Transcript

Anne Nicholson Weber: 00:00

Welcome. This is episode seven. Thanks for being here. Today, we’re talking about vaginal birth after Cesarean, or VBAC. If you are pregnant after a prior C-section and are considering having a vaginal birth this time, you’ll want to stick around as three doulas with deep experience supporting VBAC talk about informed choice, supportive providers, and physical and emotional preparation.

 

Anne Nicholson Weber: 00:32

Welcome to the BirthGuideChicago podcast, conversations about building your circle of support in the childbearing year. We connect you with experts in our community who can help you conceive, stay healthy during pregnancy, have a safe and satisfying birth, and embrace the joys and challenges of becoming a new family. I’m your host, Anne Nicholson Weber, and the founder of BirthGuideChicago.com, where every month, thousands of Chicago area families find relationship-centered care — from preconception through the postpartum period.

 

Anne Nicholson Weber: 01:10

Today, I’m talking to three doulas who have expertise supporting women who want a VBAC, which is a vaginal birth after a prior cesarean. Because c-section is so common in the US  —  something like a third of babies are born by cesarean — many families face the decision in a subsequent pregnancy whether to have a repeat cesarean or try for a vaginal birth this time around. So this podcast is for women in this situation, either trying to decide whether to try for a VBAC or who’ve decided that’s what they want and are interested in learning what they can do to prepare. My guests to talk about this are Rebekkah Carney with Supported Serenity Doula Care; Heather McCullough with 312 Doulas; and Lexi Zuo, The Elgin Doula. So thank you so much for joining me. Um, and especially to Rebekkah, who was up all night at a birth and is here nonetheless. Thank you for that. So I think what I’d like to start with is asking each of you to talk very briefly about your experience supporting VBAC and any personal experiences you might have. And we’ll start with Heather.

 

Heather McCullough: 02:16

Thank you so much for hosting us, Anne. We really appreciate this and all you do with BirthGuideChicago. What brought me to this VBAC advocacy and work as both a midwife and a doula is my opportunity to work at a birth center in Portland, Oregon, with a midwife who primarily spoke Spanish. And we would have families coming from Mexico to live in Oregon, and many of them had cesarean birth. At that time, Mexico City had nearly a 98% cesarean birth rate. And so . . .

 

Anne Nicholson Weber: 02:49 Holy Moses! <laugh>,

 

Heather McCullough: 02:49

Right? Yes. And so families would come to Oregon and they wanted to have VBACs. They wanted to have large families, and yet the hospital community had not really moved to a common protocol program for VBAC. It was common for people within hospitals to not be offered a trial of labor, to be risked out for many reasons. And especially for our clients who were coming from Mexico and South America, they rarely had their records. And so we knew if people were going to give birth in the hospital for many reasons, they may not be offered a trial of labor. So we really opened up the birth center for VBACs in a radical way. And at first — I was a brand new midwife, so I have to be honest, I was like, oh, is this okay? I don’t know. But everyone else around me supported us and, and what I got to see was probably about a  fifth of our clients were VBACs and went on to have unmedicated, uh, generally water births that were really supported.

 

Heather McCullough: 03:53

And that grew my confidence. So at this point, I’ve been practicing as a midwife for 27 years, and I’ve been to around 3000 births, and right now about a third of our practice at 312 Doulas are VBACs. And I also have the honor of teaching a VBAC workshop that I’ve been doing for about 10 years, and will now be moving into something called VBAC University so that families all around the country can gather the information. And I’m sure we’ll be talking about this, but there are so many barriers to people accessing even the option of VBAC or having the rug pulled out from underneath them once they arrive in the hospital.

 

Anne Nicholson Weber: 04:34

Great. Thanks. Um, Lexi, why don’t you talk about your experience with VBAC?

 

Lexi Zuo: 04:41

Sure. Yeah.I have five children. My oldest was adopted, and then I have four biological children. My first was a cesarean in Uganda when I lived in East Africa. And then when I came back to America to Chicagoland for my next birth, it was not even really a discussion that I would be having a VBAC. I was so thankful that my providers at Evanston Hospital and Highland Park Hospital were so supportive of a VBAC. And I went on to have two very successful VBACs. But it wasn’t until I became a full-time doula about two years ago that I realized that that is not the norm here in Chicagoland and elsewhere around the US. For far too many women, it’s “once a C-section, always a C-section”. And I really started to see through my doula practice that I had been really blessed personally to have providers that were so supportive. And that’s unfortunately pretty rare. So as a birth doula, I do not do primarily VBACs. The vast majority of my clients are first time parents or having high risk pregnancies. That’s one of my main specialties is really more complicated pregnancies and more complicated deliveries. But I’ve done, I would say,  maybe a third of my births so far or fourth have been VBACs, and so far all of them have been successful.

 

Anne Nicholson Weber: 06:14 Oh, great. And Rebekkah.

 

Rebekkah Carney: 06:16

So I, when I became a doula, I didn’t know a lot about VBACs and cesareans until I really started to immerse myself in the culture of what people are going through when they find themselves in a cesarean and what they’re hearing from their providers, which sometimes aren’t always the nicest comment. “Oh, the cesarean happened because, you know, something is wrong with your body.” Um, and they’re hearing these mental pieces that then when it comes the second time, they don’t have that confidence to be able to even have a trial of labor. When I started to experience that with my own clients, it made me wonder why this was happening. And so I took the VBAC Link certified doula training and started to focus on supporting those clients. I’m also a GentleBirth childbirth educator, and GentleBirth is all about the mindfulness of where your brain is at and how you can prepare your brain to have the type of labor that you want. And whether that’s an unmedicated or a medicated birth or even a c-section, really getting your brain in that space so you can kind of practice ahead of time, in your brain, what you want your birth to look like.

 

Rebekkah Carney: 07:35

One of my very first clients when I started as a doula hired me — She lived in Las Vegas and hired me to have a VBAC without meeting me. And to be honest, I was really scared to support her because I just wanted her to have a really great success story. And she had her VBAC, it was great. But to be able to be a part of that experience and see somebody go through something so trying, there’s so much emotion and support that’s needed, not just physically, but then the emotional support ahead of time. getting them prepared and moving forward. That really has inspired me to support VBAC clients. So about two thirds of my practice are folks that are hoping to achieve unmedicated births, and about one third of my practice is folks that are looking to have VBACs.

 

Anne Nicholson Weber: 08:27

So that’s a lot of experience, communal experience among the three of you. And I’m always so amazed by the resources that there are in the Chicago area, which is one of the things that BirthGuide exists to help people find. So what do you think are the biggest barriers to making the decision to try for a vaginal birth after cesarean? And Heather, maybe you’ll start us off on that one. 

 

Heather McCullough: 08:55

Sure. Uh, one of the biggest barriers I think that I see is that on the other side of belly births or cesarean births, so often people’s hearts are hurt. They’re grieving that process and they feel maybe a little tricked by their bodies or their providers or the support that they received. And putting their eggs back in that basket might not feel like the safest gamble. And I think the other challenge we have are partners. I think it’s very common that partners have this perception that cesarean is the safest option and also the easiest option for the partner and for their family. Now that they have this toddler, likely, scheduling it can feel amazing, especially if we don’t have a lot of resources or a lot of family around to support going into birth who knows when over that last six weeks. And so bringing people into the knowledge of both how optimal a trial of labor or a VBAC can be, both for mom and baby, the risk of second C-section, especially scheduled C-section, which is often what they’re thinking about, and then ways that we can support them.

 

Heather McCullough: 10:13

And we don’t have all of the answers to those pieces, but it’s not unusual that people take my VBAC class and the partners on the other side of it had been against the idea of doing a trial of labor, and now are actually more for a trial of labor VBAC than even the pregnant person. And now I’ve even had people send me an email saying, “oh, shoot, uh, I actually sabotaged myself —  now it looks like I really do have to have a VBAC.” Um, so I think education and support can be a big piece to it.

 

Anne Nicholson Weber: 10:43

So Lexi, can you talk about why . . . Given there is kind of a feeling that VBAC is more dangerous — and that I think is part of what Heather’s referring to that can be a barrier —  as well as the kind of convenience that she talked about, which I had never thought about, but is obviously very compelling — what, what are the countervailing considerations that you would put forward when a family says, well, we’re trying to decide what to do?

 

Lexi Zuo: 11:13

Yeah,  I think there’s a lot of fear-mongering and a lack of information. I’m also a Lamaze-certified childbirth educator, and one of the big things I talk about in my childbirth classes that I teach is just, you know, what is the absolute risk of whatever intervention or things that you’re thinking or opting in or opting out? And obviously with a VBAC, the number one concern is always uterine rupture. And sometimes OBs or even midwives will use language like, “oh, if you try for VBAC, you’re double the risk of a uterine rupture.” Well, what is that absolute risk? You know, helping, um, parents to be actually informed about what those total risks are. For example, with the risk of uterine rupture, a mom that has never had a cesarean birth and is having her first vaginal birth has a .5% chance of uterine rupture, even without a scar on her uterus. So the “double the risk” of a percent chance trying for VBAC sounds really scary. But really, when we’re talking about total absolute risk and likelihood of that happening, it’s still very, very, very low. And it’s still considered a very safe option in comparison to the risks that come with a repeat cesarean

 

Anne Nicholson Weber: 12:41

And maybe Rebekkah, you could pick up from there. So, um, there’s a real but very small difference in risk of one particular complication, which is uterine rupture. What are the other considerations that balance that risk in terms of considering having a vaginal versus a repeat cesarean birth?

 

Rebekkah Carney: 13:01

Well, it’s not a surgery. you know, every time our bodies go through surgery, it’s major. It has impacts for the rest of your life. And the postpartum recovery tends to be a lot easier when people are having a vaginal birth, uh, which can therefore lead to even the mental health piece, um, in the long term of how they’re feeling with their bodies, with how they are as parents after the baby is born. So I think there’s a lot of benefits to, focusing on having a VBAC. But it can be really challenging.

 

Anne Nicholson Weber: 14:11

Mm-hmm. <affirmative>. So, um, Heather, do you want to add anything to either the reasons you see why a woman or a pregnant person might be inclined towards a VBAC or the reasons you think that she should be?

 

Heather McCullough: 14:26  

I love to consider informed consent versus informed choice in this conversation. And there’s a lot of power people can gather in themselves when they make a choice. And for many people doing a repeat cesarean is less of a choice:  I don’t want a surgery, but I’m going to consent to a surgery because everything else seems hard. And as I think we all know, there’s no easy way to meet a baby. The unknown though can be very, very scary. So when people feel they had power in their birth experiences, made a choice that was right for them — and especially even if they didn’t get to have another vaginal birth, but had to have a cesarean at the end of a trial of labor —  if they can feel like this was a choice that they made, that has a lot of power long term for their physical and mental health and who they are as parents. And we know that when people have surgery, there’s a state of inflammation that can create challenges around breastfeeding and the microbiome, both for moms and babies. So the sequelae of surgery just is not considered in the true informed consent. So I always come back to that conversation.

 

Anne Nicholson Weber: 15:51

So at a minimum, can I, oh yeah, Lexi, go ahead.

 

Lexi Zuo: 15:54

I would say that —  I don’t know — encouraging or saying that it’s always a good thing, I think might be taking it a little bit too far, at least in my opinion. I like what  Heather said about just making sure people have full information about their options. Um, for my last birth, I was offered a third VBAC, and I chose a planned C-section due to various reasons. So I don’t think in any way that choosing a plan C-section or not choosing to have a trial of labor is in any way bad or a bad choice. Um, it’s just important for the patient and the family to have the full knowledge of the benefits and risk of all the options. And then they get to decide with a supportive provider what is right for them, you know,

 

Anne Nicholson Weber: 16:46

And not having a finger on the scale, so that information is presented in a really fair and neutral explanation. Well, Lexi, since you’re the one of us who’s had a VBAC, can you just talk a little bit about what those experiences were like for you and how you felt about the decisions that you made?

 

Lexi Zuo: 17:07

Um, yeah. So everyone is different. Everyone’s experience with a cesarean is different. I’ve had two VBACs and two cesareans, and I would say personally I’ve had positive birth experiences all around. So going into my first VBAC, I was not personally trying to redeem a sort of traumatic birth the first time around with my first cesarean, which I know can be really common. A lot of people, um, that had cesareans feel like they were traumatic or really difficult. Um, in my case with my first cesarean, I was in a third world country, my water broke at 33 weeks and I never went into labor. After two and a half days I developed an infection and then a c-section became a wise decision at that time. So for me, going into my first VBAC, it really wasn’t an issue of can I VBAC or not.

 

Lexi Zuo: 18:06

For me, at the time, my biggest concern was, can I make it to full term and not have another preemie baby? That was, that was my big win with that. Um, but my first VBAC was done at Evanston Hospital. It was an induction due to pretty high blood pressure — I’ve always had that in my pregnancies —  and it was long <laugh> At the time, I thought this was abnormal. It was a 41 hour birth. Um, and they did it really, really safely and very slowly so that I could hopefully have a VBAC. They were really committed to that. For me, I don’t even think I knew to be as committed as my medical team was. It was really sweet. Um, but halfway through that birth, 20 hours in, I was like, I’m done. Like, I want to meet my baby. You know, classic first-time induction parent. And they’re like “you’re doing fine. See you later.”

 

Lexi Zuo: 19:03

And eventually, 20 hours later, I had my precious baby boy, and it was great. But I did have a third degree tear with that VBAC. That was pretty difficult. And so that’s why I think I’m a little more, uh, VBAC or cesarean neutral. I know that significant tearing can be a reason why parents choose to have a planned C-section later on. And ACOG supports that as well. That is an evidence-based practice if a parent feels like that would be the best choice for them. So that was a really, it was a good experience. But I remember thinking, everyone said a vaginal birth is way easier than a cesarean. And for me, it was a positive experience, but it came with a significant recovery. 

 

Lexi Zuo: 20:01

Um, my next VBAC was at Highland Park Hospital, way easier, way shorter. I think it was like seven hours, again, induced because of a very high blood pressure. Um, but it was really easy. And I had a baby that was almost three pounds bigger and no tearing, and it was a really good experience, <laugh>. And I was like, oh, ok. This is what people are talking about with, uh, vaginal births that are pretty easy to recover from compared to the other experiences I had had. Um, and then for my last birth, I wanted to get a tubal ligation and my provider was heavily encouraging me to go for a third VBAC and then have a surgery six weeks later to get my tubes tied. And I said, I know myself, I know my family, I know the risk of going under general anesthesia to get that done six weeks postpartum versus doing it with a spinal, with a planned C-section.

 

Lexi Zuo: 21:01

And so I think I decided about halfway through my pregnancy that I would not be seeking a third VBAC, and instead I would be planning a C-section. Which I’m really thankful for it because at the tail end of my pregnancy, I had severe, severe, the worst I’d ever had, gestational hypertension. I was in and out of the hospital constantly. And a c-section did become medically necessary at that point. So I had had a few months of leading up to it to like, think and prepare. But, um, yeah, so those were my experiences, <laugh>. But even my, my last birth, I almost felt the other way around. I felt almost a little peer pressured by my doctors to have a third VBAC. They were like, no matter what, like, just do it. Just do it. Like we can give you medicine so you don’t have a stroke due to your high blood pressure and all of that stuff. And I was like, I decided I want the C-section. Um, but yeah, so I’ve experienced a full range of support. But as a doula, based on what I’ve seen professionally, I’m just shocked at how encouraging and how kind and how positive my medical team always was regarding, um, a VBAC. Cuz I know that’s really not common.

 

Anne Nicholson Weber: 22:15

You’re shocked because by contrast you’ve seen, uh, medical support that was not at all supportive.

 

Lexi Zuo: 22:22

Yes. Yeah. For, for most of my clients. Um, I think for my first VBAC, I literally think we had the discussion at my very first prenatal visit, and my provider was like, yep, so you want a VBAC? Okay, great. Sign this form. Awesome. We’re gonna do it. And that was it. There was not a lot of discussion. I never had to argue or advocate for myself with that. Versus, I know as a doula, that is not the norm with most of my clients. It is a continual — they feel like it is a continual battle. A lot of times their provider is not very encouraging about it. They are not willing to commit to letting them have a trial of labor. Um, it seems to really be an uphill battle for most families, unfortunately.

 

Anne Nicholson Weber: 23:07

Well, there’s so much in what you just shared. And first of all, just that your range of experiences is so illuminating about what matters is not the choice, but how the choice is made and how clear you feel and how listened to you felt. And your obvious sophistication as a doula, that made it easier perhaps in that last pregnancy to <laugh> to resist this kind of counter-cultural peer pressure to have the VBAC when you didn’t want to. Yeah. So I think that’s a really helpful context that, you know, this, this podcast is not about why anybody should have a VBAC, but it’s about why if you want a VBAC, you’re gonna have to be sensible and aware that it can be an uphill battle — depending on your providers. And that’s a topic I want to go to. Um, but Rebekkah, before we do maybe, uh, as a doula, have you seen, I, I remember, um, Lexi started by talking about she was not in the situation with her first VBAC where she was trying to, I think she said, redeem a traumatic C-section. But I imagine that is a scenario that you as a doula have seen. Um, is that true?

 

Rebekkah Carney: 24:17

I feel like that’s probably the more common scenario. Lexi and I have talked about her birth before, and every time she tells me about them, and I’m so grateful that you shared them, Lexi, I am always like in awe that that occurs.  Because most of the clients who hire me, the conversation we have in our consultation is, “I had this really traumatic experience, I don’t want to have it again.” Um, and that’s, you know, time and time again what I’m hearing. And so then that’s why they are, you know, trying to have a really successful and supportive birth team moving forward so that they give themselves the best chances to have a successful VBAC.

 

Anne Nicholson Weber: 24:57

And is it your experience that having a VBAC after a traumatic C-section actually does kind of reset or redeem?

 

Rebekkah Carney: 25:07

Well, I think — yeah, absolutely, I think for most folks it does feel that way. If they had a traumatic first experience and their second experience is better. And even, um, you know, I’ve had clients before who had a c-section at one hospital, and we had conversations about finding a supportive birth team, and they changed providers. Um, particularly I’m thinking about a client whose baby then turned breech at, um, 40 weeks and she wound up having a second cesarean. Uh, but the birth team that she chose the second time provided that redemptive experience. She had a team that, you know, she had a gentle cesarean, she was able to see her baby as it was being born. She was able to do skin to skin right away. And unfortunately, that’s not even the norm at many places in the Chicago land area. Babies are taken away from their moms for this reason or that reason. And so it’s even in those situations when maybe a trial of labor doesn’t go on to be successful, or they’re not able to have a trial of labor due to a breech baby, uh, it’s great to see people with supportive birth teams, collaborative birth teams that are supporting them.

 

Anne Nicholson Weber: 26:25

Yeah. So, Heather, is there anything you want to add to this picture? We’re kind of painting  what a VBAC experience can look like.

 

Heather McCullough: 26:35

Uh, I, I think that when people really get to move back into that seat of power around these decisions, that impacts them for way past this birth, no matter what that looks like, and I think it also can bring partners together. One of the things that we see so often is when people come to us for a VBAC, generally they will have some sense that during their first birth there was a lack of support, lack of support from partners or not having a doula or a doula who is newer or didn’t know how to support them. And on the other side, not only did they need to recover from surgery, but they may have feelings about whether or not they even are in a supportive relationship. And when people can walk this together and decision-make how they’d like to meet this baby and really create a plan for all of the different ways that this could look, how we can cope together, what this can look like, and how we can thrive in what is always going to be a challenging process, I think that can just, again, pay dividends down the road.

 

Anne Nicholson Weber: 27:44

Yeah. You know, one thing I don’t think anybody said, although Rebekkah referred to it broadly,  which is the risk of repeat cesarean. And you talked about, Rebekkah, in general, that surgery has risks and inflammation and is, you know, better to avoid. Um, but I just want to add what I happen to know, which is that there is also risk associated with one cesarean that increases with two, that increases with three for future pregnancies. And that seems to be something — I don’t know, Rebekkah, do you want to just explain that better than I will?

 

Rebekkah Carney: 28:19

Yes. I think that the more surgeries you have, the more scar tissue there is on your uterus, the more increased risk there is of in future pregnancies, potentially having the placenta attached to that uterine scar and grow into the uterine scar. And then that can become . . . ultimately it could become fatal. I mean, worst case scenario. Normally they catch it sooner. But it’s a bigger risk the more scar tissue you have on your uterus. In future pregnancies, it becomes more challenging. It’s a lot more high risk and they’re watching a lot more. And then potentially babies may have to be born sooner if there are, you know, increased risks, even if that isn’t a cesarean and, and then you’re looking at potentially – -, you know, it goes on and on. I feel like that’s the hard part about this job is that you can kind of see all of the what ifs of what could happen in the future just from one situation or one decision that’s made, um, from a birth team or from a birther and, um, a trial labor or even in their first birth.

 

Rebekkah Carney: 29:30

So, um, I was just with a really great provider who talked about all these risks, and it was so refreshing to have somebody, um — and it wasn’t an emergency section that was needed — but she just went through very explicitly like, how in the future this could impact your births. And that’s what we need. And I’m so glad, Heather, that you were talking about the informed decision making, because then you really get to paint a picture of what could happen in the future versus, okay, we need to do this now, you don’t have a choice, let’s do it. And then it happens to somebody versus them really fully making a true decision that feels good for their family.

 

Anne Nicholson Weber: 30:09

Yeah, I think that you just referred, Rebekkah, to how little decisions end up playing out with these very major consequences. And there are all kinds of ways that that’s true. And one is, for instance, a c-section now could make a future pregnancy riskier. But on the other side, what Heather was talking about, a really redemptive birth experience, whether as vaginal or C-section, that gives people confidence in their relationship and in themselves, plays out then their whole lives in how they parent and how they are married or partnered. So it, it’s —  I think all of us who love birth and are passionate about birth, that’s part of why, because it just feels like everything is so significant. It’s this beginning that then sets a course, a trajectory for the future that just matters so much. Um, well, so what are circumstances of a prior c-section that might make a VBAC now more difficult? And maybe Lexi, you want to talk about that?

 

Lexi Zuo: 31:19

I think it greatly depends on why your first C-section was done. If there’s some of the more standard reasons of, like, failure to progress or fetal distress, that definitely shows us, Hey, this could be an entirely different situation in a different birth or with a different baby.

 

Anne Nicholson Weber: 31:39

And how about Rebekkah, the same question, but more with an emotional focus. Like what are the emotional barriers that get in the way of a successful VBAC?

 

Rebekkah Carney: 31:49  

I think Heather touched on a lot of this earlier when she was just talking about the relationship dynamic that you may have, you know, not just with your partner, but your entire family. There’s a lot of pressure that folks get from, um, you know, even other people who aren’t educated on birth. “Hey, you’ve already had a C-section, this is the safest.” Um, because they’re hearing that statistic that Lexi mentioned earlier, right? “It’s double the risk of uterine rupture when you are, um, you know, having a trial of labor.” And that risk is still so low. It’s still so low. And so to the emotional piece is that confidence. And that’s something that I think all three of us can probably attest to, and please speak up if I’m speaking for you, but education is so important if you’re having a VBAC. To be educated, to know what your choices are, and to be able to confidently go into provider appointments prenatally before your birth and have those conversations.

 

Rebekkah Carney: 32:48

And if you’re working with a group of folks and different providers, making sure that everybody’s on board. You know, one thing to do is  ask the same question at every single appointment and see what answers you’re getting from all the different providers. Because you can work with your favorite provider and go to them for, you know, 75% of your appointments, but that might not be the person who walks in the room on the day that you’re having your baby. And so really emotionally being able to prepare yourself for what’s to come and identify, “Is this a good fit? What is my, what is my intuition telling me about this group that’s gonna be my birth team, the folks that are gonna support me best in this decision?” So I think a lot of the emotional piece comes from the people that you’re surrounding yourself with daily, but then also the people that you plan to surround yourself with in your birth. And if you have that support, it emotionally is gonna feel like a really good choice. If you don’t, then it constantly feels like you’re fighting these battles. And when you’re constantly fighting battles, you wind up feeling, um, you know, like defeated, if you’re always feeling like you have to put up a front, unless you have that education, that confidence that you know that this is the decision that is best for your family.

 

Anne Nicholson Weber: 34:06

And, and in labor, having that feeling of being defensive is going to make it a lot harder to labor effectively. I’m always so interested in the mind-body connection in labor, and how that feeling of safety and confidence and trust will actually make your labor go differently physically.

 

Rebekkah Carney: 34:24

A hundred percent.

 

Anne Nicholson Weber: 34:25

Yeah. Uh, all of you have referred to the importance of choosing providers who are truly supportive of VBAC. And I just want to call out that BirthGuide has an article that lays out which hospitals have the highest successful VBAC rates, which is a beginning point, I don’t think it’s an end point. But one obvious way to increase your likelihood — if you’ve decided that you want to have a VBAC — your likelihood of succeeding is going to a place where they do that a lot, where that’s part of the culture. Um, so as doulas, when a client comes to you who either is deciding whether to have a VBAC or who has decided to have a VBAC, do you give them . . . are there kind of advice or guidelines you can give them about  how to identify a truly um, supportive provider? Heather, do you want to talk about that?

 

Heather McCullough: 35:20

One of my favorite subjects! How to choose a truly supportive provider. And we have so many resources. Of course, your website, BirthGuideChicago. Evidence-Based Birth has great articles about this. And my favorite place to always refer people to is VBAC Facts, Jen Kamel’s site. And of course ICAN. One of the joys of our specialty as birth workers is that we’re kind of like the Wizard of Oz. We get to see behind the curtain, we get to go to all the different hospitals, birth centers, homes, and see different providers in their element. And one thing I find so interesting is that most providers have never even seen their colleagues catch babies before. So they may have a certain way of being with a VBAC family, but then a shift change happens and it can be a completely different shift. So it takes that experienced doula to be able to say, gosh, I wish I could refer to the group that you’re with.

 

Heather McCullough: 36:19

But I do know that there’s one provider or two providers there that are not going to be supportive in the same way. And doulas can’t change providers policies. We can support, we can bring lots of love into the room, we can help people ask questions, but we can’t change a provider’s plan or their own risk value. So what we do here at 312 doulas is during our interview, we actually ask clients what their goals are for their birth, and then help them find spaces that are in alignment with them. And one of the challenges that we see —  uh, of course, BirthGuide is a big part of this —  is that people might be able to get hospital level data on VBAC, but they cannot yet get group practice or very, very much so not individual practice VBAC stats. And until that changes, doulas really are probably the only answer.

 

Heather McCullough: 37:18

We do really love to match our clients up with providers that we know are going to be in alignment, and then they’ll find all of these conversations are just so much easier from the beginning. They don’t even have to have their guard up in the same way. Um, and we also offer our clients huge financial incentives to switch to providers that are in alignment with their preferences. Now, if they’re already in alignment, let’s say I have a client who’s a first time family and they absolutely know that they want an early epidural and they’re with a provider that that’s their standard of care. Excellent. I’m not gonna talk about it at all. You found the perfect provider for you. But if they’re not in alignment with their provider, we can, uh, help try to move that needle. And because we also have classes as part of it, people will often slowly find themselves at 34 weeks, 36 weeks asking those tougher questions and then being brave enough to switch providers.

 

Anne Nicholson Weber: 38:16

Um, so Lexi, how hard in your experience is it to find truly VBAC supportive providers? 

 

Lexi Zuo: 38:22

I would say there’s a fair amount of choices, and I always say with both my doula clients and people that take my childbirth classes, that we are so blessed in Chicagoland to really have a buyer’s market or patient market. We do not live in the rural middle of nowhere where there’s one hospital and like three providers. We have so many hospitals, so many birth centers, so many home birth practices. It really is —  you can go where you want, even if you have no insurance or even if you have Medicaid. It is accepted at many large hospitals throughout Chicago. And, and I always tell clients and families that if you feel like your provider that you’re talking to is not supportive, don’t sit there and think, “oh, I’m gonna be the one person that changes their mind and I’m gonna battle with them my whole pregnancy and I’m gonna go to war with them during my birth.” No. Like, don’t do that to them. That’s not kind or  considerate of them if they’ve made their stance very clear. And don’t do that to yourself. You know, find a provider you love, like Heather said, where you both feel like you’re on the same page, you both have the same birth philosophy, you both have the same philosophy of care. Do that kindness to both yourself and the provider, you know?

 

Anne Nicholson Weber: 39:43

Right. So do any of you find that there are particular questions that a client can ask providers that are really effective at flushing out, uh, essentially ambivalent support for VBAC? Does anybody of you have something you want to suggest, Heather? 

 

Heather McCullough: 40:03

So when it comes to talking with providers first for first time families, I encourage people to ask what percentage, again, data, what percentage of your first time clients are induced? What percentage of your first time clients have belly births? What percentage of your first time clients have operative vaginal birth — which is forceps or, uh, vacuum? None of those statistics should be zero. And also none of those statistics should be 80%. So for VBAC, I would add the question, what happens or what does your practice recommend when people are reaching 39, 40, 41, 42? And I think that’s probably one of the bigger challenges we see so often is that they will say they’re VBAC supportive, but then they will have so many barriers and then you find that by 39 weeks a person’s BMI or age or, uh, how late they are in their pregnancy . .  they’ll begin this litany of risk factors.

 

Heather McCullough: 41:04

And those conversations often start at 36 weeks. So by the time people reach 39 weeks, they will consider it almost a gift to even have continued the pregnancy and then move forward with induction or scheduled cesarean. And again, that can depend on just the tone of the counseling. And because in pregnancy, people switch to that “tend and befriend” from their “fight or flight”, they are just very likely to say yes to whatever their provider is suggesting. It is very hard in those moments to decline that repeat c-section or the induction or whatever it is. And of course, there are awesome reasons, medical reasons to do any of those things. But if somebody’s with a provider who is not truly VBAC supportive, these questions will help them, based on data, discover those providers who are likely to change their tune as people get further along mm-hmm. <affirmative>. Right? And the providers know in pregnancy, it’s scary. It can feel hard to switch providers. And they know if they just wait to have that birth plan conversation until 37 weeks, it doesn’t matter what they say, they could absolutely say, “we don’t do any of those things,” and clients are not likely to switch. 

 

Anne Nicholson Weber: 42:20

Right, right. So it sounds like one simple thing is to have that conversation much earlier in pregnancy. How late can you change and how would you go about finding someone to change to? Rebekkah, you want to take that?

 

Rebekkah Carney: 42:33

There is no time that is too late to change providers. I have had clients change providers in the middle of their labor, um, understanding that their provider walked in and they just did not feel supported. And at that point, they asked for somebody different. If you want to do it prenatally, the earlier you do it, I think the easier it becomes, because then you get to grow that relationship with your new provider and that trust. And what you were talking about, Anne, earlier is, you know, being able to walk into a space and know that you’re fully supported really does help with the flow of labor and the oxytocin and the birth hormones and just not having to fight or feel like you are going to have to fight any battles. But also, you can change providers at any point. Um, that’s the great thing about hiring a doula is that if you do start getting that spidey sense that it’s not a good fit, you reach out to your doula and say, “Hey, I need some help with this. I, I’m feeling like this isn’t a good fit, and can you help me figure out how to, to find a good fit and make this the birth that I’m really hoping for.”

 

Lexi Zuo: 43:43

Can I share one thing real quick? Um, so here in Illinois we are really blessed. There is a law in place called the Illinois Healthcare Medical Records Transfer Act. Medical offices are legally not allowed to make it difficult to change providers. They’re not allowed to harass you or coerce you, and they have to make that transfer very easy electronically. They’re not allowed to charge you exorbitant fees for this. So I think this is something . . .   just that administrative part can feel really overwhelming and really scary, and it really is, uh, patient-centered to protect you and your best interests if you decide that you are not getting the care that you desire with your provider.

 

Anne Nicholson Weber: 44:28

Yeah, that’s great to know. And the other impediment is it can be really hard when you’ve been working with someone and been imagining them as your provider and you’ve had jolly prenatal visits with them where you’ve laughed and they’ve been so nice, uh, and now suddenly you’re having uncertainty about whether —  as nice as they are, as good as your relationship might be — whether the way they practice is a good fit for you, which is a completely different question than personality and your chemistry with them.  And there’s a feeling of being disloyal and are you gonna hurt their feelings. So I think maybe Rebekkah, you could just talk about how do you counsel someone in that situation?

 

Rebekkah Carney: 45:10

I always just tell them to use the phone, call over the phone. It makes, uh, the conversation seem less personal and a little bit easier to have when you’re just calling somebody from the office and saying, “Hey, I’d like to transfer my records. This is where I’m transferring to.” There might be a piece to it where you have to sign some sort of form and you can just walk into the office and sign it, and you don’t have to have that conversation with the provider. Some folks want to, and some folks feel like they don’t want to. And so it’s great to be able to have those options.

 

Lexi Zuo: 45:41

I tell clients, you don’t have to break up with them <laugh> like face to face. You just make an appointment at your new provider that you’ve chosen, you sign a disclosure paperwork saying that they can get your medical records. And that’s often it, depending on the practice, but it doesn’t have to be this like painful, awkward, like,” oh, I don’t like you. I think I like them better.”  Like, you don’t even have to have a conversation. And unfortunately, I also tell a lot of clients,  they’re probably not even gonna notice that you leave, unless you’re leaving a smaller home birth practice or birth center. If you’re in a larger obstetrics practice, they’re probably not even gonna notice that you left their client roster. So don’t feel super guilty about it, don’t feel worked up, you know, just do what feels right for you.

 

Anne Nicholson Weber: 46:30

And I would just add, even if they did notice, and even if their feelings were hurt, those stakes are so much smaller than the stakes for you. They have a lot of patients, they do a lot of births. If one or two happen to not be a good fit and leave them and they feel sad, that just does not matter. <laugh>, it just doesn’t, compared to how —  and this goes back to that point about the stakes are so high for you in your birth and your future as a parent and your baby’s future —  that just matters so much more than a provider’s hurt feelings. Um, so, and I think one more thing. You’re right that — all of you said this — we’re so lucky in Chicago, there’s so many options. But it’s possible that you might want to be changing to someone and you have to travel a little further. How far . . .how do you address that when you’re counseling clients? Yeah, Heather?

 

Heather McCullough: 47:27

I’d love to take this one. One of the challenges that we see first is that there are still very few, if any, out of hospital or community birth options for VBAC. And here in the state of Illinois at this moment, certified nurse midwives are able to do home VBACs, but very few are choosing to, there’s only one, uh, provider generally that does. And then we also don’t have many providers who are offering breech birth, which is when baby’s butt is coming first. So I’ve driven as far north as Hudson, Wisconsin, which is about seven hours north of Chicago, for a family who was having a VBAC for a breech baby. And we went on to have a successful, wonderful breech birth. And I’ve now gone to Hudson a few times for clients who, uh, can go to this specialist who’s experienced in VBAC after two or three C-sections, and breech birth, and those, those more complicated stories.

 

Heather McCullough: 48:28

And people often worry about this travel conversation, even within the city of Chicago — “ I can’t imagine going 30 minutes to my hospital!”. And while yes, every car ride sucks when people are in labor, um, it’s worth it. It’s absolutely worth it. And when people consider that once we have a VBAC, our third birth is lower risk than a first time mom for any other intervention. So it’s a  complete reset, uh, after that first VBAC. So it really is an important piece. And one of the things that we love to do is kind of reset people’s stories, because having a surgical birth sometimes can — or, or for many of us having health issues —  sometimes becomes our definition of who we are. And so we love to help people start rebuilding that image of who they are in a state of health. And we start with nutrition. And when we talk about nutrition, when we talk about working through their experience the first time — like we love emotional freedom technique, which is tapping. There’s so many tools people can use. And then regardless of what their birth story looks like, they can come from it at a place of health and with a set of tools that are just so much more complex than they had the first time around. And that can also help them recover if they do have a cesarean birth.

 

Anne Nicholson Weber: 49:55

And that brings up two thoughts. So you’re saying there’s the trauma for some women in their previous birth that they carry with them into this birth that can be problematic unless they find the ways to work through that and kind of prepare themselves. There’s also  just the physical constraints that may have led to that previous C-section. And I know there are a number of chiropractors who will work with you to get your pelvis in better alignment so that the baby’s more likely to come down. Are there other resources like that that you recommend to  VBAC clients, either for emotional working through or for physical preparation? Rebekkah or Lexi, is there anything you would throw in there?

 

Lexi Zuo: 50:39

Take a childbirth class. I find a lot of people, uh, regret . . . if they had a c-section, a lot of families regret that they weren’t as informed going into that first birth or whenever the cesarean happened. So, um, like we’ve talked about all along, being able to make informed decisions.

 

Anne Nicholson Weber: 50:58

Rebekkah, was there something you were gonna add? 

 

Rebekkah Carney: 51:00

Yeah. One  other thing I would add is,  I think there’s so, so much to what you were saying, Anne, about preparing the body and the mind. So, um, definitely focus on mindfulness.  I even say, like, five minutes a day of just being able to calm your body. will  bring you calmness in your birth. And there’s lots of great apps for that. I mean, there is Expectful, GentleBirth, even Spotify has some mindfulness tracks and relaxation tracks. And the other thing, both Heather  and I are Spinning Babies parent educators. And so taking a Spinning Babies class can be a huge thing in creating space for your baby and your pregnancy. Um, and then also giving you the empowerment and the tools of what to do in labor and how to create space for your baby during the labor experience as well.

 

Rebekkah Carney: 51:54

So you’re working through your pregnancy to lengthen your ligaments, get your pelvis as roomy and spacey for that baby as possible. And then, um, in the labor experience, having those tools in your back pocket for not just you, but also for your partner and your partner being able to support you in that experience physically.  When I think so many times partners just feel a little out of touch or they’re not sure exactly how they can help, taking a class like spinning babies can help bring them closer together during the pregnancy and the labor experience too.

 

Anne Nicholson Weber: 52:28

So another question is, when a family has made the decision to do a trial of labor and gets invested in the idea of a VBAC, of course not every VBAC attempt is successful. What can you do either during pregnancy or after the repeat cesarean to make that better or to make that great? 

 

Heather McCullough: 52:54

Thank you for that question. So when it comes to belly birth, especially if I think about our clients who have breech babies or scheduled cesareans, but also when people have unscheduled cesareans, we love to always help our clients envision what a family-centered — or what’s also called a gentle cesarean might look like and begin the conversation with their providers about what options they have. Now that’s not  a clear term, nobody’s defined family-centered cesarean. So it’s a broad spectrum, but there’s so many pieces to it that depending on who’s available to us, we might be able to get more or less or or fewer of those options. And that could also be a reason that somebody chooses a certain provider or group because they offer more support that could include the doula being in the room, more photographs or choice of music, lowering the drape or a clear drape.

 

Heather McCullough: 53:51 And then on the other side, we love to talk about nutritional support; belly taping, which is just incredibly exciting; continuing the use of the tens unit for both bringing healing to the area and speeding healing. And then bengkung belly binding or belly binding with the Velcro binders. So all of these things, we wrap our clients up from beginning to end with so many tools, they don’t . . . I think one of the challenges is sometimes when people have c-sections, they feel abandoned on the other side, like their doula didn’t get to be in the OR or maybe we didn’t get to join them in recovery. And so our relationship kind of comes to this halt. When if we can offer some of these support tools on the other side. 

 

Anne Nicholson Weber:

Rebekkah, do you want to add anything to that? 

 

Rebekkah Carney: 54:39

You’re right that afterwards there can be some challenges mentally being able to be that support person for them afterwards. Having that postpartum visit, being able to digest and have somebody there to help them digest how their birth went and what they experienced and hearing it from their lens can be really helpful. But also having the supportive tools to if, if they need more, um, knowing where they can turn to, if there is, um, a therapist that might better help them. There’s PSI has great support, Postpartum Support International, and there’s really great providers in our area that have certifications that are able to support clients as well. So being able to help them find the tools that they might need, but also being their person that they can lean on, knowing that they can reach out, that you were there in the room, you were able to know what happened and it’s not just the partner, so they have somebody else to talk to as well.

 

Rebekkah Carney: 55:43

So I think that being able to share it from your lens and how powerful they were in that experience, even if it doesn’t necessarily go the way that they were anticipating it going, can be a great part of being a doula because so many folks, I think, say, “I had this planned VBAC and it didn’t go well, I didn’t do it, I failed.” And there’s so much more to it, there’s so much more success. And in the planning piece and the trial piece and, and ultimately in any birth, not just the VBAC, some things are just out of our hands, right? Where there’s only so much we can control and sometimes things in birth come up. And so we need to also explore the successes of their trial of labor and how wonderful they did to support themselves through that experience.

 

Anne Nicholson Weber: 56:36

So what question didn’t I ask that I should have? Is there anything else you think we need to cover?

 

Heather McCullough: 56:41

I just want to really celebrate that if they’re with a supportive provider, they should have a success rate higher than 80%. And that’s really how they could define a supportive provider too, when they’re asking those questions.

 

Anne Nicholson Weber: 56:54

Great. Yeah. Rebekkah, anything else other than that you want to go to sleep?

 

Rebekkah Carney: 56:58

No. Anne, I think you’ve done such a lovely job and I just so appreciate you putting this on, highlighting what doulas can bring into the support of a VBAC. I just wanted to thank you so much for inviting us all here today and, and bringing this topic to your podcast because it is so important.

 

Anne Nicholson Weber: 57:17

 

Well, thank you all for joining me despite the challenges of getting three doulas into a room at the same time, which has taken us four attempts. Um, but we did it. And thank you so much for being here. I really appreciate your help.