Tew, M. Place of birth and perinatal mortality. J R Coll Gen Pract 1985; 35(277): 390-94
Using the raw perinatal mortality rates (PMRs) from a 1970 British national survey, the hospital PMR was 27.8 per 1000 births versus 5.4 per 1000 for homebirths/general practitioner units (GPUs). This was not because hospitals handled more high-risk births. When PMRs were standardized based on age, parity, hypertension/toxemia, prenatal risk prediction score, method of delivery, and birth weight, adjusted hospital PMRs for each category ranged from 22.7 per 1000 to 27.8 per 1000 while homebirth/GPU rates ranged from 5.4 per 1000 to 10.5 per 1000.
The 1970 survey assigned a prenatal risk score to predict the likelihood of problems during labor. When PMRs for hospital versus home/GPU for the same level of risk (very low, low, moderate, high, very high) are compared, the hospital PMR was lower only at the very highest risk level. All differences, except in the “very high risk” category, were significant. The PMR for high-risk births in home/GPUs (15.5/1000) was slightly lower than that for low-risk births in the hospital (17.9/1000). Moreover, the PMRs in home/GPUs for very low, low, and moderate risk births were all similar, but hospital PMRs increased twofold between categories, which suggests that hospital labor management actually intensified risks.
The percentage of infants born with breathing difficulties (9.3% versus 3.3%), the death rate associated with breathing difficulties (0.94% versus 0.19%), and the transfer rate to neonatal intensive care units for infants with breathing problems who survived six hours (62.0% versus 26.2%) were all higher in the hospital (all p<0.001), further evidence that hospital interventions do not avert poor outcomes. Although no national study has been undertaken since, smaller studies confirm that increasing use of hospital confinement is not the reason for the overall drop in PMR since 1970. In fact, those years when the proportional increase in hospital births was greatest were the years when the PMR declined least and vice versa. (End of quote) Preterm labour study by M. Tew (link to abstract) http://www.midwiferyjournal.com/article/S0266-6138%2805%2980228-1/abstract

Quote from the book, Safer Childbirth by Marjorie Tew:

“The degree of pain in childbirth perceived by a woman depends not only on the physical stimulus, but also on her emotional state and her cultural expectations.
Her perceived pain is less when she feels relaxed, unafraid and reassured by the continuous, comforting support of her birth attendant.
Not all doctors or midwives can inspire peaceful confidence and this is rarely the atmosphere in a large obstetric hospital where the obstetric practices themselves have the effect of intensifying physical pain.”

“Safer Childbirth” by Marjorie Tew, p. 172

Quote for thought