1

The VBAC Link

VBAC Certification for Doulas

© 2018 Utah VBAC Link

Salt Lake City • Utah
Julie Francom & Meagan Heaton
Phone 385.429.2012 • Email info@thevbaclink.com
thevbaclink.com

All rights reserved. This material is protected by copyright and has been copied by and solely for the
educational purposes of The VBAC Link. You may not sell, alter, or further reproduce or distribute any
part of this material to any other person. Where provided to you in electronic format, you may only
print from it for your own private study and research. Failure to comply with the terms of this warning
may expose you to legal action for copyright infringement under the full extent of the law.
Acknowledgements
Creating a course and manual was more work than we ever thought and more rewarding than we could
have imagined. None of this would have been possible without our incredible husbands, Nick and Ric.
From late night caffeine runs and early morning motivation, to always being our sounding boards and
biggest cheerleaders (the most masculine type, of course)—thank you so much! You have both stepped
up to fill in the spots of our lives that got neglected in the hundreds of hours we have spent pouring over
these manuals and countless other business projects.

Our kids perhaps deserve the biggest thank you for sacrificing time with their moms while we worked
every spare second to get this course ready. Our older children especially deserve more kudos for
helping out with the younger ones—thank you!

Special thanks to Meagan’s father-in-law, Kirk Heaton, for assisting with legalities like copyrights,
trademarks, and other essential business contracts.

We would be a couple of grammatically incorrect and poorly punctuated business owners if not for the
talented Jess Nielsen Beach, who spent hours editing, commenting, suggesting, and getting two very
different writing styles to sound cohesive. We owe you so much more than our gratitude! Thank you for
making us sound better than we do in real life.

The stunning look of this manual is due to Rowan Steiner of Salt City Birth and Newborn Photography, a
Utah-based birth photographer, for her birth photos and Arielle Richards for her artwork. Your images
are striking and your eye impeccable. Thank you for letting us use your inspiring images in our books.

To Danielle Demeter, CNM, and Melissa Mayo, LDEM & CPM, the midwives who gave us our most
beautiful VBAC birth experiences. You helped us develop this empowering belief in ourselves and inspire
us even more to help women on their individual birth journeys. Thank you.

To our own doulas and doula mentors, your support and inspiration has built us up and encouraged us
when we needed the kindest strength and warmest advice. Thank you.

Last, but certainly not least, our own doula clients, podcast guests, and those who have shared their
stories. We have witnessed incredible strength, beauty, and poise as we have watched and listened to
you share your breathtaking journeys with us. Thank you so much for allowing us into your most
intimate moments!

-Julie & Meagan

 TABLE OF CONTENTS
MEET THE INSTRUCTORS ............................................................................................................................................................................... 1
I. OVERVIEW AND PURPOSE ..................................................................................................................................................3
II. WHY ARE VBAC CLIENTS DIFFERENT? .........................................................................................................................4
SPENDING EXTRA TIME PRENATALLY ......................................................................................................................................................... 5
DETERMINE ADDITIONAL NEEDS ................................................................................................................................................................. 6
ASSISTING IN TRAUMA PROCESSING ............................................................................................................................................................ 9
MENTAL PREPARATION FOR YOU AND YOUR CLIENT.............................................................................................................................11
ESSENTIAL PHYSICAL PREPARATION .........................................................................................................................................................16
III. VBAC INFORMATION AND STATISTICS .................................................................................................................... 29
A BRIEF HISTORY OF VBAC........................................................................................................................................................................29
WOMEN OF COLOR ........................................................................................................................................................................................33
FOUR MAIN REASONS FOR INITIAL CESAREAN AND WHAT TO KNOW ................................................................................................35
UTERINE RUPTURE .......................................................................................................................................................................................39
VBAC VS. REPEAT CESAREAN ....................................................................................................................................................................43
THE INFAMOUS VBAC CALCULATOR.........................................................................................................................................................46
SPECIAL CIRCUMSTANCES ............................................................................................................................................................................47
ACOG BULLETIN #184...............................................................................................................................................................................50
CONTRAINDICATIONS FOR VBAC ...............................................................................................................................................................52
IV. VBAC BIRTH TEAM AND BIRTH PLACE OPTIONS ................................................................................................. 56
VBAC BIRTH LOCATIONS ............................................................................................................................................................................58
CHOOSING A CARE PROVIDER .....................................................................................................................................................................60
HIRING A DOULA ...........................................................................................................................................................................................64
V. THE ART OF BRAIN ............................................................................................................................................................ 69
WHAT IS BRAIN? .........................................................................................................................................................................................69
ASSESSING INTERVENTIONS ........................................................................................................................................................................69
VI. VBAC LABOR....................................................................................................................................................................... 81
WHEN YOUR CLIENT’S DUE DATE APPROACHES .....................................................................................................................................81
SUPPORTING A VBAC CLIENT WITH AN EPIDURAL.................................................................................................................................83
THE SIGNS OF RUPTURE...............................................................................................................................................................................85
FAMILY-CENTERED CESAREAN SECTION...................................................................................................................................................87
POSTPARTUM RECOVERY .............................................................................................................................................................................89
POSTPARTUM MOOD DISORDERS ...............................................................................................................................................................91
VII. CONCLUSION ..................................................................................................................................................................... 97
APPENDIX 1 – DEFINITION OF TERMS ............................................................................................................................ 99
APPENDIX 2 – RECOMMENDED RESOURCES .............................................................................................................. 103
APPENDIX 3 - REFERENCES .............................................................................................................................................. 104
Meet the Instructors

We are so glad you’re here. We are Julie Francom (right) and Meagan Heaton (left), the founders of The
VBAC Link. As VBAC moms and professional doulas, we saw a HUGE need for a detailed VBAC and
Cesarean-prevention education system and support model. It was frustrating to us that there was not
one place that a birthing parent and her partner could go and find out what they need to know in a
simple, consolidated format. Making sense of medical talk and determining what is truly necessary can
feel almost impossible.

Here at The VBAC Link, we believe in making birth after Cesarean better by providing education,
support, and a community of like-minded people. Welcome to our circle, we are so glad you are here!
We are a team of expert doulas trained in supporting VBAC, have had VBACs of our own, and work
extensively with VBAC women and their providers. Feel free to contact us at any time in your journey by
using one of the contact methods on our website: www.thevbaclink.com/contact.

Julie & Meagan

Page | 1
Page | 2
 VBAC Certification for Doulas
Course Instruction for Doulas Supporting VBAC

I. OVERVIEW AND PURPOSE

A
ccording to the APA, 90% of women who have had a C-section are candidates to attempt a Trial
of Labor (TOLAC) for VBAC (Vaginal Birth After Caesarean) in a future pregnancy yet, only 10%
will try. Most published studies show that up to 80% of women with a Cesarean birth who
attempt a VBAC have a safe vaginal birth (American Pregnancy Association, 2015).

This course is designed to provide you, as a doula, with information and direction to help guide your
birthing parents in making their own unique and specific birth-after-Cesarean choices. This will increase
your ability to facilitate emotional healing, mental preparation, and physical preparation in order for
families to understand their options for VBAC and to plan a safe and satisfying birth. We encourage you
to continue your learning and growth beyond this course and have provided resources in the appendices
to help guide you further. This course is not to replace advice or counseling from any qualified medical
professional about your client’s specific birthing circumstances.

QUICK REVIEW

Only 10% of women with a history of Cesarean will attempt a VBAC. Why do you think that percentage is
so low?

Page | 3
 II. WHY ARE VBAC CLIENTS DIFFERENT?

A
lthough a VBAC mother should be seen as just another mother planning to birth her baby out of
her vagina, she is treated very differently—sometimes drastically so. As a doula, your approach
will typically need to be different as well. She may have mental blocks, trauma from her
Cesarean, fears that she hasn’t yet spoken about to anyone, and, the biggest difference for care
providers, a uterus that has had a previous incision. All of these things can make supporting her through
this journey different than a first-time mom or any other client. When you meet her for the first time in
your interview, she likely will go over some or maybe even all of her previous birth(s). It is important to
listen with an open mind and heart and let her tell you everything she wants to. Knowing how she feels
or what she has been through is going to help you, as her doula, to know how to best support her during
this next birth. Most Cesareans performed in the United States likely could have been prevented
somewhere along the way; learning this can be devastating in and of itself.

One of the reasons we founded The VBAC Link was because it can be so difficult to make sense of all the
medical talk and learn all the essential definitions. One of the most common acronyms used in the VBAC
world is TOLAC. Doctors often use it seemingly in place of the term VBAC, but what does it mean exactly
and, more importantly, how does it impact your client?

What Does TOLAC Mean?

TOLAC stands for Trial of Labor After Cesarean, or Trial of Labor (TOL). All it really means is that a
woman is going to attempt to have a vaginal birth after a Cesarean (VBAC). The act of trying and working
towards VBAC is called TOLAC. The “successful” TOLAC is a VBAC, make sense? We hate referring to
labor as success or failure but, for lack of a better word and for differentiation we think, in this case, it is
appropriate. It is easy to get hung up on the word “try” in trial of labor, so how can you help resolve that
in your clients’ mind?

Knowing that TOLAC simply means someone is “preparing for a VBAC” makes it easier to turn it into a
positive. Mentally preparing moms for those conversations with a provider who only refers to their
patient as a TOLAC rather than a VBAC makes it easier to understand. In fact, it would be a great idea to
just beef up that definition a little and make TOLAC mean “Ready for VBAC” for your client! Mental
preparation accounts for so much, especially when preparing for a journey such as this.

Page | 4
Spending Extra Time Prenatally

Be prepared to spend some extra time with your couple in their prenatal visits. You may have already
received a lot of information about their birth history in your interview. If you haven’t, you will want to
gather that information in your first visit. As she tells you her C-section story, listen to what she liked,
didn’t like, and what she wishes she’d known. This is your chance to learn how to educate her on the
things she didn’t know, learn of the things you can do this time that she may like, and educate her on
the things she didn’t like and what things can be done this time around to encourage those things not to
happen again. It will also help you be hyper-aware of those possible triggers and obstacles in the birth
space. Encourage the expectant person to obtain their operative reports from the hospital and know
what is in the report regarding the reason for her Cesarean, as opposed to what she was told. What
mothers are told and what is in the report can be VERY different.

Take time to get to know her birthing partner’s experience leading up to, during, and after the C-section.
What is their perspective on what happened last time and what they are planning now? It’s so
important to learn about them as an individual; often times, the birth partner has felt helpless and
unsure. They may have witnessed their partner in tears being wheeled into the O.R., watched
uncertainly as their arms were strapped down to the table, and thinking what they could possibly do to
help as they watched their baby being born in a way they didn’t foresee.

Helping them process and work through that

trauma is important. They want to have a much
better experience this time around, too. Trauma,
regret, fear—all those emotions can surface during
birth for the partner, too. Really getting to know
your client and her birthing partner(s) is a very
important role as a doula, in general, and even
more so when dealing with a “bad birth.”

VBAC moms tend to have a very defensive approach to birth. They may have been taken advantage of
and lied to and had procedures performed on them without proper consent. Helping them channel that
defense and turn it into a great offensive strategy will help them become empowered and prepared to
navigate their journey.

Page | 5
Determine Additional Needs

Every mother has different needs. As we stated above, you’re going to find out what those specific
needs are by spending extra time working through their birth history. Jen Kamel, founder of VBAC Facts,
writes for DONA International and lists six very specific ways that a doula can help support her VBAC
client (Kemel, 2016):

1. Be Aware of What She is Up Against

Something we don’t want our client to do is go into a birth space with her boxing gloves on. This is
where we as doulas can help. Before birth starts, find out where she is delivering. Encourage her to
know what the policies are at the place she has chosen to give birth.

2. Educate

Educating your client AS MUCH AS POSSIBLE before the birth can only help her feel more empowered
and have less fear walking in. Helping your client make sense of all the medical talk and “political
barriers” can truly bring more confidence and assurance for them. By providing solid facts and
information, it takes a lot of the questions and doubts away and will hopefully help them achieve their
end goal of a VBAC. Recognizing if there is any sign of perinatal depression or anxiety is difficult, but if
it’s addressed before labor, it can benefit the outcome of the birth. If there are signs, encourage her to
talk to her healthcare professional to discuss how she is feeling. ACOG (The American College of
Obstetrics and Gynecologists) states:

“Anxiety is a prominent feature of perinatal mood disorders, as is insomnia. It may be helpful

to ask a woman whether she is having intrusive or frightening thoughts or is unable to sleep
even when her infant is sleeping. Women with current depression or anxiety, a history of
perinatal mood disorders, or risk factors for perinatal mood disorders, warrant particularly
close monitoring, evaluation, and assessment. These women may benefit from evidence-
based psychological and psychosocial interventions and, in some cases, pharmacologic
therapy to reduce the incidence and burden of perinatal depression” (ACOG, 2015).

3. Help Her Find A VBAC Supportive Provider

Many doctors will say that they are VBAC supportive, but when due dates get closer or the mother goes
into labor, their perspective changes. Knowing their providers’ C-section rate, policies, and views on

Page | 6
VBAC can help mothers know if a provider is truly VBAC supportive (see Section IV). Talk to them about
provider red flags and let them know it is never too late to change a provider and follow their intuition.
Knowing her birth team and her birthplace can really help you, as a doula, as you enter the birthing day.

4. Be Honest
If your client has hired a provider that you know is not supportive, it can be nerve-wracking and
downright scary to talk to them about what you know. If you were in their shoes, would you want your
doula to share that information with you?

“Women unanimously report that if their doula knew their provider wasn’t supportive of
VBAC, they would want to be told. If you withhold this information, it can erode the trust
between you and your client.” (Kemel, 2016)

5. Be Open-minded and Validate Their Feelings

It is important to remember that not every C-section is traumatic for a woman. Every woman is going to
feel different about her Cesarean and that is normal and okay. Some may feel like they “failed” and that
a Cesarean birth is not giving birth. On the other hand, there may be women who feel proud of
themselves, and although they may not want another Cesarean, they didn’t see their previous birth as
anything but medically needed. Every feeling is valid. Those are their feelings and it is important as their
doulas to help support them. If there is something that is beyond a doula’s role (depression, mental
illness, etc.), it is definitely appropriate for you to refer her to someone more educated on supporting
them in that topic.

6. Prepare and Know How to Support a Cesarean

Going into labor, we know that any mom—including those who are not going for a TOLAC—has a risk of
having a Cesarean section. We as doulas need to be able to understand when a Cesarean section is
medically necessary and know how to support our clients emotionally, physically, and educationally
through this process.

Get Her Connected

In any birth setting, support is extremely important. Family and friends tend to worry about them and
often, usually unknowingly, share negative information or unwanted thoughts. Helping her be
connected in her VBAC supportive community can make a BIG difference. Learn who her support system

Page | 7
is at home, help her find her local ICAN (International Cesarean Awareness Network) chapter, and be
willing to be the person who may need to answer questions or take doubt away. Providing her with up-
to-date data and resources can help her feel comforted if negative thoughts or stories come and will
help her feel confident and unwavering in her birth choices.

Use Thoughtful Language

A mother in labor who may have already felt like she “failed” last time will possibly be triggered if she
hears the word “fail” again. Be cautious of what language you’re using during the prenatal visits and
birth. Use words that are positive and uplifting other than scary or fake. A C-section is a C-section. In our
experiences, both personally and
professionally, a woman who has undergone
an unnecessary Cesarean does NOT like to
have her C-section referred to as a “belly
birth” or an “abdominal birth”, despite the
emerging trend of trying to change the
verbiage. On our Instagram page, we asked
women what they thought of the new terms.
Here are some of their responses:

“It’s a Cesarean. Always will be. I learned to accept it as being called that and that is what it will
always be in my heart and mind.”

“I don’t like it. It feels patronizing.”

“NO. It doesn’t make sense, honestly.”

“Noooooo. If anything, this takes away the trauma and seriousness of a C-section. Hard pass.”

“Hopefully it doesn’t catch on.”

“Flipping hate it. Makes me hurt.”

“I don’t understand how it makes people feel better. The name didn’t bother me. My C-section
experience did.”

Page | 8
The way we word things impacts the way we feel about things. Calling a C-section, a “belly birth” or
“abdominal birth” lessens its severity and the impact it will have on a mother’s future pregnancies. It is,
in fact, a Cesarean. It will always be a major abdominal surgery and calling it by any other name will only
cause people to feel more comfortable with turning to it more quickly, which will eventually cause the C-
section rates to rise.

One of the most commonly accepted terms we have found as we have worked with VBAC parents is the
term “Cesarean birth”. While we have yet to come across a woman who prefers that term, you might in
your journey. You might feel more comfortable asking a woman ahead of time how she wants you to
refer to her C-section, but please, don’t just automatically call it a “belly” or “abdominal birth”.

Assisting in Trauma Processing

As many as 45% of women will describe their birth as traumatic (Beck, Driscoll, & Watson, 2013). In her
research and work with women who have experienced a traumatic birth, Cheryl Tatano Beck identified
four main themes that surfaced from the stories of their births:

1. Women did not feel cared for. They felt alone and abandoned at some point during childbirth
or immediately postpartum. They experienced a lack of empathy from their caregivers. The care
they received was perceived as reflexive and emotionless.

2. Their obstetric caregivers did not communicate with them in labor. Mothers felt invisible and
neglected when clinicians talked to each other about them without addressing them or including
them in the conversation about their care.

3. Women perceived that their caregivers did not provide safe care for themselves or their
babies. When things went wrong, mothers felt their caregivers did not respond appropriately as
they trusted them to do. This experience left them feeling powerless and out of control.

4. Mothers felt that their traumatic experience was ignored. Everyone talked about the baby,
but no one asked about their own emotional well-being. They felt they paid a high price for the
safety of their baby.

“Caregivers who are dedicated to the health and well-being of mothers and their babies have
a very difficult time understanding how the care they provide, often with the best of
intentions, can have such a negative impact.” (Beck, Driscoll, & Watson, 2013)

Page | 9
Processing Birth Trauma

It is important for your client to work through any past trauma she may have from her C-section.
Unresolved issues may bring on fear, trauma, or doubt for her upcoming births. Talking about past
experiences with someone supportive of her decisions is important. Ask your client to think about 2-3
people they can include in their safe space. Tell them to keep those people near and turn to them when
they need to vent, ask questions, get suggestions, etc. You may want to ask her the following questions:

● What was it about your previous birth that brings on this fear, trauma, or doubt?
● Did something happen unexpectedly? Was everything going fine, then quickly turned from fine
to dangerous?
● Did anyone talk to you and explain your options or what was happening?
● Was anyone in danger?
● Did you develop a life-threatening condition that may have affected you or the baby that caused
you to be induced? Was there something that happened that the doctors felt made a vaginal
birth too risky?
● What made it feel like it was too much to handle?
● What about your birth plan/expectations didn’t go as planned?
● Did you feel ignored and like everyone talked about the baby, but no one asked about your own
emotional well-being?

They may have felt like they paid a high price for the safety of their baby.

Birth trauma may not always be something that sticks with mothers in a negative way, but if it does, it is
important to work through prior to the arrival of their next baby.

Birth Trauma for The Birth Partner

As a birth partner, it can be hard to watch someone you love suffer through such a large event. It’s
important for not only the mom, but also the birth partner to process his/her birth fear, trauma, or
doubt. The feeling of helplessness felt for a loved one can be very upsetting and frustrating. With birth
PTSD, birth partners can have flashbacks, nightmares, uncertainty with decisions being made, and
intuitive thoughts that may cause a partner to be upset. Addressing these fears and finding the best
support system prior to the baby arriving is important. Sometimes a partner who appears withdrawn is

Page | 10
angry or scared and asking open-ended questions about their previous experience can help discover
where the withdrawal is coming from.

Understand that a partner does not always know how to make their partner happy or fix their problems.
Encouraging them to talk openly with each other and actually listen to what the other has to say will
open up feelings of security for both people.

Fear Release Activity

Helping your client recognize what their fears are is very important. We have a wonderful fear release
activity that you can work through with your clients or give to them as homework to discuss at your next
visit. This activity can be used for any fear and will help you better understand where they are coming
from and what fears you can work through
with them. It is ideal to process their fears
as soon as possible to prepare the mind for
their upcoming birth.

In today’s world, there is a lot of negativity,

false assumptions, and bullying, especially
when it comes to birth and VBAC. Although
social media and the internet can be a
fantastic resource, it can also tear
someone’s hopes, desires, and dreams apart in minutes. It can also create more fear, sometimes
unintentionally.

It is important that we remind our clients when browsing social media forums, internet forums, and
Google, that it is important to take information given with a grain of salt. Using our BRAIN (see section
V) is going to play a big factor in processing and understanding their fears and knowing what is best for
them and their baby. As you process their fears with them, remind them that it is okay to have more
than one fear and it’s okay to do this activity more than once.

Below is a step-by-step example of what you can say and things you can do to walk them through this
activity. We encourage you to do this activity yourself about any fear you may have, it doesn’t have to
be birth related, so you know how it feels to go through this process.

Page | 11
Page | 12
Page | 13
Page | 14
Mental Preparation for You and Your Client

It is important as we prep for the VBAC journey that we enter it with peace of mind and as free of fear as
possible. Leading up to your client’s baby’s birthday, there is a lot of prep you can do together to raise
the overall chances of a successful VBAC.

Take a Good VBAC and Birth Education Course

This course may be different for everyone. There are many childbirth education classes and methods out
there: Hypnobirthing, Hypnobabies, The Bradley Method, Birthing from Within, Birth Boot Camp, etc.
But why is it important to take an education class?

Taking a course results in more education, hands-on practice, and knowledge about the entire birth
process. Helping her know what to expect from that first contraction to the final push will go a long way
toward reducing overall anxiety and preparing her for the incredible journey she’s about to go through,
while also understanding the risks and benefits. It is important to make sure the class is compatible with
her visions of an ideal birth.

What she will learn: Ways to help her relax and cope, pain relief options, various positions to try during
labor (you as their doula will help keep these options fresh), knowing what’s normal and what isn’t,
stages of labor, pushing options, etc.

Learn How to Meditate and Relax the Mind

Meditation is healthy for anyone to do on a daily basis. Meditating stimulates the brain and allows it to
organize itself, which then helps our thoughts be more rational and reduces the stress hormone,
cortisol, which will then return lower blood pressure and anxiety and helps our mind and body relax. We
ALL should meditate daily.

There are many ways to meditate. If you have taken a childbirth education class that works with scripts,
you may want to meditate that way, or maybe you have a favorite medication podcast. There are a lot
of apps that we like including:
• Headspace
• The Mindfulness App
• Mindbody,

Page | 15
 • Smiling Mind
• Simple Habit

A Doula’s Role in Mental Preparation

Yes, we think doulas are pretty cool—as a doula, you can help prepare your clients mental state leading
up to birth and can recognize triggers during labor. In your prenatal visits with your client, work with
them and their birthing partner(s) and learn how you can best help them through any fears and mental
blocks. You can do so much to help bring a positive space for both your client and their partner.

Coping as a Doula

As doulas, we gravitate towards taking care of our clients first and making sure we can help them cope
and process their birth experience—but what if the birth was traumatic for you as well? What do you
do? Who do you turn to?

It is very important, as a doula, to have a solid support team that you can turn to and process a birth
with. It may be other doulas, family, or friends. It’s difficult, but it is important not to put yourself down
by questioning yourself, or beat yourself up if you think you should have done something different.
Birth is something that, unfortunately, we can’t control. It is vital to understand that we did the best we
could—and as much as we’d like to, we can’t save everyone.

Essential Physical Preparation

Taking proper physical care of the body is important for all pregnancies and especially when preparing
to VBAC; being in optimal health overall will ensure the labor and birth processes run as smoothly as
possible, and decreases risks of several birth complications.

Hydration

Expectant women should drink at least 80 ounces of water per day (Blount, 2005). Staying properly
hydrated is important to an expectant person’s overall health, especially in the last trimester.
Inadequate water intake leads to swelling, water retention, constipation, hemorrhoids, bladder
infections, and can even cause preterm labor. So, if your client is feeling any of these symptoms, have
her check her water intake, grab a big glass of water, and soak in an Epsom salt bath, as Epsom salts

Page | 16
provide fast absorption of magnesium, which helps with hydration and has many heart and circulation
benefits.

Encourage her to stay hydrated throughout the day and, if she is nauseous, adding lemon or lime to her
water might help. While drinking water is ideal, juice or other beverages are acceptable as long as
alcohol is avoided and caffeine intake is limited to less than 200mg per day.

Nutrition

Have you ever heard the saying, “You’re eating for two” when you’re pregnant? Although a woman may
be eating for two and need to increase calories, it is important she keep in mind what she’s eating. It is
recommended that a pregnant woman eats 300-400 extra calories in her second and third trimester. It is
important to discuss her specific personal nutritional needs with her healthcare provider. Her body is
working hard to grow a baby, so it’s essential to give it what it needs.

Studies have shown that women with poor diets tend to have harder labors and their children run a
higher risk of other health issues (Blount, 2005). During pregnancy, it is likely your client will be weighed
at each prenatal visit. This is something so many expectant mothers stress about, but encourage her not
to. Her body is growing a baby and weight gain is normal. The big question should be: what do I eat?
Feeding our bodies well is important, so if your
client asks what types of food to eat, encourage her
to eat a healthy variety of the following:

● Protein
● Vegetables
● Grains
● Fruits
● Dairy

Good nutrients will benefit both her and her baby

during pregnancy, labor, birth, and postpartum.
Studies are showing that good nutrition is linked to fewer premature babies, and more energy during
pregnancy (ACOG, 2018). After birth, babies are healthier, have a better pattern of weight gain, and
mothers experience more weight loss in the postpartum stage, quicker healing, and even greater
elasticity of tissues during pushing.

Page | 17
Exercise

In addition to good nutrition, it is also important to exercise. ACOG suggests that a pregnant woman get
a total of 30 minutes or more of activity every day. This may be done all at once or in sections. If she has
not been active before pregnancy, encourage her to take it slow. Always have her check with her
provider first and see what type of fitness best fits her and her pregnancy.

ACOG suggests avoiding activities with a high risk of falling, such as horseback riding, winter sports,
water sports, etc. It is important to start workouts with a good stretch and in the correct clothing.
Swimming, yoga, Pilates, walking, cardio, strength, pelvic floor strengthening, and jogging are all great
options according to ACOG (ACOG, 2017). Exercise can help a woman’s body prepare for labor. It will
also give her a head start in getting back into shape after her baby arrives. A return to physical activity
post-baby has also been associated with decreased incidence of postpartum depression.

It is important not to push herself too hard. Remind her to drink and rest when needed. Staying
hydrated is very important. We lose water every day and, if not replaced, dehydration occurs. Water
plays a critical part in healthy fetal development.

Pelvic Floor Health

What is the Pelvic Floor?

The pelvic floor is a layer of muscles that supports our organs and helps us have the control of our
bladder, bowels, and uterus. Our pelvic floor muscle stretches from the front to the back and side to
side. This muscle is very important, and although it isn’t seen like our arms and legs after lifting weights,
it can be controlled and trained. The pelvic floor also provides support during pregnancy and birthing
stages. When the pelvic floor muscles are contracted, it tightens the vagina and anus. When the pelvic
floor is relaxed, it allows a passageway for us to use the restroom and birth a baby.

How Can the Pelvic Floor Affect Birth?

The birthing process stresses and strains the pelvic floor so it is important to have good tone and
elasticity. Preparing her pelvic floor during pregnancy, will have a positive impact on your clients’ birth
outcome. Although she may spend a lot of time strengthening the pelvic floor before pregnancy, it’s
important to have a relaxed pelvic floor during pushing. A tense pelvic floor can slow down labor
progress.

Page | 18
Failure to progress is one of the leading reasons for a Cesarean. Often, failure to progress may be due to
a poorly-positioned baby, or the body not producing the correct amount of oxytocin to get labor going.
With this said, knowing the inner female anatomy can truly benefit your clients labor progress.

We strongly recommend pregnant persons see a pelvic floor specialist leading up to their delivery. They
can help teach your client the correct techniques to both strengthen the pelvic floor before delivery, feel
prepared during labor, and even help in the postpartum stages. There are many pelvic floor exercises
online, and finding a pelvic floor specialist may help her learn more about her specific needs.
Techniques are always best used when tailored to the individual to help you meet their specific needs.

Cesarean Scar Massage Benefits

Sometimes, the Cesarean scar can be tender, thick, and uncomfortable for months, or even years after
birth. There are so many variations of normal but taking the time to massage or touch the scar can help
break up scar tissue that may be causing pain. It is suggested for moms with Cesarean scars to see a
physical or pelvic floor therapist who can provide many physical and emotional benefits as they prepare
for birth.

As mothers trace over the scar, they may notice emotions and sensations they didn’t know existed. It
may hurt, tingle, or feel uncomfortable. It may feel weird, unusual, or perfectly normal. Let them know it
is okay to feel those feelings because, as with childbirth, these scars have their own unique and specific
meaning to each of us. How they feel as they trace over it will increase awareness of those meanings
and emotions.

They can start massaging the scar as soon as they feel ready and their provider has cleared them to do
so; typically, within six weeks, which is when it has physically healed. They can start out by gently
rubbing it. That helps increase lymphatic drainage, loosen up thicker scars, decrease swelling, decrease
poor muscle recruitment that may in the abdominal wall, and increase lymphatic absorption. All these
things will be helpful for them as they physically and mentally prepare (be sure to encourage them to
visit a pelvic floor therapist or provider to discuss the appropriate techniques for them).

Herbs and Supplements

Medical Disclaimer: The following recommended herbs and supplements are generally recognized as
safe for women in normal health. However, due to the possible changes of dose recommendations or

Page | 19
changes in formulation, we always recommend that each person speak with their provider before
starting any of these recommended tinctures and teas.

Red Raspberry Leaf Tea (RRLT): Red raspberry leaf tea comes from the leaves of the red raspberry plant.
This herbal tea has been used for centuries to support respiratory, digestive, and uterine health,
particularly during pregnancy and childbearing years. This is not something that will induce labor but is
known to help tone the uterine wall to be more efficient when contractions do start.

Disclaimer—Unfortunately, the tea does NOT taste like raspberries. It tastes more like a black tea.
Adding honey and lemon can help the taste.

Birth Prep by Dr. Christopher: A unique whole herb formulation designed to support an expecting
mother’s body for the last six weeks of pregnancy and prepare her physically for the birthing process. To
be taken ONLY in the last six weeks of pregnancy. It is known to help prime the cervix and create
elasticity to the perineum to help avoid any tearing during the pushing phase.

Red Clover: Red Clover is a nourishing food herb. It is rich in a variety of vitamins and minerals and is
one of the best blood-purifying herbs. This blood-purifying action is wonderful for pregnancy
preparation, aiding in detoxification of environmental pollutants prior to conception. According to Susun
Weed (one of the most well-known Western herbalists), Red Clover is one of the best pregnancy
preparation tonics.

“It is my experience as an herbalist using Red Clover that are the richest and most real for me.
I have used Red Clover as a nourishing herb for years, with no negative side effects.” (Weed,
1986)

Chiropractor/Prenatal Massage

Seeing a chiropractor to help a woman get balanced and aligned for when baby decides to arrive is
important. Attending a chiropractor after the first trimester is fantastic, because this gets you on the
right track of being balanced. We suggest finding someone who is Webster-trained and/or is trained to
work with pregnant women. He/she can help balance your pelvis and get your body ready for a vaginal
birth. As baby grows, there can be body aches, spasms, bad posture, and a lack of decent sleep.
Chiropractors can show you effective stretches to help take some or all of this discomfort away.

Page | 20
If a pelvis is off or a sacrum is out of place, it is possible for a baby to not come down into the pelvis in
the correct way. This doesn’t mean it is impossible to get the baby in the correct spot; however, it could
cause extra discomfort during pregnancy and labor.

To find a Webster-certified chiropractor near you, go to www.icpa4kids.com.

Massage is another great way to help ease discomforts and soften tight tendons and muscles that
should be soft and relaxed in labor. Seeing a good massage therapist a few times in the second and third
trimesters will benefit relaxation and create better rest. Some mamas find acupuncture and myofascial
release also helps get their bodies balanced, relaxed, and ready for a natural birth.

Get familiar with these types of providers in your area so you have recommendations for your clients
when they need them.

Fetal Position Makes a Difference

Fetal positioning in labor plays a HUGE part on how labor flows.

“The occiput-posterior (OP) fetal head position during the first stage of labour occurs in 10-
34% of cephalic presentations. Most will spontaneously rotate in anterior position before
delivery, but 5-8% of all births will persist in OP position for the [second] stage of labour.”
(Guittie, Othenin-Girard, & Irion, 2014)

Along with posterior, there are other positions the baby could be in that are not optimal, such as
asynclitic, transverse, facial or brow presentation, shoulder presentation, and breech. The most ideal
position for a baby to be in before and during labor is Occiput Anterior (OA). This is where the baby’s

Page | 21
back is against the mother’s belly. She will feel kicking up front and more than likely feel the baby’s back
as a hard spot on the front.

How can you tell a baby is not in an optimal position? Other than a cervical check or an ultrasound,
there are signs or symptoms that may indicate the baby is not in an optimal position. A major sign is a
woman experiencing hard back labor or back pain, labor may be prolonged or stalling, the belly may be
flat or soft up front and kicks will be mainly up front, contractions may show a “coupling” pattern, or
prolonged pushing with little progress. Even with all of these, sometimes babies can be OP and not show
any of those signs. As a doula, it is important to recognize these symptoms early on and try and
encourage a better position through labor position changes, movement, and rebozo to help minimize
the length of labor.

What Can You Do to Help?

Changing positions during labor is the number one thing we as doulas can do to help encourage an
optimal fetal position. For mothers who are unmedicated, movement is a little easier. For those who
have an epidural, this can make things a little trickier; however, there are still things you can do with
positioning to help her sweet baby come down into the pelvis in the correct position. Using tools like the
peanut ball, rebozo, squat bar, and pillows can help when you have a momma who is not able to move
around as well as an unmedicated mom. The best way to help her baby be in a good spot is starting
before labor begins, with positions and paying attention to posture. In your prenatal visits, you may
want to incorporate talking about fetal positioning and how to get a baby in an optimal spot before
labor begins. Remember, even if the baby starts in the right spot, there is always a chance that the baby
may change positions and end up in an OP or other position at some point in labor. Positions that
encourage good fetal position are listed below.

The Miles Circuit and Spinning Babies are wonderful sources of information for you to give to your
clients. You may also want to give her some information on how to belly map. Spinning Babies has great
links on how to map a baby’s position (see Appendix 2). Something that you can do is try your best to
make sure the baby is in the best position prior to a woman’s water breaking. This is good information
for ALL vaginal births, and ESPECIALLY relevant in VBAC, as providers tend to be less patient with a mal-
positioned baby. If labor is not progressing, she is having signs that the baby is not in a good spot, and
it’s recommended that she rupture her membranes, encourage your client to ask about waiting and
working really hard to get the baby in a better position before proceeding with that option.

Page | 22
The Miles Circuit

Miles Circuit preparation should start around 37 weeks of pregnancy and should be performed
approximately 10 minutes per day, adding a few minutes each day until it can be done for the full 90
minutes.

There are three steps to the circuit. The circuit was created for getting babies well-aligned before labor
begins. It is ideal for a baby to be in the LOA position before labor begins, which will hopefully avoid
posterior babies in labor. If labor is not progressing, the circuit may be suggested to try and get that
sweet baby in the right spot.

This position will work if your client is having any of the following symptoms:

• Back labor or history of back labor.

• Labor is not progressing or has gone erratic.
• Your client is experiencing PROM (Premature Rupture of Membranes).

How to do the Miles Circuit

Step 1: Open Knee Chest

Try to stay in this position for up to 30 minutes. Start in the cat cow position. Drop your chest as
low as you can and bring your bottom as high in the air as possible. Keep your knees wide apart,
keeping the angle between torso and thighs at 90 degrees. Feel free to wiggle around and prop
with pillows if needed. It is important to be extremely relaxed. This position allows the baby to
move around out of the pelvis. Some mommas like to carefully position with a rebozo under the
belly with gentle tension from a support person behind to help her maintain that position for
longer (up to 30 minutes).

Step 2: Exaggerated Side Lying

This position is one we tell our clients to do even in their sleep. It’s one that looks impossible
because of their belly, but it’s not. Showing women this position during a prenatal may be
greatly beneficial for them. Ask them to lie on the left side, with the left leg straight and the
right leg up and bent over pillows. Next, have them roll as far forward as possible, scooting their
hips back (it will feel like they are on their belly). Pillows are great for adding support to the belly

Page | 23
Page | 24
 and legs. Some moms may fall asleep (which is fine) but it is encouraged to be in this position for
another 30 minutes. If this circuit is repeated again in the same day, try the right-side next time.

Step 3: Get Moving

The final step is to GET MOVING! Whether lunging, walking up and down your stairs sideways
(skipping two at a time), curb walking, sitting on your ball moving

your hips, or just going for a good walk, spend 30 minutes doing this to help your baby get in the
right spot.

Note: The key with the lunge is that the toes of the higher leg and mom’s belly button should be at right
angles. Do not lunge over your knee, that closes the pelvis (Miles, 2008).

QUICK REVIEW
Why is it important to spend extra time with your VBAC clients BEFORE their birth?

How can you help a VBAC client prepare mentally for birth?

Why is it important for YOU to mentally prepare?

What are some coping tools you can use as a doula to help you process through a rough delivery?

What amount of daily exercise is recommended by ACOG for pregnant women?

Page | 25
VBAC Story: Nicole
I was staying in a camper with my two young children and my parents. We were three-and-a-half hours
from home so that I could have a VBAC—my husband, Dayle, was still home. I had prodromal labor for
many weeks, but the morning of September 15, I woke up at 3:30 a.m. and knew that this was the day I
was going to have my baby. I sent my husband and my doula a text so when they woke up, they would
know what was going on. Turns out, they were both awake. My husband was up cleaning (I think he was
nesting for me, haha). I told him that he should plan to come that day. I was having a little spotting and
very mild contractions consistently at that point. I got up, got a snack, and my mom woke up. We just
chatted about how I was feeling and I tried to go back to sleep.

I had gestational diabetes, so I had my NST that day and an OB appointment afterwards. I went in for my
NST and it took longer than normal. I was having contractions every five minutes at that point, but they
still felt mild. I told the nurse that today was the day and I felt like I was in early labor. She told me there
was no way I was in early labor because I was handling the contractions too well.

When I was finally okayed to leave from the NST, my mom and I went to lunch. I wanted to keep my
energy up so I would be strong for labor later. Then we went to my appointment. I first saw my midwife,
and she checked me. I was 90% effaced, but still barely 1cm dilated. She said she was sorry, but today
wasn’t going to be the day. She said she was sure it would happen sometime in the next week, though. I
was crushed and felt completely defeated. I had been so sure and it really took me down. I then felt
horrible that I had told Dayle to head our way (he arrived while I was at my appointment). I saw my OB
next and he said we could induce later in the week if I didn’t go on my own.

I left the appointment and just cried. My poor husband kept trying to reassure me that it was okay that
he had driven out. He also wanted to talk about why I was so upset, but I just couldn’t. I wanted to stay
composed and strong in front of our children and I knew if I talked about it, I would just keep crying.
Meanwhile during all this, I kept having mild contractions every five minutes.

I don’t remember the time, but it was a while after we had been back at the camper. I was scolding my
daughter for not leaving my parents’ dog alone when he went into his crate; she just wouldn’t listen. So,
I reached down and pulled her up by her arms off the floor. When I lifted her, I felt a small gush. I got my
dad’s attention and asked him to put her in timeout so I could go to the bathroom to see if my water
had broken.

I went to the bathroom and I couldn’t tell if my water had broken or if I’d just peed myself a little. My
water had broken with my first baby, but there was meconium in it so it was pretty easy to tell. This was
clear and with the spotting, it was impossible to decipher. I texted my doula (Meagan Heaton) to see if I

Page | 26
could stay home for a while even if my water had broken. We both agreed that as long as I could feel
baby moving and I didn’t have a fever, I could stay.

I then got into the shower to try and relax for a minute. My contractions were progressively getting
stronger and closer together. When I got out of the shower, I tried lying down for a bit so I could sit up
and see if I felt another gush, as I still wasn’t sure if my water had broken. I could not get comfortable at
all at this point. I was using my phone and a labor app to time my contractions. I would periodically send
my doula a screenshot of them to keep her in the loop.

I ended up sitting on my exercise ball because that was the only place I found remotely comfortable. At
this point I was having to vocalize (I chose to use a low moan) through contractions. I would lean into my
husband and he would rub my back through each one.

At this point, my doula called me and stayed on the phone with me through two contractions to see how
I was doing. I was having a lot of guilt about when to ask her to come, because I still felt very negative
being told that today wasn’t the day by all my healthcare providers. I didn’t want to take her time away
from her family if this wasn’t it. About 5-10 minutes after we talked, she texted me and asked if she
could come. She felt like it was time. I said yes, please. I was so thankful she took the initiative so I didn’t
have to feel guilty for asking her to come.

She arrived at the perfect time. My contractions were getting steadily stronger and closer together. As
soon as she walked in, she starting applying counter pressure to my hips while I sat on the exercise ball.
It helped so much! At this point, Meagan, Dayle, and my mom were trying to get me to go to the
hospital. I didn’t want to because I didn’t want to be sent home (still feeling defeated).

I was finally willing to at least move outside of the camper. They were worried I was holding back for the
kids’ sake, and once outside, we all decided we should head to the hospital and at least get me checked.
Meagan rode in the back with me and applied counter pressure. I concentrated on relaxing everywhere
and using low moaning through each contraction.

We got to the hospital and Meagan and I slowly made our way upstairs to check in. I had to stop for
each contraction. My husband and my mom joined us once they were parked.

Things got very busy once we got checked in. They checked me and I think I was dilated to about a five
at that point and they confirmed my water had broken. They moved me to a room to labor in. A doctor
came in to talk to me about the risks of having a VBAC and to sign a consent. Meagan continued
applying counter pressure for each contraction.

I remember feeling like I was urinating for each contraction and it felt so weird. I also felt the slight urge
to push a couple times while sitting on the ball. I just went with whatever my body was telling me to do.

Page | 27
At some point, I was done. I didn’t want to do this anymore. I told them all that. Meagan and my
husband asked if they could check me first and then we could make some decisions after that. I agreed.

They got me into bed and the nurse checked me. I was 9cm dilated. I knew it was too late at that point
and that I would have to get through it. Meagan suggested using a peanut ball and so we did. My mom
stayed at my head, held my hands, and talked me through it. Meagan and Dayle helped me with my legs
and tried to apply counter pressure at the same time. Shortly after this, I pushed. The nurse noticed and
asked if I pushed. I couldn’t answer. She immediately called for help. She checked me again and said I
was completely dilated and could push when I felt like it.

The next contraction, I felt a very strong urge

to push, and push I did. It felt so good—so
much better than the contractions had been
feeling. While I was pushing, I vaguely recall a
lot of people coming in the room. I quickly got
the baby’s head, and the next push the baby
was out. They put the baby in my arms.

When they took the baby away to check the

blood sugar, I asked if the baby was a boy or
girl. I had thought maybe I’d seen a penis, but wasn’t sure. Everyone laughed and said it was a boy.
Apparently Dayle had said it was a boy, but I never heard him.

This was one of the best experiences of my life. I felt so strong after this. Like I could conquer to world. I
also felt really good about my body. I was amazed with what it had just accomplished. My birth team
was incredible and I know I could have never done it without them.

Page | 28
 III. VBAC INFORMATION AND STATISTICS

A Brief History of VBAC

I
t is common to feel like nobody cares why the Cesarean rate is so high and wonder why attitudes
towards VBAC have changed so much over time. With knowledge comes power, so we want to give
you a brief history of VBAC in the United States for a better understanding of why the general
attitude is the way it is right now.

Once a Cesarean, Always a Cesarean?

In 1916, Dr. Edwin B. Cragin wrote an article called “Conservatism in Obstetrics”, where the phrase
“once a Cesarean, always a Cesarean” originates (Cragin, 1916). It comes from the final paragraph,
where he emphasizes that one of the risks of an initial C-section is that a repeat C-section MIGHT be
required. You can see how this phrase is definitely being misquoted.

Interestingly enough, Cragin also pointed out that there are many exceptions to this presumption and
that even one of his own patients had gone on to have three vaginal births without difficulty after an
initial Cesarean birth. The reason for this generalization was, because up until the low transverse uterine
incision was championed in the 1920s, the rupture risks from a vertical incision were greater and even
more severe. Initial Cesareans were also performed significantly less and only used in truly life-
threatening situations, after all other options had been exhausted. During the early 1900s, doctors
realized that the choice for a Cesarean had a great impact on a woman’s entire childbearing life and had
more life-long consequences. For these reasons, the Cesarean rate for the United states was in the 1%-
5% range all the way up until the 1970s.

The Rise of Cesarean Rates

Over time, the techniques and technology evolved, making Cesareans a lot safer and even easier to
perform. Antibiotics became more readily available, blood transfusions became easier, anesthesia
improved significantly, and the surgical procedure itself evolved from a “classical” (vertical incision)
technique to a “low-transverse” (side-to-side incision) technique. The low-transverse incision greatly
reduces the risk of rupture and comes with the reduction of other complications as well.

Page | 29
Year 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979
Cesarean Rates 5.5% 5.8% 7.0% 8.0% 9.2% 10.4% 12.1% 13.7% 15.2% 15.7%
VBAC Rates 2.2%
Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989
Cesarean Rates 16.5% 17.9% 19.3% 20.3% 21.1% 22.7% 24.1% 24.4% 24.7% 22.8%
VBAC Rates 3.2% 6.6% 8.5% 9.8% 12.6% 18.9%
Year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Cesarean Rates 23.5% 22.6% 22.3% 21.8% 21.2% 20.8% 20.6% 20.8% 21.2% 22.0%
VBAC Rates 19.9% 21.3% 22.6% 24.3% 26.3% 27.5% 28.3% 27.4% 26.3% 23.4%
Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Cesarean Rates 22.9% 24.4% 26.1% 27.5% 29.1% 30.3% 31.1% 31.8% 32.3% 32.9%
VBAC Rates 20.7% 16.4% 12.6% 10.6% 10.4% 10.1% 8.5% 8.3% 8.4% 8.4%
Year 2010 2011 2012 2013 2014 2015 2016 2017
Cesarean Rates 32.7% 32.8% 32.8% 32.7% 32.2% 32.0% 31.9% 32.0%
VBAC Rates 9.3% 9.7% 10.2% 10.6% 11.3% 11.9% 12.4% 12.8%

Page | 30
These reasons combined caused the Cesarean rates to jump from 5% in 1970 to 24.7% in 1988 (Selma,
Taffel, Paul, & Teri, 1987). This was a HUGE jump in a relatively short period of time. This jump was
incredibly alarming to healthcare professionals, and efforts were made to reduce the rate, leading to a
slight drop after 1988, but never dropping below 20% again.

With the increasing ease and convenience of Cesareans came the loss of knowledge on how to get a
poorly-positioned baby out vaginally. Things like manual repositioning of the baby, vacuum extraction,
and forceps delivery when reasonable became all but forgotten; many hospitals and doctors were not
being taught how to properly do these things anymore.

Many hospital care providers didn’t even know how to tell what position a baby was in before birth
began without using ultrasound technology. These reasons caused Cesarean delivery to be the go-to
choice for births deemed “more risky” either legally or medically, and more and more breech and babies
suspected to be “big” were automatically sent to a C-section even though other options still existed.

New technology like Continuous Fetal Monitoring (CFM) and new induction methods caused the
Cesarean rates to skyrocket without improving fetal outcomes (Selma, Taffel, Paul, & Teri, 1987).
Induction allows providers to schedule their births, making things convenient for their practice but at
the cost of higher bills for families and more NICU stays for babies.

Some saw this drastic rise in Cesarean rates as highly controversial and many public health officials
strongly opposed the rising rates and actively looked for solutions, while others saw how convenient
Cesareans were as a way out of more difficult deliveries and the increasing risks of malpractice suits. So,
the debate for what is the “most optimal” rate rages on and continues today.

VBAC Becomes More Common

Public health officials saw VBAC as a way to keep the Cesarean rates from turning into a public health
crisis. With the safer methods of Cesarean delivery, came the reduction in risk for uterine rupture and
other complications in subsequent deliveries, making women question the need for “once a Cesarean,
always a Cesarean.” VBAC became a safe and reasonable option, although there were still care providers
who objected and many women had to fight for their right for VBAC.

Page | 31
 “Out of this struggle, a grass-roots women’s health movement began, pushing for more
choices in childbirth. Women like Nancy Wainer Cohen, Esther Zorn, and Lois Estner pushed to
make VBAC a choice for all women, while other pioneers like Suzanne Arms, Penny Simkin,
Robbie Davis-Floyd, Sheila Kitzinger, and many others pushed for reform of outdated
childbirth practices like universal episiotomy, pubic hair shaving, mandatory drugging of the
mother, prolonged separation of mother and baby, promotion of formula feeding over
breastfeeding, etc.” (Vireday, 2009).

In 1982, the International Cesarean Awareness Network (ICAN) was founded and women had a more
structured voice demanding their rights for childbirth. All of these things made an impact, and by the
1990s, VBAC was an option in most United States hospitals.

VBAC Starts to Change

VBAC reached its peak in 1996, albeit very cautiously managed by providers due to the potential of
uterine rupture. They were hardly ever induced, Pitocin was rarely used, and when it was, it was used
incredibly conservatively. But, as induction became a normal option for women without prior Cesarean
births in the 1990s, so was it for VBAC women as well.

The induction drug Cytotec (misoprostol) was introduced and it took several years before anyone
realized that the drug significantly increased uterine rupture risk in VBAC women. Routinely inducing
VBACs increases the risk for rupture, depending on the method used, and routine induction for VBAC
women using Cytotec/Misoprostol lead to the beginning of a VBAC crisis.

VBAClash Begins

Because VBAC had been so mismanaged, there was a movement starting in the 1990s against VBAC.
Insurance companies saw VBAC as a way to cut costs (vaginal birth is cheaper than Cesarean), so in
some places, VBAC became required and some women were not even given a choice. Not all women
wanted to VBAC and not all women were good candidates for it, so there was a lot of backlash
surrounding women who were treated poorly, not given appropriate treatment when showing signs of
rupture, and induced with dangerous methods that had a very high rupture rate. This resulted in lost
babies, hurt babies, loss of uteri, or other severe complications. These mistreated families were
rightfully upset and well within their rights to sue.

Page | 32
This obviously resulted in more lawsuits surrounding VBAC directed against hospitals and some
providers. Rather than blaming overuse of induction, mandatory VBAC despite contraindications, or
mismanagement of labor, VBAC was blamed by being deemed as unsafe, despite the opposite being
true (more on that in the next section).

Cesarean Rates Rise Again

So, almost overnight, VBAC was deemed to be too dangerous and doctors’ perception of VBAC shifted.
Some doctors even stopped attending VBACs at all, resulting in a HUGE reduction in the overall VBAC
rate for the United States. 90% of women who have had a Cesarean will have a Cesarean for every
future pregnancy (American Pregnancy Association, 2015). While we are not quite back to the “once a
Cesarean, always a Cesarean” mentality, we are too close for comfort.

The anti-VBAC mentality, the increased cost of benefits for providers and hospitals, and the convenience
of Cesareans, has created a C-section epidemic in our country. Some providers and hospitals in this
country have a 60%+ C-section rate. Into the 2010s, more than one out of three women in this country
will have a C-section (Martin, Hamilton, Osterman, Driscoll, & Drake, 2018).

Women of Color

You might be surprised to know that we, as Caucasian doulas from predominantly Caucasian Utah, have
encountered racism directed towards our laboring clients. In addition to that, as we keep digging into
VBAC and the issues surrounding it, the more
we learn about the unique challenges that face
Women of Color.

1. The VBAC Calculator is Biased Against

Race
The VBAC Calculator is a collection of data from
7,600 women who had a TOLAC (ACOG, 2017).
It calculates any woman’s chance of success
against that data. There are several data points used for the calculation including maternal age, BMI,
reason for past C-section, if there has ever been a vaginal delivery before and/or after the C-section, and
race. Yep, Race. Being African-American or Hispanic decreases your chances a LOT. Go ahead and play
around with it at bit.ly/vbaccalc. Enter your information and then check and uncheck the boxes asking

Page | 33
about race and refresh to get an updated calculation. When I put my information in and adjust only the
race options, it drops my predicted chances by 19%, and I have already had three VBACs.

The unfortunate thing is that a lot of providers will not support VBAC if someone’s predicted success
rate is less than 70%. That pretty much rules out most Women of Color for VBAC (really, you NEED to
play around with the VBAC calculator). The good thing is, ACOG states that a predicted success rate of
less than 70% is not a contraindication for TOLAC.

Julie’s very first VBAC client, who just happened to be Hispanic, had a predicted success rate of just 4%,
yes FOUR. She pushed her baby out in 20 minutes. Take that, VBAC calculator!

2. Women of Color are Significantly More Likely to Have a Cesarean Birth and Even Die During
Childbirth
Racism during childbirth is not limited to just VBAC. Women of Color are twice as likely to have Cesarean
births and are 3-4 times more likely to die during childbirth (Perry, 2016). These numbers hold true
despite education level, income level, or socioeconomic status. This. Is. Not. Okay.

Julie had a client early this year whose first language was Spanish. She was born in Mexico, as was her
husband. They both understood and spoke English very well. When they got to the hospital, the nurse, a
white woman, mid to late 50s, would only speak to her in a slow and loud tone asking questions
followed by, “Do you know what that means?”. However, that was much better than when she started
using broken Spanish to try to talk to the birthing couple so that Julie couldn’t understand what she was
telling them.

Sadly, this was one of her most educated and intuitive clients. She was judged immediately by the color
of her skin and her accent, and, as the birth went on and some unexpected things happened, all the L&D
and even postpartum staff were very vocal on blaming this mother for “endangering her baby” and for
“listening to her doulas medical advice” when her doula never once offered anything resembling
medical advice. Assumptions were made. Incredibly incorrect assumptions took a heavy toll on this
mother’s heart--all due to her race.

3. Women of Color Are Significantly Less Likely to Have a Successful VBAC

In an analysis of over 100,000 births, this study shows that white, non-Hispanic women are almost 10%
more likely to have a successful VBAC than black, non-Hispanic women (Holland, et al., 2006). Again,
these outcomes are despite education level, income level, or socioeconomic status. Sadly, these

Page | 34
numbers are similar among various studies and time frames for the last 20 years. Women of Color in the
Southern parts of the United States have the highest chances of Cesarean birth and lowest chances of
VBAC while women in the Northeast see less of a racial disparity.

Four Main Reasons for Initial Cesarean and What to Know

There are four common reasons that women have initial cesareans. Just because they are common,
does not mean they are always unnecessary, but sometimes they are. There are also many other
reasons that a woman may need a C-section that are not included here. The best way for you to
determine what your C-section was for is to contact the medical records office at the hospital where you
birthed and make a request. It is not uncommon for the reason noted in your operative report to be
different than what you were told. Knowing what is in your operative report can help you better prepare
yourself with the information listed here:

Failure to Progress

Historically, evidence has shown that many care providers do not give women the chance to progress in
the first stage of labor (dilated to 10cm) or enough time to push the baby out when they do get there. In
2011, ACOG and SMFM (the Society for Maternal-Fetal Medicine) put out an updated definition on time
limits for the first and second stages (the pushing stage) of labor. The new guideline says that a woman
is not considered to be in active labor until six centimeters and cannot be termed as “failure to
progress” until she is at least six centimeters dilated, her waters have ruptured, and no cervical change
has been made in six hours of labor (ACOG, SMFM, 2014).

For the second stage of labor, there is no time limit for pushing the baby out and pushing can continue
for up to three to four hours as long as mom and baby are stable. Many women certainly had their
primary Cesareans because their care provider did not give them enough time to labor or push (ACOG,
SMFM, 2014).

Labor progress is not just about cervical dilation either. Labor progresses through these six stages:

● The cervix moves from posterior to anterior position

● The cervix ripens and softens
● The cervix effaces
● The cervix dilates

Page | 35
 ● The baby’s head rotates, flexes, and molds
● The baby descends, rotates further, and is born

A mother’s emotional state and ability to cope with physical discomforts also plays into the body’s
ability to labor effectively.

Fetal Heart Problems

In a hospital setting, continuous fetal monitoring is usually a requirement for VBAC women, and in about
70% of rupture cases, EFM has picked up an abnormal heart rate pattern that can suggest separation of
the scar (ACOG, 2017). However, it is also
normal for the heart rate to fluctuate outside
of normal readings. A heart rate dropping
several times or one that drops and doesn’t
recover may be resolved by simply changing
positions to adjust baby’s position in relation
to the cord.

Malpresentation (Baby in Wrong Position

or Breech)

There are many things that can be done to ensure baby is in a good position prior to labor starting and
to get baby in a good position during labor. Things like getting on your hands and knees, squatting, not
laboring on your back, and being mobile help significantly. Your doula should have a rebozo that can
work magic on a baby’s position. In 2018, ACOG released Committee Opinion 745 on breech
presentation and it states:

“There is a trend in the United States to perform Cesarean delivery for term singleton fetuses
in a breech presentation. The number of practitioners with the skills and experience to
perform vaginal breech delivery has decreased. The decision regarding the mode of delivery
should consider patient wishes and the experience of the healthcare provider. Obstetrician-
gynecologists and other obstetric care providers should offer external cephalic version as an
alternative to planned Cesarean for a woman who has a term singleton breech fetus, desires a
planned vaginal delivery of a vertex-presenting fetus, and has no contraindications. External
cephalic version should be attempted only in settings in which Cesarean delivery services are

Page | 36
 readily available. Planned vaginal delivery of a term singleton breech fetus may be reasonable
under hospital-specific protocol guidelines for eligibility and labor management. If a vaginal
breech delivery is planned, a detailed informed consent should be documented—including
risks that perinatal or neonatal mortality or short-term serious neonatal morbidity may be
higher than if a Cesarean delivery is planned.” (ACOG, 2018)

Macrosomia (Big Baby) or CPD (Small Pelvis)

A ‘big baby’ is defined as a baby who is more than 9 lbs., 15 oz. Macrosomia, literally meaning “big
body”, is when a baby is born weighing 11 pounds or more. 16% of indications and 9% of C-sections are
due to suspected big babies, when in reality, only 1.7% of babies are born bigger than 9 lbs., 15 oz.
According to the 2010 National Vital Statistics, the average weight of suspected big babies was 7 lbs., 13
oz (Declerg, Cheng, & Sakala, 2018).

But don’t take our word for it. We LOVE the article Dr. Mazumdar, MD (2016) wrote defining everything
in layman’s terms and spelling out the truth about small pelvises and big babes. He states:

“Diagnosis of CPD is very difficult. This is because it is difficult to estimate exactly how much
the mother’s ligaments and joints will ‘give’ or relax before labor starts. The fetal head also
has a great capacity to mould - the skull bones can overlap to some extent and decrease the
diameter of the head. So, a baby who appears to be too big to pass through its mother’s birth
passage before labor, may do so without much problem when active uterine contractions
start.

A ‘trial of labour’ should always be given to all women with average-sized pelvis and an
average-sized fetus even if the pelvis appears apparently too small for the baby.”

When a provider tells a woman that her pelvis is too small, he is referring to CPD, which stands for
Cephalopelvic Disproportion. Actual CPD is actually incredibly rare and very hard to diagnose; it is very
discouraging for women, and more often than not, leads to a woman having repeat C-sections for her
subsequent pregnancies. The pelvis is able to mold during labor and, when laboring on positions other
than your back, can expand by up to 30%.

If your client has EVER been told her pelvis is too small to birth a baby, or that she makes babies too big
for vaginal birth, she NEEDS to read this article gynaeonline.com/cpd.htm and have an educated

Page | 37
conversation with her provider. The exception to this would be if your client has diabetes, type I or II or,
gestational diabetes. If either of these apply, we recommend having your client talk with their provider
to find a birth plan conducive with her specific circumstances.

Things you can do if your client has had a diagnosis of CPD

We know that CPD is hard to actually diagnose; however, women are told that their pelvises are too
small all the time. We have heard it repeatedly. Encourage your client to get her OPT reports from her
previous Cesarean section(s) to see what is written in there. Some women are not told that they have
CPD and the provider states they have CPD in the OP report.

CPD or not, how do we help our clients when they are having a baby that is not engaging well, meaning
that the station of the baby is still -3 or -2? Here are some techniques you can share with them:

• Abdominal lift
• Sit on birthing ball and do rapid hip circles
• Dip the hip
• Walchers, opening the brim
• Open the knees
• The Miles Circuit

Ultimately, finding out what position the baby is in may help you know what steps to suggest. Giving
time to rest and descend may also allow for the baby to rotate and engage on its own without the mom
having to use all of her energy pushing. For more information, check out this website:
https://spinningbabies.com/start/in-labor/engaging-baby-in-labor/

Encouraging your clients to get their Cesarean operative report(s) by contacting the records office at the
hospital they delivered at will help them understand what the actual diagnosis for their Cesarean was. It
is not uncommon for the reason on the OP report to be different than what they were told at the time.
We have included a worksheet on the next page for you to help your clients decipher what is in their
report.

Page | 38
Page | 39
Uterine Rupture

Up to 80% of women who attempt a VBAC will be successful, and VBAC is generally associated with
fewer complications than a repeat Cesarean. The biggest risk and the most influencing factor for VBAC is
uterine rupture. A uterine rupture is defined as a tear through all three layers of the uterine lining.
However, uterine rupture can even occur in women without a prior Cesarean, albeit not as likely
(0.07%), or one in 1,146 pregnancies (Nahum, 2018). When a uterine rupture happens, it is critical that
the baby is born immediately, typically by a repeat Cesarean.

Uterine Rupture vs. Uterine Window and Dehiscence

Uterine rupture is rare, although it does happen; uterine dehiscence is often mistaken and classified as a
uterine rupture. Uterine rupture is when the uterine scar completely opens along the scar going through
every single layer of the tissue. A dehiscence
is when a very small amount of the scar
begins to separate but doesn’t quite make it
the entire distance. A uterine window is when
the scar is so thin that you can see through it
but it does not tear or open. After a Cesarean,
our bodies heal and create scar tissue. That
scar tissue is not as stretchy as our original
tissue, but it still has the ability to stretch.

Uterine Window
As a baby grows, the uterus stretches and can become thin. In order to know if there is a uterine
window, a Cesarean would need to be performed or an ultrasound may show the thinning. A provider
would be able to tell during the Cesarean because of how thin it would look. Evidence has not shown
thus far if a uterine window is an indication that a rupture would be more likely or not. A lot of parents
will likely go on and VBAC without knowing if their uterine lining ever was thin.

Uterine Dehiscence
There are three layers to the uterus. If the uterine scar opens partially, stretching the scar tissue and
opening the bottom layer, this would be classified as a uterine dehiscence. Uterine dehiscence is often
harmless and doesn’t have any harmful effects on the baby or the mother.

Page | 40
A 10-year Canadian study was done on full uterine rupture vs. uterine dehiscence. Over the 10 years,
there were 114,933 deliveries with 39 cases of uterine rupture: 18 complete and 21 incomplete, or
dehiscence (Kieser & Baskett, 2002). Uterine dehiscence did not have any fetal deaths. Uterine rupture
is a scary topic for providers. It can often be hard for women to be able to find a supportive provider for
VBAC due to this fear.

How to Determine Uterine Dehiscence

As with the uterine window, a repeat Cesarean would need to be performed in order to confirm uterine
dehiscence. Historically, providers would explore the uterus more during a Cesarean to see if there were
any other tears, but currently that practice is not likely to happen. Taking the mother’s pulse rate
carefully and consistently during labor may be the only sign that uterine dehiscence is happening or has
happened. When the scar tissue starts to separate, fluid can enter the body cavity and leak into the
membrane that separates the organs from the cavity wall. When this happens, the body reacts with
shock and the mother’s heart rate may increase dramatically.

In the same 10-year study, in 92% of cases, uterine rupture was associated with previous Cesarean
delivery (Kieser & Baskett, 2002). Uterine dehiscence was associated with minimal maternal and
perinatal morbidity.

Length of Time Between Pregnancies

We hear from a lot of people who want to know when they can get pregnant again after their C-section
in order to have a VBAC. There are plenty of recommended lengths of time out there, and it seems that
every doctor has their own recommendation for when they will or will not “allow” VBAC, based on how
far apart the C-section and next pregnancy are. But what does evidence say?

In a study investigating whether or not short- or long-term pregnancy intervals increased or decreased
chances of uterine rupture, it shows that any length of time six months or longer between pregnancies
has no impact on increased risk for uterine rupture. In other words, if it is six months or more from the
time of the C-section to conception, there is no increased risk of rupture. Six months between
pregnancies is 15 months between births. With pregnancies less than six months apart, the risk of
rupture doubles or triples to roughly 2.2% (Stamilio, et al., 2007); however, this does not automatically
exclude someone from VBAC. It just means that the risk is higher, and, if that is an acceptable risk for
your client, you can encourage her to look for a provider who is comfortable with that risk as well.

Page | 41
Putting Uterine Rupture into Perspective

Statistically, uterine rupture happens in 0.4% of TOLAC (Motomura, 2017). That equals one in 240. Now,
as will all things, probability should be considered and assessed. When uterine rupture does happen,
most of the time it is quickly detected and a provider is able to get the baby out quickly (usually by
repeat Cesarean) before any long-term damage happens to the mom and/or baby. In fact, only 6% of
uterine ruptures are complete or catastrophic.

“The overall risk of perinatal death due to uterine rupture was 6.2 percent. The two studies of
women delivering at term that reported perinatal death rates report that [less than] 2.8
percent of all uterine ruptures resulted in a perinatal death.” (Guise, et al., 2010)

To put it differently, of the women who had a uterine rupture, one in 16 resulted in infant death. When
looking at the overall chances of infant death when attempting a VBAC, the National Institute of Health
(NIH) reports the odds as 0.13%, which ends up being one infant death in every 769 TOLACs. For
comparison, the average neonatal mortality rate for the U.S. in 2014 was 5.8 per 1,000 births (Kaiser
Family Foundation, 2017). That’s one in approximately 172.

Just for fun, and because Julie is a statistics geek, let’s take a look at some things more likely and a little
bit less likely to happen than a uterine rupture:

• One in 160 - Chance of having a heart attack each year (CDC, NCHS, 2015).
• One in 216 - Chances the person you are dating is a millionaire (Baer, 2003).
• One in 4 - Chances of your death being due to heart disease (CDC, NCHS, 2015).
• One every 18 years - How frequently you will be in a car accident (Property Casualty Insurers
Association of America, 2018).
• One in 30 - Odds of conceiving twins (Martin, Hamilton, Osterman, Driscoll, & Drake, 2018).
• One in 300 - The risk of cord prolapse (Lore, 2018).
• One in 160 - Odds of being audited by the IRS (Heath, 2018).
• One in 199 - Odds of falling to your death (McCarthy, 2018).
• One in 14 - Odds of having your identity stolen if you are 16 years or older (Matko, 2013).
• One in 100 - Odds of dying from an obesity-related conditions (Allison, Fontaine, Manson, &
Stevens, 1999).
• One in 38 - Chance of developing melanoma (American Cancer Society, 2018).

Page | 42
Reducing the Risk of Rupture

There are a lot of things that can be done to minimize the chances of uterine rupture during TOLAC. It is
important for the mother to discuss these things with her provider and have a solid plan ready if any
interventions are necessary.

● Stay away from induction unless absolutely necessary.

● Avoid augmentation of labor (something to stimulate contractions, usually Pitocin).
● Avoid excessive Pitocin and upping the dose too fast.
● Avoid Cytotec (misoprostol) COMPLETELY.
● Avoid providers who aggressively intervene with and manage labor.
● Encourage her to stay mobile. Walk, change position and posture when in active labor.
● In early labor and if labor stalls, encourage her to rest or sleep.
● Do EVERYTHING you can to make sure the baby is in the most optimal position BEFORE labor
begins.
● IF baby is not in a great position and labor stalls or there are signs of labor: try spinning babies,
MILES circuit, abdominal lifting, side lying, or get her on hands and knees to try and help baby
settle into a better position.
● Avoid rupturing membranes if baby is not in optimal position.
● Avoid an epidural if possible.
● Be attentive and aware of what is going on in the birth space ALL THE TIME.
● Be aware of typical labor patterns. Any stalls in labor are usually indicative that something needs
to change (emotional processing, baby position, rest/sleep, and even Pitocin in some instances).
Figure out what needs to change and fix it if you can. A long stall combined with high doses of
Pitocin is a prime scenario for uterine rupture.
● HONOR YOUR CLIENT’S INTUITION. If she feels that something is not quite right or if baby’s
movement is significantly decreased, insist that the provider or their staff pay attention. In many
instances, uterine rupture occurs when a mother knows something is wrong intuitively before
providers pay sufficient attention.

VBAC vs. Repeat Cesarean

The most controversial risk for VBAC is potential uterine rupture (which we discussed in the previous
section), but unfortunately, many providers do not go into detail on the risks of repeat Cesarean.

Page | 43
Risks for Baby

Babies born by scheduled Cesarean are more likely to be born pre-term, with breathing problems, have
fetal injury (1.5 babies per 100 will be cut during the surgery), and/or need admission to the NICU. Due
to separation immediately after birth and delay of skin-to-skin contact, maternal attachment may be
delayed and breastfeeding issues can arise
(Jukelevics & Wilf, 2009).

More and more studies are showing that,

while passing through the birth canal, babies
receive microorganisms from their mothers
that play a huge role in developing their
immune systems. These microbiomes are
essential to overall health and well-being.
They also assist in the production of vitamins
and anti-inflammatory substances. These substances play an important role in protecting against
autoimmune diseases and other chronic illnesses (Proctor, 2013).

Risks for Mother

“Although Cesarean delivery can be life-saving for the fetus, the mother, or both in certain cases, the
rapid increase in the rate of Cesarean births without evidence of concomitant decreases in maternal or
neonatal morbidity or mortality raises significant concern that Cesarean delivery is overused. Therefore,
it is important for healthcare providers to understand the short-term and long-term tradeoffs between
Cesarean and vaginal delivery, as well as the safe and appropriate opportunities to prevent overuse of
Cesarean delivery, particularly primary Cesarean delivery.” (ACOG, SMFM, 2014)

Most of the risks of a repeat Cesarean for the mother are the risks for any kind of major abdominal
surgery. Here are the risks and statistics associated with a second Cesarean:

● Infection of the incision, the uterus, bladder, or other pelvic organs.

● Hemorrhage. There is more blood loss with Cesarean delivery and chances of hemorrhage; six in
100 women require a blood transfusion.
● Injury to organs happen to one in 50 women.
● Adhesions (scar tissue causing pain, blockages, or future pregnancy complications).

Page | 44
Page | 45
 ● Longer hospital stays and recovery time.
● Higher risks of additional necessary surgeries like hysterectomy and other Cesareans.
● Higher maternal mortality rates (Jukelevics & Wilf, 2009).

We often only talk about uterine rupture during labor and wrongfully assume by choosing elective
repeat Cesareans, we can eliminate any chance of uterine rupture. Although focus is usually on uterine
rupture during labor, it is possible for uterine ruptures to occur before labor even begins. These types of
uterine rupture are usually more devastating and can cause serious health complications or worse in
mother and baby. It is NOT true that deciding against a VBAC means that you won’t have any risk of
uterine rupture. In fact, occasional studies have even found a higher rate of rupture in the elective
repeat Cesarean groups. Keep in mind that it is the PREVIOUS CESAREAN that puts you at risk for uterine
rupture, NOT attempting VBAC.

The Infamous VBAC Calculator

Your client’s care provider might refer to a predicted chance of having a successful VBAC. This prediction
is attained using a VBAC calculator. The calculator uses data such as age, BMI, ethnicity, history of
obesity, and reason for prior C-section to spit out an estimation of a woman’s chances, based solely on
statistical data. Sometimes, on admission to the hospital for delivery, an additional calculator is used to
take into consideration cervical changes and any pregnancy complications. The calculator is based on
data from 7,000 TOLACs in the United States with one Cesarean and a low transverse scar (National
Institute of Child Health and Human Development, Maternal-Fetal Medicine Units Network , 2007).

In a nutshell, the “chances” drop for an older mother, with a BMI higher than 30, with any ethnic
background, and if the prior C-section was labeled failure to progress or failure to descend. This
calculator obviously has its limitations and should not be the sole decision-maker regarding a woman’s
attempt to VBAC. A more important thing to do would be to suggest to your client that she have an
educated conversation with her provider about her medical history, past birth experience(s), her incision
type, and plans for her family size. One of our favorite VBAC stories is one of a client that was given a 4%
chance at success by the calculator. She ended up pushing her baby out in twenty minutes.

Curious about the numbers? Play around with the calculator here: bit.ly/vbaccalc

Page | 46
Special Circumstances

Anterior Placenta and VBAC

When the egg implants into the uterus, typically it implants on the back (posterior) side. Wherever the
egg implants is where the placenta will grow. An anterior placenta happens when it implants on the
front side, the side against the belly of the mother, and is a perfectly normal place for the placenta to
grow. Having an anterior placenta does not automatically exclude a person from VBAC, however; at the
20-week anatomy scan, there are a couple things the care provider will look at to make sure it doesn’t
interfere with a vaginal delivery.

The main concern with an anterior placenta is making sure it has implanted far away from the previous
Cesarean scar so that it is not likely to grow into or over the scar as it grows. At the 20-week growth
scan, a sonographer will measure how high above the scar the placenta lies. As long as the bottom of
the placenta is more than 2cm above the scar, it is typically good to go. If it is less than that, the provider
will likely want to do another scan around 30-32 weeks gestation to make sure everything is growing in
an uncomplicated way.

If the placenta grows into the scar (Placenta Accrete), or partially or fully covers the cervix (Placenta
Previa) an early, repeat Cesarean delivery is typically necessary. Good news though: as the baby and
belly grow, the placenta grows upwards, so even with a lower-lying placenta, it is likely there will be no
issues as it gets closer to delivery day.

If your client has a special scar AND an anterior placenta, she is at a higher risk for placenta
complications and careful consult with a specialized provider would be necessary, but should not
automatically rule out VBAC.

Additional facts about anterior placentas:

• Typically, it will take longer for her to feel baby’s movements, especially on the outside as the
placenta essentially shields his/her kicks.
• It will be harder to find the baby’s heartbeat, mainly in the first trimester.
• It can interfere with medical procedures such as amniocentesis.
• An anterior placenta can cause your client to feel labor more in her back if it hasn’t moved up
high enough late in the pregnancy, especially if the baby is posterior.

Page | 47
VBAMC

VBAC after two or more Cesareans is often considered significantly higher risk by care providers. Here is
what the evidence says:

Chances of a successful VBA2C are similar to those of VBAC after just one Cesarean.
On page four of ACOG Practice Bulletin 184, two large studies are referenced. These studies had sample
sizes large enough to account for small variances that might influence the results. It is significant for
ACOG to recognize studies like this as credible. In other words, the fact that they are even cited there is
wonderful. The results of those two studies, referenced in the bulletin, concluded that the success rates
vary by 2% or less, depending on which study you look at (ACOG, 2017).

ACOG recommends VBA2C as a safe option.

Speaking of ACOG...since 2010, their stance on VBA2C is that it is “...reasonable to consider women with
two previous low-transverse Cesarean deliveries to be candidates for TOLAC and to counsel them based
on the combination of other factors that affect their probability of achieving a successful VBAC” (ACOG,
2017). It is important to note is that there is no mention of a requirement to have had a prior vaginal
delivery to be considered. If your client is preparing for VBA2C, this bulletin is very important to have in
her back pocket as she works with her provider to determine birth options.

The risk of rupture for VBAMC is incredibly low.

The limit of most VBAMC research is that almost no studies have controls for Pitocin/other drug use,
and this may well be a significant factor. Although there is still some debate, uterine rupture rates may
be somewhat higher in VBA2C when Pitocin or multiple induction agents are used. Nearly all VBAMC
studies analyzed aggressively used Pitocin, etc. for 50% or more of their participants. It is therefore
impossible to know what the true underlying rate of rupture in VBAMC may be. Although hard data is
lacking, it seems likely that the average VBAMC rupture rate of 1.4% found in the ACOG bulletin could
probably be drastically reduced by inducing less, inducing only when the cervix is ripe, when induction is
truly necessary, and using drugs and interventions a lot less (and much more judiciously when they are
used).

Page | 48
Special Scars

Most Cesareans are performed using the low transverse incision. It is horizontal in the lower part of the
uterus. Because it cuts through horizontal muscles, it tends to stretch more. However, in some
instances, other incision types are used. In many circles, this is automatically considered a
contraindication to VBAC—but, in many cases, women go on to have successful VBACs even with a
special scar, and the chances for rupture are only slightly higher than with a low transverse scar. There
are three types of scars deemed “special scars.”

Low Vertical- A low vertical incision is also made in the lower part of the uterus. These incision types are
used when the baby is large, transverse (sideways), or for placenta previa. Your physician will probably
want to see a copy of your OP report and see how high into the uterus your scar extends. If it extends
far enough up, it might increase the chances of rupture. In the cases of a premature delivery, it is likely
to extend higher. Current ACOG guidelines, as we talk about in the next section, allow for TOLAC with a
low-vertical incision.

Inverted T and J: These scar types happen when a surgeon needs more room to get the baby out after
they have done a low transverse incision. Sometimes they happen on accident as well. These scar types
are rare.

Page | 49
Classical: This vertical incision is in the upper part of the uterus and is sometimes used for transverse or
breech babies, for premature babies, or for Cesareans that need to be done rapidly and/or in an
extreme emergency. The upper part of the uterus is thicker and does more contracting. When classical
scars rupture, they tend to do so a lot faster and with more damage to the uterus.

Unknown Incision Type: Sometimes women are not told what type of scar they have and are not able to
get a copy of their OP report. In these instances, knowing the reason for the Cesarean and, by looking at
the incision on the skin, a provider can usually determine what type of scar is likely. Some studies have
been done that show no increase of rupture rates when women with unknown scars labor, likely
because most of them are low transverse scars.

Studies show that women laboring with special scars have virtually no increased risk of rupture (Goer &
Tomano, 2012). In ACOG’s 2017 Bulletin, they do not recommend TOLAC for those with classical or T or J
scars; however, low vertical scars are okay. They do specifically note that “individual circumstances must
be considered in all cases” (ACOG, 2017). Find more information on the website specialscars.org.

ACOG Bulletin #184

ACOG, or the American College of Obstetrics and Gynecologists, was founded in 1951 with the sole
mission of improving women’s health in the United States. It is a professional membership organization
with over 58,000 members as of 2017. ACOG fellows are practicing, licensed, and board-certified
OBGYNs and have attained high ethical and professional standing. ACOG is the organization that sets the
recommended guidelines for maternity care in the United States. You can learn more about ACOG and
its mission at www.acog.org. Here is what they have to say about VBAC in their 2017 Practice Bulletin
184:

● “The preponderance of evidence suggests that most women with one previous Cesarean
delivery with a low-transverse incision are candidates for and should be counseled about and
offered TOLAC.”
● Recommendations for and against VBAC are given, but there is no blanket statement defining
what is or is not “allowed.” ACOG also adds that individual circumstances should be
considered. This is important to remember and discuss with your provider because VBAC
qualification is not a checklist but rather a discussion including many variables. The provider
consults, the MOTHER decides.

Page | 50
 ● “…The balance of risks and benefits appropriate for one patient might not be acceptable for
another…The decision to attempt TOLAC is a preference-sensitive decision, eliciting patient
values and preferences is a key element of counseling.” We have often heard providers make
recommendations or even policies claiming what THEY or their wives would do, but the ultimate
decision should be the patient’s.
● ACOG counsels on family size when they state that making “decisions regarding TOLAC should
consider the possibility of future pregnancy.” They discuss the risks with repeat Cesarean
almost right off the bat.
● When referencing the VBAC calculator, “[A] predicted success rate of less than 70% is not a
contraindication to TOLAC.” It also focuses on how population-based statistics cannot
accurately predict a person’s personal chances of VBAC success. It is ill-advised to use statistics
as a primary indicator when making VBAC decisions.
● Things that are NOT contraindications to VBAC include suspected big baby, going beyond 40
weeks, short intervals between pregnancies, having a classical or unknown scar type,
expecting twins, or having a high BMI. These things do not automatically exclude women from
TOLAC.
● “Available data confirms that TOLAC may be safely attempted in both university and community
hospitals and in facilities with or without residency programs”; “Trial of labor after previous
Cesarean delivery should be attempted at facilities capable of performing emergency
delivering…women attempting TOLAC should be cared for in a level I center (one that can
provide basic care) or higher. Level I facilities must have the ability to begin emergency
Cesarean delivery within a time interval that best considers maternal and fetal risks and benefits
with the provision of emergency care.” This references rural hospitals and any other VBAC bans.
Also, they stated that having an anesthesiologist “immediately available” is ideal, but not a
requirement for TOLAC.
● “Respect for patient autonomy also dictates that even if a center does not offer TOLAC, such a
policy cannot be used to force women to have a Cesarean delivery or to deny care to women
in labor who decline to have a repeat Cesarean delivery.”

The full the full bulletin can be found in the materials accompanying this manual. This is great to bring
with you to your prenatal appointments to discuss evidence-based VBAC recommendations.

Page | 51
Contraindications for VBAC

Sometimes a VBAC is not an option due to medical reasons. We discuss recommendations by ACOG in
the next section, which states that in most circumstances, the ultimate decision for VBAC should be
made by the birthing woman. However, there are some very specific things that make a vaginal birth
very difficult or impossible. The following are the contraindications listed by ACOG:

● Previous classical or “T” incision

● Previous uterine rupture
● Excessing trans fundal uterine surgery
● Any contraindication for vaginal delivery in general (i.e. placenta previa, transverse baby, etc.)

That’s it. Even then, with incision type and history of uterine rupture, your specific circumstances may
be deemed eligible of a TOLAC by the right medical professional.

Lastly, we want to reinforce that there is no one right way to birth. If, for whatever reason, your client
does not feel comfortable choosing VBAC, honor her choice, encourage her to trust her intuition, and
assist her as she pursues a different plan for her birth.

Quick Review

What happened in the 1990s to cause a backlash towards VBAC?

What are some risks for VBAC?

What concerns are there for an Anterior Placenta and VBAC?

Page | 52
What are some risks for repeat Cesarean?

Is the VBAC calculator a good indicator for chances of having a “successful” VBAC? Why or why not?

Page | 53
VBAC Story: Karina
At 35 weeks, I had a growth scan done with Maternal Fetal Medicine (MFM), due to Type 1 Diabetes,
and they said she was around eight lbs., 11 oz. Two different MFM doctors told me that I should have a
repeat C-section, especially since my first baby was eight lbs. 13 oz. and had shoulder dystocia. On top of
that, baby girl was breech and she would more than likely be bigger at delivery if I went to 40 weeks
around August 28, 2016.

After two weeks of prodromal labor and an external cephalic version to turn baby girl head down (since
she was breech), my birthing time had finally arrived at 36 weeks, five days.

Contractions started on August 5, 2018 around 9:00 a.m. My contractions were getting a lot stronger
now and I started losing my mucus plug. I tried sleeping through the contractions, because that was the
only way they would stop the previous two weeks, but now they were waking me up. Around 7:00 p.m.,
the contractions got more intense and closer together. My husband, Chase, and I decided it was time to
leave for our pre-birth place, Little America, and call our doulas and birth photographer. Being a VBAC,
we wanted to labor somewhere closer to our hospital in case anything happened, but not at the
hospital, so I wouldn’t be disturbed. Little America also had great tubs!

When we arrived at Little America, I waited in the car while Chase got the keys to our room. The
contractions were pretty strong now. Once we got up to our room, he filled up the tub for me and I
labored there while my birth team arrived. After laboring for six hours at Little America, I was getting
tired and things seemed to be moving slowly, so we decided to go to the hospital to see what was
happening and decide our game plan from there.

We arrived at St. Mark’s Hospital and walked to Labor & Delivery, stopping every so often to breathe
through the contractions. They took us to room 13. I let the nurse do a cervical check, but told her not to
tell me what I was. I found out later that I was 5cm and 100% effaced.

We talked about breaking my water because of my polyhydramnios and thought it might help speed
things along. After three more hours, I decided to let them break my water, because I was getting
exhausted. My doctor, Dr. Edmunds, did a cervical check at the same time and discreetly told Chase
what I was (6cm).

The contractions were so intense and it felt like it was taking FOREVER! I went to the bathroom and
before I sat on the toilet, another contraction came. This one felt different and I started pushing at the

Page | 54
end of it. As I was on the toilet, my nurse said I needed to come to the bed after I was done so that I
didn’t have my baby in the bathroom. I went to the bed and hung over the back of it while on my knees.
The nurse checked my cervix and told the room I was 8cm. She probably forgot that I didn’t want to
know, and I was so mad that I was only an eight!

My doulas had me get on my hands and

knees, hanging over the bed again so they
could provide counter pressure. A lot of these
contractions felt like I needed to push now,
so I did. I’m not sure when Dr. Edmunds came
in, but he came in and checked me and I was
finally 10cm. I just pushed when I needed to
and rested in between contractions. My arms
were feeling very tired and shaky, so my birth
team convinced me to lie down on my left side and continue pushing that way. I plopped down, I was so
tired. My butt was basically hanging off the side of the bed, but Dr. Edmunds was fine catching in that
position. I pushed a couple more times before baby girl came out. Her body felt massive coming out,
much bigger than my first baby. Baby girl was born at 7:28 a.m. on August 6, 2016, via an un-medicated
VBAC, weighing nine lbs., 10 oz. and 20 inches long. She was only four oz. lighter than my C-section baby
and almost a whole pound heavier than my baby that had shoulder dystocia!

Page | 55
 IV. VBAC BIRTH TEAM AND BIRTH PLACE OPTIONS

C
hoosing a VBAC or repeat Cesarean is a personal decision and ultimately should be made by the
birthing woman and her family after considering ALL the risks for each path and based on the
unique circumstances of her previous birth(s). Help her evaluate and navigate through her
desires and fears and what motivates HER. Weigh the benefits and risks based on her specific needs and
circumstances. Consider the advice of her providers, but remember that each provider differs,
sometimes drastically, in their support, knowledge, and how they approach VBAC; because of this, they
may not be up-to-date with current recommendations and guidelines. Moving forward, seek out the
current recommendations and research with her, encourage her to talk to several providers, and get
their opinions until she finds one whose knowledge and philosophy align with hers, weigh the potential
risks and benefits, and remind her to check her own intuition to decide what is best for HER and HER
family.

Policies Surrounding VBAC

As a doula, it is important you know what VBAC policies providers and locations have so you can prepare
and support them in an educated way. Generally, the more VBAC policies a provider and location have,
the less VBAC supportive they will be. Some of the VBAC policies you need to know about, and may
experience are listed below.

Continuous Fetal Monitoring- In 70% of rupture cases, an abnormal heartbeat of the baby was one of
the first signs (Guise, et al., 2010). While intermittent monitoring may be an option in some birth
locations, a hospital is likely to require your client to be constantly monitored. Good news is, most
hospitals have wireless and even waterproof monitors so she can remain mobile and even labor in the
water if she’d like. Encourage her to find out about options for wireless, waterproof monitors ahead of
time so you know what’s available.

Epidural Placement- Sometimes a provider or hospital might require an epidural to be placed but not
turned on in order to VBAC. The idea behind this is in the case of uterine rupture, they can quickly
administer the epidural and perform a Cesarean without having to put the patient under general
anesthesia, which is riskier. The problem with this logic is simple; during a catastrophic uterine rupture,
a baby needs to be out within 17 minutes in order to prevent brain damage or other serious
complications. To administer an epidural at the strength it needs to be for surgery, it takes 20-30

Page | 56
minutes, so the patient would need to be put under general anesthesia in order for them to not feel the
Cesarean anyway. The point is, this practice is simply not evidence-based.

VBAC Bans- We touch on this briefly in Section III about ACOG Bulletin 184. We love the updated version
on VBAC that came out in 2017 for many reasons, one of them being the clarification on a key phrase
that hospitals were misinterpreting and using as a reason to ban VBAC. The misinterpreted phrase was
that in order for a hospital to perform VBAC deliveries, they needed to have an anesthesiologist and
obstetrician “immediately available” which was misinterpreted to mean “onsite”.

The 2017 version of the VBAC bulletin clarifies that by stating that while having them onsite is ideal, not
having them onsite does not mean that a facility is unprepared to handle VBAC emergencies. In other
words: if a facility can perform typical vaginal deliveries and handle emergencies related to them, it can
handle VBAC and potential uterine rupture. Forcing a woman into a Cesarean is wrong, not giving her
the option to assume the risks she is prepared to take on is wrong. It will take time, but we believe this
attitude will spread and VBAC bans will no longer exist.

Saline Lock- Also known as a hep-lock, historically, is an IV catheter, placed in a vein in the arm or hand,
flushed with saline, and capped off in case an IV is needed later on in labor or birth. Most hospitals have
this as standard policy and are generally less willing to negotiate it for a VBAC mother due to the
possible need of having to immediately administer general anesthesia in the case of a uterine rupture.
As with all other birth options, the decision is ultimately your client’s. Talk with her and see if this is
something worth declining based on her circumstances.

Induction- Induction is a hot topic in the VBAC world. It is interesting what policies exist surrounding
VBAC and how a policy at one location can contradict a policy at another. As stated in Section V,
Mastering the Art of BRAIN, induction is a safe and reasonable option for normal VBAC pregnancies.
While Pitocin does increase the chances of uterine rupture slightly, it is still within the ACOG
recommended acceptable risk guideline. While it is ideal for labor to start on its own, when there is a
true medical need, induction is a safe option. The only contraindication for VBAC induction is using
Cytotec/Misoprostol for cervical ripening, more info on that in Section V as well. Some policies you
might encounter surrounding induction include:

• Providers or hospitals not willing to induce VBAC at all.

• Providers or hospitals that insist on induction at 39 or 40 weeks.

Page | 57
 • Not wanting to use a Foley bulb or IUPC for manual cervical dilation.
• Not using Pitocin to stimulate uterine contractions.

While these policies all have the intention of decreasing uterine rupture risk, they are simply not
evidence-based. If you encounter any of these policies, it would be wise to encourage your client to
have an open discussion with their provider and get a second opinion.

Water Birth- Very few hospitals allow water

birth at all, and typically do not allow for VBAC
women to birth in the water; however, we are
hoping that once water birth turns into a
common available option for hospitals, will
have fewer restrictions, and become available
to VBAC mothers.

VBAC Birth Locations

Hospital

Most women give birth in a hospital. In a hospital, they are cared for by several different types of
people, including nurses, technicians, medical residents, and in some cases, supervised medical
students. Women who have a great hospital experience usually describe it as being able to make
decisions for their care and the staff explaining everything that was going on. Women who have bad
experiences in the hospital usually say that they felt ignored, or mistreated, or felt like they were part of
a system and not allowed an individual experience. ACOG recommends hospitals for VBAC based on the
risk of catastrophic uterine rupture. Some hospitals may have VBAC bans despite ACOGs guidelines
against them.

Birth Center

For women in low risk pregnancies, using a midwife-based model of care in a birth center setting is an
option. Midwife-led care results in lower Cesarean rates, lower intervention rates, and great outcomes
for both mom and baby. In one U.S. study, out of 15,000 mothers, those using birth centers with
midwives had a 93% spontaneous labor and vaginal birth, 1% had an assisted delivery, and only 6%
needed a C-section. The neonatal mortality rate was one in 2,500 (Rutledge, Osborne, & Illuzzi, 2013).

Page | 58
More and more women are choosing this option because of the greater autonomy, more personalized
care, and more comfortable birth environment. If your client chooses a midwife and birth center,
encourage her to find out about any licensing, accreditation, and experience. Not all birth centers and
midwives are the same.

Home Birth

“In 2013, 1.4% of U.S. births took place outside of a hospital. Surprisingly, 64.4% of these occurred at
home. The number of women who gave birth at home, 36,080, was the highest since 1989 when
reporting of home births began” (Martin, Hamilton, & Osterman, 2015).

Home birth in general and especially home birth for VBAC, also known as HBAC, is growing in popularity.
A planned birth at home is at least as safe as a planned birth in a hospital, as long as four criteria are
met. These criteria are that:

• The woman has a low risk pregnancy

• Home birth was chosen, planned, and prepared for
• The care provider involved is qualified and trained in home births.
• A backup transfer plan is in place in case of emergency.

Sixteen years’ worth scientific studies on home birth gathered by the Coalition for Improving Maternity
Services Expert Work Group showed that, when compared to low risk women who plan a hospital birth,
low risk women who plan a home birth have similar or better outcomes with fewer medical
interventions and fewer Cesareans (Sagady & Romano, 2007). However, there are very few documented
and studied cases of VBAC at home in the United States to date, so there is not enough data to compile
showing an increased risk for VBAC women.

Ultimately the choice for birth location should be based on what makes a woman feel safe and is an
environment where she has confidence in her chosen provider. There are many things that can be done
to make a birth space more cohesive with any parent’s needs, no matter where that is. Some
suggestions include:

• Hanging up pictures or affirmations in the birth space

• Lighting candles (LED candles only for hospitals)
• Dimming the lights

Page | 59
 • Wearing her own comfortable clothes
• Creating a quiet space, or turning on their own music

Talk with your client to see what else she may want to implement for her birthing time.

Remind her that how and where she chooses to give birth is HER decision and she can find someone
capable of supporting her no matter what her desires are.

Choosing A Care Provider

Women with a prior Cesarean birth have a greater chance of achieving VBAC when they have 100%
support from their care provider and when their providers encourage and promote normal, physiologic
birth processes not involving unnecessary medical interventions. There are several options for care
providers based, of course, on birth location choice and include OBGYN, Hospital Midwife (CNM), or
home birth or birth center midwives.

Knowing what questions to ask potential VBAC providers can be frustrating, especially when they aren’t
sure if they are being honest or are just telling the mom what they want to hear. Below, we will suggest
some topics of discussion and then show you how to interpret their answers. We suggest you give your
clients these questions to ask their providers in your prenatal visit. This way, you’ll also know if that
provider truly is supportive.

Most importantly, while she is searching, it is important to make sure to ask open-ended questions. Any
provider can agree to any birth plan put before them initially but knowing how they personally feel
about VBAC and knowing what requirements they might have can let you know more about whether
they are VBAC-friendly or will just “allow” it if everything goes perfectly. Knowing what your client is up
against can help you know what to expect during labor and delivery.

The ideal is to find a provider who views vaginal birth after Cesarean as a normal process, who is not
afraid to support a woman preparing to VBAC, will only jump in with interventions when there is a TRUE
medical indication, and who the woman can form a great relationship with beforehand. Suggest
discussing VBAC and TOLAC in the provider’s office, across the desk from one another rather than in an
exam room in a gown. This puts a lot of power back in her court.

Page | 60
Here are some great questions to give to your client:

● How do you feel about supporting TOLAC/VBAC and how many of your patients who attempt
VBAC are successful?
● What are potential long-term and short-term risks of a repeat Cesarean for myself and my baby?
● If I have a repeat Cesarean, how will this impact future pregnancies and births?
● What requirements do you have to support a woman in TOLAC?
● What is your hospital policy surrounding VBAC?
● What do you consider as “absolutely necessary” reasons for a C-section?
● What do you and your hospital do to avoid patients having an unnecessary repeat Cesarean?
● Are there others in your practice who might be at my birth if you are not available? How do they
feel about TOLAC/VBAC?

Studies have shown that a mother would much rather her doula or support team be honest with her if
they know the provider is not supportive. This can put us doulas in a very difficult spot. It is so important
for you to be honest while not stepping outside of your scope. If your client asks you if that certain
provider is supportive and you have seen them not be supportive, be honest. Just keep it very
professional. It’s okay to say something like, “I have worked with VBAC women in the past and have
seen XYZ.” However, it is not your place to say, “YOU SHOULD SWITCH, RUN FOR THE HILLS, HE/SHE
SUCKS!” Stay professional by giving them these questions; it is a good way for them to interpret what
they think is best. If your client stays with an unsupportive provider, bring your ‘A’ game and make sure
to support them the best you can, because they will likely need it.

Interpreting Their Responses:

Now you have all these discussion points, what do you do with them? We have divided things into three
categories with suggestions on what to consider when evaluating the provider interview.

Their Personal History

The higher their VBAC success rates and lower their Cesarean rates, the better. You can start by getting
a good idea what those are by visiting Cesareanrates.org. This allows you to break down rates by state,
hospital, and provider. Knowing what the baseline is for your area is a great way to start off in
determining where her provider ranks. Ask for actual numbers here. Answers like, “I only intervene or
perform a C-section when absolutely necessary” might be a red flag if they are reluctant to share actual

Page | 61
statistics. Asking what their personal belief and philosophy is surrounding VBAC will give both of you a
great idea, and don’t let anyone tell her they will let her try. That itself is a giant red flag.

Their Requirements

Many providers have stipulations for allowing a woman to TOLAC. Some of these requirements involve
induction methods or even induction at all, giving birth by a certain gestational age, the reason for
previous Cesarean, and if they have ever had a vaginal birth. A provider that insists a VBAC client go into
labor before 40 weeks or she automatically
goes to a C-section is probably not VBAC-
friendly, for example. The more requirements
or policies a provider or birth place has for
VBAC, the less likely they are to be
supportive. Also, if they insist a woman’s
pelvis is too small or her baby too big, check
around and find a provider who practices evidence-based care. A VBAC should be treated as any other
type of birth, personal and unique, and not be given blanket requirements based on what may or may
not increase or decrease chances of success.

What Do the Others Think?

A lot of providers work in a practice with an on-call schedule. Just because one doctor in the practice is
VBAC-supportive does not mean that all of them are. Know if the doctor your client sees will be the one
at the birth, if they have any time off scheduled around her due date, and what the hospital policies and
the standard of the other providers they work with are. Knowing what the standard of care is for the
entire group may make her want to seek other providers if it is not in line with what HER provider does.

VBAC Supportive vs. VBAC Tolerant

Some doctors may appear to be VBAC supportive, but actions speak volumes. Here is a list of
characteristics that make a provider tolerant of VBAC, meaning that they allow VBAC if everything goes
perfectly, or supportive of VBAC, meaning they are up to date with evidence-based practices and really
support VBAC.

Page | 62
Lastly, if she ever finds herself in a position where she is faced with a birth space or birth provider who is
clearly unsupportive, she ALWAYS has the right to seek new care, even in the middle of her labor. We
know she likely has already hired you to support her, so there is evidence for doula support in labor. Dr.
John Kennell, who co-authored one of the first studies on continuous labor support, said in reference to
continuous doula support:

“If anyone said that a new drug or electronic device could reduce problems associated with
fetal distress and labor progress to a third, or even that it would shorten labor by half and
facilitate mother-baby interaction after the birth, there would be a stampede to make sure
this new drug or equipment was available in every maternity unit in the country, whatever
the cost involved.” (Kennel, Kalus, Robertson, & Hinkley, 1991)

Page | 63
Page | 64
Hiring a Doula

We think you are awesome. In addition to providing physical, emotional, and educational support, you
as a doula may help decrease the chance of a C-section by 39% (Dekker, 2017). It’s true. See why we
think doulas are awesome? We love the quote from Evidence-based Birth’s website that says:

“Advocacy is defined as supporting the birthing person in their right to make decisions about their own
body and baby.” -Rebecca Dekker

A study that included more than 15,000 people was done with 26 trials on continuous support of a
woman in labor. The studies included different types of continuous support, such as a nurse, midwife,
and doula. The researchers looked to see if the type of support made a difference. Continuous support
should be continuous support, right? The overall findings were quite interesting.

● 25% decrease in the risk of Cesarean; the largest effect was seen with a doula (39% decrease)
● 8% increase in the likelihood of a spontaneous vaginal birth; the largest effect was seen with a
doula (15% increase)
● 10% decrease in the use of any medications for pain relief; the type of person providing
continuous support did not make a difference
● Shorter labors by 41 minutes on average; there is no data on if the type of person providing
continuous support makes a difference
● 38% decrease in the baby’s risk of a low five-minute APGAR score; there is no data on if the type
of person providing continuous support makes a difference
● 31% decrease in the risk of being dissatisfied with the birth experience; mothers’ risk of being
dissatisfied with the birth experience was reduced with continuous support provided by a doula
or someone in their social network (family or friend), but not hospital staff (Bohren, Hofmeyr,
Sakala, Fukuzawa, & Cuthbert, 2017).

Overall, hiring a doula can benefit the overall labor/birth experience in many ways, from avoiding
unnecessary interventions to providing continuous physical and emotional support to both the birthing
woman and partner. Although this type of support can be provided by others, such as the nurse,
midwife, or family/friend, studies show that doulas have a stronger effect than other types of support. A
doula is a member of your birth team and will be there to help everyone have as positive of an

Page | 65
experience as possible. So, keep being awesome. You are changing the birth culture with every birth you
attend.

QUICK REVIEW
What are some VBAC specific policies you will face in your time as a doula?

What are some signs that a provider is VBAC supportive?

What are some red flags that will tell you if a provider is not very supportive of VBAC?

Page | 66
VBAC Story: Megan
My start to motherhood was unimaginably painful. I was pregnant with spontaneous boy/girl twins, and
after an otherwise smooth pregnancy, I woke up in preterm labor early in the morning on May 9, 2011. I
had made it to 32 weeks, and up until then, both babies were head down. We hurried to the hospital
and despite interventions, my contractions got closer and closer together. We had planned a vaginal
birth and were unprepared to advocate for ourselves when we were told Baby B was breech and a
Cesarean section was recommended.

During the C-section, Baby A, Madelyn, sustained a birth injury. Baby B, Jackson, came into the world
one minute later without issue. On May 13, our daughter, Madelyn Alice, died after four days in the
Level III NICU. Our son spent two weeks in the special care nursery and came home to bereaved parents,
figuring out how to care for a fragile preemie while also grieving the loss of Madelyn. Under these
circumstances, I have no idea how we went on to have more children.

Days before the twins’ first birthday, I found out I was pregnant again. I immediately researched VBACs,
as I couldn’t imagine going back into the OR after such a traumatic loss. At 16 weeks, we found our
doula, and it was truly a birth match made in heaven. For me, labor and birth are much more mental
exercises than physical, and what I need from a doula is emotional support, especially from 32 weeks on
until the delivery. I was so lucky to have found that with our doula, Nina.

Once my doctor determined I was a good candidate for a VBAC, she was with me all the way. I came to
her with insecurities and hesitations, and she reassured me with evidence-based research that babies
delivered via VBAC had the best outcomes compared to scheduled Cesareans. She helped me stay the
course and in addition to a doula, I think a VBAC-supportive provider is so important for a successful
Trial of Labor After a Cesarean.

On January 8, 2013, I woke up in the middle of the night, just like I had on May 9. We left home right
away and met our doula moments after being checked and admitted. She was also a massage therapist,
and I can imagine no better time for a massage than labor! Counter pressure, encouragement, and
switching positions often got me through the first hour. At that point, I was 4cm dilated. While I had
planned on an unmedicated birth, I couldn’t believe I was just at a four and didn’t think I could take
much more pain. My intuitive doula sensed I was close to transition, but still supported me through

Page | 67
discussions about an epidural. However, she was right – the next time they checked me, 30 minutes
later, I was complete.

The doctor on the floor couldn’t deliver me

due to liability, so we had to wait another 20
minutes for my OB to arrive. While holding off
on pushing, I screamed to a resident, “This
isn’t natural!” She mistook what I was saying
and said, “You aren’t using drugs, this is
totally natural!” What I meant was, I couldn’t
wait to push anymore! My doctor literally
came running in, and 18 minutes later my
second daughter, Margot, was born. She came out braying like a lamb, and I can’t think of a better
sound. I’ve gone on to have two other unmedicated VBACS in hospitals, and at my last delivery, my baby
was literally caught by midwives.

Jackson is now seven, Margot is five, Amelia is two, and our “caboose”, Holden, is eight months. Our
family is complete and I am so thankful, as I can’t imagine having such a large family without having
experienced Margot’s safe delivery. I never take for granted my children’s safe deliveries and the
privilege of leaving the hospital with them.

Page | 68
 V. THE ART OF BRAIN

H
aving a good idea of what you want for their birth is important. Knowing what the options are
and what choices are available can be frustrating for her. As a doula, you are likely already
aware of the BRAIN antonym. We recommend mastering the art of BRAIN, teaching your client
how to use it to make decisions up to and during labor, and using it to facilitate positive discussions with
everyone in her birth team.

What is BRAIN?
Benefits- What are the benefits of this intervention, option, procedure? How does it benefit me
and baby?

Risks- What are the risks of this intervention, option, procedure? How may it affect baby and I
negatively?

Alternatives- Are there other alternatives to this intervention, option, procedure? How do they
compare to XYZ? Are they gentler or more invasive?

Intuition- Ask yourself how you personally feel about the situation? What does your momma
gut say?

Nothing- What happens if we do nothing? Is it safe? Is it possible things can change? What
happens if we wait?

Assessing Interventions
In labor, there are many interventions that can come into play. An intervention is anything done to a
woman’s body during the labor process and even before labor begins. Knowing what these interventions
are and what the BRAIN truly is will increase your client’s chances of having little to no intervention
vaginal birth.

Induction

True or false: VBAC moms can’t be induced. FALSE. Although it’s ideal for labor to start on its own, VBAC
moms can still safely be induced and have a VBAC. According to ACOG, a prior low transverse C-section
is not a contraindication to induction (other than the use of Misoprostol/Cytotec), so a Foley balloon or

Page | 69
Pitocin may be used safely in most women. The problem arises when a practitioner does not believe in
doing inductions on women with prior C-section.

Let’s talk about induction some more. There are many ways of inducing labor, and part of mastering the
art of BRAIN is knowing what these are and what the pros and cons are to each one for your client and
her baby. But how can you really know if induction or interventions are needed? Providers will often
give a Bishop Score before induction. Doctors rate a woman’s cervix from 1-10. Anything less than a six
means her cervix may not be ready for labor.

*Signs a cervix is not ready to have a baby: Posterior cervix, high and hard/thick cervix, and the body
not showing any signs of labor starting. If induction is something mentioned by the provider, have her
ask why. Why is it medically necessary for labor to be induced? Look for evidence-based information in
their answers.

Evidence-based reasons for induction include conditions like polyhydramnios, preeclampsia, fetal
growth restrictions, and other dangerous complications. Other examples include if the water has broken
but your clients haven’t gone into labor on her own after 48+ hours, low amniotic fluid, or decreased
fetal movement.

Evidence-based reasons for other interventions include when the cervix is not favorable for induction
but it is medically necessary to proceed with birth, labor has not started after two weeks past the due
date, or labor has significantly stalled. We have included information you can go over with your client if
it becomes necessary.

Natural Induction Methods

Stripping of membranes: This is something that is typically performed in the office of your provider.
Your medical provider inserts their finger into your cervix and separates (sweeps/strips) the amniotic sac
from your uterine wall. This can release prostaglandins and stimulate labor contractions. This method
may be effective, but often may take 2-3 times. If labor is not yet ready, it may start contractions that
don’t bring progress. You may experience cramping and spotting. It can increase your chances of
unwanted bacteria and weaken your membranes, increasing your chances of your water breaking too
early, and in turn increasing chances of induction with other methods and raising the chances of a C-
section.

Page | 70
 (Vita, 2014)

Evening Primrose Oil is the oil from the seed of the evening primrose plant. When due dates are coming
up and induction looks like it may be necessary, many moms and midwives will look into Evening
Primrose Oil (EPO). The idea is using it vaginally or orally to soften and ripen the cervix to prepare it for
labor. We do NOT recommend taking this during pregnancy. There are only two studies available on its
safety and effectiveness. Neither study showed that it helped progression of labor and one of those
studies, referenced below, defines it as not supported during pregnancy and it should be avoided. It is
linked to bleeding issues and complications during Cesareans.

“The effects of EPO supplementation during pregnancy and lactation remain largely unknown,
and their use cannot be recommended. Extensive but transient petechiae and ecchymoses
have been reported in a newborn infant whose mother took a total of 6.5 g of EPO during the
week before giving birth. The oral use of EPO during pregnancy may also be associated with a
more protracted phase of labor and an increased incidence of premature rupture of
membranes, arrest of descent, oxytocin (Pitocin) administration, and vacuum
extraction. Additional concerns have been raised about adverse effects of EPO
supplementation on conditions including platelet aggregation, cholesterol, and blood
pressure.” (Bayles & Usatine, 2016)

Medical Induction Methods

Cytotec/Cervidil: Cytotec/Misoprostol does have its place for inducing women without a history of
Cesarean; however, as stated above, the use of a Misoprostol for a VBAC is NOT safe. In a case-
controlled study of 512 women attempting VBAC, 5.6% of women receiving Misoprostol had
symptomatic uterine rupture compared to 0.2% of women having a Trial of Labor without Misoprostol.
It is HIGHLY recommended to NOT use a Misoprostol for VBAC induction (Rath & Tsikouras, 2018).

Page | 71
Foley Bulb- A small catheter that is inserted into the cervix, where one side of the catheter is deflated.
Once your provider inserts it into the cervix, they will then inflate the balloon with saline. This causes
pressure on your cervix and will encourage your cervix to dilate. You must be dilated a little (1cm) to
insert the Foley. Usually a Foley Bulb will help the cervix dilate (medicine/drug free) to about 3-4,
sometimes 5cm before falling out. It is very important to know that once your Foley falls out and you are
checked, the number you are told is a mechanical number. Your cervix is usually in actuality one cm
behind what number you are given. This also takes some time, so once a Foley is removed, it may take
some time before things continue to move forward.

It may or may not kick labor into gear. Often after a Foley induction, the body will need something more
to get labor going, and “staying put” for some time after a Foley is removed is normal. Studies have
shown that the use of a Foley catheter in the induction of women with a previous Caesarean delivery
appears a safe option with a good success rates and few maternal and fetal complications.

Pitocin: A synthetic version of Oxytocin. Oxytocin is the hormone that your body naturally produces to
induce contractions, as well as serving as the famous “love” hormone. Pitocin is administered via IV and
increases the frequency and strength of contractions which can cause dilation. It is typically started at
2ml. For VBAC mothers, we recommend starting on the lowest dose possible, 1ml. Providers will up the
Pitocin slowly until contractions have appeared to reach a good pattern, typically 2-3 minutes apart,
lasting 60 seconds and are strong enough to create cervical change.

If too much Pitocin is given, it can raise risks of fetal distress and uterine rupture. Something important
to know is if the cervix is not “favorable” or “soft”, providers will usually opt for another option prior to
starting Pitocin. Once on Pitocin, it is important to know the mother must be strictly monitored and
remain in or near her bed unless there are wireless monitors. Pitocin can always be turned off.
Sometimes, once the body kicks into “labor gear”, Pitocin is no longer needed. A sign that the body is
weighing heavy on Pitocin is if it is shut off and labor seems to stop or slow significantly.

Breaking the Water: The amniotic sac lines the uterus and houses the amniotic fluid, baby, and
placenta. It provides a barrier to infection for the baby during pregnancy and cushions the baby when
the mother moves. It is made up of the amnion and the chorion. When the bag is broken, it contains
amniotic fluid, which has chemicals and hormones. When released, is likely will stimulate labor.
Physically, the bag of waters can provide a cushion between the baby’s head and the cervix so when it is
removed, baby’s head will apply itself against the cervix. When contractions happen, it will cause

Page | 72
 pressure to the cervix which will then cause
dilation of the cervix. Sometimes when the bag of
waters breaks, if the body is not ready, it may
take time for the hormones to kick in telling the
body it’s time to have a baby. Also, if baby is not
in an optimal position, it can cause labor to
show/have irregular patterns, slower dilation due
to the pressure on the cervix being weaker, back
labor, increase risk of infection, and raise chances of a C-section.

Other Non-Induction Related Interventions

IUPC (intrauterine pressure catheter) is a device placed into the amniotic space, between the uterus and
the baby, during labor to measure the strength of uterine contractions. It will determine if the strength
of the contractions is strong enough to cause significant cervical change. There is an increased risk of
maternal infection and fever which raises risk of C-section.

FSE is a small electrode that goes into the scalp; a spiral wire placed directly on the fetal scalp. Fetal
Scalp Electrode plays a key role in intrapartum fetal surveillance when there is a non-reassuring fetal
heart rate. This essentially can help avoid a Cesarean if the external monitors are not reading a valid
heart rate. Being placed on the fetal scalp puts a fetus at risk of scalp abscess but does not provide a
route of ascending infection to the maternal uterus.

Epidural: An epidural block is a numbing medicine given by injection (shot) in the back. It numbs or
causes a loss of feeling in the lower half your body. This lessens the pain of contractions during
childbirth. It can lessen the sensation of a contraction and help a laboring mom relax. If the mother is
very numb from the block, she may have a harder time bearing down to push the baby through the birth
canal. Contractions may lessen or slow down for a little while, but labor will still move along as it should.
In some cases, it may even go faster. If labor slows down, the provider can give some medicine to speed
up contractions. It is best to wait until active labor to have the epidural placed. NOTE: Your client may
shiver after an epidural, but this is common. Many women shiver during labor even without an epidural.

Fentanyl is a synthetic opiate that provides mild to moderate sedation which brings mild relief during
contractions and takes the edge off. It lasts for 30-45 minutes. Mother and baby can experience some

Page | 73
sedation and/or nausea. According to Danforth’s Obstetrics and Gynecology, babies born to mothers
who used Fentanyl to relieve pain during labor were less likely to need Naloxone (medication to help
with breathing) than babies born to mothers who used Demerol. Due to its sedative nature, Fentanyl
will not be administered unless there will be at least two hours before the baby is born in order to avoid
the sedative effects being present in the baby when it is born.

Assisted Vaginal Delivery- In assisted vaginal delivery, a device, such as forceps or a vacuum, is used to
assist the mom during delivery to achieve a vaginal birth. Approximately 3% of deliveries in the US are
operative vaginal deliveries (ACOG, 2016). The overall rate of operative vaginal deliveries is going down;
however, we are seeing an increase in vacuum-assisted deliveries which now accounts for almost four
times the rate of forceps-assisted vaginal births.

A vaginal birth can be assisted, but when is it appropriate? Situations include: prolonged pushing with
lack of progress for three hours with regional anesthesia (generally an epidural) or two hours for women
without; suspicion that the fetus may be compromised such as the heart rate is not recovering or has a
non-reassuring pattern; the vacuum may be used electively to shorten the second stage of labor
because of maternal cardiovascular or neurologic disease, and is not well defined with maternal
exhaustion. If the baby has some underlying fetal disorders, such as a bleeding disorder or a
demineralizing disease, an operative vaginal delivery may not be appropriate. If the cervix has not
dilated completely, membranes are still intact, or the baby’s head has not engaged well into the pelvis. If
the baby has a malpresentation, such as breech, transverse or facial presentation, it may also be
contradiction as to why an assisted birth may not qualify.

QUICK REVIEW

What does the B.R.A.I.N. acronym stand for?

What are some ways you can help your clients make appropriate decisions for their birth?

Page | 74
Page | 75
Page | 76
Page | 77
VBAC Story: Mandy
I knew there was a special baby missing from our family. One morning, I woke up with a calm, peaceful
feeling. In my mind’s eye, I saw the sweet little outline of a baby across the room in a little hospital
bassinet. I felt a very clear prompting come into my mind: “In about six months, you need to start trying
to have a baby. And you need to go to Portneuf Hospital.”

I'm a VBA2C mom. I've had a C-section with a special scar (an inverted T incision), a repeat C-section,
and at the time, I had had three VBA2Cs, which were attended to by amazing midwife, Chris Miller, in
Ogden, Utah.

Just over six months later, I was expecting baby number six. I kept second-guessing the thoughts that
had come into my mind, but knew I needed to follow what I had felt. I discovered that Portneuf still only
allowed VBAC after one C-section. I had heard great things about a certain doctor there, Dr. Cox. I was
so nervous for my first appointment that I asked my husband for a blessing (a special prayer offered to a
person by a priesthood-holder in the Church of Jesus Christ of Latter-day Saints). The words of the
blessing mentioned that the doctor would be there to help me and advocate for me.

I expected to be turned away, and then I could say I had at least done my part. One of the first things the
doctor said was that he supported my choice and that he agreed with the path I had taken. He told me
that he would take me on, but that unfortunately his hands were tied because of hospital policy. After
leaving for a bit, he came back into the room. He said that the other hospitals in the area had changed
their policy to VBAC after two Cesareans, and that it was “just ridiculous” that they hadn’t as well. He
told me that if I were willing to be in limbo, he was going to try and change it. I had friends asking me
the whole pregnancy about the policy and it was kind of funny, but I wasn’t too worried about it. I just
felt like it would work out.

I felt really nauseous and dizzy the entire pregnancy. Apart from that, my labs and everything were
completely normal. After about a month of feeling really well, I started to develop bad swelling. I was
concerned, because the only pregnancy where I had swelling like this was my first, which ended in a C-
section after an induction for preeclampsia. I tried to up my protein, drink tons of water, and do the
things that help to hold it off. I have amazing friends that helped with encouragement and advice. I
really think these remedies slowed the process. I had one appointment with the nurse midwives the
week my doctor was out of town, and sure enough, I had proteins, rising blood pressure, and a jump in
weight.

I had to do additional labs and went back to my doctor a couple of days later. That was when he told me
that the policy had passed. Because my labs were still okay, we were able to continue to watch and
check in. We hung in there for a week or two and then I did a 24-hour urine test. I prayed on the way to
my next appointment that I would know what to do and that the doctor would know what to do. I came
in and Dr. Cox told me that not only was the policy was officially in place, but he also had the results of

Page | 78
the 24-hour urine test. His guidelines said immediate delivery for +2 proteins or higher after 34 weeks,
and mine was +6. He said we would deliver the following day—but instead of a C-section, we could try a
gentle induction.

I was 35 weeks and so scared. I felt like I was failing my baby because my body wasn’t cooperating and
that he had me as a broken vessel. Dr. Cox inserted a Foley bulb catheter to help with dilation, gave me
a steroid shot, and sent me home after they were able to get a lower blood pressure reading. The Foley
catheter popped out after four hours. I was having little contractions, but nothing serious. I finally called
my doula; I had been waiting for the policy change, so I hadn’t set up an official plan with her. I ended
up texting her at 11:00 p.m. My mom came to stay at our house and we left in the morning. I was so
weepy and afraid that I couldn’t eat. I felt like I was facing the fears of the very thing that started my first
birth and C-section.

It took over an hour to get the baby on the monitor because he kept moving. We did a small dose of
Pitocin and they also had to do magnesium. My husband was very supportive and the staff was nice. The
head nurse had to come in to help with the monitor and she kind of scared me about going natural
because of my blood pressure and said that I couldn’t move too much because of it; I may need an
epidural to keep it down. I was terrified to go natural in this environment, but also terrified to get pain
relief because I’d also experienced a failed spinal, which led to general anesthesia, and a failed epidural
in the past. They had to get me nose drops because I was so stuffy from crying. I was an emotional
wreck.

I decided to be open to what I needed to do. My doula, Robyn, said that she could come right at the
beginning or anytime I needed her. I felt so emotionally fragile that I almost was afraid to call. What if I
couldn’t handle it and needed to get pain meds? She came in, calmed me down, had my husband grab
some lunch, rubbed my feet, and did a calming meditation. She also reassured me that she was there to
support me no matter what.

It’s amazing how the presence of one person can totally impact the entire room. Instead of fear, I felt
peace now. I had a check close to 12, and was still very high and maybe 2cm. My water was broken; the
Pitocin didn’t feel like it was doing too much, but I didn’t let on. Then, as the contractions picked up, I
had my husband to hold onto and Robyn to put pressure on my back. She kept us both calm. I was able
to relax into my contractions despite being tied to an IV and a monitor. I agreed to an internal monitor,
which was a lot easier to work with. I would have tried harder to avoid continuous monitoring, but
because of my preeclampsia and being a VBAC mom, I decided to let them win on that.

My little birth team of two was wonderful. My husband and I both agreed that doulas are amazing.
Besides a really obnoxious anesthesiologist coming in, the next couple of hours were quiet and peaceful.
I could feel the contractions getting stronger and asked for a check. 7cm! I hoped I wasn’t too much
longer, and after 30 minutes, I felt the need to push.

Page | 79
They wanted me to deliver in the OR just in case, so I told them they needed to tell the doctor. No one
seemed in a hurry, but I was pretty sure I was complete. I yelled for a vaginal check and the resident
doctor agreed that I was complete. I was on all fours on the bed, just hoping to push out a baby right
then.

The doctor came in, and unfortunately the head

nurse kept nagging me to flip over; I finally relented.
It was awful. The doctor said that we would be
staying in this room. When I flipped over, I
accidentally ripped out my IV and I didn't even feel
it. I had a small lip on my cervix, and baby was
posterior. They put me up on my bed and got the
stirrups, one which I broke somehow. I had a nurse
trying to replace the IV, someone checking my blood
pressure, eight or so people in the room, all while
trying to push. It was so difficult. Plus, I was pushing
uphill, while they were trying to rotate my baby.

Somehow, I was able to push him out, and have him

on my chest. He was crying instantly and I felt
amazing relief. I needed just a couple of stitches. I
hemorrhaged a little, but it didn’t seem too bad
compared to my other deliveries. The baby had really low blood sugar, so he had to go into the NICU.
This was difficult, but I was blessed with amazing postpartum nurses that were so kind and comforting.
One even arranged for me to stay two extra nights in an extra room so I didn’t have to leave my baby
yet. He ended up needing a feeding tube for a few days, and then oxygen. He had a three-week NICU
stay and is currently home on a portion of oxygen. It’s been an emotional ride, but thankfully, he is
breastfeeding well and is alert and active.

There have been many tender mercies and wonderful people helping our family. One morning, on my
drive to the NICU, I heard the words of this Christian song, and it really touched my heart.

“Before I spoke a word, You were singing over me.

You have been so, so good to me,
Before I took a breath, You breathed Your life in me,
You have been so, so kind to me.”
(Reckless Love by Cory Asbury)

I could see that Heavenly Father cared enough about the birth of this little one to tell me months in
advance when he needed to come and where to go. He even paved the way for a policy change to take
place. Even though it was hard and I had so much anxiety, I feel so blessed.

Page | 80
 VI. VBAC LABOR

B
irth is something that, unfortunately, can’t be totally predicted. Even during something like a
scheduled C-section, we have no way of telling the outcome until the baby is here. Labor looks
different for everyone and it’s hard to predict how long labor may last, what the contraction
pattern will look like, and what interventions may take place. Something important to keep in mind is
that a woman’s body is not a robot or a time clock. Sometimes things unravel and go a different path
than we had hoped. There are some things, as a doula, you should know to pay attention to when your
client is in labor.

When your Client’s Due Date Approaches

The end of the third trimester can be especially stressful when waiting for a VBAC. Some providers start
talking about scheduling inductions and/or a repeat Cesarean as early as 32/34 weeks. This can really
throw a tired pregnant mom for a loop. As we talked about in section IV, induction is a hot topic in the
VBAC world, and as your client approaches 39-40 weeks, it can start to feel like there is a timeclock on
their birth. This is the time where providers get anxious and friends and family start asking them if they
have had the baby yet, and last-minute emotional triggers arise.

To parents approaching their due date, it is important to remind them to stay grounded and focused.
Reassure them: they have prepared for this. They know in their mind what is factually correct. They
know in their heart and gut what the best choices are for their family. Help them to trust those things,
now more than ever. You have worked with them through the preparation process. Use what you have
learned about them specifically to guide them through if they get questioned by family, friends, or even
their provider. If plans need to change, that’s okay too, but remind your clients that they are the ones
making the decisions.

If induction becomes necessary for whatever reason at whatever gestation, suggest that they speak with
their provider about options that are available and start with the lowest, slowest option possible. We
have seen amazing success with the following method:

1. Outpatient Foley Bulb. This is where they insert the Foley bulb into the cervix and then send
them home with instructions to come back when it falls out. NOTE: A lot of providers in hospitals

Page | 81
Page | 82
 2. will not allow the mom to leave once the Foley induction has started, the mom may have to stay
in the hospital.

3. After the Foley bulb falls out, if contractions haven’t started yet, request to start Pitocin slowly
and on a low dose. Starting at a 0.5 or 1 unit and upping it by that amount every 45 minutes is a
great gentle nudge to let the body know its being asked to have a baby.

4. Once their body is in a regular contraction pattern and they are in active labor, it is reasonable
to ask for Pitocin to be turned down or even off completely. Often, once Pitocin has helped
things get started, contractions keep going without that additional stimulation.

This is not the only way a gentle and slow induction can happen, but it is a great option and usually
works very well. Sometimes, slow induction is not always possible or available, but remind them that as
long as the mom and baby are safe, it’s reasonable to request.

Supporting a VBAC Client with an Epidural

When movement is restricted due to an epidural, it can make things more difficult, but not impossible,
to help baby get in a good spot. There are still so many benefits to having a doula, even with an epidural.
Historically, an epidural restricted a mom from any or most movement, meaning she would not be able
to do much more than lay side-to-side or even flat on the back in the bed. These days, anesthesiologists
have made it possible for these women to be able to feel comfortable while also still being able to have
some strength in their legs and move around but remain restricted to the bed. It’s recommended to
change positions every 30-45 minutes. NOTE: If a mom is sleeping and comfortable, it’s okay to leave
her in that one position until she wakes. Rest is so important and can do so much for the mom and baby
alone.

Positions with an epidural:

Left and Right Side Lying or Exaggerated Sims

Get the mom’s hips on the far side of the bed so she can really exaggerate laying on the other side. It is
most ideal to have the arm back like in the Miles Circuit, with the top of the bed on the flatter end to
allow movement for the baby. If possible, place a peanut ball between her legs, making sure the knee is
not over the tips to avoid strain on the back. Switching sides with a throne or sitting up position in the
middle is ideal.

Page | 83
Throne
Throne is where the mother is sitting straight up. Get her bum as close to the back of the bed as
possible, supported with pillows on her upper back. Drop the end of the bed with her knees in a
butterfly position. This helps mom let gravity do the work for her and get baby more engaged.

Assisted Squat
You may be thinking, “WHAT? A mom with an epidural squatting?” Trust us, it may sound crazy, but it is
possible. The staff likely may not want her to try, but if she feels strong enough, this is a good position to
labor and push in. Keep the bed set up like you would have it in a throne position. Ask for a squat bar to
attach to the bed and give it a try. You can get a sheet or a rebozo and put it under mom’s bottom or
legs and when desired or when it is time to push. Partner on one side, with you on the other, she leans
forward onto the bar and the two of you hold her up with the ends of the chosen fabric. When she is
done, you then assist her back onto the bed in a seated position or on the edge of the bed.

Rebozo Sifting
If your client is able to move well and turn to their hands and knees, you can put the back of the bed up
and let them lean over it while you or their partner support the knees from sliding and the other person
performs “shaking the apples”. You can also sift around the belly gently. These positions can help
posterior babies rotate and engage. You can find more on each of these techniques for rebozo sifting at
spinningbabies.com.

Additional information about the rebozo: Do not use the rebozo if your client has round ligaments that
are tight or cramping or if there is a worry about excessive bleeding. Is they have an anterior placenta,
avoid aggressive and/or rapid sifting.

Tug-of-War While Pushing

Using your rebozo or a sheet, wrap it around the squat bar and help your client place her feet on the
bar, she holds on to the end and pulls to assist her in pushing.

Education!
Sometimes, when an epidural comes into play, other interventions can come up. Helping her use her
BRAIN in all scenarios can help her look back at the experience knowing she was in control and felt

Page | 84
empowered. Another great thing to educate on is epidurals themselves. Helping your clients know what
to expect can help eliminate any stress or fear if the staff reacts quickly.

Epidural Side Effects

• The mothers blood pressure can drop and so can baby’s heart rate. This is something normal
and is watched closely so it doesn’t drop too low.
• The shakes; it’s normal for the body to shake and tremble after receiving an epidural and as it is
wearing off.
• Itchiness. It is normal to get itchy as things are wearing off.
• The epidural only working on one side. This is where the labor pains will be felt on one side
while the other side is numb.
• Not working well at all. Although very uncommon, some women may still have a decent
amount of or even feel all the labor pain.

The Signs of Rupture

Uterine rupture happens in 0.4% of pregnancies (Motomura, 2017). Although the chances are low, it is
important to know the signs and symptoms before going into labor. If she seems to be experiencing any
of the following symptoms, ask her to describe it to her care provider and/or nurse. Often, because
doulas are with the mom the entire time, they may notice these symptoms before anyone else.

Although this may be a hard or scary thing to talk about with your client, it is important not to ignore it,
because it could make a big difference in someone’s outcome. As a mother in labor, if your doula saw
the signs, would you want to know? Every client may need to be approached differently. At this point in
time, you should hopefully know the best way to talk to her and tell her this news.

So how do you tell her? Simply talk to her. Tell her what you are noticing and ask her how she’s feeling.
How bad is her pain? She may not always experience a lot of pain at first, and heart tones may also not
be dropping. Because of this, knowing the signs and symptoms below is something that is very
important. If she is having any of these symptoms, it may be good for you to express your concern to her
in a positive way and encourage her to speak with her provider.

● Excessive vaginal bleeding; heavier and more severe than any period you’ve had
● Sudden sharp pain between contractions

Page | 85
 ● Contractions that become slower or less intense in active labor after having a great pattern
● Abnormal abdominal pain or soreness
● Recession of the baby’s head into the birth canal
● Bulging under the pubic bone
● Sudden pain at the site of a previous uterine scar
● Loss of uterine muscle tone
● Rapid heart rate, low blood pressure, and shock in the mother
● Abnormal heart rate in the baby
● Failure of labor to progress naturally

Labor Timing - What to Expect

It is impossible to tell how long a labor may last. Women who are having a VBAC that have not had any
previous vaginal deliveries could be like a “first-time mom.” It’s also important to remember that not all
first-time moms have long labors, so being aware of her contraction pattern is important. That said,
even moms who have had vaginal deliveries
before may not have a fast labor. Preparing
your client for all outcomes is a good thing,
so when they start their labor, they don’t
have high expectations of a labor that may or
may not happen as fast as they hoped. As
mentioned previously, fetal position may
play a part in a longer labor. Really educating
your client on how to help get a baby in an
optimal fetal position prior to labor is really beneficial.

You Are NOT There to Save Anyone

As a doula, it is common to get attached to your clients. This is especially true when helping someone
heal from a bad birth experience. You really get to know them intimately when you meet with them in
their prenatal appointments. You process their fears together and develop a connection. One of the
hardest things as a doula may be when your client is working very hard to achieve her dream birth and
things don’t go as planned. Sometimes interventions are chosen or decisions made that increase the
chances of a repeat Cesarean. It is important to remember you are NOT there to save anyone. That is

Page | 86
when you, as their doula, can truly help them respond to each event and validate their ability to make
their own choices. Even if that choice is a repeat Cesarean. Even if you think it might not be necessary. If
things don’t go as planned, it’s very important for you to not let it outwardly affect your support. We
want to help, but we cannot save everyone. It is so much easier to be emotionally invested in a VBAC
mom’s birth; some of the deepest connections we’ve made with clients have come through VBAC
journeys. However, it is still important to disconnect yourself from the outcome of the birth. You can’t
want a specific type of birth more than they do.

Preparing for a Repeat Cesarean

You’re in the room with your client(s). What do you do? How do you approach a family? This may be a
hard thing to do, but a doula can truly help this moment be a better one for the family as they are trying
to decide what to do. Be sure to encourage family to ask ALL their questions (remember BRAIN from the
previous section). If it isn’t an emergency, give them a minute alone to process.

Family-centered Cesarean Section

In the event that a Cesarean is necessary, there are many emotions that may take over for the mom and
her support team. She may be content with the decision or she may be crushed. Let her know that it will
be okay and remind her that she is strong and what she is about to do is a selfless act of love for her
baby. Remind her that she has prepared herself in all possible ways and that she can be confident that
this is the best choice for her and her baby. It is emotionally difficult to accept that a Cesarean is the way
your baby is going to be born, but feeling loved and supported during the process can truly make a
difference. Helping her know her options as plans change is a great way for you to offer support. Some
hospitals allow a mother to have two support people in the operating room; however, often the hospital
will only allow one person. Educate them as much as possible on what their options are. You can also
have her ask her provider before labor begins if the hospital will allow a gentle Cesarean/family-
centered Cesarean section. Knowing if her provider and hospital staff are able to provide this option can
change the entire feel/experience during a Cesarean.

What Exactly is a Family-centered Cesarean?

A family-centered Cesarean allows a mother and father to have a peaceful and calm atmosphere while
mimicking what happens during natural childbirth. It often allows a mother to see her child be born

Page | 87
through a clear drape, have immediate skin-to-skin, and allow the mother to breastfeed if desired. You
may ask if music can be played through the speakers in the operating room or through a small speaker if
you have one. Ask if the placenta may be saved (if the mother wants to keep it for encapsulation), if the
provider can milk the cord, or have the option to delay the cord until it stops, as well as doing a vaginal
swab (see below). You should also ask if you can have a loved one, doula, or photographer for extra
support or photography.

“Having my sweet baby placed on my chest right

after she was born created a whole different
bond for her and I.” - Meagan Heaton

It is important to remember that this is their birth

experience. It’s a day that should be very special and one
that they reflect back on with positive thoughts. If a
Cesarean happens, a family-centered birth can be very
healing for both mom and partner, as well as make the
transition from utero to world more natural for baby. As things are discussed with her provider in
prenatal visits, it is important to have her also call her hospital of choice. Although a provider may agree
to some of the options above, it’s possible that hospital policies may override. Tell her not to be scared
to make her wishes known and learn all she can going in.

Family Centered Cesarean Options:

• Using a clear drape for your client to see her baby being born.
• Immediate skin-to-skin in the operating room.
• Breastfeeding in the operating room or recovery room.
• Music being played through the speakers in the operating room or a small portable speaker.
• Saving the placenta.
• Milking the cord or delayed cord clamping so baby gets all of the cord blood.
• Vaginal swab for vaginal seeding (microbirthing).
• Additional support in the operating room such as a doula and/or birth photographer.

Vaginal Seeding (Microbirthing)

Above we talked about the provider doing a vaginal swab. This is a very easy step that may be done if a
Cesarean section is something that is needed. Your provider will take a cotton swab and insert it into the

Page | 88
vagina, collect vaginal fluid, and transfer it to the newborn, via mouth, nose, or nasal cavity. This is
something that you may want to discuss with your provider.

“Cesarean delivery performed before the onset of labor or before the rupture of membranes prevents
the fetus from coming into contact with vaginal fluid and bacteria. The intended purpose of vaginal
seeding is to transfer maternal vaginal bacteria to the newborn. As the increase in the frequency of
asthma, atopic disease, and immune disorders mirrors the increase in rate of Cesarean delivery, the
theory of vaginal seeding is to allow for proper colonization of the fetal gut and, therefore, reduce the
subsequent risk of asthma, atopic disease, and immune disorders.” (ACOG, 2017)

Postpartum Recovery

In addition to the normal physical postpartum recovery, there is the mental and emotional part of
recovery. It’s important that you don’t always assume you know how the mother feels about the birth.
Even when a mother gets the outcome she was hoping for, she may not feel happy about it. Sometimes
VBACs can be traumatic and repeat Cesareans can be healing.

There are a few things that typically affect a woman’s view of her birth:

● How long labor lasted. Was it so fast she couldn’t process things? Was it long, difficult, and
emotional?
● Did she end up using pain medication when she didn’t initially want it?
● Were there a lot of interventions that she didn’t want or that played a role into the type of
delivery?
● What type of delivery was it? Vaginal, calm, peaceful and in control, or fast and scary where she
didn’t feel like she was in control? Was there a large amount of tearing? Was it a C-section that
she didn’t want or was it a healing C-section experience?

Is she able to talk about it or is she shutting down? A mother who shuts down may be experiencing
sanctuary trauma. Sanctuary trauma is when an individual may not be able to process or talk about her
fears when the negative feelings take over. Mommas can experience this in both vaginal and Cesarean
birth outcomes. Know and understand if a mother does not want to talk about her birth experience—
she may be suffering from some trauma or even guilt. Be mindful and don’t force her to talk about it.
She may also want to talk about the entire experience. Everyone is different and processes things

Page | 89
differently. If you can learn how they process in your prenatal visits, it may benefit you during this time
because you may be able to read how they are doing based off of what you know.

What Type of Support Can You Provide as a Doula?

Practical Support:
It is important for someone who has experienced trauma or is struggling emotionally to try and return to
as normal of a schedule as possible. This can be hard after having a baby, because there is going to be
lack of sleep, a new baby’s schedule, and for families with more than one child, they also have to carry
on with the kids’ normal schedules. Being utterly exhausted can make it even more difficult to cope and
process—offering practical support and encouraging a “normal” routine is a start. Below are some ideas
to help your client with practical support. Please know that there may be a need to call in or refer to
additional support.

● Understand that they may be struggling inside.

● Recognize that they may need space to process, and writing them asking how they are doing
may not always benefit them.
● Accept that they may not want to talk for a while, and don’t take anything personally.
Sometimes those who are struggling emotionally tend to be short and even lash out on the ones
closest to them.
● Encourage them to rest.
● Help them find the professional help they may need.
● Encourage them to take some time away from social media and their phone.
● Acknowledge their accomplishments.

If none of these things are helping and/or you feel that the safety of mother or baby is jeopardized, call
in additional support or, text the crisis help line that is available 24/7 for support. Text CONNECT to
741741 in the United States.

Emotional Support:
Emotional support looks different for everyone. It is important to remember that not everyone wants to
talk about things and some may want to talk about every detail. If they don’t want to talk quite yet,
follow up with them and let them know you’re there for when they do. Being there to listen, discuss,
and help process their emotions will mean the world to them.

Page | 90
 ● Understand that they have been through an emotional time.
● Help them know that their feelings are real and valid and it’s okay to be sad, frustrated,
angered, etc.
● If there seems to be something beyond your help, offer the support from a professional. Be
aware of what’s happening, so if things are going down a road where she needs extra help, you
can offer that resource.
● Understand that talking about this trauma or pain may be very hard. Emotions may come out
and that’s more than okay.
● Encourage them to take a break from “extra stuff”—social media, visitors, willingness to get
help for things around the house, etc.

Postpartum Mood Disorders

Most women will have some sadness or anxiety as our hormones regulate postpartum. However, if the
sadness or other negative emotions last longer than 1-2 weeks, they may be experiencing one of five
postpartum mood disorders, which include: postpartum depression, postpartum anxiety, postpartum
obsessive-compulsive disorder, postpartum PTSD, and postpartum psychosis. One in 10 (or more)
women will experience postpartum depression or another postpartum mood disorder. Often, your
spouse or other support person will be the first to notice these things, so make sure they are aware of
the signs as well. Things to watch for that may indicate postpartum depression vs. regular baby blues:

• Worrying constantly, feeling worthless, feeling alone all the time, constantly crying.
• Always feeling like something bad is about to happen.
• Not bonding with her baby.
• Feeling like she not doing a good job as a new mom.
• Not eating, sleeping, or showering because of her despair.
• Sudden outbursts of anger and/or anxiety.
• Being hyper focused on keeping herbaby safe.
• Repeating acts that make you feel less anxious.
• Having repeated nightmares, flashbacks to a traumatic birth, or insomnia.
• Suicidal thoughts, hallucinations or delusions, or thoughts of harming your baby.

If you feel like any of these things apply to your client, speak to her and closest support person, ask
them if they need additional resources, and connect them with what they may need.

Page | 91
Page | 92
QUICK REVIEW

What are some good questions to encourage your clients to ask their providers in their third trimester?

List three things that can encourage a successful VBAC:

What are some things that can be requested for a gentler Cesarean experience, if it becomes necessary?

What are the signs of uterine rupture?

How can you identify if a mother is experiencing normal postpartum hormone fluctuations vs. mental
health issues that need additional support?

What are some resources available to support mothers in the postpartum stage?

Page | 93
VBAC Story: Erin
My birth story begins three years ago while pregnant with my firstborn (a daughter), when at 35 weeks,
after a completely uneventful, straightforward, and healthy pregnancy, we discovered my baby girl was
in a Frank breech position. Following a consult with Maternal Fetal Medicine (MFM), we ultimately
decided against moving forward with an external cephalic version (ECV) and instead opted to wait and
see if she would turn on her own. Unfortunately, as the weeks passed, baby girl remained snug inside,
head up and bottom down.

At 40 weeks and one day, I woke around 3 o’clock in the morning to a ping in my stomach that
resembled a period cramp. I told my husband I thought I might be in labor, but that he could keep
sleeping since it would probably be awhile until we’d need to head to the hospital. Around six in the
morning, I decided to call the hospital when my contractions were about 7.5 minutes apart. By the time
we got checked into triage at 7:05, contractions were closer and a lot more intense. It had been about
four hours since my first labor pain; after a cervical check, the attending OB shouted out, “She’s an
eight!” My beautiful daughter was born on 8/17/14 at 8:17 a.m. via Cesarean with APGAR scores of nine
and nine. Surgery was respectful and straightforward; the OB explained to me what she was doing at
every junction; she even told me as she sewed me up that I was “the perfect candidate for a VBAC.” I
knew my body could birth a baby and I was already planning my VBAC in my head.

Skipping ahead 19 months, we found out we were pregnant again. My first step in the journey was
changing providers; I switched from the OB/GYN practice I had been with while pregnant with my
daughter to a midwife practice. As part of my care plan, I was required to meet with an OB from the
midwives’ consulting obstetrician group. I specifically scheduled a meeting with the head OB from that
group, whom I had heard good things about and whom I was told was very VBAC-friendly.

Upon reviewing my health records, the first question he asked me was, “So, why didn’t you have a
vaginal breech birth the last time?” My jaw dropped. I couldn’t believe he asked me that, since the topic
never came up once as a possible option. I knew this time around I was with the right group of
providers; a huge weight had been lifted from my shoulders and I felt I could finally start to enjoy my
pregnancy. From that point on, my pregnancy progressed much like my first (complication-free and
uneventful). Starting around 14 weeks I began doing twice-weekly prenatal yoga to ensure better body
balancing, in hopes of giving baby the best chance of getting into an optimal position.

Around 30 weeks, I started seeing a chiropractor certified in the Webster technique for weekly
adjustments. Baby luckily got into a head-down position around 28 weeks and we never looked back.
My due date of 11/24/16 came and passed along with the Thanksgiving holiday. We had family in town
and everyone was excited and eager to meet our new addition.

I had been having increasing Braxton-Hicks contractions for a couple of days surrounding the holiday,
but nothing resembling a consistent labor pattern. Early morning on 11/27/16, I woke up around 3:30

Page | 94
a.m. with period-like cramps. I got up and decided to start timing to see if these were the real thing or
just pre-labor. I woke my husband and told him I was going to the living room for a while to time them
and I’d come wake him if it looked like they were turning into something more consistent. After timing
contractions for about an hour, I texted my doula to let her know I was awake and contracting, but that
there was no distinct pattern. She suggested I have some water and lay down to see if they might go
away. I took my doula’s advice and eventually contractions dissipated around 6 a.m. and I was able to
catch about 2.5 hours of sleep before getting up again to officially start the day.

I woke again around 8:30 a.m. on 11/27/16 and contractions picked back up soon after, although still
spaced out and not very intense. I called my doula in the morning and gave her an update. We decided
since they were still infrequent and mild, to keep an eye on them to see if they would turn into
something more consistent.

Around 1 p.m., my husband, daughter, and I headed out for afternoon brunch. At around two, while at
brunch, the contractions started to become more uncomfortable, coming about every 15-20 minutes.
This is when I suspected it was the real thing. My doula called me while at brunch and I filled her in.
Since contractions were still 15 minutes apart, we decided to stay in touch about progress. She
suggested I go for a walk and see how they progressed from there.

After brunch, we gathered our daughter and decided to head to a nearby reservoir that also had a big
play area and park. As we made our way for the play area in the park, the contractions began to
intensify and started getting closer (about 13 minutes apart). As we approached the playground, I told
my husband I was going to follow behind them so as not to cause concern for my daughter. A short
while after, I felt as though I couldn’t be in public any longer and needed to go home soon (contractions
were about 9-11 minutes apart).

Once home, contractions were still quite spaced out and we figured we still had some time, so I sent my
husband off with my daughter to see if he could get her to nap before leaving her with family. As I
finished gathering our last items, I called my doula and told her contractions were about 7-8 minutes
apart by that time and very intense. She said most likely today was going to be the day and that I should
start making the necessary calls to arrange for my daughter’s care. Then, I had a monster contraction
that shook me to my core; all of a sudden, I felt a trickle of fluid and then a full gush; it was my water!

Simultaneously, I felt a major shift inside of me – the baby was “at the doorstep” and I was
home...alone. As the physical sensation overtook me, a moment of panic set in; I guided myself down to
the living room floor into a side-lying position; I quickly spotted my cell phone on the couch and reached
for it immediately. I dialed my doula to let her know my water had broken and the baby was coming.
Sensing the panic and urgency in my voice, my doula told me she would be there in five minutes (luckily,
she literally lived five minutes from me).

Next, I tried my husband, but, to no avail—I got his voicemail. As I laid on my side, my contractions
started to space out. I reached my hand down and could feel the top of my baby’s head; I could feel he

Page | 95
had some hair and remembered that my daughter was also born with hair. There he was! Right there! I
knew this VBAC was going to happen. In that moment, I realized I needed to calm down and pull myself
together. I told myself someone would be there soon, but that it was likely I was going to have to deliver
my baby on my own.

I knew I needed to be focused for my baby and remember telling myself to breathe, that I needed to be
there for him. I found my calm the best I could, and tried to take some good, deep, cleansing breaths.
During this time, my cousin called me back (I called her when I couldn’t get ahold of my husband) and
stayed on the phone with me as my body began to push. Then, all of a sudden, I heard a pounding on
the door; it was my doula! The college girls that live across the hallway from us had let her in our
building, but I had forgotten the door to our apartment was locked as well and my doula didn’t have a
key! She shouted that the door was locked and that she needed me to let her in, but, at that point, there
was no way I could physically stand up to let her in; the baby coming then and there and my body was
pushing all on its own.

It wasn’t more than another push and my son’s head came out. Almost simultaneously, the rest of his
slippery little body followed. As he slipped out and softly landed on the carpeted living room floor, he
began to immediately cry; I remember being so incredibly amazed, not only at how painless it felt, but
that he came out of me so quickly and easily. The second I saw him land softly on the carpet, I scooped
him up and shouted to him, “I got you! I got you!” I brought him immediately to my chest, hugging
him tightly since I didn’t want to drop him (he was so wet and slippery).

Although I had not planned for an unassisted

home VBAC, I felt I was as prepared mentally,
emotionally, and physically as anyone could
be for this kind of experience. I am in
absolute awe of the female body and am
certain all women have the same instinct and
ability to birth their babies unhindered. The
love and respectful care I received from the
first responders, medical team, doula, and
family was priceless and I have never felt
more powerful, capable, transformed, and
healed as I have as a result of this birth. I hope, if anything, my experience shows other moms who are
on their VBAC journey that their bodies are not broken and that it is possible to birth with strength and
intuition.

Page | 96
 VII. CONCLUSION

S
upporting a family through VBAC or repeat Cesarean can be an incredibly demanding, meaningful,
and poignant experience. Families will benefit greatly from the presence of you as their doula.
Doula self-care is vital as you see their story unfold. Make sure you are taking time to process
yourself. Find another doula to work through the story with. Sitting and processing through something
like birth trauma can be a heavy burden to bear. We are confident in your ability to do it. The most
important thing you can do to prepare your client for VBAC is to encourage her to do three things:

EDUCATE HERSELF

We offer a course like this just for your clients to help them learn things that compliment what we are
teaching you now. This will make you an even better team preparing for her birth.

GET A SOLID BIRTH TEAM

The most important thing she can do to achieve the birth she desires is to go to a VBAC-friendly birth
place and have a VBAC-friendly provider. A provider that trusts a woman’s body to birth is so, so, so
important. Also, you guessed it: get a doula. She has already placed great confidence in you to support
her, and you already know how much having a doula can help a woman navigate her birth space.

TRUST HERSELF

It goes without saying that sometimes there are circumstances where a baby just won’t come out
vaginally. However, there is a lot to be said about the power of the mind and a woman’s intuition. Belief
in oneself and your ability to give birth is a huge chunk of the battle. Faith and fear cannot coexist in the
same space. Where there is fear, there is tension, and when a person can release that doubt and bring
in full confidence, amazing things can happen. Birth is awesome. It’s messy, complex, simple, and hard,
but somehow easy, and plays out in SO MANY different ways. If you can help your client trust the
process, trust her mind, and trust her body—she has conquered a large part of the battle.

Most importantly, encourage her to trust in and be kind to herself. There is not a single “right way” to
give birth. The right way is for a woman to be empowered and educated in order to make the best
decisions for HER. She should feel in control of what is happening to her while she births. It is her

Page | 97
labor—only she can give birth to this baby and no matter which way she does it, she did it and that is a
huge accomplishment.

Congratulations! Now that you are at the end of the course,

head over to thevbaclink.com/certify to start your
certification process and get listed in our VBAC doula directory
at thevbaclink.com/certify.
QUICK REVIEW

What are three things you can do to help your client have the most positive birth experience possible?

Page | 98
 APPENDIX 1 – DEFINITION OF TERMS
ACOG- The American College of Obstetricians and Gynecologists, a professional association consisting of
physicians who specialize in obstetrics and gynecology in the USA. ACOG advocates for higher standards
of practice in women’s healthcare.

American College of Nurse-Midwives (ACNM)- A professional that represents CNM (Certified Nurse
Midwives) and other certified midwives.

Anterior Baby- When the baby’s back is along the front of the mother’s stomach, the optimal position
for labor.

Anterior Placenta- When the placenta is attached to the front of the uterus, on the belly side, rather
than the back side.

APA- The American Pregnancy Association is a non-profit organization that helps promote pregnancy
awareness and wellness and addresses other pregnancy needs.

APGAR- Appearance, Pulse, Grimace, Activity, & Respiration; a number from 1-10 that is given to a baby
at the one- and five-minute mark after birth.

AROM- Artificial Rupture of Membranes; when the bag of waters breaks by force or is punctured
artificially.

Augmentation of Labor- Starting labor before it has started on its own.

Bishop’s Score- A score from 1-15 that the cervix is given prior to labor starting to gauge how ready it is
for labor. A score of eight or more indicates that the cervix is favorable for induction and has a good
likelihood for vaginal delivery. A Bishop’s Score of six or less means the cervix is not ripe nor favorable
for induction and a vaginal delivery is less likely.

CBAC- Cesarean Birth after Cesarean; when a mom has a Cesarean after a previous Cesarean.

CFM- Continuous Fetal Monitoring; instruments used to continuously monitor the heartbeat of the
fetus.

CNM- Certified Nurse Midwife; a registered nurse who has additional training and can deliver babies.

Page | 99
CPD- Cephalopelvic Disproportion; a pelvis that is misshapen or malformed (this is incredibly rare).

CPM- Certified professional midwife; a skilled and knowledgeable midwife who has met the needed
standards to deliver babies.

Contraindication- A condition or factor that automatically excludes someone from a medical treatment
or, in this case, method of delivery, because the harm that it would cause the person is too great.

Cytotec or Misoprostol- A hormone inserted vaginally or taken orally to help prime/thin the cervix. This
is contraindicated for VBAC.

Dilation- The opening of the cervix.

Effacement- When the cervix starts to prepare for labor by thinning out.

EFM- Electronic Fetal Monitoring; a monitor that is placed on the belly to read the baby’s heart rate.

Evidence-based Care- Decisions for care based on scientific data and research.

FSE- Fetal Scalp Electrode; a monitor that is placed on the baby’s scalp that reads an accurate heart rate.

GD: Gestational Diabetes; causes high blood sugar and can negatively affect a pregnancy and baby’s
health.

HBAC- Home Birth After Cesarean; when a mother chooses to have a vaginal birth after Cesarean at her
home.

ICAN- International Cesarean Awareness Network; a group that strives to improve maternal and child
health by lowering unnecessary Cesareans through education, supporting recovery, and continuing to
advocate for VBAC.

IUPC- Intrauterine Pressure Catheter; a small catheter that is placed between the cervix and the baby’s
head to detect the exact pressure of how strong contractions are.

Malpresentation- When a baby is not in the correct position.

NCBI- The National Center for Biotechnology Information is a part of the USA National Library of
Medicine, and is a national health institute.

OB- Obstetrics or Obstetrician, a physician that delivers babies.

Page | 100
Pitocin- A synthetic version of Oxytocin, the “love” hormone, that helps labor start and progress.

Placenta Accrete- A serious pregnancy condition when the placenta grows too deep into, or even
through, the uterine wall.

Placenta Previa- A condition where the placenta partially or fully covers the opening of the uterus
(cervix) and causes problems with vaginal delivery.

Polyhydramnios- Excess of fluid in the amniotic sac.

Posterior Baby- Also known as “sunny-side up”, when the baby’s back is along the mother’s back.

Posterior Cervix- When the cervix is tilted towards a woman’s back. A posterior cervix is low and closed
and hard, and will move forward as it started softening and opening.

Rebozo- A long scarf used as a comfort tool during labor and to adjust baby’s position before and during
labor.

Ripening Cervix- The softening of the cervix before labor begins.

ROM- Rupture of Membranes, when the bag of waters breaks.

Saline Lock- Also known as a hep-lock, historically; this is an IV catheter, placed in a vein in the arm or
hand, flushed with saline, and capped off in case urgent administration of a drug is needed later on.

TOCO- Short for cardiotocography, a monitor that measures uterine contractions and fetal heartbeat.

TOLAC- Trial of Labor after Cesarean; the term describes a woman who wants to try to have a vaginal
birth after a C-section but has not yet completed the vaginal birth.

Tocolysis- An anti-contraction medication to stall or stop labor.

Transverse Baby- When the baby lies sideways or the baby’s head is looking to the side.

Uterine Dehiscence- When the uterine scar opens slightly but not through the entire distance of the
uterine scar.

Uterine Rupture- When the uterine scar opens through all three layers of the uterine wall.

Uterine Window- Where the scar tissue of the uterine scar is stretched thin and you can see through it.

Page | 101
VBAC- Vaginal Birth after Cesarean; the official title after a woman has a Cesarean and then delivers
vaginally. A successful TOLAC.

VBAMC- Vaginal Birth after Multiple Cesareans; when a mother chooses to have a vaginal birth after two
or more Cesareans.

Webster-certified Chiropractor- A chiropractor certified to perform a specific type of sacral adjustment

to help the mother’s pelvic alignment and nervous system.

For more definitions visit:

https://www.betterhealth.vic.gov.au/health/ServicesAndSupport/medical-terms-and-definitions-during-
pregnancy-and-birth

Page | 102
 APPENDIX 2 – RECOMMENDED RESOURCES
We encourage you to study and dig even deeper into the areas that resonate well with you. Here are
some recommended resources that we love.

Optimal Fetal Position Resources

The Miles Circuit: www.milescircuit.com
Belly mapping: spinningbabies.com/learn-more/baby-positions/belly-mapping
Truths and Myths about OP Baby: spinningbabies.com/learn-more/baby-positions/other-fetal-
positions/op-truths-myths

Books
Birthing Normally After a Cesarean or Two by Hélène Vadeboncoeur
How to Heal a Bad Birth by Debby A. Gould and Melissa J Bruijn
The VBAC Companion by Diana Korte
Ina May’s Guide to Natural Childbirth by Ina May Gaskin
Birthing from Within by Pam England and Rob Horowitz
Cut, Stapled, & Mended by Roanna Rosewood

Websites
The VBAC Link Blog: www.theVBAClink.com/blog
ACOG: www.acog.org
ICAN: www.ican-online.org
VBAC.com: www.VBAC.com
Evidence-based Birth: evidencebasedbirth.com
From Dads to Dads: www.fromdadstodads.org.uk

Podcasts
The VBAC Link Podcast: TheVBACLink.podbean.com
The Better Birth Podcast: TwoDopeDoulas.libsyn.com
The Birth Hour: TheBirthHour.com

Page | 103
 APPENDIX 3 - REFERENCES

ACOG. (2015). Screening for Perinatal Depression Committee Opinion 630. From
https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-
Obstetric-Practice/Screening-for-Perinatal-Depression
ACOG. (2016). Assisted Vaginal Delivery. From https://www.acog.org/Patients/FAQs/Assisted-Vaginal-
Delivery
ACOG. (2017). Excercise During Pregnancy. From ACOG: https://www.acog.org/Patients/FAQs/Exercise-
During-Pregnancy
ACOG. (2017). Practice Bulletin No. 184: Vaginal Birth After Cesarean Delivery. From
https://journals.lww.com/greenjournal/Fulltext/2017/11000/Practice_Bulletin_No__184___Vag
inal_Birth_After.48.aspx
ACOG. (2017). Vaginal Seeding, Committee Opinion No. 725. From https://www.acog.org/Clinical-
Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Vaginal-
Seeding
ACOG. (2018). ACOG Committe Opinion Number 745. From https://www.acog.org/Clinical-Guidance-
and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Mode-of-Term-
Singleton-Breech-Delivery
ACOG. (2018). Nutrition During Pregnancy. From https://www.acog.org/Patients/FAQs/Nutrition-
During-Pregnancy
ACOG, SMFM. (2014). Safe Prevention of the Promary Cesarean Deilivery. From
http://www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Pre
vention_of_the_Primary_Cesarean_Delivery
Allison, D. B., Fontaine, K. E., Manson, J. J., & Stevens, T. (1999). Annual Deaths Attributable to Obesity
in the United States. JAMA, 1530-1538.
American Cancer Society. (2018). Key Statistics for Melanoma Skin Cancer. From
https://www.cancer.org/cancer/melanoma-skin-cancer/about/key-statistics.html
American Pregnancy Association. (2015). VBAC: Vaginal Birth After Cesarean. From
http://americanpregnancy.org/labor-and-birth/vbac/
Baer, G. (2003). Life: The Odds. London, England: Penguin Publishing Group.
Bayles, B., & Usatine, R. (2016). Evening Primrose Oil. From
https://www.aafp.org/afp/2009/1215/p1405.html
Beck, C. T., Driscoll, J. W., & Watson, S. (2013). Traumatic Childbirth. London: Routledge.
Blount, D. (2005). Growing a Baby: Diet and Nutrition in Pregnancy. The Birth Kit, pp. 28-29.
Bohren, M., Hofmeyr, G., Sakala, C., Fukuzawa, R., & Cuthbert, A. (2017, Bohren, M; Hofmeyr G; Sakala,
C; Fukuzawa R; Cuthbert A.). Continuous Support for Women During Childbirth. From
https://www.ncbi.nlm.nih.gov/pubmed/28681500
CDC, NCHS. (2015). Heart Disease. From CDC: https://www.cdc.gov/heartdisease/facts.htm
Cragin, E. (1916). Conservatism in Obstetrics. New York: NY Med.

Page | 104
Declerg, E. R., Cheng, E. R., & Sakala, C. (2018). Does maternity care decision-making conform to shared
decision- making standards for repeat cesarean and labor induction after suspected
macrosomia? From https://www.ncbi.nlm.nih.gov/pubmed/29934981
Dekker, R. (2017). Evidence For Doulas. From https://evidencebasedbirth.com/the-evidence-for-doulas/
Goer, H., & Tomano, A. (2012). Optimal Care in Childbirth: The case for a physiologic approach. Seattle:
Classic Day Publishing.
Guise, J. M., Eden, K. C., Denman, M. A., Marshall, N., Fu, R., Janik, R., . . . McDonagh, M. (2010). Vaginal
Birth After Cesarean: New Insights. Evidence Report/Technology Assessment No.191. Rockville,
MD: Agency for Healthcare Reasearch and Quality.
Guittie, M. J., Othenin-Girard, V., & Irion, O. (2014). Maternal Positioning to Correct Occiput-Posterior
Fetal Position in Labour. From https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3942064/
Heath, T. (2018). Your Chances of an IRS Audit Are Way Down. From
https://www.washingtonpost.com/business/economy/your-chances-of-an-irs-audit-are-way-
down-but-keep-it-on-the-up-and-up/2018/04/06/cb6c5794-3779-11e8-9c0a-
85d477d9a226_story.html?noredirect=on&utm_term=.10e4c2e8d339
Holland, A., Chung, D., Wing, D, Rumney, P., Saul, L., Nageotte, M., & Lagrew, D. (2006). Ethnic disparity
in the success of vaginal birth after cesarean delivery. The journal of maternal-fetal & neonatal
medicine, 19, 483-7.
Jukelevics, N., & Wilf, R. (2009). Breastfeeding is Priceless. From
http://www.motherfriendly.org/downloads
Kaiser Family Foundation. (2017). OECD Health Data: Health Status: Health Status Indicators. OECD
Health Statistics Database.
Kemel, J. (2016). 6 Ways Doulas Can Support Families Planning VBACs. From https://www.dona.org/6-
ways-doulas-can-support-families-planning-vbacs/
Kennel, J., Kalus, M., Robertson, S., & Hinkley, C. (1991). Continuous emotional support during labor in a
US hospital. A randomized controlled trial.
Kieser, K. E., & Baskett, T. F. (2002). A ten year population based study of uterine rupture. From
https://journals.lww.com/greenjournal/fulltext/2002/10000/a_10_year_population_based_stu
dy_of_uterine.22.aspx
Lore, M. (2018). Umbilical Cord Prolapse and Other Cord Emergencies. From
https://www.glowm.com/section_view/heading/Umbilical%20Cord%20Prolapse%20and%20Oth
er%20Cord%20Emergencies/item/136
Martin, J. A., Hamilton, B. E., & Osterman, M. J. (2015). Births: Final Data for 2013.
Martin, J. A., Hamilton, B. E., Osterman, M. J., Driscoll, A. L., & Drake, P. (2018). Births: Final data for
2016. Hyattsville, MD: National Center For Health Statistics.
Matko, K. (2013). Your Chance of Becoming an ID Theft Victim Is Greater Than You Think. From
https://www.moneytalksnews.com/your-chance-of-becoming-an-id-theft-victim-is-greater-
than-you-think/
Mazumdar, M. D. (2016). Cephalopelvic Disproportion (CPD). From http://gynaeonline.com/cpd.htm

Page | 105
McCarthy, P. (2018). Falling Injuries & Fatality Rates. From
https://www.offgridweb.com/survival/falling-injuries-fatality-rates/
Miles, M. (2008). The Miles Ciruit. From http://www.milescircuit.com
Motomura, K. (2017). WHO Multicountry Survey on Maternal and Newborn Health. Science Report, 10.
Nahum, G. G. (2018). Uterine Rupture in Pregnancy. From
https://reference.medscape.com/article/275854-overview
National Institute of Child Health and Human Development, Maternal-Fetal Medicine Units Network .
(2007). Development of a nomogram for prediction of vaginal birth after cesarean delivery.
Obstetrics and Gynecology, volume 109, 806-812.
Perry, J. C. (2016). From The Black MAternal Mortality Rate in the US Is an International Crisis:
https://www.theroot.com/the-black-maternal-mortality-rate-in-the-us-is-an-inter-1790857011
Proctor, L. M. (2013). The Human Microbiome: A True Story about You and Trillions of Your Closest
(Microscopic) Friends. From
http://www.actionbioscience.org/genomics/the_human_microbiome.html
Property Casualty Insurers Association of America. (2018). How Many Times Will You Crash Your Car.
From https://www.forbes.com/sites/moneybuilder/2011/07/27/how-many-times-will-you-
crash-your-car/#7721f4df4e62
Rath, W., & Tsikouras, P. (2018). Misoprostol for Labour Induction after PreVious Caesarean Section -
Forever a "No Go"? From https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4678051/
Rutledge, S. S., Osborne, C., & Illuzzi, J. (2013). Outcomes of Care in Birth Centers: Demonstration of a
Durable Model. Journal of Midwifery and Women's Health, 3-14.
Sagady, L. M., & Romano, A. (2007). Coalition for Improving MAternity Services: Birth Can Safely Take
Place at Home and in Birthing Centers. Journal of Perinatal Education, 81-88.
Selma, M., Taffel, B., Paul, J., & Teri, L. (1987, Augusy). Trends in the United States Cesarean Section
Rate. American Journal of Public Health, Vol. 77, No. 8, pp. 955-959.
Stamilio, D., Stamilio, E., DeFranco, E., P. A., Odibo, J., Peipert, J., . . . Stevens, G. (2007). Short
interpregnancy interval: risk of uterine rupture and complications of vaginal birth after cesarean
delivery. From https://www.ncbi.nlm.nih.gov/pubmed/17978122
Vireday, P. (2009). A History of VBACs and Cesareans in the USA. From
https://wellroundedmama.blogspot.com/2009/03/history-of-vbacs-and-cesareans-in-usa.html
Vita, M. (2014). Stop Stripping Membranes. From
https://www.nurturingheartsbirthservices.com/blog/?p=22
Weed, S. (1986). Red Clover: Fertility Herb and Tonic.

Page | 106