HBAC: Home Birth After Cesarean

I simply love this poem.

Because we are too short,

too tall,

too thin,

too small of foot,

too old,

too young,

too wide,

and our pelvises are too narrow,

too small,

too untried,

or unproven,

or the wrong shape,

and our uteruses are too scarred,

or pointing the wrong way,

or we are too multiparous,

too fertile,

too infertile,

too female,

too small,

too big,

too fat,

too emotional,

too detached,

too strong,

too weak,

too intelligent,

too well designed to birth,

not designed well enough,

and our vaginas are too scarred,

too unproven,

not stretchy enough,

or too stretchy,

and we're too inconvenient,

too unpredictable,

too demanding,

too informed,

too loud,

too messy,

and our bodies labour too long,

or not long enough,

and our cervices don't dilate 1cm an hour on command,

and because when you hire a surgeon you get surgery,

and hospitals are for sick people,

and for so many other reasons,

we are part of the HOMEBIRTH movement.

~ Janet Fraser

Too often, we realize Fraser's words to be true too late.

The Ax Forgets; The Tree Remembers
~ African Proverb

Now the whole room only cares about him,
why is he crying too
what are they doing to my baby let me see
him let me have him let me hold him
I can't ask with this mask on my face,
my empty arms strapped down,
my legs numb I cannot move.
Why am I here alone, no one left
to hold my hand and they're putting
bloody organs back inside me,
I am open to the wind and so alone
I don't even have my baby anymore.

~ Mary Most, "War Story"

BIRTH MATTERS!!

And for that reason, I share this article: One woman's story of her gentle homebirth after cesarean (what we refer to as HBAC). My hope is that someday soon we stop cutting up women for so many unnecessary reasons and start supporting them instead in gentle, peaceful, empowering, positive birth experiences. (Note: I am one who also bears the birth cut).

By Rachel Gathercole
Read more from Gathercole at: RachelGathercole.com

When I tell people I had a VBAC (vaginal birth after cesarean) and did it at home, they are often incredulous. "Is that safe?" they ask. "Did they know you'd had a cesarean before?" Perhaps in their minds they ask other questions: "What kind of quack let you do that?" "Are you crazy?" The truth is that many women have had home VBACs. And, although some people believe that we sacrificed safety to have our babies at home, nothing could be further from the truth. In fact, I believe that being at home actually made my VBAC safer.

Five years ago I experienced a classic interventionist birth under the care of a highly respected obstetrician at one of the best hospitals in town, boasting state-of-the-art technology and home-like birthing rooms. As someone who appreciates doctors and their commitment to serving the public, I was confused by the way my labor was handled. No sooner was I admitted to the hospital than I was given a hospital gown, enema, catheter, IV, and internal monitor. To my surprise I was not allowed to eat or drink, and I received frequent internal exams to check my progress. Most of these interventions were administered as a matter of routine within 30 minutes of my arrival. Soon I received an epidural. Though I had written a birth plan, it was ignored ("The doctor's not even going to read that," one of the nurses said) in favor of standard operating procedure. The hospital norm reigned supreme; resistance was futile.

Thoroughly undignified, I lay in my room connected by tubes and wires to various machines, the television blaring Wheel of Fortune, while anyone who wanted to came in and out, including hospital personnel and acquaintances of mine who had heard that I was in labor. Various staff members performed internal exams throughout the day. When I was in pain, they turned up my epidural, even though these are known to cause a number of side effects, including an increased incidence of cesarean section.

Indeed, I did end up having a cesarean, although the record notes no sign of distress or infection in either fetus or mother. The obstetrician's report indicates that my labor was augmented with Pitocin due to "prolonged labor." And cesarean section was performed due to "failure to progress." In fact, the same report indicates that I was in the hospital for fewer than 12 hours and in labor for fewer than 16-not prolonged labor by any accepted definition.

After the birth, my healthy baby was bathed, weighed, held over my head for a moment's viewing while I was stitched, and then carried off to the nursery. There, I later learned, he cried all night and was fed two bottles of formula, though I had indicated to the staff that I planned to practice only breastfeeding, while I slept in my room under the influence of intravenous sleep medication I had received without my knowledge. My baby was brought to me in the morning when I "came to."

I was left with a fever, exhaustion, and breastfeeding difficulties that resulted in severe engorgement for myself and jaundice for my son. I spent the next few months recovering from major surgery, and I ultimately suffered postpartum depression-certainly not the idyllic, safe birth I had hoped for. And to add insult to injury, I later discovered that the cesarean and other interventions were very likely unnecessary. Although not everyone who births in a hospital suffers these extreme circumstances, they are not uncommon. Since my son's birth I have seen the same scenario happen to other women who, like me, obtained the care of respected obstetricians and hospitals, expecting this to increase the safety of the births. My obstetrician was certainly a competent surgeon, and his savvy in selecting a low-transverse incision allowed me to safely choose a VBAC years later. But I didn't need a surgeon or a hospital; I just needed support in birthing a baby.

A few years later I happily found myself pregnant again. Not wanting a repeat of my first birth experience, I combed the library and the Web for all available information. My research was eye opening, to say the least. I found numerous studies in the medical literature showing that planned homebirth attended by a skilled midwife is as safe or safer than hospital birth, and not a scrap of sound evidence to the contrary.

Research statistician Marjorie Tew, for example, compiled a large amount of evidence regarding the safety of homebirth, expecting to prove that it was unsafe. Instead she found that prenatal mortality was lower for out-of-hospital births, and for every level of risk but one ("very high risk") the difference was statistically significant.1,2 And the well-known Cochrane Database, after reviewing the published literature, concluded that "no empirical evidence supports the claim that hospital births are a safer option than planned homebirth."3 Study after study also shows that midwife-attended births result in better outcomes than those attended by doctors.4,5,6

Likewise, the safety of VBAC for mothers with a low-transverse (low horizontal) incision has been thoroughly documented. Many practitioners still resist this fact, due to an inflated fear of uterine rupture. But let's look at this fear. Statistically, VBACs with low-segment scar are considered low-risk, and with good reason. According to Bruce Flamm, author of the world's largest study on VBAC, "The risk of a baby dying because of uterine rupture appears to be less than one in one thousand. To put these numbers in perspective, remember that in the United States the [overall] perinatal mortality rate is around 1.1 percent."7 In contrast, mortality and morbidity rates associated with cesarean section are higher than these average rates. In addition, rupture can also occur in an unscarred uterus, and these ruptures tend to be much more catastrophic than those in VBACs.8 In fact, in one study of 93 reported cases of uterine rupture over a five-year period, 61 were in unscarred uteri and 32 in scarred. Nine maternal deaths occurred, and all were women who had not had cesarean sections.9 It may be these catastrophic ruptures in unscarred uteri that cause the misguided fear of cesarean scars rupturing.

I began to see that the popular assumption that the hospital is the right and safe place to birth was a myth. I realized, too, that although doctors are trained in highly specialized procedures and equipment, this was not reason enough to actually use these or to birth in a hospital, where they would be available. Nancy Wainer Cohen coined the term VBAC-vaginal birth after cesarean. I like to think of the birth I chose as HBAC-homebirth after cesarean. I reasoned that if VBAC is safer than repeat cesarean, and homebirth is safer than hospital birth, and midwife-attended births are safer than doctor-attended births, then VBAC at home with a midwife would be the safest route for me.

My water broke early one Wednesday morning. I had no contractions and, after calling my midwife to tell her the news, spent the rest of the morning playing with my son and reading in peaceful anticipation. Later in the day, when there were still no contractions, someone suggested I take an herbal remedy to get them started, but the midwife assured me it was safe to wait a little longer. Since I was not comfortable with the idea of pushing my body into labor, I decided to wait.

The next morning, some 24 hours after my water had broken, I awoke to definite labor contractions. I labored through the morning, and around noon the midwife and other assistants arrived and set up a birth tub, which I had requested. I continued laboring throughout the day in various rooms and positions and ultimately in the tub, and my midwife and husband used a variety of natural methods to help me through the contractions. At 7:30 in the evening I began to have the urge to push, and at 8:15, in the birth tub, I delivered a beautiful, roly-poly, 10 pound, 4 ounce baby girl!

I sat in the tub holding my baby for perhaps 45 minutes. Then we sank into the couch, and nursed for the first time. I remember the sensations-my arms wrapped around the warm, tiny bundle, and the fuzzy brown cushions puffing up around us, holding up my body that was so worn out. It was such a welcome rest after many hours of hard work. Eventually, my husband took the baby, and I went to the bathroom with the midwife to take care of some postpartum business, such as trying to urinate and getting stitched. I did not have any perineal tearing (or episiotomy) but did have some "skid marks"-minor scrapes in the vaginal area. Meanwhile, the baby was checked, weighed, and diapered. Three hours after she was born, the visitors left and my husband, son, new baby, and I went to bed together and slept seven hours, the baby nursing in her sleep. Though I had been prepared to feel "run-over-by-a-truck" for weeks, I instead awoke the next morning feeling refreshed and energetic. I was genuinely startled at how great I felt. My baby was healthy as well, and nursing went smoothly, my milk coming in on the second day without my even feeling it. There were no problems with engorgement, jaundice, fever, or infection, although I did experience some mild depression for a day or two. Naturally, having a new baby was an adjustment, but this time the adjustment was happily free of troublesome medical concerns.

My two experiences of birth were decidedly different. In both situations I started out a healthy, full-term mother with a healthy fetus; in both cases the baby was a full, healthy birthweight, and both pregnancies were uncomplicated and low-risk. But in the hospital birth I ended up recovering from major surgery, exhaustion, long-term depression, fever, and engorgement while the baby had to recover from jaundice, separation, labor medication, and breastfeeding difficulties. In the homebirth there were no such negative outcomes. My medical record shows that during my son's birth the doctor "decided to do a cesarean" despite a lack of any mentioned medical indication for one. Had I been at home that first time, I believe I would very likely have ended up with a healthy baby, but without the complications and trauma. Moreover, there is no question that my VBAC was safer than a repeat cesarean would have been. VBAC experts have stated, "[T]he incidence of fetal death associated with VBAC is agreed to be less than that with elective repeat cesarean even by the most reluctant VBAC skeptics."10 And maternal death, a risk of cesarean section, is today almost unheard of with VBAC.11,12 It seems I was luckier to have had a healthy baby with the cesarean, not with the VBAC. And having it at home, with a midwife, made a safe VBAC possible.

Why Homebirth Is Safer
The medical community is aware that many families want out-of-hospital births, and it has attempted to make its facilities "home-like" and "baby friendly." Some families do choose to birth in a hospital, and for these families changes toward baby friendliness are certainly helpful. But many hospital personnel mistakenly believe that women who choose to birth at home are seeking some intangible, spiritual birth experience and are willing to put their babies at risk to get it-something that is not the case. Although some mothers do want and often get such a sublime experience from natural and/or homebirth, what they are after when they make their birth plans is precisely safety. Many mothers know instinctively as well as from research what much of the medical community would rather ignore: that home, not the hospital, is the safest place for most women to give birth (even when you "adjust" for high-risk populations), and that "home-like" is not the equivalent of home. For me and many other mothers, it was being literally at home, with a skilled midwife, that made it safe. Here are some of the reasons why.

Absence of Technology
Many people view the absence of technology as a downside of homebirth-a source of risk-as though one must sacrifice the availability of technology in exchange for a homebirth. For me the opposite was true--the absence of technology made the birth safer. Every technological intervention introduced into the birth process is associated with known risks, many of them quite serious. They are detailed in any good book on birth, some of which are listed at the end of this article, and include, in the short term, everything from nausea and discomfort to cesarean section and maternal or fetal death.13,14,15 The long-term risks are largely unresearched and remain to be seen. Certainly any intervention (including monitoring, exams to check dilation, etc.) that involves an object or hand entering the birth canal also poses a risk of infection. Still, just having the technology there doesn't mean it will necessarily be used-or does it?

My doctor, puzzled by my desire to birth at home, or perhaps hoping to win me over to birthing at the hospital, said, "You know, we can do a noninterventionist birth at the hospital." But just being at the hospital is by its very nature interventionist, and is based on the assumption that the natural process will probably fail, thus making intervention necessary. Why else would a hospital be considered the place for most women to birth? Ironically, this assumption is often self-fulfilling. Even the act of going to the hospital during labor is itself an interruption in the natural birth process and has been shown to slow, stop, or sometimes even reverse the progress of labor.

More important, the presence of technology creates expectations, for both laboring woman and staff, that can themselves interfere with the birth process. Placing myself in a hospital full of technology and staff who use it routinely and consider it safe, so that it would be available if needed, and then hoping for it not to be used, would be, quite simply, a losing bet. Even a staff truly interested in helping a woman birth naturally would have to exercise extreme restraint to do so. To have a noninterventionist birth at the hospital, doctors and labor nurses, who are after all human and have devoted their careers to helping patients, would have to wait patiently, watching the woman labor in extreme pain for a long time, and knowing that with the push of a needle or the snip of a pair of scissors they could take away the pain or even end the whole fiasco. What would be the harm, they might understandably reason, in using just one little intervention to speed things up a little or to take the edge off? After all, why would a woman be there at the hospital in the first place if not for the benefit of their assistance? But once one intervention is used, it will often make another necessary, and then perhaps another, and so on, each adding to the overall risk. Before long the result might be a cesarean, a difficult delivery, or some other undesirable outcome. Obstetricians and hospitals are in the business of intervening, which is what makes them so useful in the event of an emergency. But normal birth is not an emergency, and for a customer in the market for a non-interventionist birth, the hospital and obstetrical practice are probably not the places to shop.

Midwives, on the other hand, are in the business of gently helping the laboring woman do her work and knowing when outside help is called for. And in a homebirth for which hospital backup has been carefully planned, the technology is nearby and available in the event that it becomes necessary, but it is not hovering around begging to be used.

It was also a benefit to me during my homebirth that the technology would not have been there even if I had wanted it. If I had birthed in the hospital, when the pain became so great that I thought I couldn't endure it, it would have been easy for me to demand drugs, even though I had decided not to use them, and would regret asking for them, and the staff would most certainly have obliged. At home, this simply was not an option, and I had chosen a homebirth partly for that reason. To refuse pain medication at a time when one (or one's partner) is exhausted and in possibly the greatest pain of one's life seems to me a heroic feat indeed! Though I know that some brave and strong women do just that, I preferred not to expect this of myself and my husband, and so made the technology unavailable. As a result I had to, as planned, focus on and use the more natural resources available, such as the birth tub, and I found to my amazement that there really were effective ways to reduce or eliminate pain without the use of drugs. And when the birth was over, I had no regrets. Not one.

A Competent, Positive Midwife
The midwife's confidence in me and the birth process was another factor that had a positive effect on the safety of the birth. Being at home guaranteed that my attendant would possess this confidence, which could not have been lacking in a midwife willing to attend a home VBAC. Manifested constantly throughout my prenatal care, labor, and delivery, my midwife's confidence was reflected most noticeably in her lack of fear regarding the birth. Knowing that VBAC and homebirth are safe, and skilled in the art of midwifery, she approached my birth as any other and never said or did anything that made me feel unsure.

If this seems insignificant, consider that the prenatal literature and consent forms many doctors and clinics hand out to pregnant women refer to vaginal birth after cesarean as a "trial of labor," a term fraught with doubt and suspense. Apparently what distinguishes a "trial of labor" (VBAC) from a "labor" (any other labor) is the idea that it might end in repeat cesarean--though any labor can end in cesarean--and this repeat cesarean is distinct from other cesareans in that it would presumably occur if the scarred uterus were to "rupture."

Once again this idea of rupture risk can be deflated. Most consent forms say something like, "One percent of women with a uterine scar from a previous cesarean section will rupture their uterus during labor." What they don't mention is that (1) any uterus, scarred or unscarred, has a small chance of rupture;16 and (2) the 1 percent includes both ruptures that are problematic and those that are completely benign.17,18,19 In fact, 75 percent of these ruptures are totally harmless and are often just dehiscence (windows) left over from the previous cesarean. When we eliminate these harmless openings from the statistics of rupture "risk," the odds of real rupture become .25 percent. To put it another way, during a VBAC the odds are 99.75 percent that there will be no problems associated with rupture. To me, this minute risk would hardly justify being in the hospital, where a variety of other risks, such as a 10 to 40 percent cesarean rate, are present. Robert Silver clarifies the difference between true uterine rupture and incomplete rupture or uterine dehiscence in his book Ob/Gyn Secrets. "True uterine rupture," he says, "is often sudden and associated with pain, blood loss, and fetal morbidity. It is most commonly seen in spontaneous or traumatic rupture of the unscarred uterus" [italics added]. When rupture is associated with uterine scars, Silver goes on, these scars are usually classical (i.e., high vertical) scars and often rupture without labor. "Conversely, uterine dehiscence is partial separation of the uterine wall that is usually asymptomatic and rarely contributes to fetal or maternal morbidity. This is often the type of separation seen in lower segment scars, and usually occurs during labor."20

Having a midwife allowed me to labor and birth effectively and safely in several ways. For one thing, there was no need for her to check my dilation frequently and thereby create a risk of infection, because she was experienced in identifying where I was in labor through other means, such as my behavior. She also offered constant encouragement, conveying at all times a belief that birth is safe and natural and all would go fine. There were a number of moments when an intervention could easily have been employed that would likely have led to a repeat cesarean. However, at times when my pain seemed insurmountable my midwife offered me not medication, which carries risks, but support, which carries none. She used eye contact, breathing guidance, massage, and relaxing and encouraging words. Her skilled touch (effleurage) physically reduced the pain of contractions, and without nasty side effects. These methods, especially eye contact, were so important to me in getting through the contractions that I am amazed at how infrequently some of them were mentioned in all the reading I did and classes I took in preparation for two births.

It is no wonder that so many women end up requiring medication in the hospital, where so little labor support is offered, and where doctors and nurses are very busy and are untrained and inexperienced in assisting natural labor. The fact that my midwife anticipated success was obvious and crucial. As parents we know that children do what is expected of them, and the same applies to adults, including laboring women. Whether these expectations are manifested in the attitude of the practitioner or in the presence or lack of technology, to overlook their impact would be to miss an important aspect of labor attendance.

My Own Turf
Pregnant women are often told to practice relaxation conditioning-for example, to relax with the same music every day during the last weeks of pregnancy--so that in labor they may set up the same circumstances and experience a relaxation response. I myself spent much of my labor lying on my side with my husband and midwife in the bed in which I sleep soundly every night. In addition to the relaxation I had practiced, I was able to use this familiar, conditioned circumstance as a resource during my most difficult contractions-a time when every bit of help was needed. Being on my own turf was a very significant factor in determining the safety of the birth, and one that certainly could not have been duplicated elsewhere.

By staying home I was also spared the trauma of being transported to the hospital in the midst of labor; there was no rushing anywhere, no forms to complete, no wheelchairs, Ivs, or separation from anyone I wanted to be with, including my older child. I just lay in the bed, laboring until I was ready to push. Not only was this a happy way to labor, but it also offered safety benefits, since stress and adrenaline have been linked to difficulty in labor.

At home I also enjoyed a much lower risk of infection than that present in an institutional setting. The risk of infection is minimal at home because the environment and its germs are familiar, and this is reflected in lower morbidity rates for homebirth.21,22 My case was no exception; though my water was broken for some 40 hours before the baby was born, I remained infection-free.

Perhaps the biggest benefit of being on my own turf, however, was the lack of a standard policy, resulting in my ability to remain in control. When my water broke on Wednesday morning, this immediately became apparent. I consulted my midwife, evaluated the need for action to induce contractions, and made a decision to wait. I waited safely until contractions started spontaneously, and all went smoothly. Had I planned an "out-of-home" (hospital) birth, it seems doubtful that I would have been allowed to go 24 hours without being induced. The fear of infection among hospital staff, who are generally accustomed to the increased risk of infection at the hospital, would probably have been simply too great. But going to the hospital when my water broke, or to be induced, would itself have increased my risk of infection, creating a self-fulfilling prophecy. Labor induction (for example, with Pitocin) carries a host of risks, including compromise of the baby's oxygen supply, increased risk of uterine rupture, more painful labor, newborn jaundice, fetal distress, cranial hemorrhage in the baby, maternal hemorrhage, and an increased rate of cesarean section.23,24

Could I have had a VBAC successfully at the hospital? Maybe. Although people have done it, certainly, it would have been harder. I might have had to fight to make it happen, and that may well have been more than I could have handled in labor. I can say with the authority of hindsight that it was safe for me, at least in this case, to have a home, whereas I cannot say with any confidence that it would have been safe at the hospital.

We are at a turning point, I think, in the history of modern birth practices. Both the homebirth movement and the VBAC movement are growing, side by side. Still, it is not often that mothers have had VBACs, and even less frequently at home. The territory remains largely uncharted. In the future, I believe that more and more parents will consider the possibility of having a VBAC at home and more people will ask themselves, their midwives, childbirth educators, and doctors the same questions that so many individuals have asked me.

I hear all these questions in my mind as I lie, nursing my daughter on the fuzzy brown couch in the same cozy room in which she was born one year ago. And now I have at least one reply. To those who ask the important question, "Is home VBAC safe?" I offer this, the humble story of my sublime and life-changing experience, and an answer: Mine was. And I wouldn't have had it any other way.

NOTES

1. Diana Korte and Roberta M. Scaer, A Good Birth, A Safe Birth, 3rd rev. ed. (New York: Bantam, 1992), 49-50.
2. Marjorie Tew, "Home Birth and Midwifery: Safer Than We Thought," Napsac News 15, no. 2 (1990).
3. Cochrane Database; taken from www.cochrane.org [1].
4. Marjorie Tew and S.M.I. Damstra-Wijmenga, "Safest Birth Attendants: Recent Dutch Evidence," Midwifery 7 (1991): 55-63.
5. American Journal of Public Health 82 (1992): 450-453.
6. Birth 1 (1994): 141-148.
7. Bruce L. Flamm, Birth after Cesarean: The Medical Facts (New York: Prentice Hall, 1990), 28.
8. Nancy Wainer Cohen and Lois J. Estner, Silent Knife: Cesarean Prevention and Vaginal Birth after Cesarean (South Hadley, MA: Bergin & Garvey, 1983), 84.
9. Ibid.
10. Ibid.
11. See Note 7, 30.
12. See Note 8.
13. See Note 1, 123-149.
14. See Note 8, 153-210.
15. Robert S. Mendelsohn, How to Raise a Healthy Child…in Spite of Your Doctor (New York: Ballantine Books, 1984), 38-42.
16. See Note 8.
17. Robert Silver, "VBAC," in Ob/Gyn Secrets, Helen L. Frederickson and Louise Wilkins-Haug, eds. 2nd ed. (Philadelphia: Hanley and Belfus; St. Louis: Mosby-Year Book, 1997).
18. See Note 7, 30-32.
19. See Note 8, 83-88.
20. See Note 18.
21. See Note 1, 50-52.
22. David Stewart, The Five Standards for Safe Childbearing (Marble Hill, MO: Napsac Reproductions, 1981), 207-211.
23. See Note 8, 177.
24. See Note 1, 135-137.

For additional information, see: VBAC, HBAC & VBAMC Resources

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