Episode 215 Dr. Christine Sterling + Board-Certified OBGYN Answering Your Questions

It’s so hard to believe that 2022 is coming to a close. Today is our last episode of the year! We have had so many inspiring guests on the podcast in 2022 and are so thankful to all of our listeners. No topic is off-limits in today’s Q&A episode. Dr. Christine Sterling is a board-certified OBGYN and founder of Sterling Parents. Meagan is here today asking Dr. Sterling questions sent in by our listeners. We cannot emphasize enough the importance of interviewing multiple providers, researching evidence-based information, and paying attention to how YOU feel about their responses! Additional LinksDr. Sterling’s Instagram: @drsterlingobgynSterling ParentsBebo Mia’s WebinarHow to VBAC: The Ultimate Prep Course for ParentsFull Transcript under Episode DetailsFull Transcript Meagan: Turn your love of babies and bellies into cash. If you love babies and bellies and want to provide care and support to families, then Bebo Mia’s webinar is the right place for you. Get answers to those burning questions like how to be the voice you wish you had at your birth and how babies and families can be supported by doulas. Learn all about the different kinds of doulas. You can work in fertility, pregnancy, birth, postpartum, or just enjoy working with those squishy babies. Supporting families by becoming a birth worker, aka doula, is perhaps an option that hasn’t even crossed your mind. That’s why we want you to join this webinar. You can have great earning potential while doing something you love. Bebo Mia is the one-stop shop for education, community, and mentorship. Reserve your spot today at bebomia.com/freewebinar. Meagan: Hello, hello. You guys, this is our last episode of the year. 2022 has come and gone and I cannot believe it. So many things have changed this year as you know. Julie has left the company and I’ve been solo for a little bit. That was a big, big change for us, but I am doing one of our first, I should say one of my first, episodes with a birth professional Dr. Christine Sterling. I cannot wait for this episode to be aired because it’s going to be amazing. Dr. Sterling is a board-certified OBGYN and a founder of Sterling Parents which is a membership that provides the heart-felt support, expert advice, and timeless wisdom people deserve as they grow their families. After becoming a mother herself, she discovered first-hand how little support Western medicine offers to women moving through the life-altering transition into motherhood. Amen to that. It makes me sad. It breaks my heart how little support there is. So now as a mom, she is on a mission and dedicated to ensuring women get the maternal care and support they deserve. Dr. Sterling has developed a signature body, mind, and heart model of care combining cutting-edge science and ancient wisdom with her years of patient care, thousands of births, and long-standing meditation practice. So, Dr. Sterling, we are so happy that you’re here. I am so happy. I still say we. We as in The VBAC Link. I don’t know if you know, but I used to have a partner named Julie. We had been together for years and years and she has just recently left, so I just can’t get out of the ‘I’ and the ‘we’. I’m always going to be a ‘we’. Dr. Sterling: You know what? In medicine, we always talk about the ‘we’ when you are part of a team, so I will oftentimes always use the ‘we’. Meagan: Yes, yes. Thank you so much. Is there anything else that you would like to share that I did not cover, all of the amazing things that you do? Dr. Sterling: I think we will get all into it, but that is the long and short of it. Meagan: The long and short of it. There’s so much because you are so amazing. Okay well then, we will just dive right in. Dr. Sterling: Let’s do it. Meagan: As we were getting questions, a lot of people asked very similar questions. One of the number one questions that people are asking is how do you truly advocate for yourself? What is the best way to advocate for yourself? As a VBAC mom, you can feel very much against the world when you are entering a birth space, and sometimes when you are entering a birth space where there’s an on-call provider like you said, when you work in a team and you don’t know that person and you haven’t really established the relationship of them knowing what you want, it can be hard and with different nurses and all the things. So what would you say is one of the best ways to advocate for yourself as a patient? Dr. Sterling: Yeah, so I think that sometimes the word ‘advocate’ can sometimes put a lot of pressure onto the individual that, “I need to advocate.” Meagan: “I need to be strong.” Dr. Sterling: Yes, exactly and it feels like this really heavy weight. There’s a mental weight to this, “I have to advocate to get what I need.” I completely understand where that comes from especially when you are wanting a VBAC. It can feel like there are policies going against you and that people aren’t working with you, so I think that the first thing is to hopefully get into a therapeutic relationship with a midwife, a doctor, or a practice of doctors in which there is a collaborative relationship in which advocating isn’t so heavy. It’s a conversation. It is a discussion that you are having with each other. For me, I think that oftentimes physicians and patients are communicating to each other on different levels. We are not really understanding where the other party is coming from and we don’t understand what’s the tape that’s playing in their mind. As a patient, you may be playing this tape of, “They’re trying to get me to have a C-section and the odds are against me and I’ve got to fight my way through it.” And as a physician, you have a whole other tape playing. One of the things I encourage with my members is really, I share the behind the scenes and the thought process that is going on for their OBGYN when they’re having that conversation so that the patient can show up with a perspective and in the space that creates that really strong, collaborative environment. I can go through some of the things that I typically talk to my members about with that, but I like to tell my members, “This is not about you having to advocate so hard for yourself, but rather to invite your provider into a collaborative relationship with you and there are ways that individuals can do that.” I want to caveat that with I wish that it wasn’t something that patients had to do so much. I wish it was something that as physicians, we showed up in that space. A lot of physicians do, but not everybody does. I like to think of it as it’s not the problem of each healthcare provider being, “Oh, you’re bad and you should be showing up and collaborating with patients better.” It is a system problem very much. We have burnt-out physicians. We have hospitals that are coming down on them so we have a system that does not foster a collaborative relationship between patients and there are things that individual patients can do to invite their providers to have a more collaborative relationship. I wish patients didn’t have to do that, but I do think that it can be beneficial. Meagan: For sure. I think sometimes too as a patient coming in, we do know that our providers are burning out a lot of the time. They don’t have a ton of time, so you have a lot that you want to bring to the table, but at the same time, you hold back and restrict that because you don’t want to drill your provider with a million questions. Sometimes the provider, although they really want to answer, they don’t have time to have that conversation. Dr. Sterling: 100% yes. Meagan: It’s not even that they don’t want to, it’s that they can’t because they are seeing 60 patients that day. Dr. Sterling: Oh trust me, we would much rather, much rather—when physicians leave and stop taking insurance and go and do a private practice that is just cash-based, which that’s how some physicians solve the burnout issue is, “You know what? I’m exiting the insurance realm,” because what do they do? They have longer appointments with their patients. They take fewer appointments. That’s what we want. You only want to see 10 patients a day and give each patient 45 minutes. 100%. But you can’t if you take insurance. We are locked into this system that makes us not able to have the type of therapeutic relationship with our patients that all of us at our core want. Some of us have awakened to the fact that the patients aren’t the problem, the system is the problem. Some physicians will say, “Oh, the patient Is asking too many questions and I’m annoyed at the appointment.” But they’re not saying, “You’re not annoyed at the patient,” but that patient was paying whatever amount of money for that appointment and if you had a whole hour with them, you would be so happy to show up and educate. Meagan: Yes, yes. Well then and sometimes too on the patient side of things, we can see it as, “Oh, well my doctor is not supportive. My provider is not supportive because they don’t even want to listen to me or they are very quick to answer.” From a VBAC standpoint, a lot of the time when we’re coming into these providers to ask them these questions, we really want a heartfelt answer. Dr. Sterling: Of course you do. Meagan: We don’t just want to hear ‘yes’ or ‘no’,  so that’s another one of the questions that a lot of people have asked is what are some of the signs or red flags I should be watching out for that maybe my provider although probably wonderful, may not be the best provider for me or for that patient, right? How can someone decipher through that and try to understand that that provider doesn’t have a lot of time as well? There’s this happy medium. What are some red flags or signs that you would say, “That might not be a good provider for you”? Dr. Sterling: Perfect, so there are two main issues here. One, how do we have a conversation about VBAC when we have so little time? I want to address that. The first question though is, what are the red flags? How do you know if you have the right provider to support you in having a VBAC? This is actually really, really simple and very easy to do. What you’re going to do is you’re going to go to your provider and you’re going to say, “What do you think about VBAC?” You’re going to be quiet. You’re not going to lead them to that you want a VBAC. Nothing. And just let them talk. If you have a provider who is like, “You know, VBACs makes me really nervous. I’ll do them but they make me really nervous and I’ve been burned. I’ve had some bad experiences.” Or if you have someone who’s like, “I love VBAC. When I get a pregnant person who has a quote-on-quote ‘successful VBAC’, it makes me happy. It makes my day.” Those are very different people, right? It’s not that somebody who has that more negative view of VBAC can’t provide you with appropriate medical care, but it’s that whole extra level of your experience. Do you know what I mean? If you are going for a VBAC and you feel like your provider already has the scalpel in your hand, it puts extra stress and extra pressure on you to advocate for yourself whereas the person who is in a relationship with someone who loves a VBAC is like, “We’re doing it together. We’re collaborating.” Also, when that provider who loves VBAC and who is gungho with you says, “You know what? We’ve got to call it. Let’s do it.” You come to that from a place of, “You know what? I trust this person. I know she wanted this for me and I trust that what she’s telling me right now that I really do need—” Meagan: It is best. Dr. Sterling: It is best. That’s why I think you just ask a question. Stay very quiet. Don’t let them know how you feel about VBAC or that you want a VBAC and you just let them tell you their perspective. Both providers can provide excellent medical care, but you want to be in an environment with someone who’s into it and who’s excited about VBAC. Meagan: Yeah, who’s just going to create that extra level of experience because like you said, this provider over here may be more hesitant and is quote-on-quote going to let you ‘try’ but may not have that extra oomph, energy, and positivity in your experience but you still might get your VBAC with that provider. That doesn’t mean that they’re not totally unsupportive. We talk about tolerance and stuff like that, but yeah. This other provider over here may be the perfect provider for your experience. Dr. Sterling: Exactly. There are really great physicians who have attempted VBACs themselves and had bad experiences. The reality is that physicians are human beings and we bring our experiences to the table. Too, ideally, we would maybe do a little less than that but that’s just the reality of human beings. We are bringing our experiences to the table. If we’ve been burned, it can be hard to work past that. Meagan: Well and just like you were saying at the beginning, that provider might be playing a different tape in their head and that was based on their experience, right? Okay, I love that. Anything else you want to touch on with that? Dr. Sterling: Oh, so in terms of the VBAC, how do you have this conversation with your provider about VBAC? I want us to look at having the conversation about VBAC over an entire pregnancy. Please do not try to fit it in—it is okay to start talking about VBAC at maybe not your first appointment because there’s so much going on with all of that, but it’s okay to start talking about it in the first trimester. I’m a big proponent of that. I’m a big proponent of and I believe that a lot of pregnant people are carrying around this mental weight of uncertainty and unanswered questions and concerns and worries. For me, part of having the VBAC discussion early is let’s start relieving some of that weight. So that’s really important is if it’s on your mind and if your provider is saying, “You know, we’ll talk about that closer,” just say, “You know what? I get it. I’m so far away from my VBAC. I totally get it but it’s on my mind and I think that it would really help with my stress levels and with my quality of life if I can start having some of these questions answered now so I don’t have to carry them around for my whole pregnancy.” Meagan: Right, yeah. Something that one of our followers asked was about—I’m sure you’ve heard of it—bait and switch where they seem supportive and then at that last minute where you really start talking about it, they kind of shift their gears. Sometimes I feel like if we can do what you said and start talking about it in the first trimester then we may recognize earlier on whether that provider and you are a good match or not because the bait and switch a lot of times feels like it comes at the end where they’re like, “Yeah. Yeah, we’re supportive,” but they’re never having that full conversation. There are so many questions but like you said, there’s a whole pregnancy so we can keep asking these questions at each visit taking a little time that a provider does have and having that to avoid that final trimester, the last few weeks, feeling like your provider just switched on you. So I don’t know if there’s anything that you want to talk about with bait and switch. It seems very negative to talk about people doing a bait and switch but it does happen where providers shift their gears and it sucks to be in that spot at the end. Dr. Sterling: Yeah, so the parting line of the OBGYNS—if you’re in the United States and you’re an OBGYN, ACOG encourages VBAC. We want people to VBAC. We want people to VBAC. So what it often is is that you’re kind of getting the parting line at the beginning of pregnancy because it’s far off and it’s like, “Yeah, yeah. We support VBAC. You can do a VBAC,” whatever. And then push comes to shove and you do understand that “Oh, this provider has some more nuance to their support for VBAC.” You know? I think it’s again, it is about talking to them about and asking very—sometimes you want to hear what you want to hear. Sometimes we have to ask the hard questions and ask in a non-leading way because human beings and all of us to some degree are people pleasers. It’s just a natural human behavior thing. So if you can just say, if you can ask more-detailed questions like, “Is there anything about me and what happened to me last time and my personal, medical, and obstetric history that makes you more nervous or reticent to recommending a VBAC?”Understanding that what you’re getting at there is yes, you’re getting at their medical assessment of what kind of candidate you are for a trial of labor after a C-section, but also, you’re getting an idea of what are they going to bring up at the end of pregnancy? Is there anything that I can address now? And really, it is okay to evaluate your provider as you move through and make sure that you are on the same page. Meagan: Yeah, for sure. I love that. I love that question. Write that down, listeners. Write that down. Okay, so one of the questions is, of the VBACs that you have seen, what are some of the things that have stood out to you about TOLAC and about people who go for a VBAC? Is there anything good and bad that you’re like, “Okay, this is something that stood out to me in a positive way or this is something that I never knew about and then I saw this and now I’m watching for this for the future births”? Dr. Sterling: Yeah, so I talk about this thing with my members all of the time. The thing that I have found to be most important when we’re thinking about the mode of birth is to understand that the most important thing is that regardless if you end up with a repeat C-section or you end up with a successful vaginal birth after a C-section, what we want is somebody who had as empowering of an experience as possible. Hopefully, it was also a beautiful, empowering experience. You can have a beautiful birth experience by having a C-section and have it with a vaginal birth. What I have my members do is have them come up with their birth values. We usually stick to three or five. What are your birth values? And understand the why behind it. “I want a vaginal birth because—” what’s my why? And underneath that, there’s oftentimes some really good stuff, and if you can bring that to the surface, those values. “I want to feel present in my birth. I want to feel that I have autonomy over my body.” It's different for everybody, but these values come up and what’s important is that we talk about how you can honor those values and those deep desires regardless of the mode of birth so that if we set up, “I want a vaginal birth and that is the success for me and if I don’t get that, I have failed. The birth has failed” if you can fail at giving birth. What we want to do is to work towards a vaginal birth while also acknowledging that at the core, even if the vaginal birth doesn’t happen, we want these values to be honored. Let’s talk through how we can honor these values in a C-section. What can we do to prepare you for a C-section that is beautiful and I will tell you, some of the births that really stick out in my mind from experiences I’ve had with patients were the most beautiful belly births. I mean, really beautiful experiences and experiences that still bring tears to my eyes. I think a lot of times we act like the only time birth can be beautiful is if it’s vaginal. Meagan: Is if it’s vaginal, yeah. It’s not true. Dr. Sterling: It’s not true. Oh my gosh. The births actually that I think about the most in terms of a beautiful birth experience was a belly birth. That was me as a provider. That’s not me as my personal birth experiences but they can be really, really beautiful birth experiences. Meagan: Yeah, with my second it was undesired. I didn’t want a second Cesarean, but it was a beautiful experience and I will cherish it forever. It helped me grow and it helped me heal from my first one too. Okay, I love that. The next question is about induction and VBAC. At what weeks would you suggest induction for VBAC in general and I know further down in the questions there is when would you suggest induction for VBAC with gestational diabetes? Maybe they’re the same. Maybe they differ, but yeah. That’s one of the questions. Induction and VBAC are also controversial depending on the provider. Dr. Sterling: So the issue with induction with VBAC is that two things are true. This is the part that really trips people up. We have some data that an induction at 39-40 weeks with a VBAC may increase your chances of a vaginal delivery. We also have data that people who go into labor on their own have a higher chance of having a VBAC with a trial of labor so both things are true. If we had a crystal ball and knew that you were going into labor on your due date with a VBAC, we would not induce you before that because that would be best for you to go into labor on your own. However, if we had a crystal ball and we knew that you were not going to go into labor and you would need to be induced at 41 weeks and 5 days, we would have wished that we had induced you at 39 weeks. There is no right answer here. I’m a huge believer in membrane sweeps for people who really want a vaginal birth. Ideally, around 39 weeks, I’ve had many membrane sweeps myself. They are not necessarily the most pleasant experience. Meagan: And sometimes they work and sometimes they don’t. Dr. Sterling: Sometimes they don’t. So membrane sweeps reduce the chance that you will need a formal induction of labor. They are kind of considered a method of induction so we usually don’t do them too early. They reduce the chance that you will need a formal induction of labor. On average, they are going to shorten your pregnancy by about four days. They don’t always work to put you into labor, but with a VBAC, we also want to think about how much medication we have to give you if we do need to induce you. We would like to reduce the amount of medication we give you so that may help your cervix just be a little bit more ripe, ready, and primed for labor. We don’t have data to support this so that’s why I’m saying this. It may be helpful to reduce the amount of Pitocin we need to use for your induction. That’s why I’m a big proponent of membrane sweeps in the right patient and with informed consent. That is very, very critical because unfortunately, that does not always happen and that’s absolutely not acceptable for someone to undergo a membrane sweep without informed consent. Meagan: Right, going over anything. Yeah, I love that. Like you said, it’s so hard because there’s no crystal ball. You have to go through and look at where you’re at and what’s best for you and your situation. Another question about induction is, are there any methods you will or will not use? We do know through the history of Cesarean, there are certain things like Cytotec that we really don’t use but then there are random providers out there who you will hear give Cytotec and things like that. Dr. Sterling: And your other question about gestational diabetes, when you are induced for gestational diabetes depends on how well your glucose is being controlled, if it’s requiring medications, and oftentimes, your provider is going to prioritize the recommendations for your gestational diabetes induction especially if you are on insulin or say your fasting glucose is not where we want it because with some types of gestational diabetes and with certain levels of control, there is that increased risk of stillbirth, that is typically where they will put the priority. So if your glucose is poorly controlled, even if it might be the best thing for your potential VBAC to be induced at 38 weeks, if you have poorly controlled glucose and we are looking at an increased risk of stillbirth because gestational diabetes is mostly a risk when the glucose isn’t well-controlled, then your provider is going to say, “Yeah. It might not be the best thing for a VBAC situation,” but for the health of the pregnancy, this is going to be our recommendation. I just wanted to answer the gestational diabetes question. Meagan: Yes, so let’s go back into induction methods and what you’ve seen. We talked a little bit about membrane sweeping and I am going to quickly run. My daughter is sick and screaming for me so keep talking. I’m going to block my screen out for a second and I’ll be right back, but if you want to talk about induction methods. And maybe too, what you’ve seen work better and maybe also where the cervix is or not. Does that make sense? If you’re not dilated at all, how can you induce and all of those things? Dr. Sterling: There is a bit of a question mark when it comes to induction with a trial of labor after a C-section. There are medications that most OBGYNS are not going to use. Cytotec is one of those medications that when we are inducing labor at term, we don’t like to use because there is some data that it has a higher risk of uterine rupture which is when the scar of the uterus breaks open. We really, really want to do everything we can to avoid that. That’s the complication that we are most concerned about with  We really, really want to do everything we can to avoid that. That’s the complication that we are most concerned about with a TOLAC. Some providers won’t do any kind of medication for an induction. They’ll only do mechanical, so membrane sweeping, the Foley balloon or a Cook balloon. They’ll do ruptured membranes, but once it comes to any medication, that will be a hard stop for them. The reason why some providers don’t use Pitocin is that we don’t have enough data to say that this level of Pitocin is a-okay but once you get to this level, that’s where we see the increased risk. We know that using Pitocin can increase the risk of rupture, but we don’t know where the line is. So some providers are like, “Okay. In that setting with that doubt, I’m just going to say no to Pitocin altogether,” whereas other providers will say, “You know what? We will use a lower dose protocol for our people who are undergoing a trial of labor and inform the that we are going to use Pitocin.” It does slightly increase the risk of rupture, but it’s not unreasonable to use Pitocin. It isn’t, but the person has to be informed that this may increase the risk of rupture. We’re going to use a lower-risk protocol to try to mitigate that risk, but we don’t actually have the data to say, “This amount is okay. This amount isn’t okay.” And so this is where it comes to how different providers land when there’s nuance and when there’s gray. Some providers are going land in the, “No. I don’t want to do anything that could increase your risk of rupture,” and other providers are saying, “Hey, if you’re aware of this risk and you’re okay with it, I’m okay doing Pitocin.” It just depends. Meagan: Yeah. I know it’s such a hard one because there are different providers. With my second, I was begging for Pitocin. First of all, who begs for Pitocin? Not normal, not a lot of people, but I was begging for it. He was like, “No, no, no, no,” but then I was a doula and I started working and I was like, “Wait. There are all of these providers doing Pitocin, but then there are also providers that won’t.” It’s like you said, “Okay, I’ll a Foley or a Cook, or I’ll break your water. And sometimes I’ll use Pitocin if we have an IUPC and we can monitor the strength.” So it’s just so hard. Again, it’s one of those questions where there are two answers. Dr. Sterling: That’s the thing is that there are some things in medicine and some things in obstetrics where you will get clear answers. That’s always really comforting as a patient to be like, “Oh. Everybody agrees on this. Okay. I feel comfortable.” But then when you get to the situations where there is a gray zone and there is nuance and you see some providers doing something this way. Where I trained, they gave Pitocin for vaginal births. That was my standard practice. I left residency and I joined a practice and they were like, “No. We as a group do not do Pitocin for TOLAC.” And so it was like, “Oh, okay. This is different.” Patients would ask me what my perspective is and I’m like, “My perspective is that I’m used to doing this and I think that it can be done safely, but I’m part of a practice where that is a no-go.” Meagan: That is restricted. Dr. Sterling: We’re restricted. So you know, one physician could feel a certain way about what they do but then be in a setting where this is not how it’s done. Meagan: And that’s hard too because a lot of time, they would be viewed as unsupportive, but it’s actually not that they're unsupportive but that they're restricted. From a patient’s point of view, we have to remember that sometimes it’s not that the provider doesn’t want to, it’s that they can’t within the practice that they’re in. And again, that’s where it’s like, “Okay, well maybe that practice isn’t the right practice for you.” Dr. Sterling: Exactly. Even if you were with me and you loved me, you’re like, “I love Dr. Sterling. We get along so well,” but her practice and some physicians are their own bosses. A lot of physicians are employed and they are dealing with an employed physician that has a group that says, “We don’t do this and you are an employee and not an owner of the practice.” Then you’re like, “I love her, but she can’t offer me Pitocin so I may have to go with someone else, and maybe I don’t have the rapport that I had.” So it’s unfortunately with physicians, oftentimes you’re compromising on something. The question is what do I need? What are my non-negotiables within the practice? Stay firm on those. Your non-negotiables are your non-negotiables. Be clear. Some people may say, “You know what? I don’t like that they don’t offer Pitocin but the rapport is more important to me.” Other people may say, “You know what? I need to go somewhere that’s willing to induce me if that’s what I need with Pitocin.” Meagan: Yeah, with my third, I really wanted a VBAC again and I had a super supportive provider. He was top-notch supportive and known in Utah as one of the most supportive providers, but in the end and at the end of things, I was just feeling like I shouldn’t be there. Everyone was like, “Why? You have the most supportive provider,” and I’m like, “Because I know that he’s going to be restricted. I don’t want to have that restriction although there are other providers who just don’t have restrictions but not as many,” so I changed. I had a VBAC after two Cesareans and it was beautiful and amazing. Maybe I would have with that provider but I don’t know knowing my birth story. I think he would have been cut off. He wouldn’t have wanted to but he would have been cut off. Okay, so one of the questions was is a C-section always safer than a vacuum or a forceps delivery? So if you’re coming to the point where you’re pushing and you’re about to get this VBAC and you’re so close, but you might need an extra little bit of assistance, do you feel like a Cesarean is quote-on-quote “safer” or a better route than those other assisted delivery methods? Again, everybody has a different perspective and their history of using these things might come into play. But just share some of your thoughts. Dr: Sterling: You can’t make a blanket statement that a Cesarean is always safer than a vacuum delivery or a vacuum is always better than a Cesarean. It really is each individual situation. What I can tell you is that if the vacuum is successful, if the forceps are successful and you have a vaginal birth and baby is okay and you’re okay, then yeah. That was a better decision than going for a C-section in the second stage of labor. C-sections in the second stage of labor are not risk-free. As we know, there are a lot of risks to that too. The thing that becomes the more unsafe situation is when you have a failed vacuum or a failed forceps and then you go to a C-section. Meagan: That’s what I was going to ask. Dr. Sterling: That situation, we want to avoid because that’s the highest risk situation. Failed vacuum, failed forceps, then go to a C-section. If we knew that was going to happen, it would have been way better to go straight to a C-section than to attempt a vacuum. So I think that what I would want if I was in that situation, I was going through a trial of labor and my provider offered me a forceps or a vacuum. I would want to know their confidence level with that.  I would not want to be the one pushing, “Can we try a vacuum? Can we try a forceps?” I would want the other person on the end of the table saying, “I think we’ve got this. I think if I just put a vacuum on real quick, we’re going to pop that baby out and we’re going to be good. We’re going to have a baby.” I want that level of confidence. I want somebody who’s like, “Let’s do this. I have no problem. I think we’ve got it.” I do not want somebody who’s like, “Mmm, we could.” Meagan: We could, we could. Dr. Sterling: If it was me at the other end of the table, somebody saying, “We could,” is like are you feeling good about this? Meagan: Are you confident? Dr. Sterling: Yeah, when you’re about to do a vacuum, I’ve never done forceps. On the West coast, very few people do forceps. On the East coast, a lot more people are still doing forceps. West coast, we have them on labor and delivery, but not something that we did. It was some reasons for that and some of it is medically legal, just the lawsuits from forceps, departments are like, “We don’t do forceps anymore. We’re not doing that.” There are patients where I’ve been like, “Let’s do a vacuum. I think with a few pulls, this baby’s going to come out,” and then there are vacuums where it’s like, “Listen, I could do this. There’s a shot,” but I didn’t feel really good about it and in that setting, I was always super honest with patients that if they were highly, highly motivated for that vaginal birth, they might be willing to take that risk of, “I’m thinking there’s a 50/50 shot here,” but me personally, I would want a provider to feel really good that it’s going to work. Meagan: It’s going to be [inaudible]. Yeah. That makes sense. Another question, we’re just drilling out the questions here. This person had felt during her VBAC, and she did have a VBAC, but she felt burning sensations around her previous incision. She wants to know what that could have been. Could it have been scar tissue? Could it have just been that baby was passing through and stretching out that weakened uterine spot? I will admit, I had that a couple of times with my VBAC where it felt like a muscle being strained. Dr. Sterling: That’s how my first labor felt was burning— Meagan: In your abdominal cavity. Dr. Sterling: Yep and I’ve had other patients where that’s how they described contractions was this burning, stretching pain. My thought is that I can’t answer that question specifically, but that could have nothing to do with the fact that you had a scar in you because that was my first labor experience. It felt like that, but then with my other labor experiences, the contraction pain felt different. People experience contraction pain differently and depending on the baby. My contractions when I had a baby who was sunny-side up when he was occiput posterior, they felt different than the contractions that I had with my other kids. It could have something to do with the scar, but also, it could just have been how your contractions felt. Meagan: Yeah, yeah. Mine seemed like it was a variant. Right before I started pushing. Maybe baby was just descending and the wider part was stretching. I don’t even know. I don’t know the details as far as her labor. She just said that she had it. Could it have been scar tissue or what could it have been? Dr. Sterling: It’s always so difficult to point out what the cause is of a bodily sensation, but I think that there are a lot of different possibilities of what it could be. Some of them are related to a scar and some of them have nothing to do with a scar. Meagan: Yeah. There was another one in regard to talking uterine scar and VBAC. She said that after her first C-section, she was told that the lower uterine segment was thinner, so she was saying, “Could I still VBAC? Is this a total hard no, I absolutely shouldn’t VBAC?” What are your thoughts on that? Dr. Sterling: It’s an area of active research. It’s an area of active research looking at, can we on ultrasound or even MRI measure the lower uterine segment and thus determine the risk of rupture and successful VBAC? It’s still a question mark here, but if you do have an extremely thin lower uterine segment, sometimes we open people up after they’ve had a C-section and there’s a window, right? Meagan: Yeah, that’s another one of the questions. They said they had a window. I’ve actually had a window as well. Dr. Sterling: Yeah. So the window depends. Some of the research didn’t really define what is a uterine rupture. Is a uterine rupture only when you get in and you open up the belly and the tissue is bleeding and it’s clear that it’s just ruptured and this was previously tissue that was together? Or what if you open up the abdomen and you look and there’s this separation but it looks like it had been there for a while? Is that a uterine rupture or a uterine window? Not all of the research and the data have clearly said, “This is what we consider a uterine rupture. This is what we consider a uterine window.” Meagan: Or dehiscence. Dr. Sterling: Or a dehiscence, exactly. There are all of these different terms. There’s a window, dehiscence, and rupture. Meagan: But sometimes it goes to rupture. Dr. Sterling: Yeah, so I think that personally in this gray zone of where the cut-off is for how many millimeters we want to see the lower uterine segment, it’s hard for me to separate that from my own personal experiences having patients have uterine ruptures and have them go through these long labors and then open them up and they’ve got a window. I think that I would lean more towards if my physician was telling me, “Hey, you have a really thin lower uterine segment,” I personally would probably lean more towards a repeat C-section in that setting because to me, if I’m thinking about being in labor and also having the weight of, “What if my uterus ruptures?” If that weight is too heavy, I feel like that’s not what I want to feel and that fear. Meagan: That constant questioning. Dr. Sterling: That constant questioning, and “Oh, they said it was thin. Am I making the wrong choice?” That to me would be very heavy. That isn’t necessarily how another person would feel. What I think is important to think through for you as an individual is, “Is that fact that you have been told that you have this thin lower uterine segment? Is that going to be really prominent and heavy for you when you are in labor or do you still feel light? Does your body still feel light and you still feel like that’s the right choice moving forward, that’s the right path?” With my members, when I take them through—we have our confidence in VBAC path—when I take them through that, I have them ask their body. Ask your body, “Is this a yes and a no?” You have to figure out, “What does a yes feel like in your body? What does a no feel like in your body?” Ask your body, “Does this feel good or does this not feel good?” And then that’s part of making a confident decision about whether you go forward with a repeat C-section or a trial of labor. That doesn’t make the decision for you because you still get to ask your mind and you still get to ask your emotions and you still get to have a collaborative relationship with your provider, but you need to know how your body feels about the decision. Meagan: Yeah, we talk about intuition all of the time and digging deep into what is that saying. What is that intuition saying? A lot of times, that’s the first thing where it’s like, “I shouldn’t have a C-section,” or “I want a C-section”, but then it’s like, “Oh, there’s this VBAC thing. Maybe.” But our initial gut was saying, “I think I should have a C-section,” or vice versa, “I want a VBAC.” Dr. Sterling: 100%. Meagan: I think that’s such a good thing, talking to your body, asking your body. I love that. Okay. I know we don’t have a ton of time left over, but a few more questions we have. Would you suggest an ECV for frank breech wanting to VBAC or would you just say C-section or would you say maybe find a provider if there is one in your area that could support that? Dr. Sterling: Yeah, okay. Meagan: Breech is a whole other podcast. Dr. Sterling: Breech is a whole other thing and it’s so funny. For me, when people talk about breech vaginal delivery, all OBGYNs have birth trauma themselves. It’s called the second victim. We all carry. I don’t know a single OBGYN out in the world who doesn’t have their own trauma from birth. One of my traumas is breech. Of course, this is an unplanned breech so it’s different. I have to always calm myself when breech vaginal birth is brought up because I want to talk about it in an impartial way. An ECV, an external cephalic version, when we do a procedure to turn baby from a non-cephalic, non-head presenting position down into the head presenting position is going to increase your chances of having a vaginal birth. We know that. It also has some risks to it. Some of the risk is that your water breaks. We cause a placental abruption. We cause the placenta to separate. We injure the fetus. That would be super rare, but it’s always something that we educate people about. I’ve never seen it but it could certainly happen. One of the things is that we typically do an external cephalic version before 39 weeks because we know it’s more successful. We typically do them around 37 weeks. If your water does break at 37 weeks because you had an ECV, then we’ve got to do a C-section at 37 weeks and that’s a higher-risk situation for your baby. We want babies to get to 39 weeks if we can. There is that risk of an earlier delivery or an emergency C-section because something happened, but it does increase your chances of vaginal birth. To me, it’s how confident is your provider that they can turn the baby? It depends. There are different characteristics of a person and of how good of a candidate they are for ECV. If you have a provider who’s like, “I’m super confident.” Sometimes I’d be ultrasounding patients and I’m like, “I feel like I could in the office, I’m not going to do it, but I feel like I could push this baby down. There’s a lot of laxity to the uterus. Baby seems to be letting me move them.” So sometimes, it’s like this is a very clear yes. Sometimes it’s a very clear no. Meagan: Then there’s all of the gray. Dr. Sterling: Yeah and then there’s everything in the middle. So what risk do you feel comfortable with? If you want to be able at the end of the day to say, “I did absolutely everything to get that vaginal birth,” then yeah. ECV may be the way to go for you. Most of the time, even if it doesn’t work, everybody’s fine. But there’s that 1% of the time where we’re running back to the OR because baby is having a heart rate deceleration and not recovering. I have certainly been in that situation more than once so it happens. It’s not common, but I don’t classify it as rare. Meagan: But also not that it doesn’t happen. Yeah. It’s just less common. Dr. Sterling: Yeah. To me, rare things are things that I may never see but if I see them every year I’m doing it, to me, that is not rare. Meagan: Right. Right. Someone asked if you’ve ever seen VBAC after multiple Cesareans. ACOG says VBAC after two Cesareans is reasonable for VBAC, but it really kind of falls of the ledge after that. VBAC after three, four, all of the things and we know they happen. They’re out there, but there is very little research. So someone just said, “What about a VBAC after three C-sections?” What would you say and again, I think it’s important to note that it depends on every certain person that you’re with and it also depends on your whole history and the reasons and all of those things, but anything that you would like to bring to the table for VBAC after 3+ Cesareans? Dr. Sterling: After more than two C-sections, yeah. At the end of the day, you have to consent to a Cesarean. You have to consent to a Cesarean. A Cesarean cannot be performed on you without your consent unless you were unconscious and you were brought into the ER and we needed to perform a Cesarean to save your life or you are not medically capable of making your own medical decisions. Meagan: Usually then, they have someone else too. Dr. Sterling: Sometimes. I trained at the place where we got most of the data on VBAC. I trained at LA County Hospital, USC. That’s where back in the heyday of 1% of the US population was born there. It was such a maternity ward that we got the data on VBAC because we couldn’t get those patients back to the OR. They were giving birth in the halls. So a lot of the VBAC data, the initial VBAC data comes from where I trained. Where I trained, we had a lot of people who would come in and give birth and they were very unfortunate stories and circumstances with drug abuse, homelessness, and mental illness. They would not know how many C-sections they had had. They would be coming in and they would give birth and sometimes after they gave birth, we would dig in through the charts looking for who this person could be and we found out that person had had four Cesareans before. Meagan: Wow. Dr. Sterling: I have been part of that. I have never had a patient who had three C-sections where we did that intentionally. I want to be upfront about that, but I think that it’s all about what had happened. Let’s say your first birth was a C-section for breech and then you go on to have a vaginal birth and then you had another C-section for breech and then you had another vaginal. If you’ve had multiple vaginal births, then you’ve had three C-sections, then I’m like, yeah. You are at increased risk of rupture. You’ve got three scars on your uterus for sure, but that’s a very different situation than somebody who’s had three C-sections in a row for failure to progress and then you’re like, “You haven’t had a vaginal birth. We are just putting you at a lot of risk with very little prospective of it being successful.” I have never been in a situation where somebody has had three C-sections and we’ve made the decision to proceed despite the risk with vaginal birth, but I have been part of deliveries where they had had multiple C-sections and we didn’t know because they were actively giving birth and were not able to communicate how many C-sections they had to us. Meagan: That’s an interesting thing to me in my mind. In so many ways, I wonder. Like you said, you didn’t know. But if you would have known, would care have changed? Dr. Sterling: Yeah, it probably would have. We would have made a different recommendation because-- Meagan: Because of what you knew. Dr. Sterling: To us, getting up to a 2% risk of rupture or higher, it’s a difference of perspective on percentages in a risk. As a physician, 2% is a lot of freaking people. That’s 2 out of every 100 and when you’re doing hundreds of deliveries a year, that 2% with a potentially very dire outcome, that 2% weighs much more heavily than somebody who’s like, “Well, 2% is so small.” There’s a whole different weight to that 2%. Meagan: Well, and we talk about that. We talk about how you have to decide what percentage is enough for you. If 2% is fine, then go find that provider that is supportive in that because it might not be like you said, a 2% from your standpoint is a lot but then to someone else, it might not be a lot. Dr. Sterling: Exactly, exactly. Meagan: It’s interesting, yeah. Okay well, that’s good to know. That’s just so interesting. I wouldn’t have even thought of that. You don’t even know the history and you have to go find out who that person is. Wow, I’m sure that was an experience. Dr. Sterling: Unfortunately, I had that experience quite a bit. Meagan: Oh my goodness, yeah. Crazy. Okay well, last question. This one is what can cause a swollen cervix and what would you suggest if anything to help get that unswollen? Is there anything from an OB standpoint that you can do to help the swelling? This is something that a lot of people are like, “Oh, well I went in and I was 8 centimeters dilated and then all of a sudden, I was a 5.” It’s not that you are literally going backward, but swelling can happen based on a lot of things like disruptions of checks and heads and babies’ heads and all of these things, but yeah. Anything you would like to speak to about swollen cervix? Dr. Sterling: Yeah, we don’t necessarily know why sometimes the cervix swells. It’s a really unfortunate situation. What I have seen anecdotally in my experience is oftentimes when a cervix swells and then I have ended up doing a C-section not just for cervical swelling because that’s not an indication for a C-section, but if that person did not progress after that is oftentimes, we have found that baby is not in the optimal position to move down the birth canal. That is something I have experienced personally and it’s very frustrating because when you’re in labor and when you’re giving birth, you feel like it’s all you and your body. We put a lot of pressure on ourselves. I want to remind people that you are only half of the equation at birth and babies can be cooperative and they can be very uncooperative. I have had an uncooperative baby and it was really, really hard. We can try things like Benadryl. We can try. Sometimes, it’s like, if everything is safe, if you’re on Pitocin, maybe we turn it down. We just give it a little break. We can try some Benadryl. We can try some Tylenol. These are things that are aimed at anti-inflammatory. Meagan: Do you take that orally, I assume? Dr. Sterling: You can, or you can give it intravenously if somebody is not tolerating oral. There are some mixed data out there about Tylenol and about Benadryl and their use in labor. But fixing the swelling once it’s occurred doesn’t always happen. Sometimes you can dilate past it. You certainly can dilate past it and I have seen that many times, but I think that the important thing to keep in mind is that it’s not something that you have done wrong. We don’t necessarily know why sometimes that happens. It may be that baby’s just not in the ideal position because really, baby is dilating your cervix. It’s this nice feedback loop whereas baby descends into the birth canal, it sends signals into your brain to release oxytocin. It’s a collaborative process between you and baby. I have had three births and in my first birth, I pushed four contractions and baby was out, phenomenal. Then all of a sudden, my third birth, I was pushing for an hour and nothing. Not a budge. Not a budge. We thought that maybe he was sunny-side up, but we also knew that he was big. He was essentially 11 pounds when he was born, so he was big. I was so down on myself. I was like, “I shouldn’t have pushed the epidural button the last time. Why did I forget how to push?” Meagan: You blamed yourself. Dr. Sterling: Oh my gosh and I know better, but I did. I was blaming myself like, “Why can’t I do this? How did I forget to push?” OB comes in and she’s like, “Yeah, I agree with you. I think he’s OP. I can try a manual rotation.” I looked at her and I was like, “Girl, just do it.” Meagan: That’s another one of the questions by the way. Dr. Sterling: So she goes in and she does. Listen, she was better at manual rotation than I am. I have not had as much success. The fact that this manual rotation worked was a little bit of a surprise to me because in my experience it has always been really hard to do. She went in. She pushed him up. She turned him down and he came out. I didn’t even have to push. The whole time, I’m thinking, “I’m not pushing correctly. How did I forget how to push?” putting all of the pressure on myself. There we go. It wasn’t me. It wasn’t me. Meagan: I love that. That just gave me the chills. Dr. Sterling: I didn’t even have to push. I had to push past my perineum but he came all the way to crowning once he was in the proper position and that was a huge eye-opening moment for me. I instantly felt bad for all of the patients who I had coached and tried to get to push correctly. I was like, “What?” Meagan: Yeah. Dr. Sterling: Yeah, yeah. Meagan: We really do as a society. We need to stop not just in birth but in all things. Motherhood, so many things like, “I’m a bad mom because I did this” or “Oh, this happened.” We put so much pressure and going right back to the very beginning of this whole conversation is being an advocate saying that we have to advocate for ourselves, it puts all of this extra pressure because not only are we saying that you have to go into labor. You have to dilate. You have to efface. You have to bring your baby down in the right position. Then you have to push the baby out. Then you have to nurse the baby. All of these things, right? So it’s like, why are we adding all of this extra pressure onto ourselves where you were doing all of the right things? You were doing everything but it was just this little factor that you needed to change and it was out of your control. You were trying to do everything you possibly could. Dr. Sterling: Exactly. Meagan: I love it. And going back, I said the last question but that was one of the questions. Can you as an OB help if I have a posterior baby? I’ve seen it as a doula. I’ve seen the same thing. This provider who I think is amazing goes in. He did the same thing. Goes up and I could just see him. He closes his eyes and he does this whole thing with the head and he’s like, “Okay, we’re good.” It’s like okay! That is a thing. The very, very last question is how as a patient if you’re like, “I think my baby is OP” or your doula, or your nurse, or your doctor is saying, “I think this baby is OP,” how can you as a patient ask? If we say, “Can you help me rotate this baby? I’m having a hard time doing it with pushing.” Dr. Sterling: Yeah. You do have to be completely dilated. You have to be completely dilated and I find that it can be really difficult to perform, but in the right patient, it is a wonderful tool to have in your toolkit. But there are some providers who are so good at it and there are some providers who haven’t done it as much. I was really impressed by this OB. She was a newer graduate. She had just graduated that year from residency and I actually have some friends in common. She had trained where I had friends do their fellowship, so I texted them after and I was like, “She was so good at that manual rotation.” They were like, “Yeah. That program really pushed manual rotation. They do a ton of it so they come out really well trained in that.” I was like, “That’s so awesome,” because I feel like in our training, that wasn’t something that we did a ton of but I always was like, “Yeah, I can do it” and I would try and once in a while, I would have succeeded but I didn’t feel super confident in that skill. That’s the thing. Where you train really depends on the skills that you pick up. But anyway, so yeah. I think that if you think that your baby is OP and your provider really does have to feel like they’re OP because they don’t want to turn a baby that is OA. You don’t want to turn it the opposite way. But you can say, “Hey, if we think this baby is OP, can we do a manual rotation and try to get him head down?” I think it’s important to ask what the risks are and communicate to your provider if that is something you want. You have to say, “Yeah, I’m okay with those risks,” and then you put your provider in a place of comfort. We get uncomfortable when patients, for me, when a patient is signaling to me that they don’t understand the risk or they don’t believe the risk is possible, that’s when you put your provider into a nervous situation. Meagan: Right, yes. I love that when your patient is confident, it helps you. Yeah. That makes so much sense. Dr. Sterling: If they’re like, “Well, I don’t think that would happen,” then you’re like, “I need you to understand that this very much could happen.” Meagan: Yes, it could happen. This one provider that I was talking to about how there was one time where he was going the way that you would normally go and he was like, “Nope. This baby has to go the other way.” I was like, “What?” And seriously, just rotated it and was like, “All right, now it’s good.” Sometimes too, talk to your provider and say, “Can we try one more time?” or “I understand that it’s not working. Can we take a little break and try again?” Or whatever, assessing. Dr. Sterling: And asking questions. I think it’s really good to just ask questions. If somebody is saying no, it’s okay to say, “Can you walk me through your reasoning?” Meagan: Yeah, I love that. Can you tell me why? Dr. Sterling: It’s totally okay. It’s totally okay to ask that and sometimes when they walk you through your reasoning, you may say, “You know what? I’m actually okay with that risk” or when they walk you through your reasoning, you might be like, “Yeah. I feel you there. I feel much more confident about this decision. It’s not the outcome that I wanted, but I am resonating with your thought process and thus I feel more comfortable with this decision,” so that a month later after this birth, I’m not thinking back on that situation and wondering, “Should I have pushed just a little bit harder?” Even if you’re not getting the birth outcome that you had envisioned, it’s important for you to understand the why-- for many people, I should say, it’s important to understand the why so that your birth story becomes part of your story. I don’t want people to always be questioning, “Should I have done this? Should I have done that?” I think a lot of the time because we feel uncomfortable asking for more explanation and we’re not necessarily always given the explanation then we have all of these questions that we carry with us for literally years. Women who gave birth 20 years ago will comment in my DM’s and be asking questions about that and it breaks my heart that they’ve been carrying that weight for so many years. Meagan: Yeah. I think that is such a great spot to end on is ask questions. It’s okay. It’s okay to ask those questions. It’s okay to have that doubt too. It’s okay to have that doubt and have that question because sometimes it’s like, “Oh, well it’s a stupid question,” but it’s not a stupid question because it’s a question that you want to know. Dr. Sterling: It’s a question you have and there really is no such thing as stupid questions. There really is no such thing. Meagan: Well, thank you so much for taking the time. I know that so many people are going to be just waiting so patiently for this episode to air because we had so many questions we didn’t even get to. Again, thank you so much. Dr. Sterling: Oh, you’re welcome. It was an honor. Meagan: Can you tell everyone where to find you on social media and maybe talk a little bit more about your program? Dr. Sterling: Yeah, yes. I’m @drsterlingobgyn on TikTok and on Instagram and then I have a membership where I support people through trying to conceive, pregnancy, postpartum, and the whole journey and that’s sterlingparents.com. We have a beautiful curriculum that we put people through to help support them through the physical and emotional challenges of the whole journey. We have a really lovely database that I’m really proud of that really can replace all of the internet searches and Google. That database all has three E verifications so all of our information is evidence-based, expert-based, and experience-based so we like to talk about things and with people who have had that experience themselves. Meagan: Yeah, I love it. Awesome. We’ll make sure to drop all of those links in the show notes, so listeners, check out the show notes. We’ll also have you on our social media today and we’ll have everything tagged as well. If you’re not knowing how to do it in the show notes, go to our Instagram. Thank you again, so much. Dr. Sterling: Oh you’re so welcome. Thanks for having me.ClosingWould you like to be a guest on the podcast? Tell us about your experience at thevbaclink.com/share. For more information on all things VBAC including online and in-person VBAC classes, The VBAC Link blog, and Meagan’s bio, head over to thevbaclink.com. Congratulations on starting your journey of learning and discovery with The VBAC Link. Support this podcast at — https://redcircle.com/the-vbac-link/donationsAdvertising Inquiries: https://redcircle.com/brands