In today's episode of theVBACpodcast, we will continue exploring and understanding ACOG VBAC Practice Guidelines.
On last week's episode we discussed VBAC Candidacy according to ACOG and learned that most women should have the option to plan a vaginal birth after cesarean. This week we will dive into what ACOG advises regarding policies for managing a TOLAC or Trial Of Labor After Cesarean (aka VBAC labor). You can use these guidelines to help determine certain decisions regarding interventions during your VBAC labor. Understanding ACOG's VBAC Guideline can help you write a better VBAC Birth Plan.
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After three successful VBACs, one in the hospital with an epidural and two at home, and after supporting countless women through pregnancy and labor, I learned there's so much more to a positive birth experience than just understanding the data and Science. Inside the VBAC With Confidence Complete Birth Preparation Program, I teach you how to balance physically working with God's design of YOUR body, how to emotionally safegaurd yourself for a better birth, and how to understand sometimes-confusing information about birth.
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What I want you to take away from this is you have options.VBAC is an option for you if you want to be back to be an option for you.
Welcome back to the VBAC podcast.
Today is day two of "what do the ACOG guidelines say about VBAC" and we are going to go ahead and dive into what exactly ACOG recommends for labor management during your TOLAC or VBAC. They use the term TOLAC, so that's what I say when I'm talking about their guidelines but I don't love the term TOLAC because it says trial of labor after cesarean. And as a VBAC mama,
that term always made me feel like um I was making a cute little attempt at having a VBAC instead of actually planning it and preparing for it. So when I use that word,
please know that I'm doing it simply because that's the language they're using and when I'm talking to you I won't use that word... anyhoo we are going to dig into this a little deeper today and I'm excited that you are here and I want you to know that if you have any questions you can reach.
Welcome to the VBAC podcast. I'm your host, Jamie Zaki and I am a licensed practical nurse international Board certified lactation consultant and birth doula. I'm also a mama to four little bears and a three time VBAC mama. My mission is to help you cultivate confidence for a positive and peaceful VBAC.
This is a disclaimer that any of the information, experiences opinions and stories told on this podcast are with the intention of inspiring educating and informing parents This information is not intended to treat or diagnose any medical conditions. If you have questions,
you must consult your provider. Jamie's Zaki does not accept liability for any decisions that you make After listening to this podcast.
Before we dive in today, I wanted to remind you about the VBAC with confidence,
complete birth prep program. You know when I was having my C-Section, all I could think about was having my VBAC one day at my pre op for my C Section because my son was breached my O.B. Even said don't worry, we're going to do everything we can to make sure you have your VBAC one day.
That was so important to me. And I spent over two years learning about VBAC to try and make sure that I knew all the things to do To increase my chances of having a VBAC.
Well I was very blessed to achieve my view back in the hospital and then go on to have two more VBAC at home. And then I have been even more blessed to support other mothers,
achieve their VBACs through my own birth experiences and supporting other women through pregnancy and labor.
I learned that there is so much more to a positive birth experience than just understanding the data and the science and checking things off the list of the dos and do not.
I learned that you have to learn how to balance physically working with God's design for your body with your emotional strength and learn how to navigate this Sometimes confusing data inside the VBAC with confidence Complete birth preparation program.
I can teach you how to balance all of these different inputs of information to help you have a better birth experience. You will learn how to strengthen what I call the three pillars of confidence for a more peaceful and positive VBAC.
If you're ready to get started reframing your fears and reclaiming your power for a better birth.
The VBAC with confidence. Complete birth program is for you.
If we did this self paced course in person it would take weeks to cover all of the information and it would probably cost over $600. But right now you can take the class with your birth partner whenever you want on your terms for just 147.
Your birth is worth investing in mama bear.
What are you waiting for?
The sign up link is in the show notes.
Or you can head over to little bear lactation dot com slash links to access all of my resources for you.
INTRODUCTION
I am so excited to dive into today's part two of ACOG guidelines episode with you today.
I have been getting super sassy.
I have like tried to record this four or five times and I keep getting super sassy.
I know I ended the last episode on the sassy side and getting there again because I keep reading this word, trial of labor after cesarean and that really hits me.
I feel super salty about that phrase and I understand why they use that term,
but I don't like it and it's just, I'm having an emotional reaction to that. So I apologize for being too sassy or I don't, I don't apologize for being sassy because I'm sassy and we're just going to go into this.
I am being super weird today, although like I'm drinking this kombucha, my husband has been begging me to buy and I feel like it's just, I don't know,it's giving me a different personality. I like the fizz, I like the, it's ginger, so it's giving me this like punch, I don't know, punchy personality ginger makes sense I guess.
INDUCTION of Labor vs AUGMENTATION of Labor
So we're gonna talk starting about induction and augmentation of labor. What is the difference between induction and augmentation of labor? I want you to understand that first induction of labor is getting labor started without babies saying, hey, I'm ready for labor to start.
So artificially starting labor.
Augmentation of labor is artificially speeding up labor.
So labor "stalls" and they use some type of intervention to get it to keep going or to go faster speed along, move along.
Typically when a first time mom or anybody else who has not had a C section is induced, they will use something called prostaglandins medicine.
So this they have a couple different types of prostaglandins medications but it is often the first step to an induction and it is with the purpose of softening the cervix so it begins to face and makes dilation easier.
Pitocin for VBAC Labor Induction & Augmentation
Unfortunately what had been found is that prostaglandins use for VBAC moms was ending in an increased risk of uterine rupture and so then they kind of stopped recommending that and started talking about, okay well what about Pitocin, right And so there's conversation on whether or not Pitocin is safe for labor induction.
And then we talk about while some providers won't use it for an induction but they'll use it for augmentation.
So what does the data say? As always, the data is all a little confusing. But there was one study that quotes that I want to share with you and what they say they found was when comparing to spontaneous labor. They found that There was a 1.4% chance of uterine rupture for induction with prostaglandins with or without oxytocin.
I hate when they say oxytocin because it's not oxytocin that's Pitocin, it's fake. Oxytocin is real.
It comes from your body. Pitocin is fake anyhow...
Then they said they saw a 1.1% chance of rupture for oxytocin alone, 0.9% chance for you to rupture with Augmented labor and a 0.4% chance of uterine rupture for spontaneous labor, I find that quite interesting.
You can interpret that data as you will.
However, what ACOG says is basically that using oxytocin is an option.
However, studies have not identified a clear threshold for rupture and an upper limit for oxytocin dosage with TOLAC has not been established. So basically it's reasonable to assume that maybe low doses and slow doses of oxytocin or Pitocin are less risky for to lack, but we don't know what that upper limit is.
So some providers understand that as, "Well, we don't know what that upper limit is, so we're not even going to try it." Other providers are like, "oh we don't know what that upper limit is, But we also know that if we go low and slow it's probably not as risky as if we just push it."
They do recognize that when compared with spontaneous labor induced labor is associated with a lower likelihood of achieving VBAC. And they say that this can be the case whether the cervix is favorable or unfavorable although if you have an unfavorable cervix, it further decreases the chances of a successful VBAC with induction.
Again. However, this does not mean it is the rule just because that's what we see because many,
many, many women have amazing VBACs with induction. There has been other studies that show that labor induction is associated with a lower risk of C section delivery at 39 weeks.
So again, conflicting data, What do they say?
They say the use of oxytocin for augmentation of contractions separate from induction of labor during toland has been examined in several studies. Some studies have found an association between augmentation and rupture, whereas others have not. Again conflicting data,
therefore, "given that the results of these studies vary and that the absolute magnitude of the risk reported in these studies is small oxytocin augmentation may be used in women attempting TOLAC."
There's also more new data on this showing that oxytocin induction can be safe came out after this was published. So take that as you will.
I've mentioned it in other episodes,
Cervical Ripening For VBAC Labor Induction
we talk more about the cervical ripening.
And Again, they have conflicting data on cervical ripening.
What they do say is studies examining the effects of prostaglandins on uterine rupture have demonstrated inconsistent results because data is limited.
It is difficult to make a definitive recommendation regarding the use of Prostaglandin E two.
They do specify that prostaglandins might be more likely to be reasonably considered if delivery is indicated in the second trimester.
I'm going to assume that the theory here is that the uterus is not as stretched,
therefore it might be a little more durable and can handle contractions a little better and that the super tall or whatever medication they use is not going to be as risky a lot of times.
Mechanical Labor Induction for VBAC
What you will see is a mechanical induction basically using like a cook's catheter or something similar.
And they do say that given the lack of compelling data suggesting an increased risk of uterine rupture with mechanical dilation and trans cervical catheters.
Such interventions may be considered as an option for tola candidates with an unfavorable cervix meaning even if you don't have prostate gland dance you can still be physically mechanically stretched and it seems generally safe.
Some providers are running around out there telling women that's not true and I would like to just know why.
External Cephalic Version
Anyway let's move on to external cephalic version aka ECV.
Is basically the procedure they use to flip a breech baby.
That's a whole different conversation in itself.
However the data shows that the likelihood of successful external cephalic version has been reported to be similar in women with and without prior cesarean delivery and it is not contraindicated in women with a prior low transverse uterine incision.
So if they are a recommendation or they are a candidate for external phallic version and VBAC then they can have an ECV if they so desire.
There are some providers out there running around telling moms if they have a scar on their uterus they can't have an ECV. So they're going to have another c-Section of a breech baby because they refused to try and flip them even though that's not what ACOG says.
Epidurals for VBAC
Angalgesia, epidurals, pain relief is what we're talking about.
I'm going to do a whole episode going into the conversation on epidurals basically what a cock says is use it, Don't use it up to YOU, mom, up to you mom.
Just like everything else: up to you mom.
Anticipated Labor Curve for VBAC Labor / TOLAC
All right, anticipated labor labor curve.
This is interesting.
This is interesting.
So basically they say they expect, you know if you have had a vaginal delivery a C.
Section and then you're attempting VBAC.
They expect your labor to be that of a multi right?
Multiparis mother is a mom who has had multiple labors.
However, if you have only given birth once via C section and you are having a VBAC now they expect that your labor is going to be similar to that of a first time mom.
They think that the labor curve is what they call it is going to be similar to that of a first time mom because your body hasn't done it before or done it all the way before.
Thus they say "similar standards should be used to evaluate the labor progress of a woman undergoing TOLAC and those who have not had a prior cesarean delivery."
So first time moms and first time laborers/ vaginal deliverers should be treated the same.
Mhm That's true.
I've seen that sounds sounds reasonable but um I kinda call BS on that at the same time because labor doesn't fit in a pretty little box.
Labor curves are a whole other conversation themselves.
What we expect to see yada yada yada yada yada.
Um There are variations of normal, there are wide variations of normal and too many providers.
I see putting first time moms in a box and then what they do is they decide their labor is not progressing well enough and they cut them open, give them a C section unnecessarily and then they go for VBAC and they tell them, oh you're like a first time mom again and we're going to compare you to a first time mom.
But you didn't know how to manage a first time mom the first time.
What does it mean? At the end of the day it means that I want you to understand that your birth does not need to fit in a pretty little box and if your provider want your birthday fit in a pretty little box, find a provider who doesn't expect birth to fit in a pretty little box,
Diagnosis of Uterine Rupture
Like I said before in the last episode, uterine rupture is going to get its whole own episode, (you can also learn more inside VBAC With Confidence Complete Birth Prep Program)
So I'm just gonna run through this real real quick, basically they say that to be able to diagnose uterine rupture most efficiently and effectively, They recommend continuous fetal monitoring during TOLAC.
This is still up for a great debate, especially between midwives and OBs.
However that is one of the recommendations and I don't disagree with it, I don't agree with it.
I think it is something that every mom has to decide for herself if she has a problem with it.
And I think that more importantly than whether or not fetal heart rate should be continuous is we need better options for how we monitor that heart rate.
And what I see too often is these providers, or not providers but like these hospitals with this archaic fetal monitoring when we have better options.
We have wireless monitoring. We have waterproof wireless monitoring that allows mom to be in the shower or the tub during her labor and still get continuous monitoring up moving around working with her body. We even have these cute little monitors...
This is what I had for my hospital bag and I loved it because I cannot imagine having the band around my waist that most hospitals want you to have.
But it was this cute little sticker monitor.
It looked like a flower is like a monitor that sticks right by your belly button.
And it has these four little leads that come out kind of similar to EKG Leads I guess and they stick around and it just sticks on your belly and it's not the most comfortable thing.
I mean I personally prefer no monitoring at all because I don't like being touched.
I don't want anything on me. Um But this was a great option for me because I didn't feel claustrophobic. I didn't feel like I had this band wrapped around me that was extremely uncomfortable for me.
You might not have that experience.
I had that experience where I didn't want anything touching my skin literally anything like I didn't even want, I tried to have a water birth with my second VBAC, I didn't even want the water touching my skin when it was time to give birth.
So everybody has their own preferences and these hospitals need to have better options.
I have been to hospitals before where the OB Unit says oh we can't use wireless monitoring because it interferes with the telemetry unit upstairs and I think that's a load of shit.
Okay maybe it does interfere with it but and I understand that critical care cardiac patients are important but they are not any more important than a laboring mother and her rights and her patient experience and her care and her right to make decisions that are best for her.
So the hospital should be finding a way to safeguard against that instead of just sitting there and well I think it interferes with the other floors stuff so our patients matter less.
Guess again administration figure it out, figure it out delivery.
Stage Three Labor Management for VBAC
There is nothing unique about the delivery of the fetus or placenta during VBAC.
What some providers want to do is they want to manually explore the scar after VBAC to determine if there was any sign of rupture or dehiscence and ACOG says you do not need to do that and you should not do that.
Some providers, I think, like to do it as a way to punish mom because I have heard of providers who tell their patients prenatally that they will have to do this so they might as well just get a C.
Section so that they don't have to shove their hand inside the uterus after birth.
ACOG says you don't have to do that unless there are signs of it which would include excessive vaginal bleeding and signs of hypovolemia. AKA: major major major blood loss.
Like major blood loss.
It's just it's not a thing it's not a thing that has to be done.
ACOG says it doesn't have to be done.
But we've got doctors out here telling moms that they should have a repeat C.Section because they don't want a hand shoved up their hoo-ha after they push a baby out.
Oh my gosh I like guys I'm literally just like telling you things that moms have told me their doctors said to them and I know it's not all doctors: if there are any doctors listening to this:
I know not all of you feel this way and practice this way.
But unfortunately too many do because one practicing this way is too many.
Too many practice this way because the things that I hear these patients,
these moms telling me their doctors are telling them.
It's it's terrifying.
It's just absolutely terrifying.
Pregnancy Management After Uterine Rupture
They then go on to talk about future pregnancy management after uterine rupture.
They recommend early C. Section delivery if you get pregnant again after uterine rupture.
But then again they also talk about differences in where the scars confined on the segment of the uterus.
So some people might have a very very very minor dehiscence and that's associated with a lower rate of risk.
Whereas you have a higher rate of risk If the scar goes up into the upper segment,
kind of like what we talked about before. Again that is some nuance that we will talk about in the uterine rupture episode
HOW PROVIDERS SHOULD COUNSEL WOMEN PLANNING VBAC
Next how should women considering a trial of labor after previous cesarean be counseled?
They write a lot on this,they write a lot.
What they do say is that checklists are helpful guides for documentation of counseling,
that all counseling should go over the benefits and risks of TOLAC and repeat C section.
It should all be made available to the client and discussed and documented that it was discussed and they recommend the information.
More information is available on for more information page and that global mandates for TOLAC are inappropriate because individual risk factors are not considered well, I agree with that because they don't mean global worldwide. They mean blanket statements, blanket policies.
ACOG has said yet again that they do not support blanket VBAC policies because individualized care is the best way to have positive outcomes.
And yet we have providers with this like pathetic informed consent sheet that goes over all the risks of TOLAC and none of the risks of repeat C section or it makes TOLAC look very biasly riskier than repeat C section instead of just going over the data.
Uh and then they turn around and have blanket policies and ACOG is saying no, no, no, no no no no that's not okay y'all can't see my face.
Like I'm I'm speechless.
I'm speechless.
I don't, I don't get why this seems to be the standard when ACOG standard iss that that should not be that standard.
Ah I am hot y'all.
Mm This just gets me very upset when it it's right here in black and white.
They're constantly telling providers not to have blanket policies to individualize care.
And every single day I see, I talk to, I message with moms who are experiencing blanket policies and gatekeeping of options.
....
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