VBAC or vaginal birth after Caesarean is possible for lots of women.
There are a few ‘rules’ to help get you to your goal of a vaginal birth after having a Caesarean but the primary driver is…you have to want it.
There are some extra interventions that will happen and knowing this before your labour is key so the interventions don’t detract from your experience.
And we have a guest. The lovely Lucy, editor of @uncovervic
In this podcast we talk about:
What makes you a good candidate for a successful VBAC
Why there needs to be monitoring during a VBAC labour
What pain relief is available
How to get in the right mindset for your VBAC
Why knowing the ‘rules’ of a VBAC labour helps
What the elephant in the room is when it comes to VBAC.
Photo by @hergoldenpoint
Brigid: [00:00:36] Well, welcome everyone. This is episode 34. and we've got a little treat for everybody today. We've invited one of Pat's patients in
Dr Pat: [00:00:45] special guests,
Brigid: [00:00:46] special guests.
Actually, we haven't invited her in. It's still in COVID lockdown. So it's on the phone. So thanks for your tolerance if the quality isn't up to our usual perfect quality of sound.
Dr Pat: [00:00:58] So, what we're discussing today [00:01:00] is a VBAC, which is for vaginal birth after Caesar, which is my preferred term, for the situation where someone's had a, caesarean section before and, wants to have that next baby by a vaginal birth.
Brigid: [00:01:16] Yep. So let's introduce Lucy. So, we've got Lucy Gilbert. Lucy is a mother of two little girls. and Lucy is also the editor of an incredible magazine that does the, region of Ballarat and beyond, called UncoverVic. So welcome Lucy.
It's so exciting to have you on. You're kind of like our first interactive, caller we've had. We had somebody talking about miscarriage, but she recorded her story, which was really lovely, but we've got you here with us.
So we want to start by asking Lucy, after your first Caesar. What actually made you want to have a VBAC?
Lucy: [00:01:55] I carried breech. My first pregnancy from really early on [00:02:00] about 24 weeks, Bobbi my now three year old, was breech and never turned. So I had a planned Caesarean for that. But she decided she wasn't going to go by that date.
And I went into spontaneous labour, just before 36 weeks. I had no idea. I was in labour. I completely ignored my body. So I went about my day, went to work, I went shopping. It was Valentine's day. I went out to lunch and then thankfully I had a breastfeeding class that night and the midwives, pretty much took one look at me and knew that I was in labour.
She, yeah, let me do the class. Cause she knew that it was going to be beneficial to me. And then she sent me up to the hospital where I, within 20 minutes was, in an operating theatre. I had to have a Caesarean and, it was very overwhelming. I was a first time mum and I, had a beautiful baby girl, but she obviously being, a 36 weeker she was taken off to the nursery. I struggled from tachycardia, so I was in recovery for quite awhile. and I think just that overwhelming experience, I really wasn't prepared for it. I had no idea what was about to happen to me. I hadn't really thought much about this is Caesarean yet. So, for me, I felt a real disconnect to Bobbi in those early days.
And that really panicked me. Obviously it was all fine. And we got to take her home with us after about six days, which was amazing. And it all, cleared itself up, but going into a second pregnancy, I just knew that I wanted to have some more control and, not that it was a bad experience, but I just, I wanted to have an experience that I was, I guess, much more knowledgeable about.
So the aim was for me to have a VBAC.
Brigid: [00:03:44] So did you know the term VBAC or did you know that that was an option before. You got pregnant with the second baby?
Lucy: [00:03:50] I did, but only because I had a close friend who, had had a VBAC, so she had sort of explained it to me, to be honest, before that, I just thought that once I had a caesarean that was it. That was the path I had to go down for future pregnancies. She had mentioned that she'd had a well, she's actually had two successful vaginal births since her first Caesarean. So, I, yeah, so it's gotta be in my head and I was determined that I was going to be able to pull that off.
Dr Pat: [00:04:19]
Fantastic. And Lucy, when I was looking after you for the VBAC pregnancy, we would have spent, I hope we did spend, a lot of time talking about how VBACs tend to go on the day. And when you come into hospital to have a VBAC baby, it's a bit more, intense, in terms of monitoring than a woman having a Vaginal birth who had not had a previous Caesar?
I'm talking about things like having to come into the hospital relatively early in the labour, an intravenous line in your hand, continuous fetal monitoring. Did those things, from the other side from where you are now, did that seem such a big deal at the time?
Lucy: [00:05:06] No, I was sort of in the mind that if I did get to have a go at, natural birth and I obviously do a lot of work mentally to prepare myself, but any scenario, whether it was a Caesarean or I got to have a go at an actual birth. So for me having to be monitored from the start and having to have the line was completely okay because that meant that I was getting to have a go at an actual labour.
So, because of those things, I got Loretta from Calmbirth to help me, learn all about calmbirth. And I think that really helped prepare me mentally to not really be able to move around the room and to have to stay being monitored and, all the rest of it. So to me, that was, yes, I was absolutely fine with.
With those things, I knew it was to keep me and the baby safe.
Brigid: [00:05:51] Mm. And before you went into labour, did you have any sort of concerns about VBAC?
Lucy: [00:05:57] only concern was that I wouldn't even get to go into labour naturally. And my last appointment with Pat, I thought I was on my due date. but it turns out I was 40 plus 4. I think at that point, that was a real blow to my confidence because in my mind I knew Pat was going to let me go to 41 weeks. So I had a whole week to go into labour. and then to sort of hear that I was already 40 plus for, I sort of lost all my confidence and. I didn't think that I was going to be able to do it.
And I had prepared myself that I would be having a Caesarean. And it just so happened the next day I went into labour. So. ,
Brigid: [00:06:39] what were your signs of your labour when you went into labour?
Lucy: [00:06:42] I'd been having Braxton Hicks. Well, pretty much since before Christmas and I was starting early, like I did with my first but I didn't obviously didn’t know it then. So the Braxton Hicks sort of went away for a few weeks and then come back again before I went into labour. They did feel stronger for that whole week and I think we just watched something on TV and we went to bed and about 10 minutes after I'd closed my eyes, one woke me up.
I do get told by so many people that it was going to feel really different. Like, I was definitely know the difference between a Braxton Hicks and a contraction, but to me they were really, really similar. So for about two hours, I umm'd and ahh'd whether or not it was different enough. That it was labour, or if it was still just Braxton Hicks, but about midnight it got to the point where I could no longer sit and watch Gray's autonomy through them, and I started walking around the house .
And I was, you know, having to, employ some of my calm breathing techniques to get rid of them. So then I was like, Oh no, I actually think this might be labour. So a call to the hospital and I had a couple of them when I was on the phone to them and they knew straight away that it was obviously labour.
So they said to come in. So yeah, I didn't have any show. I didn't have, my mucus plug or anything like that. It was, it was really just that.
Brigid: [00:08:01] Yeah and Lucy, I don't actually know what happened in your labour obviously, so just if you could tell me because Pat already, will know what happened! Did you have any sort of, need to break your waters or was there anything that you needed to, kind of push labour along?
Lucy: Well, I got into hospital about 2:30 in the morning and, the midwives called Pat to let him know that I was in there. And then they came back and said, yeah, see you in the morning.
And about five minutes later, Pat walked into the room.
Brigid: [00:08:32] Must have had second thoughts.
Lucy: [00:08:33] The midwife said I wasn't going to see Pat until the morning. I was like, oh no! Okay. And thankfully he couldn't go to back to sleep. I did have my waters broken, which then we saw, that the baby had done a bowel movement in utero, so I went straight onto the monitor to keep an eye on everything.
Brigid: [00:08:54] Did that make you feel a bit worried at that point?
Lucy: [00:08:57] To me. I, I had complete faith, in my body at that moment, I knew that I just had this feeling that it was all gonna work out. So, also Pat was so calm and he didn't seem that stressed about it.
Dr Pat: [00:09:10] The perfect thing had happened and that is that you'd come into spontaneous labour at term.
Yeah. and when we look at them, when we look at the VBACs that really, really go well. it's, it's the women who labour spontaneously at term that's, that's the best thing to happen.
Brigid: [00:09:25] Yeah. And Lucy, what was different about having a vaginal birth for you and I'm not talking perhaps physically, but what did you feel after?
Lucy: [00:09:36] Oh, it was honestly the most overwhelming experience of my life, I guess having been able to work through it. And, I think Loretta from Calmbirth had really set me up to those definitely what my body was doing when I was doing it. Because of that, there was this, I feel a much more instant connection when that baby came out and straight onto my chest, it wasn't so much the connection with the baby that was different, but it was, I just a sense of pride in myself, I guess. Yeah, just a completely, completely different experience and not taking anything away from the birth of my first child, because that was also stunning.
But, yeah, it was, it was more that I've set myself a challenge and I wanted to give it a crack and I I've been able to do it. So. Yeah. It was just different in my mind, I guess.
Brigid: [00:10:21] Yeah. and what would you say to someone who, who is, you know, they have been defined as a good candidate for VBAC and so they're on that VBAC path.
What would you say to that person? About going for a VBAC.
Lucy: [00:10:34] I think my biggest piece of advice is to prepare for not being able to have a VBAC. So, like I said, I've done a lot of work, making sure that I had an alternative plan, so I've spoken a lot to Pat about, I'm fine with having a Caesarean but if I do have this Caesarean, can we talk about maternal assisted delivery? Can we talk about, you know, delayed cord clamping and. skin to skin. So I guess I just made sure that I had my preferences either way and that I was going to be OK whatever scenario happened.
Dr Pat: [00:11:08] Yeah. I think that's fantastic.
Lucy: [00:11:10] So when it said, like my biggest thing was, I just wanted to go into labour.
I wanted that experience of sitting at home and, the contraction starting or my waters breaking or, you know, whatever it is. So, I sort of figured out that that was the most important thing to me is just, which I did get with Bobby, but I just didn't know that I was in labour. yeah.
Brigid: [00:11:30] Yeah.
It's such, it sounds like such an amazing, experience for you Lucy where I was thrilled when Pat came home and said, yeah, she was a trooper, you know, all good. Oh, I was, I was at home doing high fives,
Lucy: [00:11:44] but I just, I know like I'm going to be one of those annoying people that just says how great their birth was.
But to me it truly was, like. I think when Pat broke my waters. The contraction definitely, they were harder to handle because I couldn't move around. Previous to having my waters broken, I was walking around the room and, and that type of thing. And so because of that, I could get through them without any pain relief, but then as soon as I was sort of on the bed and sort of strapped to the monitor, that's when things got a little bit harder.
So, I asked for the Remi, which I'd did use for a couple of hours. And that was amazing. obviously it doesn't take all the pain away, but it's definitely makes it more bearable. But I think by about. 5:30 in the morning and the contractions were like a minute apart and that was the Remi wasn't doing anything.
So we gave up on that. and I just had to try with all my heart not to push, which was the hardest thing I've ever done in my life to not push with the contraction. And then I think Pat came in around seven o'clock and said that he just wanted to give me one more hour to try and get Veda down as far as, as far as she could go without pushing and at 8 o'clock my midwife said, I'll let you have a little push and we'll see where we're at. And about two pushes later Veda was out and Pat was in the room about a second after that.
It was really, really quick. And yeah, it was. the pushing for me was the best thing ever, because all I wanted to do is push for the last two hours. Right.
Dr Pat: [00:13:19] Fantastic.
Brigid: [00:13:20] That's an exciting story. Thanks so much for sharing with us. And it's so good for people to hear a positive sort of VBAC story. So we're very grateful. Thank you..
Brigid: [00:14:45]. Well, good old Lucy. Wasn't that a good story.
Dr Pat: [00:14:49] Fantastic. And so grateful to her for coming on our podcast and sharing her story and all my other patients I don't expect you to do that.
Brigid: [00:15:01] Okay. Then again, maybe you want to, yeah. All right. So, we know that Lucy said that she didn't even know that it was an option that she could go on and have a VBAC. And that's true, isn't it? There's like 80% of women who have had a Caesarean and will go on and have another Caesarean.
Dr Pat: [00:15:19] Yeah. I mean, I'm, I'm sure most of those women do know it's an option, but, but lots of people don't go on to attempt to have a VBAC.
Now remember, a lot of that's for perfectly good reasons. Yeah. Yeah. So, one of the reasons why the VBAC success rate. In terms of, if you define success as vaginal birth, then it looks pretty good. Is we fiddle with the numbers a little bit by, by not starting with everybody. We start with the people who are good candidates.
Brigid: [00:15:50] Yeah. I don't think that's fiddling with the numbers. Like I, this is where I'll come in with my own little story. And that is that after a very long labour with my first. 26 hours or so, and then an emergency Caesarean. And I tried for a VBAC with the second. And, I actually don't think that we, I had a proper assessment as to whether I was a good candidate.
So I'd really set myself up to want this VBAC. And I pinned all my hopes on having a VBAC and didn't even consider having a Caesarean as an option, unlike what Lucy said, and I think. That was a way better mindset to have, like she said, look, if it worked, it worked, but I had all these other options, like the maternal assisted caesarean.
Dr Pat: [00:16:35] And that was perfect. Yeah. I think that was perfect. So, she was setting herself up for, a good psychological outcome, no matter what actually happened. And I think that's brilliant. Yeah. and, you know, I didn't know you back when you were
Brigid: [00:16:52] time, listeners,
Dr Pat: [00:16:53] I didn't know you back when you were having your second baby, but I, I bet you were going about that.
With one goal in mind. [00:17:00] Oh yes. I was,
Brigid: [00:17:01] you know, bloody minded about not, not seeing another obstetrician ever, and then I married one.
Dr Pat: [00:17:08] So, so I think that, that a really good way to do this, is, and certainly, you know, if I'm looking after, a woman for her first pregnancy and for whatever reason that.
By that first baby is born by cesarean section. I like to bring VBAC up early, and, and the midwives laugh at me. They go, come on. Can we just have this baby first now? Wait a minute. I think if I plant the seed at the time of the first birth, then that might help the woman. Who's disappointed that her first baby is born by cesarean section it might help her hold onto that idea that she may still have a vaginal birth in the future if she wishes. So that everyone, I think it'd be, it'd be nice for when she goes home from that first primary Caesarean section, whatever it was done for, knows that it's not true that she definitely has to have another section.
For a small number of people it they would be well advised to have another section. Definitely But, but for a good number, I would say the majority, VBAC is a possibility that warrants discussion in that second pregnancy
Brigid: [00:18:17] and there's some stats isn't there. So, those women who are then chosen as good candidates or assessed as good candidates for VBAC, they have a good rate. of, vaginal birth, like 60 to 80%.
Dr Pat: [00:18:29] Yeah, yeah, yeah. And again, it's by changing the denominator a little bit. So the denominator is not everybody. It's good candidates. So who's a good candidate. I think the first thing that we should talk about is that you have to want it. Yeah. Yeah. So Lucy wanted it. Yes. She really wanted it.
whereas, you know, if you.
Brigid: [00:18:53] Are ambivalent
Dr Pat: [00:18:55] or real, or you really don't care. Yeah. And that's okay too.
Dr Pat: [00:19:02] Absolutely. It's gotta be discussed in a, in a judgment free zone. and you know, these days you might only be having two babies and, and if you decide. If my patients say to me, look, the first one was born by cesarean section.
and let's just give me another one guys. Yeah. Yeah. And, and I'm sure a planned section is going to be nicer than the emergency section I had last time. Anyway.
Brigid: [00:19:22] Yeah. And when I tell everybody a planned section is just so much nicer. It's really nice. Yeah.
Dr Pat: [00:19:27] It's not such a, I would say this everyday. It's not such a bad way to have a baby at all.
Come in on
Brigid: [00:19:32] a, if that's your option. Yeah.
Dr Pat: [00:19:33] Yeah. So that is not. that is not, not a problem. And if that's what the, the woman and her partner want, then decision made, that's fine. so I think VBAC's a number one for people who want them
Brigid: [00:19:46] and the people that want them, like for myself, it was a deep, psychological need to have a vaginal birth.
And it, it, it took me years and years to work with my mindset after. My [00:20:00] babies, to accept the fact that I didn't have vaginal births.
Dr Pat: [00:20:04] Yeah. So that's, that's the thing, because some people are very fixed on that. and there are other people for whom it's not such a strong, deep need, but it's a strong preference.
They'd rather that, and there are a good number of people who. Don't mind. Yeah, yeah, yeah. Or don't, or really aren't fussed at all and it, and it's not part of what they would look at when they're looking back on that birth and saying, do they feel good about it psychologically or not? If they honestly don't mind.
So those people might just elect to have another section for the people who prefer it or really, really want it. The discussion should start early.
Brigid: [00:20:48] Yeah. Yep.
Dr Pat: [00:20:50] So moving onto, who's moving on to more of who's a good candidate.
Brigid: [00:20:54] I read on a, I thought a reputable website until I talked to you about it, which said 90% of [00:21:00] women are good candidates for VBAC.
Dr Pat: [00:21:02] That's gotta be overstating. It,
Brigid: [00:21:04] it wasn't a reputable website. I found that
Dr Pat: [00:21:07] it's gotta be overstating it. Yeah.
Brigid: [00:21:09] It's so tricky. I mean, it was a pregnancy association and I thought oh well. yeah,
Dr Pat: [00:21:13] look, you know, it depends what your definition of good candidate, 90% of people may tick someone's technical boxes about what you have to, what you have, what has to be there for the VBAC to be safe.
but, I look at more than that, about a good candidate. And one thing you've got to look at is the circumstances of the first birth.
Brigid: [00:21:33] Yeah. Yeah. So Lucy had a breach.
Dr Pat: [00:21:35] Yeah. Right. So she's, she had a breach in her first pregnancy, baby is in breach position. And the vast majority of obstetricians, including myself, would have delivered that baby by Caesarean section.
and, but, but what. That tells us though, if we do a Caesar for that woman, because the baby's breach for all, we know that woman labour's like a complete champion. and [00:22:00] it's just that she didn't go into labour or certainly didn't get to advanced. so, , in some ways that, you know, in many ways that's a good start.
Yeah. Yeah. let's say we've got for argument's sake, another patient who, is a very small, very short. Petite woman with a very tall, husband, who made a very big baby and obstructed at four centimeters in that in a first labour couldn't get beyond four centimeters. Did the Caesar, the baby came out four kilos.
So, she has another baby with the same partner. I'm nervous. Already? Yeah. Okay. I'm thinking not a great candidate. Yeah. That'll probably happen again. Yeah. And there are two ways we can go with that. We could, we could decide not to do it, not to do the VBAC and just do a book section or we could say, let's see how you go, but you're really going to have to, progress very nicely , in that labour.
and, you know, the, [00:23:00] the art of this is working out which way to go.
Brigid: [00:23:03] Yeah. And experience, I would imagine. And, yeah,
Dr Pat: [00:23:05] that's right. Because there isn't a strict rule book about things like that.
Brigid: [00:23:08] No. and are there any other, things that you would say, okay, well that makes somebody not a good candidate.
Dr Pat: [00:23:14] Yeah. I think, if, well, it's my belief that if you've had more than one previous section that you shouldn't have it.
Brigid: [00:23:21] I know. I remember when we had a, when we were pregnant with our third. Your first, my third. Yeah. And I was trying to convince you, Pat I want to have a vaginal birth.
Dr Pat: [00:23:32] so that is, in my view, that's a, that's a problem. there are some people out there who believe that the numbers. Are okay. For two previous sections and virtually no one thinks that the numbers are okay for three previous sections. Yeah, no, thankfully it doesn't come up that often. but, if we look.
At two previous sections. It's my view that that significantly the risk is [00:24:00] significantly higher than for one. And I don't think in 2020, where we expect very, very good outcomes from a childbirth, that that's one we can live with.
Brigid: [00:24:10] I'm very pleased that I had a plan section in the end. Only because the obstetrician, it wasn't Pat people, Pat didn't deliver it.
Dr Pat: [00:24:18] I was there holding your hand,
Brigid: [00:24:19] the obstetrician at, my obstetrician was saying, well, you know, I don't remember her saying was, I'm not sure what to sew what to, what here. So things had thinned and, and
Dr Pat: [00:24:29] yeah. So if you've had multiple, previous cesarean section is the lower segment of the uterus gets very thin
Brigid: [00:24:35] and two long labours.
Dr Pat: [00:24:37] So we worry about the ability of that tissue to withstand the forces of a subsequent time labour. Yeah. If you've had one previous cesarean section, the lower segment of the uterus will be a little thinner, but not so that it adds a huge amount of extra risk.
Brigid: [00:24:53] What about the woman?
That's had a vaginal birth, then Caesarean birth because perhaps the baby was in breach. What sort of [00:25:00] candidate is she?.
Dr Pat: [00:25:00] Perfect. Okay. Okay. Cause we know that we know she can have a baby vaginally. Yes. so, if she has another, another baby of roughly the same size, she's a, an ideal VBAC candidate. Okay. and, yeah, that happens from time to time for vaginal birth for the first, Ceasar, for the second for breach or twins or previa and then back to vaginal again.
Brigid: [00:25:19] Yep. and I think can things happen? Like I remember, Lucy was telling me on the phone. I'm not sure we talked about it during our interview just then, but she was saying that you would check in every single appointment and say, yes, we're still on track for a VBAC. So can things happen within a pregnancy that can change your plan?
Dr Pat: [00:25:38] Absolutely. So that sounds like me, , I definitely, would return to it each antenatal visit in a fairly methodical way. Yeah. And in my mind, I'm thinking, yes, we still meet. The sort of requirements. Yeah. Okay. So, so the things that might arise during the pregnancy that would really make us rethink the plan for a VBAC, might be [00:26:00] complications.
and, those might be things like a baby that was really too big. Yeah. a consistent, reliable ultrasound evidence that the baby was very big.
Brigid: [00:26:12] Yeah. And, and can we just recap? What's a very big baby again.
Dr Pat: [00:26:16] Well, if for, in a VBAC situation I would start to get a little concerned about a baby in the top 10%.
Yeah. Okay. because, it seems, it's sort of stands to reason that that baby might be slightly harder to get out and might, and might, might put more forces on the scar from the previous section. Yeah. then other things that are, that are potentially a complication and might just add one risk on top of another significant diabetes, insulin dependent, you know, preeclampsia, Things that those are things that might arise during the pregnancy and then things that we would know right at the start that might just make us think this isn't a goer would be placenta, previa.
Brigid: [00:26:58] Yeah. VBAC with twins. That'd [00:27:00] be.
Dr Pat: [00:27:01] Risky
Brigid: [00:27:02] Yeah. Yeah. And what about like, my problem really was that I just did not go into spontaneous labour. I avoided the, I was a, terrible patient Pat. I avoided the healthcare people and got to 42 weeks.
Dr Pat: [00:27:16] So yeah. Well, So, the perfect time I think to labour with a, with a VBAC is, is spontaneous labour at term.
So let's break that down a little bit. Spontaneous labour is, is definitely preference because if patient wants a VBAC and there's some reason to induce, then our options are quite limited
Brigid: [00:27:38] in terms of how to induce.
Dr Pat: [00:27:40] So. with the, the VBAC patient by definition has got a scar on the uterus from the previous, previous pregnancy.
And, if she suddenly needs to be induced for whatever reason, the toolkits, a little, a little lean. Prostin jelly that we put in the vagina to mature the cervix. We pretty much can't use that. [00:28:00] It's not thought to be safe in the way that it can overstimulate the uterus. the, the drip that we might run during, an, in an induction to get those contractions up and cooking.
Most of us don't use those that Drip for some people consider it to be acceptable, as long as we're using the drip, just to tip somebody in, but not to whoop them along as I, as usual as I usually put it, So there's risks there. So the best induction of course is the one you don't do at all. Yeah. And if, if, if the patient comes into too spontaneous labour at term, fantastic.
Yeah, outpost dates to problems. There's some issue that, that woman's not coming into labour and that might need effort to get her into labour, including the use of drugs that we should probably shouldn't be using for a VBAC. And secondly, the baby's getting bigger all that
Brigid: [00:28:54] time all the time. Yeah. I definitely think that's why my babies were so big.
You know, they had the two oldest boys had [00:29:00] to yeah. More weeks of cooking.
Dr Pat: [00:29:01] Well, that's right. So, so, there is a tide, you know, the perfect time in the tide for a VBAC in any, if you come into to labour at that time. Fantastic.
Brigid: [00:29:09] Yeah. Yeah. It's a very big pressure. If you're wanting a VBAC and you're not going to spontaneous labour, you're doing everything and nothing.
Dr Pat: [00:29:17] Yeah. Sometimes if someone's very keen, and we're up to. Up to a post dates, the sort of term plus seven days, term plus 10 days, wherever, wherever your institution's post dates cutoff is, it is possible to come in and break the waters.
Brigid: [00:29:32] That's safe. Yeah.
Dr Pat: [00:29:34] What it does do is set the timer ticking.
Yeah. So if we do that, First thing in the morning, then we are either going to come into nice, strong, natural labour and had their baby vaginally, or we're getting a section at some point. when the, because, you know, the timer will start to tick when the, when the water's broken.
Brigid: [00:29:54] and Lucy mentioned remyfentanyl.
now in our GrowMyBaby program, we've got our whole, bundle on [00:30:00] pain relief. so I kind of know what it is, but I don't think we've actually talked about Remyfentanyl before.
Dr Pat: [00:30:05] If we haven't Remy Remy is a, a drug that we should think of as a super fast acting version of morphine. So if we use morphine as a pain reliever in labour, it's not a terrific drug.
It hangs around for a bit too long. And the worst case scenario is, the woman's labour is ramped right up she has a lot of pain, so we give her some morphine and 10 minutes later, the baby comes out full of morphine and the baby comes out. Sedated, flat, requiring, resuscitation. And that's not a great outcome.
And sometimes it's, it's a, it's an outcome that we can't really predict sometimes in labour. the woman might be six centimeters. And we think we've got four hours to go. And the baby's out 15 minutes later, especially if it's not her first. So morphine's a drug that can be used in labour, but must be used with a lot of [00:31:00] caution.
Remy is a different story. It lasts just a few seconds in the bloodstream. so, It's perfect to use during a uterine contraction. And then when the contraction has passed, the, the drugs, the drug has gone has gone. Yeah. not available in every labour ward, but, but quite successful in centers that use it.
Yeah, you have to be careful, it's a powerful drug and we have to be very careful to give the right amount. And also the patient controls that she's got a button to push and as the contraction comes, push the button as the contraction fades off so does the effect of the Remi. Yeah. Yeah, yeah. It's I find it great for using in women who are in really great labour.
Seven or eight centimeters. and who wants something just to take the edge off and help them get through those last few centimeters. but maybe they don't want something as full on as an epidural
Brigid: [00:31:54] and for a VBAC situation. epi is not in your toolkit, is it?
Dr Pat: [00:31:57] Yeah, it is. It is. So, yeah, you [00:32:00] absolutely can.
Yeah. So the data is quite clear on that. there were a number of things that we look at, When a woman is going through a VBAC labour to make sure that the uterus is holding up to the forces. Cause it's got a scar from last time and one is the, One is what the fetal heart rate is doing. And that's why if I'm there for a VBAC labour, I liked the heart fetal heart rate to be monitored continuously, not from the absolute get go, but from the start of regular painful contractions.
Yeah. Yeah, because the baby might tell you. If there's a problem,
Brigid: [00:32:36] right? Yeah. And is that what Lucy was saying? That was, she was immobilized by then. Like she felt like she was stuck on the bed.
Dr Pat: [00:32:42] Yeah. So it's not immobilized immobilized, but yeah, but it's hard to, you can walk around as far as the range of the machine which has either got a long cable or a, you know, a radio one, but still can't go too far.
Yeah. Yeah. Remember [00:33:00] though, we're talking about. People in good cracking labour. So where have they got to go.
Brigid: [00:33:06] You might just want to get on the side of the bed and
Dr Pat: [00:33:08] yeah, sure. Oh, well that's still doable. Yeah. Yeah. So, but it is. An extra level of intervention. And that's why I said to Luce at the start of that discussion.
Was it worth it on the day? Was it that bad? And people looking back will, will usually say, well, no, that wasn't the end of the world.
Brigid: [00:33:28] It means to an end.
Dr Pat: [00:33:29] It means to an end. That's what that's, that's what, that's what ensured the safety to get me what I wanted. Yeah. So. You know, if we look at epidurals, yeah. I like continuous, fetal monitoring with feedback?
you gotta be making good progress. Okay. A bad VBAC labour is the one that's taking way too long. And I might, yeah, I might see you at two o'clock in the afternoon and do an internal examination we are four centimeters. And the next time we do another one, still four centimeters is a bad sign for VBAC, right?
Brigid: [00:33:59] like [00:34:00] a centimeter an hour or something, is it? Yeah.
Dr Pat: [00:34:01] Yes. so, whatever an individual, units, definition of good progress, the VBAC labour is the one that really super duper has to be making that good progress. So, so all of those things, other things we have to monitor, but it doesn't matter if you've got an epidural or not, the signs of poor progress or problems will still be there.
Brigid: [00:34:24] So, I mean, if you can have Remy and you can have every epidurals , I'm imagining you can have nitrous oxide. So your whole pain relief suite is available.
Dr Pat: [00:34:34] Yes, absolutely. Yep.
Brigid: [00:34:35] That I did not know. Good. Alright. So we've sort of skirted around the issue a little bit, with a uterus, not, staying intact, what are the main risks for VBAC?
Dr Pat: [00:34:47] So the worst thing that can happen is you're labouring away and the uterus comes open along the, along the scar from the previous cesarean section. If you've never had a Caesar, uterine [00:35:00] rupture is extremely rare. So really strong muscle that's completely intact and it's very unlikely to break. If you've had a previous, Caesar, there's a risk of uterine rupture.
And it's difficult to say to people exactly what that risk is. The problem is that most of the data that's been collected over the years from VBAC births. Doesn't in my view, adequately delineate between. What we call asymptomatic dehiscence, which means the uterus, the uterus thins out a little bit, and perhaps even comes open just a tiny bit, but nothing bad happens versus a catastrophic situation where it comes right open the baby's expelled out into the woman's abdominal cavity, stillborn mum mother's life's in danger.
So, [00:36:00] So if we take a sort of a commonly quoted figure about uterine rupture, somewhere around one in 400, it's a gray area about exactly what that one, one in 400 really is,
Brigid: [00:36:12] whether it is a, just a mild rupture or I didn't actually know there was classifications of rupture.
Dr Pat: [00:36:18] Well, there, there needs to be because they're not the same thing.
Sometimes you'll have a, a patient undergoing a VBAC. Yeah. Who, for whatever reason, it doesn't, it doesn't go vaginally and you need to do the Caesar. And when you open the uterus, you can see that the scar has broken a little bit. Yeah. Yep. And it might be broken right down. So that the only thing between you and the baby is the membranes and you can look straight through and see the baby
Brigid: [00:36:43] waving at you.
Dr Pat: [00:36:45] So that's happened. But the woman isn't sick and the baby isn't sick,
Brigid: [00:36:50] yeah, Okay. So do you class, do you
Dr Pat: [00:36:52] Some classifications call that a dehis and some as something much more serious? Yeah. So that's the, that's the problem. Yeah. [00:37:00] so when we're talking to people in advance about the risk, one of the things I like to say to people is we don't know absolute numbers about the absolute risk of this for you.
But what I can tell you is that very serious, bad outcomes are very, very, very rare. If we follow the rules.
Brigid: [00:37:21] So the rules are, you're a good candidate to begin with. You come into spontaneous labour, you labour well and progress. Well, yes. And, is that about it?
Dr Pat: [00:37:31] Yeah. So, so that they are the main ones and the reasons why I, I really think that on the day, Is not the time to be discussing what the rules are, so that during the pregnancy, I like to really get into this discussion on a number of occasions.
So that come the day of the birth, the patient and her partner are ours. They know the rules as well as I do and it's as obvious to them. If it's going poorly as [00:38:00] it is to me. Cause I don't want, I don't want to be arguing the toss over this at the time. and I don't want to be pushing my luck with VBAC. By making the labour go much longer than I would be comfortable.
Brigid: [00:38:16] Yeah. You don't argue anyway, what are you talking about?
Dr Pat: [00:38:21] Don't argue with you.
Brigid: [00:38:23] That's not worth it. I think we've done really well. Is there any other,
Dr Pat: [00:38:27] I think, I don't know. I'm a big believer in VBAC. I think it's right, but it's not as the discussion. I hope we've. I hope we've sort of enlightened people that the discussion is not.
Straightforward. and it needs a number of separate discussions with your caregivers about, you know, am I a good candidate? What's it about? And what are the rules going to look like on the day? Cause if you don't like those, they may not be an option you can take.
Brigid: [00:38:55] Yeah. Yeah. And I think it's important to remember too, that the decision is [00:39:00] your decision with your obstetrician and your partner.
It's your decision alone. And it's perfectly reasonable for you to say, well, none of those options sound good. I'd like to have a plan section, and S Luce did, mention, assisted or what we call it as the maternal assisted Caesarean yeah. So that's another option. and really briefly that is.
Where the woman is scrubbed in.
Dr Pat: [00:39:23] Yeah. That's where you can, you can have a severe section where the patient is scrubbed in like the surgeon. Okay. So, so the patients have scrubbed up as I am, and then they can bring their hands down into the sterile field and receive the baby directly from the abdominal incision.
Brigid: [00:39:38] Yeah. So there's no drapes up or anything like that. You can actually see the baby as it is brought towards you. And
Dr Pat: [00:39:45] so again, not for everybody. Yeah. Yeah. But, what we're trying to do is, is, is give women a suite of acceptable solutions, within the bounds of safety. Yeah.
Brigid: [00:39:58] So, if you're interested in that [00:40:00] we do have one on our Instagram feed to scroll through.
It's a fair way done. And I'm not sure
Dr Pat: [00:40:05] another private patient of mine who was generous enough to give us the video.
Brigid: [00:40:08] Yeah. Yeah. Alright. Well, everyone, I hope that that was a fascinating for all those people that are perhaps had their first baby. And it was a Caesarean and thinking, well, what next? What do I do now?
A VBAC is something for you to learn about and to talk to your partner and practitioner about it and see if that's for you.
Dr Pat: [00:40:25] Yeah. Don't hesitate to ask the curly questions of your practitioners.
Brigid: [00:40:28] Yes, exactly. Good. Good. All right. Well, have a good week everybody. See you next time.