Monthly Archives: May 2011
Is home birth after caesarean an option?
| May 11, 2011 | Posted by admin under Birth, Ceasarean, vbac |
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Some mothers believe that the way to give themselves, and their babies, the best chance of a good and safe VBAC (vaginal birth after caesarean) is to plan a home birth. Home birth need not be dismissed as an option because a woman has had a previous caesarean birth, but it does need careful consideration.
Some health professionals will not even consider attending home VBACs, rejecting it as an unacceptable risk. Yet there are others who support home VBAC as a sensible choice, or who believe that a home VBAC (‘HBAC’) can sometimes be safer than a hospital VBAC.
What I hope to do in this section of the Home Birth Reference Site is to help you to consider the relative risks and benefits of home VBAC for your own circumstances. I will include references to all relevant research I find, whether the conclusions are what I would like to hear or not.
Your best chance of avoiding another caesarean?
We know from research on home birth in general that a woman who tries to have her baby at home has a greatly reduced chance of ending up with a caesarean, than if she had opted for hospital birth in the first place. For example, see the National Birthday Trust study.
There is not, as far as I know, any research which looks at the success rate for home VBACs compared to hospital VBACs. However, it seems reasonable to suppose that the factors which reduce the rate of caesareans in women planning home births generally, would also apply to women planning home VBACs. Women’s bodies generally labour better at home, which means that labour progresses more easily, and there is less need for pain-relieving drugs.
Women who plan home births after a prior caesarean often say that they felt they would be “set up to fail” in an attempt at a hospital VBAC. Overall we know that the vast majority of women who attempt a VBAC in hospital do in fact get one – but if your first caesarean was for slow progress, then perhaps your labour is more affected by the hospital environment than others. If this is the case, it may be that labouring at home is the best ‘treatment’ you could have.
One authority on vaginal birth after caesarean, Gina Lowdon, points out that women whose bodies do not labour well in hospital should recognise that their body is acting in a perfectly natural way – if you are anxious, then labour is inhibited. This is a mechanism which has evolved to help mammals prolong their labours until they can find a safe place to give birth. It works only too well for some women who plan hospital births, even if they consciously believe that hospital is the best place for them.
If your labour did not progress in hospital, it may not be the case that your body was “no good at labouring”; perhaps it was too good at the task of trying to give birth safely.
The National Birthday Trust’s 1994 study of home births in the UK detailed the final place of birth for women planning a home birth who had a previous caesarean section. Only 53 women in the study fell into this category, and of these 38 mothers (72%) gave birth to their babies at home. The remaining 15 (28%) transferred to hospital, before or during labour, where some (but certainly not all) had repeat caesareans – no further details are given, but some of these women probably gave birth in hospital without further intervention, while others will have had treatment ranging from augmentation of labour to assisted delivery or caesarean section.
No uterine ruptures were noted, but the sample is too small to allow any conclusions to be drawn about rupture risk at home births.
Although this study only covers 53 women planning HBAC, it is still valuable. The 72% of women with a caesarean scar who gave birth at home will have done so either with no intervention at all, or with minimal intervention. It would be an achievement in most hospitals for 72% of women to give birth without significant intervention, let alone 72% of women who were supposedly ‘high risk’.
How safe is home VBAC?
The simple answer is – we just don’t know. There have been many studies demonstrating that VBAC leads to better outcomes generally, for mother and baby, than planned repeat caesarean. However, these studies have so far all been conducted in hospitals where continuous electronic fetal monitoring is available, and where an emergency caesarean could be performed if necessary. On the other hand, these hospitals may also have used interventions which can increase the risk of rupture, such as inducing or augmenting labour, expecting women to labour on their backs or semi-recumbent (in order to make continuous monitoring easier), and performing ventouse deliveries.
There have also been many studies demonstrating that planned home birth for low or moderate-risk mothers is as safe, or safer, than planned hospital birth. However, these studies did not usually look at mothers with past caesareans. However much we support women who want home VBACs, even the most radical childbirth activist must acknowledge that a woman with a past caesarean is not low-risk. She has the known additional risk factor of uterine rupture, and this makes her medium-risk or high-risk in the eyes of most medical practitioners. Her first caesarean is a medical intervention which will affect all her subsequent births – she has already had intervention in each birth, before she even goes into labour.
But home birth is not just an option for low-risk women; it is up to each individual to make her own decision, rather than to have others dismiss her ambitions on the basis of broad statistics.
Remember that the VBAC mother’s chance of uterine rupture is less than 1 in 200. Overall, amongst mothers planning home births, 10-15% transfer to hospital for further observation or intervention not available at home. These transfers occur for slow progress, suspected fetal distress, maternal exhaustion, and so on.
If the transfer rate for mothers attempting home VBAC is similar, each woman is around 30 times more likely to transfer to hospital for any other reason, than she is for a uterine rupture. But the transfer rate for VBAC mums is likely to be higher, as midwives and mothers will probably be cautious and transfer at the first signs of trouble. The National Birthday Trust study found that 28% of its small sample of mothers planning home VBACs transferred, for instance [4]. Bear in mind that intervention levels are generally far lower for women planning home births, than for women of an equivelent risk level planning hospital births, as that study shows. So we could guess that a mother planning home VBAC is perhaps 50 times more likely to transfer for any other reason, than for uterine rupture.
Now, we know that in general (ie not looking at VBACs specifically, but at home birth overall), outcomes for planned home births are on average as good as, or better than, planned hospital births for similar women, even after including the results for those women who planned home birth but ended up in hospital. So on average, the trade-off between the advantages of home birth and the disadvantages – the delay in getting to hospital if help is needed – seems to be worth it in safety terms.
The question is, does this apply to VBACs? We cannot say for certain one way or another. We know that the risks are higher once you have a scarred uterus, whether you plan a repeat section or a VBAC – what we do not know is how much being at home might benefit VBAC mothers and babies. All you can do is make an educated guess at which option would be, on balance, best for you and your baby.
In what ways is home VBAC less safe than hospital?
Monitoring the baby
Continuous electronic fetal monitoring is not usually available at home. Instead, the midwife or doctor can monitor the baby by listening to its heart with a Sonicaid or stethoscope, and she can monitor the mother by watching her carefully, and taking her pulse and blood pressure.
One of the first signs of uterine rupture is often variations in the baby’s heart rate. This can happen quickly, and if the baby’s heart is being monitored every 15 minutes or so with a Sonicaid, the early warning signs might be missed. If the baby’s heart rate changes soon after one monitoring, it may not be noticed until the next check, 10-15 minutes later.
On the other hand, these warning signs may not be noticed for some time in a hospital, even when the baby is continuously monitored. A mother at home will have one-to-one attention from a midwife who will be looking out for other indications. She might identify potential problems earlier than hospital staff who are relying on monitors and usually a lower ratio of midwives to labouring mothers. Will a mother labouring in hospital have one midwife there, dedicated to her care, watching the monitor continuously during labour? If the monitor is only checked every 15 minutes, is there any advantage over intermittent monitoring?
Emergency facilities
Emergency caesareans are not performed at home. They cannot usually be performed immediately in hospitals either, of course – the mother must be transferred to an operating theatre, the staff and equipment assembled, and an anaesthetic given before the operation can start. In most hospitals the ‘call to cut’ time should be less than 30 minutes, although sometimes it can be longer if a key member of staff cannot be found. Sometimes it might be as short as 10-20 minutes.
If a midwife suspected a uterine rupture at a home birth then she would phone ahead and warn the hospital that the mother was coming in and a caesarean would be needed immediately. The operating theatre and surgical team should be ready when she arrived, but an anaesthetic would still need to be given before surgery could start. If the mother lived relatively near to a hospital then her transfer journey might not take long, but remember that she would still need to get out of the house and into an ambulance, then from the ambulance to the operating theatre.
There can be little doubt that a hospital is the safest place to have a uterine rupture… BUT that does not necessarily mean that it is the safest place, or the only place, for all mothers to have a VBAC.
In what ways is home VBAC safer than hospital?
There are two separate elements to consider regarding home birth safety. First of all, general safety and outcomes, and secondly, whether uterine rupture is more or less likely at a home birth.
Home Birth Safety in general
The ways in which home VBAC might safer than hospital VBAC will be similar to the ways in which home birth generally compares well to hospital birth. For example, mother and baby’s safety will be increased by reduced need for pain relieving drugs, reduced possibility of fear or anxiety slowing progress in labour, and reduced risk of infection. These and other factors are responsible for the home birth outcomes discussed in the research on home birth summarised on this site.
Induction and Acceleration of Labour
The risk of uterine rupture may be reduced too; induction or acceleration of labour with synthetic oxytocin (Syntocinon or Pitocin), or prostaglandin gels, can increase this risk. For references, see the ‘VBAC and induction or acceleration of labour‘ page. These drugs are widely used to speed up labour in hospital, but not at home, so this risk factor is removed from the woman having a home VBAC. At home there are fewer time limits on labour, and there is far less risk of infection, so there is less rush to get the baby out.
So, which is safer on balance?
It is probably impossible to identify all of the factors which might affect the relative safety of home and hospital birth under any circumstances, whether for a VBAC or not. Most of those factors which can be identified, cannot be quantified. Our bodies react to different circumstances, interventions and drugs in different ways. This means that the safest option for one woman may not be the safest option for another.
It seems entirely possible that labour will progress better and the woman’s ability to manage the labour will be best, in the place where she personally feels safest. For some mothers that place will be a hospital, but for others – and this includes some VBAC mothers – that place will be home.
Let’s not forget that there are other factors to be taken into account, besides basic physical safety. The emotional wellbeing of the mother, and that of the whole family, is vitally important. If a woman finds the prospect of hospital birth terrifying, her psychological scars may have more impact on her life than the scar on her uterus.
It is up to each woman to weigh the relative risks and benefits of hospital and home VBAC in her individual circumstances, and to make her own decision. It is not up to anyone else to tell you that it is ‘too risky’ or, conversely, that they ‘cannot see what you are worried about’; it is your job to decide which risks are appropriate for you and your baby, whether in hospital or at home.
Home birth after caesarean is an option; it is up to each mother to make an informed choice about whether it is right for her. The resources listed below may help you decide whether it is the right choice for you.
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Vaginal Birth After Caesarean?
| May 11, 2011 | Posted by admin under Birth, Ceasarean, vbac |
Women who have had a previous caesarean birth are a higher-risk group for future vaginal births. VBAC is the usual term for Vaginal Birth After Caesarean, and is pronounced ‘Vee-back’. These pages were initially written after requests from women considering home VBAC, but they are also relevant for those planning hospital births.
Why consider VBAC?
Many women who have previously had a caesarean will be offered the option of an elective repeat caesarean section, rather than a ‘trial of labour’ (which means an attempt at vaginal birth).
However, overall VBAC appears to be safer for mother and baby than elective caesarean.
‘A Guide to Effective Care in Pregnancy and Childbirth’, a famous text for obstetricians and midwives which assesses the ‘gold standard’ of evidence-based care, has an expanded section on vaginal birth after caesarean in its new edition. It says:
“Overall, attempted vaginal birth for women with a single previous low transverse cesarean section is associated with a lower risk of complications for both mother and baby than routine repeat cesarean section.”
“The morbidity (illness) associated with successful vaginal birth is about one-fifth that of elective cesarean. Failed trials of labour, with subsequent cesarean section, involve almost twice the morbidity of elective section, but the lower morbidity in the 80% of women who successfully give birth vaginally means that overall women who opt for a planned vaginal birth after cesarean suffer only half the morbidity of women who undergo an elective section.”
Babies born by elective caesarean are at increased risk of breathing difficulties, while mothers have a longer recovery from the major abdominal surgery of a caesarean, compared to a vaginal birth. Certain complications are more likely with a caesarean – haemorrhage, for example, or emergency hysterectomy.
Hysterectomy
The risk of a mother who has one past caesarean ending up with a hysterectomy after a subsequent caesarean was 1 in 90, according to a recent study from the UK. However, for women having a vaginal birth who did not have a past caesarean, the rate was only 1 in 5,189.
The rate for women having a VBAC is not given, but is likely to be between these two figures.
The risk of some complications, such as hysterectomy or placental problems (see below) rises with every past caesarean a woman has. This means that the balance of risks and benefits of elective repeat caesarean versus attempting VBAC will change, according to whether the mother hopes to have more children after her current pregnancy. It has been said that each caesarean section shifts some of the risks from that baby, on to all the mother’s future children. If it is important to a woman that she can have more children, then VBAC should be seriously considered.
Maternal mortality
Now let’s consider the risks of a mother dying during a caesarean. A study of mothes in the Netherlands between 1983 and 1992 found that the death rate from caesareans was seven times that from vaginal birth. A similar study of mothers in Sweden during the 1970s found that caesarean sections were twelve times more likely to end in death of the mother. These are the first two studies which I found on a Medline search, and are not picked for any particular reason. More references will follow in time.
Why do people worry about VBAC?
Uterine Rupture
A mother who has had a past caesarean is at higher risk of uterine rupture than a mother whose uterus has not been operated on. This means that the old caesarean scar might not stand the strain of labour, and could tear open. The risk of this happening with a standard, modern caesarean scar is around 1 in 200. For more details, see VBAC and Uterine Rupture – there are various factors which increase your risk of uterine rupture, such as having your labour induced or augmented with drugs, or decrease your risk, such as having previously had one VBAC.
Uterine rupture can also occur before labour starts, so planning a repeat caesarean is no guarantee of safety. The sad fact is that, once you have had a caesarean, your risks are increased, whatever route your future births take.
If the uterus ruptures, the baby must be born as soon as possible by caesarean section, and any delay carries risks that the baby will be brain-damaged or will die. The mother could also lose a lot of blood.
But a mother planning VBAC is not just a walking uterus threatening rupture. There are many other complications of pregnancy and birth that are far more likely to happen to any mother, than uterine rupture is to happen to her. Around 75% of VBAC candidates do give birth vaginally, but the remaining 25% who have repeat caesareans will do so for many reasons – rarely for uterine rupture. A VBAC mother is at least five times more likely to need an immediate caesarean for other acute conditions (eg antepartum haemorrhage, severel fetal distress) than she is for uterine rupture. In a typical planned hospital birth, she is around 50 times more likely to have another caesarean for any other reason, than she is for uterine rupture.
Placental problems
Two placental problems are significantly more likely when a woman has had a previous caesarean. They are placenta praevia, and placenta accreta.
Placenta praevia
‘Placenta praevia’ means that the placenta has implanted over the cervix, making vaginal birth impossible or very dangerous. Placenta praevia is easily diagnosed by ultrasound scan, and elective caesarean is the only solution for a complete praevia, where the placenta is actually over the os (the top of the cervix, which is the exit from the womb). Confusion often occurs with definitions, though – a woman whose placenta is merely close to the cervix, but not actually over it, may be told that she has placenta praevia. As the lower segment of the uterus stretches in later pregnancy, the placenta may move away from the os so that vaginal birth and home birth is still a reasonable option.
Placenta Accreta
Placenta Accreta occurs when the placenta attaches deeply to the uterine wall, and does not detach normally in the third stage of labour. It can cause severe blood loss as the uterus is unable to clamp down while the placenta remains in it. The placenta usually has to be surgically removed afterwards. The rate of placenta accreta is much higher in women with a prior caesarean, than otherwise. It is most likely to be found in combination with placenta praevia. If the placenta is nor implanted over the cervix, then the rate of severe placenta accreta is very low. However, when severe placenta accreta occurs, it can life-threatening, whether it was diagnosed beforehand or not, and whether you planned a vaginal birth or a repeat caesarean. The only advantage to having a repeat caesarean is that you are already in the operating theatre when the emergency happens.
Placenta accreta can be diagnosed by MRI (magnetic resonance imaging) scans, but this check would normally only be used when a woman has already been diagnosed as having placenta praevia. If it is confirmed that you do not have placenta praevia, then your caregiver is unlikely to be worried about the possibility of placenta accreta.
Some doctors and midwives worry that the chance of placenta accreta is increased if the placenta is implanted over the scar from a past caesarean, and the uterus was closed with a single layer of stitches rather than a double layer [3]. If the location of your placenta is checked with a scan and confirmed to be clear of the scar, then presumably you should be able to rule out this worry as well.
If the scan suggests that the placenta is implanted on the front (anterior) wall of the uterus, rather than the back (posterior) wall or top (fundus), as is more common, then you might want to discuss this with your midwife. Your risk of placenta accreta is still extremely low if you do not have placenta praevia, but it is a factor you might wish to consider.
Choosing a Repeat Caesarean?
Some women would rather plan a repeat caesarean, than face the worry that an attempt at vaginal birth would end in caesarean anyway. Your chances of a successful vaginal birth vary according to various factors, such as the reasons for your past caesarean, and the number of past caesareans you have had. These and other factors are discussed on the ‘Chances of a VBAC‘ page.
If you decide to choose an elective repeat caesarean, rather than attempting VBAC, you may find that the experience is less upsetting than your unplanned caesarean. Planning a Good Caesarean is a collection of suggestions from mothers and midwives on the Association of Radical Midwives website which may help you.
