Once A Section, Always A

Section?

Actually, No. Not these days.

Everything moves on and attitudes to repeat sections are no different. Nowadays, depending on the reasons for your previous section, you may well be offered the opportunity for vaginal birth, or VBAC, when you birth your next baby.

VBAC is the acronym for Vaginal Birth After Caesarean.

You might also see other acronyms. For example:

VBA2C – Vaginal Birth After 2 Caesareans

HBAC – Home Birth After Caesarean

WBAC – Water Birth After Caesarean

HWBAC - Home Water Birth After Caesarean

But what’s the issue with having repeat sections?

Surely that’s safer for mother and child?

Not necessarily.

It all depends on why you had a section in the first place.

Now, before you jump on me and tell me that your section was required to save the life of you and your baby, I’m not disputing that for a moment.

We know that around 10% of women have complications that may warrant an operative birth.

But, the national section rate for the UK is around 27%. Does that mean that 17% of women who have sections just might not have truly needed them?

It’s also a fact that our section rate has risen astronomically in the last 18 years, yet our maternal death rate shows no change in the same time period. The expectation is that if all the sections that are performed in the UK are absolutely critical to the saving of lives then the maternal death rate should be lower. (1)

Yet it hasn’t changed in nearly 20 years.

This suggests that perhaps too many sections are being carried out, when, if some women were let be, they might not have had a Caesarean birth at all.

Another point that many women don’t realise is that having an ‘emergency section’ does not always imply an absolute blue light situation. This is not saying that there are not births that fall into this category, of course there are. But, you do need to be aware that these cases are much rarer than we think.

Any section that is not ‘elective’ or ‘planned’ is categorised as an ‘emergency’ regardless of the urgency of need for surgery. It is not unusual for a woman requiring an ‘emergency’ section to wait for an hour or more before actually being wheeled to the operating theatre. Certainly, with my nursing hat on, this does not fit in with my concept of what constitutes an ‘emergency’.

If you birth in hospital, even though you may not be aware of it, you will be cared for under the regulation of protocols and clinical pathways. These protocols and pathways will lay out precise guidelines for things like how long your first stage should last; exactly how many centimetres per hour your cervix should be dilating; how long you are ‘allowed’ to push for during the second stage of birth.

Mother Nature has never read any of these guidelines and does things her own sweet way. If nature’s way takes longer than the hospital policy ‘allows’, then you may find you are classed as ‘failure to progress’ and a section may be offered.

You also have to consider that specific interventions may have contributed to the fact your previous birth ended in a section.

The two most common interventions associated with this are:

• Induction
• Continuous Foetal Monitoring (CFM)

Induction

I am not talking here of inducing birth where there is known to be a medical problem. It’s more the situations where you are offered an induction without there being a specific medical need. One very common example of this is being offered induction for no other reason than you have gone past your due date. And, don’t forget, the World Health Organisation defines ‘full term pregnancy’ as 37-42 weeks, so technically you’re not overdue until you’re 42+1 weeks.

The validity of inducing birth at 40 weeks or sooner, and for no other medical reason, is of great debate. It is true that research suggests that there may be a risk of stillbirth associated with prolonged pregnancies but this risk is small. The debate rages over exactly what this risk may be. (2)

This is what the Royal College of Obstetricians and Gynaecologists and NICE ,(National Institute for Clinical Excellence), have to say about routine induction because a woman is ‘overdue’:

“Recommendations on prolonged pregnancy

Women with uncomplicated pregnancies should be given every opportunity to go into spontaneous labour.

Women with uncomplicated pregnancies should usually be offered induction of labour between 41+0 and 42+0 weeks to avoid the risks of prolonged pregnancy. The exact timing should take into account the woman’s preferences and local circumstances.

If a woman chooses not to have induction of labour, her decision should be respected.

Healthcare professionals should discuss the woman’s care with her from then on.

From 42 weeks, women who decline induction of labour should be offered increased antenatal monitoring consisting of at least twice-weekly cardiotocography and ultrasound estimation of maximum amniotic pool depth.” (3)

This is very different from being told ‘You have to have an induction because you’re over your due date.’

The whole point of induction is that it is forcing a woman’s body to birth when neither mum nor baby may be physiologically or emotionally ready. It’s hardly surprising that some research studies indicate that you are twice as likely to end up having a section if your birth is induced. (4)

Continuous Foetal Monitoring (CFM)

Women are still monitored continuously during birth as a matter of routine in many UK maternity units. This happens despite the fact that research has systematically shown that CFM does not predict all problems and does not improve birth outcomes.

CFM has only shown two consistent outcomes:

• It is associated with higher section rates without improving outcomes. (5)
• It restricts a woman’s mobility and prevents her from instinctively adopting birthing positions that would enable her birth to progress naturally.

The majority of women undergoing CFM do so lying on their backs or in a semi-recumbent position. The focus of getting a reading from a machine takes precedence over the woman’s needs or wants.

In the western world we are so used to seeing women giving birth on their backs that we have forgotten that this is for the convenience of birth attendants and not how nature intended. When women give birth with complete freedom of movement they will instinctively adopt postures and movements that help their baby move through the pelvis. Many women tend to stand, squat or birth on hands and knees - all positions that use gravity to help the birthing process along.

One of the difficulties of birthing on your back is that due to the way our bodies are made; you actually have to push your baby uphill in order to birth him or her. Talk about making a hard job even tougher.

Have a look at this to see what I mean:

Now, let’s get back to deciding if you want to VBAC.

The first thing is to find out why you had a section for a previous birth.

It can be very helpful to obtain a copy of your old maternity notes to get more information about your previous section. There’s a link at the end of this article by NHS Choices explaining how to do this. (6)

You can ask your midwife to go through your old notes with you. In fact, she may very well obtain them for you saving you the cost of obtaining them unless you want a copy you can keep. If you’re not yet pregnant or feel your midwife is not the right person, then you could ask someone else that you trust and who is competent to do this. Many Independent Midwives, (IM), offer a Note Reading And Debriefing Birth Service to women. There’s a link at the bottom of the article explaining how to find your nearest IM. (7)

The point of looking at your old notes is to gain some perspective on why you had a section at all. From this you can begin to make decisions about whether you should have another section or a VBAC.

Wherever possible, women are being advised that you should have a vaginal birth next time.

The simple reason for this is that it’s safer.

Many people are very surprised to find this out. In the west, it’s assumed that surgery must be the safest way to birth for both mother and child. In fact, research shows that this is not true. A caesarean section carries significant risks for both mother and child. For babies, some of these risks may affect them for the rest of their lives. Again, there’s another link at the bottom of the article detailing these risks. (8)

Uterine rupture will be mentioned as a major risk for any woman planning to VBAC.

A uterine rupture is when a tear develops in the womb usually along the line of the scar from the previous sections. It can be a full rupture, (very rare), or dehiscence of the scar which means only part of the scar opens up like a little window. Whilst a full rupture may have catastrophic consequences for mother and child, the more common scar dehiscence carries far less risk of harm.

But what are the actual chances of it happening?

Looking at research studies, the risk of uterine rupture varies from around 0.07% per thousand to around 2.4% per thousand depending on the evidence you read. So, it’s generally accepted that the risk for uterine rupture is about 1% per 1000. (9)

BUT two things to bear in mind:

• These studies count all events as rupture regardless of whether the woman experienced a full uterine rupture or whether she had scar dehiscence which is not as dangerous as a full rupture.


• The other thing is that many of these studies included women whose VBAC was induced or augmented with contraction inducing vaginal gels or pessaries or intravenous drugs. It is an established fact that the risk of uterine rupture may be twice as high when birth is induced and for this reason is not recommended for women choosing a VBAC. Preliminary work suggests that risk of uterine rupture could be lower again if these issues were excluded.

In addition, what has also never been looked at is whether these risks would decrease even further in VBAC-ing women who are not restricted in their mobility and choice of positions during birth.

So, when you are told that by choosing to VBAC, you risk a uterine rupture, this is true; but it does not automatically mean it will happen. The real risk of it happening is very low; this risk is decreased even further if your birth is as intervention-free as possible.

Only you can decide what is right for you.

Back to Continuous Foetal Monitoring (CFM)

CFM will certainly be mentioned as something that ‘must be done’ if you have a VBAC birth. This is because CFM is seen as the detector of all problems during birth when in fact, as outlined earlier, research shows this is not true. That is not say that you shouldn’t have it or that it never detects uterine rupture. It is simply that there are other options if you feel the restrictions of CFM would have a negative effect on your VBAC birth.

The list below gives alternative means of monitoring for scar rupture:

• Regular monitoring of pulse (10)
• Close observation for pain particularly when a woman says the pain is different to her birthing pains
• Intermittent monitoring of the baby with a Pinard stethoscope or Sonicaid.
• Monitor temperature
• Observe for undue vaginal bleeding

Many experienced practitioners feel that these measures are equal to CFM plus mum’s mobility is not restricted in any way.

What You Can Do To Help Yourself VBAC Successfully

• Tell your midwife you’re planning a VBAC. Do this as early as you can. You need a supportive and confident team around you and it can take time to reshuffle people to get the right mix.


• VBAC-ing at home or in water is perfectly possible and your choice regardless of what anyone else tells you. The risk of uterine rupture does not change just because you happen to be birthing at home or in water or both.


• Read, read, read – information is knowledge, knowledge is power.


• Question your care providers to ensure that you are receiving all the correct information and are being offered all the options.


• Consider looking into Optimal Foetal Positioning, (OFP),from around the beginning of the third trimester of your pregnancy, or even sooner. (11)


• Join the Yahoo VBAC group – an extremely informative and supportive group for women planning to VBAC in the UK. (12)


• Try to plan for your birth to be as intervention-free as possible. Interventions may decrease your risk of a successful VBAC.


• Avoid induction as it is associated with higher risk of rupture and you’re more likely to end up with another caesarean.


• Try not to have an epidural if you can. You will have restricted movement and this alone is associated with a higher rate of instrumental deliveries and sections.


• Get a doula!


• Expect to worry. It is perfectly normal to be anxious about having a VBAC. This is why it’s so important to surround yourself only with competent, confident people. Positive attitudes will make you more confident about your body’s ability to birth vaginally.


• Deal with worries and anxieties in whatever way works for you – talk about them; consider Hypnobirthing (13) ; consider EFT (14) ; consider meditation and visualisation; but just don’t leave your concerns to fester as they will affect you even if you think you’ve successfully walled them off.

Useful links

The list here corresponds to the bracketed numbers you'll have noticed scattered through the text. Click on the links for more information.

1. UK Maternal mortality rates
2. Risks of Induction
3. RCOG/ NICE Guidelines for Induction of Labour
4. Induction increases risk of Caesarean section
5. Pros & Cons of CFM
6. NHS Choices - How to access your records
7. More about Independent Midwives
8. C-section Risks (Click this link,then 'Download this' then 'Open' or 'Save')
9. RCOG Guidelines - Birth After Ceasarean Section
10. Alternative ways of monitoring during VBAC
11. More info on Optimal Foetal Positioning
12. Yahoo VBAC Support Group
13. More info on Hypnobirthing
14. More info on EFT

Kath Harbisher is a Birth & Postnatal Doula serving parents across South Wales, UK.

If you have any queries or comments about this article please contact Kath via her website.

Contact Me at The Doula Effect

Copyright © Kath Harbisher 2010. All rights reserved.

Disclaimer: None of my articles are intended to replace the advice or care of qualified health professionals