As I mentioned in an earlier post, the decision as to whether or try for a VBAC or schedule another c-section was left up to me. There were some caveats in my ability to decide. Before I get into that, I want to stress something – all women are entitled to make their own medical decisions. You as a pregnant person retain control over whether or not you do or do not want to do a procedure or intervention, from how you labor to where, or how, you deliver. I know that can be contentious so let’s get that out there. I fortunately do not have an adversarial relationship with my medical team where I have to fight for my rights. They’ve been awesome and supportive of me making my own choices, but I know not everyone has that.
I have high risk pregnancies and I rely on my team’s combined years of medical school and experience, as well as their specialized knowledge, to inform my decision making. My A-Team consists of the following cast of characters:
- Dr. K, My regular OB – insanely kind woman from upstate New York who has the world’s shittiest poker face. She can’t hide anything, which is great when you want to know what she really thinks. She’s also funny and addicted to J. Crew.
- Dr. B, OB who specializes in more high-risk cases – tall, lanky, and a bit too attractive to have that cervical check be anything less that blush-worthy. He’s a little like Zach Braff on Scrubs, but he also stood by his wife’s vaginal birth of twins, is incredibly gifted at patient care and will tell you exactly what he thinks and why.
- Dr. Z, Maternal Fetal Medicine, who does the super-high risk stuff – he’s your friend’s weird dad. He told me that I can’t poop a baby. Smart, but such an odd bird. He told me he became an MFM because if he had to deal with one more pap smear or yeast infection he was going to lose his mind. Ummm…okay.
- Dr. S, Rheumatologist – As a Department Head she focuses on research but has kept me as her patient because I have markers for something that should have had me stroke out by now, and I’ve never had any issues. Due to these markers she will not gamble with anything, and will override the OBs if she thinks they’re playing fast and loose. She’s also British which makes everything she says, like “it’s a miracle you survived years as a smoker on birth control pills,” that much more entertaining.
You may notice that I spent so much time with this crew that I know all about their shopping habits, marital quirks and children. I had to rely on this team. There is no evidence that I could find online or by contacting related patient organizations on pregnant women in the same or similar situation as me with the same risk factors.
Due to the underlying issues that Dr. S keeps tabs on, I cannot safely carry a baby past 39 weeks. Believe me, Dr. Z suggested I carry to 40 weeks to see if I would go into labor on my own and Dr. S went bananas. The risk isn’t minor – it’s death to me and to the baby, in that order – and it spikes after 39 weeks. She said that she wouldn’t mind the baby exiting at 38 weeks, but I wasn’t into that and neither was the rest of the team.
The VBAC Plan
I would arrive Monday night at 38w6d, take some Ambien to get comfortable while a foley bulb would be placed in my cervix to blow it open and get me to 3 centimeters overnight. In the morning they would start Pitocin and hope for the best. My doctor told me it could take a long time, and in the best case scenario a baby would exit my vagina sometime by or before Wednesday night. I wanted a time limit and what a failure would look like because I’m controlling and was scared, and she wasn’t willing to give me a deadline. She said labor can be long and unless I was in distress or I decided to pull the plug there would be no need to do a section.
After my 38 week appointment I did what I could to try to move things along. I had a prenatal massage, multiple acupuncture appointments, ate spicy curries and pineapple, and even had very awkward, hugely pregnant sex.
Monday rolled around and I wasn’t in labor, so the plan was set in motion. My mom came to stay with our toddler. We ate dinner and headed for the hospital.
Driving across town I cried over the loss of being a family of three, over leaving my big baby for a few days, over what was to come, etc. It was a weird time.
When we arrived at Labor and Delivery we confused the nurses slightly by showing up with pizza. My friend who had been overdue was in labor and her husband hadn’t left her side, so we figured we would help him out. After the momentary confusion of why a pregnant lady arrived packing pepperoni, we were settled into our delivery room.
The hospital is a teaching hospital and it was a resident, Patti, who checked my cervix. She was very excited that I was at 3 centimeters and didn’t need the Foley after all; “your cervix is awesome!” Her enthusiastic conclusion was confirmed by the attending, and the plan changed to starting the Pitocin at midnight when I would be 39 weeks exactly. Of course, that’s not what happened. L&D was busy that night – I could hear my friend’s baby born across the hall around 3am – and the Pitocin wasn’t started until 6am. I was tired, nervous, and hungry.
I was started on a Pitocin drip that was increased very slowly over the course of the day. There is a maximum dose that can be given, but for a VBAC they wouldn’t go anywhere near the max.
This is a good time to mention the deal with an induction for a Trial Of Labor After Cesarean (TOLAC) when you want a VBAC as the end goal.
From what I’ve read, seen and heard, it’s not that common to be induced for a TOLAC. In general for any delivery, an induction can increase your risk of complicating factors in labor that would result in an emergency c-section. When you are induced for a TOLAC, the risk of uterine rupture increases. I learned conversationally from a Mohel who is also an OB that there was a study around 1996 that showed an approximate 6-fold increase in uterine rupture for an induction. He said that prior to that, it was common practice to treat all women like they could and should VBAC, and that after this paper he saw a spike in RCS as the first-line, pushed option. This was his opinion when I asked him why he was surprised I would be induced when I wanted a VBAC, so take it at that.
There is good evidence that supports TOLAC for women after one or even two prior c-sections. If you want, you can read all about the NIH conference in 2010 to discuss VBAC. Or you can shortcut that and look at what the American College of Gynecology has to say about VBACs more recently – hint: they’re supportive even for an induction.
To be clear, there are risks associated with having a second delivery after the first one is a c-section. This is a dated but still relevant piece, “Labor Induction for Vaginal Birth After Cesarean May Lead to Uterine Rupture” from the Guttmacher Institute:
Overall, uterine rupture was uncommon, occurring among 4.5 women per 1,000 (91 women). Women who underwent a repeat cesarean had the lowest risk (1.6 ruptures per 1,000 women); the risk was somewhat higher among women whose second labor began spontaneously (5.2) or was induced without prostaglandins (7.7) and was markedly higher among those who had prostaglandin-induced labor (24.5). The investigators calculated the relative risks of this complication for the four subgroups, and found that women who had spontaneous labor or induced labor without prostaglandins were about 3-5 times as likely as those who had a repeat cesarean to experience uterine rupture (relative risks, 3.3 and 4.9, respectively). Those who had prostaglandin-induced labor, however, were nearly 16 times as likely to suffer this complication (15.6).
If you didn’t follow that, your best option is always to have a baby come out of your vagina for your first delivery, as a c-section the first time around sets you up for potential complications on any subsequent delivery. But, if you already had a c-section, your lowest risk for rupture is a RCS followed by spontaneous labor, and then an induction without a cervical ripening agent.
I didn’t know all of the risks as clearly as this when I decided to go for it. I trusted my team and they were on board, so that seemed like a good plan. It’s not the right call for everyone, and weighing the risks are important. One OB’s husband couldn’t understand why anyone would take the risk to try to VBAC. His thought was “if there are 100 glasses of milk on the table and one is poison, would you drink any of the milk?”