Navigating Cesarean and VBAC Advice

by Laura Shive

Cesarean

Photo used with permission from Michelle Sokolich at www.lovethelittlethings.com 

Have you ever had a conversation about birth with someone who doesn’t have an opinion? We’re not surprised when discussions of politics or religion elicit passionate responses, but expecting parents are often caught off guard by how readily friends, family, coworkers, and even strangers are willing to pass judgement about their birth plans.

Whether you are preparing for your first baby, adding to your family, or think your family is complete, as your bump expands you can probably expect at least a few unsolicited comments about your baby’s impending arrival.

If you’ve had a cesarean for a prior birth, or if you’re concerned about a surgical birth for this pregnancy, these comments and suggestions can take an especially heavy emotional toll and make you doubt yourself.

Take heart – we have several simple steps to help you handle the birth advice foisted upon you.

When our clients are feeling frustrated or hurt by criticism about their hopes for birth, we suggest they try to imagine that the opinion is offered by a stranger in a grocery check out lane instead of a loved one or coworker. It’s easier to give an internal eye roll and brush off suggestions from the nosy grandma you’ve never met than someone you care about. And the intent is often as benign – they think they have information that‘s going to be so helpful to you (even when it’s anything but welcome)!

Once you’ve escaped being “enlightened” about your choices, consider the source:

  • Has the person given birth in the past couple of years?

    It is amazing how quickly evidence about best practices in birth is emerging. What was considered optimal care five or more years ago may be completely outdated now. And if the birth was more than a decade ago… iPhones didn’t even have Siri and Alexa was just another girl’s name. So your loved one may truly believe they’re sharing facts, when it’s really more of a history lesson.

  • Has the person given birth where you plan to?

    Working as a birth doulas in eight area hospitals, I see a great deal of variation in approaches to even routine interventions. For example, some hospitals readily provide clear fluids in the form of ice pops and juices. Other facilities will halt a lengthy induction to allow the mother to eat a meal. Still other hospitals restrict intake to just ice chips from the time a mother is admitted until the baby is born. So unless you are speaking with someone who birthed recently at the same location you have chosen, their advice may be more about their own experience with their hospital’s rules than anything you are likely to encounter.

  • Do you have the same provider?

    Just as “routine care” varies considerably from one hospital to another, different providers subscribe to different practice guidelines. Some providers tell clients that they will be induced at 40 weeks if their baby has not arrived yet. Other providers don’t routinely induce until closer to 42 weeks. Your neighbor may have given birth a few months ago at the hospital you are planning to use, but your provider may have a completely different approach to managing pregnancy and labor.

This is especially true for TOLAC (Trial Of Labor After Cesarean, or the labor portion of a VBAC). Providers differ significantly in their comfort with TOLAC. Some providers encourage most of their clients to schedule repeat cesareans while others are supportive of TOLAC for a majority of their clients. You’ll find many providers who will offer labor induction to mothers with a prior cesarean, and other providers who refuse to entertain induction for TOLAC clients. So if your friend “had” to schedule a repeat cesarean because she didn’t go into labor before 40 weeks, it is more likely that her provider is one with a restrictive TOLAC/VBAC policy.

  • Do you have the same health history and risk factors?

Pregnancy and birth is not one-size-fits-all. It’s difficult to find one mother with multiple identical labors and births, let alone expect that your labor and birth will be just like someone else’s. Before placing too much value on someone else’s experience, consider how closely their health history and risk factors match yours.

What if the advice you are receiving is from your provider?

If your midwife or obstetrician is giving you advice that mirrors your hopes and goals for your birth, then congratulations! If you are given recommendations that are contrary to your wishes for your birth, you still have options.

We suggest our clients try to consider their pregnancy care provider as they would their auto mechanic. Both are skilled and knowledgeable service providers participating in running businesses. And in both of these situations, you are the client with the purchasing power. If your mechanic gives you a listing of several recommended repairs and a couple of upgrades to consider, there’s a good chance you’ll pick and choose what to do now, what to wait on, and what you have no interest in. And if you start to suspect that your mechanic is recommending services that you really don’t need, likely you’ll find a different mechanic.

Your pregnancy care provider, like the mechanic, has a wide range of options and also opinions on the best course of action (do they trust pregnant bodies, and only intervene when something is concerning, or do they believe they can eliminate some risks by actively controlling labor and birth). As the consumer, you get to decide if their approach is a good fit for you. Several area providers will accept transfer clients well into their third trimester.

When you see signs that a provider may not be a good fit:

  • First, try to have a discussion with your provider about why the recommendation is being made. Open-ended questions give you the best chance of deciphering what is driving the recommendation.

    Examples of open ended questions could include:
    How do you decide if I am a candidate for TOLAC?
    Can you explain why you want to schedule a cesarean now?

  • Don’t be afraid to ask your provider to back up their opinion with current research or practice bulletins. The conversation doesn’t have to be hostile – simply saying “I hadn’t considered that. Where can I read the study to educate myself more?” implies that you are open-minded, but also want to be an informed consumer when making your decisions. It may turn out that your provider is trying to practice evidence-based medicine, but isn’t quite up on the latest quality research.
  • Consider whether you have been given both risks and benefits for scheduling a cesarean and for a trial of labor. If you’ve been given reasons why one option is good and the other is poor, then you have not received the information you need for informed consent. Both cesareans and trials of labor have potential benefits and risks, and often there isn’t an accurate way to predict who will experience specific outcomes. It is important that you have all of the facts to make an informed decision you are comfortable with.
  • If you are considering a cesarean birth, has your provider discussed your thoughts about future birth control and family size, and counseled you about placenta acreta? If not, your provider may not be fully informed about the most recent research. Unfortunately, cesareans increase the chance of dangerous implantation of the placenta in future pregnancies. This should be a part of every conversation about cesarean delivery.

Local resources for exploring cesarean and VBAC/TOLAC options include the Cesarean and VBAC Support of Harrisburg (find it on Facebook or attend its monthly meetings on the third Tuesday at 6:30pm at Om Baby) and area VBAC classes.

National and online resources devoted to quality information about cesarean and VBAC/TOLAC include VBACFacts.com, International Cesarean Awareness Network http://www.ican-online.org/vbac-education-project/, and Childbirth Connection http://www.childbirthconnection.org/giving-birth/c-section/ http://www.childbirthconnection.org/giving-birth/vbac/

April is National Cesarean Awareness month. Look for articles, podcasts, and blog posts about cesarean births, VBAC, and TOLAC next month!

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