20. Separating Birth Culture from What You Want (or How Do I Decide Between a VBAC and a Repeat C Section?)
The other day on Instagram, there was a post about fetal scalp electrodes and the importance of an informed discussion about the benefits and risks and the issue with calling the FSE a “sticker.” In the comments, a birther had posted how the FSE had ended up being a great tool for her. At first, she had declined, but eventually the external monitors only worked when she laid perfectly still, and she felt like she needed to move. She then decided to get the FSE, it was placed, she was able to get up and move, and then her labor progressed. I thought this was a great example of informed decision-making. The intervention was recommended to her, she thought over the pros and cons, she declined, but then circumstances changed and she decided to use it.
There was lots of discussion in the comments, as there is with any birth-related post on Instagram. What was most interesting to me though were the people who jumped onto that one person’s experience and tried to explain that continuous fetal monitoring doesn’t improve outcomes and that what she should have done was just decline continuous monitoring all together and then she could’ve gotten up and moved without resorting to the internal monitor. And while it’s true that we have the research to show that for almost everyone, continuous monitoring does not lead to better outcomes for birthers and babies and in fact comes with many harms (see everything Birth Small Talk writes about), that doesn’t mean that every individual person is responsible for declining it if that’s not what they want.
That leads me to a core belief that heavily influences my work with clients as a birth doula: birth culture and the larger issues within it can and should be separated from our support of individual birthers.
Here’s what I mean. While (I personally think) it’s true that:
birth is over-medicalized in general
there are interventions suggested in labor that don’t have a ton of good quality research and evidence behind them
true informed decision-making is much rarer than it should be
and providers don’t always have or take the time to really go into the pros and cons of different approaches in “managing” labor
it’s also true that individual birthers:
should make the individual decisions that feel best to them
may make decisions based on a combination of factors: provider recommendation, previous experience, personal beliefs and values, research, resources available to them, etc
and their experiences and choices are valid
As a doula, I can be frustrated about a culture that recommends elective inductions at 39 weeks without fully discussing the pros and cons with birthers, and I can support a client who decides that an elective 39 week induction is best for them. I can work to change the system, and I can support people within that system as they make whatever decisions they want. I can direct my frustration at the system and not let that dilute my support of my individual clients.
Now let’s talk about how this relates to VBACs and repeat C sections.
There’s a cultural component here, and there’s an individual component as well. Culturally, many people who’ve had a Cesarean section are not presented with a supportive opportunity to VBAC even though most people who’ve had C sections are good candidates for VBACs. Doctors may perceive VBAC as “too risky” to support at all, or they may support them but only under specific circumstances. (Side note: check out VBAC Facts for great information on all things VBAC.)
We’ve actually got two cultural forces at work here: we’ve got the outdated belief that VBACs are “too risky” or “too unlikely to succeed” to support by many OBs, and then we’ve got the opposite side, which is focused on making VBAC a more accessible option for anyone who wants it.
And yet, I see the same thing on Facebook that I mentioned at the start of this post. Someone will post about how they want to have a repeat C section, and the comments will fill up with people asking them if they’ve thought about a VBAC. I think the intention is good — everyone should know about all their true options so they can pick what feels best to them — but sometimes it can come across as shaming someone for the choice they’re making. I’ve even heard of people who are planning a repeat C section not reaching out to a doula even though they want one because they’re worried the doula might not support them in their choice.
So once again, two things can be true: I can feel frustrated at a birth culture that doesn’t support people’s rights to a VBAC, and I can enthusiastically support someone who decides that a repeat Cesarean section is the best choice for them.
If you’re faced with this decision, what are some things you should think about?
Is your gut leaning in one direction over the other?
When you think about planning a repeat C section, how does that make you feel?
What were the circumstances of your previous C section(s)? How did you feel during it?
When you think about planning a VBAC, how does that make you feel?
If your VBAC were successful, how would you feel?
If your VBAC were unsuccessful, how would you feel?
What do you think you really need to make this decision? More information? Unconditional support from a trusted friend/loved one/professional? A debrief from your last birth?
For some people, the control involved in a repeat C section might feel really good. You can generally pick the day you want baby to be born, who the surgeon will be, and what options you may have during and right after your baby’s birth.
For other people, the recovery from a vaginal birth, the experience of it, and/or the benefits of (spontaneous) labor may influence their decision for a VBAC.
Many people also have questions about the risks of VBACs and repeat C sections. I love this decisional aid from the Association of Ontario Midwives that goes into detail about the risks and also the emotional pros and cons of each choice.
There is no right or wrong answer. It’s only about what is right for you in this moment. That’s truly what it means to support people during their pregnancies and births. We can fight the system by demanding change at a high level, and we can also do it by standing by a birther as they decide what is right for them on an individual level.