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 ba