Doula Wisdom: How to VBAC
Last night, my friend Shannon Staloch and I hosted our third conference call Q&A on birth. We focused on VBAC--vaginal birth after cesarean--and heard from a special guest, Muneera Fontaine. Muneera is a childbirth and postpartum doula (and mother of three, and PhD candidate!) in the Washington D.C. area. She shared her own experience of birth, including a frustrating first birth during which she was pushed to schedule a c-section for an estimated "large baby," only to find out later that it wasn't medically necessary (read more about the evidence for induction/c-section for estimated big babies here). She went on to have two successful VBACs, and to train as a doula. Here are some takeaways from the call, representing the wisdom of three birthworkers:
- Process: Muneera talked about the importance of emotionally processing previous c-section births. The emotional toll of undesired birth experiences, including those we would categorize as traumatic, is very real. This is especially so when women are treated as if they have no choice or say in the decisions around their bodies, births and babies. In birth, women are especially sensitive and vulnerable to care provider messages, and many moms walk away from the experience believing that their bodies are broken. Connect with a meetup group hosted by the International Cesarean Awareness Network to talk to other women who are planning or have had successful VBACs, or find support in a Facebook group. Examples include Solace for Mothers (to process trauma) and Black Women do VBAC.
- Prepare: Some possibilities here include: prenatal yoga, a VBAC-positive childbirth class and especially one that addresses specific fears (HypnoBirthing is a good option), and chiropractic care for pelvic balancing and encouraging the baby to enter the pelvis in an optimal position. Shannon mentioned that she recommends that mothers planning to VBAC in her homebirth practice strengthen uterine scar tissue by taking 1,000 mg of vitamin C and treating the external scar with vitamin E oil.
- Hire a Supportive Provider: I always like to remind parents that their provider works for them, and not the other way around. You hire an OB team, a midwifery team, or an individual midwife, and they work for you. It is critical to find a provider in a practice with a low c-section rate and a high VBAC rate. That way, you know that they walk the walk and don't just talk about supporting VBAC. Respect, information, clarity, and informed decision making are critical, regardless of the outcome, so work with someone who prioritizes those elements of care. Talk with local childbirth educators, VBAC mamas, ICAN groups, or other resources to find out names of providers with the best reputation for VBAC. Check out your hospitals c-section rate here (USA only).
- Birth in a Supportive Environment: Not all hospitals allow VBAC, and of those that do, some hospitals have a higher c-section rate than others (see #3). I tell any birthing parents to investigate the options available to them in the birthing room. What are the policies in that space? Are you able to move, eat, shower, use a birth ball, have supportive people present, etc? Consider birth centers and homebirth as alternatives. Shannon noted that she has had numerous homebirth clients who came her way because they could not find a hospital or birth center that would permit them to VBAC. On that note, if you're curious about homebirth but unsure, you can always interview one or more local midwives to learn more without making a commitment to an out-of-hospital birth.
- Review Your Records: Request the records from your previous birth and review them with your new care provider. Muneera noted that going over her records made her realize that it wasn't her body that didn't "work, it was that she hadn't been allowed to even try to birth at all! A sensitive record review can help shed light on where different steps could have been taken to avoid a cesarean, or can highlight how and why a cesarean was necessary. Both outcomes can help mothers process their initial experience/s and release feelings of shame or grief around their body.
- "Positivity: Surround yourself with positive affirmations, positive people (ICAN members and Facebook groups, for example) and positive VBAC stories. Connect with others, be vulnerable about your fears, receive love and support, and build positive expectation around VBAC.
- Hire a Doula: Studies show that doulas significantly reduce the risk of an initial cesarean. They help to create and maintain a supportive environment for birth, help parents stay focused on their goals, provide information and space for conversations with care providers during birth, and give so much of the emotional encouragement that mothers need during VBAC.
- Avoid induction. Induction, especially when using combined prostaglandins (cervical ripening agents such as Cervidil) and Pitocin, increase the risk of uterine rupture and overall have a three-fold increased risk for a subsequent c-section.
Though overall VBAC rates are low in this country (the most recent number I saw was 9.2% in 2010), it's important to remember that most people (75% according to one study I saw) who attempt a VBAC will indeed have a vaginal birth. Some women will not be able to birth vaginally, and for them, a cesarean may be a critical intervention for her and her baby's safety.
Process, Prepare, Surrender
My take on a repeat cesarean is this: we question information that is provided to us as authoritative, based not on antipathy towards our providers but because we must advocate for ourselves and our families first with skepticism. From skepticism we gain information, and knowledge. We take steps to prepare ourselves for the best birth outcomes--including emotional processing, physical preparation, and building a fantastic birth team--and we do our best.
At the end of the day, birth is not about being in control. It's about relinquishing control, surrendering to the force of our bodies, to the force of birth, and framed by whatever our belief systems teach us. This never means giving our power to a system that sometimes chews and spits women out; it means acknowledging that we do our best as mothers, we make the best decisions we can for ourselves and our families in the moment, and we must honor all of that.
Let's say you did require another cesarean; how might it be different? Include in your birth preferences a list of preferences should that occur. Thinking through a subsequent cesarean is not about chipping away at positive expectations for VBAC, it's about contingency planning and empowering yourself with information. For example, you can request to have the curtain lowered in order to see your baby being birthed (without seeing the incision site), you can request delayed cord clamping (60 seconds), immediate skin-to-skin, music, and quiet conversation.
For Mothers in the Seacoast New Hampshire, Maine and Greater Boston Area
Here are some resources that I like to share with doula clients birthing in the greater Boston and Seacoast, NH area.
- Comparing Childbirth at Massachusetts Hospitals (WBUR) Cambridge Hospital in Cambridge, MA has the lowest c-section rate (15%), thanks to the Cambridge Birthing Center, located on the hospital grounds. The highest is Tufts Medical Center (30%), which sees more high-risk patients. High risk means that practitioners think in terms of risk. Low risk means that practitioners are more comfortable with normal, physiological birth. The MA VBAC rate as of 2013 is 13.1%. See VBAC rates by state.
- New Hampshire Cesarean Rates: As of 2010, the lowest c-section rate in New Hampshire was at Alice Peck Memorial Hospital (14.6%) and the highest at Androscoggin Valley (42.6%). Our current VBAC rate is 13.5%. See VBAC rates by state.
- Maine Cesarean Rates are here, though date to 2009
- ICAN of Seacoast, New Hampshire
- ICAN of Eastern Massachusetts
- Massachusetts Birth Trauma therapists
- Northern New England Perinatal Quality Improvement Network (NNEPQIN) information on VBAC
- I offer HypnoBirthing classes through Portsmouth Regional Hospital (calendar is here, search "HypnoBirthing")
- "The Best Compilation of VBAC/ERCS Research to Date" from VBACFacts
- "Induction, C-Section & VBAC Facts" from Improving Birth
Photo Credit: popularpatty, Flickr CC: http://bit.ly/29nT1ej