As a doula (since 2005), I often get emails from women looking for support to achieve a VBAC (vaginal birth after caesarean), under the care of someone who they claim to be a ‘VBAC friendly’ obstetrician (or hospital if she’s going public – however in Australia its the private establishments that have higher caesarean rates). I only need to read a few lines into their emails and it quickly becomes very clear that the obstetrician or hospital that they have chosen is actually very VBAC UN-friendly, because restrictions have been put into place that can greatly sabotage any mother’s VBAC hopes and dreams. While there are some genuinely pro-VBAC doctors and hospitals out there (who we love and dearly thank for their belief in women’s capable bodies), they really are few and far between..
I don’t believe in creating reasons for women to distrust their carer – its very important that you trust who you’ve chosen to birth with. If you don’t feel like they have your best interests at heart, then you need to find a new carer – pronto. As a woman who wants a VBAC, I am sure you also want to do as much as you can to help make it a success. This article has been written so that you can understand common reasons why VBAC attempts often fail before they even begin.
So what are some of these restrictions that can de-rail your chances of a VBAC? Here are 9 major causes of VBAC sabotage which are commonly adopted by VBAC UN-friendly obstetricians and hospitals – who are putting such restrictions on women which are not based on good solid evidence and best medicine.
VBAC Sabotage #1: Restricting Pregnancy Duration
Bearing in mind that a pregnancy is classed as full term up to 42 weeks, most doctors have a ‘cut-off’ time that they prefer pregnant women to go into labour by. When you reach that cut-off time, they will likely want to schedule you in for an induction – and often for VBAC women, the deadline is even shorter than a non-VBAC woman.
I’ve heard a wide range of VBAC and non-VBAC cut-off dates from many different obstetricians, starting as early as a week or two before the baby’s estimated due date (guess date I prefer to call it). Some doctors will want to induce VBAC women on or before the estimated due date, some a few days later, some a week post-dates… so there is no defined or known time-frame a VBAC mother MUST give birth by, it’s all based on that doctors opinion. However, in the case of a VBAC, there is much less leniency to let a baby be born on the day he’s actually chosen.
Babies tend to defy their guess dates and deadlines and for good reason – they’re still putting the finishing touches on their development, making sure that when they’re born, they’re good and ready and have the best chance at survival.
Think of it this way – if you broke your arm, would you take off your own plaster cast a week or two earlier than your doctors appointment, because you think it’ll be fine by now? Whats a few days anyway? Besides, it’s really frustrating not being able to do what you need to, you have a life, you know? Also, you really want to know what the heck is going on in there – how are you supposed to know if you can’t see?
Of course we wouldn’t do this, because we trust that our body can heal itself – and if we did take it off, we’re going to have to be super careful because our arm would then be vulnerable and could easily end up with added complications than if we left the plaster case on. Your arm is safer and more protected inside, just in case it hasn’t quite healed yet.
Another reason a restriction on your pregnancy duration can cause problems is that your guess date could be off (as most are), resulting in your baby being born days earlier than you think you are pregnant. Miscalculation is very common, mainly because the method of calculating a ‘due date’ is based on a textbook average menstrual cycle of 28 days, ovulating on day 14. Not everyone fits that ‘average’ – only 3-5% of babies are born on their estimated guess date. If your dates are not accurate and you have a short time to get into labour, chances are its not going to happen.
Ironically, ACOG (American College of Obstetricians and Gynaecologists) have this to say about due dates:
“Waiting for the birth of a child is an exciting and anxious time. Most women give birth between 38 and 42 weeks of pregnancy. But very few babies are born on their due dates. It is normal to give birth as much as 3 weeks before or 2 weeks after your due date.”
Yet despite this, American women have the very same struggles with far too many unnecessary birth interventions, including with a VBAC, like we do here in Australia.
So, if a woman hasn’t gone into labour by the time her doctor wants her to, then he may either suggest a repeat caesarean or an induction of labour to get things going… which leads me to my next point…
VBAC Sabotage #2: Induction of Labour
I’m sure the risk of uterine rupture has been drummed into you already – it can be waved around like a big scary monster, even though the actual risk of a rupture (this does not mean your baby dying) of less than 1%, similar to that of an amniocentesis (resulting a miscarriage) and other pre-natal tests, which doctors have no trouble in performing.
However, you may be surprised to know that pharmaceutical inductions (syntocinon/pitocin drip, prostaglandin gels or other drugs designed to get you into labour) have a risk of uterine rupture even on their own, no matter if you’ve had a previous caesarean or not. So thats two risks of rupture combined in one. A woman wanting a VBAC should ideally not be given anything that will increase the strength of normal, natural contractions, let alone an induction of labour with a synthetic drug. This is INCREASING the risk of complications including uterine rupture – not REDUCING the risk, which is why doctors convince women that they need to get them into labour in the first place. Even if you are induced without drugs, e.g. having your waters broken – if it doesn’t trigger off labour and you end up with a failed induction (which can happen no matter what form of induction you have) then the only choice is to keep ramping it up with other drugs or procedures. Once you start an induction process, you can’t stop or get off. It’s all the way.
It is well known in the medical profession that you should avoid inducing VBAC women with drugs where possible – however there seems to be an increased number of inductions again. If you have an induction, you are guaranteed to have other forms of intervention, including restrictive continuous electronic monitoring. Your VBAC dream can quickly fly out the window with this one because induction of labour increases the risk of caesarean section – and thats without even having a prior caesarean.
At the end of the day, an induction only introduces real risks to what could be a perfectly normal birth, with many ending up in emergency caesarean sections. Even obstetricians will admit that there is a clear link between induction of labour and caesarean section. So inducing with drugs, especially when you want a VBAC, is truly playing with fire.
VBAC Sabotage #3: Restricting Time Allowed to Labour (First Stage)
Many VBAC women are told they can only be in labour for a set amount of hours. Considering a ‘textbook’ labour is on average 12 hours of active labour, I often hear that VBAC women are given even less than this to have their baby.
Again this is another unfounded scare tactic with the rupture card thrown in. A doctor may say that a prolonged labour may place stress or strain on your scar, which may result in rupture. Yet there is NO research supporting this. Also, because the length of time that the doctor or hospital ‘allows’ a VBAC woman to labour for varies greatly, this shows further reason that restricting time in labour is being based on individual opinions and not fact.
If your baby and body is labouring normally, there is no reason to to have a deadline and there is no evidence to back up a reason for doing so. Interventions should only be done when there is a problem.
VBAC Sabotage #4: No Doulas Allowed
A VBAC friendly doctor or hospital should know that many studies have consistently shown that a doula significantly reduces a woman’s chance of a caesarean section. A doula’s support has also been found MORE effective than that of hospital staff or the mother’s friends and family, based on a review of 21 doula studies around the world. You can read about it in the BellyBelly Forums here.
If your doctor has told you that he or she does not want you to have a doula, this is another clear indication that they don’t have your needs at heart and/or do not realise the huge benefits of a doula at birth. If the doctor or hospital is open to receiving information and studies from you, this is great – there are plenty you can provide. But if they are dead against it, this is another reason to consider changing caregivers, as this is not a way to help you achieve a VBAC – especially when an obstetrician wont be by your side during labour, encouraging and supporting you to reach your goal – and a doula will be.
VBAC Sabotage #5: Continuous Fetal Monitoring
The evidence is clear: continuous electronic fetal monitoring has been proven to significantly increase the rate of caesarean section without saving lives or improving outcomes. You can read the Cochrane Database study review (which analyses all available studies and makes an independent, non-biased conclusion) here. Here’s a snippet:
“Overall, there was no difference in the number of babies who died during or shortly after labour (about one in 300). Fits (neonatal seizures) in babies were rare (about one in 500 births), but they occurred significantly less often when continuous CTG was used to monitor the fetal heart rate. There was no difference in the incidence of cerebral palsy, however, other possible long-term effects have not been fully assessed and need further study. Continuous monitoring was associated with a significant increase in caesarean section and instrumental vaginal births. Both procedures are known to carry the risks for mothers although the specific adverse outcomes were not assessed in the included studies.”
VBAC Sabotage #6: Restricting Time Allowed to Push (Second Stage)
I’ve attended births, VBAC or not, where women have been told they have 10-20 minutes to push. If mother and baby are fine, there is absolutely NO reason for such unrealistic time restraints – some women need an hour or longer and the labour can remain normal and healthy. Pushing can take longer and/or be more painful if you are on your back or reclining, which will be the case if you’ve had an epidural or other pain relief. It’s likely that you’re pushing for the first time too, so its a new experience. All these things can prolong labour but it doesn’t make it reason to intervene further.
Also, for women who do end up giving birth vaginally, sadly its common for those women to have assisted births with forceps or vacuum. There is such a rush to get the baby out when a different approach can make all the difference.
On average, women who have doulas at their birth have labours that are 90 minutes shorter and result in 40% reduced use of forceps. Doulas not only help with comfort measures but can actively help you find effective positions to push to work with gravity and your body, not against it. So it just goes to show that support and environment play a huge part in the birth – not rushing it just because.
VBAC Sabotage #7: Suggesting an Epidural, ‘Just In Case’
An epidural, you say, just in case? Is that, just in case your other earlier attempts to de-rail my VBAC doesn’t work, so I end up stuck in the bed, flat on my back and am unable to move around during labour… following that, just in case my baby gets stuck in a bad position as a result… followed by, I can’t push really well because I can’t feel a thing? Then you may need to rescue me and my baby by getting me into theatre…. and thank goodness the epidural was in, just in case?
Not only is an epidural totally unnecessary and adding an intervention (remember, when you need one, you need more, starting with a urinary catheter as you wont be able to feel your bladder), but it’s not a very good energy to have hanging over your head, knowing that your doctor put something in place for anticipated failure. If you or your doctor thinks its hard to trust your body now… well it’s much harder to trust your body to work like it should under the effect of an epidural.
Epidurals result in more operative births, from forceps, to vacuum, which may even turn into caesarean sections, because the mother is no longer able to be active and working with her body to help bring baby down where he or she needs to be, ready for birth.
A simple, ‘no thanks,’ to the epidural offer will suffice.
VBAC Sabotage #8: Suggesting a Bung (for i/v line), ‘Just In Case’
See above. Thanks for trusting her body and her resolve, doc. I don’t know about you, but she’s focusing on a VBAC, not surgery, and would like to be free to move, not restricted to an IV line.
VBAC Sabotage #9: Telling Women to Come Into Hospital As Soon As Labour Starts
Tick, tock, tick, tock…. can you hear that? That’s the clock your doctor just placed above your head the moment you walked through the labour ward doors. And if you don’t hurry up and get that baby out in the time he or she sees fit – while you bolt (or should that be waddle, because pregnant women aren’t designed to bolt) barefoot across the minefield of booby traps listed above – then I am sure by now you know where this is headed…
Usually, the longer you stay at home, the better your labour will progress. You may consciously or unconsciously assume that the sooner you’re in hospital, the sooner you’ll have your baby, but unless you’re planning on a caesarean section or induction, this isn’t always the case. In an environment of familiar sights, smells, safety, relaxation, comfort and privacy, your labour will establish quicker and easier than an environment of timers, lights, pressure, pokes, prods, noise, sterile smells and anxiety triggers. Unless you feel frightened or unsafe at home, its the best place to be in early labour.
An investment of time at home before going in will pay off – going in too early can slow down or stall your labour and you will be put on the clock. You’ll know when you really need to go in.
What Can You Do?
If your baby and your body are well and happy, then you can rightfully refuse any medical procedure being offered to you. It is important to educate yourself about VBAC so you feel confident making your own choices and decisions, and most importantly having the confidence saying NO, which many women and men struggle with when speaking to doctors.
If your doctor or hospital has one or more of the above restrictions in place, then they are NOT VBAC friendly. They might agree to give your labour a go (which they may call a ‘trial of labour’), and ironically many women feel grateful and appreciative of being given a chance to prove that their body works. Well, it does. However when being given a ‘trial of labour’ your carer is not trusting your body – until it proves itself capable. You need a carer who trusts your body, even at some point if it shows that it needs help – not put it on ‘trial’. Some labour is so much better for your baby than no labour.
Each and every one of the above restrictions piles on the likelihood that you wont get your VBAC.
Things you can do to take control over your experience and increase chances of a VBAC include any of the following:
- Choose a new obstetrician if you are in private care
- Choose public care – some public hospitals have higher VBAC rates than some obstetricians
- Hire a doula – there are so very many benefits to having a doula no matter what sort of birth you are having.
- Hire an independent/homebirth midwife – you can privately hire your own independent midwife who will support you as a doula would, but with more extensive training. I believe independent midwives are the gold standard in maternity care for low risk women. At less than 1%, I think you’re low risk for uterine rupture. Thats more than 99% that says you will be perfectly fine.
- Consider a HBAC (home birth after caesarean)
It’s up to us as women, together with our partners, to put our feet down, research and make our choices very wisely, based on whats best for our babies. You’d research what big screen television you’d like to buy – so make sure you research for what will be a life long memory at your next birth.
Recommended Reading For VBAC’ers
- Birthing Normally After a Cesarean or Two
- Silent Knife: Cesarean Prevention and Vaginal Birth after Cesarean
- The Thinking Woman’s Guide To A Better Birth by Henci Goer
VBAC Support Groups
It’s important to be involved with some form of VBAC ‘cheersquad’ – online is great but offline is even better. The BellyBelly forums have a VBAC Support Forum where you can get suport, advice and cheered-on by other VBAC’ers and VBAC’ers to be. There is also a Facebook support group for VBAC.
Here are some links of offline support groups, which I will add to as I find more.