Episode 248 Henci Goer + Let's Talk Uterine Rupture

We are so honored to have today’s guest, Henci Goer, joining Meagan today. Henci has made it her life’s work to help women make informed decisions about their care in the birth space. She has written multiple books, received countless awards, and has made current obstetric research more accessible to women worldwide. Henci defines uterine scar separation and talks about what factors may contribute to or help prevent this from happening. Meagan and Henci talk extensively about VBAC, VBA2C, birth plans, induction, and epidurals all using evidence-based research. We love that Henci’s mission is to empower women and families to make the choices that are best for them. Here at The VBAC Link, our mission is the same!Additional LinksHenci’s Blog: Is VBAC Safe?Henci’s WebsiteLabor Pain: What’s Your Best Strategy? By Henci GoerOptimal Care in Childbirth: The Case for a Physiologic ApproachNeeded WebsiteHow to VBAC: The Ultimate Prep Course for ParentsFull Transcript under Episode DetailsMeagan: Hello, hello. Welcome to The VBAC Link. This is Meagan and you guys, we have an amazing, amazing, amazing episode for you today. This episode has actually been kind of a long time coming. We have our friend, Henci Goer. She is just a wealth of knowledge. You’re going to absolutely pick this episode apart. I know it. You’re actually probably going to want a notebook so if you’re one of the listeners that goes on walks or is driving, you might want to press pause or listen to it and come back with a notebook because I know you’re going to want to write these stats down. We’re talking about uterine scar giveaway, you guys. I know that this is something huge. All of our listeners, every single one of our listeners that has had a VBAC is aware of uterine scar separation so this is going to be a really great episode filled with wonderful evidence and all of the things for you. So buckle up. It’s going to be amazing. Review of the WeekBut of course, we have a Review of the Week so I am going to quickly share that with you. This review today is actually on our How to VBAC: The Ultimate Parents Course. This is from Rosie. It says, “As someone who had an unplanned Cesarean myself and as a doula, I really appreciated how well-balanced this course is. There’s no shaming. There’s no bias. It’s just the facts.”Thank you, Rosie. I’m so glad that you are enjoying the course or have enjoyed the course. And if you didn’t know, we do have a How to VBAC Parents Course and a Doula Course for all of you birth workers out there who want to learn how to support your VBAC clients. We have this course. You can check it out at thevbaclink.com. Henci GoerMeagan: Okay, Ms. Henci. I am so honored to have you on the show today. I mean, really, it seems like we’ve been talking for months. I really think it was the beginning of the year, right? Henci: Something around there, yeah. Meagan: Yes. Oh my gosh, it’s been so long. Just for anyone out there who wants to know a little bit more about Henci and why we are having her on the show today, she actually started out as a Lamaze teacher and a doula. Her life’s work soon became analyzing and synthesizing obstetric research in order to give pregnant women, birthing people, and birth professionals access to what continues to be optimal care in childbirth. Just that right there, that little bit right there, I’m telling you guys, it really is her life’s work. If you Google her name, you’re going to find a ton of research. She’s an author of four books. Four books, you guys. Labor Pain, What is Your Best Strategy?, Optimal Care in Childbirth: The Case for Physiological Approach with co-author Amy Ramana– is she on MSN and CNN or has been mentioned? Tell me about that. Henci: She’s a nurse-midwife. That’s Master of Nursing. Meagan: Oh, I was thinking CNM in my head. MSN, so what is that? Henci: It’s a Master of something. I don’t know what that degree is. She’s a nurse-midwife. Meagan: She’s a CNM. Certified Nurse-Midwife, yes. In my head, I read CNM. The Thinking Woman’s Guide to a Better Birth and Obstetric Myths Versus Research Realities. You guys. In addition, she has written numerous blog posts, articles, given lectures around the world, and here she is today on our podcast. I’m so honored. In recognition of her work, she has received among so many others, the American College of Nurse-Midwives’ Best Book of the Year. Henci, congratulations on that. Henci: Yeah, that was a thrill. Meagan: That is amazing. Lamaze International Presidents Award, DONA International Claus– Henci: Both of their memories are a blessing. Meagan: I know. Seriously, a research award on that. Life Achievement Award, I mean, you guys. She has so many awards and here she is to talk with you, Women of Strength, all about one of the biggest topics in VBAC. Right? Uterine separation, also known as uterine rupture. When I started talking with Henci, I love that she was like, “You know, I don’t love to call it uterine rupture. It’s uterine separation.” I have really grown to love that over the last few months that we have been talking. Yeah, so let’s talk about it. What is uterine scar separation, Henci? What is that? Henci: Well, before we get started because I think we are going to be giving a lot of information. I want to emphasize that one of the things that took so long is that what we decided to do is that I would do a blog post that had all of the detailed information in it.Meagan: And it does. Henci: So, not to worry. I imagine that with the notes for the podcast, you’ll post a link to the blog post which will have detailed numbers in it. My life’s work– and I love the review of your course because just sits where I sit. My life’s work has been wanting to give women and birthing people the ability to make choices having all complete, accurate information on the pros and cons of their option which is really difficult to get as you probably know and your people probably know. Meagan: It is. Yes. Henci: What they choose to do with it, it’s just that I’m there for the information. No judgment. I’m here to help people decide they want to plan a repeat Cesarean. Whatever it is, I want people to have accurate, balanced information to the best of my ability to create a space where they can make the choice that’s right for them and their families. Meagan: Absolutely. I love that so much and that is really what we are here about at The VBAC Link. There’s no shaming in choosing a repeat Cesarean. There’s no shaming in choosing an epidural over unmedicated, right? There’s no wrong way to birth, but the most important thing to us here at The VBAC Link is that you know the facts, you know the options, and you choose the best route for you. Henci: And then the other piece which is part of my work as well is to go beyond the information and say, “So now you have this information, what can you do with it?” What are the tips, ideas, and recommendations that will help you craft a plan that will help take you in the direction that you want to go? I’m very careful. This may be one of the more important things that I say to your group and it’s not informational. I’m very carefully not saying “goal”. I think it’s very important to distinguish intention from goal. Goal assumes that you have you get somewhere and if you don’t get to that place then you failed, right? The intention– is this is the direction that you want to go in?To have that in mind helps you, first of all, to plan the journey in a way that’s most likely to succeed in getting there, but it also helps you have your priorities so that if things happen along the way, you’re able to be flexible to know what’s really important, to navigate the space, but to understand that sometimes life has other plans so if you don’t take anything else away from what I say today, please take away that because I think that’s really key. Meagan: Yeah. As a doula, when we’re doing prenatals with our clients, a lot of people will be like, “Can you help me write a birth plan?” I love the idea surrounding birth plans. Let’s have this idea of how we want this birth to go, but I like to reference it more as birth preferences. “Here are my preferences and I’m going to label them from A to D, most important to less important, and have this idea and this plan, but then also know that there are other options and it’s okay if I choose those. It’s okay if my birth goes another route because I have these preferences and we’re going to do everything we can to have them, but we know it doesn’t always pan out that way. We know that. Henci: I think too that something has gone wrong. I talk about this in the introduction to my latest book. I think “plan” has gotten a bad rap. So a plan isn’t a laundry list or a blueprint. It’s more like, “Are you planning for a career? Well then, you’re going to decide what you’re going to do to take steps in that direction. Are you planning a vacation?” But it’s not something that has checkboxes on it. Meagan: It’s not a list. Henci: I think, if I may be so bold, the problem with preference is that at least, I think especially if you talk about preferences to medical staff, it becomes like, “Well, I think I’d rather wear a blue gown or have chocolate ice cream instead of vanilla.” It doesn’t have the same strength as saying– Meagan: “This is my plan.”Henci: And that can be internal to the woman or the birthing person. But yeah, let’s get into the meat of what I want to say today. Meagan: No, I love that message though. I do love that message. I think it would be really good if we did stop because the reason why we change “plan” is because if things don’t go as planned, we failed. That’s how our minds work and it’s not how it is, but that’s how the world has–Henci: Right, but this I think is what happened when birth plans became a thing in the medical environment. It became a checklist. But when you say, “I’m planning a vacation,” if your plane flight gets delayed and you miss your connection to the cruise boat, you don’t say, “Oh, I failed.” Right? Meagan: Right. Henci: It’s a plan. “All right. How am I going to get to Costa Rica?” It’s a very different mindset and I’d just like to relieve the audience from the idea that a plan is too limited. Meagan: Yeah. I love that. I love that. Let’s talk about how when we are planning to have a VBAC and when we are going for a trial of labor after a Cesarean, we have a lot of providers talking about–Henci: I’m going to plan a VBAC trial. I think language is just so key to all of this. Meagan: Right? I know. Henci: A trial suggests that– Meagan: We’re trying. We’re trying. Henci: The other word that I’d just like to take out is “success”. You either plan a VBAC and have a VBAC or you plan a VBAC and you have a repeat Cesarean. Meagan: Like you say, those words are so important. We talk about VBAC and TOLAC language in our course and talk about how you might hear TOLAC and that actually might be triggering. It is to a lot of people because you are like, “I’m not trying to do anything. I’m going to have this baby. My goal or my plan is to have a vaginal birth after a Cesarean.” I don’t love trial, but we talk about how that is how medical professionals will label it so we try to get comfortable with the term TOLAC so when we hear it at birth, we’re not triggered, but knowing in our minds, we are planning to have this VBAC. So when we are planning for our VBAC, one of the number one things that focuses on that from a lot of providers is uterine separation. Henci: Right and even there, the language that the medical practitioners use is right with the language of failure. So let’s even take that. You hear, “What are my odds of–” even if they don’t call it uterine rupture? The thing is that there are a couple of really big studies, like 50,000 because now we have these big databases and in one of them, the likelihood of the scar giving way was 5 out of 1000 and in the other one, it was 3 out of 1000. What you have to think of is, in one of those studies, the odds were 995 out of 1000 that you wouldn’t have a problem with your scar and in the other one, it was 997 out of 1000 that you would not have a problem with your scar. The other thing that people have to understand is that even if you do, even if the scar gives way, yes, it’s an emergency. The odds of having something bad happen to your baby– Meagan: Catastrophic, yeah. Henci: Catastrophic happen to your baby are again, 997 out of 1000. When that problem happens with your scar, 997 times out of 1000, your baby is going to be just fine. You’re going to have an emergency Cesarean, but your baby is going to be fine. Meagan: Usually Mom is fine too. Henci: Yes, absolutely. So you have to think in those terms so that the numbers are very low. The thing there is that it’s a general number. Meagan: Right. It is a general number. That is something that we really, really need to keep in mind. This is a general number. Henci: I want to drill down and look at some things that affect that number. The first one, and don’t worry, I go into details and give all of the numbers in the blog post. The first one is what I noticed when I started doing the research for this is that you have two factors that pull in opposite directions. One of them pulls towards having a problem with the scar and that is the use of induction or augmentation. The other pull in the direction of not having a problem with the scar and that’s having a prior VBAC. Before we get to, “Well, my last baby was big. Does that increase my chance because I might have a bigger baby this time?” Those two things are key and one of them, you sort of have control over. Meagan: Yeah. Yeah, not inducing. Henci: What I can tell you is that it’s pretty clear that the stronger the stimulus to the uterus, the more likely you are to have a problem with the scar. In other words, particularly the highest risk is if you are induced at all just with oxytocin and then if you’re induced or augmented, it really goes up– this is really the key point– if you are induced when the cervix isn’t favorable for labor and they give you an agent. Meagan: To help soften the cervix and get you ready for induction. Henci: Right. It does a great job of softening the cervix, but there actually may be a reason why the agents that soften the cervix are problematic for the scar because the cervix is made of connective tissue. What those agents do is that they cause the cervix to soften by pulling in water and softening the way you’d wet a sponge. Meagan: I love that analogy. I’ve never thought of that. Henci: Guess what the uterine scar tissue is made up of? Connective tissue. That could be where the problem is. But anyway, so the more you augment the uterus, the more likely you are to cause a problem with the scar if the contractions are stronger and longer and for longer periods of time. One thing to keep in mind is that induction is never an emergency or a necessity. If, for example, you do have a medical issue like your blood pressure is going up, there’s a real reason that induction and getting the baby out sooner rather than later is possible. I’m going to put this on the back burnerhere are studies that show if you are really careful to induce to mimic as much as possible what the body does naturally, you can induce without overstressing the scar. That’s something to say if, “Oh my god, if my only choice is induction or a repeat Cesarean, I guess I’d better choose repeat Cesarean,” then I would say, “Yes, there are ways to do this.” Like the wicked witch says, “These things must be done carefully.” That’s one thing. The other thing is that there is very strong evidence that if you have had a VBAC, you are much less likely to have a problem with a scar. Having a prior vaginal birth, a vaginal birth before a Cesarean doesn’t seem to have as much of an effect on that, but if you get a VBAC under your belt, you are very, very likely to go on having uneventful VBACs if you choose to have more children. Meagan: Why do you think that is? Just because the uterus has progressed and it has pushed a baby out? I read that question a lot and in my head, I know there is a showing that you are more likely, but in my head, I’m like, “Why? Why is it exactly why you are more likely to have a VBAC if you’ve had a vaginal birth and if you’ve had a VBAC, you’re less likely to have separation when the uterus is doing the same chemical functionality?” It’s contracting and squeezing and pushing a baby out.Henci: If that were true, then it wouldn’t make a difference whether you’ve had a vaginal birth before you’ve had a Cesarean or you’ve had a VBAC after you’ve had a Cesarean. Meagan: It’s really weird. Henci: So I have no idea. I’m just the literature lady. I just can tell you what the research says. Meagan: Yeah. Right? I don’t know that either. I can’t figure it out myself either. I don’t understand why. Yeah. Okay, I had a vaginal birth and then I had a C-section and then now I don’t have as high of a risk. It’s just interesting. It’s really interesting. Henci: Yeah, certainly. If you have had a VBAC, for anybody to say, “Oh, we just don’t do VBACs and you really need to have a repeat Cesarean,” your best option is to plan a repeat VBAC. I mean, that is a really strong link there. Meagan: Right, but we’re not having providers suggest it. We’re still having providers saying, “It is your best option to have a scheduled repeat Cesarean.” Henci: Do they say why?Meagan: We have people writing all over. One, we just don’t support it. Two, the vaginal birth that you did have– say if they had a vaginal birth– wasn’t until 41 weeks so if you have a baby by 39 weeks, it’s fine. You can have that but after 39 weeks you can’t. Henci: Yeah, that’s what I call a Cinderella VBAC. You can have a VBAC if you go into labor before 40 weeks and if your previous baby wasn’t too big and if you make progress in labor, but you know, the basic reason is, “We don’t do VBACs here because we can’t handle obstetric emergencies.” Oh, wait. Let’s think about this. You’re a hospital. You have women coming in in labor. Some of them have high blood pressure. Go down the list and you’re saying that you can’t handle an obstetric emergency 24/7? You shouldn’t be doing births here. Meagan: You shouldn’t be having babies here. That happens a lot where you’ve got more rule areas like, “We can’t support VBAC because we can’t handle an emergency Cesarean.” It’s like, “Well, if you can’t handle an emergency Cesarean, then that’s a big concern for anyone to give birth because VBAC or not, we know emergent Cesareans can be needed for first-time moms.” If they can’t handle a VBAC Cesarean, then how are they totally able to handle someone who has an emergency Cesarean just in general?Henci: Unfortunately, this isn’t something that your audience can change. They’re not going to talk that hospital into changing, so it just hurts my heart that people are put in this sort of form of dilemma where they don’t have a good option. They have a least worst option. Meagan: They feel stuck. That is the same thing with me. It hurts my heart that so many people feel so stuck out there. We have mamas that travel out of the country or out of the state just to find somewhere but that option isn’t for everyone. So it’s really hard if you feel stuck and you’re not feeling supported in your community. So yeah. It hurts. That’s a whole other type of podcast. Henci: That’s a whole other topic. Meagan: Yeah, so let’s talk about what uterine separation is. We talk about uterine separation. I’m going to use the word that a lot of providers use as rupture. So when we hear this really big word, when I picture a water balloon breaking– Henci: That’s why I don’t like that word. Meagan: That’s what we hear. That’s what we hear. We hear “rupture” and that’s what I hear is a water balloon breaking and popping. That is really terrifying to hear and to think of when in actuality, it’s not usually how that happens, right? Henci: Right. Meagan: Our uterus doesn’t just break open and explode. It doesn’t so let’s talk about separation. What does it mean? What does that mean? And there are multiple types of separation. Henci: Actually, it’s been interesting to see because I’ve actually been involved in this work since the 1980’s so to watch the evolution when VBAC started coming in and went out again, as the research has grappled with an agreement on a definition of exactly what that meant because they find this all the time in repeat Cesareans that little windows can open up in the scar. It’s not a big deal. Scars are tough. They don’t cause any problems so what they finally ended up with is the scar completely gives way to form an opening in the uterus between the uterus and the abdominal cavity. That would be in combination with symptoms, usually heavy bleeding or the baby being in distress. Meagan: Or baby going high up. Henci: There is no clinical significance to a window. There are no symptoms. Nobody is hurt. Nobody is at risk, but if the scar gives way to the extent that there is heavy bleeding and in very rare cases, the baby or part of the baby can actually be in the abdominal cavity, that’s a scary situation. Meagan: Yeah. Yeah, and talking about the uterine window– as she was saying, it’s where it thins out so we’ve got this thinning. The crazy thing is that there really aren’t any symptoms. Henci: There are none. Meagan: You really wouldn’t know if you had a uterine window unless you were opened up. Henci: Unless you had a repeat surgery, yeah. So there is the interesting thing about that. One of the things they tried to do– and I hope that none of the doctors they are encountering are doing this– was they thought, “Hmm. Why don’t we do an ultrasound to see how thin the scar is? Maybe that will help us predict whether the scar will give way.” It turns out and there is absolute agreement on this that you can’t use that. It isn’t accurate enough to tell you anything and what’s more, the correlation in that study was when she was pregnant, we did this ultrasound and we measured the thickness of the scar. Then, when they had their surgery, we looked to see if in fact there was a problem with the scar. They found some little windows, but that didn’t mean they would have had a problem if they would have gone into labor. So that whole idea of, “We have some way of predicting when the scar will give way so that we can advise whether it’s a good idea to try a VBAC,” all of the studies that have been done of that have said that they aren’t accurate enough to be used to counsel a person about VBAC. So anybody that’s using that one is not scientific. Meagan: Yet we get those messages all the time. “Hey, my doc said I can’t have a VBAC because my uterine thickness is too thin.” We get that reason all of the time, being told that they cannot VBAC because of that. It’s so disheartening when we’ve got evidence showing certain things, but we have providers not following evidence-based information. Henci: Yes. You can always find a reason to do something you don’t want to do. Meagan: Yes. That is what I was going to point out too. Sometimes when we have providers saying things that are completely opposite of what evidence even says or just don’t support evidence in general. We got a message saying that they had a 60% chance of uterine rupture. Henci: Oh sheesh. Meagan: Yeah. They said that their uterine scar would give way 60% of the time. I’m like, “No way. No.” Where do we even get that? But a lot of the time, these providers are, like you said, saying things because they don’t want to do things or they’ve seen things that make them scared so they put people under this general umbrella and they’re like, “Oh, you’ve had a C-section. You’re under this umbrella and this umbrella is not going to let you have a VBAC.” Henci: I have a dear friend who was interested. She was a marriage and family counselor and she was doing work with PTSD, child-related PTSD. We were sitting at a conference and there was an obstetrician who was lecturing who started actually talking about an emergency birth where things went wrong and she actually started to tear up. My friend had an epiphany. She said, “Oh my god. It’s not just women who develop PTSD.”Meagan: Yeah. It’s these providers. Henci: It’s birth professionals as well and if you’ve been at a crisis birth even if everything turned out right, but if it was that sort of an emergency, “Oh my god, we might lose this mother or we might lose this baby,” that’s going to change the way you practice because what is the signal effect of PTSD? It’s intended to be protective. Your brain says, “I never want to be in that situation again. What do I need to do to avoid it?” Meagan: Right. Henci: I have compassion for that, but it doesn’t help your audience who is stuck with these people who have no idea what is actually driving their decisions. Meagan: Right. I guess I want to mention that just because sometimes I feel like, and even on this podcast, we’re guilty of saying things that make it feel like we’re painting bad pictures of providers and putting them in a bad light. That’s not the goal here in this podcast. That’s definitely not what we want to do but we do know that a lot of people have been let down. Henci: Yeah. Meagan: I mean, here’s this failed word but there are a lot of people out there who have been failed. Henci: They’ve been failed by their care provider. I will use failed in that case. Meagan: They’ve been failed by the staff or by their care provider or their location. A lot of the time, it’s really hard because we don’t know what that other person has experienced. We hope that those professionals will work through those and stop putting these general umbrellas over people, but we know that it’s probably not going to ever stop happening. Henci: No, unfortunately. But I want to move back to how we just talked about a case where the research doesn’t back up what the doctor says, but I want to talk about a couple of cases where- and this is where being more critical of what the research has to say. It does on the surface back doctors up. So now let’s get into some of the categories for induction. The big one is, “We don’t want you to get past 40 weeks because we know that with longer pregnancy duration, there is more chance for scar rupture.” That sounds good and it’s actually in the research, but here’s the catch. Underneath that is what happens at 40 or 41 weeks? They induce labor and there is research that shows that the reason that you get more is that all of the scar ruptures were in induced labor. We know that induction increases the risk of scar rupture. It creates the illusion that it’s pregnancy duration. It’s not. It’s pregnancy management. The other one where that happens and it’s actually in the research is women who are expecting a big baby or they think the baby is big. Meagan: Suspected big baby. Henci: First of all, if your doctor says, “Oh, you know. This baby is going to be on the big side. We did the ultrasound. I’ve been feeling your belly.” You might as well flip a coin because there is a 50/50 chance that that is incorrect and your baby isn’t going to be on the big side. So number one, they may be anxious about something that isn’t even true. Meagan: It’s so true. Henci: The second thing is, then what happens next? Let’s induce before the baby gets bigger. So again, you find an association between VBAC labors with bigger babies and an increased risk of scar rupture but that’s not the root cause. The root cause is those laboring women were induced. So that is something to take into account when you hear those things and again, I’ve got the numbers. The reason I keep coming back to the importance of the blog post is one of the things that I think is less than helpful is vagueness like, “There is a chance.” The first question I’d have is, “How big?” so I wanted to as much as possible give people the numbers so that they can do what feels right for them but also know how those numbers are distorted by management. The VBAC rate itself is distorted by management because VBAC studies outside of the hospital coming from home births and birth centers show a VBAC rate in women who have not had any prior VBACs– the first birth was the Cesarean and this is the second delivery. The VBAC rate was 81%. Out of the hospital-based studies, they range up to the low 70 percentile, but the hospital studies don’t get up that high.Here’s the important thing. If it’s at all possible, find a care provider who’s really comfortable with VBAC and knows how to manage them because where do you see the bad outcomes? To a huge extent, they’re in labors that were induced and labors in which there was a problem with the scar which is much more likely if they were induced or augmented or she wasn’t given enough time and then she went to C-section.The complications happen in C-sections so the more you are able to have a birth that proceeds at its own pace with no stimulation and there is a spontaneous vaginal birth, your birth by your own efforts, that’s when it’s minuscule in terms of having complications. Meagan: Right. It’s so hard because yes. We talked about this earlier. Oh, we’ve got hypertension and oh, we’ve got this thing and we have options. Do we induce or do we have a C-section? It still is very possible to have a VBAC with an induction. We’re just talking about uterine giveaways and the chances. You increase your chances by choosing to be induced. That doesn’t guarantee you’re going to have that happen or anything but you have to know walking into it, “Okay, I have this, this, and this, and I’m going to choose to induce.” You have to know the risk that you are taking. We have to weigh out the risks and say, “Okay. I know it increases a little bit. I’m comfortable taking that risk or I am not comfortable taking that risk.” Henci: Right. Or how can I minimize my risk? Because it still is possible. You have to do it diplomatically but if you have a care provider who is willing to be flexible and is like, “Yeah, I’m not sure about this one,” but you’re able to have that conversation where you feel like they can hear you and you’re going to be respectful and hear them, then I think there’s a lot that can be done. You can say, “No or not yet.” Meagan: Yep. We just made a post on Instagram and Facebook about that saying, “I appreciate the time that we just took. I’m going to choose to wait” or “Thank you so much for that, but I’m not going to do that.” Henci: The other thing I would suggest if you’re in a situation where you’re saying no is to have a discussion around which new information would change your mind because that again creates space with, “Oh, I don’t have one of these patients that’s just being difficult,” but to say and talk about, “If my blood pressure goes up–”. I don’t know what it might be, but to have a conversation about under what circumstances might you consider changing your mind. Meagan: Right, yeah. It’s powerful. Conversation and information are powerful. I always encourage someone to ask questions and to get their research. If we have a provider saying you have a 60% of uterine scar giveaway, let’s talk about that. “Wow, that seems really high. Is there any way that you can provide me with that information so that I can study that and see what’s comfortable for me?” And then you’ll look and it and go, “Oh, there aren’t statistics showing that I have that? Okay.” Then you might make a different choice, but if you just hear that number and don’t ask any questions, then you automatically might say, “That seems really scary. I’m not even going to go there.” We have these myths and these numbers and if we don’t ask for information, we’re doing ourselves a disservice. Henci: I’ve got the American College of Obstetricians and Gynecologists practice bulletin. I wonder if there is any way– I mean, a summary of recommendations and conclusions backed by level A evidence, good and consistent scientific evidence. The first one on the list is, “Most women with one previous Cesarean delivery with a low transverse incision are candidates for and should be counseled about and offered TOLAC.” Meagan: Yes. Henci: My eye goes down and I want to talk about women who’ve had two prior Cesareans. I know we wanted to talk about that. Meagan: We do want to talk about that. Yes. Henci: I will say that they’re not enthusiastic about it, but nonetheless, this is under level B evidence which is limited or inconsistent scientific evidence, and what it says is, “Given the overall data, 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.” They have all of these VBAC predictions which I’m just going to be blunt, they’re crap because they’re evaluating the wrong thing. What they should be evaluating is the doctor’s propensity to care for VBAC and their confidence in VBAC. Then you’d get the numbers that would really correlate with whether labor would end in VBAC or they wouldn’t. Meagan: Right. Right. I know. Then just going one step further, vaginal birth after two Cesareans, then we’ve got people talking about vaginal birth after three or more. There’s no evidence in there because we’re not doing them very often. Henci: The evidence is not there for three. It is there for two, although again, you can get very low, again, the equivalent of sort of the average. There are some Israeli studies where there is a very large population of women there who have large families so you do get people with two Cesareans, but the thing there is they need to be managed carefully. In one case, it was like, “We don’t do inductions other than by rupturing membranes in someone whose cervix is ready to go.” There are ways to do that. But what I wanted to say is that now here’s a case where you have to look at the other side which is that there are studies that show there are consequences because as you accumulate uterine scars, the complications in subsequent pregnancies go up. So when you get to two prior Cesareans and there are studies that looked at the branch in the road. You had two prior Cesareans. Did you plan a VBAC or did you plan a repeat Cesarean? And guess what? The severe complication rates were identical. It was an identical rate of hysterectomies. There was the same rate of perinatal mortality so it’s not like, “Oh, I’ll just choose that safe third Cesarean.” There are increased risks, but there are also increased risks to taking another Cesarean on board. Meagan: And then to add to that, future pregnancies. With each Cesarean that we have, we have also risks in future pregnancies that are not discussed when we’re counseling in this medical world from what we’re finding. We’re being counseled for VBAC. We’re being counseled about the risk of uterine separation and the VBAC issues, but we’re not talked to about the blood loss or the risk of hysterectomy. We’re not talking about those things. Henci: Or chronic pain. Meagan: Chronic pain or dense adhesions or placenta accreta. We don’t talk about these issues or even deeper issues. We’re not talking about them. That is where I think is one of the places we’re going wrong in this medical world. We’re not truly counseling on all sides of things to really give people the opportunity to make that really informed decision. We’re kind of just prefacing over here, but like, “Oh, but we could schedule your baby’s birthday and get your hair done the day before because you know exactly when your baby is coming.” We’re not counseling. Like you said, there are issues and there are risks. So with VBAC after two C-sections, through your education and ACOG not saying, “Yeah, go for it for sure, for sure,” But they’re saying, “It should be reasonable.” Through your uterine scar separation research, is it substantially larger? I know there are going to be numbers in the blog and we talk about it in our course and things, but is it like you have a 0.4% to what? To 10% if you’ve had two to 1%? We’ve got people being told things all over the place. I guess my question is through your research with VBAC after two Cesareans, we’re going to specifically talk about two Cesareans here, is it increased and truly that much higher? I mean, I know the answer, but let’s talk about it. Is it really that much higher or is it pretty low statistically? Henci: Well, I actually turned to that page in the blog post and I had a couple of different studies. There was an increase in both studies. It was quite small. The difference in these studies, I really think, had to do with the fact that in one of the studies, that was the one where they would only allow the rupture of membranes as a means of induction. So in one case, it went from 3 per 1000 with planned VBAC after one Cesarean to 6 in 1000 with planned VBAC after two Cesareans, and in the other one, it went from 7 to 1000 to 16 per 1000. But that’s still a 98% chance of not having a problem with your scar. Meagan: Right. Henci: The thing is, there is a consciousness, but if you’re planning a large family, that maybe I think a lot of care providers will say, “Well, if you’re only planning on having two children, it really is not that big of a deal to have another Cesarean.” But the thing with that is that I think it is really important to understand that you may plan to complete your family with two children. That doesn’t necessarily mean that’s what’s going to happen. Meagan: That’s true. That is so true. Henci: I think unless you or your intimate partner are planning on doing something permanent about your fertility, you have to consider the fact that you may choose to have another baby or you may find yourself pregnant and decide you’re having another baby. Meagan: Right. Henci: I think you always have to take that possibility into consideration when you’re making that first decision. Personally, this is totally my opinion and my judgment. No pressure here. I think the best thing that you can do is get off the Cesarean track if you can. Meagan: Mhmm, yeah. I mean, it really is. There’s proof in the pudding that a vaginal birth is the ideal route in the long run overall. Henci: Yep. Meagan: I guess as we’re wrapping up here, let’s talk a little bit about, well, how you do you decide? How do we decide? Henci: I know that I wanted to get to something because we talked about this. I wanted to get to the epidural issue. Meagan: Epidurals yeah. Let’s talk about that too. Yeah. Henci: What you are saying is you’re hearing both sides. One is that you can’t have an epidural and the other is that you have to have an epidural. Meagan: Literally, they say that you have to have an epidural to have a VBAC. Some of them are like, “Well, yeah. You can VBAC. Just know.” I feel like it’s used as this fearful thing. “Just know that you can’t have an epidural so you’re going to have to go unmedicated.” Henci: Let’s take care of that one that you can’t have an epidural first because that’s the easy one. Again, I go back to ACOG. Level A evidence. “Epidural analgesia for labor may be used as part of a TOLAC.” I mean, I was jaw-droppingly shocked because it’s at least two decades since that myth about, “Oh, we can’t give you an epidural because then we won’t know if there is scar separation.” So that is totally bogus. But let’s get to the, “You have to have an epidural.” The thing about that is that there are two problems, I think. First of all, the idea is in case there is an emergency, we can deal with it faster. The thing is, an epidural is problematic in a couple of ways. One is, one of the more common side effects of an epidural is that there is a drop in the mother’s blood pressure and the baby’s heart rate. Guess what is the best predictor that the scar has given way? The number one predictor that the scar has given way– and again, in most of those cases, it hasn’t but nonetheless, it’s a better predictor than pain, is the baby’s heart rate. You are adding, number one, something that will possibly provoke concern and a Cesarean you don’t need. But the other thing is that it interferes with mobility. I think the number one reason– I mean, you want everything in your favor in terms of making good progress and an epidural interferes with that. Plus, you then have the problem of epidural fever because obviously, they want to give you that epidural early. You’d maybe have it for hours and then you’d start to develop a fever and they’d be like, “Mmm, it’s time to get the baby out.” An epidural actually decreases your chance of a VBAC. But about the emergency piece, the thing is if you have a sterile water lock where you’ve got the business end of the IV, the needle is there but it’s not hooked up to anything. Meagan: Are you talking about the “just in case” epidurals? Henci: Right, the “We want you to have an epidural because of the emergency possibility. We’ll already have you anesthetized.” We first talked about, “We’ve given you a procedure that may lead to an unnecessary Cesarean,” and they decreased your probability of progressing to a vaginal birth. So that’s already like, “Umm, really? Do you want to do that to me? Why?” The answer is, “Well, in case there’s an emergency.” You can do a spinal a lot faster than an epidural. It is perfectly possible to get you numb within a very short period of time and sufficient to do the Cesarean surgery. It really is kind of bogus. Meagan: Yeah. I want to talk about this too because if it is a true, serious, serious surgery where we’ve got minutes if that, we’re going to usually be put under general anesthesia. Henci: Well, that’s a possibility too. Meagan: Yeah, so that’s the thing. Henci: The other thing is that I also want to move into that gray zone of, well, I just talked about the drawbacks of having an epidural, but I mentioned that there’s a fair number of members of your audience who are thinking, “I’d really like to have an epidural.” For some of them, depending on what their first labor was like, it may have been like, “I can only contemplate VBAC if I can also contemplate having an epidural.” This is where my new book comes in. The full title is, Labor Pain, What’s Your Best Strategy? Get the Data. Make a Plan. Take Charge of Your Birth. In that book, I give all of the evidence, pros, and cons of all of the different other methods of do-it-yourself comfort measures to epidurals and then the last chapter is again, the fork in the road. You would like to avoid an epidural and here are all the ways of doing that, and you would like you plan an epidural. You want to make an epidural plan A and then here are all of the ways of maximizing your chances of having one that goes smoothly. I don’t think I need to go into all of the details here on the show, but if anybody is interested in finding out more about the pros and cons of their pain-coping options including epidurals and how to plan to avoid an epidural if it is plan A or the reverse, then I think my book could be helpful. Meagan: That is amazing. Just to let you guys know, we’re going to have so many things in our show notes here. We’re going to have, of course, the blog with all of the numbers going deeper into what we’re talking about today. We’re going to have a link to all of her books because I think it is important to know things from all of them. Henci: I mean, I would actually stop you because I think Thinking Women’s Guide was a great book. It was published in 1999. Meagan: Yeah, so it’s a little older. It’s a little dated. Henci: Optimal Care was really intended for birth professionals. Meagan: We have a lot of birth professionals. Henci: Even that was in 2012. Meagan: We have a lot of birth professionals listening. Henci: So I really want to preface the new book. It’s been out less than a year so it’s really current. Meagan: Mhmm. We’re definitely going to have that number one. I haven’t read it yet, so I’m going to read it myself because I think it’s important too. I know you and I trust you but I want to know even more so I can keep referring it out and also learn by reading it myself. Henci: Yeah, I think you’ll get some ideas for your classes. Meagan: Yeah, for my clients, and keep referring them out. I mean, you guys. The more information you have, the better. The more knowledge that you have under your belt as you are entering into these births, it’s going to help you along the way. It’s going to help you feel more prepared, more educated, and more confident. Right, Henci? Don’t you feel like confidence is something that no matter what, VBAC or not, just with birth in general that we need? Henci: That’s why the name of my new series– I’m working on a book on induction– is Take Charge of Your Birth. You can’t take control of your birth because you don’t know what’s going to happen. Life happens. But you can take charge in terms of having the information, having thought through what is really important to you, and there is actually research on this. Feeling in charge is the key component in having a positive experience. If you felt helpless, if you felt like you didn’t have any say in what was going on and you were scared and you didn’t feel supported, you could have a lovely, uneventful vaginal birth and be traumatized. If you were in charge, you were a full participant in all of the decisions, you felt like your options were presented, you made the best choices you could, the people around you were encouraging and supportive of what you were trying, and you could have a very difficult experience in terms of what actually happened and it would still be a positive experience. Trauma is a very personal experience. It’s what you feel in the moment. No one can say of you that you shouldn’t have been traumatized by that birth because it wasn’t traumatic enough. It’s subjective. Meagan: Right. Right. Henci: But as a whole, feeling like you are in charge is powerful.Meagan: It’s really powerful and there are actual stats behind that. My second birth didn’t go the way I desired. I still to this day believe that I wasn’t allowed enough time or wasn’t given enough resources that I deserved. But at the same time, once the decision was made to have a second Cesarean, a repeat Cesarean, there were a lot of things that I communicated. I took charge at this moment. “If this is how it’s going to go, this is what I need and want.” My providers were really receptive to that. With my second Cesarean, although still not desired at all or even felt that it was necessary, I actually have a very different viewpoint on it because I was actively involved in that birth and in the decisions that were being made. Again, even though I didn’t feel that the decision that I made for the repeat Cesarean was really warranted, it was a decision that I made. I accept that. The other decisions along the way, I literally can look back at that birth and say that it was healing. A lot of people are like, “Wait, what? You’re saying that you didn’t want your second C-section but it was healing?” I can say, “Yeah, absolutely. It was healing because I was able to really participate in this birth in a different way.” I just think it’s so powerful because I could have looked back with a lot of anger and hate. I probably could have beat myself up even more, but I viewed that as a positive, healing experience. I think that’s what I needed to end my C-section journey. I needed that birth to say, “Okay. This is a better experience. I’m ending the C-section journey now. VBAC from here on out, but I needed this experience to have a different view on the C-section experience as a whole.”Henci: I think I heard something else which is key and correct me if I’m wrong, but it sounds like when you agreed to the second Cesarean, you were making the best decision that you could at that time. You still had a decision. It sounds like you weren’t sort of bullied into the repeat Cesarean. It sounds like there was a discussion and you felt like, “Yeah, I think I’ll go along with the repeat.” I think that’s key too is when you do make a decision and it is your decision and you can own it, I think that helps too because later, you can say, “You know, if I were in that same spot again, I might do something different. I’ve learned something from that. But you know what? That was also what made sense to me at the time and now I can let go of it.”Meagan: Yeah, you know, when I got my op reports when I was going to interview all of the providers for my VBAC after two Cesarean baby, which I wasn’t even pregnant, but I started interviewing before, I was reviewing my op reports. As I was reading them, I did get a little triggered and I got a little bit angry. My husband looked at me as I had a tear rolling down my face saying, “These were unnecessary.” He said, “Babe? We made the best choice we knew at the moment with the information that was given to us at the moment.” Henci: Mhmm. Meagan: He said, “Do not ever shame yourself for making these choices because you were not given the information and you were not in a space mentally where you could be in that– oh, the statistics say–”. Right? That’s one of the reasons why I think doulas are so important because they can help remind you of those things, but I wasn’t in a space where I could go through my journal of information and say, “Oh, but this and this.” I was given these facts, this information, and I made a choice based off of the information that I was given. I can never shame myself for that. When he said that, I was like, “You know what? You’re right.” I would go back and do things differently if I were to look back. If I were there again, I probably would have made different choices or I would have done different things, but I’m loving the journey that those experiences have given me and brought me to. Does that make sense? Henci: Yes. Meagan: This journey that I’m on right now, I probably wouldn’t be on if I didn’t have those experiences. I wouldn’t be with all of you here today talking about VBAC and repeat Cesarean and what the evidence shows and sharing these absolutely amazing stories and bringing on these incredible professionals without those experiences. So yeah. I had two births that I didn’t desire the outcome of the Cesarean, but I will be forever and ever grateful for those experiences. Henci: I will add that I wouldn’t be who I was here today if I hadn’t had an emotionally very negative experience. I talk about that in the prefaces of who I am today and why I wrote the book and the difference between my first birth and how I experienced my second. Well, the first one, I was delivered. The second one, I gave birth. That in a nutshell is the difference between the two and that started me on my journey. I wanted other women and birthing people to know that the choices that they made were crucial to how they were going to end up feeling about themselves, their partners, their babies, and their everything, that it was not trivial, and making my life’s work looking at the research, because that’s my skill so that they would have that information. Information that I didn’t have until I started reading stuff after my first delivery. Meagan: Yeah. That’s how a lot of us doulas and birth professionals start based on an experience where we want to help people have a different experience. We want to empower people. Henci: I’m so glad that you’re in the world. It sounds like you are doing a great service for a lot of people out there. Meagan: Aww, well thank you so much, and likewise. You are incredible. All of your blogs are amazing. Seriously, people could spend hours and hours and hours on your blogs just picking apart the information and the stats and putting these large studies into English because honestly, that’s one of the hardest things about studies. You go through and you’re like, “I don’t even know what this means. Can I just get a clear conclusion?” But your blogs make sense. They’re English to me. Henci: Oh, thank you. Meagan: I know they will be for so many of our followers as well. Well, thank you so much for being here today. Seriously, I am so, so grateful. If you guys want to go follow Henci, like I said, we’re going to have all of the links for all of the things in the show notes but you can also go onto Instagram and Facebook @takechargeofyourbirth.Henci: Yes. That is correct. Meagan: Or hencigoer.com. Henci: And actually, I think there are places on social media but if you go to hencigoer.com, you can also sign up for my newsletter. I have a monthly newsletter. Meagan: That’s what I was just going to say, hencigoer.com. Like I said, we’ll have this in the show notes. Go in there. Sign up for the newsletter. Sign up for all of the amazing things that she’s putting out because you really are. You’re a wealth of knowledge and it’s really so fun and I’m so honored that you took the time today to be with us. Henci: Well, it’s been my pleasure to be here. 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