Episode 312 VBAC Basics with Meagan & Julie

This episode goes back to the basics and is a great place to start on your VBAC journey! Julie joins Meagan today as they talk about many common questions beginning with reasons why providers tell women they can’t go for a VBAC. Topics today include: Nuchal cordsBig babiesSmall pelvisesArrest of descentThird-trimester ultrasounds Cervical dilationInductionDue datesThe ARRIVE TrialWhy there is so much contradicting VBAC infoPregnancy intervals EpiduralsMeagan and Julie also reflect on how their perspective toward each of these topics have changed over the years. Allowing for nuance is so necessary when approaching birth. Know that you always have options and never feel pressured to make a decision that doesn’t feel right for you.The VBAC Link Blog: Pregnancy IntervalsNeeded WebsiteHow to VBAC: The Ultimate Prep Course for ParentsFull Transcript under Episode Details 04:24 Review of the Week07:48 Intro to the basics09:53 Nuchal cords13:30 Big babies, small pelvises, fluid levels, and third-trimester ultrasounds17:08 How will this change my care?18:47 Cervical dilation25:54 Due dates28:18 Vulnerability and the ARRIVE trial30:44 Inducing a VBAC36:15 Julie’s social media story38:29 Contradicting information41:36 Pregnancy intervals46:38 Epidurals54:13 Allowing for nuanceMeagan: What’s up, everybody? This is Meagan. We have Ms. Julie with us today and we are going to be talking to you about what we need you to know about VBAC. We obviously like to talk about different topics but Julie and I decided this morning as we were getting ready to record that we need to do an episode on just the basics again. Don’t you feel like it’s the basics? It’s not to shame anyone for not knowing the information. It’s honestly to– I don’t even want to say the word shame– but providers are not educating their patients. They are just not. We see it time and time and time again where people just don’t know. We saw a post, I don’t know, maybe a month or so ago. I think maybe Julie sent it to me. It was just saying, “Hey, so can you have a VBAC no matter what reason the C-section was for?” Someone said, “Well, it depends because if it’s something like a cord wrapped around the baby’s neck, if that was the reason you had your previous C-section and if your last baby had its cord wrapped around their neck and was having struggle, yes. You have you have a C-section.” Julie: I am getting a little salty. I feel like maybe salty is not the right word, but direct. I jumped in and I’m like, “That’s actually not true. The cord wrapped around a baby’s neck preventing them from descending is a perfect VBAC candidate because it’s not anything to do with the pelvis or labor stalling or anything like that.” Anyways. Meagan: Even with that said, even with that said– Julie: People still argued with me. Meagan: Well, but even if it was due to someone being told that their pelvis was too small or their baby didn’t descend– Julie: That’s also false. Meagan: That’s also false. Julie: I mean with actual pelvis trauma where it’s actual CPD and is legitimately diagnosed and that type of thing. Honestly, most people are good candidates for VBAC but we are going to talk about that. Meagan: Yeah, we’re going to talk about that today because it’s obviously something that we are really passionate about and it’s something that we want you guys to know so let’s talk about it. 04:24 Review of the WeekMeagan: We do have a Review of the Week. You guys, it’s a really long one and I might have specifically been waiting for Julie to come on with me so she can read it because she’s a lot better at reading long reviews sometimes. I’m just going to pass the time over to Julie to read this amazing review. Julie: Now I feel pressure, man. Meagan: Don’t mess up. Julie: The pressure’s on. Are you ready for this? This review says, “This is such a tremendous resource for VBAC mamas.” See? There I go. I knew it. I’m going to start BBAC mamas. Try and translate that, Paige. Anyway, okay. It’s fine. I’m going to circle back around. “This is such a tremendous resource for VBAC mamas. I sadly only discovered your podcast after my VBAC in April 2022 but having caught the birth bug during my prep for that birth, I still listened to each episode as if I’m preparing for my VBAC all over again. I think having a special place for this very unique scenario helps those planning and hoping for a successful VBAC feel less alone, more supported, and very well-informed. “The balance of evidence-based information with the age-old practice of sharing birth stories makes this one of the best birth resources out there. I only wish I had this when I was planning my VBAC but maybe someday I’ll get to share my own story and help inspire a fellow Woman of Strength. “Prepping for and achieving the unmedicated birth of my daughter absolutely flipped a switch in me and I feel determined to become a birth worker one day.” I feel like all of us go through that, right? “Knowing that this podcast team also has a course for prospective doulas like me thrills me to my core. I want to be there for other anxious, hopeful VBAC mamas like me and the amazing work that you are doing is changing birth and lives everywhere. Keep it up. It is so needed and appreciated. Adrianne.” I love that so much. I feel like that’s all of us like you and me. We all go through this journey like, Hey, I had a really bad birth experience or I had a really bad one and then an empowering one and I want to be part of this change so that other people don’t have to suffer like I did. I love that and I feel like almost all birth workers’ stories start like that. I know mine did and yours too, Meagan. We all are there at some point. Meagan: We are. Yeah. I couldn’t agree more. I definitely have been there. 07:48 Intro to the basicsMeagan: Okay, all right. Let’s talk about the basics. What basic do you want to talk about first? We were talking about just a second ago where we were like, Hey, this was being told to you and you are being told you may not get to have a VBAC. So maybe we just start with reasons people are told that they have to have a C-section and they can’t have a VBAC. Julie: My gosh. I want to speak to a couple of different points in that direction. I have a couple of different ideas in my head. First of all, I feel like it’s important to acknowledge that we are all ignorant to things at some point. Right? We all have to learn that VBAC is an option at some point or maybe we always knew. For me, I feel like I never was like, Oh, I can have a vaginal birth? I just always thought I could have one, but I also feel like the age-old “once a C-section, always a C-section” thing is so ingrained in some parts of our culture that you really do have to have that awakening that, Oh, I can do this. It is safe.So I just want to acknowledge that. Sometimes, even for me, I’m scrolling through Facebook and I see this post about something or the ARRIVE trial with induction at 39 weeks is safer and it’s really easy to eye roll or it’s really easy to be like, Oh my gosh, how come you don’t know this? But I feel like let’s circle back when I see these things and remember that we all start somewhere. Not all of us have access to supportive providers, supportive hospital systems, supportive families, supportive providers. We don’t all have access to those things. If you’re advanced in your VBAC thoughts or thinking or whatever, I encourage you to still stay on the episode because you never know when you’re going to learn something new. You never know when something is going to click right for you and you never know when you’re going to gain the perspective that you need. If you are a seasoned VBAC pro, please also stick along with us. 09:53 Nuchal cordsJulie: I feel like I hear a new reason why someone is told they can’t have a vaginal birth every day. Not every day, that’s a little dramatic. Meagan: But a lot. Julie: It still surprises me. I’ve been a doula in the birth scene for 9 years now and I still get that cord prolapse one. I have never heard that as a reason why someone would have a repeat C-section. I mean, I had a VBAC client. She was trying for a VBAC at home and it ended up in a hospital transfer. The baby’s cord was wrapped around her neck four times. They had to cut the cord in four places to get the baby out via C-section. Meagan: I remember you saying that. Julie: Yeah, that baby was stuck so tightly in there. In those circumstances, that C-section was necessary. That baby was not coming out, but that doesn’t mean she can’t try for another VBAC. I think she is done having kids, but that is completely circumstantial and specific to that pregnancy. So I feel like that’s a really important thing to note is that most things are circumstantial. Even stalled labor or arrest of dilation or failure to progress or a big baby or whatever these things are circumstantial. The cord around the neck preventing baby from coming down– totally circumstantial. I feel like even the American Pregnancy Association– did I say that right?-- says that 90% of women who have had C-sections are good candidates for VBAC. I think that’s important to note is that if you’re being told that you are not a good candidate for a VBAC, I would really question why because most of the time, you are a good candidate. Big baby, sure. That’s one. We can throw these around. People say, “Oh, your baby is too big. You have to have a C-section.” That is not evidence-based. Even ACOG says that big babies are not a reason for either induction or automatic C-sections. Meagan: Suspected big babies. julie; Right, suspected big babies. Meagan: Let’s just say that they’re not always big. Julie: They are not always big and we know this is something we automatically know like, everybody knows this but not everybody does. Your ultrasound measurements can be off by 1-2 pounds in either direction. They can measure small or big. The only accurate way to determine how big your baby is is to weigh it after it is born. Meagan: To birth your baby. Right, to birth your baby. Julie: Not only that, but big babies come through petite pelvises all the time. Babies’ heads mold and squish through pelvises that flex and open and move to work together. The baby and the pelvis are this really cool diad where they have this great relationship of working together and the pelvis opens and the baby’s head smooshes together. Anyway, I feel like that’s probably the biggest thing that I’m hearing lately, “My baby’s too big and my provider won’t let me.” Or there was a post in the community today that Meagan shared with me and she said, “Is it really possible to have a VBAC after a C-section? Because I feel like you always have to have C-sections. Is it really possible to have a vaginal birth after a C-section?” We need to remember that we live in a country and in a world where many people still have this way of thought. Many people don’t question their options and many people, most people go in and just automatically schedule a C-section because that’s what their provider says, that’s what’s most convenient, and they don’t take the initiative to learn and ask questions. 13:30 Big babies, small pelvises, fluid levels, and third-trimester ultrasoundsJulie: it’s a failure in the system. We were just talking about this before. Meagan, go ahead. Meagan: Yeah, I was just going to circle back around with the size thing. What I’m seeing more is people doubting their ability because we have people saying, “Well, your baby is this size,” but the reason why they are even saying that is because I’m seeing an increase in third-trimester ultrasounds. Julie: Yes. Third-trimester ultrasounds are trouble. Meagan: They are trouble. Julie: Just routine to check on baby’s size and check fluids– no. Just say no to third-trimester ultrasounds unless there is a valid concern for baby. Meagan: Yeah. Yeah. It is getting me. It is getting me that I’m seeing it so often. It’s just getting me irked a little bit. Julie: Gosh, Meagan, I swear though. The reason you are getting irked is because we have seen these things go south so many times. Guess what happens? They go in for a third-trimester ultrasound and there are no published statistics for this. I don’t know. I haven’t looked. But I feel like people go in and they get their third-trimester ultrasound and then they are like, “Well, my baby is measuring big,” and then they start to get worried like, “I don’t know if I can have a big baby,” because their provider is like, “Oh, your provider is measuring big.” Their provider is saying it like that. It casts doubt. It casts that doubt in their mind and that little seed of doubt gets planted. That little seed of doubt gets nourished like, “We will let you try for a VBAC but your baby is kind of big so we will just have to see how it goes,” and then these parents get set up for wanting to have an earlier induction for big baby because they don’t want their baby to get too big or just scheduling a repeat Cesarean because they are terrified of a bigger baby and the problems that a big baby could have which are not actually that many. The risk of shoulder dystocia I feel like doesn’t increase significantly more with big babies. We just think it does. Smaller babies get shoulder dystocia just like bigger babies do. Or, “Oh, my fluids are too big or too little,” and those ultrasound measurements are just so inaccurate first of all, but most of what they find isn’t evidence-based either. You’re walking into a situation where your provider will cast doubt on you whether intentionally or not. I don’t want to villainize providers because most providers I don’t think have ill intentions. They are just doing what they know and doing what they are comfortable with. But that happens nonetheless. So if your provider is recommending a third-trimester ultrasound, here is something that I encourage people. Ask them, first of all, why. If they will be like, “Oh, just to check on baby and check the size.” I feel like you can politely decline unless you want to. It’s fun to see your baby and things like that, but what would change? This is what you can ask your provider. “What will change in my plan of care based on what we find in the ultrasound?” What will change? What direction would shift? What answers are we looking for? What will change in my care based on what we find in the ultrasound? If your provider says, “Well, we just want to make sure that your baby is not too big,” that’s a red flag. Right? Meagan: Yes. Julie: “We want to make sure your waters are okay,” which could be a legitimate reason. If you are measuring more than 10 weeks ahead or behind, it’s probably a good idea to get your fluids checked by ultrasound but if you are only measuring 3 or 4 weeks ahead or behind, that’s not necessarily an evidence-based reason to do that. I would just ask that. I mean, that’s a good question to ask for any type of intervention or checks or whatever.17:08 How will this change my care?Julie: “You want a cervical check at 36 weeks? Okay. What would change in my care? What are we looking for? What would change in my care plan if this happens and if that happens?” because most of the time, cervical checks before labor– actually cervical checks during labor too– don’t tell us anything. They don’t tell us anything. I just missed a birth a month ago or about three weeks ago because a first-time mom went from 3 centimeters– she was at 3 centimeters for 12 hours and went from 3 centimeters to baby in less than an hour and a half. Cervical checks tell us nothing. Anyway, before I get off on a little more of a soapbox there. Sorry, I’ve been rambling. Meagan: You’re just fine. I absolutely love that you pointed that out and that you specifically said that it can really apply to anything in your care. What does this thing do or how does it change my care? I just think everybody should take that nugget from this episode right now and just hold onto it tightly. Put it right in your pocket and keep that because you nailed it right there. How does this change my care? If you’re getting things like she said, yeah. That’s dumb. It’s silly. Or with a cervical exam, it’s like, “Oh, we just want to see what your BISHOP score is. We just wanted to see if you’re progressing.” Why? At 36 weeks? First of all, that’s preterm. Second of all, to actually be, especially if we never made it to 10 centimeters before in our first labor, the chances of us being very dilated at 36 weeks–18:47 Cervical dilationMeagan: Okay. This is going to lead me to the next thing that we see all of the time. The chances of you being dilated at 36 weeks is pretty low actually. This is something else I see that breaks my heart actually in our community and not even just in our community, in other communities, and honestly even in consults I’ve had people talk about this. “Oh, I’m 37 weeks or 38 weeks and I’m not dilated so my doctor is telling me that it’s probably not going to happen.” Do you see this all the time, Julie? “Oh, guys. I’m so sad because I’m 38 weeks and my provider is telling me that I’m not dilated so I probably need to schedule a C-section the next week.” Women of Strength, if you are not dilated at 36, 37, 38, 39 or even 40, even 41 weeks honestly, that’s okay. Your body will do it. Some bodies don’t do it until they are in labor. They just don’t. Julie: Yeah, and honestly at 36 or 37 weeks, anytime before labor starts and you’re not dilated, guess what? Your cervix is doing exactly what it’s supposed to do which is keeping your baby safe and keeping your baby in until it’s ready to come out. I can’t reiterate that enough. You’re not supposed to be dilated before it’s time for the baby to come out. I say supposed because some bodies shift and change a little bit sooner and that’s okay. But whenever I was a doula, I mean I don’t get to talk to people prenatally as much anymore since I’m just doing birth photography, but I would always say, “You know what? If you want a cervical check, that is totally fine. You get to decide. You get to make the choice about whether you get a cervical check or not.” But if having a cervical check, if you go in and you have a cervical check and you know that if you’re not dilated at all that it is going to make you depressed and frustrated, then don’t do it. If you go in and you’re like, “Hey, I’m prepared to be low, hard, and closed and I just want the information because I love information,” and you are not going to be sad if you hear that you are low, hard, and closed, then sure. Get one if you want. But just know that anything beyond being low, hard, and closed is just– Meagan: Lucky, great, awesome. Julie: Lucky, sure, great and awesome, but it’s also not an indicator because guess what? I’ve also had a client, a first-time mom, walk around at 4 centimeters dilated for 10 days and then she went into labor and had a 24-hour labor at home and ended up in a hospital transfer and a C-section. I swear. Your cervix is not telling you anything before labor and during labor most of the time, it’s not telling you anything. It’s telling you that you have progressed this far. It’s doesn’t tell you how anything is going to go in the future. It doesn’t tell you how anything is going to look moving forward. It just doesn’t. Meagan: Yeah. So if you are having someone tell you, “You’re not dilated” or “Oh, it’s probably not going to happen. You should probably schedule a C-section–”Julie: Just say, “Julie Francom said–” Meagan: If you want that, do that. But if it’s not what you want, don’t let someone bully you into believing that your body is not working when it’s actually doing exactly what it’s supposed to be doing. Julie: Exactly. that’s the thing too. Sometimes at the end of pregnancy, it is hard. Being pregnant is hard. Being close to your due date is hard. Everybody is asking you, “Have you had your baby yet? What are you going to do? What are your plans for induction?” We’ve all been there and it is really, really hard to stay strong. I feel like some people could just benefit by just saying no. Just saying no because it’s so easy if your baby is measuring big or if you feel like your cervix is hard and closed. Be like, “Aw, flip man. I’m going to be pregnant forever and my baby is going to be big and it’s going to have a hard time coming out so I might as well schedule a C-section.” If you feel like you could be easily swayed by those things which a lot of people are. It’s so easy to be swayed by those things, especially at the end of pregnancy. Then maybe just say no. Obviously there is nuance here so if there is a true medical need and there is some medical concern for baby or if there is some worry for your cervix being in preterm labor or things like that, obviously those are valid reasons but if it’s a just because, I’m not a big fan of doing medical things just because. Meagan: Just because I agree. Yeah. Exactly. If there’s no real reason, then just because doesn’t. Unless you want it. Unless that’s really what you want. 25:54 Due datesMeagan: Okay, so we talked about babies. We talked about dilation before due dates and can we also talk about due dates? Julie: Ew. Meagan: Ew. Julie: Yeah, just kidding. That was weird. I don’t know why I said that. I’m a weirdo sometimes. Meagan: Well, due dates are hard. Due dates are a really hard topic because especially after the ARRIVE trial which Julie Francom herself wrote the blog about the ARRIVE trial if I recall. I don’t think I did. I think you did.Julie: I’m pretty sure I did. Meagan: I think you did. I feel like since the ARRIVE trial, we really have seen a major shift in due dates. Julie: You mean induction? A major shift in interventions? Meagan: Well, sorry. Induction because of due dates. Julie: Right. Gotcha. Meagan: We see people at 38 weeks being checked, not dilated, being told that they either like I said, have to have a C-section or have to be induced in the next week because they are 39 weeks but really, do we have to? We do not. We do not have to. A lot of bodies do go over that 40-week mark. I think it’s important to know when you are approaching your due date that you may start getting an influx of pressure to do those things, to sweep your membranes, to induce, to schedule a C-section, and I think that is something that I find frustrating. I mean, you guys, obviously as a doula, I work with a lot of pregnant people and Julie even being a photographer now, I’m sure you have situations where you are like, Oh, this person is being induced now, and now you’re planning and induction. We’ll get to induction in a second. But the pressure that starts coming at people at 38 or 39 weeks for induction or a scheduled C-section is unreal to me when sometimes we just need to let the body be. Julie: Yep. Meagan: Right? 28:18 Vulnerability and the ARRIVE trialJulie: I agree so much. It’s so funny because we all know that induction is safe and we’re going to talk about that in just a minute. It’s safe for VBAC when it’s necessary. it does slightly increase the risk of uterine rupture and a couple of other things, but it’s frustrating when we have providers taking advantage of this vulnerable group of people. Meagan: Very vulnerable. Julie: By offering induction at 39 weeks and who doesn’t not want to be pregnant anymore at 39 weeks? I think everybody. There’s a small group of people who just like being pregnant and that’s totally fine. I like being pregnant but by my last one, I was like, Get this baby out! I was content for baby to pick their birthdate every time, but with the last one, I was like, Get this baby out! Anyway, I feel like most providers don’t think they are taking advantage of these people when they are offering 39-week inductions, but it really is. It’s taking advantage of a woman in a vulnerable position and could skew their birth plans in ways that they don’t want. It’s hard to say no when you are that pregnant and unless you have a super strong resolve which even the strongest resolve can weaken in that type of emotional and hormonal state. It’s really frustrating because we have this ARRIVE trial that was published in– what was it? It wasn’t 2020. Meagan: 2019. Julie: In 2019 and the medical world jumped on that so fast. They were like, Yes. Let’s induce at 39 weeks. Meagan: It was a leech situation. Julie: Yes. And then now that multiple studies have proved it invalid and it has been picked apart and even ACOG doesn’t recommend that anymore. It doesn’t stand by the validation of the ARRIVE trial, there have been multiple studies showing otherwise since then, but guess what? Oh my gosh. This is so frustrating. It normally takes 10-15 years for the medical community to catch on to updated information, but this one took on so fast and now it is going to take 10-15 years to undo that. Meagan: To go back. I agree. Julie: Yeah. It’s frustrating. Meagan: It is. It’s so frustrating. 30:44 Inducing a VBACMeagan: It’s hard to see so many people, like you said, in a vulnerable state feel that pressure of induction. I think where I even struggle more is seeing people in the last weeks of their pregnancy which can be hard because they are uncomfortable and Julie wanted to get that baby out. They actually can be some of the most precious times with your other kids before your family grows and your husband before you have a baby and you are a family of three or your partner. They can be really great spaces and a place where we can really get our head in the space for labor and delivery and for birth. But we have so many people out there being scared that they are going to have to have a scheduled C-section. We know that even though evidence shows induction for VBAC is safe and reasonable, there are many people and many providers out there all over the world who absolutely refuse to induce a VBAC. They refuse and induction. It’s either a scheduled C-section, spontaneous labor, or that’s it. Those are your options. We see so many people out there spending these last few weeks that could be so amazing and getting ourselves in that positive headspace in frantic mode because they are trying to induce themselves. They are trying to do all of the things. Julie: Yeah, they are like, Oh my gosh. My provider is going to schedule a C-section at 40 weeks or induction at 39. Meagan: What can I do to get this baby out? Julie: Yep. Meagan: It makes my heart hurt because it just really isn’t where you deserve to be in your last weeks of pregnancy. Let me tell you one thing, when you are so hyper-focused on getting your baby out, tension and cortisol is high in the body and when we are stressed, that’s typically not a space where we can let our cervix go and have a baby. So when we are doing those things, we are entering a space full of tension and we are already setting ourselves up for a harder experience. Julie: Mhmm, it’s true. You go in there ready to fight then your cortisol levels are high and cortisol is the opposite of oxytocin which gets baby out. Your stress hormones are fighting your baby coming out and it’s not optimal. Can it happen? Yeah, sure. People do it. But it’s going to be harder. Meagan: It is. Julie: It’s just going to be harder. Meagan: It is. Like I said, back to the head space, it really puts us in the wrong head space. It just is not optimal. Know that if you are receiving pressure to have a baby because you’re not being supported in an induction that you should just change your provider. No, really. You need to take a step back and decide if that provider is the right choice for you and if that’s the right space for you to be birthing in and if what you are doing in your mind and to your body because a lot of people do some crazy things, is really what is going to be the best for your labor journey. Julie: And sometimes, people don’t have that much of a choice too. Sometimes, that’s the only choice you have. Sometimes, home birth is illegal in your state for VBAC even and– Meagan: You have no providers in your area. Julie: You have one hospital within 6 hours and sometimes that’s going to be your only choice and it sucks that people have to choose between that and an unassisted birth at home which I feel like if you are going to have an unassisted birth at home, that’s a whole other topic. You should do it because you are educated and informed and that’s what you want not because you don’t want to have this horrible hospital birth where you are going to have to fight the whole time. Meagan: Yeah. It’s a tricky spot. To Julie’s point, we understand that. There are so many people who are just flat-out restricted and they feel like they are walking in with their hands tied behind their back and just have no choice. But there are other options too. There are other options. But laboring at home a little longer or just saying no. Just saying no which is really hard. Julie: Yeah, it is really hard especially when you are in labor. Especially, maybe you have this resolve and your partner doesn’t have that resolve. Maybe you can’t find a doula in your area. You can’t afford one. It really sucks to be your own biggest supporter and believer in birth. You have to have other people in the room who are just as resolved and want this for you as much as you do if you are birthing in that type of environment. 36:15 Julie’s social media storyJulie: Okay, back to basics. What are we doing next? Oh, let me tell this story about induction. I think this is so funny because there are so many people who think that induction isn’t safe and they think that induction isn’t safe for a VBAC to go past 40 weeks so you have a provider who won’t induce you and won’t let you go past 40 weeks so what are you supposed to do? It’s really interesting because I hired someone recently to post on my social media recently for my birth photography. She is a birth photographer and doula and has attended many births before. She just recently shifted over to social media and website management for birth photographers. She knows that I’m really passionate about VBAC so I want one post a week to be about VBAC. She’ll write up posts for me to approve and one of the things that she wrote up for me about VBAC was things you can do to– I think it was things you can do to increase your chances of having a VBAC or something like that. In her post, she even made the comment and I’m glad I read through these all in detail because she said something that, “We know that induction isn’t safe for VBAC because it increases the chance of uterine rupture.” She said in my post that is on my page that is supposed to be written in my words that induction isn’t safe. I deleted it. I shot her a little message to be like, Hey, VBAC induction is safe. Does it slightly increase the risk of uterine rupture? Yeah, it does, but as long as it’s managed well, the increased risks are very, very small. Meagan: Still pretty low. Julie: Yeah. It was just so funny that someone who has been in the birth world still for so long operating on more of an evidence-based side of things has that view still. I don’t know. It’s just interesting. We all have things that we need to learn still. Meagan: We do. We are always learning and we are even still learning here at The VBAC Link. It’s just important to know that if you see information and you’re like, Oh, I already know that, you still need to check it out and see if there is something new to that. 38:29 Contradicting informationMeagan: Okay, so back to the basics. We’ve talked about the pelvis. We’ve talked about induction. We’re talking about due dates. We are talking about the cervix dilating. We’ve talked about baby sizes. What else do we have? Julie: Epidurals. Meagan: Oh yeah. Epidurals. Julie: This is so funny. The opposites. It’s the same thing about the opposite. VBAC has to be induced before 40 weeks. I will not induce VBAC at all. You have to have a C-section by 40 weeks. All of these things. Epidurals are the same way. You have to have an epidural placed in order to do a VBAC and then we also have you cannot have a VBAC with an epidural. Meagan: Yeah. Yes. I’ve seen that. Julie: Isn’t that so stupid? I’m sorry. I just think it’s so stupid, all of these polarizing things. It’s so funny because sorry, time out. I will let you talk about that. I promise I will let you talk about that. I think it’s so funny because we know that Facebook can do so much good and it can also do so much bad. There will be a post like, “Hey, my provider said I have to have an epidural with a VBAC,” and there will be 50 comments on there and every comment will be different like, “Oh, yeah. You absolutely have to. It’s safest in case you have to have an emergency C-section.” Then the next comment will say, “No, you don’t. You can’t because then you won’t notice the signs of uterine rupture.” Everyone says something different and it’s really funny because it’s the same thing about the length between pregnancies or C-sections to VBAC. People will be like, “My doctor said it has to be 18 months from birth to birth. My doctor said that you can’t get pregnant within a year of having a C-section. My doctor said–” or they say. I love it when people say, “They say 18 months birth to birth is best. They say don’t get pregnant within 9 months. They say 2 years between births is the best.” Who is they, first of all? Who is they? Whenever someone says they, I say, “Who is they?” Because there are so many sources and everybody is so resolute in their answers. “My doctor said this. They said that this is the right answer. 6 months, 9 months, 12 months, 24 months, 3 years.”Everyone is so firm in their answers. How freaking confusing is that? Meagan: Very. Julie: P.S. the optimal range for births actually hasn’t had any definitve say yet because there are different studies that show different lengths, some as short as 6 months between pregnancies. Some are as long as 24 months between births. Is it between births? Is it between pregnancies? I just laugh every time I get on Facebook and see these people who all say, “They say” in their resolve. I don’t know. I just think it is so interesting and can be so overwhelming and confusing which is why we started The VBAC Link so we can bring you the evidence so that you know. Sorry, go ahead and let’s talk about epidurals. I had to go on that tangent. Meagan: Well, you just brought that up and that’s another big basic. When can I get pregnant? 41:36 Pregnancy intervalsMeagan: When can someone get pregnant? We’ll buzz back to epidurals. Julie: Yeah, luckily we wrote a blog. We will link it in the show notes with the studies cited. Meagan: A lot of people are confused. Is it birth to birth? Is it birth to conception? Right? Julie: Yeah. Yeah. Meagan: Do you want to talk about that? I’m going to sneeze. Hold on. Julie: Yeah. It’s really interesting because you are getting these different numbers– 6 months, 9 months, 24 months, 15 months. You’re getting all of these different numbers then you are also getting these different ranges. Between birth to birth, so between the time when your C-section baby is born to when your VBAC or your attempted VBAC baby is born is different than from the time you have your C-section to the time you conceive the baby. 18 months birth to birth is 9 months pregnancy to pregnancy so 6 months pregnancy to pregnancy is 15 months birth to birth. Of course, everyone is confused. That’s all I have to say about that. What do you want to add, Meagan? Meagan: It is confusing. It is absolutely so confusing and I think when you are talking to a provider, it’s important to talk to them about their view on intervals because there are different views. People, like she said, do have different views. People will say, “If you are pregnant before 15 months from birth to conception” or not before 15, before 24 months even sometimes or before 18 months, that’s not okay when it really might be from birth to birth. We do have a blog about it. We’re going to link it so you can see the studies and how they view it, but I also want to point out that if you are being told you absolutely can’t VBAC because you have a shorter interval, say from birth to conception is whatever, 15 months. You conceived 15 months after your C-section and providers are saying, “No, it’s too close,” there are studies that show and talk about an increased risk of uterine rupture but I also want to point out that a lot of people do it with no complications. Julie: A lot of people do it. What it all comes down to is what is the acceptable level of risk to you and can you find a provider who is willing to take on that risk with you? In our blog, I’m just remembering off the top of my head. It might not be 100% true but one of our studies showed that a 6-month pregnancy interval so after you have your C-section, you get pregnant 6 months or beyond, there is no increased risk of uterine rupture. Within that 6 months, there is an increased risk of uterine rupture. I think it is 2.4% up from 0.5%. Now, a 2.4% risk, I think it’s that. I think it’s 2.4%. You’ll have to look at the blog. I’ll send you on a treasure hunt for the blog. But that level of risk might be acceptable for some parents and providers and it might not for other parents. For me, I would go totally try it. I would do it because that means I have a 97.5% chance of not having a uterine rupture. Heck yeah. That’s pretty solid to me, but it might not be solid to you. That’s what matters. The other one showed that an 18-month pregnancy interval is optimal. 24 months birth to birth, I think, was the other one. We are having a bunch of different ranges and all three studies that were cited the blog are credible studies. The real answer to that pregnancy interval question is we don’t know what is the optimal pregnancy interval. We just don’t know. They say, they will tell you– I feel like most people and most providers are about on the 18 months birth to birth side. Some providers want 12 months between pregnancies. Meagan: Yeah. I see a lot of people saying that. I even see 12-24 months or 12-18 months before conception. I see a lot of conception as well. It’s just important to talk to your provider about that and when you are looking at the studies and you see a 15-month, see what it is talking about. Is it talking about C-section to VBAC or to birth or to conception? Julie: Yeah. 46:38 EpiduralsMeagan: Okay, epidurals. We were talking about it a minute ago where so many providers say, “Yes, you have to have an epidural. No, you can’t have an epidural.” I think I’ve shared this story before. The only uterine rupture I have ever witnessed in my life was with an epidural. I’m going to guess that she probably had a delayed feeling because I’m assuming she would have felt it sooner and this pain. She felt it later on and when she felt it, it was above where the epidural site numbed so up in her rib area, up below the breast. That was where she felt it with an epidural. There weren’t any heart decels or anything like that. There were other signs of things like a stalled dilation and things like that but she still felt it with an epidural. A lot of providers are telling people that they can’t have an epidural. I think that this scares a lot of people. Julie: Mhmm. Meagan: Birth unmedicated can scare someone who doesn’t want to birth unmedicated so the thought of going unmedicated can scare someone to the point where they are like, I’ll just schedule a C-section. My point in sharing this story is that even with an epidural, you can often still feel a uterine rupture happening and there are usually other signs that are happening even before that that are pointing things out. There is a pretty, I think it’s a debate in the medical world, on if epidurals actually increase Cesarean. Have you seen the blogs and different things? Julie: I absolutely do think they do. I’ve seen it. My gosh. Meagan: I know. I know. A lot of the evidence out there or a lot of the opinions out there on the blogs and the National Institute of Health publications and things like that show that maybe not, but then there are things that show actually it does seem like it can. Julie: I think it’s how you act when you have the epidural. If you have a nurse in there who is content on changing your positions every 30 minutes or whatever, I don’t know. Maybe not. Keep the pelvis moving. But if you are flat on your back for 20 hours, then yeah. It probably increased that risk. Meagan: Yeah. There’s not a lot of evidence showing that it for sure does increase the risk of Cesareans but as doulas and people who have gone into a lot of births– obviously, there are a lot of providers who have gone to way more births than we have as doulas. I don’t know if it’s a cause, but it does seem to correlate. It can correlate and there are a lot of different things. We see an epidural come into play and I actually have seen moms dilate really fast. I have seen an epidural be the best tool–Julie: That’s true. That’s true. Meagan: –for a laborer to get a vaginal birth. I really, really, really have seen this, and not even just vaginal birth after Cesarean, just vaginal birth. Julie: That’s true. There is a lot of nuance there for sure. Meagan: But to what you are saying, a lot of the time it really does depend on what comes after the epidural. A lot of the time after an epidural comes in, we know that there are two things for sure that have a higher chance of happening. One, you have a higher chance of sitting and doing nothing. Just hanging out like Julie said. Not really moving, working with the pelvic dynamics, and getting baby out and down. And two, we know that PItocin often comes into play after an epidural because a lot of the time, it can stall labor. We want to get labor going again and sometimes instead of just waiting and letting the body– I use the body acclimate a lot, but really, the body has to acclimate so much in labor. We are going from home to a hospital. We have to acclimate from that place to the car to the hospital and then we are getting there and we are not even just acclimating to that space. We are acclimating to new voices. Julie: Mhmm, new smells, new sensations, new temperature, new germs– that’s probably not really a thing. Meagan: Yeah. It’s not even just being in a different place. It’s all of the things that come with the different place. So we get an epidural and our body is like, Oh, cool. I can rest. This is my opinion, okay? I don’t have any research to show this. But my opinion is that when an epidural is placed and a body “stalls”, that is our body saying, “Thank you. I’m going to take this opportunity to rest.” Can it continue laboring at some point? Yes. Will it always? Maybe not. Maybe Pitocin does need to come into play at that point because it has decreased our bodies’ ability to register and acclimate, but sometimes I feel like with getting the epidural, we need to just acclimate to that and see what happens versus just immediately starting Pitocin and acclimate to new ways to change. But yeah, did you want to say anything, Julie?Julie: It’s interesting because I like that and I feel like sometimes that is exactly what a body needs maybe not necessarily for the body as much as for the psyche to just be able to rest and relax and let go because a tense body and a tense mind sometimes isn’t going to be very efficient at laboring because of that. Again, we talked about this before with the cortisol levels so if you can get someone to relax easier and let the body take over what it is supposed to do intuitively or instinctually– and it doesn’t always and it’s okay if it doesn’t and it’s okay if we need other things to help us, but sometimes just that rest and relaxation and that 30-minute power nap is exactly what the body needs to continue on throughout the rest of it. I think a lot of people when they are going for a VBAC think they need to go unmedicated to have their best chances. While yeah, that may or may not be true, it just is completely dependent on the person and the labor and how things go and how long it is and all of those types of things. I just think about the cascade of interventions. 54:13 Allowing for nuanceJulie: I was going off on a daydream over here when you were talking about the cascade of interventions because we always demonize that a little bit or villainize it like, Oh, the cascade of interventions as soon as you get to the hospital or as soon as you get the epidural or as soon as you whatever. You know, it’s true. We’ve seen it a dozen times, but I’ve also seen the cascade of interventions help parents have the exact birth that they wanted as well. So like with all things in birth, there is that nuance there. I’ve used the word nuance a lot and I feel like maybe it’s a thing for my life lately and everything that we have to allow for the nuance and we can’t be super rigid in our thinking. I think maybe at the beginning of The VBAC Link, Meagan, you and I did a lot of that villainizing of the cascade of interventions. But as we have grown and talked more to people and had more experience as doulas and in the birth space, I feel like we are allowing ourselves to be a little more fluid in that thinking and allow for that nuance to come into play. Meagan: Yes. Yes. 100%. Julie: But I will say this. I will say this with 200% certainty, okay? There is no nuance allowed here. People who tell you that you have to have an epidural for a VBAC are 100% full of crap. This is why. Because the reason why they say you have to have, and I say “they say”, I’m saying they like your provider or anyone who says that. The reason why is because in case of a uterine rupture, the epidural is already placed and they can get you back for a C-section faster and not have to put you under general anesthesia which is riskier. That is true. General anesthesia is riskier than an epidural. That is 100% true. It is safer overall to have an epidural for your C-section than it is to go under general anesthesia. Now, here is where I call B.S. because even with an epidural placed and dosed, when you have an epidural going, it is not at the strength it needs to be in order to do a C-section without feeling any pain. Meagan: It’s not enough. Julie: From the moment the epidural is dosed up, now keep in mind it takes time for the anesthesiologist to come in and everything like that too, you’re looking at a minimum of 12 minutes if the anesthesiologist is there and pushing the bolus. 12 minutes for the epidural to take effect enough to have surgery. Now, listen to me. If it is a true emergency and a catastrophic uterine rupture, you do not have 12 minutes to save the baby. You will be put under general anesthesia because minutes matter. Seconds matter in those true emergent situations. So, Karen, if you have an epidural placed and it’s a true emergency, then you will have to be put under general anesthesia. If it’s not a true emergency, then guess what? You have enough time for a spinal block which takes effect in about 3-5 minutes. Go into the OR. You can still have your baby out in 15 minutes or more but usually what we see called an emergency C-section, they’re like, “All right. Baby’s heart rate is not looking good. Let’s get the doctor in here. Let’s have you put your scrubs on. Oh, look Dad. Let’s get your scrubs on.” You get dressed and you are getting wheeled in the OR 45 minutes later, that’s not an emergency. Having an epidural placed when you don’t want one or need one– some people need one and some people want one and that’s fine. Having an epidural placed is preparing you for surgery. It’s preparing you for surgery. That’s why I say there is no room for nuance because you just can’t magically make an epidural surgical strength in minutes. You just can’t. There’s no nuance there. It doesn’t happen. Meagan: Okay. We’ll just end right there. You guys, there are so many things but hopefully, we covered a lot of the basics. Know that you always have options even if you feel like sometimes you don’t have options, there probably is another option there. It’s crazy, but there really is so keep looking at your options. Look at your blog. Look at the show notes. We’ll create and leave the links today. Check out our How to VBAC course. It’s going to cover a lot of information and help you hopefully find the right stats and evidence-based information so when you see posts on Facebook or TikTok or anything like that that are saying things like, “If your baby’s cord was wrapped around their neck the first time, you can’t have a VBAC the second time,” or if you are told that your pelvis was too small the first time and you can’t have a VBAC or going on and on, that you will be able to know the evidence-based information. All right, okay. All right. Julie: Yeah. Meagan: See you guys later. Julie: Bye! 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. 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