Thursday, October 24, 2013

Questions To Ask A Provider When Hoping To VBAC

Hi there,
If we are just meeting for the first time, my name is Lydia and I had a c-section delivering my first in 2010.
I desperately wanted to VBAC after that and I was able to have a really wonderful one in 2012.
I am not a professional of any kind, just a momma who did a lot of research.

A friend of mine was recently asking me what she should be asking when going into the office to talk about potentially VBACing in the future.
After I wrote her back she told me I should put it on my blog, and I thought, "You know what, she's very right!"

I explained in my letter a bit more than just what I would ask in that specific office visit --- I started out explaining what I did initially to learn out more about my c-section, and then how I located VBAC-supportive providers.  Then I gave her some questions I would ask in the office.

Please note that this list of questions can be used by any mom who is hoping to avoid having a c-section.  Asking these types of questions (tweaked for yourself) the first time could potentially save you from ever having one.  In some cases, delivering by c-section may have much less to do with you and your labor, than the provider who oversees it.  

So here ya go, all the goods:
If you haven't had a c-section the first paragraph will not apply, but don't skip too far ahead because the rest is still a great idea, for even first time mommas!  

I spent any time in the office after my c-section (like my 6 week check, my annual, the times I ended up in there for thrush) asking what happened with stuff.
I couldn't get enough info on my baby's position (which was what wound us up in a c-section).  (I actually learned the most about that from this website.)
And I asked anything about anything I thought might help me VBAC.  (My first baby was nine pounds so I asked how I could have a smaller baby.  See here for information on how.  I went past my due date to 42 weeks, I asked all sorts of stuff about that --- which I didn't get many good answers on initially, but did eventually.  See here for more on that.)
And I spent countless hours reading online anything I could about my situation as well as trying a few books.
After doing that for a while, and then learning I would be moving to a new area, I looked up which hospitals allowed VBACs where I would be living.  (See this link for ICAN's list.)

Then I found a doula who has focused on helping women VBAC for more than 15 years.  (I used this website to get a list of doulas and then did my own sort of screening via their personal websites.)
 I emailed her months before I moved (I was pregnant at the time), explained my situation and asked her what my options where and which provider had what kind of stance.  I just needed to know who would be on my side.  I knew I couldn't just walk up to every doctor and ask them --- so asking someone who's watched them all working for years and years was exactly what I needed.  She called me up and she talked me through it all.  I could tell she was being diplomatic but very honest.  (By the way, she told me everything long before I hired her --- so it was free information.)
I found this to be the best gauge of what I needed to know.

I also started to attend ICAN meetings, which I found to be incredibly emotionally healing, being around other women who understood what I was feeling --- which was a brand new thing for me.  But it was also a wonderful place to learn about which doctors behave in what ways.  (They get the horror stories and know who's to blame for them.)

**I can't recommend doing something like that yourself enough.  Experienced Doulas and ICAN are  great places to get the dirt on who does what.**

Side note, I learned something amazing amidst all of this researching:
Strangely enough, around here, one of the hospitals that is technically a "VBAC-banned" hospital, is actually one of the best places to VBAC.
When the hospital is termed "VBAC-allowed" it basically just means they have an anesthesiologist on staff 24/7.  It doesn't always mean they like doing VBACs.  The "banned" title is based on the anesthesiologist not being there all the time.  But there is a hospital near to me that is "banned" but is super supportive of VBACs.  So in order to make VBACs safe there, once a women who's had a c-section shows up in labor and says she'd like to VBAC they call in the anesthesiologist to be there on hand if you need them.
The crappy thing about all this is that if you've had a c-section then you can't get your prenatal care there because of the ban.  BUT you can just show up in labor there and be cared for well.  Silly rules.
All that to say, it's worth it to talk to people who know things, because I would have never learned ANYTHING like that without my doula and midwife and ICAN.
I'm not saying that will be the case everywhere --- I am saying learn what you need to learn about the hospitals and staffing in your area!  You might be amazed!  

Having said all that, once you are ready to speak to a provider you can flat out ask what his/her c-section rate is.  How they address you after that can speak volumes.  

     Keep in mind that midwives see low risk women so they have lower rates, whereas some doctors specifically see high risk women so they will have high c-section rates in comparison.  But perhaps they are still are very pro-VBAC.  But they can (and likely will) explain that to you, if they believe in VBACs.  
And keep in mind too that not all midwives are created equal, the term midwife does not guarantee they will have a natural approach.  You NEED to investigate to find out what each provider believes and adheres to.  

You can ask them their philosophy on VBACs.  That should be very telling.

Some other Questions to ask to get this type of information: 

Do you work with a lot of VBAC moms?  How often do they have a vaginal delivery?

Under what circumstances do you advise a mom to have a repeat cesarean instead of a VBAC?  During labor what would cause you to suggest another cesarean?  (Cesareans are advised in cases of transverse presentation of the baby, complete placenta previa, and a few other circumstances that may become apparent during labor such as cord prolapse.  They are not necessarily needed due to an estimated “big” baby, going past 40 weeks gestation, breech presentation, twins, water broken more than 24 hours, etc.  It will, of course, depend on a variety of factors but those cases should not automatically rule out a VBAC.)

What do you feel the risks are for a VBAC?  How often do you see serious complications?  How often do you see uterine ruptures?  What were the circumstances and outcomes?  (The generally-accepted uterine rupture rate based on numerous studies is 0.48% for moms with no prior vaginal deliveries, and even lower for someone who has delivered vaginally before.  ACOG says 0.4%--0.9% based on mom’s personal situation.  If the doctor says rupture rates are higher than one percent, be concerned!)
What is your protocol when working with a VBAC mom?  (This is a very open-ended question if you want to hear the doctor’s genuine response, and not have them be biased by the questions you ask.  If you want examples of more questions to facilitate discussion then keep reading!)

Something else that is important to know is how long they want you to go between pregnancies after a C-section in order to be eligible (for their VBAC care.)

A question that was HUGE for me was:

How long will you let me go overdue before scheduling a c-section?  (Some doctors won't let you go even one day past your due date.)
I went to 42 weeks with my first.
But I think this is a good question for anyone to ask because it shows their stance on pregnancy and birth.  And you never really know how long you might go, it's a very valid question.
I had made up my mind that I wasn't going to see anyone who would cut me close to my due date just because of my due date (not for health reasons).

If I don't go into labor by my cutoff date, what methods would you use to induce or augment labor?  (Pitocin CAN be used with VBAC moms with close monitoring, but other types of medication can be riskier – do your research.  You also want to be able to bake your baby up to 42 weeks without them insisting on a repeat cesarean.)
Will you use pitocin on me?
Do you have any other ways of encouraging labor or do we just go into a c-section?

What if my baby is estimated to be larger than average?  [This is NOT a good reason to schedule a repeat cesarean (the means of estimating are not reliable) unless there are other factors at play.]

I wanted to know the labor rules for me as a VBACer: 

Do I have to have a fetal monitor on at all times, or can you come check me by doppler?  If I have to be hooked up: external or internal?  (Internal means breaking the water.)  (Baseline monitoring of 20 minutes is standard, with intermittent monitoring for a few minutes at intervals advised by your doctor – it may be 15, 30, or 60 minutes.  They need to see certain behaviors from your baby’s heart rate and how the baby responds before, during, and after contractions so you may be monitored longer at times to assess those things.)

If I have to wear a monitor can I get in water with it?

What comfort measures can I use for labor?  May I get in the shower, sit on the birth ball, get into the tub, etc?

What is your stance on internal exams?  (The more they do, the higher the risk of infection.)

Do I have to have an IV hooked up the whole time or can I just get the hep-lock?

Do you advise moms to have an epidural?  If a cesarean becomes necessary, how is anesthesia handled?  If I need an emergency cesarean how quickly will the hospital be able to be prepared?  May my partner be with me?  (The hospital should be prepared with an anesthesiologist in-house and the ability to get you into the OR promptly – in a true emergency you have minutes, not an hour.  If they do not have someone ready then they are not prepared for emergencies for any laboring mom – not just VBAC moms.  An epidural is NOT necessary for a VBAC mom and in fact can increase the risk of a repeat cesarean because of the associated interventions.)

Can I eat?  (Most likely, very likely, they will say no.)

At what point in labor do you advise a VBAC mom to come into the hospital?  What if my water breaks and contractions have not begun?  (The sooner you come into the hospital the higher the risk of interventions and infection, so it’s good to wait until active labor is established – which may not happen for a few hours after your water breaks.  And if it were me and I had no health concerns I would stay home as long as I could.  But please use your best judgement, I am not a professional.)

If I mistakenly show up in really early labor will you let me go home until I get to active labor or do I have to stay?  (If they make you stay that puts you on the clock.)

How long are you comfortable with me laboring (with bag of waters still in tact)?  If my water is broken?  (If your water is broken the standard answer is you need to deliver with 24 hours, but if there’s no indication of fever or distress then this is something important to discuss – will your doctor automatically advise a c-section at that 24 hour mark?  In that case will your doctor avoid amniotomy (manually breaking your water) during your labor so as to not start that countdown?)

If I get an epidural does that shorten the time you will allow me to labor?

If my labor slows down at any time (and the baby is doing fine), how long will you give me to allow it to pick back up?

How long will you let me push (assuming baby is fine)?

What positions have moms used for birthing – with a squat bar, all fours, assisted squat, etc?  (You want an OB open to catching babies in whatever position is the most comfortable for you.)

How often do you perform episiotomies?  Vacuum or forceps assisted deliveries?  (Episiotomies should be RARELY performed, and assisted deliveries should also be unusual.)

How much time do you spend with a mom in labor?  A VBAC mom?  (Many doctors aren’t called in until mom is pushing, but current ACOG guidelines advise the OB to be quickly accessible for the duration of labor with a VBAC mom.  They may be in their office on the hospital campus but they generally are not in L&D with you the entire time.)

Do you attend your VBAC moms’ births or do you share call?  Do your partners share your views on VBAC?  What experience do they have?  (You do not want to go into labor one weekend and find out your OB isn’t on call and their partner isn’t supportive of a VBAC.)

How do you feel about working with midwives and doulas?  (Whether or not you plan to receive some of your prenatal care from a midwife or hire a doula, if your doctor speaks negatively about other care providers then this is a red flag!!)

You may want to ask about how they do c-sections for your own peace of mind.  I found I felt better knowing, rather than letting it be a vague unknown that I could invent into something bad.  

If you are a first time mom it is a good idea to prepare for the "what ifs." I wish that I had been more prepared.

Stuff like:

Can my partner be in the room when I get the spinal?

Do my arms have to be strapped?

Can I play music while in the OR?

Can anyone else be in the room for the birth (parent, doula, photographer)?

If a photographer is allowed, what can they photograph?

If I'd like the curtain lowered for the birth is that okay?

Can my partner cut the cord if desired?

Can I hold my baby if I want to while you stitch me?

Can we do skin-to-skin?

May I try to nurse in the OR?

Can my baby be in the recovery room with me?

Do you stitch or staple the incision?  Will I need to come back to have them removed?

*Asking these questions ahead of time can provide more opportunity to have the birth you want.  Sometimes a nurse may try to bar these from happening, but if you have already spoken to your OB you can relay that you've been given permission, and it should all go much more smoothly.  

Here are a few more things you may want to consider discussing with your provider in regards to a c-section.

If you like this provider and they are on the same page as you ask: 

What can I do to improve my odds towards VBACing?

Ask if they have any general recommendations for you.  Just try to get any info you can.

(I got some GREAT information from my VBAC midwife based on my previous experience which helped me tremendously.)

Ask whatever you wanna know about, even if its silly like can I video tape the birth.  If you are in there to interview and discover, use this time to ask it all.

What are the things you think about most?  Ask that stuff!  You are doing the hiring!  You have a right to know!  

If this post has been helpful for you, I encourage you to check out my Healthy Pregnancy Page where I have many more posts about all the things I learned through my two experiences!  

*Research Credit: After writing my own questions out I wanted to make sure I really covered my bases for this post, so I looked at some lists online and did borrow some questions directly from Heidi of Better Birth Doula Services in Texas because she had such great ones, all worded so well!  And I wanted to credit her for those.

1 comment:

  1. Thank you so much for this. I'm a mother of an almost 4 year old, and we are considering our second. I felt rushed and pushed into a C-section with my daughter, and I am going to do everything in my power to avoid another. These are exactly the kinds of questions I will be asking my OB/GYN!


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