The findings are presented in four main categories: “parameters for VBAC”, “organisational support and resources for women undergoing a VBAC”, “fear as a key inhibitor of successful VBAC”, and “shared decision making – rapport, knowledge and confidence”. Each category contains a number of subcategories.
Parameters for VBAC
Successful VBAC depends on several factors, not least a careful consideration of the previous obstetric history, the present obstetric factors, a positive attitude in all who are centrally involved, and strategies such as early follow-up after the first CS and antenatal classes.
The importance of the obstetric history
A key theme that emerged is that not all women are suitable candidates for VBAC – hence the importance of the obstetric history (in particular, progress in a previous labour) and consideration of potential risk factors in the selection process. Of interest, clinicians in Ireland and Italy considered obesity to be a factor that militates against offering a VBAC.
A good history, I think, is very important, so that one really knows in preparation of the birth why the first was a CS, and discussions can take place at that point. (G)
Clinicians in Ireland were also concerned as to whether the previous CS was planned or was an emergency procedure.
If you look at the outcomes … the morbidity from an emergency CS is three times that of an elective one. So … there isn’t any massive benefit clinically in terms of reducing risk. Then you have the big risk of a very bad outcome [with a VBAC] hanging over you, which you don’t get with an elective CS. (IR)
Present obstetric circumstances
Even when a VBAC is planned early in pregnancy, the plan is often reviewed again as the woman approaches term and, in particular, if the pregnancy extends beyond the expected date of delivery. Although opinions varied on whether women should or should not be offered an induction of labour once the pregnancy is prolonged, clinicians expressed increasing concern about the associated risk of uterine rupture. Clinicians highlighted that even when a decision to induce labour is made, a level of uncertainty exists as to the best time to undertake the procedure.
I am happy to induce; are we happy to induce? I am in my own practice. I would prefer to induce them at T + 3 or 4 rather than let them go to T + 10 personally. … I look at these women who have had one previous CS as normal, so I don’t think about doing anything until they were postdates, as if they were normal. (IR)
Although there was some discussion regarding the potential of a maternal request for VBAC, not all clinicians thought that the women should have an automatic right to choose their preferred option without consideration of the associated obstetric risks involved.
I think that women shouldn’t have a right to choose a vaginal birth after CS. The decision should be the result of an overall evaluation, which can’t exclude vaginal birth. A process of assessment of suitability is necessary, leaving flexibility for the clinician. (IT)
A positive attitude to VBAC in all who are centrally involved
Clinicians indicated that for VBAC to be successful, the woman must be motivated and willing to consider the options. Clinicians in Ireland were keen to stress that even when a woman has an open mind towards VBAC, the final decision on the mode of birth cannot be made until late in the pregnancy. Clinicians in Italy suggested careful evaluation of the woman’s suitability for VBAC is required. Clinicians in Ireland indicated they were positively disposed to supporting a woman to have a VBAC if they had laboured previously, and were enthusiastic about supporting these women to labour.
At the first visit, I always put down are they open minded about it or are they keen for CS. And if they are keen for another CS, I put down: “Not un-keen on another CS”. … If they are open minded, you can play along with them, like if they come in spontaneous labour. (IR)
Clinicians indicated that the impact of a negative attitude towards VBAC among their colleagues should not be underestimated as a potential barrier to increasing the rate of VBAC. This was particularly the case for those working alongside clinicians in private practice. In addition to hospital-based colleagues, clinicians in Ireland found the support, or lack thereof, from the family doctor, known as the GP (general practitioner), as crucial in achieving a successful VBAC.
The GP is vital because there are some GPs who will send the women in and say: “She had a CS last time and I really feel she needs a CS this time” at 6 weeks of gestation. They are not always a barrier. There are some who are very supportive and some who are extremely negative. If the GP will support you, then you are in business. (IR)
Supporting women to have a VBAC requires a positive attitude, good teamwork and sufficient experienced staff available to ensure success. Clinicians commented that the obstetric and midwifery staff must be convinced that it is possible for carefully selected women to give birth vaginally after a previous CS, and must cooperate with each other in supporting these women to achieve success. If this is not the case, then the woman may lose confidence in her ability to give birth vaginally.
A woman was sure she wanted to give birth with a VBAC, but the obstetrician wanted her to sign an informed consent where he wrote that, despite his having explained all the risks of VBAC, the woman wanted to deliver vaginally and that he was available for CS any time during labour. The woman’s husband was shocked. After all this, the woman started saying: “Perhaps a CS would be better!” Everything went well, but the woman spent the whole time wondering if she was doing the right thing. (IT)
The family and the social environment are also influential in the decision-making process. Women are influenced by family members and require a level of determination to achieve a VBAC. Hence, clinicians in Germany reported that it is important to know that the woman herself is motivated to achieve a VBAC.
Yes, quite clearly also the motivation of the partner, the woman’s attending gynaecologist, the motivation of the midwife who leads the antenatal class, the motivation of female friends who have had a CS, who say that a spontaneous delivery was possible and somehow went well. (G)
Early follow-up and antenatal classes
The topic of the potential for a VBAC in the future should be raised soon after the first CS birth (including information about why the CS was required), to “sow the seeds” and increase a woman’s confidence for giving birth vaginally next time.
Well, actually, you would have to begin in prenatal care because that is when you have the first contact with the woman, perhaps even after the first CS. That you somehow make it clear to her that it does not mean that your second child also needs to come into the world by CS; you can also give birth naturally. (G)
Clinicians in Ireland and Italy also commented that focused antenatal education classes, targeted at encouraging VBAC as an option, would offer the opportunity to provide women with consistent evidence-based information. It was suggested that these classes might include the participation of women who have already experienced a VBAC, either face to face or through sharing a recorded interview, in order to inspire the other women and reawaken a confidence in their potential to give birth vaginally.
Organisational support and resources for women undergoing a VBAC
A successful VBAC requires clinical expertise and resources during labour.
VBAC requires clinical expertise
The staff must also have the requisite clinical experience in caring for women labouring after a previous caesarean section. Clinicians in Italy raised concerns that changes to obstetric training in the past decade have led to more clinicians choosing to sub-specialise in areas other than labour ward management, such as fertility and endoscopic surgery. Maintaining an appropriate level of competence in managing VBAC in a culture that favours sub-specialisation may be problematic in the future.
Nobody can tell what will happen during a trial of labour (TOL), so we should say that a TOL is possible, but only if we have staff who are not overworked and exhausted. (IT)
Obstetricians in Italy reported that in the past few decades, many have left the field of obstetrics in favour of other specialities with fewer unsocial working hours and higher remuneration packages. They indicated that lack of training due to the very low VBAC rates has an impact on clinical competence and consequently on the potential to increase VBAC rates.
Nowadays we can see how the culture has affected the training of residents [junior obstetricians]. For residents, a previous CS means another CS. They have to be told that a woman can have a VBAC. (IT)
However, clinicians in Italy emphasised that it is critical that VBACs are undertaken in a unit with expertise to support these women in labour. If that proficiency or experience is not available, then it is safer to repeat the CS.
The patient shouldn’t get to a hospital where she’ll find a negative attitude to VBAC. (IT)
VBAC requires resources during labour
Clinicians’ attitudes to and confidence in caring for women having a VBAC do vary, but appropriate staffing of birthing suites by those with relevant expertise was considered essential by the Irish and German clinicians.
If you come on duty and you know you have someone who is having a trial of labour and there is another midwife who is very confident at that too, that is reassuring for you too. … And it goes back to staffing levels and to managers on the labour ward. (IR)
In Ireland, it was suggested that specific expertise in managing VBAC is required. This could be achieved through the provision and staffing of a dedicated area to monitor these women in labour. In addition, such an area must have speedy access to an operating theatre in case a repeat CS is required.
We need a place for the group of VBAC women, something between the labour ward and the antenatal ward. (IR)
Fear as a key inhibitor of successful VBAC
Understanding women’s fear of labour and vaginal birth is a key component in successful VBAC. Fear in clinicians may also be transferred to the women and may influence the outcome.
Understanding women’s fear of childbirth
Clinicians reported that fear of childbirth after a previously traumatic birth experience is a key component, and it is important to understand the basis of that fear when discussing VBAC with women.
You have to think about what the fear is really about. Is the fear about pain or is the fear about having a labour, getting to 8 cm, getting stuck and then having an emergency section? (IR)
A previous negative or traumatic birth experience is highly influential, and following up after the first birth is therefore critical. A previous negative childbirth experience with a long labour that ended up in an emergency CS was considered to be a barrier by clinicians in Italy. The clinicians in Germany stated that if women have a negative or traumatic first birth experience (for example, emergency CS or a baby born in poor condition), in an effort to avoid a repeat of this experience some women ask for an elective CS with the next pregnancy.
I find the idea to reflect on the first birth quite good. …. If I know that the woman had a traumatic birth experience, I would tell her: “Listen, go home. I would like to see you in 6 weeks and again in 3 months.” Time enough to process the first birth. And when she is pregnant again, the issue must be revisited, simply to process it. (G)
However, as a woman approaches term, clinicians indicated that, in their experience, the woman’s resolve may weaken as she acquiesces to outside influences such as family and information sources on the Internet.
Sometimes it is not even us; it is not the mother. Sometimes it is the mother’s mother and her sister and all that out there [general agreement], and they come in with all the baggage into the clinic. They are all set up for a VBAC and they come into the clinic at 37 weeks freaking out, even though they are all set up for a VBAC and you are really in trouble then. It is very, very difficult to handle that “I am afraid, I am reading this”. And it is the Internet, it’s Dr. Google. (IR)
Understanding clinicians’ fear of VBAC
The reassurance that VBAC is possible requires that the treating clinician also believes that this is the case and adopts an evidence-based approach to care planning and delivery. Despite a personal belief in the value of increasing VBAC rates, clinicians in Ireland and Italy also feared the consequences (personally) of a poor neonatal outcome.
The medico-legal issues in Ireland are probably adverse compared with Sweden, where there is absolutely no chance of you being sued over a VBAC. … A high VBAC rate with a poor neonatal outcome is not acceptable. We live in a small community. … Your reputation is important. If you have a serious event, everyone knows and keeps talking about it for about 6 months … no one will give you a gold medal for a VBAC rate of 95 % if you make one mistake. It’s a cultural issue; the culture in Ireland is they [women in the community] keep talking and keep talking, and if the mother requests a planned CS, it’s very hard to refuse. (IR)
Therefore, shared decision making between the clinician and the woman is a critical factor in achieving a VBAC, and having a fearful mother and a reluctant clinician will not bode well for success. If women are informed of the evidence indicating that VBAC is a safe option and are included in the decision, then it is harder for them to think of suing the obstetrician following an adverse outcome.
Fear is very negative during labour. The obstetrician’s anxiety is transferred to the woman in labour, who hasn’t got the will she had before labour … after being in labour for a long time, the woman goes in the operating theatre and she hasn’t achieved her goal. (IT)
Clinicians’ fear can be transferred to women
Clinicians in Germany indicated that their personal attitude to and motivation for VBAC are important, in both public and private practice settings. The clinicians in Germany were of the opinion that clinicians’ self-confidence is important because if the clinicians are confident, they will transfer this feeling to the women. Furthermore, if obstetricians are not authentic in their support for VBAC, the clinicians also believed that women sense that too.
Whereas I do believe that they are sensitive to our personal attitudes. They are very sensitive and know: “She is quite confident” and “That is okay”, or if they themselves think: “Oh, they are all standing there”. That creates, I think, uncertainty. … And I think that it transfers quite quickly, before you know it yourself. Maybe a wrinkled nose; they already get the impression … before we are actually aware of it. So I think that our personal attitude is not to be underestimated as we approach the women. I believe that being genuine is still very important. (G)
Clinicians in Ireland expressed concern as to who was fearful of VBAC – the woman or the clinician. Clinicians in Italy mentioned that clinicians should aim to control their anxiety. If not, midwives, for instance, may be called on to manage “triple anxiety”: their own, the obstetrician’s and the woman’s.
A midwife is the link between the woman and the doctor, and if [the midwife] often normally is a little bit anxious, you can imagine if the woman has had a previous CS. The anxiety of the midwife is double; the obstetrician will enter the room and ask: “Is there progress? Only 1 cm?” It is a kind of anxiety that is difficult to manage: it is difficult to work impartially while dealing with the woman’s anxiety, the obstetrician’s anxiety and your own anxiety! (IT)
Shared decision making between women and clinicians – rapport, knowledge and confidence
Shared decision making requires consistent, realistic and unbiased information, and trust within the clinician–woman relationship.
Providing consistent, realistic and unbiased information
For women to make an informed choice, the information they receive must be factually correct and readily accessible. While all the clinicians agreed that women should be made aware that VBAC is an option, it is also important to address the risks and to highlight that a repeat CS is also a potential outcome.
These women must be informed about everything – what being in labour involves after a CS, what is involved in a repeat CS – because it wouldn’t be fair if we only talked about the risks [of VBAC] and not about what will happen with a repeat CS. (IT)
However, clinicians in Ireland thought that having faith in her obstetrician was highly influential in the woman’s decision-making process.
The presence of her own personal obstetrician [is important]. I think it is an issue certainly with the small number of patients who are private … they want to know that you are going to be there. I think if you are transferring a patient to your colleague and they have only met you during the visits: “Oh look, just do a CS on the Thursday before you go on holidays”. … I think the barrier is the uncertainty about who is going to be looking after them. (IR)
Trust within the clinician–woman relationship
Clinicians in Ireland and Germany suggested that giving information early in the pregnancy helps to build a woman’s confidence that she can achieve a VBAC. It can also help her to view VBAC as the “norm”, which is vital.
Not many of them will make a decision at the first point of contact. They will want to go home and have a think about it. If we don’t start the discussion at the booking. … The idea is to have the decision taken before 36 weeks. (IR)
Consequently, a relationship between the woman and the clinician that is based on trust is important to success, and a high level of continuity of carer is essential if this relationship is to be maintained. In the Italian context, a woman who would like a VBAC should be looked after by either her obstetrician or a pro-VBAC obstetrician when she is in labour. If the obstetrician in charge on the day is not pro-VBAC, the likelihood of success is diminished.
Continuity of care is of fundamental importance. If a colleague and I believe in VBAC, when a woman wants to have a VBAC, we have to be on duty when that woman is in labour; otherwise, it will be a total failure. (IT)
Therefore, when continuity of carer is not feasible, the clinicians suggested that a plan for the birth needs to be clearly documented in the woman’s case notes.
It is very important that the plan that is made between woman and clinician is documented because of different people [on duty], different consultants, different registrars … as we do not cover the labour ward over 24 hours with the same person/consultant. (IR)
There was much debate within the focus groups as to whether the woman should ultimately have the choice to request a VBAC or indeed a repeat CS given the risks associated with both options. Ultimately there was agreement that a shared decision was in the best interest of all concerned. It was also suggested that midwives and partners should be part of the process, to maximise support for the woman in labour.