“Mailbag #15: What does the Fox say” – with Dr. Nathan Fox

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and maternal fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

Hey, welcome to our fifteenth “Mailbag: What does the Fox say?” Our first question is from Orly. All right. So, Orly asked a question about parvovirus. “I’ve read that it’s dangerous for a pregnant woman to be around someone exposed to this virus, also known as fifth disease, or slapped cheek disease or erythema infectiosum. One doesn’t usually know a child or individual had the virus until they get the rash on their cheeks, and at that point, they’re no longer contagious. What are the risks for a fetus? Does it matter where one is in pregnancy when they’re exposed? And if they have antibodies for parvovirus, does it clear them from any adverse problems?”

All right. Great question, Orly. So, yes, parvovirus is the name of a virus, and frequently, children will get this infection when they’re younger. It’s called fifth disease, like the number five, because traditionally, it was the fifth virus that they got, I don’t know exactly, probably going back 100 years or something like that. And one of the symptoms is they, in addition to having typical virus symptoms, you know, fevers and this, they have a rash on their face that looks like a slapped cheek, like a red cheek. Now, parvovirus itself is not usually a particularly dangerous infection to get for children, or for adults. Adults can get it too. Usually, in adults, it’s even less severe than in children. And so it’s not an infection that we really worry about from a medical perspective, typically for children or for adults.

Parvovirus can be very dangerous for certain immunocompromised people. So, people chemotherapy, HIV, whatever it is. So, that is something that could potentially be an issue. Now, in pregnancy, it can be an issue, and I’ll explain why. So, parvovirus, most viruses that pregnant women get do not directly affect the fetus. So, for example, a common cold, right? So, the mother might be, you know, a little bit under the weather, a little bit sick. The cold does not infect or hurt the baby. Even the flu, right? So, when pregnant women get the flu, and we do flu vaccines and we worry about the flu, it’s not because we’re worried about the flu directly harming the baby. It’s because pregnant women are all a little bit immunocompromised. Their immune system is a little bit lower, so when pregnant women get the flu, they can be much sicker than non-pregnant people. So, we do worry about the flu, but it’s really for the mother’s health.

When COVID came around, there was this big concern that it would infect and affect the fetus. That seems to be very unlikely and very unusual. But COVID did, like the flu, it could be worse in pregnant women, so we were, again, similarly concerned, and vaccinations and whatnot. There are a couple of viruses that can, when contracted by the mother, even if she is not very sick, it can go through the placenta, and infect and affect the fetus. But those are the exceptions. There’s one of them called CMV. One of them, there’s toxoplasma. Those two are ones that can potentially cause issues with organ formation. They can cause certain birth defects, or can really affect the development of the baby, potentially, in different organs.

Parvovirus is unique. So, parvovirus could travel through the mother’s body, through the placenta to the baby, but parvovirus does not cause birth defects, or issues with the brain or the heart or anything. But it can cause a very unique problem of fetal anemia. The parvovirus can affect the baby’s ability to produce red blood cells, and can cause fetal anemia. So, yes, we do get concerned if pregnant women are exposed to parvovirus, fifth disease.

Now, it turns out that many, if not most, adult women are already immune to parvovirus. So, parvovirus is one of those things that you typically would only get once in your life, sort of like chickenpox, right? Once you get it, or you’re vaccinated against it, you have antibodies against it. These are IgG antibodies, and you would not typically get it again. So, let’s say a pregnant woman is exposed to chickenpox. For the record, chickenpox is one of those viruses that actually also is more of an issue with the mother getting sick more so than the baby. But if she’s exposed to chickenpox, but we know that she’s already immune to it because she has antibodies, we don’t typically get concerned about her getting chickenpox and getting very ill.

So, for parvovirus, similarly, many, if not most pregnant women will go into pregnancy already having been exposed to it, either when they themselves were children, or some time in adulthood, or if they’ve had kids and got exposed from their other kids. And so they’ll have antibodies. So, those women do not seem to be at risk from getting parvovirus and infecting their baby. So, that’s not who we’re talking about. But for someone who’s never been exposed to parvovirus, never had it, and they don’t have antibodies, there is the potential, if she got exposed to someone, usually a child, who has active parvovirus, that she could, number one, get the infection. Number two, the infection can travel through the placenta to the baby, and infect the baby. And number three, could cause the baby to get anemic, which would be potentially dangerous to the baby.

So, from the point of someone saying, hey, I’m pregnant, and I was exposed to someone with fifth disease, with parvovirus, to the point of a baby actually being very, very sick, there’s a lot of steps that would have to happen. So, for most, the vast majority of pregnant women who are exposed to someone with fifth disease, they won’t have any issues whatsoever, because, number one, they have to be someone who already does not have antibodies. So, either we’ll already know, like, in our practice, we usually routinely check for parvovirus antibodies at the beginning of pregnancy, just so, in case this situation comes up, we’ll know already if she’s potentially at risk to getting it. So, it would have to be someone who does not have antibodies already, meaning she’s at risk. Number two, she would actually have to contract the virus. Not everybody who’s exposed to someone with the virus gets the virus, right? So, if she’s someone who does not have antibodies, we will then check. Like, did she get ill? Does she have a fever? Did it seem like she had a viral illness? We can check a couple weeks later, does she now have antibodies, when previously she didn’t? Which would indicate she got infected between the first and the second time we checked the antibodies.

So, that’s the second step, that she may or may not actually get the virus. And if she gets the virus, then what we do is we sort of check if there’s any sign of the baby being anemic. And so, the way we do it is with serial ultrasounds. And we can measure blood flow in a certain blood vessel in the baby’s brain. It’s called the middle cerebral artery. And that blood flow pattern actually is a very good screening test for fetal anemia. We use it for other conditions where the baby’s at risk for fetal anemia, but for parvovirus, we do it specifically. And so, if she was exposed, and she got the virus, we do this weekly, for about two months, give or take, sometimes 10 weeks, because generally, if the baby’s going to get sick, it’s gonna happen in that time period. And most of the time, nothing happens with the baby, or the test is mildly abnormal, but then gets better on its own, and then it’s gone and nothing to worry about later.

There are times, low percent, where in fact we do have someone who gets exposed to fifth disease, and they get the virus, and when we do the screen, the baby appears to be very anemic, and might be getting sick. And so, in that case, we would set them up for a fetal blood transfusion, which we can do. There’s a procedure where basically, it’s like an amniocentesis, where we take sort of a long needle, and it goes through her belly and into the uterus. But then we guide the needle into the umbilical cord, which is like the baby’s blood vessel, and we can, A, draw out blood, to double-check how anemic the baby is, and B, infuse blood into that cord, into the baby, and do a transfusion. Usually, for parvovirus, since it’s a temporary infection for the baby, meaning the baby clears it after time, we would only have to do this once. Again, for most people exposed to parvovirus, they have no risk whatsoever because they’re already immune to it. Even for people who are at risk of getting parvovirus, because they don’t have antibodies, if they’re exposed, they either won’t get infected, or if they do get infected, the baby won’t get anemic, or if the baby does get anemic, it’ll be mild, and not need treatment. And if it does progress to the point where it’s severe, there is a treatment available.

So, what ends up happening, practically, is if someone calls our office and says, “Hey, I think I was exposed to parvovirus,” we’ll first go back and check, all right, does she have antibodies, preceding this, to parvovirus? If the answer is yes, we say, “Don’t worry about it. You’re already immune. You’re good to go.” If she doesn’t, we’ll say, “Okay, let’s check your antibodies again, see if they’ve become positive,” and probably a week or two later, check it again, to see if they’ve become positive. If she has no signs of an infection, and these antibodies never what we call seroconvert, meaning going from negative to positive, then even though she was exposed, she did not get parvovirus, so she’s good. If, let’s say, it turns out she did get parvovirus, either it’s obvious because she got sick, or it’s obvious because of the blood testing, the antibodies change, then we will do the weekly ultrasounds, for about 8 weeks or so, sometimes 10, from the point of her getting exposed and infected. And then if nothing happens, and they’re normal, basically she’s done. And if there’s abnormal findings based on how severe it is, we’ll decide whether we’re just gonna continue to watch closely and hope the baby recovers on its own, or whether we need to do the fetal transfusion. But again, parvovirus is very, very common, it’s around there all the time, and we do very few fetal transfusions for parvovirus per year. So, even though it’s a very common virus, it’s not that common that it ends up leading to this. And again, it does not cause direct birth defects or anything like that. It’s really just if it causes fetal anemia. All right. Orly, great question. Thank you.

Next question is from Maria. “Hi, Dr. Fox. Thank you for your podcast. I’ve been enjoying it. Here’s a question for your next mailbag session. Can you address variations and diagnosis of placenta accreta, and risk factors other than prior caesarean sections? Some background. I had two uterine surgeries prior to conceiving my first child via IVF. Both were uterine septum resections, done via hysteroscopy. During the anatomy scan on my second child, also IVF, there were placental lacunae noted, and some increased placental vascularity. [inaudible 00:11:31] better as I got further along, and I delivered vaginally at 41 weeks. After the delivery, the placenta seemed to be staying somewhat attached, and I had a small…and had a manual removal, with some hemorrhaging, that was resolved with medication, thank God. What is the likelihood of such a complication occurring again, and possibly needing more extreme measures?”

Okay. So, there’s two parts to this question. The first is sort of, are you at risk for a placenta accreta when you have surgeries other than a C-section? And the second thing is if you’ve had sort of what you had, Maria, are you at risk for this in the next pregnancy? And if so, how bad is it? So, as a review, and we had a whole podcast on placenta accreta, as a review, placenta accreta is a condition where the placenta is basically stuck to the uterus. And after delivery, instead of the placenta just sort of, like, shearing off the uterus, and coming out, like it normally does, either the entire placenta, or a large portion of the placenta, remains behind. The reason it’s a significant problem is, until the placenta comes out, there’s typically heavy, heavy bleeding. So, someone who has a placenta accreta after they deliver, and you take out the placenta, and only a portion of it comes out or none of it comes out, it can cause life-threatening hemorrhage.

So, someone has a complete placenta accreta, the typical treatment is we have to do a hysterectomy, remove the uterus entirely, which is obviously a very drastic treatment. When the placenta accreta is partial, that’s not always necessary. So, again, the entire placenta could be stuck, but you could also have smaller portions of the placenta that’s stuck. And based on how much of the placenta that’s stuck will sort of dictate how much hemorrhaging there is, what it’s gonna look like clinically, what kind of treatments we need to do. The most classic presentation, as someone with a placenta accreta, is someone who has a placenta previa, where the placenta is low down in the uterus, and also has a prior cesarean delivery. The reason that’s the most common presentation of placenta accreta is because both of those are relatively common, right? There’s a lot of people have C-sections in the world, and about five percent of people have a placenta previa. So, it’s not so uncommon that someone will have both. And so, statistically, most people with placenta accretas are going to have a history of a C-section, and have a placenta previa in this pregnancy. However, anyone who has had any uterine surgery whatsoever is at risk for the placenta attaching in that area of the scars in the uterus, and potentially having an abnormal attachment, such that it’s too stuck to the uterus.

So, for example, someone who’s had, like you did, a septum removed by hysteroscopy, where we go inside, the hysteroscope, and sort of shave off a septum, there is the potential of the placenta getting stuck there. Someone who’s had other surgeries on the uterus, like D&Cs, or myomectomies is at risk for placenta accreta. Fortunately, the risk of those procedures leading to a full-blown placenta accreta is pretty low, fortunately. However, there does seem to be an increased risk of the kind that you had, which is really, a very small portion of the placenta being stuck, causing extra bleeding, leading to maybe an extra procedure, either at delivery or several weeks later, to remove that portion of the placenta, and it doesn’t tend to be as drastic and dramatic as the classic placenta accreta, with the prior C-section and the previa, that requires a hysterectomy, so tends to be a story, either that nothing happens, or similar to yours, where there’s, like, a little portion of the placenta that’s stuck, and needs to be taken out separately, and it causes bleeding, and then people recover and they’re okay.

So, if someone has had that in the past, they’re definitely at risk for it happening again, either because they’ve had it in the past and they’ve had these risk factors in the past, the prior surgeries, or, clearly, if someone had an abnormal attachment of the placenta to the uterus, there is something about that uterus, probably, that is at risk for it happening again. So, what I would say is, it’s hard to say exactly what the likelihood is. It depends on the circumstances. There’s a very wide range, probably from, like, 10% to 50%, based on exactly what the clinical circumstances were, but it’s high enough that it should be watched for. But I would say that, in a story like yours, typically, it doesn’t get much worse. Not always, but typically doesn’t get much worse, meaning you didn’t have a full-blown accreta. You obviously did not need a hysterectomy. You had a little bit of placenta that was stuck, had to remove separately, had some extra bleeding. And so I would say the next pregnancy, what’ll happen is either nothing will happen, and you’ll be perfectly fine, or it’ll be somewhat similar to what you have. It may be slightly better, may be slightly worse, but the likelihood of it getting crazy worse is probably not that high, especially because you didn’t need surgical procedures to remove that portion of placenta. So, if you needed to, like, multiple D&Cs, or this or that, then maybe you’ve now added surgeries to the uterus, but all they had was a manual removal, which mean the doctor went in, and sort of grabbed the last remaining portion of placenta and pulled it out, so hopefully, it should be the same or better moving forward. All right. Thank you, Maria.

Next question is from D. “Hi, Dr. Fox. I absolutely love your podcast.” Thanks, D. We love that you listen. “You’ve already answered so many questions I didn’t even know I had. Keep up the great work. My question is pretty basic, as I’m not, and I’ve never been, pregnant. When women get pregnant, do we just keep going to our regular old OBGYN? I ask because I moved to my city a few years ago, and see my OBGYN once a year, meaning I don’t feel like I have a super deep connection with her. Ideally, I’d like to establish a relationship with someone now, before I get pregnant, who would be with me through the whole process. Any tips/tricks for finding the right provider in a new city before you need them? Thanks so much.”

So, great question, D. We did a podcast, sort of, pre-pregnancy, preparing for pregnancy. And this is a really important part, I think, of this, if you can do this before pregnancy, like you’re talking about, or even early in pregnancy. Now, for most people, who go once a year or twice a year, or whatever it is, to their OBGYN, that person, that doctor, is usually going to be someone who also takes care of people when they’re pregnant and for delivery. So, OBGYN stands for obstetrics and gynecology. When we train, after medical school, we do our four-year residency. It’s about 50% obstetrics, which is prenatal care, delivery, postpartum care, all of that, and 50% gynecology, which is well woman exams, you know, issues, you know, problems, gynecologic surgery, office-based surgery, menopause, you know, all of those things. And so, someone who finishes training in OBGYN, typically, in their practice, will do both obstetrics and gynecology. And frequently, they’ll see patients for gynecology when they’re younger. Then, when they get pregnant, they’ll take care of them, you know, and do their deliveries. And then when they’re done having children, they’ll take care of them through menopause.

Now, there are definitely OBGYNs who don’t do that. There are some OBGYNs who either, right away, or after time, stop doing deliveries, and they just do gynecology. And so, if your doctor is one of those people, then certainly she would not be the one to take care of you in pregnancy. But if she is someone who does both, then she could be the person who takes care of you in pregnancy. There are some OBGYNs, like myself, who don’t do general gynecology anymore. So, I do just obstetrics, mostly because I went on and did fellowship training in high-risk obstetrics, so my practice is maybe not 100%, but almost 100% obstetrics. And so I don’t see, like, routine gynecology patients. You know, I wouldn’t be doing someone’s annual exam, typically, for example.

So, it really depends, is what I would say. If your OBGYN is someone who does obstetrics, you could start to have those conversations with her, and say, “Hey, you know, I probably will get pregnant at some point in the future,” whether that’s two months or two years or whatever it is. “Is that something that you do? What should I be doing to prepare for that?” And you can start those conversations then. And you can get a sense of what she’s like, how she’s, you know, her philosophy on pregnancy, and if it aligns with yours, or if she says, “You know what, I don’t really do that. I’ll refer out for that.” Now, if you’re starting from scratch, you don’t have a doctor ready, you know, you move to a new town, whatever it is, and you’re looking for someone, it’s really a very personal decision. I’m not saying that to, like, not answer your question, but I would say it really depends what you’re looking for, right. There’s a lot of variables that come into play. There is convenience, right. Is this doctor or this practice close to where you live or where you work, so it’s easy to go to appointments? Is the hospital they deliver at a place that’s convenient for you or inconvenient for you? Do you have a lot of medical issues that might need more attention and you might need either, like, a more high-risk doctor, or you might need a hospital that is a higher level of care, potentially. There’s obviously financial concerns. So, this does this practice or person participate with my insurance, if you have private health insurance.

And then, there’s obviously all of the other things that we look for to getting a doctor. And I’ll tell you that the golden question is how do you know if your doctor is any good? It is very, very difficult to know. I’m, myself, always, you know, I’m a patient. My family goes to doctors, I go to doctors, and we see doctors. I have no idea if the doctor is any good, right? Unless you get, like, a word-of-mouth recommendation from someone you trust, it’s very, very hard. And what I would say is that one of the things I would try to sort of separate in your brain is, number one, there’s the doctor’s sort of, like, technical skills. Do you feel that he or she has, you know, experience, has training, you know, those types of things? And then there’s also the personality side of it, which you definitely don’t wanna discount, right? You want a doctor who you can trust, a doctor who’s gonna listen to you, a doctor who’s available if you have any questions. And based on what your needs are, right, if I need an emergency operation because my spleen ruptured, I don’t particularly care how nice the surgeon is. I want the surgeon to be excellent, right? Whereas, if I’m thinking about long-term care with someone, because I just got diagnosed with diabetes, and this person’s gonna be my doctor for 40 years, right, I want them to be competent, but I really want this person to be someone I can have a relationship with, because I’m gonna need to have a relationship for a long time.

And prenatal care and delivery’s somewhere in the middle, because it’s, like, a year-long relationship, and if you have multiple children, it’s multiple year-long relationships. So, I would make sure that it’s someone that’s feasible, sort of, like, logistically and financially. And then, meet the person. And ultimately, it’s almost like going on a first date. When you meet with the person, if your personalities connect, and you click, and you think that this is a person who I like and I trust, and listens to me, and has sort of a personality that works with me, and sort of makes me feel comfortable, then you’re probably in a good place. Whereas if you don’t have that sense, that person may not be the right person for you, and they might be for somebody else. And I guess that’s what I would do, and you are allowed to shop around. I would do it early, either before you’re pregnant, or early in pregnancy, so you can find the right match for you. But it happens all the time that people say, “And this doctor might be great for one person, but not great for me,” and vice versa. And that’s totally cool.

All right. Next question is from Madison. “Hi, Dr. Fox. I’m a toaster, and 38 weeks first-time mom as of today. I have a fun question. What’s your record for number of deliveries in 24 hours, including moonlighting, residency, general practice? Love your podcast. It’s been so helpful during the past nine months.” Well, thanks, Madison. Good luck to you. I suspect you already delivered, based on when you sent this question in. So I hope it went well. Congratulations. I was actually thinking about this, because I read your question, and the short answer is, I don’t know. It’s certainly going to be when I was a resident. You know, when you’re a resident, the way you sort of cover patients is very different from when you’re in practice. So, when you’re a resident, basically, you know, there’s a team of, let’s say, three or four residents on the labor floor, plus, you know, one or two attendings. And you’re basically taking care of the entire labor floor. So, there could be 15 people in labor, and your team is in charge of those 15 people. Now, the numbers are fine. Like, having five or six doctors for 15 people in labor is a perfectly fine sort of coverage. But if you’re, let’s say, the first or second year, and your job is, like, I’m the one who does deliveries, it is entirely possible that you’re literally going room to room to room to room to room, just doing delivery, delivery, delivery, delivery. And then the other resident with you will be the one that, say, they do the paperwork, or this.

So, when I was a resident, I definitely remember, you know, 24-hour shifts or 12-hour shifts, where I did 7, 8, 9, 10, 11 deliveries. Absolutely, that happened. I don’t know what the record is, but it’s somewhere north of 10, is what I would say, maybe 12 or 13 or something like that. Now, in practice, nowadays, that would almost never happen. First of all, we almost never have 12 people delivering on the same day. And if we did, since I couldn’t be the only person taking care of 12 people in labor, there would be other people from my practice there. So, nowadays, that number, for one person, would definitely be lower. I can say that it’s a really fascinating thing when you’re training. I remember, you know, people ask, how many deliveries have I done? And I remember, like, the answer I had for such a long time was, “I stopped counting at a thousand.” And that was, like, in my second or third year of residency, right. When you’re a resident, you do so much volume, which is good, because you wanna get trained, and know what you’re doing. And after that point, it’s like, what’s the point of even counting? So, I think the answer to your question is somewhere north of 10, but definitely was when I was a resident. That would not happen nowadays.

All right. Our last question is from Haley. “I was told by my doctor that because I’m having a VBAC, or trying for one, I cannot be induced. Is this true? And if so, what do you recommend to women to help induce labor naturally, and how to help progress labor, to help avoid a cesarean because labor is not progressing? Thanks.” So, Haley, really good question. So, for background, right. So, VBAC stands for vaginal birth after cesarean. Some people use the acronym TOLAC, trial of labor after cesarean. But basically, conceptually, as you know, we’re talking about someone who’s, has a history of a C-section in the past, and now they’re trying to labor and deliver vaginally with this pregnancy. And for anyone who’s doing that, one of the risks that we talk about, the main risk that we talk about, in terms of importance, is the risk of something called uterine rupture. And that’s where the scar of your uterus from your prior cesarean, due to the forces of labor in this next pregnancy, that scar, like, burst open during labor, internally, in your body. And that’s not good. Right? So, if the uterus ruptures during labor, that’s not good. It can be very dangerous to the mother. It can be very dangerous to the baby.

And because of that risk, we always have a conversation with people about, all right, you’ve had a prior C-section. Are you a good candidate to TOLAC, which is sort of, like, the attempt of it? To attempt a VBAC? That’s sort of, like, the successful version of this. And one of the things we talk about is the risk of rupture. Now, for most people, the risk of uterine rupture is approximately 1%. And that assumes a certain kind of incision in the uterus, what they call a low transverse incision, and nothing else going on. And the other aspect we talk about is, okay, what’s the chance it’s gonna work, right? Meaning, if you are gonna labor, and I say, “Listen, you only have a 5% chance of it working and delivering vaginally,” you might feel differently about that 1% risk than if you had a 95% chance of delivering vaginally.

So, how does this relate to your question? It is possible. There are some data that indicate that if you induce labor with someone with a prior C-section, instead of that risk of uterine rupture being 1%, it might be slightly higher, in the range of 2%. Now, the data on that are a little bit mixed. It’s not perfect data because it’s retrospective. But what I tell people is, as far as we can tell, the risk of uterine rupture in general is a little less than 1%. And if you are inducing labor, it might be 1% to 2% percent. And so, you can look at that in different ways. You could say, “All right. It’s a little bit higher, but it’s still in the range of 1% to 2%, which is pretty low.” Or you could look at that and say, “It’s double,” right, “what my typical risk is.” And the first one doesn’t sound so bad, and the second one sounds horrible. And, because of that potential slightly increased risk, people sometimes decide differently about VBAC, or TOLAC, if they need to be induced.

So, it’s possible that either a patient or a doctor might say, “I’m comfortable with VBAC if I go into labor on my own, and that risk is about 1%. But if I need to be induced, I’m not so comfortable, because I don’t want any slightly increased risk, like 1% to 2%, versus 1%.” It also happens to be that typically, if you go into labor on your own, your chance of a vaginal delivery, of a successful VBAC, is higher, versus if you get induced, it’s a little bit lower. So, getting induced sort of changes the odds, on both sides of the equation. On the side of the equation of risk, it slightly increases the risk of a uterine rupture, which may be a deal-breaker for some people. May not. But also, on the other side of the equation, it slightly lowers your risk of a successful VBAC, which, again, might be a deal-breaker for some and not others.

There are definitely hospitals, there are definitely obstetricians or practices that will be comfortable with VBAC, but will not be comfortable with induction of labor in VBAC, sort of what you’re describing. There are also places that aren’t comfortable with VBAC, period. And there’s other places that are comfortable with both. So, in our practice, and in our hospital, we are, again, we’re comfortable with VBAC, again, in the right person, who understands what we’re doing. You know, we talk to them. It’s, you know, depends. Each person is specific, but in general, we are comfortable with VBAC, and we will induce labor in someone who is a VBAC. There are certain methods of induction that we don’t use, because they seem to be much less safe, but…and the ones that we use, that keep that risk in a 1% to 2%, we do, in our hospital, allow for induction of labor in VBAC, assuming they understand the slightly, potential slightly increased risk of uterine rupture, and the potential decreased risk of a successful VBAC.

In terms of if you’re not allowed to, and you’re looking for natural ways to induce labor, well, the problem is, number one, they don’t tend to work so well. But number two, it’s not entirely clear, let’s say, that the natural ways are safer than some of the induces. Again, the data on this is very weak. So, I don’t usually have people try various things at home to go into labor with a VBAC, again, mostly because they don’t seem to work, all the things that people talk about. So, ultimately, I tell people, in our practice, we would induce them, but if someone said, “Hey, you know, I’m in another hospital, and I’m allowed to VBAC if I go into labor on my own, but I’m not allowed to VBAC if I need to be induced,” I would say, “Okay, well, how long will they let you go until they’re like, ‘You have to either, you have to deliver by now.’?” And so, that might be 41 weeks. That might be 40 weeks. It might be 39 weeks. It sort of depends on all the other risk factors for that pregnancy. But I would say if that’s the case, schedule a C-section for, like, the latest date possible, and hope you go into labor before then, so you have a chance to VBAC. Hope that answered your question.

All right. Thanks, everyone. Hope you enjoyed our latest installment of “What Does the Fox Say?” We’ll see you next week.

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