Giving birth after a C-section? Here are 11 steps to advocate for a vaginal birth

This project was originally published in The Sacramento Bee with support from our 2023 California Health Equity Fellowship.

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Huge numbers of women in California have C-sections — particularly for first-time, low-risk births. If those people want to have more children after that first uterine surgery, they may find access to health care providers willing to consider vaginal birth after cesarean — or VBAC — is limited.

A C-section increases the risk of uterine rupture, but repeat C-sections also increase the risk of serious complications, including severe placental abnormalities with any future pregnancies.

Kairis Joy Chiaji, a doula based in the Sacramento area, offered some tips for self-advocacy around VBAC for those who are interested in pursuing it.

This Q&A has been edited.

1. Do your homework.

Your first advocacy move is education, right? Like really knowing what it is you’re asking for, what the risks are, what your doctor is basing their decision on. One of my most favorite resources is VBAC Facts — it’s available to birth workers, but it’s also available to birthing families. You can look at all of the studies and have them explained. Health care providers can say things that are scary that don’t line up with the data. But if you don’t know what the data really means, then you can make decisions out of fear. It gives you all that information plus things you can print, you can study and share with your provider. So just having that as a backup is a wonderful tool to start.

2. Consider the timing of your pregnancy.

There needs to be a conversation around your timing for subsequent births for people who want to have VBACs. Babies 12 months apart? That’s hard for either kind of delivery. And so if a family knows that they have a history of C-section, then maybe they want to give it that extra year just so that they know that they can do that VBAC without it creating additional risks.

3. Know your own medical history and your own individual risk factors.

Know why you had your C-section. If you had a C-section 10 months ago, and you’re having another birth now, that might not be the scenario for pushing through a labor, but like if your last kid is 10 years old, and you had a C-section, that could be the scenario. It helps if you have your records from the previous birth.

4. If your previous birth was traumatic, try to heal yourself before talking to your doctor.

Do your own work around whatever trauma and triggers you might have from having a C-section if it wasn’t planned. If it was an emergency, if you’re a mom who woke up to, “there’s a baby here now, and I missed the whole emergence.” I think that it helps families to be settled emotionally when they are approaching their providers.

5. Proceed with confidence.

It helps to approach it as if this is absolutely what we’re going to do: That it’s normal, that it happens all the time, that people have babies after they’ve had a surgical birth. And that it’s not it’s not a question as to whether or not the families have a right to do it: The families do.

6. Ask around to find out which providers and hospitals support VBAC.

There are hospitals that have a no-VBAC policy, right? So another thing that you would need to know is, who supports VBAC within a given system. That might mean jumping through hoops with your insurance coverage, or finding, within a given system, a doctor that’s more supportive of it. It’s just kind of knowing where to shop for the product that you want.

7. Even if your doctor supports VBAC, be aware that they may not be at the actual birth, and plan accordingly.

One of the challenges that VBAC candidates face is that the doctor that they see every month, every two weeks, every week, is not necessarily who will deliver their baby. So that doctor might be totally, totally supportive, but they’re not going to be the one there to do it and to manage it. If you encounter a new doctor, how you would advocate for yourself would be, I think you start off with setting an expectation that this new doctor will support your birth plan. The conversation is, “I’m sad that my doctor couldn’t be here. But I’m grateful that you’re here to support me with my plan. What would you recommend, in addition to what I have discussed with my doctor, to help us be successful with this birth plan?” You set that expectation that this person really is there to honor the things that you have planned with your support team for your birth.

8. Be cautious about inductions.

Another challenge is that right now, it is very trendy to induce laborers. You can be totally supported by your provider through your whole pregnancy, and then at the very end, they’re like, “Oh, go get induced.” And that changes everything. It changes all of the birth planning, it changes all the labor planning. It makes stronger contractions and it tries to shorten the time for labor to happen. It limits the participation from family members, because your family members are not gonna live in the hospital with you, at least not all of them, for the three days that you’re in there. And you’re in there and in a strange environment and you’re anxious. It’s kind of a setup. It’s a setup for ending up not having a VBAC, because if you induce, then that changes the dynamic of your labor, of your contractions. The risks are different when you’re forcing contractions than they are when your body eases into them.

9. If you think you’re being pressured into another C-section, look for signs of a true emergency and ask these questions.

If there’s an emergency, that room is filled with people. All of a sudden, a third of the hospital staff is in your room, there’s lights flashing. In a true emergency, mom is out and baby is out in two minutes. If there’s time to prepare, if there’s time to go find out what time the OR is available, if there’s time to go get Dad to put on the bunny suit and the shower cap and they take a while to do it? It’s not an emergency. There isn’t time for scheduling in an emergency. There isn’t really time for discussion. In the same way, if somebody has a stroke while they’re in the ER, nobody takes the time to ask questions. They just deal with it.

“What’s the emergency?” is a good question to ask. “What would happen if we waited an hour?” is a good question. “What is it you’re trying to prevent with this procedure? And what is my risk of that thing that you’re trying to prevent?”

10. If you’re a person of color — especially if you’re Black — take extra precautions.

As a Black person seeking VBAC, sometimes when you hold firm to your boundaries as far as how you want to labor, you are labeled “combative.” And so there’s a shift in the mood and the energy of the people who are assigned to you as a patient in that hospital. Often, for people of color, if they really want to avoid all of that, look for out-of-hospital birthing options or the hospitals in the area that are really person-centered in their care. There are birth centers within hospital systems. Sometimes it’s just a space where they have births, but other times there’s a midwifery model of care that is a lot more user-friendly for people who want to have minimal intervention.

It can be hard. Hospitals are not used to people going there and then not having to do something — if you’re at the hospital, they want to be doing something. I guess in the same way that restaurants like for you to order food when you are sitting at a table, and they might not love you as a customer if all you do is order a water with a squeeze of lemon. It can be that way in hospital settings where you’re like, “No, I’m here for this process, but I don’t want you to manage it, I don’t want to order things on your medical menu, I just want to let this happen the way my body would dictate.”

Try to figure out if you can have your provider who you’ve formed a relationship with at least come through during the labor or during the birth, even if they aren’t technically the person that will be on shift when your baby is being born. That helps, for staff to know that you’re not just a random customer — that somebody who is valuable to that system values you.

It helps to have conversations with the staff at the place where you’re going to deliver. Not just with your OB, but like literally have those conversations so that when you’re talking to folks, it’s not a bunch of strangers.

Having your birth plan is good; asking them to read the birth plan is good. You can even make it cute and give each person their own copy — the new nurse comes, she gets her own copy of your birth plan. There’s a fine line sometimes that we walk as people of color to not be seen as disruptive or intense.

11. Birth is a vulnerable experience. Use strategies to steady yourself.

You can ask for a moment. You can ask to clear the room and just have your support person or support persons to have a minute to breathe, to talk, to decide what you want to do next. Also, depending on where you are in your labor and your birth, if you’re early on, and there’s not a lot happening yet — birth is not imminent — you can leave and come back again. “Can we pause? Can we try this again tomorrow?” You’re not a prisoner. You get to decide. That may not always go well with the staff — they may not like that idea. But it’s absolutely an option. With one client, I assured her that she could treat each person that she encountered like a contraction and breathe through it.