It used to be a case of once a Caesarean, always a Caesarean, but many women are now opting for a VBAC – vaginal birth after Caesarean – for their other babies
LOUISE McCANN felt like a “freak” when her first baby was delivered by Caesarean section, after attempts over three days to induce her failed.
In the immediate aftermath, she was just glad Darragh had finally been born and they were both okay. “It is only down the line, when the initial elation wears off, you kind of think what went wrong?”
It was a question that came back to haunt her when she was pregnant again within a year. Everything had been fine the first time until she went overdue; she was 28 years of age and had had a straightforward pregnancy.
“I was a bit naive, it being my first baby, and I assumed that if I was being induced it was going to work.”
She was told afterwards that it was rare for induction not to work – something she now disputes on the basis of research she has done. “I found out later I wasn’t ready to be induced.”
On her second pregnancy she was determined to try for a VBAC – vaginal birth after Caesarean. She found the consultant initially supportive but, at 38 weeks, he told her to prepare herself for another section.
She believed he was trying to scare her into it by overstating the risks of a VBAC. “He was throwing stats at me and I would have to come back and say, ‘I looked that up and it is not true’.”
McCann was resolute that there was no need for a section; she was healthy, there were no complications and she had not even gone full term at that stage.
"VBAC is often a very lonely road for Irish mums," says Tracy Donegan, author of a new book, The Irish Caesarean and VBAC Guide – Challenges and Choices. Hospitals and consultants vary widely in their support of women who want to try for one – and in recommending it to women who initially don't.
If a first-time mother has endured labour which ended in an emergency Caesarean, it is hardly a surprise on her second pregnancy if she wants a planned section or believes it is the only option.
In fact, women who go into spontaneous labour after one previous section have about 80 per cent chance of vaginal delivery, says Dr Peter Boylan of the National Maternity Hospital, which has one of the highest VBAC rates in the country.
“When a woman has an unhappy experience with a first labour, she does not want to repeat the experience. That is very understandable. But what we always say to women is that was a unique experience – you can only have your first baby once.”
As the second pregnancy progresses, inevitably the memories flood back and they get extremely anxious. They are assured the same thing won’t happen.
“If they come in in labour, then decisions will be made an awful lot quicker. Instead of 10 or 12 hours in labour, a decision will be made within three or four hours.
“Also, if they are overdue, any attempt at induction will be a lot shorter, whereas in a first birth, because the uterus is intact, an induction could go on for three days because there is no risk to the mother. Whereas if she had a section before, then we are a lot more cautious.
“Women who have had a normal birth and then a section can never understand why somebody would elect for a section,” he says.
“The majority of women who have had a section and then a normal birth say, ‘I am glad I did that’.”
One in four women in Ireland now give birth by Caesarean section – a trend which is causing concern.
The HSE is co-ordinating a national working party in obstetrics and gynaecology to review the Republic’s Caesarean section rates and plans to issue its results within the next 12 months.
Donegan says research in Scandinavian countries shows that if women are debriefed and counselled after an emergency section, they are more likely to opt for VBAC.
“We are far from debriefing mothers, unless they go looking for it.”
She advises women who feel traumatised after a section to go through their birth notes with a midwife or the consultant – “somebody in the unit who can sit down and explain what happened every step of the way.
“Just to know it was not avoidable, or it was – to give you some closure on what happened and help you plan for the next pregnancy.”
Sometimes on subsequent pregnancies women are presented with the choice of a planned section or to try for VBAC, “as if you are comparing apples to apples and you are not”, she says.
“Women are not getting the information to make an informed decision as to what is the safest option in their case.”
Generally, VBAC is associated with a lower risk of complications, for both mother and baby, than a repeat section.
Donegan, who was founder of the first professional doula service here and advocates self-hypnosis for childbirth with her GentleBirthprogramme, is regarded with suspicion by some women and medical professionals – something of which she is "very aware".
“They might think a book from me would be preaching VBAC at all costs, but it is definitely not,” she stresses. “The book was to help mums who maybe do have a choice.”
A mother of two boys, one aged seven and the other four months, Donegan is a student midwife and, contrary to a view of her as being “alternative”, she is “comfortable within the system”, although she believes Ireland is a bit behind more enlightened maternity practices in other parts of the world.
To people who argue that all that matters is a healthy baby, not the method of delivery, she says that is exactly where VBAC comes in. “If that in the end is all that you care about, then VBAC is something you should seriously consider.”
Unfortunately, the VBAC rate is going down nationally, says Boylan. “It is a bit like the US was 30 years ago where VBACs were just not done – it was ‘Once a section, always a section’ and then that belief was challenged in the 1970s and 1980s.”
Donegan found rates in hospitals here vary from 60-70 per cent to less than 5 per cent.
There can be no fixed policy on VBACs, explains Boylan, “because they are such a mixed bag”. It would be ruled out in the case of placenta praevia or breech; if it is twins, a section would be more likely but not inevitable.
“Every woman’s circumstances are different,” he adds, “but the best way is to go into labour spontaneously.”
That is what Louise McCann was holding out for in her second pregnancy. The consultant scheduled her for a section at 12 days overdue – although she had no intention of going in – but she went into labour at home in Naas, Co Kildare the night before.
“Things had been progressing well at home, but when I arrived in the hospital everything stopped – I suppose it was nerves and fear.
“They were trying to push me for induction and telling me I had 12 hours and that was it. I knew the fight wasn’t over until she was born.”
When her daughter Aoibheann arrived, 12 and a half hours later, McCann was relieved that she was healthy and had been born without unnecessary surgery.
“The main thing for me was if I had to have another surgery, we could not have had any more kids because I could not have put myself through it again,” she says. “We always wanted a large family and it would have been awfully hard to make that decision. And the main thing was I wasn’t a freak, as I was led to believe.”
Less than a year later she was pregnant again. Having had a VBAC, there was no pressure on her this time and she was allowed to opt for the midwifery scheme – something which had been ruled out when her history was just one section.
With the second baby, McCann had faced both the fear of the unknown, having not experienced labour, and the fear of having another Caesarean. The third time she was much more relaxed. She went just four days overdue with Caoilagh, who is now nearly three.
As a result of her dissatisfaction with her care, McCann became one of the co-founders of the Association for Improvements in the Maternity Services, Ireland, but is not involved any more.
“It is so important that women have somewhere to turn for advice. I know plenty of women who had similar experiences to me first time around who would not even consider a VBAC and just go straight down the Caesarean route. That’s fine. People will be very understanding.
“You will find a lot more support for that than you would for women who just want to go and have it naturally,” she adds. “It is a pity.”
THE RIGHT DECISION: 'HAVING HAD A SECTION BEFORE, BEING ABLE TO DELIVER HIM MYSELF WAS EMPOWERING AND HEALING'
Ruth Doggett was in labour for 12 hours with her twins before it was decided to deliver them by Caesarean section.
“Iseult was breech and there was always a chance a section would happen, so it was a matter of let’s cut our losses here,” she says.
The official reason given was “failure to progress” and she was also told that a high percentage of twins are delivered that way.
However, she says, “if I was doing it again, having learned more about sections and things, I probably would have fought that more.”
When Iseult and Lachlan were 15 months old, Doggett became pregnant again. She wanted a home birth but was told that having had a section, she was considered too high risk – nor was she eligible for the midwifery scheme.
Although she had gone private for her twins, she did not want to be under the care of one consultant this time.
“Consultants are great but they all have their own opinions and, [by] not knowing them well enough, it is hard to tell will they really have the same values and beliefs that you have – especially when the day comes.”
She opted for semi-private care, where she was seeing midwives and registrars. “I found it fantastic. Every doctor had a different view of my situation, so it reaffirmed my belief that I had to trust my own instincts and my own bit of research of what was best for me and my baby. Then take all the information I was getting and make a decision for myself.”
She was very keen to try for a VBAC and medical staff were supportive, telling her she had a 70 per cent chance of having one.
However, she took issue with some of the hospital’s policies for VBACs, such as that she would be allowed only seven hours of active labour, after which she would need to have a section.
“I was really concerned about that – the possibility of being on a clock and saying I had seven hours to give birth, to me that was just crazy.”
She was told she would need continuous monitoring because of the risk of scar separation (which is less than 1 per cent when women go into spontaneous labour), but she wanted intermittent monitoring so she could be free to move. Also there was a policy for induction at 10 days overdue, but she wanted to be allowed to go 14 days over.
As it turned out, she went into labour at five days over, early one Thursday morning last April. She spent the day at home in Marino, Dublin, with contractions 10 minutes apart. “I wanted to get as close to delivery at home so I would not be on the clock.”
At 10pm she went into hospital to be checked. “I was 4cm [dilated] , the baby’s head was down and I was told I was going into the delivery room.”
Then Doggett was questioned about things she had specified in her birth plan – such as longer time limits and no continuous monitoring. A registrar explained all the risks and asked her, she says, was she prepared to be in labour 24 hours, to have her baby flat-lining at birth or to have cerebral palsy.
“It was an awful thing to be asked. I said, ‘I want what is happening to me in my labour to be dealt with; I don’t want to be dealt with on the basis of statistics. Obviously I want my baby to be healthy’.”
Although she was sent to the delivery ward, she remained at 4cm. “I actually love being in labour, I know that it is a strange thing to say. I don’t find it painful; it is just a cramp. It is quite an exciting time.”
But, conscious of the clock ticking, she was becoming stressed as she heard talk of another section. However, then she was told she was not in established labour and was being moved back to the labour ward where she should try to get some sleep.
On Friday, one registrar said if nothing was happening by 6pm she should have her waters broken. But then word came down from a consultant that, “if I did not want any interruptions or interventions and everything was progressing fine – slow but no distress – that there was no need to get involved”.
She was delighted with that news and was moved into the pre-natal ward. “It was fantastic; I could eat what I wanted and I was off the clock. I relaxed completely there.”
By 10pm she felt the contractions changing and by 1am needed her Tens machine. She was found to be 7cm dilated and moved to the delivery suite.
She agreed to her waters being broken when she was almost 10cm dilated. “Nothing happened for about 15 minutes then the second phase started and that was incredible.” One and a half hours later, at 6.50am on the Saturday morning, Caelan was born, weighing 9lb 9oz.
“Having had a section before,” says Doggett, “being able to deliver him myself was empowering and kind of healing in lots of ways.”
