Background
Methods
Settings
Data collection and participants
Ireland | FGI 1 (rural) | 11 (4 midwives, 4 consultant obstetricians, 1 neonatologist, 2 non-consultant hospital doctors) |
FGI 2 (urban) | 8 (4 midwives, 2 consultant obstetricians, 2 non-consultant hospital doctors) | |
FGI 3 (rural) | 12 (7 midwives, 3 consultant obstetricians, 2 non-consultant hospital doctors) | |
Italy | FG 1 (urban) | 9 (4 midwives, 5 obstetricians) |
FG 2 (urban) | 7 (5 midwives, 2 obstetricians) | |
FG 3 (urban) | 7 (3 midwives, 4 obstetricians) | |
Germany | FGI 1 (urban) | 6 (2 midwives, 4 obstetricians) |
FGI 2 (urban) | 3 (1 midwife, 2 obstetricians) | |
FGI 3 (urban) | 8 (5 midwives, 3 obstetricians) |
Data analysis
Results
Parameters for VBAC
The importance of the obstetric history
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)
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
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)
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
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)
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)
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)
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
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)
Organisational support and resources for women undergoing a VBAC
VBAC requires clinical expertise
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)
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)
The patient shouldn’t get to a hospital where she’ll find a negative attitude to VBAC. (IT)
VBAC requires resources during labour
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)
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 childbirth
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)
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)
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 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)
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
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)
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
Providing consistent, realistic and unbiased information
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)
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
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)
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)
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)