How to Prepare for a Successful VBAC

Considering a VBAC?

If you’ve had a Cesarean birth by necessity or choice, and have decided to attempt a vaginal birth in a current or future pregnancy, the idea of planning a VBAC (Vaginal Birth After Cesarean) may seem overwhelming. There are so many emotions that often surround this decision.

Many blog posts have been written on how to have the best chances of achieving a VBAC from a medical standpoint, covering all of the things you should and shouldn’t do in labor and the tests you should and shouldn’t have late in pregnancy. This article has some great starting points for things to think about when considering a VBAC.

My experience, planning my own VBACs and working with other Cesarean and VBAC moms, has shown me that the best advice I can give is to educate and empower yourself. Emotional and educational support is key so that you can make the best choices for YOUR birth and feel prepared and empowered for your VBAC journey. This post will cover the ways in which you can prepare before labor ever starts. Much of that preparation involves finding the best support and education that you can.

Find a Supportive Provider

One of the single most important factors in having a successful VBAC is finding a truly supportive provider. Depending on the area you live in, the birth climate, and availability, this may be an OB/GYN or a midwife.

The midwifery model of care is often times more supportive of VBACs, as they tend to practice in a more natural, less-is-more environment. Midwives also tend to spend more time with their patients during pre-natal exams and during labor, helping their patients to feel more supported.

Midwifery care seeks to protect, support, and avoid interfering with the unique rhythm, character, and timing of each woman’s labor. Midwives are trained to be vigilant in identifying women with serious complications. Medical expertise and interventions are sought when necessary but are not used routinely. (1)

It is incredibly important to find out as early in your pregnancy as possible (or before you are pregnant) if your provider is truly VBAC supportive or just VBAC tolerant. Many women are led to believe that their providers will “allow” them to try for a VBAC only to find in the last trimester, the conversations often turn towards a repeat Cesarean and their doctor seems to be trying to find a way to schedule a Cesarean. Here is a great list of ways to find out if your provider is VBAC tolerant or VBAC friendly.

Two very important questions you should ask your provider, are:

“How many VBACs have you attended this year?”

and

“How many of your patients have had a trial of labor after a Cesarean (TOLAC) and of those how many have had successful VBACs?”

It’s important to know, not just how many women have had VBACs, but also how many have tried for them and how many have actually achieved them. If a doctor’s VBAC rate is only 30% (after a trial of labor) then that’s not a good sign. Statistically, women who attempt a trial of labor after a Cesarean have about a 70% success rate.(2) If your provider’s VBAC rate is much lower than this, it could be a major red flag that they are not truly supportive of VBACs.

Despite the high VBAC success rate for women who have a trial of labor after a Cesarean, only about 10% of women will ever try for a vaginal delivery. The other 90% will go on to have repeat Cesareans in their subsequent pregnancies. One of the biggest reasons for this is the fact that so many women don’t feel supported by their providers in attempting VBACs or because they are simply told that they cannot or should not attempt a VBAC.

Here is an article with some great ideas of other questions to ask when interviewing a potential care provider for your VBAC. Remember, you are interviewing them to find the best provider match for you and your birth.

If you are not satisfied with your provider’s answers, it may be time to find a new provider.

Switching providers during pregnancy can be scary, but it’s your right and can make a world of difference for your birth experience. This is your birth and you are paying your provider for a service. It’s never too late to switch providers during your pregnancy.

Location: Different Hospitals, Birthing Centers, & Home Birth

If you have the option of birthing at multiple hospitals, tour them all and if possible, talk to the nurses and ask them specific questions about their labor and delivery procedures and protocols.

I recently visited a friend who was delivering in a larger city with multiple hospitals. Her doctor had privileges at two hospitals in town. She asked me to tour both hospitals with her and tell her what I thought of them. The first hospital had a very inviting and comforting atmosphere (it seemed more like a birth center than a hospital). When we talked to the nurses, they were very open to moms being able to move freely and walk during labor, the use of a hep-lock instead of an IV, intermittent monitoring, using the large shower for pain relief, and pushing in different positions.

The second hospital had a very sterile feeling to it. Their rules were very black and white and the nurses let us know that there was not an option to not have an iv and once your water broke you would be in bed, on your back, with constant monitoring. The difference between the two hospitals and their procedures was night and day.

One of the nurses we talked to at the second hospital suggested going to a local birth center staffed with midwives in order for my friend to find the birth that was more in line with her birth plan.

That brings up another good point…A hospital may not be the best setting for you personally, to achieve your VBAC. You need to birth where you are most comfortable (and that may well be in the hospital) but thoroughly investigate all of your options.

Depending on where you live, a birth center may be another option for your VBAC. Freestanding birth centers are typically run by midwives and are often times in very close proximity to a local hospital.

One study by the National Institutes of Health showed that 87% of women attempting a trial of labor in birthing centers had successful VBACs. That’s a much higher number than for hospital births.

Another VBAC option is a home birth, often referred to as an HBAC (Home Birth After Cesarean). Many home birth midwives (CPM’s and CNM’s) attend HBAC’s and have very high VBAC success rates.

According to this study by The Journal of Midwifery and Women’s Health, the success rate of VBACs at a planned home birth was also 87%.

Find Personal Support

Another extremely important factor is having a support system around you who believes in what you are doing. Is your spouse/partner supportive of a VBAC? Do you have friends/family members who are supportive of a VBAC? Everyone in your family and circle of friends doesn’t need to be supportive or in agreement with you (and they likely won’t be), but it’s important to have key people who you can talk to, knowing they are cheering you on.

If you don’t have this support system, it might be time to find it or make it for yourself. Look to see if there is a local ICAN chapter in your area.

ICAN is the International Cesarean Awareness Network. Their mission is “to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery, and promoting Vaginal Birth After Cesarean.”

Local ICAN chapters have monthly or bi-monthly support meetings. These are wonderful opportunities to process through your previous birth experience with others who understand what you have been through. They also hold meetings focusing on the 3-fold-mission of their organization (preventing unnecessary Cesareans, Cesarean recovery, and promoting VBACs).

Here is a list of other support groups. Some of them offer online options if attending a face-to-face meeting isn’t an option in your area or for your life circumstances.

Find a local La Leche League chapter or similar breastfeeding support group. Look for a parenting group that has a natural mind set such as Attachment Parenting International or The Holistic Moms Network. These are the places where you will find other mommas who have been there and can the offer the support that you may need when you face moments of doubt. These groups are also a wealth of knowledge when trying to choose a truly supportive doctor or midwife.

Hire a Doula

A doula is a word “used to refer to a trained and experienced professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth.”

Studies show that having a doula decreases the length of labor, the need for pain medication and Pitocin, the use of forceps/vacuum extraction deliveries, as well as decreasing the chances of a Cesarean. These same studies show that having a doula also increases the health of the newborn, as well as increasing the women’s satisfaction of her birth experience.

Doulas are not only there to offer support during labor. Much of the work and support that doulas provide is done before labor ever starts.

They offer education regarding birth options as well as empowering the families they are working with to become more comfortable advocating for themselves. Becoming an advocate for yourself and your birth will be one of your biggest jobs while preparing for a VBAC. Your doula can guide and support you in this journey.

Doulas typically know the local hospital protocols and procedures and can help you to navigate within them. Your doula will also help you to learn and practice the comfort measures you will use during labor as well as helping your partner to put these into practice.

Take a Childbirth Education Class

Attending a reputable evidence-based childbirth class will help you find and sift through the information that you and your partner may need during pregnancy and labor. You can then make informed decisions regarding your pregnancy and birth. Being faced with these options for the first time at week 40 of your pregnancy is not the optimal time to start your research. Neither is when you are in the throes of labor in between contractions.

If you don’t know your options, you don’t have any. –Diana Korte.

There are so many decisions to be made regarding your birth but in order to make the best decisions for yourself, your baby, and your family, you will need to know all of your options as well as the benefits, risks, and alternatives. You also need to have time to weigh those options.

This is exactly what a quality evidence-based childbirth education class does: it gives you the information you need to be armed with in order to make the best possible choices for your pregnancy and birth.

There are many evidence-based childbirth education classes out there. Among some of the most popular are: Lamaze, Bradley, ICEA, Mama Natural Birth, Hypnobirthing, and Birthing from Within. Take a look at the curriculum they use and the structure of the classes and see which appeals most to you and your spouse.

Some of these methods offer online/distance courses. Although I recommend taking an in-person class if possible (this is another great way to build your support circle), I realize this is not always possible. In such cases, an online course is a great alternative.

Read Books that Will Encourage and Empower You

My favorite book to read when I was planning my first VBAC and natural birth was Ina May’s Guide to Childbirth. It can be a little hippy dippy for some, but it really allows you to see the beauty of what childbirth can be and it has so many amazing birth stories.

I’ve talked to many women who have read this book and have told me that it took away much of the fear that they had about childbirth in general or about a vaginal birth.

Birthing from Within is another book that really helps to alleviate the fears that many women often struggle with surrounding childbirth.

Katie has a list of her 10 favorite pregnancy books here.

Here are a few other book recommendations:

• Pregnancy, Childbirth, and the Newborn by Penny Simkin et al.
• The Thinking Woman’s Guide to a Better Birth by Henci Goer
• The Birth Partner by Penny Simkin
• This is a great book for your husband to read.
• The VBAC Companion: The Expectant Mother’s Guide to a Vaginal Birth After Cesarean by Diana Korte

Watch Informative Movies About VBACs and Childbirth

This is even better if you can get your partner to watch the movie with you. My husband wasn’t interested in reading my birth books, but he was willing to watch the movies with me. These movies are filled with information and encouragement for VBACs and birth in general.

• Trial of Labor
• The Business of Being Born
• More Business of Being Born Part 4:VBACs
• Microbirth  (highly recommend!)

Create a Birth Plan

Your birth plan shouldn’t be more than one page long. It can simply be bullet points of the things that you would like to happen and not to happen during your labor.

Typically, nurses have shift changes in the hospital every 12 hours. If you are there during a shift change you may have multiple nurses caring for you. You want each nurse and health care provider to be clear about your choices for your labor and birth, but those choices need to be easy and quick for them to read.

Remember, plan for the birth you want but realize that sometimes (due to medical necessity) plans may change. Make contingencies for the possibility of those changes (such as a Cesarean).

Here is Katie’s simple but effective birth plan.

Make Preparations for a Repeat Cesarean

Don’t ignore the fact that you could end up with another Cesarean. Don’t dwell on it either, but have a plan in case it happens. One of the worst things that can happen to a woman who has planned for a VBAC is to end up with a needed repeat Cesarean, only to find herself completely unprepared for it.

We’ve had several moms in our support groups who, after preparing for a VBAC, ended up with a repeat Cesarean and were very happy with their experiences. They were able to hold their babies right away, breastfeed in the operating room, and not be separated from their babies at all, despite the fact that these preferences went against the hospital’s typical protocols. This was because the conversations about what their preferences were, in case of a Cesarean, was discussed several times with their OBs, long before labor ever started.

Often times the ultimate decision of what happens during the surgery rests with the anesthesiologist. If your OB knows your preferences and desires for your birth, he/she may go to bat for you and be able to make it happen simply by them discussing it with the anesthesiologist.

A VBAC can be very healing after a previously traumatic Cesarean, but so can a C-Section that is planned well. What has made the biggest difference for the women I have worked with seems to be that they felt more prepared and empowered the second time around, planning what they wanted their Cesarean to look like in the event that it became necessary.

Here are some questions to think about and discuss with your OB when preparing for the Cesarean portion of your birth plan:

• Do you want to see your child being born? The drape can be lowered as baby is emerging. (Some hospitals are even offering clear drapes and a new drape has just been invented which offers “a sealable flap opening that allows the doctor to pass the baby to the mother.”)
• Do you want skin-to-skin contact immediately after birth?
• Do you want to breastfeed on the operating room table after baby is born?
• Can baby stay with mom in the operating room and not be separated?
• Can you have more than one support person in attendance during the surgery so that one can stay with mom and one can go with baby if baby needs to be separated from mom? An additional support person, such as a doula, can also help facilitate skin-to-skin contact and immediate breastfeeding in the operating room.
• If there is a need for separation, will you immediately be reunited in the recovery room or do you have to wait until you are in your postpartum room?
• Do you want to delay a bath (and other procedures) for the baby in order to have more time bonding/breastfeeding immediately after baby is born?

Many of these procedures are currently changing in hospitals across the country, to allow for more gentle/family centered Cesareans. It takes time for procedure and protocol changes to happen within hospitals. The more women who request and push for these options to be made available during their Cesareans and in their birth plans, the sooner hospitals will change their current protocols and these options will be available to all women in the US.

Don’t make the mistake of ignoring the fact that you may have to have a repeat Cesarean. Despite the goal of a VBAC, there are circumstances when a VBAC may not be possible and you’ll want to be as prepared for that as you possibly can be.

For more information on gentle Cesareans or family centered Cesareans, check out this NPR article and this National Institutes of Health article (I would suggest printing this one off and bringing it in to your provider because it is from the National Institutes of Health. It will give your provider much of the necessary information regarding the options you would like available to you during a Cesarean. Your specific provider may not be familiar with these options and it may take some “education” to get them on board.)

Katie wrote an excellent post about how to have a gentle and natural c-section, and here is an example of a family centered birth plan.

Read the VBAC Success Stories of Others

When I was preparing for my first two VBACs I had quite a bit of fear. I find that this is very common with VBAC moms. We tend to have quite a bit of doubt that our bodies are capable of a vaginal birth after having a previous Cesarean.

One of things that helped me most was reading the successful VBAC stories of other moms. It gave me the feeling that because they had done it, so could I.

Katie’s beautiful birth story of her healing VBAC breech home birth is a great story to read as well.

Labor at Home

I know, I said that I wasn’t going to give you “in labor” advice, but I do want to say: Labor at home (preferably with a doula) until contractions are well established. Many providers use the “5-1-1 rule”, meaning that contractions have been 5 minutes apart and lasting for at least 1 minute for at least 1 hour, as a guideline to know when to come into the hospital or birth center.

In my experience (and the experiences of many birth professionals I work with), VBACs tend to be longer in length than non-VBAC labors. This is especially true for moms who have never had a vaginal birth. These births are essentially more like a first birth because despite the fact they have given birth via Cesarean, they have not birthed vaginally.

It is very common once you are at the hospital to be put on the birthing time clock, meaning that you are given a range of time in which you need to progress to 10 cm and push baby out before most OB’s will start pushing for a repeat Cesarean.

Research shows that women who arrive at the hospital with “advanced cervical examination findings (cervical dilation and cervical effacement)” have a higher rate of a vaginal birth. This study found that women who were dilated to 4 cm or more when they arrived at the hospital, had an 86% rate of VBAC.

Study the VBAC Education Project

The VBAC Education Project is a wonderful new resource available through ICEA and ICAN. It is a free evidence-based educational project with modules for both parents and professionals. There is a wealth of knowledge regarding VBACs in these modules. Because these are brand new, I haven’t been through every module, but the ones I have been through are wonderful! Take advantage of all of the free information provided here.

Conclusion

So, now that you’ve read this very long post, I would say that my VBAC advice could be broken up into 4 basic points:

1. Choose a VBAC supportive provider
2. Do your research
3. Build a support system
4. Trust your body

I’ll leave you with one of my favorite birth quotes:

Remember this, for it is as true and true gets: Your body is not a lemon. You are not a machine. The Creator is not a careless mechanic. Human female bodies have the same potential to give birth well as aardvarks, lions, rhinoceros, elephants, moose, and water buffalo. Even if it has not been your habit throughout your life so far, I recommend that you learn to think positively about your body.
-Ina May Gaskin

Other Helpful VBAC Websites:
www.vbacfacts.com
www.theunnecesarean.com
www.cesareanrates.com
www.vbac.com

Have you had a VBAC? What did you find helpful in preparing for your VBAC?

About the Author: Jennifer West is the mother of 5 and a DONA trained doula, specializing in VBAC’s, and currently working towards her midwifery certification. She founded and for 3 years co-led her local chapter of ICAN, working with local women to prevent unnecessary cesareans through education, providing support for cesarean recovery, and promoting Vaginal Births After Cesarean (VBAC). She is an administrator for a VBAC and C-section support group, and is a regional liaison for the Kentucky Home Birth Coalition. Jennifer has been married to her husband, Adam, for 12 years.