Thursday, June 18, 2009

Finding the Right Practitioner

If you are hoping to attempt a VBAC it is crucial to find a caregiver who is supportive, encouraging, and trusting of VBAC's. They should also be knowledgeable and experienced in VBAC deliveries. It is important that your caregiver be comfortable and confident in order for you to feel safe and trusting in them and their judgement. Unfortunately it is becoming more difficult to find a caregiver who will offer the choice of a VBAC. I feel this is because of the fear of lawsuits and the high cost of insurance doctors and hospitals have to pay if they are doing VBAC's, not to mention the money they make by preforming surgery instead of allowing VBAC. I of course personally prefer midwives but there are good VBAC doctors out there as well. I suggest taking the time to interview a few different practitioners to compare their responses and attitudes to really have a better feeling as to which one is really going to help you the best to achieve the birth you desire.. Discuss with them your desire to have a VBAC, your goals and preferences and find out their philosophies, experience, success rates, and how they will work with you to have the birth you desire. If their responses don't satisfy you, or they don't seem like they would be supportive of your decision, if they have too many protocols to follow, etc..I would suggest finding someone who is a better fit. Also if you have different hospital choices or birth centers I encourage you to visit them and find a place you would be most comfortable in.

Sometimes doctors seem supportive but as time goes on they change their tune. I have heard many stories of this happening. Hopefully if you get that feeling you will be able to change and find someone who truly is supportive. I had a friend who did that in her last trimester and was so grateful she did. So how do you go about finding one who is truly pro-vbac? Here are some things to keep in mind when first meeting your caregiver:

  • They should believe that women should labor unless there is a medical reason not to, and talk about the benefits of labor for the mom and baby.
  • They should respect the woman's right to make the ultimate decisions about their birth.
  • They should view pregnancy and birth as a natural process, not treated or viewed as a medical condition.
  • They do not have policies that discourage VBAC such as having a "big baby", gestational diabetes, pregnancy going past 40 weeks.
  • They should have a high success VBAC rate of 70%.
  • They should show acceptance of your choice to have a doula present if that is what you want.
  • They should not routinely use interventions during labor.

To understand their views on the above subjects here are some good interview questions to ask:
I got most of these off of the ICAN website.
  1. What are your beliefs about birth and prenatal care in general?
  2. What are your beliefs about VBAC births and prenatal care?
  3. How do you feel about VBAC delivery? Do you support VBAC?
  4. Do you feel a VBAC is a safe option for women?
  5. Approximately how many VBACs have you attended?
  6. Of those patients in your practice who wanted a VBAC, how many were successful?
  7. What do you think my chances are of a VBAC success, given my childbirth history?
  8. What is your rate of cesarean sections and under what circumstances do you usually advise them?
  9. Are VBAC patients treated any differently than patients who have never had a c section?
  10. Who is your back-up? Is he/she VBAC friendly? Would he/she support my birth plan?
  11. What hospital(s) do you have privileges at? (Which would you recommend for a VBAC?) (Natural birth?)
  12. What book(s) would you recommend that I read?
  13. Are you familiar with ICAN?
  14. What prenatal tests/procedures do you usually require? Recommend?
  15. What do you think of Birth Plans/ Preferences?
  16. How do you usually manage a postdate pregnancy? Or a suspected Cephalopelvic Disproportion (CPD)?
  17. Do you have a vacation scheduled near my estimated due date?

Questions regarding Labor & Delivery

  1. What’s a reasonable length of time for a VBAC labor if I’m healthy and my baby appears to be healthy?
  2. Do you know any kind of restriction I should expect from the hospital on a VBAC? (Who do I need to have policy exceptions approved through?)
  3. How many people can I have with me during the labor and birth?
  4. How do you feel about doulas?
  5. What is your usual recommendation for IVs? Pitocin? Confinement to bed?
  6. What’s your approach if the bag of waters has broken at full term but the mothers feels no contractions?
  7. How often do women in your care give birth un-medicated? How many with minimal medication? In what percentage of your patients do you induce labor?
  8. Approximately how many of your patients have un-medicated births?
  9. Do you do breech deliveries?
  10. What would you suggest if I had another breech baby? (Before labor? During?)
  11. At what point do you arrive at the hospital during labor/delivery?
  12. What labor positions do you recommend to your patients? Do you encourage movement during labor?
  13. How much fetal monitoring do you routinely use during labor? Intermittent?
  14. Do you allow light eating/ drinking during labor? Does the hospital?
  15. Are you OK with No IV – but a Hep Lock?

Increase your VBAC chance--Decrease Cesareans

Even though about 80% of women have successful VBACs I think it is important to be proactive to help increase your chance for VBAC and decrease your chance for a repeat c-section. We shouldn't just sit back and hope for the best, but seek out ways to improve our chances and be prepared.

I think the most important way to increase your chance for a successful VBAC is to find a doctor or midwife that 100% supports and encourages your decision. They should be offering advice on how to be successful and not focus on what would cause you to not be successful. Some doctors might be tolerant of your decision or say "well, you can try" while others help you realize that you can do it! Those that are "tolerant" are usually either looking for reasons/excuses to end up with a c-section or if anything seems at all "abnormal" might just end up saying you need to have the c-section. I have even heard of some that seem supportive, only in the last couple weeks of pregnancy totally change their tune and recommend a c-section. When that happens many women feel it is too late to change doctors so end up with the c-section they were trying to avoid and often times was not necessary. It is important to take the time to interview a few different people and to ask the right questions so you can really see what their philosophy is. Don't just end up with someone because you used them before or your sister/friend uses them and says they are good, or they are the closest, etc. To increase your chances it is necessary to find just the right person. I highly recommend midwives but also know there are some great very pro-VBAC doctors as well. You might even consider hiring a doula to help and support you through your delivery.

In my research I found these other tips to also better your chances of having a successful VBAC.

  • Wait at least 9 months before trying to conceive again, even longer is better: I think I was actually told wait a year before trying to get pregnant again while others say even 18 months. I know the longer you wait allows your scar to heal better and become stronger, which is what you want to help decrease any chances for problems with the scar that could lead to complications and a c-section.
  • Avoid induction of labor, whenever possible: My research said that induction agents can increase the risk of uterine rupture. Along with that though is that inductions significantly increase the likelihood that you will end up with a c-section---this is true in any vaginal birth, not just VBAC. Because you don't want to be induced you need to find someone who will not pressure you to be induced due to being "overdue" or for having a "big baby". If for some necessary medical reason you need to have labor induced you should avoid the cervical ripening agents such as prostaglandin found in Prepidil, Cervidil, Cytotec.
  • Avoid use of synthetic oxytocin (Pitocin or "Pit") early in labor:
  • Avoid interventions: Some of these were listed above but the more interventions that happen during any birth have greater likelihood for ending up with a c-section.
  • Wait until your cervix is beginning to open to be admitted: You are less likely to have a VBAC if you are admitted before your contractions are well-established. If you go to the hospital before labor is under way the more interventions are usually pushed on you as well. Also some hospitals have time limits for how long they allow VBACers to labor.
  • Avoid epidurals and spinals: A common side effect of these pain relievers is that they slow down the baby's heart rate. This is also a symptom of uterine rupture so even though it most likely would be the side effect of the drug most doctors would push for a c-section whenever the heart rate drops even when they are unsure of the cause. I had my baby naturally and there are many techniques, positions, etc. that can ease the pain. I will talk more about these in another post.
  • Work on a healthy diet and exercise: The stronger our body is will help during the hard work of delivery. I already talked about the diet changes my midwives suggested but I will list them again: going off sugar, limiting wheat and carbs, no milk, lots of protein, taking magnesium.
  • Healthy mental well-being: Take the time to process and work through whatever emotions you went through after your c-section. Don't ignore or suppress them. Visualize the whole labor, pushing, and delivery with the beautiful outcome of a precious baby and a successful VBAC. Positive outlook can do wonders for the mind and body.

Friday, June 5, 2009

VBAC risks

Of course the main risk everyone hears about is the risk of uterine rupture. This is what most doctors bring attention to, unfortunately sometimes too much. Yes, this is a real and serious risk but as I have said before the risk is less than 1%. Since I want us all to be informed this is an important topic to discuss.

So what is uterine rupture anyways? There are different degrees of rupture. The least likely is a complete rupture. A complete uterine rupture is a tear through the full thickness of the uterine wall, usually at the sight of the previous c-section scar. A minor rupture is also known as a dehiscence or window. This is when the opening is very small or does not go through all the layers of the uterus.

If this occurs it is serious and potentially, though rarely, life threatening to the mother or the baby and needs to be taken care of right away. The rupture can take place during labor or even before. A rupture can also happen in women who have never had a previous c-section.

Usually there are warning signs before a rupture occurs but not always. Some warning signs include: vaginal bleeding; sharp pain between contractions; contractions that slow down, become less intense, or stop; abdominal or uterine pain; bulging under the pubic bone; sharp pain at sight of scar; low blood pressure; fetal distress; fundus may feel "boggy" or seem to be expanding; the baby can be clearly felt in the abdomen; woman in shock; extreme maternal heart beat.

Some of these warning signs occur anyways during birth but it is something to pay attention to and to be aware of. Also women might experience some, all, or none of these warning signs.

Though rare it can be serious and cause minor to major complications. When medical response is quick usually mother and baby do well. It is wise to have surgery available within 30 min for the best outcomes. In minor dehiscences there is usually no risk to the mother or the baby. For ruptures, they can happen in the lower segment of the uterus, the upper segment or where the two join. A rupture in the upper segment is the rarest but also the most serious because the baby could leave the uterus and move into the abdominal cavity and it has the most blood supply so the mother would lose the most blood and the baby would be deprived of oxygen. More likely the rupture would be in the lower segment where the baby still stays in the uterus and the mother loses less blood. Both of these would require an emergency c-section.

Fortunately if a rupture occurs mother and baby are usually fine. If a rupture occurs with excessive bleeding a clamp of an artery is needed and in some serious cases the woman might need a hysterectomy. In extreme cases when the bleeding can't be stopped a woman can go into cardiac arrest and death can occur. For the baby due to loss of oxygen brain damage can occur along with the rare risk of death.

Remember there are risks in any birth, c-section or vaginal. Although rare, death and serious complications can also happen during any birth. I found a website that put it all in perspective for me. The website is Here are some statistics from that site.
Risk of mother dying due to uterine rupture during VBAC---.0095%
Risk of mother dying in any vaginal birth---.0098%
Risk of mother dying during c-section---.0409%
Risk of mother dying during repeat c-section---.0184%
Risk of baby dying due to rupture during VBAC---.095%
Risk of baby dying during any VBAC---.2%
Risk of baby dying during any type of birth---.12%

So as you can see the likelihood of a fatal outcome of a uterine rupture is no higher than in any normal birth and actually a lot less than in c-sections. This is important to realize in case your doctor or anyone else stresses on the risks of uterine rupture in VBACs.

***Most of this info was taken from,1510,5926,00.html

Monday, June 1, 2009

Why not just schedule a C-section?

I realize this is a very personal choice and there are risks with both but after doing my research and learning about how there are more risks with a c-section I personally would never just schedule one. I explained before too that the only way for me to know if I could do it was to try.

Most women will be successful with the VBAC---80%. Even though my midwives never used a scoring system with me, I read that some doctors use a scoring system to try to figure out the likelihood of the patient ending up with a vaginal birth. The scoring goes from 0 (least likely) to 10 (most likely). This might be helpful but again I would be careful because of course it isn't always correct. Just because a doctor gives you a low likelihood score does not mean you can't succeed. The studies found that half the group that scored 0-2 still were able to have a VBAC.

So if the high success rate doesn't encourage you to try for a VBAC instead of just scheduling surgery there are a lot of other reasons I personally would not want a repeat c-section. Here is what the research shows:

  • There are increased physical problems for mothers: Compared to a vaginal birth, c-sections have increased risks for many physical problems from mild to severe. These problems include hemorrhage (severe bleeding), need for transfusion, blood clots, injury to other organs, bowel obstruction (due to scarring and adhesions from the surgery), anesthesia complications, scar tissue, longer-lasting and more severe pain, infection, increased risk of hysterectomy, psychological complications and maternal mortality 2-4x greater than vaginal birth.
  • Longer Hospital stays: Usually women need to stay longer in the hospital after a c-section and takes a lot longer to recover as well.
  • More expensive: C-sections cost a lot more even with having insurance. Average cost is twice the amount of a vaginal birth.
  • Issues with emotional well-being: I already mentioned how this can take a toll on your overall mental health and how after a c-section women are more likely to experience depression and even post traumatic disorder. She is also more likely to rate a birth experience poorer than a woman who has had a vaginal birth.
  • Mother-baby relationship: You usually don't get the chance to hold your baby until quite a while after surgery as compared to usually immediately after a vaginal birth. Even though I never experienced this many women have a harder time bonding with their baby.
  • Breastfeeding: Many times the recovery from surgery can cause challenges with breastfeeding and delays immediate breastfeeding along with having your milk come in later. I remember being in so much pain it was difficult to even find a position that was bearable.
  • Effects on babies: Studies have shown that many c-section babies experience added difficulties as well. Such as having breathing difficulties, greater chance of developing asthma and also being cut during the surgery, though usually mild. Also there is more chance that the baby is not ready to come out out yet when a c-section is done early and has issues concerning prematurity.
  • Impact on any future pregnancies: Some research suggests babies born after multiple c-sections are more likely to be preterm, have low birth weight, along with more serious and deadly complications. With each surgery there is more scar tissue which makes things more difficult as well. There is also higher rates of infertility, miscarriages and ectopic pregnancy.
So many times women are told how dangerous VBACs are and are encouraged to just have another c-section making it seem like there are not risks involved. As you can see there are many risks concerning c-sections and I think all doctors should carefully go over these with their patients.
***Most of this information was found on the and websites

Necessary C-sections

There are only a few medical reasons when a c-section would be medically necessary. These are having a prolapsed umbilical cord or placenta previa, the mother has an outbreak of genital herpes or the baby is lying in a transverse position.

According to, almost all care providers, including those who usually encourage VBAC, would strongly recommend planned cesarean in the following situations:

  • certain uterine scars from a cesarean that aren't the usual horizontal cut made at the bottom of the uterus (low transverse scar): In these rare situations, the concern is that the scar on the uterus may be weaker and more likely to give way (rupture) and cause serious problems than the usual cesarean scar.
    • a high cesarean scar that runs up-and-down (vertical or "classical" uterine incision): a vertical incision may have been used if you had a placenta that grew over the opening to your uterus (placenta previa), for some urgent cesareans, or in some cases previous baby was in a buttocks- or feet-first (breech) position. (It is possible to have a low horizontal scar on your skin but a vertical cut on your uterus.)
    • inverted T- or J-shaped incision
  • mother had previous uterine surgery for gynecologic problems, such as for removal of fibroid tumors
  • uterine scar opened and caused problems in a prior labor: The key point here is that the scar has caused problems before. Many times, scar openings are small, harmless "windows" (dehiscences). These windows are not thought to have any ill effects in future labors.
  • uterus does not have the usual pear shape: Examples of this are a heart-shaped (bi-cornate) uterus or a uterus that is partly divided down the middle (septate uterus).
  • ultrasound in late pregnancy finds that the area of the scarred uterus is unusually thin: There may be a concern if the scar is 2.5 millimeters thick (about the height of 2 stacked dimes) or less.