Tag Archives: guideline interpretation

Judgment in the birth community: Fitting in after a cesarean

A woman who had four cesareans, after planning VBACs and home births, recently contacted me. She didn’t know where she fit into the birth community.

My heart went out to her because there have been periods in my life when I have felt isolated and alone. And it’s a crappy feeling.

I replied to her:

A vaginal delivery is not required to participate in the birth community. There are many cesarean moms just like you who are seeking compassion, connection, and understanding. You could be a soft place for other women to land as they mourn (or celebrate!) their cesarean deliveries.

The mission of VBAC Facts goes above and beyond our personal birth preferences. Really, the goal is education and access to VBAC.

The goal *is not* for everyone to have a VBAC because, as you know, there are many reasons why someone would have a cesarean birth, including scheduling an elective cesarean. And that is that parent’s choice! And those mothers are no less of a parent, advocate, or sister to those within the birth community.

I know one woman who had four cesareans and runs an ICAN chapter. Again, it’s not about how her births played out, but rather education and, ultimately, respecting the choices other parents make while holding space for them when birth doesn’t go as planned.

If you are feeling rejected, perhaps you need to find a new group of people to hang with! 🙂

We all don’t have to birth the same to support each other

The judgment that this mom is experiencing is why I spend so much time in my workshop, “The Truth About VBAC” talking about individualized risk assessment. This is a fancy way of saying, “There are a lot of different reasons that go into why someone plans a specific type of birth.”

I discuss this subject at great length, including all the factors that one might consider and the fact that both VBAC and repeat cesarean are valid options.

I really want to assure students that there is no Right Way to Birth. Only what is Right for Them.

Releasing the judgment about how other people birth

I also want to explore the subject so that people who staunchly believe that there is a Right Way to Birth can see how there are so many reasons why someone might choose to birth differently than them… and possibly release that judgment.

(That’s also why I recently revamped the VBAC Facts homepage to feature two cesarean births.)

The whole point is: How you birth, is up to you. It’s frankly no one else’s business. Not mine. Not your girlfriend’s. Not the PTA president’s. It’s Your Birth.

And no matter what birth you choose, if you believe that parents should have access to VBAC, VBAC Facts is your birth community.

I have said this so many times in so many venues and yet I still receive comments like this from email subscribers:

I’m leaning toward repeat c-section. I already feel you scrunching up your face. I feel shamed for going with repeat c-section. People assume I am ignorant to the facts. They assume a lot of things. I feel like I have to justify this decision to everyone.

Ouch. Dear reader, I don’t feel that way at all. It hurts my heart that what should be a joyous time in your life is filled with deflecting the unsupportive opinions of others. Regardless of how you birth, your choices should be respected because it’s Your Birth.

Supporting access and respect, not dictating outcomes

It’s tough because there is so much judgment and so much defensiveness when it comes to birth and even what advocacy really means.

For me, VBAC advocacy is about access to VBAC, which is very different than saying, “I think everyone should have a VBAC.” And because my focus is access and not a specific mode of delivery, I don’t judge women who plan to have a repeat cesarean section. Full stop.

One of the reasons why I started VBAC Facts is that I saw people cherry picking information, misinterpreting the conclusions of medical studies, and basically manipulating the facts in order to convince other people to make the same birthing decisions they did.

Because they judged those that birthed differently than them.

How what other people think can impact your options

I created VBAC Facts, and I ultimately developed educational programs, so parents, birth professionals, and even medical providers could get the actual facts. The actual statistics. The actual recommendations. Rather than basing their opinion on someone else’s personal risk assessment of what was “safe” or “risky.”

And sometimes what other people think – like the Head of Obstetrics at your hospital or your hospital administrator – can set of the tone of your facility and even if they “allow” you to attend VBAC.

And for pregnant people, it can be the well-intended, but misinformed opinion of their friends and family. And that judgment and disapproval is enough to persuade some mothers to schedule a repeat cesarean just to keep the family peace.

It’s all about learning the facts so you can make your own decisions… and giving others the space to make theirs. And once people realize that there is no Right Way to Birth and that everyone knows the Right Way for Them, we can truly celebrate how we each start and grow our families without judging each other for how we do it. That’s what I call #factsoveragenda.

How do you describe your birth community? As a cesarean parent, how were you received and did you feel supported? If not, where did you go to find support?

“Hospitals offering VBAC are required to have 24/7 anesthesia” is false

In 2010, I was sitting next to an OB/GYN during a lunch break at the National Institutes of Health VBAC Conference. She was telling me about how she had worked at a rural hospital, without 24/7 anesthesia, that offered vaginal birth after cesarean (VBAC).

I asked her what they did in the event of an emergency. “I perform an emergency cesarean under local anesthetic,” she plainly stated. She explained how you inject the anesthetic along the intended incision line, cut and then inject the next layer and cut, all the way down until you get to the baby.

It certainly wasn’t ideal, but it was how her small facility was able to support VBAC while responding to those uncommon, but inevitable, complications that require immediate surgical delivery.

CLICK to share on Facebook.

CLICK to share on Facebook.

They had everything a hospital needs to offer VBAC: a supportive policy, supportive providers, and motivation to make VBAC available at their hospital.

From a public health standpoint, it’s to our benefit to offer VBAC because repeat cesareans increase the rate of accreta in future pregnancies as well as hysterectomy and excessive bleeding.

And rural hospitals are NOT capable of managing an accreta because it requires far more than (local) anesthesia and a surgeon. (Read more on how morbidity, mortality, and ideal response differs between uterine rupture & accreta.)

When I hear of smaller, rural hospitals telling women that they can’t offer VBAC because “ACOG requires” 24/7 anesthesia, I think of that OB/GYN and ACOG’s (2010) guidelines which state

Women and their physicians may still make a plan for a TOLAC [trial of labor after cesarean] in situations where there may not be “immediately available” staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk.

So, yes, it is possible and reasonable to offer VBAC without 24/7 anesthesia.

It is ideal? No.

But do you know what else is not ideal?

It’s not ideal to have VBAC bans mandating repeat cesareans that expose women to the increasing risks of surgical birth across the board as a matter of policy—risks that can be far more serious and life-threatening than the risks of VBAC.

It’s not ideal to have any vaginal delivery at a hospital that doesn’t offer 24/7 anesthesia, because any woman giving birth may require emergency surgery.

It’s not ideal to have a cesarean (scheduled or emergency) at a hospital that doesn’t have a blood bank.

It’s not ideal nor realistic to have every pregnant woman drive hours in labor to larger hospitals that offer blood banks, 24/7 anesthesia, and various obstetric sub-specialties for planned VBAC.

It’s not ideal to have state troopers attending roadside births for some of those women.

And it’s deadly for rural hospitals to be managing a surprise accreta.

So, we have to come up with better options.

We can’t continue to pretend that banning VBAC is in the best interest of families.  It does not serve our communities in the long run because it simply exposes the ones we love to a more serious complication in future pregnancies.

Learning how to perform a cesarean under local anesthetic makes hospitals—regardless of geography—safer places to give birth. It enables them to perform cesareans more quickly when they don’t have an anesthesiologist in the hospital but the baby needs to be born NOW.

This could make a huge difference in the outcomes for any laboring mom—VBAC or non-VBAC—as well as her baby.

Learn more about VBAC barriers and watch me debunk the four reasons why hospitals ban VBAC in my workshop, “The Truth About VBAC.”

Does your rural hospital offer VBAC or not?

Does your urban or suburban hospital offer VBAC or not?

Leave a comment below!


American College of Obstetricians and Gynecologists. (2010). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology, 116 (2), 450-463,http://m.acog.org/Resources_And_Publications/Practice_Bulletins/Committee_on_Practice_Bulletins_Obstetrics/Vaginal_Birth_After_Previous_Cesarean_Delivery

Kamel, J. (2015, April 2). Too Bad We Can’t Just “Ban” Accreta – The Downstream Consequences of VBAC Bans. Retrieved from Science & Sensibility: http://www.scienceandsensibility.org/placenta-accreta-vbac-ban/

Kamel, J. (2010, July 22). VBAC ban rationale is irrational. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/22/vbac-ban-rationale-is-irrational/

Komorowski, J. (2010, Oct 11). A Woman’s Guide to VBAC: Putting Uterine Rupture into Perspective. Retrieved from Giving Birth with Confidence: http://www.givingbirthwithconfidence.org/p/bl/ar/blogaid=181

VBAC Ban Rationale is Irrational

Virginia of Hagerstown, Maryland left me this comment in response to the article Why if your hospital “allows” VBAC isn’t enough:

my hospital says that they will do a vbac but they aren’t set up for it because the labor side is far away from the c-section side so if i try to do a vbac and end up having a c section it will take a lot longer to get me to surgery. do you think this is a legitimate reason to consider not having a vbac? im too close to my due date (7 days left) to change hospitals or doctors although i am beginning to wish i would have. ..
-NERVOUS in hagerstown maryland

Hi Virginia,

The short answer is: No, that is not a legitimate reason to deny you a VBAC.

The reality is, you are less likely to experience an uterine rupture than a complication that has absolutely nothing to do with your prior uterine surgery.

Since obstetrical complications arise during labor in women with no history of uterine surgery that require immediate surgical delivery, or more commonly in women with multiple prior repeat cesareans, how can a hospital claim that they are fit to attend those births, but not yours?

Any birth (VBAC or not) could end in a medically necessary cesarean and any hospital (urban or rural) set up for birth should have a plan detailing how they will respond to those inevitabilities.

I have also often wondered how often women with true obstetrical complications requiring immediate cesareans or even car accident victims requiring surgery, have been unable to receive that care due to otherwise healthy moms and healthy babies undergoing  scheduled elective repeat cesareans occupying the operating rooms?  With 92% of American women having repeat cesareans (Martin, 2006), I’m sure it’s happened, especially in smaller hospitals.

The ability of rural hospitals to safely attend VBACs, as well as a specific plan that they could implement, was extensively discussed at the March 2010 National Institutes of Health VBAC conference.  One doctor spoke during the public comment period and stated that her rural hospital  – without 24/7 anesthesia – had a VBAC rate of over 30%!  It turns out, if a hospital is supportive of VBAC and motivated, they can absolutely offer VBAC safely.  (I also welcome you to read the commentary of two obstetricians and one certified nurse midwife who argued against the VBAC ban instated at their local rural hospital.)

As David J. Birnbach, M.D., M.P.H (2010), who presented on the impact of anesthesiologists on the incidence of VBAC asserted:

Lack of immediate available of anesthesia may not always be a key factor in outcome [during a uterine rupture], especially in cases where the obstetrician is not present. Many cases of uterine rupture can be stabilized while the anesthesiologists becomes available, and examples have been suggested of ways to reduce the risk associated with such a crisis. These include antepartum [prenatal] consultation of VBAC patients with the anesthesia departments, development of cesarean delivery under local anesthesia protocols, finding methods of improving communication on labor and delivery suites, practice “fire-drills,” and development of protocols matching resources to risk.

I urge you to watch Dr. Birnbach’s presentation along with all the presentations from the 2010 NIH VBAC conference.  The American Association of Justice article entitled “When every minute counts,” also discusses improving response times.

These drills would also be helpful to the women who have other obstetrical emergencies including placenta previa, placenta accreta, and other complications that are more common in women with multiple prior cesareans.

Additionally, as I argued here:

Scheduled cesarean section puts anyone else who experiences a medical emergency requiring surgery in danger because those operating rooms become unavailable. I wonder how often women with true obstetrical complications requiring immediate cesareans, such as your wife, or non-obstetrical emergencies such as car accident or gunshot victims, have been unable to receive that urgent, time sensitive care due to otherwise healthy moms and healthy babies undergoing scheduled elective repeat cesareans and tying up the operating rooms? With 92% of women having repeat cesareans (Martin, 2006), I’m sure it’s happened, especially in smaller hospitals, many of which only have one or two operating rooms.  These routine repeat cesareans impact everyone and it’s only going to get worse.

I highly recommend you read the Final Statement produced by the conference as it was the catalyst for the subsequent revision of ACOG’s (2010) VBAC guidelines in the Practice Bulletin No. 115 where they affirmed:

Women and their physicians may still make a plan for a TOLAC in situations where there may not be “immediately available” staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk.

This is a huge change.

The term “immediately available,” first introduced in the 1999 Practice Bulletin No. 5 and then reiterated in the 2004 Practice Bulletin No. 45, was the reason why many hospitals ultimately banned VBAC.  Hopefully the removal of that recommendation in this new Practice Bulletin will result in the reversal of VBAC bans and an overall greater support for VBA1C and VBA2C.  ACOG acknowledged that their prior recommendation was resulting in way to many cesareans and the increasing risks that multiple cesareans bring are significant and unacceptable.  (Please read the risks of multiple cesareans detailed by Silver 2006 in Another VBAC Consult Misinforms.)

The removal of the “immediately available” recommendation is supported by the NIH (2010) Final Statement which found it, if implemented in all hospitals, to be an impossible standard that could result in the closing of many Labor & Delivery units:

Would provision of an anesthesiologist standing by waiting for an emergency at every hospital that practices obstetric care increase patient safety?  In truth, that person would need to be doing nothing else clinically, so even being in the hospital might not qualify for “immediately available.”  Looking at the numbers of anesthesia staff currently available, the minimum requirement to provide immediate anesthesia [per the recommendation of the American Congress of Obstetricians and Gynecologist] care for all deliveries would be to have all deliveries accomplished at facilities with greater than 1,500 deliveries annually.  This would require that approximately three-quarters of all obstetric programs nationwide be closed (Birnbach, 2010).

I am excited and hopeful to see the ripple effects of this new Practice Bulletin especially for women in rural areas.  Hopefully the option of VBAC will become a reality for more women.


American College of Obstetricians and Gynecologists. (2010, July 21). Ob-Gyns Issue Less Restrictive VBAC Guidelines. Retrieved July 21, 2010, from ACOG: http://www.acog.org/from_home/publications/press_releases/nr07-21-10-1.cfm

Birnbach, D. J. (2010). Impact of anesthesiologists on the incidence of vaginal birth after cesarean in the United States: Role of anesthesia availability, productivity, guidelines, and patient saftey. Vaginal birth after cesarean: New Insights. Programs and Abstracts (pp. 85-87). Bethesda: National Institutes of Health.

Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., & Kirmeyer, S. (2006). Births: Final Data for 2004. National Vital Statistics Reports , 55 (1), 1-102.

National Institutes of Health. (2010, June). Final Statement. Retrieved from NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights: http://consensus.nih.gov/2010/vbacstatement.htm

National Institutes of Health. (2010, March 8-10). NIH VBAC Conference: Program & Abstracts. Retrieved from NIH Consensus Development Program: http://consensus.nih.gov/2010/vbacabstracts.htm