114. Quick Kick: Am I a good candidate for a VBAC?

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Welcome everyone, I'm Rigid Maloney, and today I've got a bit of a different format for you. Every now and then, we're going to add in what we're going to call the quick Kick. Now, this is where Pat and I have chosen snippets from our entire catalog that we may not have dedicated an episode to yet, but they answer a commonly asked question that need an immediate answer. So we're starting off with one that we often get asked, and that is who makes a good v back candidate.

So if you've press play on this quick kick, you've possibly had a.

Previous caesarean section to birth your baby, and your thoughts are now turning to how you're going to birth the next baby.

I want to start first with a quick definition.

A V stands for vaginal birth after cesarean, and another term you might hear is TOLAK, which stands for.

Trial of labor after cesarean.

Feedback has its own set of considerations which Pat and I talk about, using a patient's story as an example. The full episode is number thirty four which will be linked in the show notes. But for this quick kick, we've honed in to one of the most important questions to ask if you're thinking about a vaginal birth after cesarean. That is, am I a good candidate for a feedback?

Let's get quick on the kick.

So who's a good candidate?

I think the first thing that we should talk about is that you have to want it.

Yeah, yeah, so Lucy wanted it. Yes, she really wanted it. Whereas you know, if you are ambivalent, yeah, really, or you really don't care.

And that's okay too, It's really, it's really okay.

Absolutely, it's got to be discussed in a judgment free zone. And these days you might only be having two babies. And if you just say, look, if my patients say to me, look, the first one was born by caesarian.

Section, and they'll just give me another of those.

Yeah, And I'm sure a planned section is going to be nicer than the emergency section I had last time anyway.

And can I tell everybody a planed section is just so much.

It's really nice. Yeah, it's not such a say this every day. It's not such a bad baby to all come in on.

If that's your option, yeah, yeah.

So that is not that is not not a problem. And if that's what the woman and her partner want, then decision mate.

That's fine. So I think feedbacks are number one for people who.

Want them and the people that want them. Like for myself, it was a deep psychological need to have a vaginal birth. It took me years and years to work with my mindset after my babies to accept the fact that I didn't have vaginal births.

Yeah, so that's a thing.

Okay, some people are very fixed on that, and there are other people for whom it's not such a strong, deep need, but it's a strong preference, yeah, and rather that.

And there are a.

Good number of people who don't mind, yeah, or don't or really aren't fast at all, And it's not part of what they would look at when they're looking back on that birth and saying do they feel good about it psychologically or not? If they honestly don't mind. So those people might just elect to have another section.

For the people who prefer it or really really want it. The discussion should start early.

Yeah, so moving on to who's moving on to more of who's a good candidate?

I read on I thought a reputable website until I talk to you about it, which said ninety percent of women are good candidates for feedback.

That's got to be overstating it.

Yeah. Yeah, it wasn't a reputable.

It's got to be overstating it.

Yeah, it's so tricky. I mean it was a pregnancy association, and I thought I will Yeah.

Look, you know, it depends the definition of good candidate. Ninety percent of people may tick someone's technical boxes about what you have to have, what has to be there for the v back to be safe. But I look at more than that about a good candidate. And one thing you've got to look at is the circumstances of the first berth.

Yeah.

Yeah, so Lucy had a breach.

Yeah right, so she's she had a breach in her first pregnancy. Babies in a breach position and the vast majority of obstrations, including myself, would have delivered that baby by section.

Yeah, but what that.

Tells us though, if we do a Caesar for that woman because the baby's reach. For all, we know that woman labors like a.

Complete champion, Yes, and she never win, just.

That she didn't go into labor or certainly didn't get to advance. So in some ways that you know, in many ways, that's a good start. Yeah, let's say we've got, for argument's sake, another patient who is a very small, very short petiitue woman with a very tall husband, who made a very big baby and obstructed at four centimeters in that inner first labor, couldn't get beyond four centimeters, did decease, the baby came out four kilos. So she's

Yeah, and experience, I would imagine, and yeah, that's.

Right, because there isn't a strict rule book about things like that.

No, And are there any other things that you would say, Okay, well that makes somebody not a good candidate.

Yeah, I think if Well, it's my belief that if you've had more than one previous section, that you shouldn't have.

I know, I remember when we had when we were pregnant with that, you know, our third, your first, my third, and I was trying to convince.

You, but I want to have so that is in my fear. That's that's a problem.

There are some people out there who believe that the numbers are okay for two previous sections, and virtually no one thinks that the numbers are okay for three previous sections.

Yeah.

Yeah, I think that it doesn't come up that often. But if we look at two previous sections, it's my view that that's significantly the risk is significantly higher than for one. And I don't think in twenty twenty, when we expect very very good outcomes from the childbirth, that that's one we.

Can live with.

I'm very pleased that I had a plan section in the end, only because the obstrition. It wasn't people didn't deliver the baby'sus.

I was there holding your hand.

The obstrition at my obstrition was saying, look, you know, I don't remember her saying. Was I'm not sure what to s what to what here? So things had thinned and yeah, So.

If you've had multiple previous caesarian sections, the lower segment of the uterus gets.

Very thin and two long labors, so.

We worry about the ability of that tissue to withstand the forces of a subsequent tum labor. If you've had one previous caesarean section, the lower segment of the uterus will be a little thinner, but not so that it adds a huge amount of extra risk.

What about the woman that's a vaginal birth, a cesarian birth, because perhaps the baby was in breach. What sort of candidate is she?

Perfect?

Okay, okay, because we know that we know she can have a baby vaginally. Yes, so if she has another baby, you're roughly the same size, she say, an ideal feedback candidate. Okay, and yeah, that happens from time to time, vaginal birth, the first caesar for the second for breach, or twins or previa and then back to vaginal again.

Yep, And I think, can things happen like I remember Lucy was telling me on the phone. I'm not sure we talked about it during our interview just then, but she was saying that you would check in every single appointment and say, yes, we're still on track for a fback, and things happen within a pregnancy that can change it absolutely.

So that sounds like me. I definitely would return to it each.

Anti natal visit in a fairly methodical way, and in my mind, I'm thinking, yes, we still meet the sort of requirements. Okay, So the things that might arise during the pregnancy that would really make us rethink the plan for a feedback might be complications, and those might be things like a.

Baby that was really too big.

Yeah, a consistent, reliable ultrasound evidence that the baby.

Was very big.

Yeah, And can we just recap what's a very big baby? Again?

Well, if for in a vback situation, I would start to get a little concerned about a baby in the top ten percent. Yeah, okay, because it seems it sort of stands to reason that that baby might be slightly harder to get out and might and might put more forces on the scar from the previous section.

Yea.

Then other things that are potentially a complication and might just add one risk on top of another significant diabetes insulin dependent you know, preclams here, things that those are things that might arise during the pregnancy. And then things that we would know right at the start that might just make us think this isn't a goer.

Would be placenta previous twins, Yeah.

Yeah, wow, vback with twins that would be risky, risky yeah yeah. And what about Like my problem really was that I just did not go into spontaneous labor. I avoided the I was a terrible patient pat I avoided the healthcare people and got to forty two weeks.

So yeah, well, so the perfect time I think to labor with her with her vback is spontaneous labor term. So let's break that down a little bit. Spontaneous labor is definitely preference because if the patient wants are feedback and there's some reason to induce, then our options are quite limited.

In terms of how to induce.

Yeah. Right, So with the vback, patient by definition has got a scar on the uterus from the previous previous pregnancy, and if she suddenly needs to be induced for whatever reason, the toolkits at a little lean that pross and jelly that we put in the vagina to mature the cervix.

Can't use that pretty much.

Can't use that. It's not thought to be safe in the way that it.

Can overstimulate the uterus. The drip that we might run during an induction to get those contractions up and cooking. Most of us don't use those that drip. For some people consider it to be acceptable as long as we're using the drip just to tip somebody in, but not to whoop them along as as I usually put it.

So there's risks there. So the best induction, of course, is the one you don't do it all.

Yeah.

Yeah.

And if the patient comes into spontaneous labor term fantastic.

Yeah.

Out post dates two problems.

There's some issue that that woman's not coming into labor and that might need effort to get her into labor, including.

The use of drugs that we should be using for a VBAC. And secondly, the baby's getting.

Bigger all that time, all the time. Yeah, I definitely. I think that's why my babies were so big. You know they had the two oldest boys had two more weeks of cooking.

Well, that's right.

So there is a tide, you know, the perfect time in the tide for a v back, and if you happen to labor at that time, fantastic.

Yeah, it's a very big pressure if you're wanting a v back and you're not going to spontaneous labor, you're doing everything and nothing nothing works.

Yeah.

Sometimes if someone's very keen and we're up to post dates, the sort of turn plus seven days, turn plus ten days. Wherever your institutions post dates cut off, is.

It is possible to come in and break the waters. Yes, that's safe.

Yeah.

What it does do is set the timer tick.

Yes.

Yeah, So if we do that first thing in the morning, then we're either going to come into nice, strong, natural labor and have that baby vaginally, or we're getting a section at some point, because you know, the timer will start to tack when the water's broken.

Thanks for listening. Now head over to the floor episode if you want to hear one of our beautiful patients, Lucy, describe her successful vback she had for her second baby, and in this full episode, we also explore the additional monitoring that you might need during a vback, what questions to ask your care provider, what pain relief options are available if needed in a vback, and how to set yourself up to feel satisfied with your birth really no