Friday, November 13, 2015

My CBAC series on Science and Sensibility

This month, we are talking about Cesarean Birth After Cesarean, or CBAC.

CBAC is the preferred term for when a mother works for and wants a VBAC but ends up with another cesarean. Medical researchers usually call this a "failed" VBAC or a "failed trial of labor after cesarean" but this terminology is insensitive. Women who did not get a VBAC are not failures. The reality of birth is much grayer than a black-or-white, success-or-failure binary equation.

I had a CBAC with my second child, as I wrote about on this blog last week. Although I did go on to have two VBACs afterwards, the CBAC experience left a strong imprint on my soul, and pointed out to me the need to improve our emotional support for women who experience one.

In honor of this topic, I wrote a 3-part series on Supporting Women When VBAC Doesn't Happen, and it was published over on the childbirth blog, Science and Sensibility. The different posts include:
  • Part One: A Unique Grief - discusses how a CBAC is not the same as a primary cesarean or a planned repeat cesarean that was gladly chosen, as well as the vacuum of support that many CBAC mothers experience from care providers, friends and family, and the birth community 
  • Part Two: The Forgotten Mothers - discusses how CBAC mothers are largely ignored in medical research, reviews what little research there is on CBAC, and discusses what we can learn from it and from CBAC mothers' experiences
  • Part Three: Supporting CBAC Mothers - discusses concrete suggestions on how birth professionals and friends/family can support CBAC mothers

There is also a new brochure on CBAC that I helped write for the International Cesarean Awareness Network. This gives birth professionals something concrete to give to new CBAC mothers. (There are other ideas for supporting CBAC mothers available in Part 3 of the Science and Sensibility series linked above.)

In addition, I helped write a new CBAC support website, using materials brainstormed by CBAC moms for a workshop I did at an ICAN conference.

I am also offering two webinars on CBAC for ICAN this month (they will be listed with ICAN once they have been recorded; members can access them afterwards). One is for folks in the birth field to learn how to support CBAC women more effectively, and the other is for CBAC mothers themselves.

When I had my CBAC so many years ago, there was a real dearth of information on supporting CBAC mothers. No one knew how to help, and I got precious little support. Eventually we built a community of CBAC moms who helped each other. Together we brainstormed what kind of support was and was not helpful. We built the support network that we needed. It didn't take the pain and disappointment away of course, but it helped ease the process of coming to terms with it.

Far too often, there is still a dearth of support for CBAC mothers because few people know what support resources exist. My hope is that this Science and Sensibility series, the new brochure, the new website, and the webinars can help fill in gap, along with ICAN's Facebook support page.

But this shouldn't be the end of it. We need to continue to dialogue on what's needed to improve support for CBAC moms. However, that dialogue won't happen if other folks in the birth community are not aware of these concerns or have no concrete ideas on how to help.

So please, go check out the series and "like" or "share" it on Facebook and other social media. Make sure that people in the birth field, whether care providers, doulas, advocates, or moms themselves, have access to the message about improving support for CBAC moms.

Let's make sure that women who don't get a VBAC know that they are not alone and that all the work they put in their pregnancy and towards their birth still counts. ALL women deserve support; let's raise awareness of the needs of CBAC mothers and reach out to them with kindness and empathy as they work towards emotionally processing the experience and integrating it into their lives. 

Wednesday, November 4, 2015

Cesarean Birth After Cesarean, 18 Years Later

Image from Wikimedia Commons, here
  Remember, no effort that we make to attain something beautiful is ever lost. –Helen Keller

This month, we are focusing on CBAC, or Cesarean Birth After Cesarean. The following was expanded from an article written for the Spring 2015 Clarion, a publication of the International Cesarean Awareness Network (ICAN), now appearing on the ICAN blog

My CBAC Story

Eighteen years ago, my second child was born. He was born by repeat cesarean after a long, hard “trial of labor” which included 5 hours of pushing with no progress because he was big and posterior with an upright (“military”) head position.

I’ve second-guessed that birth for many years. It’s possible that if we’d pushed even longer, his head would have molded enough to fit through my pelvis and turn anterior on the perineum, as many posterior babies do. However, at that point, I was absolutely exhausted, in a lot of pain, and was worried about the wisdom of continuing when things had gone so long without progress. I knew a non-progressing labor was a risk factor for rupture, plus my baby had experienced some issues with his heart rate. They resolved, but I didn’t want to go into a repeat cesarean in true emergency mode because of a rupture or fetal distress, and emotionally I needed to make sure that I didn’t have an anesthesia failure like I did with my first cesarean.

At that point, I just had a strong sense of Inner Knowing that it was time to be prudent and stop before things became a real emergency. I believe I made the right decision, but it was hard to communicate that to my husband and support team. My doula treated me like I had wimped out and thrown in the towel too easily. I never heard from her again after the cesarean. It was clear she viewed me as a failure.

I dreaded having to go back to my VBAC groups and tell them I’d had a CBAC, but I gritted my teeth and did it anyway. I got some sympathetic responses, but mostly I got a lot of silence or tepid responses that felt judgmental. No one knew how to reply to someone who hadn’t gotten their VBAC . 

Over the years, there was a lot of armchair quarterbacking about my decisions. People meant well, but I was left feeling pretty unsupported. And I didn’t feel I could really emotionally process the birth fully in birth spaces because I was afraid of discouraging new mothers or those planning their VBACs. No one wants to hear about when VBAC doesn’t work out.

Eventually I was able to access some resources that helped me emotionally process my first two births. It took a lot of hard, emotionally grueling work, but in time I came to peace with those births, and I did have two VBACs afterwards. 

In some ways, the CBAC was healing from my highly traumatic first cesarean, but in other ways it would always remain hard, even though I felt like it was a prudent and wise call under the circumstances. My consolation was my precious child, but his birth would always remain bittersweet to me in some ways, especially because of the initial lack of support. And that led me to trying to improve support for other women who had difficult or traumatic births, especially CBAC mothers. 

Expanding CBAC Support

If about 75% of labors after cesarean end up with a VBAC, that means that about 25% of these labors end with another cesarean. Where is the support for women who have an undesired second cesarean? Where is the acknowledgement of all the work they put in towards a VBAC, the hours of labor, the pain, the worry? Does all that preparation and work not count if you don’t end up with a VBAC? 

In time, I began to realize there was a vacuum of support for the mothers who didn’t VBAC. It wasn’t just about my own experience anymore, but also about other moms. How could we make it so that all mothers felt supported, regardless of outcome? Shouldn't we offer emotional support after any cesarean, whether it’s your first or another one?

I wasn’t the only one, of course. A number of us shared this experience of another unwanted cesarean, including people in the leadership of ICAN, and we began to talk about how to offer better support. One of the first things we did was ditch the terms used in the medical literature, terms like “Failed VBAC” or “Failed Trial of Labor After Cesarean.” We felt this was too judgmental and insensitive. We were not “failures,” we did not fail, and we should not have been on trial.

We created the term Cesarean Birth After Cesarean (CBAC) as a more mother-friendly alternative. It refers to a cesarean that occurs when the mother really wanted and worked for a VBAC but didn’t get one. These women had different emotional needs than those who wanted a repeat cesarean, and terminology needed to reflect that difference. So we used “CBAC” to differentiate another unwanted cesarean from Elective Repeat Cesarean Section (ERCS), where women truly wanted another cesarean and voluntarily chose it. Neither one is good or bad; they are simply different experiences.

There are many shades of CBAC. Most of the time, it refers to someone who labored and ended with another cesarean, but it can also refer to a cesarean performed before labor for medical reasons, because the mother had no choice, or because the mother was coerced or scared into a repeat cesarean. Some women prefer "CSAC" (Cesarean Surgery After Cesarean) because they consider the term “birth” too emotionally loaded. Women get to choose the term that seems right for their own experience. The important thing is to acknowledge and validate the range of feelings that women have over this experience.

Of course, all CBAC mothers are not alike. Having the shared experience of a CBAC doesn’t mean other details of our situations are similar. Each CBAC is unique, and each carries its own particular color and resonance of pain. 

Some had disappointing or traumatic experiences, and some didn't. Some felt very betrayed by their caregivers, while others had very supportive caregivers. Some felt they had a “prudent CBAC,” where although it was difficult, a repeat cesarean felt like the right choice under the circumstances. Some had an “empowered CBAC,” where even though there was disappointment and sadness, there was powerful learning and healing too.  

Some CBAC mothers go on to have a VBAC eventually, while others never do. Some have multiple CBACs, each with their own emotional resonance. Some have a VBAC and then a CBAC, which has its own particular pain. A few have had the bitter experience of having lasting physical and emotional damage from their CBAC, including uterine rupture, hysterectomy, and damage to or loss of their baby. As always, each person’s experience is different and unique, and each CBAC mother needs safe space to process all the varying feelings about those experiences. But this can be difficult to do within regular birth forums.

Some people don’t think there needs to be any separate support for CBAC mothers (“a cesarean is a cesarean”), and to this day, many of us with CBACs still have our decisions questioned and second-guessed in birth forums. Although many doubters have come around to offer more support, CBAC still remains a topic of friction at times within the birth community. This needs to change. 

New CBAC Resources

Over the years, we have tried to expand resources for CBAC mothers. We have offered several CBAC sessions at ICAN conferences and at local chapter meetings, and until recently we had a Yahoo group for online support. 

In 2011, I offered a CBAC workshop at the St. Louis ICAN conference. The session was derived from discussions by mothers on the Yahoo CBAC Support Group, and many graciously consented to sharing their thoughts and quotes to help others. At that session, we brainstormed ways to offer further support for CBAC moms. 

One of the main ideas was to have an online website devoted to CBAC support and information. So last year, Melek Speros, Catherine Kowalik Harper, and I created a CBAC Support website, based on my material from the 2011 workshop and suggestions I got there. On this site, we share CBAC research, websites where CBAC moms can go for emotional healing, information on the unique emotional needs of CBAC mothers, suggestions for processing a CBAC, CBAC birth stories, inspirational quotes for healing, and suggestions for birth professionals to help them better support CBAC mothers. 

ICAN has also created a new online support group via a Facebook page for CBAC mothers. This is a closed group; you have to be a CBAC mother to join. It offers intensive, personal support for those dealing with the aftermath of a CBAC. 

ICAN is also about to publish a brand-new brochure on CBAC. It is intended for ICAN leaders and other birth professionals who may encounter a woman who has recently had a CBAC and is in need of extra support. We encourage birth professionals to include this brochure in a resource packet that they can send to women shortly after a CBAC so these mothers realize that they are not alone, that others have walked the CBAC trail and survived, and that there are resources for further support if they want it. 

In future years, I hope we can create even more ways to help support CBAC mothers. If you have other suggestions for how we can do that, please add them in the comments section. 

Final Thoughts

Eighteen years after my own CBAC, it remains a potent memory. My sweet little boy is a strong and independent man now, flying off on new adventures, but his birth is still a touchstone for many different emotions. Although I did eventually go on to have 2 VBACs after the CBAC, those experiences didn’t "fix" the CBAC or make it go away. They simply are different entities – not better or worse, just different. Although there are things I still mourn about my CBAC, I have learned to honor all my birth experiences, difficult or easy, because they are a big part of the person I am today.

The lessons I learned from my CBAC remain powerful and still resonate in my life. My CBAC helped me to be more compassionate about other people’s births, to recognize that sometimes there are just things that are beyond our control in the moment. It helped me to realize that sometimes birth is more about the willingness to heal and change; that birth is more about the journey and less about the destination. 

In time I learned to honor both the disappointment and the joy in all my births, to remember that what counts most is the parenting we do throughout life rather than how we birth, but also that how we feel about our births counts, even years later. Our deep love for our children is a different and separate thing from our emotions about their births, and while these things intertwine, one does not take away from the other. We can honor the disappointment and mourn the difficulty of a birth while still celebrating and fiercely loving the child that came from that birth. 

I found that out of my suffering came the ability to transform pain into advocacy. I found my voice in a new and potent way, and I have endeavored to channel the power of that voice to create change, as well as to create and hold safe space for other women and their unique experiences.

A CBAC is never an easy thing. The pain and disappointment of it stays with you forever, but like other grief, it does ease some and you find a way to live with it, just as you find a way to live with other disappointments in your life. You can celebrate certain aspects of it, you can mourn parts of it, you can still be upset that it occurred, but you honor what it has brought to your life, both difficult and wonderful. 

You also learn that in time, out of the pain and conflicting emotions that accompany a difficult experience, there can also come great growth and power to create change for yourself and others. Just give yourself the gift of time and space for that healing. It will come.

Monday, November 2, 2015

A Discussion of the Barriers to VBAC

Dr. Mark Landon
The majority of women who have a cesarean in one pregnancy go on to have cesareans in subsequent pregnancies. Sometimes it's because that's what they want (which is perfectly fine), but often it's because they are not given any choice in the matter. That's not fine.

Sadly, many hospitals or caregivers will not "allow" Vaginal Births After Cesarean (VBACs). Some say they allow it, but in the end the caregiver ends up scaring or pressuring the mother out of VBAC, or put so many restrictions on it that it's practically a miracle if the mother gets one.

There are risks to VBAC that are real and must be considered, but there are also real risks to repeat cesareans, especially multiple repeat cesareans. The rise in the incidence of placenta previa and placenta accreta, both life-threatening conditions, is tied to the rise in cesareans, especially repeat cesareans. Yet women are often not being adequately counseled about the risks of cesareans.

The "trial of labor" (TOL) rate for VBACs in the United States now is much lower than in Europe, and much lower than it used to be here in the U.S. The U.S. medical community, by and large, turned its back on VBAC in the early 2000s. While the rules around VBAC were loosened a bit a few years ago in order to help make it more available to women, this hasn't really happened. Many providers and hospitals still do not allow women to choose VBAC, even though about 70% of women who try for a VBAC will have one.

The following article is an excellent overall summary on the barriers to VBAC in the U.S. from one of the leading experts on VBAC, Dr. Mark Landon. If you haven't had a chance to read it yet, definitely check it out.