Let me start by saying that I'm sorry that you have had two such
difficult experiences. I suggest that you find out more about your
doula's concerns because perhaps she knows something specific about
this hospital or doctor, but from where I'm sitting, getting a VBAC
at all is a coup these days, and getting one after two prior c/secs
is a miracle.
This is not to say that it should be this difficult. Certainly
there are risks associated with planning VBA2C, but there are also
serious risks associated with accumulating cesarean surgeries.
Moreover, the likelihood of the scar giving way is not any higher
with multiple prior cesareans (see below), a point you and your
current ob may wish to make in your discussion with the head
OB. You may also wish to point out respectfully and calmly that it
is your right to make informed decisions about your care,
including refusal of surgery. Take along
this booklet on patient's rights, which is put out by the Joint
Commission, the organization that certifies hospitals.
While I am at it, your best option for safe vaginal birth is to
start labor on your own and continue laboring without stimulation.
This means avoiding an epidural if possible because epidurals
increase the likelihood of needing I.V. oxytocin (Pitocin or
"Pit"). It is true that scar problems are more likely in VBAC
labors after the due date, but the excess rate is in women who were
induced. (I can provide more detailed information on this if you or
your ob would like.)
You will definitely want a doula if for no other reason than you
and your partner are likely to be laboring in an environment
hostile to VBAC, and you may need support and encouragement to
counteract this. I would have a frank discussion with her, though.
Seeing as she is uncomfortable with your choice, you do not want
her to become part of the problem instead of part of the
While I am also at it, I refer you to Lamaze's Six
Healthy Birth Practices.
I hope that this next birth goes as you would hope. Please let
us know how things work out.
Landon MB, Spong CY, Thom E, et al. Risk of uterine
rupture with a trial of labor in women with multiple and single
prior cesarean delivery. Obstet Gynecol 2006;108(1):12-20.
OBJECTIVE: To determine whether the risk for uterine
rupture is increased in women attempting vaginal birth after
multiple cesarean deliveries. METHODS: We conducted a prospective
multicenter observational study of women with prior cesarean
delivery undergoing trial of labor and elective repeat operation.
Maternal and perinatal outcomes were compared among women
attempting vaginal birth after multiple cesarean deliveries and
those with a single prior cesarean delivery. We also compared
outcomes for women with multiple prior cesarean deliveries
undergoing trial of labor with those electing repeat cesarean
delivery. RESULTS: Uterine rupture occurred
in 9 of 975 (0.9%) women with multiple prior cesarean compared with
115 of 16,915 (0.7%) women with a single prior operation (P = .37).
Multivariable analysis confirmed that multiple prior cesarean
delivery was not associated with an increased risk for uterine
rupture. The rates of hysterectomy (0.6% versus 0.2%, P =
.023) and transfusion (3.2% versus 1.6%, P < .001) were
increased in women with multiple prior cesarean deliveries compared
with women with a single prior cesarean delivery attempting trial
of labor. Similarly, a composite of maternal morbidity was
increased in women with multiple prior cesarean deliveries
undergoing trial of labor compared with those having elective
repeat cesarean delivery (odds ratio 1.41, 95% confidence interval
1.02-1.93). CONCLUSION: A history of multiple cesarean deliveries
is not associated with an increased rate of uterine rupture in
women attempting vaginal birth compared with those with a single
prior operation. Maternal morbidity is increased with trial of
labor after multiple cesarean deliveries, compared with elective
repeat cesarean delivery, but the absolute risk for complications
is small. Vaginal birth after multiple cesarean deliveries should
remain an option for eligible women. LEVEL OF EVIDENCE: II-2.