You've had one or more cesareans and you're looking ahead to your next birth. "Once a cesarean, always a cesarean" is no longer the rule, and for reasons that are uniquely yours, you want to have a vaginal birth this time. Good for you! You are about to join the growing number of women who have planned for a vaginal birth after a cesarean (VBAC).

Why have a VBAC?

Many women want to have a VBAC because of the feeling that they missed out on an important life experience when they had a cesarean. They want to feel a baby move through and out of their bodies and into their arms. Other women and medical professionals know that labor is important for the newborn's adjustment to life outside mother. They also know that vaginal births are safer for mothers and infants than planned cesareans. Still others want a faster recovery from their births and to go home much sooner than when they had a cesarean. They want to mother and nurture their infants (and other children) without the restrictions that accompany surgical delivery. They want to avoid surgery and its risks and complications.

You may share these reasons or have different ones, but it's important to remember that any reason to want a VBAC is a good reason.

What do I need to know about my previous cesarean?

It's helpful to know why you had your cesarean(s). Most reasons for a cesarean don't necessarily repeat themselves. These include:

• Fetal distress - baby in trouble;
• Cephalopelvic disproportion (CPD) - "too-big baby for too-small pelvis;"
• Failure to progress - labor lasts too long;
• Breech position - baby comes bottom or feet first;
• Transverse - baby lies sideways;
• Abrupted placenta or a placenta previa - location or separation of the placenta causing bleeding and problems with the baby's supply of oxygen;
• Prolonged rupture of the membranes - the bag of waters breaks, and either labor does not begin or the baby is not born within a specified amount of time;
• Previous birth(s) by cesarean - including planned, repeat cesareans.
• Despite cesareans for the above or other reasons, countless women have successfully and safely had their later babies vaginally.

What about my scar?

It is important to know the type of incision that was used on your uterus. The two most common incisions are the horizontal (low transverse), which is considered the safest, and vertical (classical or low vertical). You should check with your doctor or hospital records to see if your abdominal scar (outside, on your skin) is different from you uterine (inside) scar. It is encouraging to know that some women who did not know their type of uterine incision have been permitted to labor and gave birth vaginally without any problems.

In the past the most common reason for planned, repeat cesareans was a belief that the uterine scar would rupture (or separate) during a vaginal birth. Recent medical findings, however, show that this is extremely rare, particularly in the case of the more common low transverse incision. The risk of uterine rupture is far less than the risk of complications associated with a cesarean.

What about a caregiver?

In many places women planning VBAC can choose between midwives, obstetricians and family physicians. As VBAC becomes more common, it is easier for women to be accepted as VBAC clients by all practitioners.

The way a woman is treated in pregnancy and labor varies from one caregiver to another. Because midwives use fewer medical interventions, women under their care are less likely to have a cesarean section.

What about medical interventions?

Common interventions in pregnancy and labor might include the use of ultrasound, electronic fetal monitoring, drugs to start or speed up labor, breaking the bag of waters, intravenous fluids (IV) and the use of a wide variety of drugs for pain relief. Although advantages may exist for such practices in some instances, routine use of such interventions may interfere with the progress of labor and increase the possibility of another cesarean.

Not all midwives or doctors follow the same guidelines and procedures for VBAC. Some prefer using interventions, whereas others offer care with fewer restrictions and more choices. Recent medical guidelines state that women with one previous low-transverse incision should be treated the same as the woman without a previous cesarean! Professionals now even recommend that women with two or more cesareans can have a VBAC if they wish.

As with any birth, it is important for you to discuss with your caregiver and hospital what options exist for you during labor and birth. If you know your choices, you can negotiate for something different or even change to a caregiver who will respect your preferences and treat you as individually as possible.

How can I guarantee that I will have a VBAC?

No one can guarantee that you will have a VBAC, although current medical information makes it clear that most cesarean mothers can later give birth naturally. But there are some things that VBAC women have found helpful to increase the chances for a vaginal birth.

What can I do before I get pregnant (or in early pregnancy)?

• Inform yourself and take personal responsibility for your birth experience. Learn as much as you can before you get pregnant and during your pregnancy. There are many excellent books, films, tapes and written materials on VBAC and birth in general. Such information can help you make informed choices and accept the responsibility for your birth.
• Join a support group. Don't overlook the value of cesarean or birth support groups that may exist in your area. The information and caring atmosphere in such groups can help promote healing of any past unhappy birth experiences and offer encouragement for upcoming births.
• Take childbirth classes. Consumer-oriented childbirth classes or special VBAC classes offer a wealth of information and skills. They also give you and your partner an opportunity to consider this new pregnancy and birth as a separate experience from your cesarean(s). Learn and practice the skills you are taught to cope with the reality of labor.
• Get in touch with yourself. Techniques such as visualization, meditation and affirmation can help you heal and accept feelings inadequacy, grief and failure from past births. Recognizing these feelings, even if they are not totally resolved, will help clear the way for more positive thoughts and more confidence in yourself and the birth process.

My partner is nervous about a VBAC. What can I do?

Talking to each other about past birth(s) will help clarify ways in which you can work together toward VBAC. Involve your partner as you read and research. Reassure your partner that vaginal birth is safe and the best choice for you and your baby - and important to you! Another labor support person can assist both of you during labor. You might also ask your partner to read this booklet.

What about additional companions?

Some women have found it helpful to have one or more additional people with them as they labor and give birth. Such companions, professional or not, should be available to the woman throughout her labor and should know exactly what the pregnant woman wants from her birth.

If you choose to have others at your birth, let them know your desires before labor begins. For example, do you want a birth without medication or are you willing to accept medication under certain circumstances? When are you planning to go to the hospital? And so on...

What can help me in labor?

There are simple measures that can help a woman work with her labor. Many women have found it a good idea to wait until labor is well established before they telephone their caregiver or to go the place where they will give birth. Still others have found that eating and drinking in labor, walking, making noise, taking a warm bath or shower, being upright and/or avoiding interventions and drugs have helped them work better with their bodies. It is also important to know that lying flat on your back in labor is not helpful and can cause complications to your baby.

My friends think I'm crazy to want to labor.

VBAC is a very personal decision, and sometimes a lonely one. If you find that family and friends are not supportive of your goals, it's probably best to keep your feelings and plans to yourself, or to share them only with those friends who understand your feelings. A local support group can be especially helpful at a time like this and give you any additional information you may need.

Being pregnant and planning a VBAC are not everyday occurrences. You deserve a supportive environment. You probably don't agree with your friends and family about everything anyway. What you want for you, your baby, and your family is your responsibility.

What if I end up with another cesarean?

This is a difficult question. Certainly if you have planned and worked for a VBAC, having another cesarean can be, at the least, a disappointing or sad experience. You will have physical and emotional reactions common to cesarean mothers - some of which may be familiar to you. However, you will not be a failure, because you have worked at having the best possible birth experience for you and your baby. Sadness and grief over any loss (including the loss of a vaginal birth) is a part of living. As time passes, you will find that you have grown and learned from this experience too. Women who have repeat cesareans after planning vaginal births often say how glad they were to have tried. Many are delighted that labor began on its own and their babies were naturally ready to be born.

Is all this effort to have a VBAC really worth it?

Women who have traveled this road have found new strengths and confidence as a result. They have filled spaces in themselves emptied by previous births and have been pleased with the new discoveries of their abilities as women.

Combination of relief, fear, shock - if labor has been long or difficult, if there has been anxiety for the mother or baby - a sense of not knowing what to expect, or having lost control.

Disappointment - especially common when parents have expected and prepared for a more active participation in the birth.

Loneliness - being separated at a time when support, closeness, and the need to be together occurs.

Failure - feelings of inadequacy because delivery was not vaginally. Support person may feel that she/he let the mother down by not being present for the birth.

Anger - "Why" and "why me", anger at the doctor, nurses, baby's father, and/or the family.

Resentment - towards the baby for the cause of her pain, discomfrot, and trouble. Cesarean mothers often have less energy at first and may resent the demands and responsibilities of child care.

Self blame and depression - turning anger inward - "if only I hadn't gained so much weight, if only I didn't do this, or had done that."

Self esteem - sometimes suffers because they couldn't do it "right" and that they are failures as women.

Body Image - may suffer. Not only have their bodys not worked "right", but the scar is an ever present reminder. Some women may feel rejection from their mate due to the scar.

Depression - a period of the "blues" may be common after any mothod of childbirth. Cesarean parents may feel that the birth was a "let down".

Mixed feelings of future births - many dread the anxiety and pain of another cesarean. Others may see it as a relief from the labor.

Guilt - over having negative feelings at a time when a mother (or parents) is/are to be happy with their new baby.

In the United States and Canada almost one in four babies is born by an operation called cesarean section. Consumer and medical groups alike have expressed concern over the rising numbers of cesarean sections. Yet many families seem to believe that a cesarean is just another way to have a baby. Are there definite disadvantages to a surgical birth? It's time to look at some important facts about cesareans.

Why are there so many cesareans?

Researchers have listed many reasons for the high number of cesarean sections. These include a difficult or long labor, fetal distress, a breech presentation (when the baby is not arriving head first), placental problems, and other conditions in the mother such as toxemia, diabetes and severe bleeding, a greater use of technology such as electronic fetal monitoring and one or more previous cesareans. Some reasons are valid; others are not necessarily beneficial for the mother or the baby.

But cesareans save lives, don't they?

Of course they do, when they are absolutely medically necessary. They also have risks and side effects that can physically affect the mother and her baby right away and can change the relationship among mother, infant and family by adding more and different stresses than those following a normal vaginal birth.

But a cesarean can prevent the pain of labor and birth.

That's an interesting thought, but cesarean mothers usually have much more pain after their babies are born. After all, a cesarean is major surgery where several layers of body tissue are cut open and then repaired. This certainly makes it difficult to move, walk, urinate, and to hold and feed a newborn for at least several days or even weeks afterward. Mothers often need much medication to cope with the constant pain following a cesarean. Gas pains, which can be severe, and a sensation of one's insides failing out are also quite common. Other discomforts include an itching or oozing at the incision area and a general feeling of exhaustion.

In addition, cesareans carry all the same risks of major abdominal surgery including:

•  Infections of:
  • the uterus
  • the bladder
  • the wound (incision)
• Excessive loss of blood
• Blood clots
• Adhesions (scar tissue) within the abdominal cavity
• Injury to nearby organs (bladder, bowel)
• Blood transfusion complications
• Pneumonia
• Death related to surgery
• Injury to baby

Major complications such as death following a cesarean are rare. Others such as infections are more common. When a cesarean is a possibility, you need to know about these risks. You should also find out about the possibility of even suspected long-term risks such as infertility due to scar tissue. At the very least, recovery from a cesarean section takes longer since mothers are usually in more pain and more tired afterward. Mothers also need more support physically and emotionally than those who give birth vaginally.

Well, then, aren't cesareans better for babies?

Once again, that is sometimes true, when the risks associated with a cesarean are outweighed by the benefits of having a baby born surgically. Sometimes a cesarean is performed before labor begins. However, even with advanced techniques (ultrasound or amniocentesis), there is a greater risk of respiratory problems even in term infants than when the start of labor determines the baby's birthday. Truly premature infants are subject to breathing and other physical difficulties of low birth weight, whether they are born surgically or vaginally. In addition, cesarean babies can also have anesthesia complications and may be sluggish and slow to start breathing. They may also suffer from some neurological problems. Such a start can impair relationships with the new baby, including a more difficult beginning to breastfeeding.

I never knew such a simple procedure could have such effects.

Oh, but the point is, as cesareans have become more commonplace, we've accepted them as simple procedures. But, although cesarean sections are safer than ever and, when necessary, a true blessing, a cesarean is clearly not a simple procedure. And we haven't even talked about those other side effects that are harder to measure.

What does that mean?

Well, there is no doubt that the immediate relationship between the cesarean mother and her baby is different from the relationship after a natural birth. The mother may be groggy and unable to hold her baby and baby is often moved out of sight and touch for an examination during the important introductory moments following birth. Infant and parents may be separated for a time while the baby is observed in a central nursery. After a cesarean, mothers often describe a wide range of feelings that include failure, anger, disfigurement, inadequacy and resentment, while at the same time feeling glad that their babies are born. Such opposite feelings can sometimes lead to an uneasy and confusing start for parenting. It's harder to care for a baby when you need so much care yourself. Fathers and other companions may feel frustrated at having to give so much more physical and emotional support. After all, besides learning to care for her newborn and/or taking care of other children, a cesarean mother is recovering from surgery. The time following a baby's birth is tiring. As sleep, housekeeping and general life patterns change to meet the needs of the new family, the additional needs of the cesarean mother may increase the typical difficulties of adjusting to the new baby.

If I really don't need a cesarean, how can I avoid one?

Education is the key word in preventing unnecessary cesareans and having a safe and memorable birth experience. Find out about birth practices in your area. Why and how often do caregivers recommend and perform cesareans? Choose a supportive caregiver and birthplace with the lowest possible rate of cesarean sections. Contact local childbirth educators, midwives and consumer groups such as childbirth education or breastfeeding associations for their information. Even before you become pregnant, look for the many available publications and resources to help you find ways to have a more natural pregnancy, labor and birth. Find out about how you can naturally cope with labor and about trained labor support persons who can help you avoid pain medication and anesthesia. Read Unnecessary Cesareans - Ways to Avoid Them. If you have had a previous difficult birth (whether cesarean or not), you will want to consider what happened and why. Was the difficulty caused by a chain of events that changed the natural process? Unpleasant memories of events and interventions in labor can make it painful to look forward to another birth. It can be helpful to work through such past experiences before you become pregnant again.

Develop a confidence and belief that birth is a safe and natural process that generally succeeds without intervention. Recognize that when a cesarean section is necessary, it can be truly life-saving, but that giving birth naturally is the way it is meant to be.

 Recommended Reading:

• Caring For Yourself: a guide to self-care after cesarean birth
• Caring For Yourself: a guide to self-care after vaginal birth
• Caring For Your Newborn: a guide for new parents