Wednesday, November 30, 2011

{Ottawa Doula} Swimming Upstream: Vaginal Birth after Two Cesareans

I have been immersed in a dilemma lately - not my own personal dilemma, but one of my client's.

This woman would like to attempt a vaginal birth after two cesareans. We hear A LOT of information out there about VBAC (pronounced v-back) after one cesarean, and most doctors and midwives would agree that it is a safer choice than scheduling a repeat cesarean (as long as you meet the "qualifications" - no ongoing medical problem where another c-section would make sense, and a low, transverse incision).

The American Congress of Obstetricians and Gynecologists (who issued the report I linked to above) also agree that a Trial of Labour (TOL) for a woman with two or more cesareans is a viable option. The risks of uterine rupture are higher, but variable. Studies differ in their methods and conclusions, and "risk" is communicated to patients in different ways.

For example, read this statement, as stated by my client's doctors (the numbers are not accurate here - this is just to illustrate how they have portrayed risk):

Your risk of uterine rupture triples after 2 cesarean sections. In all the cases of uterine rupture I've seen, the baby has ended up with cerebral palsy.

Now, read these statements, as a properly conducted study may present them:

Women who attempt TOL after 2 cesarean sections have a 1.9% risk of uterine rupture. Of these, only 0.06% experience a complete rupture (where the baby actually enters the abdominal cavity).  

1 in 6000 women who attempt TOL after multiple cesareans experience uterine rupture. 

The first one sounds a lot worse, doesn't it? If you're trying to scare a woman into scheduling a c-section, the first statement packs a lot more oomph.

OBs who have personally witnessed a uterine rupture are much more likely to inflate the risks, because their perception of risk has changed. It's no longer a magic number (eg. 0.5% of women who attempt a TOL after one cesarean section risk a uterine rupture), and instead the one case they've seen colours the way in which they treat all future patients.

To make matters worse, there are no doctors here in Ottawa (at least none I have come across) who support a woman desiring a TOL after multiple cesareans. My client has been continually hassled about her decision, and with each prenatal appointment she attends, a new resident provides more scary stories. No one seems to talk about the risks associated with another cesarean section, which I find interesting.

When you want to do something that goes against the grain, and no one in your community is willing to support you, what should you do?

1) Remember that as a patient, you have rights. You have the right to refuse interventions and treatments offered. You have the right to informed consent.

2) Become armed with research. Doctors are busy people, and often don't have time to stay abreast of new research. Do your own looking around, and begin compiling all the papers that support your decision (start with the new ACOG guidelines, which support your decision to try for a VBA2C). Bring them with you to every prenatal appt., as you'll often be seeing many different doctors and residents.

3) Yes, the health of you and your baby is important. But so is your experience, and oftentimes, doctors will play the "healthy mommy, healthy baby" card, in order to dissuade you from your desire for a positive birth experience. Seek the help of a professional (social work, counsellor, or doula) who can look at the benefits/risks objectively with you, and help you come to the right decision.

4) Did I say that health was important? You betcha! If you're desiring a VBAC (or VBA2C), you best be sure that you're eating really well (see a nutritionist or naturopath for help), exercising every day (gentle exercise such as walking, swimming or yoga) and reducing stress (do some yoga and you'll check two things off your list!). Many women also seek treatment from alternative health practitioners, such as acupuncturists, homeopaths and chiropractors.

5) Read the positive stories. There are women all over the world who have tried and successfully had a VBA2C (I've even read of a VBA4C!!)

Bottom line: if you're taking the plunge, first make sure you know how to swim. Oh...and a little faith goes a long way. Faith in yourself, your body, and your ability to do something that others think is impossible.

Share your story below of something you have accomplished when others tried to tell you it was impossible.


  1. So nobody tried to tell me this was impossible but I wanted to mention the shock and awe when I tell people I delivered twins vaginally.

    I'm more shocked that people are shocked to be honest. I was lucky enough to have a super awesome and supportive doctor who didn't refer me to an OB just because I was having twins and who was very relaxed about the whole thing - surely helping me to stay more relaxed.

    As long as baby A was head down I could deliver naturally, which I did. And it baffles me that people think delivering two babies would be SIGNIFICANTLY harder than one. I know I'm not every woman, but if you think about it, once one baby has been through the "door" so to speak, surely you can see the second one would have a lot easier time getting through too.

    Sorry, I know I'm slightly off topic here, but my point is, just because something sounds hard/impossible doesn't mean it is.

  2. I'm a week or two away from my own TOL (after 1 cesarean) and really appreciate all supportive blogs and stories I've read. Your patient is lucky to have you. Good luck to her!

  3. For those reading this now, my client did end up having a successful VBA2C, although not without a fight. Her doctor at The Ottawa Hospital stated that he only "allowed" her to birth vaginally because she was so well-educated and came armed with research. So a lesson to you - get all your research in order! Please contact me directly if you have any questions


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