 And let's go. Let's talk about, I see my picture covered up my title there. It's Vaginal Birth After Caesarean, not Aginal Birth. I knew you were there, Andrea. Hello. Why would we care about vaginal birth after Caesarean? Well, if some of you were around for Gene DeClerk's presentation this afternoon, where he showed that in many countries, Caesarean section rates range from 30% to 90%. We want to be concerned about VBAC. We don't want mothers to be doomed to the old saying, once a Caesarean, always a Caesarean. But there are very good reasons for mothers, even after one Caesarean to have a vaginal birth subsequently. There's an informed consent discussion that we should be doing with women to tell them that a VBAC has a lower surgical risk. It's lower risk for the newborn. You know, instead of the newborn suffering its way through the pelvis, there are actually benefits for the amount of stress and squeezing that the birth canal does on the ribcage to help the fetus expel fluids in its lungs and have that recoil of the ribcage to stimulate breathing. Mothers also have a faster post-birth recovery with a VBAC than a surgical birth. Here's a table that shows the estimated risk during a Caesarean delivery and the same risk during a trial of labor. These are US statistics that are widely quoted here. So the risk of uterine rupture, even in a trial of labor, is still well below 1%. Maternal mortality is much lower with a vaginal birth, even when it's a VBAC. The statistics say there is a higher rate of transfusion for women with vaginal birth after Caesarean. Of course, you will have more potential operative injuries with women during surgery. But there are different types of injuries if we're counting apesiotomies and lacerations that occur during instrumental births with our statistics with estimated risk during trials of labor. It looks like trials of labor even have a higher infection rate, but we have to remember that these are a greater number of births than Caesareans. Yes, Lindsay, these are statistics from all over the United States, all states inclusive. Mothers go home much sooner after a VBAC. And if they're home sooner, the risk of their complications starts falling. Women should be informed that a planned VBAC is associated with approximately a 1 in 200 risk of uterine rupture. That's the figure that the Royal College of Obstetricians and Gynecologists uses. I also looked at the literature from the United Kingdom because I knew we would have a lot of British midwives listening to this presentation. So no matter whose numbers you use, the risk of uterine rupture is less than 1%. The nice guidelines from the UK say that clinically there's little or no difference in the risk associated with a planned Caesarean section and a planned vaginal birth in women who have had up to four previous Caesarean sections. If a woman chooses to plan a vaginal birth after she's previously given birth by a Caesarean section, she should be fully supported in her choice. You'll notice that this differs from some guidelines from other countries that ideally want women to have no more than two previous Caesarean sections. Much of the counseling we do with women about a planned trial of labor needs to consider where the women will be giving birth. So here is the V-Back eligibility to have the lowest risk for mothers and newborns. These are the routines that come from guidelines from the American College of Obstetricians and Gynecologists. So first, we consider what the previous Caesarean section or sections were like. The incisions need to be a low-transverse uterine incision. There should be no incision extensions. So when you make a low-transverse incision, as the baby is being delivered, that incision can rip at the sides or sometimes in the middle. Those extensions or tears will not stand labor contractions. They increase risk of subsequent rupture. There should be no other uterine surgeries. Now that surgery on the uterus, like a uterine fibroid being removed, a myomectomy, removal of a single tube or ovary will not prevent a vaginal birth after Caesarean. Ideally, the operative report is in the medical record so that you can see that there was a low-transverse uterine incision and that there was a double-layer closure on the uterus. In the United States, for a period of about six years, it was the style to shorten the length of surgery by doing a single-layer closure on the uterus. This was also thought to reduce blood loss and reduce formation of scar tissue, adhesions around the uterus. While that may be true, we did learn that single-layer closures are more likely to rupture during a trial of labor. So we have gone back to double-layer closure in the United States. Again, ideally, we want mothers to have two years between surgeries. And that's two full years between surgery to surgery, not between the surgery and the start of the next pregnancy. We know that two years between births gives the mother ideal time to recover and that newborn statistics are better for mothers who wait two years. But uterine outcomes are also better. There's probably more time for the scar tissue to harden. So here are the contraindications that we use in the United States and are talked about in the United Kingdom for a trial of labor. A classical or a vertical uterine scar will not stand contractions. I can't remember the last time I saw a vertical uterine scar on an operative report. By and large, we've learned that we can even do cesarean births for breaches through a low-transverse uterine incision. An extension of a transverse scar is a contraindication to a vaginal birth. And if the scar is unknown, most obstetricians will say, no, for safety, we want to do a repeat cesarean. Here are some cases of mothers with different ages, different races, different reasons for their prior cesarean, and whether they had a prior vaginal birth or not before this cesarean. I'm seeing Rachel saying she's seen many women come from abroad, like Africa, with vertical incisions. OK, our experience in Florida and now in Connecticut, the women that we've seen have low-transverse incisions. But it may be in Africa that there are still many physicians using the vertical. So just think about these mothers with very different backgrounds. We're going to come back to them. There is a VBAC risk calculator that's used heavily in the United States. You can access this for free. It's from our Agency for Healthcare Research and Quality. And it takes a multiple of factors into account. So here is this calculator in use. I know that this slide is a little bit small. But it looks at maternal age, pre-gravid height and weight, NBMI. We even have outcomes by ethnicity and race for the United States, because we do know that some ethnicities have better VBAC outcomes and some have poor VBAC outcomes. Previous vaginal births are considered. And a vaginal birth, since the last cesarean, is particularly important. And then the indication for the prior cesarean section is factored in. Once you put in those factors, you hit Calculate and you come up with a score for the mothers. Here's the website for that calculator. You can even put it on your smartphone so that it's very easy to use in home settings or clinical settings. So here's an example of the figures that the calculator would give you. The predicted chance of vaginal birth after cesarean for this particular woman that I entered was basically 49%. Now, I will agree that this is a very medical and mathematic approach to calculating success with a vaginal birth after cesarean. In the practices that I have been in and the practices that I visit as a midwifery educator, these numbers are used to give women a rough estimate of their success. With that in mind, we encourage all women to try a vaginal birth after cesarean, assuming that they're in a site where we could quickly change to a surgical birth if needed. So here are those mothers again. What I've done with them is gone through and used the calculator to give them a score. That score is the percent likelihood of their having a vaginal birth after their cesarean. So you see that the mother who has a BMI of 40, who has not had a prior vaginal birth, only has about a 44% chance of having a VBAC. That would not stop us from supporting her during a trial of labor. But a mother of the same age, who's also Hispanic, who also had a prior arrest of descent as a diagnosis, who has a lower BMI and had a vaginal birth after cesarean, has an 86% chance of having a successful trial of labor. I can tell you that I just analyzed the data. We have a physiologic birth center in Connecticut, where all births are midwifery led. And we have, with our mothers, who have a trial of labor, only a 10.8 cesarean section rate. That's even for mothers who have BMI greater than 40. So I want this to be a message of hope for you all, that with the patience of midwifery and our best midwifery support, women have very good success rates. Yeah, Rachel's really reinforcing a personalized approach. I know many practices give 70 or 75% kind of across the board as a blanket rate. And we really can give women better guidance than that. The calculator really assists us in our practice as clinicians in deciding how hard we push for a vaginal birth. And that's no pun intended, because it's most often in stage two where we start to question whether we will really be able to have a vaginal birth or not. Yeah, Crystal, you've brought up a good point. So much of our research in the United States, which is so well published, does not come from midwifery-led units. Hopefully, we'll evolve to the point in the United States where we can better promote midwifery-led statistics. So let me ask you all, what's a midwife to do? Here are four cases where we're looking for records and they're not as easily obtainable or readable as we would like. So in the first case, the surgical record can't be found. This mother has had her cesarean at the Parkland Hospital in Dallas, which I think does something along the lines of 16,000 to 20,000 births per year. And it's not unusual for about 10% of medical records to be unattainable. What would some of your practices do in that case? You can type an answer in the chat box. I think the typing slows down when multiple people are chatting. Yeah, Catherine says that's one tight corner. Ask the woman if she knows? Good option, Rachel. Listen to the woman first. Now, Lindsay's saying they often have translators. Yeah, ask the woman. Catherine sounds like she's been with many of the practices that I've been at. For example, I have had a Chinese record translated and shown the physician to have the physician say to me, I don't trust the translator. It's not a certified translating agency. I also have had many physicians now who will say, if we can't find the record, we're in a hospital with immediate surgical access. There's a low transverse abdominal skin incision I'm going to trust that there was a low transverse incision with no extensions. These are physicians who are really sticking their neck out. Becky, that approach is similar to the way the physicians I was just talking about would approach VBAC. As long as they can't find a contraindication, they're going to proceed. What I do now, when I do postpartum care, is we have electronic medical records in my settings. And I print a copy of the operative report, and I highlight on that report for the mother low transverse incision, no extensions, two-layer closure. That is what our obstetricians put into their reports. I give it to the mother, and I have a conversation with her about a vaginal birth if there's another pregnancy, and tell her to hang on to this record. So even if in the future the mother loses that record, I'm hoping she might remember that I said to her, you had the type of surgery where you could labor again. Something else I'd like to pose to you all. There's an informed consent process that should happen in the prenatal period so that women have a plan and know what to expect with a trial of labor. Who does that informed consent, and who signs the consent form? The surgeon, the midwife, the nurse at the bedside. Those of you from the UK, remember that here in the United States we have three separate roles. The midwife may be managing and assisting multiple women while there's a nurse who's the primary continuity person at the bedside. Wow, Becky. Three V-backs with no access to surgical records, and nothing has ever been questioned. I'm wondering, did they know you were a midwife and assume that you wouldn't try to labor unless you knew you had the optimal surgery for a trial of labor? Oh, okay. So in other places, who does the informed consent? The surgeon, the midwife, the nurse, the obstetrician I'm seeing in the UK. That makes me happy. You have a midwife-led clinic booking for previous caesareans. So Rachel, when you do that, are you doing some group education with the mothers and having the consent signed? That's a nice organization, Rachel. That even permits if you're in a room around a table, that permits the mothers to talk with each other so that they're supporting each other in whatever decisions they're making. While the others are typing, I have been in practices where physicians say to us, you do the education and you sign the surgical consent. By convention in the United States, surgeons obtain their own consents. I really prefer that the woman have some time, even if she's very educated, about a trial of labor and vaginal birth after caesarean. I prefer that she have some time to talk with the obstetrician because the obstetrician is much better at answering surgical questions than I am. And they do have their little bit different routines. So Crystal, the Virginia Medical Board has an informed consent document. And are you using that for home births and birth center births? Yeah, I'm seeing now that I'm reading it. Lisanne from South Africa said a little bit earlier, very few obstetricians allow for VBAC in private practice in South Africa. That was a problem in Florida. And it wasn't as much the obstetricians, it was the anesthesiologists. In the United States, many small hospitals do not have in-house anesthesia 24-7. And the anesthesiologists would say women cannot VBAC unless we're in-house. So many hospitals stopped offering that. Excuse me, hopefully that gave you a little time to read Andrea and Carol's postings. Yeah, there are many different decision-making tools in the United States. And in Florida, when small hospitals refused to offer VBAC for women, they would travel to other places, other cities, the way Eliza is describing that they do in Romania. Catherine, I'm going to ask Andrea to take the mic when I finish and talk to us about VBAC at home. That's data that I'm not strong on. So preparing for success starts with the first prenatal visit. Early in pregnancy, we should be introducing the subject of vaginal birth after cesarean. It helps us determine eligibility and the lowest risk. And from an administrative standpoint, it gives us months to try to get our hands on the surgical records. And sometimes it takes months. When we start, we can work with mothers so that they're having the healthiest pregnancy possible. They can work to limit weight gain to international recommendations. We can encourage maternal exercise, and that's simply 30 minutes of walking a day. Can even be in two 15-minute periods. Just those two health measures increase success for vaginal birth after cesarean. So we have ways of using calculators to help us predict success. And you may consider whether or not the mother could benefit from talking with the surgeon. So what are we to do when the woman arrives at 31 weeks and there's no signs of labor? An induction of labor has been agreed on. What cervical preparations will you do? We became so successful and so convinced about the safety of vaginal birth after cesarean about 20 years ago that we started using prostaglandins to assist with cervical ripening. Mesoprostyl cytotech. We quickly found that the prostaglandins are so good at dissolving collagen in the area of the cervix that it greatly increased the risk for rupture of the uterine scar. So no prostaglandins should be used in women with a uterus that's had a surgical incision. There are a variety of potential induction of labor methods that can be used. Women and their partners might be encouraged to have intercourse. There are prostaglandins in seminal fluid. Some women will try castor oil. It's more successful the higher the cervical ripening score and the closer women are to labor. They might be using black cohosh capsules or teas. Nipple stimulation can be used. You can look in the Cochrane reports for examples of these routines. In the hospital we may also encourage nipple stimulation. We might use a trans cervical Foley catheter with the balloon filled up to encourage not only mechanical dilation of the cervix but release of prostaglandins. A cooked catheter works the same way but they're much more expensive. Some people, once you have some uterine contractions and some cervical dilatation, still try amniotomy and then you can use intravenous pitocin on a woman who meets the criteria for a trial of labor. Induction of labor does increase the risk of rupture two to three times. But do keep in mind that still keeps the risk of rupture lower than 1%. Pitocin is the method that most increases the risk of rupture. Success takes time. Now I'd normally open up for questions. But Andrea, if you're willing and then Crystal, we could also hear your experience in Virginia. Andrea, if you turn on your microphone and let me see if I can enable it for you. Maybe if I temporarily make you a presenter. Andrea, do you have a microphone on your computer? Go ahead and use the mic on the computer. It's going to give us some feedback but you have such a wealth of wisdom about home birth. Try it again now Andrea. For those of you who don't know Andrea, I believe she's the chair of the home birth section for the American College of Nurse Midwives. Very experienced with home births. And as you can see, Catherine is more experienced with Adobe than I am. It takes a village to run this chat room. You have the village there at your house Crystal. So Crystal, while Andrea is trying to come in, let me clarify. In Virginia, the CPMs and the midwives who attend home births have an informed consent form from the state. And when they talk with a woman and they have that form signed. Then they will do a trial of labor in the home setting. Is that correct? Yeah. We had a similar experience in Florida when hospitals were not, many of them offering V-backs. Women left the hospitals and either free birthed on their own or went to the home birth midwives. So we know that there are many vaginal births after cesarean occurring in Florida in areas where trials of labor aren't available in the hospital. So Becky, do the nice guidelines support V-back at home? Okay. Actually, we have the same guidelines here in the United States. Continuous monitoring that there be at least a saline lock for IV access. And it looks like the same thing is happening in New Zealand. Okay. So the midwives are giving women the choices that they're looking for. So Andrea, the Manistats, for those of you out of the United States, that's the Midwives Alliance of North America. They show good success, but they can't say that there are higher V-back rates at home. Yes, you're right, Lindsay. We do have many small hospitals that are isolated and women might be traveling as long as an hour to get to those hospitals for birth. We're coming up on time to end. Any last questions that Andrea or anybody else might be able to answer? Crystal's comment about their needs to be trust, it always comes back to trust, doesn't it? And how we can form a mutually trusting relationship with women so that when we're providing a trial of labor, whether it's at home, in a birth center, or in a hospital, when we no longer feel safe from mother and baby, they're willing to decide with us to change the plan. Exactly, Crystal. Yes. The women who most want to be protected from unnecessary surgery are sometimes the ones that are most difficult for even home birth and birth center midwives to make good relationships with. I am going to thank you all for participating in this discussion. Got a few ending slides. There are my resources. They're available online for those of you who I saw, for example, I think from Romania, who were interested in trying to establish V-back. I am going to turn off the recording. Thank you.