Podcast: VBAC with Dr Hazel Keedle

VBAC with Dr Hazel Keedle

Season 3, Episode 4

If you're pregnant after a previous caesarean birth, you might be starting to explore your options for birth this time around.

In this episode I am joined by midwife Dr Hazel Keedle who specialises in supporting birth after caesarean choices.

This episode focuses on vaginal birth after a caesarean, complimented by S2E6- episode on caesarean birth, including planned repeat caesarean birth.

In this episode we look at-

The statistics and research around the safety of vaginal birth after a caesarean

How to make choices and advocate for yourself

Your wider options including birth place, monitoring etc.

How to maximise the chances of a VBAC

The importance of emotional safety and value of experience

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TRANSCRIPT

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Let's go.

Hi everybody.

Welcome back to the birth-ed podcast.

Today, I am delighted to be joined all the way from Australia by Dr.

Hazel Keedle.

Hazel is a midwife specializing in supporting birth after caesarean choices and author of the incredible book, Birth after Caesarean, Your Journey to a Better Birth.

Hazel, thank you so much for joining me all the way from the other side of the world.

Well, thank you for having me on today.

It's great to be here.

So in this episode, we are going to be looking at the choices when planning a birth after a previous caesarean.

And whilst we will be talking through kind of both plans that somebody could make, a vaginal birth after a caesarean that we might refer to as a VBAC throughout this episode, and a planned or an elective caesarean birth, we might end up swinging kind of further towards looking into your options and plans for a vaginal birth after a caesarean, because we do actually have a whole episode on planning caesarean birth with consultant obstetrician Florence Wilcock.

So you can absolutely have a listen to that alongside this.

And then hopefully you'll get a really good picture of what your kind of options are.

So Hazel, to kind of kick us off, whilst most of this episode is going to focus on research and statistics and decision-making and supporting families to kind of weigh up their options, I wondered if you'd be happy to share kind of a little bit about your own experience and what led you to specialise in this area of research and birth support?

Absolutely.

So back in 2007, I was pregnant with my first baby.

I was a new graduate midwife.

I'd been a nurse for many years.

I actually did my nursing in the UK.

I'm from the UK originally, came over to Australia with a backpack and never left.

And so by this time, I've met my husband.

We were having our first baby together and I was planning a home birth, but I didn't have one.

I ended up being in hospital and having an emergency cesarean.

And I didn't do so well after that.

I had been brought up with a granny who was a midwife.

It was all about normal birth and home birth growing up.

And I thought that's what I would have.

And then to have the cesarean was quite a bit of a shock.

I was quite unwell around it and my mental health wasn't great either.

So we thought, you know, there'd be a few years before having the next baby, but no, within four months I was pregnant again.

And then that sent me on a massive spiral because I spent a weekend reading about VBAC and uterine rupture and realizing that there was this short, if you had a short interpregnancy interval, you had this higher uterine rupture rates, which sent me into a bit of a tears.

And I went to my husband who's very much a numbers person and I said to him, look, I can't have a VBAC because of this interpregnancy interval, blah, blah, blah, I've got a 2.7% chance of having a uterine rupture.

And he turned around and said, well, you've got a 97% chance of that not happening.

It's more dangerous to get in the car and drive to the hospital than it is to plan for a VBAC.

And I was like, oh, okay.

So I liked his stats and his way of putting it.

So I did plan for a VBAC, but I had to fight and certainly during my labor, I also had to fight with the clinicians that I was working with, even though they knew me, even though I was a midwife.

And I did push her out of my vagina.

At the time that they said that they were going to take me off to theaters.

And I felt amazing afterwards.

Like I just felt so healed from the first birth.

But I also was left with a couple of questions.

One question was, do other women feel as amazing as I do after my birthing experience or is it just me because I'm a bit of a birth nerd?

And secondly, how on earth does any woman do this?

When I was a midwife and I had to fight so hard, how do they do this in Australia?

So those two questions stayed with me.

I managed to bump into the awesome Professor Hannah Darling at an event, and we got to know each other and I told her what my story was, and she said, you must research this.

So by the time my baby was then about two, I did start my research journey with a Master's of Research, first of all, into why women or women's experiences of having a VBAC at home.

And then straight after that, I went into my PhD, which was on women's experiences of planning a VBAC in Australia.

So it was my personal experience of having a VBAC.

It was my experience of being a midwife, supporting women planning a VBAC, and then I went on the research journey and never looked back.

Amazing.

And I mean, I already have 100 questions and there's so much to kind of unpick and that people are going to want to know.

So if somebody has had a caesarean birth in the past, they, if they're having another baby, they will now be facing a decision.

Sometimes it's really a really obvious decision.

And sometimes you can really feel kind of pulled in two directions about how to plan for the birth of their second or subsequent baby.

Now, the main options, as you've mentioned, are planning for a VBAC or planning for a caesarean birth.

So that's the sort of most obvious decision that you might be kind of considering.

So where on earth does somebody start?

If they don't know for sure which one they want to do, what considerations might they take into account?

What might they want to know about or think about?

There's so much there because everything comes into play at this point.

Because you've got what happened last time, and that is a major influencer on how you're going to feel.

Not only obviously you had a caesarean, but was there birth trauma around that?

Was there a labor?

Did you go into labor naturally?

Were you induced?

Were you part of the cascade of interventions?

There's so much to explore.

But then there's also what you have been absorbing from your family and your friends as well about attitudes around having a VBAC, or having a repeat caesarean.

So it's really quite a complicated decision, I think, and there's so many layers to it.

And then not only when you're thinking about those decisions, you then got the healthcare providers views and attitudes on top of it, which can complicate it.

So, I think very much at its core, when we asked women in my VBAC survey that we did, you know, why did you choose a VBAC?

Why was having a VBAC important to you?

Then one of the key themes that came out of that was that women wanted to experience birth.

It was this kind of innate feeling inside of women to be able to experience birth.

And that being a vaginal birth.

But I think for women who are thinking about this decision and what's really best for them is to sit down and imagine, like, what is your ideal birth scenario?

Like, if you were to dream up the ideal birth, what would that look like?

And then go from there because that will, that could tap in to, I guess, what your real desires are, and what your real thoughts are.

In my book, I actually have a practice that people could do, which is...

I loved it.

I loved this so much.

I was like, this is absolutely brilliant.

I do something similar, but I haven't done it in so much depth.

But yeah, please do explain how it works.

So in the chapter of having control, it's looking at, and this is usually when people have already made a decision, but I think it can be done in that early time as well when you're not sure.

It's actually kind of bypassing your analytical brain and going into your creative brain.

And it's sitting down and drawing three pictures.

And the first one is during your idle birth.

And in loud words and text, you're literally going to draw it.

And people get a bit stressed.

I used to do this one-on-one with couples.

I used to do this in classes, and now I do it in workshops with clinicians and I'm teaching them how to support.

And I make them do it too, because I'm thinking, you know, if you're going to ask people to do it, you need to know what it's like.

And I did this myself when I was pregnant.

So it's drawing this, drawing what does an idle birth look like for you.

And that can be whatever.

And seriously, stick figures are fine.

Mine were all stick figures because I am not an artist.

So you do that.

And that's kind of, you know, when you're really not sure what type of birth you want, it will make you draw it.

And you might start drawing one thing and rip it up and decide to draw something else.

That was really a really amazing time I spent with a woman once.

And we were having pizza around at her house.

We hadn't had pizza yet.

At that point, we were just drawing.

She was just drawing.

I was there with her partner.

I had a continued care relationship with this woman.

And we got to this point, and she drew a type of birth.

And then we thought she was done.

And then she looked at the picture, and she ripped it up, and she said, that's not actually the type of birth I want.

And I said at that point, let's order some pizza.

So then we sat down for the rest of the night, and she actually drew what it was that she wanted.

And it was actually the process of drawing it and then looking at it and going, you know, that's actually not my dream.

So it can actually be quite an inspirational moment.

And then the next picture you draw is your worst case.

And that can be really quite a dark place to go, but I think we have to go there.

I think as women going through this unexpected and challenging time of birth, we know it's not always sunshine and flowers and rainbows.

It's going to be challenging.

And there are sometimes some challenging outcomes.

Now, those outcomes are different.

That worst case can look different for many different people.

I've done this with people who have had loss.

I have done this with people who have had, you know, emergencies as areas under general.

Like, I've done this drawing.

These drawings have been done with all sorts.

And what comes up there is really, what are those fears?

What is that worst case?

And then the healing part of that really is the third journey, which is your worst case made better.

What does that look like?

And yes, you're going to that kind of worst case again, but actually what's most important?

How does that look different?

It's not the ideal, but it looks different.

And what comes out of those drawings are really what the woman is seeing as different.

I will add, I normally do this with the woman or both in person and their partner, but they would draw them separately.

They could not like, you know, it's not like doing an exam and cheating and trying to look at what the other person's doing.

It's not a people-pleasing event.

It's actually going to be done separately because a lot of other traumas can come through in that worst-case one that can actually generate some really interesting discussions between couples as well.

So that, if you've got no idea, if you're really unsure, then actually starting with what does, what does our deal look like for you can actually bring out some things.

Maybe it brings out things that make you go, you know what, I can only achieve that with a vaginal birth, or I can only achieve that with a cesarean birth.

There's no right or wrong.

There's never any right or wrong, because what is important to try and decrease birth trauma, which I've done a lot of work on too, is for the woman to feel that she's got a sense of control over the whole experience.

And those drawings help that.

Because if you are, if you get your idle birth, that's fantastic.

You know what that looked like.

That can turn into a written birth plan if you like.

And that's it, you've got that sense of control because you got that.

But if it isn't going to that plan, then the fact that you've thought about what is important, if things are going into a different direction, what's most important, that worst case made better, then the women find they've still got that sense of control in an environment that sometimes isn't what they initially wanted.

So you can have, that can be either type of birth plans, and you can go anyway with it.

There's something, I think, really almost honest about drawing rather than writing.

Like it can feel less scary, less daunting.

Sometimes it's difficult to articulate in words.

It can feel quite daunting to articulate in words to say, I want this, because then you're like, or if I don't get it, then what?

People are going to roll their eyes at me, or I'm going to think I'm an idiot or whatever.

But drawing it just somehow feels almost like less high stakes and more, yeah, tapping into a different kind of part of yourself, I suppose.

Yeah, it came from a book.

Well, it was inspired by the book Birthing from Within, which is a beautiful art therapy type book, all about pregnancy and labor and birth.

But I read it on a night shift when I was pregnant, and I then did the drawings.

So this is like 16 years ago, but I cannot find it in the book at all.

I have gone through page by page to find it.

So that's why I say inspired, in a kind of night shift pregnant brain type of way.

But it's the one that I went with and I continued using.

So I give credit to being inspired by that book, but I can't find it in the book.

Brilliant.

So you mentioned, as we were talking, that one of the kind of key things that women or people that are planning their birth after cesarean, or actually people that are planning any kind of birth, what they need for that to feel like a positive, safe experience is sort of an element of control over their choices, I suppose.

And in your research, that was kind of one aspect of things that led to a sort of positive experience, positive outcome.

What were the kind of overarching themes that we are kind of reaching for when hoping for a good birth experience?

Absolutely.

When I went into my PhD, I did honestly think it was all about the vagina and thinking it was all about vaginal birth after caesarean.

But as I went through the research process, and I followed women all throughout their pregnancy, labor, birth, and interviewed them afterwards, I had all this data because they were doing recordings after every single appointment.

And truly through the research process of narrative analysis, looking at all their stories, comparing and contrasting, what I saw were these four factors that came out.

And these four factors, if the woman had a good experience on those four factors, then she was more likely to feel positive, elated, resolved, you know, those kind of positive feelings.

And if she was lower or had less, a worse experience on those four factors, then she was more likely to feel devastated, traumatized, disappointed.

So they're very theoretical.

It's not a level that you can be on them, but they're factors to then consider.

So I then tested them in an online survey and came out with the same type of findings.

So what those four factors are, one of them obviously is having control that we've mentioned.

And it's important to realize that when you look at birth trauma data, a lot of the qualitative stuff shows that the most common theme is a loss of control.

So the flip side of that is actually having control, being in control of your choices, your wishes and your outcomes.

Then the next one is having confidence.

And so that's confidence in your own ability to have a feedback, but that's not very easy because when you've not done something before, then it's hard to know if you've got that, if you can do that.

So you're always going to have that doubt, or certainly I did and certainly other women that I've seen through my research have as well.

But there was more to that having confidence.

It wasn't just about how confident you were in your own ability, but it was also how confident you felt the healthcare provider was in you.

So did they have their back?

Did they have your back?

Did they believe that you could get the ideal birth that you wanted?

Or were they just trying to move the goalposts all the time and making it, you know, making it difficult for you?

Were they doing the switch and bait, bait and switch, sorry, at the end of pregnancy?

Were they changing what they said at the beginning and changing it to the end to be more negative?

If you went along and you felt that they, at every appointment, they were doubting your ability or doubting the fact that you might have the birth that you like, that you were choosing, then you're not going to feel that they're confident in you.

And you need that confidence.

In my book, I use the analogy of the Olympic coach.

So when you're planning to go to the Olympics, I will admit I am not an Olympian.

It's just, you know, my, that wasn't my options.

But I've met a few.

And it takes, when I was writing the book, it was the Olympics, the last set of Olympics that we had.

And I don't know if you ever remember seeing this amazing, it turned into a meme, but there was one of the swimming competitions and the camera got, realized that there was this person in the sand, like really, really cheering.

And the meme was, I want that coach, because the coach was like, whoa, hey, you can do this.

And there was more attention on the coach who was so excited than the person winning.

And if that was your coach, you felt that you were a winner, regardless of where you came in the race.

So that coach really believed in that Olympian's ability to do that.

And it started making me think, well, what if I was planning to have, to win the Olympics or to run a race, and say I was doing the 100 meters, and I had to choose a new coach.

My coach had retired.

I had to have been chosen for the Australian or for the England team.

And my coach retired, and he needed a new coach.

And you went along to interview two, and one of them turned around to you and said, well, you could do that, but I don't think your feet are the right shape.

I don't think your pelvis is quite right.

I think you're a bit short.

I think you probably could die halfway through.

Why don't you just sit down and watch it?

What's the point?

You're probably never going to get what it is that you want anyway.

You wouldn't feel that they've got a lot of confidence in your ability.

The next person you interview says, I completely believe in you.

You've got this, and I will be there every step of the way.

I will help you train.

I'll refer you to the best nutritionist in town, and you've got the best physio on town.

We're all here to support you.

And regardless of whether you get gold, silver, or bronze, I know that you will get your personal best, and I'm here to facilitate that for you.

Like, who would you kind of go to?

Like, you kind of go to the person that is really rooting for you.

And for women having babies, you know, we do generally only do that a few times in our lives.

And we need to kind of think about our team supporting us to be as supportive as that supportive coach.

So it's in the stands cheering on that person because that's the kind of team I want to cheer me on through my birth.

They've still got the knowledge, they've still got the expert skills, but they firmly believe that I can do that.

So that was the having confidence.

Then there was the actual team.

So having a relationship.

And that obviously crosses over the confidence one, but it's actually choosing the team around you that are going to believe in you, but are also evidence-based to, that are more likely to give you a relationship based on trust and equity.

And when we look at our medical systems being a very patriarchal model, then traditionally we have our doctors, our managers at the top, our medwives coming down, and women right at the bottom of that.

So it's very difficult to have control or have your wishes listened to when you're right down at that bottom.

So which kind of relationships with health care providers can equal that out?

And what does the evidence say about that?

And certainly the evidence to show that continuity of care with a midwife, and I got that from my PhD, meant that there was more equality and trust in that relationship and more time spent to build a relationship.

And then finally, there was active labour.

So if you were planning a VBAC, then how active were you in labour?

The more active you were, the way, if you were able to take everything off that you had done, you'd swung by the chandeliers, you'd done your mobozo, you'd been in the bath, you'd had the shower, you'd been upright the whole time.

And then at the very end, the decision was made by you and your healthcare providers, not only by you, that the caesarean would be best.

And you could look back and go, well, I did absolutely everything I could.

I was active and this little thing just didn't happen at the end.

And so then I had the caesarean, but I felt like I made that decision.

And comparing that to women who were maybe told to be on the bed the whole time, you're not allowed to move, you need to have the medication because you can't get up and use other skills.

And then maybe if they went to the caesarean and they went down that same cascade again, they could look back and go, but what if I had done this?

And what if I had done that?

What if I'd been supported to be more upright and active?

We also know that being upright and active does reduce your labour time and increase your chance of having a vaginal birth.

So it's actually setting you up for success rather than setting you up for not achieving the birth that you want.

I won't use the term failure.

So they're the full factors.

Yeah, amazing.

And it is still, I mean, I know that I hear this all the time, but it's still wild to me how blatantly ignored basic physiology is for so many people.

Like, lie on a bed, strap you to these straps, and don't move, and have the lights on, and all of that.

So that's really, really helpful.

And I was going to kind of ask what women can do in preparation to ensure that they're achieving those things or reaching for those things.

But I think you've sort of answered that kind of as we've gone.

But there is more because, you know, there's often a relearning that you've got to do.

You may have done all the birthing classes first time round.

But sometimes I found women wanted to learn that little bit more.

So they might go to more alternative birth classes next time round.

They may have thought, you know, I didn't learn about the acupressure or the use of the breath or the hypno, whatever.

There's lots of different terms for the trademark for that part.

But, you know, using, you know, using your mind and your body and a massage and you might not have learned all of those things first time round.

So often, you know, one of those important parts for confidence is for women to increase their knowledge because that knowledge is power.

And some of that knowledge is around learning what else can you do in labour and who can be there to support you.

So it might be that time, that next time round you choose a doula to be there to help you for that particular point so that you're learning how to do that.

And it's looking at, you know, what birth education and preparation is out there to support physiology.

And to, with that, I believe there becomes an increased confidence in your body when you learn more about that.

And then there is also realizing that, you know, preparing your body physically for what can be seen as a bit of a marathon.

So how do you prepare for that marathon?

That doesn't mean, you know, heaps and heaps of exercise, but just having your body in the most healthy space that you can for you.

And recognizing that, you know, especially if it's a vaginal birth, then you want to be in peak physical health.

Even if it's a repeat caesarean, you know, you want to be in good health so that you have good healing after that caesarean.

Yeah, absolutely.

And when we talk in the caesarean episode that we've got, we talk about, you know, the hormones that are involved in a physiological birth, like oxytocin, they don't go out of the window if you're having a planned caesarean, like actually having a feeling of harm, a feeling of safety, a feeling of being relaxed is important for things beyond just having contractions and a vaginal birth, you know, bonding and feeding and everything.

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So I'm going to kind of come down to like the nitty-gritty.

This is the first question on everybody's lips.

And I think actually the conversation we've had so far is to me the more important one is the emotional safety.

Like what does it feel like you want to do and how can you most create that feeling?

But the question that will often come up, the question that the information is often thrown at women as like this is what you base your decision on is around the clinical or physical safety of their options.

So let's break it down.

How safe are both of your options?

So how safe, what are the risks?

How safe is a vaginal birth after a caesarean?

How safe, what are the risks of a repeat caesarean birth?

Kind of short term, long term.

What are we actually looking at in terms of statistics?

Absolutely.

And I mean, the book almost starts with that chapter, not quite, but it almost starts with that chapter about let's talk about the risks.

Because it is important and we need to be aware to be able to make an informed decision to be able to understand what the risks and the benefits are of each type.

A lot of it does depend on what studies that you look at and also how they reported that information.

So when we're looking at studies that group, those that are planning a vaginal birth after a caesarean and those that are planning an elective caesarean, you've got to realise even though there's two options going in, there's three types that will come out.

Because the elective caesarean, they generally have an elective caesarean.

Very few might go into labour early and they might pop a baby out while they're waiting, but not very many.

But in the planning of a vaginal birth after a caesarean, the planning VBAC group, there's going to be some that have a VBAC and there's some that have a repeat emergency caesarean.

Now, I won't use the terms, there's certain terms I won't use.

And so I'd like to mention those in this podcast because people will tend to use them.

And I want to tell you why not to use them.

There's no such thing as a successful VBAC because if there is a successful one, then that means other women have failed.

And I'm sick of the failure language.

If you had a VBAC, you may well feel that you succeeded that.

I did.

Oh, my goodness.

I had a fight on my hands and I got that.

But if we use the language success, that means we also use the language failed.

And it's just too much failure.

As women, we are doomed to fail from the minute that we're born in our body.

You know, from a very, but we are from the very beginning.

Like we are told that we are too short or we're too tall, that we're too skinny or we're too fat.

As we develop, our boobs are not big enough or they're too big.

Our bums are not round enough or perky enough or they're too perky.

Like you cannot get it right.

We're told to be an ideal woman, even though that doesn't exist.

So we are very good at taking on negative thoughts about our body.

And so when you then go through your birthing experience and say for your first, you got told that, say you joined that cascade of intervention, as in you're being induced.

And in Australia and I'm sure in the UK, our induction rates are going sky high at the moment.

So you go and get induced.

And then the induction, because it's a fake labor, it doesn't, your body doesn't kind of pick it up, your baby doesn't come down, and you get told that you've had a failed induction or your body failed to dilate, or your pelvis wasn't big enough for the baby to go down.

We don't even question it.

We're like, oh yeah, yeah, my body failed.

What a surprise.

My body wasn't made for birthing.

My body wasn't made for birthing.

How do you think you exist on this planet?

It's crazy, but we are so good at taking on the failure language that we don't even think about it.

So the next time around, you're going, that's it.

I'm going to plan for a VBAC.

This is what I want.

And then maybe you're part of that cascade of intervention again, and you then get told, no, you failed at VBAC.

So yet again, we're taking on that failure language.

I want to throw that out the window.

There's no failure in your birthing options because generally it's generally not your body that's at fault.

It's usually the system that hasn't given your body enough time or enough support to be able to birth in the way that your body is made to do it.

It's not a failure.

And even if something does go wrong in your body, you can't blame yourself for it.

These are just physical things.

So the other term I want to use is trial of labour or trial of scar.

Because for goodness sake, when I was having my baby, I can tell you what, I was not a criminal.

I was not on trial.

I didn't need to be seen as a criminal.

I think I was sometimes treated like that.

But when we think of trial or something, we think of a criminal court.

There's the judge, there's the jury.

And then the minute that you're beyond some parameters, the gavel goes down, that's it.

You're guilty, off to Caesarean you go.

Caesarean gets seen as a punishment.

And again, you have been found and you're a criminal off to jail.

We don't need that language.

It's not worthy.

Women are planning a VBAC.

They either have a VBAC or they have a repeat emergency Caesarean, or they're planning a Caesarean, they have their Caesarean.

It's simple as that.

Going back to the research, you will have these two groups, planning a VBAC, planning a repeat Caesarean, and then there's the three outcomes.

When we look at some data, they will report the outcomes still in two.

They'll say, well, the planned elected Caesarean group had a better mobility and mortality, blah, blah, blah, compared to the planned VBAC group.

But they don't bother, or maybe they'll choose not to, to separate out the VBAC group into the emergency Caesarean and the VBAC group.

When you do that, and more recent studies have done that, where we look at, yes, there were two options going in, but three types of birth coming out.

We could throw a fourth one in there too, you know, instrumental birth.

When we look at that and compare morbidity and mortality, so, you know, death rates of mothers and babies and health outcomes, then the VBAC group does best.

And then it's the elected Caesarean group and then it's the emergency Caesarean group.

But overall, in our high resource countries, those risks are still very, very low.

But the one thing that VBAC has that other type choices of birth don't have is for women who've had a repeat Caesarean, women who've had a Caesarean, they've got a previous Caesarean scar.

And the problem with that is that it can increase the rates of uterine rupture.

But women can have uterine rupture without having a previous scar as well.

There can be other causes of uterine rupture.

Having a car accident and having a direct impact on the uterus can cause uterine rupture.

Having lots and lots of babies can cause uterine rupture.

Lots of different things can cause it, but it's just less likely to cause it.

So then people get told, well, uterine rupture means if you have one, you're at higher risk of having one if you plan a vaginal birth, and then when it happens, everything will explode.

You will die, your baby will die, and you don't want that to happen to you.

And people kind of get scared into it.

But if we actually break down what does happen, what are the rates and what does happen in high-resource countries, we're looking at a less than 1% chance of uterine rupture happening.

This really good study that came out in 2019 that looked at a lot of births across Europe had a VBAC rupture rate of 0.22%.

So it's very small.

Even from that 0.22%, 90% of babies survived, and only two women died out of 800.

So you can't even say if a uterine rupture happens, then this will result in death, a very small proportion of that will.

So generally, I tend to say that both options are safe in our high-resource countries because we've got great care.

And the genre birth-artistic area is safe for the majority of women.

That's a very confident answer, I'm afraid.

And within what you've talked about there, is there data to break down that group that planned a vaginal birth after caesarean?

How many have a vaginal birth or a vaginal birth including instrumental birth?

And how many have a repeat emergency caesarean birth?

Yeah, we do have that data, but interestingly, it is impacted by model of care.

So in a hospital, we might look at a fragmented model, so you're seeing someone different all the time.

Potentially, you've got a VBAC rate of maybe about 60%.

So there'll be about 60% of women that will have a vaginal birth after caesarean, and maybe about 40% that have a repeat caesarean.

But it does change by model of care.

So we've got some studies that show out of hospital.

Now, I'm not saying go and have a home birth, but it is a place of birth.

And there were higher VBAC rates there, but also within who you see.

So there are some smaller studies that have been looking at if you have continuity of care with a midwife, does that change VBAC rates?

And there's some promising results with that, but we don't have large enough studies to really prove that at this point.

So potentially as well, if you've got someone who, if you've got continuity of care with someone who believes in and has the ability to support you to focus on vaginal birth, then that can have higher VBAC rates as well.

So it does to me, it shows that that's not so much about the woman and her body, even though that's where we got a lot of blame, it's actually more to do with the system, how you're being cared for, how you're being supported, and what the team is, and what their beliefs are around you has more of an impact on VBAC rates.

And so when, I think this is all really, really useful for when you are otherwise having an uncomplicated pregnancy, right?

You're low risk in inverted commas other than the fact that you have got a caesarean scar.

Now, I think the time when it becomes particularly tricky for people is when care providers or reality or whatever it is starts to layer like what we would call risk factors, just basically complexities of pregnancy upon you.

And it always feels like, yes, certainly locally to hear VBAC is supported if otherwise everything is fine.

As soon as you have a slightly higher BMI or you have had more than one caesarean, or you might be thinking about having an induction of labour, or add a hundred other million potential things that you could add on top of it, then suddenly it feels like, oh no, absolutely no way.

Having a vaginal birth would be the most dangerous thing in the entire world.

So how do we kind of navigate this?

Does research exist on these things?

If it doesn't, where are these assumptions and things coming from?

Yeah, so I would get on my social medias, I would get questions all the time like that.

And they'll say, I've got this and I'm planning a VBAC, can I do this?

So I wrote a whole chapter called, can I have a VBAC if?

And then I looked at a lot of that information and I wrote, sometimes there was more information than others.

And then I also had stories of women.

When I wrote the book, I actually reached out and asked for women around the world.

If you had had a VBAC with some extra complexities, could you share your story?

So in the back of the book, there's 15 stories from women around the world, different backgrounds, and they all had a VBAC with something, with another layer, as you're mentioning, on top of it.

So that means you can kind of read them and go, oh, okay, that's interesting.

That's what their experience was.

But certainly it's more of our issue with managing risk than it is on the impact on uterine rupture.

And where does the uterine rupture rate increase?

And so then what level are you comfortable with that?

So if we're looking at the highest VBAC, the highest uterine rupture risk that we've got the data on at the moment for a lower segment scar would be a short interpregnancy interval of less than six months from the caesarean to conception.

Now, if you remember to my story, I conceived at four months.

Not that I knew I was conceived at four months, but I found out a few months later.

But that's what I conceived, and that certainly was not a plan.

So I had that 2.7% risk.

And if I've gone through, like I did learn how to navigate the system because I was a midwife, so I tried to avoid appointments as much as I could.

If I had gone to them and when doctors did pull me aside at work, there was a lot of language about how riskiness was going to be, and blah, blah, blah.

But I had flipped it, remember.

I've looked at, but am I comfortable with that level of risk?

And I was.

And I did not have a uterine rupture.

So even when these risk factors on top of risk factors might increase your uterine rupture rate, it's not a causality.

It doesn't mean that you're going to then have a uterine rupture.

It just slightly increases it.

Still, we're talking very small numbers, and we very rarely get above 3% being it.

And that's the same with induction as well.

Again, we'd be looking at 1% to 2% compared to less than 1%.

Those numbers seem huge, but when we look at it in the bigger scheme of things, not so much.

And it's got to be what you feel comfortable with.

It should never be that you can't do it because that choice has got to come down to the woman.

And I think when you're being told that you can't, you can't do it because of this, you need to turn around and say, well, why not?

What does that increase?

What does that increase?

Why are you trying to up your rate to?

Because I would even want to know that so that I can think about it.

There's a group of women who, and I had a group in my PhD as well, who don't have a lower cesarean segment scar that most women have.

And they might have an alternative, so it might have a little dip at the end, it might look like an inverted T scar, it might be an up and down scar as well, like a vertical scar.

And we don't see those very often, but sometimes we see those in very early premature births because the uterus hasn't come up enough to be able to do a lower segment incision.

So we do still see some women who've got that, and then they're like, well, what do I do?

And the policies here in Australia say that you must have a repeat cesarean at 37 weeks before you could even start contracting.

But in my survey, no, women wanted that.

There were actually a group of women that wanted to have a VBAC, and they fought for it, and they had it.

And yet that layer on top would be like, oh my gosh, that's really high.

We don't actually have the data because when we look at our VBAC studies, they exclude anything that has any extra complexity on it.

So we don't always know.

It may well increase it.

You need to ask, what is the risk?

Is it because it will increase major and larger risk?

What does it increase that to?

Where are the studies that you've got that from?

And I then want to still make a decision on whether or not I'm comfortable with that level or not.

That's the woman's comfort level, not the provider's comfort level, because that's your body.

They're not going home with your baby, caring for it.

You are.

So it's got to be what you're comfortable with.

Yeah, I think it's helpful to know, for people to know that sometimes research doesn't exist.

Sometimes they just haven't researched it.

So for somebody to say kind of definitively that it's going to increase the risk of this, that, or the other, unless they can actually show you where that information is coming from, it is potentially just theoretical at that point.

And the other part of the conversation that is often missed there is that some things that might make VBAC more complex may also make a Caesarean birth or recovery from a Caesarean birth more complex.

And if we're only attaching that added risk factor to one of your options, then we're not getting like a fully balanced picture of like, OK, but how is that going to impact a Caesarean birth?

You know, if, I don't know, Bailey's being born a few weeks earlier than they might come spontaneously.

Like, there's so much to weigh up.

And I think sometimes Caesarean is often presented as a way of knowing exactly what is going to happen and a way of having full control over it.

And you don't have full control over a Caesarean birth.

Caesarean birth also carries risks associated with it.

And it's, yeah, weighing up, which of those potential complexities do you feel most comfortable with?

But with a focus on the vast majority of both options, as you mentioned, are very safe.

Yeah, absolutely.

We know that there are those complexes with multiple Caesareans.

So the more Caesareans you have, the more likely you're going to have complications next time.

You've got scar tissue to deal with.

You've got pelvic pain that can be happening because of that scar tissue that builds up.

You've got the increased risk of infections, both in the uterus and on the wound.

And it's major surgery.

And then also more complicated placental location issues and adhesion issues with further pregnancies because of the scar being there, and it can embed into the scar.

So there can be ongoing complications from having Caesareans, which there isn't actually with once you've got that first VBAC in.

Once you've had that first VBAC, then if you continue to have vaginal births, there's no further risks with that that has been looked at in research.

So again, if you're looking at family size or looking at that as part of your options, you've got to think about that as well.

What are going to be the ongoing options of having ongoing caesareans compared to vaginal births?

They're complicated decisions to make, but often women are told a lot about VBAC risks of uterine rupture and not given the same amount of information about caesarean risks.

And that's not fair.

That's not informed decision making.

If you don't know the benefits and the risks for both, then you can't make an informed decision.

Exactly.

And something that I often support people to make a similar decision in my work and something that it often feels like at the beginning is having this appointment at 32 weeks of pregnancy, you've got to turn up and you've got to tell them, are you planning a caesarean or are you having a vaginal birth?

And it's like that when it is so black and white can feel really daunting.

And I think it's often helpful for people to realize that actually even there, there is still like a breadth of decision-making.

So I don't know, I often meet people that had an unplanned caesarean birth as a result of an induction of labour that was quite traumatic.

And they go, well, the bit that I don't want is the induction.

So then you can go, okay, well, when at what point do you feel like you would accept an induction?

And if you don't want the induction, then have a plan for a caesarean at that date.

It is not necessarily 39 weeks have a caesarean or that's it, you're planning a vaginal birth and that's your plan.

There's actually so much nuance in those decisions.

It's like, actually, do I consent to continuous monitoring in labour?

Do I consent to an induction of labour?

Do I consent to having stretch and sweeps?

Do I want the planned caesarean on this date or do I want to plan caesarean at a later date?

Do I consent to this amount of labour or induction?

And if that's not working the way I want, do I want to change my plan earlier to move to a caesarean?

And so it is not, as it is often presented, a kind of like, yes, no decision that you have to make.

Absolutely, because we know that those decisions for emergencies are going to happen at any point and can happen when the woman is fully dilated and seems to be just about to have a baby.

It can be the decision to go for a caesarean.

So it's about women knowing what goes back to those pictures.

What is the worst case?

What can you do to prevent that bit happening?

What is the most important at that point?

I've worked with and supported women that have made that decision in labour because they wanted the opportunity to go into labour.

They wanted the baby to be able to have the opportunity to have the hormonal impact of going into labour.

And then because you never know what's going to happen, to an extent in labour, wanted to have the opportunity of having contractions and to see if things were going to develop in the same way or to get to a point where they're no longer comfortable to continue being in labour.

And they would then prefer to make a different decision.

And that should be respected.

Interestingly, we do see some, we see when we look at, when we ask women about their decisions for different types of births, we see similar women saying, you know, I want to have an electric cesarean because of fear of what happened last time.

But we also see some women using that for having a VBAC too.

So I think we're actually not very good at supporting women in their decisions because what we should be doing instead, I think, is actually not burying the fear, not saying the fear doesn't exist or just trusting your body, we can do some little sage sticks and you'll be fine.

We actually need to dig a bit deeper with women and go, what is it that you're really fearful of?

Identifying that, like you're saying, was it this or was it that?

And how did that impact you?

And if that means getting psychological support to go through that, then do it.

You know, we use it for lots of other fears.

You might have a fear of spiders and go and get yourself, go and get therapy so you can come and visit us here in Australia.

That's why I keep saying to my cousins, we're not coming with spiders.

It's fine.

There's none in my room that I can see right now.

So, you know, we will go and get that support for things that are maybe not quite so threatening.

But we're not always very good at supporting women who maybe have a, have had a traumatic experience through labor and birth.

And then it's impacting how they feel for their next birth.

And that's certainly an area that we need to do a lot more work in.

Yeah, and it's, I mean, in terms of accessing that, those resources, like they just don't, unfortunately, just don't seem to exist in the way that they should do.

But actually, what can be really helpful, there's, I don't know if you're familiar with her, there's an amazing doulet here in the UK called Natalie Meddings, and she runs a service called Tell Me a Positive Birth Story.

And it's like almost like a peer support matchmaking service where they will match you with somebody that has basically gone and done whatever it is that you are hoping to do.

And it's basically like mum to mum tips of like, this is what helped, this is what I was scared of, this is what helped at this moment.

And so if you can't access, I mean, ideally, it would be accessing like professional mental health support alongside everything else.

But in your book, there are so many birth stories at the end.

And sometimes the sort of like, almost like retraining that subconscious part of our mind is we just need like proof.

We need proof that somebody has done it.

We need proof to say that it is actually possible that people have felt how we are feeling and then they got what you wanted, the feelings that you wanted to have.

And so it might be as a kind of initial point, I suppose, reading all of those stories that are, they're details, aren't they, those stories in the book?

Yeah, some of them are, yeah.

So that can be really, really helpful.

Or finding somebody that has been and done it and made choices and quizzing them and asking them what they did.

Absolutely.

In the chapter on confidence, in that factor, I look at that peer support is vital.

It's absolutely vital because we are by nature storytellers.

This is how we get our oral histories by people telling us stories.

We might have our grandparents or our elders, if you call them, telling you the stories of your own family, of your own background.

Even looking at the different religions out there, they are through stories or through parables or whatever language that is used.

We identify with stories because stories tap in to our emotional connection.

The statistics can help with some point, but to be honest, can you really visualize one in 100,000?

Does that make any sense to you at all?

No.

So looking at stories do make sense, which is why my whole PhD, even my master's, all my research has been about women's experiences of maternity care.

And women have given me their stories, and then I've used that to create research.

So I know how important stories are, and I also know how awesome women are at telling stories if they're given the right opportunity.

So I actually, you know, I really advocate for listening and reading to stories.

In Australia, we're a little bit spoiled.

We've got some podcasts specifically on VBAC stories.

And so, you know, certainly you can listen to them from overseas as well.

And that's why I put the stories in the book, because even though my research was based on stories, I wanted more contemporary stories that had happened.

And we've also, you know, go online, find your peer group online.

I would, you know, make sure that you look at a few posts first and see what kind of their ethos is, because some can be quite, I don't know, dichotomous in what they believe in.

But we've got a beautiful one in Australia, which is, I think it's VBAC Australia support page.

It started with just a few people.

It's now got thousands of people in there.

And they share stories, and they share, you know, their VBAC stories.

There were pieces, Aryan stories.

But you know that if you have a fear in the middle of the night and you put something on there, there's someone breastfeeding a baby who's going to be able to answer you in support.

So that peer support is so, so important.

And we can't, as clinicians, we can't try and minimize that either.

We actually need to encourage it.

And when I'm teaching clinicians about the confidence factor, I say to them, you need to get confident.

And the way that you can get confident is to figure out the why.

And that's important when you're listening to stories.

And as a clinician, sometimes when we read something, we kind of want to nitpick it and go, oh, but oh, but oh, but oh, but oh, but oh, that's not quite right.

And that's just rubbish.

It's not about that.

I get clinicians to listen and read stories and actually just pinpoint why.

Why was planning a VBAC important for that woman?

Because it would generally come out in that story.

So absolutely.

But there's a plethora of ways of doing that.

That can be listening to podcasts, reading the stories in the book.

I love that peer support one on one, you know, matching you with the story and online.

It's so important.

Amazing.

Thank you so much.

I mean, I probably keep asking you questions all day, but I think I'm going to direct people to your app.

It is a really brilliant book.

It is written in a way that if you're reading it as somebody who is about to have a baby, it is really, really easy.

You know, sometimes you get books that are written by people with PhDs and you're like, I don't really understand a word that they're talking about.

This is really, really easy to understand.

It is all broken down.

So if you are considering and you're having a baby and you're thinking, do I want a VBAC?

Do I want a planned cesarean?

There is a whole section in there on planned cesarean as well.

Like, what do I want to do?

I don't know.

I need to explore both holistically the kind of emotional side of things.

And I want like, I need the stats.

I need to know what that is.

It is all in there.

It's called Birth After Cesarean, Your Journey to a Better Birth.

And I will post a link to it in the show notes of this.

Hazel, I always ask everybody a question at the end of the podcast, which is, if you could gift a pregnant woman one thing, this can be real or hypothetical, what would it be alongside your book, obviously?

Oh, you know, if I could wave a magic wand, then every woman would have access to continuity of care with a midwife.

I have worked in that model myself.

I've been a continuity of care midwife.

I know the research.

We've got so much positive research out there.

And midwives rock.

And when you have continuity of care with one who really believes in you and develops that relationship, there's nothing better.

So I would gift continuity of care with a midwife.

Yeah, absolutely.

I've had that and not had that.

And from my personal experience, yeah, it really does make the world of difference.

So if people would like to find you or follow your work, where are they best directed?

I'm most active on Instagram, so at Hazel Keedle on Instagram, and I put videos up there.

And I'm a researcher, so I have a lot of...

We've had two papers come out in the last couple of weeks, so I always put little videos up there about the papers.

So we've got lots of current research coming out too.

Thank you so much.

Thank you for having me.

Thank you so much for listening to The birth-ed podcast.

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