Wednesday, July 24, 2013

Be prepared. Ask questions.

Finding the right care provider is important with any pregnancy, but especially if you want to have a VBAC.  You need a provider who is experienced and knowledgeable and is truly supportive of your desires. Here are 18 questions to get you started (via

What is their philosophy on going past 40 weeks? ACOG’s latest VBAC Guidelines, Practice Bulletin No. 115, (which from here on out I will refer to as “PB115″) states that going overdue should not prevent a woman from planning a VBAC.
What is their philosophy on “big babies?” PB115 states that suspecting a big baby should not prevent a woman from planning a VBAC.  Further, ACOG Practice Bulletin No. 22, which appeared in the November 2000 issue of Obstetrics and Gynecology, found no value in inducing for “big baby” since it simply doubles the CS rate and does not prevent shoulder dystocia or reduce newborn morbidity.  Nor do they support cesarean section for suspected “big babies:”
While the risk of birth trauma with vaginal delivery is higher with increased birth weight, cesarean delivery reduces, but does not eliminate, this risk. In addition, randomized clinical trial results have not shown the clinical effectiveness of prophylactic cesarean delivery when any specific estimated fetal weight is unknown. Results from large cohort and case-control studies reveal that it is safe to allow a trial of labor for estimated fetal weight of more than 4,000 g. Nonetheless, the results of these reports, along with published cost-effectiveness data, do not support prophylactic cesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g (11 lb), although some authors agree that cesarean delivery in these situations should be considered.
How many VBACs have they attended? Word spreads fast on pro-VBAC OBs.
Of the last 10 women seeking VBAC from them, how many had a VBAC? If it’s less than 7 or 8, I would ask what happened in those 2-3 labors that ended in a cesarean.  This would give you a great idea of how they manage labors.
Do they attend VBACs with an unknown or low vertical scar? PB115 states that an unknown or low vertical scar should not prevent a woman from planning a VBAC.
Do they have any standard VBAC protocols that differ from a non-VBAC mom? If so, ask what they are.  Compromises almost always have to be made in order to birth in a hospital.  If your care provider requires an intrauterine pressure catheter, you can read more about those here.
Under what circumstances would they induce a VBAC?  It is a myth that a VBAC mom should never be induced.  Inducing a VBAC mom increases the risk of uterine rupture which should be weighted against the reason for the induction.  “Big baby” (less than 11lbs) and “over due” (meaning you are 40 weeks, 1 day) are not legitimate, medical reasons.
However, if a medical reason for induction is present, women should be given that option rather than required to have another cesarean.  As Dr. Stuart Fischbein, a breech & VBAC supportive Southern California OB, recently shared on my FB page,
According to ACOG, prior low transverse c/section is not a contraindication to induction (other than the use of misoprostol [Cytotec]) so a foley balloon or pitocin may be used safely in these women. The problem arises when a practitioner does not believe in doing inductions on women with prior c/section. Despite the evidence and the ACOG clinical guideline the reality is that many doctors will just not want to deal with it.
If I was overdue and my care provider was concerned about the baby, I personally would request a biophysical profile to check on baby and as long as baby and I are fine, I would request to wait for labor to start instead of inducing or scheduling a repeat cesarean.
However, if my provider was unwilling to wait for spontaneous labor, or if there was a medical reason for the baby to born, and it was the difference between a VBAC and a repeat cesarean, and I had a favorable Bishop’s score (download the app), I would consent to a foley catheter or low-dose Pitocin induction (not Cytotec or Cervidil).  If I was induced with Pitocin, I would be comfortable with continuous external fetal monitoring (preferably telemetry – call the hospital beforehand to confirm that it’s not lost in a closet.)
What methods do they use? PB115 states “Misoprostol [Cytotec] should not be used for third trimester cervical ripening or labor induction in patients who have had a cesarean delivery or major uterine surgery.”
PB115 also said, “Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC [trial of labor after cesarean.]“
Landon (2004) reviews how uterine rupture rates vary by drug: 1.4% (N = 13) with any prostaglandins [such as Cytotec or Cervidil] (with or without oxytocin), 0% with prostaglandins alone, 0.9% (n = 15) with no prostaglandins (includes mechanical dilation with or without oxytocin), and 1.1% (N = 20) with oxytocin alone.  Women who were not induced or augmented had a rupture rate of 0.4%.  Overall, they found 0.7% of women experienced a true uterine rupture with an additional 0.7% experiencing a dehiscence.
Do they attend vaginal breech births? 3% of babies are breech at term, so it’s good to know what would happen if you were in that 3%.  Some hospitals do support vaginal breech birth.
Do they attend vaginal twin VBACs? PB115 states that suspecting twins should not prevent a woman from planning a VBAC.  Read stores of twin/multiples VBAC births.
How many uterine ruptures have they witnessed? This can be an indicator of their induction rates or simply how many VBACs they have attended.  It’s a numbers game.  The more births you attend, the more complications you see.
What kind of monitoring do they require? PB115 states, “Most authorities recommend continuous electronic fetal monitoring.  No data suggest that intrauterine pressure catheters or fetal scalp electrodes are superior to external forms of monitoring…”
Routine continuous electronic fetal monitoring (EFM), compared with intermittent auscultation, increased the likelihood of instrumental vaginal delivery and cesarean section and failed to reduce rates of low Apgar scores, stillbirth and newborn death rates, admissions to special care nursery, or the incidence of cerebral palsy.
In June 2009, ACOG released new heart rate monitoring guidelines where they affirmed,
“Since 1980, the use of EFM has grown dramatically, from being used on 45% of pregnant women in labor to 85% in 2002,” says George A. Macones, MD, who headed the development of the ACOG document. “Although EFM is the most common obstetric procedure today, unfortunately it hasn’t reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions.”
What is their CS rate? This seemingly simple statistic is actually quite complicated. If they are a perinatologist who specializes in high risk births, then a higher CS rate would make sense, but for your average OB, going above WHO’s recommendation of a 15% cesarean rate could be a red flag.
As the 2009 edition of WHO’s “Monitoring Emergency Obstetric Care: A Handbook” states, “It should be noted that the proposed upper limit of 15% is not a target to be achieved, but rather a threshold not to be exceeded.”
Do they perform an automatic CS if waters have been broken for more than 24 hours, even if there is no evidence of infection and mom and baby are fine? If they say yes, this could be a red flag.
Do they have a time-limit on how long your labor can be before they c-section you? Generally, as long as mom and baby are fine, labor should be permitted to continue.
Do they require epidurals for VBAC? PB115 states that pain medication “for labor may be used as part of TOLAC, and adequate pain relief may encourage more women to choose TOLAC.”  One reason that some OBs require epidurals is because if they deem a cesarean necessary, you are already numb.
Do they require an IV or heplock? IVs can restrict your movement. A heplock means they put a line in your arm, but it isn’t connected to a bag.  Heplocks & IVs can be annoying and get you into the “patient” rather than “healthy, birthing mom” mindset.
Are you permitted to move and deliver in your position of choice? Laying on your back or the “on the edge of the bed with your knees by your ears” are great for their viewing, but may not be the most effective positions for you. It’s always nice to have options other than the standard birthing position, such as those demonstrated in this chart or using items like a birth/squat bar or a birth stool (which has the same concept as the bar, but you can sit) for delivery.
You might have to interview several providers until you find one who is truly supportive of VBAC. If you do find such a provider, refer all your friends, VBAC or not, to this provider so that they can reap the benefit of someone who supports non-interventive birth! I really think that true change won’t occur in the medical community in terms of supporting natural non-interventive birth and VBAC until the OBs and hospitals see their revenue decrease. For this reason, we all need to support OBs, midwives, and hospitals that support VBAC.


ob said...

Thank you for this post. However, as a VBAC doc I need you to know that Baptist hospital of Jackson now offers VBAC again. The ban has been lifted so that I can practice there and offer the choice of VBAC, vaginal twins, and vaginal breech deliveries. For more information contact Magnolia Woman's Clinic, Jackson Ms.

ICANofJacksonMS said...

Thank you for letting us know about this change! Is the ban lifted only for your practice or are other OB's planning to attend VBAC at Baptist Hospital?