Introduction and Welcome
Britta: Britain. Hello folks, and welcome to transformed by birth, a podcast about the rite of passage of pregnancy, birth and new parenthood. I'm your host. Britta Bushnell, author, mythologist, childbirth educator and all around deep diver with a side of goofball, I'm so glad you're here. Today's episode explores surgical births, often referred to as C sections, as well as vaginal birth after cesarean. So grab your comfy beverage of choice. I've got an earl gray latte in my mug today, or take us along for a walk as we connect with my friend and trusted colleague, Jen camel. Before we begin, we start the way we always do by lighting a candle. If you want to join me, please do or just take a breath as I light mine. Today's candle is for cesarean births.
Navigating Birth in Today's Climate
Britta: The very first birth I supported as a doula was a cesarean it was an intense rite of passage for me into understanding the pressure and often coercive measures a parent might face with their own labor journey. To say the experience was an eye opener is an understatement. It initiated me into a better understanding of how complex birth decisions can be, and how parents often feel they have fewer choices than they actually do and less power than they actually have. But we're navigating a time in obstetrics where the system and providers are simultaneously trying to change outdated practices while reinforcing others. My guest Jen camel and I have both been in the world of childbirth for many years, and have seen the ebbs and flows of change rock the boat back and forth. Just when it feels like things are starting to improve, we see a giant wave hit the bow of our collective ship, and we find ourselves headed back to the shore of problematic rules based protocols that keep us from making real progress. Over and over again, we've witnessed these changes, and we're professionals in this field. For parents, these turbulent waters often feel unnavigable. So my hope is that our conversation today will help you step into the waters of birth in the current birth climate, not just with greater understanding, but also with tools, wisdom and grace. So about Jen. Jen Campbell is the CEO and founder of vvac facts. V back facts. Let me get that so that you really hear it. Since 2007 her focus has been to provide objective, accurate information about the data available on vaginal birth after cesarean, also known as V back and repeat Cesareans, to parents, professionals, policy makers and the court, so all decisions can be informed, ethical and just she envisions a time when every pregnant person seeking a VBAC has access to unbiased information, respectful providers and community support so they can plan the birth of their choosing in a setting they desire. So welcome, Jen. I'm honored and excited to have you here. And I want to start with, is there anything in my intro that you want to respond to as I spoke about all of that?
The Slow Progress of VBAC Rates
Jen: Oh my gosh. Well, you know one thing, the immediate thing that comes to mind is how the V back rate has changed since I started this work back in 2007 and really, I mean, I had my daughter back in 2004 when I had my own C section, and I believe that year, the V back rate was about 8% nationwide. So now we're at 15% nationwide. It has now been 21 years, and we've gone from about 8% to 15% so we could look at that number a couple different ways that change. We could either say, Gosh, this is happening really slowly, right? Like, 8% and now we're at 15% like, okay. And or we could look at it and say, wow, it's happening slowly, but it is happening, and we have almost doubled VBAC access in this last 20 years. So we have a tremendous opportunity for improvement ahead of us to be able to align the care that people receive with what the. And national guidelines actually recommend, but we also have done some really great work, and there are a lot of people who were able to avoid an otherwise unnecessary surgical birth and have a VBAC, which overall lowers their risks in future pregnancies. So you know, I mean, again, I think we can look at all this data in a variety of different ways, and I choose to see it as like opportunity for growth, and also like, yes, we're here. We're doing the work.
Britta: All right, so there's progress, and there's also, it's really slow. It's so slow,
Jen: so slow. And this is why it's so important. You know, if someone's had a C section and they don't want another C section, you cannot just be like, Well, I'm just gonna go ask my provider what they think, and I'm just gonna do what my doctor says. Because, you know, doctors know best. I mean, if that was the case, and if all doctors practice evidence based medicine, and if all doctors followed national guidelines, which urge everyone to have the opportunity to V back, we would not see an 8% V back rate or 15% V back rate. You know, our V back rates would be like 40% or 50% or even 60% across the country. So this is an opportunity for everyone to decide, first, what it is that you want, and then, second of all, how are you going to get it and and with any decision in life, we have to be realistic, right? And rather than just saying, Oh, I hope my car mechanic is is honest with me, we say, well, Brita, who's your car mechanic? Oh, you really like them and trust them. Oh, okay, great. Well, then I'll go to them. I'm going to look on Yelp. I'm going to look at different areas for me to find someone who I can trust. The same thing is at play with health care. Not all practitioners practice the same not all providers are going to give you the same information. This is why we have the concept of our second or third opinion. So exercise your power, decide what you want, decide where you want to go, and then figure out how you can get there. And that's exactly what we help you do over at V back facts. Okay,
Understanding National Guidelines
Britta: love that. So I want to back up just a little bit in two things. One, you said, national guidelines. So where are these national guidelines coming from? Like, for somebody who's like, okay, national guidelines. Well, wait, who sets national guidelines for obstetric obstetrical care? Like, where is that National Guideline coming from? Yeah.
Jen: So typically, when I say national guidelines, I'm referring to those that are published by the American College of Obstetricians and Gynecologists now we also have, like the American Academy of Family Physicians, who publishes documents on VBAC. We also have the American Association of certified nurse midwives who publish documentation on VBAC and guidelines, but typically I'm referencing acogs guidelines, because those are the guidelines that obstetricians tend to look to and that hospitals tend to look to when they think about how to craft their VBAC policy. Now I say that with a huge caveat, because they can look at what ACOG says, and they can decide, do we want to do that or not, and then they get to literally decide whether they want to do that or not.
Britta: Here's so it's a guideline, and it's a guideline coming from from a panel and a board and a whole collection of professionals in the field who say, Hey, this is what we think should be the guidelines. But then hospitals and providers and practices get to kind of look at that and say, Well, I don't know. I think I want to do this instead. Is that accurate?
Jen: That is accurate? I mean, theoretically, we should all be working off of the same sort of foundation of medical ethics and then medical research and informed decision making. That is what medicine is supposed to be, and that's what a lot of people think it is. So when people say, Well, I'm just going to trust my doctor, that's what they're referring to. They're referring to this, this objective, this wish list that we all wish medicine was and then, as anyone who has interacted with medicine, you understand that that's not necessarily the case.
Britta: So or even folks who have interacted with medicine may have had that reinforced that it actually that they've worked with somebody who really was, you know, taking care of their care. They've had an accident or an illness where they got the kind of care that they're looking for. It is a little bit different with birth, right? So different, it's why is it so different with birth? What's your take on it? Well, I
Jen: think there's a variety of things at play. I think we have the historical how we view physicians relative to pregnant you know, pregnant mommies and and. And how obstetrics has historically been pretty paternalistic, and where a lot of women would just go to their doctor and just say, Okay, tell me what to do. And the doctor would say, this is what you need to do, little missy. And then the woman would be like, okay, and then she would go do that. And now we're coming to this place where we're understanding that there is a variety of variation in care in obstetrics, and so the information that you will be given and the options presented to you is really driven by who you're talking to. And you could go talk to five different OBS about VBAC, and you may very well get five very different recommendations, and that's because not all of them are practicing based on these three, these three concepts, which are medical ethics, medical research, and then informed decision making. And so it's almost like a Rubik's Cube, you know, you mix up those three concepts, and who knows what you're going to get. So this is why it's so important for people to have a basic foundational knowledge about VBAC. And one of those things is just that VBAC is a mainstream option to which everyone should have access. And so if you go to your provider and they're like, Oh, well, you know, I recommend repeat Cesareans for everyone, or in your situation, I think you should have a repeat cesarean, the question is, then, well, why? And if they say, well, it's safest, okay, well, why? And really dive in there, because there needs to be a reason behind that recommendation, other than just you've had a prior cesarean, and I think a repeat cesarean is safest, because that is not the full message. That's not the full story, and you're not getting the risks and benefits on both sides, if that's what your clinician is telling you
Failure to Progress and Primary Cesareans
Britta: all right, so I want to come back to VBAC specifically, but I also know that some of the listeners are parents for the first time, and so your expertise has some value for them as well, Even if they're not on the other side of birth yet. So, yes, so this because, because Cesarean birth, surgical birth C sections, are in their awareness to heading into their first birth, they're thinking about this. It's often a fear concern, a worry that I hear from first time parents of something they are hoping won't happen. It's a pretty common thing, and yet, you and I know that primary Cesareans, or first time Cesareans, are pretty common. Yeah, what are can you speak to some of the trends happening in this area? For first timers? I know your focus is mostly on on repeat birthing families, but Yeah, can you speak to some of that for those who are looking down the journey of their first birth,
Jen: yeah, so I think you know, one of the things to consider is that when you think about, well, will I have a C section or not, I think it's good to look at what are the reasons why those first time C sections typically occur. The number one reason is for this diagnosis called failure to progress. And so what does that mean? It means that your labor has been deemed to be no longer productive. It will not result in a vaginal delivery. And so therefore they're recommending a C section. And on the face of it, that sounds like, yeah, that's that's a good thing. Sounds reasonable times, yeah, it sounds pretty reasonable, and it is. But here's the challenge we have, again, from ACOG, these guidelines of what criteria should be met when we talk about FTP, cesarean, and one of those criteria is that in order to receive that diagnosis, in order for them to say you are now a failure to progress, we recommend a C section. You have to be at least six centimeters. So if you are two centimeters,
Britta: which, by the way, changed, that definition changed about 25 years ago, and it used to be four centimeters, I know, right. So yeah, so even I like to kind of highlight that, because when we hear something like a diagnosis, a failure to progress, or the idea of active labor, they sound like fixed definitions, yes, yeah. And that that appeals to the part of our brain that likes certainty, yeah, and yet, if these definitions change, does how does that land with our idea of it being a fixed definition or something certain? I think it's valuable to be able to say, Wait a second, what you're about to go into a little bit further. Further about you have to get to six centimeters for that to be you know, a even meet the criteria, the basic criteria for failure to progress even that has changed in the last couple of
Jen: decades. I mean, we literally make up the rules, right? You know what? I mean?
Jen: Like, subjective. They're not objective, yeah, yeah,
Jen: yeah. It's like, and I think that's something that's so important for people to hear, like, we make like human beings make up these rules, and they decide when to change the rules. It's not like, this is the truth with a capital T. It's just the criteria that we're using right now. And so the point is, is that a lot of these C sections occur and do not actually meet the criteria that ACOG sets forth. And there are other parameters, but that's just one of them, because one study found that 50% of people who had their C section for failure to progress or not even six centimeters. Right now, this is relevant, because when you get pregnant again, if you choose to, when someone pulls out a VBAC calculator, which is another tool that seems like, Oh, this is totally scientific, right? Like it has to
The VBAC Calculator and Its Limitations
Jen: so why that's relevant is because if you choose to get pregnant again and your provider pulls out a VBAC calculator, which looks like a completely scientific tool, right? You're right. Another one of those certain things, exactly? Yeah, your doctor's in the white coat. They pull out the feedback calculator. Oh, they're going to type in some numbers, and it's going to like, ding. It's going to tell you what your future is, right? Well, one of those questions is, I'm so sorry. My printer is printing. I don't know. Why is that showing up. Can you hear that? I didn't okay. I can't hear it. Okay. So one of those questions is, did you have a cesarean for FTP? And if you check yes, then your predicted odds for VBAC dramatically drop. Oh, interesting. All of these things are tied together, yes. And so when we look at, let's look at the whole through line, right? So 32% of primary C sections are for failure to progress, and 32% 32 Wait, is that right? That's a lot, or like a third, okay, you're saying, Okay, let's, let's pause. Let's pause for a second. Let me, let me do a little. So about a third of those first time C sections are for failure to progress. That's a lot. So it is a lot. And so this is why this is something that needs to be on people's minds, right? And so, you know, if your doctor starts telling you, oh, well, you know, I really think you should have a C section. You know, questions you can ask are well and is it okay if I continue laboring, you know, Is it harmful to my baby? If I continue laboring? Is there any reason why I can't continue laboring? And so these are just a few questions that you can ask to just sort of pause the moment and to just make your to ask your provider to really reflect on these questions. And then also these questions reiterate your desire to not have a C section, because you could very well be tired then. And if you want a C section, I mean, that's your choice to make. But if you want more children, the thing to keep in mind is, how will that C section impact your options and risks in future pregnancies? And we know that if you have that first time C section, you will encounter a greater obstacles if you want to have a V back, and there will be increased risks of complications in that pregnancy, whether you plan a VBAC or not. So. So that's the thing to keep in mind, and that's why we can't be cavalier about these for first first time pregnancies and these first Cesareans, they have implications for not only your reproductive health, but your health after the reproductive
Emergency Cesareans vs. Failure to Progress
Britta: years, right? And I want to, I want to just highlight that if we're talking that it's about a third are for failure to progress. And often folks speak about after the fact. They often are speaking about their births as emergency Cesareans, right? That because it's really hard as a first time parent to differentiate the difference between failure to progress and and this is an emergency that we need to. To to move in this direction. It might even be that they go back and look at their chart and it says failure to progress, but in the moment, it felt urgent. Yeah.
Jen: I think the thing to keep in mind is that if, if you, if your cesarean really was an emergency, they would be running you down the hall, and you'd be having that surgery, and your baby would be born in like 10 minutes. If they're telling you it's an emergency, but they're going to wait like two hours for your C section. That inherently is not an emergency,
Britta: right? That's that's a really important piece, is kind of acknowledging what is the pace. But even that can be tricky, because time moves differently. When you are in the hormonal bath of birth, the hormones of what's happening in labor slows down our thinking, cognitive brain, so that we move more at that pace of labor, and so things can feel like, like they're urgent, or like it's happening quickly, even if to a brain that isn't on that labor cocktail. It feels like it's moving pretty slowly.
Jen: Yeah, so it's tough, yeah, absolutely. Well. And the other thing this makes me think of something else. You know, sometimes people say, Well, I had an emergency C section, whatever that actually was in their first C section, and so therefore, now I'm, quote, high risk, and my OB has told me I'm not a candidate for a VBAC. And there's a lot of things to unpack there. First, this concept of an emergency C section, which we talked about, I mean, that's something that you could verify with your medical records. The second is this idea of now you are high risk. I mean, there are certainly people who are high risk, right? I see,
Once a Cesarean, Always a Cesarean
Britta: Yeah, well, and so that makes me think of the old statement that we used to hear. And I don't know is it still happening? I think it is in some places, the once a cesarean, always a cesarean.
Jen: Yeah, you know, it's like that jingle from your childhood that you just never forget and it's stuck in your mind. It's like that little phrase. I think it's just like embedded in the crevices of our brain. And it's very hard when something like that is sort of accepted and often repeated, and then we see, you know, people having a lot of fear about VBAC, and it's hard to sometimes reconcile these statements that we hear time and time again with what the evidence and guidelines actually recommend?
Britta: Yeah, no, it makes it really challenging. And again, that puts me in my tender feels for parents, navigating all of this, because there's there's the dance, and maybe you can speak to this a little bit between the aspects of birth that we can prepare for and ready ourselves for, and then there's a certain element that is let go and ride the waves of the experience. So yeah, how do we because you're you're a strong advocate for vaginal birth, and you also know that cesarean is a and surgical birth is a tool that has
has importance and value. How do you help people walk that for themselves?
No One Gets a Medal for How They Give Birth
Jen: Well, I would say I'm a strong advocate for people knowing that they have an option of V back or repeat cesarean, because when Cesareans are wanted or needed, brilliant, but people who don't want or need a cesarean should not be pushed into a surgical birth. And why is that? What difference does it make? Right? Like we hear time and time again, no one gets a medal for how they give birth.
Britta: So roll my eyes, though
Britta: it's a tough one for me. I roll
Jen: my eyes too, because what a fantastic way to make someone, one feel foolish, to question themselves, and three, take five steps back from what it is that they actually wanted. Yeah, it's so minimizing, So minimizing and so when someone says that to you, the first thing you need to ask yourself is, what does this person want from me? Because they're telling you what you want doesn't matter, so just forget what you want. I want you to think of all the times in your life that someone has made you think that, or made you want to think that, or I want you to think of all the times in your life that someone has tried to make you believe that that what you wanted wasn't important, that person probably didn't have the best intentions for you, because this is about what you want. This is what's important to you. And your provider might have made XYZ decisions about their birth and that was appropriate for them. And you, Brett, made your decisions, and I made my decisions, and we all get to make our own decisions, right? Like, that's the point is for us to all be able to make our own decisions and be like, Oh, you chose XYZ. Fantastic. That was right for you. Oh, I did ABC, yeah, it was wonderful. And, oh, she made these other choices. That's fantastic. I think part of the thing is, is that there is so much judgment about what other people do. And one of the things that I say frequently is that it doesn't matter what anyone else does. It matters what's right for you. And if that's a repeat C section, you do that, and if that's planning a vaginal birth, then you do that. And you should have support for both of those options. So how do you find someone who will Yeah?
Preparing for VBAC or Primary Birth
Britta: I was gonna ask you, yeah. I mean, there's a couple of questions here, right? It's not just about a provider who will value you, but also like the whole gamut of V back preparation or birth preparation that can support you. Like, where do you begin to to have that kind of possibility for for respectful care.
Jen: Well, I think the place that you start is at V back facts.com and you can download our V back planning checklist at V back facts.com/checklist right? That gives you your five steps for planning a vaginal birth. One of those steps is to learn the facts. Okay, so we have our. Podcast. We have our email list. We have courses for parents who want to learn more. Follow us on social media. Okay, learn the information, because if you've if you've not heard anything else on this episode yet, hear this who you talk to about VBAC, everyone has their own opinion, but opinions don't necessarily mean the truth, right? And so you know, how do we get to the truth? You get to the truth by looking at what the evidence says, What looking at national guidelines say, and then deciding for yourself what you want. So Learning the facts is one of those five steps reading, and
Britta: for a primary cesarean, that's also true. And that can be like knowing that failure to progress can't even be really diagnosed until that six centimeters place and other aspects like that. Okay, yeah,
Jen: so, and just a general childbirth education course like Brita offers, that is how you best prepare yourself, because going in, I mean, birth is so multi layered, right? We have our bodies functioning. We have what we want. We have going into these facilities that may or may not support what we want. How do you navigate that? How do you figure out whether what you want is reasonable or not, because everyone wants a healthy baby, and unfortunately, providers will sometimes use that against you. You know, I was just talking with an OB this morning who said, Look, I could convince anyone to have a C section. It's very easy to do. You plant seeds of doubt. You water those seeds of doubt. And then when it comes time, when the doctor decides I'm done waiting around, they can just be oh well, remember we talked about how big your baby was and oh yeah, your baby's not doing so great. But then somehow you're sitting around for an hour or two before your C section happens.
No Risk-Free Way to Give Birth
Britta: No, we, I mean, that's a really important piece to highlight, right? Is there's no risk free way to give birth. There's no risk free way whether it's your first, your third or your eighth. There is no risk free way through this. There is also no way through it
Jen: that is certain Exactly, and
Jen: that's hard.
Jen: It is like
Jen: certainty. That's right. I want to put it in my spreadsheet, and I want to have one plus one equals two. Excellent. I know exactly how this is going to play out. But you know, life and birth are not like that. So you know, we can do all of our things that we can. And so when we talk about, how do we optimize our VBAC success, we learn the facts. We create a good have a good team, including our provider. If you want to hire a doula, whatever that looks like. And then that also one of those steps is now you've done all the planning. Now you've done all the things. Now sit back in the comfort of knowing that you've done everything you can to maximize your odds and enjoy being pregnant and enjoy that labor, and ride those waves and get the epidural if you want it, don't get the epidural if you don't like do what's right for you, right? And find that voice, because, especially if this is your first baby, or if this is your second baby, and if you haven't found your voice yet, as a powerful woman in this world, now is the time, because now's a baby time. Now's a great time, because those babies are going to need their lion mother there to protect them,
Britta: not just goosebumps and birth, not just
Stepping Into Your Power
Jen: for the rest of their life. You are going to have endless uncomfortable situations where you are going to get to protect your children and you get to do that, yeah, and this is the time for you to just roar, because your power is here. Your kids are looking to you, and you are the one who is going to be the one to protect them in this world. And so now is that time to step into that power and you start protecting them right now, because there is no one on this planet who loves your baby more than you do. And there's no one on this planet who is more invested in your health care and your outcome than you are. And so you get to step forward and be that person that you might have been waiting for that person to, like, step in and sort of save you. You, my friend, are that person you get to save you. So I love that us come I love us. And let's do this. Let's find the birth that's right for you, and let's capture that moment in your life where you have now really transitioned into womanhood, where you have found that voice and you're not afraid to say it.
Closing
Britta: Thank you so much. Jen, often I close with a single question, but I think you just answered it, so I'm gonna let that stand all on its own, because that was boom, right right there, and you've already mentioned your website, but do you want to just say it one more time?
Jen: What? Sure you can go to feedback facts.com we have courses for parents. We have continuing education programming for professionals. We are a nursing continuing education provider. I do political consulting, legal consulting, expert witness work. I am the VBAC subject matter expert. So if you want to talk about VBAC, whether that's your hospital policy, your your practice guidelines, like whatever it is that you're working on, relative to VBAC, and I also offer consulting calls for parents if you want to talk about your situation. I'm not a clinician. I don't give medical advice, but I do know the research, so let's talk.
Britta: I love that, and I know you and I could keep talking, because, oh, we could we have done that. Thank you so much, Jen for being with us today, and thank you listeners for sharing this time with us. If something shared today impacted supported or moved you, please share this episode with a friend. I produced this podcast myself, and your support makes it possible, possible to show a little love for the podcast and these conversations, please follow rate and review. If you'd like to continue the conversation, please join us on Instagram at transformed by birth. I look forward to being with you again on the next episode of transformed by birth. Now let's gather what we want to take away from this episode and bring that in on an inhale, and when you're ready on your exhale, I'm going to blow out my candle. And if you have one lit, you can blow it out too. Until next time bye, friends bye.
