So You Want A VBAC

OCmidwifery.com

Introduction

Congratulations on your choice to pursue a VBAC! Making this decision is the first step in success. In this handout, you will find ways to increase your chances of a successful VBAC, providers in this area who are known to take VBAC patients, and how to interview a potential provider. 

How to Increase Your Chances of a Successful VBAC

The following are suggestions that help to increase your chances of a successful VBAC by decreasing unnecessary interventions and minimizing risk. 

During Pregnancy

• Talk to your partner.  Make sure that your partner is aware of, and supportive of, your desire for a VBAC. A supportive partner can help give strength and encouragement when the going gets tough, the mother gets weary, or the support seems minimal.
• Select care providers and a birth place that are VBAC-friendly. Be sure both your practitioner and your hospital are supportive not just in words but in policies and routine procedures. If a woman is under the care of a truly VBAC-friendly practitioner, is birthing in a setting that is truly cohesive to a successful VBAC, and who uses the suggestions below to help labor progress optimally, the VBAC success rate is 75-90%. For a list of purportedly VBAC-friendly providers in the Houston area, feel free to contact me.
• Join a support group. There are great support groups for mothers who need processing their prior cesarean, healing from it, and planning for a VBAC. These groups also have additional tips, resources, and recommendations ready to help you have the best odds at a successful VBAC. Houston has it’s own chapter of ICAN and can be found here: http://www.facebook.com/group.php?gid=295872951561
• Hire a Doula. It may seem we are biased, but the help of a professional labor assistant can help you to navigate the policies, regulations, and patient’s rights; this allows you to make an educated decision about your health care by knowing all of your options and their benefits, and risks.
• Consider an early ultrasound to have a better grasp on your ‘true’ due date. Many women have their labor induced because they have been told that their pregnancy has gone past their due date. Early ultrasounds have a better rate of accuracy in determining estimated due dates than later ultrasounds.  Calculating the due date by the Naegele Wheel alone is often less accurate than an early ultrasound.
• Avoid a routine ultrasound in late pregnancy (after 24 weeks gestation). Some care providers recommend a late pregnancy ultrasound. Research shows that routine late pregnancy screening does not improve health outcomes for mothers or babies when compared with women who do not have the screening. However, routine late pregnancy ultrasound screening has been shown to increase the use of major interventions including a cesarean section.
• Don't let 'big baby' get in the way. VBAC studies fail to show any correlation between the size of the baby and the chances of uterine rupture. Also, estimates of fetal size and weight by ultrasound are not always accurate, especially in the final month.  In short, VBAC is a “safe and appropriate choice for most women” with one prior cesarean and for “some women” with two prior cesareans.  Being pregnant with twins, going over 40 weeks, having an unknown or low vertical scar, or suspecting a “big baby” should not prevent a woman from planning a VBAC  - Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery
• Avoid an induction of labor. An induction carries its own set of risks, often requiring additional medical interventions, and reducing a mother’s mobility during labor and birth. Because of these risks, it also reduces the chances of a successful VBAC.

During Labor

• Avoid routine hospital practices known as “the cascade of interventions.” From Childbirth Connection:

Many things in life have unintended consequences: they may or may not have the effect that we want, and they may also have other unplanned and possibly unwanted effects.

Many maternity interventions have unintended effects, especially during labor and birth. Often these effects are new problems that are "solved" with further intervention, which may in turn create yet more problems. This chain of events has been called the "cascade of intervention."

The maternity interventions that can lead to a cascade of intervention include: using various medications to induce labor, artificially breaking the membranes surrounding the baby and releasing amniotic fluid before or during labor, giving medications for pain relief, using back-lying positions for labor or for birth. - http://www.childbirthconnection.org/article.asp?ck=10182

• Move around and stay upright as long as you can during labor. Staying upright and mobile, trying a variety of positions to labor in, allows baby the most space in your pelvis to navigate downward. It also helps to facilitate a labor that progresses more readily, reducing the chances of your provider being worried about failure to progress. 
• Take your time. Become well-versed in patience, knowing that labor can sometimes take time and need your trust. Making sure that your provider is ok with you laboring ‘off the clock’ as long as baby and mom are healthy will alleviate the stress of needing to birth within a certain time frame and allow baby ample time to navigate your pelvis and get into the best position for a vaginal birth.

During Birth

• Get off your back. Trying different positions to push in will, again, give baby the most room to navigate your pelvis and birth canal. Upright positions like squatting, kneeling, and hands-and-knees all provide better positioning for baby and a roomier pelvis. Pushing on your back decreases your pelvic outlet and increases the effort needed to push baby out. 
• Breathe. Purple pushing (holding your breath and pushing) may get baby out a few contractions faster, but it also decreases the amount of oxygen that gets to baby, increasing the chances of fetal distress. It also is known to fatigue mom a lot faster than simply listening to your body’s cues on how and when to push.

When Interviewing a Provider:

As childbirth professionals, we can offer a list of doctors who have been known to accept VBAC clients. There is a wide range of true VBAC-friendliness, though, so be sure to use the interview questions below to determine a care providers VBAC-friendliness. Also, just because the doctor is listed as one who attends VBACs does not mean that the partners in their practice do. Thoroughly research and interview each provider.

Interviewing A VBAC-Friendly Provider

The following is an outline of tips and questions to ask a provider when interviewing them to see if they are truly a VBAC-friendly provider. When calling an office to interview a provider, it is best not to mention VBAC. Simply calling to make an appointment with the doctor of choice is best. Then, at the time of the appointment, when they ask if you have any questions, you can proceed in interviewing them.

What is your policy on going past 40 weeks? (ACOG’s latest VBAC Guidelines that going overdue should not prevent a woman from planning a VBAC).

What is your policy on epidurals/spinals for VBAC patients? (routine epidurals ‘just in case’ only increase the risk of a RC after TOL and are not justifiable when weighing benefits and risks)

What is your philosophy on suspected ‘big babies’ and VBACs? (ACOG states that suspecting a big baby should not prevent a woman from planning a VBAC)

How many VBACs have you attended? (a VBAC advocate should know their numbers)

What are your success rates for women who attempt VBAC? (if the numbers are ‘not good’, ask the reasons for the RCs, a high rate of uterine ruptures can mean high induction rates)

 

Do you attend VBACs with an unknown or low vertical scar? (ACOG states that an unknown or low vertical scar should not prevent a woman from planning a VBAC)

Under what circumstances would you induce a VBAC? (‘40-42 weeks overdue’ or ‘big baby’ are not good reasons)

 

If you are to induce a VBAC, what methods do you employ? (Cytotec (Misoprostol) should not be mentioned as it is contraindicated for use with VBACs, best odds are cervidil (prostaglandin), and next, pitocin (oxytocin))

Do you have any other standard VBAC protocols that differ from any other pregnant/laboring woman? (ACOG states that continuous fetal monitoring is warranted but internal fetal monitoring is not. Some providers require mom to birth in an OR, which might be a deciding factor for the woman)

Legend of acronyms:

VBAC – Vaginal Birth After Cesarean

VBAmC - Vaginal Birth After multiple Cesareans

EDD – Estimated Due Date (40 weeks)

ICAN – International Cesarean Awareness Network

NCB – Natural Childbirth Friendly

ERC – Elective Repeat Cesarean

TOL – Trial of Labor

Resources and further reading:

• ICAN – ican-online.org/
• Callahan C ; Chescheir N ; Steiner BD J Reprod Med, 44(7):606-10 1999 Jul
• Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery Obstetrics & Gynecology: August 2010 - Volume 116 - Issue 2, Part 1 - ppg 450-463
• Dr. Sears – www.askdrsears.com/
• Childbirth Connection ACOG Guidelines Breakdown - www.childbirthconnection.org/pdfs/ACOG-VBAC-guideline-comparison.pdf
• Childbirth Connection - www.childbirthconnection.org/article.asp?ck=10211&ClickedLink=293&area=27
• VBAC Facts- vbacfacts.com/
• VBAC dot com - www.vbac.com/
• href="http://www.childbirthconnection.org/article.asp?ck=10211&ClickedLink=293&area=27%3C/li%3E%3Cli%3ECIMS">CIMS - motherfriendly.org/downloads.php style="font-size: 9pt; font-family: Symbol; color: black; font-weight: normal;">
• Landon, Mark B., et al., “Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery”, N Engl J Med 2004; 351:2581-2589 December 16, 2004