"The unfortunate politics of VBAC"
Saturday, June 4, 2011 at 4:38AM
Thanks so much for sharing your story. We’re currently trying to conceive our second child and even though I’m not even pregnant I’m already debating the VBAC or RCS question. This should be a decision that is made by DH and me but for some reason I have this idea that if I was a “real” woman and a “real” mother I would try for a VBAC. Like pushing a baby out of my vagina would somehow undo my c-section failure. Intellectually I know it’s totally silly. I’m a real woman and a real mother regardless of how my daughter was delivered. But I think that deep down the NCB rhetoric has influenced me. My daughter’s birth wasn’t “normal.”
Unfortunately I feel like my decision about whether my next birth should be a VBAC or a repeat c-section isn’t personal. That my decision has ramifications for other women. I also feel like the people who are advising me aren’t motivated by what is best for me but instead by what promotes VBAC access.
I feel like if I decide to do the repeat c-section that people will be disappointed in me. I feel like those same people will pity me or think it’s because I’m too afraid or something. And that totally annoys me. I’m a grown woman and am capable of making decisions for me and my family.
That’s the unfortunate politics of VBAC. On one side the doctors and hospitals see every VBAC patient as a potential lawsuit and want to encourage us to schedule repeat c-sections. (I know I’m speaking very generally here and that some doctors are very pro-VBAC.) On the other hand, the VBACactivists want all of us who have had prior c-sections to VBAC to advance the cause. And then there’s a subset of that group that wants us to VBAC “correctly” which either means no epidural or a homebirth.
But again thanks for sharing your story and I’m sorry that you felt judged for your decision to have an epidural. It’s unfortunate that we women do this to each other.
Reader Comments (35)
Or, there is the subset of us who truly want you to make the most informed and best choice for you and your family.
I am an ICAN chapter leader in a city with a hospital that delivers the most babies per year in the state of Florida (something around 16k/year), the third busiest in the country, and they have close to a 50% cesarean rate. I cannot describe the pain in my heart I feel when I survey OB offices and I hear "vbac is illegal" or "why would you do that, do you want your baby to die?" It gives me heartache and also pause. If I am just some random woman calling around asking "do you do vbac's?" and these are the answers I'm getting, how do I know that ANYONE in town is getting adequate information? I don't.
So, I have to trust that women are thinking for themselves, taking all of the risks, benefits, and alternatives into consideration, and not blindly accepting what their OB has to say about vbac (or what s/he doesn't have to say, for that matter). It has taken me YEARS to get to this point, yet I still have to bite my tongue when I find out someone had a cesarean. It is a conscious choice on my part and I hear myself every single time say in my head "never assume anything".
I guess that's part of my point, that we should never assume anything about a woman's birthing choices. With that said, oftentimes we have no other option but to assume simply because we live in such an individualistic society where few women publicly discuss their decision making process for their birthing choices leaving the rest of us to wonder what the heck happened. This poor communication our society prides itself on is its downfall, especially when it comes to reproductive choice.
When I was in the battle of my own VBAC, I was drowning in everything VBAC. I ate, breathed and slept VBAC. After the dust settled I had 2 very good friends that were pregnant with their second child, both deciding whether or not to go for a VBAC. One of my friends would not even speak to me and I assumed it was because she thought I would shove VABC down her throat.
And sadly, she was right.
But, after I came to this realization, I stopped. I told my friend I supported her decision whatever it was and ultimately she knew what was best for her and her baby. Yes, I had to bite my tongue when when I found out she was uninformed and that her husband pushed her to have a RCS so she could get her tubes tied instead of him getting a vasectomy. But, it wasn't worth losing the friendship.
I do disagree with your statement, "the VBACactivists want all of us who have had prior c-sections to VBAC to advance the cause." Not all of us. I just want women to be able to choose the way they birth. What they do with their their vagina should be up to them.
I would probably be considered a VBACtivist, but I don't think every woman should VBAC. I think every woman needs to make informed choices and have accurate information in order to choose which set of risks she is most comfortable with. I don't judge a woman who is informed and chooses ERCS, just as I don't expect her to judge my informed choice to VBAC. I do feel really bad for a mama who wasn't informed and chose ERCS, and is now on the harder journey on VBA2C. That's why I think its hard to know who to tell what. Maybe a woman just doesn't know there are options and Lord knows I wish I had been informed the first time around.
You are all assuming that it should be a choice. a Ceasarian Section is a major operation and should only be performed to save the life of mother and baby and not under any other circumstances. It's not about being an activist of any sort. If you don't feel like opening your bowels in case you split your sphincter wide open just get a colostomy bag. Now doesn't that sound stupid.
It's absolutely true that each woman's choice has ramifications for other women. That's not a statement intended to make anyone feel bad or pressured, it's simply a fact (not limited to this issue): we all live in this world together. I don't condone guilt-tripping anyone into any birth choice or demonizing people whose choices are different than my own. And, because of the nature of birth and its relationship with women's power in contemporary society, any choice has political significance. Understand and recognize the politics of your choice, and do what you will. Your choice is still yours alone--the result of a very personal decision-making process--at the same time as it is rooted in a highly complicated and uneasy political context.
"You are all assuming that it should be a choice. a Ceasarian Section is a major operation and should only be performed to save the life of mother and baby and not under any other circumstances."
So are you saying that I shouldn't have the choice to have a repeat c-section? Who gets to make the decision, if not me?
Do you not consider the risk of uterine rupture, although small, to be enough of a risk to "allow" me to have a repeat c-section if I want it?
Remember we're not discussing primary c-sections here. Primary c-sections based only on a mother's choice are a different matter. We're discussing births after c-section where there are risks with both options (VBAC or RCS). Because there are risks with both options, a mother should be able to make the choice, IMHO.
Forcing women to undergo VBAC is no better than forcing women to undergo a repeat c-section.
I pushed very hard for a VBAC for baby #2...because it WAS something I wanted to do. Not b/c I thought it would undo the damage from my first birth but b/c I did not know how many more babies I wanted...and I knew that CS would effect that. I was living in Florida - like where someone mentioned you might get many doctors telling you that "vbac is illegal!"
I had a deadline. If I couldn't find a VBAC friendly provider by 22 weeks I would reconsider (I found out I was pregnant very early - I had lots of time - and I thought by this time I might be weary and be more thoughtful about the choices at this point). I found a provider at 15 weeks.
At 39 weeks my baby turned breech. My provider was no longer allowed by law to assist me...even though she said she "might be in the area" when I went into labor and could "stop by". I felt it was too risky for her, her practice, & for other women that might want an opportunity to use her services in the future. I didn't want to be the statistic & ruin things for her & everyone that relied on her. (And I did not feel comfortable being unassisted.) She found an OB who was willing to do surgery (and also willing to send me back to the previous provider if my baby changed position in the next week or two). I walked into the hospital on the morning of the c-section & felt GOOD. I had made a conscious choice to say yes to a RCS.
It did not undo the damage from my first birth, but I don't feel damaged from it...I had time to think about my choices, to make an actual informed decision...and say YES. My husband and I have talked about having a 3rd child. I absolutely would attempt another VBAC if I got pregnant. But if something happened to make me feel like that was no longer the best decision, I feel like at least I got the change to say yes...unlike that first time when I was just wheeled away...screaming, "no," at the top of my lungs...When you have that first section...It does effect our future choices...And how we VBAC (if we choose to). But I don't think anyone can say for anyone else that those choices are wrong.
Of course its a choice! It may be a choice that you completely disagree with, but it is still a choice. People choose to have major surgery every single day. Some of it is needed, some of it is not. Who are you to tell them they can't make that choice for their own bodies?
I find the key statements in this post to be “doctors and hospitals see EVERY VBAC patient” and “VBACactivists want ALL of us”. For women to have truly informed choices, the information must be specific for that one INDIVIDUAL woman. A woman who had a very difficult first labor and then had a necessary cesarean delivery may actually have less risk (Birthrisk) if she schedules a repeat cesarean delivery whereas a woman who had a cesarean because her doctor had dinner plans may have less Birthrisk if she attempts a VBAC. Each woman is an individual with her own individual Birthrisk based on her unique combination of physical characteristics, we shouldn't group them together into “EVERY” or “ALL”.
If we want to improve outcomes we need to get informed. One way to get informed is from analyzing what has happened to similar women and learning from this history (Cesarean Rate History). You might want to call this “experience”. I have been helping women to delivery their babies for twenty five years and I have developed software that can give every woman and every obstetrical care provider the “experience” of over 285,000 deliveries.
My software is not intended for VBACs, but a woman contemplating a VBAC can get a free Cesarean Rate History at my website. Fill out the information like it is your first birth and you will at least get a ball park estimate of what has happened to women with similar physical characteristics who have attempted labor. GET INFORMED.
I always feel so sad that some women feel that all vbactivists would pillory them for deciding on a repeat c/s. I don't think most of us are like that at all. We simply want women to fully understand their choices, to make well-informed decisions, and to make sure that women really DO have a choice in the first place.
However, there are some folks who are really that judgmental, and sadly, they make the rest of us look bad. I definitely get frustrated with that element of the movement. But let's be fair....every activist movement has its extremist element. That doesn't negate the importance of the movement or its work; it just reinforces the need to keep lines of communication open so others don't think that extremists represent the view of most folks in the movement.
Yes, I do want more women to opt for a VBAC if that's right for them, because from a public health point of view I think there will be fewer downstream health problems on a societal basis with fewer cesareans. But on an individual basis, each person has to choose what's right for them, and no one should be forced into VBAC or ERCS.
I do think women can be truly informed and still choose RCS. And in fact I have supported women who chose ERCS. My support is done on an individual basis and is not dependent on their choices, but my vbactivism is done more for a public health point of view because of the large-scale changes that need to happen in the system. The problem comes when you advocate on a public health basis and people hear it as being about their individual choices. For me, anyhow, it's not.
What I tell individual women who are struggling with the choice is to "try on" both choices and to remember that they have plenty of time to make their decision. You really don't need to make this decision NOW, it's perfectly normal to feel ambivalent about the choice, and there's NOTHING WRONG with considering both choices, or even with deciding not to decide for a while. Sometimes it's great just to be pregnant for a while without having to make any choices.
Then, when you are ready, take a few weeks and "try on" each choice. It's not enough to try them on for a couple of hours or days; it's really more optimal to work through this by trying them on for longer periods. That way you get past the surface reactions and emotions and get deeper about what your concerns are with each choice.
Try on the repeat cesarean first. If you are like me, you'll feel a real sense of relief at first....at having the decison made for you, at not having to worry about going through labor again, at not having to worry about "failing" etc. Perfectly normal responses. After a while, picture yourself really going through with this choice, including going into the hospital at xxx weeks and laying down for that surgery. Does that picture bring a sense of relief or anxiety, or some of both? Picture the surgical recovery too, which might be uneventful and no big deal or which might include difficulty with movement, sleeping, and a fair amount of pain. Then try to anticipate how you'll feel about the decision afterwards. Some feel nothing but relief about not doing labor again, while others end up disappointed in themselves for not trying VBAC, and still others feel a little of both. 5 years down the road, how do you think you will feel? Glad or not?
Then take a few weeks to try on a VBAC. How does that make you feel? Does it create a huge sense of anxiety, or does voluntarily signing up for further surgery create more anxiety? Which makes you feel more worried....the idea of surgery or the idea of labor? Why? If labor makes you anxious, what can you do to make this birth different so it's not just a repeat of last time? What if you had a really supportive caregiver and birth support team? What if you could have a VBAC? How would you feel about that 5 years down the road?
Most people consider the what-ifs of "what if I 'fail' and have another cesarean anyhow?" and that's certainly a worthwhile consideration. Not everyone has a VBAC....but although that's hard, a CBAC doesn't have to be life-destroying. It takes time to process but many of us have done so and survived. But don't forget to also consider the what-ifs of "what if I DO have the VBAC?" If you did have the VBAC (which you have about a 2/3 to 3/4 chance of doing), how would that make you feel? Would that feel like a real sense of accomplishment or not that big a deal? What does it mean to you?
You have to consider the big bad what-ifs, of course. People nearly always consider the big bad what-if with VBAC, which is uterine rupture. Having known women who have had UR, I never minimize that. It really is a big bad to consider. However, what people often fail to consider is the big bad what-ifs with ERCS, and I've known folks with these as well (pulmonary embolism, hysterectomy, massive hemorrhage, damage to bladder and bowels, etc. etc.). Both UR and serious morbidity from ERCS are unusual outcomes; the chances of them actually happening to you are quite small. But because they can be so serious, they certainly are worth considering.
But also worth considering are the big GOOD what-ifs. What if everything goes perfectly fine? What if baby and I both have a great outcome, either way? Chances are quite high of a good outcome with either VBAC and ERCS, much more likely than a big bad outcome. So if you had a big good what-if outcome, would you rather that come from a VBAC or ERCS? Would it make any difference to you emotionally?
Additionally, think beyond to any future children. If you planned more (or had an ooops), this birth influences that one. Think through those long-term decision trees too. Think of your possible downstream outcomes. What would you prefer from that point of view?
These are all things to ask yourself as you try to process this decision. Truly, I'm not trying to tell you which way you "should" feel, just communicating the possibilities. I hope I don't sound patronizing; I'm just trying to give you some tools that some (including me) have found useful in making this difficult choice. I've been in ICAN for many years, had a CBAC and then 2 VBACs, and wrestled pretty hard with the ERCS vs. VBAC choice myself with #3. Yes, in the end I chose VBAC, but I very much understand the appeal of ERCS and have supported women who have chosen that, as well as women who have chosen VBAC. I know the things that helped me in my own decision tree on the topic, and what seems to have helped others, which is why I include them here. If these ideas aren't helpful to you, please feel free to totally disregard them.
I can tell you are well-informed about your choices, but I'm sorry you feel pressured one way or the other. Wouldn't it be nice if women could make these choices in a neutral space, free from rhetoric from all sides? But alas, we don't live in such a world yet. In the meantime, try to free yourself from the pressure and expectations of others, try on the decisions one at a time, get in touch with your deepest feelings about each and their what-ifs, and then in time I bet your decision will come clear to you.
Trust yourself to know what you need to do. Just remember that you don't have to decide this right NOW; you have time and space to think it through and consider all the angles. But trust yourself......you'll be able to make this decision and figure out what you need.
I totally relate with you in your "there's no way of keeping everybody happy" feeling. Eventhough I´m a homebirther and never had a cesarean, I understand that it can be overwhelming to read all the comments/opinions on how to "Birth RIGHT", I've had lots of criticism too when our decision to birth at home became public to our families and friends.
But as a mother, I can assure you that every decision, every approach, every determination or path you take as a parent will always be subject to complaints/critisism from others. There is no "better way to give birth" as there is no better way of parenting, but you might have another chance to make birth better FOR YOU! I hope you can achieve the birth YOU want, Good luck, and hugs :)
My dad used to tell us, "When I want your opinion, I'll give it to you!" He was (usually) being funny.
At the risk of revealing my own arrogance, we are all humans who observe and think and process and opine, sometimes openly, sometimes accurately and of course, sometimes erroneously. With (usually) five senses and (usually) a brain, it is impossible to avoid doing and impossible to avoid being the subject of someone else's doing.
Having said this, I don't know which bothers me more: The fact that others are wiling to openly share their opinions of others (myself included, I'm doing it right now) or the fact that others who share something personal are upset by the opinions of others.
For myself, I have learned two things. The first, and usually the more difficult one since I tend to suffer from verbal diarrhea, is to keep personal plans on a need-to-know basis. The second is to use my opinions, in particular my strong ones, sparingly. In a sense, they are really the same thing - my personal plans being the culmination of ongoing assessments of facts, the opinions of others and my own opinions.
I have come to realize that there are extremists on every side of every truth. Most people really are among the live-and-let-live crowd, but most people also have a hot-button (or two) where they simply cannot tolerate an answer that differs from the one they've found. And sometimes that relates to the way we give birth.
It is that fine line between knowing what is universally right or wrong vs. what is right or wrong for an individual. But that is all the more complicated when we don't know the "whole story" - and in birth what I mean is when we don't know every single reason why a person is making a decision that contradicts what we know and what we advocate for. And as much as it may be our responsibility to provide education and to advocate for the rights of birthing women, as educators and advocates we must realize that we cannot possibly know all the reasons that factor into each woman's decision, and as a woman who is on that journey where a decision must be made, we must recognize that it is impossible for each woman/person we encounter to understand fully what our individual process is.
I'll admit that when I spoke with the head OB of our biggest L&D here who told me that "When women hear 'uterine rupture' they always opt for a repeat cesarean," I had to do everything in my power to resist the urge to break into his practice's files and track down each pregnant woman with a prior cesarean and educate them "properly". (WOMEN OF THE WORLD TAKE HEED! VBAC **IS SAFE**!!) It is INFURIATING and sometimes it feels like education will never prevail. I do silently shudder when I know a woman is going under the knife again and I try to be supportive but at what point does a gentle "Oh, I had a VBAC" become an accusation to someone who is planning on going the other way? Nor can we expect every educated woman to take up our cause by doing something that doesn't work for them.
At the end of it all my only suggestion to this sometime vicious circle is for women to simply accept others for where they are at, even we are at the receiving end of it. It is much easier to say "Thank you for sharing", and take what you want so you can leave the rest behind. Accept what you receive as nothing more than a gift, because it will either open your mind more or reinforce what you already know.
But then, that's just my opinion ;-)
I think Rachel Z makes an important point that fleshes out some of what we're talking about. Because there are two sides to the situation - the one talking and the one listening. And it's so true that just as there are sometimes judgmental zealots giving you a$$vice, there are sometimes people listening who react defensively to everything they hear, especially if part of them feels like what you're saying is "right" but they don't want to do it & feel guilty about it. So part of resolving the situation is being respectful and careful of how we frame our opinions, but also not taking other people's experience or comments as *necessarily* personal or judgmental. Saying 'VBAC is actually very safe" is not the same thing as saying "and you are a selfish stupid person if you don't do go for a VBAC." If you hear A like B, then you might want to think about why you're reacting defensively to the comment, and consider that it may have been an innocent remark, or even a desire to inform but not an attack. Disagreeing with someone about what's right for you is not a personal attack, and shouldn't be construed as such.
Rachel, those are some wise words that go far beyond anything related to VBAC.
I'm not so sure I'd go so far as to suggest that VBAC is safe (in a general way), but I'm well aware of the risks of RCS . . . and they're not just the straight-forward medical ones.
The anonymous poster wrote: "On the other hand, the VBACactivists want all of us who have had prior c-sections to VBAC to advance the cause. And then there’s a subset of that group that wants us to VBAC “correctly” which either means no epidural or a homebirth."
I know she was generalizing here, but just as Kmom says above, all 'movements' have a vocal, radical minority that sometimes seems like a majority because of how assertive they will be. I consider myself a VBACtivit, but from time to time a comment from this subset will really piss me off and distance me from my network. So, I feel her pain.
I really think most of us are just desperate to educate and to share what we've learned along the way about our bodies, our herstories, the future for our reproductive organs, the future for our children, and the failings of the medical model. I strongly believe RCS should be a choice, but even when it's (sort of) presented as a choice by a surgeon, it's not usually painted as a wise or fruitful choice. Surgeons are more willing to stake their bets on their own surgical skills than stand by waiting for your body to 'perform' or to support the surgical skills of those who performed the prior cesareans.
At this point, I'm preparing for a HBA2C. I'm excited. I'm terrified. Why am I doing this? I trust that God gave me this body and this amazing ability to conceive, carry, and birth a baby. Because of this faith, I trust my body. Because of this faith, I trust that my body is not too damaged to fail me now. I can't say at this point that 'failure' would be CBA2C. I don't know. I'm also doing this for my daughters - the fact that my oldest (age 6) doesn't want to get married because she doesn't want to get pregnant because she doesn't want to have a baby cut out of her body JUST BREAKS MY HEART. I'm doing this for my female students - many of them are already terrified of pregnancy and birth thanks to the cultural portrayal of birth. I'm doing this to not be another statistic in my community and my state and my country. It grieves me that I'm now part of that 75% cesarean statistic for twins in my state.
I suppose if I advocate for anything, it's for patient autonomy, informed consumerism, and women's rights. None of my friends who've consented to RCS have made their decisions themselves. They've been lied to. They've been scared into accepting these interventions. They've not found providers to help them achieve an ethical, satisfying, and safe birth.
A terrifying and vicious cycle . . .
labortrials wrote: "I'm not so sure I'd go so far as to suggest that VBAC is safe"
The funny thing is that ACOG does say it flat out. "Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans, according to guidelines released today by The American College of Obstetricians and Gynecologists."
http://www.acog.org/from_home/publications/press_releases/nr07-21-10-1.cfm
Jill, I wasn't being as articulate as I would have liked. I suppose the sticky point for me, if there is any with regard to VBAC safety after 1+ cesareans, is the word 'some.' We still don't have any reliable indicators for who might experience an uterine rupture, and the 'unnecessary risk' (as asserted by OBs) tends to overwhelm women into going the 'safer' route of RCS. I suppose I should have said that I don't personally believe that VBAC is uniformly safe - this is why kmom's suggestion of 'trying on' both VBAC and RCS makes a lot of sense. Both choices have risks and rewards, and the mother needs to help determine which set of risks are most worth taking in her situation. Heh, is that any better?
Oh this is bollocks. If you don't like what the NCB or the VBAC community has to say, AVOID IT.. It's not that hard! REALLY! It's a damn HUGE minority! loud, but MINORITY!
If you want pat-a-pats on your back for choosing ERCS, go over to babyzone or join cafemom or moms-like-me or facebook and join a due date group and block a couple people or complain to the moderators that you are being picked on and there you freaking go. Just block out the dissenting voices from what it is you want to do.
Unless there's been some sort of web or cultural revolution, I see much more support for you than for them. They announce it to one another and nod and get excited about their elective due date and start bitching when they hit X number of weeks that it couldn't come sooner and worry worry worry about possibly going into labor (without any real medical contraindication for labor, even), are often induced early or sectioned rather early in my opinion (38 or 39 weeks often I see, to prevent labor, again which is often being prevented without a real medical contraindication to labor) and any dissent is silenced by being booted from groups or told to just say "congrats" or ignore something if you do not agree with it. And oh my good grief, if you DARE to say anything to someone who is planning ERCS in real life?? You're told somethign along the lines of, by everyone mouth agape around you, "WHY WOULD SHE WANT TO RISK HER LLIIFFEEE??!?!!" lol The irony, is amusing.
Mind you, the other side boots out people just as easily... but.. they're the minority.
If you've been made to feel like you have to justify your choices to others, then you are not talking to the correct people OR you need to make differing choices. One of the two.
Good day.
Btw, this is assuming you have laid out why you want to choose what you want to choose... assuming you've chosen.
If there is a good reason (which is pretty much any reason to most people) they will support you.
Mind you, NOT if you are talking to the "wrong" people, which is like, someone like me.. but if you are talking to most average humans they will not question you once you've said you have "researched it".
Good day again.
Btw I am not good at being subtle. If you want someone who is more like handy-holdy, well-rounded-mama's response is better.
Fogedaboudid you've said it well. It puzzles me how a minority group can manage to be oppressive. Only you can own your choices and if it is the right choice for you, you should have no guilt about that choice. If a choice is made out of fear, it is common to lash out at those who you see make you "feel guilty" as you may regret the choice you made. Only you are responsible for how you feel. As VBACing and Hombirthing women are still a tiny minority of the birthing population, we need to speak out and be a LOUD minority.