Suggestions for VBAC Delivery

Neither of us has any formal medical training, yet we feel that we can offer the following suggestions to anyone considering a vaginal birth after cesarean delivery.

1. Refrain from using pitocin or oxytocin to induce the labor. When your body is ready to deliver, it will. If you try to encourage a birth before your body is ready, you risk causing trouble. There may be occasions (like macrosomia -- big babies) where it is preferable to induce rather than wait several weeks when the baby's size may increase the probability of rupture, but be aware of the risks in either case, and make an informed decision.
2. Do not get a cesarean just because you are at 40 weeks. Many healthy babies are delivered past 42 weeks. Only at 42 weeks would you want to start thinking about a cesarean, but a trial of labor is still an option. Due date estimates are just that -- estimates -- and can be off by several weeks.
3. Do not artificially rupture your membranes ("break your water"). Of course, if they break on their own, that's another story; it starts the clock ticking and you need to get labor well established within 24 hours or so. In this case you may need to resort to pitocin or have a cesarean.
4. Do not get an epidural before 6 cm whatever you do. You risk increasing the probability of "failing to progress (FTP)". Ideally you can wait until 8 cm or forego an epidural altogether. Epidurals have been shown to cause problems that require a cesarean.
5. There was a recent paper which describes a technique to predict when you are very unlikely to have a uterine rupture. It uses ultrasound at 37 weeks to measure the thickness of the uterine wall. If it is thick, then you are almost assuredly not going to have a uterine rupture. However, if your uterus is thin, the test is not able to say anything. So if you happen to be in the thick category, you need not worry. If you're in the thin category, you really don't have any more information than before you took the test, so you have nothing to lose. The paper citation is:
   • Rosenberg, P., Goffinet, F. Philippe, H., Nisand, I., Ultrasonic Measurement of Lower Uterine Segment to Assess Risk of Defects of Scarred Uterus, The Lancet, vol. 347, Feb. 3, 1996, pp. 281-284.
6. Ask questions about every procedure. Ask whether it is necessary, what the benefits are, and what the risks are. Discuss with your doctor in detail the methods that would be used in your delivery. Write them down on a piece of paper, sign it, and have your doctor sign it. Post it in the delivery room where the staff can see it.
7. Consider giving your doctor a copy of Catherine Grace's story to read.
8. Get a certified doula. Interview a few of them, and find one that seems knowledgeable, responsive to your concerns, and willing to help you understand what you're about to go through. She will be your advocate, intermediary and counselor. She can provide individualized instruction about the techniques and risks. She will try to give a "balanced" presentation, but will most likely spend more time describing alternatives to your doctor's preferences. Compare opinions between the doula and your obgyn. If they both agree, you have a good decision. If they don't, you should explore other options, or read up on more medical literature about the technique.
9. Read. There's a number of suggestions of books to read on www.childbirth.org.
10. Know what's happening in the delivery room. If one of the staff is concerned about something, ask why. If they say that you needn't be concerned about it, say that you *are*, and want to know everything!
11. Make sure you can trust your doctor. Change doctors if yours does not want to answer your questions. Make sure s/he understands you and that his/her answers indicates that s/he understood the question. If you feel that the doctor gives you answers to different questions than the ones you asked, change doctors. If the doctor uses terms that you are not familiar with, ask him/her to define them for you. Learn his/her lingo. In the delivery room, things can move real fast, and there is no time to give definitions of terms. If s/he can say a couple of words that communicate exactly to you and s/he what the situation is, you can assist.
12. Have your doctor read the following:
    • Weinstein, D., Benshushan, A., Ezra, Y., Rojansky, N., Vaginal Birth after Cesarean Section: Current Opinion, International Journal of Gynecology & Obstetrics, 53 (1996), pp. 1-10.
    • Farmer, R., Kirschbaum, T., Potter, D., Strong, T., Medearis, A., Uterine Rupture During Trial Of Labor After Previous Cesarean Section, American Journal of Obstetrics and Gynecology, October 1991, pp. 996-1001.
    • Jones, R., Nagashima, A., Hartnett-Goodman, M., Goodlin, R., Rupture of Low Transverse Cesarean Scars During Trial of Labor, Obstetrics and Gynecology, v. 77, no. 6, June 1991, pp. 815-817.

• Take a look at them too, and playfully give your doctor a pop quiz on what he would do if a certain complication arose.

1. The risk of uterine rupture in a VBAC delivery is 1 or 2 out of 300. Sometimes there are no ill effects, but sometimes there are catastrophes. The above papers have shown that all catastrophes can be avoided by "rapid diagnosis and prompt intervention", which means to have a clue and be prepared to do a cesarean. After all, they do call it a "trial of labor".
2. If the fetal heart monitor indicates distress, insist on a fetal scalp blood sample or an internal monitor, especially if the doctor wants to wait it out.
3. Never be by yourself. This is where the doula can really come in handy. You are paying her to keep an eye on you. The doctors and nurses have other commitments, and your husband/partner does not have much medical experience.
4. If your doctor seems perturbed by some test results, encourage him to get another opinion. Some doctors forget that they have that option.