VBAC (Vaginal Birth After Caesarean)
VBAX2C – From the Midwife’s perspective
Supporting women with VBAC has always been a special interest of mine. This interest stems from when women wanting VBAC were ‘allowed’ to labour and birth in the Family Birth Centre (FBC) (where I was team leader at the time) and have predominantly midwife care all the way through their pregnancies and births. This decision was accepted by a progressive obstetrician that I worked with at the time, who realised that midwifery support for these women was very important.
After having women wanting VBACs in the FBC for a few years I remember being at a Maternity Care forum where Dr James King from the Perinatal Data Collection Unit presented the statistics on the uptake and outcomes of VBAC in Victoria. For the hospital where the birth centre was, the uptake of VBAC overall was low (as the FBC was really the only model offering VBAC), but for two years running, the success of VBAC was the highest in Victoria. I remember looking over to one of the obstetricians (who was at the forum with me) and gave him the thumbs up, acknowledging his support for us as a team of midwives, and for these women wanting VBAC. Unfortunately women wanting VBAC’s were no longer able to have care in the FBC due to changes in head obstetricians putting an end to a great model of care for VBAC.
Over the years, being able to support women to have a VBAC in a hospital setting has been a constant struggle. The need for VBAC support by midwives is higher than it’s ever been with so many women having caesareans ( 1 in 3 births ends in caesarean), so many women not wanting to go down the same pathway for their next pregnancy. But I find many obstetricians are not willing to accept women’s request for a VBAC, or if they are, there are so many rules that a woman has to fit into in order to be able to attempt a VBAC in a hospital setting, with continuous monitoring, IV bungs and rigid time frames for progress in labour. This is because of the risk of uterine rupture that I will discuss later.
The other day, I was privileged to work with a woman wanting VBA2C in a hospital setting. I have her approval to discuss her story on this blog, and wanted to write about it from my perspective as a midwife in private practice as although working through the hospital system was difficult, it was achievable, and maybe writing about her experience from a private midwives perspective will help someone else wanting to achieve the same.
My client came to me when she was about 7 weeks pregnant. She had X2 previous caesareans, the first for breech 5 years ago, and the second was a repeat elective caesarean 2 yrs ago as she wasn’t offered the choice of VBAC. Unfortunately my client didn’t recover well from her second caesarean and was pregnant again with her third child, and wanted a VBA2C. Initially she went to see an obstetrician at a level 3 hospital in Melbourne and he discussed the risks of uterine rupture with her. My client was happy to take on this risk, and wanted to attempt VBA2C at that hospital, and this he said would be supported, except that she was likely to meet a lot of differing views from different Dr’s within the hospital.
Then she met me and stated that she had done some searching and found out that having a private midwife would increase her chance of having a successful VBAC. I agreed, but told her at our first meeting that a lot of work needed to be done! She needed to lose weight, needed to get fit, and had some work to do to prepare her so that she believed she could achieve a VBAC. I advised that if she could not gain any weight this pregnancy it would be good (a loss of 12-15kg approximately) and to get a jogger pram and walk for at least 30 mins every day (which she did almost every day!). She did some of my Calmbirth classes with her husband to prepare them emotionally for what was ahead!
Her next appointment at the hospital was not so positive where she met an obstetrician who was so rude to her and literally told her she was stupid and irresponsible for wanting VBA2C and that she should have another elective caesarean. My client was devastated, and explained that she had already met an obstetrician that had informed her of the risks, and that he had said it was alright for her to have the option of VBA2C. It was decided that a meeting with the head of obstetrics was required after my client wrote in a letter of complaint to the hospital. I was to accompany her.
Before meeting the head obstetrician, we met another obstetrician at the hospital who once again frowned upon my clients decision to have VBA2C stating that the risk of rupture was very high, at least 1 in 20 and that of those many babies die. “Are you still sure you want VBAC”? said the Dr.
My client was so strong and brave and stated that the risks varied from what she had read and that she was supposed to be meeting the head obstetrician for this appointment. Thankfully the head obstetrician was there at the hospital and we saw her promptly. The first thing she stated was “It must be obvious to you now that there are different views to VBA2C at this hospital. She went on to say that she had cared for women wanting VBA2C before with varying success and that she was happy to care for my client if this is what she wanted. She was happy for my client to await labour up until 42 weeks, but wanted her to have an ultrasound at 32 weeks to see whether baby was really big, and that my client would need continuous monitoring during labour with an IV bung. She also discussed that most ruptures if they do occur happen during the second stage of labour, and that active pushing for a long time was not advised, and in this case she may need some assistance with a ventouse birth.
Although I don’t agree with ultrasound as a tool to assessing unborn babies weight in utero and the success of VBAC has nothing to do with the size of the baby, my client agreed to the above care plan. She continued to see this obstetrician and did shared care with me.
Over my clients pregnancy I observed a huge amount of personal growth in her. My client did not gain any weight for her entire pregnancy, and walked about 5km every day. She had become very determined to have a successful VBAC and had very positive thoughts about how her labour and birth would go on the day. She trusted her body’s ability to give birth and was not fearful of the process involved in labouring and giving birth. Also her husband was very supportive of her, their family and her wishes.
At 39 weeks gestation my client thought her membranes might have ruptured at midnight, and she was GBS positive! She was already having regular period type pains so I advised her to put a pad on and see for sure if her
membranes had ruptured. I discussed going to the hospital soon for antibiotics, and what this would mean in relation to caesarean if she wasn’t in established labour. It was decided to wait until the morning to see if labour established in this time frame. I had to think hard about balancing risk in this situation as my client had ruptured membranes and was GBS positive. Leaving this situation too long may give rise to an increase in the chance of baby contracting GBS, albeit small, but if we were to go straight into the hospital, a caesarean would be more likely as we would be presenting in not yet established labour. I told my client that I would not be doing any vaginal examinations as this would increase the chance of infection, and regardless of whether or not she was 2 cm or 8cm, I would have to take her to hospital at that point. So I decided to use my clinical judgement alone to decide when was the right time to go in.
At 0430 I received a message saying contractions were 6-8 mins apart, mild, but I decided to head over. At 7am my client was in the birth pool having mild to mod 6-8 min contractions. It was decided to get out of the bath and go for a walk. This is where her labour really began to accelerate, she vomited on the nature strip and the frequency of her contractions increased to every 3 mins, lasting 60 seconds. A person offered to drive us home, but I said all was well, and encouraged her to continue walking all the way home, and during contractions! On returning home from our walk my client said she couldn’t stand anymore and needed to rest. She lay on her left side on the couch and her thighs began to shake. This is a sign of very active labour, and we moved into hospital.
Going for a walk had done the trick! We decided to wait for peak hour traffic to ease before we made our way into the hospital. The car journey was difficult, but she still managed to remain very calm and focussed. At admissions, the midwives were so supportive and encouraging, and in birth suites we were lucky enough to have a midwife who used to be a private midwife in another state! She quickly told my client how she had worked with several women who had successful VBA2C.
After a short while my client felt lots of pressure and at this stage the registrar walked in and wanted to do a VE. I didn’t think it was necessary as I was sure my client was now fully dilated as she had a bright show and was starting to sound a bit ‘pushy’ in her voice, but I also realised that having the Dr examine her to find she was fully dilated would also work well for the medical team, as they would realise she was going to have a successful VBAC and let her get on with the job at hand! Little did I know there were lots of rules being applied to how long she could labour and push for outside the room, but thankfully my client pushed her baby out gently and beautifully all within about 20 mins of finding out for sure that she was in fact fully dilated. I remember her husband shaking his head in amazement and saying ‘Oh my gosh, Oh my gosh’ She was on her left side and was so beautifully controlled and breathed her baby’s head out. Her perineum was intact and she had given birth by successful VBA2C to a beautiful baby girl.
Needless to say my client was over the moon and very proud of her achievements, and so she should be. I was on such a high afterwards too that I couldn’t sleep that afternoon, so I had been awake since 7am the morning before!
The real risks associated with VBAC
The first place I always go to get ‘best available evidence’ is the Cochrane Library, as this collaboration investigate the RCT studies, eliminating bias that can interfere with other studies. In 2012 the collaboration concludes that no RCT’s of high quality exist comparing the outcomes of VBAC with elective repeat caesarean. Looking at the available evidence, the risk of uterine rupture varies from 2.4 per 100 births to 0.5% per 100 births. The risk of a baby dying because of the rupture is incredibly rare, reported as low as 1.9 per 10,000 births to as high as 10 per 10,000 births, which is about the same odds as a baby dying with a woman’s first uncomplicated pregnancy.
Factors associated with Increased / Reduced Risk of Uterine Rupture
The risk of uterine rupture is increased by induction of labour, an inter pregnancy interval of less than 18 months, and more than one previous caesarean section. Augmentation of labour is also associated with an increase in scar rupture. Fetal weight of > 4000g is associated with an increased likelihood of emergency caesarean birth if vaginal delivery is attempted, and a 1.6x (ns) risk of scar rupture. A previous vaginal birth reduces the risk of uterine scar rupture.
Risk associated with elective repeat caesarean section ERCS
In comparison the risks associated with caesarean births need to be discussed. I will report on elective caesarean only as this is what we are comparing here, the outcomes of VBAC compared to elective caesarean. According to a statement put out by RANZCOG Epidemiological data attribute higher maternal mortality to ERCS than trial of labour TOL. However, women with complex medical and obstetric problems are much more likely to feature in the ERCS than the TOL group, confounding the apparent association.
Important in the decision-analysis for many women is the intended future family size. With rising caesarean section rates, the serious complication of placenta accreta is becoming more prevalent. Silver et al (2006)17 found that placenta accreta was present in 0.24%, 0.31%, 0.57%, 2.1%, 2.3% and 6.7% of women undergoing their first, second, third, fourth, fifth, and sixth or more caesarean deliveries, respectively. This was a consequence of both an increasing incidence of placenta praevia with repeated caesarean sections and an increased likelihood of placenta accreta where the placenta was located over the uterine scar.
Some women may consider the above risks associated with VBAC to be unacceptable, and choose to have an ERCS. This woman’s choice should be respected (and usually is quite readily in the hospital setting). For other women, such as my client, the risk to her was considered small enough (Rupture after VBA2C is 0.9% compared to 0.5% after VBA1C) to attempt VBA2C. I believe her choice should also be respected.
As I am unable to draw on my professional experience of witnessing uterine rupture (as I haven’t seen any), I went to the internet to read stories of women’s experiences of uterine rupture, so that I could offer a balanced view.
What I noticed in all of the birth stories I read, was there was a degree of intervention with labour, or labour care was substandard (in my opinion) with the exception of one birth story. Either prostaglandins were used, women received ARM, syntocinon infusions were used, or women were left to labour or push for extended lengths of time (in my opinion once again). In the one story I read where the woman did not appear to receive any intervention in her labour, the woman described her pain as continuous, which is a warning sign with VBAC, and it was decided upon caesarean birth, even though there was no sign of fetal distress on CTG (this can be an early sign of a uterine rupture). During the operation it was noted that the uterus had ruptured, and her baby was born alive in good condition.
Given all of the information above, I have set my own guidelines for keeping women safe during VBAC. Women need to labour spontaneously, without any methods of induction or augmentation. Labour should progress steadily, but not necessarily quickly and the woman should be encouraged to breathe her baby down during the second stage of labour until the urge to push is so overwhelming. During the active pushing phase, there should also be steady progress, but not necessarily fast progress. If these guidelines are adhered to then it is my belief that a uterine rupture rate could be even lower than what is stated in the literature.