The International Cesarean Awareness Network has tracked over 300 hospitals across the U.S. that have instituted policies seeking to ban vaginal birth after cesarean (VBAC), misleading women to believe they must undergo cesarean surgery whether there is a medical need for it or not. Clinical research shows the risks of VBAC are small and that repeat cesarean surgery carries its own risks. In spite of this, many hospitals have attempted to ban VBAC in order to limit their exposure to liability. As a result, many women around the U.S. have been told they must choose unnecessary surgery or forgo hospital care altogether. Below is a guide for women in this situation. Women who are seeking to avoid other medical interventions will also find this information useful.

Q: Does my doctor or hospital have the right to force me to undergo surgery?

A: No. You have the legal right to refuse any medical treatment, including cesarean surgery. VBAC “bans” exist only because they have not been challenged by patients. The doctrine of informed refusal is upheld by common law, case law, Constitutional law, federal law, state law, state mandated medical ethics and the ethical guidelines of the American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG). Any facility or care provider claiming that you must undergo a cesarean you wish to refuse is violating the governing principles of their respective institutions and professions, as well as the rule of law.

Q: What can I do to protect myself from being forced into surgery?

A: There are multiple steps you can take to protect yourself:

• Know your rights. Visit BirthPolicy.org to learn more about the illegal and unethical status VBAC “bans.”

• File a grievance with the Chief Compliance Officer at the hospital where you plan to give birth. Hospitals that attempt to ban VBAC are in violation of the Center for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP), which require all federally funded hospitals (approximately 80%) to honor the rights of patients to be informed of the risks, benefits, and alternatives of all procedures, to refuse any proposed treatment, including cesarean surgery, and to participate in all treatment decisions. To hold your hospital accountable under these regulations, you must first file a complaint with the hospital’s Chief Compliance Officer, who is required to issue a ruling within 60 days. If the CCO rules against you, then you have the right, first, to appeal to the your state CMS office and then to Office of the Inspector General’s Office at the Department of Health and Human Services. If HHS rules against you, then your appeal goes to the Department of Justice, which is authorized to bring litigation against the hospital on your behalf. You can read the CoP regulations by going to the Code of Federal Regulation’s main page. Enter “42CFR482.13″ into the search engine, which will bring up all of the CoP regulations on patient rights and filing grievances. To find contact information for your state CMS office, go to MedLaw.

• Replace your birth plan with a customized form documenting your refusal to consent. By law, you are not required to sign the hospital’s consent form. You can either customize the hospital’s form or write down your refusal to consent to treatment on any piece of paper and sign it. Put a line through any listed procedure you want to decline and then add the list of routine procedures, including cesarean surgery, you want to refuse, initial each change or addition and make sure you have all the required signatures. Doing so will legally document your refusal to consent and alert staff that you understand and are prepared to protect your rights. In addition, such a document will require staff to obtain direct, verbal consent from you each time they want to do a procedure you’ve already declined in writing. If possible, pre-register at the hospital no sooner than thirty days before your due date and take the forms home with you to review, add to, and sign. Be sure to keep personal copies of any forms you sign ansk your partner or doula to record any changes that were made during the course of your labor.

Q: What if the hospital refuses to admit me unless I consent to a cesarean?

A: The federal Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to admit women in active labor and to abide by their treatment decisions until after the baby and placenta are delivered. The act was originally designed to prevent hospitals from “dumping” patients who couldn’t pay but has since been widely used to hold hospitals accountable for violating other patient rights, including the right to refuse treatment. If your hospital threatens to perform a cesarean despite your refusal, notify them that they are in violation of your rights under EMTALA and that you plan to file a complaint. To find out where to report an EMTALA violation, go to MedLaw.

Q: What happens if my care provider ignores my refusal to consent and performs a cesarean anyway?

A: Many women have been threatened by their care providers that they would be put under general anesthesia and sectioned if they sought care in the hospital, even if they were close to delivering the baby naturally. While these threats are intimidating, they are not supported in either legal or ethical guidelines. If your care provider performs surgery in spite of your refusal, you are within your legal right to file criminal assault and battery charges and, if you or your baby suffer an injury, you may also sue for negligence.

Q: What if I challenge my care provider and he or she decides to drop me from care?

A: Professional ethical guidelines state that a physician may only drop you from his care after giving you 30 days notice. This means that if you are within 30 days of your likely delivery date, your care provider cannot terminate your care. In addition, if you are pregnant and are outside of that 30 day time frame, your provider must give you a referral and ensure you are transferred to a specific provider. Physicians who fail to meet these guidelines may be charged with patient abandonment, which is grounds for malpractice and constitutes a violation of ethical conduct that could result in loss of licensure.

Q: What if my care provider or hospital seeks a court order to perform a cesarean?

A: While there is always the possibility that the local court could grant an order forcing you to undergo a cesarean, these cases have become very rare in the aftermath of several court rulings declaring that such orders violate the rights of pregnant women. As a result of these rulsing, both the AMA and ACOG have revised their ethical guidelines to state that court-ordered cesareans are rarely, if ever, justified, and are most definitely not justified in instances where the proposed treatment poses any risks to the mother.

Q: I want to give birth in a hospital, but I am afraid that this is too much stress on my pregnancy and my family.

A: Unfortunately, the options for women whose hospitals have attempted to ban VBAC are limited. Your choices are to fight and assert your legal rights, submit to surgery, or opt for homebirth, either unassisted or attended by a midwife. Educate yourself about the benefits and risks of each option, and make the decision that is best for you and your baby. Call your local ICAN chapter for more information on your options and on the resources available to facilitate your decision.

International Cesarean Awareness Network

• These facts are presented by the International Cesarean Awareness Network with the hope that parents, childbirth educators, doulas, nurses, midwives and doctors together can effectively reduce the rate of unnecessary cesarean sections and their effects.
• A cesarean (si-‘zar-E-an) section is major abdominal surgery used for the delivery of an infant through an incision in the mother’s abdomen and uterus. The incision may be made across the bottom of the abdomen above the pubic area (transverse) or in rare instances, in a line from the belly button to the pubic area (vertical). Learn More: Cesarean section – what happens during delivery.
• When a cesarean is necessary, it can be a lifesaving procedure for both mother and baby.1 However, psychological outcomes such as negative feelings, fear, guilt, anger and postpartum depression are common consequences of both emergent and elective cesarean sections.2,3,4 A cesarean section is only indicated in the following situations:

• Complete placenta previa at term
• Transverse lie at complete dilation
• Prolapsed cord
• Abrupted placenta
• Eclampsia or HELLP with failed induction of labor
• Large uterine tumor that blocks the cervix at complete dilation (Most fibroids will move upwards as the cervix opens, moving it out of baby’s path.)
• True fetal distress confirmed with a fetal scalp sampling or biophysical profile
• True absolute cephalopelvic disproportion or CPD (baby too large for pelvis). This is extremely rare and only associated with a pelvic deformity (or an incorrectly healed pelvic break). Fetal positioning during labour and maternal positioning during second stage, most notably when women are in a semi-sitting position, cause most CPD diagnosed in current obstetrics.5
• Initial outbreak of active herpes at the onset of labor
• Uterine rupture

• Many reasons given for cesarean, especially prior to labour, can and should be questioned. This includes macrosomia (large baby),6,7,8 maternal age,9 and parity,10 assisted reproductive technology,11 CPD,12 dystocia, failure to progress, breech,13,14 fetal distress or even prolonged second stage.15 There are very few true indications for a cesarean section in which the risks of surgery will outweigh the risks of vaginal birth.16
• The cesarean section rate remains at an alarmingly higher rate in many industrialized countries than the 10-15% average recommended by the World Health Organization, causing unnecessary risk to both mother and baby.17 Healthy People 2010 recommends a reduction in cesarean births in the US to 15% by 2010.18
• A cesarean poses documented medical risks to the mother’s health. These risks include infection,19 blood loss and hemorrhage,20 hysterectomy,21,22 transfusions,23 bladder and bowel injury,24,25 incisional endometriosis,26,27 heart and lung complications,28 blood clots in the legs,29 anesthesia complications,30 and rehospitalization due to surgical complications,31 rate of establishment and ongoing breastfeeding is reduced,32 and psychological well-being compromised and increased rate emotional trauma.33 Potential chronic complications from scar tissue adhesions include pelvic pain, bowel problems, and pain during sexual intercourse.34 Scar tissue makes subsequent cesareans more difficult to perform, increasing the risk of injury to other organs and the risk of chronic problems from adhesions.35 One-half of all women who have undergone a cesarean section suffer complications, and the mortality rate is at least two to four times that of women with vaginal births. Approximately 180 women die annually in the United States from elective repeat cesareans alone.
• Each successive cesarean greatly increases the risk of developing placenta previa, placenta accreta and placental abruption in subsequent pregnancies.36,37,38 Both of these complications pose life-threatening risks to mother and baby. Cesareans also increase the odds of secondary infertility, miscarriage and ectopic pregnancy in subsequent pregnancies.39,40
• A cesarean poses documented medical risks to the baby’s health.41 These risks include respiratory distress syndrome (RDS),42,43,44,45 iatrogenic prematurity (when surgery is performed because of an error in determining the due date), 46,47 persistent pulmonary hypertension (PPH),48 and surgery-related fetal injuries such as lacerations.49,50 Preliminary studies also have found cesarean delivery significantly alters the capability of cord blood mononuclear cells (CBMC) to produce cytokines.51 An elective cesarean section significantly increases the risk to the infant of premature birth and respiratory distress syndrome, both of which are associated with multiple complications, intensive care and burdensome financial cost. Even with mature babies, the absence of labor increases the risk of breathing problems and other complications. Far from doing better, even premature and at risk babies born by cesarean fare worse than those born vaginally.
• Cesareans can delay the opportunity for early mother-newborn interaction, breastfeeding, and the establishment of family bonds.52,53,54
• Cesarean rates are influenced by nonmedical factors. These include: individual philosophy and training, convenience of doctor or patient, the patient’s socioeconomic status, peer pressure, fear of litigation, and financial gain.55,56,57
• In the United States, obstetricians offer defensive medicine as an excuse for the astronomical and sharply rising U.S. cesarean rate. Deliberately performing unnecessary surgery in the belief it avoids lawsuits is indefensible. That many obstetricians seem oblivious to the profound violation of ethical principles is shocking.58,59
• Vaginal Birth After Cesarean (VBAC) is safer for both mother and infant, in most cases, than is routine elective cesarean, which is major surgery.60,61,62,63,64,65,66 Learn More in our VBAC Section.
• The risk to your infant from the very low incidence of uterine rupture (less than 1%) after a prior cesarean is much less than the risk to your infant from respiratory distress as a result of a scheduled cesarean.67,68,69,70

The International Cesarean Awareness Network (ICAN) founded as Cesarean Prevention Movement in 1982, has chapters, individuals, an international newsletter (the Clarion), email line and website ready to give you support and information. For more information, please call               1-800-686-ICAN        or visit http://www.ican-online.org/.

References:

1. Wagner M. Choosing Cesarean Section. Lancet 2000; 356: 1677-80.
2. Ryding, Elsa Lena, Wijma, Klaas & Wijma, Barbro. Experiences of Emergency Cesarean Section: A Phenomenological Study of 53 Women. Birth 1998; 25 (4), 246-251.
3. Soet, Johanna E., Brack, Gregory A. & DiIorio, Colleen. Prevalence and Predictors of Women’s Experience of Psychological Trauma During Childbirth. Birth 2003; 30 (1), 36-46.
4. Koo, Vincent, Lynch, Janine & Cooper, Stephen. Risk of postnatal depression after emergency delivery. The Journal of Obstetrics and Gynaecology Research 2003; 29 (4), 246-250.
5. Gupta J, Glanville J, Johnson N, et al. The effect of squatting on pelvic dimensions. Eur J Obstet Gynecol Reprod Biol 1991;42: 19-22.
6. Parry S, Severs CP, Sehdev HM, Macones GA, White LM, Morgan MA. Ultrasonographic Prediction of Fetal Macrosomia: Association with Cesarean Delivery. J Reprod Med 2000;45:17-22.
7. Haram, Kjell, Pirohonen; Jouko, Bergsjo. Suspected big baby: a difficult clinical problem in obstetrics. Acta Obstetricia et Gynecologica Scandinavica 2002; 81 (3), 185-194.
8. Sandmire, Herbert F. & Woolley, Robert J. IN THE LITERATURE Macrosomia: Can We Prevent Big Problems with Big Babies? Birth 25 1998; (4), 263-267.
9. Kozinszky, Zoltán, Orvos, Hajnalka, Zoboki, Tünde, Katona, Márta, Wayda, Kornelia, Pál, Attilla, Kovács, László. Risk factors for cesarean section of primiparous women aged over 35 years. Acta Obstetricia et Gynecologica Scandinavica 2002; 81 (4), 313-316.
10. Qublan, Hussein, Alghoweri, Ahmad, Al-Taani, Mohammad, Abu-Khait, Sami, Abu-Salem, Areej & Merhej, Ahmad. Cesarean section rate: The effect of age and parity. J Obstet Gynaecol Res 2002; 28 (1), 22-25.
11. Kozinszky, Zoltán, Zádori, János, Orvos, Hajnalka, Katona, Márta, Pál, Attila & Kovács, László. Obstetric and neonatal risk of pregnancies after assisted reproductive technology: a matched control study. Acta Obstetricia et Gynecologica Scandinavica 2003; 82 (9), 850-856.
12. Brabin, Loretta, Verhoeff, Francine, Brabin, Bernard. Maternal height, birthweight and cephalo pelvic disproportion in urban Nigeria and rural Malawi. Acta Obstetricia et Gynecologica Scandinavica 2002; 81 (6), 502-507.
13. Usta, Ihab M., Nassar, Anwar H., Khabbaz, Antoun Y. & Abu Musa, Antoine A. Undiagnosed term breech: Impact on mode of delivery and neonatal outcome. Acta Obstetricia et Gynecologica Scandinavica 2003; 82 (9), 841-844.
14. Keirse, Marc J.N.C. Evidence-Based Childbirth Only For Breech Babies? .Birth 2002; 29 (1), 55-59.
15. Janni, Wolfgang, Schiessl, Barbara, Peshcers, Ursula, Huber, Sandra, Strobl, Barbara, Hantschmann, Peer, Uhlmann, Natalie, Dimpfl, Thomas, Rammel, Gerhard & Kainer, Franz.. The prognostic impact of a prolonged second stage of labor on maternal and fetal outcome. Acta Obstetricia et Gynecologica Scandinavica 2002; 81 (3), 214-221.
16. Wagner M. Choosing Cesarean Section. Lancet 2000;356: 1677-80.
17. World Health Organization. Appropriate technology for birth. Lancet 1985; 2:436-7.
18. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000.Objective 16-9.
19. Henderson EJ & Love EJ. Incidence of hospital-acquired infections associated with cesarean section. J Hosp Infect 1995; 29: 245-255.
20. van Ham MA, van Dongen PW & Mulder J. Maternal consequences of caesarean section. A retrospective study of intra-operative and postoperative maternal complications of caesarean section during a 10-year period. Eur J Obstet Gynecol Reprod Biol 1997; 74: 1-6.
21. Engelsen, Ingeborg Bøe, Albrechtsen, Susanne & Iversen, Ole Erik. Peripartum hysterectomy-incidence and maternal morbidity. Acta Obstetricia et Gynecologica Scandinavica 2001 80 (5), 409-412.
22. Bergholt, Thomas, Stenderup, Jens Karl, Vedsted-Jakobsen, Agnete, Helm, Peter & Lenstrup, Carsten. Intraoperative surgical complication during cesarean section: an observational study of the incidence and risk factors. Acta Obstetricia et Gynecologica Scandinavica 2003; 82 (3), 251-256.
23. Naef RW III, Washburne JF, Martin RW et al. Hemorrhage associated with cesarean delivery: When is transfusion needed? J Perinatol 1995; 15: 32-35.
24. Eisenkop SM, Richman R, Platt LD & Paul RH. Urinary tract injury during cesarean section. Obstet Gynecol 1982; 60: 591-596.
25. Davis JD. Management of injuries to the urinary and gastrointestinal tract during cesarean section. Obstet Gynecol Clin North Am 1999; 26: 469-480.
26. Wolf Y, Haddad R, Werbin N, Skornick Y, Kaplan O. Endometriosis in abdominal scars: A diagnostic pitfall. Am Surg 1996; 62(12):1042-4.
27. Wolf GC, Singh KB. Cesarean scar endometriosis: A review. Obstet Gynecol Surv 1989; 44(2):89-95.
28. Lydon-Rochelle M, Holt VL, Martin DP, Easterling TR. Association between method of delivery and maternal rehospitalization. J Amer Med Assoc 2000; 283(18):2411-2416.
29. Lydon-Rochelle M, Holt VL, Martin DP, Easterling TR. Association between method of delivery and maternal rehospitalization. J Amer Med Assoc 2000; 283(18):2411-2416.
30. Kawashima, Y., Takahashi, S., Suzuki, M., Morita, K., Irita, K., Iwao, Y., Seo, N., Tsuzaki, K., Dohi, S., Kobayashi, T., Goto, Y., Suzuki, G., Fujii, A., Suzuki, H., Yokoyama, K. & Kugimiya, T. Anesthesia-related mortality and morbidity over a 5-year period in 2,363,038 patients in Japan. Acta Anaesthesiologica Scandinavica 2003; 47 (7), 809-817.
31. Lydon-Rochelle M, Holt VL, Martin DP, Easterling TR. Association between method of delivery and maternal rehospitalization. J Amer Med Assoc 2000; 283(18):2411-2416.
32. Lydon-Rochelle MT, Holt VL, Martin DP. Delivery method and self-reported postpartum general health status among primiparous women. Paediatr Perinat Epidemiol 2001 Jul;15(3):241-2.
33. Ryding, Elsa Lena, Wijma, Klaas & Wijma, Barbro. Experiences of Emergency Cesarean Section: A Phenomenological Study of 53 Women. Birth 1998; 25 (4), 246-251.
34. Hesham Al-Inany. Intrauterine adhesions; An update. Acta Obstetricia et Gynecologica Scandinavica 1998; Vol. 80, 11: 986-993.
35. Almeida EC, Nogueira AA, Candido dos Reis FJ, Rosa e Silva JC. Cesarean section as a cause of chronic pelvic pain. Int J Gynaecol Obstet. 2002 Nov;79(2):101-4.
36. Zaideh, SM et al. Placenta praevia and accreta: Analysis of a two-year experience. Gynecol Obstet Invest 1998; 46(2):96-8.
37. Ananth, CV et al. The association of placenta previa with history of cesarean delivery and abortion: A meta-analysis. Am J Obstet Gynecol 1997; 177(5):1071-78.
38. Miller DA, Chollet JA & Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol 1997; 177: 210-214.
39. Hemminki, E and Merilainen, J. Long-term effects of cesarean sections: Ectopic pregnancies and placental problems. Am J Obstet Gynecol 1996; 174(5):1569-74.
40. Hall MH, Campbell DM, Fraser C & Lemon J. Mode of delivery and future fertility. Brit J Obstet Gynecol 1989; 96: 1297-1303.
41. Wagner M. Choosing Cesarean Section. Lancet 2000;356: 1677-80.
42. Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode of delivery at term: Influence of timing of elective caesarean section. Br J Obstet Gynaecol 1995; 102:101-6.
43. Hales KA, Morgan MA, Thurnau GR. Influence of labor and route of delivery on the frequency of respiratory morbidity in term neonates. Int J Gynaecol Obstet 1993; 43(1):35-40.
44. Levine EM, Ghai V, Barton JJ, Strom CM. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 2001;97(3):439-42.
45. Parilla BV, Dooley SL, Jansen RD, and Socol ML. Iatrogenic respiratory distress syndrome following elective repeat cesarean delivery. Obstet Gynecol 1993; 81(3):392-5.
46. Lydon-Rochelle MT, Holt VL, Martin DP. Delivery method and self-reported postpartum general health status among primiparous women. Paediatr Perinat Epidemiol. 2001 Jul;15(3):241-2.
47. Lydon-Rochelle M, Holt VL, Martin DP, Easterling TR. Association between method of delivery and maternal rehospitalization. J Amer Med Assoc 2000; 283(18):2411-2416.
48. Levine EM, Ghai V, Barton JJ, Strom CM. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 2001; 97:439–42.
49. Smith J, Hernandez C, Wax J 1997. Fetal laceration injury at cesarean delivery. Obstet Gynecol 90:344-6.
50. Fawcett J, Pollio N & Tully A. Women’s perceptions of cesarean and vaginal delivery: Another look. Res Nurs Health 1992; 15: 439-446
51. Brown, Mark A., Rad, Parmis Y. & Halonen, Marilyn J. (2003) Method of birth alters interferon-gamma and interleukin-12 production by cord blood mononuclear cells. Pediatric Allergy and Immunology 14 (2), 106-111.
52. Soet, Johanna E., Brack, Gregory A. & DiIorio, Colle en. Prevalence and Predictors of Women’s Experience of Psychological Trauma During Childbirth. Birth 2003; 30 (1), 36-46.
53. Dahlberg, Karin, Berg, Marie & Lundgren, Ingela. Commentary: Studying Maternal Experiences of Childbirth. Birth 1999; 26 (4), 215-217.
54. Rowe-Murray, Heather J. & Fisher, Jane R.W. Baby Friendly Hospital Practices: Cesarean Section is a Persistent Barrier to Early Initiation of Breastfeeding. Birth 2002; 29 (2), 124-131.
55. Sleutel, Martha R. Intrapartum Nursing Care: A Case Study of Supportive Interventions and Ethical Conflicts. Birth 2000; 27 (1), 38-45.
56. FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health. Ethical aspects regarding cesarean delivery for non-medical reasons. Int J Obs & Gynae;64:317-322, 1999
57. Beilin, Y., Friedman, F., Andres, L. A., Hossain, S. & Bodian, C. A. The effect of the obstetrician group and epidural analgesia on the risk for cesarean delivery in nulliparous women. Acta Anaesthesiologica Scandinavica 2000; 44 (8), 959-964.
58. Greene, M.F. (2001).Vaginal delivery after cesarean section-is the risk acceptable? N Eng J Med 345:54-5.
59. Wagner M. Choosing Cesarean Section. Lancet 2000;356: 1677-80.
60. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with prior cesarean delivery. N Engl J Med 2001;345:3-8.
61. Mozerkewich, EL and Hutton EK.Elective repeat cesarean delivery versus trial of labor: A meta-analysis of the literature from 1989 to 1999. Am J Obstet Gynecol 2000 Nov.; Vol. 183, 1187-1197.
62. Gregory KD, Korst, LM, Cane P, Platt, LD, Kahn, K. Vaginal Birth After Cesarean and Uterine Rupture Rates in California. Obstet Gynecol 1999 Dec; Vol.94, 985-989.
63. Rageth JC, Juzi C, Grossenbacher, H. Delivery After Previous Cesarean: A Risk Evaluation. Obstet Gynecol 1999 Mar; 93: 332-337.
64. American College of Obstetricians and Gynecologists (1999). Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin, No. 5. Washington, DC: American College of Obstetricians and Gynecologists.
65. Society of Obstetricians and Gynaecologists of Canada. Vaginal Birth after Previous Caesarean Birth. SOGC Clinical Practice Guidelines Policy Statement No. 68. JSOGC 1997;19:1425-28.
66. Mozurkewich. VBAC Safer than You Think. ObG Management 2002; 14:56.
67. Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode of delivery at term: Influence of timing of elective caesarean section. Br J Obstet Gynaecol 1995; 102:101-6.
68. Hales KA, Morgan MA, Thurnau GR. Influence of labor and route of delivery on the frequency of respiratory morbidity in term neonates. Int J Gynaecol Obstet 1993; 43(1):35-40.
69. Levine EM, Ghai V, Barton JJ, Strom CM. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 2001;97(3):439-42.
70. Parilla BV, Dooley SL, Jansen RD, and Socol ML. Iatrogenic respiratory distress syndrome following elective repeat cesarean delivery. Obstet Gynecol 1993; 81(3):392-5.

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© International Cesarean Awareness Network, Inc. All Rights Reserved.

Read good pregnancy and Vaginal Birth After Cesarean books. Two suggestions are: “The VBAC Companion” by Diana Korte and “Open Season” by Nancy Wainer Cohen.

Focus on good nutrition and exercise. Make a daily checklist to ensure you are getting essential nutrients. Engage in daily exercise such as swim, walk, yoga, prenatal fitness class- whatever feels good. For information on diet throughout pregnancy, we recommend reading, “What Every Pregnant Woman Should Know” by Dr. Tom Brewer and Gail Sforza Brewer or The Brewer Diet.

Register for VBAC, refresher or another quality, independent prenatal program. Even though you may have taken classes in a previous pregnancy, an evening out together with your partner will help to prepare you both, promoting discussion, giving you ideas on coping with labor and bringing a focus to this baby and its birth.

Enlist the encouragement of a supportive care provider. Find a caregiver/hospital who ALREADY provide the options you want. Find someone who believes in VBACs, has a VBAC success rate over 75% and a cesarean rate that is lower than the community average. Consider having a midwife as your primary caregiver. Midwives have a very low rate of cesarean birth. If you are unsure about anything, get a second opinion. Trust your inner strength and knowledge.

Hire a doula/labor assistant/support person. It is worth every penny to be reassured during labor by someone who believes birth is a natural function. This person will have supportive non-medical skills to help you through labor for the birth you want. This person will assist you from your first contractions at home right through postpartum. A labor assistant, or doula, takes the pressure off fathers and family members so that the whole family can be supported.

Throughout pregnancy practice relaxation and visualization with exercises, tapes, massage, affirmations and touch. Use affirmations such as “Each contraction strengthens my baby and me.” Or “I will birth my baby vaginally, naturally, and joyfully.”

Write a birth plan. Discuss everything that is important to you with your care provider, putting it all into your birth plan. Make extra copies to be put in your chart. Know your hospital’s VBAC policies and negotiate well before the birth for anything different. Things to consider when writing your birth plan are:

• Establish a safe, supportive birth environment to encourage labor.
• Try a variety of positions. Instead of lying down, try standing or walking. Squatting to push can be most effective. Try the birth ball. Try walking the halls. Try ‘dancing’ with your partner.
• Continue your calorie and fluid intake. Labor is work and takes energy. Far from eliminating the risk of aspiration with general anesthesia, total fasting (NPO) may increase the risk by raising the acidity of the stomach contents.
• Avoid medical intervention whenever possible. Continuous electronic fetal monitoring may restrict your movement. Ask for noninvasive options. Ask what will be done with the results.
• Artificial induction should be avoided, if possible. Medical induction is linked with high rupture rates and many interventions.
• Ask for time to try non-medical methods to stimulate labor if your labor is not progressing. These include change of position, walking, nipple stimulation, aromatherapy, acupressure. Every labor is different. Unless you dilated to five or six centimeters during a previous labor, consider this one your first labor.
• Avoiding an epidural may increase your chance for a vaginal birth. An epidural interferes with the baby being optimally lined up and will reduce your ability to push effectively. Try natural pain relief measures, such as: hot/cold compresses, bath/shower (once labor is established), tenns unit, massage, relaxation, guided imagery, birth ball. If you start to think you really need an epidural, give yourself a few more contractions, or request that you be checked one more time. You may be moving quickly into transition without realizing it.

Having a birth plan cannot guarantee that your wishes will be followed. Working with a careprovider who believes in birth is easier than fighting one who does not. No amount of demanding or asking nicely will get you the birth you want.

Many cesareans are done due to posterior or asynclitic presentation. Avoiding reclining positions prenatally. Read Val el Halta’s “Posterior Presentation – A Pain in the Back” article and “Understanding and Teaching Optimal Fetal Positioning” by Jean Sutton and Pauline Scott.

Believe in yourself and the process of birth. Repeat affirmations to yourself constantly. Encourage yourself to believe that you are capable of delivering your baby vaginally. Get in touch with your inner self; your resources and abilities. Forget about your scar and focus on the positive aspects of your pregnancy.

Work on leftover negative emotions (guilt, disappointment, anger) from previous cesarean birth(s). Two wonderful books for this are Lynn Madsen’s “Rebounding From Childbirth”, and “Ended Beginnings” by Claudia Panuthos.

Learn to trust, cooperate with and listen to your body and baby. Listen to your own unique labor pattern.

Feel good about yourself and your relationship as a couple and keep a positive outlook.

Enlist the support of family and friends. Remember that according to medical studies VBAC is usually safer for both you and your baby than a repeat cesarean. Don’t be afraid to let your family know how much you need their unconditional emotional support.

Attend VBAC support meetings and join national organizations. Through meetings and newsletters, you will hear from others who have been there, sharing their VBAC experiences. Read “The VBAC Experience” by Lynn Baptisti Richards, a collection of VBAC stories.

Having a VBAC is worth it! You can do it. Not everything is within our control — however, it is within all of us to prepare ourselves as best we can to maximize the chance of VBAC.

This may be copied and distributed with retained copyright.
© International Cesarean Awareness Network, Inc. All Rights Reserved.