by Diana Korte

What's in This Book

Chapter 1 describes the many advantages of a VBAC over an elective cesarean for both you and your baby. It also includes information about cesareans and VBACs in other countries. Chapter 2 describes women's common fears about VBAC and suggests ways to cope with these fears. Planning your VBAC based on your cesarean history is covered in Chapter 3, followed in Chapter 4 by a description of common insurance options and ways to get the most out of your coverage. Chapters 5 and 6 give tips on the two most critical issues in having a VBAC: finding a VBAC-friendly doctor or midwife and hospital or birth center. Chapter 7 provides information about your other helpers--your partner, labor assistant, and childbirth educator as well as supportive VBAC organizations.

Everything you need to know about having a VBAC labor is in Chapter 8. Chapter 9 focuses on appreciating your birth experience, with all of its surprises--whether you have a VBAC or another cesarean--and includes information on how to plan the "ideal" cesarean.

Appendix A contains charts of VBAC, cesarean, and infant mortality statistics from other countries so that you can see how the United States measures up. Appendix B is a Resource Directory, which lists helpful organizations and provides phone and fax numbers and e-mail addresses. (Many of these groups will give referrals to support hotlines, healthcare providers, and publications.) The Bibliographic References detail the publications on which my information is based. In case you would like to send me your VBAC story, comments, or questions, a questionnaire appears at the back of the book.

A Note an Gender: Because the enrollment of women in medical schools has increased fourfold in the past twenty-five years, and because virtually all midwives, nearly all nurses, and most obstetrical residents are now women, I've used female pronouns throughout this book when referring to medical providers.

And one last comment: Take only what you want from this book, and ignore the rest.

Practice visualization and affirmations to help your body and your mind know that your past is not necessarily your future. By "visualization" I mean seeing your desired goal in your mind's eye, as if it's already happened; top athletes often use this technique. Different types of visualization have produced good results in many areas of health care. Affirmations are positive statements you repeat every day, especially when you're deeply relaxed, to send your body the messages you want it to have.

Here's a simple way to get into a relaxed state. Sit or lie down in a comfortable position. Close your eyes. Relax your muscles. You can start by letting your shoulders go limp. Breathe slowly and naturally. As you breath out, feel yourself beginning to relax. Feel the tension leave your body. You might want to imagine that you're doing this in a calm and relaxing place--say, at the beach or in the mountains. Don't worry about how well you're doing. Continue this exercise for 10 to 20 minutes. Do this once or twice a day. Your concentration will improve over time, with practice.

While you're in this favorite place, visualize your baby's impending birth exactly as you wish it to be. Be quite specific: think of your VBAC fears and turn them around into positive images and words. (Examples: See your uterine scar getting stronger and stronger. Watch your baby move smoothly through the birth canal. Feel the power of the contractions and know that you can work with them.) Write down your statements and post them around the house or carry them with you in your pocket as daily reminders. Here are some affirmations to get you started:

• I believe in myself and my body.
• My body is always strong and capable
• I will give birth vaginally with effort, but also with joy.
• I see myself easily getting past where I was stuck in my last labor.
• I enjoy watching my baby start down the birth canal into my waiting arms.

Look for the professionals who offer what you want, instead of trying to fit what you want into what they do. This is true whether you want a high-tech pregnancy and birth or whether you're looking for a midwife to assist you with unmedicated childbirth. As you interview possible doctors and midwives, eliminate the people who you know will not give you what you want. Remember, you're looking for cooperation and enthusiasm, not reluctance.

If some of the healthcare providers you interview tell you that your ideas are unsafe or unnecessary, isn't it better to determine their attitude early while you can still change doctors more easily? When calling hospitals, ask about everything on your birth plan list. Don't assume that if you're breastfeeding, they won't offer your baby formula in the nursery. Don't take for granted that if they have a Jacuzzi for laboring women to help relieve labor pain, it will be available to you. Ask first.

I started with a big upscale OB practice with seven OBs and, as I found out, seven different opinions on how to treat a VBAC. One doctor said external monitoring was fine; another wanted an internal pressure catheter, et cetera. At thirty-two weeks, I finally got the nerve to investigate the other OB practices available through our HMO. I actually interviewed the doctors about their VBAC procedures, quite a change from my "trust your doctor" mindset in my first pregnancy. I ended up switching to a "no-nonsense" HMO group--no fancy examining rooms, no classical music piped into the waiting room. They all knew me as the lady who wants a natural childbirth. But they gave me respect and treated me as an educated adult who wanted to be an active participant in her birth experience. I spoke to all four OBs in the group about my birth plan, brought my doula with me to an appointment with the doctor I was least comfortable with, and took a proactive role in my pregnancy.  -Alexandra G., Tennessee

HMOs, PPOs, point-of-service plans, and even the old-fashioned fee-for-service plans are all bought by an individual company for its employees from one of many giant insurance companies, each of which has accounts with hundreds, if not thousands, of businesses and corporations. Your employer might offer only one insurance plan, but some of you may be able to choose from all of the options outlined here. If your employer offers more than one insurance carrier, you might be able to switch plans only during one designated month in each year.

Unlike the insurance options I've discussed so far, an independent practice association, which is similar to an HMO in benefits, is a group of physicians who contract with several insurance companies--not just one HMO--to offer insurance benefits to you or your company.

A decade ago cesareans added $1.5 billion to the total U.S. tab for childbirth. Today's total cesarean cost is unknown, but surely it's still more than a billion dollars. If your insurance covers all costs for your birth, then perhaps the price of childbirth, whether VBAC or repeat cesarean, is not a pocketbook issue for you. More and more couples, however, are having to make larger co-payments for hospital charges, whether for extra days in the hospital or for medications. An epidermal costs $500 to $2,500, for example, depending on the hospital and the anesthesiologist. An extra day in the hospital in 1994 averaged $931, up from $245 in 1980. And at least some insurance plans, especially HMOs, encourage VBACs to the point that all cesareans have to be prepared by the insurance company. If the cesarean is not approved, the doctor does not get reimbursed for the cost difference between a vaginal and cesarean birth.

Ten Interview Questions for a Doctor or Certified Nurse-Midwife

1. Approximately how many VBACs have you attended?
2. Of those patients in your practice who wanted VBACS, how many were successful?
3. What do you think my chances are of VBAC success, given my childbirth history?
4. What is your cesarean rate?
5. How do you usually manage a postdate pregnancy or a suspected CPD?
6. What's a reasonable length of time for a VBAC labor if I'm healthy and my baby appears to be healthy?
7. What percentage of your patients do you deliver yourself?
8. How many people can I have with me during the labor and birth?
9. What is your usual recommendation for IVs, Pitocin, prostaglandin gel, amniotomy, epidurals, confinement to bed, EFM (and so on)?
10. How close together are your appointments?

Non-Hospital VBACs and the Risk for Uterine Rupture

You might be wondering why I've included information about nonhospital VBACs when uterine rupture is possible with any VBAC. The answer is that there will always be reasonable women who choose to have VBACs in out-of-hospital birth centers or at home.

These women believe they have a 99 percent chance of having a successful non-hospital VBAC, and they are correct. Thousands of women have had VBACs in homes and birth centers, sometimes after multiple cesareans, with no problems whatsoever. But when a dreaded rupture happens, the baby's death is likely to follow unless a cesarean is performed within 30 minutes. To avoid any neurological damage to the baby, a 1993 study found, the cesarean should ideally take place in 17 minutes or less.

Sometimes women who give birth at home or in birth centers erroneously believe they can't have a rupture because they are not using Pitocin or prostaglandin gel. Although a rupture is more likely to happen after labor is induced with one of these products, some ruptures have developed without induction. In Arizona, California, and Colorado, and probably elsewhere, babies have died in home births because of uterme ruptures.

Some women who plan non-hospital VBACs choose birth centers that are only a few minutes from hospitals. Others arrange to labor at friends' houses that are quite near hospitals. A few even take nearby motel rooms. While pursuing the benefits of VBAC outside a hospital, these women also take steps to reduce the risks.

One More Word on Midwives

Unlike doctors, midwives, whether CNM or direct-entry, are not readily available everywhere in the United States. Obstetricians and family physicians who deliver babies outnumber CNMs 11 to 1. In addition, midwives (the word means, literally, "with woman") tend to be a well kept secret. You may have heard about them, but you may not be quite sure what they do. Maybe you didn't know that midwives, unlike doctors, are trained to stay with you in labor. Perhaps you assumed that the women who go to midwives are uneducated, careless, or part of the counterculture. However, statistics reveal that women who give birth at home or in out-of-hospital birth centers, whether in the United States, Canada, Europe, or Australia, are usually older, married, and white; they are from the educated middle class, are well informed about childbirth, and are very willing to accept responsibility. That's a good description of the women who seek the care of CNMs in hospitals, too.

Many women who choose midwives are familiar with the large body of research that shows the safety of midwifery care for childbearing women who are "low-risk"--a label that covers about 90 percent of pregnant women.

One reason you may not have considered a midwife is that you don't know anyone who has ever worked with one.

It's just as important for you to find a VBAC-friendly hospital or birth center as it is to have a doctor or nurse-midwife who will enthusiastically support your efforts. Some observers say that the place you give birth is the most important childbirth issue of all, because even the most VBAC-friendly physician or CNM cannot be as accommodating as you might want if she is practicing in a hospital that has regulations that make VBAC difficult.

In the United States, 99 percent of births occur in hospitals, including most midwife-attended births. Out-of-hospital birth centers, which started to sprout up in the 1970s and grew more rapidly in the 1980s, are often considered the place midway between having a baby at home and in a hospital. Operated by certified nurse-midwives, direct-entry midwives, and the occasional physician, out-of-hospital birth centers offer low-tech births (only for healthy women) at an affordable cost: an average fee of $3,600, versus the $6,378 for an obstetrician and hospital. The fees at birth centers run by direct-entry midwives might be less.

Some hospitals offer their own birth centers, which are integrated into the maternity wing and are usually staffed by CNMs. Although only 1 percent of births occur outside of hospitals in the United States--a rate that hasn't changed in ten years--the perceived competition from out-of-hospital birth centers and homebirths may have encouraged hospitals to offer more maternity options.

A labor assistant, or doula, cuts your risk for another cesarean in half--what a boost for a woman having a VBAC! A growing body of research literature reveals that the presence of a female helper reduces requests for epidurals by more than 50 percent, while also reducing the use of oxytocin, analgesia, and forceps. Women who had a labor assistant with them and no epidural reported pain that was no different in intensity than that of laboring women who had epidurals and no labor assistant with them. Best of all perhaps, having a labor assistant at your birth can shorten your labor by 25 percent.

The labor assistant enhances the role of your partner--she doesn't eliminate it--and increases your sense of security because you and your partner are not surrounded by strangers in a strange place. Having other women with laboring women is not a new concept--it's just been newly studied and appreciated. It's a tradition that goes back for millennia and has been practiced in societies the world over. As to why it works, the constant presence of a doula reduces psychological stress during labor, and helps keep the vulnerable laboring woman focused on getting her baby out, rather than on the pain she is experiencing. As necessary as your partner is, there's no evidence that a partner's presence shortens labor or reduces the use of interventions. The woman-to-woman link is essential; it's no accident that nearly all birth assistants have given birth themselves.

Can nurses provide this kind of support? Yes, but nurses come and go from laboring women's rooms, and often care for six to eight patients at once. Nurses don't have the luxury of spending all of their time with one laboring woman. And physicians typically don't arrive until the end of labor (although midwives arrive earlier and usually spend more time with mothers in labor).

I surrounded myself with a wonderful birthing team. My husband's labor coaching and belief in me provided unconditional love and support. A wonderful and tender midwife's commitment and devotion led me through labor with confidence. It was also heartening to share the event with my mother, who witnessed the birth of her newest granddaughter. My sister-in-law, with her love and laughter, added a spark of levity. And there was the proudest member, my three-year-old Raina, whose eyes beamed as she saw her baby sister enter the world.  - Meryl F., New Jersey

Pain-Relieving Techniques for Labor

Labor pain occurs because uterine muscle contractions have to be very strong in order to move the baby down into the birth canal. Pain also comes from the pressure exerted by the baby's head as it widens the path to get through the canal. Much to many women's surprise, drugs, including epidurals, don't always relieve all of the pain of labor.

Whether you only want pain relief up until you can have an epidural at 5 centimeters, or you want to go all the way without drugs because your labor stalled when you had your epidural with your last birth or the drugs ruined your concentration the last time around, here are ten suggestions to shorten your labor, increase your birth pleasure, and reduce your pain.

Looking back, I am grateful for all my birth experiences--especially my cesarean. If not for that birth, I would not be the person I am today. It changed me in more ways than I can mention. A birth such as my first VBAC--would not be acceptable to me now, but at the time it was the most empowering experience of my life. I have grown and expected more of myself and my births since then, but it was that experience that allowed this metamorphosis.  - Sunday T., Ohio

Excerpt reprinted with permission from foxcontent.com