Hello, class!

Today, we are talking about vaginas.

Are you still there? Great!

Chances are, that means you are a mom, a not-easily-grossed-out baby daddy (hello, all three of you!), or you’re just into reading about super-important-but-kinda-gory stuff.

Whichever you are, welcome!

Today we are talking about a topic that so many moms want to know more about—the VBAC, or Vaginal Birth After Caesarean (delivery). It means moms who want to push out their baby the way nature intended after they’ve had a C-section on their first or any other previous birth.

And, while I am many things, doctor is not one of them. So our guest on today’s post is the fabulous Dr. LaKrystal Warren, OB-GYN at Contemporary Women’s Care in Orlando, Florida. She’s an incredible doctor, she’s amazingly knowledgeable and compassionate with her patients (rare combo), and obviously she is chock full o’ knowledge. So we are happy to have her weighing in.

Wondering why so many friends of yours—and maybe you included—ended up with a C-section? Here’s Dr. Warren:

“The C-section rate doesn’t just seem high, it is high. Nationally, the C-section rate was approximately 32% in 2015.”

And there are lots of reasons why:

“1 – The introduction of electronic fetal monitoring. The goal is to decrease bad outcomes, but it has not been shown to do that. As a result of variation in interpretation of the fetal monitoring strips, intervention by Cesarean section often occurs and in hindsight is not necessary.

To combat this, there has been an effort to standardize terminology to improve communication and decrease unnecessary cesarean sections, especially in first time moms.

2 – A decrease in operative deliveries (vacuums or forceps) due to lack of training and fear of litigation.

3 – The initial decree of “once a Cesarean, always a Cesarean” and the shift in the late 70’s to try and labor after Cesarean, combined with fear of litigation due to catastrophic outcomes (with increasing VBACs, there were increasing reports of uterine ruptures and other outcomes and with this came increased lawsuits, so there was another shift where VBACs declined).”

And that’s just the tip of the iceberg of the insight Dr. Warren is offering. Keep reading for my advice first, then Dr. Warren’s full interview below.

So, here we go. Want a VBAC? Here are some helpful tips to get you started on your journey.

1 – Call your OB-GYN to figure out your chances

Obviously, this is where you start. Call your OB-GYN and set up an appointment, and come armed with all your questions. You may want to ask not only what your chances are, but what about your particular birth experience/s either precludes you from attempting, or allows you to pursue a VBAC.

 

Checklist:

            Start with your provider. Call your OB-GYN and ask if he/she will allow you to attempt a VBAC.

 

2 – Reach out to the VBAC community

Another resource, in addition to your doctor, is the community of women who have done, or attempted to do, a VBAC.

Go to ICAN.org and check out their message boards. Read about how they were able to achieve VBAC. What doctors did they use? How did they prepare? Were they successful in their attempts? If so, why? If not, why?

Check message boards. Send emails. Just talk.

Reading other women’s experiences not only informed me, but it also inspired me to pursue VBAC.s

After coming up with a list of doctors, pick up the phone. Ask to speak to the birth coordinator at the practice. Explain to her your desire for VBAC, and see if a doctor at their practice is open to at least meeting with you to discuss it.

 

Checklist:

Go to ICAN.org.

Search VBAC friendly doctors in your area.

Call, call, call. Then call some more.

Book appointments.

 

3 – Adjust your expectations/Prepare yourself

Even if you find doctors who are willing to meet with you about the possibility of VBAC, know you may not qualify.

If you do find a doctor who is willng to work with you, you may have to switch practices even if you’re well into your pregnancy. I switched at nearly 7 months. I absolutely LOVED my OB-GYN, but when I had the opportunity to try for VBAC, I followed it to another practice, and thankfully, with success.

This leads me to my next point:  Be prepared that it may not happen. No matter how much homework you do, there is still a chance an attempt at VBAC won’t work. This doesn’t mean there’s anything wrong with you, or that you won’t have a positive birth experience.

 

Checklist:

Know your doctor may not allow you to attempt a VBAC.

If not, consider if you are you open to switching practices.

Be prepared if you can’t find a doctor to accommodate your wishes.

 

4 –Prepare a list of questions for your consultation

Come with a list of questions and concerns, and ask them to be frank with you about the possibility of VBAC in their hands.

This may include bringing your partner with you to discuss his/her questions and concerns as well.

 

Checklist:

Write down all your questions, hopes and concerns.

Be honest with the doctor at your consultation.

Bring along your partner and have him/her weigh in.

 

5 – Trust the process

Chances are, if you had an unplanned C-section with your first delivery/deliveries, there was some sort of healing or understanding process you went through. You may feel a little anxious about pursuing VBAC, only to have your hopes dashed. But in birth as in life, we can only do so much. After you’ve done your research, asked your questions and tried to make it happen, you have to leave it to fate.

As we are always reminded, having a healthy baby is the most important thing, no matter how he or she gets here.

 

Checklist:

Chill out.

***

Did you attempt a VBAC? If so, how did it go, and how did you get there? I would love to hear your experiences and thoughts in Comments!

And here’s my full interview with Dr. Warren:

 

Sonni:  Why are VBACs so hard to do? Does it vary state by state, and is it dependent on insurance concerns? How often do women get the okay to proceed with a VBAC after 1 C-section?

 

Dr. Warren:  Our practice of OB/GYN and our goals of a healthy mom and healthy baby are based on the recommendations and guidelines of ACOG (see below). VBAC (Vaginal Birth After Cesarean) and TOLAC (Trial of Labor After Cesarean) are very hot topics and we do actually have guidelines that we follow and combine with our clinical acumen.

Simply put, the fear of litigation from possible bad outcome influences whether providers and hospitals offer TOLAC and this is the case all over the country. It is up to the individual hospital or provider to decide whether VBAC is offered and there is always a policy/guideline to follow for each specific facility.

There are no state to state requirements that I am aware of that mandate whether or not TOLAC must be offered; however, it is required that hospitals that offer TOLAC must have the appropriate personnel (OB/GYN physician and Anesthesiologist) immediately available to perform a Cesarean section in the event of emergency. If this is not an option, then TOLAC cannot be offered.

Our reimbursement from insurance companies does not differ based on mode of delivery, so contrary to popular belief; we do not get paid more for a C-section. There is an assistant needed during a C-section, so that may increase the cost to the patient but that is not taken into consideration when determining mode of delivery.

Many women with a prior Cesarean section are candidates for TOLAC. The majority women with one prior low transverse incision (meaning the cut on the uterus—not the skin—is horizontal) are candidates for TOLAC and should be offered TOLAC if the provider and hospital allow it.

Some women will decide to have a repeat cesarean section, and some will decide to TOLAC. In some cases, women with two prior low transverse may be a candidate for TOLAC but this will be provider and hospital dependent. In both cases, the risk of the most serious outcome of Uterine Rupture (meaning the prior scar on the uterus bursts open during labor resulting in decreased blood flow and oxygen to the baby and requiring emergency Cesarean delivery which could result in excessive blood loss to mother and baby and ultimately end in fetal or maternal death) is less than 1%. There is not a formula, but there is a calculator for success rate but it does not accurately predict success so should not be the basis for the decision to TOLAC.

Women that have had a Classical or other vertical incision (meaning the cute on the uterus—not the skin—is vertical) have an unacceptably high risk of uterine rupture (4-7%). Once this particular type of delivery is performed, the patient is told immediately after the surgery that she should not ever labor.

 

Why does the C-section rate seem so high?

The C-section rate doesn’t just seem high, it is high. Nationally, the C section rate was approximately 32% in 2015. There are many reasons for this increase:

1 – The introduction of electronic fetal monitoring. The goal is to decrease bad outcomes, but it has not been shown to do that. As a result of variation in interpretation of the fetal monitoring strips, intervention by Cesarean section often occurs and in hindsight is not necessary.

To combat this, there has been an effort to standardize terminology to improve communication and decrease unnecessary cesarean sections, especially in first time moms.

2 – Decrease in operative deliveries (vacuums or forceps) due to lack of training and fear of litigation.

3 – Initial decree of “once a Cesarean, always a Cesarean” and the shift in the late 70’s to try and labor after Cesarean, combined with fear of litigation due to catastrophic outcomes (with increasing VBACs, there were increasing reports of uterine ruptures and other outcomes and with this came increased lawsuits, so there was another shift where VBACs declined).

The shift now is to decrease the first C-section and increase the TOLAC rate.

 

If we get the okay from our doctor, what things do we need to do to prepare for a possible vaginal delivery?

 

1 – Avoid induction of labor and await spontaneous labor—this will increase your chance of success.

2 – Maintain a healthy exercise regimen.

3 – Gain the recommended amount of weight during pregnancy.

 

What resources do you suggest (online, etc) for women who want to learn more about VBAC?

 

Link here

 

Is there anything a woman can do to increase her chances of having a VBAC? What do you say to comfort women who want to try it, but don’t qualify?

There is nothing specific that a woman can do to increase her chances of having a VBAC because she can’t change the size of her baby or the shape of her pelvis.

Check out Dr. Warren online here, and on Facebook here!