Midwifery Care for the VBAC Woman
This article originally appeared in Midwifery
Today Magazine, Issue 57, Spring 2001.
-by Gloria
Lemay
Someone asked me recently what things are done
differently with vaginal births after cesarean
(VBAC) as opposed to a first baby. Midwives usually
reply to this question with a reassuring, "Oh,
we treat you normally," but there are differences
in the two situations that can be distinguished
in midwifery practice.
Prenatal Preparation
The full history of the events leading to the
cesarean is very important. With a VBAC client,
ask her to get her operative record, nurse's notes,
anesthetist's report, pediatric report-get all
the records and go over them thoroughly. Often
the couple did not get full or accurate information
about what was going on. Sometimes there's a little
"clue" as to what went wrong that could
help to prevent a cesarean from reoccurring. Sometimes
there is a big chunk of information that didn't
get communicated. I saw one set of records where
the only indication for the cesarean was the note
from the obstetrician that "this woman is
a natural childbirth fanatic."
Another set of cesarean records had no indicator
whatsoever of why the woman received abdominal
surgery when she had given birth at l9 years old.
When she told her parents that the midwife was
perplexed and could see no reason for the surgery,
her father admitted to her that he had stayed
in the visitor's lounge all day and had been verbally
threatening to the doctor: "If anything happens
to my daughter, I'll sue you!" This helped
the daughter to understand what had happened to
her and also helped her to be firm with her father
that he was to be nowhere near her VBAC birth.
With VBAC births it is important for the midwife
to work with the dad prenatally. A VBAC father
is in a horrible place because, despite the fact
that his wife had an operation and a long recovery,
he still got a live wife and baby at the end of
it all. VBAC dads are often "fantasy bonded"
to the medical system and terrified of childbirth
in general.
The good thing is that they listen very carefully
and really know when the care is better and more
thorough and when the practitioner is authentically
on their team. I find that if the midwife talks
to them very honestly, they can trust and be fully
supportive when the birth time arrives.
If the woman has dilated past five centimeters
in the first birth, I plan for it to be fairly
fast-like any second baby. If the woman has not
gone into the birth process or not dilated past
five the first time, that's all right, she'll
still give birth vaginally, but we have extra
midwives on call to bring fresh energy if the
others get discouraged or tired. We plan for it
to be like going to two births in a row. The point
that the woman reached in her first birth is often
a psychological hurdle for her. If she dilated
to six centimeters the first time, the news that
she is seven or eight will be a relief and a breakthrough.
One of our clients, a minister's wife, said over
and over again in her pregnancy: "I just
want to feel what pushing is. If I only get to
push, I'll be happy. I just want to know what
other women mean when they say they had to push."
She'd had a Bandl's ring in the first birth process
and the cesarean was done at five centimeters.
We were praying that the complication wouldn't
repeat. She dilated smoothly and began to push.
With each push she would exclaim "Thank you
Jesus, thank you Jesus!" What a wonder it
was to watch her push out the baby, a girl whom
she named Faith.
All humans have a certain propensity to self-sabotage,
and the VBAC woman must be guarded against her
own defeating patterns. The midwife must be bold
in pointing out ways that the woman is repeating
dumb moves-there's no place for us being "nice"
if it will mean another cesarean. An example of
this: If the woman had a cesarean with five support
people, we won't let her have extra people at
her VBAC birth.
Privacy and quiet are a must, and we will be
very forceful about setting up logistics before
the birth so that the woman can birth in peace.
In short, the VBAC is high priority because this
woman's whole obstetrical future rides on its
success.
We show the couple lots of videos of beautiful
VBAC births because one video is worth a thousand
words. If you don't have your own, I recommend
"Gentle Birth Choices" by Barbara Harper,
which includes footage of a beautiful VBAC birth.
Art therapy is helpful in creating the environment
before the birth day. I place a big sheet of drawing
paper in front of the father and mother with lots
of colored pencils and instruct them to, "Draw
your birth cave" or, "Color your birth."
When they are finished, I write the date on the
two drawings and put them away in my files. After
the birth, we take them out and are amazed at
the details that were drawn weeks before and later
manifested in the actual birth.
I have longer appointments with VBAC women because
they seem to need to obsess. I don't have solutions
to many of their fears but it seems to help to
just be able to talk to someone who cares and
understands. I usually also ask them to, "Tell
me how you know that this time you're going to
have a vaginal birth?" The answers always
amaze me. One woman said, "Because this time
I'm not depending on my doctor or my midwives-me
and my husband are going to have this baby."
I suggested that she give up depending on her
husband, too. She looked terrified at that idea
but I could see that she understood; she looked
me in the eye and said, "Right!" That
was the moment I knew she would do it. She's had
three water homebirth VBACs since then, and after
each birth her first words were, "I did it."
VBAC women are so grateful for the opportunity
to birth normally that they are often shy to ask
for the extra things that make a birth beautiful,
such as a Blessingway ceremony or a waterbirth.
The midwife must remember to offer and encourage
the mother to think "really beautiful birth"
rather than "bare minimum birth." I
find it helpful to ask, "This is the only
second baby you will ever have-what would make
it really special?"
The Day of the Birth
In my well-woman birth work, no one gets induced
in any way or gets pain medication. This policy
is very important for all women but especially
for VBAC women. If there is a small chance of
uterine rupture, we must have everything on our
side to prevent it (the rate of VBAC uterine rupture
without induction is 0.4 percent or less than
one in 200*). It is beyond my comprehension how
anyone could give a VBAC woman misoprostol (Cytotec),
oxytocin or castor oil or strip the membranes
or use any other form of induction when that would
triple her chance of having a uterine rupture.
I believe that VBAC women have longer, gentler
births because Nature is compensating for the
scar. There is no hurrying. I would be terrified
to induce a VBAC woman but feel safe to attend
her at home if her body is pacing itself naturally.
We keep it in the back of our heads that the signs
of rupture are stabbing pain, unusual bleeding,
decels of the baby's heart, or a peculiar shape
of the abdomen but we don't look for problems
if they don't exist.
We are especially careful with the birth of the
placenta in a VBAC because there is a slightly
increased chance that the placenta might be adhered
to the scar, and we do not want to have a uterine
prolapse caused by pulling.
Postpartum Differences
After the birth, VBAC women need to be told that
they can walk upright. They can't believe that
they can straighten at the waist right after giving
birth. Then, they can't believe it when we ask
them to do sit-ups and leg raises on day one.
Usually by day three when we go to visit, their
husbands say, "Oh, she's gone to the gym."
With VBAC women, the complaints are very few in
the postpartum period because they are comparing
to post-surgery pain and any minor scrapes and
bruises seem like nothing.
In the years following the birth, these women
and men send us more clients than anyone else,
and if we're in legal trouble, they'll be at all
the rallies, raise money, stamp the envelopes,
write letters to legislators, and be our true
friends for life. A VBAC is an amazing experience
for the birth attendants as well as the family.
Very Beautiful And Courageous (VBAC).
Gloria Lemay is a Private Birth Attendant
in Vancouver, British Columbia, Canada and a frequent
contributor to Midwifery Today and The Birthkit.
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