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Want a VBAC? Ask your care provider these questions.

While there are care providers who may mislead you about your risks, benefits, and options, this article is written assuming that you are meeting with an ethical care provider who supports the option of VBAC.  Read more on how to find a providers like this.

Ask Questions 3d buttonIf you are a good candidate for VBAC, the single most important decision you can make that will have the greatest impact on your chances of VBAC success is who you hire to attend your birth.   This is why it’s important to interview several care providers and ask specific questions.

You will often receive different information when speaking to the doctor or midwife directly than you would from the people who answer their phones.  When calling their office, be sure to state that you want to have a consultation.  Ideally, you want to meet in an office, not in an exam room.

How to present yourself

Go to your consultations like you would a job interview.  You are not hanging out with your girlfriends.  You want the care provider to perceive you as an intelligent, thorough, and reasonable woman who has done her homework, collected all the info, and would really appreciate the opportunity to VBAC/VBAMC.  Trust is fundamental here and flows both ways. If you can make a human connection with the care provider, then all the better.  Humor is an excellent way to do this.

  • Wear your most professional looking clothes.
  • Get a babysitter for your younger kids if possible so you are not distracted.
  • Bring your medical records and operative reports from your prior cesarean(s).
  • Read, be familiar with, and bring a copy of the 2010 ACOG VBAC guidelines.
  • Google the care provider, their practice, and the hospital/birth center and note any special awards or recognition they have received.  Bring this up in a complimentary way during your appointment.

Remember, a lot of care providers are concerned about being sued, so they are sizing you up as much as you are them. They want to know that you understand the risks and benefits of your options and that you have realistic expectations.  Be sure that you don’t repeat birth myths while speaking to them as that will reflect poorly on you.

Once you connect with them on a human level, and they see that you are an educated, rationale, and reasonable woman, then you can determine how willing they are to negotiate on some of their terms (if necessary.)  For example, if they require moms to stay in bed during the entire labor, ask if their hospital offers telemetry units (wireless fetal monitoring).  Some hospitals even have them in a tube top so they don’t move around as much and are less noticeable to moms.

It’s very important to not come across as angry or argumentative, because that decreases the likelihood that they will attend you.  Express your frustration, anger, and pain with support groups online.

The three types of care providers

There are three types of care providers: those that are VBAC supportive, those that are not, and those that pretend to be until the last minute.   When an care provider says that they are VBAC supportive, but every single one of their clients got risked out for VBAC, ask yourself what is more likely: For every single one of their patients to develop a medical condition that ruled out VBAC or that they really weren’t supportive in the first place? This is why it’s a huge red flag if your care provider says, “We can wait later/ until your third trimester/ 36 weeks to talk about that.”  Your care provider should be comfortable discussing their VBAC philosophy with you now.  You deserve to know if they are genuinely supportive or not so that you can hire another care provider who is more in-line with your goals if needed.  You don’t want to be in a position where you are 36 weeks and your care provider says, “Let’s schedule a cesarean at 40 weeks just in case.”  You can switch providers late in pregnancy, but it can prove difficult.  Keep in mind that you may have better luck getting names when speaking to someone face to face.  Sometimes, people don’t want to give out names to someone they don’t know over the internet.

To give you an idea of how some non-VBAC supportive care providers talk, and what you should look out for, please read:  Another VBAC Consult Misinforms, Scare tactics vs. informed consent, and Hospital VBAC turned CS due to constant scare tactics.

If your husband/partner wants more information, direct him to: A father says, Why invite the risk of VBAC?

Top 18 Questions

Here is a list of questions that are relevant to all birthing women, VBAC or not. What I’ve added is my commentary on how I think their answer reflects how supportive they really are of VBAC.

I think the most important questions relate to going overdue and suspecting a big baby.  Many women have been risked out of VBAC as a result of these two variables, so I will address those two questions first.  Then I will list the rest of the questions in the order of their importance from my perspective.

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 per ACOG.

However, if a medical reason for induction is present, women should be given that option rather than required to have another cesarean.  As a 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.  My personal preference would be to have telemetry (the wireless monitors) because I need to move during labor.

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…”

CIMS asserts in Mother-Friendly Childbirth: Highlights of the Evidence,

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.

As the 2009 edition of the World Health Organization’s “Monitoring Emergency Obstetric Care: A Handbook” states,

Both very low and very high rates of caesarean section can be dangerous, but the optimum rate is unknown. Pending further research, users of this handbook might want to continue to use a range of 5–15% or set their own standards…. Earlier editions of this handbook set a minimum (5%) and a maximum (15%) acceptable level for caesarean section. Although WHO has recommended since 1985 that the rate not exceed 10–15% (125), there is no empirical evidence for an optimum percentage or range of percentages, despite a growing body of research that shows a negative effect of high rates (126-128). 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. Nevertheless, the rates in most developed countries and in many urban areas of lesser-developed countries are above that threshold. Ultimately, what matters most is that all women who need caesarean sections actually receive them.

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.

Additional questions for out-of-hospital providers

I’ve collected the follow questions over the years as I saw various discussions of questions to ask an out of hospital provider.  Not all of the issues raised here are relevant to every woman, but I include them all so you can pick and choose which ones speak to you. Since OOH providers are often women and midwives, those are the terms I will use.

Her background

  • How many births has she attended?
  • How many years has she been attending births?
  • Number of births attended as primary midwife vs. doula vs. assistant?
  • What is her training?  DEM, CPM, CNM?
  • What equipment does she bring to each birth?
  • How often does she use it?
  • What is her post-partum hemorrhage protocol? Does she carry Pitocin or Methergine?
  • What is her position on ultrasounds?
    • Does she recommend them for HBAC/HBAMC?
    • How many weeks gestation?
    • Where would you have this done?
    • How does payment work?
  • Would she attend you at home as a monitrice and then transfer to hospital as a doula?

Other birth professionals

  • Does she recommend/offer concurrent care with an OB?
  • Is she required to have OB sign-off for HBAC?
  • When and how often would you meet them?
  • Does she have partners or is she a sole practitioner? What is their training/ experience?
  • Does she have assistants? What is their training/ experience?
  • How many midwives and assistants will attend your birth?
  • How many births does she attend per month?
  • How often does she miss births?  Reasons?
  • Does she have a backup midwife? What is their training/ experience?
  • Does she recommend a doula?
  • Which doulas does she work with most often?

Licensing & payment

  • Does her state offer/require licensure?
  • Is she licensed?  Why/why not?
  • Can she legally attend HBAC?
  • How would you get a birth certificate?
  • Does she carry liability/ malpractice insurance?
  • What insurance reimbursement should you expect?
  • What is her fee?  Does she offer payment plan?  What is the payment schedule?

Transport

  • What is her transport rate?
  • What’s her transfer protocol?
  • Does protocol differ for emergent v non-emergent transfer? Different hospitals?
  • What is the transport time by car and ambulance?
  • What are the most common reasons for transfer in her practice?
  • Has she experienced a cord prolapse, shoulder dystocia, placental abruption, or accreta?
  • Will/can she stay with you upon transfer?
  • Has CPS been called on past clients?
  • Does she have familiarity with the local hospitals?
  • Does she have a hospital contact that she can call in the event of an emergency transfer?
  • Do you have any particular concerns/issues from prior births?  How would she handle them?

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.

Last updated October 11, 2013

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