Full title: Acupuncture and Vaginal Birth after Cesarean (VBAC) Delivery: Preparing For VBAC and Recovery Post VBAC
ABSTRACT
The following is a review of current evidence-based recommendations for vaginal birth after cesarean section and how acupuncture could play an integral role in increasing VBAC rates internationally. This article provides examples of treatment protocols and point prescription. The case review provided is of a 34-year-old female presenting with numbness post-cesarean section with treatment plan discussed. Current rates of cesarean section throughout the United States are included. Recommendations for referrals to complementary care providers are discussed, as are community resources for patients.
CURRENT RESEARCH
Vaginal Birth After Cesarean, or VBAC, refers to a successful Trial Of Labor After Cesarean delivery, or TOLAC. Many women and providers chose to attempt a TOLAC due to reducing rates of maternal morbidity and a decreased risk of complications in future pregnancies.1 Despite the desire to decrease the cesarean delivery rate at the population level amongst most medical providers, current cesareans section (CS) rates vary between 30 % and 50% in the developed world. A previous cesarean delivery is cited as the primary indication in approximately 30%.2
The drive for TOLAC and VBAC also comes from women who suffered emotional and physical trauma undergoing cesarean delivery. A 2012 metasynthesis provided a qualitative review of women’s experiences on VBAC and cesarean delivery, reviewing 11 peer-reviewed articles. “The main results are presented with the metaphor groping through the fog; for the women, the issue of VBAC is like being in a “fog,” where decision-making and information from the health care system and professionals, both during pregnancy and the birth, is unclear and contrasting.” 3
The results from the study presented four themes. Women reported that:
· Being involved in the decision about mode of delivery “is difficult but important”
· Vaginal birth has several positive aspects, mainly described by women
· Vaginal birth after CS is a “risky project”
· Own strong responsibility for giving birth vaginally
The study found that women described vaginal birth as having several positive aspects, including that it was:
· Good for the baby and the mother-baby relationship
· A meaningful experience of importance for them as women
· An easier birth in relation/relative to recovery afterward
· Evident some health professionals are pro-VBAC
The study concludes the women are well informed about the risks of VBAC, but they are not being presented with significant positive outcomes from successful TOLAC and VBAC, including the laboring woman’s empowerment and positive life perspective that giving birth vaginally can provide. It urges that more qualitative international studies are needed to further support health care providers with evidence-based research to encourage VBACs. 4
There is little to no research specific to the inclusion of acupuncture care pre-CS and post CS and how it affects laboring women. We do have access to the literature regarding acupuncture care for a number of conditions that lessen CS likelihood. These include acupuncture for induction, acupuncture and moxibustion for breech babies, and acupuncture and acupressure for stalls in labor. A 2017 meta-analysis, limited solely to randomized control trials (RCT), reviewed 22 trials of the use of acupuncture and acupressure. It determined, “There was no clear difference in cesarean sections between groups” when comparing acupuncture care to “sham” acupuncture and usual care. The methodology of randomized control trials could be argued against, however, as randomized control trials have limitations in evaluating acupuncture success, and the “sham” acupuncture provided “where the needles are inserted away from the usual location, with the depth and needle stimulation being the same” proves to produce measurable positive changes in the body. “Sham” acupuncture is not an accurate blind to use in RCTs. Further, the study participants had not previously had a cesarean section. Rather, this study looked at first-time mothers, primipara, and did not review successful VBAC rates. Even so, the study does conclude acupuncture showed some benefit in improving cervical maturity. Further study is recommended.5
CHINESE MEDICAL THEORY
In Chinese medical theory, we must look at the movement of Qi and blood when evaluating the use of acupuncture in preparing for TOLAC and VBAC. Chinese medical theory would categorize recovery from cesarean section as a treatment of qi and blood stagnation and/or stasis and attempt to move the blockage. With any incision and surgery, the meridians are penetrated, and the flow of Qi is interrupted. In the case of a lower abdominal, horizontal bikini incision for a cesarean section, meridians such as the Conception Vessel, Kidney, Spleen, and occasionally the Stomach are disrupted by the incision. Further constitutional evaluation of the patient would determine if there was a depletion of Qi and blood during long, complicated labor and birth. The health of the Kidney organ system would also be evaluated, as the function of the Kidney system includes reproduction and fertility, carrying of the fetus, and labor and delivery.
TREATMENT PLANS
Depending on when the acupuncturist sees the patient, we would adjust our treatment plan accordingly. Ideally, women would be directed by care providers to receive acupuncture care post-surgery to reduce scar tissue. A typical treatment plan would include local acupuncture needles around the incision, using 1-2 cun length needle, inserted at a perpendicular angle and retained for a minimum of 25 minutes; up to 40 minutes would be acceptable. Heat would also be a treatment of choice in the immediate postpartum months, and the use of infrared heat lamps and moxibustion directly above the incision would be useful. An evaluation of the mother, a review of the labor, delivery, and postpartum period would be conducted. Often women undergo long labor before cesarean section, which leads to significant depletion of Qi and blood. Nourishing food recommendations like bone broth and congee would be suggested. Herbal formulas, safe for breastfeeding, would be considered to tonify Qi and blood of Kidney and Spleen such as Gui Pi Tang and Si Wu Tang. It would also be important to evaluate the emotional health of the woman in the immediate postpartum period and assess for postpartum depression. Referral to mental health providers would be recommended if postpartum symptoms persist after the third day post-birth.
CASE REVIEW
C.S., a 34-year-old female, presenting six weeks postpartum after first cesarean delivery. The patient presented with numbness and a “strange” feeling around the cesarean section incision site. The patient was breastfeeding with no difficulties and although appearing mentally healthy and bonding with the child, expresses desires to try for a VBAC for the next child, planning in two to three years.
Assessment: Qi and blood stagnation at the local site of incision
Treatment Plan: Move Qi and blood, reduce scar tissue. Frequency of treatments were once per week over the course of eight weeks.
Acupuncture: 2 cun needles were used, they were inserted perpendicularly and retained for 30 minutes
CV 4: (to tonify Qi and blood)
CV 3: (to tonify Qi and blood).
Surround incision site with ashi needles x8 both distal and proximal to horizontal bikini incision (move qi and blood)
GB 41: (to support Dai Mai recovery)
K 3: (to tonify Kidney Qi)
Sp 6: (to tonify Spleen Qi)
Moxibustion: Pole moxibustion is provided above all local abdominal points for 15 minutes
Home Care: Heat to the local area of the incision for 15 minutes per day with a heating pad
Outcome: Patient reported elimination of “strange” feeling around scar after four visits. She also reported a reduction in stress and sadness around her birth experience and felt less of a sense of urgency to plan a VBAC.
Recommendations: After completion of the initial series of eight visits, C.S. was recommended to return to acupuncture care if there was any return of the feelings of numbness and tingling around the incision site, to continue to work on reduction of scar tissue formation. She was also recommended to return to care three to four months prior to trying to conceive again. The next phase of treatment would include evaluation of Qi and blood movement around the incision site. Referrals to mental health providers were also included at discharge of patient care.
ALTERNATIVE APPROACHES
A referral to Mayan abdominal massage may be recommended. Mayan abdominal massage is a specialty massage practice provided by certified massage therapists. The technique involves a deep tissue massage, similar to Chi Nei Tseng in Chinese medicine, local to the abdomen. The provider assesses the location of the uterus and makes recommendations for home care self-massage. Some of the technique is limited to being performed post menses and prior to ovulation, a short window for many women of approximately one week per month. Heat and castor oil packs may also be recommended. Vaginal steams, where herbs are boiled and placed under the exposed vagina to steam, may also be incorporated. Unfortunately, there is little evidence-based literature available to support Mayan Abdominal Massage or vaginal steams. However, in my clinical experiences, the benefits of one-on-one, intensive healing focused on the women’s uterus can have profound psycho-social-emotional implications, and referral to it —for a willing patient — would be recommended.
BIOMEDICAL MARKERS
The ultimate marker of success in this situation is a successful TOLAC and VBAC. However, various markers could be in place throughout the period of post-cesarean to future deliveries. Women’s uteruses should be evaluated using a transvaginal ultrasound to review the internal healing of the incision to the uterus. This is not standard of care at this time, but if we did implement a transvaginal ultrasound protocol and treatment plan to include acupuncture for scar tissue, I am curious if this would affect VBAC rates and uterine rupture rates.
COMMUNITY RESOURCES
This is an area that could be improved for women who have given birth via cesarean. Post-cesarean, women may feel isolated, vulnerable, and like they have failed societal expectations of how women “should” give birth. The current social model of repeating “healthy mother, healthy baby” may not be ultimately helpful for a mother grieving her loss of vaginal birth. This psychology may invalidate a mother’s feelings and force her to withdraw from expressing her grief and/or anger. As a community of health care providers, standards of care suggest we continue to provide gentle cesarean sections that still allow for immediate skin-to-skin contact with the baby and mother, and allow immediate access to the breast. Delayed umbilical cord-cutting could also help women’s experiences and only offers benefit to the newborn.6
Additionally, International Cesarean Awareness Network (I-CAN) International is a great resource for all women who experience a cesarean delivery. I-CAN is a non-profit organization whose mission is to improve maternal-child health by reducing preventable cesareans through education, supporting cesarean recovery, and advocating for vaginal birth after cesarean. With local and virtual chapters, women may be able to access a community of mothers and health care providers aware of the complications of cesarean birth for the new mother. I-CAN can be found at www.ican-online.org.7
PROGNOSIS
The rates of having a successful vaginal birth after cesarean vary widely depending upon where the laboring woman is giving birth. According to 2017 statistics, the states with the lowest VBAC rates (as in, least likely to achieve a VBAC) are as follows.8
California 7.66%
Alabama 7.46%
Florida 7.30%
Arkansas 6.81%
West Virginia 6.51%
Mississippi 6.22%
The states with the highest VBAC rates (most likely to achieve VBAC) are:
Colorado 22.19%
Utah 22.19%
District of Columbia 22.07%
Alaska 21.95%
Vermont 21.48%
Minnesota 19.55%
It is unknown how the integration of acupuncture care could increase the success rates of VBAC at this time, but there is no reason it would reduce it. Acupuncture can be included in a treatment plan at four stages: the post-surgical stage immediately following cesarean section, preconception, during pregnancy, and during labor to increase successful VBAC rates.
SUMMARY OF KEY LEARNINGS
There is a lack of information due to the lack of evidence-based research regarding how acupuncture can help increase VBAC rates. Referrals to specialists in acupuncture for women health patients at various stages of the post-cesarean section, with plans to try for a VBAC, are recommended.
REFERENCES
1. ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery. Obstet Gynecol. 2019;133(2):e110-e127. doi:10.1097/AOG.0000000000003078
2. Ryan, GA., & Nicholson, SM., & Morrison, JJ. Vaginal birth after cesarean section: Current status and where to from here?. Eur J Obstet Gynecol Reprod Biol. 2018;224:52-57. doi:10.1016/j.ejogrb.2018.02.011
3 & 4. Lundgren, I., & Begley, C., Gross, MM., & Bondas, T. ‘Groping through the fog’: a metasynthesis of women’s experiences on VBAC (Vaginal birth after Caesarean section). BMC Pregnancy Childbirth. 2012;12:85. Published 2012 Aug 21. doi:10.1186/1471-2393-12-85
5. Vogel, JP, & Osoti, AO, & Kelly, AJ, & Livio, S, & Norman, JE, & Alfirevic Z. Pharmacological and mechanical interventions for labour induction in outpatient settings. Cochrane Database Syst Rev. 2017;9(9):CD007701. Published 2017 Sep 13. doi:10.1002/14651858.CD007701.pub3
6.Raju, TN, & Singhal, N. Optimal timing for clamping the umbilical cord after birth. Clin Perinatol. 2012;39(4):889-900. doi:10.1016/j.clp.2012.09.006
7. International Cesarean Awareness Network website,ican-online.org. Updated 2021. Accessed March 1, 2020.
8. Osterman, MJK. Recent Trends in Vaginal Birth After Cesarean Delivery: United States, 2016-2018. NCHS Data Brief. 2020;(359):1-8.
