Jenny Skillen

Increasing numbers of people have recently been asking for VBACs (vaginal births after Caesareans) and this has focussed attention even more acutely on what gives people the best chance of achieving a vaginal birth. It also, incidentally, draws attention to the fact that the excessively high Caesarean section rate in this country (around seventy per cent in some private hospitals) is being questioned and the requests for VBACs are largely a result of this, demonstrating in some cases dissatisfaction with the handling of the first birth and a determination to go to considerable lengths to avoid an unnecessary Caesarean section the second time.

So, firstly some facts : it is not inevitably true to say that ‘once a Caesar always a Caesar’, and if your obstetrician or gynaecologist tells you it is, find another one unless this is what you want.

It is interesting to listen to the kind of advice given to women determined to have their best shot at avoiding an unnecessary Caesarean section second time around, because in fact the same things apply to anyone who really wants to avoid an unnecessary Caesar first time around! Whatever your starting point, the very first thing to do is find a care-giver who will really support you in what you want. If your obstetrician says he’s in favour of VBACs find out how many he’s done recently and what his ‘success’ rate is.

If you aren’t satisfied, maybe you should look around for someone else. The market has to change to meet demand – if women want vaginal births they must be provided and we are not going to put our lives, or our babies’ lives at risk – we want them because they are safe.

Some people manage vaginal birth relatively easily even under normal hospital conditions, with all the restrictions of foetal monitoring, time constraints and relative lack of individual support this often entails. Most people, however, wouldn’t achieve this very easily and given a long and perhaps painful labour with no support apart from their partner would be unlikely to manage a vaginal birth without intervention.

As already suggested then, the first thing is to find the right care-giver, with similar ideas to yours about achieving the kind of labour and birth you want. You may have to try quite a few obstetricians and/or midwives to find what you want – don’t give up if you’re determined. It’s also very important to have a birth partner who is totally supportive. If family and friends think you’re crazy, don’t listen to them – go and talk to your support partner.
This is where a doula can be a Godsend – whether a professional or simply a like-minded willing and able friend.
You also need to put in a bit of extra effort yourself, both before and during – the rewards come afterwards. It is important to take good care of yourself, your general health and fitness and be as well-prepared as possible. Avoid gaining excessive weight, don’t overdo the fruit sugars in a misguided attempt at healthy eating or you may grow a mini sumo wrestler. Eat well, drink mainly water and plenty of it, avoid all stimulants, particularly caffeine (coke as well as coffee) alcohol and nicotine. Get plenty of fresh air and regular exercise but also plenty of sleep and relaxation. If you must continue working until late in the pregnancy be sure you aren’t exhausted. Reduce hours if you can, rest during the day, ensure you have a suitable chair with good support, and regular breaks.

Coming up to your due date pay even more attention to these rules – frequent small nourishing meals and lots of rest, including naps during the day as your night’s sleep is likely to be disturbed. This is all part of the basic care a baby needs before as well as after birth. Be sure you are familiar and comfortable with the place you have chosen to give birth and are ready in advance, whether for home or hospital.

When labour starts keep calm and relaxed as long as you can. Inform your care giver, but you don’t necessarily need to rush to hospital or be attended by the midwife from the start. Keep up your strength as you will need it later.

It is particularly important to keep upright and mobile once active labour is established. That is to say once the contractions pre-occupy you and you are unable to sleep or rest easily. Usually by then they will be coming every five minutes and lasting up to a minute; by this time you should be installed in the place you’re having the baby and your primary care-giver is in attendance.
Most forms of synthetic pain relief are not helpful if you really want vaginal birth. An epidural immobilises you, often slows the progress of labour, particularly if given too soon (before five centimetres dilatation) and interferes with the second stage of labour – the lack of muscle tone prevents the baby turning as it descends the birth canal and you cannot push effectively. Pethidine has unpredictable effects which may make it difficult to work with the contractions using the breathing and positions you’ve learned, as well as affecting the baby.

Instead, you will need lots of encouragement, a really positive attitude, reminding of positions to try, and help with focussing on breathing. Massage, either during contractions, especially to reduce backache, or between contractions to help you relax, is almost indispensible. Get your partner, your midwife, your doula, your consultant gynaecologist, your Mum, anyone, to massage you. Water can also be a life saver – a warm bath can give immense relief from tension and really help the progress of labour. Progress is important. Some hospitals have a rough guide of a centimetre dilatation per hour in first stage labour, but such time constraints are generally not helpful or safer, though they may be more convenient.
On the contrary, they can increase stress levels, if you’re worried about not meeting them. So long as you are making progress and no-one is distressed you should be allowed to let your labour unfold at its own pace. Your labour will be affected if your mobility is restricted, say by a drip (‘just in case’) a catheter or epidural. If you are lying on your back the uterus is effectively contracting uphill – much more painful for much less progress.

Exactly the same applies to second stage when you are pushing.
Your hormones will be working overtime and are particularly responsive to the people around you. Surround yourself with people who encourage you and help you believe you can do this. Whether you are aiming for a vaginal birth first time around or after a previous Caesarean section, be well prepared, with the right kind of help, and you give yourself the best chance of achieving this. It is also reassuring to know that if you’ve done all this and for some reason do end up needing an instrumental delivery, it’s really because of medical necessity. Then you and all your support partners will be able to feel positive about that too.

It takes considerable determination to go this route as conventional medicine in this country is not geared towards the non-medicalisation of childbirth at present. It may come as a shock to find that practices in childbirth are so widely variable and it is your responsibility and yours alone to ensure that the care you have chosen is really going to deliver what you want. Which may mean going that extra mile!
Jenny Skillen Antenatal Educator