So you’re planning a vaginal birth after cesarean (VBAC)! Although VBAC is safe for most people, VBACs sadly remain a controversial and often little-understood option in the United States, an option that’s often difficult for people to achieve. One of the most important things to consider when planning a VBAC is your provider—the more truly supportive your provider, the greater chance you have of a vaginal birth. In a birth climate where VBAC bans prevent many people from accessing the maternity options they need and deserve, it’s vitally important that the provider you do choose is practicing up-to-date, evidence-based maternity care and is willing to collaborate with you throughout your pregnancy and birth.
Many providers support VBAC in theory, but unfortunately, not in practice. Here at Improving Birth, we hear so many stories from parents who planned VBACs but who experienced a “bait-and-switch” from their providers late in their pregnancies, effectively making it impossible for them to actually attempt vaginal births. These types of tactics include scaring parents about the size of their babies, requiring VBAC patients to have internal fetal monitoring during labor, go into labor by a certain gestation, or any other number of requirements which are not based in best medical evidence.
Here are our suggestions on how to find a provider who is truly VBAC supportive.
1. Do your research: Before you even begin meeting with potential providers, do a substantial amount of research on VBACs, including including familiarizing yourself with ACOG’s current statment on VBAC, the NIH consensus statement on VBAC, and other research, statistics, and more. We recommend VBACFacts.com as a source of evidence-based information for consumers. Knowing the facts will help you communicate clearly and effectively when you meet with doctors or midwives. Talking with other VBAC parents will also be a source of research and information for you, as well.
2. Know your medical history: You can request your own medical records for any previous births, so you can be informed on the noted medical reasons for cesarean, the type of incision you had, and more. (Here’s a great article with some tips on how to request hospital records.) Become an expert on these records, and feel confident telling the story of your cesarean birth(s) from your own point of view, as well.
3. Reach out to ICAN: The International Cesarean Awareness Network, or ICAN, is an incredible advocacy organization for people who have had cesarean births. They have local chapters (where you can attend meetings and meet other cesarean, VBAC, and CBAC parents), which are knowledgeable about birth options in different areas around the country. They also have a terrific Facebook page where people can submit questions and have them answered by the community, so you might be able to ask questions specific to your own situation.
4. Contact doulas, nurses, and childbirth educators: You know who really knows which providers are supportive of VBAC and which are not? Doulas. They are on the front lines, supporting people throughout their pregnancies, and witnessing what happens during their births. Doulas have their ears to the ground in your local area and will have great tips on which doctor won’t suddenly schedule you for a repeat cesarean at 39 weeks and which midwife is likely to recommend induction for “big baby.” Childbirth educators, too, are often knowledgeable about the local birth climate. Labor and delivery nurses can also be a great source of information for you. If you know any nurses in your community, ask them who is VBAC-friendly and who isn’t.
5. Look up VBAC and cesarean rates: If you’re not sure where you’ll have your baby yet, look up both the cesarean and VBAC rates of hospitals and birth centers near you. Sometimes these statistics are difficult to find, so you may have to do some digging. CesareanRates.com and the Leapfrog Group (especially their comparison tool) are good resources for this. Consumer Reports has a recent in-depth article showing some rates in major hospitals around the country. Occasionally, local newspapers or TV stations will also have stories on the cesarean rates of area hospitals.
6. Make an interview—not an exam or prenatal—appointment: Call the offices of your possible providers and ask to interview their doctors or midwives, making it clear you want to discuss VBAC specifically. This will be a meeting, not a prenatal appointment or exam. Sit face-to-face with the provider, fully dressed, and ask them all of your questions about your previous births, the hospital where they attend births, their policies, their philosophies, and more. It is your right to take the time to make an informed decision as a consumer—without having your feet in your stirrups while you try to get information.
7. Ask about numbers: Ask your potential provider: What’s their overall cesarean rate? What’s their cesarean rate for first-time NTSV (nulliparous term singleton vertex, meaning first-time parents with single babies in the head down position at term) patients? What’s their VBAC rate? What’s the VBAC rate for the hospital where they practice? What’s the overall cesarean rate for the hospital? How many VBACs have they attended in their career? How many successful VBACs have they seen this year? Ask the same questions about rates and numbers for their overall practice, no matter how many doctors or midwives are in it. Someone who is knowledgeable about their rates and is not shy about sharing them is great. Someone who willingly shares and who also has low cesarean rates and high rates of VBAC is even better.
8. Ask about restrictions: As mentioned above, some providers have “requirements” (aka restrictions) regarding VBAC, like that people go into labor on their own or be a certain amount dilated by a certain number of weeks gestation. This is a red flag, because this shows that your provider might suddenly stop supporting your desire for a VBAC late in your pregnancy, for reasons that aren’t best medical practice. Ask if there are any requirements for your pregnancy that would prevent you from having a VBAC: maternal weight, having gestational diabetes, a suspected “big” baby, going over 40 weeks, going over 41 weeks, and more. Ask if repeat cesareans are routinely scheduled for VBAC parents at 39, 40, or 41 weeks. If so, ask why. The more restrictions on VBACs, the less chance you can actually achieve one.
9. Ask about policies: Ask your potential provider about the policies that might affect your care during your pregnancy and birth. Does the hospital where they deliver have any policies in place regarding VBAC? Does your provider induce VBAC? If so, what is the induction protocol for VBAC (a Foley bulb? A Cook’s catheter? Low dose Pitocin?)? Do they recommend VBAC patients come to the hospital early in labor? Do they require continuous fetal monitoring? Do they require internal fetal monitoring? Do they require that VBAC patients have epidurals? Are there time limits on how long a VBAC patient can labor? Not all of these policies are based in evidence or research, but that doesn’t mean they might not affect your birth—the last thing you want is to be fighting restrictive policies late in your pregnancy or during labor. Make sure you have a clear idea of what policies you might be dealing with, so you can make an informed decision about whether or not to go with that provider for your birth.
10. Ask about risk, availability, and support: A good sign is a provider who will clearly explain to you the risks of both having a repeat cesarean and the risks of VBAC—not only the risks of VBAC. You should also ask doctor or midwife what they think makes for a successful VBAC in terms of labor support—does it involve a doula, birthing classes, or other types of support or preparation? Do they welcome your ideas on how you’d like to be supported through your pregnancy and birth? Ask them what they think might best help your chances for having a VBAC—as well as what might hurt your chances. Another important aspect to consider is the availability of the specific provider you might want. Sometimes one or two doctors in the practice will support VBAC, but others don’t. Can they guarantee that themselves or another supportive provider will be at your birth, no matter when you go into labor?
Bonus! 11. Ask about family-centered or gentle cesarean: In the event that you would have to have another cesarean, either planned or unplanned, you should certainly ask about the option of family-centered cesarean. This is a cesarean birth that involves skin-to-skin in the OR and other elements, sometimes including a clear or lowered drape so the birthing parent can watch the birth, an additional support person in the room, and more. A family-centered or gentle cesarean is all about facilitating early contact between the parents and the baby and making the entire experience more emotionally-resonant for the family. Does your provider already do these types of births? If not, why not? Would they be willing work with you to plan a family-centered cesarean in the event that a VBAC did not happen? Would this provider be willing to advocate with the hospital and/or other medical professionals so you could have this type of birth if cesarean was clearly indicated?
You are entirely entitled to make informed decisions about your provider and your medical care. Finding a supportive provider who is transparent about his or her policies and practices will make a huge difference in ensuring that the care you receive is positive, respectful, and evidence-based. After all, it’s your body, your baby, and your birth—and it matters.