VBAC/TOLAC for obese mom
July 7, 2018 9:18 PM Subscribe
I had a c-section in 2015 (thanks breech baby) and really want to do a VBAC this time around. My last doctor visit included a lot of "well, at your size a VBAC may only have a 60% chance of working" and a strong feeling that while this was all up to me, the doctor who was seeing me that day thought c-section was the better path. I'd like moms who are also obese who have either done VBAC or just had vaginal births just fine to give me some info please.
I'm 32, 5'3" 260lbs (with most my extra weight around my stomach -- hello apple body). I've been obese since childhood but played sports and stayed active through my mid-20s and still remain strong. Not diabetic, hypertensive, regular blood pressure, etc. The OB said that the transverse incision I had last time (both abdominally and on the uterine wall) were pluses for having a trial of labor and the fact that I didn't have the list of fat people illnesses helped as well. Even with that, she was only willing to give me 60/40 odds at a successful VBAC. A few other things that came up were that I had a large baby last time (9 lbs 8.6 oz) and even without the fat people illnesses, my weight made it less likely that I'd be able to have a vaginal birth.
I'd really like to attempt a vaginal delivery. I really wanted one last time and did everything to flip my son and was pretty upset that I needed to do a c-section. I don't know how much of the odds the doctor gave me (or her long monologue about the benefit of a planned repeat c-section) are because of my weight and less about me. I'm being seen by a practice that rotates patients through their roster of doctors (based on availability when an appointment is scheduled) so I'm not subject to this doctor's opinion through every step of pregnancy and when I previously talked about VBAC with the first OB who saw me for this pregnancy they were encouraging.
Ultimately, the doctor said they want to avoid an emergency c-section (hey, so do I). I have months to decide what I'll do (and hope this baby isn't breech) but I'd like people's experiences, research, whatever you can throw at me for VBAC as a large person or just vaginal delivery as a large person.
I'm 32, 5'3" 260lbs (with most my extra weight around my stomach -- hello apple body). I've been obese since childhood but played sports and stayed active through my mid-20s and still remain strong. Not diabetic, hypertensive, regular blood pressure, etc. The OB said that the transverse incision I had last time (both abdominally and on the uterine wall) were pluses for having a trial of labor and the fact that I didn't have the list of fat people illnesses helped as well. Even with that, she was only willing to give me 60/40 odds at a successful VBAC. A few other things that came up were that I had a large baby last time (9 lbs 8.6 oz) and even without the fat people illnesses, my weight made it less likely that I'd be able to have a vaginal birth.
I'd really like to attempt a vaginal delivery. I really wanted one last time and did everything to flip my son and was pretty upset that I needed to do a c-section. I don't know how much of the odds the doctor gave me (or her long monologue about the benefit of a planned repeat c-section) are because of my weight and less about me. I'm being seen by a practice that rotates patients through their roster of doctors (based on availability when an appointment is scheduled) so I'm not subject to this doctor's opinion through every step of pregnancy and when I previously talked about VBAC with the first OB who saw me for this pregnancy they were encouraging.
Ultimately, the doctor said they want to avoid an emergency c-section (hey, so do I). I have months to decide what I'll do (and hope this baby isn't breech) but I'd like people's experiences, research, whatever you can throw at me for VBAC as a large person or just vaginal delivery as a large person.
This is the evidence-based calculator that obstetricians use to predict the likelihood of a successful VBAC.
posted by i_am_a_fiesta at 5:20 AM on July 8, 2018
posted by i_am_a_fiesta at 5:20 AM on July 8, 2018
The evidence-based calculator is based on this research, which found that BMI had a strong correlation to success or failure with trying labor. You might not be representative health-wise or someone at your bmi, but that’s probably what the doctor is basing it on. I haven’t seen previous baby size listed as a factor in future success, or lack of “fat person illnesses,” so either your doctor is using generalizations they’ve seen in practice or research I haven’t heard about. Maybe clarify with them exactly where these odds they’re giving you are coming from, to help you in your decision.
I am not obese, but I have had a csection and have thought about whether I’d want a VBAC with a second baby. Hopefully it’s ok to share some of my thinking? It might help you to go into what the different complications for each path are, and what’s acceptable for you. From what I’ve read about the risks, it seems like attempting a VBAC has higher rates of bad outcomes for the baby, while a repeat c-section has higher risk for the mother. Personally, I would rather take on the risk, but the vast, vast, majority of both moms and babys are fine either way and both choices are valid. I am also very afraid of a uterine rupture, even though it’s so rare, and find the outcomes from that to be so scary and unacceptable that even a very remote chance makes me not want to try labor (my economist friend told me there’s a specific term for this, which I’m not remembering). The calculators say I’d be a really good candidate, so I have the opposite fear of your situation- that some hypothetical future ob will be skeptical of my desire for another section (I live in a very pro-vbac area).
It’s really just a gamble. A successful VBAC will probably be easier to recover from than a scheduled csection. But a complicated VBAC with very bad tearing or something, or an emergency csection, will be harder to recover from. Do you like the 60-40 odds? I’m personally always in favor of the devil you know, and that colors my thinking. But it sounds like you currently want to try for a VBAC, and it sounds like your odds are not so bad that you’re crazy for considering it. Even the skeptical doctor says it’s over half! You can use whatever research to justify, but at some level we just want things, you know?
I’ve already written too much, but for me experiencing labor was horrible. I think if I hadn’t, I might be in your shoes and feeling like I missed out so I’m sympathetic to that. But for me laboring was traumatic and horrible and I had panicked mini- flashbacks after for months and still occasionally do, if I feel burning pain during exercise, or during sex, or if I hear someone counting down like they did during pushing, or even hearing like “hold on” in an encouraging voice. And it was the uncomplicated early part of labor and pushing that caused this, not csection or when the baby’s heart rate was non reassuring and they decided to do a c-section. I think currently the overall culture promotes a lot about labor being an amazing empowering experience, or talks about how horrible it is in a more joking way, so I just wanted to seriously weigh in on how it can be really negative and damaging. So for me that would be a con towards trying a vaginal birth again, but I understand how it could be a pro.
posted by sometamegazelle at 6:00 AM on July 8, 2018 [3 favorites]
I am not obese, but I have had a csection and have thought about whether I’d want a VBAC with a second baby. Hopefully it’s ok to share some of my thinking? It might help you to go into what the different complications for each path are, and what’s acceptable for you. From what I’ve read about the risks, it seems like attempting a VBAC has higher rates of bad outcomes for the baby, while a repeat c-section has higher risk for the mother. Personally, I would rather take on the risk, but the vast, vast, majority of both moms and babys are fine either way and both choices are valid. I am also very afraid of a uterine rupture, even though it’s so rare, and find the outcomes from that to be so scary and unacceptable that even a very remote chance makes me not want to try labor (my economist friend told me there’s a specific term for this, which I’m not remembering). The calculators say I’d be a really good candidate, so I have the opposite fear of your situation- that some hypothetical future ob will be skeptical of my desire for another section (I live in a very pro-vbac area).
It’s really just a gamble. A successful VBAC will probably be easier to recover from than a scheduled csection. But a complicated VBAC with very bad tearing or something, or an emergency csection, will be harder to recover from. Do you like the 60-40 odds? I’m personally always in favor of the devil you know, and that colors my thinking. But it sounds like you currently want to try for a VBAC, and it sounds like your odds are not so bad that you’re crazy for considering it. Even the skeptical doctor says it’s over half! You can use whatever research to justify, but at some level we just want things, you know?
I’ve already written too much, but for me experiencing labor was horrible. I think if I hadn’t, I might be in your shoes and feeling like I missed out so I’m sympathetic to that. But for me laboring was traumatic and horrible and I had panicked mini- flashbacks after for months and still occasionally do, if I feel burning pain during exercise, or during sex, or if I hear someone counting down like they did during pushing, or even hearing like “hold on” in an encouraging voice. And it was the uncomplicated early part of labor and pushing that caused this, not csection or when the baby’s heart rate was non reassuring and they decided to do a c-section. I think currently the overall culture promotes a lot about labor being an amazing empowering experience, or talks about how horrible it is in a more joking way, so I just wanted to seriously weigh in on how it can be really negative and damaging. So for me that would be a con towards trying a vaginal birth again, but I understand how it could be a pro.
posted by sometamegazelle at 6:00 AM on July 8, 2018 [3 favorites]
I'm no expert but my partner is a midwife and we've talked about stuff like this a lot.
Things to think about: most doctors are the most involved with birthing when things go wrong so they have a skewed perception of risk. A planned c-section is very controlled, and a natural labour is not, so given the option they'd elect a c-section every time.
An emergency c-section vs a planned one can be similar in terms of stress for your body. Any unplanned c-section is called an emergency one so just because the word emergency is used doesn't mean it's a lights and sirens code type situation. It can be very common for natural births to not progress and proceed to a ceasar and that's not really more stressful for your body in terms of the actual procedure. It might happen at 3 in the morning though, and that's another reason why a doctor would prefer to have a planned one.
A big point against would be the size of your baby last time. Our first kid was 9 pound 7 and apparently that's right on the cut off of being able to be pushed out naturally.
posted by Silentgoldfish at 7:50 AM on July 8, 2018
Things to think about: most doctors are the most involved with birthing when things go wrong so they have a skewed perception of risk. A planned c-section is very controlled, and a natural labour is not, so given the option they'd elect a c-section every time.
An emergency c-section vs a planned one can be similar in terms of stress for your body. Any unplanned c-section is called an emergency one so just because the word emergency is used doesn't mean it's a lights and sirens code type situation. It can be very common for natural births to not progress and proceed to a ceasar and that's not really more stressful for your body in terms of the actual procedure. It might happen at 3 in the morning though, and that's another reason why a doctor would prefer to have a planned one.
A big point against would be the size of your baby last time. Our first kid was 9 pound 7 and apparently that's right on the cut off of being able to be pushed out naturally.
posted by Silentgoldfish at 7:50 AM on July 8, 2018
Hey I just had a successful VBAC when I was considered obese (5’4 210 at term) and with gestational diabetes. Due to the gd, I was induced at 39 weeks. My first childbirth was an emergency c-section after 22 hours of labor and I was terrified of repeating the experience. My doctor encouraged a VBAC in my case but gave me options. We discussed scheduling a c-section and only attempting a VBAC if I went into spontaneous labor or attempting one with the option to move to a c-section after a certain amount of time with no progress. If I wanted to VBAC, They were pretty adamant about the fact that I would need to be monitored the whole time, so I’d be stuck on the bed, and it was recommended that I get an epidural early so I’d be ready if we needed to move to surgery. I struggled with what to do, but at the last minute decided I would give it a shot and it was a pretty amazing experience compared to my first time. Good luck on a safe and comfortable birthing experience, no matter what route you take!
posted by galvanized unicorn at 8:24 AM on July 8, 2018
posted by galvanized unicorn at 8:24 AM on July 8, 2018
I had a C-section and then 2 VBACs. While my non-pregnant weight was somewhat less than yours and I'm slightly taller, I was not svelte at all. The doctors never said anything to me about weight being a factor in a successful VBAC. They were supportive of me trying to deliver vaginally, and I'm grateful for that. I should mention that my final VBAC was when I was 41 - you are much younger and sound much fitter than my 41 year old self. Good luck! You might want to consider changing doctors if your current practice is not supportive. If you have to fight for your VBAC, and your doctors are going to order you into surgery at the drop of a hat, that's not the practice for you. Oh, and my first baby was 10 lbs 11 oz, and then the next two were just under 8 lbs, so there is that.
posted by molasses at 8:44 AM on July 8, 2018
posted by molasses at 8:44 AM on July 8, 2018
I’m 43, hover between 225 and 250 lbs, 5’8”. My first birth at 40 was a vaginal birth, and no one ever told me that my obesity was a factor at all. It went pretty normally, I had an epidural, etc. My second birth, twins, I had to have a c section due to a suspected placental abruption, but up until that point the doctor and I were in agreement to try vaginal birth first.
So yea I can’t say my obesity has ever been brought up as a factor in giving birth vaginally. But, one thing to consider is I’ve had weight loss surgery and I think that colors people’s perception some times.
posted by cabingirl at 1:13 PM on July 8, 2018
So yea I can’t say my obesity has ever been brought up as a factor in giving birth vaginally. But, one thing to consider is I’ve had weight loss surgery and I think that colors people’s perception some times.
posted by cabingirl at 1:13 PM on July 8, 2018
As a general rule for VBACs - this should be an ongoing conversation through the second half of your pregnancy. The different doctors will have different perspectives so do ask at each visit with a different ob. Their recommendations might change based on how things progress and you can change your mind at anytime based on how things are going, so please don't take this one visit as a final word.
If I might offer something additional from my experience - I had hoped to do a VBAC through my whole pregnancy but ended up with a second c due to some complications. The planned was SO much easier than the emergency C after labor, but I wish I had spent a little more time thinking about it/planning for it - it was a fairly last minute decision. It would have been better to be more prepared, especially logistically.
posted by john_snow at 5:46 PM on July 8, 2018
If I might offer something additional from my experience - I had hoped to do a VBAC through my whole pregnancy but ended up with a second c due to some complications. The planned was SO much easier than the emergency C after labor, but I wish I had spent a little more time thinking about it/planning for it - it was a fairly last minute decision. It would have been better to be more prepared, especially logistically.
posted by john_snow at 5:46 PM on July 8, 2018
Oh, i forgot to add, midwives tend to be more supportive of VBACs than OBs, and I believe more successful at them. so if that is an option for you you might want to try a midwifery practice, or a
practice that has both, or at least do an interview with one to see if it could be a better fit. In my practice I saw midwives through my whole pregnancy while planning for a VBAC, and while I did have a csection with an ob, a midwife assisted.
posted by john_snow at 7:02 PM on July 8, 2018
practice that has both, or at least do an interview with one to see if it could be a better fit. In my practice I saw midwives through my whole pregnancy while planning for a VBAC, and while I did have a csection with an ob, a midwife assisted.
posted by john_snow at 7:02 PM on July 8, 2018
There’s a difference between a VBAC-tolerant provider and a VBAC friendly provider. If a VBAC is very important to you, I would consider changing providers.
posted by pecanpies at 5:31 AM on July 9, 2018 [2 favorites]
posted by pecanpies at 5:31 AM on July 9, 2018 [2 favorites]
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I'm 26 weeks along and this is my first pregnancy so VBAC isn't an issue for me, but nobody has said anything about me not being able to have a vaginal birth just because of my weight.
Since the size of the baby is one of the issues, would you be able to get another scan towards the end, to help you assess your options? My baby is measuring tall, with a big head (just like his dad!) so my OB has scheduled another ultrasound at 36 weeks, and we won't be making any decisions about the birth until then.
From some googling, it looks like the average success rate for VBAC is 74%, so the 60/40 chances your doctor has quoted aren't hugely lower than the average. But if the doctor's overall manner is pessimistic about your chances, particularly if it seems like this is based on preconceived notions about fat people, it doesn't sound like she's a great fit - is there any way you can arrange to not see this doctor for future appointments, and particularly for your birth?
The Plus Size Birth website (and particularly their VBAC page) is probably a good and reassuring starting point - there are birth stories, links and resources that may be helpful.
posted by escapepod at 12:23 AM on July 8, 2018 [2 favorites]