VBAC Consultation

Well, we had the big appointment yesterday. We went to visit the new OB office that had stated they would be supportive of a VBAC-2. We had a consultation, and friends and family that knew about our appointment are wondering how things went. This is the easiest way to share.

The couple days leading up to the appointment, I noticed myself getting more and more anxious. Nervous. Worried. All sorts of feelings. I didn't want to go in and have a dr say they would "allow" me to VBAC and then feed me all of these scare-tactics - or act great about it now and then try to scare me at the last minute. The day of the appointment was getting tough, and I sat myself down while Aiden was taking a super early nap and looked over some Bible verses to try to calm myself. This one kept jumping out at me, and it gave me what I needed to refocus and get to the appointment with a better frame of mind. 

So do not fear, for I am with you; do not be dismayed, for I am your God. I will strengthen you and help you; I will uphold you with my righteous right hand. (Isaiah 41:10)

I needed that reminder that God is with me and has a plan for me. He tells me not to fear, and sometimes I just need to stop and listen to that. 

I think we're still trying to process everything from the appointment. We were there for 45 minutes, and there was a lot of information. A lot. I can easily say that most of it was what we wanted to hear. Was all of it? Not necessarily. But MOST of it was. 

We went into our appointment with a list of questions. We were quite prepared. I've done a lot of reading, and Ryan has been trying to keep up and do some of his own. This isn't something we enter into lightly. Not at all. The doctor even said he could tell I was a reader (this did not sound at all like he was being condescending), and he seemed to really appreciate the fact that we completely understood all aspects of what we were considering and that we were highly motivated. 

One of the first questions the doctor asked me was what is my main concern. Really - I told him my BIGGEST concern was finding a provider that was supportive of doing a VBAC. It's true. And hopefully that won't be such a concern now... 

Here were our questions, and some of the answers...

• How many VBACs/VBAC-2s have you attended? Well, plenty. No number, but they obviously do it. This doctor appeared to be very practiced in this area and seemed like he had plenty of experience with everything we discussed. We're not worried about that.
• What is your success rate? He guesses around 70%, which is what is to be expected, from what we understand. Anything much lower would be a red flag.
• How many uterine ruptures have you witnessed? He differentiated between the different kinds...a small tear/rupture, which is basically a hole and would be found while doing a c-section and could be repaired easily and then a catastrophic rupture, which if addressed quickly enough can be handled well. He's seen both, not as many of the catastrophic but "a handful" of them. I was pleased that he differentiated between the types and didn't lump them together and make me feel like ruptures happened often and were all terrible. He made it sound manageable, even if there was a rupture, while also being very clear about the possible dangers, even with the catastrophic ones.
• Do you have any standard VBAC protocols that differ from a non-VBAC mom? Only attending can order pitocin.
• How do you handle post-date pregnancies (going over 40 weeks)? Another thing we aren't thrilled about but want to ask more questions now that we've been home and have been thinking more about it. (This is one of the two things he said that we didn't LOVE.) He did say they wouldn't want me to go too much over 40 weeks....but if I went over, it would depend on if I was showing signs of labor, etc. If I was, they would give me a bit more time. If I wasn't doing anything, they might want to then schedule a section. They will *not* induce (which is exactly what we want to hear - induction is not desired, esp with a VBAC). I would rather have a dr that would allow me to go a week or even longer over a due date, assuming everything with mom and baby. This does not make me a glutton for punishment; it means I am aware that a due date is an estimation and my body and the baby are better at knowing when the time is right versus a date someone marks on a calendar. We'll discuss this more with him/other doctors later on to hear their reasoning. He did seem to be fairly flexible and not wanting to just rush to a c-section the second I would turn 40 weeks, but still. Something we want to consider more.
• What is your philosophy on big babies? This is in there b/c some doctors think if you have a "big baby" (which is hard to determine - guesses are often wrong) that you should automatically have a section. He seemed to not think this and is not scared by the fact that my first baby was 11lbs and my second was 8lbs11oz. Actually (and surprisingly), that 11-pounder works in my favor in this case! As he said, he would be a bit more hesitant if I had pushed for so many hours and had not been able to push out a 7lb baby...but it's easy to understand why I couldn't push out an 11-pounder after several hours. Anyway, big babies don't seem to scare him. That's good.
• What kind of monitoring do you require? IV. Just in case. I won't be able to walk around hallways, but I can move around in the room as long as I'm attached to that. They'll obviously want to monitor the baby more closely, just to be aware of any possible signs of distress. Not something I love, but I do understand.
• Do you perform an automatic c-section if waters have been broken for more than 24 hours, even if there is no evidence of infection and mom and baby are fine? He said they don't base it on a certain time schedule, it all depends on whether or not the baby is in distress and I'm progressing at a decent pace without stalling. What I wanted to hear.
• Do you have a time limit on how long my labor can be before you c-section me? Same answer as above. What I wanted to hear.
• What is a reasonable length of time for VBAC labor if I'm healthy and my baby appears to be healthy? Can't really tell; it's dependent on factors other than simply time. Mostly same answer as above. These questions are mostly to determine if the dr will be quick to section if the labor isn't moving quickly. We don't want that. We want a dr who will allow the labor to go as it naturally will, assuming mom and baby are healthy. This doctor does NOT seem to be trigger-happy for surgery. We even discussed why some doctors might push for a c-section, and he let me know that shouldn't be a problem there. (Some reasons can be having to do with time. Would the dr rather have a nice easy, scheduled section at 8am or have to stick around for a day and a half while mom labors? Money... C-sections obviously cost more. Resources. VBACs require a lot of resources on hand in case of an emergency section, which also means everyone is on high alert. Yes, a lot of resources are needed for a planned section, but when they're worried about a rupture and a baby being in danger, they want to be prepared and have ALL of those resources at the ready. You could tell he didn't agree with some of these reasons - the first couple that were more convenience-driven. And at Duke and with this office who deals with riskier pregnancies, they also clearly have the resources right there.)
• Do you require IV or helplock? Yes. IV.
• Am I permitted to move and deliver in my position of choice? Seems to be fine, as long as I'm still on the IV. Also what we wanted to hear. Lying on one's back is actually the least effective mode for pushing, and I want to be able to do whatever position my body works with best and whatever position helps to reduce chances of a stalled labor leading to a c-section. Who knows what that would be, but I don't want a dr who tells me I have to be on my back simply b/c I'm a VBAC.
• What do you think are my chances of having a successful VBAC-2, given my childbirth history? He thinks I'm a great candidate and will likely fit into the 70% that are successful. Odds are in my favor at *this* point, based on history and my current health, motivation, etc. Aside from my motivation and health, my history helps - the reason for my first c-section, the scars that I have (or how minimal they are) and how easy it was for the dr performing Aiden's c-section to get in quickly. The fact that I'm not large or overweight also helps a lot. Why? Because if he has to very quickly get in for a c-section, in case of emergency, a lot of excess weight (just like extra scarring) can hinder him being able to do that quickly. Basically, I don't have much working against me. Let's hope it stays that way. They will monitor me closely in regards to my placenta placement (multiple c-sections make it more likely my placenta could cover my uterine scar, which is not good, and they also can increase my chances for issues such as placenta previa and abruption). 
• What can I do during my pregnancy to help increase the chances of a successful VBAC? He looked at Ryan and told him that *he* would like this answer... As often as possible during the last trimester. Haha! But really...just staying healthy and motivated. Both of which I won't have a problem with doing.

The other thing we didn't LOVE was the fact that he said they would want me to have an epidural during the labor. I really want to do it naturally, no epidural. I understand the logic. If there is an emergency, they want me already medicated and want to be able to easily add more to numb me for surgery. At the same time, I also know that having the epidural automatically puts me at higher risk for having a c-section, for many reasons. So, we're not thrilled about this. He did say I could control the amount and could use the least amount possible during labor. We still want to discuss this farther and make sure we understand exactly what they would require and think about it more ourselves. Ryan thinks he heard the doctor say, after I explained I wanted as natural a labor as possible and that I was hesitant about an epidural, that they would just need to have me ready for it, have everything in, and that way they could just administer the actual epidural if a section was suddenly needed. I am not sure I remember hearing that. BUT if they can have it in and he's told me I can control the amount before they *need* it for a surgery, it would make sense that they could also just have me prepped and not actually inject it until the time...right? We're going to try to ask about this sooner than another appointment, maybe emailing him, if he will respond.

Another problem with the epidural, which I totally didn't think about while in the office (seriously, if I don't have it written down, it doesn't get said!) is that epidurals/spinals make me EXTREMELY sick. I threw up all through Camden's surgery and the next couple days. I was pumped FULL of Zofran during Aiden's section, but during recovery the nurses always waited until I was on the floor throwing up before giving me more (how fun do you think that is when you've just had abdominal surgery?!), even though I would tell them while I was still in bed how sick I was. It was horrible, and I don't want to have to worry about throwing up the entire time I'm in labor and for days afterward. I know they can also give me the Zofran with the epidural, but I also don't want to be so medicated (or medicated at all)! So, we'll also need to mention this to him... Ugh. Just thinking about it is making me miserable. I was so loving the thought that a natural labor would mean not having to deal with all of that awfulness.

So, there are two things we were told that we didn't completely LOVE. For the most part, we were very happy with what we were told, though. But those two things are bugging us and giving us plenty to think about for a while. We already have a list of questions for the next time we go in...which could be a while b/c we won't be due back until we are actually pregnant. I suppose we could call or email, but talking in person is best with this kind of thing. Actually, some of it we might email about - parts that we want to be clear we understand.

Another concern we had, knowing this was a large office, was how other doctors in the practice would feel about us doing this VBAC-2 and would some be more likely to push for a section once in labor, especially if we weren't progressing as quickly as they wanted. Of course, some will be more section-happy than others, but he thought as motivated as we were, with me being a good candidate, etc, etc, that we shouldn't have a problem with that. He also stated that, as head of the department, he would have a say in how they treated us and would let it be known we are to be supported in trying for a trial of labor and delivery. Really, he was very pro-VBAC. He never made it sound like anyone in the office would be against the VBAC - just that some might push a surgery after a prolonged labor sooner than others. We never felt like we were trying to convince him; from the start he was very supportive and encouraging. It was such a positive experience. I was really nervous about the consultation beforehand, but the second he started talking, I immediately felt much better about the whole thing. 

He even gave me an article to read....and this wasn't an article trying to show how dangerous VBAC-2s were; it's a review with a meta-analysis (a research article that uses information from multiple studies, looking at various components, etc) that compares the risks/success rates/adverse outcomes with VBAC-1, VBAC-2, and RCS (repeated c-sections, specifically a third c-section for this article). It was actually very interesting, especially when it showed that there were no significant differences in all three groups when looking at neonatal unit admission rates and asphyxial injury/neonatal death rates. I appreciate a doctor who is trying to back up the safety of what I'm trying to do with others' research instead of trying to use scare tactics to get me to do something else.

Here's a snip-it from the article, if you're interested. This is from the abstract, so it's brief. Interesting stuff. I kind of felt like I was back in college/grad school reading this article. ;)

VBAC-2 success rate was 71.1%, uterine rupture rate 1.36%, hysterectomy rate 0.55%, blood transfusion 2.01%, neonatal unit admission rate 7.78% and perinatal asphyxial injury/death 0.09%. VBAC-2 versus VBAC-1 success rates were 4064/5666 (71.1%) versus 38 814/50 685 (76.5%) (P < 0.001); associated uterine rupture rate 1.59% versus 0.72% (P < 0.001) and hysterectomy rates were 0.56% versus 0.19% (P = 0.001) respectively. Comparing VBAC-2 versus RCS, the hysterectomy rates were 0.40% versus 0.63% (P = 0.63), transfusion 1.68% versus 1.67% (P = 0.86) and febrile morbidity 6.03% versus 6.39%, respectively (P = 0.27). Maternal morbidity of VBAC-2 was comparable to RCS. Neonatal morbidity data were too limited to draw valid conclusions, however, no significant differences were indicated in VBAC-2, VBAC-1 and RCS groups in NNU admission rates and asphyxial injury/neonatal death rates (Mantel–Haenszel).

Aside from VBAC/c-section stuff, we also asked how they treat Hyperemesis Gravidarum (HG), knowing going into the next pregnancy that I have this condition, which is known for being worse with each pregnancy (yay...). He first said to start taking Vitamin B6 before getting pregnant. Get Unisom once pregnant. I've heard a lot about using both of these for HG, so I wasn't too surprised. I appreciated this b/c he didn't automatically jump to medicating like the other office we currently visit have - they say to just get right on Zofran. And yes, this still means taking supplements/medication...but it's the lowest level before going on other medications such as Zofran, which I was on during the entire pregnancy with Aiden (that and phenergan). I would rather try what he suggested first and hopefully not have to take Zofran or maybe at least  put off taking it or not have to take it as long as before. He also discussed eating and drinking...being sure to drink caloric beverages but not to worry about eating if I couldn't. Maybe, he said, we're really designed not to eat much during that time and that's why we get so nauseous; that first trimester is when so many important things are forming in a baby, and it's when toxic ingredients, chemicals, etc, will be most dangerous. This is a whole other topic, BUT we really appreciated how he answered. Learning what his approach is to various things was helping us feel we could trust him more. He did say if we needed medication, we needed it. And I agree, but we'll start with these other things first. (My fingers are crossed! How I would love to not have to take medication for another entire pregnancy...)

So, for the most part we were very pleased. We do still have a few things to ask about. I forgot to ask how they feel about me having a doula around, in case we want to go in that direction, which we are considering. He happened to mention they are looking into having midwives working with them, and I really liked hearing that. Like he said, having a midwife there with us will help increase our chances with a VBAC b/c midwives are typically very against any unnecessary c-section. (He spoke about this in a positive way, which is good. Some doctors are pretty against having doulas or midwives around.) And we want to ask more about the post-date stuff and get more information on the epidural aspect.

But overall - fairly positive. I hope the rest of the doctors are as personable and assuring as he is. We really liked how he spoke with us and what his approach seemed to be. (He wasn't crazy about the fact that we don't get the flu shot, but that's a whole other topic. And just because he thinks it's a good idea doesn't mean we have to do it. Because we won't. But I digress...) We're looking forward to asking some more questions and seeing him in the future. And if it comes to it and we don't feel comfortable, we have one more avenue to explore - another office that we hear is very VBAC (and VBAC-2) friendly...but there might be some issues with insurance and navigating that would surely be a lot of fun. 

If any of you know some things to share about VBACs, suggestions, questions, or whatever, please comment away. We would love to hear what they are! Please keep it nice, though. We're seeking support here. Anything that's pushy in the opposite direction will not be appreciated. Not to say that if you have genuine concerns or questions you can't share that, but we would appreciate no rude remarks. :) Thanks so much! 

Oh, and if you're curious about WHY we're hoping for a VBAC-2, I'm happy to explain. But that's a topic for another post. This one is long enough. ;)