The VBAC Link

VBAC Prep Class for Parents

© 2019 The VBAC Link

Salt Lake City, Utah
Julie Francom & Meagan Heaton
Phone: 385.429.2012 • Email: info@thevbaclink.com
thevbaclink.com

All rights reserved. This material is protected by copyright and has been copied by and solely for the
educational purposes of The VBAC Link. You may not sell, alter, or further reproduce or distribute any
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Acknowledgements
Creating a course and manual was more work than we ever thought and more rewarding than we could
have ever imagined. None of this would have been possible without our incredible husbands, Nick and
Ric. From late night caffeine runs, to early morning motivation, to always being our sounding boards and
biggest cheerleaders (the most masculine type, of course), thank you so much! You have both stepped
up to fill in the spots of our lives that got neglected in the hundreds of hours we have spent pouring over
these manuals and countless other business projects.

Our kids perhaps deserve the biggest thank you for sacrificing time with their moms while we worked
every spare second to get this course ready. Our older children especially deserve more kudos for
helping out with the younger ones—thank you!

Special thanks to Meagan’s father-in-law, Kirk Heaton for assisting with legal stuff like copyrights,
trademarks, and other essential business contracts.

We would be a couple of grammatically incorrect and poorly punctuated business owners if not for the
talented Jess Nielsen Beach, who spent hours editing, commenting, suggesting, and getting two very
different writing styles to sound cohesive. We owe you so much more than our gratitude! Thank you for
making us sound better than we do in real life.

The stunning look of this manual is due to Rowan Steiner of Salt City Birth and Newborn Photography, a
Utah-based birth photographer for her birth photos and Arielle Richards, for her artwork. Your images
are striking and your eye impeccable. Thank you for letting us use your inspiring images in our books.

To Danielle Demeter, CNM, and Melissa Mayo, LDEM & CPM, the midwives who gave us our most
beautiful VBAC birth experiences. You helped us develop this empowering belief in ourselves and inspire
us even more to help women on their individual birth journeys. Thank you.

To our own doulas and doula mentors, your support and inspiration has built us up and encouraged us
when we needed the kindest strength and warmest advice. Thank you.

Last, but certainly not least, our own doula clients, podcast guests, and those who shared their stories.
We have witnessed incredible strength, beauty, and poise as we have watched and listened to you share
your breathtaking journeys with us. Thank you so much for allowing us into your most intimate
moments!

-Julie & Meagan

 TABLE OF CONTENTS
Meet the Instructors .......................................................................................................................................................... 1
I. OVERVIEW AND PURPOSE .............................................................................................................................................. 3
II. PREPARING YOUR MIND AND BODY ......................................................................................................................... 4
Essential Mental Preparation......................................................................................................................................... 4
Essential Physical Preparation .................................................................................................................................... 11
III. VBAC INFORMATION AND STATISTICS ................................................................................................................ 25
A Brief History of VBAC .................................................................................................................................................. 25
Women of Color ................................................................................................................................................................. 29
Four Main Reasons for Initial Cesarean and What to Know ........................................................................... 31
Uterine Rupture................................................................................................................................................................. 35
VBAC vs. Repeat Cesarean............................................................................................................................................. 38
The Infamous VBAC Calculator ................................................................................................................................... 41
Special Circumstances .................................................................................................................................................... 42
ACOG Bulletin #184 ......................................................................................................................................................... 45
Contraindications for VBAC .......................................................................................................................................... 46
IV. PREPARING YOUR BIRTH TEAM AND BIRTH SPACE ...................................................................................... 50
Choosing Your Birth Location...................................................................................................................................... 52
Choosing Your Care Provider....................................................................................................................................... 54
Hiring a Doula..................................................................................................................................................................... 58
V. THE ART OF BRAIN ......................................................................................................................................................... 65
What is BRAIN? .................................................................................................................................................................. 65
Assessing Interventions ................................................................................................................................................. 65
VI. BIRTHING TIME ............................................................................................................................................................... 77
What to Do when You’re Due ....................................................................................................................................... 80
VBAC with an Epidural ................................................................................................................................................... 82
When Labor Begins .......................................................................................................................................................... 84
General Tips to Help VBAC Success ........................................................................................................................... 85
Knowing the Signs of Rupture ..................................................................................................................................... 85
Family-centered Cesarean ............................................................................................................................................ 86
Recovery ............................................................................................................................................................................... 87
Postpartum Mood Disorders ........................................................................................................................................ 90
VII. CONCLUSION ................................................................................................................................................................... 97
Steps to Success ................................................................................................................................................................. 97
APPENDIX 1 - DEFINITION OF TERMS ......................................................................................................................... 98
APPENDIX 2 – RECOMMENDED RESOURCES ........................................................................................................ 102
APPENDIX 3 - REFERENCES .......................................................................................................................................... 103
Meet the Instructors

We are so glad you’re here. We are Julie Francom (right) and Meagan Heaton (left), the founders of The
VBAC Link. As VBAC moms and professional doulas, we saw a HUGE need for a detailed VBAC and
Cesarean-prevention education system and support model. It was frustrating to us that there was not
one place that a birthing parent and her partner could go and find out what they need to know in a
simple, consolidated format. Making sense of medical talk and determining what is truly necessary can
feel almost impossible.

Here at The VBAC Link, we believe in making birth after Cesarean better by providing education,
support, and a community of like-minded people. Welcome to our circle, we are so glad you are here!
We are a team of expert doulas trained in supporting VBAC, have had VBACs of our own, and work
extensively with VBAC women and their providers. Feel free to contact us at any time in your journey by
using one of the contact methods on our website: www.thevbaclink.com/contact.

Julie & Meagan

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 VBAC Birth Class
Course Instruction for Preparing to Birth After Cesarean

I. OVERVIEW AND PURPOSE

A
ccording to the APA (American Pregnancy Association), 90% of women who have had a C-
section are candidates to attempt a Trial of Labor, (TOLAC) for VBAC (Vaginal Birth After
Caesarean) in a future pregnancy, yet only 10% will try. Most published studies show that up
to 80% of women with a Cesarean birth who attempt a VBAC have a safe vaginal birth.

This course is designed to provide women and their partners with information and direction to guide
them in making their own unique and specific birth after Cesarean choices. This will facilitate emotional
healing, mental preparation, and physical preparation in order for families to understand their options
for VBAC in order to plan a safe and satisfying birth. We encourage you to continue your learning and
growth beyond this course and have provided resources in the appendices to help guide you further.
This course is not to replace advice or counseling from any qualified medical professional about your
specific birthing circumstances.

QUICK REVIEW

Only 10% of women with a history of Cesarean will attempt a VBAC. Why do you think that percentage is
so low?

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 II. PREPARING YOUR MIND AND BODY

P
erhaps the best things you can do to prepare for a VBAC happen before a single contraction
even starts. Making sure you take care of your body, clear away any trauma or fears, and
mentally prepare for the VBAC journey is critical to having the best birth experience possible.
Most of these things in this section apply to any expectant parent but, it is especially important when
preparing for VBAC. There are many challenges you may experience and setting the proper mental and
physical health foundation is key.

Essential Mental Preparation

One of the reasons we founded The VBAC Link was because it can be so difficult to make sense of all the
medical talk and learn all the essential definitions. One of the most common acronyms used in the VBAC
world is TOLAC. Doctors often use it seemingly in place of the term VBAC, but what does it mean exactly
and, more importantly, how does it impact your VBAC?

What Does TOLAC Mean?

TOLAC stands for Trial of Labor After Cesarean, or Trial of Labor (TOL). All it really means is that a
woman is going to attempt to have a vaginal birth after a Cesarean (VBAC). The act of trying and working
towards VBAC is called TOLAC. The “successful” TOLAC is a VBAC, make sense? We hate referring to
labor as success or failure but, for lack of a better word and for differentiation we think, in this case, it is
appropriate. It is easy to get hung up on the word “try” in trial of labor, so how can you resolve that in
your mind?

Knowing that TOLAC simply means someone is “trying for a VBAC” makes it easy to turn it into a positive
in your mind. Mentally preparing for those conversations with a provider who only refers to their
patient as a TOLAC rather than a VBAC makes it easier to understand. In fact, it would be a great idea to
just beef up that definition a little and make TOLAC mean “VBAC Success” for you! Mental preparation
accounts for so much, especially when preparing for a journey such as this.

Processing Birth Trauma

We encourage you to work through any past experiences that bring on fear, trauma, or doubt for any
upcoming births. Talking about your past experience with someone who is supportive of your decisions

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is important. Think of 2-3 people who you can include in your safe space. Keep those people near and
turn to them when you need to vent, ask questions, get suggestions, etc.

What was it about your birth that brought on this fear, trauma, or doubt? Was it something that
happened unexpectedly? Was everything going fine and then it turned dangerous in seconds? Did
anyone talk to you and explain your options or what was happening? Was anyone in danger? Did you
develop a life-threatening condition that may have affected you or the baby that caused you to be
induced? Was there something that happened where the doctors felt it would be too risky to have a
vaginal birth? Was it just too much? Did you have a birth plan and it unraveled before your eyes due to
hospital policies? Could you move freely like you had hoped?

Birth trauma may not always be something that sticks with mothers in a negative way, but if it does, it is
important to be able to work through prior to the arrival of your next baby.

Birth Trauma for Your Partner

As a birth partner, it can be hard to watch someone you love go through such a momentous event. It’s
important for not only the mom, but also the birth partner to process his/her birth fear, trauma, or
doubt. The feeling of helplessness that you feel for your loved one can be very upsetting and frustrating.
With birth PTSD, birth partners can sometimes have flashbacks, nightmares, uncertainty with decisions,
and intuitive thoughts that may cause them to be upset. Addressing these fears and finding the best
support system prior to the baby arriving is vital.

Understanding Your Fears

On the next page, you are going to do an activity that will try and help you find out what your main fear
is. We want you to process that fear as soon as possible to prepare your mind for the birth ahead. In
today’s world, there is a lot of negativity, false assumptions, and bullying when it comes to birth—
especially VBAC. Although social media and the internet can be a fantastic resource, it can also tear
someone’s hopes, desires, and dreams apart in minutes. It can even create more fear unintentionally.

It is important to remember that, while being on social media forums, internet forums, and Google, you
must take information with a grain of salt. Using our BRAIN (see section IV) is going to play a big factor in
processing and understanding fears and knowing what is best for you and your baby. When you
complete the activity, be sure to answer the accompanying questions.

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It is important as you prep for your VBAC journey that we enter it with peace of mind and as free of fear
as possible. Leading up to your baby’s birth, there is a lot of prep you can do to raise your chances of a
successful VBAC.

1- Reliable Childbirth Education Course: Having a basic understanding of the physiology of childbirth
is important and will help you gain confidence in your body and your baby. There are many childbirth
education classes and methods available if you need that understanding:

• Hypnobirthing
• Hypnobabies
• The Bradley Method
• Birthing from Within
• Birth Boot Camp
• Even a self-study or general childbirth prep class will help

Why is it important to take a childbirth class?

Taking a course results in more education, hands-on practice, and knowledge about the entire birth
process. Helping you know what to expect from that first contraction to that final push will go a long
way toward reducing your anxiety and preparing you for the incredible journey you’re about to go
through, while also understanding the risks and benefits. It is important to make sure the class is
compatible with your visions of an ideal birth.

What you will learn: Ways to help you relax, cope, pain relief options, various positions to try during
labor (a doula can help keep these options fresh), knowing what’s normal and what isn’t, stages of labor,
pushing options, etc.

2- Meditation/Calming the Mind: Meditation is healthy for anyone to do daily. Meditating stimulates
the brain and allows it to organize itself, which then helps our thoughts be more rational and reduces
the stress hormone, cortisol, which will then lower blood pressure and anxiety, as well as helps our mind
and body relax. We should ALL meditate daily.

There are many ways to meditate. If you have taken a childbirth education class that works with scripts,
you may want to meditate that way, or maybe you have a favorite medication podcast. There are also

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many apps you can easily download to your
phone to listen to anytime you need them. Our
favorite meditation apps include:

• HEADSPACE
• MINDBODY
• SIMPLE HABIT
• Calm
• Stop, Breathe, & Think

3- Doula: Obviously we think doulas are pretty cool—a doula can help you prepare your mental state
leading up to birth and can recognize triggers during labor. In your prenatal visits with your doula, they
will work with you and your birthing partner(s) and learn how they can best help you through any fears
and mental blocks. A doula will strive to learn how to help bring you back to a positive space for both
you and your partner.

Why Can’t My Partner/Sister/Mom/Husband/Aunt Be My Doula?

We know your close family members are an incredible support, and they love you—a lot. You have been
through thick and thin together and they know how to keep you grounded, calm, and centered. Having
them in your birth space is important, and they should definitely be there with you.

What you also need, however, is someone who really knows birth. A person who can let you know what
is normal or not, who can help guide you through the birth process and navigate the shifts in the room.
Someone who is there with you all the time, who can, when you and your partner feel like everything is
chaotic, assure you that it is normal or suggest something new for you to try. A doula will bring peace of
mind to you and your partner by giving them time to use the bathroom, eat a sandwich, and tune into
you 100%. Your doula is keeping her eye on the birth team and birth space to make sure that everything
aligns with your birth preferences (as long as medically able, of course) so your
partner/sister/mom/husband/aunt can only worry about you. When you start roaring the sounds of
labor, a doula’s assuring smile and nod will help ground your partner and remind them that all is well.

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A doula can also help determine what is medically needed and when it is safe to wait. They can help you
understand other options that may be available when your nurse or provider is not able to take that
time with you. Doulas know birth, and your family knows you; together they make a powerhouse team.

Essential Physical Preparation

Nutrition

Have you ever heard the saying, “You’re eating for two” when pregnant? Although you may be eating
for two and need to increase calories, it is important to keep in mind what you’re eating. It is suggested
that a pregnant woman eats 300-400 extra calories in her second and third trimesters. It is important to
discuss your personal nutritional needs with your healthcare provider. Your body is working hard to
grow a baby, so it’s essential to give it what it
needs.

Studies have shown that women with poor diets

tend to have harder labors and their children run a
higher risk of other health issues (Blount, 2005).
When you’re pregnant, you will notice that at each
visit, your provider will weigh you. This is
something so many expectant mothers stress
about, but DON’T. Do your best and keep in mind
that your body is growing a baby and weight gain is
normal. The big question should be: what do I eat?

Protein: (6-6 ½ oz. daily) A minimum of 60 grams of protein per day is recommended. Complete proteins
are needed for growth and development of the baby. Sources of protein would be:

Chicken, Tuna, Salmon, Milk, Eggs, Dried Beans, Seeds, and Nuts

Vegetables: (3-3 ½ cups a day) Veggies provide carbohydrates, vitamins, such as A & C, folate, minerals,
such as magnesium and iron, as well as being a good source of fiber. Great veggies that provide these
nutrients include:

Spinach, Kale, Turnip Greens, Green Beans, Broccoli, Sweet Potato

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Fruits: (2 cups a day) Fruits also provide carbohydrates, vitamins A & C, folate, and minerals such as
potassium and fiber. Although there are juices that have all the servings in one day, it is still important
to eat whole fruit to get the additional vitamins, etc. Choosing citrus and berry fruits are fantastic.

Melon, Grapefruit, Oranges, Kiwi, Strawberries, Blueberries, Banana

Grains: (7-9 oz. per day) It is important when picking your grains to try and eat whole grain foods rather
than processed. Grains provide high complexed carbohydrates like Vitamin B, E, and offer good fiber.
Keep in mind that not all brown bread contains whole wheat. Good whole grain foods would include:

Oatmeal, Whole Grain Cereal, Whole Grain Bread, English Muffin

Dairy: (3 cups a day) Dairy provides protein, vitamins, calcium, and phosphorus. Some mommas are
lactose intolerant. Don’t worry, you don’t have to drink cow’s milk to have a healthy baby; however, it is
still important to get a good amount of nutrients, because as the body is making a baby, it is pulling
calcium from the mother, so you will need to be sure to get enough for both of you.

Milk (either cow, soy, or rice), Yogurt, Cheese, Cottage Cheese, Ice Cream

Good nutrients will benefit both you and your baby during pregnancy, labor, birth, and postpartum.
Studies show that good nutrition is linked to fewer premature babies and more energy during pregnancy
(ACOG, 2018). After birth, babies are healthier, have a better pattern of weight gain, and mothers
experience more weight loss in the postpartum stage, quicker healing, and even greater elasticity of
tissues during pushing.

Herbs and Teas

Medical Disclaimer: The following recommended herbs and supplements are generally recognized as
safe for women in normal health. However, due to the possible changes of dose recommendations or
changes in formulation, we always recommend that you speak with your own provider before starting
any of these recommended tinctures and teas.

Red Raspberry Leaf Tea (RRLT): Red raspberry leaf tea comes from the leaves of the red raspberry plant.
This herbal tea has been used for centuries to support respiratory, digestive, and uterine health,
particularly during pregnancy and childbearing years. This is not something that will induce labor but will
help tone the uterine wall to be more efficient when contractions do start. Disclaimer—Unfortunately,

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the tea by itself does NOT taste like raspberries. It tastes more like a black tea. Adding honey and lemon
can help the taste, or buying a prenatal blend of teas is a great way to make it easier to drink.

Birth Prep by Dr. Christopher: A unique whole herb formulation designed to support an expecting
mother’s body for the last six weeks of pregnancy and prepare her physically for the birthing process. To
be taken ONLY in the last six weeks of pregnancy. There is evidence to show that it will help prime the
cervix and create elasticity to the perineum to help avoid any tearing during the pushing phase.

Red Clover: Red Clover is a nourishing food herb. It is rich in a variety of vitamins and minerals and is
one of the best blood-purifying herbs. This blood-purifying action is wonderful for pregnancy
preparation, aiding in detoxification of environmental pollutants prior to conception. According to Susun
Weed (one of the most well-known Western herbalists), Red Clover is one of the best pregnancy
preparation tonics.

“I have used Red Clover as a nourishing herb for years, with no negative side effects.
I have used it for pregnancy preparation, through the last trimester of pregnancy,
and during breastfeeding both of my children. I never used concentrated amounts
long term. I always use this herb as I would a nourishing food.” (Weed, 1986)

Exercise

In addition to good nutrition, it is also important to exercise. You do not have to be running half
marathons while you’re pregnant; however, it is suggested by ACOG (the American College of Obstetrics
and Gynecologists) that you get a total of 30 minutes or more of activity every day. This may be done all
at once or in sections. If you have not been active before pregnancy, take it slow. Always talk with your
healthcare provider first and see what type of fitness best fits you and your pregnancy.

ACOG suggests avoiding activities with a high risk of falling, such as horseback riding, winter sport, water
sports, etc. It is important to start your workout with a good stretch and in the correct clothing.
Swimming, yoga, Pilates, walking, cardio, strength training, pelvic floor strengthening, and jogging are all
great options according to ACOG (2017). Exercise can help your body prepare for labor. It will also give
you a head start in getting back into shape after your baby arrives. A return to physical activity post-
baby has also been associated with decreased incidence of postpartum depression.

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It is important not to push yourself too hard and drink and rest when needed. Staying hydrated is very
important. We lose water every day, and, if not replaced, dehydration occurs. Water plays a critical part
in healthy fetal development. Always check with your provider before making any significant changes to
your diet and nutritional plans.

Pelvic Floor Health

What is the Pelvic Floor?

The pelvic floor is a layer of muscles that supports our organs and helps us have control of our bladder,
bowels, and uterus. Our pelvic floor muscle stretches from the front to the back and side to side. The
pelvic floor is very important, and although it isn’t seen like our arms and legs after lifting weights, it can
be controlled and trained. The pelvic floor also provides support during pregnancy and birthing stages.
When the pelvic floor muscles are contracted, it tightens the vagina and anus. When the pelvic floor is
relaxed, it allows a passageway for us to use the restroom and birth a baby.

How Can My Pelvic Floor Affect My Birth?

The day you have a baby, your pelvic floor will be stressed and strained so it is important it has good
tone and elasticity. Preparing your pelvic floor during pregnancy can benefit the outcome of your labor.
Although you may spend a lot of time strengthening the pelvic floor before pregnancy, it’s important to
have a relaxed pelvic floor during pushing. A tense pelvic floor can slow down your labor progress.

Failure to progress is one of the leading reasons for a Cesarean. Often, failure to progress may be due to
a poorly-positioned baby, or the body not producing the correct amount of oxytocin to get labor going.
With this said, knowing your inner female anatomy will benefit you and positively impact your labor.

We recommend seeing a pelvic floor specialist leading up to your delivery. They can help teach you the
correct techniques to both strengthen your pelvic floor before delivery, feel prepared during your labor,
and even help in the postpartum stages. There are many pelvic floor exercises online, and finding a
pelvic floor specialist may help you learn more about what you specifically need. Techniques are always
best used when tailored to you personally so they can help you meet your specific needs.

Cesarean Scar Massage

Sometimes, the Cesarean scar can be tender, thick, and uncomfortable for months, even years, after
birth. There are so many variations of what is normal but taking the time to massage or touch your scar

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can help break up the scar tissue that may be causing that pain. Visiting with a physical or pelvic floor
therapist can provide many physical and emotional benefits as you prepare for birth. Become familiar
with your scar. Grab a mirror and take a good look at it. This will help you become familiar with your
scar and begin physical and emotional healing.

As you trace over your scar, take a moment to notice your emotions and the sensations you feel. Does it
hurt, tingle, or feel uncomfortable? Does it feel weird, unusual, or perfectly normal? Allow yourself to
feel all those feelings because, as with childbirth, these scars each have their own unique and specific
meaning to each of us. How you feel as you trace over it will increase your awareness of those meanings
and emotions.

You can start massaging your scar as soon as you feel ready and your provider has told you that you are
physically healed, typically within six weeks. Starting out by gently rubbing it helps increase lymphatic
drainage, loosen up thicker scars, decrease swelling, decrease poor muscle recruitment that may in the
abdominal wall, and increase lymphatic absorption. All these things will be helpful for you as you
physically and mentally prepare for your upcoming birth (be sure to discuss with your personal therapist
on the appropriate massage techniques).

Chiropractor/Prenatal Massage

Seeing a chiropractor to help you get balanced and aligned for when your baby decides to arrive is
important. Attending a chiropractor after the first trimester is fantastic, because this gets you on the
right track of being balanced. We suggest finding someone who is Webster-trained and/or is trained to
work with pregnant women. He/she can help balance your pelvis and get your body ready for a vaginal
birth. As baby grows, there can be body aches, spasms, bad posture, and a lack of decent sleep.
Chiropractors can show you effective stretches to help take some or all of this discomfort away.

If your pelvis and/or spinal alignment is off or your sacrum is out of place, it is possible that your baby
will not come down into the pelvis in the correct way. This doesn’t mean it is impossible to get the baby
in the correct spot; however, it could cause extra discomfort during pregnancy and labor.

Massage is another great way to help ease discomforts and soften tight tendons and muscles that
should be soft and relaxed in labor. Seeing a good massage therapist a few times in the second and third
trimesters will benefit relaxation and create better rest. Some mothers find acupuncture and myofascial
release also helps get their bodies balanced, relaxed, and ready for a natural birth.

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To find a Webster-certified chiropractor near you, go to www.icpa4kids.com.

Optimal Fetal Position with The Miles Circuit

Having a pelvis that is too small or a baby that is too big is very rare, despite many women being told so
(we discuss this more in the next section). Ensuring your baby is in an optimal position before labor
begins and throughout labor is the best way to help get a bigger baby through a smaller pelvis,
promoting a faster and easier labor.

Miles Circuit preparation should start around 37 weeks of pregnancy and should be performed
approximately 10 minutes per day, adding a few minutes each day until you can do it for the full 90
minutes.

There are three steps to the circuit. The circuit was created to be useful for getting babies well aligned
before labor begins. It is ideal for a baby to be in an LOA (Left Occiput Anterior) position before labor
begins, which will hopefully avoid posterior babies in labor. If labor is not progressing, the circuit may be
suggested to try and help get that sweet baby in the right spot.

These positions would work if you are having any of the following symptoms:

• Back labor or history of back labor

• Labor is not progressing or has gone erratic
• You are experiencing PROM (Premature Rupture of Membranes)

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How to do the Miles Circuit

Step 1: Open Knee Chest

Try to stay in this position for up to 30 minutes. Start in the cat cow position. Drop your chest as low as
you can and bring your bottom as high in the air as you can. Keep your knees wide apart, keeping the
angle between torso and thighs at 90 degrees. Feel free to wiggle around and prop with pillows if
needed. It is important to be extremely relaxed. This position allows the baby to move around out of the
pelvis. Some people like to carefully position a rebozo under the belly with gentle tension from a
support person behind to help her maintain that position for longer (up to 30 minutes).

Step 2: Exaggerated Side Lying

This position is one you can do even in your sleep. It’s one that looks impossible because of your
pregnant belly, but it’s not. Lie on your left side, with the left leg straight and the right leg up and bent
over pillows. Next, roll as far forward as possible, scooting your hips back (it will feel like you are on your
belly).

Pillows are great for adding support to the belly and legs. Some people fall asleep (which is fine) but it is
encouraged to be in this position for another 30 minutes. If this circuit is repeated again in the same
day, try the right side next time.

Step 3: Get Moving

The final step is to GET MOVING! Whether lunging, walking up and down your stairs sideways (skipping
two at a time), curb walking, sitting on your ball moving your hips, or just going for a good walk, spend
30 minutes doing this to help your baby get in the right spot. Note: The key with the lunge is that the
toes of the higher leg and mom’s belly button should be at right angles. Do not lunge over your knee,
that closes the pelvis (Miles, 2018).

How a Doula Can Prepare Your Mind and Body

A doula is someone who can provide continuous emotional, physical, and educational support during
pregnancy and labor/birth, as well as support after delivery. Doulas will usually meet with their couples
twice before labor begins.

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In these visits, your doula will learn more about you and your desires for the birth. She will discuss
things like previous birth trauma, how you/your partner learn, cope, and want to be supported during
labor, etc. She will also offer education on how to help a fetus get in the best position prior to labor
even starting.

Encouraging good fetal position before labor

begins will increase your chances of an easier
labor, better contraction pattern, and a vaginal
birth. She will also teach counter pressure to
both the mother and any birthing partners, so
when the big day comes, they will be familiar
with what comfort measures may be desired.

In addition to being on call after these visits,

your doula is there to support you and provide resources and continuous education along the way. It is
important to find a doula who you connect with and feel will bring good education to your birth, along
with the tools needed to support you.

QUICK REVIEW

What are three things you can do to help calm your fears or concerns going into this birth?

What amount of daily exercise is recommended by ACOG?

List some ways a doula can help you prepare your mind and body for birth.

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VBAC Story: Mandy
I was staying in a camper with my two young children and my parents. We were three-and-a-half hours
from home so that I could have a VBAC—my husband, Dayle, was still home. I had prodromal labor for
many weeks, but the morning of September 15, I woke up at 3:30 a.m. and knew that this was the day I
was going to have my baby. I sent my husband and my doula a text so when they woke up, they would
know what was going on. Turns out, they were both awake. My husband was up cleaning (I think he was
nesting for me, haha). I told him that he should plan to come that day. I was having a little spotting and
very mild contractions consistently at that point. I got up, got a snack, and my mom woke up. We just
chatted about how I was feeling, and I tried to go back to sleep.

I had gestational diabetes, so I had my NST that day and an OB appointment afterwards. I went in for my
NST and it took longer than normal. I was having contractions every five minutes at that point, but they
still felt mild. I told the nurse that today was the day and I felt like I was in early labor. She told me there
was no way I was in early labor because I was handling the contractions too well.

When I was finally okayed to leave from the NST, my mom and I went to lunch. I wanted to keep my
energy up so I would be strong for labor later. Then we went to my appointment. I first saw my midwife,
and she checked me. I was 90% effaced, but still barely 1cm dilated. She said she was sorry, but today
wasn’t going to be the day. She said she was sure it would happen sometime in the next week though. I
was crushed and felt completely defeated. I had been so sure, and it really took me down. I then felt
horrible that I had told Dayle to head our way (he arrived while I was at my appointment). I saw my OB
next and he said we could induce later in the week if I didn’t go on my own.

I left the appointment and just cried. My poor husband kept trying to reassure me that it was okay that
he had driven out. He also wanted to talk about why I was so upset, but I just couldn’t. I wanted to stay
composed and strong in front of our children and I knew if I talked about it, I would just keep crying.
Meanwhile during all this, I kept having mild contractions every five minutes.

I don’t remember the time, but it was a while after we had been back at the camper. I was scolding my
daughter for not leaving my parents’ dog alone when he went into his crate; she just wouldn’t listen. So,
I reached down and pulled her up by her arms off the floor. When I lifted her, I felt a small gush. I got my
dad’s attention and asked him to put her in timeout so I could go to the bathroom to see if my water
had broken.

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I went to the bathroom and I couldn’t tell if my water had broken or if I’d just peed myself a little. My
water had broken with my first baby, but there was meconium in it, so it was easy to tell. This was clear
and with the spotting, it was impossible to decipher. I texted my doula (Meagan Heaton) to see if I could
stay home for a while even if my water had broken. We both agreed that as long as I could feel baby
moving and I didn’t have a fever, I could stay.

I then got into the shower to try and relax for a minute. My contractions were progressively getting
stronger and closer together. When I got out of the shower, I tried lying down for a bit so I could sit up
and see if I felt another gush, as I still wasn’t sure if my water had broken. I could not get comfortable at
all at this point. I was using my phone and a labor app to time my contractions. I would periodically send
my doula a screenshot of them to keep her in the loop.

I ended up sitting on my exercise ball because that was the only place I found remotely comfortable. At
this point I was having to vocalize (I chose to use a low moan) through contractions. I would lean into my
husband and he would rub my back through each one.

At this point, my doula called me and stayed on the phone with me through two contractions to see how
I was doing. I was having a lot of guilt about when to ask her to come, because I still felt very negative
being told that today wasn’t the day by all my healthcare providers. I didn’t want to take her time away
from her family if this wasn’t it. About 5-10 minutes after we talked, she texted me and asked if she
could come. She felt like it was time. I said yes, please. I was so thankful she took the initiative, so I
didn’t have to feel guilty for asking her to come.

She arrived at the perfect time. My contractions were getting steadily stronger and closer together. As
soon as she walked in, she started applying counter pressure to my hips while I sat on the exercise ball.
It helped so much! At this point, Meagan, Dayle, and my mom were trying to get me to go to the
hospital. I didn’t want to because I didn’t want to be sent home (still feeling defeated).

I was finally willing to at least move outside of the camper. They were worried I was holding back for the
kids’ sake, and once outside, we all decided we should head to the hospital and at least get me checked.
Meagan rode in the back with me and applied counter pressure. I concentrated on relaxing everywhere
and using low moaning through each contraction.

We got to the hospital and Meagan and I slowly made our way upstairs to check in. I had to stop for
each contraction. My husband and my mom joined us once they were parked.

Things got very busy once we got checked in. They checked me and I think I was dilated to about a five
at that point and they confirmed my water had broken. They moved me to a room to labor in. A doctor

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came in to talk to me about the risks of having a VBAC and to sign a consent. Meagan continued
applying counter pressure for each contraction.

I remember feeling like I was urinating for each contraction and it felt so weird. I also felt the slight urge
to push a couple times while sitting on the ball. I just went with whatever my body was telling me to do.
At some point, I was done. I didn’t want to do this anymore. I told them all that. Meagan and my
husband asked if they could check me first and then we could make some decisions after that. I agreed.

They got me into bed and the nurse checked me. I was 9cm dilated. I knew it was too late at that point
and that I would have to get through it. Meagan suggested using a peanut ball and so we did. My mom
stayed at my head, held my hands, and talked me through it. Meagan and Dayle helped me with my legs
and tried to apply counter pressure at the same time. Shortly after this, I pushed. The nurse noticed and
asked if I pushed. I couldn’t answer. She immediately called for help. She checked me again and said I
was completely dilated and could push when I felt like it.

The next contraction, I felt a very strong urge to

push, and push I did. It felt so good—so much
better than the contractions had been feeling.
While I was pushing, I vaguely recall a lot of people
coming in the room. I quickly got the baby’s head,
and the next push the baby was out. They put the
baby in my arms.

When they took the baby away to check the blood

sugar, I asked if the baby was a boy or girl. I had thought maybe I’d seen a penis but wasn’t sure.
Everyone laughed and said it was a boy. Apparently Dayle had said it was a boy, but I never heard him.

This was one of the best experiences of my life. I felt so strong after this. Like I could conquer to world. I
also felt really good about my body. I was amazed with what it had just accomplished. My birth team
was incredible, and I know I could have never done it without them.

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 III. VBAC INFORMATION AND STATISTICS

A Brief History of VBAC

It is common to feel like nobody cares why the Cesarean rate is so high and wonder why attitudes
towards VBAC have changed so much over time. With knowledge comes power, so we want to give you
a brief history of VBAC in the United States for a better understanding of why the general attitude is the
way it is right now.

Once a Cesarean, Always a Cesarean

In 1916, Dr. Edwin B. Cragin wrote an article called “Conservatism in Obstetrics”, where the phrase
“once a Cesarean, always a Cesarean” originates (Cragin, 1916). It comes from the final paragraph,
where he emphasizes that one of the risks of an initial C-section is that a repeat C-section MIGHT be
required.

Interestingly enough, Cragin also pointed out that there are many exceptions to this presumption, and
that even one of his own patients had gone on to have three vaginal births without difficulty after an
initial Cesarean birth. The reason for this generalization was, because up until the low transverse uterine
incision was championed in the 1920s, the rupture risks from a vertical incision were greater and even
more severe. Initial Cesareans were also performed significantly less and only used in truly life-
threatening situations, after all other options had been exhausted. During the early 1900s, doctors
realized that the choice for a Cesarean had a great impact on a woman’s entire childbearing life and had
more lifelong consequences. For these reasons, the Cesarean rate for the United States was in the 1%-
5% range all the way up until the 1970s.

The Rise of Cesarean Rates

Over time, the techniques and technology evolved, making Cesareans a lot safer and even easier to
perform. Antibiotics became more readily available, blood transfusions became easier, anesthesia
improved significantly, and the surgical procedure itself evolved from a “classical” (vertical incision)
technique to a “low-transverse” (side-to-side incision) technique. The low-transverse incision greatly
reduces the risk of rupture and comes with the reduction of other complications as well.

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Year 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979
Cesarean Rates 5.5% 5.8% 7.0% 8.0% 9.2% 10.4% 12.1% 13.7% 15.2% 15.7%
VBAC Rates 2.2%
Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989
Cesarean Rates 16.5% 17.9% 19.3% 20.3% 21.1% 22.7% 24.1% 24.4% 24.7% 22.8%
VBAC Rates 3.2% 6.6% 8.5% 9.8% 12.6% 18.9%
Year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Cesarean Rates 23.5% 22.6% 22.3% 21.8% 21.2% 20.8% 20.6% 20.8% 21.2% 22.0%
VBAC Rates 19.9% 21.3% 22.6% 24.3% 26.3% 27.5% 28.3% 27.4% 26.3% 23.4%
Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Cesarean Rates 22.9% 24.4% 26.1% 27.5% 29.1% 30.3% 31.1% 31.8% 32.3% 32.9%
VBAC Rates 20.7% 16.4% 12.6% 10.6% 10.4% 10.1% 8.5% 8.3% 8.4% 8.4%
Year 2010 2011 2012 2013 2014 2015 2016 2017
Cesarean Rates 32.7% 32.8% 32.8% 32.7% 32.2% 32.0% 31.9% 32.0%
VBAC Rates 9.3% 9.7% 10.2% 10.6% 11.3% 11.9% 12.4% 12.8%

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These reasons combined caused the Cesarean rates to jump from 5% in 1970 to 24.7% in 1988 (Paul &
Selma, 1988). This was a HUGE jump in a relatively short period of time. This leap was incredibly
alarming to healthcare professionals, and efforts were made to reduce the rate, leading to a slight drop
after 1988, but never dropping below 20% again.
With the increasing ease and convenience of Cesareans came the loss of knowledge on how to get a
poorly-positioned baby out vaginally. Things like manual repositioning of the baby, vacuum extraction,
and forceps delivery when reasonable became all but forgotten; many hospitals and doctors were not
being taught how to properly do these things anymore.

Many hospital care providers didn’t and still don’t even know how to tell what position a baby was in
before birth began without using ultrasound technology. These reasons caused Cesarean delivery to be
the go-to choice for births deemed “more risky”, either legally or medically, and more breech and babies
suspected to be “big” were automatically sent to a C-section even though other options still existed.

New technology like Constant Fetal Monitoring and new induction methods caused the Cesarean rates
to skyrocket without improving fetal outcomes (Selma, Taffel, Paul, & Teri, 1987). Induction allows
providers to schedule their births, making things convenient for their practice but at the cost of higher
bills for families and more NICU stays for babies.

Some saw this drastic rise in Cesarean rates as highly controversial and many public health officials
strongly opposed the rising rates and actively looked for solutions, while others saw how convenient
Cesareans were as a way out of more difficult deliveries and the increasing risks of malpractice suits. The
debate for what is the “most optimal” rate rages on and continues today.

VBAC Becomes More Common

Public health officials saw VBAC as a way to keep the Cesarean rates from turning into a public health
crisis. With the safer methods of Cesarean delivery came the reduction in risk for uterine rupture and
other complications in subsequent deliveries, making women question the need for “once a Cesarean,
always a Cesarean.” VBAC became a safe and reasonable option, although there were still care providers
who objected, and many women had to fight for their right for VBAC.

“Out of this struggle, a grass-roots women’s health movement began, pushing for
more choices in childbirth. Women like Nancy Wainer Cohen, Esther Zorn, and Lois
Estner pushed to make VBAC a choice for all women, while other pioneers like

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 Suzanne Arms, Penny Simkin, Robbie Davis-Floyd, Sheila Kitzinger, and many others
pushed for reform of outdated childbirth practices like universal episiotomy, pubic
hair shaving, mandatory drugging of the mother, prolonged separation of mother
and baby, promotion of formula feeding over breastfeeding, etc.” (Vireday, 2009).

In 1982, the International Cesarean Awareness Network (ICAN) was founded and women had a more
structured voice demanding their rights for childbirth. All of these things made an impact, and by the
1990s, VBAC was an option in most United States hospitals.

VBAC Starts to Change

VBAC reached its peak in 1996, albeit very cautiously managed by providers due to the potential of
uterine rupture. Mothers were hardly ever induced, Pitocin was rarely used, and when it was, it was
used incredibly conservatively. But, as induction became a normal option for women without prior
Cesarean births in the 1990s, so was it for VBAC women as well.

The induction drug Cytotec (misoprostol) was introduced and it took several years before anyone
realized that the drug significantly increased uterine rupture risk in VBAC women. Routinely inducing
VBAC increases the risk for rupture, depending on the method used. and routinely inducting VBAC
women using Cytotec(misoprostol), lead to the beginning of a VBAC crisis.

VBAClash Begins

Because VBAC had been so mismanaged, there was a movement starting in the 1990s against VBAC.
Insurance companies saw VBAC as a way to cut costs (vaginal birth is cheaper than Cesarean), so in
some places, VBAC became required and some women were not even given a choice. Not all women
wanted to VBAC and not all women were good candidates for it, so there was a lot of backlash
surrounding women who were treated poorly, not given appropriate treatment when showing signs of
rupture, and induced with dangerous methods that had a very high rupture rate. This resulted in lost
babies, hurt babies, loss of uteri, or other severe complications. These mistreated families were
rightfully upset and well within their rights to sue.

This obviously resulted in more lawsuits surrounding VBAC directed against hospitals and some
providers. Rather than blaming overuse of induction, mandatory VBAC despite contraindications, or
mismanagement of labor, VBAC was blamed by being deemed as unsafe, despite the opposite being
true (more on that in the next section).

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Cesarean Rates Rise Again

So, almost overnight, VBAC was deemed to be too dangerous and doctors’ perception of VBAC shifted.
Some doctors even stopped attending VBACs at all, resulting in a huge reduction in the overall VBAC rate
for the United States. 90% of women who have had a Cesarean will have a Cesarean for every future
pregnancy (American Pregnancy Association, 2015). While we are not quite back to the “once a
Cesarean, always a Cesarean” mentality, we are too close for comfort.

The anti-VBAC mentality, the increased cost of benefits for providers and hospitals, and the convenience
of Cesareans, has created a C-section epidemic in our country. Some providers and hospitals in this
country have a 60%+ C-section rate. Into the 2010s, more than one out of three women in this country
will have a C-section.

Women of Color
You might be surprised to know that we, as Caucasian doulas from predominantly Caucasian Utah, have
encountered racism directed towards our laboring clients. In addition to that, as we keep digging into
VBAC and the issues surrounding it, the more we learn about the unique challenges that face Women of
Color.

1. The VBAC Calculator is Biased Against Race

The VBAC Calculator is a collection of data from 7,600 women who had a TOLAC (ACOG, 2017). It
calculates any woman’s chance of success against that data. There are several data points used for the
calculation including maternal age, BMI, reason for past C-section, if there has ever been a vaginal
delivery before and/or after the C-section, and race. Yep, Race. Being African-American or Hispanic
decreases your chances a LOT. Go ahead and play around with it at bit.ly/vbaccalc. Enter your
information and then check and uncheck the boxes asking about race and refresh to get an updated
calculation. When I put my information in and adjust only the race options, it drops my predicted
chances by 19%, and I have already had three VBACs.

The unfortunate thing is that a lot of providers will not support VBAC if someone’s predicted success
rate is less than 70%. That pretty much rules out most Women of Color for VBAC (really, you NEED to
play around with the VBAC calculator). The good thing is, ACOG states that a predicted success rate of
less than 70% is not a contraindication for TOLAC.

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Julie’s very first VBAC client, who just happened to be Hispanic, had a predicted success rate of just 4%,
yes FOUR. She pushed her baby out in 20 minutes. Take that, VBAC calculator!

2. Women of Color are Significantly More Likely to Have a Cesarean Birth and Even Die During
Childbirth

Racism during childbirth is not limited to just

VBAC. Women of Color are twice as likely to
have Cesarean births and are 3-4 times more
likely to die during childbirth (Perry, 2016).
These numbers hold true despite education
level, income level, or socioeconomic status.
This. Is. Not. Okay.

Julie once had a client whose first language

was Spanish. She was born in Mexico, as was
her husband. They both understood and spoke English very well. When they got to the hospital, the
nurse, a white woman, mid to late 50s, would only speak to her in a slow tone asking questions followed
by, “Do you know what that means?” She acted like she was a Kindergartner leaning about birth
procedures for the first time. However, that was even much better than when she started using broken
Spanish to try to talk to the birthing couple so that Julie couldn’t understand what she was telling them.

Sadly, this was one of her most educated and intuitive clients. She was judged immediately by the color
of her skin and her accent, and, as the birth went on and some unexpected things happened, all the L&D
and even postpartum staff were very vocal on blaming this mother for “endangering her baby”. This all
took a heavy toll on this mother’s heart--all due to her race.

3. Women of Color Are Significantly Less Likely to Have a Successful VBAC

In an analysis of over 100,000 births, this study shows that white, non-Hispanic women are almost 10%
more likely to have a successful VBAC than black, non-Hispanic women (Holland, et al., 2006). Again,
these outcomes are despite education level, income level, or socioeconomic status. Sadly, these
numbers are similar among various studies and time frames for the last 20 years. Women of Color in the
Southern parts of the United States have the highest chances of Cesarean birth and lowest chances of
VBAC while women in the Northeast see less of a racial disparity.

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Four Main Reasons for Initial Cesarean and What to Know
There are four common reasons as to why women have initial Cesareans. Just because they are
common, does not mean they are always unnecessary; however, sometimes they are. There are also
many other reasons that a woman may need a C-section that are not included here. The best way for
you to determine what your C-section was for is to contact the medical records office at the hospital
where you birthed and make a request for your operative report. It is not uncommon for the reason
noted in your report to be different than what you were told. Knowing what is in your operative report
can help you better prepare yourself with the information listed here:

Malpresentation (Baby in Wrong Position or Breech)

There are many things that can be done to ensure baby is in a good position prior to labor starting and
to get baby in a good position during labor. Things like getting on your hands and knees, squatting, not
laboring on your back, and being mobile help significantly. Your doula should have a rebozo that can
work magic on a baby’s position. In 2018, ACOG released Committee Opinion 745 on breech
presentation and it states:

“There is a trend in the United States to perform Cesarean delivery for term
singleton fetuses in a breech presentation. The number of practitioners with the
skills and experience to perform vaginal breech delivery has decreased. The decision
regarding the mode of delivery should consider patient wishes and the experience of
the healthcare provider. Obstetrician-gynecologists and other obstetric care
providers should offer external cephalic version as an alternative to planned
Cesarean for a woman who has a term singleton breech fetus, desires a planned
vaginal delivery of a vertex-presenting fetus, and has no contraindications. External
cephalic version should be attempted only in settings in which Cesarean delivery
services are readily available. Planned vaginal delivery of a term singleton breech
fetus may be reasonable under hospital-specific protocol guidelines for eligibility and
labor management. If a vaginal breech delivery is planned, a detailed informed
consent should be documented—including risks that perinatal or neonatal mortality
or short-term serious neonatal morbidity may be higher than if a Cesarean delivery is
planned.” (ACOG, 2018)

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Failure to Progress

Historically, evidence has shown that many care providers do not give women the chance to progress in
the first stage of labor (dilated to 10cm) or enough time to push the baby out when they do get there. In
2011, ACOG and SMFM (the Society for Maternal-Fetal Medicine) put out an updated definition on time
limits for the first and second stages (the pushing stage) of labor. The new guideline says that a woman
is not considered to be in active labor until six centimeters and cannot be termed as “failure to
progress” until she is at least six centimeters dilated, her waters have ruptured, and no cervical change
has been made in six hours of labor.

For the second stage of labor, there is no time limit for pushing the baby out and pushing can continue
for up to three or four hours, as long as mom and baby are stable. Many women certainly had their
primary Cesareans because their care provider did not give them enough time to labor or push (ACOG,
SMFM, 2014).

Labor progress is not just about cervical dilation either. Labor progresses through these six stages:

● The cervix moves from posterior to anterior position

● The cervix ripens and softens
● The cervix effaces
● The cervix dilates
● The baby’s head rotates, flexes, and molds
● The baby descends, rotates further, and is born

A mother’s emotional state and ability to cope with physical discomforts also plays into the body’s
ability to labor effectively.

Macrosomia (Big Baby) or CPD (Small Pelvis)

A ‘big baby’ is defined as a baby who is more than nine pounds, 15 ounces. Macrosomia, literally
meaning “big body,” is when a baby is born weighing 11 pounds or more. 16% of indications and 9% of
C-sections are due to suspected big babies, when, only 1.7% of babies are born bigger than nine pounds,
15 ounces. According to the 2010 National Vital Statistics, the average weight of suspected big babies
was seven pounds, 13 ounces (Declerg, Cheng, & Sakala, 2018).

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But don’t take our word for it. We LOVE the article Dr. Mazumdar, M.D. (2016) wrote defining
everything in layman’s terms and spelling out what the truth is about small pelvises and big babies. He
states:

“Diagnosis of CPD is very difficult. This is because it is difficult to estimate exactly

how much the mother’s ligaments and joints will ‘give’ or relax before labor starts.
The fetal head also has a great capacity to mould - the skull bones can overlap to
some extent and decrease the diameter of the head. So, a baby who appears to be
too big to pass through its mother’s birth passage before labor, may do so without
much problem when active uterine contractions start. A ‘trial of labour’ should
always be given to all women with average sized pelvis and an average sized fetus
even if the pelvis appears apparently too small for the baby.”

When your provider is saying your pelvis is too

small, he is referring to CPD, which stands for
Cephalopelvic Disproportion. Actual CPD is
actually incredibly rare and very hard to
diagnose; it is very discouraging for women,
and more often than not, leads to a woman
having repeat C-sections for her subsequent
pregnancies. The pelvis is able to mold during
labor and, when laboring on positions other
than your back, can expand by up to 30%.

If you have EVER been told your pelvis is too small to birth a baby, or that you make babies too big for
vaginal birth, you NEED to read this article, www.gynaeonline.com/cpd.htm, and have an educated
conversation with your provider. The exception to this would be if you have diabetes, type I or II or,
gestational diabetes. If either of these apply to you, we recommend talking with your provider to find a
birth plan conducive with your specific circumstances.

Fetal Heart Problems

In a hospital setting, continuous fetal monitoring is usually a requirement for VBAC women, and in about
70% of rupture cases, EFM (external fetal monitoring) has picked up an abnormal heart rate pattern that

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can suggest separation of the scar (ACOG, 2017). However, it is also normal for the heart rate to
fluctuate outside of normal readings. A heart rate dropping several times or one that drops and doesn’t
recover may be resolved by simply changing positions to adjust baby’s position in relation to the cord.

Uterine Rupture
Up to 80% of women who attempt a VBAC will be successful, and VBAC is generally associated with
fewer complications than a repeat Cesarean. The biggest risk and the most influencing factor for VBAC is
uterine rupture. A uterine rupture is defined as a tear through all three layers of the uterine lining.
However, uterine rupture can even occur in women without a prior Cesarean, albeit not as likely
(0.07%), or one in 1,146 pregnancies (Nahum, 2018).

Uterine Rupture vs. Uterine Window and Dehiscence

Uterine rupture is rare, although it does happen; uterine dehiscence is often mistaken and classified as a
uterine rupture. Uterine rupture is when the uterine scar completely opens along the scar going through
every single layer of the tissue. A dehiscence is when a very small amount of the scar begins to separate
but doesn’t quite make it the entire distance. A uterine window is when the scar is so thin that you can
see through it but it does not tear or open. After a Cesarean, our bodies heal and create scar tissue. That
scar tissue is not as stretchy as our original tissue, but it still has the ability to stretch.

Uterine Window

As your baby grows, the uterus stretches and can become thin. In order to know if you have a uterine
window, a Cesarean would need to be performed or an ultrasound may show the thinning. Your
provider would be able to tell you during the Cesarean because of how thin it would look. Evidence has
not shown thus far if a uterine window is an indication that a rupture would be more likely or not. A lot
of parents will likely go on and VBAC without knowing if their uterine lining ever was thin.

Uterine Dehiscence

There are three layers to the uterus. If the uterine scar opens partially, stretching the scar tissue and
opening the bottom layer, this would be classified as a uterine dehiscence. Uterine dehiscence is often
harmless and doesn’t have any harmful effects on the baby or the mother.

A 10-year Canadian study was done on full uterine rupture vs. uterine dehiscence. Over the 10 years,
there were 114,933 deliveries with 39 cases of uterine rupture: 18 complete and 21 incomplete, or

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dehiscence (Kieser & Baskett, 2002). Uterine dehiscence did not have any fetal deaths. Uterine rupture
is a scary topic for providers. It can often be hard for women to be able to find a supportive provider for
VBAC due to this fear.

How to Determine Uterine Dehiscence

As with the uterine window, a repeat Cesarean would need to be performed in order to confirm uterine
dehiscence. Historically, providers would explore the uterus more during a Cesarean to see if there were
any other tears, but currently that practice is not likely to happen. Taking the mother’s pulse rate
carefully and consistently during labor may be the only sign that uterine dehiscence is happening or has
happened. When the scar tissue starts to separate, fluid can enter the body cavity and leak into the
membrane that separates the organs from the cavity wall. When this happens, the body reacts with
shock and the mother’s heart rate may increase dramatically.

In the same 10-year study, in 92% of cases, uterine rupture was associated with previous Cesarean
delivery (Kieser & Baskett, 2002). Uterine dehiscence was associated with minimal maternal and
perinatal morbidity.

Length of Time Between Pregnancies

We hear from a lot of people who want to know when they can get pregnant again after their C-section
in order to have a VBAC. There are plenty of recommended lengths of time out there, and it seems that
every doctor has their own recommendation for when they will or will not allow you to VBAC, based on
how far apart your C-section and next pregnancy are. But, what does evidence say?

In a study investigating whether or not short- or long-term pregnancy intervals increased or decreased
chances of uterine rupture, it shows that any length of time, six months or longer between pregnancies,
has no impact on risk for uterine rupture. In other words, if it is six months or more from the time you
had your C-section to the time you got pregnant again, there is no increased risk of rupture. Six months
between pregnancies is 15 months between births. With pregnancies less than six months apart, the risk
of rupture doubles or triples to roughly 2.2% (Stamilio, et al., 2007); however, this does not
automatically exclude you from VBAC. It just means that the risk is higher, and, if that is an acceptable
risk to you, you should look for a provider who is comfortable with that risk as well.

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Putting Uterine Rupture into Perspective

Statistically, uterine rupture happens in 0.4% of TOLAC (Motomura, 2017). That equals one in 240. Now,
as will all things, probability should be considered and assessed. When uterine rupture does happen,
most of the time it is quickly detected, and a provider is able to get the baby out quickly (usually by
repeat Cesarean) before any long-term damage happens to the mom and/or baby. In fact, only 6% of
uterine ruptures are complete or catastrophic.

“The overall risk of perinatal death due to uterine rupture was 6.2 percent. The two
studies of women delivering at term that reported perinatal death rates report that
0-2.8 percent of all uterine ruptures resulted in a perinatal death.” (Guise, et al.,
2010)

To put it differently, of the women who had a uterine rupture, one in 16 resulted in infant death. When
looking at the overall chances of infant death when attempting a VBAC, the National Institute of Health
(NIH) reports the odds as 0.13%, which ends up being one infant death in every 769 TOLACs. For
comparison, the average neonatal mortality rate for the U.S. in 2014 was 5.8 per 1,000 births (Kaiser
Family Foundation, 2017). That’s one in approximately 172. Just for fun, and because Julie is a statistics
geek, let’s take a look at some things more likely and a little bit less likely to happen to you than a
uterine rupture:

• 1 in 160 - Chance of having a heart attack each year (CDC, NCHS, 2015).
• 1 in 216 - Chances the person you are dating is a millionaire (Baer, 2003).
• 1 in 4 - Chances of your death being due to heart disease (CDC, NCHS, 2015).
• 1 every 18 years - How frequently you will be in a car accident (Property Casualty Insurers
Association of America, 2018).
• 1 in 30 - Odds of conceiving twins (Martin, Hamilton, Osterman, Driscoll, & Drake, 2018).
• 1 in 300 - The risk of cord prolapse (Lore, 2018).
• 1 in 160 - Odds of being audited by the IRS (Heath, 2018).
• 1 in 199 - Odds of falling to your death (McCarthy, 2018).
• 1 in 14 - Odds of having your identity stolen if you are 16 years or older (Matko, 2013).
• 1 in 100 - Odds of dying from an obesity-related conditions (Allison, Fontaine, Manson, &
Stevens, 1999).
• 1 in 38 - Chance of developing melanoma (American Cancer Society, 2018).

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Reducing the Risk of Rupture

There are many things you can do to minimize the chances of uterine rupture. It is important to discuss
these things with your provider and have a solid plan ready if any interventions are necessary.

● Stay away from induction unless absolutely necessary.

● Avoid augmentation of labor (something to stimulate contractions, usually Pitocin).
● Avoid excessive Pitocin and upping the dose too fast.
● Avoid Cytotec (misoprostol) COMPLETELY.
● Avoid providers who aggressively intervene with and manage labor.
● Stay mobile. Walk, change position and posture when in active labor.
● In early labor and if labor stalls, rest or sleep.
● Do EVERYTHING you can to make sure your baby is in the most optimal position BEFORE labor
begins.
● If baby is not in a great position and labor stalls or you have back labor: try spinning babies,
MILES circuit, abdominal lifting, side lying, or get on hands and knees to try and help baby settle
into a better position.
● Avoid rupturing membranes if baby is not in optimal position.
● Avoid an epidural if possible.
● Have attentive labor support with you ALL THE TIME.
● Be aware of typical labor patterns. Any stalls in labor are usually indicative that something needs
to change (emotional processing, baby position, rest/sleep, and even Pitocin in some instances).
Figure out what needs to change and fix it if you can. A long stall combined with high doses of
Pitocin is a prime scenario for uterine rupture.
● HONOR YOUR INTUITION. If you feel that something is not quite right or if baby’s movement is
significantly decreased, insist that your provider or their staff pay attention to you. In many
instances, uterine rupture occurs when a mother knows something is wrong intuitively before
providers pay enough attention.

VBAC vs. Repeat Cesarean

The most controversial risk for VBAC is potential uterine rupture (which we discussed in the previous
section), but unfortunately, many providers do not go into detail on the risks of repeat Cesarean.

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Risks for Baby

Babies born by scheduled Cesarean are more likely to be born preterm, with breathing problems, have
fetal injury (1.5 babies per 100 will be cut during the surgery), and/or need admission to the NICU. Due
to separation immediately after birth and delay of skin-to-skin contact, maternal attachment may be
delayed and breastfeeding issues could arise (Jukelevics & Wilf, 2009).

More and more studies are showing that, while

passing through the birth canal, babies receive
microorganisms from their mother that play a
huge role in developing their immune systems.
These microbiomes are essential to overall
health and well-being. They also assist in the
production of vitamins and anti-inflammatory
substances. These substances play an important
role in protecting against autoimmune diseases
and other chronic illnesses (Proctor, 2013).

Risks for Mother

Most of the risks of a repeat Cesarean for the mother are the risks for any kind of major abdominal
surgery. Here are the risks and statistics associated with a second Cesarean:

● Infection of the incision, the uterus, bladder, or other pelvic organs.

● Hemorrhage. There is more blood loss with Cesarean delivery and chances of hemorrhage and
six in 100 women require a blood transfusion.
● Injury to organs happen for every 1 in 50 women.
● Adhesions (scar tissue causing pain, blockages, or future pregnancy complications).
● Longer hospital stays and recovery time.
● Higher risks of additional necessary surgeries like hysterectomy and other Cesareans.
● Higher maternal mortality rates (Jukelevics & Wilf, 2009).

We often only talk about uterine rupture during labor, and mistakenly think that by choosing elective
repeat Cesareans, uterine rupture risk is eliminated. Although focus is usually on uterine rupture during
labor, it is possible for uterine ruptures to occur before labor even begins. These types of uterine

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Page | 40
rupture are usually more devastating and can cause serious health complications or worse in mother
and baby. It is NOT true that deciding against a VBAC means that you won’t have any risk of uterine
rupture. In fact, occasional studies have even found a higher rate of rupture in the elective repeat
Cesarean groups. Keep in mind that it is the PREVIOUS CESAREAN that puts you at risk for uterine
rupture, NOT attempting VBAC.

“Although Cesarean delivery can be life-saving for the fetus, the mother, or both in
certain cases, the rapid increase in the rate of Cesarean births without evidence of
concomitant decreases in maternal or neonatal morbidity or mortality raises
significant concern that Cesarean delivery is overused. Therefore, it is important for
healthcare providers to understand the short-term and long-term tradeoffs between
Cesarean and vaginal delivery, as well as the safe and appropriate opportunities to
prevent overuse of Cesarean delivery, particularly primary Cesarean delivery.”
(ACOG & SMFM, 2014)

The Infamous VBAC Calculator

Your care provider might refer to your predicted chance of having a successful VBAC. This prediction is
attained using a VBAC calculator. The calculator uses data such as your age, BMI, ethnicity, history of
obesity, and reason for prior C-section to spit out an estimation of a woman’s chances, based solely on
statistical data. Sometimes, on admission to the hospital for delivery, an additional calculator is used to
take into consideration cervical changes and any pregnancy complications. The calculator is based on
data from 7,000 TOLACs in the United States with one Cesarean and a low transverse scar. (National
Institute of Child Health and Human Development, Maternal-Fetal Medicine Units Network , 2007)

In a nutshell, your “chances” drop if you are an older mother, have a BMI higher than 30, have a diverse
ethnic background, and if your C-section was labeled “failure to progress” or “failed to descend.” This
calculator obviously has its limitations and should not be the sole decision-maker regarding a woman’s
attempt to VBAC. A more important thing to do would be to have an educated conversation with your
provider about your medical history, past birth experience(s), your incision type, and plans for your
family size. One of our favorite VBAC stories is one of Julie’s clients, given a 4% chance at success by the
calculator. She ended up pushing her baby out in twenty minutes.

Curious to see what your “chances” are? Go to bit.ly/vbaccalc

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Special Circumstances
Anterior Placenta and VBAC

When the egg implants into the uterus, typically it implants on the back (posterior) side. Wherever the
egg implants is where the placenta will grow. An anterior placenta happens when it implants on the
front side, the side against the belly of the mother, and is a perfectly normal place for the placenta to
grow. Having an anterior placenta does not automatically exclude you from VBAC; however, at your 20-
week scan, there are a couple things your provider will look at to make sure it doesn't interfere with
your delivery.

The main concern with an anterior placenta is making sure it

has implanted far away from the previous Cesarean scar—
that it is not likely to grow into or over the scar as it grows.
At your 20-week growth scan, a sonographer will measure
how high above your scar the placenta lies. As long as the
bottom of the placenta is more than 2cm above the scar,
you are typically good to go. If it is less than that, your
provider will likely want to do another scan around 30-32
weeks gestation to make sure everything is growing in an
uncomplicated way.

If the placenta grows into the scar (Placenta Accrete), or

partially or fully covers the cervix (Placenta Previa) an early, repeat Cesarean delivery, is typically
necessary. Good news though—as your baby and belly grow, your placenta grows upwards, so even with
a lower-lying placenta, it is likely there will be no issues as it gets closer to delivery day.

If you have a Special Scar AND an anterior placenta, you are at a higher risk for placenta complications
and careful consult with a specialized provider would be necessary, but should not automatically rule
out VBAC.

Additional facts about anterior placentas:

• Typically, it will take longer for you to feel baby movements, especially on the outside as the
placenta essentially shields his/her kicks.

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 • It will be harder to find the baby’s heartbeat, mainly in the first trimester.
• It can interfere with medical procedures such as amniocentesis.
• An anterior placenta can cause you to feel labor more in your back if it hasn’t move up high
enough late in your pregnancy, especially with a posterior baby

VBAMC (Vaginal Birth After Multiple Cesareans)

VBAC after two or more Cesareans is often considered significantly higher risk by care providers. Here is
what the evidence says:

Your chances of a successful VBAMC are similar to those of VBAC after just one Cesarean.

On page four of ACOG Practice Bulletin 184, two large studies are referenced. These studies had sample
sizes large enough to account for small variances that might influence the results. It is significant for
ACOG to recognize studies like this as credible. In other words, the fact that they are even cited there is
wonderful. The results of those two studies, referenced in the bulletin, concluded that the success rates
vary by 2% or less, depending on which study you look at (ACOG, 2017).

ACOG recommends VBA2C as a safe option.

Speaking of ACOG: since 2010, their stance on VBA2C (Vaginal Birth After Two Cesareans) is that it is
“...reasonable to consider women with two previous low-transverse Cesarean deliveries to be
candidates for TOLAC and to counsel them based on the combination of other factors that affect their
probability of achieving a successful VBAC.” It is important to note is that there is no mention of a
requirement to have had a prior vaginal delivery to be considered. If you are going for VBA2C, this
bulletin is very important to have in your back pocket as you work with your provider to determine your
care.

The risk of rupture for VBAMC is incredibly low.

The limit of most VBAMC research is that almost no studies have controls for Pitocin/other drug use,
and this may well be a significant factor. Although there is still some debate, uterine rupture rates may
be somewhat higher in VBA2C when Pitocin or multiple induction agents are used. Nearly all VBAMC
studies analyzed aggressively used Pitocin, etc. for 50% or more of their participants. So, it is impossible
to know for sure what the true underlying rate of rupture in VBAMC may be. Although hard data is
lacking, it seems likely that the average VBAMC rupture rate of 1.4% found in the ACOG bulletin could

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probably be drastically reduced by inducing less, inducing only when the cervix is ripe, when induction is
truly necessary, and using drugs and interventions a lot less (and much more judiciously when they are
used).

Special Scars

Most Cesareans are performed using the low transverse incision. It is horizontal in the lower part of the
uterus. Because it cuts through horizontal muscles, it tends to stretch more. However, in some
instances, other incision types are used. In many circles, this is automatically considered a
contraindication to VBAC—but, in many cases, women go on to have successful VBACs even with a
special scar and the chances for rupture are only slightly higher than with a low transverse scar. There
are three types of scars deemed “special scars.”

Low Vertical: A low vertical incision is also made in the lower part of the uterus. These incision types are
used when the baby is large, transverse (sideways), or for placenta previa. Your physician will probably
want to see a copy of your OP report and see how high into the uterus your scar extends. If it extends
far enough, it might increase the chances of rupture. In the cases of a premature delivery, it is likely to
extend higher. Current ACOG guidelines, as we talk about in the next section, allow for TOLAC with a
low-vertical incision.

Inverted T and J: These scar types happen when a surgeon needs more room to get the baby out after
they have done a low transverse incision. Sometimes they happen on accident as well. These scar types
are rare.

Classical: This vertical incision is in the upper part of the uterus and is sometimes used for transverse or
breech babies, for premature babies, or for Cesareans that need to be done rapidly and/or in an
extreme emergency. The upper part of the uterus is thicker and does more contracting. When classical
scars rupture, they tend to do so a lot faster and with more damage to the uterus.

Unknown Incision Type: Sometimes women are not told what type of scar they have and are not able to
get a copy of their OP report. In these instances, knowing the reason for the Cesarean and, by looking at
the incision on the skin, a provider can usually determine what type of scar is likely. Some studies have
been done that show no increase of rupture rates when women with unknown scars labor, likely
because most of them are low transverse scars.

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Studies show that women laboring with special scars have virtually no increased chances of rupture
(Goer & Tomano, 2012). In ACOG’s 2017 Bulletin, they do not recommend TOLAC for those with classical
or T or J scars; however, low vertical scars are okay. They do specifically note that “individual
circumstances must be considered in all cases” (ACOG, 2017). You can find more information on the
website specialscars.org.

ACOG Bulletin #184

ACOG was founded in 1951 with the sole mission of improving women’s health in the United States. It is
a professional membership organization with over 58,000 members as of 2017. ACOG fellows are
practicing, licensed, and board-certified OBGYNs and have attained high ethical and professional
standing. You can learn more about ACOG and its mission at www.acog.org. Here is what they have to
say about VBAC in their 2017 Practice Bulletin 184:
● “The preponderance of evidence suggests that most women with one previous Cesarean
delivery with a low-transverse incision are candidates for and should be counseled about and
offered TOLAC.”
● Recommendations for and against VBAC are given, but there is no blanket statement defining
what is or is not “allowed.” ACOG also adds that individual circumstances should be
considered. This is important to remember and discuss with your provider because VBAC
qualification is not a checklist but rather a discussion including many variables. The provider
consults, the MOTHER decides.

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 ● “…The balance of risks and benefits appropriate for one patient might not be acceptable for
another…The decision to attempt TOLAC is a preference-sensitive decision, eliciting patient
values and preferences is a key element of counseling.” We have often heard providers make
recommendations or even policies claiming what THEY or their wives would do, but the ultimate
decision should be the patient’s.
● ACOG counsels on family size when they state that making “decisions regarding TOLAC should
consider the possibility of future pregnancies.” They discuss the risks with repeat Cesarean
almost right off the bat.
● When referencing the VBAC calculator, “a predicted success rate of less than 70% is not a
contraindication to TOLAC.” It also focuses on how population-based statistics cannot
accurately predict a person’s personal chances of VBAC success. It is ill-advised to use statistics
as a primary indicator when making VBAC decisions.
● Things that are NOT contraindications to VBAC include suspected big baby, going beyond 40
weeks, short intervals between pregnancies, having a classical or unknown scar type, expecting
twins, or having a high BMI. These things do not automatically exclude women from TOLAC.
● “Available data confirms that TOLAC may be safely attempted in both university and
community hospitals and in facilities with or without residency programs”; “Trial of labor after
previous Cesarean delivery should be attempted at facilities capable of performing emergency
delivering…women attempting TOLAC should be cared for in a level I center (one that can
provide basic care) or higher. Level I facilities must have the ability to begin emergency Cesarean
delivery within a time interval that best considers maternal and fetal risks and benefits with the
provision of emergency care.” This references rural hospitals and any other VBAC bans. Also,
they stated that having an anesthesiologist “immediately available” is ideal, but not a
requirement for TOLAC.
● “Respect for patient autonomy also dictates that even if a center does not offer TOLAC, such a
policy cannot be used to force women to have a Cesarean delivery or to deny care to women in
labor who decline to have a repeat Cesarean delivery.”

Contraindications for VBAC

Sometimes a VBAC is not an option due to medical reasons. We discuss recommendations by ACOG in
the next section, which states that in most circumstances, the ultimate decision for VBAC should be

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made by the birthing woman. However, there are some very specific things that make a vaginal birth
very difficult or impossible. The following are the contraindications listed by ACOG:

● Previous classical or “T” incision

● Previous uterine rupture
● Excessive trans fundal uterine surgery
● Any contraindication for vaginal delivery in general (i.e. placenta previa, transverse baby, etc.)

That’s it. Even then, with incision type and history of uterine rupture, your specific circumstances may
be deemed eligible of a TOLAC by the right medical professional.

Lastly, we want to reinforce that there is no one right way to birth. If, for whatever reason, you do not
feel comfortable choosing VBAC, honor your intuition and pursue a different route with your provider.

QUICK REVIEW

What happened in the 1990s to cause a backlash towards VBAC?

What are some risks for VBAC?

What are some risks for repeat Cesarean?

Is the VBAC calculator a good indicator of your chances of having a “successful” VBAC? Why or why not?

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VBAC Story: Karina
At 35 weeks, I had a growth scan done with Maternal Fetal Medicine (MFM), due to Type 1 Diabetes,
and they said she was around eight lbs., 11 oz. Two different MFM doctors told me that I should have a
repeat C-section, especially since my first baby was eight lbs. 13 oz. and had shoulder dystocia. On top of
that, baby girl was breech and she would more than likely be bigger at delivery if I went to 40 weeks
around August 28, 2016.

After two weeks of prodromal labor and an external cephalic version to turn baby girl head down (since
she was breech), my birthing time had finally arrived at 36 weeks, 5 days.

Contractions started on August 5, 2018 around 9:00 a.m. My contractions were getting a lot stronger
now and I started losing my mucus plug. I tried sleeping through the contractions, because that was the
only way they would stop the previous two weeks, but now they were waking me up. Around 7:00 p.m.,
the contractions got more intense and closer together. We decided it was time to leave for our pre-birth
place, Little America, and call our doulas and birth photographer. Being a VBAC, we wanted to labor
somewhere closer to our hospital in case anything happened, but not at the hospital, so I wouldn’t be
disturbed. Little America also had great tubs!

When we arrived at Little America, I waited in the car while Chase got the keys to our room. The
contractions were pretty strong now. Once we got up to our room, he filled up the tub for me and I
labored there while my birth team arrived. After laboring for six hours at Little America, I was getting
tired and things seemed to be moving slowly, so we decided to go to the hospital to see what was
happening and decide our game plan from there.

We arrived at St. Mark’s Hospital and walked to Labor & Delivery, stopping every so often to breathe
through the contractions. They took us to room 13. I let the nurse do a cervical check but told her not to
tell me what I was. I found out later that I was 5cm and 100% effaced.

We talked about breaking my water because of my polyhydramnios and thought it might help speed
things along. After three more hours, I decided to let them break my water, because I was getting
exhausted. I lied down so they could break my water. My doctor, Dr. Edmunds, did a cervical check at
the same time and discreetly told Chase what I was (6cm).

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The contractions were so intense, and it felt like it was taking FOREVER! I went to the bathroom and
before I sat on the toilet, another contraction came. This one felt different and I started pushing at the
end of it. As I was on the toilet, my nurse said I needed to come to the bed after I was done so that I
didn’t have my baby in the bathroom. I went to the bed and hung over the back of it while on my knees.
The nurse checked my cervix and told the room I was 8cm. She probably forgot that I didn’t want to
know, and I was so mad that I was only an eight!

My doulas had me get on my hands and

knees, hanging over the bed again so they
could provide counter pressure. A lot of these
contractions felt like I needed to push now, so
I did. I’m not sure when Dr. Edmunds came in,
but he came in and checked me and I was
finally 10 cm. I just pushed when I needed to
and rested in between contractions. My arms
were feeling very tired and shaky, so my birth
team convinced me to lie down on my left side and continue pushing that way. I plopped down; I was so
tired. My butt was basically hanging off the side of the bed, but Dr. Edmunds was fine catching in that
position. I pushed a couple more times before baby girl came out. Her body felt massive coming out,
much bigger than my first baby. Baby girl was born at 7:28 a.m. on August 6, 2016, via an un-medicated
VBAC, weighing nine lbs., 10 oz. and 20 inches long. She was only four oz. lighter than my C-section baby
and almost a whole pound heavier than my baby that had shoulder dystocia!

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 IV. PREPARING YOUR BIRTH TEAM AND BIRTH SPACE

Choosing a VBAC or repeat Cesarean is a personal decision and ultimately should be made by the
birthing woman and her family after considering ALL the risks for each path and based on the unique
circumstances of her previous birth(s). Take a look at your desires and fears and what motivates YOU.
Weigh the benefits and risks based on your specific needs and circumstances. Listen to the advice of
your providers, but remember that each provider differs, sometimes drastically, in their support,
knowledge, and how they approach VBAC; because of this, they may not be up-to-date with current
recommendations and guidelines. Moving forward, seek out the current recommendations and
research, talk to several providers, and get their opinions until you find one whose knowledge and
philosophy align with yours, weigh the potential risks and benefits, and check your own intuition to
decide what is best for YOU and YOUR family.

Policies Surrounding VBAC

When choosing your birth location and provider, it is important to consider what policies that location,
provider, and/or group has that are specifically VBAC related. Generally, the more VBAC policies they
have, the less VBAC supportive they will be. Some of the VBAC policies you need to know about are
listed below.

Continuous Fetal Monitoring- In 70% of rupture cases, an abnormal heartbeat of the baby was one of
the first signs (Guise, et al., 2010). While intermittent monitoring may be an option in some birth
locations, a hospital is likely to require you to be constantly monitored. The good news is, most hospitals
have wireless and even waterproof monitors, so you can remain mobile and even labor in the water if
you’d like.

Epidural Placement- Sometimes a provider or hospital might want you to get an epidural placed but not
turned on in order to VBAC. The idea behind this is in the case of uterine rupture, they can quickly
administer the epidural and perform a Cesarean without having to put you under general anesthesia,
which is riskier. The problem with this logic is simple; during a catastrophic uterine rupture, a baby
needs to be out within 17 minutes in order to prevent brain damage or other serious complications. To
administer an epidural at the strength it needs to be for surgery, it takes 20-30 minutes—they would
need to put you under general anesthesia immediately for you to not feel the Cesarean. The point is,
this practice is simply not evidence-based.

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VBAC Bans- We touch on this briefly in Section III about ACOG Bulletin 184. We love the updated version
on VBAC that came out in 2017 for many reasons, one of them being the clarification on a key phrase
that hospitals were misinterpreting and using as a reason to ban VBAC. The misinterpreted phrase was,
that for a hospital to perform VBAC deliveries, they needed to have an anesthesiologist and obstetrician
“immediately available”, which was misinterpreted to mean “on site.”

The 2017 version of the VBAC bulletin clarifies that, by stating that having anesthesiologists on site is
ideal, not having them onsite does not mean that a facility is unprepared to handle VBAC emergencies.
In other words: if a facility can perform typical vaginal deliveries, it can handle VBAC. Forcing a woman
into a Cesarean is wrong, and not giving her the option to assume the risks she is prepared to take on is
wrong. It will take time, but we believe this attitude will spread and VBAC bans will no longer exist.

Saline Lock- Also known as a hep-lock, historically, is an IV catheter, placed in a vein in the arm or hand,
flushed with saline, and capped off in case an IV is needed later on in labor or birth. Most hospitals have
this as standard policy and are generally less willing to negotiate it for a VBAC mother due to the
possible need of having to immediately administer general anesthesia in the case of a uterine rupture.
As with all other birth options, the decision is ultimately yours—talk with your provider and doula to see
if this is something you would like to decline.

Induction- Induction is a hot topic in the VBAC world. It is interesting what policies exist surrounding
VBAC and how a policy at one location can contradict a policy at another. As stated in Section V,
Mastering the Art of Brain, induction is a safe and reasonable option for normal VBAC pregnancies.
While Pitocin does increase the chances of uterine rupture slightly, it is still within the ACOG
recommended acceptable risk guideline. It is ideal for labor to start on its own, but when there is a true
medical need, induction is safe. The only contraindication for VBAC induction is using
Cytotec/Misoprostol for cervical ripening (more information on that in Section V as well). Some policies
you might encounter surrounding induction include:

• Providers or hospitals not willing to induce VBAC at all.

• Providers or hospitals that insist on induction at 39 or 40 weeks.
• Not wanting to use a Foley bulb or IUPC for manual cervical dilation.
• Not using Pitocin to stimulate uterine contractions.

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While these policies all have the intention of decreasing uterine rupture risk, they are simply not
evidence-based. If you encounter any of these policies, it would be wise to have an open discussion with
your provider and get a second opinion.

Water Birth- Very few hospitals allow water

birth, and when we have heard about water
birth at a hospital, it typically does not allow
for VBAC women to birth in the water.
However, we are hoping that once water
birth becomes a common practice for
hospitals, it will have much fewer
restrictions and become available to VBAC
mothers.

Choosing Your Birth Location

Hospital

Most women give birth in a hospital. In a hospital, you are cared for by several different types of people,
including nurses, technicians, medical residents, and in some cases, supervised medical students.
Women who have a great hospital experience usually describe it as being able to make decisions for
their care and the staff explaining everything that was going on. Women who have bad experiences in
the hospital usually say that they felt ignored, mistreated, or felt like they were part of a system and not
allowed an individual experience. ACOG recommends hospitals for VBAC based on the risk of
catastrophic uterine rupture. Some hospitals may have VBAC bans despite ACOGs guidelines against
them.

Birth Center

For women in low-risk pregnancies, using a midwife-based model of care in a birth center setting is an
option. Midwife-led care results in lower Cesarean rates, lower intervention rates, and great outcomes
for both mom and baby. In one U.S. study, out of 15,000 mothers, those using birth centers with
midwives had a 93% spontaneous labor and vaginal birth, 1% had an assisted delivery, and only 6%
needed a C-section. The neonatal mortality rate was one in 2,500 (Rutledge, Osborne, & Illuzzi, 2013).

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More and more women are choosing this option because of the greater autonomy, more personalized
care, and a more comfortable birth environment. If you decide on going with a midwife and birth center,
make sure you find out about any licensing, accreditation, and experience. Not all birth centers and
midwives are the same.

Home

“In 2013, 1.4% of U.S. births took place outside of a hospital. Surprisingly, 64.4% of these occurred at
home. The number of women who gave birth at home, 36,080, was the highest since 1989 when
reporting of home births began” (Martin, Hamilton, & Osterman, 2015). Home birth in general, and
especially home birth for VBAC, also known as HBAC, is growing in popularity. A planned birth at home is
at least as safe as a planned birth in a hospital, as long as the following four criteria are met:

• The woman has a low-risk pregnancy.

• A home birth is chosen, planned, and prepared for.
• The care provider involved is qualified and trained in home births.
• A backup transfer plan is in place in case of emergency.

Sixteen years’ worth of scientific studies on home birth gathered by the Coalition for Improving
Maternity Services Expert Work Group showed that when compared to low-risk women who plan a
hospital birth, low-risk women who plan a home birth have similar or better outcomes with fewer
medical interventions and fewer Cesareans (Sagady & Romano, 2007). However, there are very few
documented and studied cases of VBAC at home in the United States to date, so there is not enough
data to compile showing an increased risk for VBAC women.

Ultimately the choice for birth location should be based on what makes you feel safe and an
environment where you can trust a provider you are confident in. There are many things you can do to
make your birth space more cohesive with your needs, no matter where you give birth. Some
suggestions include

• Hanging up pictures or affirmations in your birth space.

• Lighting candles (LED candles only for hospitals).
• Dimming the lights.
• Wearing your own comfortable clothes.

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 • Creating a quiet space or have your own music playing in the background.

Talk with your doula to see what else you may want to implement for your birthing time.

How and where you give birth is YOUR decision and you can find someone capable of supporting you no
matter what your desires are.

Choosing Your Care Provider

Women with a prior Cesarean birth have a greater chance of achieving VBAC when they have 100%
support from their care provider and when their providers encourage and promote normal, physiologic
birth processes not involving unnecessary medical interventions. There are several options for care
providers based, of course, on birth location choice and include OBGYN, Hospital Midwife (CNM), or
home birth or birth center midwives.

Knowing what questions to ask potential VBAC providers can be frustrating, especially when you aren’t
sure if they are being honest or are just telling you what you want to hear. Below, we will suggest some
topics of discussion and then show you how to interpret their answers. Most importantly, if they seem
to answer all the questions “right” and you still feel like something just isn’t sitting well with you, then it
might be time to look around some more.

Most importantly in your search is to make sure

to ask open-ended questions. Any provider can
agree to any birth plan you put before them
initially, but knowing how they personally feel
about VBAC and knowing what requirements
they might have can let you know more about
whether they are VBAC-friendly or will just
“allow” it if everything goes perfectly.

The ideal is to find a provider who views vaginal birth after Cesarean as a normal process, who is not
afraid to support you, will only jump in with interventions when there is a TRUE medical indication, and
who you can form a great relationship with beforehand. We suggest first discussing VBAC and TOLAC in
their office, across the desk from one another rather than in an exam room in a gown. This puts a lot of
power back in your court.

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Here are some great questions to start off with:

● How do you feel about supporting TOLAC/VBAC?

● What are potential long-term and short-term risks of having a repeat Cesarean for myself and
my baby?
● If I have a repeat Cesarean, how will this impact future pregnancies and births?
● What requirements do you have to support a woman in TOLAC?
● What is your hospital policy surrounding VBAC?
● What do you and your hospital do to avoid an unnecessary repeat Cesarean?
● Are there others in your practice who might be at my birth if you are not available? How do they
feel about TOLAC/VBAC?

Interpreting Their Responses:

Now you have all these discussion points, what do you do with them? We have divided things into three
categories with suggestions on what to consider when evaluating your provider interview.

Their Personal History

The higher their VBAC success rates and lower their Cesarean rates, the better. You can start by getting
a good idea what those are by visiting Cesareanrates.org. This allows you to break down rates by state,
hospital, and provider. Knowing what the baseline is for your area is a great way to start off in
determining where your provider ranks. Ask for actual numbers here. Answers like, “I only intervene or
perform a C-section when absolutely necessary” might be a red flag if they are reluctant to share actual
statistics. Asking what their personal belief and philosophy is surrounding VBAC will give you a great
idea, and don’t let anyone tell you they will let you TRY.

Their Requirements

Many providers have stipulations for allowing you to TOLAC. Some of these requirements involve
induction methods or even induction, giving birth by a certain gestational age, the reason for previous
Cesarean, and if you have ever had a vaginal birth. A provider that insists a VBAC client go into labor
before 40 weeks or she automatically goes to a C-section is probably not VBAC-friendly, for example.
The more requirements or policies a provider or birth place has for VBAC, the less likely they are to be
supportive. Also, if they insist your pelvis is too small or your baby too big, check around and find a
provider who practices evidence-based care. A VBAC should be treated as any other type of birth,

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personal and unique, and not be given blanket requirements based on what may or may not increase or
decrease chances of success.

What Do the Others Think?

A lot of providers work in a practice with an on-call schedule. Just because one doctor in the practice is
VBAC-supportive does not mean that all of them will be. Find out if the doctor you see will be the one at
your birth, if they have any time off scheduled for around your due date, and what the hospital policies
and the standard of the other providers they work with are. Knowing what the standard of care is for
the entire group may make you want to seek other providers if it is not in line with what YOUR provider
does.

Some doctors may appear to be VBAC supportive, but actions speak volumes. Here is a list of
characteristics that make a provider tolerant of VBAC, meaning that they allow VBAC if everything goes
perfectly, or supportive of VBAC, meaning they are up to date with evidence-based practices and really
support VBAC.

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Lastly, if you find yourself in a position where you are faced with a birth space or birth provider who is
clearly unsupportive, you ALWAYS have the right to seek new care, even in the middle of your labor.
Beyond all of this, you should definitely consider hiring a doula to support you if things get tricky (and
for lots of other reasons, too). Dr. John Kennell, who co-authored one of the first studies on continuous
labor support, said in reference to doula support:

“If anyone said that a new drug or electronic device could reduce problems
associated with fetal distress and labor progress to a third, or even that it would
shorten labor by half and facilitate mother-baby interaction after the birth, there
would be a stampede to make sure this new drug or equipment was available in
every maternity unit in the country, whatever the cost involved.” (Kennel, Kalus,
Robertson, & Hinkley, 1991).

Hiring a Doula
What is a doula? A doula is a person who can
provide continuous emotional, physical, and
educational support leading up to your birth,
during your birth, and even after your little one
arrives. A doula is not a medical professional
and does not deliver babies.

There are many types of doulas. A birth doula is

someone who will accommodate the mother’s
wishes for the birth environment (low light, soft
music, etc.) to the extent possible in the desired birth place. A doula encourages the mother to
communicate with her providers and to be informed about any procedures and interventions that may
be offered (NOTE: A doula does NOT give medical advice or interfere with the provider/mother
relationship). Doulas provide ideas, such as positions and comfort measures, to help labor progress and
reduce the pain of labor. A doula’s role also plays a big supporting factor with the father or birth partner
as well. She is there to support everyone on the birth team, helping create a calm and peaceful
environment for everyone. A doula never replaces the very important role of the birth partner. A doula
will help the birth partner by suggesting ways that he/she can support the laboring mom, which may
also reduce stress on the birthing partner.

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Why Hire a Doula?

In addition to providing physical, emotional, and educational support, a doula may help decrease the
chance of a C-section by 39% (Dekker, 2017). It’s true. No wonder we think doulas are awesome! We
love the quote from Evidence-Based Birth’s website that says:

“Advocacy is defined as supporting the birthing person in their right to make

decisions about their own body and baby.” (Dekker, 2017)

A study that included more than 15,000 people was done with 26 trials on continuous support of a
woman in labor. The studies were done by different types of continuous support, such as a nurse,
midwife, and a doula. The researchers looked to see if the type of support made a difference.
Continuous support should be continuous support, right? The overall findings were quite interesting.

● 25% decrease in the risk of Cesarean; the largest effect was seen with a doula (39% decrease).
● 8% increase in the likelihood of a spontaneous vaginal birth; the largest effect was seen with a
doula (15% increase).
● 10% decrease in the use of any medications for pain relief; the type of person providing
continuous support did not make a difference.
● Shorter labors by 41 minutes on average; there is no data on if the type of person providing
continuous support makes a difference.
● 38% decrease in the baby’s risk of a low five-minute Apgar score; there is no data on if the type
of person providing continuous support makes a difference.
● 31% decrease in the risk of being dissatisfied with the birth experience; mothers’ risk of being
dissatisfied with the birth experience was reduced with continuous support provided by a doula
or someone in their social network (family or friend), but not hospital staff (Bohren, Hofmeyr,
Sakala, Fukuzawa, & Cuthbert, 2017).

Overall, hiring a doula can benefit your labor/birth experience in many ways, from avoiding unnecessary
interventions to providing continuous physical and emotional support to both the birthing mom and
partner. Although this type of support can be provided by others, such as the nurse, midwife, or
family/friend, studies show that doulas have a stronger effect than other types of support. A doula is a
member of your birth team and will be there to help everyone have as positive of an experience as
possible.

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QUICK REVIEW

What are some characteristics of a supportive VBAC provider?

What are some red flags that will tell you if a provider is not very supportive of VBAC?

By what percentage does having a doula on your birth team decrease your chance of having a Cesarean?

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VBAC Story: Mandy
I knew there was a special baby missing from our family. One morning, I woke up with a calm, peaceful
feeling. In my mind’s eye, I saw the sweet little outline of a baby across the room in a little hospital
bassinet. I felt a very clear prompting come into my mind: “In about six months, you need to start trying
to have a baby. And you need to go to Portneuf. Hospital”

I'm a VBA2C mom. I've had a C-section with a special scar (an inverted T incision), a repeat C-section,
and at the time, I had had 3 VBA2Cs, which were attended to by amazing midwife, Chris Miller, in
Ogden, Utah.

Just over six months later, I was expecting baby number six. I kept second-guessing the thoughts that
had come into my mind, but knew I needed to follow what I had felt. I discovered that Portneuf still only
allowed VBAC after one C-section. I had heard great things about a certain doctor there, Dr. Cox. I was
so nervous for my first appointment that I asked my husband for a blessing (a special prayer offered to a
person by a priesthood-holder in the Church of Jesus Christ of Latter-day Saints). The words of the
blessing mentioned that the doctor would be there to help me and advocate for me.

I expected to be turned away, and then I could say I had at least done my part. One of the first things the
doctor said was that he supported my choice and that he agreed with the path I had taken. He told me
that he would take me on, but that unfortunately his hands were tied because of hospital policy. After
leaving for a bit, he came back into the room. He said that the other hospitals in the area had changed
their policy to VBAC after two Cesareans, and that it was “just ridiculous” that they hadn’t as well. He
told me that if I were willing to be in limbo, he was going to try and change it. I had friends asking me
the whole pregnancy about the policy and it was kind of funny, but I wasn’t too worried about it. I just
felt like it would work out.

I felt nauseous and dizzy the entire pregnancy. Apart from that, my labs and everything were completely
normal. After about a month of feeling well, I started to develop bad swelling. I was concerned, because
the only pregnancy where I had swelling like this was my first, which ended in a C-section after an
induction for preeclampsia. I tried to up my protein, drink tons of water, and do the things that help to
hold it off. I have amazing friends that helped with encouragement and advice. I really think these
remedies slowed the process. I had one appointment with the nurse midwives the week my doctor was
out of town, and sure enough, I had proteins, rising blood pressure, and a jump in weight.

I had to do additional labs and went back to my doctor a couple of days later. That was when he told me
that the policy had passed. Because my labs were still okay, we were able to continue to watch and
check in. We hung in there for a week or two and then I did a 24-hour urine test. I prayed on the way to
my next appointment that I would know what to do and that the doctor would know what to do. I came
in and Dr. Cox told me that not only was the policy was officially in place, but he also had the results of

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the 24-hour urine test. His guidelines said immediate delivery for +2 proteins or higher after 34 weeks,
and mine was +6. He said we would deliver the following day—but instead of a C-section, we could try a
gentle induction.

I was 35 weeks and so scared. I felt like I was failing my baby because my body wasn’t cooperating and
that he had me as a broken vessel. Dr. Cox inserted a Foley bulb catheter to help with dilation, gave me
a steroid shot, and sent me home after they were able to get a lower blood pressure reading. The Foley
catheter popped out after four hours. I was having little contractions, but nothing serious. I finally called
my doula; I had been waiting for the policy change, so I hadn’t set up an official plan with her. I ended
up texting her at 11:00 p.m. My mom came to stay at our house, and we left in the morning. I was so
weepy and afraid that I couldn’t eat. I felt like I was facing the fears of the very thing that started my first
birth and C-section.

It took over an hour to get the baby on the monitor because he kept moving. We did a small dose of
Pitocin and they also had to do magnesium. My husband was very supportive, and the staff was nice.
The head nurse had to come in to help with the monitor and she kind of scared me about going natural
because of my blood pressure and said that I couldn’t move too much because of it; I may need an
epidural to keep it down. I was terrified to go natural in this environment, but also terrified to get pain
relief because I’d also experienced a failed spinal, which led to general anesthesia, and a failed epidural
in the past. They had to get me nose drops because I was so stuffy from crying. I was an emotional
wreck.

I decided to be open to what I needed to do. My doula, Robyn, said that she could come right at the
beginning or anytime I needed her. I felt so emotionally fragile that I almost was afraid to call. What if I
couldn’t handle it and needed to get pain meds? She came in, calmed me down, had my husband grab
some lunch, rubbed my feet, and did a calming meditation. She also reassured me that she was there to
support me no matter what.

It’s amazing how the presence of one person can totally impact the entire room. Instead of fear I felt
peace now. I had a check close to 12 and was still very high and maybe 2cm. My water was broken; the
Pitocin didn’t feel like it was doing too much, but I didn’t let on. Then, as the contractions picked up, I
had my husband to hold onto and Robyn to put pressure on my back. She kept us both calm. I was able
to relax into my contractions despite being tied to an IV and a monitor. I agreed to an internal monitor,
which was a lot easier to work with. I would have tried harder to avoid continuous monitoring, but
because of my preeclampsia and being a VBAC mom, I decided to let them win on that.

My little birth team of two was wonderful. My husband and I both agreed that doulas are amazing.
Besides an obnoxious anesthesiologist coming in, the next couple of hours were quiet and peaceful. I
could feel the contractions getting stronger and asked for a check. 7cm! I hoped I wasn’t too much
longer, and after 30 minutes, I felt the need to push.

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They wanted me to deliver in the OR just in case, so I told them they needed to tell the doctor. No one
seemed in a hurry, but I was pretty sure I was complete. I yelled for a vaginal check and the resident
doctor agreed that I was complete. I was on all fours on the bed, just hoping to push out a baby right
then.

The doctor came in, and unfortunately the head

nurse kept nagging me to flip over; I finally relented.
It was awful. The doctor said that we would be
staying in this room. When I flipped over, I
accidentally ripped out my IV and I didn't even feel
it. I had a small lip on my cervix, and baby was
posterior. They put me up on my bed and got the
stirrups, one which I broke somehow. I had a nurse
trying to replace the IV, someone checking my blood
pressure, eight or so people in the room, all while
trying to push. It was so difficult. Plus, I was pushing
uphill, while they were trying to rotate my baby.

Somehow, I was able to push him out, and have him

on my chest. He was crying instantly, and I felt
amazing relief. I needed just a couple of stitches. I
hemorrhaged a little, but it didn’t seem too bad
compared to my other deliveries. The baby had really low blood sugar, so he had to go into the NICU.
This was difficult, but I was blessed with amazing postpartum nurses that were so kind and comforting.
One even arranged for me to stay two extra nights in an extra room, so I didn’t have to leave my baby
yet. He ended up needing a feeding tube for a few days, and then oxygen. He had a three-week NICU
stay and is currently home and on a portion of oxygen. It’s been an emotional ride, but thankfully, he is
breastfeeding well and is alert and active.

There have been many tender mercies and wonderful people helping our family. One morning, on my
drive to the NICU, I heard the words of this Christian song, and it really touched my heart.

“Before I spoke a word, you were singing over me.

You have been so, so good to me,
Before I took a breath, you breathed Your life in me,
You have been so, so kind to me.”
(Reckless Love by Cory Asbury)
I could see that Heavenly Father cared enough about the birth of this little one to tell me months in
advance when he needed to come and where to go. He even paved the way for a policy change to take
place. Even though it was hard, and I had so much anxiety, I feel so blessed.

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 V. THE ART OF BRAIN

Having a good idea of what you want for your birth is important. Knowing what the options are and
what choices are available can be frustrating. To help guide you, we recommend mastering the art of
BRAIN, an acronym to use for making decisions.

What is BRAIN?
The acronym BRAIN is the process of using questions to analyze your options and guide your decision-
making process. We will explain the acronym and then apply it to circumstances you may encounter
during birth.

Benefits- What are the benefits of this intervention, option, procedure? How does it benefit me
and baby?

Risks- What are the risks of this intervention, option, procedure? How may it affect baby and I
negatively?

Alternatives- Are there other alternatives to this intervention, option, procedure? How do they
compare to XYZ? Are they gentler or more invasive?

Intuition- Ask yourself how you personally feel about the situation? What does your momma
gut say?

Nothing- What happens if we do nothing? Is it safe? Is it possible things can change? What
happens if we wait? How long is it reasonable to wait for me to decide?

Assessing Interventions
In labor, there are many interventions that can come into play. An intervention is anything done to your
body during the labor process and even before labor starts. Knowing what these interventions are and
what the BRAIN truly is will increase your chances of having a little-to-no intervention vaginal birth.
Sometimes, interventions are necessary, and that is ok, too. Knowing the risks and benefits will help you
make the best decisions for YOUR birth. We are going to over the common interventions you may face
and have a worksheet you will use to assess them for yourself when we are done.

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Induction

There are some providers that will tell you they will not induce a VBAC. Although it’s ideal for labor to
start on its own, VBAC moms can be safely induced and have a VBAC. According to ACOG, a prior low
transverse C-section is not a contraindication to induction (other than the use of Misoprostol/Cytotec),
so a Foley catheter or Pitocin may be used safely in most women. The problem arises when a
practitioner does not believe in doing inductions on women with a prior C-section.

Let’s talk more about induction. There are many ways of inducing labor, and part of mastering the art of
BRAIN is knowing what these are and what the pros and cons are to each one for you and baby. But how
can one really know if induction or interventions are needed? Providers will often give a Bishop Score
before induction. Doctors rate a woman’s cervix from 1-10. Anything less than a six means her cervix
may not be ready for labor.

*Signs your cervix is not ready to have a baby: Posterior cervix, high and hard/thick cervix, the body is
not showing any signs of labor starting. If induction is something mentioned by your provider, ask why.
Why is it medically necessary for me to induce?

Evidence-based reasons for induction include: Conditions like polyhydramnios, preeclampsia, fetal
growth restrictions, and other dangerous complications. Other examples include if your water has
broken but you haven’t gone into labor on your own after 48+ hours, low amniotic fluid, or decreased
fetal movement.

Reason for interventions listed below include: Cervix is not yet ready to be induced but it is medically
necessary to proceed with labor, labor has not started after two weeks overdue, labor has stalled.

Natural Induction Methods

Stripping Membranes

This is typically performed in the office of your provider. Your medical provider inserts their finger into
your cervix and separates (sweeps/strips) the amniotic sac from your uterine wall. This can release
prostaglandins and stimulate labor contractions. This method can be effective, but often may take 2-3
times and doesn’t have definitive studies to support its effectiveness. If labor is not yet ready, it may
bring on contractions that don’t bring progress. You may experience cramping and spotting after a
sweep. It can increase your chances of unwanted bacteria and weaken your membranes, increasing your

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chances of your water breaking too early, and in turn increasing chances of induction with other
methods and raising the chances of a C-section. If this option is presented to you, consider asking
yourself if stripping your membranes is medically necessary or is pregnancy wearing on you and you’re
just ready to be done?

(Vita, 2014)

Evening Primrose Oil

Also known as EPO, it is the oil from the seed of the evening primrose plant. When due dates are coming
up and induction looks like it may be necessary, many moms and midwives will look into Evening
Primrose Oil (EPO). The idea is using it vaginally or orally to soften and ripen the cervix to prepare it for
labor. We do NOT recommend taking this during pregnancy. There are only two studies available on its
safety and effectiveness. Neither study showed that it helped progression of labor and one of those
studies, referenced below, defines it as not supported during pregnancy and it should be avoided. It is
linked to bleeding issues and complications during Cesareans.

“The effects of EPO supplementation during pregnancy and lactation remain largely
unknown, and their use cannot be recommended. Extensive but transient petechiae
and ecchymoses have been reported in a newborn infant whose mother took a total
of 6.5 g of EPO during the week before giving birth. The oral use of EPO during
pregnancy may also be associated with a more protracted phase of labor and an
increased incidence of premature rupture of membranes, arrest of descent, oxytocin
(Pitocin) administration, and vacuum extraction. Additional concerns have been
raised about adverse effects of EPO supplementation on conditions including
platelet aggregation, cholesterol, and blood pressure.” (Bayles & Usatine, 2016)

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Cytotec/Misoprostol

Cytotec/Misoprostol does have its place for inducing women without a history of Cesarean; however, as
stated previously, the use of Misoprostol for a VBAC is NOT safe. In a case control study of 512 women
attempting VBAC, 5.6% of women receiving Misoprostol had symptomatic uterine rupture compared to
0.2% of women having a trial of labor without Misoprostol. DO NOT USE Misoprostol for VBAC induction
(Rath & Tsikouras, 2018).

Foley Bulb

A small catheter that is inserted into the cervix, where one side of the catheter is deflated. Once your
provider inserts it into the cervix, they will then inflate the balloon with saline. This causes pressure on
your cervix and will encourage your cervix to dilate. You must be dilated a little (1cm) to insert the Foley.
Usually a Foley catheter will help the cervix dilate (medicine/drug free) to about 3-4, sometimes 5cm
before falling out. It is very important to know that once your Foley falls out and you are checked, the
number you are told is a mechanical number. Your cervix is usually (in actuality) one cm behind the
number you are given. Once a Foley is removed, it can take some time before things continue to move
forward.

A Foley Bulb may or may not kick labor into gear. Often after a Foley induction, your body will need
something more to get labor going, and “staying put” for some time after a Foley is removed is normal.
Studies have shown that the use of a Foley catheter in the induction of women with a previous Cesarean
delivery appears to be a safe option with good success rates and few maternal and fetal complications.
Ask yourself, is this the best route of induction for you? Always feel free to discuss all options with your
provider prior and choose the option that best fits your intuition.

Pitocin

A synthetic version of Oxytocin. Oxytocin is the hormone that your body naturally produces to induce
contractions, as well as serving as the famous “love” hormone. Pitocin is administered via IV and will
increase the frequency and strength of contractions, which can cause dilation. For VBAC mothers, we
recommend starting on the lowest dose possible, 1ml. Providers will up the Pitocin slowly until
contractions have appeared to reach a good pattern, typically 2-3 minutes apart, lasting 60 seconds, and
are strong enough to create cervical change.

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If too much Pitocin is given, it can raise risks of fetal distress and uterine rupture. Something important
to know is if the cervix is not “favorable” or “soft”, providers will usually opt for another option prior to
starting Pitocin. Once you are on Pitocin, it is important to know you must be strictly monitored and
remain in or near your bed unless there are wireless monitors. Pitocin can always be turned off.
Sometimes, once your body kicks into “labor gear”, Pitocin is no longer needed. A sign that your body is
weighing heavy on Pitocin is if it is shut off and labor seems to stop or falter.

Is this the best route of induction for you? Talking with your provider on what your Bishop Score is, how
low of a dose it can start on, how fast it will be turned up, and how high it will go is a great place to start
to see if Pitocin is a good option for you.

Breaking Your Water

The amniotic sac lines the uterus and houses the amniotic fluid, baby, and placenta. It provides a barrier
to infection for your baby during pregnancy and cushions the baby as you move. When your water is
broken, it contains amniotic fluid, which has chemicals and hormones. When released, it likely will
stimulate labor. Physically, the bag of waters can provide a cushion between the baby's head and the
cervix, so when it is removed, baby’s head will apply itself against the cervix. When contractions happen,
it will cause pressure to the cervix which will then cause dilation of the cervix.

Sometimes, when the bag of waters breaks, if the body is not ready, it may take time, 24-48 hours, for
the hormones to kick in telling the body it’s time to have a baby. Also, if baby is not in an optimal
position, it can cause labor to slow/have irregular patterns, have slower dilation due to the pressure on
the cervix being weaker, back labor, increase risk of infection, and raise chances of a C-section. This isn’t
to say that you should never break your bag of waters in labor, but it is important to know that if you
can avoid it in early labor before baby has had a chance to get around to a good spot and labor has had
a chance to get efficient, that would be ideal.

Other Non-Induction Related Interventions

IUPC (Intrauterine Pressure Catheter)

A device placed into the amniotic space, typically between the baby’s head and the uterus, during labor
to measure the strength of uterine contractions intended to determine if the strength of the
contractions is strong enough to cause cervical change and get a better read of how the contractions are
affecting the baby’s heart rate. It does increase risk of maternal infection and fever thereby raising the

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risk of C-section. If possible, using an external monitor is a reliable, non-invasive alternative regardless of
body habits. If this is being recommended, it is important to ask why this is being suggested. Is this the
best route for you and baby?

FSE (Fetal Scalp Electrode or Internal Monitor)

A small electrode that goes into the scalp; a spiral wire placed directly on the fetal scalp. An FSE plays a
key role in measuring baby’s heart rate when there is a non-reassuring fetal heart tones. This can help to
avoid a Cesarean if the external monitors are not reading a valid heart rate. Being placed on the fetal
scalp puts a baby at risk of scalp abscess but does not put the mother at risk. It also raises risk of C-
section due to non-reassuring fetal heart tones. If possible, monitoring externally to read the baby’s
heart tones, or a hand-held doppler can be
just as effective if a heart rate is able to be
read. Baby’s safety and well-being is key. If
this option is offered, an educated
discussion with your provider is important.
Ask why this option is being suggested, what
the baby’s heart rate is doing, and why they
feel it’s necessary.

Epidural

An epidural block is a numbing medicine given by injection (shot) in the back. It numbs or causes a loss
of feeling in the lower half of your body. This lessens the pain of contractions during childbirth. It can
lessen the sensation of a contraction and help a laboring mom relax. This can be even more beneficial if
a you need relief from a long labor without food or sleep. If you are very numb from the block, you may
have a harder time bearing down to push your baby through the birth canal. Contractions may lessen or
slow down for a little while, but labor will still move along as it should. In some cases, it may even go
faster. If your labor slows down, your doctor can give you medicine to speed up your contractions. It is
best to wait until you are in active labor to have the epidural placed.

Counter pressure from a birth team member, changing positions, receiving nitrous oxide like you would
at the dentist (depending on the birthing location), or fentanyl for temporary relief as other great
options to consider.

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Fentanyl

Fentanyl is a synthetic opiate that provides mild to moderate sedation. Due to its calming nature, it
provides mild relief during contractions, takes the edge off, and lasts for about 30-45 minutes. You and
your baby can experience some sedation and/or nausea. It is important for baby to be delivered at least
two hours after Fentanyl is administered to reduce the risk of breathing issues.

Assisted Vaginal Delivery

In assisted vaginal delivery (also known as operative vaginal delivery), a device, such as forceps or a
vacuum, is used to assist the mom during pushing to achieve a vaginal birth. Approximately 3% of
deliveries in the US are operative vaginal deliveries (ACOG, 2016). A vaginal birth can be assisted, but
when is it appropriate? Situations include: prolonged pushing with lack of progress for three hours with
regional anesthesia (generally an epidural) or two hours for women without; suspicion that the fetus
may be compromised, such as the heart rate is not recovering or has a non-reassuring pattern; the
vacuum may be used electively to shorten the second stage of labor because of maternal cardiovascular
or neurologic disease, and is not well-defined with maternal exhaustion.

If the baby has some underlying fetal disorders, such as a bleeding disorder or a demineralizing disease,
an operative vaginal delivery may not be appropriate because it will increase the risk of excessive
bleeding and other complications. If the baby has a malpresentation, such as breech, transverse, or
facial presentation, assisted delivery will likely not work, or even be offered as an option. Talk with your
provider about your options. If you change positions, can that help baby come down more? Are you safe
to continue pushing as long as baby continues to do well, etc.?

QUICK REVIEW

What does the B.R.A.I.N. acronym stand for?

In your opinion, what is the most important thing to consider when making decisions for your birth?

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VBAC Story: Megan
My start to motherhood was unimaginably painful. I was pregnant with spontaneous boy/girl twins, and
after an otherwise smooth pregnancy, I woke up in preterm labor early in the morning on May 9, 2011. I
had made it to 32 weeks, and up until then, both babies were head down. We hurried to the hospital
and despite interventions, my contractions got closer and closer together. We had planned a vaginal
birth and were unprepared to advocate for ourselves when we were told Baby B was breech and a
Cesarean section was recommended.

During the C-section, Baby A, Madelyn, sustained a birth injury. Baby B, Jackson, came into the world
one minute later without issue. On May 13, our daughter, Madelyn Alice, died after four days in the
Level III NICU. Our son spent two weeks in the special care nursery and came home to bereaved parents,
figuring out how to care for a fragile preemie while also grieving the loss of Madelyn. Under these
circumstances, I have no idea how we went on to have more children.

Days before the twins’ first birthday, I found out I was pregnant again. I immediately researched VBACs,
as I couldn’t imagine going back into the OR after such a traumatic loss. At sixteen weeks, we found our
doula, and it was truly a birth match made in heaven. For me, labor and birth is a much more mental
exercise than it is physical, and what I need from a doula is emotional support, especially from 32 weeks
on until the delivery. I was so lucky to have found that with our doula, Nina.

Once my doctor determined I was a good candidate for a VBAC, she was with me all the way. I came to
her with insecurities and hesitations, and she reassured me with evidence-based research that babies
delivered via VBAC had the best outcomes compared to scheduled Cesareans. She helped me stay the
course and in addition to a doula, I think a VBAC-supportive provider is so important for a successful
Trial of Labor After a Cesarean.

On January 8, 2013, I woke up in the middle of the night, just like I had on May 9. We left home right
away and met our doula moments after being checked and admitted. She was also a massage therapist,
and I can imagine no better time for a massage than labor! Counter pressure, encouragement, and
switching positions often got me through the first hour. At that point, I was 4cm dilated. While I had
planned on an unmedicated birth, I couldn’t believe I was just at a four and didn’t think I could take
much more pain. My intuitive doula sensed I was close to transition, but still supported me through

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discussions about an epidural. However, she was right - the next time they checked me, 30 minutes
later, I was complete.

The doctor on the floor couldn’t deliver

me due to liability, so we had to wait
another 20 minutes for my OB to arrive.
While holding off on pushing, I
screamed to a resident, “This isn’t
natural!” She mistook what I was saying
and said, “You aren’t using drugs, this is
totally natural!” What I meant was, I
couldn’t wait to push anymore! My
doctor literally came running in, and 18
minutes later my second daughter, Margot, was born. She came out braying like a lamb, and I can’t think
of a better sound. I’ve gone on to have two other unmedicated VBACS in hospitals, and at my last
delivery, my baby was literally caught by midwives.

Jackson is now seven, Margot is five, Amelia is two, and our “caboose”, Holden, is eight months. Our
family is complete and I am so thankful, as I can’t imagine having such a large family without having
experienced Margot’s safe delivery. I never take for granted my children’s safe deliveries and the
privilege of leaving the hospital with them.

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 VI. BIRTHING TIME

Birth is something that, unfortunately, cannot be predicted. Even during something like a scheduled C-
section, there is no way to determine the outcome until baby is here. Although it’s great to have a plan
going into labor, being educated about the process of labor, birth, and postpartum can help in meeting
unexpected circumstances. Labor looks different for everyone and it’s hard to predict how long labor
may last and what interventions may be needed or suggested.

Remember, a woman’s body is not a robot or a time clock. Sometimes things unravel and go on a
different path than you’ve hoped or prepared for. In the end, when a woman feels like she’s made the
best educated decision for herself, it will help in processing the birth. Having doula support is valuable,
especially when things take an unexpected turn, by providing you with essential information needed to
make an informed decision moving forward. If the birth does not turn out the way it was planned, it is
important to know that it’s okay to be upset, it’s okay to talk about your feelings, and what you’re
feeling is valid. Along with your support system, doula, and care provider, there is help to aid in
processing birth.

What to Do when You’re Due

The end of the third trimester can be especially stressful when waiting for a VBAC. Some providers start
talking about scheduling inductions and/or a repeat Cesarean as early as 32/34 weeks. This can really
throw a tired pregnant mama for a loop. As we talked about in section IV, induction is a hot topic in the
VBAC world and as you approach 39-40 weeks, it can start to feel like there is a timeclock on your birth.
This is the time where providers get anxious and friends and family start asking if you’ve had your baby
yet, and any last-minute emotional triggers arise. To this, we say one thing (well, really, lots of things but
first, just one):

Take a nice long deep breath. Inhale, exhale, repeat. Good.

Now, remember, you have prepared for this. You know in your mind what is factually correct. You know
in your heart and gut what the best choices are for your family. Trust those things. Trust them now more
than ever. Stand your ground if you get questioned by family or friends or even by your provider. Do not
let your provider, or anyone else for that matter, push you into doing something you are not 100%

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comfortable with. If plans need to change, that’s okay too, but be the one making the decisions around
that change. We have included, on the previous page, a provider notes sheet that you can use to guide
your third trimester discussion with your provider. Take it with you between your 30th & 34th week
appointment to get a good feel if your provider is still VBAC supportive.

If induction becomes necessary for whatever reason at whatever gestation, discuss with your provider
what options are available to you and start with the lowest, slowest option possible. We have seen
amazing success with the following method:

1. Ask for an outpatient Foley Bulb. This is where they insert the Foley bulb and then send you
home with instructions to come back in when it falls out.
2. After the Foley Bulb falls out and you get back to the hospital, if contractions haven’t started
yet, request to start Pitocin slowly and on a low dose. Starting at a 0.5 or 1 unit and upping it by
that many every 45 minutes is a great gentle nudge to let your body know that it is time.
3. Once your body has been in a regular contraction pattern and you are in active labor, ask for
Pitocin to be turned down or even completely off. Often, once Pitocin has gotten things started,
they keep going without that additional stimulation.

This is not the only way a gentle and slow induction can happen, but it is a great option. Sometimes,
slow induction is not always possible or available but know that as long as you and baby are safe, it is
reasonable to request and expect that things move slowly and that your provider is patient with you.
Remember, it is never too late to get a second opinion or look for a more supportive provider if you feel
that your provider is turning on you. Listen to your mind, your heart, and your gut and if it is telling you
something is off, figure out what that is and act on it.

VBAC with an Epidural

A question we often get is “Can I have a VBAC if I want an epidural?” The answer is yes, you can. There
are a few important things to know and remember that will make it easier for you when the time comes.
When movement is restricted due to an epidural, it can make things a little more difficult, but not
impossible to help baby get in a good spot. There are still so many benefits to having a doula even with
an epidural. Historically, an epidural restricted a mom from most movement, meaning she would not be
able to do much more than lay side to side or even flat on her back in the bed. These days,
anesthesiologists have made it possible for women who choose an epidural to feel comfortable while

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also being able to have some strength in their legs and move around pretty easily, but still remain
restricted to the bed. It is recommended to change positions every 30-45 minutes. If you are sleeping,
it’s good to keep sleeping and not worry too much about movement until you’re awake. Your doula and
birth partner can help you get into the following positions during labor.

Labor positions with an epidural:

Left and Right Side Lying or Exaggerated Sims.

Get as far on your side as possible. Your hips should be on the far side of the bed so you can really
exaggerate laying on the other side. It is most ideal to have the arm back like in the Miles Circuit with
the top of the bed on the flatter end to allow movement for the baby. If possible, place a peanut ball
between your legs, making sure the knee is not over the tips to avoid strain on the back. Switching sides
with a throne or sitting up position in the middle is ideal.

Throne

The throne position is where you sit straight up. Get your bum as close to the back of the bed as
possible, supported with pillows on your upper back. Drop the end of the bed with your knees in a
butterfly position. This helps gravity do the work and baby get more engaged.

Assisted Squat

You may be thinking, “WHAT? I can squat with an epidural?” Trust us, it may sound crazy, but it is
possible. The staff may not want you to try, but if you feel strong enough, this is a good position to labor
and push in. Keep the bed set up like you would have it in a throne position. Ask for a squat bar to
attach to the bed and give it a try. You can get a sheet or a rebozo and put it under your bottom or legs
when desired or when it is time to push. Partner on one side, doula on the other, lean forward onto the
bar and they can hold you up with the ends of the fabric of choice. When you’re done, they will then
assist you back onto the bed in a seated position or on the edge of the bed.

Rebozo Sifting

If you’re able to move well and turn to your hands and knees, you can put the back of the bed up and
lean over it while one of the members from your support team holds your knees from sliding and the
other support person performs “shaking the apples”. You can also sift around the belly gently. These

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positions can help posterior babies rotate and babies engage. You can find more on each of these
techniques for rebozo sifting at spinningbabies.com.

Additional information about the rebozo: Do not use the rebozo if you have round ligaments that are
tight or cramping or if there is a worry about excessive bleeding. Is you have an anterior placenta, avoid
aggressive and/or rapid sifting.

Tug-of-War While Pushing

Using a rebozo or sheet, wrap it around the squat bar and place your feet on the bar. You can hold onto
the end and help to assist you in pushing.

Education

When an epidural is given, it is common for other interventions to be recommended. Remembering to

use your BRAIN in all scenarios can help you look back at the experience knowing you were in control
and felt empowered when you made decisions about those interventions. Knowing what to expect can
help eliminate any stress or fear if the staff reacts quickly.

Side Effects of the Epidural:

• Your blood pressure can drop and so can baby’s heart rate. This is something normal and will be
watched closely so things don’t get too low.
• Shaking. It’s normal for the body to shake and tremble after receiving an epidural and as it is
wearing off.
• Itchiness. It is normal to get itchy as things are wearing off.
• Only numbing one side of the body. This is not common, but it can happen where the labor
pains can present on one side while the other side is numb.
• Not working well. Although very uncommon, some women may still have a decent amount of or
even feel all the labor pain.

When Labor Begins

When contractions begin, we get excited. We may find ourselves wanting to track them or get up and
walk some more to see if that helps things get going.

HOLD THAT THOUGHT FOR JUST A SECOND.

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(Disclaimer-This advice is not to be replaced by your medical professional)

We suggest that first, you rest as much as possible at the beginning of labor. Recognize that your body
may need time to figure out this whole “labor thing” for a bit. Rest is key during your birthing time as
well. We also suggest that you eat a good meal with protein, carbs, and fiber before things get to the
point where eating is less desirable. Laboring at home for as long as you can increases your chances of
avoiding unnecessary interventions. Keep in mind that every laboring mom is different and has different
needs, so a discussion with your provider before the big day is a good idea so you know what YOUR
provider suggests you do. As a general rule, most providers typically request laboring at home until
contractions are 3-5 minutes apart, last a minute long, and have been happening for a minimum of one
hour.

General Tips to Help VBAC Success

● Labor at home as long as possible
● Sleep and eat often while you’re at home
● Hire a doula
● Know what “problem symptoms” to look for
● Find your coping tools
● Know the red flags
● Be okay to change providers if you see red flags, even if it’s in the end; finding a supportive care
provider is SO important
● Trust your momma instincts—they are already speaking to you

Knowing the Signs of Rupture

Uterine rupture happens in fewer than 1% of pregnancies (Nahum, 2018). Although the chances are low,
it is important to know the signs and symptoms before going into labor. If you experience any of the
following, mention it to your care provider and your birthing team immediately.

● Excessive vaginal bleeding (much heavier and more dramatic than you’ve ever experienced)
● Sudden sharp pain between contractions
● Contractions that become slower or less intense in active labor after having a great pattern
● Abnormal abdominal pain or soreness
● Recession of the baby’s head into the birth canal

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 ● Bulging under the pubic bone
● Sudden pain at the site of a previous uterine scar
● Loss of uterine muscle tone
● Rapid heart rate, low blood pressure, and shock in the mother
● Abnormal heart rate in the baby
● Failure of labor to progress naturally

Family-centered Cesarean
If a Cesarean section takes place, there is a wonderful option called “family-centered Cesarean”, or you
may hear it be called a “gentle Cesarean”. Knowing if your provider, anesthesiologist, and other hospital
staff can provide this option can change the entire feel/experience during a Cesarean.

What Exactly is a Family-centered Cesarean?

A family-centered Cesarean allows a mother and father to have a peaceful and calm atmosphere while
mimicking what happens during natural childbirth. It often allows a mother to see her child be born
through a clear drape, have immediate skin-to-skin, and allow the mother to breastfeed if desired. You
may ask if music can be played through the speakers in the operating room or through a small speaker if
you have one. Ask if the placenta may be saved (if the mother wants to keep it for encapsulation), if the
provider can milk the cord, or have the option to delay
cutting the cord until it stops pulsing, as well as doing a
vaginal swab for seeding. You should also ask if you can
have a loved one, doula, or photographer in the operating
room for extra support and/or photography.

“Having my sweet baby placed on my chest right

after she was born created a whole different
bond for her and I.” - Meagan Heaton

It is important to remember that this is YOUR birth

experience and it’s a day that should be very special—one you reflect on with positive thoughts. If a
Cesarean is something that is decided, a family-centered birth can be very healing for both mom and
partner, as well as make the transition from utero to world a lot more natural for baby. As you discuss
these things with your provider, it is important to call your hospital of choice. Although a provider may

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agree to some of the options above, it’s possible that hospital policies may override. Don’t be scared to
make your wishes known and learn all you can to prepare.

Family Centered Cesarean Options:

• Using a clear drape so you can see your baby being born.
• Immediate skin-to-skin in the operating room.
• Breastfeeding in the operating room or recovery room.
• Music being played through the speakers in the operating room or a small portable speaker.
• Saving the placenta.
• Milking the cord or delayed cord clamping so baby gets all of the cord blood.
• Vaginal swab for vaginal seeding (microbirthing).
• Additional support in the operating room such as a doula and/or birth photographer.

Vaginal Seeding (Microbirthing)

Above we talked about your provider doing a vaginal swab. This is a very easy step that may be done if a
Cesarean section is something that is needed. Your provider will take a cotton swab and insert it into the
vagina and collect vaginal fluid and then transfer it to the newborn, via mouth, nose, or nasal cavity. This
is something that you may want to discuss with your provider about doing.

ACOG states that “[C]esarean delivery performed before the onset of labor or before the rupture of
membranes prevents the fetus from coming into contact with vaginal fluid and bacteria. The intended
purpose of vaginal seeding is to transfer maternal vaginal bacteria to the newborn. As the increase in
the frequency of asthma, atopic disease, and immune disorders mirrors the increase in rate of Cesarean
delivery, the theory of vaginal seeding is to allow for proper colonization of the fetal gut and, therefore,
reduce the subsequent risk of asthma, atopic disease, and immune disorders” (ACOG, 2017).

Recovery
Physical recovery from a vaginal birth is very different than recovering from a Cesarean. Here are some
things you can generally expect based on your method of delivery.

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VBAC Recovery

DAY 1: Following delivery, it is common to experience adrenaline shaking. Your provider will assess
things and see if there is any vaginal tearing. If there is, your provider will suture once the placenta has
been birthed. To avoid vaginal tearing, position during delivery can play a big factor. Listen to your body
and create the most space for delivery. After you’re done, you will be cleaned up and left alone to enjoy
your first time with your baby. It is normal for nurses or providers to perform fundal pressure every 15
minutes for the first 1-2 hours. Fundal pressure involves a nurse applying manual pressure to the top of
the uterus and pressing down towards the birth canal, to encourage the uterus to return to its normal
size.

Walking, depending on if you’ve had an epidural or not, will either be getting up right away or waiting 1-
3 hours for your epidural to fully wear off. At this point, you are able to use the restroom and shower
off. This process may take some time. Remember, your baby just passed through a small area, so your
bladder is in shock and the nerves don’t always communicate perfectly right off the bat. Use a peri
bottle with warm water, but don’t rush it. If you can’t go right away, that’s okay—it will come. You likely
will have a rush of energy and then exhaustion may kick in. It is important to refuel and give your body
the energy it needs to take care of you and your baby.

DAY 2: You will likely start feeling a lot better energy wise but may be sore and swollen down below. Ice
is your new best friend. Don’t worry—your vagina will go back down to normal size, but for a few days, it
may feel a little different. You will likely go home this day if you’re in the hospital. Continue to ice and
rest as much as you can. Enjoy being waited on—you deserve it. Milk may or may not come in on day
two. Continue to nurse (if desired) as much as possible to encourage your body to tell your milk to come
in.

DAY 3: Swelling should be going down a little. Bleeding may continue for six weeks or longer. Don’t
forget, we are women of strength but it’s still important to continue resting. If you ever have any
questions or concerns, never hesitate to reach out to your care provider.

Repeat C-section Recovery

DAY 1: If there are no complications, after one to four hours, you’ll be wheeled from the post-op area to
a room in the postpartum recovery unit. You may be offered ice chips—which will taste like heaven. You
should then be switched to a liquid diet or small bites of crackers until your doctor clears you to eat real

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food. At this point, make sure to consistently take fiber pills or a laxative of some sort—trust us on this
one! You’ll also be asked if you have passed gas. TMI? Not after surgery! It’s actually an important
milestone following Cesarean, and it will get you the golden ticket to food.

Following your surgery, nurses will massage your uterus to encourage it to contract and shrink to its
normal size. They will usually do this every 15 minutes for the first two hours after birth and then once
every hour for a few hours after that.

You will likely be encouraged to get out of your bed, if possible, on the same day. Yes, you just had
major abdominal surgery—but the activity will help speed your C-section recovery. It can also lesson
your chances of experiencing any gas pain.

DAY 2: Your catheter is likely to be removed on day two if it hasn’t been already. This means you’ll be
walking—at least to the bathroom and back, and possibly farther. Just remember to take it slow. You
should be able to shower and wash off with little to no assistance. Water and light/mild soap should be
fine over your incision, but DO NOT scrub over it; this could damage your bandages and cause stitches to
misalign. Be sure to confirm with your doctor before doing so. You’ll be wearing a giant, diaper-like pad
along with awesome and washable mesh underwear for bleeding, which may last several weeks
following delivery. This totally normal discharge is called lochia, and it’s a combination of leftover blood,
mucus, and uterine tissue.

After your IV is removed, you’ll be asked

about your pain and given pain medicine as
necessary. Take it from us: don’t be a hero.
We are women of strength, but you don’t
want to be in pain. Take what you need so you
can enjoy your new baby. It is very difficult to
get back to a comfortable level if you miss
even one dose, so encourage your nurses to
wake you up during the night so as to not miss
any. DON’T forget the stool softeners. Your organs have been shifted and are swollen, and your first
time using your bowels can be the worst pain you’ve experienced thus far—unless you’ve taken as many
stool softeners/fiber supplements as allowed.

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DAY 3: Although moms who give birth vaginally generally stay in the hospital for about two days, the C-
section recovery timeline has you staying in the hospital for approximately three days (you can always
request an early release). Before you leave, your doctor will advise you on caring for your incision and
keeping the wound clean and undisturbed.

Remember, a C-section is a major surgery. You’ll be instructed not to lift anything heavier than your
baby, and be told to avoid sex, tampons, and douching until after your six-week checkup. ACOG
recommends not placing anything in the vagina for several weeks to prevent infection. Other restrictions
may include driving (until after you’re weaned off the heavier painkillers) and avoiding stairs. Just as any
type of birth, your body is your best judge. Listen to it. If it has increased bleeding, that is your body
telling you that you have done too much. Always consult your provider if you have any concerns.
Breastmilk may take a day or so more to come in, but likely will come in around day 3-4.

Don’t be afraid to ask family members and friends for help with taking care of older children, bringing in
meals, and/or housework. Even walking up a few stairs is discouraged and recovering from a C-section
with a newborn and other children can be overwhelming. Trying to tough it out can damage you
physically and emotionally—don’t rush it. Your baby needs you, so accept help, take a deep breath, and
do what you can. Remember—this stage of recovery will pass.

If you ever feel like things are too much to process or deal with or feel like something is just not quite
right, please reach out for help from friends, family members, or any professional organization. If you
feel overwhelmed, have harmful thoughts, or want to hurt yourself or your baby, please text
CONNECT to the United States crisis hotline at 741741. There is relief, there is help, and this will not
last forever. It is okay to seek help.

Postpartum Mood Disorders

Most women will have some sadness or anxiety as our hormones regulate postpartum. However, if your
sadness or other negative emotions last longer than 1-2 weeks, you may be experiencing one of five
postpartum mood disorders, which include: postpartum depression, postpartum anxiety, postpartum
obsessive-compulsive disorder, postpartum PTSD, and postpartum psychosis. One in 10 (or more)
women will experience postpartum depression or another postpartum mood disorder. Often, your
spouse or other support person will be the first to notice these things, so make sure they are aware of
the signs as well. Things to watch for that may indicate postpartum depression vs. regular baby blues:

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 • Worrying constantly, feeling worthless, feeling alone all the time, constantly crying.
• Always feeling like something bad is about to happen.
• Not bonding with your baby.
• Feeling like you are not doing a good job as a new mom.
• Not eating, sleeping, or showering because of your despair.
• Sudden outbursts of anger and/or anxiety.
• Being hyper focused on keeping your baby safe.
• Repeating acts that make you feel less anxious, like double checking the car seat buckles.
• Having repeated nightmares, flashbacks to a traumatic birth, or insomnia.
• Suicidal thoughts, hallucinations or delusions, or thoughts of harming your baby.

If you feel like any of these things apply to you, text the crisis hotline above or reach out to a known
therapist in your area immediately.

QUICK REVIEW

What are some good questions to ask your provider in your third trimester?

List three things that can encourage a successful VBAC:

What are some things you can request for a gentler Cesarean experience, if it becomes necessary?

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What are the signs of uterine rupture?

What is your “best friend” after delivery, regardless of having a VBAC or Cesarean?

What are some resources available to support mothers in the postpartum stage?

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VBAC Story: Erin
My birth story begins three years ago while pregnant with my firstborn (a daughter), when at 35 weeks,
after a completely uneventful, straightforward, and healthy pregnancy, we discovered my baby girl was
in a Frank breech position. Following a consult with maternal-fetal-medicine (MFM), we ultimately
decided against moving forward with an external cephalic version (ECV) and instead opted to wait and
see if she would turn on her own. Unfortunately, as the weeks passed, baby girl remained snug inside,
head up and bottom down.

At 40 weeks and one day, I woke around 3 o’clock in the morning to a ping in my stomach that
resembled a period cramp. I told my husband I thought I might be in labor, but that he could keep
sleeping since it would probably be awhile until we’d need to head to the hospital. Around six in the
morning, I decided to call the hospital when my contractions were about 7.5 minutes apart. By the time
we got checked into triage at 7:05, contractions were closer and a lot more intense. It had been about
four hours since my first labor pain; after a cervical check, the attending OB shouted out, “She’s an 8!”
My beautiful daughter was born on 8/17/14 at 8:17 a.m. via Cesarean with Apgar scores of nine and
nine. Surgery was respectful and straightforward; the OB explained to me what she was doing at every
junction; she even told me as she sewed me up that I was “the perfect candidate for a VBAC.” I knew my
body could birth a baby and I was already planning my VBAC in my head.

Skipping ahead 19 months, we found out we were pregnant again. My first step in the journey was
changing providers; I switched from the OB/GYN practice I had been with while pregnant with my
daughter to a midwife practice. As part of my care plan, I was required to meet with an OB from the
midwives’ consulting obstetrician group. I specifically scheduled a meeting with the head OB from that
group, whom I had heard good things about and whom I was told was very VBAC-friendly.

Upon reviewing my health records, the first question he asked me was, “So, why didn’t you have a
vaginal breech birth the last time?” My jaw dropped. I couldn’t believe he asked me that, since the topic
never came up once as a possible option. I knew this time around I was with the right group of
providers; a huge weight had been lifted from my shoulders and I felt I could finally start to enjoy my
pregnancy. From that point on, my pregnancy progressed much like my first (complication-free and
uneventful). Starting around 14 weeks I began doing twice-weekly prenatal yoga to ensure better body
balancing, in hopes of giving baby the best chance of getting into an optimal position.

Around 30 weeks, I started seeing a chiropractor certified in the Webster technique for weekly
adjustments. Baby luckily got into a head-down position around 28 weeks and we never looked back.
My due date of 11/24/16 came and passed along with the Thanksgiving holiday. We had family in town
and everyone was excited and eager to meet our new addition.

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I had been having increasing Braxton-Hicks contractions for a couple of days surrounding the holiday,
but nothing resembling a consistent labor pattern. Early morning on 11/27/16, I woke up around 3:30
a.m. with period-like cramps. I got up and decided to start timing to see if these were the real thing or
just pre-labor. I woke my husband and told him I was going to the living room for a while to time them
and I’d come wake him if it looked like they were turning into something more consistent. After timing
contractions for about an hour, I texted my doula to let her know I was awake and contracting, but that
there was no distinct pattern. She suggested I have some water and lay down to see if they might go
away. I took my doula’s advice and eventually contractions dissipated around 6 a.m. and I was able to
catch about 2.5 hours of sleep before getting up again to officially start the day.

I woke again around 8:30 a.m. on 11/27/16 and contractions picked back up soon after, although still
spaced out and not very intense. I called my doula in the morning and gave her an update. We decided
since they were still infrequent and mild, to keep an eye on them to see if they would turn into
something more consistent.

Around 1 p.m., my husband, daughter, and I headed out for afternoon brunch. At around two, while at
brunch, the contractions started to become more uncomfortable, coming about every 15-20 minutes.
This is when I suspected it was the real thing. My doula called me while at brunch and I filled her in.
Since contractions were still 15 minutes apart, we decided to stay in touch about progress. She
suggested I go for a walk and see how they progressed from there.

After brunch, we gathered our daughter and decided to head to a nearby reservoir that also had a big
play area and park. As we made our way for the play area in the park, the contractions began to
intensify and started getting closer (about 13 minutes apart). As we approached the playground, I told
my husband I was going to follow behind them so as not to cause concern for my daughter. A short
while after, I felt as though I couldn’t be in public any longer and needed to go home soon (contractions
were about 9-11 minutes apart).

Once home, contractions were still quite spaced out and we figured we still had some time, so I sent my
husband off with my daughter to see if he could get her to nap before leaving her with family. As I
finished gathering our last items, I called my doula and told her contractions were about 7-8 minutes
apart by that time and very intense. She said most likely today was going to be the day and that I should
start making the necessary calls to arrange for my daughter’s care. Then, I had a monster contraction
that shook me to my core; all of a sudden, I felt a trickle of fluid and then a full gush; it was my water!

Simultaneously, I felt a major shift inside of me – the baby was “at the doorstep” and I was
home...alone. As the physical sensation overtook me, a moment of panic set in; I guided myself down to
the living room floor into a side-lying position; I quickly spotted my cell phone on the couch and reached
for it immediately. I dialed my doula to let her know my water had broken and the baby was coming.
Sensing the panic and urgency in my voice, my doula told me she would be there in five minutes (luckily,
she literally lived five minutes from me).

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Next, I tried my husband, but, to no avail—I got his voicemail. As I laid on my side, my contractions
started to space out. I reached my hand down and could feel the top of my baby’s head; I could feel he
had some hair and remembered that my daughter was also born with hair. There he was! Right there! I
knew this VBAC was going to happen. In that moment, I realized I needed to calm down and pull myself
together. I told myself someone would be there soon, but that it was likely I was going to have to deliver
my baby on my own.

I knew I needed to be focused for my baby and remember telling myself to breathe, that I needed to be
there for him. I found my calm the best I could, and tried to take some good, deep, cleansing breaths.
During this time, my cousin called me back (I called her when I couldn’t get ahold of my husband) and
stayed on the phone with me as my body began to push. Then, all of a sudden, I heard a pounding on
the door; it was my doula! The college girls that live across the hallway from us had let her in our
building, but I had forgotten the door to our apartment was locked as well and my doula didn’t have a
key! She shouted that the door was locked and that she needed me to let her in, but, at that point, there
was no way I could physically stand up to let her in; the baby coming then and there and my body was
pushing all on its own.

It wasn’t more than another push and my

son’s head came out. Almost simultaneously,
the rest of his slippery little body followed. As
he slipped out and softly landed on
the carpeted living room floor, he began to
immediately cry; I remember being so
incredibly amazed, not only at how painless it
felt, but that he came out of me so quickly
and easily. The second I saw him land softly
on the carpet, I scooped him up and shouted
to him, “I got you! I got you!” I brought him
immediately to my chest, hugging him tightly since I didn’t want to drop him (he was so wet and
slippery).

Although I had not planned for an unassisted home VBAC, I felt I was as prepared mentally, emotionally,
and physically as anyone could be for this kind of experience. I am in absolute awe of the female body
and am certain all women have the same instinct and ability to birth their babies unhindered. The love
and respectful care I received from the first responders, medical team, doula, and family was priceless
and I have never felt more powerful, capable, transformed, and healed as I have as a result of this birth.
I hope, if anything, my experience shows other moms who are on their VBAC journey that their bodies
are not broken and that it is possible to birth with strength and intuition.

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 VII. CONCLUSION
Steps to Success
TRUST YOURSELF

It goes without saying that sometimes there are circumstances where a baby just won’t come out
vaginally. However, there is a lot to be said about the power of the mind and a woman’s intuition. Belief
in yourself and your ability to give birth is a huge part of the battle. Confidence and fear cannot coexist
in the same space. Where there is fear, there is tension, and when you can release that doubt and bring
in full confidence, amazing things can happen. Birth is awesome. It’s messy, complex, simple, and hard,
but somehow easy, and plays out in SO MANY different ways. If you can trust the process, trust your
mind, and trust your body—you have conquered a large part of the battle.

GET A SOLID BIRTH TEAM

The most important thing you can do to achieve the birth you desire is to go to a VBAC-friendly birth
place and have a VBAC-friendly provider. A provider that trusts a woman’s body to birth is so, so, so
important. Also, you guessed it: get a doula. There are many studies that show how a doula can improve
just about every aspect of your birth. A skilled doula helps a woman to communicate her needs and
perceptions to realize her dream of having a healthy, positive birth experience. Having a doula is shown
to reduce your chances of Cesarean by 39%. A great doula will be able to help you get your baby into a
great position, help you know what positions to labor in that will open your pelvis, and has an eye for
when things might be headed towards unnecessary interventions.

EDUCATE YOURSELF

You are already a step ahead by taking this course. Keep learning. You can never learn too much
information to prepare yourself for VBAC or even birth in general.

Most importantly, trust and be kind to yourself. There is not a single “right way” to give birth. The key is
to be empowered and educated in order to make the best decisions for YOU. You should feel in control
of what is happening to you while you birth. It is YOUR labor—only YOU can give birth to this baby and
no matter which way you do it, YOU DID IT and that is a big accomplishment.

QUICK REVIEW:
What are three things you can do to ensure you have the most positive birth experience?

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 APPENDIX 1 - DEFINITION OF TERMS

ACOG- The American College of Obstetricians and Gynecologists, a professional association consisting of
physicians who specialize in obstetrics and gynecology in the USA. ACOG advocates for higher standards
of practice in women’s healthcare.

American College of Nurse-Midwives (ACNM)- A professional that represents CNM’s (Certified Nurse
Midwives) and other certified midwives.

Anterior Baby- When the baby’s back is along the front of the mother’s stomach, the optimal position
for labor.

Anterior Placenta- When the placenta is attached to the front of the uterus, on the belly side, rather
than the back side.

APA- The American Pregnancy Association is a non-profit organization that helps promote pregnancy
awareness and wellness and addresses other pregnancy needs.

APGAR- Appearance, Pulse, Grimace, Activity, & Respiration; a number from 1-10 that is given to a baby
at the one- and five-minute mark after birth.

AROM- Artificial Rupture of Membranes; when the bag of waters breaks by force or is punctured
artificially.

Augmentation of Labor- Starting labor before it has started on its own.

Bishops Score- A score from 1-15 that the cervix is given prior to labor starting to gauge how ready it is
for labor. A score of eight or more indicates that the cervix is favorable for induction and has a good
likelihood for vaginal delivery. A Bishops Score of six or less means the cervix is not ripe nor favorable for
induction and a vaginal delivery is less likely.

CBAC- Cesarean Birth after Cesarean; when a mom has a Cesarean after a previous Cesarean.

CFM- Continuous Fetal Monitoring; instruments used to continuously monitor the heartbeat of the
fetus.

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CNM- Certified Nurse Midwife; a registered nurse who has additional training and can deliver babies.

CPD- Cephalopelvic Disproportion; a pelvis that is misshapen or malformed (this is incredibly rare).

CPM- Certified professional midwife; a skilled and knowledgeable midwife who has met the needed
standards to deliver babies.

Contraindication- A condition or factor that automatically excludes someone from a medical treatment
or, in this case, method of delivery, because the harm that it would cause the person is too great.

Cytotec or Misoprostol- A hormone inserted vaginally or taken orally to help prime/thin the cervix. This
is contraindicated for VBAC.

Dilation- The opening of the cervix.

Effacement- When the cervix starts to prepare for labor by thinning out.

EFM- Electronic Fetal Monitoring; a monitor that is placed on the belly to read the baby’s heart rate.

Evidence-based Care- Decisions for care based on scientific data and research.

FSE- Fetal Scalp Electrode; a monitor that is placed on the baby’s scalp that reads an accurate heart rate.

GD: Gestational Diabetes; causes high blood sugar and can negatively affect a pregnancy and baby’s
health.

HBAC- Home Birth After Cesarean; when a mother chooses to have a vaginal birth after Cesarean at her
home.

ICAN- International Cesarean Awareness Network; a group that strives to improve maternal and child
health by lowering unnecessary Cesareans through education, supporting recovery, and continuing to
advocate for VBAC.

IUPC- Intrauterine Pressure Catheter; a small catheter that is placed between the cervix and the baby’s
head to detect the exact pressure of how strong contractions are.

Malpresentation- When a baby is not in the correct position.

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NCBI- The National Center for Biotechnology Information is a part of the USA National Library of
Medicine, and is a national health institute.

OB- Obstetrics or Obstetrician, a physician that delivers babies.

OP- Occiput Posterior, another name for a posterior baby.

Pitocin- A synthetic version of Oxytocin, the “love” hormone, that helps labor start and progress.

Placenta Accrete- A serious pregnancy condition when the placenta grows too deep into, or even
through, the uterine wall.

Placenta Previa- A condition where the placenta partially or fully covers the opening of the uterus
(cervix) and causes problems with vaginal delivery.

Polyhydramnios- Excess of fluid in the amniotic sac.

Posterior Baby- Also known as “sunny side up”, when the baby’s back is along the mother’s back.

Posterior Cervix- When the cervix is tilted towards a woman’s back. A posterior cervix is low and closed
and hard, and will move forward as it started softening and opening.

Rebozo- A long scarf used as a comfort tool during labor and to adjust baby’s position before and during
labor.

Ripening Cervix- The softening of the cervix before labor begins.

ROM- Rupture of Membranes, when the bag of water breaks.

Saline Lock- Also known as a hep-lock, historically; this is an IV catheter, placed in a vein in the arm or
hand, flushed with saline, and capped off in case urgent administration of a drug is needed later on.

TOCO- Short for cardiotocography, a monitor that measures uterine contractions and fetal heartbeat.

TOLAC- Trial of Labor after Cesarean; the term describes a woman who wants to try to have a vaginal
birth after a C-section but has not yet completed the vaginal birth.

Tocolysis- An anti-contraction medication to stall or stop labor.

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Transverse Baby- When the baby lies sideways or the baby’s head is looking to the side.

Uterine Dehiscence- When the uterine scar opens slightly but not through the entire distance of the
uterine scar.

Uterine Rupture- When the uterine scar opens through all three layers of the uterine wall.

Uterine Window- Where the scar tissue of the uterine scar is stretched thin and you can see through it.

VBAC- Vaginal Birth after Cesarean; the official title after a woman has a Cesarean and then delivers
vaginally. A successful TOLAC.

VBAMC- Vaginal Birth after Multiple Cesarean, when a mother chooses to have a vaginal birth after two
or more Cesareans.

Webster Certified Chiropractor- A chiropractor certified to perform a specific type of sacral adjustment
to help the mother’s pelvic alignment and nervous system.

For more definitions visit:

https://www.betterhealth.vic.gov.au/health/ServicesAndSupport/medical-terms-and-definitions-during-
pregnancy-and-birth

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 APPENDIX 2 – RECOMMENDED RESOURCES

We encourage you to study and dig even deeper into the areas that resonate well with you. Here are
some recommended resources that we love.

Optimal Fetal Position Resources

The Miles Circuit: milescircuit.com

Belly Mapping: spinningbabies.com/learn-more/baby-positions/belly-mapping
Truths and Myths about OP Baby: spinningbabies.com/learn-more/baby-positions/other-fetal-
positions/op-truths-myths
All things baby position related: spinningbabies.com
Books

Birthing Normally After a Cesarean or Two by Hélène Vadeboncoeur

How to Heal a Bad Birth by Debby A. Gould and Melissa J Bruijn
The VBAC Companion by Diana Korte
Ina May’s Guide to Natural Childbirth by Ina May Gaskin
Birthing from Within by Pam England and Rob Horowitz
Cut, Stapled, & Mended by Roanna Rosewood
Websites

The VBAC Link Blog: www.theVBAClink.com/blog

ACOG: www.acog.org
ICAN: www.ican-online.org
VBAC.com: www.VBAC.com
Evidence-based Birth: evidencebasedbirth.com
From Dads to Dads: www.fromdadstodads.org.uk
Podcasts

The VBAC Link Podcast: TheVBACLink.Podbean.com

The Better Birth Podcast: TwoDopeDoulas.libsyn.com
The Birth Hour: TheBirthHour.com

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