Tips for Planning a Vaginal Birth After Cesarean (VBAC)

In a prior post, I introduced the issues pregnant people need to know regarding vaginal birth after cesarean (VBAC).  That post concluded, “if you are pregnant after a cesarean, fear, politics, risk management and physician preference may filter the options and information available to you in navigating your care.”

As a result, folks planning a VBAC can benefit from taking the following measures.

Educate yourself as much as possible.

There are a number of incredible, fact-based resources out there on VBAC, uterine rupture, placenta accreta, and related issues.  My personal favorite is VBAC Facts, which runs an incredible self-paced, six-hour online class for families called The Truth About VBAC, which I have personally audited and found to be worth every penny.  The material is complex, covering everything from the politics and history of VBAC, to ACOG guidelines, to current evidence on the incidence of uterine rupture and placenta accreta, and more.   VBAC Facts also has an amazing blog, and Facebook page that you can browse for more information.  In addition, there is also the VBAC Education Project at www.vbac.com.  You can read books on VBAC, look at the National Institutes of Health (NIH’s) 2010 consensus documents on VBAC available here, read publicly available studies, download and familiarize yourself with ACOG’s VBAC guidelines, FAQs and other resources, and browse articles exploring the finer points of risks, benefits and options.  You can become familiar with resources for maternity care consumers, such as ImprovingBirth.org, Birth Monopoly, and others, where VBAC is frequently addressed as a consumer education, patients’ rights and quality of care issue.  Learn what’s evidence-based and what’s not, so you can navigate your care with full and accurate information, even if your provider is not giving it to you.  Because sadly, many do not offer patients the information they need to make informed decisions.

Select your provider and place of birth very carefully.

It is not at all ideal to pursue a VBAC with a provider that does not support it, or in a hospital that purports to “ban” it.  Unfortunately, in many areas of the country, pregnant people may not have any providers covered by their insurance or even within a 100 mile radius that offer VBAC.  Folks in this dire situation may be forced to go into a hostile environment in labor simply refusing surgery.  While refusing surgery is the patient’s right, providers can and do use physical and legal force (such as court-orders) and pyschological warfare (like bullying during labor) to get women to submit to cesarean surgery against their will and despite clear laws protecting patient bodily autonomy.  This is a terrible, traumatizing situation that should be avoided at all costs.   Thankfully, in the Twin Cities and Chippewa Valley areas, there are numerous hospitals, birth centers and home birth midwives that offer VBAC and are truly supportive.

Ideally, you should find a provider that is comfortable with VBACs, provides accurate and balanced information on risks and benefits, and respects your right to make choices about your body, including whether or not you have a major surgery that increases your risk of complications in this and future deliveries.  This may require taking the time to interview several different providers by asking open-ended questions about their practice style, VBAC philosophy and view of patient rights, and a willingness to travel for the right fit.  

It will also require thinking about things that are important to you, for example, are you more comfortable delivering in a hospital with a NICU and 24/7 anesthesia in the event of an emergency?  Or would you prefer a smaller, community hospital where the staff hold a view of birth that is less focused on potential for emergency and more focused on the strong chances of normalcy?  Would you prefer to receive your care with a midwife, a family physician, or an obstetrician?  If something other than an obstetrician, what relationships does your preferred provider have (or not have) with obstetric back-up, and how do you feel about that?   Does the back-up arrangement restrict your provider in any way, or do you feel the relationship is beneficial to you from a safety perspective?  Can you travel across state lines if a provider or hospital in another state is known to be very supportive of VBAC?  Are there any birth centers near you that offer VBAC and if so, what relationships do you prefer they have (or not have) with nearby hospitals?  Does your state permit midwives to attend VBACs at home, and if so, would you consider that option?  If so, how close are you to a hospital?  How hostile or friendly is the nearest hospital to out-of-hospital birth in the event you require a transfer in labor?   This is just a broad overview of some of the considerations you may face.  For help working through your options, and how to approach finding a provider that fits your unique needs and fears, you can schedule a consultation with me!

Know your rights.

This is critical.  In addition to the right to refuse unwanted repeat surgery, your rights are implicated in many other ways when planning a VBAC.  This is because many providers that offer VBAC purport to place serious restrictions on their patients’ ability to labor.  Examples include “requiring” that you:

• go into labor spontaneously (in other words, induction is not an option; your provider will send you straight to scheduled surgery if you don’t go into labor on your own within their desired timeframe.  Note this is inconsistent with ACOG guidelines);
• go into labor by a certain date (often 40 or 41 weeks) —  in other words, purporting to prohibit you from continuing your pregnancy;
• receive epidural in active labor (having the spinal already placed makes many obstetricians more comfortable because it reduces the time needed to prep you for surgery in an emergency);
• have continuous monitoring in labor, which may restrict your freedom of movement;
• have a heparin lock for IV access in the event of an emergency;
• have a cesarean section if there is any plateau in labor progress — in other words, your labor must progress perfectly for you to be ‘allowed’ to continue.

The patient’s legal rights are pertinent to every single one of these provider policies.  Not all are evidence-based and ultimately, the patient retains the right to decide for themselves what interventions to accept or reject, even in a VBAC.

I encourage all parents to sign up for my “Know Your Rights” classes, which I offer both one-on-one and in group format.

Get support.

Surrounding yourself with knowledgeable, empathetic support is extra important for VBAC hopefuls, because this is such an emotionally loaded, misunderstood journey.  Getting a doula who is knowledgeable about and experienced with VBAC, who can help you work through your fears and emotions, and plan for all possible outcomes, is ideal.  Attending your local ICAN chapter meetings to sit with other cesarean moms who have experienced both VBAC and RCS (repeat cesarean section) is critical.  You can check on www.ican-online.org for a chapter near you.  (Hint — I am both an ICAN chapter leader and a doula attending VBACs!).  Seek out a community of other parents who have also planned for a VBAC, and be wary of those who are critical of your choice.  Work to surround yourself only with people who respect you, and won’t inject their own fears and insecurities into your sacred pregnancy — whether friends, family or providers.  If possible, attend a childbirth education class specifically focused on VBAC.  As discussed below, therapy is also recommended as a safe and supportive place to discuss your planned VBAC.

Process your last birth.

It is critically important to have processed your last birth when planning a VBAC.  Many people carry around trauma from their cesarean that requires a lot of work to heal from, and may benefit immensely from the help of a licensed therapist specializing in helping women recover from difficult births.  Others credit EMDR (Eye Movement Desensitization Reprocessing) therapy.  Regardless, be sure to work on your emotional preparedness as much, if not more, than you work to understand things like your rights, options for care and the medical evidence.  In particular, I caution against bringing the trauma and expectations of your last birth into a VBAC.   Unresolved trauma can really derail a vaginal birth by creeping up in labor and causing even greater trauma if the VBAC does not go as planned.  VBAC is very high stakes — not just from a safety perspective, and in terms of what it means for your reproductive future — but also from an emotional perspective.  Your emotional well-being headed into, and coming out of, your planned VBAC is of paramount importance.  I advise my clients that it is well worth the expense and time of seeing a therapist to sort out how you feel about your cesarean birth, and your upcoming birth.  You will be healthier for it, no matter what happens.

Let go of the outcome of this birth.

VBACs can be healing, and with the right provider and support, your chances of success can be high.  But the reality is, not all people that plan a VBAC will have one.   Depending on your provider and place of birth, your statistical chances of having a repeat cesarean in labor are anywhere from 1 in 10 (at best) to 4 in 10 (or worse) — these chances are not small.  Thus, it is critically important that you do not approach your planned VBAC as ‘do or die,’ ‘redemptive’ or ‘healing’.  Healing must come first.  Rigid expectations can increase your trauma in the event your VBAC does not go as planned.

This is a tricky balancing act, because having a vaginal birth — in particular any vaginal birth people are highly unlikely to have, such as an unmedicated vaginal birth, a home birth or a VBAC (or all three of these at once!) — requires an enormous amount of determination and confidence.  However, it is important to recognize that determination and confidence are necessary, but not sufficient, for having a VBAC.  Factors beyond your control will always influence the path that your pregnancy and labor take.  Acknowledging and preparing for the fact that you may not have a VBAC is critical.  

I also believe it is critical to acknowledge and understand that, while rare, the uterine rupture statistics represent real people, and real babies.  Just like severe complications from cesarean section happen, and could happen to you, the same is true of uterine rupture.  There is no risk-free option.  The statistics are not so small they can’t happen.  I encourage parents to grapple openly with these things, instead of assuming for the sake of positivity that all will be fine. For example, you may get your VBAC, be relishing in the glory of a perfect birth, and then suffer a serious postpartum hemorrhage, tear or other complication that overshadows the entire experience.  Or, you may get your VBAC, but find it more traumatic than you expected.  Or, you may end up having another cesarean, but find it healing and beautiful.  Or you may have a cesarean for fetal distress that is rushed and scary, or a non-emergent but extremely upsetting cesarean for obstructed labor.  Or you may get your VBAC — even one with complications — and feel it was perfect, and amazing.  There is no silver bullet, “perfect” birth, or way to know what you’ll get.  It is important to be open to all possible outcomes.

In the end, once you have reckoned with the risks and benefits, you have to put these things in a box, and walk away.  You have to be at peace with the uncertainty of not knowing what your outcome will be, and with the fact that you made the best choices you could, with the information and resources available to you.  Getting to this place of peace is critical for all expecting parents, but especially for those who are walking the difficult path of hope, belief and bravery, toward a VBAC.