Cesarean birth and VBAC.

I recently attended a one day workshop called, Cesarean Birth & VBAC: Facts and Fiction: Improving Care for Childbearing Women and Their Families led by Nicette Jukelevics, who has been an educator, consultant and advocate in the field of childbirth with a special interest in Cesareans and VBACs, for over 20 years. I came to this workshop because, like all of us involved in education and advocacy in the field of childbirth, I am extremely concerned and yes, outraged, by the ever-rising Cesarean section rate and the equally extreme decline in the availability of vaginal birth after Cesarean (VBAC). According to the most current statistics the U.S. Cesarean section rate was 27.6% in 2003 and there is only a 10% VBAC rate.

The workshop was attended by childbirth educators, labor assistants/birth doulas and midwives. Unfortunately, despite the fact that it was held in a hospital, no nurses or doctors attended. We came from different backgrounds and trainings but our common bond was our understanding that something must shift, something must change or the rate of Cesareans will continue to climb and the Cesarean section will become the "norm" for childbirth.

The women present were spirited, passionate and well informed, contributing wonderful insights and asking pertinent questions. Nicette presented us with facts and statistics supporting our concern and confirming that Cesarean sections should be reserved for true medical reasons. I would like to say I left the workshop knowing how better to serve women, how to help them "get" a VBAC, but I did not. I sat through the workshop and became more depressed about the circumstances that are currently surrounding birth, this most significant and life-altering event.

I didn't listen with the ears of an informed childbirth educator; doula, or homebirth mother of six. Instead, I tried listening with the ears of a pregnant woman in 2005 who gave birth two years prior by Cesarean for failure to progress, who is currently reading the books and popular pregnancy magazines that her care provider and friends recommend, who listens to her friend's and family's current birth stories and watches The Baby Story and Maternity Ward on TV.

This is what "I" heard. A woman who has had a previous Cesarean IS at greater risk for a uterine rupture than a woman who has not had a Cesarean (5 in 1000). A woman with a previous Cesarean IS at greater risk for placenta previa (four times more likely), which would lead to the medical need for a Cesarean and if undetected, could lead to a possibly life-threatening hemorrhage. A woman with a previous Cesarean IS at greater risk for placenta accreta (10 times more likely). This is when the placenta grows into or through the uterine wall increasing the possibility for a hemorrhage to occur and depending on how involved the implantation is, a hysterectomy may be required. There is an increase in the baby being stillborn (12.9 per 10,000) as a result of a Cesarean history, possibly because the placenta was deprived of proper blood supply due to scar tissue from the incision. These risks are real.

What I sat listening to is what women are reading and being told. The conclusion "I" reached was once you have a Cesarean you have very few options. No more possibility for a low-intervention pregnancy, no low-intervention labor and birth, no vaginal birth after Cesarean (VBAC), maybe no more babies. "I" became frightened of doing anything BUT scheduling a Cesarean section two weeks before my due date. I wanted a live baby, a healthy baby. I wanted to be healthy and alive as well. VBAC? No way, too risky.

So as not to go down the dark hole of despair while I was sitting through the workshop, I pondered the solutions, the possible answers to these fears. How can we help women to listen with different ears? One thing

that may be helpful is to give comparable statistics on risks for other procedures and accepted medical practices during pregnancy and/or labor. An example would be that amniocentesis which is done routinely for women over the age of 35 or as follow-up for an abnormal AFP screening test, carries a risk for miscarriage of 1 in 200. A woman who has never had a baby before still faces the risk of her baby being stillborn (9.8 per 10,000), which is not a statistically significant difference from a woman with a previous Cesarean 12.9 per 10,000). A woman who is planning a repeat, scheduled Cesarean is still at risk of uterine rupture (2 in 1000), again not a statistically significant difference. There are many risks and statistics that you can site about pitocin, prostglandins, laboring on your back, etc.

The women need to understand that there is a tremendous focus right now on the issue of VBAC and a tremendous push for elective repeat Cesareans. This does not mean that everything else that is done, including the scheduled Cesarean is low-risk or risk-free. It just means that at this time the American College of Obstetrics and Gynecologists (ACOG) has set up guidelines about Cesareans and VBACs forcing providers in obstetrical care to be extremely cautious of what they offer and how they proceed in the care they are giving, whether they agree with the protocols or not.

What became very clear to me during the workshop, what I believe our focus has to be is this ... HELP WOMEN AVOID THE FIRST MEDICALLY UNNECESSARY CESAREAN. It sounds obvious to all of us but it is always to the obvious that we must return. This is so important ... we must educate, educate, educate. Women need to understand that pregnancy and childbirth is not a disease, it is not something dangerous. Left to their own the overwhelming majority of pregnancies, labors and births are without complications. When we work with women in their pregnancies we have to address the very real possibility that they may face a Cesarean section. Years ago, we addressed this issue but now we must spend A LOT of time on the topic. Now ALL women are possible candidates for Cesareans not just women having what is considered a "high-risk" pregnancy.

Throughout the day we discussed the "whys" of the rising Cesarean section rate. The whys have to be the addressed in order to understand how we might aid in bringing the rate down. The incredible rise in the induction rate in this country has greatly impacted the virtually new diagnosis, "Failed Induction" given for surgical birth. The fact that 80-90% of labors are done with the use of an epidural has also affected the Cesarean rate. Helping women to understand that these factors increase the possibility of a Cesarean birth may help them to understand that the risks for induction and epidurals may not out way the benefit of being patient and being mobile and supported during labor. Another strong factor is malpractice insurance. Care providers in obstetrics are facing ever-rising fees and their fear of being sued is always looming no matter whom they are. We can imagine that somewhere, whether it is in the forefront of their mind or just a speck in the back, they wonder, "How will this look in court?" An example of this was brought home to me the other day in a conversation with a pregnant woman who is hoping to have a VBAC. She told me that her OB was "OK" with it, but she had to first agree to watch a video about the risks of VBAC and had to sign papers that confirmed that she had been made aware of the dangers involved and that she was still willing to proceed with a "trial of labor". She admitted that the video was scary. She also believed that her OB had no choice but to show it to her as it was a state law (it is not). I asked the woman if her OB had also shown her anything about the risks involved with inductions, epidurals, pitocin, etc and her clear answer was, "No".

Anytime I am working with a pregnant woman I feel it is my responsibility to provide her with ALL the information about tests, procedures and protocols and to let her know what the risks and benefits are. I believe it is my responsibility to let her know what her options are, what alternatives there are, what her choices are. I believe that my greatest responsibility is to help her trust the process of birth and to help her sort out the difference between fact and fear. This is an awesome job, an awesome responsibility. I cannot, nor will I, make decisions for her but I can help her make the best, informed decisions for herself and her baby, for her future babies by providing information, statistics and facts. I see so many great bumper stickers out there but I have thus far been able to resist covering my car with any until recently when one phrase grabbed me and said all I needed to say ... INFORMATION IS POWER.

I believe we help not only by providing women with information, but also by helping her to find the facts herself and by encouraging her to engage her providers in the process by asking them to explain and show medical evidence to support their decisions. I believe one incredibly effective way to bring down the malpractice suits is to help women "own" their pregnancies. By helping them to be well informed and to let go of fear we are helping them to accept responsibility for their decisions and their choices. If something does go "wrong", they will be much less likely to look to blame anyone because they will accept that they were an active participant in the process all along.

Though I felt some hopelessness during the workshop, I know there is hope. The evidence to support this were the women gathered in that room. It is all of you out there who want things to change. Yes, I do think that the pendulum is swinging to one side and, unfortunately I think it will continue to for awhile. But if we do the work that we have been called to do, that we have been trained to do, when that pendulum starts to swing back toward the true normal, it will be faster with the support of all of us and all of the women, babies and families that have been positively effected.

DON'T GIVE UP! Find opportunities to talk with women, preferably before they are pregnant and most definitely once they are (no matter what number pregnancy it may be). Ask them what they know and gently but confidently guide them around the full circle of information. Become involved in groups that support and speak to normal birth. Become researchers, finding the evidence-based practices that should be upheld in the medical community. Do all of this with a heart of compassion, with nonviolent action. We cannot be heard, cannot have a dialogue if there is anger and/or aggression in our voices. Have the courage to speak, reminding yourself that the way to a peaceful world, a better humanity is through a peaceful birth, we must be models for that goal.

Resources

www.ican.org

www.vbac.com

www.maternitywise.org

Therese Hak-Kuhn is first and foremost a mother of six homebirthed children. She is also an ALACE Labor Assistant Workshop Instructor, a doula and a midwife's assistant. She lives in Richmond, VA with her family. She can be reached at [e-mail]