All About VBACs: Q&A with A Board-Certified OB-GYN
The video featured in today’s post was sponsored by AdventHealth for Women. As always, all stated opinions are my honest thoughts. I’ve paid out of pocket for all of my health care costs at AdventHealth myself and will continue to do so because I’ve loved the experience. Keep reading to get all of the VBAC information you need from this Q&A with a board-certified OB-GYN.
When I was pregnant with Summer, I was prepared for a normal vaginal birth. Unfortunately she was “sunny side up” (her face was up instead of down), and after 4.5 hours of pushing, I ultimately had to deliver her through emergency c-section. My main concern at the moment was obviously protecting her health, but I was also worrying about the risks of the surgery and if I’d have to deliver any future babies through c-section. After recovering from my c-section, I voiced my concerns about future c-sections to my OB-GYN, and she told me I’d be a great candidate for a vaginal birth after c-section AKA a VBAC if I got pregnant again.
As soon as I became pregnant with Luna, I immediately started to mentally prep for a VBAC. My first step was switching healthcare providers and choosing an OB-GYN practice that was VBAC-friendly and up-to-date with current TOLAC (trial of labor after c-section) research and procedures (highly recommend AdventHealth Medical Group OB GYN at Orlando if you’re local to central Florida) AND delivered at a VBAC-friendly hospital (LOVED my experience at AdventHealth for Women Orlando). Having a supportive and educated team in place was a HUGE asset.
The next step was learning as much as I possibly could about VBACs. In addition to asking my doctors as many questions as possible, I was THRILLED to have the opportunity to interview Dr. Ashley Hill in a Facebook Live with AdventHealth for Women. Dr. Hill is the Medical Director of Obstetrics and Gynecology at AdventHealth Medical Group, Associate Director of the AdventHealth Graduate Medical Education Program’s Department of Obstetrics and Gynecology, and a Professor of Obstetrics and Gynecology at the UCF College of Medicine. You can learn more about him here. He was so great at explaining all of the ins and outs of VBACs and answering questions that I knew I needed to share the information on my blog too.
In case you’re wondering, I delivered my daughter Luna at AdventHealth for Women Orlando and did end up having a successful VBAC! It was one of the best experiences of my life. You can read my honest birth story and VBAC experience here.
If you have had a c-section(s), are scheduled for a c-section, or are considering a VBAC, today’s post is for you! I’m sharing everything you need to know about VBACs through my video interview with a board-certified OBGYN, and I’ll also be summarizing the information in text below. Keep reading to learn all about VBACs from an expert!
DISCLAIMER: Today’s post and video is an open forum and should NOT be taken as medical advice. Please consult your physician for information that is accurate for your specific medical situation.
Everything You Need to Know about VBACs: Q&A with A Board-Certified OBGYN
I highly recommend watching the video linked above because Dr. Hill explains things so well, but I’ve also summarized the questions that were answered during the Facebook live below.
What is a VBAC?
Dr. Hill’s answer: VBAC is an acronym that stands for vaginal birth after cesarean. So some women have to have or have a c-section with their first or second baby or so, and they would like to have a natural baby the next time. So I’d like to say there’s another acronym that jumps in there called TOLAC. In medicine, we like to abbreviate everything because the words are long. TOLAC stands for trial of labor after cesarean, so a trial of labor is what you have when you want to try to have a natural delivery – a VBAC is what you have if you are successful.
Does AdventHealth for Women support VBACs?
Dr. Hill’s answer: The critical thing is to find someone you can partner with. You’re on the journey together, and you can have conversations and look at the risks and benefits. Across central Florida, we have four main delivering hospitals, and all four of those hospitals support VBACs.
What are some of the common factors that could effect the possibility of a successful VBAC?
Dr. Hill’s answer: There’s actually a calculator that you can use, and doctors use it too and midwives, and you can plug in things. It talks about your height and your weight and your race and why you had a c-section the first time. So there are things that some women can do to actually improve their chances of a successful VBAC, and those are modifiable things.
So one of those things is to keep your weight as close to normal as possible (called a body mass index). The heavier you are, the less likely it is to have a successful VBAC, so we like to ask folks who are thinking of that for their next pregnancy to try to diet and exercise – you know it’s good for you anyways.
The second thing would be to wait a year and a half between when you delivered your last baby and when you conceive your next baby, so a couple of years between deliveries. That’s been shown to improve your chances of having a successful VBAC.
Other things would be having a baby that’s a normal size. Diabetic moms if they work on their blood sugar, that helps. Not having quadruplets or triplets or anything like that.
Can your probability of having a successful VBAC change throughout your pregnancy?
Dr. Hill’s answer: It could change. So the calculator is not set in gold, first of all. I’ve had ladies who’ve had a very low predicted success rate have a successful VBAC. There are other ladies who are in the 90th percentile (for predicted success), and the baby turns sideways, and they don’t have a successful VBAC. So it’s not set in gold. It gives you a standard.
From a medical perspective, if the (predicted) rate of success is less than about 60%, then there is a higher chance of complications. That’s something you would need to sit down with your doctor and talk about.
Do moms have a choice in whether or not they have a VBAC?
Dr. Hill’s answer: Yes and no. If you find a practice that supports VBAC, absolutely. Let me back up a little bit. Back in the 1980s, around 1985, only 5% of women in the United States had a VBAC, and it went up to about 30% 10 years later. And then it dropped again, and now it’s on the upswing again. So there were many hospitals in the 1990s, mostly because of malpractice stuff, that dropped having VBAC. I think there were something like 400 or 500 hospitals that quit doing it.
As time has changed, and we know more about the process, more hospitals are coming back around. So the first step is to find a medical practice that supports you, and then the second step is to find out if that doctor goes to a hospital that supports them (in regards to VBACs). So you do have a choice.
What is the best way for expecting moms to learn if they’re a good candidate for a VBAC?
Dr. Hill’s answer: Like a lot of things in medicine, in my opinion, this requires a very careful discussion with doctor and midwife. You look at your whole picture, and if the baby, you, your age, what’s going on, and all those things, and you come up with a plan together. And then you go down that path together, and hopefully nothing jumps in the way to throw a wrench in the plan. So it’s one of those things in medicine that we value a lot. We actually make a special appointment for pregnant ladies, if they’re thinking of a VBAC, just to discuss that. Because you want the time to do it the right way.
What is the average success rate of a VBAC?
Dr. Hill’s answer: The average success rate of a VBAC is about 60-70%. And I’m gonna jynx myself. I was just bragging that over the past three or four months, I’ve had a 100% success rate. But over time, my success rate is about 70%, so most of the time in the country, that’s what you’ll see.
Can a mom who’s had two prior c-sections have a VBAC?
Dr. Hill’s answer: In most cases, yes. It depends on what the first c-section’s scar was like inside the body. There are a fair number of doctors who aren’t really comfortable taking care of ladies who’ve had two prior c-sections because there’s not as much scientific evidence, but it seems to be about as safe as having a VBAC after one c-section. So most people do it. Some doctors will do VBACs for twins.
If you have gestational diabetes, will that effect the chances of a successful VBAC?
Dr. Hill’s answer: If your sugars are in good control, and the baby’s not huge, then you should have the same risk as everybody else. Where the risk worsens is if the baby is very large, say 9.5-10 pounds, and those ladies tend not to have as high of a success rate.
What are some of the risks of choosing to attempt a VBAC?
Dr. Hill’s answer: Let me back up a little bit. There are some things where your doctor is going to say you probably shouldn’t have a VBAC, and there aren’t many things. If you have an up and down cut inside your body – not the outside cut. The outside cut doesn’t really matter. It’s an inside cut. Thankfully those are quite rare in the United States. I don’t think I’ve done one of those in five years. It just doesn’t happen very often. The other would be if you had a lot of fibroid tumors removed from the outside of your uterus, and you had a lot of scars on there. Other things would be triplets or quadruplets, babies that are sideways, or the placenta is too low. So there aren’t many reasons not to have one.
The main risk of having a VBAC is something called uterine rupture. Thankfully only about 1/100 or 1/200 times, usually when the lady is pushing the baby out, and it sounds very dramatic, but again, it’s not very common. The scar inside the uterus will separate and open up, and the baby can pop out of that, and I’ve seen my share of those. It’s very dramatic for everybody. So, as long as you’ve had a sideways cut on the uterus, the risk of that is lower.
If uterine rupture happens, are the doctors prepped in advance and ready to handle the situation?
Dr. Hill’s answer: Well, so one of the things we advise, and I advise, is that ladies who are thinking of having a VBAC have this in or near a hospital. Either in an attached birth center or inside the hospital and not at home or somewhere else. Because if you do have this (uterine rupture), and again, it’s rare, it’s a life and death, run down the hallway at top speed to get the baby out. So we like to be close to the operating room.
Is it possible to be induced and still have a successful VBAC?
Dr. Hill’s answer: You can induce a mom who wants a VBAC. In fact, some studies show that if you get to your due date and go past your due date, the success is lower. So a lot of doctors, if you make it to your due date, will say well, we weren’t going to induce you, but now we sort of suggest that we look that way.
So you can use pitocin, and there’s a really cool device called a balloon. It’s either a catheter or a two-sided balloon. Think of something the size of a golf ball. You slide it in the cervix very gently. It’s kind of like getting a pap smear. You blow the balloon up and sit there for 10 or 12 hours. You can watch streaming videos. You can walk around, take a shower, eat, and while it’s in there, it’s opening your cervix up manually. When you take it out, you give a little pitocin, dilate, and hopefully go into labor. The one thing we don’t use are medicines called prostaglandins. Those are dangerous if you’ve had a prior c-section.
What is the best way for moms to be fully informed about their VBAC options? What’s the best way to have the doctor truly listen to their concerns?
This is where it really requires some time to talk and have a doctor or midwife who listens and participates in your care. I’m always saddened to hear that doctors are dismissive. I hate that, but it’s a fact of life that not everyone listened to their mom and dad growing up and weren’t raised the right way.
So it requires a conversation. First, I’d go in with an open mind. Please don’t be defensive. Go in and talk, sit down, and have some questions written down. Sometimes people go to the doctor and get a little nervous. I think it’s kind of like going to visit Santa Clause. You have your list of things you want, so you sit down and ask some questions. And then just listen. And then ask “are you supportive of my desire to have a VBAC?” Hopefully the doctor is honest and says “we’re on your side, let’s do it,” or “you’re not a really good candidate, and I’m uncomfortable.”
Are there any other reasons or concerns why a VBAC wouldn’t be a good decision?
Dr. Hill’s answer: There are some conditions or situations during pregnancy where a woman shouldn’t have a natural delivery whether she’s had a c-section or not, and there aren’t many of those. Most women should be able to have a natural delivery.But sometimes the placenta’s too low, and it just won’t move out of the way. Or you have twins, and both babies are breech. So those things we call absolute contraindications, and you’re not going to find any doctor in the whole world who’s gonna agree to it because it’s dangerous.
So those aside, the specific ones would be a baby that’s very large, a mom that’s older, a mom who came into pregnancy quite overweight. Those are all things that can influence a VBAC success, but again, I’ve had plenty of ladies who’ve had a successful VBAC who aren’t the perfect weight. It just requires a conversation.
What are some of the pros of having a VBAC?
Dr. Hill’s answer: Shorter recovery time, shorter hospital stay, and I think, improved bonding. We, AdventHealth, do skin-to-skin as soon as we can after a c-section, but some hospitals don’t do that. And so the mom is saying “where’s my baby,give me my baby,” and they’re doing things to the baby. And mom wants her baby. She’s worked hard, right? And so I think it improves your bonding and breastfeeding with skin-to-skin.
There’s less pain. I’m always amazed when ladies say to me “I didn’t how far in there you were during a c-section.” We’re all the way in there. We’re as in as you can get. It’s a major operation. It’s similar to a hysterectomy in how deep you go inside the abdomen. So the recovery can be long and painful for some ladies. I think you have a faster time to get back to work and less chance of a wound getting infected. There’s a lot of benefits to that.
If you’ve had preeclampsia in a previous pregnancy, what are the risks of having complications with future pregnancies?
Dr. Hill’s answer: Preeclampia is a very tough condition. For folks who may not know, that’s a condition where your blood pressure goes up during pregnancy. Amazingly, we don’t really know what causes it. It affects quite a few women and can be very dangerous, so sometimes you just have to get the baby out and do a c-section. That said, there’s a couple things that the average lady can do, so talk to your doctor.
One would be to start baby aspirin around your fourth month or 16th week of pregnancy, and that has actually been shown to decrease the risk of preeclampsia in the next pregnancy. It’s a pretty great thing. When we see patients here at AdventHealth for their first visit, we actually ask them those questions, so we can get them on the baby aspirin if we need to. Baby aspirin is very safe. Not full-strength but baby aspirin.
The other thing is that if it’s the same father of the baby, your chances are actually lower. But if you’ve remarried, or there’s another man involved, then the chance goes back up to where it was before.
What can you do if you go to a practice with some doctors who are supportive of VBACs and some who are not? What happens if you go into labor and the doctor on call is not supportive of VBACs?
Dr. Hill’s answer: What we’ve done in our practice, which has eight physicians and six midwives, is we meet every month. And we don’t talk about it every month, but we talk about how we manage patients with VBACs several times a year. We try to make sure everyone is on the same page. With that said, in life, sometimes that’s difficult.
If you’re in a practice where two or three of the doctors are very positive about having a VBAC and a couple of them say “I’m not really comfortable with that,” I hate to say it, but that’s a pretty rough situation. Because you don’t know who’s going to be there, and you could try to get one of the supportive doctors to come in, but if they’re in the operating room or have been up all night, it’s not safe to do it.
I would find the medical director of that practice and ask him or her “what’s your take on this?” Let them talk it out with you. They may not be aware of the lack of support by the other doctors, and that’s a chance for them to do their medical director job. They also can get in and say “look, we’re going to move you down this track because we want you to be successful.” Great question, but I’m sorry it’s a tough answer.
How far in advance of your delivery would your provider be able to tell you that your predicted success rate for VBAC has changed?
Dr. Hill’s answer: It’s something you should talk about at every visit and say “how am I doing? Am I on track? This is an important goal for me.” And get an assessment – shared collaborative care.
I had a lady not too long ago who has breech, and she showed up at the hospital and really wanted a VBAC. I said “there’s plenty of water around the baby. I think we can try.” And we went through the risks and benefits, and we were able to successfully turn the baby. She was able to have a natural delivery, and I was really happy about that. That was great. We did something nice for her that was important to her. She was really positive about it, and it worked.
Other times, you may find out that your blood pressure is going through the roof, and you’re 39 weeks. And you’re a perfect VBAC candidate, but now we need to get the baby out. And there’s no time to induce. The hardest thing for pregnant ladies is is it’s kind of like a wedding. Most ladies who get married have their special day in mind, right, and it’s gonna be perfect. But the goal is to get married to the love of your life. So the videographer doesn’t show up, or it rains that day. Or the uncle acts crazy and does some weird things. You’re still gonna get married to the love of your life.
So from my perspective, if you’re a healthy lady and have a healthy delivery and a great experience, it’s a win for everybody. Sometimes it’s just not how you planned it to be unfortunately.
Are their risks when a mom is overweight and attempting a VBAC?
Dr. Hill’s answer: So this is a really tough conversation because weight is a very sensitive subject. but one of my jobs as a doctor is to do the best thing I can to counsel my patients for their health. So just like when I go to the doctor, and they say to lose a couple pounds and exericse more – I say the same thing to people. And I try to listen.
If you’re overweight going into pregnancy, then there are a lot of risks unfortunately. Diabetes, high blood pressure, stillbirth, pre-term labor, and having a c-section. So if there are folks out their listening and they’re not pregnant yet but thinking about getting pregnant, and this is a motivator to hit the gym a little bit and eat better, that’s awesome.
Are there any things you can do while you’re in active labor to improve your chances of having a successful VBAC?
Dr. Hill’s answer: One, shoutout to the doulas. A doula is a birth coach. I know there’s more complexity to it than that, but that’s basically what a doula does. And they’re there to support the mom. Of course the doctors and nurses and midwives are there to support the mom too, but we’re also doing job things that we have to do. So having someone with you that’s supportive, whether that’s a family member or a doula or your husband or partner, that’s really key.
Second, I think having a good mindset. Being healthy going in and having a good mindset. And then the third would be, I think, you know try to stay as mobile as you can during labor in the bed. You know, some people get an epidural – that’s fine. If you get an epidural, the nurse will roll you side to side. All of those things have been shown to decrease your chance of having a c-section.
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