The case for a vaginal birth after a Caesarean

Women are pushing back at being prescribed routine repeat C-sections

Ask around, and the prevailing wisdom is that giving birth naturally after an initial C-section is either impossible, forbidden, or just simply not an option.

This is, in fact, a common misconception, and one that is now being challenged by experts who are armed with the evidence and on a mission to empower, educate and support women. Despite the evidence showing that the majority of women should be able to have a natural birth after having a C-section, women who achieve this are in the minority.

Prof Cecily Begley, and Chair of Nursing and Midwifery in the School of Nursing and Midwifery, Trinity College Dublin, says that having a vaginal birth after Caesarean, or VBAC, should be the choice of the woman, and not dismissed by their healthcare providers.

"If a woman has had a previous Caesarean section, there has to be a decision made the next time as to whether she has a vaginal birth or a routine, repeat C-section without even trying to go into labour. That decision should be made by the woman and the obstetrician jointly, with the woman's preference taken into account but that isn't the way I think that happens in Ireland. "

READ MORE

Begley knows this, because she was co-ordinator of the overall OptiBIRTH Project, a mammoth study that was conducted across Ireland, Germany, and Italy. Many women in the study admitted to feeling pressured to undergo a routine repeat C-section as dictated by their doctors. By educating both pregnant women and clinicians, the OptiBIRTH researchers found that the rate of VBAC increased significantly in the study cohort.

“The reason we were trying to increase VBAC rates, is that it is much safer for women. When you look at all the studies that have been done, there are pros and cons for both mothers and babies, but overall the evidence points to the fact that having a VBAC is the best and safest options. But that’s not what is told to women, or certainly women in Ireland.”

Women are not being given the “honest, evidence-based information” needed to make a decision about how their next birth will ideally proceed, says Begley, and she agrees that social media and online forums are responsible for fuelling much of the misinformation around C-sections and VBACs.

“Women also say that their obstetricians tell them how dangerous their situation was the last time when they had the C-section, and that they should just aim for a C-section again. But the reality is that the reason for the previous C-section is usually never there again.”

Global caesarean section rates are on the rise while the current rate of C-sections in Ireland is north of 30 per cent, and Begley doesn’t hold back when she terms it “an utter national disgrace”.

“Caesarean section carries a risk with it – it is a much safer operation than it used to be, which means obstetricians have become happier about doing them. But if you look at the rates of maternal deaths in Ireland, the vast majority of women who die do so following Caesarean section,” she asserts.

While the risk of death for the mother is three times higher with a C-section compared with a vaginal birth, this rate remains extremely low; at 8.6 deaths per 100,000 births, this is roughly on par with the rest of Western Europe, she adds.

Unavoidable

When is a Caesarean the only option? Begley is quick to point out that many C-sections are unavoidable, for a variety of medical reasons. Cord prolapse is one, where a woman’s membranes rupture and waters break but the cord falls down first and the baby is at risk of cutting off its own oxygen supply. Foetal distress is another obvious indication, while a baby being in the breech position accounts for about 3 per cent of first-time C-sections.

Yet Ireland’s high rate of C-sections points to the operation being carried out on a far more regular basis than these relatively rare situations would allow. Begley believes this is part of a growing trend towards the over-medicalisation of childbirth.

“Having a baby is a normal physiological process, and the body’s hormones take over if they are allowed to, and they just make it all happen, slowly but surely. The trouble is that we mess around with that system. We call it the “cascade of interventions” – once you intervene at all, then you have to do another, and another, it spirals out of control.”

The World Health Organisation’s official position is that no country should have a Caesarean rate of greater than 10-15 per cent. “They say that, when you look at the literature, any country where the rate is higher than 10 per cent, there is no concomitant decrease in their rates of maternal and perinatal mortality. I don’t understand how Irish obstetricians can say that 30 per cent is okay.”

Begley notes that the C-section rate in the US is around 38 per cent, yet its maternal mortality rate continues to rise, and is currently at 28 deaths per 100,000 births.

Begley is determined to see the rate of C-sections go down and the number of VBACs increase. Women who decide to “aim” for a VBAC have a 75 per cent chance of success, she says.

“That’s as high as any other birth, when you see the Caesarean rate is more than 25 per cent. If women knew that, they would realise they have the same chance of a vaginal birth as any other woman giving birth.”

Case study 1:

‘It shouldn’t be a home birth at all costs’

Sorcha O’Driscoll lives in Swords, Co Dublin. She wanted a home birth on her first baby but transferred in labour and had a C-section. She achieved a home birth with her second child.

“My three younger brothers were all born at home. Growing up I always associated babies with being born at home, because that was my first experience of giving birth. It’s all about where you are most comfortable – some people are more comfortable in a hospital, but for me, being at home was what I was most comfortable with.

“With my first child, I had planned a home birth, but I ended up transferring in labour. My waters had been gone for 24 hours, and the HSE midwife was no longer covered to take care of me at that point. I was completely supported in my decision to have a home birth though, and the hospital I was attending had a very close working relationship with the at-home midwives. You could tell they had an amazing respect for each other and the different roles that they play. Once I said I wanted a home birth, the consultant put me in touch with them and said he hoped he wouldn’t see me again. Even when I did have to transfer, and ended up having a C-section, they were very conscious when treating me that this was not what I had wanted.

“For my second baby, I was in a different hospital. When I said at 30 weeks pregnant I was going ahead with a home birth, they did voice their concerns but again they were hugely supportive – I certainly didn’t have any big arguments. Nobody suggested that I would go for a routine repeat C-section – I was encouraged to go for the VBAC. I was even more determined not to have a C-section the second time around, as this time I would have a toddler and baby to look after. It would have been much more difficult.

“For someone who is considering a home birth, I would say there are many experienced home birth midwives out there who will not take any chances with your or your baby. It shouldn’t be a home birth at all costs.”

Case study 2: ‘My priority isn’t how I give birth’

Sandra Gouloud lives in Mullingar, and is almost full-term with her second pregnancy. She is choosing to have a repeat C-section.

“What I have found from doing my research is that there are a lot of opinions, but the strongest opinions aren’t usually backed up. It’s other mommies that are giving their opinions on what you should do, and that scares me. It’s based on their own experience but everyone is different. I have found it so difficult to get good advice.

“I had a C-section with my first child, which was a surprise. But I was never one of those women who feels they’ve missed out or anything like that. I certainly didn’t feel I had missed out. I was 30 hours in labour at that stage, and couldn’t have given a hoot what happened. When I was handed my baby, I was just so happy to have them.

“When I think about giving birth, I think what do I want at the end of all of this? And what I want is a baby handed to me. How I give birth is really secondary to that.

“I feel that I am not knowledgeable enough to fight and have more of a say. People say I am on a time limit from when my waters break – I don’t have the medical background or knowledge to dispute that or argue it. I am also an older mum this time round – I am 41, so I feel like I don’t want to take any chances. I feel right now, for me, this is the safest option. My priority isn’t how I give birth, my priority is a safe, healthy baby at the end of it.”

Case study 3: ‘My consultant was very pro-VBAC’

Yolanda Kennedy lives in Dublin She had a C-section with her first child but a VBAC on her second.

“I really wanted a natural birth with my first child but she was a breech baby, and for various reasons they couldn’t try to turn her. I was really gutted but I had a chat with a doula the day before, and she gave me great advice on how to make it my own. It ended up being a really nice birth, but I did feel I had missed out on a kind of rite of passage, as such.

“When I got pregnant with my second child, I was really determined to have a natural birth, but I didn’t know where to start. I found the VBAC in Ireland Facebook group. Reading the stories and the advice there was unbelievable helpful. Also, my husband and I did a VBAC workshop and we found out lots of information and tips and tricks that would help me have a natural birth this time around. It was great to be armed with the right information and get in the frame of mind that you can do this. Also my consultant was very pro-VBAC and I felt very empowered.

“On the day, I had a very long pre-labour, but the team knew my birth plan was for a natural birth and they supported me and kept me on track. They did think I might have to have a section as nothing was happening and I got very upset and was crying. I actually made my husband have a chat with the baby and tell him to hurry up. The contractions monitor went off the charts after that, and soon after I delivered my baby boy. I got to push him out and it was amazing, it was such an empowering feeling. That’s not to say that C-sections aren’t like that at all, I have had both. But if a natural birth or VBAC is what you want, then being supported in that is everything.”