Dear Henci.
 
I'm 36 1/2 wks pregnant with my 3rd child. I really want to have a natural birth with this child as I did with my second child. But my dr says that she will not do a second VBAC with me. My 1st son was an emergency C-Section because he was breech and my water broke.
 
My dr is a different dr from my 1st 2 children. I feel my body is in good condition to go natural. The dr also said the hospital is not equipped to do a VBAC. It has been almost 7 yrs since my last child was born. How can I get around having my child natural, and can I refuse a c-section at my local hospital?
 
 
 
Thank You,
 
Melissa Hunt

Planned VBAC is not only safe, but having had one already, absent a new indication for cesarean, a second planned VBAC is your safest and best option. The likelihood of VBAC is greatly increased and the likelihood of scar rupture is greatly reduced once you have a VBAC under your belt, so to speak. On the other hand, planning an elective repeat cesarean exposes you not only to the risks of any individual surgery but to the risks of accumulating cesarean surgeries. In other words, your ob is not practicing evidence-based medicine--not to mention denying you every person's inalienable right to refuse surgery. Moreover, if the hospital is "not equipped to do a VBAC," by which she presumably means it isn't equipped to handle an emergency, then your hospital isn't equipped to handle any laboring woman, period.
 
Your best bet is to find another doctor or midwife and possibly another hospital if there is one within reasonable distance. If there is an International Cesarean Awareness Network (ICAN) chapter in your region, they will know who is doing VBACs. If not, try the local doulas or call hospitals in your area and ask which clinicians are attending VBACs. Other options are, (1) as you suggested, refuse a repeat cesarean, but the disadvantage is that you will be under the care of a physician and possibly nursing staff who disagree with your decision and aren't happy with you for making it, or (2) planning a home VBAC with a qualified home birth attendant. Disadvantage is that while you are at very low risk of scar problems (2-4 per 1000), the risk is not 0. If you stay with this ob and hospital, I recommend hiring an experienced doula so that you and your partner have someone in your corner. Also, barring an emergency, do not agree to any intervention without understanding its potential benefits and harms, your alternatives--including doing nothing, and the potential benefits and harms of your other options. Again, barring an emergency, take time to consider your options without medical staff present so that you do not feel pressured. I would also be alert to attempts to manipulate you. You can tell if this is happening if you are getting feelings instead of information.
 
-- Henci  
 

May I follow up with a related question? 

Does the lower risk of rupture apply for the 2nd VBAC if the c-section was an inverted J incision?  The first VBAC was successful with a 10 + lb baby at home. ( There was no doctor to be found who would consider a VBAC with a classical incision.)  Would you think that a repeat home birth would be tempting fate, or would the calculated risk be lower now that we have a "proven" scar?  And if lower, do you have a percent risk? 

I am a midwife that has always felt that the risk of VBAC after an upper uterine segment incision is too risky at home. Is there more to consider here?

Thanks

First, let me clarify. So far as I understand it, an inverted J incision is not a classical incision. A classical incision is a straight, vertical incision on the body of the uterus. A J-incision is a transverse incision that has been extended up into the body of the uterus. (Here is a page, where, if you scroll down, you can see an image of the various types of cesarean incisions.) That being said, any incision into the uterine muscle is thought to increase the risk of scar rupture to an unacceptable degree, which means no one is doing VBACs in these women. The best data we have on risk of the scar giving way with an unconventional scar type comes from a large, multicenter U.S. study in which a mixed group of 105 women with inverted-T, J-shaped, and classical incisions managed to slip through the net and labor. Two percent had scar ruptures versus an rate (when labor was not induced or strengthened with I.V. oxytocin) of 0.4% in the overall planned VBAC population. That population size is too small to make a judgment on safety. For example, if one more woman had had a scar rupture, the rate would jump to 3%, nor do we know whether risk differs among the scar types. All of this is to say that there is no research that could help guide you. Since I doubt that the obs in your community will be any more willing to agree to a VBAC--although it might be worthwhile to check around--it comes down to you and your client deciding which set of risks she prefers to run: the risks of cesarean surgery and of accumulating another cesarean scar or the risk of scar rupture in an environment unprepared to deal with it. In a functional maternity care system, of course, she wouldn't be faced with this kind of choice. 

~ Henci