Birth Matters

Do you want to have a VBAC?

 I hear a lot of women comment on their VBAC hopes and fears, often after they’ve been searching for someone to attend their next birth.  Here are some of the comments, questions and my responses and rants over the years.

"Since I've had a VBAC, she said I still have a shot at another VBAC if I get pregnant again- only because I've already done it- but she said things could change by the time I would deliver."

This is true - I know of at least a dozen women who've had multiple VBACs who are now being told they must have another cesarean- just because way back when, they had a cesarean. Often, the number of VBACs you have had makes absolutely no difference in the "policy" - so beware.

"Anyway, now, because of all the regulations, I don't know if I will be allowed to VBAC."

This is an important point. It has nothing to do with your safety or the safety of your babies. I've read most of the studies there are about cesarean and VBAC (I do a lot of freelance research and writing) and nothing has changed; except how obstetricians approach VBAC. They do things which aren't all that safe (early induction, aggressive augmentation, heavy restrictions on labor, etc).

As far as the research goes, a non-interventionist VBAC (the kind that used to be the norm) is still undeniably safer for most women and most babies than a repeat cesarean. It is not, however, "safer" for the obstetrician. If you are going to let your obstetrician/hospital tell you what you are allowed to do or not do with your body and your baby, then you are right, you will not be allowed to have a VBAC.

"They expect you to go the hospital with the first contraction and an anesthesiologist and the obstetrician have to stay there the whole time until that baby is out and a lot of doctors do not want to do that since you can be in labor for a couple days."

Exactly. These instructions have nothing to do with what's best for you and your baby and everything to do with money and time management. It is up to each and every one of us to decide if those are factors that we want to dictate our birth choices.  Do we want money and politics to decide what sort of birth our children have?  Our kids only get one shot at birth; the hospital gets lots of shots at making money. We get to decide.

"Much of my information is close to 10 years old so I am concerned that I am missing some important information.   My obstetrician says that they now know VBAC is more risky than they thought.  Can someone please help me out? I need to be informed and I am very emotional about this."

You really aren't missing much - we know more about things that make VBAC riskier - like aggressive induction for any and no reason. But when you compare spontaneous labor VBAC now with spontaneous labor VBAC 10 years ago, the numbers are exactly the same. It isn't more dangerous. Really. Its just that the politics have changed; obstetricians killed or maimed babies being impatient and aggressive in their management and got sued; so they'd rather just do more cesareans because they don't get sued for those (yet) and they make more money and it's a lot more convenient. And after all, they aren't midwives to be sitting with a laboring woman all day and night, that's not why they went to school.

"I just can't visualize another surgical birth."

Don't. Chances are extraordinarily high that you don't have to have one. You absolutely do not have to climb up on that table and lie down like a good little girl and let them cut you open again. You always have options. You just have to be willing to explore them.   10 years ago, most women weren’t given the option of an automatic repeat cesarean.  It was assumed that you would labor.  Now, did a lot of women end up with de facto automatic repeats because their obstetricians either set them up or came up with bogus reasons?  Of course they did – obstetricians, for the most part, have never liked or willingly supported VBAC.  The real difference between now and 10 years ago is that most women now aren’t given the option of a VBAC.  It is assumed that they will have another cesarean and it is assumed that they are happy with that.  If you want a VBAC, you are going to have to work for it – no one is going to hand you a VBAC in the hospital of your choice with the obstetrician of your choice.  You have options, just not all the options you might want.  Which do you want more?  A VBAC or your now non-existent options?

If you are using a Certified Nurse Midwife for your primary care, what is she saying, even though some obstetrician really wants to get his scalpel in you? Is she truly and actively supporting you or is it just midwifey lip service?  Remember, for all practical purposes, she’s under the supervision of the obstetrician, who has the power to determine whether she can practice midwifery at all, depending on whether or not she practices within his guidelines.   Do you have a doula, someone who isn't in the pocket of the College of Nurse Midwives or the hospital? What does your husband say about all this? They can not make you do something you don't want to do - you don't have to schedule a cesarean, you don't have to go to the hospital at the first contraction, heck you don't have to go to the hospital at all.  There are no “cesarean police” that will show up and your house and drag you to a scheduled cesarean, even if it’s on the books already!

“At the beginning of my pregnancy my obstetrician said it was ok with him if I wanted to have a VBAC but lately he’s started coming up with all sorts of reasons why it might not be a good idea for me.  And now he says he’ll drop me as a patient because I’m 38 weeks and don’t want to schedule the cesarean for next week.” 

Ah, the good ole bait and switch.  I’m pretty sure they don’t actually teach this in medical school but I’m equally sure they learn it during their residencies by example.  Be “supportive” of whatever crazy idea the pregnant woman wants (VBAC, drug-free labor, waterbirth, whatever) for the first 2/3 of the pregnancy and then start working on her to get her in line with your plans.  This happens all the time.  This behavior is unethical on so many levels, it amazes me.  First, the patient is supposed to be in charge of their care, with the collaboration of the physician.  Being pregnant does not make you incompetent and thus unable to make decisions about your own care.   Lying at the start of a fundamentally business relationship is never ok, its fraud.  Manipulating a woman to agree to something she’s already said she doesn’t want by making unsupportable and vague accusations of danger to her unborn child is inexcusable.  If none of that works, threaten to dump her from your care.  And while it varies from state to state with regard to the exact rules about and possible repercussions of patient abandonment, most states to prohibit a physician from dumping you without a 14 to 30 days warning (depends on the state) and they must provide “emergency care” until you find equivalent care elsewhere.  I am willing to bet that most of the time, the threat to “drop you” is a bluff.

“I can’t find anyone to attend me.  Every hospital within 2 hours has banned VBAC, there are no homebirth midwives in my area and I’m not comfortable with an unassisted birth.  So, I’m just going to show up at the hospital pushing and refuse to consent to a cesarean.  After all, they can’t force me to have another cesarean.”

I am hearing this more and more often.  And honestly, it really pisses me off.  First, it’s illegal.  I won’t go into the nitty gritty details here but when it comes down to it, refusing to provide VBAC services is illegal if the hospital receives federal funding (which almost all of them do, in the form of Medicare patients).  The regulations concerning medicare patients (which interestingly enough, then applies to non-medicare patients at the same facility) states that they must be fully informed of all treatment options for their condition and then allowed to freely choose their preferred treatment.  Denying VBAC to a pregnant woman is denying her a treatment option for her “condition”.  And yes, it is grossly illegal to force someone to have surgery against their consent.  But…it isn’t that simple.  First, and thankfully rarely, forced surgery does happen.  I personally know 3 women who were cut after they explicitly said that they did not consent to another cesarean, one gassed down with general anesthetic after she was told she was being given oxygen (her baby was close to crowning and they pushed him back up and cut him out because “we don’t do VBAC here”).    We’ve all seen the news reports about court ordered cesareans – again, rare but not impossible.  More likely, and almost always, the doctor and hospital do get “consent” in the end.  Most women in labor are very suggestible, tired, and easily scared.   Their partners are often even more so.  All it takes is enough talk about “hurting the baby” or “bad outcomes” and most women cave in.  Later they realize how they were manipulated but at the time, their instincts are all about keeping that baby safe, no matter what, without a lot of concern for proof.  Medical professionals know this and use it.  I also know a couple of women who successfully did this – showed up at a hospital that didn’t “allow” VBAC and did it anyway.  I an amazed at the strength and focus these women had – I can’t imagine doing it myself and I never encourage it except as a true last resort. 

It is hard when there isn’t an active or supportive midwife community in your area.  Sometimes they just don’t exist.  Sometimes the legal/political climate in your area is incredibly hostile to midwives and they can’t risk attending a VBAC (or at least perceive it as too much of a risk).   Nevertheless, there are options.  Some midwives will travel to attend a birth – these midwives are usually not all that worried about the local situation.  You can travel to some midwives.  Are these perfect solutions?  No.  But I know women who’ve done it.  And they had VBACs.

And finally, unattended birth.  Almost always, the initial response I hear when a woman first learns about unattended birth is “oh my, I could never do that, I just wouldn’t feel safe”.  And that’s fine.  But, let’s look a bit closer…you are going to stay home until you are pushing and then go to the hospital.  You’ve just done a mostly unattended birth.  There has likely been hours of labor where you are depending on yourself and maybe your partner for a sense of whether things are going well.  Afraid that if there’s something wrong with the baby at the time of the birth you won’t know what to do?  You can prepare for that, after all, we should all be certified in infant CPR if we have babies, right?  And even a midwife attending a homebirth would be calling 911 if there was anything seriously amiss.  In your hospital room they’d be calling someone else in if there was something seriously amiss!  I’m not trying to talk anyone into an unattended birth, they have their own unique benefits and risks.  I never wanted one myself (though if I were without a homebirth midwife to attend me, I’d plan an unattended birth before I’d return to the hospital).  But, if you are willing to spend most of your labor unattended, you might just be closer to that unattended birth than you realize.

The bigger question in all of the “banning VBAC”, “not allowed to VBAC”, “have no choice about another cesarean” talk is how is it that women in the richest and most powerful nation on the planet allow this stuff to be done to them?  How is it that most women don’t question this sort of nonsense, even when they don’t like it?  How is it that a woman who would never tolerate being told what she was “allowed” to do with her body or her family in any other circumstance will docilely lay down, spread her legs or her belly without a question?   How can it be that we still act like women deserve whatever they get when it comes to childbirth and anything goes as long as she and the baby go home breathing?  I can not think of any situation where a man would acquiesce to this treatment, why in the world do we?    For the most part, no one would agree that a rape victim “got what she was asking for” and “should just be happy she didn’t get worse.”  We aren’t talking “women’s lib”, we are talking basic human rights and we hand them over with less thought than most would put into planning a party, forget planning one of the most important events in 2 people’s lives.   As a friend of mine says “If I were an Iraqi, bound to a bed, clothes taken, denied food or water and lied to...the American Media would care. But I'm just a woman giving birth in America, bound to a bed, clothes taken, denied food or water and lied to.”

You don’t have to be a birth activist.  You don’t have to join ICAN or some other organization (though it would be nice if you did).  You don’t have to write letters to the editor of your local paper or essays for online reading.  You don’t even have to be pissed off about this stuff, though I don’t understand how you can’t be.  All you have to do is not let it happen to you.  Make sure you and your baby get better.  Say no after you’ve figured out what yes is.  If that’s all we did – if even just a small proportion of women would stand up for themselves and their children, it would matter.  It would make a difference.  Remember – if you have children, one day you’ll probably have grandchildren.  Which means this isn’t just about what you can tolerate or live with.  This is about your daughters, daughter-in-laws and their children and what happens to them.

revised June 16, 2006