Birth Story: Heather’s VBA2C

January 9, 2018 by blog 13 Comments

Heather’s VBA2C Birth Story

(photo provided by Heather)

Birth story and photos shared by Heather M.; originally posted in 2014

During my last few prenatal visits, my provider had been getting more and more negative about my vba2c [vaginal birth after 2 cesareans]. I would hear comments like, “Oh, you are not dilated at all so you have a crappy cervix and might as well have a section now” (at 38 weeks). And “you are just too old, people over thirty rarely have babies naturally, let’s just do a section” (I was 31). So at my 39-week appointment when my fluid registered 5.8, I’m sure you can predict the comments… “your baby will die” and “you are a horrible and selfish mom.”

They never addressed the fact that I had been hospitalized for severe dehydration from stomach flu days prior. I elected to go receive fluids and tabled the cesarean discussion. The fluids did not bring my fluid levels up and I heard the same comments, despite a perfect score in every other way from the baby. They agreed to give me the weekend and let me be checked in three days. I decided then I was never going to be given a fair shake in the hospital and arranged for a monitrice to help me labor at home when it was time. She gave me suggestions to get my fluid up, which I followed all weekend. I went in on a Monday (at 40 weeks) and my fluid level was 8! The comments I then heard were, “well I still want to section you today, but now I guess I don’t have a reason.”

Monday came and went. Tuesday I tried an acupuncturist that had a 100% success rate of induction within 24 hours. Tuesday and Wednesday came and went. I would have contractions by the evening but in my sleep, they would all go away! As I showered Wednesday night I stayed in prayer for guidance. I was frustrated I hadn’t gone into labor and wasn’t sure I would. I was scared of the process and scared of failure. I suddenly began to sing a Casting Crowns song whose lyrics spoke to my soul, “The voice of truth tells me a different story, the voice of truth says do not be afraid, the voice of truth says this is for my glory, out of all the voices calling out to me, I will choose to listen and believe the voice of truth.” I know that was God answering my prayer and giving me reassurance in that moment that all would be well.

On Thursday I took a homeopathic remedy and went to the doctor. My fluid level was at 3. My doctor was in surgery but the nurse practitioner called her and she said I was to “rush” to the hospital. I knew if I went over there I would never get to leave. I knew if I had to labor there the whole time, I would fail. I proceeded to emotionally meltdown in front of the nurse, telling her all the hurtful things that have been said to that point and asking how I was to trust a doctor that clearly has their own agenda? (A question I know so many of you have felt at one point or another also!) Losing hope I would ever start labor on my own, I begged her to please give me an honest agenda-free evaluation of my baby’s health and safety of waiting.

The nurse put me on the non-stress test (NST) and after a good half an hour said that the strip was still reactive, the other markers were good, and I was contracting. Her guess was that I was in early labor (I was only at 1.5-2 cm dilated and 50% effaced). She said if I didn’t have a baby by the next morning I needed to go in for monitoring. Fair enough!

I left the office and went to lunch with my husband and toddler. I felt the contractions picking up steam, enough to make me want to go home and sleep… enough to give me hope this might be it, 40 weeks and 3 days in. We all went home and I laid on the couch all afternoon with my son and we watched Thomas on TV. I ate dinner and nursed my toddler to bed.

At 8 pm my doula came over and we walked. And walked. It felt amazing. The night air was perfect. Our air conditioner had broken hours before so I was contemplating just laboring in the front yard so I didn’t sweat to death.

We came home at 9 pm and I took a second dose of my remedy. With that, the contractions got intense. I told my husband, “if this is false labor, I quit!” That was the last thing I clearly remember saying (most of my labor I remember with dimmed senses, no concept of time, almost looking at my body from the outside). I know I labored on a ball in the living room, in the tub, and on the bed. I threw up. A lot. I had a lot of back pain, thank goodness for my doula and her counter pressure work! I labored and labored and labored. They checked my progress and I was 3 centimeters dilated. All I kept saying was ‘God help me.’ My midwife would say, “He is.” And he was…

Then what seemed like ten minutes later, but was actually hours later they checked me again and I was 5 cm dilated and it was time to go to the hospital. My friend came over to watch the toddler and my neighbor was in the kitchen frantically scrubbing dishes to help, or maybe to drown out my screaming, haha. She would later tell me “women get amnesia hormones after birth to forget the pain… but what do the women that have to listen to the women get to forget the pain?” 😉

My labor got intense fast, much more intense than the previous five hours had been. I climbed in the back of our minivan and my husband drove like the wind. We passed a cop going well above the speed limit while running red lights, but I guess they assumed a minivan driving like that at 3 am can only be going one place!

When we got to the hospital they had the orderly waiting. Oh, the poor orderly. He kept trying to push me and each contraction I would jump out of the chair. He would beg me to sit down and I would scream at him to let me stand. We finally reached an agreement that if he’d let me out of the chair to get through contractions, I promised I would not have the baby in the hallway. Haha. He was a young kid and I could tell he was terrified.

I got into the room around 3:30 am, checked, and I was at 7cm. I was really dehydrated from throwing up all night and needed some fluids. The nurses tried and tried and tried. They finally got an IV in. While most people would beg for an epidural at this point, I begged for some Pepcid. My heartburn this pregnancy was brutal and at that moment my heartburn was slowly killing me far worse than a contraction ever could. I labored on the yoga ball for a while until the doctor came in.

The doctor started pressuring me to get internal monitors. I said no way because until that point the only people that had been watching the external ones were my monitrice and doula! I said I didn’t want my water broken and they kept telling me I only had 3cm to go so it wouldn’t matter and that it had most likely already broken anyway. I argued for what seemed like an eternity but was really minutes, that it hadn’t and that I wasn’t having it broken until it was good and ready.

Labor was very intense at this point. I remember looking at my husband and either saying or just thinking, “I’m dying, tell our son I love him.” With that, the doctor wanted to check me. I was at 9cm and 100% effaced. I sat up for a contraction, my water broke (told ya!), I threw up and her head hit the table I was sitting on. I screamed, “I have to push her out.” They laid me back and people flew into action. Lights came on. Tables of supplies appeared out of nowhere. We went from 2 nurses and a doctor to a room full of people. I have literally never seen so many things or people appear out of thin air in my life. I had been there just under an hour at that point and I don’t think anyone expected it to go that fast, except my monitrice and doula. I think they knew things were picking up when we left the house!

I laid back and we practiced pushing for a few contractions. I had no idea how to push, this was the first time I ever tried to labor! The doctor told me her head was right there and with one good push, she would be out. I was so tired, I wanted to be done and wanted to meet my baby, so I gathered every ounce of energy I could find. I dug deep down into my spirit and fire in my belly and pushed with all I had. Out came her head. One more push and out came my baby girl. They placed her directly on my chest and I saw her perfect little eyes looking at me.

VBA2C birth story

(photo provided by Heather)

To this day, a year later, when I look at her I still see her newborn eyes looking up at me for the first time. We have a connection that is unbelievably close and I know the natural birth has something to do with that.

I am so completely grateful for the opportunity to have had her naturally, to have had a healthy baby, and to have had so many people supporting the VBA2C along the way! I found ICAN through a local Facebook group. The community was a vital part of the process in supplying ideas on talking with providers about controversial things (my VBA2C was very controversial!) and with ideas on how to raise my fluid level at the end. It was also how I was connected to the monitrice I ended up using to labor at home with. Without this group, I would have never known that this was a possibility and I don’t think I would have been successful in having an intervention free birth if I had labored at the hospital the whole time.

VBA2C birth story

ICAN Addresses ACOG Practice Bulletin 184: Vaginal Birth After Cesarean Delivery

November 3, 2017 by blog

announcement

We, the International Cesarean Awareness Network (ICAN), would like to address the recent publication of Practice Bulletin 184 from the American College of Obstetricians and Gynecologists (ACOG), titled: “Vaginal Birth After Cesarean Delivery”. ICAN 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 (VBAC).

ICAN is hopeful that ACOG’s new VBAC guidelines will enable more maternity care consumers to find the support and evidence-based care that they need and deserve. Multiple statements throughout Practice Bulletin 184, such as “Coercion is not acceptable”, and “Global mandates for TOLAC are inappropriate because individual risk factors are not considered”, lead us to believe ACOG is working to decrease the widespread hospital VBAC bans that currently exist in the United States. As ACOG states, “respect for patient autonomy also dictates that even if a center does not offer TOLAC, such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery”. While ACOG also expresses understanding that some facilities may still choose to mandate surgery for patients with a history of prior cesarean(s), they made sure to add that “patients should be allowed to accept increased levels of risk” (eg, make their own choice), and stated that “none of the principles, options or processes outlined here should be used by centers, obstetricians or other obstetric care providers, or insurers to avoid appropriate efforts to provide the recommended resources to make TOLAC available and as safe as possible for those who choose this option”.

While we are encouraged by ACOG’s apparent stance that VBAC bans should not limit a patient’s right to informed consent and informed refusal, we are discouraged that they also chose to continue their hard stance against out-of-hospital VBAC. In their “Summary of Recommendations”, ACOG cited their recommendations regarding out-of-hospital VBAC as stemming from “consensus and expert opinion”, which is “Level C”. Maternity care consumers choose out-of-hospital birth for a variety of reasons. For example, if a local hospital mandates surgery for all patients with a prior cesarean, some may feel their only option is to birth out-of-hospital. ICAN supports a person’s right to choose their preferred birth location.

We greatly appreciate ACOG’s clarification regarding Level 1 facilities. ACOG, along with the Society for Maternal-Fetal Medicine, described Level 1 facilities as those that “can provide basic care”. They also stated that although there is reason to think rapidly available cesareans can provide “small incremental benefit in safety”, there is no data available to compare “alternate systems and response times”. We are hopeful that this clarification may effect change among Level 1 hospitals with existing VBAC bans.

Possibly the most unexpected addition to this bulletin is the frequent mention of web-based VBAC calculators. In January of 2017, an article titled: “Validation of a Prediction Model for Vaginal Birth after Cesarean Delivery Reveals Unexpected Success in a Diverse American Population”, discussed the accuracy of the MFMU web-based VBAC calculator. The MFMU VBAC calculator appears to be the calculator that is most widely used among medical professionals. This study found that when using the MFMU VBAC calculator, predicted rates were “highly accurate” for those patients that received predicted “success” rates over 65%. However, for the patients that received predicted “success” rates of less than 35%, the study found the actual VBAC rates were nearly “twofold higher” than the predicted rate. In addition, ACOG clearly states that “no prediction model for VBAC has been shown to result in improved patient outcomes.” ACOG points to using individualized care several times in Practice Bulletin 184, but VBAC calculators do not take individual circumstances into consideration. For example, a previous diagnosis of ‘Failure to Progress’ can be attributed to many issues, one of which being simply a failure to wait. In ACOG’s Obstetric Care Consensus, titled: “Safe Prevention of the Primary Cesarean Delivery”, they stated that “studies that have evaluated the role of maternal characteristics, such as age, weight, and ethnicity, have consistently found these factors do not account fully for the temporal increase in the cesarean delivery rate or its regional variations”. We feel that by encouraging physicians to use web-based VBAC calculators, we may see a decrease in the rate of TOLAC, and subsequently a decrease in the rate of overall VBAC.

Multiple criteria are used in the development of web-based VBAC calculators, including maternal age, body mass index, prior vaginal delivery, and race, among others. The paragraph in Practice Bulletin 184 that discusses “obesity”, leaves a final sentence that states patients who have a BMI of “30 or greater may be candidates for TOLAC, depending on their other characteristics (eg, having had a prior vaginal delivery), and their care should be individualized”. If ACOG’s intention was not to limit options for people with a BMI over 30, we question why they chose to include the words “may be candidates” while adding an example of “having had a prior vaginal delivery”. We strongly feel this statement may lead some physicians and midwives to decrease access to TOLAC for those with a BMI over 30, that have not had a prior vaginal birth. According to ACOG, cesarean delivery poses a greater risk of “infection, bleeding, and other complications” for an “obese woman” than for someone with BMI in the normal range.

ICAN as an organization strongly opposes the use of a patient’s race in VBAC calculators. There is a lack of scientific evidence that offers an explanation of why race is included in the calculations. Until peer-reviewed research examining correlations between race and mode of delivery provides something other than results such as “possible physician bias”, or “cross-cultural differences”, race should not be part of the criteria used to estimate the probability of vaginal birth. Race has not been conclusively determined to be a causation versus correlation for higher risk of repeat cesarean, but instead appears to be due to societal issues, including systemic racism in the medical system. Our society is ethnically and racially diverse. We challenge ACOG to develop a culturally informed maternity care response to the rising cesarean rates among all people, but specifically among People of Color.

In December of 2016, ACOG clarified their stance on Vaginal Birth After Two Prior Cesareans (VBA2C), stating: “Most women with two previous low-transverse cesarean deliveries are candidates for and should be offered TOLAC and counseled based on the combination of individual factors that affect their risk and probability of achieving a successful VBAC”. With the amount of available data showing similar rates of attempted TOLAC turned VBAC between those with one prior cesarean, and those with two prior cesareans, and the studies showing similar, to a 1-2% increase in risk of uterine rupture, we are disappointed that Practice Bulletin 184 did not reflect the 2016 clarification wordage.

For maternity care consumers with Special Scars (classical, prior rupture, j-shaped, inverted T shaped, etc…), finding a care provider willing to accept the patient’s right to bodily autonomy can be extremely difficult. We feel Practice Bulletin 184 will not help these patients regain their right to “accept increased levels of risk”, or to exercise their right to give informed consent. As stated in “Safe Prevention of the Primary Cesarean”, childbirth “by its very nature carries potential risks for the woman and her baby, regardless of the route of delivery”. We agree with ACOG that pregnancy is “not an exception to the principle that a decisionally capable patient has the right to refuse treatment, even treatment needed to maintain life. Therefore, a decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected”. We feel ACOG’s label of contraindication regarding people with special scars attempting TOLAC will limit the patient’s ability to exercise their right to give informed consent and informed refusal. We do, however, thank ACOG for their continued support of TOLAC for people with a prior low-vertical incision.

The International Cesarean Awareness Network supports a person’s right to choose their preferred birth location and mode, and to choose who will provide their prenatal and delivery care. We believe it is imperative that the public becomes educated on their rights and options in childbirth, and on the risks involved with each option. A person cannot give true informed consent without first being given unbiased counseling regarding the risks and benefits of all options. Patients should be their own best advocate, and that involves researching and studying childbirth, and human rights in the medical system. We greatly appreciate the time ACOG put into updating their VBAC guidelines, and we are extremely hopeful that this information will provide greater access to evidence-based care for most people. We challenge ACOG to reconsider its endorsement of web-based VBAC calculators by evaluating the effect it will have on all people considering a TOLAC, especially People of Color and People of Size, to publicly restate their previous clarification on VBA2C- that “most women with two previous low-transverse cesarean deliveries are candidates for and should be offered TOLAC and counseled based on the combination of individual factors that affect their risk and probability of achieving a successful VBAC”, and to reconsider their stance against planned VBAC for those with special scars.

International Cesarean Awareness Network

Board of Directors

Lindsey Seger, President

Justen Alexander, Vice President

Samantha Wall, Secretary

Ann Marie Walsh, Chapter Director

Brianna Barker, Advocacy Director

https://www.acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery

https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Ethics/Refusal-of-Medically-Recommended-Treatment-During-Pregnancy

https://www.ican-online.org/huntsville/2016/12/15/should-mothers-be-denied-option-of-vba2c-acog-clarifies/

https://www.acog.org/Patients/FAQs/Vaginal-Birth-After-Cesarean-Delivery-Deciding-on-a-Trial-of-Labor-After-Cesarean-Delivery

American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins-Obstetrics, & Grobman, W., MD. (2017). Vaginal Birth After Cesarean Delivery. Clinical Management Guidelines for Obstetrician-Gynecologists, 130(5), practice bulletin 184.

Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:693–711.

Refusal of medically recommended treatment during pregnancy. Committee Opinion No. 664. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e175–82.

Vaginal Birth After Cesarean Delivery – Deciding on a Trial of Labor After Cesarean Delivery. Frequently asked questions. Labor, delivery, and postpartum care. FAQ070. American College of Obstetricians and Gynecologists. https://www.acog.org/Patients/FAQs/Vaginal-Birth-After-Cesarean-Delivery-Deciding-on-a-Trial-of-Labor-After-Cesarean-Delivery. 2011 August.

“ICAN of Huntsville » Should Mothers Be Denied Option of VBA2C? ACOG Clarifies.” ICAN of Huntsville, ICAN of Huntsville Leadership, 15 Dec. 2016, www.ican-online.org/huntsville/2016/12/15/should-mothers-be-denied-option-of-vba2c-acog-clarifies/.

Should a Woman’s Ethnicity Decrease Her Access to Birth Mode Options?

January 12, 2017 by Vice President

If you have ever wondered what the leadership of your local ICAN chapter does, the following is a good example of our work to promote ICAN’s mission of improving maternal-child health by reducing unnecessary cesareans through education, providing support for cesarean recovery, and advocating for vaginal birth after cesarean (VBAC).

Recently, in September 2016, an ICAN of Huntsville co-leader was made aware of a situation where a local office had interpreted ACOG’s Practice Bulletin 115 in such a way that did not favor offering a trial of labor after cesarean(s) to women of Non-White ethnicity. The table labeled “Selected Clinical Factors Associated With Trial of Labor after Previous Cesarean Delivery Success”, from ACOG’s Practice Bulletin 115, was cited as the source for the office’s decision. After several days of research, our team discovered many studies citing unknown sources for the decreased chance of VBAC success associated with being of Non-White ethnicity, and even some that cited possible “Physician Bias” as the source. Since we could not get definitive answers through published peer-reviewed research, the aforementioned co-leader contacted ACOG directly, in order to gain clarification on the intended use of the table titled “Selected Clinical Factors Associated With Trial of Labor after Previous Cesarean Delivery Success”. We would like to share their response with you, in order to ensure maternity care consumers are fully informed about Practice Bulletin 115.

The question our co-leader submitted to ACOG on September 7, 2016, is provided below:

Dear ACOG Medical Library,

My name is . . . , and I spoke with one of the Medical Librarians this afternoon. This email is in regards to an ICAN of Huntsville chapter member who is . . . pregnant and was told she would not be “allowed” a trial of labor at this practice because of her race and having two prior cesareans. Due to her situation, and that of one of the ICAN co-leaders of our chapter, the practice has created a new policy stating all . . . doctors MUST sign off on a trial of labor after two cesareans, before a mother is “allowed” to have a trial of labor with the assistance of a doctor from that practice. We are writing to get clarification on Practice Bulletin 115, since it was used as the reason for denying this woman access to a TOLA2C. This office has some form of “check-list” that is being used to determine ideal candidates for VBAC and VBA2C. Two of the items on this list are 1. Number of prior cesareans, and 2. Non-white ethnicity.

Were the tables showing decreased success rates for certain subsets meant to reduce access to TOLAC or TOLA2C to those subsets of women?

This paragraph lists factors that negatively impact likelihood of VBAC, but does not list “non-white ethnicity”.

“Most published series of women attempting TOLAC have demonstrated a probability of VBAC of 60–80% (4, 5, 12–14, 22, 23). However, the chance of VBAC for an individual varies based on demographic and obstetric characteristics (see box). For example, women whose first cesarean delivery was performed for an arrest of labor disorder are less likely than those whose first cesarean delivery was for a nonrecurring indication (eg, breech presentation) to succeed in their attempt at VBAC (37–43). Similarly, there is consistent evidence that women who undergo labor induction or augmentation are less likely to have VBAC when compared with those at the same gestational age with spontaneous labor without augmentation (44–47). Other factors that negatively influence the likelihood of VBAC include increasing maternal age, high body mass index, high birth weight, and advanced gestational age at delivery (44, 48–54). A shorter interdelivery interval and the presence of preeclampsia at the time of delivery also have been associated with a reduced chance of achieving VBAC (55, 56). Conversely, women who have had a prior vaginal delivery are more likely than those who have not to succeed in their TOLAC (44, 57).”

But, the box labeled “Selected Clinical Factors Associated With Trial of Labor after Previous Cesarean Delivery Success” DOES list “non-white ethnicity” as a factor leading to a decreased probability of VBAC success. What evidence led you to add “non-white ethnicity” to that list, and why was it not mentioned in the text? Were these meant to be items to counsel women on so they know their risks vs benefits, or were they meant to be exclusionary items used to decline access to TOLAC and TOLA2C?

If a woman seeking a TOLAC or TOLA2C is not an “ideal candidate” based on information in the above paragraph from PB115, should she still receive full counseling on risks and benefits of both VBAC or VBA2C, and also ERC (elective repeat cesarean), and then be allowed to give her informed consent or refusal, regardless of physician recommendation?

On September 27, 2016, ACOG replied with the following:

Hello,

The Practice Bulletin described clinical and other characteristics associated with a vaginal birth among those undergoing a trial of labor so that patients and providers can have an informed and shared conversation about plans. The list, in general, and non-white race, specifically, was not intended to be used at a facility level to decide if trials of labor would be supported. In this regard, the document does not suggest a specific chance for vaginal delivery above or below which a trial of labor should be planned or prevented. While studies have associated non-white race with a decreased chance of vaginal delivery among women undertaking a trial of labor, ACOG does not support using race to exclude any women from the option of a trial of labor.

We continue to monitor VBAC and TOLAC studies and literature. If there are any changes to ACOG guidance, it will be published in the Green Journal. Please reach out anytime you have any questions- happy to move it through our experts.

Have a great day!

American College of Obstetricians and Gynecologists

Thankfully, ACOG was quick to respond with their intended interpretation of Practice Bulletin 115, in order to end any confusion that may have occurred. We are so grateful for ACOG’s willingness to respond to our questions and are hopeful it will help the women in this country have greater access to evidence-based care.

Sincerely,

ICAN of Huntsville Leadership Team

* For privacy reasons, names, personal information have been removed. ACOG has reviewed and approved of this blog post.

Please follow these links for more information from ACOG on VBAC:

You can contact ACOG at Practice@ACOG.org if you have any questions or concerns regarding a trial of labor after cesarean.

Why is our VBAC Rate So Dismal?

December 19, 2016 by blog

vbacpost_

Improving VBAC Success Through the VBAC Evaluation

Katie Gaither had her first cesarean in 2004 for breech presentation. She got pregnant again shortly after that birth. She was told she had a high chance of uterine rupture and that she wouldn’t find a provider who would agree to a trial of labor after cesarean (TOLAC). Just 13 months later, she had her second cesarean. Fast forward 10 years, and Katie was pregnant again and she found she was still having trouble finding a doctor who would support her desire for vaginal birth after cesarean (VBAC).

In June of this year, the CDC published the National Vital Statistics Report entitled, “Births: Preliminary Data for 2015.” The report indicated a national cesarean delivery (CD) rate of 32.0% in 2015, a drop from a peak of 32.9% in 2009 and the lowest level since 2007. While this slight decline is considered good news by those who are actively addressing the US Cesarean “epidemic,” the fact remains that over 1 in 3 women will give birth surgically. The majority of women who have a CD and have more children afterward will go on to have a repeat CD. A 2008 report by the CDC reported that 92% of women have a repeat cesarean, for a VBAC rate of a dismal 8%. There are many provider, hospital and regional variations in cesarean and VBAC rates, with Mississippi having a cesarean rate of 37.7% and Alabama having a VBAC rate of just 4%.

Many professional organizations have expressed concern about the escalating cesarean rate, including the Society for Maternal-Fetal Medicine and the American Congress of Obstetricians and Gynecologists (ACOG), who released a joint statement in 2014 acknowledging that while CD can be life-saving, “the rapid increase in cesarean birth rates from 1996 to 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused.” A patient approach to normal labor, especially in nulliparous women, and avoiding elective induction were recommendations of ways to prevent a primary CD. Margaret Willbanks’ doctor induced her first labor just two days after her due date. Her membranes were ruptured when she was 1 cm dilated and Pitocin was started. Her labor never progressed and she was taken for a cesarean. Afterward, she was left wondering why her body failed her and the suspicion that her provider’s upcoming vacation caused her to be rushed along when her body wasn’t ready. With Margaret’s next pregnancy she noticed that every time she brought up VBAC, she was told it was unlikely that she would have one. Knowing through her own research that she had no specific risk factors, she switched providers twice before finding someone willing to support her desire to give birth vaginally. Margaret regretted that she didn’t know anything about her doctor’s personal cesarean rate during her prenatal care.

While preventing the first cesarean delivery is of great importance, many public health experts, providers and patient advocates agree that supporting VBAC in women who are suitable candidates is an equally important goal. In 2010, the NIH convened a Development Conference on the subject of VBAC and generated a Consensus Statement that reviewed much of the data regarding elective repeat cesarean delivery (ERCD) and TOLAC. The Consensus Statement recommended that women undergo extensive counseling regarding the risks and benefits of ERCD & TOLAC, suggested that trial of labor was a reasonable option for many pregnant women with a history of a prior CD, and expressed concern about barriers by clinicians and facilities that such women face. The NIH Conference was followed on its heels by a revised ACOG Practice Bulletin on VBAC which stated that most women with a prior low transverse CD “are candidates for and should be counseled about VBAC and offered TOLAC.” The Bulletin went on to say that women with two prior CDs could also be counseled regarding VBAC in light of their individual risk factors. ACOG also acknowledged that its own prior guidelines had in many cases made TOLAC prohibitive for many facilities and patients and reiterated that women could not be forced to have a CD against their will even if a provider or facility were unwilling to offer VBAC (a VBAC “ban”).

Unfortunately, this evidence-based support for VBAC has not translated into clinical practice in an appreciable way. Many women are still being given one-sided counseling with an emphasis on the risk of uterine rupture with a TOLAC and little, if any, acknowledgment of the risks of surgical delivery, especially in women who want a larger family. According to a recent journal article in the Lancet, the US maternal mortality rate (MMR) has risen from around 8 of 100,000 live births in 1987 to 18.5 in 2013. While older or sicker women becoming pregnant is often the reason given for this change, the risks of surgical delivery such as venous thromboembolism and increased risk for obstetric hemorrhage have contributed to the rising MMR. Abnormal placentation such as placenta previa or accreta in a subsequent pregnancy after prior CD is also on the rise. Placenta accreta, where the placenta embeds in the uterus in the location of the previous cesarean scar, has risen from 1 in 4000 pregnant women in 1970 to 1 in 533. Placenta accreta is a potentially catastrophic complication that can result in hemorrhage, hysterectomy and even death. Each CD increases the risk of this scary complication, and in the presence of placenta previa (placenta covering the cervix), the risk of accreta can be 40% or higher with three or more cesareans. Even so, many women undergoing ERCDs are never counseled regarding these risks or asked questions about potential family size in the planning for route of delivery. While the implication given to many women is that VBAC is more risky due to the chance of uterine rupture (less than 1% with spontaneous labor and one prior LTCD), the reality is that each route of delivery has its own risks and benefits. Women would be better served to be given information about the different risks for each clinical situation, in the context of her own individual maternal health and obstetric risk factors. Jessica Yancy had two prior cesareans: one for breech, and the second was “automatically scheduled” because her doctor implied that VBAC was illegal in Oklahoma, her home at the time. When she became pregnant with her third, her research led her to learn the risks of multiple cesareans and she began looking for a VBAC-supportive provider.

To help women navigate often complicated and conflicting information, Lamaze International published “A Woman’s Guide to VBAC” on their blog, Giving Birth With Confidence, which aimed to provide women with a side-by-side informational comparison guide between VBAC and ERCD. Other websites like www.VBAC.com and www.VBACfacts.com are helpful resources for women who are considering pursuing a trial of labor. Pregnant women are sought-after healthcare consumers and just as they might research buying a car, can find out about their state or hospital’s cesarean rate by visiting www.cesareanrates.com and www.leapfroggroup.org/patients/c-section. Women can also ask about their provider’s own cesarean rate.

The International Cesarean Awareness Network (ICAN) is an educational support group which advocates for informed birth choices for women who have undergone cesareans. In 2011, I was honored to present a lecture at ICAN’s “Gateway to a Better Birth” conference in St. Louis, entitled “The 3 P’s of VBAC, Pregnant Woman, Provider, Proviso: Navigating the Waters.” This talk outlined the importance of evaluating every woman interested in VBAC on a case-by-case basis of risk factor assessment by way of a thorough “VBAC evaluation,” and encouraging women to have the option of pursuing VBAC-friendly providers and facilities including OB hospitalists, midwives, and doulas. Optimizing maternal health before and during pregnancy is essential and well as providing quality prenatal care, support and education with the final goal of reducing unnecessary interventions in labor.

The keynote to the ICAN conference was given by Dr. George Macones, MFM and Chair of the OB/Gyn Dept at Washington University and author of multiple journal articles in the VBAC literature. His keynote was called “Talk with Your Feet” where he encouraged women to pursue the chance to VBAC by changing providers or hospitals if necessary. Five years later, I’m excited to report that due to the implementation of the VBAC evaluation model in conjunction with VBAC-supportive OB hospitalists, Katie, Margaret, and Jessica all went on to have successful VBACs. Several more women in my practice have had successful VBACs and 5 out of 6 women who attempted VBA2Cs were successful. Actually, one woman has now had two vaginal births since her two cesareans. The woman who did not achieve VBAC was at peace with the outcome (uncomplicated cesarean) because she knew she had taken the opportunity to try. In spite of these successes, the statistics show that we have so much more work to do to reduce the cesarean rate and encourage VBAC in those women who want it. Let’s help providers and hospitals become aware of the evidence-based support for VBAC so that many more women than currently are can explore this important option.

*All names and medical information are shared with the patients’ permission.

Poppy Daniels, MD is an obstetrician-gynecologist in private practice in Ozark, MO. You can follow her @drpoppyBHRT on Twitter. She also had successful VBACs after two cesareans. You can read her birth story here.

Click Your Way to the Best Info: finding quality VBAC and Cesarean info online

April 30, 2015 by blog

By Sharon Muza, BS, CD(DONA) BDT(DONA), LCCE, FACCE

While April is recognized as Cesarean Awareness Month in both the United States and many other countries, quality consumer information about how to prevent cesareans (both primary {first} cesareans and subsequent ones) along with information about having a vaginal birth after a cesarean (VBAC) is valuable to families all year long.

Many families scour the internet looking for practical information and best practices, as well as inspirational stories that help them to feel less isolated and alone when they are recovering from a cesarean or planning another birth.

Here are my favorite websites to share with families who have experienced a cesarean or are planning a VBAC. I like these websites because they are easy to read and contain many articles relevant to cesarean and VBAC families. The first seven are great resources for evidenced based information and best practices on the topics of cesareans and VBACs. The last three are simply great inspirational websites where you can find stories of strong people birthing their babies. Everyone needs to celebrate the strength and courage that is demonstrated by birthing families.

best vbac cesarean info online

Evidence Based Birth

EvidenceBasedBirth.com, while only a couple of years old, has quickly proven to be a valuable resource time and time again. Rebecca L. Dekker, PhD, RN, APRN is the author and she has the wonderful ability to evaluate reams and reams of research and boil it down to important information that consumers can use. Many of her articles are available as a PDF to print and bring with you to a doctor or midwife appointment. Some of my favorite posts that I think are particularly useful to the VBAC family include big babies, rupture of membranes, and due dates.

VBACFacts.com

Jen Kamel is well known nationally for both her website and her VBACFacts.com class. Her slogan – “Don’t Freak. Know the Facts.” She maintains a comprehensive list of posts that explain the research on many of the obstacles that face VBAC families – information on different types of incision repair, VBAC after more than one cesarean, induction for VBAC parents and my favorite among many – “Want a VBAC? Ask Your Care Provider These Questions.”

Well Rounded Mama

Well Rounded Mama, at first glance, seems like a website for plus or larger sized people, but honestly it is a fantastic website for any person who is having a baby, particularly after a cesarean. Pam Vireday does extensive research and her blog posts often cover issues that face many of us as we try and navigate our care after a cesarean. Her motto is “Because mothers and children come in all shapes and sizes. And because people of all sizes deserve compassionate, gentle, helpful care.” “The Fat Vagina Theory – Soft Tissue Dystocia” is one of my favorite posts, but I look forward to every post that Pam publishes.

About.com Pregnancy & Childbirth

This expansive website is written by Robin Elise Weiss, PhD, author of many pregnancy and childbirth books and current president of Lamaze International. Robin’s blog posts are short and easy to read and full of relevant links where you can get more follow up information. They are always accurate and based on current evidence and chock full of resources and suggestions. I like to search on the topics of VBAC or cesarean to find posts of interest, but really, I enjoy reading everything Robin writes.

Spinning Babies

Gail Tully is the author and creator of SpinningBabies.com and I just love her site. As a midwife, Gail has a unique perspective and I appreciate the breadth of information that packs her site. Since some cesareans are a result of a malpositioned baby, the information found here can help families to progress a labor that may be not moving along due to baby’s position. Additionally, for those facing a cesarean for a breech baby, Gail’s techniques may help to get that baby to turn head down. Lots of pictures and a new look make this site easy to use and refer to, even in labor when ideas and suggestions are especially needed. If you had a cesarean for a malpositioned baby, you will for sure want to be familiar with the information on Spinning Babies as you get ready to birth again.

Midwife Thinking

This blog comes from “down under” and is filled with great information on many topics that apply to cesarean and VBAC families. Midwife Rachel Reed takes on some of the myths that get perpetuated on birth and breaks them down in posts that are well researched and full of current information. Be sure to check out “Amniotic Fluid Volume: Too Much, Too Little or Who Knows?” and “VBAC: Making a Mountain Out of a Molehill” and “In Celebration of the OP Baby,” as well as many others that she has written. I encourage you to check out Rachel’s website and read more of her work.

Giving Birth With Confidence – A Woman’s Guide to VBAC

This consumer friendly website for all pregnant families has a very well written guide for VBAC’ing women, based on the 2010 VBAC Consensus Statement held by the National Institutes of Health. Over 10 different well-written resources make up this comprehensive guide to help people understand the research, make informed decisions and navigate the obstacles that they may face when they are planning to VBAC.

Black Women VBAC

This blog is full of stories of people of color who have had successful VBACs and is a great place for all people who are interested in inspirational birth stories to check out. People of color experience cesareans at a rate that is disproportionate to white people and the impact is significant. Read about the courage and strength that these families demonstrated and get inspired yourself.

About.com VBAC Birth Stories

A comprehensive collection of a wide variety of VBAC stories submitted by readers of About.com.

Plus Size Pregnancy Birth Stories

Collated by the same person who writes “Well Rounded Mama” (see above), this is an extensive collection of VBAC, VBAMC and Cesarean stories that will be sure to provide tons of inspiration and encouragement to families who have experienced a cesarean or are planning to birth after a cesarean. While the site is a wee bit dated, it is an extremely comprehensive collection.

These are some of my favorite websites for consumers to learn more about cesareans, VBACs, the VBAC climate, and what the current research says about both cesarean and VBAC birth. Families today need to be informed and prepared to navigate the choices and options available to them as they prepare to welcome a baby, in hopes of avoiding an unneeded cesarean and birthing after a previous cesarean.

What are your favorite websites, blogs and research sources for finding information on the topics of cesareans and VBACs? Share them with our readers in the comments section as we celebrate Cesarean Awareness Month.

About Sharon Muza

Sharon Muza headshot Sharon Muza, BS, CD(DONA) BDT(DONA), LCCE, FACCE has been an active childbirth professional since 2004, teaching Lamaze classes, including “VBAC YOUR Way” and providing doula services to many hundreds of couples through her private practice in Seattle, Washington. She is an instructor at the Simkin Center, Bastyr University where she is a birth doula trainer. Sharon is also a trainer with Passion for Birth, a Lamaze-Accredited Childbirth Educator Program. Sharon is a former co-leader of the International Cesarean Awareness Network’s (ICAN) Seattle Chapter, and a former board member of PALS Doulas and Past President of REACHE. In September 2011, Sharon was admitted as a Fellow to the Academy of Certified Childbirth Educators. Sharon Muza has been the community manager, writer and editor for Science & Sensibility, Lamaze International’s blog for birth professionals, since 2012. Sharon enjoys active online engagement and facilitating discussion around best practice, current research and its practical application to community standards and actions by health care providers, and how that affects families in the childbearing year. Sharon has been a dynamic speaker at international conferences on topics of interest to birth professionals and enjoys collaborating with others to share ideas and information that benefit birth professionals and families. Sharon lives with her family in Seattle, WA. To learn more about Sharon, you are invited to visit her website, SharonMuza.com.