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VBAC scare tactics (4): No pre-labor dilatation = no VBAC

July 21, 2009

Many women who want to have a vaginal birth after cesarean (or VBAC, pronounced “vee-back”) in the United States have faced some sort of opposition from their care providers when they have expressed their desire to VBAC.  Oftentimes, this opposition comes in the form of ” VBAC scare tactics.”

The (outrageous) statements are often misleading, exaggerated efforts by OBs (and yes, even midwives) to discourage women from VBAC and to encourage them to “choose” a repeat cesarean.  (Of course, it’s not really a choice if your provider won’t even “let” you VBAC, is it?)

And if you find yourself up against a barrage of scare tactics–as I once did–it can be exceedingly difficult to stake your claim and argue against the doctor (again, or midwife) who may or may not have your and your baby’s health prioritized higher than medico-legal concerns and who may or may not be hurling phrases like “catastrophic uterine rupture” and “dead baby” your way.

If you do find yourself facing such scare tactics, and if you do want to have a VBAC, there are some questions that your care provider should be able to answer when s/he hurls those scary and/or outrageous comments and standards your way.  And if s/he refuses to or even cannot answer these questions, then you might want to consider finding an alternative care provider–one who is making medical decisions based on research, evidence, and even respect for your patient autonomy and not on fear, willful ignorance, or even convenience.

I encourage all mothers who read this post (and others in my “VBAC Scare Tactics Series”) to  take the information contained herein as a springboard from which they can 1) continue their research on VBAC, 2) maintain a communicative relationship with their care providers, and 3) find a care provider who best supports the mother’s interests and plans for the birth of her child.

(To read my disclaimers about “why I am not anti-OB” and “why I take the gravity of uterine rupture seriously,” please see my posts on VBAC scare tactics (1) and (2).)

Scare tactic #4: Since you are 39 weeks pregnant and your cervix isn’t dilated or effaced, it looks like you probably won’t go into labor on your own “in time.”   We need to schedule a repeat cesarean and forgo a VBAC attempt.

Questions to ask your care provider:

  • How reliable is the dilation and effacement of the cervix at predicting when a woman will go into labor spontaneously?
  • Do you mean to suggest that you will not induce my labor because my cervix is not dilated and/or effaced, or do you mean that you will not “allow” me to attempt a VBAC because my cervix is not dilated and effaced?
  • Is there a particular deadline (other than 42 weeks, or ACOG’s standard definition of a “postdates” pregnancy) before which I must go into labor spontaneously under your care?  (Note: I encourage not only all VBAC-ing moms but also all pregnant women to ask their care provider this sort of question early on in their pregnancies.)
  • What would happen if I refused a repeat cesarean and waited for labor to begin spontaneously?
  • Have you had much experience with women whose cervixes weren’t dilating or effacing by 39 weeks and who were pregnant forever?

Okay, just kidding about that one!  Couldn’t resist the snarkiness!

A more nuanced analysis:

Believe it or not, I have heard multiple women who have reported hearing something along these lines (i.e. “no cervical ‘progress’ = no VBAC”) from their care providers.  As ridiculous as it may be, I’ve even heard of OBs who express concern if a woman’s cervix is not dilating and effacing by 37 weeks!  PUH-lease!

But why the snarkiness?  Why the “PUH-lease”?  Why cast this particular scare tactic as absolutely ridiculous and asinine?

The dilation and effacement of your cervix cannot tell you with any ounce of certainty (and with very little accuracy) when you will begin labor spontaneously.

Thus, for anyone–especially an obstetrician–to claim that your “lack” of pre-labor cervical dilatation implies that your body is somehow inadequate or slow when it comes to birthing babies (thereby “disqualifying” you as a candidate for VBAC) is either a) feeding you a load of horsecrap or b) wildly, shamefully misinformed and uneducated and inexperienced when it comes to pre-labor cervical dilatation.

In fact, the dilation and effacement of your cervix doesn’t even say anything about your labor whatsoever unless you are already in labor–that is, unless you are having regular contractions that are (generally) getting longer, stronger, and closer together and are continuing the dilation (and possibly effacement) of your cervix. 

Furthermore, while anecdotal “evidence” is the weakest form of evidence, I nonetheless encourage you to gather all of the anecdotes you can from girlfriends, mothers, sisters, aunts, co-workers–from any woman who has ever had a baby–and then ask them about the “status” of their cervix before they went into labor.

I can all but guarantee you that you will find a woman–and perhaps many women–whose cervix was 0 cm dilated and 0% effaced and who went into labor spontaneously (i.e. without induction) within 24 hours.  (For what it’s worth, my cervix was 0 cm dilated and 0% effaced right before I went into labor spontaneously with A.)

And I can all but guarantee you that you will find a woman–again, or many women–who walked around for over a week with a cervix dilated to 3 or 4 or even 5 cm before ever going into labor spontaneously (like my mom did with my youngest sister).

But possibly–just possibly–some OBs mean to suggest they will not induce a VBAC mom whose cervix is not dilated or effaced at 39 weeks.  And this is not entirely unreasonable.  (Know, however, that the dilation and effacement of the cervix can change not just within a matter of days but also within a matter of hours.  So if your cervix is 0 cm dilated and o% effaced at 39 weeks 1 day, it may be 1 cm dilated and 50% effaced at 39 weeks 2 days.  Or 3 cm dilated and 70% effaced at 40 weeks 2 days.) 

A woman’s favorability for induction is based upon her Bishop’s Score.  This score takes into account the following elements: the dilation of the cervix (from 0-10 cm), the effacement of the cervix (from 0-100%), the consistency of the cervix (the relative softness), position of the cervix (posterior, midline, or anterior), and the station of the fetus (or the location of the baby’s head in regard to the mother’s pelvis, ranging from -3 to +3).  Once the Bishop’s Score is calculated, it can help to determine not only the likelihood of the success of an induction (where “non-success” results either in no labor whatsoever or a cesarean section) but also the method by which the induction should begin (i.e. with prostaglandins and then pitocin, or pitocin only.)

(By the way, did anyone know there is an iPhone app for calculating Bishop’s Scores?!  It even includes modifiers for previous births, ruptured membranes, pre-eclampsia, and postdates!)

Long story short, if your cervix is 0 cm dilated and 0% effaced, then it is very likely (even given the other conditions of your cervix) that your cervix is unfavorable for an induction.  And this would be a good reason for an OB to claim, “Well, since your cervix isn’t dilated or effaced at 42 weeks, I don’t think that it is a good idea to induce your labor, especially since you are attempting a VBAC, and prostaglandin inductions significantly increase your risk of uterine rupture.”

But this comment departs dramatically from the original, ridiculous scare tactic: since you are 39 weeks pregnant and your cervix isn’t dilated or effaced, then we need to forgo a VBAC attempt and schedule a repeat cesarean.  So perhaps my question about induction gives the care provider a great, heaping benefit of the doubt.

One of the other questions I list above relates to the issue of a particular “deadline” that a care provider may have in mind when it comes to VBAC attempts.  In a separate post, I addressed the issue of creating (arbitrary) “early eviction dates” for VBACs.  As I wrote in that post, creating an early deadline for VBAC not only contradicts the American College of Obstetrics and Gynecology’s own guildelines for “postdates” pregnances but also ignores the research on the risk of uterine rupture after 40 weeks

So if a care provider claims that “no cervical dilation and effacement at 39 weeks = no VBAC,” then one needs to seriously question the reasons that s/he may have for using 39 (or 40, or even 41 weeks) as a VBAC “cut-off point.”

In that same post, I also addressed the option of refusing a repeat cesarean and waiting for labor to begin spontaneously.  Especially when one is making this decision in opposition to one’s care provider’s wishes, choosing this option takes guts–just about a much as it does to transfer to a new care provider in the middle or even the end of one’s pregnancy–but it is a choice that is, theoretically, supported by the law

And waiting for spontaneous labor and/or switching care providers is a reasonable and smart decision for the vast majority of moms who have made the deeply personal, evidence-supported decision to choose a VBAC rather than a repeat cesarean for the birth of their child.

2 Comments leave one →
  1. renbeth permalink
    July 22, 2009 11:52 am

    You know, Kristen, I’ve been reading these posts on VBAC scare tactics that you’ve been writing (even though in some ways they don’t exactly apply to me) and I just can’t stop thinking about the way these scare tactics are continuously used on ALL moms, VBAC or not. I remember how the nurses and the on-call resident tried to convince me that if I really cared about Isaac’s safety, I’d agree to continuous fetal monitoring – even though my pregnancy had no complications, Isaac was clearly healthy, and labor was progressing just fine. I find it so frustrating and also so bewildering that so many people in the medical profession seem to use parental love as fairly nasty manipulation tool. Because while there are, as you have been careful to say, certainly times when particular medical interventions are necessary, so often they are just “easier” for the medical staff.

    I guess I just want to say that I appreciate so much your efforts to help yourself and other women be more educated about these issues and how to constructively deal with them.

  2. BirthingBeautifulIdeas permalink*
    July 22, 2009 12:44 pm

    Renbeth, you are spot-on in regard to so, so many issues facing pregnant and birthing women these days. It’s bad enough when medical staff don’t want to follow evidence-based medicine when it comes to “caring” (a term I use lightly) for women giving birth. But it’s even worse when they prey on your parental love and/or try to scare you into complying with their wishes.

    And thanks for your kind words. The appreciation is…well, much appreciated!

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