Hospital VBAC vs Birthing Center VBAC - Mothering Forums

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#1 of 73 Old 07-06-2012, 05:12 PM - Thread Starter
 
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Hi everyone. I'm new to this area of the forums (and I haven't been very active period in awhile!). I'm around 7 weeks pregnant and hoping for a VBAC. My first birth was traumatic. It was a battle from the moment I checked in to the hospital due to the size of my child, my nausea (due to eating in a panic since I was afraid the hospital wouldn't have gluten free food, silly I know), and my back labor. I ended up getting an epidural out of panic since my doula wasn't there yet which is a decision I greatly regret. Due to the size of my son and the epidural, I stalled out at 5cm and developed an epidural fever so eventually, I was told it was time for a c-section. I was tested for GD, but was cleared. Despite that, I had an 11 pound 2 ounce son. :D He's still a big boy now (very tall and musclely) at almost 3 years old! 

ANYWAYS... I'm debating right now over a birth center or hospital birth. I must admit, the first OB I saw so far has me freaked out a bit about the risks, which only scared me more when I went to the AWESOME birth center near my house. I was about ready to sign on the dotted line, but when I saw those emergency risks again... I thought, maybe I would be better at a VBAC friendly hospital? The birth center is AWESOME. The women are wonderful and while they were a little hesitant due to my son's size, they are totally on board with me trying for a VBAC, especially since I eat a modified paleo diet now (so no more carby treats for me!) The only thing that freaks me out is that if there is an emergency...it's not like they can immediately move me to the OR. The hospitals are near by and they are equipped for an emergency (like a level 1 hospital), but still. I don't know. Despite my major distrust of doctors, they have engrained a fear of not having them into me. I am still definitely leaning towards the birth center since I know I won't have to FIGHT there for the birth I want, but still... I'd love to hear your thoughts & experiences.

All I know for sure is that I do NOT want another c-section. I want to give my body a chance to do what it was meant to do.


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#2 of 73 Old 07-06-2012, 09:11 PM - Thread Starter
 
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I'd still love to read your stories, but after browsing through years of threads with HBAC vs Hospital VBAC debates... I've made my decision. I'm going to go to the birthing center. :D


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#3 of 73 Old 07-06-2012, 09:13 PM
 
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I had the same experience! The long version is here http://www.mothering.com/community/t/1099931/vbac2c-in-portland-or#post_17034240   The OBs, the hospital midwives, the nurses, they all looked at me and you could just tell that they weren't seeing me.  They were seeing thier own fears.  And given that the actual risks are so low, I am not at all interested in going ito birht with me in fighting mode and them in fear mode.   I totally fell in love with the birth center environment, even the receptionist there treated me like a person (not some alien pod carrying a baby that needed extracting).   I found that the longer I kept my options open, the more I felt sure that I wanted to go back to the birth center people (I can't actually give birth there but I can get the midwife I liked there to attend a homebirth). 

 

Do what's best for you and your baby, but read about those risks if they are what's holding your brain and your gut apart.  I liked ICAN's website (and their meetings!) and have been reading "Obsteric Myths versus research realities" by Henci Goer.  The sheer number of studies that show EFM to be ineffective swayed me, but maybe something in there will pop and you'll find that you really want the hospital badly enough to fight for it.  

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#4 of 73 Old 07-06-2012, 09:58 PM
 
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Here's how I made my decision--make a prioritized list of the things/experiences that are important to you regarding this birth.  The prioritized part is important--put the most important thing first, then the next, and so on.  Then go through each item and write next to it if that item is most realistically accomplished at the birth center or at the hospital.  For example, mine looked something like this (note that this is not intended to start a war--this is how I chose to categorize things, you will likely have a different list and categorize them differently)...

 

1.  Have a baby who is alive.  Hospital.

2.  Be alive myself.  Hospital.

3.  Have a baby who does not have any permanent mental or physical disabilities due to birth injuries/emergencies.  Hospital.

4.  Avoid permanent disability myself.  Hospital.

5.  Have a birthing team that I trust is capable of correctly and swiftly handling an emergency situation.  Hospital.

.

.

.

9.  Have a vaginal delivery.  Birth Center.

10.  Have a birth team who is hands off and lets me labor as I choose.  Birth Center.

.

.

.

 

Then, using that information I chose to go to the hospital.  Yes, risks are slim.  But slim does not mean zero.  Someone's baby has to be the one that dies and someone's uterus is that one that ruptures.  No I do not trust birth, or umbilical cords, or placentas because there is no reason to trust them.  Nature/birth doesn't care if you are the one who dies or if it ends up being the woman in the next state.  I realized that although items 8-12 on the list were very important to me and were most likely accomplished in a birth center, they were not the things that were of greatest importance to me.  Yes, the experience of a birth center would be more comfortable and accomodating but not at a price (meaning the potential death of my child or me) that I was willing to pay.

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#5 of 73 Old 07-07-2012, 07:19 AM - Thread Starter
 
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Wow. I understand that was how you broke things down, but thanks for frightening me. 


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#6 of 73 Old 07-07-2012, 07:33 AM - Thread Starter
 
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And is this just how you broke it down for your own confidence or based on facts? Is your hospital's OR on standby while you're laboring? The birth center I'm looking at is just 5-15 minutes away from 3 hospitals, has an OB on call, pediatrician downstairs (if in evening, on call), and is armed with all the emergency equipment of a level 1 L&D room, emergency room & neonatal ambulance. 

 

I'm sorry to seem sassy, but I just don't see how it was productive to break it down in such harsh terms for ME. You could have just said you made a list with things you felt were important. No need to be a fear monger and try to scare me into a hospital birth.


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#7 of 73 Old 07-07-2012, 07:09 PM
 
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This is how I broke it down based on my own experience.  There was no intent to fear monger--I clearly said that your list would likely be different than mine.  Mine was mearly an example. Everyone has a different list, different experiences, and different priorities.  

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#8 of 73 Old 07-07-2012, 09:46 PM - Thread Starter
 
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True, but seriously, that was a pretty harsh list that you knew would be very upsetting. It basically implied to me that if *I* choose a birthing center based on my own list... that basically, I was putting my child's life and my own life in peril. That may be your beliefs, but there was no reason for you to share your particular fears in such a harsh and polarizing manner on here. It was incredibly upsetting. You could have phrased it simply as "I made a pros/cons list and for my own comfort, I chose a hospital VBAC, but everyone is different!" There was no reason to be so harsh and cruel by sharing your list. 


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#9 of 73 Old 07-08-2012, 09:58 AM
 
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You may not agree with my list.  That's fine.  Really.  Message boards are intended for opinions and discussion, and I have the same right as you do to post my thoughts and decisions.  

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#10 of 73 Old 07-08-2012, 10:08 AM - Thread Starter
 
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I guess I always just taught to be polite and kind. You can have opinions without being outright rude and cruel while delivering them.


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#11 of 73 Old 07-08-2012, 04:12 PM
 
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Originally Posted by shakyjelly View Post

I'd still love to read your stories, but after browsing through years of threads with HBAC vs Hospital VBAC debates... I've made my decision. I'm going to go to the birthing center. orngbiggrin.gif

I'm glad you decided this. I just had a hospital VBAC 36 hours ago, and I really wish it could have been at a center - I would not have ended up with all the interventions that did happen. Sadly, a birth center was not an option legally.

K: high school teacher and mama to DS1 (7/07), loss (10/10) and DS2 (7/12). Married to my best friend and soon to be elementary school teacher!
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#12 of 73 Old 07-09-2012, 11:49 AM
 
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So, I think there is simple exercise that can help you decide if you should try for a VBAC in the hospital in proximity to fully equipped OR and NICU. Or if you should do int the Birthing Center. Lets just assume , even thought is not physically possible, that you can get form the birthing center to OR in 10 minutes via ambulance.

 

Now, close you eyes. Think positive thoughts and hold your breath for 10 minutes.

 

 

Can you do it? No? Neither can you baby.

 

 

 

 

5-15 minutes away means that

 

1) MW calls 911

 

2) Ambulance is on the way. It may take 10-20-30 minutes if there is traffic, accidents, rain or what not

 

3) You are loaded in the ambulance, perhaps bleeding, baby in troubled. EMT really can;t do much for you but give you O2. Paramedics can start an IV. No one will do C-section in the ambulance

 

 

4) 10-20 minutes ride to the hospital

 

 

5) Unloading

 

 

6)Checking in

 

7) Assessment, blood type and cross. Anesthesiologist is paged, OR is assembled.  In emergency, there no time for epidural or spinal, so it is general.

 

 

8) Finally the surgery is commenced. I

 

That is is not a very natural experience.

 

Many people, including my friends and relatives had very nice natural childbirth in the hospital. They also had piece of mind knowning that is something went wrong, the help is is around the corner.

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#13 of 73 Old 07-09-2012, 12:02 PM
 
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Originally Posted by shakyjelly View Post

I guess I always just taught to be polite and kind. You can have opinions without being outright rude and cruel while delivering them

While I understand that the pp's list may have some scenarios that are scary on it she certainly presented it in a way that was not inappropriate considering your original question. Reality is while the possibility of complications with a VBAC are small they are very real and should absolutely considered when planning your birth. I can't see how you can accuse anyone here of being rude to you, she just posted things that you feel uncomfortable with and maybe that means you have more thinking to do before you choose a location for your upcoming birth.
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#14 of 73 Old 07-09-2012, 12:07 PM
 
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Alenushka makes some very good points. I know of a birth center near me that advises moms that the hospital is 10 minutes away. MAYBE it is ... if you're in an ambulance with lights and sirens on, going pedal-to-the-medal the whole way down the city's main drag at 2 a.m. with zero traffic. But of course, someone needs to call the ambulance, then they need to get to the birth center, then they need to assess you, then load you up, then get you to the hospital, then unload you, then check you in, then the hospital needs to assess you and decide what needs to be done, then assemble the team, etc. So it's usually at LEAST 45 minutes, all told, based on the experiences of women I know who transferred.

 

Personally, I would absolutely go with the VBAC-friendly hospital, especially because your first baby was so large. Do any of the ones near you have an in-house birth center, or CNMs on staff? Hire a doula. If you're not happy with your current OB practice, try to find one that you're a better fit with. I've had three really fantastic, intervention-free hospital births with my OB practice, and frankly, I was delighted with all of them. They were SO not what I was told hospital birth would be like!

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#15 of 73 Old 07-09-2012, 12:42 PM
 
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I remember my CNM asking me if I was fearful of the pain of laboring. "No," I said, "I'm fearful of a repeat csection." it never crossed my mind that my biggest fear really should have been rupturing and losing my son. But that's exactly what happened. Pp is right. We live 8 mins drive from the hospital. Between one contraction and the next his heart rate went from 135 to 50. There wasn't enough time to get to the hospital never mind an OR. Don't gamble on your baby's life even if the odds are stacked in your favor (but remember 1 in 200 vbac attempts result in rupture). It is not worth it. Go to a vbac friendly hospital and know you are a safe distance from an OR. Please?
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#16 of 73 Old 07-09-2012, 01:30 PM
 
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Go for the VBAC friendly hospital!!!  

I can't emphasize that enough.  I tried for a VBAC when I had my daughter.  I was one of the ones who ruptured, even though everything looked wonderful to my providers (no pit, low transverse that was almost 3 years old when I conceived her....you name the positive factors, I had 'em.  As close to textbook as it gets.  And it still happened, much to everyone's shock.)  

I would not have had enough time to make it to the hospital from a free-standing birth center, and neither would my daughter.  Even if I had been right across the street from the hospital, I would have been too far away.  I lost two liters of blood in minutes, and spent two hours getting sewn back together.  We NEEDED that OR down the hallway.    

 

I know you don't like mra's tone, but listen to what she is saying.  It may be harsh, but it doesn't compare to the frightening reality that I and LoveIsla faced when we had our ruptures.  I am a member of a UR moms group, and believe it or not.....I'm one of the lucky ones.  My daughter is still here.  She's doing beautifully, and is a completely normal little girl.  I'm doing fine, too.  Too many of the mothers there have had to say goodbye to a much-cherished baby, far too soon.    

I hope your VBAC goes well, and I hope you choose the VBAC-friendly hospital.  Please give your new little one.....and yourself, too!.....the safest option.  You have a little one already here who needs you both, not to mention other people who love and care for you, too.  

BTW, does the hospital have CNMs?  

 

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#17 of 73 Old 07-09-2012, 06:13 PM - Thread Starter
 
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I appreciate the input, ladies. It's interesting since I'm getting completely different info from the women I've met through ICAN. I'm so conflicted. :( This article (http://natural-forces.com/essays/vbac.htm) also make it seem a lot less scary. The hospital is 1.1 miles away from the birthing center and they've NEVER lost a mommy or baby. They transfer early rather than trying to push things until the last minute. I really feel like they make birthing center VBACs safe.. but I must admit, you guys have me truly frightened. 


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#18 of 73 Old 07-09-2012, 06:39 PM
 
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Rupture isn't a gradual process, it, like many emergent issues in birth and labor is extremely sudden. There is no such thing as transferring "early" in a uterine rupture.

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#19 of 73 Old 07-09-2012, 07:37 PM
 
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I appreciate the input, ladies. It's interesting since I'm getting completely different info from the women I've met through ICAN. I'm so conflicted. :( This article (http://natural-forces.com/essays/vbac.htm) also make it seem a lot less scary. The hospital is 1.1 miles away from the birthing center and they've NEVER lost a mommy or baby. They transfer early rather than trying to push things until the last minute. I really feel like they make birthing center VBACs safe.. but I must admit, you guys have me truly frightened. 

Read your link: 

"When a true rupture occurs, a cesarean must occur within 30 minutes (ideally 20) to prevent neurological damage to the baby. Death does not occur immediately. Most women attempting a home VBAC are well within 20-30 minutes of a hospital, particularly if 911 is called."

 

Being 20 minutes from the door of a hospital is totally different than being 20 minutes from the OR. How quickly has your birthing center gotten their ruptures from the center to the OR? And how many VBACs have they done? How many of those had a uterine rupture? According to your own source, uterine ruptures are relatively rare (1:1,000 VBACs) so if they've done, say, 1,000 VBACs, we would only have expected them to have encountered one "catastrophic" rupture. 

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#20 of 73 Old 07-09-2012, 08:46 PM
 
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to the OP, it can be difficult to get black and white information about VBAC because you really do have to dig around for accurate information, and i am not even sure that we have good research on out of hospital VBAC's (that i can think of off the top of my head anyway). we do practice in a culture of fear and litigation which can cloud information that is being passed along. and aside from involving the "risks", choosing a VBAC is also an emotional journey for many women that cannot be defined and limited to the risk of uterine rupture.

 

yes, uterine rupture occurs. it is very rarely a cause of death in mothers, but causes death in babies in 1.9 out of 10,000 women compared to women who have repeat c-sections. to keep things in perspective, i love what murray enkin says:

 

"To put these rates (of rupture) into perspective, the probability of requiring an emergency caesarean section for other acute conditions (fetal distress, cord  prolapse, or antepartum hemorrhage) in any woman giving birth is approximately 2.7 percent – or up to 30 times as high as the risk of uterine rupture with a planned vaginal birth after caesarean.”

 

we don't rule women out of home births or birth center births because they might have a cord prolapse or a baby with fetal distress.

 

have you checked out any of these sites yet?

 

http://www.childbirthconnection.org/article.asp?ClickedLink=293&ck=10212&area=27

http://midwifethinking.com/2011/02/23/vbac-making-a-mountain-out-of-a-molehill/

http://www.aom.on.ca/files/Health_Care_Professionals/VBAC/VBAC.pdf

http://consensus.nih.gov/2010/vbacabstracts.htm

 

i personally do not think you are putting your life or your baby's life in jeopardy by choosing a birth center birth. dig through the information and trust your gut! good luck :)

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#21 of 73 Old 07-09-2012, 08:52 PM
 
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Read your link: 

"When a true rupture occurs, a cesarean must occur within 30 minutes (ideally 20) to prevent neurological damage to the baby. Death does not occur immediately. Most women attempting a home VBAC are well within 20-30 minutes of a hospital, particularly if 911 is called."

 

Being 20 minutes from the door of a hospital is totally different than being 20 minutes from the OR. How quickly has your birthing center gotten their ruptures from the center to the OR? And how many VBACs have they done? How many of those had a uterine rupture? According to your own source, uterine ruptures are relatively rare (1:1,000 VBACs) so if they've done, say, 1,000 VBACs, we would only have expected them to have encountered one "catastrophic" rupture. 

 


right, but depending on where you are, you can phone ahead to the OR, you can draw a woman's blood while preparing to transport, start an IV and have her ready to go straight to the OR when she is in the hospital. regardless, it may be in the comfort level of the OP to accept this risk, and i hope she does not feel judged in a negative light for making such a choice.


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#22 of 73 Old 07-09-2012, 10:16 PM
 
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Straight to the OR, would occur in the hospital not in the case of the outside transfer.

 

If the birth center is ran by CNMs then IV could be started but not if it ran by CPMs. Type and Cross takes a while. Getting a doctor takes a while.  Many of the things are done ahead of time just in case is someone is already in the hospital.

 

2.7 % is not such low number. It means, practically speaking, that 3 out of 100 people.

 

 

 

My sister in law just had lovely natural childbirth in the hospital birth suite.  No one shaved her, restrained her, forced an epidural on her. She has small heplock instead of IV . Nurses encouraged her. Everything from a tub to birth ball was at her disposal.

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#23 of 73 Old 07-10-2012, 01:11 AM
 
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I understand how hard this is when you hear what you want to hear from ICAN and a midwife and other women who had a vbac at home, but as KoryO said there are those of us with horiffic stories who wish that someone had given us a story with a bad outcome so we could have been better informed. This is the problem with statistics that seem so small; it seems like it almost never happens, could never happen to you, noone has ever heard of it happening etc., and then it happens to YOU and YOUR baby and you realize that statistic exists because it has to happen to someone. Again, as KoryO mentioned, we have a whole group of women active on fb who ruptured. Let me know if you'd like me to put you in touch so you can hear their stories.

My midwife had never heard of anyone rupturing, but she stopped doing home vbacs after my rupture. It only takes the experience of one case to have a huge wake up call. Of her existing clients whom she told of my story, one carried on with her hbac and was ok. The other elected to go to hospital and ended up with an emergency section because she had started to rupture. My OB told me he was seeing more and more cases of dehiscence or windows though he couldn't explain why.

I should have mentioned that although my dd was only 7lb 4 my son was 9lb 2 and that would have been a factor in my rupture. I did not have gd and my midwives thought he was under 8 lbs.

You will, most likely, have no issues with your vbac. But if something goes wrong, and I pray it doesn't, just imagine which decision you would have to live with. I live with crushing guilt every single day.
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#24 of 73 Old 07-10-2012, 03:59 AM
 
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This blog has one of the better summaries/analysis of actual transfer times I've seen...

 

http://safermidwiferyformichigan.blogspot.com/2012/06/hospital-is-only-12-minutes-away.html


I support homebirth that meets the qualifications set forth in the AAP's 2013 policy on homebirth.

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#25 of 73 Old 07-10-2012, 05:07 AM
 
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My experience is with having a hospital VBAC.  If you are stubborn and determined and willing to do the research involved, you can be successful in the hospital.  Even though I was with a midwife practice, I had to fight for my vbac (they were wanting to induce, have me laying on my back, continuous EFM, etc.)  I fought hard and knew I was right that inducing was unnecessary (and more likey to create rupture problems), that movement was necessary to keep labor going, and that I could avoid continuous EFM by not getting to the hospital too early, taking frequent "bathroom trips", etc.  I got to the hospital in transition and only spent 4 hours there until ds was born.

 

This time around I'm planning another hospital VBAC.  I would love a birthing center experience, I think it would be more intimate and empowering, not to mention safer in many regards, but my dh is not as convinced as I am.  So, the consequence for him is that I make him read "Pushed" by Jennifer Block, and the Bradley Method book while I'm pregnant so that he is fully aware of what is going on in the hospital and how he can best support me.  It worked last time around (he kicked the mouthy nurses out of the room when they started suggestion various interventions), and I'm confident it will work again. 

 

Having said all that, I think you are perfectly justified in feeling good about a birthing center vbac.  Research completely supports you in thinking it is a safe option.  The myths surrounding vbac can be frustrating.  Of course there are the rare bad experiences.  But, there are just as many rare bad experiences with hospital birth in general, not to mention repeat c-sections.  As long as your birth is a physiological birth, you are giving yourself and your baby the best chance for a healthy and successful vbac. 

 

In sum: do your research, know everything you can, ask your provider loads of questions about various scenarios, prepare yourself mentally and emotionally for an intervention-free birth, keep yourself healthy throughout pregnancy and don't pack on the pounds, and then pray and have faith in whatever you decide to do.  Good luck!

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#26 of 73 Old 07-10-2012, 05:11 AM
 
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The thing is, being "only XXX minutes from the hospital" is always a calculation based on you being in the ambulance with lights and sirens, ready to go.  It doesn't start when it should, which is the time when your attendant first thinks, "oh, @#$%!  we have a problem here!"  It doesn't include the time getting you to the ambulance, loading you up, and strapping you in.  You may be graceful and nimble in everyday life, but in the middle of hard contractions.....you aren't going to be able to get on the gurney as quickly as you would want.  And like Alenushka posted above, you may be delayed because of things like blood typing and assembling the team (it will take longer if they don't notify the hospital they are coming, which has been known to happen.)  Your actual time to the OR could be 30 minutes or more when you are talking about the time from "we have a problem" to the repeat c, in case of rupture.  

LoveIsla didn't have that luxury of time.  Neither did I.

And speaking as a former 911 operator......you can't always count on "the closest" ambulance to be available.  Yes, there may be paramedics just down the street, but you can't guarantee that when you need them that they won't be taking care of someone else having an emergency, like a diabetic crisis or a car accident.  So tack another 3-7 minutes on top of all that to call in the next closest available crew......

What mandib50 posted about calling ahead, etc., sounds pretty and nice, but......that's not realistic.  In case of emergency, otherwise rational people tend to fall apart, especially if they have never seen that kind of thing happen before.  How much experience does that birthing center actually HAVE with rupture, or transports for reasons other than a woman deciding she wants an epidural, anyway?  If they have had one or more, how did it go?  What did they learn from it to improve outcomes the next time it happens?  How close is their working relationship with the hospital (and did you verify what they said with the hospital)?

I know those are a lot of questions, but it's better to ask them now, before the Braxton-Hicks start, right?    

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#27 of 73 Old 07-10-2012, 06:12 AM
 
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right, but depending on where you are, you can phone ahead to the OR, you can draw a woman's blood while preparing to transport, start an IV and have her ready to go straight to the OR when she is in the hospital. regardless, it may be in the comfort level of the OP to accept this risk, and i hope she does not feel judged in a negative light for making such a choice.

I understand how my post could have been interpreted as judgmental, but that isn't at all where I was coming from. OP expressed that stories of rupture frightened her, but she also had faith in her center. It seems appropriate to me to ask more questions about how they have treated ruptures in the past, and how much experience they have doing so.

Now, for me, if a center/hospital/midwife/OB told me they had never lost a baby, I would be as much disconcerted as comforted, because not all babies survive birth, so that is an indicator to me of lack of experience rather than competence.
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#28 of 73 Old 07-10-2012, 06:44 AM
 
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I agree with mandib50. You have to look at the risks of vbac in the big picture. No one is denying that rupture is real and sometimes devastating. However, you must look at that risk in the context of the other risks that exist during labor OR during a repeat cesarean. There is no right answer here, no matter what anyone says. Each woman needs to think about all the different factors and weigh them based on her own values, prior experience, etc. Women who have lost a baby or experienced a rupture are going to have a different analysis than those who have not. Women who have been horribly traumatized by a hospital previously are going to have yet another analysis. No one is right, no one is wrong. IMO, an OOH vbac is a reasonably safe option. At least one of the pp who is posting in opposition to a home vbac is against home birth in any circumstance, so you have to take that background mindset into account as well.

Fledgling midwife on hiatus, Wife to B, mama to C (c/s ribboncesarean.gif 12/04) and S hbac.gif (12/07), angel3.gif m/c (3/12) and expecting another bean 6/13 stork-suprise.gif.

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#29 of 73 Old 07-10-2012, 08:30 AM
 
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She's not talking about a HBAC.  The OP is talking about a birth center vs. VBAC friendly hospital.  Anyone's viewpoints on homebirth, in this context, are irrelevant.

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#30 of 73 Old 07-10-2012, 11:59 AM
 
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She's not talking about a HBAC.  The OP is talking about a birth center vs. VBAC friendly hospital.  Anyone's viewpoints on homebirth, in this context, are irrelevant.

Out of hospital birth whether at a freestanding birth center or in a home entail the same risks. The equipment and availability of emergency care are the same. The only difference might be the distance from the hospital. I am unaware of any other differences.

Fledgling midwife on hiatus, Wife to B, mama to C (c/s ribboncesarean.gif 12/04) and S hbac.gif (12/07), angel3.gif m/c (3/12) and expecting another bean 6/13 stork-suprise.gif.

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