VBAC After One, Two or More Cesareans

What is a VBAC?

A VBAC is a vaginal birth after cesarean.

If a woman has had a cesarean and wants to plan a vaginal birth for her next, it would be considered a VBAC, and the number after it depends on how many prior cesareans there were.

What are the chances of having a successful VBAC and who is a good candidate for a VBAC?

The stats range that 60-80% of women, who have had previous cesareans, are candidates for a successful VBAC. In actuality, most healthy pregnant women carrying healthy babies are candidates.

The chances of a successful VBAC are higher if a woman is using a midwife, even higher in free standing birthing centers and home settings.

Going to a hospital and working with an OB/GYN with high cesarean rates, will increase the likelihood that a woman will have another cesarean.

In some hospitals, there are a lot of restrictive procedures, like continuous electronic fetal monitoring, confining a laboring woman to lay in bed, not allowing her to eat or drink, routine IVs and time limits, which increase the risk of a cesarean.

There are many benefits to a VBAC, that are physical, emotional, mental, and spiritual.

These are only a few important benefits on the long list:

• No risks from major abdominal surgery. This is huge.  Unfortunately, a cesarean can lead to trauma to the internal organs or reproductive tract, risk of hemorrhage, complications with scar tissue, long term post operative pain, wound infection, blood clots, stroke, and possible respiratory problems for the baby. High rates of cesarean section contribute to high rates of morbidity and mortality – and this is occurring in modern countries such as the US, which ranks among the bottom of them in terms of outcome stats.

• Easier postpartum healing and recovery.

• Baby receives needed bacteria for optimal health, from mother when passing through the vaginal birth canal.

• Breastfeeding may be more successful

• No potential harm to future fertility.

• Feeling more positive about the birth experience

• Increased sense of empowerment.

• More involvement of family and support people.

• Less risk of postpartum depression and emotional birth trauma.

What is the main risk of a VBAC?

The risk of separation of the one prior uterine scar is approximately 2 in 1000 VBACs, but often it is a mild superficial dehiscence (slight separation of some layers of the surgical wound) that has no clinical significance and does not impact the health of mom or baby. The risk of severe life-threatening emergency from a partial or complete uterine rupture of all the scar layers is significantly lower – a highly unlikely occurrence, significantly less than 1 %., 1.36% after 2 cesareans, slightly higher after three cesareans, with a higher comparative maternal and newborn morbidity with each repeat cesarean - but still in perspective, low, and depends on a variety of factors related to your individual situation. The main risk is of a VBAC is this rare catastrophic rupture of the previous uterine incision. This rare total disruption of the uterine scar risks both the mother and her baby, and can lead to catastrophic outcomes. It cannot be ignored and must be monitored for appropriately; but it cannot be exaggerated or make the risk of repeat cesarean less alarming. Frank uterine rupture is often mistaken for more common mild separation of the previous uterine scar without consequence, happens in less than 1% of all pregnancies. Even ACOG released guidelines that it’s reasonable to consider women with two previous low transverse uterine incisions to be candidates for trial of labor and to counsel on the combination of other factors that affect their probability of achieving successful VBAC.

But, it is getting harder to find a provider to attend to your desired vaginal birth after one cesarean let alone after two or more. It is still possible, and you have the right to decline another cesarean, but it is ideal for you to find a provider and setting most supportive to birth YOUR way safely.

Although every decision has risks, a VBAC is a reasonable, appropriate and safe option. If a woman panning a VBAC decides to give birth at home, I highly recommend working with a well trained and experienced midwife and consider the distance to a hospital (30 minutes or less driving time is ideal).

There are risks and benefits to every kind of birth and in every setting. I provide women with evidence based information, encourage each family to dig deep and look at the pros and cons to having a VBAC in a hospital setting, free standing birthing center or home, vs a routine cesarean and have informed consent for her birth.

Are there benefits to a cesarean?

A planned cesarean is in a controlled environment, and some women find great comfort in that knowing. Perhaps a woman has had a previous traumatic, long labor the first time and they just don’t want to go through that experience again. Some women are very anxious about that and they just feel safer knowing they will have another cesarean.

I take that seriously, because she won’t labor well if she doesn’t feel safe.

Like I mentioned before, the serious risks for a VBAC can be often prevented, treated or transferred to surgical care in time, with a skilled midwife or obstetrician who is attending to the laboring women, aware and mindful of the symptoms that lead up to that.

Thankfully some hospitals are now at least allowing more time for baby to get the cord blood from the placenta, skin to skin bonding, and her partner or main support person in the operating room. Some hospitals and providers are performing “gentle cesareans” – cesareans that are family and woman centered, and try to provide the environment of a natural birth as much as possible. This is a wonderful attempt to restore humanity to birthing in the operating room

In most cases, a VBAC is a safe option.

I share the opinion of many concerned with improving maternity care and reducing our rising rates of maternal and newborn death and serious health consequences from the interventions in childbirth, that a woman should not be forced to have a major surgery against her will, rather provided research and empowered to make her own decision, considering she is having a healthy AAOG removed the previous unreasonable restriction requiring immediate availability of a surgical staff for an emergency cesarean, as most hospitals around the country, let alone free standing birth centers and home settings, do not meet this criteria. Most hospitals are not able to have a surgical staff at all times and cannot perform an emergency cesarean in under 30 minutes.

Despite this, research is showing that far too many obstetricians and the midwives they back do not offer VBACs after one cesarean, let alone more. They routinely recommend repeat cesareans because they may fear law suits, succumb to scheduling pressures, have restrictive hospital or malpractice insurance policies, and/or feel pressured to uphold certain standards among their colleagues who are not supportive of VBAC. The hands of a midwife whose collaborative obstetrician and hospital do not support VBAC can often be unnecessarily tied as well for these reasons. Most repeat cesareans are not actually medically necessary, and are commonly recommended due to various non-medical reasons. This is very concerning.

What also concerns me is that the risks of a VBAC are magnified in conversation with women, while the risks of a repeat cesarean are downplayed, so women may feel forced, afraid and powerless.

I want women to feel like they have a voice, as they do have a legal and medically ethical right to autonomy over their bodies, their births and their baby’s.

Some women who want to VBAC have limited options and local doctors in the area are only offering cesareans. Some feel they have no option other than having an unattended homebirth, or labor alone at home until the last minute without any monitoring, or not be truthful with their providers about their previous cesarean birth – all of which can increase the risks for her and her baby.

A trained and experienced midwife who is continuously with the woman in active labor, can detect concerning signs and symptoms before they can become a crisis, and she be transferred and treated in time to save her and her baby’s life and heath.  A midwife wears many hats, one of which is protecting the space so the natural process of birth can proceed with ease and grace, and another is a lifeguard – to know when and how to intervene to prevent problems or manage emergencies.  There are many wonderful obstetricians supportive of VBAC who have this training and style of practice as well; they are just harder to find.You have the right to decline the repeat cesarean, and find a more supportive skilled provider at home. There are midwives and OBs who do it and post about it around the globe. It is worth every penny to even travel quite a distance to a practice who honors your choices. You REALLY have to want it, and you must prepare as best you can to set yourself up to succeed, like it’s your Mount Everest to climb, to have your healing, redemptive beautiful healthy birth.

Last tips:

If a woman knows she wants to have another baby, I would start with research and education. Ask yourself: “What do I want and why?”

A woman should get the support she needs. Most women who have had one or more prior cesarean births have issues they need to discuss and heal from.  One of my dedications and areas of expertise is creating space so a mom can debrief, process and recover from her previous upsetting or traumatic birth experience, as well as plan for a better one next time around. Schedule a coaching call with me for more personal guidance if you need.

I tell mamas to do what they can to educate, prepare and empower themselves in a whole different way than last time as I want them to succeed, build their circle of support, and include in their birth team advocates to speak for them when they are in the heat of labor. I tell them to prepare for a natural vaginal birth. The mind, body, heart and spirit can prepare for a natural vaginal birth - and a deeply positive, beautiful and empowering one. Yes, it takes work and practice, but it is worth every penny, every effort and amount of time you put in, if this is the birth experience you want and dream about. This is one of my passions and main focus of my online childbirth prep course Anne’s Guide to Pregnancy, Birth and Postpartum - sold separately or bundled together in adjunct to my Natural Birth Secrets books 2nd edition and Trauma Release Formula 2nd edition if you need help previous healing birth trauma - both extensive but very different resources that compliment each other to heal and prepare for your different next birth.

I also recommend hiring an awesome doula, as those who have a doula are less likely to have a cesarean.

A doula is amazing because they offer the mothering comfort and support that our ancestors had.  When women would give birth in their tribe or village, and they were surrounded by mothers, aunts, sisters, grandmothers, and the other women of their community, they received that mothering support by women who were comfortable with birth and relaxed around it. Fear has no place in birth, and a doula provides needed calm and loving support.

Remember, In the end it’s not in our control, and we let go and surrender,

If you do all of these things and end up having a cesarean, it’s not a failure. There is no failure in birth. It is a birth, a belly birth, and it’s the birth of your baby and you as a mother. It is the birth of your family and your partner as a parent. Stay present, stay involved and keep a positive mindset. Focus on the blessing, that you did all that you could, and thankful for modern medicine, which saved you and your baby’s life and preserved health. Also, you can ask for a gentle cesarean, which restores humanity to the operating room by doing such things as allowing your support people in with you, enabling baby to emerge from the incision simulating as much as possible a vaginal birth to help baby clear his/her own lungs, enabling you to participate by lowering the drapes so you can see your birth, giving you sterile gloves to receive your baby, optimal umbilical cord clamping so baby can benefit from the cord blood, encouraging immediate skin to skin bonding and early breastfeeding.  

Healing can occur afterwards, and may take time and lots of support. But there is no place for shame and negative self judgement here.

Questions to Ask When Interviewing Your Provider, Red Flags and Choosing Your Best Provider

Here are some key questions to ask your midwife or obstetrician if you want a natural birth. Listen to them and within you. You will get your answers about best provider for the birth you want. And do pay attention to red flags.

Do you have training and experience supporting natural physiologic undisturbed birth when all is well?

What’s your rate of primary cesarean?

If I need a cesarean, are you or your collaborative obstetricians experienced and do with gentle/family centered version?

Do you encourage VBAC? What’s your rate?

Are you skilled and supportive of physiologic breech and twin birth? What’s your rates?

Do you support my birth preferences and my right to decline interventions?

Do you advocate for doulas and other support persons I want?

Do you support and have training/skills for vaginal breech and twin birth?

What’s your rate and policy for induction of labor - like going past due date, suspected big baby, water breaking before labor etc.

Is your setting when you practice in alignment with you? What restrictions might be placed on me becasue their protocol?

Most importantly, do support my legal and ethical right to autonomy over my body, birth and baby?

Will my rights to make informed decisions about my and my baby’s care be respected?

If they don't support natural undisturbed health birth or evidence based care, their rate of primary cesarean section is above 10-15%, they don't support your birth preferences & right to decline interventions, they don't advocate for doulas & any other support person you want, they don't encourage VBAC and have rates lower than 70-80%, they have high induction rates for things like going past due date, suspected big baby, water breaking before labor, they don't support and have lots of experience with vaginal breech and twin birth, and/or the setting where they practice is not in alignment with them & they place a lot of restrictions on you because of protocols and policies you have your answer. You can switch providers anytime and hire one that is most in alignment with what you want, who will work collaboratively with you.

Here are some red flags, but here are so many others, especially when all is well with mama and baby such as:

They don’t support natural physiological birth.

They don’t care to read your birth plan or respect your birth preferences.

They don’t do VBAC.

They don’t do vaginal breech or twin birth.
They advise frequent ultrasound, routine multiple tests and procedures without discussion.

They perform weekly internal exams at 36 weeks.
They induce everyone at 41 weeks or sooner.
They do not believe in or practice natural physiological birth.
They don’t like or support doulas.
They do routine episiotomies on all first time vaginal birthers.
They do immediate cord clamping, or rush clamping without waiting until it is limp, white and pulseless.

Their cesarean rate greater than 10-15%.
scheduling a cesarean because they tell you your baby is too big

Unless you are planning to birth in an out of hospital freestanding birth center or at home with authentic midwives, most maternity care practitioners and the settings they work have not seen natural undisturbed birth - and they are trained and quite used to disturbing it. They think it’s necessary to fix what isn’t broken when all is well. It’s like everyone trying to interfere with your heart beating or your lungs breathing when it’s doing just fine on it’s own. It is a sad state of affairs with what’s going on in most modern hospitals especially in the US. I’ve had obstetricians, nurses and even medwives (midwives who practice more medically like many OBs) tell me they have never seen a natural undisturbed birth. Some actually want to shadow me to see one! I love when I do hospital shifts and the med students follow me - it may be their only chance to see natural undisturbed normal physiological birth. That’s the vast majority of what I see and I don’t get how it can be otherwise. Why is this happening as if it were some cool freak show, when the research supports it, when it’s evidence based care, when this is how birth occurred for thousands of years since the beginning of time, and still is the way it happens for the majority worldwide.

Here is a wonderful testimony sent to me from a mama who took my online Guide to Pregnancy, Birth and Postpartum, prepared, informed and empowered herself to tell her obstetrician (the only provider in her rural area) who never saw natural birth, to do nothing but be a fly on the wall, just in case of emergency. He said he never did that, does mostly inductions, medicates births and cesareans. But she respectfully spoke up and he finally agreed. And who was touched to tears, crying the most at her beautiful natural birth? Think of the ripple effect that has on his care for other mamas? If you want a natural birth without disturbance-ask your provider if they’ve seen one. You’ll get your answer whether you should run or not, to a provider and setting where it’s the norm.

“I want to thank you for your online course. Because of it I was able to do a home waterbirth in Nicaragua where it is not common at all. I live abroad so it was my dream to have a natural birth in my home. Little did I know there are no doulas or certified midwives in the country. Your course helped me through it! My father-in-law who is an OBGYN in Brazil caught the baby and also has never done a home or natural birth. He only does cesarean. What a special moment for the family! Thank you again for the knowledge I was able to achieve online!!! Here’s a video of our special day :)
”

— — Brittany S, Nicaragua

If you choose to stay with such a provider with so many red flags, you have to prepare even more, fight even more for what you want, make sure to have an advocate, and know your legal rights to autonomy and informed refusal so you don't allow anyone to dictate you to do anything against your will or manipulate you with playing the fear of dead baby card when there is nothing wrong. Dig deep - is this what you want to be doing during your pregnancy and such a sensitive time as labor?

For more information on how to best prepare for having your baby, feel well educated and informed , confident and empowered, bust through fears and trust the process, and have the most beautiful birth of your dreams take my online signature comprehensive prep course - Anne’s Guide to Pregnancy, Birth and Postpartum and read my Natural Birth Secrets 2nd book edition. I created them for you to do just that, based on over two decades of holistic nurse midwifery experience and attending over 1000 births.

I’ve taken everything I’ve learned, trained, and supported women locally for over 28 years in my private practice and I’ve poured all of my love, passion, knowledge, and experience into creating something truly special for you… my new and updated Pregnancy, Birth & Postpartum Guides. Same Beloved Content Plus Over 40 Added Bonus Videos! Buy Here Now!

They can be used via the mobile App or on your desktop! It’s the most up to date combination of Love Your Birth and Walk With Anne for Mamas online courses at a cheaper price! And they have an option for direct access to me for your questions and concerns!!

Whether you’re an experienced or new parent, there are hours of videos, workbooks, and PDFs to answer all of your questions. Everything is searchable, so you can just type or talk and it’ll bring you right to the exact moment in the video where I answer your question. It’ll blow your mind! If English is not your strongest language, you can even change the captions or even the audio to the language you prefer. The Prenatal, Birth & Postpartum Guides can be sold separately or in a bundle to buy only the section you need or get ALL of the guides for a limited-time offer of 50% off -> RIGHT HERE!

The key to a positive birth is feeling confident, strong, relaxed, and empowered during the entire process, regardless of the twists and turns it may take. I give my full heart and all I know in everything I do to support Mommas.

Can't Make up This Hospital Birth Story

True story TRIGGER WARNING

There are many wonderful, supportive obstetricians and I adore the ones I am blessed to work with. But sometimes I do hospital shifts, or help advocate for people in the hospital and have personally seen things that make me cringe.

I was to labor at home with a friend’s daughter expecting her first baby as long as possible. I brought her in fully dilated with no urge to push yet. At midnight, the only door open was through the emergency room. We were told to go the waiting room. Wearing eye pads and head phones in a public area, mama slow danced with me over 2 hours. Then she suddenly roared baby’s coming. I asked the person sitting at the desk several times to please get her up to the maternity unit as soon as possible. The staff person kept saying she needs to be seen first in triage, so need to go back to waiting room.

I said “she is pushing and saying her baby is coming as you can see. There is no more time to wait. We've been waiting over two hours.” Lady said it's hospital policy - she has to be seen first by a doctor in triage to determine if she needs to be admitted.” I said “I don't care about policies that make no sense. You can see this mama is having a baby, now. I'm a midwife, I know how to catch a baby here in the waiting room but I don't have privileges in this hospital and here is not the best place for her to give birth.” She rolled her eyes, told me there is nothing she can do, and said “next” to the person behind me. Mama is continuing to roar, saying “baby’s coming out!!!”

I rushed to a security guard standing in front of a bunch of wheel chairs. I told him I needed one stat to take this imminently birthing lady up to labor and delivery. He was at least nicer about it but said “he's sorry that he's not authorized to give one to me.” And what do you think I did? I stole one right in front of him, he looked stunned but did nothing, I took mama up to the maternity unit breaking all kinds of hospital rules.

But really? What would have happened if that was just herself and partner, no advocate? They would have had an ER waiting room birth, in an atmosphere of neglect and then chaos.

As soon as we got into the room, the staff was undressing her and put her into a hospital gown. Some battles aren’t worth the fight, and she did not care at this point, what she was wearing or not wearing. As I am supporting her in the hospital room, she assumed hands and knees position on the bed and continued to push. I could see baby’s head with each push. Multiple people came in, to draw blood, get her admitted by asking all kinds of irrelevant questions - like how much weight she gained in pregnancy as she was pushing; several nurses were trying to get her to lay down to get a continuous fetal monitor strip and start IV. I said she declines both, and intermittent listening to baby’s heart rate was her preference and is sufficient. Mama anyway kept insisting she needed to be on her hands and knees and resumed that position. I then see baby’s head crowning (emerging from the vaginal opening), and prepare for birth.

I suddenly heard mama shrieking, begging for me to help and make the doctor get out of her butt hole. I could not believe what I then witnessed. An obstetrician was doing a rectal exam, obviously without her consent, she was resisting, and he started yelling at her. Mama continued to scream to get him out of her. He continued to yell at her saying he needs to check if she is fully dilated. For those of you who don’t know, if baby is crowning, there is no more cervix, so of course mama is fully dilated. And to check the cervix you need to do a vaginal exam. It’s not accessible through the rectum. Nurses rolled their eyes as he was in the wrong place and his exam was not needed anyway. Help! Don’t let him touch me she pleaded.
I said I was a midwife, her advocate, her midwife is on the way (just changing) to take over as it’s her case, I am not sure why he was in there anyway, what he was doing was abusive, and he would be reported. He left in a huff.

I looked mama in the eyes, said I was sorry for what was done but she is safe now, it’s good to be on her hands and knees. I reassured her that Baby’s heart rate was fine by Doppler, and reminded her to breathe. We breathed together as her baby gently slipped into midwife’s hands. She cried, and was so thankful…but part of the tears was how she was treated initially. I held her in her pain. Just practicing midwifery. THIS ABUSE HAS TO STOP. He was reported to no effect!

Mama and baby were wonderfully healthy, she was amazingly able to tune it all out with her eye pads and head phones, and actually loved her birth but joked her situation at the hospital was like a sit com. But…”Next time just staying at home” she said. She did not want to pursue any other action against the doctor.

Share this! We must improve maternity care. We must know what is going on with our bodies and what to expect, have an advocate or doula especially if its your first and you are planning a hospital birth, speak up and make the choices best for us.

To learn more what you can do whether you are planning to birth in the hospital, at a birthing center or home, to have the birth YOU want & will treasure forever, check out my online Guide to Pregnancy, Birth & Postpartum comprehensive prep course and in adjunct my Natural Birth Secrets book 2nd edition, for deep dive into the hot topics and research.


Story told with permission.

Tearing at birth

Worried about tearing at birth? If so, you are not alone. Although no guarantees (for example baby can come out with their hand by their head - compound presentation, that can result in lacerations), there are things you can do to help prevent tearing during pregnancy and at birth, even if you tore or had episiotomy previous birth. I have helped many mamas not tear or not tear enough to need stitching repair, despite the most serious of tears last time.

First off, say NO to routine episiotomy, in which the provider cuts your perineum and vagina at birth. It is is not only one of the most harmful, painful and unnecessary routine obstetric procedures, but also can lead to more serious tearing extending to the anus (third degree) and even the rectum (fourth degree). Make sure you maintain excellent nutrition, take in low glycemic foods and drink (especially if previous tear was related to baby’s large size - white four, fruit juices and sugar foods tend to grow bigger babies), avoid toxins like smoking, encourage baby anterior as you get close to term to prevent posterior positioning - I go into all this in more depth in my Natural Birth Secrets book 2nd edition. Research is conflicting about benefit of simple perineal massage to prevent tearing. What is more clear according to the research are devices specifically made to stretch vaginal and perinal muscles. In the last three to four weeks of pregnancy, you can prepare the muscles of your birth canal with one of the researched effective, pelvic floor medical training devices like Epi-no, or Aniball (easier to get in the US) as athletes and dancers stretch before working out or performing to prevent injury. They are like a balloon of sorts, that you insert into your vagina and gradually inflate 15-20 minutes daily, over a period of time to the size of baby’s head. They not only significantly reduce the risk of tearing or episiotomy, they also help you feel more prepared physically and mentally (and get a sense of what it feels like to have your birth canal stretch to the size of baby’s head so you relax into it), they ease childbirth, prevent stress urinary incontinence and been demonstrated to have other important benefits from reduced length of second stage of labor to improved Apgar scores - less fetal distress during the pushing phase. Incorporate the practice into your love making and have fun with it. Many mamas in my practice and midwives around the world swear by them, and urge first timers as well as mamas who have had more severe tearing or episiotomy previously to use them because of their successful results.

At the time of birth, to try to prevent tearing, you can honor the resting phase of labor, between end of transition and before feeling the urge to push. Wait for that powerful instinctual urge to bear down, when the baby descends low enough in your birth canal to elicit your natural fetal ejection reflex, and then use soft blowing breaths, to gently allow the emergence of your baby without forced coached pushing or pushing before you feel the urge, especially just because you are told your’e fully dilated. Gentle grunts to work with your body’s natural urges are not the problem. Avoid birthing positions like lithotomy (lying on your back with legs in stirrups, a flat surface or held wide open) or deep squatting. Use more upward, forward leaning, hand and knees or side lying, standing or dangling high squat positions, and if you are concerned, ask for perineal support by your attendants or have a water birth. I discuss this more comprehensively in my Online Guide to Childbirth.

You make plans for the best outcome, then surrender to the journey. Lean into the wondrous intensity of it all.

Routine Labor Interventions Needing to be Abolished

Routine interventions in healthy labor and birth that need to be abolished when all is well include not allowing food and drink, IV, laboring and pushing in bed on back, artificially breaking your bag of water, continuous electronic fetal monitoring - including the admission and periodic strip, using the outdated Friedman curve to asses progress, forced coached pushing during the resting phase before the fetal ejection reflex - during the resting phase once diagnosed as fully dilated, episiotomy, immediate and premature cord clamping.

Many labor in hospitals that don’t allow food and drink, and need IV to prevent dehydration which can cause complications needing more interventions….unless you are sneaking food and drinking plenty orally. If you’re pregnancy and labor are healthy and proceeding naturally, IV fluids aren’t at all necessary and may cause harm. Even the American College of Obstetricians & Gynecologists (ACOG), the American Society of Anesthesiologists (ASA) & of course the World Health Organization (WHO) all recommend encouraging oral fluids instead of IV fluids.

Why is this not happening? Routine intravenous fluids can over hydrate and decrease newborn weight & blood sugar & cause maternal swelling - even in the breasts which impairs breastfeeding, can be uncomfortable, get inflamed, infiltrated or cause infection; IV restricts needed movement in labor, undermines mama’s confidence and sense of feeling empowered and healthy. It’s harmful practice to restrict needed nourishment and hydration during labor and birth. As long as you are keeping well hydrated by drinking, you can absolutely feel no qualms about declining that routine IV. There is also no evidence to support the IV access called saline lock for low risk laboring mamas because in case of postpartum hemorrhage. The risk of that in this population is low, and needing treatment beyond natural remedies and medications without IV even lower. An excellent practitioner can start an IV in that rare emergency.

Artificially breaking your water is another routine intervention that has no place in normal birth. The bag of amniotic fluid is intact for a reason. Let it break on its own. Most often that is late labor or during pushing. Occasionally it breaks before labor or rarely doesn't break at all, leading to an en caul birth with baby born in the amniotic sac.

If you’re told there is little to no risk - it's just nothing - you are not getting informed consent or evidence based care. Breaking it artificially without medical reason has drawbacks like causing more intense painful contractions and use of pain medication to cope, increased risk of infection and fetal distress from cord compression without the protective barrier around baby. It can also lead to malposition of baby which can lengthen labor. All this leads to a cascade of other interventions from IV Pitocon, continuous external or internal fetal monitoring using an electrode screwed into baby’s scalp, and c - section. If your cervix is not soft, thinned out or dilated much, the risks of all the above significantly increase. If baby is presenting other than head first, or not yet engaged in your pelvis, breaking the water can cause the cord to prolapse needing emergency cesarean to save your baby’s life. It's proposed benefit of speeding up labor is possible, but no guarantee. Is that worth the risks? Sometimes a provider tells you they want to do it to check for meconium - not uncommon, which baby at some time of stress in pregnancy or labor had its first bowel movement that mixes with amniotic fluid. If there are no signs of fetal distress and heart rate is reassuring, why create more stress? Knowing there is meconium stresses the team, then you, as they now treat you as having a complication that requires more intensive surveillance. There is no need for this when all is well. When there’s a problem, such as prolonged or stuck labor and you’re exhausted or not coping well, after trying all other more natural remedies, breaking the bag can help. But make sure you are well informed by preparing in advance with my Guide to Pregnancy Birth & Postpartum.

Continuous electronic fetal monitoring (EFM) is still routine despite the overwhelming amount of evidence against its use. Non reassuring fetal heart tones is the second most common reason for first time cesarean in the States, after “Failure to progress”’, many unnecessary as babies are born vigorous without any signs of it. Per the research there is no benefit for the admission and periodic 20 min continuous electronic fetal monitoring strip either, in healthy low risk pregnancies. It isn’t just ineffective, it’s uncomfortable, harmful, leads to increased continuous fetal monitoring, other risky interventions and cesarean without making any difference in baby outcomes. There is no evidence to show that this kind of fetal monitoring is safe or effective, and has contributed to huge increase in cesarean rate without improving Apgar scores, cord blood gases, admission to neonatal intensive care unit, low oxygen brain damage and cerebral palsy, stillbirth and newborn death. Even Obstetric professional organizations like ACOG acknowledges this and endorses intermittent fetal heart rate monitoring with a hand held doppler in low risk pregnancies and those laboring without complications. Furthermore, they encourage training of staff to its use to facilitate freedom of movement and increased comfort. NICE in the UK as well as SOGC in Canada agree there is no evidence to justify routine use of continuous EFM & that intermittent hands on listening to fetal heart rate is the preferred method of monitoring. NICE goes as far as opining that providers NOT even offer continuous EFM to laboring women low risk for complications. The ACNM says intermittent listening of baby’s heart rate with a hand held device should be the preferred method of fetal monitoring in those low risk for complications. Research is not clear & guidelines differ even regarding who does benefit from continuous fetal monitoring, when it comes to certain higher risk complications. This is not what is happening in reality of US hospitals due to a variety of factors from big business of EFM, understaffing, lack of training and equipment to outdated policies, providers not keeping current or practicing evidence based care.

I don’t like to disturb a laboring mama when all is well, just periodically need to check on baby. Some mamas prefer the fetoscope but it can best be assessed with mama on her back, & most in labor don’t want to get out of tub and be on their back. I love using it in pregnancy, but in labor, find most prefer the doppler so mamas can stay in the tub, shower or any position they want to, & everyone can hear that most often reassuring heartbeat. Distressed babies usually tell us whether we use hands on doppler or intermittent monitoring - which also allows for freedom of movement and the enormous benefits of upward mobile positioning plus more contact with and support from your provider. Research also documents the benefits of continuous labor support (which can involve plenty of privacy if that’s what you need!). Being a midwife fly on the wall is often the best intervention in normal labor, who can be there if needed, otherwise keep the fly on the wall role- with a huge heart.

Assessing progress by outdated rigid parameters needs to go. According to evidence based birth, the definition of a “normal” length of labor that has been used since the 1950s based on the biased, flawed Friedman curve is obsolete. The new, evidence-based definitions of normal labor should be used, and the vague term “Failure to Progress” should be abandoned. Yet still used in many hospitals.
If the laboring mama and baby are both healthy, and as long as the length of labor does not qualify as an arrested labor, laboring mamas should be treated as if they are progressing normally, even if what seems to be slow and prolonged for the mama. Pregnant mamas - especially first time vaginal birthers should be given more time in the early phase of labor, making sure they keep well nourished and hydrated, mobile and active but also rested, and also well supported with a doula or doula like care. I have many more suggestions in my online course Guide to Pregnancy, Childbirth & Postpartum, as this can be a challenge to mamas and their partners.

If you are wanting or needing an internal exam, six centimeters—not four centimeters—should be considered the start of the active phase for most people and caregivers should keep in mind that normal early labor (before six cm) sometimes includes a period in which there may be no change in dilation for hours. People may decide, together with their caregivers, to delay birth center/hospital admission until active labor. Similar with homebirth, but there is a more intimate relationship there between midwife and mama, with periodic contact in early labor being the norm.

Still, people are still being told to labor in bed, and give birth on their back. I can’t believe this is still happening despite not just common sense but loads of research about the harmfulness and risks to this practice.

Laboring and pushing your baby out on your back goes against gravity and trying to do so is more work and stress on your body and baby. Laboring and pushing with the force of gravity is less painful and all the more easier. Lying on your back also causes your heavy uterus to exert some compression on major blood vessels that go to the baby which can cause fetal distress, let alone to your upper body and head - why people don’t feel well on their back late pregnancy. It’s a position that was created by doctors not birthing mamas, who would be more comfortable in any other position when given the choice. As it’s a position best for the provider not the mama and baby. And that’s the best birthing positions - what feels best at the time to work your baby down and out. I go over these best positions to labor and help your baby come through your birth canal and into the world with demos in my Online Guide to Pregnancy, Birth and Postpartum - sold separately or bundled.

Mamas need to be moving asymmetrically as they need to move working with their body and baby as well as using the force of gravity to help them guide baby down and out. The pelvis is three bones connected by ligaments and it can stretch to accommodate baby. It’s at is smallest capacity on your back. Pushing on your back is much harder as you have to work against gravity. Occasionally some mamas need to rest and can lay on their side, and some do want to birth on their back and it works for them. But the routine practice of insisting all mamas labor and birth on their back is harmful.

Good bye to forced coached pushing when fully dilated. If and when you are told you are fully dilated, rest, eat and drink if you need, get up and dance…but wait for the fetal ejection reflex (FER). When you wait for the FER, and naturally feel the urge to push, instinctively push, working with your body. It is a bit similar to pooping - think of what it feels like and what happens when you try to push it out for a prolonged period of time when you don’t feel the urge. Then think of how easy it is when you just go after feeling the urge. Some may need or want a little gentle guidance to get started but avoid forced coached pushing. It’s not evidence based because it’s harmful, associated with such problems as more swelling, tearing, fatigue, fetal distress etc. Honor the FER!

It happens. The sensations of pushing and FER, fetal ejection reflex can be so intense that mamas initially may want to fight it, which makes it all the more harder. What we resist persists. When we dive in and lean into the sensations we birth.
Being in the water helps. Movement in asymmetrical positions & roaring like a lion helps, as does channeling your inner monkey, letting your primal take over. Relaxation & coping techniques to practice in pregnancy so you can just tap right in to them in labor are a huge help, as is bringing fun, joy, the primal & sensual, & enhancing pleasure using all your senses into the birth experience . But a complete change in mindset and perspective is key, as is my preparation. You can learn to use different language for the sensations of labor, instead of pain which implies illness and something that needs to be remedied, and to see them for what they are. You can learn to use other words for contractions, which imply tension and negativity, and the word contraction is not empowering, and does not fully explain what is happening. Yes, the top of the uterus contracts so the birth canal can open and expand, as well as push out your baby. So expansions are also happening in labor – that is really the goal of what you are doing – expanding so your baby can emerge from your womb to the outside world, and you can both be birthed as a new mother and baby.

Suffering is a choice. And you can chose to embrace your intense sensations for what they are, as healthy signs, what is needed to birth, what your baby needs to transition earth side - not that anything is wrong. I go cover this in much greater depth in my online Guide to Pregnancy, Labor & Childbirth.

Routine episiotomy in a normal birth is of the most harmful unnecessary procedures. It’s so not evidenced based care. And if you do tear despite prevention efforts (it can still happen), little tears heal fine on their own; if we have to do a repair we do try to put everything exactly or almost exactly how we found it. The perineal and vaginal area of a mom who has given birth vaginally before never looks exactly like it did prebirth. But we do our best! Sometimes there is some scar tissue that forms and definite changes from muscle stretching. These are our beauty marks and badges of honor.

Immediate and premature cord clamping is another harmful routine intervention that needs to be stopped. Just think about it. We did not cut cords right away for most of history. No mammal cuts the cord after birth. They just allow the normal natural physiological process to proceed instinctively…or they would have not survived as species.

The number one best recipient for cord blood is baby. 1/3 of baby’s own blood backs up into the placenta during birth. Baby needs to get it back - it is loaded with blood volume oxygen, nutrients, stem cells, antibodies and ingredients essential for transitioning from womb to world and long term health. If you want to donate or bank the cord blood, if baby is doing well at least wait 10 - 15 minutes so your baby gets most of it and there is still enough to bank.

Don’t let them convince you to have it cut ever after a minute because they are in a rush or tell you some misinformation that it’s not good. Clamping right away was probably invented for the doctor but now we know it’s harmful. Delayed optimal clamping can even be done after cesarean until placenta is birthed if there is no other problem.

I have way more info on this in my Natural Birth Secrets book 2nd edition but make sure this is clearly communicated to your providers and written in your birth plan. Ideal is to wait until it stops pulsing completely, flat and white, and you can even feel and see that yourself. When all is well I don’t cut it until after the placenta unless they want a lotus birth.

The best intervention in normal labor and birth is no intervention. Beloved obstetrician Dr. Michel Odent goes further and says best intervention in healthy childbirth is to knit. Knitting keeps our hands occupied instead of trying to meddle and fix something that isn’t broken. Part of Hippocrates oath doctors have to take after training is “First Do No Harm.”

But knitting goes deeper. It is the calm presence of an experienced attendant who has seen it all, communicating to you with their body language to relax, all is well. Their calm is contagious and will make you feel more calm. Their heart, ears, eyes and mouth are open to listen, watch, support, encourage and help you as needed; and of course they can put the knitting down as appropriate, but the point is brilliant.

The ideal is birth attendants are there, so there with the laboring mama, especially towards later labor when sensations can get intense, but know that mama needs to feel private, safe and undisturbed to labor best, to not feel watched; so we try to leave her alone, on her own, until she needs us. Even then, we try to be in background so mama doesn’t feel watched, after doing needed assessments without causing much disruption, as a lifeguard just in case and there of course if more support is needed.

Prepare yourself to be empowered, have an advocate and birth YOUR way!