Back to Vaginal Birth After Cesarean

ABSTRACT

In this column, the editor of The Journal of Perinatal Education discusses the need for continued education about promoting vaginal birth after cesarean. The editor also describes the contents of this issue, which offer a broad range of resources, research, and inspiration for childbirth educators in their efforts to promote, support, and protect natural, safe, and healthy birth.

A nursing student in my maternity class who is pregnant with her second child recently came up to me after class and expressed concern about a conversation she had with her health-care provider. She had a cesarean surgery at 41 weeks with her first child and was hoping to have a vaginal birth this time around. Her health-care provider informed her that he didn’t believe in vaginal births after cesarean (VBACs) and that she would need another cesarean. No question asked! She asked my advice. Many childbirth educators are faced with similar questions and need to be well informed to respond appropriately.

Not long ago, if a woman had a cesarean, she almost always had a planned repeat cesarean and not a vaginal birth for any subsequent pregnancy. The rule was once a cesarean, always a cesarean. Physicians were concerned that the scar tissue in the uterus from the previous surgery could rupture during labor and cause serious complications for mother or infant. During the 1980s and 1990s, after a growing body of research established the safety of VBAC, health-care providers, policy makers, and informed consumer advocates started encouraging physicians to offer women with a previous cesarean the opportunity for a trial of labor and possible VBAC. Part of the reason for this change was because doctors began making the surgical incision in the lower part of the uterus which is much less likely to open during a subsequent labor. Also, because the rate and number of repeated cesarean increased, the inherent risks to mothers became clearer.

We invite readers to respond to the contents of this journal issue or share comments on other topics related to natural, safe, and healthy birth. Responses will be published as a letter to the editor. Please send comments to Wendy Budin, Editor-in-Chief (wendy.budin@nyu.edu).

Then in the late 1990s, without strong evidence, the pendulum swung back from VBAC to a recommendation for repeat cesareans. This reversal with often conflicting and sometimes misleading information about the safety of VBAC versus repeat cesarean confused many women struggling to make an informed decision about a safe birth choice.

Fortunately for many, the pendulum has now begun to swing back to encouraging VBAC because a growing body of research helps to clarify the benefits and risks of both VBAC and repeat cesareans, and women become vocal advocates for greater choice. In 2010, the American College of Obstetricians and Gynecologists issued guidelines that support the choice of VBAC. But still, many health-care providers like the one described in the scenario at the beginning of this column still have strong beliefs and may be unwilling to change. As patient advocates, it is our responsibility to provide evidence-based information and resources so that women can make truly informed choices. Lamaze International offers an excellent online class to help women know the facts, understands the benefits and risks of all options, to have the best chance of success.

In 2010, the American College of Obstetricians and Gynecologists issued guidelines that support the choice of VBAC.

As patient advocates, it is our responsibility to provide evidence-based information and resources so that women can make truly informed choices.

For information about the Lamaze online class on VBAC see https://elearn.lamaze.org/courses/vbac-informed-and-ready.

Childbirth Connection, a program of the National Partnership for Women & Families, also has a section on their website that provides reliable information and support to help women understand the issues surrounding planned VBAC versus planned repeat cesarean. It includes information about various options and results of the best available research comparing risks of VBAC with repeat cesarean, including shorter and longer term outcomes in mothers and babies and risks for any future pregnancies. Tips are provided to help women reach their goals, whether birth plan is for VBAC or a repeat cesarean.

For information about VBAC from Childbirth Connection see http://www.childbirthconnection.org/article.asp?ck=10212#decision.

The VBAC Education Project, endorsed by the International Childbirth Education Association and the International Cesarean Awareness Network, was developed to empower women to make their own decisions about how they want to give birth after a cesarean and to provide VBAC-friendly birth professionals and caregivers with the tools and resources to support them.

For more information about the VBAC Information Project see http://www.icea.org/index.php?q=content/vbac-education-project.

There are many other VBAC and cesarean resources that provide information and support. When helping women to make informed choices, be sure to refer women to evidence-based websites, books, and organizations. At the same time, it is important that childbirth educators and other health-care providers have accurate up to date information to advocate for women who are faced with sometimes confusing and often difficult choices. These tools were helpful for starting the conversation when I was approached by my student.

IN THIS ISSUE

In this issue’s “Celebrate Birth!” column, Kristen Mosier shares the inspiring story of the birth of her son. She had a rapid labor, and because she was moving so quickly, she was not sure that she could have the natural birth she planned. After a wait in triage, Kristen with the support of her husband and mother, and with the encouragement, support, and protection of her midwife, gave birth naturally to her son.

In this issue’s featured article, “Theorists and Techniques: Connecting Education Theories to Lamaze Teaching Techniques,” master teacher and long-time childbirth educator Mary Jo Podgurski, provided an overview of the importance of understanding how education theory can enhance retention of material through interactive learning techniques. Podgurski eloquently explores and provides answers to the questions “Should childbirth educators connect education theory to technique? Is there is more to learning about theorists than memorizing facts for an assessment? Are childbirth educators uniquely poised to glean wisdom from theorists and enhance their classes with interactive techniques inspiring participant knowledge and empowerment?” Podgursky argues that theory can empower childbirth educators to address education through well-studied avenues. Childbirth educators can provide evidence-based learning techniques in their classes and create true behavioral change.

This issue has three articles that help us to understand how mothers decide to initiate and continue breastfeeding. In the first, “Mother’s Beliefs, Attitudes, and Decision Making Related to Infant Feeding Choices,” Radzyminski and Clark Callister discuss the findings of their qualitative descriptive study that investigated the beliefs, attitudes, and decisions of both breastfeeding and formula-feeding mothers. Four categories were identified influencing maternal decision making: (a) infant nutritional benefits, (b) maternal benefits, (c) knowledge about infant feeding, and (d) personal and professional support. Analysis of the data indicated that mothers differed in their choice depending on whether they were infant or maternal-centered and that most women combine both methods of feeding.

In another article that explores factors associated with breastfeeding, authors Demirci, Cohen, Parker, Holmes, and Bogen discuss access, use, and preferences for technology-based perinatal and breastfeeding support among childbearing women. These authors surveyed 146 postpartum women who intended to breastfeed about their use of and preferences regarding technology to obtain perinatal and breastfeeding support. Most participants owned smartphones and used technology during pregnancy to track pregnancy data, follow fetal development, address pregnancy concerns, and obtain breastfeeding information. Internet, e-mail, apps, and multiplatform resources were the most popular technologies used and preferred. In terms of technology-based breastfeeding support, women wanted encouragement, anticipatory guidance, and information about milk production. The authors suggested that a nuanced understanding of the technology childbearing women use and desire has the potential to impact clinical care and inform perinatal support interventions.

The third article explores in depth a new mother’s experience of breastfeeding. In the article “Becoming a Mother and Learning to Breastfeed: An Emergent Autoethnography,” Brooke Haugh provides an intimate personal narrative of a woman’s journey into motherhood and first encounters with breastfeeding. During the perinatal period of her first pregnancy, Haugh kept a journal documenting her thoughts and feelings. What emerged from her journals was an autoethnography revealing new understandings of herself as a woman within a culture of mothers and a deeper understanding of herself as a learner. While learning to breastfeed for the first time, Haugh became aware of the significance of lived experience on her learning. Enjoy reading how Haugh was able interweave her personal and scholarly voices, as she presents journals layered with research.

Also in this issue, BenDavid, Hunker, and Spadaro describe the development and implementation of an evidence-based postpartum depression (PPD) screening protocol using a telephone-based format within a primary care practice to identify symptoms and initiate treatment between 2 and 3 weeks’ postpartum. The Edinburgh Postnatal Depression Scale was used, with positive screens referred for provider and support services and then tracked for follow-through. Outcomes support early screening for PPD using a telephone-based format to effectively identify symptoms and acceptance of referrals by participants.

The content of all JPE issues published since October 1998 is available on the journal’s website (www.ingentaconnect.com/content/springer/jpe). Lamaze International members can access the site and download free copies of JPE articles by logging on at the “Members Only” link on the Lamaze website (www.lamaze.org).

Finally, Coley and Nichols discuss factors that influence adolescent mothers’ doula use in a community-based childbirth education and doula program. Using a case study approach to gather perspectives from adolescent mothers and doulas through semistructured interviews, field observations, and a focus group, the authors identified multiple themes related to doula use among adolescent mothers, including relationship development and barriers to doula use at the individual and structural levels. The authors suggest that effective training and support for doulas that serve adolescent clients can improve these mothers’ birth experiences, and program planners in the United States and other countries can use process evaluations to improve doula programs for adolescent mothers.

Biography

WENDY C. BUDIN is the editor-in-chief of The Journal of Perinatal Education. She is also a research scientist and adjunct professor at New York University, College of Nursing. She is a fellow in the American College of Childbirth Educators and is a member of the Lamaze International Certification Council.

Wendy C. Budin

Editor