ļ»æEpisode 7 - Vaginal Birth After Caesarean
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host Dr Melanie Jackson. I'm a clinical and research midwife with my PhD and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth and postpartum journey.
Mel:
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Mel:
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Mel:
[1:40] So Hazel Keedle, currently Dr. Hazel Keedle because she's got a PhD, works at Western Sydney University as a lecturer and researcher, has five children, woman who herself has had a VBAP, also has a history as a midwife in lots of different settings, rural, including home birth, home birth midwife, lives in the beautiful Blue Mountains, has written a book called Birth After Caesarean. And I could not recall the name of your PhD thesis today when I was...
Hazel:
[2:13] What was the name of it?
Hazel:
[2:19] Women's Experiences of Planning a VBAC in Australia.
Mel:
[2:22] And that's what we're going to talk about today is birth after caesarean. One of the big things that's super important for women who are planning their next birth after caesarean, is if you get to 37 weeks and realized you haven't considered something and that maybe you're in a position where you haven't got the best team behind you it can sometimes be too late to find the right people to be with you to really achieve your goals we want to encourage women that if you have had a previous cesarean section and you really want to change things for the next time the time to start doing your planning and thinking is before you get pregnant with the next baby So, here we go. Hazel, if I was a woman and I had had one, two or three cesareans before, why should I consider planning a vaginal birth for my next baby?
Hazel:
[3:11] Well, what we do know from my PhD research is that women actually want the option to have a vaginal birth and vaginal birth is important to women because, But it's often downplayed, especially once you've had a cesarean, you have that age-old incorrect belief that once a cesarean, always a cesarean, and you don't even know that it is an option. But then women that are wanting to plan a VBAC, they're doing it for a range of different reasons. There is the actual desire to have a vaginal birth, but there's also a practical reason because a cesarean is major abdominal surgery. And at this point, they've got at least one other child to look after, as well as a baby coming along. And, yeah, women were smart. We know if we've had another cesarean, that's going to limit how much we can pick up our children, how much driving around we can do in that first six weeks, and how difficult it will make it to be caring for a newborn plus your other children as well. And so often women are choosing to have vaginal birth after cesarean because they want a better healing time, they want to be up earlier, and they really actually want a better birthing experience. As much as some people say that women don't want to have vaginal births, that's not what we've found. It's actually that over nearly 80% of women actually said that a vaginal birth was either very or strongly important to them.
Mel:
[4:38] And the recent Australian Women's and Babies report showed that only 12% of women are actually having vaginal births after a previous aserian section in Australia.
Hazel:
[4:52] Yeah, VBAC is in the minority. So when women have had a previous cesarean and those stats are population data. So it's looking at all the women in that year that had a previous cesarean and then what type of birth did they have. And so, yes, we sit around 11% to 12% of women who've had a vaginal birth after cesarean. They don't tell you in those stats how many planned to have a VBAC and had a repeat cesarean. And that's only for one VBAC after one cesarean. And if we start looking at
Hazel:
[5:21] feedback after multiple caesareans, then that number drops another 10%.
Mel:
[5:25] And I've read a study recently by Cox in 2015, which was about VBACs at home. And the percentage of women who were able to have a vaginal birth after caesarean at home was heaps higher. I can't remember the exact stat. I don't know if you know that off the top of your head.
Hazel:
[5:46] So we do know that there are some things that increase the VBAC rates. So first of all, just to get the numbers correct, and I've just done a session with my students, actually, about VBAC, and we broke this apart as well, is that with our population data, we only know the mode of birth that happened. We don't know what the planned group was. And so in that group of women who had a repeat cesarean, there will be some women that planned a VBAC that had a repeat cesarean. And I'm very careful about language. I write about that in the book. I won't use the term success or failed or trial of SCAR or trial of labor because we're not in the court and women are not criminals. But they either had, they planned something and had it or they planned something else and had something else. We just don't, I don't use the emotive language.
Hazel:
[6:31] So it's difficult from the population stats to know how many of those planned a VBAC and had a VBAC. And yet when we then look at numbers such as the one from Cox is what we're looking at is we're looking at a group actually renew what they plan to begin with. So then you actually end up with two cohorts. You have the group that are planning a VBAC and then you have a group that are planning an elective cesarean. And then where they get that higher statistic from is then from that group that are planning a VBAC, they then look at how many of them had the VBAC and how many of them had a repeat cesarean. And so that's where we'll get the general percentage that without impact of model of care or place of birth, about 60% to 70% of women who plan a VBAC will have a VBAC. So then in the study you mentioned, they look at out-of-hospital birth or home birth, and that's where we then get a higher than the norm. So if we say the norm is maybe about 60%, obviously it varies by different studies. Then if you add in there a different model of care or an out-of-hospital setting, then that goes up to 80% plus. So it does show to you that it doesn't Women are not changing. I mean, there's some slight demographic differences, but actually the model of care and the place of birth has a bigger impact on VBAC rates.
Mel:
[7:53] So approximately 12% of women here in Australia are having vaginal births after cesarean section, but we're not really sure about what their preference was at the time. Of a cohort of women who intended on having a vaginal birth after cesarean in
Mel:
[8:08] hospital, approximately 60 to 70% of women will do that. And then if you go to the next sort of tier up where you've got a woman who's chosen to have potentially a home birth or in a midwifery model of care, that rate of vaginal birth after caesarean could go up from 80% upwards. Yeah. Yeah. Yeah.
Hazel:
[8:31] Absolutely. And so even in that population data with that 12%, that could still have been about 60 or 70 percent of women had chosen that we just don't know that so we just don't ask that question and some of the students said well our hospital says they've got like a 70 percent VBAC rate and I said well you can get that out of 10 women that doesn't mean that it's particularly great if they're only offering it for 10 women and 300 are having and not being given the option and are having repeat cesareans that might just be the really 10 determined, difficult women who were saying, I'm going to have a VBAC regardless, and seven of them had one.
Mel:
[9:09] Yes, and historically women were told once you've had a caesarean, you need to have a caesarean for all of your next babies. But that's not true.
Hazel:
[9:19] No, that was based on when caesareans were big zipper caesareans. They were the long genitals straight down the middle and a large proportion of the uterus was cut to be able to get the baby out. I wrote about all this in my PhD in the history section, and it was a really long time ago that they actually introduced transverse cuts. And from then onwards, that saying of once a sederian was a sederian should have been thrown out with the dinosaurs, but it stayed around. There's a lot of variety in between that. So if people are unsure, there's a great group called Special Scars, Special Hope. And they're actually set up, they're a group of women who've actually all got something a little bit different about their scars. So sometimes it can be an extension. It can be a J. It can be an inverted T. It can be a previous uterine rupture. So there can be lots of different ones. They've got a whole list on their website, and then they actually have a Facebook group as well. They look at the research that's out there, and they support each other. And they have like a closed group as well for women who actually have that information to have that history to support each other as well.
Mel:
[10:26] That sounds like an amazing resource. I'll be sure to link that in the show notes below. Hazel, what advice would you have for women who would really love to have a
Mel:
[10:35] vaginal birth after a previous cesarean section?
Hazel:
[10:38] Yeah, so the big thing that came out of my PhD was that there were four factors that impact how women feel after having a birth after cesarean, regardless of what type of birth it was. And they are control, confidence, relationship and active labor. And so when I write about relationship, that's about the team that you have around you, your healthcare providers. So in that chapter, I kind of start off with when I was writing it and it was during the Tokyo Olympics. And I was really inspired by all the stuff that was going on about it, especially in the Paralympics. And it made me think, you know, these athletes that train so hard to get to the result of hopefully winning a gold or silver or bronze or, you know, just beating their personal best, they have a very carefully selected team around them.
Hazel:
[11:30] You know, they have that coach that, you know, and you see that relationship with the coach. And so they have this amazing team. They have people that care for their physical health, that care for their nutritional health. Then they have this coach that is almost like that project manager and keeps a tab of everything and really believes in them. And then they go through it. And sometimes the coach takes the spotlight in that particular case. But most of the time, the coach is sitting back and enjoying the fact that their athlete got to do what they really want to do and supported them in that way. And yet they might only do that, like the big Olympic races, they might only do that a few times in their lifetime. And women generally in our country we generally do that a few times in our lifetime but we do not invest as much in our team for something that we will remember forever and we will remember how we were treated forever in the same way that we would do in olympic sports um and sport is important that's true but once they finish being an athlete that they go on to something else when you finish having a birth you don't want to be a mother like that's a really important role to do and it's something that we should really be investing that we've got women in the best possible place to be. So then I kind of challenge women and I say, well,
Hazel:
[12:44] What kind of coach do you want? Do you want the coach that, you know, when you interview, say you're interviewing for coaches and you want to do that 100-meter sprint and that's when you want to get gold, and then the coach says, well, yeah, you could do that, but I think you'll probably have a heart attack halfway through. Like I think you're just going to drop dead. Like what is the point of doing that? Well, if you don't die, then, you know, you're going to break your leg on the way and you're not going to be able to walk any better.
Hazel:
[13:09] And what's even the point? What are you going to get from it? what is the value of even doing that race like why don't we just watch it on the tv it'd be much safer for you just be a bystander you don't need to take part like how are you going to feel at that point you're hoping your dream is that you're going to get to that race or to have a vaginal birth and this person's saying you're just going to die and what's the point of doing it or would you go for a coach that goes i believe in you like i believe in you and i will do everything i can to support you I'll get the other team around let's do this together and I know that you can do that and I see you at the end and whether that's on the gold or the silver or the bronze or beating your personal best you are going to feel amazing and I'm going to do everything I can to support you to get there and you will feel amazing regardless what happens and I'm going to support you like that's who you would go for yet in maternity care right now and certainly in the standard care received hurtful comments during their pregnancy and those hurtful comments ranged from not believing in the value of vaginal birth so not believing in the value of the race why don't you just watch it on tv rather than taking part why don't you have an elective cesarean rather than planning a feedback so they're not even believing in the value of it all the way through to threats of death to themselves or to their baby so your baby will die if you plan this
Hazel:
[14:34] One of the most hurtful quotes that I read in the survey was a woman being told, if you plan a feedback, your husband will end up with a dead wife and a dead baby and a toddler to raise on his own. That is coercion to the extreme. But women get that. 50% of women receive those hurtful comments of the variety that is there. So why would you choose to go with that person? Why would you go, yeah, I'm going to choose that person who threatens everything and doesn't believe in anything I go for. So that's kind of where I get the analogy from. It's like you want to choose the best team around you. And certainly for me, from the research I've done, that is constitutive care with the midwife and then everyone else, and that would certainly include a doula. Because women who are planning in VBAC just want to have a physiological birth.
Hazel:
[15:26] And the professionals who understand physiological birth and supporting women through labour are midwives. Doulas absolutely on the side, but as healthcare professionals, that is midwives. That's what midwives are trained to do. I'm an educator. This is what we do at university. Yes, they understand all the complex stuff too. They understand when things aren't going towards a physiological birth or need more assistance or need collaboration. But these are the experts. And so to think to even exclude that from a constituent care programme, And I just think it is nuts.
Mel:
[15:58] How would women go about finding a service or a care provider that would support their VBAC desires, that would support their plans for their birth?
Hazel:
[16:08] See what is in your area and ask around and ring up your local hospital and say, what models of care do you have for me? Because often they're there and maybe they're not being advertised to you. Maybe your GP doesn't know about them. So first of all, ask, like ring them and say, do you have a constitutive care model? If you don't, then ask, do you have a student module?
Hazel:
[16:29] So we have all of our students in Australia, our midwifery students, have to follow through 10 women all the way from their appointments on being there for their labour and birth and post-native. And some students, some universities encourage the students to find out people on social media. So you might see adverts, but others only recruit through hospitals. And so they might say, yeah, oh yeah, that's right. We have students here. We've got a student who's looking. And believe me, our students, they love supporting women planning a VBAC. They know exactly what to do and how to support you. So that's another way. And certainly in this survey that I'm working on now, the Birth Experience Survey, we've seen comments about the benefit of having a student midwife. So right now, that could be a practical thing to do. If you've got enough time for them to see you four times, which really, you know, you're going to be having weekly appointments anyway towards the end. So that could be you a month out of labour and birth. Can you find a student to support you and that's someone else that you will get to know and has some knowledge and growing knowledge about supporting women and then another factor is yeah are there doulas in your area are there doulas that are attached to particular programs are there student doulas out there if you're looking for if you have limited resources so there are other ways that you can look at you know what how could continuity look for you there are some women that actually really enjoy continuity of care with their doctor
Hazel:
[17:56] And what you I guess what you have to be aware of is any bits of baiting and switching that they might be really pro to begin with and maybe a little bit unsure at the end but certainly there are some amazing doctors out there as well that provide continuity of care so I wouldn't want if a woman's got a fantastic obstetrician and is really happy with them to hear this and go oh my god I must just dunk them and go and find someone else but have an honest conversation because every relationship with your healthcare provider or your student or whatever, it should be on a level playing field. And that means that you feel open to be able to say, how are you going to support me to have this VBAC? And these are the things that are really important to me. So how will you support me to do that? And if you don't feel comfortable to have that conversation, then you don't have an equal relationship with that healthcare provider. Break that down. If you love your doctor, you have a really good relationship with them, well, start asking them hard questions and start asking them how they're going to best support you.
Mel:
[18:52] So I'm hearing the moral of the story then with the Olympic analogy and gathering your team. But the idea is if you're planning to have really any birth after a previous cesarean section does require a team that's on board with the woman's plan. So even if that is the plan to have a repeat cesarean section, the idea is to choose the people who are going to get you to the place you wanted to go, not where they think you should go. The big message here for women who have had a previous caesarean section is really heavily explore and discuss this with potential care providers or your current care providers. And then if you've found yourself in a situation where you've got a care provider who you feel might not be completely on board with your plan, you could do a little bit of a rescue mission and try and sort of plug gaps with other people in your team like a doula. like tapping into the.
Hazel:
[19:52] Sisterhood of other
Mel:
[19:53] Women who have had vaginal births after cesarean section because there's a massive knowledge base for women who have done it themselves who can actually go in as a hero for you in a time of vulnerability and to bolster you and give you that pep talk you know at the finish line of like we're gonna keep going we can do this even if there's adversity.
Hazel:
[20:16] This support was something that definitely came up as as important one of the benefits i guess we've got social media is that it doesn't have to be people in your local community you can catch up with people all over the place you know the vback australia facebook pages thousands of women on there which means that any time of the day or night that you've got a concern there's probably somebody feeding their baby and looking at their at their social media so you know you can reach out and you get that support straight away and they and women stay on that there's a real ripple effect of feedback that we can talk about later, but one of that ripple effect is they want to support other women. And if that's even being on those support groups to provide that for women going through, it's a really vital part. The essence of all of this continuity is that it's relationship-based care.
Hazel:
[21:01] But I do also want to step in for those that maybe didn't have a great relationship. So maybe they did find someone that was going to be their doodle or someone's going to be their private midwife or MGP or doctor. And they then felt that they just didn't click. They just didn't have that relationship. And it's actually okay for that to happen. That doesn't mean that it wouldn't then move, you know, still carry on and there'll be great support for you. And maybe it's just not that, you know, kind of soft feeling. But it's relationship-based care and we know certainly when we go dating right like they might sound great online and then when you meet them there's just no chemistry so you don't really bother but it's it's it's not the same kind of chemistry you're looking for absolutely but you still you might not click with that person or they may that there may be a problem in that relationship later on so don't feel at fault if when that can happen because the basis of this is relationship-based care and relationships have got to be two-way there's got to be respect both ways, both from the woman and also from the healthcare provider and give and take. And sometimes you could be let down by that person in relationship-based care.
Mel:
[22:09] So Hazel, my next question is, I've decided I want to plan a vaginal birth. My previous birth, I had a cesarean section. I've just discovered I'm pregnant now. So what do I do now?
Hazel:
[22:23] Well, every woman will have a bit of a plant growing in the back of their head that happened after the previous cesarean. So what were you told straight after that cesarean? Were you told at the time that never have another vaginal birth or you can have a VBAC from the doctor's team or from the supposed debriefing? That has actually planted a little seed in there. And what you don't realize is that's actually been growing the whole time.
Hazel:
[22:48] So these kind of decisions don't happen when you get that pregnancy test. It's actually been growing the whole time. So kind of being aware of what's in your mind, what's in your head, and then grow your knowledge around that so that you can discern whether that little plant that's been growing, is that a reed or is it a really beautiful plant that you want to keep going? And knowledge is power. So you then need to really go on that journey of where are you going to get that knowledge from? It can be from a peer support group. It can be from books. It can be from reading research articles, whatever you like to get that information from. Because what I have found in the research is that that knowledge that women get is really important. But it actually is also a challenging journey because what it can do is it can highlight all the things that went not to plan last time. So a really important part of this journey is recognizing that women are coming from a place of trauma. So we know about birth trauma in the general population of women who've had a previous birth. It's about one third of women. But in my VBAC survey, what we found is that was doubled.
Hazel:
[23:54] So two thirds of women who'd had a previous cesarean found that traumatic experience. And I think if we really understand that women are then coming from a place of trauma, that means they need support. And sometimes that trauma has gone all the way through to a diagnosis of postnatal depression or anxiety or PTSD. and then we throw women back into another pregnancy to do it all over again. So that trauma really needs to be explored. And so whether that's you had a chat with someone who is
Hazel:
[24:23] Who is experienced in understanding traumatic birth and help you unpack that, or whether that's with your care provider, it's something that will need to be done at some point. What happened last time? Really review what happened last time with someone who you trust. You can then see if there is some of your behaviours or thought patterns that could impact it. Because if you don't unpack what happened last time, it will come up. And when you don't want it to come up is when you're in labour, because then it will just be sending out the wrong hormones. As you all know, we want that oxytocin-rich environment when you're in labor. But if you're getting triggered or if you're getting flashbacks of what happened last time, that is not an oxytocin-rich environment. You're just going to start disrupting that hormonal cycle.
Hazel:
[25:09] And then potentially there could be problems with your labor. So wherever you had trauma, it will come out. And it's better to unpack that, debrief that during your pregnancy and also then kind of plan what is it that you want to happen this time and be aware of that and then choose the best place and people to support you on that journey.
Mel:
[25:31] So we've just spoken about the people that you could have with you for a VBAC and we've identified that continuity of care is key with a care provider that
Mel:
[25:42] you absolutely trust and who is on your side. Can we talk about place of birth for women who are planning VBAC?
Hazel:
[25:49] Well, my first study I ever did before my PhD was a master's on exploring women's experiences of planning VBAC at home. And I came from a background of planning VBAC at home, although I transferred into hospital. And I also was a private practice midwife supporting women. So I kind of wanted to know what was going on with women who were planning VBAC at home. And I found a few things out. And what I did find is that women didn't always plan a V back at home at the beginning. It wasn't always like, I'm definitely going to have a home birth. It was a journey of being often being pushed out. So women would go to a hospital and say, look, I've had this previous traumatic birth. I don't want a CTG. I don't want this. I don't want that. They all, I know about the cascade of intervention. This ended up in my previous birth experience. can I negotiate this? Can I negotiate monitoring? Can I negotiate being active? Can I negotiate access to water?
Hazel:
[26:49] And then because of the impact of policies and maybe healthcare providers that aren't being so supportive, they'll say, no, this is what we do. You do it our way or you go away. It's our way or the highway. And that actually turned women into, backed them into a bit of a corner and made them really look at what is out there. And because we have access to social media these days, you're actually able to explore and maybe they found a private midwife's phone number and I am sure Mel has had many of these phone calls like I had and then they pick up the phone and they speak to a private midwife and they say, they share everything in that first phone call and then say, could I do this at home? Would you support me? And the midwife says, yeah, that sounds great. I think you can have a great home birth and I'd be willing to support you. And that could have been the first yes they'd got on that journey because all that I heard before was no, no, no, no, no, no, no, no. And then they get a yes. And then actually what I do find is someone who's really, really supportive. So that's kind of what I explored.
Hazel:
[27:50] What does the evidence say about VBAC at home? Well, it's kind of variable. We do know that VBAC at home has higher VBAC rates. Even if they then transfer to hospital with the midwife, they still have higher VBAC rate. But things can happen with a VBAC. And obviously the biggest risk is you try and rupture. it is extremely rare about 0.22% chance of it happening and even if it happens it doesn't mean that it's going to end in in the death of the baby or the mother it can but usually 10% of babies that happens to 90% of babies could even survive that but what helps along that survival is getting to hospital and being able to be to have emergency treatment and so
Hazel:
[28:31] Where there isn't good collaboration and good pathways in and delays, then that could be an issue. And certainly in a study from the US, I can't remember the numbers off the top of my head, there were slightly higher rates of neonatal issues or issues with the baby. And when they looked at that, it looked like it was because there wasn't a very good transfer. There was like delays, there wasn't good communication between midwives and the hospitals. So I think if we look at that seamless transfer make it better then potentially there could be less issues but on the whole it's very rare for any and for that to happen in the first place obviously when it does especially if it's at home it gets media attention it gets out there and people get very nervous but I will add our private practicing midwives have to have to do the highest amount of training the highest amount of continual professional education out of all of the of nursing and midwifery that is out there. They have emergency equipment with them and we do also know then that women birthing at home planning a VBAC have a higher transfer rate to hospital. Now I don't think that's a bad thing. I think what it shows is that midwives
Hazel:
[29:41] are being vigilant and aware and transferring early if needed but they still have higher VBAC rates.
Mel:
[29:49] And that's the interesting thing and so even for women who are not planning a home birth just by hiring a privately practicing midwife you actually can get those you know those the beneficial stats of above 80% possibility of having a vaginal birth regardless of if you're at home or if you're at hospital if your care provider is a privately practicing midwife and that stat that you mentioned 0.22% is 22 women per 10,000 but that's the stat 22 women per 10,000 births will experience a uterine rupture in labor with their next baby after a.
Hazel:
[30:31] Previous yeah I mean the stats vary obviously every study will come out with a different one and but it varies around but it's generally below that one percent then what's really important is well what happens with that and certainly I write about that in the book and I break it all down to actually what what occurs even if a uterine rupture does happen, because it's often given as a coercive tactic that if you do this and have uterine rupture, this will happen to you. And it seems very fatalistic. It's the worst outcomes that can happen. But actually, we have one study, the INOS study, that looked at a multi-centre, multi-country across Europe and looked at around 700 uterine ruptures that occurred. It was 800 in total, but 750 or something from previous cesarean. Looked at their outcomes and that was a really interesting study because we hadn't had something that looked at so many because it's so rare to actually look at the outcomes of the uterine rupture and I go into that in the book for women to really demystify it because uterine rupture is talked about all the time as the biggest issue but what is not talked about are the risks of multiple caesareans which are just as significant.
Mel:
[31:38] Okay so what I'm hearing then is that women who are planning their next birth after cesarean section really need to be selective about their care team and just agreeing to or accepting standard care is less likely to land them where they want to be at the end with their ideal birth scenario so being really conscious with selecting a care team it seems as though from research and women's experience and what you're learning hazel is that the best bet is privately practising midwives in terms of a vaginal birth, if that's what you're aiming for.
Hazel:
[32:13] I would say continued care with a midwife. I would go all the way to privately practising midwifery, which has a lot of amazing benefits, but only because there is that cost with it. So I would say continued care with a midwife.
Mel:
[32:25] I love that. Thank you. So continuity of care with a midwife. So that means having your own midwife, either one that's allocated from a hospital in a congenitive care midwifery program, one that you've specifically chosen. Basically, if you have midwifery care, you're going to increase your chances of getting the type of birth you want. Then, obviously, you need to grill that person in particular about how they feel about VBAC. And then that will tell you what kind of coach you've got. And I have worked for and seen, or not worked for, worked with and seen, obstetricians who are incredibly supportive of VBAC. I think it's a great tip, Hazel, talking to other women who have done it because often women have already explored every pathway and can tell you the ones with the greatest success. Basically, the widest pathway is the easiest to travel to get to the journey where you want to go. So step one, choose a great care team. The next thing I want to ask about, Hazel, is there seems to be a lot of fear language about planning a vaginal birth after having had a cesarean section. Can you talk to us about what the risks of vaginal birth after cesarean are? And then we also do want to talk about the benefits. So let's first talk about what care providers are concerned about with vaginal birth after cesarean and things that can be done to kind of mitigate the risks of fever.
Hazel:
[33:49] So most women are well aware of the term utine rupture because it gets used and they're told about it all the time I will add they're often not told about the risks of multiple caesarean and I do go into that in the book I've got a little table in the book that looks at what the what the outcomes are and what the risks are for each one so you certainly go into that and I've also broken down really what the biggest study that we've had out there which was looking across Europe with two and a half million women and then only the 800 from that who had a uterine rupture and then another about 100 drop who actually had a previous cesarean so also uterine rupture doesn't always happen for women who've had a previous cesarean it can be for other things like having having had lots of babies or maybe trauma like direct physical trauma type of thing can happen to can occur with a uterine rupture but so then there was about 750 of them that had a uterine rupture after having a previous cesarean
Hazel:
[34:50] And then I really break down in the book what actually happened because Utrendra rupture isn't a full stop. Like it doesn't mean it just ends there. Like what happens, what were the outcomes of Utrendra rupture, both on the mothers and on the babies? And so I break that down in the book to really give women an understanding of first of all, what is Utrendra rupture? What does that mean? And I go into all that detail, what actually happens at that time. But then I go into what are the rates, what are the numbers, what are the outcomes, and then even what are your options if you've had a new time rupture. So one other thing I love doing in my book was I actually reached out to women and asked them to share stories I would put in the book. And I wanted it to be, they planned to be back, but they had something different about them. So I reached out, I had 15 women across four different countries who shared their stories. and one of those stories is about a VBAC after the uterine rupture. So there's even that story in there to really give an idea that life does happen after a uterine rupture and even birth can happen after that. So often it's used, especially in a commercial care, that uterine rupture, that's it, that's the end of everything and everything around you will just stop. But actually life still goes on after that and what does that look like?
Hazel:
[36:11] So that was a really important part to put in the book too.
Mel:
[36:13] Can we break down uterine rupture a little bit? Because it's sometimes sold to women as you either don't have a uterine rupture or you have a complete uterine rupture. But there are stages.
Hazel:
[36:26] Yeah, there are. So there's partial or complete. And the partial ones are a little bit tricky. So in previous research, in older research, they would put partial and complete together, which would kind of bump up the uterine rupture rate. But a partial one is, and I'm not a surgeon. I'm not an obstetrician so this is me reading this as a researcher a partial uterine rupture is where there's maybe an opening across the scar so it but it may have also healed that way so our bodies are really quite strange plus amazing and sometimes when a wound heals on the inside it might actually leave a little bit of a window but that's not a problem it's just the way it has and then when you go to have a cesarean they open up and you see they see that that potentially could have been classed as a partial uterine rupture but actually wasn't leading to one it's just it's it has really thinned out and looks like it's going to so partials are that kind of it's starting to open we don't know if it was going to open the whole way to a complete one but a complete rupture is where you've had a complete rupture across that because it was the previous area and across that scar line or it may have extended past that scar line as well And then there'll be different stages of what happens to the baby. What is the biggest issue is the baby can then come into the abdominal cavity. And obviously, we've got a lot of bleeding that happens at that point because we've got internal bleeding and baby can have a lot of problems with a percent of intensity coming away, oxygen, there was lots of different things that can go wrong at that point.
Mel:
[37:51] And those partial ruptures, they can be missed and discovered later or just not even noticed and the birth actually still occurs.
Hazel:
[37:59] Yeah, and they may have been just a natural healing process of the uterus as well.
Mel:
[38:05] Do we know how many uterine ruptures are complete versus partially percentage?
Hazel:
[38:11] Well, it depends if they've looked at the numbers. I think in INOS they didn't bother looking at partial ruptures, they only looked at complete. So really it depends on who's doing the study and what their parameters are.
Mel:
[38:21] So one of the risks of VBAC is uterine rupture. What are the others?
Hazel:
[38:25] There has been some studies coming out recently that have looked at and state that there are higher third-degree perineal tears for women planning and feedback. But I would really have a bit of caution with that. I don't look at it in the book. And that is because they don't state the birth position of women at that point. And I think it's maybe a bit of an overreach to say that women who've had a previous cesarean are going to have a different type of perineum from everyone else and therefore this perineum is more likely to to tear I actually think we need to look at what is happening during the birth that is more likely to increase that and so what I do know when I when we did the the VBAC survey is that the most common birthing position was lying flat on your back legs and stirrup and so as a midwife I'm kind of like a little bit thinking well you know that's probably impacting the the type of tearing that you're having which is why I didn't put it in the book because I just thought well you haven't told me all that information so but really if we're looking at VBAC or risks of VBAC that's that's kind of one that has been banded about recently and and mentioned but I just want more information before I start saying that that's an outcome there were some women that had a third degree tear at home and then went in to get it sutured up and then came home again and the attitudes they got at the hospital was like, oh, you failed, you know.
Hazel:
[39:55] You've failed because you had to come in here and get this all sutured up. And the woman's like, I've just birthed a baby through my vagina at home. Like there's nothing. This is a blip. They saw that bit as a mere blip. Why do you judge me on that part? Because there's no failure here. I just came, I got it sutured, I got it cared for, and then I went home again.
Mel:
[40:16] Is there a slight increased risk of postpartum hemorrhage or is that as nuanced as the third degree tear?
Hazel:
[40:23] Well, that's interesting. And if you look in the book, I've got a table in there and what it shows you is that it just jumps all over the place. So when I do the comparisons between VBAC and then elective cesarean and then emergency cesarean, because really there's three outcomes that can happen, and then it just kind of jumps all over the place. But often what has happened when research has been interpreted is that, remember when I was talking about you have this one cohort or group of women that plan a VBAC, then you've got the groups that plan an elective cesarean. Then often the outcomes are then given just still in those two groups. But we know in that group of planning a VBAC, there'll be 30 to 40% of women, maybe more or less, who have an emergency cesarean. And their outcomes can be very different to if you've had a VBAC. But if they're put all together and then you only compare those who planned an elective cesarean compared to those who planned a VBAC and in that includes emergency cesarean, then that group looks like it's got worse outcomes.
Hazel:
[41:25] When you break it out into three different groups, so when you look at then at the outcome of VBAC, emergency cesarean, and elective cesarean, VBAC did better in all the outcomes. Then it was elective and then it was an emergency and we know that like emergencies does come with some added risks. But it's important to separate it out. And instead of saying, gosh, you shouldn't plan for a VBAC because you could end up with an emergency cesarean, it should be, let's plan for a VBAC and do everything we can to help you have a VBAC.
Mel:
[41:54] So on that then, because the risks of planning a VBAC are always really heavily focused on when care providers are discussing things with women. But what I very rarely see discussed is the risk of a repeat cesarean section. So when And planning your next birth after a caesarean, you can either plan to aim for a vaginal birth or you can opt to have a repeat caesarean section. And I love what you said at the book launch that either of those decisions, each of those women are just as deserving of continuity of midwifery care, regardless of the choice that you make for your next birth after caesarean. That even if you intend to have a repeat caesarean section, midwifery care will always see you fare better emotionally socially across all of the you know the wellness measures that you can imagine so I certainly I love that you that women who are planning a repeat cesarean section after a previous cesarean section still will benefit from continuity of midwifery care regardless of what option they're aiming for I guess it's important for women to understand that there are risks to to aiming for a vaginal birth after
Mel:
[43:02] cesarean but then there's risks to choosing a repeat cesarean section. So can you give us a bit of a breakdown as to what the risk factors are of repeat and multiple cesarean sections?
Hazel:
[43:14] Yeah, so the more cesareans that you have, then the more risk you've got of things like adhesions, which can lead to pelvic pain and ongoing pelvic pain. And that can even lead to more painful periods and other complications. There is a higher risk of infections, post-cesarean and then placental abnormalities, so placental adhesion abnormalities. What I mean by that is... Things like the placenta actually adhering to the scar or having an abnormal adhering to the placental wall. So the more cesareans you have, you've got more chances of placenta accretia and other complications that involves in that, which make it difficult for the placenta to come away, which then can increase bleeding after birth. And they're not really spoken about as much, but they're most certainly,
Hazel:
[44:03] You know, there's this major abdominal surgery and you're going into the same place. And you know it is that those adhesions people don't really talk about that pelvic pain that can happen to having repeats as areas and they just get worse than that really though one of the things that gets missed as well is that once you've had that first feedback all your other feedbacks right those those rates when we're looking when we're planning a feedback and say it's about 60 to 70 percent once you've had that first feedback your chance of having a people your rates are 80% plus regardless of model of care and what that tells me is actually that's got nothing to do with the uterus nothing to do with the uterus that's all to do with the brain and that's all to do with confidence and the woman knows that she can do it if the woman has experienced and knows that her body is capable of having a VBAC and then it just has like a
Hazel:
[44:56] Flow on effect because everyone around her feels oh I hate that term and they go oh she's proved her pelvis or she's proved that she can have a vaginal birth then they suddenly have more support for you but all your previous feedbacks all your subsequent feedbacks at much higher rates of doing them and um you know i kind of just always challenge people at that point what do you think is the most important organ in that point then because i don't think it's the uterus at that point you know we're really looking at the brain hazel
Mel:
[45:22] What can you tell us about having a vaginal birth after having multiple previous cesarean.
Hazel:
[45:27] Sections so i've got a chapter in the book it was actually going to be just part of the evidence and then it ended up being a whole chapter which was a can I have a VBAC if so there's there's a whole bunch of different things in there that I look at the evidence for and that does include multiple cesareans and certainly yes the answer is yes you can have a VBAC if you have more than one cesarean and I really I do give the most up-to-date evidence on that but what I do say to women is well it's not it's not easy though not from your part, but from the support that you're going to get. If we've got, and we do have, you know, like an Australian rate of, say, about 11% to 12%, drop 10% if you're looking at more than one cesarean. It's just harder to get your support team. You know, like you just get more and more battles. It just turns into this constant battleground. So it just makes it hard. Like it's not as if you can't, and the research supports it. Even the American guidelines supports it, but that hasn't trickled down to the healthcare workers. But that doesn't mean that you shouldn't go through it.
Mel:
[46:29] Yes. So what I'm hearing then, Hazel, is that there's very few women who could absolutely not plan a vaginal birth after caesarean section.
Hazel:
[46:40] Absolutely. And really, the reasons why you would need a caesarean, other than you trying to rupture, which we know is rare, the reasons would be the reasons why anyone else would need to. So if you've got, you know, like a placenta covering the whole cervix and, you know, you would then need to have one. And so there would be really the same, there should be the same reasons that the other women would need to have a sling, which is not very good in her healthcare system at negotiating. And certainly when I do training with midwives and I've designed, ACM got me to design a online CPD activity based on this, on the book, which I did called Supporting Women.
Hazel:
[47:22] And in that, I challenge the midwives to look at what their biases are about VBAC, but also how to negotiate. And it's actually okay to negotiate. It's actually good, and it doesn't make you at risk of being reported. You might be at risk of being bullied by your other midwives or managers, but actually negotiation is part of that two ways. So if a woman says, I don't want that cannula in, then you go, that's okay. because actually we've got really skilled people here who can put cannulas in an emergency. That's kind of what they do. That's fine. I was an emergency nurse for years. Like seriously, we used to do it when people are crashing and put in an emergency, a cannula in a pregnant woman. They've got the most beautiful veins in the world. Like seriously, we can do it at that point. You know, all those things that you actually can negotiate. Those fetal heart rate abnormalities, we can pick up with a Doppler. It's actually okay to negotiate. But midwives get very scared because it's such a penalized system.
Hazel:
[48:18] That if they don't follow a guideline, they're going to get into trouble. And the same with doctors. They're so penalised as well and they've got a very difficult structure because they're bullied by their bosses. But we also know obstetric violence exists in Australia. You know, we've got the first paper coming out on the first paper on obstetric violence in Australia. So we know it happens.
Mel:
[48:41] Well, that's the issue, isn't it, is that women like, yeah, I wanted to have a VBAC, but everyone was frightened and nobody offered me the opportunity and then there's coercion. So there's actually going to be published research that highlights this pervasive issue of obstetric violence.
Hazel:
[48:57] Yeah, for all women as well, that's coming out of the best survey. And it shows one in ten women experience obstetric violence. One in three experience birth trauma, but one in ten actually have obstetric violence. We've got a conversation article that's going to come out the same day. We've got a whole media release. It's going to be a big party.
Mel:
[49:13] This is the silent endemic thing that's going through maternity care at the moment is obstetric violence and women keep getting silenced by people telling
Mel:
[49:22] them that their baby and themselves are alive and so they should be happy and it's wrong. And so there's all this focus on preventing 22 in 10,000 uterine ruptures for women planning VBAC yet we've completely forgotten to have a look at the fact that one in 10 women are the victims of obstetric violence in Australia.
Hazel:
[49:43] That's it.
Mel:
[49:44] That was Birth After Caesarean with Dr. Hazel Keedle. If you'd love to hear more from Hazel Keedle, join us this August 2024 at the Convergence of Rebellious Midwives. It's a conference happening in Sydney. We've sold over 300 tickets and the lineup is second to none. You can see the details at melanethemidwife.com. To get access to the resources for each podcast episode join the mailing list at melaniethemidwife.com and to support the work of this podcast wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com follow me mel at melanie the midwife on socials and the show at the great birth rebellion all the details are in the show notes.
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