Caesarean sections and having a successful Vaginal Birth After Caesarean (VBAC)

There is an assumption fuelled by a continuing obsession with celebrity women, that having a caesarean section means you are ‘too posh to push’ and taking the ‘easy’ way out.

“I was called a cop-out by another mum even though I had an emergency c-section”, confides a Bristol mother who asked not to be named. “I really wanted to birth as naturally as possible and though I do feel a bit disappointed, I’m not going to let it get me down.”

Her experience of insults from other mothers is sadly not an isolated case, with other casearean section mums reporting similar abuse.

“I was called a cop-out by another mum even though I had an emergency c-section”

Despite misconceptions about the ‘lazy’ mothers who give birth this way, a caesarean section involves major surgery and will only be performed when this type of delivery is the only option.

What is a caesarean and what does it entail?

Emergency or urgent caesareans are carried out when complications develop either before or during labour.

Elective caesareans are planned and may be recommended for mothers of multiple births, vaginal birth after casearean, placenta praevia, or other noted complications during pregnancy.

– Usually performed under epidural or a spinal anaethesia, the mother is awake during the operation.

– Though pain will not be felt, an odd tugging or pulling can be felt in the abdomen whilst the baby is being delivered.

– The procedure will be shielded by a large screen though mothers will be kept informed throughout about what is going on.

– The baby is removed from the body by cutting through the abdomen and into the uterus, usually by a horizontal incision below the bikini line.

– Delivering the baby will only take around ten minutes, but the whole operation will take around 50 minutes.

– It is usually possible to hold the baby and even breastfeed immediately after delivery.

– After the operation, women may be closely monitored in a recovery area for signs of low blood pressure or other complications.

– Usually, a catheter will be fitted to drain urine from the bladder for up to 24 hours.

– The days following a caesarean will involve pain, especially during movement. Painkillers will be offered. It is important to keep the wound clean, dry and well aired where possible to prevent infection.

– Hospitals will discharge a casearean patient around three days after the operation. Though mums are advised to become mobile as soon as possible after the operation, it is not advisable to pick up or carry a weight heavier than the new baby for up to six weeks afterwards.

– The effects of a caesarean can be more serious when compared with women having a vaginal birth. There is an increased risk of bladder injury, hysterectomy, thromboebolic disease, not having more children and maternal death.

How many women are having caesarean sections?

According to figures from the Department of Health, between 1986 and 2008-09, the caesarean rate in England increased from 10.4 per cent to 24.6 per cent. Of these 24.6 per cent, 9.8 per cent were elective and 14.8 per cent emergency.  More than 20 per cent of births are being induced.

There are currently eight maternity units with a staggering caesarean rate of more than 30 per cent. The Chelsea and Westminster Hospital tops the chart at 33.3 per cent.

Bristol Fact

During the years 2006/07, St. Michael’s Hospital in Bristol induced 23.9 per cent of women.

In the same year, 12.7 per cent had an emergency caesarean and 11 per cent had an elective caesarean.

My pregnancy progressed beautifully, so why did my labour go wrong?

Whilst there are many reasons why labour can fail to progress, a serious contender is the “cascade of intervention”. Many women are simply not waiting until the baby is ready to come out and opt for the push, poke and chemicals of induction.

What is an induction?

When pregnancy goes past 41 weeks, women are considered to be overdue and induction is usually offered. The placenta is deemed by most health care professionals to function less well after this time and create a risk to the health of the baby.

There are various methods a midwife can use to get labour started. Each method becomes progressively more invasive and potentially leads to an entire cascade of intervention.

– A membrane sweep is the general starting point, when a midwife or doctor tries to separate the membranes around the baby from the cervix. This can be incredibly painful.

– If this is unsuccessful, prostaglandin may be offered. This hormone type substance is inserted into a woman’s vagina to help stimulate the uterus into contractions.

– The next stage is to artificially rupture the membranes. Also known as breaking the water, this increases the chance of the baby picking up infection.

– If all else fails, syntocinon a synthetic form of the naturally occurring hormone oxytocin, will be offered. Women can be persuaded into having this without realising what the consequences can be so it is important to be aware of the risks.

– Syntocinon is given through an intravenous drip immediately restricting free movement. Even going to the toilet involves lugging a drip around.

– There is a risk that syntocionon can cause the uterus to become overstimulated and it may cause very strong contractions that are much more painful than natural ones. This immediately increases the risk of epidural pain relief no matter how vehemently opposed a woman may be.

– Getting an epidural in if contractions are strong can be difficult for the anaesthetist, who will need the labouring woman to lay still. The needle needs to go into exactly the right place.

– The strong contractions can put your body and baby under much more stress so continuous monitoring will be needed.

– Due to having no feeling in the bottom half of their body, women may need help with delivery using a forceps or ventouse. Further complications or exhaustion can lead to an emergency caesarean.

Whilst all of this happens, the fear, confusion and intervention is interfering with the body’s natural ability to give birth.

So, can women who have had a caesarean section ever give birth normally second time around?

“Most definitely, yes!”, says Gina Lowdon from Caesarean.org.uk. “Generally it is a good idea to fully understand the circumstances and reasons for the previous caesarean and to have found enough information to have come to some firm conclusions about how to avoid the same pitfalls again.  It helps to be able to approach any birth without fear, with as little baggage as possible from the last birth and with a good level of confidence that this next birth is do-able and can be good.”

In 2004, funded by the National Institute for Clinical Excellence (NICE) the National Collaborating Centre for Women’s and Children’s Health produced clinical guidelines for the NHS on women and caesarean section. These included:

– Women who have had a previous Caesarean section and wish to have a vaginal birth should be supported in this decision by the maternity services.

– There is likely to be more interventions and women will ideally labour in a hospital with immediate access to surgery, monitoring equipment and blood transfusion.

– They should be made aware that though rare, there is an increased risk that a woman’s uterus could rupture. Statistically, this is 35 in every 10,000 women.

“Generally it is a good idea to fully understand the circumstances and reasons for the previous caesarean and to have found enough information to have come to some firm conclusions about how to avoid the same pitfalls again”

Women giving birth following a caesarean will given an appointment with a consultant at her chosen hospital. Though consultants are likely to back a woman’s request for a VBAC, it is worth questioning them on their hospital’s policy. Some hospitals will only allow a woman attempting a VBAC to labour for so long before they insist on performing an emergency caesarean.

Shockingly, the induction of labour can still be offered to women who have previously had a caesarean section despite this increasing the chances of rupture by up to a massive 240 per 10,000 women.

Gina Lowdon says: “Most obstetricians prefer not to induce women with a history of caesarean section due to the slightly increased risk of caesarean scar rupture.  Whilst the risk is still low, it is generally considered a contra-induction for induction, especially with prostaglandin gel pessaries.”

“VBAC is achievable for the majority who attempt it and is usually safer for the mother than a repeat caesarean”

UK charity, the National Childbirth Trust supports a woman’s decisions to go for a Vaginal Birth After Caesarean (VBAC) stating: “Vaginal birth has physical as well as psychological benefits for both the mother and the baby; and labouring and giving birth – that is, giving birth ‘normally’ – is something that matters a lot to many women.

“VBAC is achievable for the majority who attempt it and is usually safer for the mother than a repeat caesarean. Although VBAC does carry a very small risk of uterine rupture, the NCT believes that this level of risk should not dissuade women from choosing VBAC nor service providers from offering supporting women who choose this option.”

Advocate of the ‘optimal birth’, Author Sylvie Donna also supports natural physiological birthing, even for women having a VBAC.

Optimal birthing is about making things as good as possible when it comes to giving birth. Frequently, women giving birth optimally usually do so in the comfort of their own homes whilst having their midwife or care-provider maintain a safe, discrete distance, allowing the women to tune into her body and lead labour herself. Women achieving this even manage to do so without any intervention, tearing or pain relief!

Sylvie firmly believes it is possibly for women having a VBAC to experience this optimal birthing second time around. She says: “There is only one condition (which also applies to women who haven’t previously had a caesarean): they mustn’t be induced. Induction really does change the whole process of birth so outcomes aren’t ‘optimal’ afterwards. In addition, the risk of uterine rupture in VBAC mums increases significantly when women are induced, so induction is definitely to be avoided. (Without induction the risk hardly exists at all, provided the woman’s had a bikini-line incision, not the vertical old-fashioned type.) Beyond this, the same principles apply to VBAC labours and births as to any other: the woman needs to feel secure (and have the support of an experienced midwife), she needs to feel she is not being observed, and she must not be disturbed by any unnecessary interventions or even speech.”

“There is only one condition (which also applies to women who haven’t previously had a caesarean): they mustn’t be induced”

But it’s not easy for some women to face up to fears triggered by thoughts of childbirth. Tokophobia is the name for a phobia of childbirth. It is characterised by fear and disgust of pregnancy and childbirth pain.

Primary tokophobia pre-dates pregnancy and is strong enough for women to request elective caesareans. Secondary tokophobia develops after a traumatic first birth and can stop women from either having more children, or again, requesting a caesarean section.

The Birth Trauma Association (BTA) estimates that as many as 200,000 women every year may feel traumatised by their childbirth experience.  A 10,000 of these women may further develop Post-Natal Post Traumatic Stress Disorder (PN PTSD).

Risk factors for PN PTSD included induction, feelings of loss of control, high levels of medical intervention and traumatic or emergency deliveries including an emergency caesarian section.

Sylvie has advice for women who are left with fears from previous labours, to help them to go on and birth naturally. “The main thing I would recommend is that they read ‘Preparing for a Healthy Birth’”, she says. “It was written precisely with their needs in mind. By reading more about the physiological processes and by reading many birth accounts of normal, healthy births, these women will gradually regain confidence in their own body’s ability to give birth.”

So then, is an ‘optimal’ physiological birth suitable for everyone?  Sylvie says: “The answer will depend on the woman’s general state of health – which will screen out a very small percentage – and the interventions she has during pregnancy and labour, as well as the conditions in which she labours and gives birth. (The latter screens out the vast majority of women, simply because they are not labouring in conditions which are good.)

“Nevertheless, by becoming more aware of what good conditions are – e.g. by reading ‘Preparing for a Healthy Birth’, which explains to them in detail – the vast majority of women can correct this problem and have optimal – optimally optimal! – births.

“Health problems which screen out women, who then need carefully managed labours, include things such as kidney disease, heart problems (i.e. maternal heart disease), and diabetes (not gestational – Type I or II)… Many other conditions which seem to screen out women (anaemia, which is often misdiagnosed; Strep B; being Rhesus negative; even previous PPH – often because of mismanagement or extremely conservative definitions of what constitutes a haemorrhage) – do not necessarily affect a woman’s chances to have an optimal birth, i.e. one which is fully physiological.

“She can even have an optimal birth if she is expecting twins, if her baby is breech, or if she is ‘elderly’ (i.e. over 35), provided she can find a caregiver who is willing to attend her in labour.”

Getting birth choices right the first time around can eliminate future childbirth problems and the need for a VBAC in years to come.

– Read about positive birth stories in books and magazines to become confident in the process.

– Remember that the media love a birth horror story and your increased sensitivity to the subject during pregnacy will see you reading these everywhere. They are not as common as you might think.

– Make sure you understand everything your midwife tells you. Don’t leave an appointment confused, upset or with questions.

– If you don’t want a specific test, or you want to give birth in a certain place or position, be firm but polite if your midwife disagrees. You know your own body better than they do.

– If you are really not happy about medical advice given, then ask for a second opinion.

– If your baby is late did you calculate your due date accurately? If there is a possibility you didn’t then the baby is not late it is not ready. Don’t panic, just be patient.

– Even if you are planning to give birth as naturally as possible, labour can change the best made birth plans. Be informed so you know what treatment you would like to refuse or accept. Do read up on all the procedures and pain relief that may be offered including the side effects. Being well informed will cut out any fear of the unknown.

– Even if you do not want one, do read up about caesarean sections so you are fully prepared should this become an inevitable outcome.