Preparing for a VBAC

For women who have had a cesarean and wish to give birth vaginally for subsequent deliveries

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.

The Myth of CPD

CPD (cephalopelvic disproportion) is a common reason for cesarean section. It means that the pelvis is too small to admit the passage of the baby's head.

It is vastly overdiagnosed. True CPD is a malformation of bones. Unless medical issues such as gestational diabetes exist, babies will not be too large to fit through the mother's pelvis.

Induction for suspected big baby will often lead to cesarean section. The reasons are many: the pelvic bones will not stretch as much when labor is induced, the baby may not be in an ideal birthing position, lying in bed (common when one is receiving pitocin, and often leads to epidurals, which out of necessity restrict movement) does not help but seriously hinders the natural gravitational pull of babies out of the birth canal.

Many women who have been diagnosed with CPD have gone on to vaginally birth much larger babies.

This wonderful clip, put together by ICAN, reveals the myth that is CPD.

Let's get started!

Inducing Labor

Let me begin by assuring that there are some valid reasons for inducing an otherwise healthy pregnancy.

Life-threatening illnesses that will affect the health of mother or baby. These include preeclampsia, severe hypertension, cancer, diabetes, organ disease, or placental age or deterioration.

There are many more reasons women induce their labors to begin:

Suspected large baby. No technology exists to accurately predict the size or weight of an unborn baby. Measurements, ultrasounds, and assessments through other means can be off by several pounds, higher or lower. Even still, women commonly induce out of fear of having a big baby.

Being overdue. Early in pregnancy, women are assured that their due dates are mere estimates; by the end of pregnancy, that has changed, and going past one's due date has become undesirable. I don't think it's a stretch to assume that this is connected with the first. Merely being past the due date, however, is not a medical reason.

Being full-term. This is more common, as women take lightly the act of inducing labor and try to have their babies at an arbitrary time, so long as it's after 36 weeks (and often before 40).

Doctor scheduling. Your doctor has told you that he or she will be out of town at a certain time, and you want to ensure that you are in labor during a time he or she can attend you.

Family scheduling. Many women feel pressured to produce a baby when family will be around. "My mother will only be here for ten days!" "Grandpa will be in town on the 26th, and he'll want to see the baby!" Some women want to give birth so they can attend a family event or go on a scheduled trip.

Discomfort at the end of pregnancy. Your hips hurt. Your belly is huge. You can barely walk or stand up. Sleep is elusive. You're ready to be done. The baby, though, is not.

All of these are inducing for convenience.

Why it matters

Whether or not to induce your labor depends largely on what you want to experience in your labor and what you want to avoid.

As a result of induction you may have:

1. A vacuum or forceps-assisted birth;
2. A baby unable to tolerate contractions.
   

As a result of induction you are likely to have:

1. Increased fetal distress;
2. Pitocin administration, which will make labor contractions stronger and far more painful;
3. Epidural anesthesia to cope with the pain;
   
4. Rupture of your bag of waters, which puts a time limit on how long you will be allowed to labor and increases your baby's and your own chances of infection;
5. Problems with presentation and position of the baby in the womb;
   
6. Increased incidence and severity of jaundice in your baby.
   

As a result of induction you will have:

1. Doubled your chances of delivering by cesarean section;
   
2. A highly-medicalized and regulated birth where you have little or no decision-making power;
   
3. A premature baby. (By premature, I mean a baby born before it is ready; since we do not know when that date would have been, it is safe to assume that all babies born before that point are, to some extent, premature.)
   

The most important part of prenatal care

So, you're pregnant, for the first time -- congratulations!

You go to your prenatal appointments. You're gathering supplies and cute clothing for your little one. Maybe you're picking out the perfect crib, changing table, rocker with matching footstool. You're filled with tender visions of motherhood.

Maybe you can already feel the tiny being moving around inside your abdomen. It's magical.

Your doctor assures you that everything is normal. You continue along in your pregnancy.

As your birth looms closer, your excitement grows. So does the realization that this baby, which seems impossibly huge in late pregnancy, must come out of your body somehow.

You will probably begin to hope that your labor will begin early. This means that not only will the baby be smaller, but you'll spend less time feeling as large (and agile) as a barn. Inductions, stripping the membranes, anything you may be offered at your doctor's office to speed the onset of labor, sound sweet.

What will happen in your labor is an unimportant mystery -- after all, isn't that why you have a doctor? Whatever happens will be fine, because your doctor and nurses will make sure that you come home with a healthy baby, and that is the very most important thing.

..

Except it isn't.

..

You will find that how your baby comes into the world, and how you feel about it, matter tremendously. You might be asked to make decisions you don't understand. You will experience new sensations and emotions and not know if they are normal or aberrant. You might feel afraid, insecure, discouraged, or foolish.

On the contrary, you have the opportunity to experience your birth as a wonderful and normal passage. You can feel comfortable, even in the midst of unfamiliar sensations. You can be confident in your knowledge that you are where you should be, that what you are experiencing is normal and good, and what to expect to come shortly. You can bring your baby into the world, fearless and radiant, with no sense of unease to cloud your joy.

..

Does it depend on whether or not you had an epidural?

Not at all.

All this hinges on your education. Do not miss the opportunity to learn about childbirth. You need to know what will happen, to become very knowledgeable about what is normal and what is outside the range of normal.

Whether or not you choose pain medication does not ultimately matter. You will do what you feel comfortable with, and education may or may not change your course of action in that respect.

But if you arrive at the hospital in labor, are examined and found to be 3 centimeters dilated, and the care practitioner offers to break your waters, what will you choose? There are consequences to early rupture of the waters, not all of which may be disclosed to you in that moment.

If you are told that you need to be induced because of a large baby, what will you say? Do you know how the measurements were made and how accurate they may be? Why does the doctor want to induce for a large baby anyway? Is induction safe?

If the baby's heart rate drops to 100 bpm for a moment, is there something seriously wrong? What will the medical staff do? What does it mean?

Are you prepared to make these decisions?

Do not miss your classes. If you find you still have questions, find out. There are plenty of resources, and for most things, there is reliable, studied information available. Read about birth until you are weary of reading because you know the subject so well.

Prepare yourself.

What happens in your birth, and how you feel about it, matters tremendously.

"I have a doctor; why would I need a doula?"

The roles of doctors and doulas are in different spheres.

Your obstetrician is there to monitor your health and your baby, look for signs of presenting problems or issues, and handle all medical aspects of your care.

When you are in labor, you will typically see your doctor briefly during labor and then when you are pushing out your baby. The doctor is present for a very small percentage of the time you will spend giving birth to your baby.

You will see more of your nurse or nurses (depending on when you are at the hospital, and for how long,, taking shift changes into account). The nurse will come in to check on you, maybe check dilation through a vaginal exam, ask you to rate your pain on a scale of 1-10, take blood pressure, take a lot of notes, and then leave to do it again for however many women are laboring on the same floor as you.

Some nurses are better than others at attending women in labor and giving them help and personalized care. Many have a practical, businesslike approach to caring for laboring women. Some are downright harsh to their patients. Most are too busy.

The hole left between medical visits is what's filled by a doula. Doulas are not medically trained and will not perform vaginal exams to check dilation or blood pressure measurements, but they will remain with you at all times.

Doulas give constant emotional support. They can explain to you what is happening, help you maintain your focus and keep you grounded. They can help with positioning and comfort. They know your intentions and help to communicate them to staff and gently remind you of your goals if needed. They are there to help you have a safe and satisfying birth experience.

This is not the role of the doctor or the nurse. The nurse's priority is the hospital protocol and communicating with the physician. The doctor's priority is the health of the baby and the mother. The doula's concern is your happiness, comfort, and helping you have the birth you want.

No matter what kind of birth you desire, you can benefit from having a doula present. We do not replace the nurse or your partner; we are simply an extra pair of hands and a caring heart to help and encourage you through this amazing rite of passage.