Belly Up

* bellies * birth * babies * breastfeeding *

Monday, April 14, 2014

VBAC Odds - Lady Luck?

Don't gamble with your VBAC
When thinking about going for a vaginal birth after a cesarean(s) many are skeptical.  What are the odds of actually having a successful VBAC?  I recently heard about a VBAC calculator that attempts to predict the probability of a given woman delivering vaginally after a cesarean.  It takes into account the age of the woman, her height and weight and factors regarding her labor.  That all sounds very scientific,  but this "VBAC calculator" does not take into account possibly the biggest factor that will determine the outcome of a VBAC attempt – the care provider, i.e. the OB or midwife who is supporting (or not supporting) the woman seeking a VBAC. 

In my years as a doula I have worked with a lot of women planning a VBAC.  I dug back into my records and I’ve actually worked with 146 women who were hoping for a VBAC.  My numbers are not large enough to be a statistical sample, but they do show me a trend.  Of those 146 women, 133 had vaginal births.  That's 89% - not bad odds.
So who were the women that had repeat C-sections when they hoped for a different outcome?  It is not women with large babies, those over age 35 or even the ones that have been told they had a small pelvis....most of those women VBAC just fine.  Most of the women that have repeat C-sections are the ones with an unsupportive provider*.  In several cases, an unsupportive provider actually talked the women out of even laboring.  The most egregious example I can think of is that of a couple whose baby was breech at 36 weeks.   A few days later we all got excited because the baby turned, but the OB told the couple he could no longer allow labor because their c-section was already on the hospital's books.  (Obviously I gave them other options, but in the end they chose to show up on surgery day.)  In the cases where the women were with an unsupportive provider, I obviously can’t say how things would have ended up if they had been given a real chance, but based on my statistics, the odds were in their favor.
So why do women stay with non-VBAC supportive providers?  Here are a few common reasons I hear:  

Ask you provider, not a calculator
“I love my OB” – It is good to love your care provider and changing to a VBAC supportive care provider does not have to be framed as a rejection.  A woman may love her General Practitioner who is great when antibiotics are needed for a sinus infection, but not if the woman develops a heart issue requiring a cardiologist.  Choosing to have a VBAC is no different; a woman needs a specialist.  I tell women who want a VBAC to find a care provider that specializes in VBACs, then enjoy well woman exams for the rest of her life with the GYN they love.

“I am uncomfortable with a male OB” – I totally get this one.  Women have babies and it involves some degree of nakedness and our intimate areas.  However, if the best VBAC option in the area is a male, priorities must be decided.  Would you rather have unnecessary surgery from a person with a vagina or have a VBAC with someone who does not?   (I do work with families of various faith backgrounds where a male OB is not an option.  Usually there are some female options that strike a balance between religions convictions and the desire to have a VBAC. )

“It is too far to drive” - I also get this one.  I hate driving.  It is boring, gas is expensive, traffic stinks.  Once again, each couple will have to work through this question.  Is it worth the hassle, time and money to drive an extra 20, 30, 40 (or more) minutes approximately 15 times during the course of pregnancy to increase the odds of avoiding major surgery?

"My OB just really cares about me and my baby’s health" –  Uterine rupture is real but it is rare.  Risks to mom, baby (and future babies) from abdominal surgery are also real.  Choosing how to deliver is not a zero sum game where one choice is completely safe and the other is not.  However, ACOG states that VBAC is  "safe and appropriate" for most women with one or two previous surgical births**.  An OB that does not believe that or does not give his patients that info may not be keeping up as well with the research in his field or he may be putting his liability or scheduling concerns ahead of women and babies’ health.  

There are many other reasons why people don't switch to a supportive care provider, but a whole lot of people don’t switch because they don’t think outcomes are different from provider to provider; that one provider is basically the same as another.   This is very far from the truth.  Even the best provider is not going to have every patient have a successful VBAC; sometimes under the best of circumstances babies are best born via C-section.  However a woman will learn a lot more about her odds of having a successful VBAC not by looking at a generic calculator, but instead asking the provider for his odds based on his experience.  I am not a gambler by nature and so if I am choosing who to support me in my goal of vaginal birth, I am NOT going to lay my money (or my belly) on the provider with long odds.
* What is a VBAC supportive provider?  Stay tuned, writing that next!