Planning your VBAC - ICAN of Phoenix

Planning a VBAC can be an emotional and physical journey. Below are some helpful tips to consider when beginning your own journey. These tips are to get you thinking, and may not be a good fit for your situation. This resource is to be used as additional information and should not replace the care and guidance of your professional birth provider.

See a midwife for your care – Midwives have about 3x the rate of VBACs as OBs do, and tend to use routine interventions (like induction and augmentation) much less, which might help lower the risk of rupture. In addition, they usually spend more time with mothers during pregnancy and during the birth, which can help mothers deal with care decisions and emotional recovery from prior births more effectively.
Hire a doula (professional labor assistant) – There is little data on the utility of doulas in VBACs, but a meta-analysis of a number of studies shows that doulas lower the rate of c-sections by about 50% overall. A doula can probably help you clarify your birth wishes, give you extra and continuous support during labor, provide help and support for your husband/partner, help with expert ideas to try during the most difficult parts of labor, and give you moral support however your birth goes.
Change as many things as you can to make this birth different from the last time – Usually, changing the provider and the hospital is very important to the process of working towards a better birth, VBAC or not. This is one of the things women have the hardest time doing, even when they clearly received poor treatment previously, yet it is one of the most important (even if you liked your previous doctor). Although you do not have to change your provider or birthplace in order to have a VBAC, it usually improves your chances and should be strongly considered.
See a provider who sincerely believes that you can birth vaginally and normally – Don’t go to see a provider who sees you as ‘high-risk’ simply because you had prior cesareans. Find one who doesn’t just pay lip service to the ‘possibility’ of VBAC or who will ‘allow’ a trial of labor if you really want it, but one who sincerely believes in and will actively support your labor and birth. Listen carefully for their subtle underlying beliefs about birth, ask for their c-section and VBAC stats, and ask for their VBAC protocols.
Select a provider that is open and flexible about your birth preferences – As Diana Korte notes in The VBAC Companion, “Look for the professionals who offer what you want, instead of trying to fit what you want into what they do.” Eliminate from your list any provider that are uncomfortable with the things you feel are important to you. In Korte’s analogy, don’t try to order sushi at a pizza parlor, because no matter how nicely you ask, it’s never going to be a menu choice. Go elsewhere and find someone who offers the things that you want. You may need to reconsider your choice of provider or birthplace, depending on your priorities—keep an open mind, consider all possibilities, and then decide.
Be prepared to switch providers at any time during pregnancy, if necessary – Although it’s preferable to find the best possible provider early in the pregnancy and avoid the emotional upheaval of switching, sometimes it becomes necessary. Many VBAC moms have noted that their providers seemed to tell them what they wanted to hear early in the pregnancy, only to switch tunes to more interventive or negative messages later in pregnancy. Never stay with an unsupportive or overly rigid provider.
Read up on VBACs – Read a wide variety of VBAC and childbirth materials; don’t rely on just one resource. Actively seek out a variety of perspectives, and become familiar with some of the VBAC research so that you can discuss it intelligently with your provider. Ideas for various VBAC resources can be found on this site under Great VBAC Resources, at www.ican-online.org, and www.vbacfacts.com.
Join an ICAN support group – Join other mothers considering a VBAC for information and mutual moral support. ICAN (International Cesarean Awareness Network) has chapters in many cities, and a terrific mailing list online as well (see www.ican-online.org for information on how to join). Moms seeking a VBAC can feel isolated and disempowered by negative messages around them from friends, providers, and families; it can be VERY helpful to have a support network that is non-judgmental and nurturing. Although ICAN is definitely pro-VBAC, it can and has supported mothers who have chosen ERCS in the past, and can help find a way to make a c/s (elective or after a TOL) a better birth experience as well.
Picture normal birth as often as possible – Be sure you know what normal birth looks like. Watch videos of normal un-interventive births (try “Birth in the Squatting Position”, see Great VBAC Resources). Avoid images and films that show abnormal births, lots of intervention, or poor outcomes. Fill your mind with positive images and films, and watch them over and over again. Then picture yourself doing that!
Emphasize excellent nutrition and exercise habits – Superb nutrition can often help prevent some complications of pregnancy, and exercise can help you get in better shape for the demanding task of labor. Create a daily checklist to be sure you are getting all the essential nutrients every single day.
Consider additional childbirth education classes – Even if you have taken childbirth classes before, consider registering for additional classes this pregnancy. Find a class that is not hospital-based; Bradley, Birthing From Within, or particularly Birth Works classes may be helpful. Spend plenty of time discussing your birth plans, practicing your labor coping techniques, and focusing on bonding with the baby.
Find ways to relax – Find a prenatal yoga class, practice meditating, go for solitary walks or solitary swims, get a massage (by someone trained in pregnancy massage), take warm baths, practice deep breathing exercises, post affirmations about birthing around the house, etc. Build in time for regular relaxation.
Promote bonding with the baby – Make it a practice to talk and sing to your baby, tell it what you need, tell it the best position to be in for birth, play it soothing music (down low near your pubic bone to encourage a head-down position), picture your baby and uterus surrounded by healing light, picture your incision strong and pliant, picture your placenta high up and safely attached, put up pictures around the house of a baby in the most optimal position for birth (see pg. 129 of Natural Childbirth After Cesarean), stroke the baby lightly through your belly, picture the baby inside, tell it about its wonderful birth coming up. Let the baby know it is welcome and loved and wanted deeply.

Medical Considerations

Medically, there are a number of things to consider that may help you towards a VBAC or to minimize the risk of rupture. Again, none of these are medical advice, and of course your situation may dictate a different approach. Consult your provider for advice on your specific situation.

Get your full medical records from your c-section births – It is very important for women to read through their medical records (including the operative report and the nursing notes during labor) in order to figure out what happened to cause their prior c-sections. (Electronic Fetal Monitoring strips are too expensive to copy and are not usually needed.) By law, every patient has a legal right to a copy of their records, though you will have to pay reasonable copying expenses to the hospital or doctor. You can find help deciphering the meaning of the records online in the ICAN email support group. Even if you think you know all about your prior birth and what caused your c-section, it is still important to get a copy of your records. There is nearly always something useful to be learned from your old records. Although they may be emotionally hard to read, it’s usually a very good idea to get your records from all prior births.
Consider getting more than one opinion – If you are told that you must meet certain conditions in order to have a TOL (i.e. constant monitoring, IV, dilate a cm/hour, pelvimetry, etc.), consider interviewing several different providers (include more than one type of provider–interview a family doctor, a couple of OBs, nurse-midwives, Certified Professional Midwives, etc.). Ask their opinions of these issues, do the research so you can consider issues fairly, and then select the approach you feel most comfortable with.
Beware of last-minute emotional ‘sandbags’ – Many women are talked into ERCS at the last moment because they are emotionally vulnerable near the end of pregnancy. Their fears overwhelm them, they may fear a possible repeat of what caused their prior cesarean(s), their partners may not be truly supportive of a VBAC, or their families may pressure them into the ‘convenience’ of an ERCS (convenient for whom?). Have a plan ready for emotional support–people to worry and sympathize with you, and to help you distinguish if any worries might be legitimate and which are more due to the uncertainty factor.
Beware ‘Bait and Switch’ tactics – Many providers do this near term, seeming supportive of a VBAC and your birthing preferences at first, but near term the tune changes. Suddenly, the baby is ‘too big’, you won’t be ‘allowed’ to go over your due date, it ‘doesn’t look good because the baby isn’t engaged yet’ or ‘your cervix isn’t ripe yet’ or whatever. Or the provider suddenly adds extra conditions to your TOL. This is very common, and women are very vulnerable to this kind of discouragement and pressure tactics. This is why it’s extremely important to discuss these issues ahead of time, and why some women find it necessary to switch providers even late into pregnancy (some even switch during labor!).
Write a Birth Plan and discuss it with your provider – Write down the things that are most important to you in your birth and make time to discuss it beforehand with your provider. Although it is not an absolute guarantee of anything in labor, it does help organize your priorities for birth and is a valuable opportunity to discuss these priorities with your provider, which may help clarify ahead of time if there will be a problem honoring your wishes during labor. Also request on your birth plan a nurse that is supportive of natural childbirth, and state clearly your preferences regarding breastfeeding, circumcision, supplementation (if necessary), protocols if c/s becomes necessary, vitamin K, eye antibiotics, etc.
Read up on baby malposition and how you can prevent it/change it in labor – Subtle baby position problems are underacknowledged causes of many c-sections. There are things you can do to reduce the likelihood of position problems (like regular chiropractic care, careful posture near the end of pregnancy, spending lots of time on all fours, etc.), and things you can do during labor to help fix malposition more easily. See the FAQ on this website on Baby Malposition for ideas, read Optimal Foetal Positioning (see section on Great VBAC Resources for more info), or check out www.cefcares.org/fetal/position.htm. Be sure you hire a doula and/or provider who understands the importance of baby position as well and can take proactive measures to correct it if it’s a problem (usually a midwife is more attuned to this).
Stay mobile in labor – Don’t let yourself get tied down onto the bed. Laboring on your back is the least desirable position for tolerating pain, for correcting baby malposition, for helping baby to engage and move down, or for optimal oxygenation for the baby. Even if you are on pitocin and must be continuously monitored, you can usually negotiate for at least some mobility (i.e. short walks, sitting in the rocking chair or on a birthing ball, lying on your left side, rocking your hips, etc.). It’s very easy to get settled into a pattern of being a lump in bed, so consider hiring a doula to remind you to switch position and to help find optimal position ideas for labor. And explore alternative positions for pushing as well.
Continue calorie and fluid intake in labor – Labor takes energy! If you were running a marathon you wouldn’t completely abstain from all food and drink. Total fasting does not reduce the risk of aspiration with anesthesia; it may even increase the risk by making stomach contents more acidic. You can’t do your best work unless you have energy to do it with. Let your body be your guide to light food and drink.
Avoid pain medications if you can, or delay them for as long as possible – Some research shows that getting an epidural increases the risk for c/s (compared to natural labor), and particularly so if you get it before 5 cm dilation. If you feel strongly that you want an epidural, you can certainly have one; most women who have epidurals do still end up with a VBAC. However, your chances are probably enhanced if you do avoid an epidural so don’t automatically elect one. If you find you truly need one, try to wait till at least 5 cm before getting one (a doula can help you cope with labor more constructively). Many women find laboring in water a big help as well. Many women refer to this as the ‘aquadural’.
Avoid induction if at all possible – Although induction can be utilized if truly needed, it is probably wisest to avoid induction unless absolutely medically necessary. In particular, some data seems to indicate that it is particularly important to avoid inducing on an unripe cervix, especially using the ‘active management’ style of induction, where prostaglandin gels are administered frequently and over a short period of time, then pitocin is added shortly thereafter and cranked up frequently. This seems to present the highest risk of rupture, and may be particularly risky for women with multiple cesarean scars. If you must be induced, consider ripening the cervix over several weeks ahead of time with Evening Primrose Oil, frequent sex, or nipple stimulation, etc. If you are induced, try to avoid high dosages of induction drugs, keep the frequency of application/dosage increase as low as possible, and take it slower and easier in general.
If labor stalls, try alternative ideas before resorting to pitocin augmentation – Labor that stalls early on may mean that your body is simply not ready to labor yet and you could go home. Many providers are reluctant to ‘let’ a VBAC mom go home in early labor because of the fear of uterine rupture happening outside of the hospital, but Leung 1993 shows that the ‘cure’ may be even more dangerous, because once you are in the hospital and your labor does not progress ‘quickly enough’, aggressive pitocin augmentation is usually added and this may be implicated in higher rates of rupture. You have to decide which seems to be the greater risk to you. If labor stalls further along in the process, try changing positions, going for a walk, talking out your fears, getting on a birthing ball, etc. Consider the possibility of a baby malposition (a stalled labor is one of the classic signs of malposition) and consider laboring on hands and knees or in the open knee-chest position (see www.cefcares.org/fetal/position.htm) to help baby adjust its position. Again, a doula would be extremely helpful in this situation because they know lots of ideas to help get things moving before resorting to pitocin augmentation. Consider buying The Labor Progress Handbook (see VBAC resources section for info) for your labor coach; it has many wonderful ideas to consider for many different labor scenarios, and extensive illustrations of all positions, including the ‘open knee-chest’ and ‘all-fours’ positions that can be so useful in certain situations. If you must utilize pitocin augmentation at some point, request the lowest possible dosage, the least possible frequency for increasing it, and to turn it off once labor re-establishes itself regularly.
Ask your provider to give you references (and be prepared to do the same) – It’s a deplorable fact that many OBs (and others!) do not always base their obstetric practices on evidence-based protocols. For example, episiotomy has repeatedly been shown to be more harmful than helpful in most cases, and still doctors routinely overuse it. Elective c/s because of fear of a big baby (or inducing early to get a smaller baby) has been shown in a number of studies not to improve outcome (and usually actually worsens outcome), yet is still thought of as helpful by most OBs and remains extremely common. Although your providers are busy people, they should be able to at least give you some references on which they base their practices. You should also be prepared to (nicely and briefly) share what you base your requests on; if they understand that you are responsibly well-read and understand potential risk/benefit tradeoffs, they may be more willing to be flexible. Not all providers are able to keep up with the latest research; they may not know of recent studies and their implications for VBAC, and many welcome well-informed patients. However, if your provider reacts negatively or patronizingly when you request references or nicely try to discuss things further, this is a red flag that this may not be the provider for you.

Emotional Homework

Finally, as previously noted, emotional homework is often an extremely important component to preparing for a VBAC, and probably particularly so for a VBA2+C. Many women find that pregnancy is a wonderfully rich opportunity for working on life issues, grieving old hurts, and resolving fears. Think of this as a powerful opportunity for healing, regardless of mode of birth. Here are some ideas that may help you ‘shake your soul and let the glory come out’.

Read lots of VBAC stories – Many women find that reading other women’s VBAC stories is very helpful in preparing for their own VBAC. It may offer inspiration, cautionary notes, laboring ideas, information previously unknown to you, or a chance to believe it really can happen, even under less-than-ideal circumstances. Check out or buy Silent Knife, The VBAC Experience, Natural Childbirth After Cesarean, etc. (Information on finding all these can be found at the Great VBAC Resources FAQ.) Also read the many VBAC stories available online, on this website (see VBA2+C Stories), or join the ICAN mailing list ( www.ican-online.org) for discussions of VBAC issues, personal support, and lots of birth stories!
Visualize a VBAC over and over – Find a quiet time on a regular basis to sit down and visualize yourself giving birth vaginally. See yourself laboring and coping effectively, feel the baby moving down and out, sway your body as you visualize pushing that baby out, ‘see’ the baby coming out easily and naturally (be sure what you are visualizing is correct, including baby position and resolution!), envision the entire process including the placenta delivering naturally and normally, nursing a healthy baby afterwards, etc. Visualize yourself birthing vaginally and actively in a variety of circumstances, so you expand your emotional repertoire of possibilities and can see yourself birthing normally no matter where you are or who you’re with. It is also extremely important to specifically visualize getting well past the place where/why your cesarean happened last time, and then finishing the process of birth afterwards. For example, if your past labor stalled at some point, visualize yourself dilating past that point and going on to birth vaginally. If you dilated fully but had difficulty pushing baby out, repeatedly visualize yourself pushing easily and naturally, then picture the baby coming out (face towards your back!), turning, and the shoulders slipping out quickly and easily as the rest of the baby follows. Don’t forget to birth the placenta too! ‘See’ the baby breathing on its own, see the joy in your partner’s face, feel your own emotions as you birth, see the baby nursing at your breast, etc. Visualization is a powerful tool; athletes use it all the time and find it quite helpful. Many cesarean moms find it difficult to visualize the entire birthing process; some do visualize themselves past the point of prior problems but forget to finish or they focus on the prior problems and de-emphasize the rest of birth. Visualize the ENTIRE process, as specifically as possible. It may not be easy at first, but moms usually find it gets easier over time if they practice it as often as possible, in as much sensory detail as possible, and in multiple media (see it in your mind, listen to it on tape, write it out, sing it, make artwork of it, etc.). Many women report visualization to be a very powerful VBAC tool.
Acknowledge your fears and address them through journaling – Unacknowledged fears can really impact labor and birthing, and especially so in a VBAC. Many women have found that acknowledging and working through their fears greatly eases the birthing process. Journaling is a powerful way to express and work through fears and anxieties about birth and life in general. Although it is hard to find the time for journaling and it can be a pain to do, many women have found it to be a compelling agent for change. Simply sitting down to explore your feelings on paper often leads to surprising insights over time, and there are specific exercises that can be helpful for exploring fears. One book that contains a number of ideas for addressing fears through journaling and artwork is Creating a Joyful Birth Experience by Capacchione and Bardsley. Although its techniques tend to be a bit ‘out there’ and ‘granola-crunchy’ for people with strong left-brain leanings, they really CAN be helpful. If you are haunted by a previous birth, fear something going wrong in this birth, or are just generally anxious about decision-making, take a leap of faith and try some of these exercises, as strange as they may seem. They really DO help many women.
Consider hypnotherapy or relaxation tapes – Another tool many moms use in preparing for a VBAC are hypnotherapy or relaxation tapes. Relaxation tapes contain potent affirmation messages set to calming background music, and are listened to during meditation times or just before sleep. Hypnotherapy tapes also contain affirmations and calming influences, but may also use self-hypnosis techniques to resolve fears from the past, quiet and work through anxieties and decisions in the present, increase bonding with the baby, and to actively visualize normal and healthy birth. The concept of these tapes may sound silly but many VBAC moms have found them quite helpful indeed. Contrary to popular belief, hypnotherapy cannot make you do anything you don’t want to do, but some studies show that it can help mothers work through fears and towards a more healing birth experience (see the work of Dr. Lewis Mehl and Gayle Peterson, PhD). Resources for finding these tapes can be found in the FAQ on Great VBAC Resources.
If you have a background of sexual or physical abuse or other big issues in your life, consider therapy- Providers who regularly work with women who have been abused know that sometimes this can impact the birthing process, but that it does not have to—it can be worked through. Penny Simkin has done remarkable work on this, and is due soon to publish a very important book, When Survivors Give Birth (written with Phyllis Klaus, a therapist). Information on when and how to get this book when it becomes available will be on her website at www.pennysimkin.com. She and others have found that therapy can be an important part of recovery, especially during the emotionally vulnerable time of pregnancy, birth, and new parenthood. Although it’s best to find a therapist that specializes in working with birth-related issues (Penny may know of one in your area), many women find that working with a therapist who is sensitive to birthing issues can be helpful to Survivors during pregnancy. Many women who have had prior difficult births have past abuse issues in their lives; this does not have to be a continuing pattern. Pregnancy is a POWERFUL time for healing, and many such women go on to have wonderful births.
Write letters to the people who attended your prior births – This may be difficult to do (and most people do not send their letters), but it often helps to write to the provider, nurse, and anyone else who was involved in your prior births. Make it a point not to hold anything back. Even if you know you have no rational reason to be angry, let yourself be irrational for a brief while and let those feelings out. Uncovering these feelings is often an important component of beginning to heal. If you find it very difficult to do this exercise, you will know that there are some important issues that need real attention before your next birth.
Try ‘rebirthing’ your cesarean births – Although it is often a very emotional exercise, many women find it particularly helpful to recall every detail of their cesarean births, and then later re-script the labor and birth so that it goes the way they would have wanted it to go. Start by recalling (either verbally or by writing it down) every sensory detail of a prior birth. Concentrate on how things looked, how they smelled, how they felt. Go through the birth chronologically, recalling as many details as you can. Let yourself be as emotional as you need to be—don’t try to intellectualize the experience or retell it at arm’s length. Feel the birth as if it were happening again, and let yourself be angry, sad, hurt, joyful, violated, etc. all at the same time, however it happened before. Don’t try to blunt the experience (see the next suggestion, ‘no way out but through’). Then, when you feel ready, re-script and re-experience the labor and birth the way you would LIKE it to have gone. Change whatever needs changing, as small or as big as needs be. Concentrate particularly on healing things with your child, having the wonderful birth and nurturing time afterwards that so many of us grieve missing. Write out the storyline of the changed birth so you will have it and review it as needed. Take your cesarean child in your arms while he/she is sleeping and whisper to him/her what you wish to change about their births, relate to them the story of the birth as it should have gone, say the words to them you wanted to say then, snuggle them to your heart’s desire as you wanted to snuggle them then. Take the time to restore the bonding time you may have missed out on, to experience the birth as it should have happened, to REBIRTH your baby optimally.
There is no way out but through – Grieving is important work, and many of life’s great rites of passage have elements of grief involved in them. Birthing is no different. As the saying goes, “What you resist, persists.” If you resist working on healing and working through the grief, it is likely to remain and appear in your life in some other way, looking for healing. Going into the pain can be very hard, but ultimately is the only path to healing. Resisting feeling the pain fully only postpones and magnifies that pain. Commit to working though the pain and discovering the underlying issues so you can face them head on.