In today's episode of the VBAC podcast, we're going to answer questions like "What is ACOG?" "What are ACOG Guidelines" and what does ACOG say about vaginal birth after cesarean?
When you're planning a VBAC, your OBGYN is likely to refer to the American College of Obstetricians and Gynecologists (ACOG) guidelines for VBAC management. However, women frequently find themselves in a situation where there OBGYN is making VBAC recommendations that do not follow ACOG guidelines.
While guidelines are not rules, and it is up to each provider and patient to consider benefits and risks TOGETHER, too often, ACOG's guidelines are being misapplied or blatantly ignored and warped. Mothers planning a Vaginal Birth After Cesarean should take the time to get to know the ACOG VBAC Guidelines published in the ACOG VBAC Practice Bulletin.
In this episode of the VBAC podcast, we will explore what exactly ACOG says about vaginal birth after cesarean, the risks, the benefits, and the birth plan options available to VBAC candidates.
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Jaimie Zaki is an LPN, Doula, IBCLC, hostess of the VBAC Podcast and Author of Baby's First Year for New Parents. Jaimie is an Air Force Wife, Homeschooling Mom of Four, c-section mommy and three time VBAC mama! Jaimie's mission is to inspire women to birth and breastfeed with confidence. Jaimie offers private virtual consulting to women across America and in-person support to families in Wichita Falls, TX
Transcript for this episode of theVBACpodcast
in today's episode of the podcast,
we are going to answer questions like what is ACOG,
what are guidelines and what does ACOG say about vaginal birth after cesarean.
When you're planning of back your O.
Is likely to refer to the american College of Obstetricians and Gynecologists.
ACOG guidelines for VBAC management.
women frequently find themselves in a situation where they're O.
B G Y.
Is making recommendations that don't follow ACOG guidelines.
While guidelines are not rules and it is up to each provider and patient to consider benefits and risks together.
Too often ACOG guidelines are being misapplied or blatantly ignored and warped.
Mother's planning a vaginal birth after cesarean should take the time to get to know the ACOG guidelines published in the ACOG back practice bulletin.
That way they can have better deeper clearer conversations with their providers.
Hey mama bear was your last birth A.
Section and you have been dreaming of a vaginal birth ever since.
Maybe you're newly pregnant and planning of back but struggling to get straight answers and support if you're dreaming of a healing positive and peaceful vaginal birth after cesarean.
You're in the right place.
Welcome to the V back 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 V back mama.
My mission is to help you cultivate confidence for a positive and peaceful V back.
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 get started today I wanted to let you know about the V.
VBAC with confidence.
Complete birth prep program.
When I was on the operating table during my C.
I remember thinking I need to have a VBAC next time.
From that moment on I was constantly researching and learning everything I could to understand what I needed to do to improve my chances of my dream VBAC 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 is so much more to a positive birth experience than just understanding the data and the 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 safeguard yourself for a better birth and how to understand sometimes confusing information about birth.
You will learn how to strengthen what I call the three pillars of confidence for a more peaceful and positive feedback.
If you're ready to get started.
Reframing your fears and reclaiming your power for a better birth.
The VBAC with confidence,
complete birth prep program is for you.
If we did this self paced course in person,
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Your birth is worth investing in.
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 already mama's.
Let's get started.
Welcome to this episode of the VBAC podcast.
Um Today we are going to talk about the ACOG practice guidelines for VBAC as we talked about.
Um and this is probably going to be split into two episodes just because there really is like so much to cover here.
It's so much information,
it's just crazy.
Um So I have in front of me the ACOG back practice bulletin that was published in,
Well this is number 205.
It was published in February 2019.
They made some minor updates to what they already had.
So I've got this printed out in front of me and it is covered with all kinds of highlights notes,
scribbles all over it.
Um And I want you to keep in mind as we go through this episode that I am not a doctor and I am not your doctor.
I'm not telling you that you should or shouldn't do anything.
I just want to stress that there are guidelines and these guidelines are not rules and requirements.
I do think it is important for you as a VBAC mama to understand these guidelines to a degree.
You don't have to understand them to the depth of a doctor or physician or whatever.
But I think you need to understand them to a degree so that you can start speaking your provider's language and really dig into deeper conversation.
Um Just a quick story for you.
When I was planning my VBAC,
my first one with an O.
In the hospital.
I would actually bring these guidelines printed out and highlighted to every prenatal appointment so that I could discuss things with my provider.
And there was one point where they actually told me that they were only allowing a certain option quote because I was educated and asked for it.
Whereas according to them,
they typically did not offer that option because women didn't know to ask and had pissed me off to be honest.
Um but this is a reality and it's a sad reality.
This sad thing is this practice was actually very very,
very VBAC friendly.
It was a very VBAC friendly provider.
Um and I don't use that phrase lightly,
but they were super supportive even though they were super supportive of VBAC,
They were still gatekeeping some options and it shouldn't be this way.
But it is.
And so unfortunately the burden is on us to make sure that we are educated and advocating for ourselves.
And I say unfortunately really like that should just be the standard.
But it would be really nice to people to just trust that your doctor has your best interest at heart.
Some of them do,
some of them have your best interests but make really bad recommendations and some of them are just amazing.
Some of them suck.
So the only people who care about our birth experience as much as us is us.
We're the only ones who are going to be impacted by our birth experience,
So it's up to us to be the change,
So more women need to be educated and the more women are educated,
the more these providers will realize that they will not continue to get away with gatekeeping options.
So what we're going to do today is we're going to go section by section through the guidelines.
I'm going to read important parts of the guidelines to you and I'm going to give you my two cents on that information and how it could or should be applied and then you can decide what to do with that.
You are free to thank Jamie,
you're not a doctor.
I don't like your perspective.
I'm turning you off.
I completely understand.
Um you are also welcome to say,
well that's a unique way of looking at that.
I will have to consider digging deeper into this conversation and topic to.
So that's kind of how we're gonna do this today.
I hope that if you have any questions you feel free to reach out to me about them and get ready to dig in because we are going to get started mm hmm already.
So the first page is the number 205 bulletin and this one is actually an interim update.
The practice bulletin includes limited focused update to align with committee opinion number 6764 medically indicated late preterm and early term deliveries regarding delivery for previous uterine rupture.
So that is something that we'll talk about in the second half because today we are actually just going to go through the first half of these guidelines because this is quite a few pages um and you can access these online somewhere.
They can be really hard to access though.
Um I don't remember where I found them.
I just remember it took me a really long time to find them a lot of times.
If you google the ACOG VBAC guidelines,
you will find the ACOG website,
ACOG is the american college of obstetricians and gynecologists and it's just a group of professionals who get together examine data and make recommendations on what standard practice should be based off that data anyhoo you can find their very elementary version of this on their website which is right there for everybody to access when you type in feedback.
Um and it is an extremely elementary version which I get but I think it really is holding back a lot of information and a lot of nuance to that information.
Like they give you very very basic answers to very simple questions.
They don't even touch on a lot of stuff on the website.
So the guidelines are a lot deeper and they are one of the resources I have available for moms inside the back with confidence birth prep program.
Um So if you want to read them for yourselves you can find them online or I have them available for you anyhoo Let's get started.
Okay so I am not going to go through and read the whole background,
I really want to but um it's just a lot of reading what I do want you to know though is kind of the history of back.
So between 1970 and 2016 the cesarean Delivery rate increased from 5% to 31.9 which is like super dramatic.
And this had a lot of consequences,
good and bad and something that became very accepted was the idea of once a cesarean always a cesarean.
so this contributed to the increase of c section deliveries.
Um but in the 70s some investigators began to reconsider this paradigm and accumulated data and began supporting TOLAC which is child of labor after cesarean.
I hate that term but that's how they speak.
So that's what we're going to use today.
The data they started collecting actually started supporting TOLAC.
Um as a reasonable approach to certain people's pregnancies.
So what we saw then was an increase in VBAC rates.
So in 1985 VBAC rates were around 5% 1996 they were up to 90 or I'm sorry in 1996 they were up to 28.3%.
Which is amazing.
That's a lot higher than what we have today.
Right And the C section rate declined also.
So in 1989 the c section rate was about 22% And by 20 or 1996 it was about 20%.
The option for VBAC made a huge difference in the Cesarean rates.
So what we also saw was that as more women were pursuing to lack there were more cases of uterine rupture and other complications related to TOLAC.
So basically what happened is doctors totally freaked out.
They were like oh my God wait this is so super dangerous and they did a total 1 80 by 2006 the VBAC rate had decreased to 8.5% and the total c section delivery rate went up to 31% and a lot of hospitals actually stopped offering to lack altogether.
So We can see that we are still on kind of the tail end of this because the current VBAC rates I want to say are about 13%.
So we're like still battling this right and this was a knee jerk reaction because it was like okay well I think we have data for this and now we're seeing these problems,
we're going to stop altogether and what that highlights to me and what I want you to think when we see that is that science is always changing.
Data is always changing and there is nothing black and white about birth,
birth is so full of nuance that these blanket decisions.
These blanket recommendations do not work,
they don't work.
So In 2010 National Institute of Health started examining safety of Tolac and VBAC and all the different factors and they realize that it probably is a reasonable option for many women but it depends on certain things.
So going through this I told you a cog kind of sits down and what they do is they evaluate all the evidence and decide if it is good quality,
bad quality and what the recommendation should be.
The tricky thing about VBAC is we have had so much of this pendulum swinging and not a lot of studies.
So a lot of the evidence that we have for VBAC is older and weaker and we're constantly learning more doing more studies.
But the truth is it takes time for those studies to get into practice.
So I'm going to read a few lines from the evaluating evidence section of the ACOG guidelines and what they say is before considering the results of any analysis.
It is important to note that the appropriate clinical and statistical comparison is by intention to deliver TOLAC versus elective repeat cesarean.
So in this,
in these guidelines we're not talking about successful VBAC versus repeat cesarean.
We're talking about anybody who tried to have a VBAC and repeat cesarean.
So that means anybody who tried to have a VBAC and succeeded and anybody who ended up having a repeat C section in an emergency situation after beginning their TOLAC.
So that kind of does skew some of the numbers in comparison is a little bit and I just want you to keep that in mind.
So TOLAC versus comparing outcomes from VBAC or repeat cesarean delivery after TOLAC with those from a planned repeat cesarean delivery is inappropriate because no one patient can be guaranteed a VBAC and the risks and benefits may be disproportionately associated with failed TOLAC.
So this is kind of good and bad.
What they're saying is we can't compare a planned repeat C section risk with a successful VBAC risk because we don't know who's going to have a successful VBAC to that,
I can say like true but a big factor we know in who has a successful VBAC is how well supported they are.
So just because it ended in TOLC does not mean that it had or I'm sorry just because it ended in a repeat C section and therefore had complications because of the repeat C section does not mean that was by nature because they attempted a VBAC.
It could be that the provider was not supportive of VBAC,
gave them a repeat C section in an emergency situation and created a danger or risk.
And then of course there are situations where there's signs of rupture or other complications that do warrant a C.
Um but I just I just want you to remember how nuanced this is.
And just because we say something,
see something or read something does not mean that it's going to fit in that box.
Nice and perfectly when we're talking about birth.
so then they say however elective repeat cesarean delivery and TOLAC are associated with maternal and neonatal risk.
so they both come with risk.
We know that,
That is like something,
it seems like a very obvious sentence.
But I think it's so important like both options come with risks and the risks of either option include maternal hemorrhage infection,
hysterectomy and even death.
It is really important to note that most maternal morbidity related to.
TOLAC occurs when the repeat cesarean delivery becomes necessary.
Thus VBAC is associated with fewer complications than elective repeat cesarean delivery.
Whereas quote failed TOLAC.
I hate that term is associated with more complications.
That makes sense when we understand birth.
The thing is this is why women are so afraid of VBAC because they know that okay there might be according to these numbers there could be a slightly higher risk.
to moms who attempt VBAC.
But if they get their VBAC it's a lower risk than a repeat C.
But if they don't get their VBAC they;'re at a higher risk than a repeat C.
Section or planned repeat C section.
So it becomes very nuanced and difficult.
And then it just kind of makes for some women they're like okay so why even risk it?
Like let's just go for the repeat C.
So we're not playing roulette.
But the question becomes how can we reduce the need for the emergency repeat cesarean?
Are these emergency C.
Sections happening out of necessity or or can they be reduced?
That's the question that we really need to dig into and we're not going to dig into that today.
Um to be completely honest but but we'll let you come to some of your own conclusions on that it's food for thought.
So then they go on to talk about different risks.
Um They have charts on that and they talk about the differences between dehiscence and rupture and how information on uterine rupture can be ambiguous.
Okay so yes let's do this.
uterine rupture or deHisense associated with TOLAC results in the most significant increase in the likelihood of additional maternal and neonatal morbidity.
So the biggest risk to VBAC is uterine rupture.
We all know that because that's what everybody is so afraid of.
It should be noted that in terms of uterine rupture and uterine DeHisense are not consistently distinguished from each other in the literature and often are used interchangeably.
the reported incidents of uterine rupture varies in part because some studies have grouped true catastrophic uterine rupture with asymptomatic scar dehiscence.
early case series did not stratify rupture rates by the type of prior cesarean incision incision,
transverse versus classical.
So basically this what this is telling us is that a lot of the early data we have on uterine rupture um is not nuanced.
It's not nuanced and therefore it's hard to apply but we know that this is the biggest risk right?
So we need to understand it in detail and we've just been taking this kind of rupture versus not rupture approach where we can start to break down those ruptures and say well they had all these markers that showed that they might have been at a higher risk for rupture and we didn't take that into consideration.
Unfortunately the early studies don't look at those factors.
They just don't look at them.
So then we don't have that information.
So then we have any direct reactions.
Um I will go into uterine rupture in more detail in its own episode.
But next we talk about,
so we talked about how the scar makes a difference.
So we go into the stratification section,
it's a stratification of candidates when it talks about who is a good candidate for VBAC and then they go on to start talking about VBAC calculators.
Um This is another nuanced conversation um that I will do an episode in more detail,
but what I want you to know about the VBAC calculators is the big takeaway is the very last line in this section.
They talk about all the different attempts at creating a VBAC calculator that's reliable.
They talk about the one they recommend most.
And then the very last line says no prediction model for VBAC has been shown to result in improved patient outcomes.
So there is no way of truly predicting how successful your VBAC will be,
how likely you are to have a VBAC.
And any method that anybody uses to try to prove that actually um doesn't it's not shown to improve patient outcomes overall.
So making the decision to have a repeat C section because you have a low VBAC calculator,
chance or odds is not shown the actual not,
save you from anything.
So that's just something to consider who are candidates for trial of labor,
they go into that again in more detail.
Um Similarly because neonatal morbidity is higher in the setting of a failed TOLAC than in a VBAC.
Women with higher chances of achieving the bag have a lower risk of neonatal morbidity.
So that makes some sense.
But again we have to look back at how are we calculating those chances?
Um And that's not to say that if you have a quote lower chance that you're going to necessarily be at risk And then they say however,
a predicted success rate of less than 70% is not a contradiction to TOALC.
The decision to attempt to TOLAC is a preference sensitive decision and eliciting patient values and preferences is a key element of counseling.
Did you hear me clearly?
ACOG makes it very clear that their VBAC calculators mean nothing.
They mean nothing.
Like I said,
we'll go into that deeper in a different conversation.
Um But they're making it very clear right now,
it means nothing.
So we've got some studies on uterine rupture and they compare first times with two previous this and that All right.
And they say that One of the studies showed that one of the big studies that they refer to showed no increase in uterine rupture in women with one Previous C section or multiple previous c sections and the other study noted a risk of uterine rupture.
That increased from 0.9% to 1.8%.
Um In women with one versus two,
both of these studies reported some increased risk in morbidity among women with more than one priority section.
Although the absolute magnitude of difference in these risks was small.
The likelihood of achieving v back appears to be similar for women with one previous cesarean delivery and women with more than one previous cesarean delivery.
Give it the overall data.
It is reasonable to consider women with two previous low transverse cesarean deliveries to be a candidate for TOLAC.
So right there ACOG tells us they have data and it is limited data and that data conflicts with each other and they believe it is reasonable to allow you.
I say allow,
I know I know it is reasonable to allow vaginal birth after multiple cesareans.
Next they go to talk about macrosomia.
Macrosomia is big baby.
And so macro,
macrosomia is typically described as or defined as birth weight of greater than 4000 or 4500 g.
Which I'm trying to remember what that translates to in pounds.
I believe it's about £8.8.04 ounces.
I could be wrong on that though.
I am not good at conversions and I should have figured that out ahead of time.
However if you're good at math you can figure it out and let me know anyway.
Um So what they say is women attempting TOLAC who have who have macrosomic fetuses have a lower likelihood of VBAC than women attempting TOLAC,
who have non macroscomic fetuses keep in mind macrosomia,
cannot be diagnosed before birth because it is defined as a birth weight,
not a predicted birth weight.
We'll talk about that more in a second.
Um And I think it's really important to ask the but why question here.
so we see that women who plan to VBAC with a quote big baby are less likely to achieve a VBAC than women who don't have a big baby.
But why is it really because they can't birth a big baby?
Or is it because of how their pregnancy and labor is being managed?
Is it because of positions that they are in and they are not using optimal positioning and don't get me wrong,
there are times that you can do all the right things and a baby just isn't born vaginally.
Um But so often there are a lot of things that can be done that are not being done a lot of times women are not working with their body,
therefore their baby gets quote stuck and then we have problems.
Um And it's really hard to,
It is really hard to determine if these higher risk of C section for big babies is really because of the baby's size or is it because we're not working with mom's body.
Mom and baby are not working together as a team?
Three studies have reported no association,
whereas 1/4 study suggested an increased risk of uterine rupture for women undergoing TOLAC who have not had a previous vaginal delivery.
So basically what they're saying is these studies are using actual birth weight as opposed to estimated weight,
meaning that there was not space for people to apply prenatal decision making.
And you know,
we know that there's not strong evidence for estimated fetal weight.
And the studies show that okay,
like there's been four good studies on this.
One study showed that it made no difference or I'm sorry,
one study showed that it made a difference and three other studies showed it made no difference and I haven't gone into these studies in depth.
I do plan to do that.
But what I can imagine is each of these studies were very limited and not the best level of evidence because they probably do not have the best controls.
something to take into consideration.
they say it remains appropriate for the obstetrician or other obstetric care providers and patients to consider past birth weights and current estimated fetal weight when making decisions regarding TOLAC and then they follow that with suspected macrosomia.
alone should not preclude offering TOLAC.
So my question is this is it really prudent to take previous weights and estimated weights into consideration as part of this conversation? for some people it will be very important and that's okay.
But I want to know if the risk really is the baby's size or if the prediction of a big baby affects the mindset in a way that it creates a self fulfilling prophecy,
It creates um fear,
it creates internal thoughts of I can't do this,
It creates thoughts from the provider of we have to be extra cautious and jump on a red flag sooner than watching it play out and jumping on it when it becomes appropriate.
Um I believe firmly that mindset plays a huge role in birth mindset of provider and patient alike plays a huge role in birth.
And I believe that when we are having the macrosomia conversation,
a much bigger factor than the baby's weight itself is the mindset associated and the overall holistic approach to that birth.
I find it very interesting that they say suspected macrosomia
alone should not preclude offering TOLAC right after making it sound like it's super dangerous and risky.
And I I have biases about this because my C section baby was £8.04 ounces.
My VBAC babies were £9.04 ounces,
£10.04 ounces and £10.04 ounces.
And I have watched many babies larger than £9 be born safely and vaginally.
Um I know many women who have VBACd large babies and I know many women who are terrified to VBAC because their doctor told them that their baby might be large and then they have all the things happen.
Don't end up with the VBAC they dreamed of and worked so hard for believing the problem was their baby was too big just to find out.
Their baby was six or £7. And that's why I believe that mindset plays a huge role and is a bigger role than the weight itself.
But that's not something we can do studies on.
I mean I don't think we can do studies on that.
I'm not the best scientists in the world.
So if there is somebody that knows how to design a study on mindset um that would be pretty amazing ....Next Section Gestation Beyond 40 weeks.
Bottom line literally the bottom line says Although likelihood of success may be lower in more advanced gestations.
Gestational age greater than 40 weeks alone should not preclude TOLAC There.
You have it you do not have to give birth by 40 weeks.. Previous
Low vertical incision.
So this is an interesting conversation.
We talk a lot about having a low transverse incision as being really important for being a good candidate for VBAC And how a classical incision which is that kind of vertical incision up and down is one of the most risky incisions for VBAC.
But what this is talking about is actually that it may be reasonable.
So there's a different kind of incision they do.
So they do a low transverse vertical incision.
I'm sorry low vertical incision basically what that means is it's vertical up and down.
Just like you think of when you think of the classical cesarean.
However it only includes the lower segment of the uterus.
It does not go all the way up,
it doesn't go into that upper segment of the uterus.
So it's on the bottom half only still vertical.
And what they actually say is a patient may choose to proceed with TOLAC in the presence of a documented prior low vertical uterine incision mind blowing because this was not even on my radar for the longest time.
As far as I understood it had to be low transverse.
And then we started talking about you know I started learning about special scars meaning like um classical or inverted T.
Or a J.
Yeah there's a lot of different a lot of different types of incisions for your uterus.
Um And I remember learning that there just wasn't a lot of information on whether or not you could safely feedback with those special scars but that some women had done it.
Um And so I find it really interesting to hear that ACOG does support the option of TOLAC in the presence of this vertical incision as long as it does not include the upper segment of the um uterus.
And then they go on to talk about unknown types of prior uterine incision.
So sometimes they just can't confirm what kind of incision is on the uterus.
And they say you know they have some data on this and basically what they found is that if they don't know what the previous scar looks like the previous incision shape location is you can still try for VBAC.
Now it is important to note that this kind of study was done was done in a large hospital where they are well equipped for crazy kinds of emergencies but that doesn't mean that it can't be applied to any location.
Um Someone's probably gonna argue with me on that.
My point is like yeah they had better resources available which is great for safety.
But it also just shows really interesting information that you can still be a candidate for TOLAC.
If you don't know what kind of scar you have unless there is quote
Unless there is a high clinical suspicion of a previous classical uterine incision such as cesarean delivery performed in an extremely preterm gestational age.
So sometimes if you have a super super super premium baby they will have to perform a classical incision.
So if they don't know what kind of decision you have but you like had a super super preterm they will probably assume you know it was most likely a classical incision.
So probably not a great candidate for VBAC.
But overall if you don't know your scar type,
still try to be VBAC.
If you have this low vertical scar type,
you can try VBAC.
So while a low transverse makes you the best candidate,
you can still be a candidate if that's not what you have.
The next two topics in whether or not you're a good candidate twin gestation.
A lot of people think oh God,
I cannot have a VBAC because I'm pregnant with twins this time being pregnant twins,
it's gonna stretch my uterus,
Obviously I can't VBAC false.
I'm getting weird today guys,
I'm like really into this and I'm getting weird.
So they say that women with twin gestations who attempt to lack are similar to those women with singleton gestations who attempt TOLAC.
So what they did find is that women with twin gestations did not incur any greater risk of uterine rupture or maternal or perinatal morbidity than those with a singleton gestation.
If you are otherwise a candidate for VBAC if you were pregnant with just one baby being pregnant with two babies means you are still a candidate for VBAC.
I find that mind blowing fascinating.
Amazing and wonderful.
Because everybody tries to tell you that oh,
you're pregnant with twins,
you have to have a C.
That's a whole different conversation.
Maybe I should do a series on reasons for first C.
Section and go into those interesting.
If you like that idea,
let me know because I will do a series on that anyhow back on track back to our topic.
We're talking about twins.
Everybody's going to tell you you need to have a C.
Section for twins.
That's not true.
And so that also means you can have a VBAC with twins.
Now I know the twin conversation gets nuanced.
Everything is nuanced.
I'm not making any blanket statements just like they're not making any blanket statements.
Um but if your doctor is making blanket statements,
that's where we have a problem.
Last topic on candidacy for VBAC obesity.
This talks about B.
I don't like this conversation.
I don't like the obesity conversation in birth because it is one of the most nuanced ones.
And there's a lot that goes into it.
There's the science,
there's the data,
there's personal feelings,
there's a lot of opinions.
There's the fact that the data is limited and the data is biased and um I'm gonna have to have somebody come on the show to talk about this because I know there are some doulas and providers who specialize in vaginal birth for obese mothers and I don't know if that's the right word to even use.
So I'm going to have to do that too.
If you know somebody who is an expert on that topic,
let me know because I would love to bring them on the show,
connect me with them because I would love to talk more about this and give you guys more information on this because what what ACOG says is that women with a greater bot B.
I have higher rates of complications with repeat C.
Section and VBAC.
So overall they say women with a Bmi of over 30 are possibly great candidates for TOLAC.
If they have other things that should um Like if they don't have other risk factors,
but people with a B.
I over 30 might have more risk factors,
therefore might not be a good candidate.
Kind of confusing.
Um basically what they say though is that the care should be individualized.
It should not be blanket statements based off.
Am I in every section,
I am reading this factor alone should not preclude TOLAC.
This factor alone should not preclude TOLAC This mom can still be a great candidate for TOLAC this.
Mom can still have a successful VBAC.
This should be individualized.
You need to take mom's values in personal feelings into consideration.
So why are so many doctors not doing that?
Why are so many doctors saying,
oh you check this box?
Therefore I'm not going to support your VBAC without having a conversation without understanding why it's important to that mother Without talking about the risks and benefits and deciding that mom can choose which risks she is willing to assume.
I know doctors can choose which risks they are willing to assume as well.
But that gets into a whole different conversation because then you have mothers who are being told,
you can't have a VBAC.
But it is so important to them that they end up in a really dangerous situation.
A feeling like their only option is an unassisted home birth and I am not against unassisted home birth.
I also do not think that they are the right answer for everybody and I think most women do not want an unassisted home birth,
but they feel cornered into it.
And that's when it becomes dangerous.
That is dangerous.
That is when VBAC is dangerous,
That is when birth becomes dangerous.
That is when home birth is dangerous.
When a mom is cornered into an unassisted birth that she doesn't want because no provider is willing to take her on as a liability.
Maybe if providers were doing their jobs,
everything wouldn't be a liability.
And I know that's easy to say someone from my perspective who is not a doctor.
I get it,
I get it.
I'm coming from a different perspective and I get that not everybody is a good candidate for VBAC,
but too often mothers are being told that they cannot have a VBAC because for some arbitrary reason,
that doesn't actually exist.
For some reason the doctor is afraid might become a problem,
that doesn't currently exist.
Let's stop treating women with one size fits all medicine and start individualizing care.
That's literally the starting point.
But doctors are too busy to overworked,
too complacent and they just start treating everybody as if it's their job because that's what it is.
It's their job and it's nothing more than their job.
It's just what they do every day.
It's what they're used to.
They get into their habits,
they get set in their ways and many of them don't have the emotional intelligence to self reflect and see that they need to make changes because they are causing emotional trauma to their patients.
as long as their patient is alive,
that's all that matters right?
I'm getting really freaking sassy over here today guys,
someone's not gonna be happy with me after this episode.
And that's okay because I stand by what I say.
The point of everything I'm saying is that maternity care should be individualized every single time,
every single time and we need to take into consideration more than just statistics and numbers because you are not just a statistic and a number.
You are a human.
You have a soul.
You have values,
you have emotions,
you have mindset,
you have so many things that make you unique that need to be part of the conversation when you are making medical decisions,
making medical decisions based solely off of numbers and data.
And science is extremely,
extremely nearsighted because it,
it literally is not taking the whole equation into consideration especially when we acknowledge that a lot of that data is extremely limited and flawed and I know some of you are going to say well that data is extremely limited because it is so dangerous that we cannot even study it because it's just too dangerous.
And I don't buy that,
I don't buy that because when we look at the history of bach and how this pendulum swung,
it went from being totally unsafe to being totally safe.
Let's just do it to being like holy crap.
That was crazy to back to like wait maybe there's just more nuance here,
Maybe this just takes more nuance and that's what it is and it's what 2006,
is that what they said?
is when we started acting like it might be a reasonable idea again.
So we're not very far out from that.
It's only been 12 or 16 years like and half that time people weren't studying things or they were wasting their time on half a studies that didn't even adjust for all the different things we need to adjust for and that's not because they were doing anything wrong.
I say half fast,
like they did it on purpose that way.
They didn't they just you know each study you learn more and then you learn what to study next time and you learn what to study next time and you learn this different thing to study and that different thing to study.
My point is data and science are limited and cannot be the whole conversation anymore.
And guys this is when I start getting into faith and start talking about faith because at the end of the day we are mere mortals.
We are humans.
We cannot know everything.
We cannot control everything.
We can try really hard to know and control everything.
And some of us even believe we can but we can't we can't and that's when we need to learn how to surrender.
So what we can do is learn how to make the best decisions that we can from a place of faith.
Not fear from a place of information that we have not fear but also acknowledge and accept that we can't control everything.
We can't not everything is up to us.
We don't know everything.
We make a decision from a place of information.
That's the information we have.
We have to acknowledge that there is information we don't have and it could be good or bad information but we don't know it so we can't be fearful because we don't know it.
So let's get informed.
Let's get inspired and let's learn that we've made the best decisions we can and sometimes the cards will fall where they will and we can accept that and we don't have to wonder what if if we know we've done everything.
We can alright.
That's where I'm going to leave you guys for today.
We will come back next week and talk more about this,
acog practice guidelines and we will talk more about actual labor management.
Not just if you're a good idea,
if it's a good idea for you to have a vbac but actual labor management.
Thank you for joining me on today's episode of the podcast.
I hope you feel seen supported and inspired.
If you haven't already,
make sure to check out the free I said free combatting fear during class at little bear lactation dot com slash links.
That's little Bear lactation dot com slash l I N K s.
And real quick.
If you could take a moment to leave a review of the podcast,
I would so appreciate it.
Reviewing the podcast.
Can let more VBAC mamas to be know that I can help them the same way I'm helping you.
Can't wait to hang out with you again soon.