Choosing Your VBAC Care Provider

A few months ago, I had the privilege to present at an ICAN meeting on the topic of Choosing Your VBAC Care Provider. Because there is trauma from birth sometimes and because having a sudden c-section can add to that trauma, moms are usually more anxious during the subsequent pregnancy about birth. I hope this post from my presentation will help you to pick your best team for your healthiest in every way birth. Although it was presented at an ICAN meeting, any mom or mom to be may find the information helpful AND empowering. So …here goes!

When we mention care provider, most of us will think in terms of an OB or a midwife. I would like to expand that definition to your whole care team of nurses, the place you choose to give birth, your partner, your family and friends, your doula, and mostly importantly – yourself. Each member of your team can help or hinder. That is why it is so important to access and choose a team that supports your vision for your birth.

Let’s start with the most important member of your care team: you! This is all happening to you and in you. You know you better than anyone else. During your pregnancy, it will be important for you to have honest conversations with yourself.

Becoming your own best Care Provider

Birth is very physical, but it is also very spiritual and emotional. Many women who have had c-sections have experienced grief, trauma, and depression.  To prepare for a VBAC, any unresolved emotional hurdles need to be addressed. This is not an easy process, but it brings healing and empowerment into your new motherhood. It is very much worth the work. Here are some things to think through:

• Assess your fears, traumas, and triggers.
  • Remnants of previous pregnancy and birth experiences
  • Personal traumas such as abuse or abandonment
• Assess relational traumas
• Be aware of your emotional signals for fears, traumas, and triggers that need to be worked through during pregnancy.

ICAN has many resources to help with processing a c-section birth and for planning a VBAC.  Many areas have local ICAN meetings that also have local online facebook support groups. They are invaluable.

Another great resource for women specifically about VBAC is vbacfacts.com  The evidence-based information found on both of these sites helps empower you to make the best choices for yourself and to advocate for care to support your choices.

Choosing Your Medical Care Team

Doctor Groups:

You may love your doctor for your well woman care, but not feel as comfortable with their support for your VBAC labor and birth.  It is ok to have one provider for well woman and a different provider for your VBAC.   Trust your instincts.  Here is a list of considerations in a doctor group:

1. What is their c-section rate?
2. What is their VBAC rate?  Will they support VBAC after more than one c-section?
3. What is their unmedicated birth rate?
4. What is their induction rate?  Their rate of augmenting labor?  What is their induction practice for VBACs?
5. Do they support starting an induction, taking a break during the induction to allow mom to rest and eat before resuming the induction process?  Do they support outpatient use of a Foley or Cook Catheter?
6. What is their practice of monitoring VBAC labor?  Do they routinely use of IV fluids or only when necessary?
7. What are their thoughts about waiting on labor to begin until 42 weeks + unless medically necessary?
8. What are your thoughts on eating and drinking during labor? Do they support your thoughts regarding eating and drinking during labor?
9. Does the care provider team take the time to listen, hear, and validate your concerns, experiences, and past traumas? Do you feel seen, heard, and emotionally validated and supported by them?
10.  What are their thoughts on movement during labor? Having a labor doula? Changing positions during pushing?  Ask how often do they use stirrups.
11. What are their thoughts on time limits on labor?
12. What is their policy if labor begins with spontaneous rupture of membranes? (SROM)
13. Do they practice informed decision making…offering solid evidence-based information, present pros and cons, and give you the space to make a decision that is best for you and your family?
14. Do they make a practice of asking your permission before performing a procedure or touching you?  Are they respectful of your need for privacy or your discomfort or pain during an exam?
15. Do they support your wishes surrounding delayed cord clamping, the golden hour, skin to skin, etc?
16. How many doctors are in the group? How often do they rotate being on call?  Honestly ask yourself if it is important to you to have a relationship with the doctor who may be on call when you are in labor.

Nurse Midwives

Nurse midwives usually practice in the hospital setting.  Their model of care is generally based on birth as a normal event, and their care is generally more personal. You can learn more about the midwifery model of care HERE.

Many of the same questions that surround doctor care also apply to nurse midwives who work in the hospital environment. Additional question for nurse midwives:

1. Who is your back up physician?
2. May you meet them? (if you wish)

Hospital:

While insurance may play a part in your choice of place of birth, you may still educate yourself about the hospital beforehand to be prepared to advocate for your wishes.  Ask for a copy of your hospital’s policies. You may discuss any concerns you have with your individual medical care provider.

Hospital Nursing Staff:

When you arrive at the hospital, you may ask for a nurse who is especially enjoys supporting VBACs.  If you desire as few interventions as possible, you may also request a nurse who enjoys working with more unmedicalized labors.

If you are not feeling supported by your nurse, you can always ask the charge nurse for a different nurse.  Your nurse will be who you see the most.  The support or lack of support you feel from your nurse may affect how you view your birth long term.

Home Birth Midwife

Sometimes women feel safer having a home birth.  This also applies for women wanting a VBAC.   In this case, a home birth midwife is an option. To learn more about this model of care, you may follow the link under nurse midwives above.  Here are some questions that you may want to discuss as you interview midwives for a home birth. 

1. What is their c-section rate? Their primary reasons for c-sections?
2. What is her VBAC policy?
3. What is her percentage of VBAC clients and VBACs?
4. How many VBACs has they supported?
5. What medical concerns would lead her to transfer care to a doctor during your pregnancy?
6. What are her thoughts on length of pregnancy before transferring care to a doctor?
7. Who makes up her care team?
8. Who is her back up?  May you meet/talk with them?  (if you would like)
9. What is her transfer rate during labor? What are her most common reasons for transfer?
10. Where would you go in the event a transfer became necessary during labor?
11. What is her experience with the doctor and hospital in event of transfer during labor?
12. In the event of a transfer, what would her role become?
13. In the event an induction or augmentation became necessary, would she provide labor support?
14. What is her experience with medical induction?  Does she feel comfortable advocating in the hospital with the doctor for your wishes?  Give specific examples to her that would be important to you.
15. Does she and her team seem trauma informed?  Do you feel your concerns are genuinely validated and understood?

Your Doula

Having attended dozens births including VBACs, I believe having a doula that you are comfortable with and who is seasoned is even more valuable during a VBAC birth. DONA, INT. provides information on how to hire just the right doula for you.

Back to your best care provider – You

 While your medical care provider and your doula are an important part of your birth team, the most important person on your team is you.  Here are a few additional thoughts:

• Have you prepared an in depth evidence based birth plan and discussed it with your care provider?  Sometimes what you think they agree with is different than what they really agree with.  A birth plan makes this black and white. Developing a birth plan with your doula educates you in the language of labor and birth, goes over all of the options and what they entail, and empowers true informed decision making.
• Have you taken a through childbirth education course?
• When interacting with your care provider, have you had any red flags?  Pay close attention to anxiety levels during and after your appointment and be very honest with yourself especially by week 31.  You should be able to interview other care providers and switch at this point.
• Think through what your non-negotiables are surrounding your pregnancy and birth.  Women’s care makes us very vulnerable and causes us to place a lot of trust.  If during interactions with your care provider you question their genuine support of your non-negotiables, it’s ok to give yourself permission to believe their signals. It is ok to seek out a provider who will support your non-negotiables.

Early on in my doula career, a client had seen a doctor over the years of her marriage and years of trying to conceive. Changing care providers is huge when that much vulnerability is involved.  But around 30 weeks into her pregnancy, she sensed a lack of support for her birth plan.  In one prenatal, her husband confessed they were so frustrated that he thought he would get to the hospital and lock everyone out of the room! 

We talked about her wishes and exactly what her care provider was saying.  She decided to interview another care provider whose practice was more in line with her birth wishes.  She spent the rest of her pregnancy amazed at the difference at each prenatal visits.  Her birth was just what she wanted.  

You know you and your needs.  Honor those needs and the mother they will empower you to become.