The conventional wisdom used to be that “once a Cesearean, always a Cesearean,” but no longer. The medical cultural climate, as well as the AMA advice on the subject ebbs and flows, sometimes encouraging, sometimes discouraging attempting a VBAC (vaginal birth after Cesearean). But with the current style of uterine cutting, a VBAC can be attempted in most cases. But it is up to you to make the circumstances the best they can be for success.
The “classical” c-section cut was a long vertical cut into the uterus, making for a relatively unstable healing process. Because cutting through this large portion of upper uterine muscle does not heal as well, and has a larger instance of scaring problems, women with a classical incision are urged not to try a VBAC. No doctor in the U.S. will do a VBAC after a classical cut, and no midwife with the proper credentials will either. Weighing the rate of c-section complications versus the rate of uterine rupture, it is simply not worth it to have a VBAC in this case. As anyone who has looked into VBACs knows, the risks to the baby include fetal distress, brain damage and death. The risks to the mother include hemmoraging, loss of the uterus, and death.
Fortunately, if you have had a c-section in the past 10 years or so, you most likely have the low transverse incision, or “bikini cut.” This portion of the uterus is much more likely to heal well and have less problems with scarring. One of my low transverse sections did have a lot of scar tissue, but that is not the norm. For a doctor to attempt a VBAC with you, you must have documentation that your previous c-section was not a classical cut.
Most midwives will no longer do VBACs, no matter what their incision, due to a spate of lawsuits in the past five years. There are some midwives who will, but they are few and far between. If you are able to find a midwif who will do a VBAC at home, I still would not recommend it due to the slight risk of rupture ( 1/2 of 1 percent). If there were to be an unlikely rupture, it is best to be in a hospital where help is close by. If there were a complication at home, you would likely not be able to make it to the hospital in time for help.
If you are trying to have a hospital VBAC, I have a few secrets that your doctor is not going to tell you about, due to the conflict of interest. Doctors want you to have a c-section. They make twice as much money and the birth takes about a third as long. There is a saying among OB/GYNs- “The only C-section I’ve been sued for is the one I didn’t do.” And it’s true, unfortunately.
1. Try to get by without the epidural. It’s hard. I know. I was stuck in transition for six hours once with no meds, so believe me, I know. But, if you are free of epidurals and pain medications, you can do several things to help your chances of a VBAC.You can walk around, which often makes your labor progress faster. This is important both for your labor and for the doctor who may get ansy if the labor is too long and will push for a c-section. You are also free to try many different position for both labor and pushing, many of which are highly effective for pain management and for making the pushing stage shorter. The epidural also tends to slow down labor. If labor stalls, they have a reason to section, and they will use it. IV pain medications also dull your thinking, and doctors can and will use that time to talk you into a c-section. A clear headed, though in pain, person has a much better chance of making their own decisions.
2. Don’t let them talk you into induction. This can be a hard one too, especially when you are uncomfortable and can’t wait to see the baby. Believe me, I know that too. I once went to 41 weeks 6 days. But under normal, healthy circumstances, there is no reason for an induction. The main reason in the U.S. for inductions is not for any medical reason, but to make it more convenient for the doctor. Many, many more babies are born on weekdays than on weekends in the U.S. Hang around any maternity ward and you will see it almost empty on the weekends. This is because so many doctors induce during the week so they can have their weekends free. This also means they don’t have to get a call at 3 a.m. to come to the hospital for your delivery. What they will not tell you is that unless there is a real medical reason, like high blood pressure, prolapse, diabetes, etc., there is no reason for an induction. No, going past the due date is not a reason. A normal pregnancy is from 38 to 42 weeks, so the due date is right in the middle of that. No, having a “HUGE baby” is not a reason. All doctors will tell you your baby is huge. They will look at the ultrasound and say – look, it’s so huge, we need to induce. An informal poll of six people who have had babies in the past three year showed that every single one of them were told this, and it was not true for any one of them. Three of them had babies in the 6.5 pound range. What your doctor won’t tell you is that the weight estimate for an ultrasound has a margin of error of 15 percent! This means essentially that it is completely useless. They use the estimate to get you an induction and hopefully a c-section.
With an induction, you are given pitocin, a synthetic labor hormone that gives you extremely strong contractions. Most people are unable to cope with these “titanic” contractions, which can be many times stronger than normal contractions, and need an epidural to cope with the pain. Then, you have the stalled labor and the c-section.
3. Have a birth plan. Old ladies will tell you that no one in their day had a birth plan. No, they didn’t, and they didn’t need them. No one was standing over their shoulder waiting to give them a c-section either. The plan must be very specific in nature, and you must get the doctor to agree and sign the plan in advance. If you don’t, they will later say they “forgot” about it. Been there, done that. If the doctor signs it, it is amazing how well they remember it! You should also bring the plan with you to the hospital, and show it to your nurse once you are assigned one. The plan can include directives such as, you are not to be offered pain medication unless you request it, and that you are to be allowed to walk around unless there is a real medical reason that you can’t. I was once told that I was not allowed to walk at all. Once I convinced them that as a healthy adult, yes, I could walk around, I was told that I had to sign a form first. Amazingly, it took a full hour for them to find the form for me to sign. So, be ready for anything.
