“VBAC to the Future” – with Dr. Stephanie Melka

Dr. Stephanie Melka returns to discuss VBAC, or vaginal birth after cesarean. In this episode, she and Dr. Fox review risks associated with VBAC, which patients are candidates for VBAC, and choosing between cesarean and vaginal deliveries.

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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 OB-GYN 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. All right, Melka, welcome back. How are you doing? 


Melka: I’m doing well. How are you? 


Dr. Fox: I’m doing great. Really excited to have you back. 


Melka: Happy to be here. 


Dr. Fox: Yeah, we’re gonna be talking about VBAC today. 


Melka: I’m so excited. 


Dr. Fox: We’ve been talking about this topic for a while that we wanted to do a podcast. It comes up a lot, obviously. And I think, you know, it’s another one of these topics where there’s a lot of, I don’t know if it’s so much misconceptions, but there’s such a wide range of how people feel about this. And some of it is maybe not accurate, I would say, from what the data shows. 


Melka: Yeah. 


Dr. Fox: We’re just gonna jump right into it. For those who don’t know, VBAC stands for vaginal birth after cesarean. You’ll hear the acronym of TOLAC, T-O-L-A-C, which is a trial of labor after cesarean. But basically, they both refer to someone trying to deliver a baby vaginally after they’ve had a C-section in the past. Why is this such a big deal? Like, why is this such a hot topic? 


Melka: The main concern and the biggest risk with a VBAC is what we call a uterine rupture. So when you deliver a baby by C-section, you’re obviously opening the uterus and then sewing it back together. So, that area, when it heals, forms a scar. And that scar in future deliveries can be a little bit weaker. The big complication with a VBAC is that weakened area can basically open. It’s one of the true medical emergencies we have as obstetricians, you know, emergency cesarean, deliver right away, save the mom, save the baby. And mainly because of that risk or the lack of ability to quickly manage that outcome, people do often shy away from VBAC. 


Dr. Fox: Right. I mean, if you go back, you know, a long time ago, you know, 50-whatever-plus years ago, the adage was once a cesarean, always a cesarean. So if someone had a C-section, they would have C-sections for the rest of their deliveries. Now, first of all, at that time, maybe 5% or less of babies were born by C-section. So it wasn’t “as big of a deal” because it didn’t happen that often. And they didn’t have the same capabilities for emergencies in terms of getting someone in an operating room very quickly, having anesthesia very quickly, having a pediatrician very quickly. So, it’s possible that that was the right decision at the time. 


And then in the second half of the 20th century, you know, mostly in the ’80s, ’90s, and early 2000s, there was a big push to do VBACs, to have people deliver vaginally because these capabilities were available, and the thought was, you know, the risk is only 1%. And a lot of people were sort of pushed into it, even if all of the situations weren’t appropriate or maybe the hospitals weren’t right, and they started seeing complications. So then it backed off again, and then people stopped doing it. And so we’ve seen sort of swing back and forth based on, sort of, when someone trained, or where someone trained, what the numbers will be. And that’s also part of it. It’s whether, sort of, societally, or in a hospital, or in a practice, they’re in the phase where they’re pushing it or the phase where they’re shying away from it. And so people hear different things for that reason.  


The other thing is, in general, the C-section rate in this country has gone up over time. And this was thought to be one way to lower that number, that part of the reason C-sections are going up was because of the second or third C-section. And that was another reason this has been pushed a lot but I think most people realize it’s really the first C-section… 


Melka: Yeah, definitely. 


Dr. Fox: …you need to prevent if you wanna sort of lower the C-section rate because, you know, the second, and the third, and whatnot, you have decreasing gains with each of those. In terms of the risk of uterine rupture that you’re talking about, so number one, how common is that in someone who’s having a VBAC? 


Melka: Just under 1%. So what I quote women, one prior C-section in labor, the risk is 0.8%. So if you had 1,000 women undergoing a VBAC, 8 will rupture their uterus. The risk goes up a little bit in the setting of inducing labor, where you’re giving Pitocin in somebody with two prior C-sections, I quote people about 1%. 


Dr. Fox: And so, in that 1%, what are the consequences if it happens? So, if someone has a uterine rupture, you know, you mentioned that, you know, emergency cesarean, save the mom, save the baby but, you know, what is the problem with that? 


Melka: So, when the uterus opens, you know, it’s dramatic. The baby can come out of the uterus. The placenta can detach. Mom is losing blood quickly. Baby is losing blood quickly. So babies can have neurologic deficits, rarely a baby that doesn’t survive, a mom that doesn’t survive because of the blood loss. 


Dr. Fox: Right. And it’s fortunately, even amongst women whose uterus ruptures in labor, those outcomes are not typical, meaning that… 


Melka: Very rare. 


Dr. Fox: …yeah, the chance of a long-term problem for the mother or baby because of uterine rupture is somewhere around 10% to 20%. So that’s, you know, 10% to 20% of 1%. So it’s a very, very low chance. And listen, horrible things happen to people who have elective cesareans and to people who have vaginal deliveries with no prior…I mean, these things…very rare outcomes can occur, but this is one specifically. And the likelihood is very, very low. And so, it’s sort of a situation where people have to decide what is their comfort level with risk, that’s a significant risk in terms of the actual outcome, but the likelihood is very, very low. And different people look at that differently. 


Melka: It’s always interesting when I’m counseling patients, you know, I’ll say, “About 1%. You know, in your case, I would quote 0.8%,” and sometimes people’s eyes widen,and they say, “That’s way too much. I don’t wanna take that risk.” And other people’s eyes widen and they say, “Oh, that’s nothing.” You know? “I thought it was much more unsafe than that.” It’s entirely perspective. 


Dr. Fox: That is a big part of it, which is why, and we’ll talk about this more, VBAC is not really one of those decisions where I believe, you know, at least we believe that we tell people what to do. We sort of tell people what we think are safe options. Like, we’re happy to tell someone if we think VBAC is not a safe option for them. But if it is a safe option for them, we don’t say, therefore you have to do it, and you can’t have an elective cesarean instead because there is a risk. It’s known. and if for her that risk is too, you know, worrisome, then she’s not the right person to attempt a VBAC. And so, the other issue with people who have a prior C-section who are attempting to deliver vaginally is even they don’t have a uterine rupture, they may end up with another C-section in labor like anybody else. 


Melka: Yeah. And those are the C-sections that are higher risk than a scheduled C-section. That also goes into the counseling where there’s so much about labor we don’t know. We don’t know whose labor will progress normally and have a vaginal delivery, who’s gonna have an emergency. So you’re also factoring in that uncertainty, 


Dr. Fox: Right. It’s sort of like, you know, if someone is trying to VBAC or someone has a prior C-section, there’s several ways this can go. They can try to VBAC and if they’re successful and have an uncomplicated vaginal delivery, that’s sort of the best outcome typically in terms of risk, in terms of recovery, in terms of ease of recovery, fine. But she can also end up if she goes for that with the worst outcome, which is the very rare uterine rupture, or she could end up with another C-section labor, which is not typically, you know, horrible or dangerous and maybe, you know, annoying that she labored again and ends up with a C-section. And, you know, sort of she’s like, “Oh, I can’t believe I did this again.” But okay, she has that.  


And then there’s the middle road, which is doing the elective C-section without labor. So you’re not gonna get the best outcome because you’re certainly not gonna have a vaginal delivery, but you’re not gonna have that C-section after labor. And I guess in theory, you could have a uterine rupture before, you know. you show up for your C-section. But let’s assume that’s, you know, not gonna happen, it’s pretty unlikely, and you’re not gonna have a uterine rupture, and it’s sort of the one in the middle. And so, is it worth going for the vaginal delivery and taking the risk of those other outcomes versus just taking the middle of the road? And that is really so much, number one, of a personality decision, how people look at risk, then also percentages. Because people say, “Okay, well, if I try for a vaginal delivery, how likely am I gonna succeed?” 


Melka: I also find it helpful stepping back from the numbers. Somebody who had a C-section who’s young, who wants to have six or seven kids is probably gonna look at the risk of a VBAC as more acceptable than somebody who is older, had one kid, maybe this is the second and the last, and just doesn’t have that same looking forward interpretation of the risk. 


Dr. Fox: Right. Exactly. And I think that when we’re trying to help women decide which way to go, and sometimes we don’t need to help them because they know right away what they want, and, you know, they walk in, “I want a VBAC,” or someone walks in, “I want a repeat C-section,” we talk about it, but okay. But for women who are really trying to make a decision, sort of the way we go about this is the first thing we do is we first figure out who is it that really should not try a VBAC? Like, who, it’s not a good idea, the risk is too high, we don’t recommend it, it’s not on the table as an option? And so who might be someone who we say, “You cannot VBAC for safety reasons?” 


Melka: Mainly women with the classical or high transverse cesarean section in the past, meaning because of the cut that was made on the uterus, their risk of rupture is unacceptably high. 


Dr. Fox: Right. So, as a little bit of background, when we do a cesarean and we make the incision on the skin, nowadays, almost always, the incision on the skin is transverse, meaning from left to right or from right to left, across. It could be up and down, but it’s usually across. When we get inside and we’re actually at the level of the uterus, there’s also two ways we can make the incision. We can make it across in the very lower portion of the uterus. We call that a low transverse cesarean delivery or we can do it up and down on the uterus, what we call vertical, sometimes called the classical, or in theory, we can go across but high up on the uterus, what Melka was saying, a high transverse. The type of incision that we make on the uterus affects the risk of it opening up in rupturing next pregnancy. The best one, in terms of the lowest risk is that low transverse one. And that’s what we do probably, I don’t know, 99% of the time, almost always, we’re gonna do that. But there are circumstances when we don’t because we can’t or because there’s a reason not to. 


And so someone who comes in whose history is that she had a cesarean but it was against something called the classical cesarean and vertical or what we call a high transverse, we say you really shouldn’t because your risk is no longer 1% or less. Now it’s 5% to 10% or something like that. There’s also something called the T-incision. There’s different ways to do it. So those people, they’re just not candidates. It’s just that the risk is too high. It’s not worth it, and we say no. Or there may be another reason not to…labia, placenta, something unrelated to the prior cesarean. So, those people are sort of not in the conversation. They’re just not an option. And then we talk about the risk of the VBAC, you know, the risk of the uterine rupture, the risk of having another C-section, you know. And we also have to talk about the risks of just doing a repeat cesarean because that’s not risk-free either. So what are the risks of just doing a second C-section on somebody? 


Melka: Slightly increased risk of bleeding and infection compared with vaginal delivery. The biggest difference is gonna be the increased risk of damaging internal organs, you know, typically the intestines or the bladder. Anytime you do surgery, that’s a risk. And it’s slightly higher with these repeat C-sections based on scar tissue that had formed in previous pregnancies. 


Dr. Fox: Right. And it also tends to be under 1%. So, when we’re talking about sort of the straight-up risks to her, you know, doing the VBAC, there is a risk of a uterine rupture or having, you know, some need for a C-section in labor that has its own risk. And it tends to be 1% or less. And on the other side, just doing the C-section also has risk but it also tends to be 1% or less. So it’s not so much the magnitude of the risk, it’s what risk are we talking about? And then the other things we really go into the likelihood of success, right? If you’re gonna try a VBAC, if someone has a 0% chance of success, she’s not gonna try. And if she has 100% chance, she’s more likely to try obviously. So what are the things that make her more or less likely to be successful with a VBAC? 


Melka: So the first thing I look at is why did they have their C-section in the past? It was some type of a labor abnormality, for example, in labor, stopped dilating or it got to fully dilated, push, the baby did come down. Those are the women within a lower likelihood of success the second time around. Whereas somebody who had a C-section for another reason, such as the baby’s heartbeat was dropping, the baby is breech, that doesn’t have that same predictive factor. 


Dr. Fox: Right. Sometimes you’ll hear these referred to as recurring and non-recurring reasons, meaning recurring is the thought that for whatever reason, in your first pregnancy, the baby “didn’t fit,” right, it didn’t come out easily. The thought is that, well, that’s more likely to happen the second time as well. It’s somewhat true. It’s also kind of false because sometimes someone can push for three hours and end up with a C-section, and the next pregnancy, the baby comes right out. A lot of it is not just related to the size of the mother and the size of the baby. There’s so many other factors that go into it.  


But it’s true that if someone had the type of C-section that was done for the reason of my labor stalled or I can’t push the baby out, she’s more likely to end up with a C-section the second time too. Whereas if it’s a C-section just because we told her you shouldn’t labor, you have twins, you have a placenta previa, whatever, then her likelihood of successfully delivering vaginally the next time is a little bit higher. So that’s one reason. What about women who’ve had vaginal deliveries before, like either before their first C-section or they’ve subsequently had a VBAC already? 


Melka: Those are the easiest VBAC conversations because they’ve already delivered vaginally. So their risk, I quote like 95-plus percent. Like, yeah, there’s a rare chance they don’t die late or you have an emergency, but very, very often they’re successful in VBAC. 


Dr. Fox: If you have someone who’s had a vaginal delivery before her C-section, right…So she has two kids, the first was vaginal, the second was C-section, and now you’re in the third. Her labor typically behaves like someone who’s had vaginal deliveries before, which means it typically goes faster. There’s a, you know, 90-plus percent chance she’s gonna deliver vaginally, low chance of a C-section. All true. If she’s had two children, and the first one was a C-section, the second one was a VBAC, and now this is her third pregnancy, that still holds, obviously. And, in fact, interestingly, her risk of uterine rupture is a little bit lower. It’s probably about 0.5% or 0.4% since she’s had a successful VBAC. Why that is exactly, we’re not sure, maybe it’s just self-selection or this but her chance of success is higher and her risks are a little bit lower. So that’s obviously the best candidate, as you said, someone who’s had a vaginal delivery before. There are other things that do go into this, like you said, being induced versus spontaneous labor. And what exactly does that effect? 


Melka: So that also affects the success rate. You know, I think somebody coming in, in labor, is gonna have a much higher, like…not a much higher but a higher likelihood of a vaginal delivery than somebody who has to come in and be induced. 


Dr. Fox: Yeah. And then you had mentioned before in relation to risk, there is a slightly increased risk of having a uterine rupture if your labor’s induced compared to spontaneous. It’s not very high. It’s just instead of less than 1%, it’s slightly more than 1%. But it’s not very high. How about the number of prior C-sections? Let’s say someone’s had prior two C-sections. 


Melka: So that also increases the risk of rupturing the uterus. 


Dr. Fox: Right. And what about the chance of success? 


Melka: Lower, as well. You know, we generally don’t induce people when they’ve only had two prior C-sections. So if they don’t go into labor, then they’re sort of just stuck with the C-section. And I think in those settings, it’s not common to have two non-recurring prior C-sections. You know, it’s usually one or both of the C-sections were they didn’t dilate or their labor didn’t progress. 


Dr. Fox: It’s an interesting situation because we do have women who come to us with two prior C-sections who are interested in a VBAC. And what ends up happening is it’s not known to be, like, very dangerous, but, like you’re saying, you have the risk of uterine rupture than you did another C-section so you have a slightly higher risk, and then your chances of vaginal delivery is slightly lower times two. And if you get induced, the risk goes up a little bit more. And so at a certain point, when do you sort of say enough is enough on the risk end? And different people, you know, cut off differently because there isn’t like a for sure yes, a for sure no to illustrate that. I’m old enough. You know, it used to be that the American College of Obstetricians and Gynecologists, which is like our national body, had a statement out about VBAC. And the statement said, “If you had two prior cesareans and no vaginal deliveries, you should not attempt a VBAC,” right, “because the risk is too high, success rate is too low.” 


And then several years later, they updated their statements, and they said, “If you have two prior cesareans and no prior vaginal deliveries, it is appropriate to VBAC.” Nothing actually happened between those two statements. There was no study that came out. There was no research that came out. They just sort of said, “We’re gonna change our mind because it just seems, like, you know, maybe we were too conservative the last time.” And they’re not, like, at fault for that. It’s just people’s minds think differently about this at different times, like I said, you know, based on, sort of, where we are and what people are thinking about. But the risk, you know, it’s not unreasonable to try in those circumstances, but it does require longer conversation because the risks are higher and the success rate is a little bit lower. What about the age of the mother? Does that have an impact on VBAC? 


Melka: Yeah, I mean, maternal age is also associated with success rate of vaginal delivery, in general. 


Dr. Fox: In which direction? 


Melka: Lower likelihood of vaginal delivery the older a woman gets. 


Dr. Fox: Right. As women get older, their risk of a C-section goes up. In all regards, that’s true even on a first baby. But with a VBAC in the same way, it lowers their success rate. It does not seem to increase the risk. It just lowers the success rate. And the same is true also for her weight, or BMI, or body mass index, as that goes higher, her chance of a vaginal delivery goes lower or her chance of a C-section goes higher. And then how do we take all this information together and, sort of, try to quote someone what is their likelihood of success? 


Melka: Oh my God. It’s so hard. You know, what I generally do is, like, you know, I give them the general rates at their age, and I look at what their prior C-section was for. You know, why was it done? Was it two prior C-sections? Just sort of estimate. I try not to give numbers. You know, I think you have a good chance. I don’t think you have a good chance. 


Dr. Fox: Yeah, I think it depends on who I’m talking to. There are calculators that exist that have been created based on, you know, large data sets, where you can plug in her age and how many C-sections she’s had, and sort of all these things, and it’ll tell you, you have an X percent chance of success. Some people find those numbers very helpful, other people don’t. I say for most people I’m talking to, we don’t have to get to the calculator. They sort of just…you know, do I have a sense that this is more likely than not gonna end up, you know, with the vaginal delivery versus more likely they’re not gonna end up with a C-section or are we in the high 90s versus the 54% sort of range? And for most people, that’s enough to, sort of, make a decision about what they wanna do.  


And the other thing you mentioned before is, how many children do they wanna have? Right? If someone says, “Well, my plan, I always thought about, you know, just two kids. And so, my first one was a cesarean, I’m fine in having another C-section.” And so, she may be a little bit less inclined to go for the VBAC where someone who says, “You know, I wanna have five or six kids.” And so, having the second one as a vaginal delivery will make her third, fourth, and fifth, much more likely to be vaginal delivery, whereas if the second one’s a C-section, you know, then 10 years from now, she’s having her fifth C-section, and that could have its own set of risks and whatnot. So that goes into A, the mindset that the woman has, and also in terms of the risk-benefit ratio because when you start looking at risk, you have to look at the future. And if someone wants to have five kids, I know I have to include the risk of a fifth C-section in sort of that calculation. 


And so that definitely has something to do with…It’s a question I always ask women, you know, “Do you have an idea of how many children you thought you would have?” Some people don’t but many people do to, you know, within one. Usually, they know, you know, plus or minus one. They typically have an idea. And that also, like we’re saying before, where is she gonna deliver? And there’s sort of the hard data. You know, do they have 24-hour anesthesia available for obstetrics? Do they have a 24-hour NICU coverage? Is the operating room…you know, are you able to get in there quickly? So that’s, like, important, you know, criteria. I mean, if you don’t have those things, it’s probably not wise to have a labor that might end with an emergency. 


But I’ve also found that different hospitals, there’s just a different culture about VBAC. I know that where we practice now, people are pro-VBAC. If someone wants to do it and it’s safe, pretty much all the obstetricians, even the midwives are comfortable laboring somebody with a prior cesarean. The nurses are comfortable. The pediatricians are comfortable. Like, everyone sort of is on board. But I’ve been to hospitals where it’s mixed feelings. If you have one doctor who is in favor of it, but the entire nursing staff thinks it’s a crazy thing to do, it’s gonna be hard because the patient will get sort of that encouragement and that positive reinforcement that you’re making a good decision. If every person sort of looks at you funny because you’re doing a VBAC, it’s gonna change your perspective on it. 


Melka: Yeah. And I think that perspective even carries through to when there are complications. You know, when we do have a uterine rupture, it’s handled quickly. But nobody ever turns around and is like pointing fingers at you, like, “Why were you laboring her? You shouldn’t have done this.” You know, we all just sort of understand it’s an accepted part. And I think, you know, especially at Sinai, we’ve all been in the complicated cesareans, you know, where people going through that really do see the benefit of a VBAC and of avoiding multiple C-sections. 


Dr. Fox: Right. Yeah, I mean, if you’ve been on one of those fourth C-section placenta accretes, you know, where, you know, it’s really dangerous, you’re like, “Man, I wish she had her second and third baby vaginally because then we wouldn’t be here.” And so you do get that perspective. And I think that’s an important part of the conversation that women should have with their doctors about this. It’s not just, you know, what are my risks? What are my chances of success? How do you feel about this? How do I feel about this? It’s also, where do you deliver? And is the hospital comfortable with this? Are you the only person there who does VBACs or is it something that everybody does? Are the nurses gonna be, like, sticking their nose up in the air or are they gonna be really encouraging, are they gonna be supportive? And that’s an important question that I don’t think people realize they can ask. 


And, you know, one that can be…you know, how many VBACs does your hospital do in a year, in a month, or whatever way you wanna ask that question, just to see if it’s something that’s done? If they say, “Yeah, I’m the only one who ever does it. And I maybe do one or two a year,” even if he or she’s comfortable with it as a doctor, I think that it’s less likely to be successful because not everyone is gonna really be on board with it. You just sort of get that sense. And it’s sometimes hard to figure that out. But I think it’s important to start asking those questions and have that conversation with people. 


And sometimes people ask me that, you know, should they transfer to our practice because they want a VBAC. And I say, “You know, we’re not, like, better than anybody else at, you know, managing someone who has a prior cesarean.” I’ll say, “If your doctor is really comfortable with it, and the hospital that they’re delivering at is comfortable with it, it really shouldn’t make a huge difference. But if your doctor is really squeamish about it, and the hospital is really squeamish about it, then yeah, you probably should come to us or any of the doctors at our hospital to do this. It’s just sort of the location more so than the actual, like, physician skill in doing it. And I think that’s pretty important. What have you found in terms of what your patients want? 


Melka: So, we were just talking about perspective. And I think that comes up in every single conversation. You know, it’s not just what happened in the last delivery, but it’s the perspective around the delivery, and the recovery, and everything. You know, I have patients that will say, “Oh, my last C-section was…you know, the baby was breech. It was a breeze. I don’t understand why everyone has C-sections. Like, sign me up for a repeat.” There’s other people who say, “No, I got induced. It was, you know, two days of induction. It was miserable. I didn’t sleep, and then I ended up with the C-section. I couldn’t walk for a week. I really wanna avoid that.” That situation always gets a little tough because that tougher recovery is more related to the long induction than the C-section. And I tell…you know, those patients, I think, have the hardest time deciding. They’ll say, “Well, I don’t want another C-section, but I don’t wanna end up like I did last time.” And always whenever they do decide on the repeat section, the next day, they’re like, “I feel great. You were right. I feel great.” 


Dr. Fox: It’s also different people feel differently about vaginal delivery. For some women, it’s, “I want an easier recovery. I want less pain. I wanna be more mobile. Not only am I gonna have a newborn, but I have a 2-year-old at home, and so it’s even more important to me.” “I don’t have a baby nurse,” or, “I live in a walk-up now,” whatever it is. It’s recovering. For other women, it’s just, “I really want a vaginal delivery. This is sort of…I’ve been looking forward to this. It’s meaningful to me to experience that. And even if this is my last child, it’s something I really wanna do. And I couldn’t have it last time because, again, the baby was breech, or the baby was 10 pounds,” whatever. And it’s just something that they feel connected to. And that’s also a good reason. I mean, unless it’s, you know, medically not a good reason, that’s perfectly fine. 


And so, a lot of it has to do with it. So, like you said, if it’s a recovery issue, it’s the same thing, it’s a gamble. Like, yeah, if you have a long labor and deliver vaginally, it’ll probably be better. But if you have a long labor and have a C-section, your recovery may be worse. And so then it comes into, like, “Well, do you wanna, like, you know, go for it, knowing that?” And different people feel differently. And I think what this all comes down to is it really requires a conversation. It requires a lot of thought, and a lot of inquiry, and going back and forth about the risks, about the benefits, about her particulars. Why did she have a C-section? How does she feel about vaginal delivery? What is she looking for? And it’s not something that you can just, you know, look at someone and say, “You’re good, you’re bad,” like in terms of a candidate. 


You have to really talk. And these are conversations I generally encourage people to start early in pregnancy, but not tie themself to any particular decision because things change over the course of pregnancy. If you really, really thought you’re gonna have a VBAC, and then suddenly, you know, in the third trimester, you realize your baby’s, like, measuring really, really big, you may change your mind. On the flip side, you may have thought you wanted a repeat C-section, but now suddenly, you’re 35 weeks and you’re in preterm labor, and you’re 5 centimeters dilated, plans change. Like, maybe this is a great time to try to have a vaginal delivery. And so, there has to be some room for modifying the plan based on how circumstances change. How often, you know, do you have these conversations? With a particular patient, how often might you discuss this over the course of pregnancy? 


Melka: Several times at least. You know, typically at the first visit, I’ll say your last delivery was a C-section. We’ll talk about the options as the pregnancy goes on. I personally don’t like the conversation too early because I think it just doesn’t allow for the time of seeing how things go. You know, I think by 24 or 28 weeks, make sure somebody is not a diabetic, doesn’t have other complications, then that’s usually when I bring it up again. Sometimes it’s easy at the first visit, they say, “Oh, I had a C-section. I want another one. Sign me up.” You know, and then I’ll ask them again, 24, 28 weeks, “Is that still your plan? Do you wanna go ahead with scheduling?” And then probably again, about 34, 35 weeks, I’ll start the conversation of, “Okay, I know your plan was to VBAC. But what’s your endpoint? If you don’t go into labor, do you wanna take the risk of induction? Do you wanna just have a scheduled C-section?” 


Dr. Fox: Right. Yeah, I do very similarly. The first visit, I really just ask them… 


Melka: Of course, you do. 


Dr. Fox: Yeah, it’s a good point. Yeah, Melka trained me. So, basically, the first visit, I’ll say like, “You know, what were your thoughts? You know, what was it? Do you have a plan? Do you have any thoughts?” And some women say, “I want a VBAC.” And I just make sure it’s not, like, a crazy idea. And I’ll say, “Okay, we’ll make that as our, sort of, starting plan and we’ll re-address it.” And if someone said, “I want a C-section,” fine, and the same thing. And then usually in the third trimester, just to revisit to make sure we’re still on the same page because sometimes things change. 


And then at the end, just to confirm, “Right, this is the date of the C-section, it’s scheduled. You know, what if you go into labor beforehand, what do you wanna do? Or if you’re trying for a VBAC, same thing, and you get to like a week past your due date, would you rather us induce you or do a C-section?” So we just, you know, logistically plan. And I think most people appreciate having multiple opportunities to talk about this and to make sure everyone’s on board. I’m just curious, if someone does have a prior C-section and there are in labor, you know, they’re attempting a VBAC, do we do anything different for them in labor? Like, is there anything that’s…? Like, should they expect something different in terms of, you know, monitoring or how we make decisions? 


Melka: No, it’s pretty much continuous monitoring. I can’t keep track of the hospital policies on this. I believe there’s something in writing about VBACs once they’re in active labor being on continuous monitoring. 


Dr. Fox: Right. Fetal monitoring. Yeah. 


Melka: Fetal monitoring. Yes. 


Dr. Fox: Right. Because ironically, the way we find out someone’s having a uterine rupture is most often that the fetal heart rate starts showing changes because usually, they have epidurals. It’s not a requirement, but it’s typically a good idea because…Yeah. 


Melka: You read my mind, I was going to say, I could never…It’s the same with twins for VBAC. I can’t require you to have an epidural, but I do think it maximizes safety. 


Dr. Fox: Yeah, because if you have to rush back for a C-section, it’s so much easier if there’s an epidural in place, and it’s safer because you can dose up the epidural fast versus trying to put it, you know, intubate or… 


Melka: General anesthesia. 


Dr. Fox: Yeah, so typically, an epidural, so it’s not like they’re gonna have a change in pain. Occasionally, it’s because we see bleeding that was unusual or maybe there’s this thing called loss of station, where the head is suddenly much higher than it was before. And the thought is maybe the uterus opened. But usually, it’s the fetal heart rate that changes. So we do have continuous monitoring. I tell them it’s really the same other than not a good, you know, labor to do most of it at home. You know, it’s like, “If you’re in labor, come to the hospital. Let us make sure everything’s okay.” And I say, “We’ll just watch a little bit closer.” But otherwise, it’s not markedly different. We don’t manage the labor differently. The actual pushing is the same. Everything is pretty much the same other than we have eyes on a little bit closer. Great. Melka, VBAC. 


Melka: Awesome. 


Dr. Fox: Good stuff. 


Melka: I have several friends on Facebook anxiously awaiting this. 


Dr. Fox: Are they pro or con? 


Melka: I think they’re undecided, and I think that’s why they needed this. 


Dr. Fox: Yeah, I’ve got friends who’ve done it are very pro. Listen, my third, Neely, was VBAC. She was born…My twins were born by C-section, and then Neely was a VBAC. And subsequently, Mia was as well. Worked out great because they’re both my kids. And, you know, we have people I know and friends or patients who’ve tried a VBAC and they’re super happy because they were successful. And we have other people who’ve tried it and are miserable because they hated the experience. And there’s everything in between. It’s really…there isn’t one right answer for one person, you know, for anybody. And you can’t predict reliably, necessarily, how it’s gonna end up. So like any birth, there’s a level of uncertainty of how it’s gonna ultimately play out. 


Melka: I’m gonna retire off of being able to figure all that out. 


Dr. Fox: Melka’s gonna do it. 


Melka: My key. 


Dr. Fox: You’re gonna take the VBAC eight ball, and just shake it. Like, you will be fine. All right. Good stuff. Well, thanks for coming on. We’re gonna obviously have you on many, many more times, and we’ll talk about something else. Cool. All right? 


Melka: Thank you. 


Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day. 


Male: The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.