Birthing Beautiful Ideas

Many women who want to have a vaginal birth after cesarean (or VBAC, pronounced “vee-back”) in the U.S. have faced some sort of opposition from their care providers when they have expressed their desire to VBAC.  Oftentimes, this opposition comes in the form of ” VBAC scare tactics.”

The (outrageous) statements are often misleading, exaggerated efforts by OBs (and yes, even midwives) to discourage women from VBAC and to encourage them to “choose” a repeat cesarean.  (Of course, it’s not really a choice if your provider won’t even “let” you VBAC, is it?)

And if you find yourself up against a barrage of scare tactics–as I once did–it can be exceedingly difficult to stake your claim and argue against the doctor (again, or midwife) who may or may not have your and your baby’s health prioritized higher than medico-legal concerns and who may or may not be hurling phrases like “catastrophic uterine rupture” and “dead baby” your way.

If you do find yourself facing such scare tactics, and if you do want to have a VBAC, there are some questions that your care provider should be able to answer when s/he hurls those scary and/or outrageous comments and standards your way.  And if s/he refuses to or even cannot answer these questions, then you might want to consider finding an alternative care provider–one who is making medical decisions based on research, evidence, and even respect for your patient autonomy and not on fear, willful ignorance, or even convenience.

I encourage all mothers who read this post (and others in my “VBAC Scare Tactics Series”) to  take the information contained herein as a springboard from which they can 1) continue their research on VBAC, 2) maintain a communicative relationship with their care providers, and 3) find a care provider who best supports the mother’s interests and plans for the birth of her child.

(To read my disclaimers about “why I am not anti-OB” and “why I take the gravity of uterine rupture seriously,” please see my posts on VBAC scare tactics (1) and (2) .)

Scare tactic #3: I’ll let you attempt a “trial of labor” just as long as you go into labor before your due date.  After that, we’re scheduling a repeat cesarean.

Questions to ask your care provider:

• Does the risk of uterine rupture go up after this point in a woman’s pregnancy?
• Why can’t we extend the deadline until 42 weeks, after which point my pregnancy is truly “postdates” by ACOG’s standards?
• Instead of scheduling a cesarean, would you consider inducing labor?  (Even if your care provider refuses to induce VBAC labors with prostaglandins or pitocin–and s/he may have very good reasons for this policy–you can always ask about a non-chemical induction, such as a foley catheter induction or an amniotomy.  More on these options in a bit.)
• What happens if I refuse to schedule a repeat cesarean and wait for labor to begin spontaneously?
  

A more nuanced analysis:

It is my opinion that these “due date deadlines” for VBAC moms often demonstrate the care provider’s underlying lack of support for VBAC–especially when the deadline falls before the mother’s due date.  (For what it’s worth, I’ve heard of some care providers who state that they will only “allow” their patients to attempt a VBAC if they go into labor before 39 weeks.  As I’ll explain in a bit, this policy all but guarantees a repeat cesarean for most moms.)

First, due dates themselves are only estimates.  The very fact that these dates are estimates is represented in both acronyms that obstetricians and midwives themselves use to refer to a woman’s “due date”: ‘EDD’ (estimated due date) or ‘EDC’ (estimated date of confinement).  So it should come as no surprise to one’s care provider that the due date is not like an expiration date but is rather an educated guess about the length of gestation.

What’s more, calculating one’s due date based on one’s last missed period (or LMP) is not a foolproof or perfectly accurate way to determine when one’s baby is “due.”  For this method of estimating due dates assumes that the mother ovulated and conceived her baby exactly fourteen days after her last period began.  And if, like many women, she did not ovulate or conceive on the fourteenth day, then an estimated due date based on her LMP can be off by a couple of days, and even by a couple of weeks.

Finally, while (early) ultrasounds can offer fairly accurate due date estimates, they are not foolproof either.  In fact, ultrasounds in the late first-trimester and beyond can be “off” by as much as two or three weeks!

Accordingly, since due dates are “only” estimates–hopefully educated estimates, but estimates nonetheless–it is important to ask your care provider why this estimated date should confer so much concern upon your VBAC attempt.

What’s more, since a normal gestation can last up to 42 weeks (at least as defined by the American College of Obstetrics and Gynecology), it is even more important to keep in mind that many mothers will not go into labor spontaneously before their estimated due dates.  Some perfectly normal pregnancies–again, even within the confines of ACOG’s guidelines–will extend well past the “39 week” or “40 week” deadlines set by the care providers to which I refer in the aforementioned scare tactic.

And if these mothers follow the VBAC “guidelines” established by their care providers, then they will end up with repeat cesareans for pregnancies that are not truly “postdates” (i.e. lasting beyond 42 weeks) and that may not even be as close to the estimated due date as they think, especially if the due date is (unknowingly) inaccurate.  And this should be of special concern given the current research on the health risks posed to babies born via elective cesarean before 39 weeks.

Furthermore, it is exceedingly important to ask one’s care provider about the research that s/he is using to make his or her decision about the “VBAC deadline.”  And thus far, there is no research recommending that all VBACs take place at or before 40 weeks gestation.

It is worth noting, however, that the recent NIH Consensus Statement on VBAC does find attempting a VBAC past the estimated due date (i.e. past 40 weeks gestation) does decrease the VBAC success rate slightly.  But the VBAC success rate is vastly different from the uterine rupture rate:  the VBAC success rate represents the rate of women attempting VBAC who give birth vaginally, and the uterine rupture rate simply represents the rate of uterine ruptures following a VBAC attempt.  What’s more, there might be other factors (such as increased induction rates) that contribute to the decrease in VBAC success beyond 40 weeks.

Notably, the 2004 Landon study concludes that induction with pitocin or prostaglandins does increase the uterine rupture risk in VBAC attempts.  Accordingly, this increased risk may be one of the reasons that your care provider would choose to schedule you for a repeat cesarean rather than a chemical induction.  (Worth noting is that pitocin induction increases the uterine rupture risk to approximately .7-1.2%, as opposed to .2-.7% for spontaneous labors.  This increased risk may be acceptable for some women who agree to a pitocin induction, especially a “low-dose” induction.)

Nonetheless, instead of a pitocin induction–and instead of a repeat cesarean–you can always ask your care provider to attempt a foley catheter induction or an amniotomy to induce labor.  Neither of these forms of induction poses any additional risk specific to moms attempting VBAC. And while the amniotomy in particular has some specific disadvantages (particularly an increased risk of infection), and while neither form of induction guarantees that labor will begin, it may be worth attempting one of these forms of induction if 1) you choose to stay with your care provider, 2) s/he refuses to budge (or will only deviate slightly) from the “due date deadline,” and 3) you are committed to attempting a VBAC rather than agreeing to a repeat cesarean.

Moreover, it is entirely within your right to refuse a repeat cesarean and to await for labor to begin spontaneously.  In fact, ICAN has a tremendously helpful and well-researched resource on the disadvantages of (non-necessary) induction and the advantages of awaiting spontaneous labor in a vaginal birth after cesarean.  What’s more, in addition to citing research regarding the fetal brain development that occurs all the way through the 41st week of pregnancy, Lamaze International’s Practice Paper on Letting Labor Begin on its Own describes the many ways in which awaiting spontaneous labor is beneficial to both mother and baby.  Combined, these include the facts that:

• Studies generally show that induction increases the cesarean rate, especially for moms attempting their first VBAC.
• Studies also show that induction increases the risk of vacuum or forceps-assisted vaginal delivery, jaundice, low birth rate, and admission to the NICU.
• Chemical induction interferes with the body’s production of the hormones that help to loosen the pelvis in preparation for birth.
• Synthetic oxytocin (or pitocin) carries with it a number of risks, including (but not limited to) postpartum hemorrhage and cardiac arrhythmia in the mother and fetal bradycardia and low Apgar scores at five minutes for the baby.
• Because of the increased need for monitoring during an induction, the mother is usually confined to the bed or to the immediate area surrounding the bed, thereby making it extremely difficult for her to move to help her cope with the intensity of labor.
• Induction increases the likelihood of a mother requesting an epidural, which itself carries extra risks to both mother and baby.
• And finally, both pitocin and prostaglandin inductions increase the risk of uterine rupture for moms attempting VBAC.

Accordingly, it bears asking your care provider what would or could happen if you simply refused to undergo an induction and/or the recommended surgery–even if this would certainly become a potential uphill battle for you and your attempt to have a VBAC.

In this respect, I strongly encourage you to become familiar with ICAN’s White Papers,  particularly with the document entitled “Enforcing and Promoting Women’s Rights.”  This document explains not only the doctrine of informed consent but also the laws and ethical guidelines that should protect you and your right to attempt a VBAC.  (Yes, it can be construed as an actual right!)  It also  explains your rights and your options in regard to your care provider and in regard to the hospital at which you plan to give birth.

And from someone who has not only defended herself against the scare tactics of a VBAC-denying obstetrician but also changed care providers at nearly 37 weeks to a truly VBAC-supportive obstetrician, I know from experience that this knowledge–the knowledge of one’s rights and options–can be empowering.