Episode 242 Q&A with Dr. Barry Brock, "The King of VBAC"

We are joined today by Dr. Barry Brock, aka “The King of VBAC” along with one of his VBAC-hopeful patients, Kara. Kara and Meagan ask Dr. Brock VBAC-related questions similarly to how we hope you interview your providers during your VBAC preparation. Dr. Brock touches on topics such as gestational diabetes, big babies, preparing for your VBAC, induction, placenta previa, preeclampsia, HELLP syndrome, VBAC after multiple Cesareans, and vaginal breech delivery. Additional LinksNeeded WebsiteHow to VBAC: The Ultimate Prep Course for ParentsThe VBAC Link Facebook CommunityFull Transcript under Episode DetailsMeagan: Hello, everybody. Welcome, welcome. We have a really cool episode for you today, an episode that we have been really anxiously waiting for and so honored to be having. We love having birth professionals on the podcast and today we are so honored to have Dr. Barry Brock chatting with us today about birth and VBAC and all of the things. And then we have an extra special cohost today, Kara Sutton, who is actually one of Dr. Brock’s patients. Hello! Kara: Hi guys. I’m so excited to be here. Meagan: So excited to have you guys. I just wanted to share a little bit about the amazing Barry Brock before we get going into all of these amazing questions that this community has asked. Dr. Barry Brock has been a doctor for over 30 years and has experience in obstetrics and gynecology. He has been attending as a doctor at Cedars and I believe Dr. Barry Brock, you had your residency there, right? Dr. Brock: I did. Meagan: That’s really cool so you’ve been there for a while. Dr. Brock is amazing and takes pride in giving quality care to all of his patients. Seriously, one of the coolest things—I mean there are a lot of cool things—but especially with me in the VBAC world, one of the coolest things to me is that you have an outstanding Cesarean rate. It’s very low. I think that’s one of the things that you are very well known for along with helping people have vaginal breech deliveries which we know is kind of trickling out in the world and vaginal twin deliveries and of course, VBACs. So welcome, Dr. Brock, and thank you so much for being here with us. Dr. Brock: It’s my pleasure. Meagan: Oh my gosh. Yes, and as I mentioned, we’ve got Kara who is a patient of Dr. Brock. Kara, tell us how it is to be a patient. Kara: I am a mom of two. I had an emergency and I had a planned C-section due to PTSD from that first emergency C-section. Now I am four months pregnant with my third baby girl and Dr. Brock is my doctor. I’m excited to try and achieve a vaginal delivery with this one. Dr. Brock has the LA rep as the go-to VBAC doctor if you’re trying to achieve VBAC so that is why I am seeing him. I switched doctors specifically for this pregnancy which I think is super important to find the right doctor. I feel really excited and comfortable with Dr. Brock for this particular delivery, especially after the trauma from the first two. For those of you guys who don’t know, Cedar Sinai is a really famous hospital in LA. We’re in Beverly Hills here today. Everyone from Kylie Jenner allegedly and Jay-Z and Beyonce and all of the people have delivered there so he’s kind of a rockstar. So I’m excited. Meagan: Yes. Oh my gosh. It is such an honor. Such an honor so thank you both for being here.Kara: Yeah, so I kind of wanted to jump in right away and wanted to ask Dr. Brock, why do you think the national average C-section rate is so high and why do so many doctors just schedule a C-section? Dr. Brock: Well, the docs are very concerned about a healthy baby and a healthy mother. It takes the stress off of the doctor if there are any problems getting the baby out, but there’s no evidence that we’ve improved the Cesarean section. We have massively increased the Cesarean section rate and we have not improved the fetal outcome. So obviously the system that we’re going with here needs to be tweaked a little bit. But they also need experience. To do a vaginal breech delivery, you have to have the skill and expertise to be able to do that and if you’re not doing that, you don’t have the skills so for a lot of doctors, for them, it’s safer to do the Cesarean section than to do a vaginal breech delivery. I understand that. You’re not skilled. Among the criteria that the American College of OBGYN recommends is that if you’re doing a vaginal breech delivery, you have to know how to do it. Of course, if you don’t do it, you don’t get it done. Another thing is that doctors are very concerned with fetal monitor tracing and they are concerned about the baby’s health and well-being. So when the baby comes out, the other side of the coin is that we do lots of Cesarean sections for fetal distress but most of those babies come out screaming. Well, you can say that we saved this baby from getting in trouble or we did an unnecessary Cesarean section. Remember there is also the mother’s health and the baby’s health. There’s a higher risk to the mother’s health– ten times greater having a C-section than a vaginal delivery– but extremely rare. So that’s not a major factor. You say ten times greater but the incidence is so low. It’s much greater that you walk outside when it’s raining and get hit by lightning. But still, in LA, it’s a very rare thing so I’m not concerned about that. Doctors want the best for the baby. It seems like this. A lot of the time they can get away with a Cesarean section. Some insurance companies pay for more Cesarean sections. You don’t have to go ahead and spend hours and hours in labor. My philosophy is a little different. But you need the skill and expertise. That’s when obstetricians can deliver a healthy baby vaginally. Meagan: Yeah. Wow, I love that. I feel like we could do a whole podcast just on this question alone because it is such a big question. Like you said, I love that you touched on what if we’ve got a Cesarean but the baby comes out screaming? We’ve had people say, “I’ve had this emergency C-section but then my baby had an 8/9 APGAR so was my baby in distress?” So thank you so much for touching on that. Another big question that we have that a lot of people ask is the big baby question. What if I’m being told that my baby really is too big to give birth vaginally? Is that really a thing? What’s the accuracy on that and how would I know if choosing a Cesarean is the right choice versus going for a vaginal birth after a Cesarean? What’s the safety there for the baby?Dr. Brock: Well, a major concern is– the American College addressed that. It is with mothers that are diabetic and have gestational diabetes. If the baby’s over 4500 grams, which is a very big baby, then consideration should be for Cesarean section for the risk of shoulder dystocia. But that’s it. At 5000 grams, if you do not have gestational diabetes, that’s a huge baby. Kara: What is that in pounds? Meagan: It’s like 9 pounds. Is it 9?Dr. Brock: 12 pounds or something like that? It’s a huge baby. Meagan: Yeah, anything over 11 is an extra large baby, and then at 9 pounds, 15 ounces is where they start paying attention, right? Dr. Brock: Yeah, but the biggest problem with shoulder dystocia is if you have a very large baby and you do a mid-vacuum or forceps, then the incidence of having shoulder dystocia is very high, like 25%. But most of the time, mother nature goes ahead and plants the hat and wants a vaginal delivery. It’ll tell you. Maybe it’s stuck or something like that. But to me, it’s always worth a try because basically, you’re saying that mothers who are diabetic would have died in labor. Mother Nature knows what to do. When you give it a chance to prove it, I’ve seen it all. I’ve had a mother who had two Cesarean sections for a 6-pound baby so she really wanted a vaginal delivery. I waited and waited and waited and she delivered her 9-pound baby.  Mother Nature knows what to do. Meagan: Right. So for gestational diabetes, maybe if they are controlled and everything is looking good and the baby doesn’t look like it’s 12-13 pounds or a really large baby, you still feel that it’s reasonable to go for a vaginal birth? Dr. Brock: I practically always think it’s better for a vaginal birth. I mean, there are exceptions. I do VBACs after two Cesareans. I don’t do it after three. The incidence for you to rupture after one Cesarean is 0.5-1% which is very small. For two Cesarean sections, it’s 5% but then it climbs dramatically after that so I don’t do that. Obviously, you have to look at if the placenta is implanted properly. If the patient is of an abnormal presentation of the placenta with placenta previa or accreta. Accreta is when the surface of the placenta digs itself into the wall of the uterus and that presents a major problem. That’s a good idea to get a good center who knows how to handle it. Meagan: Absolutely. Dr. Brock: But Mother Nature– give it a chance. Meagan: Give it a chance. Kara: I’m interested. So why won’t all doctors induce VBACs? What’s the best method for induction and what should I do if my doctor refuses? Dr. Brock: I induce for medical reasons. When someone has a previous Cesarean section, we don’t give prostaglandins because that has shown an increased chance of rupture. I much prefer all my patients to go into labor spontaneously. I sign for a lot more testing after 40 weeks. It depends if we find medical problems but they’ll test twice a week to make sure the fluid’s normal, the Doppler flows are normal, and the NST are non-stress tests where we see baby’s heartbeat. I consider 42 weeks as normal. If someone’s, like I said, diabetic, I’ll do 40 weeks unless there are other problems. But I prefer them to go into labor naturally because I think it’s easier on the mother and it’s a higher success for a vaginal delivery. But saying that, this week, I’ve had a mother who had a baby who was abnormal and it was going to be fine. He needed heart surgery. She had two previous Cesarean sections. We induced her and she had a vaginal delivery. The baby, thank God, is doing fine. We will do heart surgery probably in 3 or 4 months. Each person’s different and we have to take everything into consideration. Right now, I like to wait for Mother Nature to do its thing. Keep an eye on Mother Nature, but let mother nature do its thing. Meagan: I love that. Keep an eye on mother nature, but let Mother Nature do its thing. Because we do, we have so many people writing in saying, “My doctor says I have to have a baby by 39 weeks spontaneously or my chances of VBAC are completely out the window and I have to schedule a Cesarean.” It puts people in a fight or flight mode where they are out there trying to do all of the things to try to be induced but it’s not working because their body is not ready when really what we need to do is step back and let Mother Nature do its thing. Dr. Brock: Well, there are exceptions. Obviously, someone who is sitting in my office and is 3-4 centimeters dilated and she’s 39 weeks then she’s an easy induction. If you’re closed and high, then don’t rush to an induction. Meagan: Right. Right. Dr. Brock: For each person’s safety, individually you have to do that.  Meagan: And that is one of the most important things I think any provider out there should view is that everyone is an individual. I’m not the same as Cara and Cara’s not the same as this mom that just had her VBAC after two Cesareans. We’re all individuals and have different situations. So one of the big questions is breech. If we have someone that is having a breech baby or their baby is breech and not turning, a lot of people just have these repeat Cesareans and we know that you are really big in supporting that. Obviously, there are again, things that have to pan out. But why do you think breech is really going away? If someone is having a breech baby, what can they do to help avoid that C-section if they don’t have a provider like you that’s maybe more supportive of having a breech delivery?Dr. Brock: Well obviously, because in today’s society of birth, people don’t have the skills to do a breech delivery. You can’t have a breech delivery unless your provider knows how to do it. The first thing I want to do is try to turn the baby. At 37 weeks, we will schedule you. We do it at 37 weeks because statistically if the baby hasn’t turned at 37 weeks, there is less chance that he will do that. Also, the fact that if something happens in a version– I’ve done hundreds of them and I’ve never had a problem but theoretically if something happens and we do a Cesarean section, baby is at term at 37 weeks. That’s the first thing I would do. With the breech delivery, I treat a breech delivery– I don’t care if it’s a first-time mother or a second. I do the same thing. Just like Kara, when she gets around 6-7 centimeters dilated, which means the active phase of labor– she can labor at home or wherever, but once she gets to 6 or 7 centimeters, I want everything to go quickly. What I mean is that I want her to dilate quickly. I want the butt to settle down quickly and I want to push her out quickly. You’re not going to push for 3 or 4 hours. I’ll do that for first-time mothers or with any mother head-down but not with a breech. I want it to go quickly. A lot of babies don’t do that, but that’s where I stay safe because if it flies out, it flies out. The biggest problem with breech delivery is that the head is coming last. The cord is beside the head so you’ve got to get the baby out quickly. Using those criteria, I’ve had very good success and no problems, but I’ve done many Cesarean sections because obviously, I remember one patient who came in. She was 9 centimeters. It was fantastic. She was doing great. She started pushing and all that came down was the testicles. So I sectioned for a 10-pound baby. So mother nature is telling you, “Just because you’re committed to a vaginal delivery, you don’t drag the kid out.” The idea is to let the baby do its thing. The reason we want butt down, especially in first-time mothers, is that if it’s not his feet coming out, the cervix may dilate to 6-7 centimeters and the feet come out and the body comes out and the cervix is not fully dilated when it gets to the head and it gets trapped. The cervix never clamps down. It just never fully dilates. That’s why we usually don’t do footling breech. We don’t do vaginal delivery. There are exceptions, but rare exceptions. If a multiparous patient comes in and the feet are there and the cervix is completely dilated, the baby just falls out. That’s really an exception to the rule. The other concern with a footling breech is especially if the mother is dilated, that patient is concerning because if the water breaks and she’s dilated and just the feet are there, the cord may fall out. It’s called a cord prolapse. That’s a contraindication to try to do something at home. If someone is dilated and footling breech, that’s the kind of patient I would bring to the hospital and do a C-section for cord prolapse. Meagan: Yeah, which makes sense. There are not a lot of you out there that will support or is trained and educated in vaginal breech delivery and from what we’re gathering is that it’s not really being taught a ton in medical school anymore. Is that correct? Dr. Brock: Well, not in my residency. I mean, I may offer to do that but it’s easier. I mean, you schedule a C-section. You walk in. It’s an hour. You’re done versus spending 8, 10, or 12 hours laboring this patient. So the incentive isn’t there to do that. So the skills are disappearing. I mean, I’ve offered to come in and assist anyone who wants to do a breech delivery and I’ve done that but not that often. The residents are always invited. They can do that but just because they do it in residency, it’s a big staff to get through. They may do one or two breech deliveries but they don’t feel comfortable to keep on going out in the private practice. It is dying out. Meagan: Yeah. It makes me sad. It makes me sad. Kara: I have a question because I have had two C-sections. How long should somebody wait to conceive after a C-section? I’ve heard mixed things about this. I’ve been told mixed information about this and I just would love to hear your point of view on that. Dr. Brock: Well, there’s some data to show that ideally it is two years apart but everybody’s facts come into play. For someone who is much older and has trouble getting pregnant, if someone had a baby at 40 and wants another child if she is waiting until 42, she may never get pregnant. I’ve not found it to be a big factor but statistically, it does seem to be safe. I would do psychologically what’s better for you how far apart you want to have your kids. Besides, mother nature does help. It takes some time to get pregnant as you get older. Kara: Great. Is the thought that the longer you wait, the more healed your C-section scars are and your uterus is stronger or is that not real? Meagan: Like is there less chance of rupture that way? Dr. Brock: Literature is in my mind, not that clear. Statistically, it’s probably true but it’s like saying you’re at a greater chance of dying if you’re driving at 58 miles an hour instead of 55. It’s true, but statistically, is it really a factor? Meagan: It’s not substantial. It’s not anything that’s a concrete yes or no. Okay, and talking about VBAC after two Cesareans or more, what are the complications surrounding a C-section or even a repeat C-section? We talk here a lot about the risks of VBAC– rupture and things like that– but we don’t talk a lot about complications, especially even years later. Are there complications for people who have had Cesareans even years later? Dr. Brock: Years later, I don’t know much about that. I do know the higher the Cesarean section rate, you’re going to have an increase of abnormal implantation of the placenta from accreta or things like that. It goes up. Instances of rupture with more Cesarean sections go up. I’ve done Cesarean sections, 5, 6, and 7 Cesarean sections. It depends. The doctor who goes in there with all of the scarring, while it’s very, very difficult and dangerous, it may pass on to the next time, but most of the time, it’s not a problem at all. I have no limitations per se on how many Cesarean sections someone can have. I have a patient right now. She had a Cesarean section then I did a VBAC. Now she’s pregnant again but she wants a repeat Cesarean section because she had anal problems and she had surgery so her surgeon recommended that she doesn’t try for a vaginal delivery. I’m not 100% in agreement but I have no problem respecting her wishes and we set her up for a Cesarean section. Each case has to be individual. There are no absolute rules for anything. As far as consequences, most of the time for later on, there is but it’s more related to how many times you get pregnant, not how you deliver. Bladder dropping and things like this, each pregnancy puts a toll on that. I think mother nature plans for you to have your first kid when you get through puberty. I think it’s a very bad idea for 13-year-old kids to have kids. But mother nature, that’s the whole plan. That’s the animal kingdom. That’s what we do. Of course, for millions of years, you were dead at 20 but that’s a different story. Meagan: So kind of piggy-backing off of that question too, we had someone write in talking about how she had a Cesarean and then they went in for a second Cesarean but they didn’t use the same incision so she’s got two incisions which I had never actually heard of, in her uterus. In the uterus, they cut a different spot is what she said. She’s asking– okay, so now she’s got two incisions in her uterus. Is that something that would be suggested for her to VBAC because she’d really like a vaginal birth? Dr. Brock: No, that’s fine. First of all, the patient doesn’t know about the scar on the uterus. It’s the doctor. When I go in there unless someone had a vertical incision and there’s no such thing as a classical. They call it a classical incision, but that was done 100 years ago and they went up and down incision on the belly and they went up and down incision on the uterus. The top of the uterus is the fundus is what we never do. That’s at a much higher instance of uterine rupture. We used to do that. Somebody added, “Once a section, always a section.” That’s where that falls. I would say 95% of Cesarean sections are low-transverse. They are very low on the uterus. But when I go down and do that, I see the bladder there. I don’t know where the last Cesarean section was. I can’t see. I just tape down the bladder and make an incision so I have no idea in the uterus. But we do know that, like I said, during Cesarean sections and repeat, it’s not a problem. We do know that.I’ve given it to patients that had previous fibroid surgery. The American College recommends, what is the indication for the surgeon? Does he recommend you for vaginal? He should tell you that. My philosophy is when I do that, it depends on if I enter the cavity of the uterus and whether I would recommend a Cesarean section. Sometimes the fibers outside of the cavity, I have no problem recommending a vaginal delivery. I’ve done vaginal deliveries after another doctor did multiple fibroids laparoscopically. They sewed it up and I asked him. He said, “Well, it should be fine. We did multiple scars and she did great.” Yeah, individuals.Meagan: Exactly, yeah. Thank you. Kara: I have a question. I did not have supportive providers in regard to my first two deliveries. I had an emergency C-section and then a planned C-section and nobody brought up that I could deliver vaginally or any of that. I just felt like I had a C-section so I had to have one the second time around. So I wanted to know what are the ways to really help someone find a provider who actually tries for that? I think a lot of women can’t find the right doctor who can do that. Meagan: Yeah. Dr. Brock: It’s hard to say. Some hospitals publish the C-section rates of their doctors. That’s one way to look into it. But blogs and things like this, you have to talk to your doctor and see what’s comfortable. You can’t force your doctor to do something he’s not comfortable with. Many years ago, one of the doctors, an old-time doctor, refused someone to do a VBAC because he had a bad outcome with a baby. Your personal experience comes in. Everyone’s trying to do the best thing. They’re trying to do what’s safe for you and your baby. You just have to find a match that works for you. Kara: When you’re interviewing your doctor, what are the types of questions you can ask to get a sense of his or her skill level with it or comfort level with VBAC? Dr. Brock: Well, I’ve had a patient come in. She had three previous Cesareans sections. She wanted me to do a vaginal birth. I said, “Don’t. My limit is two.” They have it out to think that it’s the same but it’s not. It’s about talking to your doctor and asking them personally. “I’m thinking about having a VBAC. What do you think about it?” You want to be comfortable with your doctor and listen to his advice, but there are different opinions out there. If you’re comfy with your doctor and you trust your doctor, I have no problem if he feels that he did a section and recommends another section, I understand that. We do know that certain things that change behaviors. They talk about measuring the thickness of the scar, of the uterus, and things like this. A study just came out that found no correlation whatsoever. Meagan: I was going to ask that. That is a huge question too. “My doctor said I can’t because my thickness isn’t thick enough.”Dr. Brock: Well, there was no correlation. It made me nervous. I had one who had a scar. They said she had a window in the ultrasound. She had two previous Cesarean sections. I delivered her baby vaginally no problem. After that article came out saying there was no correlation, and my experience showed there was no correlation but each case is individualized. I may have a previous rupture and that’s a different story. There is no good literature on that and it’s probably not worth the risk. Meagan: Right. What about single and double sutures?Dr. Brock: The data shows that I will always use the double closure. The only thing I would make an exception for is that sometimes when they get their tubes tied and it will save some time while having a C-section or vaginal delivery. But no, literature says that double closure has lower chances of rupture. Meagan: Would you support someone wanting to VBAC if they had in their op reports a single-layer suture? Dr. Brock: Yes, I would. A higher instance doesn’t mean it’s going to happen. As all patients, with this one especially, when you have a previous Cesarean section, I don’t want you to deliver at home. *Inaudible* Usually, it’s not unreasonable to place an epidural catheter in. Not actively, but if something happens, we can just give you some medication so you don’t have to put them under general anesthesia. Just to be prepared.Meagan: Right, right. Be prepared. Kara: You prefer that they labor at the hospital and not at home? *Inaudible*Dr. Brock: Yes, yes. Right, because that’s a concern we have. The baby will tell us something. I did a VBAC last night and she’s not that tall. She’s only about 5 feet. This baby seemed huge but it was way out of bounds. The reasons are that the pelvic, mother nature doesn’t know about these Cesarean sections. So first-time babies go down low in the pelvis. The cervix is firm and holds the babies in there prematurely but after the first delivery, the cervix can get soft so mother nature keeps an eye until you go into labor otherwise you’ll deliver prematurely. But that’s when the head is high. The higher the head is, that’s going to put pressure on the scar. I feel much more comfortable as the head drops in the pelvis, it’s getting below the scar, and the chance, I think, of rupturing drops dramatically when the head drops. But mothers may not drop until they go into labor. Meagan: Right. Talking about preterm, if someone had a preterm Cesarean birth, are they a candidate in your eyes for a vaginal birth after a Cesarean? Dr. Brock: It depends on how premature. Babies vary with premature. We talk about if she didn’t go into labor, and they had to have it done. It depends on the thickness of her lower uterine segment. The doctor goes in. He may feel like there’s not enough safe room to make a transverse incision so he has to do a low vertical. The low vertical is associated with a lower instance of rupture. Mind you, before we say you have to find your records and find exactly what type of scar on the uterus it is. But now, American College says, “No. If you had a previous Cesarean section, unless you know that it’s a low vertical, then you can try for a vaginal.” If it’s a high vertical, definitely. Low vertical, it is a little different but we have to wait and see. I’m not against going for a repeat Cesarean section if someone had a 25-week Cesarean section. If the lower uterine segment was not developed, the doctor did it appropriately. There is no harm to the baby coming out low vertically extended up. Meagan: Right. That makes sense. Cara, did you have another question? I know that we were talking about it before. Kara: I was just wondering if I’m preparing for a VBAC, which I am in four months. Is there anything you recommend that patients should do to prepare for a VBAC? That’s something I think about all of the time. Is there anything that patients should do to prepare for that? Dr. Brock: There’s nothing. There’s really nothing that you can do.Kara: No running?Dr. Brock: You don’t want to gain too much weight during pregnancy. The more weight you gain, the bigger the baby so that’s a major factor. If you start gaining 40, 50, or 60 pounds, then the baby may be bigger and things like that. Most things to prepare are like with any pregnancy. Get yourself into shape before you’re pregnant. Get your weight down before you get pregnant. Those are major things that you can do. Once you get pregnant, we tell you not to gain too much weight, but we don’t want you to lose weight. Exercise can always be done during pregnancy, but I always prefer getting into shape before you get pregnant. Kara: No one ever tells you that. I swear. Or at least no one’s ever told me that. I think that’s a good thing to know. Dr. Brock: Yeah, because you’re slim. Meagan: Yeah, well just being healthy overall and overall healthy. That’s not even just for VBAC. It’s just if you’re going to have a baby, try overall to be healthy in general every day. Even if you’re not having a baby. Good nutrition and all of that. Preeclampsia is something that is sometimes developed. Is that something that someone could TOLAC and have a VBAC with? Dr. Brock: Yes. It really depends but nowadays, with previous history, we give baby Aspirin and try to lower the incidence of recurring. We keep track of the blood pressure throughout the pregnancy. But yes. If I knew the cause of preeclampsia, I’d win the Nobel Prize. It’s the mystery of mankind. We know it’s associated with first-time mothers, elderly mothers, and twins, but we don’t know exactly the cause. All we can do is keep an eye on it and make sure it doesn’t occur. Now if it does occur, unfortunately, the delivery for that and the treatment for that is delivery. Meagan: Right. This is a spinoff but HELLP syndrome. If someone develops HELLP syndrome and their platelets are good and everything, are they still candidates for VBAC or is a Cesarean delivery really safer? Kara: Can I ask, what is that? Dr. Brock: First of all, it’s a subset of preeclampsia hypertension *inaudible* where the mother can get elevated liver enzymes and low platelets. That is an absolute indication that we have to deliver the baby. Okay? Now, people go ahead and say, “Oh, well you were *inaudible* delivery. We should do a Cesarean section.” I have nothing against doing that but if a patient is, it may take a long process because she’s not ready, but I think that she has to be managed in a hospital, her blood pressure is under control, and she has to go for delivery. Now, it may take a day or two and maybe she’s not willing to wait that long or her doctor isn’t or things like that, but I have no problem as an independent event to have a vaginal delivery if you have HELLP but it’s definitely an indication. Meagan: Yeah, isn’t that really the only way to help is to get the baby out? Dr. Brock: Correct. The only way to help HELLP syndrome is to get that baby out. Meagan: The only way to help HELLP syndrome is to get that baby out. Yeah. Okay, that is so good to know. It’s not as common in our community, but we have definitely seen people ask and then they worry about the platelets and surgery. They never know what’s safe or not. Dr. Brock: The other thing is that if the platelets are low or under 100,000 the anesthesiologist is very leery of putting in an epidural. The reason that over a spinal is because platelets are used to clog your veins and if he hits a blood vessel in your spine putting it in, then it can cause damage and cause paralysis so they really don’t do spinals. They do general anesthesia, not regional anesthesia if someone has low blood platelets. I had a patient who had very low platelets not from HELLP, *inaudible* and she couldn’t get an epidural. We definitely didn’t want to do a Cesarean section because she had low platelets so we did it the old-fashioned way. She didn’t have an epidural. She had a vaginal delivery and it hurt. Meagan: Yeah, well that’s good to know though. That’s really good to know. So as someone who’s had a vaginal birth after two Cesareans myself and obviously Kara is preparing, we talked a little bit about how to prepare. But is there anything that we need to know? We talked a little bit about the risk earlier but is there anything that we need to know about vaginal birth after two Cesareans that we may not hear about with just VBAC after one?Dr. Brock: I mean, like you said. The risk is higher. The doctor who might be a little nervous or leery obviously, stress shows that doing a Cesarean section may be higher which I understand. If there are concerns, he may cross-match for blood and have it available in case you need that. That’s how the doctor is not the issue. Like I said, labor in the hospital and not at home because if something happens, “Oh, I’m five minutes away from the hospital,” but that’s not true. You may be five minutes but you’re at least 45 minutes before you can get the baby out. You try to hold your breath for 45 minutes, so that’s why in the hospital. But like I said, everything is done before you get pregnant. Try to get in the best shape you can and not gain too much weight and make sure the baby isn’t huge. If someone had a macrosomic infant and is diabetic, the doctor may take that into consideration. Meagan: Right. We have a lot of people in our community that don’t have the support in their area and do find themselves having to travel long distances to their provider that is supportive. I think a big worry is uterine rupture. We talk about uterine rupture and it sounds really scary. We talked about getting to that hospital as soon as you can. But for those who are driving or are further away, are there any signs or symptoms that you would say, “Okay, you need to seriously deviate your plan and go to the nearest hospital at this point?”Dr. Brock: Well, certainly massive bleeding. If you go ahead and have searing pain, that would be from the uterus. There are no absolute signs of anything, but stars up early, that’s why you go in early so these things don’t happen. Thank god the instance of rupture is very small. In a hospital setting, even with a rupture, there’s no guarantee that the baby is going to get in trouble but it’s considered a greater risk. If you’re not in the hospital, it’s a risk to the mother’s health and the baby’s health. But the instance is small. But common sense is. If you’ve had four Cesarean sections and now you decide you want a vaginal delivery, you’re putting yourself at greater risk. It’s not worth the risk. Babies don’t do well if mommies aren’t around so you want to make sure you’re doing fine. Meagan: Make sure everyone’s good. Yes. Awesome. Kara, do you have any other questions, especially as a patient? I’m sure you guys have this time in the office to ask as well. Kara: We have an appointment right after this. No, I just feel really grateful to have found Dr. Brock and I really feel that I wish more doctors were as skilled and as knowledgeable as you are. I am really, really impressed with your experience level and your support of mothers trying to do things the way they want and the way were made to do. I’m just very grateful and thank you for being with us today. I know how busy you are with eight deliveries this week. Meagan: Literally, I know. You just had births last night. I’m sure you’ll have births today. It’s always such an honor to have birth professionals on the podcast because these people who are listening to the podcast really are in a very vulnerable state and want to get all of the information. So it’s so fun to have a skilled OBGYN here answering these questions from the community. It really does. It helps people guide and feel better. Honestly, just hearing the support you have, no wonder you’re the VBAC king in LA. Dr. Brock: There are a lot of other people who do VBACs. Kara: You’re being humble. He’s being humble. Meagan: There are. There are a lot of people out there that do VBACs but it does seem to be harder to find people that do VBACs in the manner that you do like, “Let’s monitor mother nature, but let’s let mother nature do its thing.” It doesn’t seem like you have a lot of restrictions. We have a lot of providers out there that do have a lot of restrictions so it’s humbling to hear that you’re like, “Hey, let’s do this. Let’s trust the process. I’m going to be here. I’m going to guide you along the way and I’m going to monitor but I want what’s best for you and I want to listen to what you want to do and I want to support you.” Thank you so much for being that person for this community. Dr. Brock: Well, the other thing that I was saying is that for someone who is in labor, I do monitor the baby. It’s not intermittent monitoring because that’s how I keep track of the baby. The other thing I do when I do the tracing is that a good baby can look bad on the tracing, but a bad baby cannot look good. So you have to understand that. If a baby is a healthy baby and has some variation but it comes back and it’s back to normal, that’s a healthy baby. But even with the worst tracings, statistics say that 50% of the time, the baby gets in trouble. But just a terrible tracing, follow your doctor’s advice and do what he says. But still, hopefully, results will come back good. Meagan: Right. Standard practice all over the world really is continuous monitoring with VBAC because we know that fetal heart dropping and distress are one of the main signs that something, some separation may be happening. If you’re listening, know that it’s pretty standard. That’s pretty standard care all over the world. Dr. Brock: It keeps your doctor’s *inaudible*. If you’re not monitored, we don’t know what’s going on. Meagan: Right, yes. Okay, well thank you so much for taking the time out of your day and being with us. We really do appreciate it. Dr. Brock: All right, have a good day then. Kara: Thanks, Meagan. Meagan: You too. Bye, you guys. ClosingWould you like to be a guest on the podcast? Tell us about your experience at thevbaclink.com/share. For more information on all things VBAC including online and in-person VBAC classes, The VBAC Link blog, and Meagan’s bio, head over to thevbaclink.com. Congratulations on starting your journey of learning and discovery with The VBAC Link.Support this podcast at — https://redcircle.com/the-vbac-link/donationsAdvertising Inquiries: https://redcircle.com/brands