How to know if you really have a VBAC-supportive obstetrician or midwife

    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:

1. How many VBAC’s do you perform on any given month? If your doctor or midwife is not regularly performing VBAC’s, it is a red flag. It could mean they simply don’t have many VBAC patients or it could mean they are not routinely offering a trial of labor to their patients with a previous cesarean. It could also mean that they are not managing labor in a way that is allowing their VBAC patients to succeed. Even if your provider seems open and supportive of your plan for a VBAC, if they do not regularly perform them, they are not likely to be as comfortable performing one as a provider who commonly cares for VBAC patients. An alternative version of this question gets to the same point is: “What percentage of your patients with a previous cesarean deliver by cesarean the next time around?”
2. Do you think that I am a good candidate for a VBAC? There are some patients who are not good candidates for a VBAC. Patients with a history of a classical cesarean or a prior uterine rupture, for example, would be much safer having a repeat cesarean and most consider these contraindications to a trial of labor. Other patients who may not be good candidates are those with a significant maternal medical complication or fetal complication, such as growth restriction or low amniotic fluid. However, often women will be told they are not a good candidate on the basis of their previous labor history: such as a history of a big baby or a failure of labor progression or inability to push their baby out. These are often described as “recurrent indications for cesarean” on the basis of presumed pelvic insufficiency, or too big of a baby for too small of a pelvis. In truth, less than 5% of cesareans are performed for true cephalopelvic disproportion...most of the time there is only a relative disproportion...the baby couldn’t fit in the way it entered the pelvis. These stories may also simply be cases of doctor impatience, where aggressive augmentation was initiated or a section was called in a labor that didn’t progress quite quickly enough. Regardless of the reason your doctor or midwife may not think you are a good candidate, if they don’t believe you a great candidate, they are not likely to be very supportive of your VBAC on the day you go into labor. You are better to VBAC with a provider who thinks it will work!
3. Do you manage labor any differently during a VBAC? The answer to this question actually should be yes. Patients undergoing a trial of labor after a previous cesarean should have continuous fetal monitoring, rather than intermittent, as changes in the fetal heart rate tracing, specifically recurrent variable decelerations, are the most common warning sign of an impending uterine rupture. You want a provider who takes that risk seriously and wants to do everything they can to recognize it and respond to it. Most providers will also recommend at least a hep lock IV, in order to have the ability to perform an emergency cesarean without any time delay, should that worse case scenario occur. Some providers will also insist or strongly recommend an epidural, also with the goal of being able to perform an emergency cesarean without the patient needing general anesthesia. However, this is a shortsighted recommendation and is not indicative of a VBAC supportive philosophy of care. Epidurals are associated with a number of different factors that are associated with higher rates of cesarean and thus VBAC failure, such as maternal fevers, blood pressure changes, and fetal heart rate changes. Epidurals are  also associated with higher rates of pitocin use. Pitocin should be minimized in a VBAC and only used if truly necessary to avoid a cesarean, both because it is associated with a small, yet higher rate of uterine rupture and is also associated with a higher rate of fetal heart rate tracing abnormalities which a provider must take more seriously. However, VBAC patients are not in any more danger from a long labor or malpositioned baby than other patients and strict time limits on VBAC’s are not necessary, though some providers impose them. Meconium, or fetal stained amniotic fluid, is also not any more dangerous in a VBAC than a normal delivery, and, in and of itself, should not be a reason to abandon a VBAC.
4. Will you schedule me for a repeat cesarean at any particular gestational age? Some providers claim to be VBAC friendly, but schedule all their VBAC patients for a repeat cesarean on their due date or a few days past their due date. A history of a previous cesarean section does not necessitate delivery by any earlier gestational age than any other patient. If there is a medical indication for delivery prior to labor, a truly VBAC-supportive provider should be willing to discuss all options, including induction, and not simply assume a cesarean. Scheduling a cesarean according to some artificial time constraint is also a signal that a provider may be unwilling to discuss options if challenges occurred during  even a spontaneous, timely labor.   

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