10.20 MB | 25:36 Min
Dr. Mark Landon is a specialist in maternal-fetal medicine at Ohio State University Medical Center who authored a landmark study and vaginal births after cesarean sections that received national and international attention.
Welcome to your Pea in the Podcast, I’m Bonnie Petrie with everything you need to know about your body, your baby and the big changes ahead in your life in your journey to becoming a mommy.
This week, we’ll help you have that vaginal birth after a c-section, also known as a VBAC. We’ll talk to an expert who says VBAC is not as dangerous as you may have been lead to believe…
“The modern-day studies on VBACs support the fact that it’s still a relatively safe option.”
We’ll talk to two moms who did it about how to prepare…
“Get a doula, that’s for sure. You know, try to get a doula.”
And we’ll talk about how they felt when their baby was born the old-fashioned way…
“I was so proud of myself.”
We’re preparing for a vaginal birth after a c-section in this Pea in the Podcast.
Throughout the 80’s and the 90’s, women who had had cesarean sections had been routinely encouraged to try for a vaginal birth with subsequent children. This climate lead to 28% of all women giving birth after a c-section having a vaginal birth.
But an abrupt turnaround of the position of many OBs in the mid-90’s means that if you want to try for a vaginal birth after a c-section now, you may have to fight for it.
In 2004, only 9% of moms did. What changed?
“Insurance companies that may be malpractice carriers, in some instances, have denied coverage or told obstetricians that they will not cover them if they perform VBACs, so they, in essence, have eliminated this option for some women. And obstetricians themselves may be biased towards performing a repeat cesarean since it is easier for them. It’s a timed delivery, and they do not have again the liability exposure.”
So why are insurance companies doing this?
There is a perception that VBAC puts mom at greater risk for uterine rupture, a complication that could put mother and baby in danger during delivery. Dr. Mark Landon is a Professor of Obstetrics and Gynecology at Ohio State University in Columbus, and he is also the lead author of a study that found the risk of uterine rupture is overstated.
“In our study of term pregnancies undergoing a trial of labor, the risk of the baby either dying or sustaining brain damage from a uterine rupture at term was approximately 1 in 2,000 women undergoing a trial of labor.”
The study found those who’ve had had multiple c-sections were no more likely to have a uterine tear or rupture than those who had only had one c-section.
And many women are still having VBACs. Like Oana, whose road toward a surgical birth began toward the end of her first pregnancy.
“In the last month or so I started retaining fluids and swelling and my blood pressure began creeping up which looked like preeclampsia but it wasn’t yet at that dangerous level. But in the last couple of weeks the protein in my urine had started coming up. They did the 24-hour count of the urine, the protein of the urine. That was actually pretty high.”
Preeclampsia can be a very dangerous condition to a mom and to a baby, and the usual treatment for it is delivery. Oana was on her way to an induction. When she finally did agree to that induction, her labor began and progressed, but when she got to 8 centimeters dilated her labor stalled leaving her with a couple of options.
“The midwife said ‘well, we can have you on an epidural so you can relax and maybe open more and then we can start some pitocin and so forth or we can have a c-section now.’ And I told them ‘just give me one more hour to labor’ you know, it was 10 o’clock, I said ‘give me until 11 to just try more and just try to relax internally and I don’t know.’ And they left and for an hour I just managed the pain and bounced some more and rolled my hips and I was even trying to push a little bit to see it that would do anything and then after one hour I was at 7, okay, so to me that was somebody telling me alright you’re not going anywhere. You should probably find alternatives to this process, and then my husband and I just decided at that point to have a c-section.”
Kim’s VBAC story started when she was nearing the end of her pregnancy with her first child, and she went to a scheduled OB appointment.
“I was 3 centimeters and the doctor had said if I’d like, he could do the thing around the cervix to increase, to stimulate labor and make me dilate more. So I said ‘why sure, go do that.’”
So Kim’s doctor stripped her membranes. Now that is what it is called when your practitioner sweeps a finger in a circular motion between the cervix and the amniotic membranes, and it is supposed to spur labor, as Kim mentioned. And Kim left the doctor’s office and started to contract some more.
“And the contractions got a little painful, so we came back to the hospital 2 hours later and I had not dilated anymore, but they wanted to admit me so we went in because we had never done it before and I got hooked up to all of the monitors and there was the fetal monitor and all of that stuff and he said ‘if you like, we can break your water and that will increase your labor.’ And I said ‘why sure, let’s do that.’ So we did that and meanwhile I didn’t get to walk or do anything and then around 8:30ish I asked for some painkillers and we went for the epidural and then I never dilated past 6 and a half was as far as I really got. And every time I had a contraction, the baby’s heart rate went down. And after a while, the epidural also made me sick after a couple of hours. And then I had a cesarean section at 2:04AM Friday morning.”
Kim’s labor and delivery had not gone as planned at all.
“Initially we signed papers about things that you didn’t want, and on my paper I signed that I didn’t want an IV, I didn’t want an epidural, I didn’t want an episiotomy and I didn’t want a cesarean and I didn’t want drugs and I ended up having everything that I didn’t want with the exception of the episiotomy. And that, of course, is because I had the cesarean.”
She wasn’t upset about that, but she did know if she had another baby, she would try for a vaginal birth. Oana did, too.
“The first time I saw the surgeon and he was talking to me about why he thought I needed a c-section and so forth, my first thing was ‘can I have a VBAC next time, what’s your take on that?’ Even before we even agreed to the c-section, the VBAC was on my mind because I just didn’t want this to become the way I birthed my babies.”
So why would a woman opt to try for a vaginal birth after a c-section? Dr. Mark Landon says there are a lot of reasons.
“Clearly for women undergoing trial of labor attempting VBAC if successful, the length of hospitalization will be reduced, the recovery time will be reduced, there perhaps will be better bonding with the infant and just a general sense of satisfaction of having achieved a vaginal birth, which can be enormous for certain women.”
But of course, there are risks.
“The principle risk is failing a trail of labor and requiring a cesarean section, in which case risks of infection increase, risk of blood transfusion increase. One of the greatest fears of VBAC trial of labor is that of uterine rupture. Fortunately, this occurs in less than 1% of trials of labor. If uterine rupture does occur, then there are substantial risks to both the mother and the fetus. For the mother, the greatest risk is blood loss and the need for hysterectomy. For the fetus, the risk would be that of placental separation or cord compression leading to birth asphyxia, lack of oxygen, or even death. But fortunately these traumatic, catastrophic outcomes are relatively uncommon and thus, VBAC is still a relatively safe option.”
After calculating the risks and benefits, both Kim and Oana decided VBAC was right for them, and both faced opposition from their doctors. Oana says her doc said sure she could try for it…
“Yeah, sure you can have a VBAC, but you realize you have a chance of less than 50%. And I said ‘if I don’t try, then my chance is 0.’ And he said ‘yeah, that’s right, ha ha ha.’ And his feeling was that because of the way my labor progressed, you know, I would be one of those cases that have something intrinsically wrong with their pelvis or something and, you know, the chances would be less than 50, which is not the case. I read up on that, too, and they weren’t that low. So I got a feeling that, you know, I obviously won’t be very supported; they may tolerate me VBACing and knocking myself out, but I won’t get support in that area and, you know, I needed it.”
Kim’s doc was even less encouraging. He told her VBAC was a bad idea and tried to scare her into a repeat c-section. That approach did not work with her.
“It definitely made me stubborn, but I’d also had, there were a lot of people that I know who did VBAC and they said ‘well, I was never informed of that, I was encouraged to have a vaginal birth and they actually preferred the vaginal birth.’”
Dr. Landon said it can be difficult to find supportive doctors these days, but that can make all of the difference.
“A supportive medical team is the key. The greater the comfort level of the medical team, provided that they are truly in favor of the option of a trial of labor for VBAC and convey those feelings to the pregnant woman who desires VBAC, the less fear she in fact will have.”
So if your doctor or midwife doesn’t fully support your decision to VBAC, find another provider. Oana did, at 24 weeks.
“I switched to these people, I went down and met Margaret, the midwife, and just when I saw her I had a strong vibe that she will deliver my baby and it will be a VBAC. I just had that feeling when I saw her, I just thought, ‘ooh I’m home,’ you know? And that was very nice.”
Kim stuck with her unsupportive doc, but during the last two weeks of her pregnancy, he was on vacation. Someone else stepped in.
“And he said, ‘whatever you want to do, we can work through it.’ He was all for me and what I wanted.”
So both moms went to their labors with teams that backed them 100%.
What else can you do to increase your chances at a successful VBAC? Well, it depends on why you have the cesarean in the first place. For Oana, it was about trying to work through the positioning problems she had with her first baby and focusing on her health.
“I was very focused on avoiding preeclampsia this time and the stats were for me because in subsequent pregnancies, the chances are much lower, but still I wanted to make sure I avoided and do what I can. And then positioning this child hopefully on the left this time, because that is the best way for them to twist and can come out and then knowing what to do if I stalled. And then I also started looking into getting a doula because that is some support so how much of an impact they have in the rate for a c-section.”
For Kim, it was about practicing patience.
“With the first one, it was the big anticipation — I’m gonna have a baby, can’t wait to have my baby. You know, you want it to get there now. So I feel I rushed everything to hurry up and get her. Whereas for my second child, I already had a child, I knew what it was like and I was more patient to wait for the other one, wait for my boy to come when he was ready. I always felt like I rushed her. I figured when he’s ready, he’s ready.”
So she didn’t plan on allowing that cascade of interventions from membrane stripping to water breaking that she felt may have lead to her c-section.
Both Oana and Kim did their early laboring at home the second time around.
“I did want to try to stay away from the hospital if possible because I knew they would put me in a hospital bed. And I wanted to be able to walk around and move because all of the books say to walk around and move and to use the ball and do all of that stuff. Whereas once you get into the hospital, a lot of times they say you can do that and when you get there suddenly they don’t want you to do that stuff, they want to keep you tied down.”
Then it was time to go to the hospital, Oana near a major metropolitan area and Kim at a small hospital in rural upstate New York. Both prepared for what has become a very controversial birthing option, both convinced they could do it.
But after 40 hours of labor Oana had dilated to 8 centimeters and then stopped.
“I had the 8 in my mind, I mean, I stalled at 8 with my son, right, and I was now basically at 8, staying there. So I’m at 8, then I’m at 8 again, then I’m at 8 again, she checked me. She says ‘well, how about just a little bit of pitocin?’”
The use of pitocin or oxytocin is controversial in VBAC.
“Studies are mixed in terms of whether oxytocin augmentation of labor increases the risk of uterine rupture. If it does so, it does this marginally. It might increase the risk, say, from a half a percent or 1 in 200 trials of labor to one percent or 1 in 100. But the bottom line is if labor is not progressing sufficiently and intrauterine pressure catheter readings indicate that the strength of the contractions is inadequate for the labor process to result in vaginal delivery, then either oxytocin is going to need to be administered in most of these cases or cesarean section is going to need to be performed.”
So when it comes to augmenting labor, that’s between you and your doctor or midwife.
“So I look at my doula and I said, ‘how difficult are the risks for rupture?’ She said, ‘I am not worried about that at all. It would just be the smallest dose that we could start with, so it will just be whiff of pitocin.’”
So she agreed to the pitocin, knowing it might make her labor more painful, which brings us to another controversial topic in VBAC — epidurals.
“There is very little evidence that the use of regional anesthesia, epidural anesthesia substantially affects the VBAC process. It doesn’t seem to affect the diagnosis of potential uterine rupture, it doesn’t seem to affect VBAC success overall very much, so that if a woman requires an epidural for pain, it should be administered.”
Both Kim and Oana had decided against that particular pain management tool, but Oana was starting to reconsider. She told her husband she needed some pain medication.
“And he said, ‘what are you saying?’ And I said, ‘I just don’t think I can do this. I need an epidural. It’s just too much pain,’ and I started crying, ‘it’s too much pain, it’s been too long, it’s not about the baby anymore, it’s all about the pain, I don’t think this is fair. I mean, I am okay with pain, but I need to see some progress and there is no progress that I can see and I think I need an epidural.’”
But — and this may sound silly to you, but she and her husband had agreed on a code word before labor. If Oana really, really needed an epidural she would say ‘flamingo’ — she did not say ‘flamingo.’
She says having that extra layer in place allowed her to hear herself say she wanted an epidural without actually committing to getting one. But after one hour of pitocin, she was still at 8 centimeters. Her midwife suggested she might try pushing.
“She just waited for a contraction and then told me to push. And I did that, I mean I pushed like I knew I could push because I can feel my body and I want the baby out, so why could I not push. And I read about pushing and stuff. So I pushed really hard and she said ‘push again.’ Then I pushed another time and she says, ‘that just got you to complete.’ And I was like, ‘oh my God.’ I was stalling then all of the sudden in like 2 minutes, you know, after having worked for that many hours, her head just fell through basically, through the cervix which was very soft and it wasn’t in the way anymore.”
Oana was in the home stretch, time to push her baby out, vaginal birth after c-section.
“The 50 hours of labor and the 17 minutes of intense pushing, and then there was my baby. And I didn’t think, ‘oh I VBAC’d! I did it, I had a VBAC.’ I was just like, ‘ahhh, I am not in pain anymore. The baby is out!’”
Kim’s story is just as inspiring and it starts with contractions at home.
“I felt an occasional contraction, not a lot. And every once in a while, I would get a gush of fluid, but it was very far between, every couple of hours. And then gradually as the day went on, I would get another contraction and by that night they were coming a little more frequently and I would get up, and I had one of those big workout balls that I never really worked out on, and I would get on those because I heard they can help get through labor, I had read, and I would just pretty much sit on that and rock through it. And then I’d go lay down and get up again and it was kind of like an all night process.”
Now the next day she went to her OB appointment and then on to the hospital. She began dilating slowly, and for pain management, she settled on a narcotic called stadol to take the edge off the pain. But progress toward delivery was slow for awhile.
“At 7:30, I was still only 4 centimeters so we were depressed again and they let me have another dose of the stadol. And then about an hour later, I would say, I asked for another dose and each time they would have the doctor check me. And I was 6 and a half centimeters, I got a dose of that and it only seemed like 10 -15 minutes, so I must have been dozing off, but I didn’t think I was sleeping in between the contractions but I could really, it was actually wonderful, I could feel them, but they were not overbearing, they were not too much. I could breathe through them all and like I said when it got to where they were very uncomfortable, I’d get another dose and it was great. And around 8:30, I asked for more and I was at 8 centimeters and we were like ‘yeehaw we’re making progress, I am actually dilating!’ because I didn’t do that for the first. And it seemed like 10 minutes after that, I felt like I had to push and I literally felt like I had to push, it was almost like when you have to go to the bathroom, you can’t control it. You get to a certain point where it’s coming out. That’s how it felt and I told the nurse, I go ‘I need some more because I feel like I have to push’ and she went and got the doctor and the doctor looked at me and said ‘well she can start pushing.’ So I, that quickly I dilated. We thought that we were going to be in there for days and I thought I only pushed for, it seemed, 5 to 10 minutes. My husband says it was about an hour. Then, bang, my boy was born at 9:52.”
Two successful VBACs, two happy mommies!
“I was so proud of myself. I cried. I was just so proud of myself; I just kept saying ‘I did it! I did it! I can’t believe I did it.’”
And Kim says it was nowhere near as difficult as she had prepared for it to be.
“I don’t want to say it was easy, but it wasn’t as hard as I expected it to be, and thought it was going to be. I am sure if I did it again, I will feel the wrath of every mother who has had the worst labor in the world, I’ll get it all. But I really felt like I got out of it easy kind of.”
Who should consider a VBAC? Obstetrician Mark Landon says many, many women who’ve had c-sections are, in fact, candidates for a vaginal delivery.
“Well, provided that she has had a low transverse cesarean section, that is a cut in the uterus involving the lower segment of the uterus that goes side to side and not up and down, then she may very well be a candidate for a trial of labor in a subsequent pregnancy. Contraindications to VBAC would include traditional obstetric contraindications such as placenta previa or perhaps breach presentation, for which very few vaginal deliveries are performed today. But if they baby is head first and not particularly large and the placenta is not in the way, most of these women are in fact candidate for a trial of labor in a subsequent pregnancy.”
So how do you decide if VBAC is for you? Oana says explore your options.
“It’s a little hard sometimes for women to know what they really want when they don’t know what their options are, you know, and if you just take your cues from one OB that you see, you know, during your pregnancy, then you’re not going to know all your options. You’re just going to know the options that are more convenient to that OB — not for malicious reasons, necessarily — but not also for the reason that may be in your best interest. So I would say just research it. Read birth stories on both sides, you know, maybe meet people that have done it both ways.”
Kim says be prepared, your doctor might give you a hard time. She felt she was able to stand up to her doc because she is an older mom, 37 at the time of delivery.
“I felt like ‘there is no way you are going to tell me what to do’ whereas I was still 30 with my daughter, but I had never done it before. So I was easily kind of intimidated into it, but now after been there, done that I kind of had decided I wasn’t going to be pushed into something. So just stand your ground”
But if you and your doctor or midwife come to an agreement that you are a good candidate for a VBAC, Kim says go for it.
“Oh, I would definitely tell them to do it.”
Doctor Landon, though, says if you don’t decide on a VBAC, you should feel no guilt.
“We have to respect every woman and every couple as individuals and for some individuals and for some women, VBAC simply is not an option, that even the smallest level of risk, numerical risk, is too much risk in terms of fetal risk. And for those women who cannot overcome or choose to accept that risk, then a repeat cesarean section is a reasonable option.”
Like with everything else, mommy, it’s your body, your baby and it’s ultimately up to you and no one else.
In our next Pea in the Podcast, we’ll take you through the first trimester. It’s an in-depth look at the first third of your pregnancy.
We hope you’ve enjoyed this Pea in the Podcast: Preparing for a Vaginal Birth After a C-section. Please visit our website peainthepodcast.com for more information about our experts, to find links and transcripts and to register to get tailored week-by-week shows for each week and stage of your pregnancy. It’s everything you need to know about your body, your baby and the big changes ahead in your life in your journey to becoming a mommy. For Pea in the Podcast, I’m Bonnie Petrie. Thanks for listening.
A Special Thanks To…
Oana in Georgia and Kim in New York for sharing the inspiring stories of their vaginal births after c-sections (VBAC) for this podcast.
For those of you who may be considering a VBAC, there is support for you online at the International Cesarean Awareness Network (ICAN).