VBAC Rehab: Confessions of an OB/GYN Physician

I am an OB/GYN physician and…

I am a former VBAC denier. VBAC stands for Vaginal Birth After Cesarean. It’s something we are supposed to offer and push our patients to consider. I want to do the right thing. But, I’m conflicted, confused and wary. Let me explain.

VBAC was all the rage in the 80’s and 90’s, until a slew of research articles, committee opinions and studies demonstrated the risks. The brakes were applied and the birth centers offering VBAC decreased. The cesarean section rate soared and more studies revealed the accumulated risks of performing multiple cesarean sections on patients. Recently, the pendulum has swung back to the VBAC corner.

So, why all the fuss? What’s the big deal about VBAC? Well, it’s all because of uterine rupture. At least that’s my take on it. A patient has a scar on their uterus as a result of a cesarean. There is a risk that the scar can burst open, or rupture, while in labor. The results and consequences of uterine rupture can be quite dramatic. As obstetricians, we all have at least one story about uterine rupture. But, one story is all it takes.

You would think an event described by the word “rupture” would make a sound. But it doesn’t. Not even a signal. Silent until the moment it happens. No warning. No sign.

I can still see her face.

She left the hospital without a baby and without a womb. Devastating.

I can still see her face.

Sometimes she flashes before me, without a trigger.

It’s easy to hide behind hospital policy. After residency, my first job was at a hospital that did not offer VBAC delivery. It was simple. If the patient wanted a VBAC, she had to go somewhere else. But, policies change and I didn’t have anywhere else to hide. I had to face my fear.

We opened the door to VBAC in 2011. The slow trickle turned to a steady flow. Now, they seek us out and travel long distances. I’m trying to be brave. Recently, we allowed patients with two prior cesarean sections to attempt VBAC.

I’m still trying to be brave.

I can still see her face.

And then there is the patient perspective. I get it. Sometimes she comes through the door, begging me to cut her again.

“I already have a scar, might as well use it…”

“I’m a planner. I want to know the exact date the baby is coming…”

Sometimes she comes to my office in a rage. She is holding a wad of papers. Her records from the last hospital that “wronged” her and cut her open. They denied her a vaginal birth. I wasn’t there. Maybe they did. We obstetricians have been known to be quick to the knife. We have probably done too many cesareans. We should probably do less. We are trying.

She wants a VBAC. What do I tell her? I don’t want to scare her.

How do I help her understand? The statistics tell us that her risk is small. The best evidence supports giving her this option. But, what about the person that gave us the statistic? What about her? What about her story?

Do I try to talk her into it if she is a good candidate? Even if she doesn’t want to? Do I try to talk her out of it if she is a poor candidate? Even if she felt cheated? Will she ever get closure if she never gets to try? What if she ruptures her uterus? Will she forgive me? Will she forgive herself?

She signs the five different consent forms and decides on a VBAC. She is doing the right thing. We are doing the right thing. Right?

Here I sit with a scar across my abdomen. Yes, as a patient. Twenty-six hours of labor and failure to progress at seven centimeters dilation. Yes, me. I cried my eyes out as they rolled me back to the OR…

As a woman, a vaginal delivery is a rite of passage. As an obstetrician, a vaginal delivery is an experience I want so I can relate. As a patient, a vaginal delivery just seems like the best option.

So, I get it. I know why my patient feels the way she did. As much as a I know I was not cheated of my right to a vaginal birth, I still feel that longing. It will never go away. Just might be numbed a bit. How can we help her grieve the loss of a vaginal delivery? How can we help her not think of herself as a failure?

As an obstetrical community, we need to be supportive of each other. We should be thinking of the patient, first and foremost. Egos aside. Listen to the patient. What is she saying? What is her story? What does she need? We also need to listen to each other. The lead perinatologist in our community meets every month with the lay midwives and licensed midwives that practice in our region. Why? Why would he do that?

Why not? He says it is better for the patients. Better for us to stay connected. Better for us to be accountable to each other. Better for us to be able to reach out and learn from each other. It is better.

I can still see her face.

There is data and there is emotion. There are statistics and there are stories. There is evidence and there is practice.

I have more questions than I do answers. That’s why I need rehab … VBAC rehab.

I am an OB/GYN physician. I am a recovering c-section survivor. I am a former VBAC denier…

I’m ready for rehab. Will you join me?

 

Disclaimer: All medical stories are fictionalized.

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12 thoughts on “VBAC Rehab: Confessions of an OB/GYN Physician

  1. Can you still see the face of the woman who lost her uterus, her baby, then her life, after the placenta grew through her cesarean scar and attached itself to her vena cava? That woman’s husband left the hospital without a wife and child after placenta percreta killed a young, healthy woman thanks to a cesarean scar. I’ll never forget that happening in my community. Women are at great risks from cesareans, especially placental abnormalities. They can be deadly. I’ll never understand why there are 5 consent forms for VBAC but no consent forms for having repeat cesareans, which carry great risks. I’m glad you’re rehabbed. Just don’t forget that having a baby after that first cesarean is a risk no matter which way it comes out. Maybe remembering that will inspire doctors to stop cutting too quick the first time.

    Liked by 1 person

    1. You make a great point. There are risks to everything we do in medicine. We do have a consent for repeat cesareans, just not several of them. I think the point is that we often carry so much emotion around these types of catastrophic circumstances and it is hard to see past the incident and practice according to the best evidence and best practices. We must push ourselves, as providers, to do that. In addition, VBACs gone wrong have historically been a source of large amounts of malpractice settlements, thus the need for so many consent forms. At the end of the day, I’m not sure a consent form protects us from litigation, but it does force us to have the conversations with our patients and support an informed decision.

      Liked by 2 people

    2. Wow, when I read this comment I kinda lost my breath. Not because what you say isn’t true, but that you took, at least from what I read, the most personally vulnerable piece in the post, “Can you still see her…” and used it against the person writing the blog to make your point. Perhaps I read it incorrectly, but yikes. It just came off pretty harsh in my head and this is a pretty vulnerable, honest piece. . . As a person who had a first very traumatic home birth and then a much better second home birth, as well as a HypnoBirthing Instructor, nurse, and breastfeeding educator and mom, I believe in birth. But I think appreciating the positive of what this posts offers too would have been kind…

      Liked by 1 person

      1. Hi Rachel, I appreciate your comment. There is an obvious disconnect between what patients really want and need when it comes to this issue and the obstetrical community that surrounds them. We need to talk about this more and we need to debrief with our patients and colleagues when things don’t go well. We have a very robust Centering Pregnancy program in our practice and through that experience I have learned a lot about the sense of loss our patients feel when they end up with a cesarean or a failed VBAC. Thank you for everything you do as a nurse, hypnobirth instructor and BF educator. It is very important work.

        Liked by 1 person

      2. To clarify, my comment was directed @ The Feminist Breeder. I just felt it was a harsh comment when we are all fighting the same good fight. Trying to give moms and babies better. It’s like don’t shoot the messenger. Thanks for sharing your truth, your heart, your personal experience, your learning curve, and your open mind. I really loved what you wrote. And I thought it was a very brave piece. Your work is hard! I can’t imagine carrying the load you must take on as a physician. I know I couldn’t do it. Can’t wait to read more of what you have to share with the world.

        Liked by 1 person

      3. It did come off as slightly harsh, and yet it should. There are a great many women out there experiencing situations just like that because of placental issues after c-sections. And yet that always seems to get ignored and the risk of rupture harped on and harped on. Both are risks, it should come down to which the woman is more comfortable with.

        I feel very fortunate to have had a supportive OB when I went for my VBAC. According to most ACOG standards I was technically not a good candidate. Only 15.5 months between births. My first baby was 8lbs 10oz, so this one was likely to be bigger. I’m not sure what my chart would have said. I got to 10cm, pushed for over 2 hours, we could see all his blond hair. But he wouldn’t come out. Well, turns out he was asynclitic and also had a double nuchal cord.

        Anyway, I had a very successful, easy VBAC with my 2nd. Who turned out to be 9lbs 9oz and pushed out in only 35 minutes. The thing was that it was MY choice. I understood the risks and made the choice. I did a lot of research, I was well educated.

        I ended up with a c-section for #3, posterior, 10lbs 5oz, and his skull was already fused at birth (sagittal craniosynostosis). My OB was willing to be with me to have a VBA2C with #4 until we discovered she was breech at 40 weeks.

        I’m very thankful I never ended up with placenta issues. But yes, there does need to be discussion. Perhaps education classes at hospitals explaining the risks of both VBACs and repeat c-sections.

        Liked by 2 people

      4. Hi Stephanie,
        thank you for your comments. Yes, education classes would be ideal. We have a class for our patients that would like to sign up for a waterbirth in our hospital. We also have breastfeeding and childbirth ed classes. We should consider doing the same for our VBAC and Repeat c-section patients as well. This is an excellent idea. Good to hear that you had such a supportive OB!

        Liked by 1 person

    3. @stephanie- what’s the point of being harsh? She’s the one trying to make the change and clearly carries enough guilt. When my husband and I are arguing about something and he softens to connect and all I do is come back and say something harsh again, I’ve actually harmed what could have prospered. If we want to make changes, I believe connecting is the key. The Internet/blog world can be a pretty unloving awful place to hang out. We want to give moms better. The first place we have to start is loving them in labor so that they can actually successfully allow their bodies to open. Perhaps, modeling by example is a good start? And again, this OB didn’t do it, so why is she taking it out on her? It just felt unjustified and misdirected. Sure there are OBs who arent this awesome, but again she’s not the one to take it out on…I’m no politician, but sounds like this Doc is one to KEEP in our corner.

      Liked by 2 people

  2. I too had a c-section, it was necessary to save the life of my child and myself. I have also dealt with the feelings of loss from not having a vaginal birth. I often think about how I won’t experience this “rite of motherhood.” I take comfort in knowing that there are amazing doctors who carefully weigh the decisions they are educating their patients to make, this education helps to bring peace of mind. Thank you for sharing such personal thoughts.

    Liked by 1 person

  3. TFB is like that sometimes, & I love her.

    I appreciate the VBAC rehab sentiment. I nearly died in my 3rd cesarean because there is a local VBAC ban. And when pregnant again, again my only vbac option was homebirth, or hba3c at that point, and it was a great birth! Homebirth can be great! It was my best chance at living.

    But if doctors think a vba3c is dangerous, why can’t I VBA3C at the hospital? Wouldn’t that make more sense than “Get cut or stay home”? Doctors and hospitals have a long way to go in even making sense of their own policies.

    What really confuses me: why is my midwife or doctor held responsible for my informed decisions? That’s probably more important than tort reform. Our care providers are human. You’ll always see her face. You’ll feel a dead baby in your arms forever. You’ll feel a fathers fingernails in your shoulders forever as he sobbed and you held him. And that’s punishment enough.

    Liked by 1 person

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