Was your first birth by caesarean? Were you happy about that? Many women spend months writing their birth plans. They decide how they want it to be and what they want it to look like. As part of the process, we are typically informed that birth is nothing like what you see on TV and you may have even watched a video of the “real thing” to help you have a better understanding.
I know for me, my first birth plan was the following: I didn’t want an epidural, I didn’t want to spend hours at the hospital labouring – I wanted to do most of it at home, and I didn’t want a caesarean! I only got one of the things on my list – I didn’t have a caesarean, but there was definitely a lot of intervention involved in the birth of my son – he was posterior aka “sunny side up” so the birth plan went out the window. For many women, the birth plan is definitely just a guideline and something that changes throughout the labour.
What if you are experiencing your second pregnancy and the first did end in a caesarean? B.C. has the highest C-section rates in Canada at almost 37 percent, compared to the national average of 28 percent. In some areas like the Fraser Health Authority, nearly 42 percent of babies are delivered via C-section. Many families in B.C. are unaware that vaginal birth after caesarean aka VBAC is considered safer for both mom and baby in low-risk pregnancies.
To help families and care providers decide whether a repeat Caesarian (C-section) is the right choice a new interactive tool was needed. The My Next Birth program was created by Dr. Sarah Munro, a qualitative health services researcher who was inspired by her friend Alice* that became pregnant with her second child.
“Alice had had a difficult, unplanned caesarean for her first birth and had contemplated not having any more children. Early in the pregnancy we chatted on the phone weekly. Alice needed someone to bounce questions and concerns of off. We talked a lot about Alice’s memories of her first birth – why did it ‘go off the rails’ and turn into a c-section? Alice was especially worried that the rotating group of maternity care providers she saw each visit didn’t know her well enough to answer her questions. She read dozens of websites, including the BC Women’s Hospital “Power to Push” resources, but felt that something was missing. All of the information was focused on general risks and benefits. She wanted personalized information related to her own experience. Something that could help her make sense of her own chances for a vaginal birth after caesarean.”Dr. Sarah Munro
While Dr. Munro was completing her doctorate at UBC, working on a quality improvement program for birth after caesarean in partnership with Perinatal Services BC and regional health authorities, the same issues that Alice identified were surfacing in her interviews and surveys with health care providers. They had a strong desire to have conversations with patients early on about the reasons for their first caesarean.
Dr. Munro and her collaborators saw a great opportunity to meet both patient and provider needs through shared decision-making with a ‘patient decision aid’. Patient decision aids are tools that support patients prepare for a clinical decision. They provide information on the options, the pros and cons of those options, and help patients to clarify what attributes of the options matter most to them. My Next Birth is a program that includes a patient decision aid for families considering mode of birth after a caesarean. It also has a suite of tools for care providers to help guide their conversations and provide tailored support. Dr. Munro developed the program in partnership with patients like Liz – mentioned below, as well as a multidisciplinary team including Perinatal Services BC, the Ministry of Health, regional health authorities, and clinical experts from midwifery, obstetrics, family practice, and nursing.
We held design workshops together for two years and over 200 people were involved in building the program. Just like my early conversations with Alice, the development of My Next Birth has always focused on putting patients needs first and supporting them to identify what type of birth matters most to them. This collaborative work also led to four academic studies, on patient needs, providers’ perspectives on birth after caesarean, on the complexity of the decision, and what approaches can support shared decision making for birth after caesarean. The hope is that the My Next Birth decision aid, and the science behind it, can help other regions to make choices for birth after caesarean more patient-centred.Dr. Sarah Munro
A mother’s next birth
The My Next Birth program is now up and running and mothers are starting to use it. One of those mothers, Liz Wilcox, was involved in the development and was able to test My Next Birth when she became pregnant with her second child.
I had had an emergency c-section with my first son – after envisioning a natural birth, free from interventions, I was induced for being well over my due date and the baby went into distress and needed to come out. The c-section experience at BC Women’s was great. Aside for a few minutes while Graham was weighed and checked (during which I got to watch him on a tv), he never left my side. Still, I was interested in the benefits of vaginal birth, both for my baby and myself. I had thought that having one c-section meant that any subsequent births would also be via the belly, but it turned out that wasn’t true for everyone. VBAC was an option for me. The tool helped me think through what was important to me for my next birth. One factor that stood out was ‘Returning to my usual activities.’ I had a high-energy toddler and was worried about what a major operation (plus a new sibling) would mean for taking care of him. After using the tool, I felt more informed and better able to discuss possible options with my partner and care providers. I wanted to try for a vaginal birth.
The day before he was born, my second baby was sideways and, according to the OB, was “trying to find another way out.” Not an ideal position for a VBAC! Although he went back into head-down position, and I did go into spontaneous labour (which was one of my goals), he wouldn’t engage in the birth canal and I opted for a second emergency c-section. With hindsight this turned out to be a good choice – Nathan was nearly 2lbs bigger than Graham at birth! Neither of my births were what I expected. Still, using the tool gave me needed information, helped to clarify my values, and empowered me to participate in decisions about my care. This – plus my beautiful babies – made both births positive experiences for me, no matter what was planned.Liz Wilcox
There is no denying that child-birth can be a tricky time, but being as informed as possible going into it is an advantage. Thank you to Dr. Munro and Liz for helping develop an amazing tool to help both mothers and their health care providers come to a well-informed decision when choosing to pursue a VBAC or not.
- Munro, Sarah, Patricia Janssen, Elizabeth Wilcox, Kitty Corbett, Nick Bansback, and Jude Kornelsen. “Seeking Control in the Midst of Uncertainty: Women’s Experiences of Choosing Mode of Delivery after Caesarean.” Women and Birth 20, no. 2 (2017): 129–36. https://doi.org/doi:10.1016/j.wombi.2016.10.005.
- Munro, Sarah, Jude Kornelsen, Elizabeth Wilcox, Kitty Corbett, Nick Bansback, and Patricia Janssen. “Do Women Have a Choice? Care Providers’ and Decision Makers’ Perspectives on Barriers to Access of Health Services for Birth after a Previous Caesarean.” Birth 44, no. 2 (2017): 153–60. https://doi.org/doi:10.1111/birt.12270.
- Munro, Sarah, Jude Kornelsen, Elizabeth Wilcox, Sarah Kaufman, Nick Bansback, Kitty Corbett, and Patti Janssen. “Implementation of Shared Decision-Making in Healthcare Policy and Practice: A Complex Adaptive Systems Perspective.” Evidence & Policy: A Journal of Research, Debate and Practice Epub ahead of print (2019). https://doi.org/10.1332/174426419X15468571657773.
- Munro, Sarah, Elizabeth S. Wilcox, Leah K. Lambert, Monica Norena, Sarah Kaufman, Jana Encinger, Tamil Kendall, and Rachel Thompson. “A Survey of Health Care Practitioners’ Attitudes toward Shared Decision-Making for Choice of next Birth after Cesarean.” Birth, 2021. https://doi.org/10.1111/birt.12529