Are you a mumma who had a caesarean for her first birth? Wanting to know what your options are for subsequent births? Confused by all the acronyms? This is for you.
Previously the obstetric mantra was “once a caesarean always a caesarean” but more and more studies are coming out with evidence that contrary to this wide-held belief a vaginal birth is safer for both mother and baby. You may be told that a vaginal birth after caesarean (VBAC) holds higher risks of uterine rupture. But this information really must be put into clear perspective in order for any post caesarean birthing mumma to make an informed decision about her future births.
So what is a uterine rupture and what are the real stats?
Without going into a full anatomy lesson the uterus has two distinct segments, an upper and lower. A rupture can occur anywhere on the uterus however is more common at the site of an existing scar or at the join line between the upper and lower segments. Even if a woman has an existing scar this does not mean that a rupture would automatically occur in that place. Women without a scarred uterus can also experience a rupture. A rupture can be minor, in which case it is referred to as a dehiscence or window. When more major a rupture is a complete tear through the entire uterine wall. The obstetric community gets concerned about these things because when a rupture is major the outcome can be catastrophic for both mother and baby.
The statistics on this issue vary and it must be stated are muddied by the issue of pharmacological labour augmentation. The reason this point is important is that the drugs used to induce or augment labour have been clinically proven to link to an increased rate of rupture. Unfortunately a lot of the data available doesn’t duly separate this fact which means that some studies have quite high rates of rupture as the outcome. Generally though for a low risk, i.e. a mumma with one previous low lying transverse caesarean section scar who goes into spontaneous labour, the rate is 1 in 200.
I firmly believe it is important here to consider that every birth has an inherent element of risk. If you were to compare this statistic with other complications such as cord prolapse , placental accreta, breech presentation, shoulder dystocia etc. the risk of rupture is in my eyes relative. With great respect to one amazing blog (referenced below as a resource) I concur that the issue of rupture is often made out to be a mountain when really it is a molehill. When it happens it has the potential to be really really bad but in the majority of births it doesn’t happen. That is however my humble opinion and the crucial point I would like to stress is the importance of any mumma researching HER options so that she can make CHOICES about HER birth based on true informed consent. After all, every birth has risk involved, know your risks and know your options mummas!
What factors can increase the likelihood of a rupture?
Put simply the more trauma your uterus has the more potential for a rupture. If you have more than one existing scar then the risk percentages increase. Studies also show that use of synthetic oxytocin, known in Australia as Syntocinon or in the USA Pitocin, or prostaglandins (all of which are common pharmacological approaches to induce or augment labour) has a correlation to increased rates of uterine rupture. Some care providers will express concern about post-dates however this has not been proven to result in an increased incidence of rupture but instead increased incidence of repeat caesarean section.
What are the benefits of a spontaneous vaginal birth?
Ahhhhh where to start here. Any opportunity for a baby to choose it’s own birthing day means that, in most cases, baby is ready to be born. Baby will gain the birthy hormones and ideally lung compression from uterine contractions to prepare it for life on the outside. Baby will be less likely to suffer respitory distress. Mumma will gain the benefit of the wonder hormone oxytocin which will help in bonding and establishing breastfeeding. And in my mind one of the biggest motivators for a spontaneous vaginal birth is, in most instances, a more pleasant recovery process. Mumma will ideally be up and walking within minutes of baby’s entrance earth side. There won’t be restrictions on mobility. All of which can be crucial when you are caring for not only a newborn baby but also older children in the home.
What are the benefits of an elective caesarean birth?
Some studies indicate a decreased risk of uterine rupture. As this is the primary issue discussed, dare I say “harped on” by care providers it is important to note this. But aside from that further benefits can include a sense of control in that baby’s birthday is known. Some women also fear failing at an attempt to VBAC so electing for the caesarean up front empowers them. While these points are valid I would strongly implore all mummas to consider that a caesarean birth is full abdominal surgery. It has huge risks. And the more caesarean births you have the higher your risks of quite scary issues including maternal mortality.
How can I get my VBAC?
Find a supportive care provider and build your birth team. A trained surgeon who has a high caesarean rate is less likely to support the natural physiological process of birth. Find out what your care provider’s stance is on VBAC, what their “protocols” are, how they feel about monitoring, post-dates, duration of labour, the use of pharmacological induction methods. Ask what their success rate is.
Get a doula! Doulas are proven to reduce the likelihood of caesareans along with decrease the use of pharmacological pain-relief. For many VBAC mummas the path to a vaginal delivery has not only physical but also emotional ties. A doula will provide you and your birth partner with extra emotional support. They can assist in advocating and negotiating with your care provider as well as debrief from your past birth experience(s) and provide physical birth support.
Do all you can to keep out of the other “high risk” categories. Eat right, exercise, practice optimal foetal positioning techniques. Be informed and know your options for negotiation in protocol, understand what “best practice” may actually hinder your chances of a vaginal delivery and consider birthing at home for a HBAC (home birth after caesarean) or in a birth centre under midwifery-led care. There is so very much I could write on this issue so will perhaps defer more detail for another post….
How can I own my caesarean birth?
Even the most well intended plans can go astray. A VBAC can easily, and for the right reasons, become a CBAC (caesarean birth after caesarean). You can however still have ownership and influence in a surgical birth. You can OWN your birth! At the risk of a shameless self-promotion please go and check out my post on this very issue http://ownyourownbirth.wordpress.com/2013/08/30/how-to-prepare-for-a-natural-empowered-caesarean-something-all-birthing-mummas-should-consider/
Wishing you lots of birthy love and light in your future birthing journeys…. VBAC, CBAC, HBAC…. Whatever the acronym may you feel empowered, informed and rock your post-caesarean birth like you own it!
For a detailed semi-clinical analysis on this issue, complete with statistics and empirical references please see http://www.birthrites.org/uterinerupt.html
For a midwife’s views on the issues of risk of rupture including references to clinical studies inclusive of data pertaining to induction or augmentation please see the ever AMAZING blog http://midwifethinking.com/2011/02/23/vbac-making-a-mountain-out-of-a-molehill/
Other great resources are: