Confessions of an OB/GYN: A Doctor's Thoughts on Labor

I am an OB/GYN physician and I am a former VBAC denier. That's VBAC for vaginal birth after cesarean. It's something we are supposed to offer and push our patients to consider. I want to do the right thing. But, I'm conflicted, confused and wary. Let me explain.

VBAC was all the rage in the 1980s and 1990s, until a slew of research articles, committee opinions and studies demonstrated the risks. The brakes were applied and the birth centers offering VBAC decreased. The cesarean section rate soared and more studies revealed the accumulated risks of performing multiple cesarean sections on patients. Recently, the pendulum has swung back to the VBAC corner.

So, why all the fuss? What’s the big deal about VBAC? Well, it’s about uterine rupture. At least that’s my take on it. A patient has a scar on their uterus as a result of a cesarean. There is a risk that the scar can burst open, or rupture, while in labor. The results and consequences of uterine rupture can be quite dramatic. As obstetricians, we all have at least one story about uterine rupture. But, one story is all it takes.

She left the hospital without a baby and without a womb. Devastating. I can still see her face.

You would think an event described by the word “rupture” would make a sound. But it doesn't. Not even a signal. Silent until the moment it happens. No warning. No sign.

I can still see her face.

She left the hospital without a baby and without a womb. Devastating.

I can still see her face.

Sometimes she flashes before me, without a trigger.

It's easy to hide behind hospital policy. After residency, my first job was at a hospital that did not offer VBAC delivery. It was simple. If the patient wanted a VBAC, she had to go somewhere else. But, policies change and I didn't have anywhere else to hide. I had to face my fear.

We opened the door to VBAC in 2011. The slow trickle turned to a steady flow. Now, women seek us out, often traveling long distances. I'm trying to be brave. Recently, we allowed patients with two prior cesarean sections to attempt VBAC.

I'm still trying to be brave.

I can still see her face. 

She signs the five different consent forms and decides on a VBAC. She is doing the right thing. We are doing the right thing. Right?

And then there is the patient perspective. I get it. Sometimes she comes through the door, begging me to cut her again.

“I already have a scar, might as well use it.”

“I'm a planner. I want to know the exact date the baby is coming.”

Sometimes she comes to my office in a rage. She is holding a wad of papers. Her records from the last hospital that “wronged” her and cut her open. They denied her a vaginal birth. I wasn't there. Maybe they did. We obstetricians have been known to be quick to the knife. We have probably done too many cesareans. We should probably do less. We are trying.

She wants a VBAC. What do I tell her? I don't want to scare her.

How do I help her understand? The statistics tell us that her risk is small. The best evidence supports giving her this option. But, what about the person that gave us the statistic? What about her? What about her story?

Do I try to talk her into it if she is a good candidate? Even if she doesn't want to? Do I try to talk her out of it if she is a poor candidate — even if she felt cheated? Will she ever get closure if she never gets to try? What if she ruptures her uterus? Will she forgive me? Will she forgive herself?

She signs the five different consent forms and decides on a VBAC. She is doing the right thing. We are doing the right thing. Right?

Here I sit with a scar across my abdomen. Yes, as a patient. Twenty-six hours of labor and failure to progress at seven centimeters dilation. Yes, me. I cried my eyes out as they rolled me back to the OR.

As a woman, a vaginal delivery is a rite of passage. As an obstetrician, a vaginal delivery is an experience I want so I can relate. As a patient, a vaginal delivery just seems like the best option.

So, I get it. I know why my patient feels the way she did. As much as a I know I was not cheated of my right to a vaginal birth, I still feel that longing. It will never go away. Just might be numbed a bit. How can we help her grieve the loss of a vaginal delivery? How can we help her not think of herself as a failure?

As an obstetrical community, we need to be supportive of each other. We should be thinking of the patient, first and foremost. Egos aside. Listen to the patient. What is she saying? What is her story? What does she need? We also need to listen to each other. The lead perinatologist in our community meets every month with the lay midwives and licensed midwives that practice in our region. Why? Why would he do that?

Why not? He says it is better for the patients. Better for us to stay connected. Better for us to be accountable to each other. Better for us to be able to reach out and learn from each other. It is better.

I can still see her face. 

There is data and there is emotion. There are statistics and there are stories. There is evidence and there is practice.

I have more questions than I do answers. That’s why I need rehab — VBAC rehab.

I am an OB/GYN physician. I am a recovering c-section survivor. I am a former VBAC denier.

I'm ready for rehab. Will you join me?