5 P’s from the VBAC Playbook: Lessons for Every Pregnancy

These 5 P’s have come to us by way of families who have been down incredibly difficult roads and have emerged wizened. You can use their wisdom to jump into your own best health and birth outcomes.

Parents who have birthed by cesarean often talk about what they didn’t know for their first birth.  By the time we meet, there is normally some recognition that they didn’t know because they didn’t access the information they could have. This is said without judgement of self or other.  We all do the best we can in the moments we have to navigate decisions.  But the list of “I didn’t know…” is a common thread in our prenatal conversations and VBAC support groups.  Every expecting family can use the lessons these families have grown to embrace.

“Preventing the Primary C-Section” is a phrase used in research that demonstrates the fallout from a first birth that falls into the 20-60 percent of all American births (depending on where you live) that end in an operative delivery.  Some cesareans are necessary, this is not an article slamming those of us who’ve had surgical births.  Regardless of origin, the data clearly shows that we tend to struggle with a host of problems as a result of that surgery. These extend well beyond the first baby and can have severe impact on the health of future pregnancies. (As a midwife who has cared for many, many VBACing moms, the data collected does not reflect the emotional and mental health implications, which is a whole other book we want to write book we need to write, or maybe just a blog post–check back frequently).

The American College of Obstetricians and Gynecologists put out a consensus statement called, “Safe Prevention of the Primary Cesarean Delivery” in which they state:

A large population-based study from Canada found that the risk of severe maternal morbidities––defined as hemorrhage that requires hysterectomy or transfusion, uterine rupture, anesthetic complications, shock, cardiac arrest, acute renal failure, assisted ventilation, venous thromboembolism, major infection, or in-hospital wound disruption or hematoma––was increased threefold for cesarean delivery as compared with vaginal delivery (2.7% versus 0.9%, respectively).  (source) There also are concerns regarding the long-term risks associated with cesarean delivery, particularly those associated with subsequent pregnancies. The incidence of placental abnormalities, such as placenta previa, in future pregnancies increases with each subsequent cesarean delivery, from 1% with one prior cesarean delivery to almost 3% with three or more prior cesarean deliveries. In addition, an increasing number of prior cesareans is associated with the morbidity of placental previa: after three cesarean deliveries, the risk that a placenta previa will be complicated by placenta accreta is nearly 40%.  (source)

The most important moment of your pregnancy might be right now.  Did you just skim that last paragraph–assuming that these things won’t happen to you?  Take a deep breath, exhale, and know that with some preparation and education the one single thing during your pregnancy or birth that you can be assured of is that nothing in your birth experience happened because you made the choice not to face it, grapple with it, ask questions about it, become educated and engaged with your provider about it.  Take a step into becoming a highly informed consumer.  It is your right.  Pregnancy and birth are the first links in a long and multi-string chain of decisions and consequences that you will make for yourself as a parent and for your baby.  Approach with curiosity, flexibility, and a mindset that you can learn all you need to know.  Sink into the idea and the belief that you can rely on that knowledge along with your inner wisdom to forge your way into parenthood. Don’t relinquish your power by standing by, looking the other way, or ignoring the questions and ideas in your mind.

So let’s get to it.   The explanation with these is intended as a starting point for you to begin your exploration of the options–if you have questions ask them!! Ask people you know and trust, read books that are evidence based or thoughtful and inclusive.  There is no one answer that is right for everyone and your answers might change as your pregnancy progresses.  That’s normal, act on your education and knowledge!  Don’t be afraid to ask in the comments and we can identify some resources together.

The 5 P’s that can help Prevent that Primary Cesarean birth:

Place
I know, this is not the first item you might expect to find on this list.  But for planning your birth, you need to work backwards.  The place you want to birth determines what kind of provider and even specifically which provider you can choose.  Hospital, Birth Center, Home birth?  Where do you imagine yourself when you meet your baby?  Who is around you?  What does it sound like?  If you are unfamiliar with out of hospital birth options, take a gander at this great book for a stress-free introduction to it all.  If it is a hospital, take a look at their cesarean section rate.  A huge percentage of your birth will be impacted by where you are and the system at work there.  In a hospital the protocols and procedures generally determine the way that a provider acts.  If the hospital has high rates of intervention you should expect that to effect your experience.  Some would argue that certain hospitals have high rates because they see high risk patients.  Guess what?  We believe what we will see long before we actually see it.  If the experience is that women fall apart and need saving during labor, one might ask how much of the beliefs and behaviors affect outcomes for all women who birth there. It is not born of neglect or bad intention, but we know what we know what we know what we know.  And we do, what we know.
Model of Care
Your provider has been trained in a specific way–and they have adapted their training and developed their own style.  There’s no way to know what you’re getting until you ask.  Typically speaking you can get all of the same tests and screens from and OB or a midwife (nurse or licensed).  The focus of care differs with each provider–the time, approach to education, resource-sharing, and commitment to shared-decision making will all vary.  What do you want?  Go and meet with a few different providers who offer births at the location of your choosing.  The right fit will be clear after three interviews for most families.
Participate
Not to ring a bell too many times in one blog post.  You can go back and read why it is so important to take active, intentional steps to become a highly informed consumer.  If you don’t hesitate to ask what comes on the turkey sandwich and tell them what you like and don’t like at a restaurant, you certainly need not hesitate to ask what to expect from your care, state your needs as they arise, and switch providers if something is not working well, or you get an impending sense of discomfort.  Read, gather, discuss, bring your ideas to your visits, ask all the questions, tell all the ideas you have–it all matters so so much.  Taking the step into your strength as an informed consumer will change your life.  It will also show you if you have a provider who will engage with you on mutual terms.  This is not about fighting or being obstinate, it is about learning and engaging in the learning process with a person who should be a great teacher for you.
Prevent
Your pregnancy is a time to set up the environment of your body for optimal health.  A lot of people approach chronic conditions during pregnancy with the mindset that if we can just “get through this time” we can work on it after the baby.  But you are laying the brickwork for how you feel everyday.  You don’t have to suffer.  You don’t have to greet your baby in anything less than vigorous good health–find a provider who will approach you as a whole person and a mother, not just a vessel that needs to stay together just enough to support the life of your baby.  You are your baby’s health–the chances are that if you don’t feel well, the placenta isn’t going to get the life support it needs to do what it is designed to do for all the days your baby needs it.  You are the soil, sun, and water of your baby’s growing physical and mental health.  Rich in nutrients, full of energy, and supported with just enough of all of the building blocks–not too much or too little, you can grow a healthy, full term baby.
Predict
A provider who pays attention to you and the messages your body is giving will better offer care that answers the prediction of what might happen next.  This can be long-term:  something in your health you want to work on that you feel is at a tipping point.  Labs that come back that can be corrected before they get out of control.  Or it can be short term.  A provider who knows you will believe you and act immediately if you have a sign or symptom that is a red flag.  A provider who knows you knows your family health history and will work closely with you to see into the future and offer solutions and resources to support you in writing the health story you want for your and your baby’s life.
The more healthcare consumers approach their healthcare as consumers with consumer rights the more providers feel like this applies to them. 
These 5 P’s have come to us by way of families who have been down incredibly difficult roads and have emerged wizened.  Families can use their wisdom to jump into your own best health and birth outcomes.
What have your best moments been as a healthcare consumer?  What advice would you give other families as they prepare for pregnancy and birth?

Author: Midwifery

Jodilyn is a licensed midwife (WA, TN) and certified professional midwife. Recently relocated to Memphis, TN, and passionate about the intersection of social justice and perinatal healthcare. She owned Essential Birth & Family Center in South Seattle's Seward Park neighborhood. She is co-founder of South Seattle Women's Health Foundation, an organization dedicated to providing midwifery-led maternity care in a collaborative community-based setting and to increasing capacity within the community to support healthy birth and breastfeeding practices.

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