VBAC vs. Repeat Cesarean: "Try on" both choices


To wrap up a conversation, here is a comment left by Well-Rounded Mama, who blogs here, in response to this comment.


I always feel so sad that some women feel that all vbactivists would pillory them for deciding on a repeat c/s. I don’t think most of us are like that at all. We simply want women to fully understand their choices, to make well-informed decisions, and to make sure that women really DO have a choice in the first place.

However, there are some folks who are really that judgmental, and sadly, they make the rest of us look bad. I definitely get frustrated with that element of the movement. But let’s be fair….every activist movement has its extremist element. That doesn’t negate the importance of the movement or its work; it just reinforces the need to keep lines of communication open so others don’t think that extremists represent the view of most folks in the movement.

Yes, I do want more women to opt for a VBAC if that’s right for them, because from a public health point of view I think there will be fewer downstream health problems on a societal basis with fewer cesareans. But on an individual basis, each person has to choose what’s right for them, and no one should be forced into VBAC or ERCS.

I do think women can be truly informed and still choose RCS. And in fact I have supported women who chose ERCS. My support is done on an individual basis and is not dependent on their choices, but my vbactivism is done more for a public health point of view because of the large-scale changes that need to happen in the system. The problem comes when you advocate on a public health basis and people hear it as being about their individual choices. For me, anyhow, it’s not.

What I tell individual women who are struggling with the choice is to “try on” both choices and to remember that they have plenty of time to make their decision. You really don’t need to make this decision NOW, it’s perfectly normal to feel ambivalent about the choice, and there’s NOTHING WRONG with considering both choices, or even with deciding not to decide for a while. Sometimes it’s great just to be pregnant for a while without having to make any choices.

Then, when you are ready, take a few weeks and “try on” each choice. It’s not enough to try them on for a couple of hours or days; it’s really more optimal to work through this by trying them on for longer periods. That way you get past the surface reactions and emotions and get deeper about what your concerns are with each choice.

Try on the repeat cesarean first. If you are like me, you’ll feel a real sense of relief at first….at having the decison made for you, at not having to worry about going through labor again, at not having to worry about “failing” etc. Perfectly normal responses. After a while, picture yourself really going through with this choice, including going into the hospital at xxx weeks and laying down for that surgery. Does that picture bring a sense of relief or anxiety, or some of both? Picture the surgical recovery too, which might be uneventful and no big deal or which might include difficulty with movement, sleeping, and a fair amount of pain. Then try to anticipate how you’ll feel about the decision afterwards. Some feel nothing but relief about not doing labor again, while others end up disappointed in themselves for not trying VBAC, and still others feel a little of both. 5 years down the road, how do you think you will feel? Glad or not?

Then take a few weeks to try on a VBAC. How does that make you feel? Does it create a huge sense of anxiety, or does voluntarily signing up for further surgery create more anxiety? Which makes you feel more worried….the idea of surgery or the idea of labor? Why? If labor makes you anxious, what can you do to make this birth different so it’s not just a repeat of last time? What if you had a really supportive caregiver and birth support team? What if you could have a VBAC? How would you feel about that 5 years down the road?

Most people consider the what-ifs of “what if I ‘fail’ and have another cesarean anyhow?” and that’s certainly a worthwhile consideration. Not everyone has a VBAC….but although that’s hard, a CBAC doesn’t have to be life-destroying. It takes time to process but many of us have done so and survived. But don’t forget to also consider the what-ifs of “what if I DO have the VBAC?” If you did have the VBAC (which you have about a 2/3 to 3/4 chance of doing), how would that make you feel? Would that feel like a real sense of accomplishment or not that big a deal? What does it mean to you?

You have to consider the big bad what-ifs, of course. People nearly always consider the big bad what-if with VBAC, which is uterine rupture. Having known women who have had UR, I never minimize that. It really is a big bad to consider. However, what people often fail to consider is the big bad what-ifs with ERCS, and I’ve known folks with these as well (pulmonary embolism, hysterectomy, massive hemorrhage, damage to bladder and bowels, etc. etc.). Both UR and serious morbidity from ERCS are unusual outcomes; the chances of them actually happening to you are quite small. But because they can be so serious, they certainly are worth considering.

But also worth considering are the big GOOD what-ifs. What if everything goes perfectly fine? What if baby and I both have a great outcome, either way? Chances are quite high of a good outcome with either VBAC and ERCS, much more likely than a big bad outcome. So if you had a big good what-if outcome, would you rather that come from a VBAC or ERCS? Would it make any difference to you emotionally?

Additionally, think beyond to any future children. If you planned more (or had an ooops), this birth influences that one. Think through those long-term decision trees too. Think of your possible downstream outcomes. What would you prefer from that point of view?

These are all things to ask yourself as you try to process this decision. Truly, I’m not trying to tell you which way you “should” feel, just communicating the possibilities. I hope I don’t sound patronizing; I’m just trying to give you some tools that some (including me) have found useful in making this difficult choice. I’ve been in ICAN for many years, had a CBAC and then 2 VBACs, and wrestled pretty hard with the ERCS vs. VBAC choice myself with #3. Yes, in the end I chose VBAC, but I very much understand the appeal of ERCS and have supported women who have chosen that, as well as women who have chosen VBAC. I know the things that helped me in my own decision tree on the topic, and what seems to have helped others, which is why I include them here. If these ideas aren’t helpful to you, please feel free to totally disregard them.

I can tell you are well-informed about your choices, but I’m sorry you feel pressured one way or the other. Wouldn’t it be nice if women could make these choices in a neutral space, free from rhetoric from all sides? But alas, we don’t live in such a world yet. In the meantime, try to free yourself from the pressure and expectations of others, try on the decisions one at a time, get in touch with your deepest feelings about each and their what-ifs, and then in time I bet your decision will come clear to you.

Trust yourself to know what you need to do. Just remember that you don’t have to decide this right NOW; you have time and space to think it through and consider all the angles. But trust yourself……you’ll be able to make this decision and figure out what you need.