Sunday, February 14, 2021

The Elusive VBAC


I love to listen to birth stories. Many of the stories that I hear are a testimony to the pregnant woman’s great ability to “animal out” on her attendants. One of my favourites is the story of a young woman who had her first daughter by cesarean section. She became pregnant again the same month (yes, I know … but true), and it turned out she was carrying twins. Her doctor was very alarmed and booked her for a cesarean at 38 weeks. She went into labor at 36 weeks and delivered two lovely girls, vaginally.


Two remarks have stayed with me over the years, and these were both delivered by obstetricians to a labouring woman: “Childbirth is like war, and I am on the front line” is one. “This is Monday morning in a busy hospital. There are road accidents, emergencies…” is the other. This was said to a woman who wanted to labor a little more before going to surgery, implying that the birth of a child had to be scheduled in somehow between a messy car accident and some other horrific case.


Why did the first man want to become an obstetrician? How did he feel about his “patients”? How had he been born? What was it about birth that gave him images of war? The second remark came from a woman. What was it about birth that frightened her so much? How could the birth of a child be imagined in the same breath as a car accident?


What is it about childbirth that makes people think in terms of war, accidents, and death? Is it just fear? And if it is, what exactly is everyone afraid of? And, more importantly, where does the midwife fit into this mosaic of fear, or does she fit in at all?


The doctors and midwives who are afraid of childbirth are partly afraid because of their training. Allopathic medicine teaches about pathology rather than about the whole healthy being. In obstetrics, pregnancy is often seen as a pathologic condition that can throw the whole system out of sync.


If we look deeper, however, we can see that there is another, more complex root of this fear, and it has to do with the fact that Western medical training teaches health workers to rely only upon their own knowledge. How can this lead to fear?


Let me explain. During childbirth there is something present that is outside of us as individuals; outside our knowledge; even outside our experience or our skills. That “something” has to do with faith. It is only with a leap of faith that you can appreciate or even accept that a new human being comes out of a woman’s vagina. Without that leap of faith, what happens? Two things: more obviously, you have to interfere: pull it out, or cut it out another way.

Another thing happens as well. Strangely, your faith (most of us have faith in something) gets turned inwards. As an obstetrician, or as a midwife, you begin to have faith only in your own skill. And that is what is frightening – that an event that cries out for the presence of the Divine (or whatever it is that you would name that) gets reduced to the simply human.


I know that there are obstetricians who work differently, but I think that it is easier for a midwife to accept that there is something else, something larger than herself, working through a birthing woman. It is quite noticeable how many midwives do live in sight of that something which many of us name God.


But what happens to a sympathetic midwife or physician who is working within the medical system? What happens to her sensitivity to that Other that touches us when we give birth?


What do we see in a hospital? We see, first of all, an exaggerated reliance upon technology. The use of technology has a snowballing effect, creating the need for more and more complicated interventions. Secondly, the hospital maintains a rigid hierarchical structure in which usually one person is calling the shots. Finally, we see the “spiritual” infrastructure, upon which this hierarchy is based, to be inward-looking and grounded only in human knowledge.


What happens in the hospital when things start to “go wrong”, when things don’t follow the prescribed path? When I went into hospital in labor with my first child, the nurse, who was actually a Scottish midwife, touched my belly and said cheerfully: “This baby will be born by noon!” As time went on, she touched me less and less. By the next morning at the start of her shift, she didn’t even greet me. As the nurses let me eat and drink less and less, my cervix closed tighter and tighter. I was touched less and I began to feel more and more isolated. Finally, I was only touched when absolutely necessary. The baby’s heartbeat was checked less often. I began to feel abandoned.


Our national cesarean section rate is quite a bit higher than the rate suggested by the WHO, which is 10-15%. In Canada overall, the rate is closer to 25%. I’m not interested in exploring why the rate has shot up so precipitously in the past 30 years, leave that to others who love statistics and platitudes. What I am interested in, is threefold:

To create an environment in which every woman has access to a safe and sacred birth.

To provide access to first-time mothers to be able to experience a vaginal birth BEFORE cesarean.

To facilitate VBAC (vaginal birth after cesarean) for women who are seeking that route: to provide information, support, informed choices and LOVE.


Here is some advice to midwives, doulas, and physicians who are working with women who want to give birth vaginally after a cesarean:

Remember that the previous cesarean(s) have left scars not so much on the uterus as on the woman’s sense that she is capable of giving birth. Accept that having a cesarean can hurt.

Please don’t describe to her how a ruptured uterus may feel. Watch for danger signs yourself; keep your concerns to yourself and your co-attendants.

Remember that “failure to progress” means that a woman was probably afraid and stressed. She does not need to be reminded of her failure.

Keep things easy when they get tough. Remember that a woman working for a VBAC will do well in the comfort and security of her own home.

Remember that she may need to work on building confidence, on throwing away fear, on finding her “animal” self.

Tell her you love her. Give her and her partner some time to be alone together during labor.


Remember as well, that if she ends up giving birth by cesarean another time, don’t abandon her. Give her the support through the birth and afterwards that you would give to any birthing woman.


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