1. Your Care Provider
The most important factor in your VBAC journey is the support of your care provider.
No matter how much preparation and determination you otherwise have, if your care provider is not comfortable with VBACs, your chances are diminished.
Whether you choose a doctor or a midwife, you must talk openly and specifically about VBACs. You need to gather information as well as find out what your care provider's attitudes towards VBACs are.
Here are some questions to which you will need direct answers:
How many VBACs have you attended? Keep in mind that the number might not be very high. Many women do not have the support or confidence to achieve a VBAC, and in our current medical climate, the numbers are low. Watch for how enthusiastic your care provider is.
How many women attempting VBACs in your practice were successful? This is to find out who simply says "I will support you" but won't, and who is truly capable of supporting women who want VBACs. Some care providers give lip service to VBACs early on while never intending to allow post-cesarean women a fair chance at a vaginal birth.
Do you think I will be able to have a VBAC? This is your chance to discuss your childbirth history. Your reason for a previous cesarean should not matter, but watch for warning signs, such as "I will consent to a VBAC attempt so long as your baby is less than X pounds" or "You can have a VBAC if you go into labor within seven days of your due date" or "VBACs are much riskier than repeat cesareans" or if they put a time limit on labor or use the phrase "trial of labor." These are red flags indicating a care provider who is unwilling to offer the support you will need.
What do you do about a suspected CPD or past due pregnancy? VBACs should not be induced, if it can be at all avoided. Going past your due date, by itself, is not a reason to induce. Doctors are inducing earlier and earlier, often with the reason of "large baby" (macrosomia), but inducing for suspected large baby will often lead to cesarean section, rather than avoiding complications. If you had one or more cesareans for CPD, there is no reason to believe that you will never have a vaginal birth. Many CPD diagnoses are disproved by subsequent vaginal deliveries of larger babies. CPD, FTP (failure to progress), malposition, and the body's unpreparedness for an induced labor, are often one and the same reason. Your care provider should not assume that a previous diagnosis of CPD is accurate and permanent. Ask specifically how long past your due date your care provider believes it is safe to go. Change providers if your time is limited to one week or less.
Who can be in the room with me during labor and birth? If you can bring one, hire a doula. Doulas with VBAC experience will be able to provide invaluable support to you during labor. VBACs can be difficult. You will need as much encouragement, advocacy, and support as you can get.
What are the medical guidelines for women having a VBAC? Find out if you will be required to have constant external fetal monitoring (EFM). Are you required to have an IV or heplock? How about free movement? Will you need to labor in an operating room? Is pitocin routinely given to all women, including VBACs?
Do you personally attend all your patients' deliveries? Some doctors may not be able to control whether they are the physician present at any delivery, while others make a point of being with all their patients' births. Find out if you will be unexpectedly working with another doctor when you go into labor. Talk to that care provider as well to gauge how supportive they are of VBACs.
2. Your Physical Self
To maximize your ability to birth safely and without complication, take excellent care of your health. Eat well, including lots of fresh fruits and vegetables, and exercise. The better care you take of your body, the better it will function. Also, eating well helps your tissues to stretch farther without injury. Do not drink alcohol, caffeine, or smoke. Cut sugar. Do your Kegels. Yoga is wonderful, too, but make sure you are doing the prenatal kind, since you do not want to harm yourself.
3. Your Psychological Self
Do not underestimate the impact your first cesarean has on your outlook. Many women whose dreams of vaginal birth were undermined by their c-section experiences carry a heavy burden of doubt in their birthing capabilities.
All fears will manifest themselves the most strongly when you are in labor. You are best prepared to face them when you deal with them before labor. And keep in mind that all women who have had VBACs began by thinking they may not be able to accomplish it.
One of the most effective means of facing your fears is through hypnosis. Hypnobabies and HypnoBirthing courses are designed for the express purpose of building your confidence, understanding and handling your fears about labor and birth, and nurturing a positive outlook of birth. It also teaches women how to relax during childbirth, which is a fundamental part of preparation for any birth, but will be especially helpful for VBAC women.
The fear of repeating your previous experience(s) is very real and must be confronted if it is to be overcome. Your mind has a tremendous influence over what happens in your body. If you are scared, your body will respond and hold back; if you are confident and unafraid, your body will work more smoothly. Work with a counselor or hypnosis instructor to sort out your fears. Read everything you can. Take charge of your life, of your body, and begin your preparation for your VBAC.
Many women need a good deal of determination to have their VBACs. With supportive doctors and hospitals lined up, the last and greatest obstacle is the mother's belief in herself to give birth. This may be where your personal support team steps in, but you would be best served by working through as much of your fears and doubts as you can before they seem overwhelming.
4. Your Educated Self
I separate this section from the one above because they are truly distinct. Any facts you learn about VBACs and cesareans are likely to have no bearing on what you believe about yourself. Even if you learn that VBACs are safe, you may still harbor extreme doubt about your own ability to birth vaginally at all. Your self-belief is predominant.
However, education is still valuable, and in the case of VBACs, it is solid and startling.
The only reason VBACs are termed 'risky' is because of the chance of uterine rupture. Scar tissue does not generally have as much flexibility as unscarred tissue, and so the incision line along the uterus has a slightly higher chance of separating. Uterine rupture is a serious and life-threatening medical emergency, for both the mother and the baby.
For a woman with a previous cesarean, the chance of uterine rupture is about 0.5%. The chance of the uterus rupturing along the scar line is increased by the following factors: chemical induction (pitocin, prostaglandin, misoprostol), suturing type (previous cesarean incision closed in single-layer suturing rather than double-layer suturing), timing (previous cesarean less than two years before), age (the numbers rise as the woman ages past 30 years), classical incision in previous cesarean, and frequency (two or more previous cesareans).
If the sole risk for VBACs is uterine rupture, and the chances of it happening are so low, why is there so much controversy? Why is it difficult to find doctors supportive of VBACs? Why is the VBAC rate plummeting?
The answer is not in the increase of risk. It is in the expense.
Most hospitals require more staff for VBAC attempts. This means an anesthesiologist, an obstetrician, and increased nursing staff, just in case there is an emergency (read: rupture) and the woman needs immediate surgical attention.
If all goes smoothly and the woman delivers vaginally, it is possible that this staff would have been on call, at the hospital, paid, and not used. The woman is also not billed for their services.
Many hospitals are understaffed, a fact shown most clearly through the nursing crisis. Hospitals want to either save money or make money. With our national cesarean rate rising to an all-time high of one in three births, the number of VBAC candidates has also risen. Repeat cesarean is currently the number one reason for all c-sections. Obviously most hospitals are attempting to make money rather than cut costs, and VBAC is a primary target.
The other reason for the trend is malpractice costs. As lawsuits continue to be the standard response for anything having gone wrong in a hospital birth, malpractice insurance has risen accordingly. Not offering VBACs to women is a way of cutting the cost of malpractice insurance; if you don't offer it, you don't need to cover it. (Case in point: Last year, a local CNM was forced to stop offering VBACs because malpractice insurance to cover them had increased by over $10,000 in a single year). Another example is this quote from the vice president of a hospital, referring to the risk associated with VBACs: "99 out of 100 times it works, but I'm not willing to play those odds."
The alternative is that you, the taxpayer, the insured, are footing the bill for the increase of cesareans.
Cesareans are not without risk. Terming them a 'safe' alternative is both relative and circumstantial.Cesareans cause much higher incidences of infection, hemorrhage, depression, have far longer recovery times, and the risk of unpredictable complications such as accidental severing of nerves or tissues. Babies born vaginally are generally in better condition, with the benefit of catecholamines released during vaginal birth, healthier lungs, higher Apgar scores, earlier contact with their mothers, and better breastfeeding success.
The bottom line: VBACs are safe. They are safer than repeat cesareans. But they are not inexpensive.
5. Resources
Take advantage of the availability of information on the internet and do your homework.
Here are some very helpful resources:
ICAN (International Cesarean Awareness Network) -- Read The White Papers. Find a local ICAN chapter, if one is available to you, and attend regularly.
Childbirth Connection -- A fantastic site for information. Provides evaluations of current studies and medical research.
Pushed -- Informative blog about our current birth culture and a few sections specifically addressing VBACs.
Henci Goer -- The author of The Thinking Woman's Guide to a Better Birth and Obstetric Myths versus Research Realities has several articles on cesareans and VBACs.
Birthrites -- A site devoted to VBACs and healing after cesarean surgery.
VBAC.com -- A comprehensive resource for women wanting to know more about and prepare themselves for VBACs.
Hypnobabies and HypnoBirthing -- While similar in both philosophy and practice, the main difference is that Hypnobabies classes can be taken independently (a workbook and CDs may be purchased from their site), while HypnoBirthing requires an instructor and in-person classes.
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