Friday, March 27, 2009

How to Plan Your VBAC (Vaginal Birth After Cesarean)

I just had a great VBAC a few weeks ago and learned a lot in the process. The climate for VBAC in the US is pretty hostile most places, even if your doctor seems positive in the beginning, by the end, many change their tune. There are some things you can do to give yourself an edge for success.

First of all, if you know you are going to have to have a cesarean due to baby position (try an External Version first if all natural methods fail), placental condition or other health issue, make sure you ask for a low, transverse incision with double stitching. Some doctors will say that double stitching makes no difference, but it is a criteria for VBAC consideration for many practitioners, so insist on it.

That, said, if you had another type of incision or only single stitching, you can still have a VBAC, but will have to work harder to find a practitioner.

The other thing you can do if you know you are going to have to have a c-section, is wait to go into labor before you have the c-section. That way, the baby gets the dose of hormones from labor that stimulate lungs and you know the baby is ready to come. You will have an urgent c-section, but not critical emergency.

Whether you had a scheduled, planned or unexpected c-section, you should do your research on VBAC. Find an ICAN chapter, read books like Henci Goer's The Thinking Woman's Guide to a Better Birth, and find support from like-minded people, either in real life or online in places like the Mothering discussion boards.

Before you get pregnant again, you need to research the VBAC policies of the providers in your area. Many providers like to see 18-24 months between births. That is very common. Don't try to get pregnant before that. The uterus needs to be well-healed from your c-section before it starts to stretch again. This is something that you can control so why not meet this criteria?

Get your medical records from your first c-section to find out the type of incision and suturing you had. Your new provider will want to see your records and sometimes there is information in your records that can help you figure out contributing factors to your c-section or other issues about the pregnancy.

Then, research natural childbirth. The fewer interventions you have (like epidural) the better your chances of VBAC because one intervention often leads to another. Also, pitocin and cervical ripeners cause more stress on the uterus than natural contractions and are linked to higher instances of uterine rupture. Pitocin can be used on a VBAC, but I think it should be avoided for your best chances. Both pitocin and epidural can cause fetal distress which would lead doctors to call for a c-section.

Reduce your health risks before you get pregnant. If you are overweight, before you get pregnant again, exercise and improve your eating. It is better for you, better for the baby and will reduce your risk of gestational diabetes, high blood pressure, etc. which can lead to providers pushing a repeat c-section. That doesn't mean you need to get down to a size 0, but if you incorporate some regular exercise, cut out junk food and add in healthy foods, you will be in better shape and reduce your risks.

Find a truly supportive provider. This is key. If you don't have a supportive provider, your chances of VBAC are very low. How do you know if a provider is truly supportive? Ask for their VBAC policies:

*How far past your due date can you go?

*Will they induce if you go past your due date or schedule a repeat c-section?

*If they induce, what type? Will they do balloon cathetar inductions?

*What are the reasons for suggestion induction/repeat c-section? (If you hear "big baby" that is not a good sign.

*What kind of monitoring? If continuous, external fetal monitoring, does that mean you'll be confined to the bed? Do they have telemetry units?

*Can you labor and push in any position that you choose or do they require you to be on your back?

*What is the c-section rate? VBAC rate?

Ask for provider recommendation from the local ICAN chapter, from people who have had VBACs, from natural childbirth advocates in the community. They usually know who is supportive of VBAC.

Don't be afraid to keep changing providers until you find the right one. I went through 4 providers, 4th times the charm!

I started out at a Korean doctor in Seoul, but the c-section rate is higher than the US (who would have thought?) and they don't allow VBACs in most hospitals. There was one provider in one hospital who would let foreigners try, but I decided to go back to the US instead (I have since learned of other options in Korea for VBAC such as midwives and OBs in Women & Children's hospitals, but I was originally told my choices by a Korean OB).

I did the rest of my prenatal care in Korea at the US military hospital because they would bill insurance and then headed back to the US. I planned a homebirth, but my baby was breech and so I needed to find another plan. I had to look outside of Erie, to Pittsburgh. I had already traveled half way around the world, what's another 2 hour drive? I got the baby turned and had a great birth with the right birth team.

Next, prepare your mind. I highly recommend Hypnobabies for labor management. It also programs you with positive messages about pregnancy and teaches you to resist all the negative messages which will be coming at you. Watch VBAC and natural childbirth You Tube videos. Talk to people who have had successful VBACs. Read positive VBAC birth stories and positive natural childbirth stories.

Also, start chiropractic work before, or soon after you become pregnant. Chiropractic work can help prevent or correct poor fetal positioning. Many scheduled c-sections are for poor positioning: breech or transverse. Many c-sections after "failed labor" are because of posterior position. Chiropractic can help prevent or correct these positions. Find someone trained to work with pregnant women, certified in Webster technique.

Spinning Babies is a great site for exercises to prevent or correct poor positioning. You can also find out things to do in labor if you have back labor due to posterior baby. Interestingly, the worst thing you can do is lay on your back--exactly what most doctors want you to do.

Now even if you do Spinning Babies and chiropractic, you may have a fetal positioning problem like I did. In that case, try External Cephalic Version. Many doctors do not like to do this, but you just need to find another doctor. You may need to go to a bigger city to a teaching hospital to have it done, like I did, but it is totally worth it. A confident provider is more likely to be successful and less likely to have a problem like placental abruption during it. They use ultrasound so they can see where everything is and see if there are any obvious reasons for the breech/transverse position. If your baby is meant to be breech, the baby will turn back. The procedure was not painful at all (unlike stories I had heard), just a little discomfort, mostly feeling faint from lying on my back. I think the Hypnobabies really helped with it, but the other thing is that the procedure takes only a minute. You'll be in the hospital for a few hours for monitoring before and after, but most of the time, they are only pushing on your belly for a minute or two. It can take longer, but if the practitioner knows what they are doing and you relax, it is usually very quick. Even if it is takes longer, it is much shorter than a c-section recovery.

Finally, hire a doula. It is worth every penny to have an objective person who is experienced in natural childbirth. She can help your partner help you, She can help you stay focused and relaxed and remember your wishes and remind you of them when you do not. Even if you have a midwife, a doula is necessary. Midwives are not always with you the whole time. Even if they are with you the whole time, like mine was, the presence of a doula allows the midwife to take care of medical things so there is no break in the emotional physical support of you. I really needed a doula because there was a chance my husband wouldn't make it ( turns out he didn't make it) so she supported me through my labor. My mom was with me, but she had never had a vaginal birth and though she was willing to do whatever needed to be done, she was grateful for the doula's presence. She was able to see her grandchild being born which was very special for her, but it was all she could do to keep herself calm. My mom is very good and pretending to be calm and pushing through to get something done--like making the 2 hour drive to Pittsburgh when I was in active labor--but the doula really helped.

In summary, you can do it and it is worth it! In fact, it was so much work to get to the point of being allowed to labor and deliver, that the actual labor and delivery was very easy in comparison. I credit the chiropractor, Spinning Babies, staying healthy, being confident in my birth team and Hypnobabies for a short and easy labor and delivery.

Reasons for repeat c-section: your age, your weight, big baby, gestational diabetes, high blood pressure, pre-eclampsia, placenta previa, danger of uterine rupture, not enough time between pregnancies.

Some of these, like placenta previa, you have absolutely no control over. The placenta implants where it implants and it usually moves up in relation to the cervix, but not always. If they tell you that you have placenta previa or marginal previa (like they told me), just put it aside and stay positive because the odds are in your favor. If you get to the end and you still have previa and have to have ac-section, just make sure you get the right type: low, transverse incision with double stitching.

Other things are bogus like:

* big baby: (often wrong because ultrasound can be off by 1-2 lbs either way and even if it is not wrong, many women have VBAC babies bigger than their c-section babies for CPD)

*your age: risks go up with age for many things during pregnancy, but not necessarily, many OBs treat women who will be 35 or over when they deliver like geriatric patients.

*danger of uterine rupture: it is less than 1%, especially if you avoid cervical ripeners or pitocin.

Some, like I wrote before, you have control over like you weight, time between pregnancies and your health. There are some people who have gestational diabetes or high blood pressure despite a good diet and exercise, but you can reduce your chances so it is worth doing. Again, the better your health before pregnancy, the better your health during pregnancy, but it is never too late for changes to have a positive effect.


mel817ski said...

Congratulations on your VBAC! And thanks for this post on "How to plan your VBAC." I am an L&D nurse in the Northeast of the US and was recently honored to be a part of a BEAUTIFUL VBAC birth of one of my patients. I blogged about her story because it was so great!

Thanks again and happy mommy-ing!


eriedoula said...


What a wonderful summary on VBACS! Excellent advice, comprehensive and encouraging. I intend to share it with any woman I meet who wants to pursue VBAC. Thanks for sharing your experience and all that you've learned, and again - Congratulations!! I remain so very happy for you!! Michelle

Mama Seoul said...

Thanks, Melissa and Michelle!

My actual birth was very easy, but getting to be "allowed" to birth was hard. (I know you can UC, but I didn't want to do that).

Connie said...

Congrats on your VBAC :) You worked so hard, and pulled it off so well!

I had my second child at a John Hopkins hospital in Maryland. I had not even considered a VBAC because my first born was an emergency C-section. Started with a low bikini cut, but ended up with an inverted T-incision, internal and external, 34+ staples.. my son was stuck and had to be pulled out breech. I thought there was no way I could VBAC. There wasn't :D but .. even after seeing the scar, my daughter's doctor (not me, the doctor!) said we should think about VBAC and she ordered my medical report from the first hospital herself. She told me that it was possible to VBAC if the scarring was only on the skin, and not the uterus, but the incision matched the scar. O well. With me, it was probably good. I was in labor when I went to surgery (which they had not wanted in my case) and the doctor said I pretty much tore right open as soon as she touched me with the knife... I would have ruptured. I just thought it was very nice that it was the doctor who promoted the possibility of VBAC.

Kimberly J said...

CONGRATULATIONS on your VBAC mama! So happy for you!

Thank you so much for this blog post... so much good information on it that so many other mamas need to see. Would it be ok if I referred to your post on my blog? I have some readers that need to see this.

Congrats again!

Kim in Seattle

Mama Seoul said...

Of course, that would be great, Kim!

Amynf said...

This really is a fantastic post. I linked it in my VBAC post. I could not have provided the information as well as you did, I didn't even want to try. I am so happy for you that you got your VBAC and proud of you for doing whatever it took.

Mama Seoul said...

Thanks! The easiest thing about my VBAC was actually giving birth that is why I am so passionate about empowering people to ask the questions and make the changes necessary to give yourself and your baby your best shot.

Birdy!!!! =D! said...

What a beautiful inspiring account of a successful vbac...i applaud you and you in turn have given me the courage to try a vbac.i just turned 44 years old, have eight beautiful children(naturally),except for the last, who was an 11 pound emergency c-section,only because his head was turned and it had been hours of pushing and he would not come down.i am told to have no more due to age , rupture possiblilty , and the fact that my babies are big.again, i have been inspired. thank you

yourinnerglow said...

Beautiful! We need to hear more of successful VBAC stories!!! I am a birth doula in NJ and just returned from NIH consensus on VBAC future...they are supporting a TOL!!! Thank you so much for sharing your story.....!