VBAC: is it safe for my baby and me?

Did you know that if you had a previous C-section you are still able to have a safe vaginal delivery?

Yes, it is totally possible and the odds are in favour of a successful and safe vaginal birth.

According to the Society of Obstetricians and Gynaecologists of Canada (SOGC) practice guidelines, the success rate of Vaginal Birth After Cesarean (VBAC) in Canada is of 76.6%.[1]  They also recommend that a woman with a healthy pregnancy and no contraindications should be offered a Trial of Labour (TOL) or VBAC. [1]   (Canadian Guidelines for VBAC-SOGC-Feb-2005)

One of the reasons why VBAC is emphasized by SOGC recommendations, as well as by the American College of Obstetricians and Gynecologists (ACOG) is that a repeat Cesarean can increase the risks of placenta accreta (e.g. placenta abnormally attaches to the uterine wall. It does not detach normally after the baby is born). In fact, the rate of placenta accreta after two Cesareans is greater than the risk of uterine rupture after one Cesarean. Potential problems with placenta accreta include maternal and/or neonatal death. [5]

What are the benefits of a VBAC?

The benefits of a VBAC instead of a repeat Cesarean include [2]:

  • No risk of complications from an abdominal surgery;
  • Decreased risk of blood loss;
  • Less pain;
  • Decreased risk of a postpartum fever;
  • Decreased risk of an infection;
  • Being able to walk sooner after birth;
  • Much shorter recovery time;
  • Satisfaction of having a vaginal birth;
  • Earlier start to breastfeeding and better success with breastfeeding at three to six to six months;
  • Fewer potential complications for the newborn.[2]

What are the Contraindications to VBAC?

The contraindications to a woman planning a VBAC by most guidelines and professional organizations are:

  • Previous uterine scars of the following types: classical or inverted “T” (Uterine Incision Types);
  • Previous surgeries entering the uterine cavity, such as hysterotomy (an incision in the uterus, normally performed during a C-section, or fetal surgery, and/or various gynaecological procedures) or myomectomy (surgical procedure to remove uterine fibroids — also called leiomyomas);
  • Previous uterine rupture;
  • Presence of a contraindication to labour such as placenta previa or baby in breech position.
  • A woman declining VBAC and requesting a Cesarean section.[1] [2] [3]

What are the risks associated with VBAC?

  • Uterine rupture. This is a tear near the scar on your uterus from your previous Cesarean birth(s). If this occurs, an emergency C-section birth will be done. Uterine rupture can lead to the need for a blood transfusion and/or the removal of your uterus. [2] The risk of uterine rupture is about 0.4% to 0.9% after one prior Cesarean and is dependent on multiple factors. This is a similar rate to other obstetrics emergencies that first time mothers can experience. [4]

Risks associated with a VBAC are higher for women who:

  • Have had a Cesarean birth less than 18 months ago;
  • Are older than 35 years of age;
  • Have a body mass index (BMI) greater than 30 kg/m2;
  • Are given medication to start (induce) or speed up (augment) their labour;
  • Even after 2 or more Cesarean births, a VBAC can be attempted, although the risk of complications is higher. [2] [3]

It is important to be informed of the benefits and risks associated with VBAC, as well as of what is happening to your own body. Also to know the reasons why VBAC is recommended as a first choice to women who had previous C-sections.

I hope this info brings valuable information to your decision making regarding your pregnancy and birth choices and empowers you as well.

References:

  1. Martel MJ, MacKinnon CJ; Clinical Practice Obstetrics Committee, Society of Obstetricians and Gynaecologists of Canada, Guidelines for Vaginal Birth After Previous Caesarean Birth, J Obstet Gynaecol Can. 2005 Feb;27(2):164-88.
  2. http://www.ontarioprenataleducation.ca/vbac/
  3. https://www.ontariomidwives.ca/sites/default/files/CPG%20full%20guidelines/CPG-Vaginal-birth-after-caesarean-section-PUB.pdf
  4. https://vbacfacts.com/2018/05/07/six-confusing-facts-large-canadian-vbac-study/
  5. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Placenta-Accreta
  6. https://nursekey.com/caesarean-section-2/

 

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Umbilical Cord Blood Collection: Is it a good choice for our family?

What is the purpose of saving or collecting umbilical cord blood?

Umbilical cord blood (UCB) is being collected for the purpose of preserving stem cells for future transplants. The collection of stem cells are easier to obtain from UCB than from bone marrow transplant.

So what are stem cells?

Stem cells are undifferentiated cells that are capable of giving rise to all tissue and organ cells of the body. There are three main sources of stem cells in humans: embryonic stem cells, adult stem cells, and umbilical cord stem cells. [1]

What diseases can stem cells transplant treat?

There are 4 main groups of diseases which stem cells transplant can treat: cancers, blood disorders, congenital metabolic disorders, and immunodeficiencies. [1,2]

Examples of Conditions Treated With Stem Cell Transplants [1]

Cancers

Blood Disorders

Congenital Metabolic

Disorders Immunodeficiencies

Acute lymphocytic leukemia Sickle-cell anemia Adrenoleukodystrophy Adenosine deaminase deficiency
Acute myelogenous leukemia Fanconi’s anemia Gunther’s disease Wiskott-Aldrich’s syndrome
Chronic myelogenous leukemia Thalassemia Gaucher’s disease Duncan’s disease
Myelodysplastic syndrome Evan’s syndrome Hurler’s syndrome Ataxia-telangiectasia
Neuroblastoma Congenital cytopenia Hunter’s syndrome DiGeorge’s syndrome
Hodgkin’s disease Aplastic anemia Krabbe’s disease Myelokathexis
Non–Hodgkin’s lymphoma Diamond–Blackfan anemia Sanfilippo’s syndrome Hypogammaglobulinemia
Burkitt’s lymphoma Amegakaryocytic thrombocytopenia Tay-Sachs’ disease Severe combined immunodeficiency

What are the indications of UCB collection?

When expectant families have a relative or immediate family member with a known disorder that is already treatable by stem cell transplants and infant is not preterm and not for potential future use. [2]

Advantages of Umbilical Cord Blood Stem Cells Versus Bone Marrow Stem Cells [1]

  • Ease of collection
  • Almost no risk for mother or child
  • Less time needed for processing (more quickly available for use)
  • Less costly than bone marrow collection
  • Less risk for transmission of infection
  • Less need for stringent antigen typing
  • Less rejection

What are the contraindications of UCB collections?

Umbilical cord collection in Preterm infant (< 37 weeks gestation) is contraindicated. [2]

The reason is that delayed cord clamping is necessary in preterm infants to prevent complications at birth, as per World Health Organization (WHO) recommendations. [3]

For UCB collection, delayed cord clamping implies in less amount of blood, with less quality stem cells, therefore collection may render useless by either amount of quality.[2]

Disadvantages of Umbilical Cord Blood Stem Cells[1]

  • Slow engraftment (Ability of blood-forming cells start to grow and make healthy blood stem cells that show up in your blood – speed is important for transplant recovery)
  • Limited cell dose, yielding small volume of unit and additional cell doses are usually unavailable
  • Specimen from the same individual donation may have limited benefit owing to hereditary disorders
  • Storage issues
    • Unknown length of long-term storage
    • Cost related to long-term storage can be high
    • Quality control is unknown.

Public versus Private Blood banks

If you choose to collect UCB you can either donate to a public bank or pay to a private bank to store it for you.

Key differences between Public and Private banks [1,2,4]:

Public Private
no charges associated with cord blood banking Charges around $1125 upfront + $125 per year of storage[4]
makes stem cells available to anyone who needs them Only available to you. Not available for transplant centers to search HLA type database.
increases the number and diversity of cord blood units available for patients making it easier to find a match No diversity available if needed
Your cord blood may not be available to you/family Only available to you/family
Units not approved for transplant are donated to research Private banks typically do not use the same banking criteria as public banks in terms of collection volume and total nucleated cell doses

Public Cord Blood Banks in Canada:

Canadian Blood Services[5]

Collection Centers in Canada:

  • The Ottawa Hospital General Campus and Civic Campus;
  • William Osler Health System’s Brampton Civic Hospital;
  • Alberta Health Services’ Lois Hole Hospital for Women in Edmonton;
  • BC Women’s Hospital + Health Centre in Vancouver.

Info vídeo: https://youtu.be/K5WRgK9L52M

Recommendations[1,2]

It is recommended that expectant families only consider cord blood banking in private banks when they have a relative with a known disorder that is already treatable by stem cell transplants.

Moreover, expectant families should not rely on commercial cord blood banks as their sole source of information about cord blood banking.

Other important points an expectant couple need to consider:

  • They should not base their decision to bank the umbilical cord blood on the type of anticoagulant used to preserve the sample;
  • They should not obtain all of their information on cord blood banking from the private cord blood bank, whose major agenda is to gain another client;
  • They must be encouraged to research various resources for reliable information;
  • Consider private banking only if they have evidence that stem cells are used currently to treat a specific disease process affecting a family member, but be aware that simply banking the cord blood does not ensure a cure, and they would most likely be banking the blood not for the current baby, but for some other family member;
  • They must also be aware of the cost involved in the banking process;
  • Finally, if they do not have a relative with a disease process treated with stem cells or there is no evidence that stem cells are used to treat the diseases that are known to be in their family, then they could consider public banking of the umbilical cord blood (if they have access to a public cord blood bank).

References:

  1. Renece Waller-Wise, Umbilical Cord Blood: Information for Childbirth Educators, The Journal of Perinatal Education, 2011, vol 20, 1
  2. Anthony Armson, David S. Allan, Robert F. Casper, SOGC CLINICAL PRACTICE GUIDELINE – Umbilical Cord Blood: Counselling, Collection, and Banking, J Obstet Gynaecol Can 2015;37(9):832–844
  3. World Health Organization (WHO) Recommendations http://who.int/iris/bitstream/10665/120074/1/WHO_RHR_14.19_eng.pdf
  4. http://cellsforlife.com/pricing/
  5. https://blood.ca/en/cordblood

Pregnant and need to find a caregiver in Canada?

Like many of us, you have experienced a different health care system before coming to Canada. Now here you are. You just learned you are pregnant and need to find a caregiver to help you during your pregnancy and labour.

Here are a few tips to help you choose a caregiver that best meet your needs so you can have a positive experience during your pregnancy and the birth of your child.

How does the Canadian health system work?

First, it is important for you to learn about your rights and about what is available in the Canadian Health Care System. In this article, I will be focusing on Ontario residents, as the healthcare coverage varies by province in Canada. However, I hope most of the information here can help you choose a caregiver that best fits your needs anywhere in Canada.

If you live in Ontario, and need to find out more on how to obtain your health card and eligibility, please visit: http://www.health.gov.on.ca/en/public/programs/ohip/

For other provinces, please visit the link below:
http://healthycanadians.gc.ca/health-system-systeme-sante/cards-cartes/health-role-sante-eng.php#card

In Ontario, the health care system offers you two great options of caregivers, which are totally covered by your OHIP (Ontario Health Insurance Plan) card, meaning you do not have to pay for these services. They are:

  • Midwives
  • Physicians Obstetrics / Gynecologist (OB/GYN)

In the Canadian health care system, you need a referral from your family doctor to see an OB/GYN. This referral is not needed if you are choosing a midwife as your caregiver. However, since midwives are in high demand, I suggest you contact more than one midwifery clinic directly early on in your pregnancy, so you can increase your chances of finding one.

How to choose between these two types of professionals that will best fit my needs?

When choosing your caregiver it is important not only to consider their educational background, credentials, knowledge and experience, but also consider your state of health and what resonates with you or your belief system. Please see a brief introduction of these two models of care:

Midwifery Care Model

This type of care is intended to enhance and maintain a woman’s physiological and psychological resources for giving birth. The midwifery model is based on the following principles:

  • Birth is a natural physiological process and an experience that can bring great emotional transformations.
  • A woman’s feelings influences the labour process, so there is need for individualized care
  • Childbirth preparation is necessary, as a woman’s active participation increases the chances of a healthy pregnancy, labour and birth.
  • Lower rates of interventions and Cesareans are desirable
  • Caregivers not only check the mother’s and baby’s safety and well-being, but also offer education and support. If problem occurs, they start with tools that cause the least intervention to regain a healthy physiological function. They are also highly trained to address emergencies as they arise.
  • Midwifes provide care wherever you choose to have your baby. It can be at your home, at a birthing centre or at the hospital.
  • They also provide pain management ranging from natural to pharmaceutical options including access to epidurals in hospitals.

Registered midwives are health professionals who provide primary care to women and their babies during pregnancy, labour, birth and the postpartum period. They’re trained for at least 4 years in Bachelor of Health Sciences (Midwifery).

Midwives’ services include physical examinations, screening and diagnostic tests, the assessment of risk and abnormal conditions, and the conduct of normal vaginal deliveries. Midwives work in collaboration with other health professionals and consult with or refer to medical specialists as appropriate. The midwifery model of care promotes normal birth, enables women to make informed choices, and provides continuity of care and support throughout the childbearing experience.

For more information on Midwifes please visit:
http://www.ontariomidwives.ca/midwife/q-a

To find out if midwives are covered by the provincial health care across Canada please visit:
http://www.babycenter.ca/a1038259/midwifery-across-canada

Medical Care Model (Physicians Obstetrics / Gynecologist)

This model is designed to replace or alter the body’s own resources with medical and technological interventions. It is based on the following premises:

  • The natural childbirth is perceived as unreliable, unpredictable and potentially unsafe.
  • Uses a routine care protocols for all women (not considering individual needs), which gives the caregivers a sense of control over the birthing process
  • Medical interventions can improve labour and birth
  • Cesareans are believed to be as safe as vaginal birth for mother and baby. Some believe cesareans are a safer option to vaginal birth
  • Caregivers use routine interventions before problems occur. If a problem arises, doctors intervene rapidly with tools that will deliver the quickest result.

These professionals are medical school graduates with additional training in obstetrics (a medical and surgical sub-specialty focused on pregnancy, birth and the postpartum period) and gynecology (medical and surgical treatment of diseases). Much of their education is focused on detection and treatment of complications and disease as well as pharmaceutical agents, so they are well skilled in procedures and surgical interventions. Depending on your state of health, perhaps you have factors that contribute to a high-risk pregnancy that requires the skill-set of an OB/GYN.

The majority of OB/GYN’s are focused on high-risk cases and procedures and as a consequence are likely not to focus on the psychological needs of a pregnant / labouring woman.

For more information on OB/GYN physicians go to:

http://sogc.org/about-sogc/

Can I change caregivers, if I am dissatisfied with the service provided?

You absolutely can.

It is important to find a caregiver who is concerned for your well-being, whom you feel comfortable with, feel listened to and trust his/hers recommendations, so that you can have a satisfying birth experience. However, do not drop your current caregiver until you have found a more suitable match to your needs that will be able to take you in as a patient.

Before rushing into making a decision to end the relationship with your caregiver, try to improve the communication with him/her, by conveying, in a kind and respectful way, the things that are making you uncomfortable. For example:

You may feel this way: “Dr. Smith, you seem always in a rush and you don’t let me ask you questions. You don’t care about your patients”. However, if you communicate directly in this way, it may sound accusatory and that can make your caregiver defensive and break any chances of good communication.

Here is how you can convey your feelings in a kind and respectful way using “I” statements: “Dr. Smith, sometimes it is hard for me to say, but I am under the impression I am an inconvenience to you. When I need more information, I feel that you are quick to dismiss my question and that I shouldn’t ask you anything.”

If this does not improve the relationship with your caregiver, definitely look for another one.

What is the difference between Midwives and Doulas?

A birth doula is a trained labour support person who provides informational, emotional and physical support to a woman in labour and her partner. As a doula, she can offer a wide range of comfort measures, but she will not perform any clinical tasks (clinical exams, risk assessment, screening tests, etc.) as the midwife or doctor would.

Doula services are privately funded, denoting that her services are not covered by the provincial healthcare system as of yet.

For more information on Doulas and how they can be of assistance, please check my website or email me.

Article written by : Simone Costa, ND grad., Doula, BodyTalk Practitioner

References:

  1. Penny Simkin, et al, Pregnancy Childbirth and The Newborn: The Complete Guide, 4th Edition, ISBN 978-0-88166-531-4 (Meadowbrook)
  2. http://www.canadianmidwives.org/
  3. http://www.ontariomidwives.ca/
  4. http://www.health.gov.on.ca
  5. http://sogc.org/about-sogc/
  6. http://healthycanadians.gc.ca/health-system-systeme-sante/cards-cartes/health-role-sante-eng.php#card
  7. http://www.babycenter.ca/a1038259/midwifery-across-canada