VBAC or Caesarean Birth Questions and Answers

Question: What are the risks of a cesarean section?

Question: My first baby was born via cesarean because of CPD and I am pregnant with my second baby. What are my chances of giving birth vaginally with this baby?

Question: My baby is 9 months old and I got pregnant again. Are my chances of having a vaginal birth with this baby obsolete because it's too early? Or is it possible that I could manage to have a vaginal birth with me only having 8-9 months to recover from previous C-section?

Question: I had a cesarean for the birth of my first daughter, I was told she was too big. I am now pregnant with my second baby and my doctor is strongly urging me to schedule a repeat cesarean. I don't want this!

Question: I am a birth doula, helping a woman who has some questions about VBAC. She is pregnant with #9, had 7 vaginal births and then #8 was a C/Sec due to a Bandl's Ring. Have you known of anyone to have a VBAC after a Bandl's Ring? She is interested in hearing some success stories. Her OB is quite supportive so far.

Question: I would like to know if in Ontario, Canada whether I have the right to ask for a c- section ? My baby is going to be large, quite large.

Question: What are the risks of a cesarean section?

Answer: Cesarean section is major abdominal surgery which exposes the mother to all the risks of major surgery, including a higher maternal mortality rate, infection, hemorrhage, complications of anesthesia, damage to internal organs, scar tissue, increase incidence of secondary infertility, longer recovery periods, increase in clinical postpartum depression, and complications in maternal-infant bonding and breastfeeding as well as risks to the infant of respiratory distress, prematurity and injuries from the surgery. Risks to the baby include respiratory distress syndrome and lacerations from the scalpel as it cuts the uterus open. Long-term risks include an increased incidence of uterine rupture (when the uterus incision opens compromising the baby) and placenta accretia, when the placenta attaches deep into the uterine tissue leading to postpartum hemorrhage, retained placenta which has to be surgically removed and possibly a hysterectomy).

Question: My first baby was born via cesarean because of CPD and I am pregnant with my second baby. What are my chances of giving birth vaginally with this baby?

Answer: CPD or cephalo pelvic disproportion, when baby's head is too large for a mother's pelvis, is very rare. In today's society with almost all women being well nourished during the pelvis's critical growing stage during puberty, our pelvises are amply sized for our babies. Only if our pelvis was compromised by severe rickets or an accident should there be a concern of CPD.

Another interesting fact is our pelvises incredible ability to move and open during labour. Relaxin, a hormone our body releases during the last weeks of pregnancy, softens the cartilage and ligaments surrounding our pelvis. That combined with movement and positions can open our pelvic outlets up to 30% larger than normal! And don't forget that baby is also part of the equation. His skull is made of several bony plates held together with cartilage and it can mould easily to fit through your pelvis. The plates will move back into position within hours of birth and there is no risk to baby at all.

Unfortunately, our modern birth practices and our fear of birth play a large role in babies not moving easily through our pelvises. I wrote an article called Pushing Positions that you may want to read, but in essence the common practice of sitting on our bottoms or lying on our backs to push our babies out compromise the ability of our pelvis's to move as the need for baby to come down and out. Our fear can also play a big role as women tend to lock their pelvises in response to pain. By relaxing the pelvis and assuming open positions, CPD is not only avoided but labour is shorter and less painful and babies don't stress as easily with an efficient labour combined with an open pelvis to move through.

Question: I am planning a VBAC and now that I am overdue my doctor is recommending induction. What are the risks of induction?

Answer: Induction risks include: increased use of forceps and vacuum extraction; increased risk of uterine rupture; and increased fetal stress, need for resuscitation, admission to NICU, and jaundice and treatment of jaundice. But most importantly, the risk of cesarean birth is significantly increased, with women are five times more likely to have a cesarean after induction.

Question: Now my baby is 9 months old and I got pregnant again. I fear my life as well as the baby's because I have not healed. I have had a very slow recovery as it is, as well as a hernia on my incision that i just got over (didn't perform surgery) just kept off my feet and it got better.

Are my chances of having a vaginal birth with this baby obsolete because it's too early? Or is it possible that I could manage to have a vaginal birth with me only having 8-9 months to recover from previous C-section? I am scared to death and don't think I mentally or physically could go through it again.

Answer: First of all, congratulations on your new pregnancy! I know you have a lot of doubts and fears right now, I truly understand. 

Cesarean recovery is seldom a six week process like doctors lead us to believe. I have had three cesareans and I truly didn't feel like I was healed until after six months for the fastest (using homeopathy to help heal), more like 9-12 months, and this is what most women tell me. Studies show that the optimal time between a cesarean and a VBAC is 18 months (you actually have 18 months, 9 months un-pregnant and 9 months expecting your new baby)... your timing couldn't be more perfect. Prior to that they found a slightly increased risk of uterine rupture. Your risk is actually very low, with one prior cesarean the uterine rupture risk (in the absence of induction or augmentation) is 0.7% or 7 in 1000 may experience a uterine rupture. Do note that even in the event of a uterine rupture, when a cesarean is performed in a timely manner, almost all mothers and babies have no problems.

More importantly, you need to prepare for your new baby's birth. You have eight months or so to prepare both emotionally and informationally... lots of time. ICAN is a great place to learn about your options and find support for you as you grieve your previous experiences. You can access them online at www.ican-online.org or you can call their toll free number 1 800 686 ICAN to find the closest chapter.

I would love to discuss your fears, your options, and walk with you along this journey to a wonderful, healing birth experience with your new baby. But first, give that baby in you a big hug... you will both be embarking on an incredible journey together through this pregnancy, baby's birth and beyond.

Question: I had a cesarean for the birth of my first daughter, I was told she was too big. I am now pregnant with my second baby and my doctor is strongly urging me to schedule a repeat cesarean. I don't want this!

Answer: (In conversation form)

Connie: I am so sorry to hear of their giving you an unnecessary cesarean with your first daughter Kelly. Macrosomia (baby too big) is the number one reason for elective cesareans and sadly it is the least likely reason for a cesarean as almost all women can birth the babies they grow.

Mother: Should I let them do the c-section again?

Connie: That is an intensely personal question which only you can answer. You need to realize that a truly necessary cesarean is rarely indicated and it is major abdominal surgery with all the risks that entails to you and your unborn baby. However, with restrictions on your ability to labour normally, sometimes a cesarean is a better choice than the stress and interference with your labour (like induction or augmentation which increases uterine rupture risks to you and your baby) that is common in hospitals today.

Mother: They say that so far everything looks good and that I am progressing very well, as well as my unborn child.

Connie: Wonderful! This is important in your ability to birth vaginally. When you and baby are healthy, the success of a vaginal delivery are very good.

Mother: If I am to have a natural birth in this town they (my doctors) told me I have to do it between the hours of 8am-5pm.

Connie: This bothers me greatly and I would avoid this hospital at all costs. In their wanting you to deliver in this time frame, they will be interfering with your labour and greatly increasing the chance of a cesarean simply by the interventions they will use.

Mother: Also I could give birth at two other hospitals that are an hour from where I live. The problem with that is, it is so far away and these doctors here know my history and my first daughters history.

Connie: I know the attraction of giving birth in a nearby hospital and your doctor knowing your history... believe me. My second cesarean was the direct result of my doctor "knowing" my history and thus not believing I am able to birth my babies (mine too were average size). Many, many women go outside of their towns to find a supportive caregiver (doctor or midwife) and a hospital which will allow them to labour unimpeded and unhindered by timelines.

Mother: Please guide me in the decision I am about to make, because I'm not sure if they are really looking out for my best interests or not.

Connie: It grieves me greatly to say this, but more and more doctors are not working for our best interested. I cannot speak for your doctors, but given the highly questionable reason for your first cesarean and the time constraints placed on your labour, I would recommend seeking a second opinion from a caregiver who not only supports VBAC but works out of a VBAC friendly hospital. Doctors are only human and they have their own lives, their malpractice insurance and their own fears which come into play at every birth they attend. The dynamics of how their lives affect their advice to you will have a huge impact on your birth.

Question: I am a birth doula, helping a woman who has some questions about VBAC. She is pregnant with #9, had 7 vaginal births and then #8 was a C/Sec due to a Bandl's Ring. Have you known of anyone to have a VBAC after a Bandl's Ring? She is interested in hearing some success stories. Her OB is quite supportive so far.

Answer: It is great to hear from birth professionals like yourself in supporting clients through a VBAC. There is very little known about Bandl's Rings beyond their being very rare. Because of their rarity, not a lot of women are known to VBAC after them. I do personally know of one, she also had prior vaginal births and a cesarean for a Bandl's Ring. She had a successfully HBAC. I have not heard from her since her VBAC, she lives in a small commune in New Mexico. From my research, Bandl's Rings are not known to repeat in the same woman. Every women I have talked to who has experienced a Bandl's Ring and every caregiver who has had a patient/client experience one has not had one before or after.

For you information, during normal birth, what is known as a 'retraction ring' forms in the uterus. This is a ridge that forms between the upper and lower part of the uterus as a result of contractions. Usually, when a muscle contracts, what happens is that the muscle fibers get shorter while it's contracting, and then go back to their normal length afterwards. When the uterus contracts in labour, though, the muscle fibers retract, which means that they hold part of the contraction and don't go back to their normal length afterwards, so that they become progressively shorter with each contraction. In labour, it's mainly the upper part (segment) of the uterus that contracts and retracts. This pulls on the bottom part (the lower segment), especially on the area of the cervix, causing it to thin out. (Incidentally, if you have a caesarean, it's the lower segment that is opened to perform the operation). The retraction ring is the ridge that gradually forms between the shortened, thickened muscles of the upper segment of the uterus, and the thin, stretched lower segment.

A Bandl's ring is an exaggerated pathological form of this retraction ring. It forms when, for some reason or another, labour becomes obstructed. This may happen when there is CPD - cephalopelvic disproportion (the baby won't fit through the pelvis), or it may be associated with the baby being in an unfavourable position. The ring actually becomes visible through the abdomen above the symphysis pubis (the pubic joint), and means the baby can't be pushed out vaginally. If left untreated, the uterus would eventually rupture. This is why a caesarean is performed.

I personally believe that CPD and asynclitic/malposition concerns - and a subsequent Bandl's Ring - can be reduced dramatically with prenatal preparation. CPD by it's very definition is extremely rare because both the mother's pelvis and the baby's head are quite flexible during labour due to varying factors, thus both can move to accommodate a tight fit, allowing baby to pass through when aligned (baby is anterior and well-flexed). Use positioning exercises such as hands and knees and avoiding reclining or leaning backwards to avoid posterior positioning (Sutton/Scott's books on posterior presentation are excellent for this, both available through ICAN). Pelvic movement will reduce asynclitic presentation both prenatally and in labour (I recommend belly dancing as a unique way to learn pelvic movement). Learning her pelvis and what positions to use which open her pelvis (inlet, midpelvis and outlet) will dramatically improve her VBAC success and labour progression (an excellent tool for learning and teaching this is the Pink Kit, also available through ICAN). Finally, facing her fears of labour and birth, whatever they may be, will certainly reduce her risk of emotional dystocia which I find fairly common in VBAC labours after a previous stalled progression ending in a cesarean (read The Labor Progress Handbook by Simkin/Ancheta for excellent information on all dystocias). Please read my article Pushing Positions for information on reducing second stage dystocia as well. 

Question: I would like to know if in Ontario, Canada whether I have the right to ask for a c- section ? My baby is going to be large, quite large.

Answer: It truly is up to your caregiver as it is their decision to allow or not allow an unnecessary cesarean without reason. You certainly can ask for a cesarean, but it will depend on your doctors beliefs as to your being granted one. I understand your concern about your baby being big, there is a lot in the media and even stories from other's birth experiences that make us fear large, healthy babies. However, your body is perfectly designed to birth your baby, however big he or she grows. Remember, you have a long history before you of women giving birth normally or you would not be here today.

The concern for many (myself included when I was expecting my first three) was not being able to deliver a baby that is deemed large and yet this has not been the case when mothers are allowed to birth without interference and in a good position. I wrote an article on just this called Pushing Positions. My own babies were big and I was told my cesarean sections were because of my large babies. Yet my daughter born vaginally last spring practically fell out of me she was born so quickly after I was completely dilated and she wasn't small! By assuming an open pelvis position during labour and the birth, it made all the difference in the world.

More importantly, I want you to make a good decision. In doing so, you need to weigh the benefits and risks of major abdominal surgery for your baby's delivery. Please take the time to read Dr. Bernstein's article Elective Cesarean Section: An Acceptable Alternative to Vaginal Delivery? and ICAN's Position Statement: Elective Cesarean Sections Riskier than Vaginal Birth for Babies and Mothers. And please don't miss the wisdom of Henci Goer, award-winning medical writer, is the author of The Thinking Woman's Guide to a Better Birth. Her previous book, Obstetric Myths versus Research Realities, is a highly acclaimed resource for childbirth professionals, and she is an acknowledged expert on evidence-based maternity care. Her two articles, Cesareans: Are they really a safe option? and Cesarean Section: What You Need to Know will truly explain the option of a cesarean birth.

And finally, please do talk to your doctor about your concerns. I know nothing about your circumstances, but I know the difficult decisions to be made for any woman who has fears surrounding her upcoming birth. Have you talked to your childbirth educator or possibly a doula about this? There are several ICAN (International Cesarean Awareness Network) chapters in Ontario as well, you could contact them for local information and/or support. I wish you the very best, regardless of the decision you make, and have a wonderful pregnancy!

 

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