VBAC Scare Tactics: Big Baby, Big Problems

by Kristen Oganowski, CD(DONA)

beautiful pregnant bellyMany women who want to have a vaginal birth after cesarean (or VBAC, pronounced "vee-back") in the U.S. and elsewhere have faced some sort of opposition from their care providers when they have expressed their desire to VBAC. Oftentimes, this opposition comes in the form of "VBAC scare tactics."

The (outrageous) statements are often misleading, exaggerated efforts by OBs (and yes, even midwives) to discourage women from VBAC and to encourage them to "choose" a repeat cesarean. (Of course, it's not really a choice if your provider won't even "let" you VBAC, is it?)

If you find yourself up against a barrage of scare tactics -- as I once did -- it can be exceedingly difficult to stake your claim and argue against the doctor (again, or midwife) who may or may not have your and your baby's health prioritized higher than medico-legal concerns and who may or may not be insinuating that VBACs are synonymous with driving your child in a car without a car seat.

If you do find yourself facing such scare tactics, and if you do want to have a VBAC, there are some questions that your care provider should be able to answer when s/he hurls those scary and/or outrageous comments and standards your way. And if s/he refuses to or even cannot answer these questions, then you might want to consider finding an alternative care provider -- one who is making medical decisions based on research, evidence, and even respect for your patient autonomy and not on fear, willful ignorance, or even convenience.

I encourage all mothers who read this post (and others in my "VBAC Scare Tactics Series") to take the information contained herein as a springboard from which they can 1) continue their research on VBAC, 2) maintain a communicative relationship with their care providers, and 3) find a care provider who best supports the mother's interests and plans for the birth of her child.

Scare tactic: Baby is too large. Based on this recent sonogram, your baby is getting way too big for a vaginal birth, especially a VBAC. You can't safely have a VBAC with a macrosomic baby. We're going to need to schedule a repeat cesarean as soon as possible.

Questions to ask your care provider:
• How accurate are sonograms at predicting fetal size, particularly at the end of a pregnancy?
• What special concerns do you have when it comes to a woman birthing a big baby?
• Does fetal macrosomia increase the risk of uterine rupture?
• What does ACOG recommend when it comes to fetal macrosomia and VBAC?

A More Nuanced Analysis:

When a physician or midwife uses terms like "suspected fetal macrosomia" or "LGA" or "large for gestational age" in reference to your baby, what s/he means is that your baby's estimated weight has exceeded a particular cut-off point: typically, either 4000 g (or 8 lbs 13 oz) or 4500 g (or 9 lbs 15 oz).

The reasons for denying women the opportunity to plan a VBAC with a suspected macrosomic baby may vary. Some care providers might think that this increases the risk of uterine rupture. Others might want to forego the slightly increased risks associated with fetal macrosomia. And many might regularly schedule cesarean sections for all suspected macrosomic babies, whether or not their mothers have scarred uteri.

And, to be fair, there are some increased risks associated with fetal macrosomia, particularly if women have diabetes or uncontrolled gestational diabetes/gestational diabetes mellitus/GDM.

For one, fetal macrosomia is associated with a greater risk of shoulder dystocia, a labor complication that is serious but nearly impossible to predict, especially before labor even begins. Notably, the overall risk of shoulder dystocia during labor is approximately .6-1.4%. What's more, approximately one-half of all cases of shoulder dystocia occur with infants who weigh less than 4000 g -- that is, who are not macrosomic.