The VBAC Wars

 
The VBAC Wars
By Cas McCullough
 
On Thursday 6 November, 2008, CANA National Spokesperson and Birth Matters Editor Cas McCullough gave a presentation entitled ‘The VBAC Wars’ at the Australian Midwifery Expo in Brisbane. Here’s what she had to say.  
 
About six weeks ago, I was in hospital recovering from emergency surgery for an ectopic pregnancy. I had lost more than a third of my blood supply, requiring four blood transfusions, and then developed pneumonia because my lungs had collapsed after the surgery.
 
Next door to me was a woman who had just had an emergency caesarean. Like a fly on the wall I listened that first night as she struggled with a very unsettled baby who would not stop crying. I could hear the bewilderment in her voice as she talked with the midwives. She hadn’t expected it to be like this. In quiet conversations I heard her express disappointment about the way things had turned out, but at least she had a healthy baby, I heard some of her visitors say.
 
What really struck me, was that starting life as a new mum while recovering from major surgery is hard. It reinforced my view that surgery should be reserved for sick people who need it, not healthy people in the prime of their lives.
 
Sadly, this is not what happens in the real world. Australia’s caesarean section rate is currently 30.3%, and about half of all caesareans performed are repeat caesareans. Less than 17% of women who birth after caesarean have a Vaginal Birth (VBAC), and of those who do, few emerge from the experience unscathed, due to a birth care system that undermines their ability to birth normally.
 
So today we head into the trenches, because I want to show you what women are up against, the impact of this battle on their emotional health, and the repercussions for their families. I also want to share with you my vision for a better way forward.
 
The Context Behind the War
The current situation in Australia, particularly in the private sector, is to actively or subversively encourage caesarean section and discourage VBAC, even for those women who have had only one prior transverse lower segment caesarean section (LSCS) (Fenwick et al, 2007).
 
While the media and some medical associations would have us believe that the reason the repeat caesarean rate is so high is because women are asking for caesareans, Australian women wanting a VBAC are routinely denied access to supportive birthing programs because:

1. There is a distinct lack of VBAC or BAC programs available for women, despite the fact that one in three women have a caesarean section, and the majority of women who’ve had a first caesarean, have another.
2. Health professionals do not know where to send women for information because there is so little ‘formalised’ community/public information.
3. Health professionals do not know how to provide positive support to women unless they can feel positive about it themselves.
4. Despite good evidence on the safety of VBAC, the current RANZCOG info sheet is insufficient and still covertly suggests a caesarean section might be the better option.
5. VBAC after two prior caesarean sections (VBA2C) is actively discouraged, and there is only one hospital in Australia (a private hospital in Nambour, Queensland) that fully supports VBA2+C (vaginal birth after two or more caesareans).

The landmark US survey ‘Listening to Mothers and Babies II’ (Declercq et al, 2006) showed that only 12% of women in the survey had a VBAC despite 45% of survey participants being interested in having a VBAC. Of these, about half were denied the option of VBAC due to hospital or practitioner recommendations and policies. New research in Australia suggests the same is happening here (Staff, 2005).
 
Other research identifies that despite a preference for vaginal birth, women tend to follow the advice of their care giver and “consent to a repeat caesarean section in the belief that it is the safest option for them and their baby (Hopkins 2000, Gamble & Creedy 2001, Potter et al. 2001, Bainbridge 2002, Donati et al. 2003, Fenwick et al. 2006, in Fenwick et al, 2007, p. 1562).”
 
In Australia, the situation is dire. Caesarean Awareness Network Australia (CANA) has received reports of even level two hospitals denying women the opportunity to try VBAC. Women are simply not being given the option.
 
Battle no. 1: The Big Scare
Most women who enter an antenatal appointment requesting to plan VBAC, leave bewildered, frightened and anxious, with bloody images of dead babies and hysterectomies planted firmly in their minds. I know this because I have heard it from many, many women and I have also experienced it myself.
 
At 34 weeks I was given the option of elective caesarean, stating uterine rupture as the reason. I responded: “Yes, but isn't it only a 2% risk or something?” The reply from the registered nurse was, "Yes, but when it happens all hell breaks loose …" and other gory details. I found this unnecessary and not an objective discussion of the risks and benefits of VBAC. I was forced to obtain more accurate information myself – information which should be readily available to any pregnant mother with a prior caesarean.
-Woman planning a VBAC
 
Fear of the mother and/or baby dying from a catastrophic uterine scar rupture casts a huge shadow over VBAC. It is argued that the uterine scar is put under immense stress from labour, which can cause it to burst open causing massive bleeding and the protrusion of the baby’s body from the uterus.
 
However, a rare catastrophic rupture is 30 times less likely than any other rare adverse event requiring an urgent caesarean section to happen to any pregnant woman regardless of her risk factors (Enkin et al, 2000).
 
In fact, A Guide to Effective Care in Pregnancy and Childbirth, based on a systematic review of the literature on childbirth, states that care of the VBAC woman should be “little different from that of any woman in labour (Enkin et al 2000).”
World Health Organisation statistics on uterine rupture show that this rare complication is much more likely to occur in developing countries in women with no prior history of caesarean section, but where there are high levels of poverty, high birth rates, and lack of access to primary medical care.
 
Statistics from the Australian Institute of Health and Welfare suggest that babies and mothers have more chance of dying from major car accident, heart attack or deep vein thrombosis, but we don’t drive with intravenous drips in our arms just in case.
People must accept that life involves risk, and it is for women themselves to determine what constitutes ‘acceptable’ risk in the VBAC context. The job of health professionals is to give women all the information and support their choices.
Medical research literature overwhelmingly supports the safety of VBAC for the majority of women with one previous LSCS (Dodd et al, 2004; Gregory et al, 2007).
 
A recent study in Canada showed that the risk of severe morbidity or mortality in VBAC women and their babies was about 1-2%. More than 70% of women attempting VBAC who had no complications in the current pregnancy gave birth vaginally, and in the group that developed complications during pregnancy, 50% of those still had a vaginal birth (Gregory et al, 2008). The most problematic complications were those that could happen to any woman in any pregnancy and could have been due to poor management of care.
 
Further research indicates that women who seek VBA2+C should also be supported in their choice (Enkin et al, 2000; Wood et al, 2001). And yet, women who ask for this option are actively discriminated against and undermined in our birth care system.
One woman I know was a refugee from Bosnia who desperately wanted the option of VBAC for her third pregnancy. She went to a level two hospital and was told that they would reject her as a patient if she refused a repeat caesarean. When she made a complaint about this treatment to the Queensland Health Quality and Complaints Commission, she was told that the doctor was only doing what was safest for her and her baby, and that she should just accept it. There was no acknowledgement of her right to informed consent, let alone informed refusal. Nobody batted an eye at the fact this woman’s rights were completely ignored, and at a hospital with 24-hour emergency cover.
 
For some reason, when it comes to VBAC, some people think it’s okay to badger, pester, bully and coerce. For some reason it’s okay to deny a woman her rights and to treat her with no respect whatsoever. And it’s okay to emotionally abuse her.
I’m here to tell you, it is not okay!
 
Battle no. 2: Treaty on the table, but no one’s backing down
If getting someone to support you in VBAC is the first battle, the next is getting someone to support you for a normal birth, no strings attached.
 
In Australia, the most common practice is to insist on prophylactic intravenous cannulation and continuous electronic foetal monitoring (EFM) during labour (Dodd & Crowther, 2003). However, a search of medical research database Medline reveals no evidence to support prophylactic cannulation. Furthermore, in the Royal College of Obstetrics and Gynaecology evidence-based guidelines, continuous monitoring had a poor basis in evidence, and was recommended only because:

1. it was common or ‘accepted’ practice, and
2. it provided a detailed record of labour for use as evidence in court should an adverse event occur.

A more thorough review of the literature reveals that the benefits of continuous monitoring do not necessarily outweigh the risks (McCullough, 2008).
 
Here is an example of standard policy on VBAC from the Royal Women’s Hospital in Melbourne, Victoria:

• Notify registrar and anaesthetist that a VBAC woman is in birth suites.
• IV access with 16G cannula from onset of labour.
• Blood to be taken for: Group and save, Hb.
• ARM to be performed once the cervix is: 3cm dilated, and effaced, and applied to the presenting part.
• Continuous EFM throughout the labour.
• Aim to deliver within 12 hours of onset of active labour.
• Vaginal Examination every 4 hrs until 7cm dilated, and 2-hourly thereafter.
• Progress: anticipate 1 cm dilatation/hour (after achieving 3cm).
• In general, oxytocin augmentation is not contraindicated in women undergoing a VBAC.
• Epidural may be used as indicated.
• Second Stage: Duration should not exceed 2 hours: 1 hour to allow for passive descent, but no more than 1 hour of active pushing (or 30 minutes if the woman has had a prior vaginal delivery).
• Any assisted vaginal delivery to be performed in the operating theatre.

When I had my VBAC, if I had been forced to submit to any of the above interventions, had my labour or even just my second stage been timed, I have no doubt that I would have had a repeat caesarean. I cannot help but wonder how many women’s attempts at VBAC have been foiled by restrictive and unnecessarily interventionist policies like this?
 
I often get told that a woman “had to be monitored” and “had to have a cannula just in case”, even by educated and fairly informed midwives. But evidence does not support this.
 
There is extremely scant evidence, or no evidence in some cases, in support of artificial rupture of the membranes, starvation, time limits on first or second stage, or time limits on the pregnancy (RCOG, 2007; Zhang et al, 2002; Cesario, 2005; Watson, 1994; Zelop et al, 2001; Odent, 2004; Goer, 1999; Priddy, 2004; Clement, 1994; Enkin, 1992; Hofmeyr, 2005; Rageth et al, 1999; Leung et al, 1993; ACOG, 2002; Sheiner et al, 2000; Fraser, 1993; Fraser et al, 1997; NCT, 1989; Robson & Kumar, 1980; Donald, 1979)
 
For women, routine interventions such as cannulation and continuous EFM which might seem benign to an obstetrician or even some midwives, suddenly take on a level of symbolism: that of failure, that of danger, that of “no one believes I can birth my baby.” So, in effect, women are filled with fear even before they reach labour, then given a double dose of it once in the labour room. Tell me, what impact do you think all this fear has on a woman in labour?
 
These things don’t help a woman have a normal birth, which is why women who are educated about VBAC and who are motivated to achieve a normal birth take their business elsewhere, hire a doula, and stay home as long as possible, only going into hospital to push! There is no trust there, and there is no real safety either. This leads me to the next battle.
 
Battle no. 3: Psychological Warfare!
Commonly, as soon as they reveal they want a VBAC, women are met with a barrage of hostility, negativity, misinformation, and fear. And women are often surprised when initial support early in pregnancy is withdrawn at term:
 
“My 40-week hospital appointment became my worst nightmare. The registrar started talking induction. After an exam, she told me that I wasn’t ‘favourable’ for induction and that I would need another caesarean. I was in shock. Why was she even talking induction in the first place? I wasn’t even ‘overdue’.”
 
This from a mother (and registered nurse) who ultimately decided to stay at home during labour and birthed her baby unassisted.
 
The victims of war: Collateral Damage
In the bid to get women to comply, there is the potential to do great harm. Stress and anxiety have been shown to cause problems not only for the mother but also for the baby following birth. How we treat women antenatally and in the labour room matters.
 
Some researchers have documented the damaging effect of anxiety and depression during pregnancy (Monk et al, 2003; Rodriguez & Waldenstrom, 2008) on the mental health of the mother and the physical and mental health of the baby, not to mention the impact on other family members.
 
Fenwick et al (2007) found that the way women were treated in the lead up to and during childbirth “had implications for how women felt about themselves following the birth, and ultimately how they went on to interact with their newborn within the family environment (p.1566).”
 
What will bring peace?

• Respect for a woman’s right to choose to VBAC
• Accessible evidence-based information (Childbirth Connection’s booklet a good resource)
• Peer support (Birthtalk, BaBs, NBAC Clinic in WA, Birthrites, CARES-SA)
• Respect for her right to decline routine interventions
• Primary midwifery care
• Time, space and encouragement to give birth normally

 
Regarding primary midwifery models of care, there are significant flaws in current thinking including beliefs that:

1. primary midwifery care is only applicable for women who are deemed statistically to be low risk, and
2. a model of primary midwifery care operates in isolation from other care providers.

The recently released Cochrane Review on midwifery-led versus other models of maternity care recommends that all women should have access to primary midwifery care regardless of their risk status (Hatem et al, 2008).
 
The safest labour will result when there is effective communication and positive support by a skilled attendant for the labouring woman. To deny women this option puts her at greater risk of harm, not less risk. Women who have had uterine surgery, especially those planning for VBAC may need more support and attention during labour for a number of reasons.

1. Women may present with increased risks (in other words, continuity of carer in labour makes birth safer for these women).
2. They may need extra emotional support and encouragement. 
3. Continuity of care enhances normal labour and reduces the need for obstetric intervention (Hatem et al, 2008; Hodnett et al, 2003; Simkin and Bolding, 2004).
4. They require care that facilitates open and honest communication and fosters an atmosphere of trust. Having a known midwife would be a distinct advantage in terms of both physical and emotional safety.

In a higher needs labour such as VBAC, or in situations where a woman has had other prior uterine surgery or issues that may complicate the pregnancy or labour (such as history of child sexual abuse, a learning disability etc), continuity of carer with a midwife the woman trusts should be routine policy.
 
In the Northern Territory, VBAC women are able to access the Darwin Homebirth Program. Fifteen VBAC women have birthed through the program, 10 of whom have had homebirths. Five were transferred, and the program has a caesarean section rate of 14.5%. While these numbers are very small, it is encouraging that the vast majority of VBAC women have been able to give birth at home. There is hope!
 
I want to challenge each and every one of you to go back to your hospitals and take a good hard look at your VBAC policies. If they’re not evidence-based, revise them; if they are, then see them for what they are: a guide for staff, not law for the woman.
The next time you care for a VBAC woman, ask her what she needs to feel comfortable and safe and give her what she needs.
 
Don’t settle for less, because women and their babies deserve the best.