Thursday, March 4, 2010

VBAC- a vital option

In anticipation of the National Institue of Health's policy conference on VBAC next week and ICAN's blog carnival on this topic, I wanted to share some thoughts on VBAC.
For the uninitiated, VBAC stands for Vaginal Birth After Caserean. It is a subject that is near and dear to my heart, not just because I am a doula but because I have had two successful VBACs myself.
The question posed is, why is VBAC a vital option. To my mind, the more important question may be- how can VBAC not be an option for so many women? How can we be limiting women in the size of their families, subjecting them to major abdominal surgery and depriving them of the life-changing opportunity to find their own inner strength? All this is done in the name of safety although it is not so clear that a Cesarean is a safer option than a VBAC.
Let's start at the beginning. The main risk to VBACs is that of uterine rupture. Although there are differing numbers, the risk is usually thought to be 1 in 100. That may seem like a high risk for someone to take, but consider these factors and risks associated with cesarean sections- higher rates of infant and maternal mortality, risks of infection, double the bloodloss of a vaginal birth, complications such as adhesions to scar tissue as well as the life threatening complications of placenta previa, accreta or percreta in following pregnancies.
Not to mention that the baby is subjected to drugs during the surgery, there is a delay in mother-infant bonding, and cesareans are associated with greater difficulties establishing breastfeeding. Additionally, the more difficult recovery can affect the mother's ability to care for her newborn.
I was fortunate to have had my first VBAC in Israel, a country where doctors are more open to VBACs in general. The large orthodox Jewish population who aspire to big families has motivated doctors to shy away from automatic repeat cesareans. While he did insist on the protocol of continuous monitoring, I felt confident that my care provider was committed to my VBAC and I indeed had a wonderful experience.
Once I moved to the US, a different picture started to emerge. Because of my husband's pastoral involvements, I was privileged to be part of many life cycle events, particularly celebrations of births. Over and over I would hear the same stories- primary cesareans for failure to progress, botched inductions and twins. Repeat cesareans because the doctor convinced the woman that the risks of VBACs were just too great, whereas the risks of cesarean where virtually non-existent (untruth #1). Additionally, they would often question a woman's ability to birth vaginally, thereby destroying any confidence she may have had in her body (untruth #2).
Women who had already scheduled their sections were told to come to the hospital if by chance they went into labor because their uterus may burst any minute (untruth #3).
If, for whatever reason a woman was allowed a trial of labor, she often did not get very far before a cesarean was recommended. During these surgeries, the doctors would often say how fortunate it was that a c-section was performed because they could see that the uterus would not have withstood the "stress" of labor and delivery. How doctors could make such claims I still do not know (untruth #4).
When I was expecting my third child I was determined to find a care provider who supported my desire for a VBAC. I was not interested in becoming another statistic.
I had a wonderful experience and I felt greatful and empowered. I was also aware that my positive birth experiences are a product of the choices I made- to educate myself, to know my options and advocate for myself.
That is part of what is missing in our maternity care- women don't know what their options are. They do not know what questions to ask and although they consent to procedures performed on them, it is not informed consent because they often do not understand the risks involved and do not know that there are alternatives.
It is unfortunate that there are many places where a woman cannot try for a VBAC because the hospital policy does not allow for it. The fear of litigations and the constraints of malpractice insurance have created some difficult scenarios for careproviders and pregnant women alike.
I am curious to hear what the outcome of the NIH conference will be. VBAC is a vital option because it is a viable option for the vast majority of women, if we would only believe in them and give them the tools to succeed.

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