Many of my scheduled appointments each week are what we call in our office a “preconception consult.” This is a visit where a patient is planning a pregnancy and wants to get to know our practice, make sure they are healthy before getting pregnant, and receive information or help with conceiving. There are also a certain percentage of these visits that are what I call “the VBAC interview.” These are patients who had a previous cesarean and are trying to find someone who will “let” them have a vaginal delivery in a future pregnancy. They will often dance around the questions they really want to ask, trying to figure me out and whether I am really VBAC (Vaginal Birth After Cesarean) friendly. I try to quickly relieve them of this anxiety and cut to the chase: “I see you had a previous cesarean, where you hoping for a vaginal delivery with this upcoming pregnancy?”
Unfortunately, more and more women are finding themselves in the position of having to explore their options after a previous cesarean. According to the CDC, 21.8% of women, 1 in 5 women, who have never had a cesarean before, will deliver via cesarean. If these women go on to have another child and desire a vaginal delivery, their chances of actually delivering that way are small. Only 12.4% of women with a previous cesarean will have a VBAC in a future delivery, despite the fact that a VBAC can be successful over 80% of the time it is actually attempted. While there are certainly patients who make an independent decision to have a repeat cesarean, there are many more who want a VBAC who are not being given the chance.
As an obstetrician with a large percentage of patients who choose me specifically for a VBAC, I have an insiders take on what it really means to be a VBAC-supportive provider and how women can identify whether or not they have one. Here are the four most important questions women who desire a VBAC should be asking:
There are certainly many other questions that can signal incomplete VBAC support, but these questions get to the heart of VBAC support and can quickly help a woman decide if her current care provider will really help her reach her goal of a vaginal delivery. For help in finding a VBAC-friendly practice, reach out to your local ICAN chapter
I was recently giving a presentation regarding natural birth and low intervention models of care to a group of physicians at one of my local hospitals, which coincidentally has one of the highest cesarean rates in the country. I am accustomed to receiving push-back regarding my support of natural birth from members of the medical community, just as many women seeking a natural birth receive push- back from their providers. However, one of the comments at the end of my presentation struck me, particularly because I did not have the chance to respond, as his comment dragged past our time limit and he claimed the last word. The commentator was obviously very disturbed by my argument that women should have autonomy over their birth process and a right to share in the decision making with their care provider. He insisted that obstetricians were like pilots on a plane. No one questions the pilot’s decisions regarding how to safely get a plane from point A to point B and, likewise, patients should not be questioning their doctor’s judgement, given their years of training and expertise, to safely care for them during labor and delivery.
Many in the room agreed with him and at first blush, it is a convincing argument. Of course, any surgeon provides care that is comparable in the skill level to that of other highly specialized professions, such as pilots. Certainly, when the time comes to actually perform the procedures needed by their patients, such as a cesarean or vaginal delivery, women must trust that the training and credentialing of their physician is sufficient to enable them to safely perform that procedure, as we trust when we sit down in our plane seat that the pilot on board has the proper training, credentials, and oversight to carry us to our destination in one piece.
Women are not asking to fly the plane.
They simply want to be able get up and move around during the flight, except during the higher risk times of takeoff, landing, or turbulence. But, if that fasten seat-belt sign is left on too long or activated too often, the passengers may begin to question whether it is truly necessary and a brave few might even begin to roam the isles.
They want to be seated with their travel companions and have enough space to relax. They want to be able to turn off their passenger light and have a quiet environment to travel in. They want comfort and care from their flight attendant. They want to eat and drink, even if there is a chance they might get a little nauseous while on board.
They want to be able to pick their flight and they don’t want to be forced to take a sedative before getting on board.
They also want guidelines and check-off's in place to promote safe, uneventful flights with very little use of the pilot’s many highly specialized skills. The pilot shouldn't fly the plane too fast just because they believe it is more efficient or they want to go home. The vast majority of the time, the flight should be on autopilot. While a pilot may be skilled enough to perform a crash landing, if he or she was doing that on any regular basis, it would not be considered a good thing.
It is okay to question the judgement of a system that is landing at the wrong airport 32% of the time, which is the national rate of cesarean, and crash landing far too often, with frequent near misses in maternity care. It is okay to say that level of restriction on ambulation, diet, time in labor, and access to alternative comfort strategies is not necessary for patient safety. It is okay for women to have a say about their flight experience.
Dr. Michelle Aristizabal is a board-certified General Obstetrician and Gynecologist in Montclair, NJ. She is the author of Natural Labor and Birth: An evidenced-based review of the natural birth plan and runs a busy, private practice, with a special focus on supporting women who desire low-intervention, un-medicated births.