The Johnson family of Chandler (from left): Cooper (4), Natalie, Quinn and Lincoln (1).
Everything Natalie Johnson of Chandler knew about labor and delivery she learned from watching “A Baby Story” on The Learning Channel. In the months leading up to the birth of her son Cooper, in the spring of 2009, scenarios from the show resonated.
“I thought everyone had the same type of birth,” says Natalie. “You get induced, you go to the hospital, you pop out a baby. If you’re lucky, you go into labor on your own. I kind of thought that was the way everyone had babies.”
Johnson and her husband Quinn attended a hospital birthing class, and she did begin labor on her own. But Cooper’s birth was nothing like what she had imagined. It was a scary, unsettling experience—from the timing of the epidural, the administering of IV fluids and the moment her OB-GYN broke her water to the positioning of the baby as Johnson struggled, unsuccessfully, for almost three hours to push him out.
Cooper was born in the operating room and whisked away. “When it was over, I had a baby that was stuck in the NICU (neonatal intensive care unit),” Johnson says. “It never occurred to me that would be a possibility. I didn’t think the interventions would lead to a C-section.”
It was a rough start. Breastfeeding didn’t work; it was too exhausting. And although Cooper was healthy, the entire birth experience would dog her. “When you start off feeling like a failure, that you made the wrong decisions for yourself, for your baby, you don’t feel like a good mom,” says Johnson. “How you have your babies is a lot more important than what people let on.”
When she became pregnant with her second child, Johnson began researching new options. “I decided I would become more informed and take way more control. And I was going to do everything differently.”
She contacted the local chapter of the International Cesarean Awareness Network (ICAN), a non-profit organization that educates women on avoiding unnecessary cesarean births. She went to meetings, asked questions and sought an obstetric practice that would be open to her attempt to deliver vaginally, known as a Trial of Labor after a Cesarean, or TOLAC.
“I went gung-ho with the birth process,” says Johnson. “I was determined to feel better and more confident after this birth—no matter how he came out!”
In 2008, the cesarean delivery rate reached a record high—32.3 percent of all births in the United States, according to the American Congress of Obstetricians and Gynecologists (ACOG). One of the reasons was the decrease in Vaginal Birth after Cesarean, or VBAC deliveries, which have been in steady decline since 1996. ACOG points to such factors as restrictions hospitals and insurers have placed on TOLAC efforts, medical liability and the expectant mother’s own decision-making process.
The main reason to consider a repeat cesarean is the risk of uterine rupture. Yet for women with the most common type of C-section incision (a low-transverse uterine incision), the chance of rupture is fairly low—just one half of one percent, according to ACOG.
In 2010, a consensus panel from the National Institutes of Health concluded that with the available evidence, TOLAC is a reasonable option for many pregnant women with one such prior incision.
Recently issued ACOG guidelines state that women with two previous low-transverse cesarean incisions and even women carrying twins may be considered appropriate candidates for TOLAC. An estimated 60 to 80 percent of appropriate candidates who attempt a VBAC will be successful.
Phoenix OB-GYN Bruce Culbertson, MD, is an ACOG Fellow (FACOG) who has been in practice for almost 20 years. Culbertson says he considers two important factors for his patients who want to attempt VBAC. The first is determining the nature of the scar. Visual examination of the scar on the skin is not enough; Culbertson insists on reviewing the dictated operative notes from the doctor who performed the cesarean to determine exactly how the internal incision was made.
Learning the circumstances behind the cesarean is the second key factor when determining if a woman will be able to have a safe VBAC. If the past cesarean was necessary because of the mother’s physical situation, such as a congenital defect or another unique maternal medical condition, a VBAC may not be possible. But for the patient who meets the guidelines and wants to try, Culbertson says he is on board with planning a TOLAC: “If she expresses that desire, I am very interested in helping her realize that.”
In her practice with Valley Women for Women Obstetrics and Gynecology, Diane Ortega, a certified nurse midwife, sees a number of women who wish to try VBACs. “Our practice is large, and the physicians are supportive. The midwives wouldn’t be able to do it without their backup.”
But not all practitioners are willing, says Ortega, and not all hospitals will allow the procedure. The interpretation of earlier guidelines and a difficult medical liability climate for OB-GYNs combine to influence TOLAC frequency, according to ACOG.
Ortega encourages women who want to try a VBAC to think ahead. Make a birth plan with a supportive, trusted care provider. Consider any unexpected emergency. Work to be as healthy as possible.
“If you are overweight, lose it. Exercise. Wait a good 12 months between pregnancies,” says Ortega. “And know that toward the end of the pregnancy, you will need to be patient and let your body go into labor.”
Jenni Froment is the chapter leader of ICAN of Phoenix. Her youngest child, Milo, who just celebrated his first birthday, was a VBA2C, or a vaginal birth after two cesareans. She hopes that any woman who is considering a VBAC will tap into the “wellspring of knowledge” that ICAN provides and seek the group support of other moms.
Froment also encourages any expectant mother to consider hiring a doula—a trained, non-medical professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth—as she did for Milo’s birth.
“A doula serves the mother,” Froment says. “She’s a strong, experienced woman to be your battle partner. She is able to work through the decisions of labor and delivery with you.”
TOLAC birth plans are very personal decisions, says Culbertson, who adds that every woman should weigh the pros and cons. There are cases when a TOLAC ends with surgery. For some women, an elective cesarean birth that follows a prior cesarean is not nearly as difficult as when a second cesarean follows a long TOLAC, says Culbertson. That’s when tissues are swollen, the mother may have a fever and everyone is exhausted.
“You tell them, ‘I don’t have a crystal ball.’ The only way to find out is to give it a try. Let them weigh in and decide for themselves,” says Culbertson.
Johnson had a VBAC delivery with her second son, Lincoln, one year ago. There was pain, of course, and at times she felt completely overwhelmed. But there was no need for the NICU this time. Immediately after the delivery, Lincoln was placed on her chest. “It was that moment everyone talks about. I immediately fell in love.”
Johnson says the experience could not have been more different than her first labor and delivery. She felt empowered. “How confident I was after I had Lincoln! I left the hospital feeling like I could run a marathon,” she says. “Nothing is ever going to be as hard in life as pushing that kid out!”