What to Expect about VBAC? Not Much.

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What to Expect about VBAC? Not Much.

19

So we all know that What to Expect When You’re Expecting is the preeminent source on pregnancy and childbirth for women in the United States, right?

I mean, copies of that books are everywhere right?  So it must be “the best,” right?

Well, that’s what some clever (and aggressive) marketing would have us think.  But it’s not necessarily true.

(And for the record, WTEWYE is not the “best” book on pregnancy and childbirth, in my honest opinion.)

Now, I’m not here to “take down” the whole book and all of its paternalistic and even mis-informative advice.  Others have taken on that critique long before I sat down to write this  post.

But I am here to offer a “critique” of the “What to Expect” website’s advice-ish page on VBAC.  (Yes, I’m blogging about the silly things people say about VBAC uh-gain.)

Because if women are reading the “What to Expect” site when they’re trying to make a decision between VBAC and repeat cesarean, then they are gaining some seriously misleading and unhelpful information about VBAC.

Just take a look at some of the statements I found on the site:

“Forty percent of women who had a prior cesarean section do end up having a repeat.”

This is a misleading statement, though perhaps unintentionally.  Of all women with prior cesareans in the United States, less than 10% currently even attempt a VBAC.  So this means that over 90% of women will “end up having a repeat.”

But even if the author of this page meant to convey the rates of VBACs that are successful or unsuccessful (or that end in a vaginal birth or a cesarean section), this statement is still misleading.  With VBAC success rates ranging between 6o% and 80%, it seems more accurate to state that “twenty to forty percent of women who had a prior cesarean section and who attempt a VBAC do end up having a repeat.”

Even better?  How about, “Sixty to eighty percent of women who try for a VBAC do end up having a vaginal birth.”  (See how much more accurate and positive that statement is?)

*

“Causes like fetal distress, preeclampsia, a breech position, or placenta previa don’t generally spill over from pregnancy to pregnancy, nor is having had a large baby before any reason to think you’ll have one this time (especially if you kept your paws off the Krispy Kremes and kept your weight gain under control). If the reason was a chronic condition like high blood pressure or diabetes, though, you’d better steel yourself for another surgery.”

Why don’t we throw in a few fat-slurs in there and call it a day!

GOOD LORD.

I mean, I appreciate some good “girlfriend advice” as much as the next gal,* but this seems more like advice from some passive-aggressive chick who likes to put down her overweight pals with snarky comments about doughnuts.

NOT!  HELPFUL!

Why not offer some information about prenatal nutrition and its role in helping women to achieve healthy pregnancies and healthy births?  (And for what it’s worth, being classified as “overweight” or “obese” does not necessarily mean that a woman isn’t eating a good prenatal diet!!!)

And why not point women who might need to “steel themselves up for another surgery” toward some cesarean support groups such as ICAN?

Otherwise, the advice here just seems insensitive, and even a bit mean.  (Or perhaps I’m the overly insensitive type?  Perhaps.  I do love me some Krispy Kremes after all!)

*

“Remember that there’s no advantage (moral or otherwise) to a VBAC, so even if you could try for one, you’re absolutely entitled not to go for it if the risks make you uneasy.”

Okay.  You know those cartoons where the character’s face turns red and then steam starts shooting out of their ears and there are all sorts of steam engine or train whistle sound effects?

That’s exactly what was going on inside my head when I read this sentence.

A moral advantage to VBAC?  You mean the sort of advantage where St. Peter is gonna be all like, “Well, lady, you’d be getting through these here gates to heaven if you had just chosen that VBAC over your repeat cesarean.  TOO BAD YOU DIDN’T TAKE THE MORAL PATH!!!”

Jay-zus.

No!  There isn’t a moral advantage to VBAC!  And there’s no moral advantage to repeat cesarean either!  (Although there are moral advantages to making sure that women are accurately and thoroughly informed about the risks and benefits of both of these birthing options!)

Look, I agree with the end of this statement: any woman with a scarred uterus is absolutely entitled not to go for a VBAC if the risk (of uterine rupture) makes her uneasy.

But, as should be obvious, any woman with a scarred uterus is absolutely entitled not to go for a repeat cesarean if the risks make her uneasy.

Oh, and there are some “otherwise” advantages to VBAC.  In fact, there are advantages for women (e.g. a lower maternal mortality rate when compared with elective repeat cesarean) and for their babies (e.g. a significantly lower rates of respiratory morbidity and NICU admission when compared with babies born via elective repeat cesarean)!

So don’t go telling women that there are no advantages!  Exclamation point!

*

“…they might want to keep you off the meds to avoid masking the pain that could point to potential rupture.”

Well, sure, they might.  I’ve heard of some individual practitioners having a “no epidural during VBAC” policy in place.

But it should also be noted that even ACOG notes that epidurals “rarely mask the signs and symptoms of uterine rupture.”  So while there may be good reasons to approach epidurals with some level of caution in any labor, there are also good reasons for women to question those “no epidurals during VBAC” policies.

*

“Finally, if it doesn’t work out (and remember one in five births are cesarean), try to take it in stride.”

No, remember this: One in three births are cesarean.

Mmmkay.  Thanks.

*

“The happy ending — healthy you, healthy baby — is really all that matters.”

*

BLAAAARRRRRRGHHHH!  STEAM COMING OUT OF THE EARS AGAIN!!!!

I wrote about statements such as this one a long time ago.  In brief?

Healthy moms and healthy babies do matter.  They matter a whole hell of a lot.  But they’re not all that matters.

*

So in the end?  While I’m sure that the authors of WTEWYE are really, truly well-meaning individuals who just want to help out a pregnant women or two (million), I think my expectations of their advice have been tremendously lowered after reading their “lowdown on VBACs.”

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

* Your Best Birth: Know All Your Options, Discover the Natural Choices, and Take Back the Birth Experience is much better at the “girlfriend advice” on pregnancy and childbirth, in my opinion.



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19 Comments

  1. Desirre Andrews
    Desirre Andrews03-25-2010

    Go K.O. frankly this post is a KO to WTEWYE franchise. Not evidence-based– To me it is fear embellished with some artwork.

    Popular does not mean good….

  2. Blair
    Blair03-25-2010

    I had gd w/insulin in both pregnancies and I certainly did not steel myself for another cesarean! Much the opposite, in fact!

  3. Molly
    Molly03-25-2010

    I’m still gaping back there at “if you kept your paws off the Krispy Kremes.” Holy shit. Just … no.

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  5. Mrs. Spit
    Mrs. Spit03-26-2010

    I absolutely share your feelings about WTEWYE. I think it’s a horrible book. (And I particularly liked the not so discrete link between fat and pre-e. Funny that none of the experts agree.)

    Having said that, and I’m sure I’ve said this before, but I do firmly agree, what does matter is a living mum and a living babe. That may just be my experience talking.

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas03-26-2010

      Mrs. Spit, I don’t disagree with you. Not one bit.

      I just don’t like how some people seem to equate c-sections with “the women who care about healthy/living moms and babies” and VBACs with “the women who care more about the experience.” I think that it not only obscures the risk of life-threatening complications on both sides but also demeans the experiences of those families who have lost mothers and/or babies.

  6. Jenny
    Jenny03-26-2010

    This Comment from you:

    Why don’t we throw in a few fat-slurs in there and call it a day!

    Made me darn near spit out my OJ! I haven’t read that book. One of my friends read it when PG with her first and had to stop because she said it just freaked her out. She advised me not to get it and I haven’t. I tell every woman to avoid that book at all costs as I think all it does it make people paranoid about everything (and apparently misconstrue the facts). I’ve been pointing friends to Ina May’s books and Your Best Birth – books that focus on Birth as a normal and natural thing. I try to tell them that (particularly Ina May) can come across as a little crunchy but the important take away in my opinion is that pregnancy and birth are normal experiences and they don’t need to be filled with constant anxiety and fear.

  7. TheFeministBreeder
    TheFeministBreeder03-26-2010

    I think when I start teaching classes, I’ll do a ceremonial burning of WTEWYE for my students. :)

    This kind of shit is what we’re all up against, and as we saw in January, more uninformed shit like this just keeps getting pumped into the hands of unsuspecting, well-intentioned women. That’s why you MUST keep writing about VBAC when ever you can stand it.
    .-= TheFeministBreeder´s last blog ..Wordless Wednesday — VBAC Conference Style =-.

  8. Weekly News Round-Up, Digital Divide Style « Women’s Health News
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  9. Ren
    Ren03-28-2010

    I agree with Kristen that WTEWYE is not the *best* book out there. I think her critiques of the section on VBACs are more than deserved, and one can hope (wish?) that future editions of the book would be better.

    But.

    In light of the comments on this post, I felt compelled to say that I used WTEWYE a lot when I was pregnant and I found it really helpful. And I had an awesome, empowering natural childbirth. The friend (not Kristen) who first gave me the book had an incredible waterbirth – and I don’t think she used any book other than WTEWYE! I think the book has points of real utility for pregnant women – or at least for some. I think no one book is perfect and that a book that works well for one person may not work for another and vice versa. Sometimes its just nice to have a lot of different books to peruse and compare and contrast (which I did).

    If I took a childbirth class and someone told me I had to “ceremonially burn” my copy of WTEWYE I would leave the class and never come back. Because even though I think there are other important books out there and that WTEWYE has flaws, the book worked for me in ways I needed it to work. Blanket condemnations of a text that many women have found useful seem counter-productive to me. It seems much more constructive to specifically highlight passages in the book that are misleading or negative in order to encourage critical thinking and informed birth. Just my opinion.

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas03-28-2010

      Ren, I totally agree that the book has some helpful information in it. I think the “month-by-month” account of the fetus’s growth, the list of things not to eat/do (as scary as they can seem), and the explanations of some procedures can be useful to read. I even think that the question/answer format makes it easy to read (in a good way). And as you well know, I read the book throughout both of my pregnancies! :-)

      That being said, I do not think that it is a book that encourages critical thinking about birth. In fact (and especially in some earlier editions), it downright undermines critical thinking about birth. (I’m looking right now at the sections on routine IV and artificial rupture of membranes, and nowhere in these sections do they include a risk/benefit analysis or any discussion of the woman’s right to refuse these interventions.)

      Nonetheless, I think that it is fair to say that a vast majority of women in the United States consider WTEWYE to be the “pregnancy and birth Bible.” I’m not saying that they (or we) are “stupid” for thinking or ever having thought so. Quite the contrary, in fact. I just think that we live in a culture that is deeply wedded to the idea that “the doctor and the hospital are always right”; that has a remarkably low level of media and marketing literacy; and that does not always have the sorts of skills needed to thinking critically about a “beloved” text such as this one. And this makes it difficult for me to currently endorse WTEWYE.

      This doesn’t mean that the WTEWYE franchise is a lost cause. The format is great, and it could be updated in such a way that it could integrate the risks and benefits of birth interventions (and not just pregnancy hazards :-)) and could place greater emphasis on informed consent and refusal.

      (For what it’s worth, I also think that it is much easier to read only WTEWYE and have an incredible waterbirth in certain maternity systems outside of the U.S. :-))

  10. Renee
    Renee03-28-2010

    Keep you off the meds? What about the women whose providers require an epi for VBAC?

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas03-29-2010

      That’s a good point, Renee! Interestingly, the recent NIH consensus panel found that there is no conclusive research on the relationship between epidurals and VBAC. And really, there are potential “pros and cons” of either option. While an epidural has generally been found not to mask the signs of uterine rupture, it can “slow” the fetus’s heartrate, which can lead to a “false alarm diagnosis” of uterine rupture. (There are, of course, other general negative side effects associated with epidurals that can affect all women–not just those having a VBAC.) On the other hand, even with an epidural in place, the medication itself will need to be increased before a doctor can perform a cesarean section. Thus, an epidural does not guarantee that a c-section can be immediately performed once a uterine rupture is diagnosed. (And general anesthesia would still be a much quicker anesthetic option, even with an epidural in place, in case of an emergency.)

      Long story short, I always ask women to ask their doctors what research or evidence or even expert opinion they are using to make their “epidural and VBAC recommendations.” And if there isn’t any research, evidence, or expert opinion to support their recommendations, then I think this is more than a bit troubling! :-)

  11. Ren
    Ren03-28-2010

    I didn’t at all mean to suggest that WTEWYE should be considered a “bible” or that anyone has to “endorse” it – I certainly never considered it a bible myself. I only meant that I personally used it productively in combination with other birth resources. And I think plenty of other woman can do so also (and have done so – whatever country or situation they happen to have been in).

    I agree that constructively critiquing WTEWYE is a positive project. My disagreement is with blanket condemnations that reject any possibility of the book being useful for any woman. I would support any effort to educate women about how to use WTEWYE thoughtfully in conjunction with other materials. I just would not support an effort that would insist the book must be scrupulously avoided. I don’t think that teaches critical thinking, either.

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  13. TS
    TS04-05-2010

    Well, it is the author’s book and they can put whatever comments they want in it. Maybe you can write the next book refuting what was in this book.

    I don’t particularly know that a woman over eating and gaining more weight than recommended for pregnant women will automatically make for a fat baby. I know women who gain a lot of weight and their babies didn’t appear overweight. That’s one part of the book I’d have to question, but since I haven’t read the book, and have no plans to, I don’t imagine I’ll ever have enough information on what’s in the book to question any of it.

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas04-05-2010

      TS, I totally agree that any author of any book can put whatever comments they want in a book. But I also think that especially when it comes to matter of health–and especially when it comes to matters of pregnancy and childbirth–authors should write as responsibly and accurately as possible. And while much of WTEWYE is unproblematic in this respect, some parts of it are irresponsibly and even inaccurately written. This is particularly unfortunate considering how many readers the WTEWYE franchise has.

  14. Melissa
    Melissa11-06-2011

    I am a big gal. I hate Krispy Kremes. I don’t eat sweets and at week 37 I have gained 5 pounds. I am anxiously awaiting my VBAC with a supportive doctor and supportive husband. I have found the majority of pregnancy books have little to no support for VBACs, so I went straight to the local VBAC association and the ICAN group. They were the most helpful and I was positive my VBAC would be successful from the moment I spoke to them. WTEWE was not my fave book…I much preferred “Up The Duff” by Kaz Cooke which was lent to me by my cousin. It is positive, funny, light-hearted and directs you to other books if you are craving certain information. A much better choice for me! Great article!

  15. Sarah
    Sarah02-15-2012

    Thanks for writing this! While I still appreciate WTEWYE, and it’s still my quick go-to book for symptoms and whatever, I do find myself having to grab other books/articles to supplement the information. Being a woman who will be attempting a VBAC this time around, the information in that book was pretty pathetic. After reading your page, it has inspired me to continue looking for information elsewhere, and not just accept that there isn’t much out there.

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