Ob wants to wait until I am 30 weeks to discuss "VBAC restrictions"? Why?

[SweetTooth]

Hi everyone!

I just saw my OB yesterday and although she seems very willing to answer questions, when I brought up my wanting a VBAC she said that it would be better to wait until I was further along, about 30  weeks, to discuss if I would be a good candidate for a VBAC. I guess I must have looked confused when she said that, because she went on to say that at around 30 weeks she'll have a better idea of how my pregnancy is progressing and be more able to discuss VBAC restrictions with me. It didn't seem like she wanted to pursue the topic further at that moment, so I just agreed to hold off with my questions...

My question is, what are the standard "VBAC restrictions"? And also, why the 30 week mark? What happens around that time of gestation that indicates whether or not one would be a "good" or "bad" candidate for a VBAC?

Any help/advice is much appreciated. Thanks!

[liberal_chick]

Uh, nothing happens.  A lot of times when doctors talk about being a "candidate", they want to know if the c-section was caused by something likely to repeat itself.  But the doc should be able to look at your chart and see that NOW.  And even that is not a good indicator as to if you'll end up sucessfully having a VBAC (just ask all the women who were sectioned for big babies and went on to have BIGGER babies vaginally the next time!).

This sounds very bait & switch to me, personally.  I would almost guess that at 30 weeks she'll find some reason to deny you a VBAC and want to schedule your c-section.

Did you research this doctor at all?  What is her c-section rate?  She should tell you if you ask.  How many VBACs does she do in a year?

[fayebond]

Every OB or midwife with a hospital is going to give you the same basic line for VBAC, at least in my experience.  Essentially, they wait until you are 6 months along or so to talk about the details of whether or not you will actually have a shot at VBAC in their care, and then, if you do have a shot, what red tape you will have to put up with.  

There is nothing that I can find about gestation that relates to the timing, its all about paperwork for the OBs.  The ACOG and subsequently the hospitals have made many changes to their VBAC recommendations over time, even every few months, and the OB can't honestly tell you what new rules will be in place and what procedures they will want done.    My actual statistical VBAC chances aren't going to change any time during the pregnancy, short of some rare unusual event, but because of all the litigical concerns over VBAC and the changing rules, the OBs hands are tied to a set of obstacle courses for me to jump through.  

A good example is the recommended wait time for conception of a VBAC baby.  I was told 6 months between birth of baby by CS and conception of baby for VBAC safety, so I waited 7 months.  Then I go in and am told, oh, three months ago it was changed to 12 months and you'll have to wait until 30 weeks to hear about your candidacy at all because they are considering a hard and fast 18 month rule.   I left that appointment really hurt, because here I am, scolded like a baby for not keeping up with their red tape.   

I'd recommend you do next what I did: read up on VBAC, your hospital probably has a research section of their website you can look at

also read up on the ACOG guidelines for VBAC as they stand, 

http://www.acog.org/Search?Keyword=vbac

and VBAC supportive groups like ICAN

http://www.ican-online.org/

I would add, consider finding a plan B if this OB doesn't work out.  DH was really annoyed when he found out that we'd have to wait until basically the last minute to find out what our birth plan was "Allowed" to be, so I went around to alternative OBs (who all said the same thing) and then birth centers and home birth midwives too just for thoroughness sake.  Whatever you end up being comfortable with for a birth plan, please, don't settle for less than YOUR BEST BIRTH PLAN.  It can have plan A, B, C, and D involved, but at least have a plan B so that you have choices in the end.  Your health, your choice.

[SweetTooth]

liberal_chick, I am really hoping it's not a bait and switch, as I really do like my OB since I had a good experience with for my daughter's birth. Granted she did do an emergency c-section, but I never once walked away from that experience feeling bad or traumatized. I got to hold my daughter right afterwards with my husbands help, albeit for a little while. I had her with me soon after I got to my recovery room. She was calm and kind throughout the entire process.

I know the hospital she's affiliated with just lifted their VBAC ban early last year and now has a 2.0% VBAC rate and a 24% c-section rate. I am planning to call the hospital's L&D department to see if they could give me the stats on my OB and verify the hospital's stats as well... Thanks for your advice!

[VBACmama4]

In my personal experience, anytime an OB stalls in explaining or seems skeptical about the possibility of having a VBAC, it's a huge red flag. I have had 3 VBAC's and every time I had to change doctors at least once because of all of them started off telling me it was something they'd "consider" and at some point told me I'd need to be induced, consider repeat CS, etc even though I have never had a single complication during pregnancy. I learned as much as I could about birth and the processes that take place, potential complications, and my options as a patient and that was the only way I was able to get 3 VBAC's. Thinking back, if I'd followed doctors orders, I would have ended up with at least 3 inductions and probably multiple CS's. I've had doctors do everything from inflating rate of risks and berating me for not following their advice to blatantly lying about potential complications and the only way I was able to figure out what was factual concern and what was BS was by learning everything I could beforehand. 

My point is this: if you have no complications present at this time, without some major disaster occurring during your pregnancy (and I sincerely hope not) you are absolutely able to at the very least give VBAC the college try. The reason a doctor suggests 30 weeks is because that is the point when most doctors will refuse to accept a pregnant patient, so if you're 30 weeks along and your current doctor says, no VBAC, you'll be more likely to have to stick with that doctor because no one else will take over your prenatal care. It's a sneaky, horrible thing and SO many docs do it. There is NO reason why she can't explain risks, benefits, rates and outcomes with you right this second. 

[VBACmama4]

Sorry, forgot to mention, a VBAC rate of 2% is absolutely pitiful! A hospital that is supportive of VBAC should have at least a 25% success rate and some are as high as 75%. I've had 3 myself, and I know midwives who have 90-99% success rates. 

[katelove]

I agree with the PPs, there is no legitimate clinical reason to delay discussing VBAC with you. I discussed it and was given some written info at my booking appointment with the midwife which was about 15 weeks and again at the booking obstetrician appointment which was about 20 weeks. At the 20 week appointment, at the obstetrician's suggestion I signed the paperwork stating that I intended to have a VBAC and not book a repeat caesar. We also had a long talk about risks and benefits, the likelihood of success given my previous history and particular issues pertinent to this pregnancy.

I had another appointment at the obstetrician's clinic last week (30 weeks) because I now have GDM and we discussed VBAC again in light of this new issue.

I imagine we will discuss it further at later appointments when we start to know things like whether I end up needing insulin, whether the baby descends this time and whether my anterior placenta is over my scar.

It has also been touched on briefly at each of my midwives appointments.

So, a long way of saying that this has been an ongoing discussion with my care providers and I think we all have a pretty good idea of what each party hopes to achieve and how we'd like to do it.

[MeepyCat]

I think a lot of OBs have seen themselves progress from dreamy to evil in patient estimation over issues like VBACs, and don't want to raise hopes they have to dash later.

I can't say how many times I've seen the same doctor described as fantastic and really supportive of VBAC after an initial appointment, and then as misleading and awful 35 weeks down the road, when the mom has gestational diabetes, and maybe a really big baby, or the hospital policies have changed. I think it's reasonable to ask if there's anything in your record now that would be likely to affect your chances, but you can't expect your OB to predict the future.

A VBAC rate of 2% over the last year doesn't tell you much about how supportive the hospital is if allowing VBACs is a recent change. It does tell you that they don't have a lot of practice.

[womenswisdom]

You know what else happens around 30 weeks? Many OBs stop taking new patients at that gestation so you might be out of luck if you want to switch.

There is no medical reason for waiting until 30 weeks to discuss vbac. Do they wait to discuss the birth *at all*, with any patient, until 30 weeks? Because any patient might have complicating factors during their pregnancy that might change the course of their birth plan. You are a competent adult who could understand that a conversation at 6 weeks might not necessarily be the same as a conversation at 30 weeks, depending on medical factors that might influence your pregnancy. There shouldn't be any reason not to discuss general policies about vbac at this point. I would see that as a huge red flag.

[VBACmama4]

I don't think asking an OB to discuss the birth of your baby at any point during your pregnancy is asking them to predict the future, and it also isn't asking them for permission. If there's no presenting medical complications then any OB has an obligation to answer patients question to the best of their ability. It's not a matter of predicting the outcome, it's a matter of discussing the best and safest route to the outcome the patient hopes for and giving the patient the right to informed consent. Asking them to wait til they are nearly due is equivalent in my opinion as withholding information for no real purpose other than to avoid the conversation. 

A VBAC rate of 2% is pitiful no matter how many years a hospital is practicing according to the new policy because no matter how many women have entered the hospital attempting a VBAC - whether it's 1000 women or 10 women - that means that only 2% of those women were able to successfully have a vaginal birth as opposed to a fully supportive hospital with a rate of 25% or better. If 1000 women are attempting VBAC at hospital #1 with a 2% rate of success, that means that 20 women get their VBAC. At hospital #2, of 1000 women attempting, 250 are successful. That's a HUGE difference and it's totally irrelevant how many patients they have assisted during what period of time. If it were me, and I had to make a decision based on the information the OP gave, I would be researching other OBs and hospitals, or alternatives. I've been through this process 3 times, red flags become really super obvious, and I would be worried if I'd heard what she's heard from her doctor. 

Womenswisdom, I agree with you completely! 

[Bmorefarmgirl]

Originally Posted by VBACmama4 


A VBAC rate of 2% is pitiful no matter how many years a hospital is practicing according to the new policy because no matter how many women have entered the hospital attempting a VBAC - whether it's 1000 women or 10 women - that means that only 2% of those women were able to successfully have a vaginal birth as opposed to a fully supportive hospital with a rate of 25% or better. 

You are interchanging vbac rate with vbac success rate. A vbac success rate of 2% is pitiful. A vbac rate of 2% for a hospital that, until recently had a vbac ban, is frankly pretty meaningless. A vbac rate of 2% means that 2% of the people who gave birth in the hospital were vbacs. It says nothing about how many of those vbac attempts were successful or not.

Op: as others said, you should be wary of a doc who puts off your questions. I am a vbac due in November. My first pregnancy, I had a failed induction at 33 weeks for preeclampsia. I sat down with my midwife with a list of questions about every possibility of preeclampsia, induction, post-dates, etc etc. She patiently and clearly explained the likely scenarios and policies for everything I asked. If the rules change, the rules change. Neither she nor I can predict that, but it's her responsibility as my care provider to answer my questions and explain the risks and benefits of the care she is giving me. It's the least courtesy a doctor or midwife can offer.

Even of she said you might get gestational diabetes or have a big baby or twins or placenta previa or something else unforeseen and that's why she wants to wait, she should still have a pretty good idea of what the risks and chances of success for a vbac would be and she should be able to discuss that with you during your regularly scheduled appointments.

[fayebond]

A side note on VBAC rates, it depends on the area (at least, the US state :)).  The national VBAC rate is about 18%, in my state the average is 20%.  At the big city hospitals its higher, between 25-36%.  In rural areas, 2% is pretty standard even in my oddball but birth heaven state.  Also, if you look at overall hospital rates, even the success rate is rarely over 20%: for a midwife practice within a hospital the rates are always over 75%, but standard patients seem to always fall below the 10% line.  

If you have a midwfie, your odds seem to be drastically better than the average patient.  I'm told this is because nurses on shift tend to self-select to work more, or less, with a given group of midwives: said midwives have more VBAC patients on average: midwives can usually offer more personal attention and information to you: vicariously, that gives those particular nurses more experience with VBACs and the latest data about them.  Since who you get at L&D is rather random, that makes sense to me.  When I went to my hospital (which is a very good hospital for VBAC), the nurses at the front area of the department knew nothing about VBAC, orwhether you could even DO one at thier hospital.  The midwife and her assistant at the front, on the other hand, were much more informed and informative.  

[SweetTooth]

Hi Everyone! Thanks for all your thoughful responses. After thinking this over and doing some research, I'm seriously  thinking about switching providers. I'd like to stay in a hospital setting, and so far, in my area, it's looking like switching over to the Midwifery Group at UCLA will be my best bet. I read on a another thread here on Mothering that their VBAC success rate is 80% and that the overall hospital's VBAC success rate is around 23.4% - which is supposed to be good for a teaching facility. I did read in another thread though (found here http://www.mothering.com/community/t/1040901/los-angeles-midwives/20), that the Midwives at UCLA tend to get rather "sketchy" around mothers wanting a VBAC who are "above normal weight" -- as in being "about size 16 and not morbidly obese." I'm quoting directly from that thread.

I'm wondering if my weight may be the main issue for my current OB, as that is the only "medical" thing I can think of right now that may be a complication. I do not have hypertension or diabetes, and did not have them with my first pregnancy. However, I got pregnant at a heavier weight this time around (about 185 lbs at 5' 2") and I've already gained about 10 lbs. I'm estimated at 19 weeks, so I still have quite a ways to go. At my last appointment, my OB did encourage me to excersize, saying that she didn't want me to end up with gestational diabetes. I am actually doing more  to watch my weight this time around than I did with my first by doing prenatal yoga and eating more healthfully (more protein and veggies, less refined carbs). Yet somehow, I'm still gaining weight rather steadily. Maybe some light aerobics may help keep my weight in check? I certainly hope that I don't get flack for my weight if I end up switching and then having to find yet another provider...

[akind1]

I waited until about that point to really discuss it with my OB. Here is why: I wanted to make sure that any other reasons that might preclude me from having a VBAC had resolved themselves by then, or at least we might know better about how to proceed. Such as: placenta previa (complete or not) - I think in most cases placenta previa resolves by 30 weeks or so, Breech presentation - while babies certainly can, and have, been born successfully breech vaginally, finding a doctor with any experience or skill with breech vaginal birth can be problematic, and while yes, babies can and do flip head down in the last couple of weeks, most babies are head down by 30 weeks or so IIRC - size of baby -while I absolutely agree that ultrasound assessment of baby size is not an exact science by any means, you should be able to get a general idea if the baby you are carrying is going to be on the larger side or not. Also, gestational diabetes screening is usually finished by this point - and depending on how severe you have GD, (re: insulin use or not) may affect what restrictions any patient would face.

IMHO - in any pregnancy, these are things that would affect your ultimate birth plan and whether or not you would be a candidate for vaginal birth. But for a woman planning a VBAC, I think it's importnant from both the patient and provider side to rule out all the other predictable things that might take a VBAC or TOL off the table.

In my own case, I did wait until around 28 weeks to have "the talk" with my OB. And ran like hell once I did. (she gave me very inflated rupture statistics, insisted on an epidural at 5cm, and said they wouldn't let me go a day past 40 weeks due to "supposed" increase in rupture rates after that mark). Should I have talked to her earlier about VBAC (for the record, they knew from day 1 that VBAC was my goal, but didn't discuss it beyond that until I brought it up) - perhaps, but I doubt she would have answered as frankly until all the other things were taken off the table - baby was head down, placenta anterior but high, etc. It worked out well for me in the end - I had a great doula, OB's that listened to me, and a successful VBAC.

As far as restrictions: most want at least a saline lock/heplock/IV access (whatever your hospital calls it) and continuous monitoring. Depending on your provider, they may or may not want to induce/augment with Pitocin unless absolutely necessary (it does or can increase the rate of rupture) this particular caveat was just fine with me. Also, depending on what your hospital offers or allows, I can see them not wanting any water labor/birth due to the difficulty or inability to monitor you continuously in the water.

Also: in regards to weight: with my first (c-section) baby, I started at 225, gained 25 lbs, and baby was 6 lbs 14 oz. No GD. some higher readings towards the end. but I think that was stress (I went to 41+6). My second pregnancy, I started at 225, gained a total of 10 lbs, most of that in the first 1/2 of the pregnancy, no GD again, again higher readings towards the end, and again  baby born at 41+6. She weighed 7 lbs 12 oz. (nearly a pound bigger than her brother LOL) and that was my VBAC.

I am pregnant again, starting weight about 220, and I've lost about 4 lbs. I am 14 weeks tomorrow.  I am not saying weight isn't a valid concern, but I don't think it's as valid as the comorbidities, like HTN, GD, etc. And I am shorter than you by 4 inches.

I hope some of this helps.

[fayebond]

OP, they gave me alot of flak for my weight at the midwife practice I looked at in our local teaching hospital. I got labelled obese, at 170 lbs 5'6".  So there really isn't a healthy weight, IMHO, that you won't get flak for.  Its part of the hospital deal, unfortunately.  But you sound like you feel confident in yourself, and that's the most important part.  You're curvy!  Enjoy it!

[AlexisT]

Originally Posted by fayebond 

If you have a midwfie, your odds seem to be drastically better than the average patient.  I'm told this is because nurses on shift tend to self-select to work more, or less, with a given group of midwives: said midwives have more VBAC patients on average: midwives can usually offer more personal attention and information to you: vicariously, that gives those particular nurses more experience with VBACs and the latest data about them.  Since who you get at L&D is rather random, that makes sense to me.  When I went to my hospital (which is a very good hospital for VBAC), the nurses at the front area of the department knew nothing about VBAC, orwhether you could even DO one at thier hospital.  The midwife and her assistant at the front, on the other hand, were much more informed and informative.  

The most important factor with midwives is patient selection. A woman who has already decided on an RCS won't choose a midwife, because she can't do a CS. They'll all choose OBs. So most of the ERCS group is eliminated (a few will change their minds later in pregnancy). Then all the poor candidates/high risk patients get eliminated. I would've had an OB regardless of my plans with my second, because I have high blood pressure and most CNMs won't take women on antihypertensives. So, midwives have a really good patient pool before we even get into practice specifics, and will have a higher VBAC rate than even a VBAC friendly OB (who will still have some ERCS patients). 

[VBACmama4]

I've had good and bad experiences with midwives, some have lied to me about safety factors because they were afraid to have poor outcomes and possibly damage their reputation with the hospitals they were affiliated with. Some have been absolutely fabulous and willing to work with me no matter what, only to later drop me like a hot potato when I went past my "due date". And still some have been professional, honest and knowledgeable and helped me reach my VBAC goals. It's kind of the luck of the draw, even someone who is highly recommended for their particular views on topics like VBAC can become less than supportive if they feel it puts them in the hot seat - which is understandable, no one wants to be the reason a mother and child suffers complications. 

What I'm saying here is this: interview more than one doctor or midwife. Don't decide til you feel the person you are dealing with is being honest, open and able to at the very least discuss your hopes or plans at any time. 

As far as the comment above claiming that I'm interchanging VBAC rate with success rate: judging that the hospital just lifted it's VBAC ban, I imagine that 2% is its success rate since it's noted also that the CS rate is 24%. If only 2% of women choosing that hospital are attempting VBAC that is another red flag, it means that more than likely those physicians affiliated with the hospital are not supportive or encouraging of those patients attempting VBAC. 

Sweettooth, I'm 5'11" and with baby #4 I was 225lbs at 9 months and I was called obese too, even though he was 9lbs at birth and quoting the delivering OB, I had "the largest placenta he'd ever seen in his life". So there's like 15lbs of the weight right there - weight is only really an issue if you are completely out of shape because labor really can take longer and be a little tougher, but if you're getting some exercise and eating right don't let them pressure you about your weight. Everyone is different, it's your health that matters!

[AlexisT]

Usually the "VBAC rate" is the percentage of women with previous CS who had a VBAC, regardless of their plans. It doesn't distinguish between planned and unplanned CS. (I know this is how it is calculated in my state.) VBAC success rate should always be used alongside the overall rate, because it only includes women who had a TOLAC; you can get an impressive apparent success rate by restricting which patients have one. 

If they have just lifted a ban, then the rate will be low because it includes women who made their plans before the ban was lifted, and it will take some time for women who want a VBAC to choose this hospital again. When I had my 2nd last year, I chose based on stats that were at least a year out of date and indicated that one hospital rarely did them. The newer stats show a rise.

The VBAC rate is typically under 30% calculated this way, and are more reliable at the very low and high ends of the spectrum, IME, because providers within a hospital may vary substantially. 

[Bmorefarmgirl]

My very vbac-friendly midwife practice has stats for jan-June of 2012. They say 5% of their clients are vbacs. They have an overall c-section rate of 11.4%. Of their c-section patients, 80% were primary c-section. 20% were repeat. a small number of vbac attempts does not preclude a high vbac success rate.

[sarahknavy]

I just wanted to say: When I was referred to a different hospital for a VBAC, the dr called me and scheduled a VBAC consultation. He reviewed my chart, talked to me about the risks, told me they they would not induce me and what could change during the pregnancy that could lead him to lean toward repeat c-section (big baby, high bp, etc.) It really sounds like she doesn't really support you and would wait til then because you are less likely to change drs at that point in your pregnancy. I would push the issue now and at least be prepared for a fight if she is going to be a pain. :/