Episode 271 Dr. Nathan Fox Returns Sharing Evidence on Uterine Rupture, Induction, Cervical Exams & More

“I think that’s why there is so much discussion about this because it is not the numbers. It is the attitudes. It’s the opinions. It’s just trying to make sure that you have an aligned vision with your provider and with your hospital.” One of the most important things you can do during pregnancy is to find a provider who loves and believes in VBAC. Dr. Fox is back today giving more tips on how to know if an OB is VBAC-supportive and why there is so much variation out there in how practices feel about it. Dr. Fox answers questions like: Why do some providers refuse to induce VBACs? Why do some providers require it? Are routine cervical exams necessary for VBAC? Does a uterine window in my operative report mean my uterus will rupture during my VBAC? Additional Links Needed Website How to VBAC: The Ultimate Prep Course for Parents Full Transcript under Episode Details Meagan: Hello, guys. This is The VBAC Link. Welcome back or if you are new to the show, welcome. We are so happy that you are here. My name is Meagan and I am so excited to have a returning guest with us today. We have Dr. Nathan Fox who is a board-certified obstetrician and gynecologist with a sub-specialty in maternal-fetal medicine. He is here answering your guys’ questions. This community is amazing and every time we reach out and say, “Hey, what are your VBAC questions?” We do. We get a ton. I love bringing on guests, especially within the medical world, OBs and midwives talking about these things with you and what they are seeing and what the evidence says. It’s always fun to get a different provider’s perspective and get a better idea on what really the research is showing. Review of the Week So welcome back, Dr. Nathan Fox. But of course, we have a Review of the Week so I wanted to quickly get into that and then get into these amazing questions. By the way, they are questions about induction– when or is it really necessary? Can I be induced with a VBAC? We are going to talk a little bit more about uterine rupture and the risk which is, of course, a burning question that everyone always has. We are going to talk about maybe if a provider has told you that they have seen something like a uterine window, dehiscence, or even a niche. We are going to talk a little bit more about those so definitely stay with us because this is going to be a really great episode. This review is by Elizabeth Herrera. Hopefully, I did not botch that. She actually sent us an email. If you didn’t know, we love getting reviews in emails as well. You can leave us a review on social media. On Instagram, you can message it on that. You can email us at info@thevbaclink.com or you can leave us a review on Spotify or Apple Podcasts. You can even Google “The VBAC Link” and leave us a review there. All of your reviews help Women of Strength just like you find us and find these incredible stories and these incredible episodes like today’s episode with these providers to learn more about their options for birth after Cesarean. Elizabeth says, “Thank you so much for creating this whole community. After my emergency C-section in 2019, I looked up everything possible about being able to VBAC. This led me to your wonderful podcast and blog. I devoured everything. I owe my knowledge to you all and my doulas. I’m happy to say that I had my VBAC on March 31st and it was the most magical experience ever. Thank you so much for all of the materials that you have provided which all helped me succeed. I hope to one day share my story on your podcast. Many, many thanks.” That was in 2022 so a couple of years ago she left that review. So hopefully, Elizabeth, you are still with us and listening to all of these amazing stories. We would love to share your story which also leads me to remind you that we are always looking for submissions. You can submit your story on our website at thevbaclink.com/share. Dr. Nathan Fox Meagan: Okay, you guys. We have Dr. Fox back on the show today with us. How cool is that that he has come on now twice with us to talk about VBAC and answer your guys’ questions? Dr. Fox, welcome to the show again, and thank you again for being here. Dr. Fox: Back on VBAC. Meagan: Back on VBAC. Back talking about VBAC. Tell me what you think about this VBAC topic and how VBAC looks for OBs. I think a lot of the time, OBs and midwives and providers in general can get some backlash honestly, even from us here at The VBAC Link where we are like, “Oh, that’s not a good, supportive provider.” I think there is a lot from the community that we really don’t take into account on where a provider is coming from maybe with what they’ve seen or what they’ve gone through. Maybe they want to support VBAC but their location doesn’t support it. Can we talk about VBAC from an OB’s standpoint? What does VBAC look like for an OB? Dr. Fox: Yeah, listen. It’s a great question. Thanks for having me again. I’m always happy to come on. I really like this topic medically, but also, it’s just very interesting because there is so much that comes up with VBAC in terms of the medicine surrounding it. It’s also a really good paradigm for how people look at risk. By people, I mean doctors. I mean nurses. I mean hospitals. I mean women who are pregnant, thinking of being pregnant, their families, and their friends because there isn’t a ton of disagreement about the numbers. What is the risk percentage-wise? We have that worked out pretty well. I mean, there are some things that are maybe a little bit more nebulous. There are those situations, but most people agree on what the actual numbers are. The issue is what do you do about that when someone has a small risk of a big problem? Right? Meagan: Right. Dr. Fox: What do you do? That personality comes into that. I think that’s part of the reason that there is so much variation in VBAC practices, VBAC attitudes, and VBAC rules. It’s risk. I talk to people about this all of the time in other contexts like with genetic screening. I tell people, “All your genetic tests are normal. All of the screening tests were normal that we did. Everything is fine which means that your risk of having a baby with a genetic condition now is 1%.” I’ll tell them that. Some people hear that and say, “That’s awesome,” and then they walk out. Other people go, “Oh my god. 1%. That’s unbelievably horrible,” then they sign up and do a CVS and amnio. Neither of them are wrong. 1% is 1%. It’s 1 in 100. People are going to look at that differently based on their understanding of math, based on their personal experiences, based on the stories they’ve heard, based on their own anxieties, based on who is in their family. All of these things contribute to someone’s opinion about a risk that is low. Take VBAC for example. If everything is otherwise ideal– a healthy woman who had a prior C-section that was standard with nothing crazy about it. Pregnancy is going fine and she is deciding whether to attempt a VBAC or whether to do a repeat Cesarean, people are going to talk to her about the risk of uterine rupture. That risk is a ballpark of 1%. Whatever. It’s about 1%. Okay. It’s the same thing. How does everyone look at 1%? I could look at it and say, “Well, 1% is pretty low. It’s only 1 in 100. I really want a vaginal birth because I want it or because it’s going to give me an easier recovery potentially or because I’m afraid of a C-section” or whatever. Or they can look at it and say, “Holy crap. 1%. I don’t want any part of that risk and I’m just going to do a repeat C-section.” I don’t think any of those opinions are unreasonable. I think they are both reasonable based on how you look at it. So if you have a situation where everyone’s aligned– the doctor thinks it is reasonable, the patient, the woman thinks it’s reasonable, and the hospital thinks it’s reasonable, then it’s not a big discussion. Okay, we talk about it and the VBAC happens. Where I practice, that’s the culture in my practice and in my hospital amongst my patient population. We talk about it. Many people want to do a VBAC. They want it. We are supportive. The hospital is supportive. The nurses are supportive. Great. Some patients don’t want to have it. Fine. We’re supportive of a C-section. The hospital is supportive. All is good. I think the issue comes up when there is a disconnect like the patient wants it. The doctor thinks it’s too risky for the patient and the doctor thinks it’s fine, but the hospital thinks it is too risky or whatever. There are all of these situations. Meagan: Yes. Dr. Fox: Since doctors are humans and patients are humans and even though the hospitals are buildings, they are run by humans, you are going to have a lot of humanity and humans and all of our fallabilities and flaws and quirks come into this. That’s a very long-winded answer to your question, but I think that’s why there is so much discussion about this because it is not the numbers. It is the attitudes. It’s the opinions which is why so much about VBAC is not trying to figure out your number. It’s just trying to make sure that you have an aligned vision with your provider and with your hospital. Meagan: Right. I love that you pointed that out. It’s the perspective on this number. We know the number is say 1%, but to some people, that 1% may be 60% in their mind. It might as well be 60. Do you know what I mean? I love that you talked about being aligned. That is something that we talk about here a lot is really being aligned with your team. Find your team because your team is super important. The mom, the doctor, the hospital, the location, and the nurses, everything is aligned so that maybe we don’t have to fight so hard. I feel like this community ends up feeling like they have to fight for their birthing right. Dr. Fox: Yeah. Meagan: Like the way they want to birth, they feel like they literally have to come in with punching gloves and punch their way through to get this vaginal birth. That’s where it is just so hard. We are so vulnerable as pregnant women. Dr. Fox: Yep. That’s an unfortunate reality. It’s obviously a reality, but I would not counter it because I don’t disagree with it. I would advise that instead of coming in with gloves up ready to fight, you need a different provider. I’m not saying this to disparage a provider who is less pro-VBAC. They are humans. Whatever it is. Maybe the doctor had a really bad outcome once with a VBAC and they are scarred from it. Meagan: Exactly. Exactly. Dr. Fox: Maybe where they were trained, the attitude is very anti-VBAC so they are just not used to it. Maybe they would be okay with it, but they practice in an environment where the hospital is not so happy with it or the nurses aren’t. Whatever it might be, if your provider is telling you, “I am not a big fan of VBAC,” they are telling you this. Listen to them. Okay, that doesn’t mean they are a bad person. It doesn’t mean they are a bad doctor. It just means that’s who they are. So if you have an opportunity, seek someone who is more aligned with you. And again, obviously, that is easier said than done. It requires some work. It requires some legwork. It requires asking around, going on message boards, and finding people. If you have a prior C-section and you’re interested in a VBAC, if the doctor says that he or she is uncomfortable, I would first ask why. If they give you, “Listen, normally I am in favor of VBAC, but since you had a classical C-section, it’s too dangerous.” All right, that’s a very reasonable explanation that pretty much everyone is going to tell you, and switching around is probably not going to help you. But if they say, “I just don’t do VBACs or my hospital just doesn’t do them,” they are telling you that for a reason. Say, “Thank you. Have a good day,” then try to ask around and find someone or some hospital or someplace that is in favor of them as opposed to trying to convince someone to do something they are not comfortable with. Meagan: Absolutely. Dr. Fox: That ends up being a combative relationship and ends poorly for everyone. It would be great if all doctors were totally supportive. It would be great if all hospitals were totally supportive. There are sometimes logistical issues meaning since VBAC has the potential for an emergency, hospitals need to have 24/7 anesthesia. They need to have a blood bank. They need to have certain things in place in order to safely offer a VBAC. Some hospitals are just too small to do that. It’s not an attitude. It’s, “Logistically, we just can’t do this.” Fine. Again, try to go to a major medical center that does a lot of VBACs. Most major medical centers are comfortable with VBAC. Most doctors who practice in those centers are comfortable with VBAC. So I think if you do the legwork, you can probably, not always, but probably find someone who is a better match for your VBAC as opposed to trying to convince someone to do something they are not comfortable doing. Meagan: Yes. I love that, so we don’t have to try to convince. That’s why listeners, when you are with your provider– OB, midwife, or whoever it may be– talk to them. Have that discussion. Ask that question. Don’t be scared to ask them why. For me, with my second, I had this feeling that maybe he wasn’t as on board for VBAC as I wanted him to be. I was scared to leave or scared to hurt his feelings. But I think that it probably would have been better for both of us in the end to have found a different provider that was more on board and comfortable versus me trying to go in and push and try and make him do something that again, he wasn’t comfortable with. He wasn’t comfortable with that and that’s okay. For a long time, I had a lot of anger, and a lot of our community has harbored anger, but I’d like to drop a message to our community. Try not to harbor the anger. My provider is a great guy and a great doc and all of these things. He just wasn’t the doc for me, so find the doc for you. Dr. Fox: Right. Listen, obviously, there are a lot of doctors in the world and I’m sure that there are bad doctors or mean doctors or people who aren’t good people out there. I’m sure they exist. But I would say in my experience that most doctors are good people who are trying to do right by their patients. It’s too much work to go into medicine and train to go into it to dislike patients. It just doesn’t make any sense. My experience is that most people are trying to do right by their patients. But we are all human. We all look at risks differently. We all have different experiences. That happens. Humans are varied. It’s part of the reason it’s wonderful to be a human. We are all different. That’s all great. But it’s not complicated to get this answer from your doctor. I think it just requires some preparation meaning ask these questions very early either before you get pregnant or early in pregnancy. Again, they are not complicated questions. I would say the first question you should ask is something related to the numbers. Say, “What is my risk if I try a VBAC? Me, personally?” If they say, “Well, your risk of it is a uterine rupture,” say, “What is the number risk?” The risk is uterine rupture and if they say, “Well, it’s probably about 1%,” okay. That is the number. If they say it is much higher than 1%, well why? Is it because I have had a classical C-section or I have had three prior C-sections, okay, but get the number. Then the second question is very open-ended. Nonjudgmental. Say, “What are your thoughts or opinions about VBAC?” That’s it. Open-ended. They will tell you. Right? No one’s going to hide it from you. They will tell you overtly and say, “I love it. It’s awesome. I’m all over it. This is great. I hope you try it.” Or they’ll say, “Not a big fan. I don’t really like it. It’s not my thing. We don’t do it. I haven’t done it in 20 years,” okay. Or potentially, they will be somewhere in the middle and say, “I kind of like it,” but you’ll know. You’ll know right away what their thoughts are. Then the second question is, assuming they are supportive, about the hospital where you deliver. What’s the attitude there about VBAC? If they say, “You know, I am really in favor of it, but the hospital is awful. They torture me every time there is a VBAC. They make me be there the entire time. They always make me do C-sections. It’s just a terrible environment–” Meagan: Maybe not right. Dr. Fox: Right. Either of those two reasons is probably a reason to look elsewhere but if they tell you, “I’m on board. The hospital is on board,” it doesn’t mean you will have a VBAC, but you have a plan in place and you are ready to go. If they tell you, “I don’t like that. I don’t do that,” then turn around and say, “Okay, I really appreciate that. Thank you for your perspective. Thank you for your honesty. I am really interested in VBAC. I might be seeking a different doctor or a different hospital. Please don’t take that personally.” They will probably say, “Thank you.” Meagan: Yeah, exactly. Dr. Fox: Doctors don’t want a situation where they have a combative relationship. That is horrible. We hate that. It’s awful. That is what keeps us up at night. Do it at the very beginning and no one is going to have hard feelings over that. I would say it’s unusual that people are going to try to convince you to stay for the money. Doctors don’t want that. They would rather have you go to someone else than go to them and want something that they don’t want you to have. That’s just how doctors are. Meagan: I love that you just made that point because it is hard to leave. You get worried about hurt feelings and all of that, so thank you so much for saying that. Dr. Fox: Yeah. Induction Meagan: Okay, so let’s shift gears a little bit and talk about induction because this is a really hot topic when it comes to someone wanting to TOLAC or have a VBAC. I guess the question is when is it really necessary? What is the evidence on induction and VBAC? Because just like support, it varies all around where some people are absolutely no induction. You have to go into spontaneous labor. Some are like, “Yeah, cool. No problem. You can be induced.” Some are like, “You have to be induced.” Then when it comes to induction, that also ranges. Maybe we can’t do a Foley or a Cook or we can’t use Pit and we can only break your water and all of these things. Can we talk about the evidence specific to VBAC? Induction can be necessary. There are a ton of reasons for induction, but when is it really necessary? Dr. Fox: Right. Instead of talking about when it is really necessary, I think the question is why is it even a question? The reason is that the best evidence we have– it’s not perfect evidence, but the best evidence we have is that for someone who is undergoing VBAC who has induced labor, her risk of uterine rupture is about 1.5 to 2x as high as if she went into labor on her own. For example, if your risk was about 1% for a uterine rupture and you get induced, your risk is now about 2%. 1.5-2%. If your risk was a little bit lower because maybe you have had a vaginally delivery before so if you have had a vaginal delivery before, your risk isn’t 1%. It’s closer to .5%, it will raise it to maybe 1%. Again, I say it’s the best data available because the studies that were done, there is a little bit of a flaw in them because they are not randomized, but it seems to be correct that inducing increases your risk likely. The one exception is if you induce with misoprostol, the risk seems to be much higher so pretty much no one induced with misoprostol if there is a prior C-section. That’s usually something that nobody does, but the other ways of inducing whether that’s breaking the water, whether it’s Pitocin, whether it’s a Foley balloon, and all of these things seem to increase the risk slightly. Again, it’s the same thing as before. If now I have a risk in someone whose risk isn’t 1% but 2%, how do I view that? How does the hospital view it? How does the patient view it? Obviously, 1% and 2% are not hugely different from each other, but you could also look at it and say, “It’s double.” You can think of it in two different ways. Based on that, there are definitely doctors or hospitals who would say, “I’m comfortable with VBAC, but I’m not comfortable with inducing labor in someone who is a VBAC.” In our practice, that is not our position. We will induce someone’s labor. We tell them, “Your risk is a little bit higher. It’s 2% versus 1%,” or something like that, but again, if there is a reason not to, we would induce someone’s labor but different people look at it differently. So again, another question to ask to your doctor is, “Not only how are you with VBAC, but how are you with inductions and VBAC?” If they say, “Well, I’m okay with VBACs if you go into labor on your own, but I’m not okay with VBAC if you have to be induced,” does that mean you have to switch doctors? Well, it just means you have a potential limitation. Meagan: A potential roadblock in the end. Dr. Fox: Right, a potential one. Again, it depends on the circumstances. Obviously, each case might be unique. So that’s number one. Number two, there is some data that when you induce labor in a VBAC, your success rate is lower. That data is weaker and it’s a little bit complicated because the data in non-VBACs is that if you induce labor, the success rate is not lower meaning it does not increase your risk of C-section. Whether it’s different for someone who had a VBAC has not been studied appropriately to know for sure. It either has no effect like in everyone else, or we can use the older data that is flawed and say it does increase the risk of needing a C-section, but that’s really more related to the chance of success not so much related to the risk. Now, some people will use in order to make a decision about VBAC, they are weighing the risk versus the chance of success so it may impact the balance of the scales, but that’s really the concern with induction. Now, the only reason that I can think of that someone would insist that someone who is having a VBAC be induced always is only because they are concerned about them laboring at home and they want to have their entire labor watched in a hospital. That’s not the strategy we use, but again, it depends geographically on how far people live from the hospital. Meagan: We talked about that on our last episode. Dr. Fox: Yeah, do they typically wait forever to come to the hospital? Again, is it worth a slight increase in risk of 1% to induce as opposed to having them go into labor and wait four hours before they get to the hospital? That’s a strategic decision that is going to be very individualized obviously, but that would be as far as I can think of off of the top of my head the only reason one would say, “You need to be induced because it’s a VBAC specifically.” There are reasons to be induced all over the place obviously obstetrically, but as someone we are talking about here, if someone needs to be induced then they need to be induced and there is a decision about that. When I counsel people about VBAC, essentially they fall into three groups. Again, assuming it’s a safe option for them. Option one is, “I want a VBAC.” Option two is, “I don’t want a VBAC. I want a C-section,” and option three is, “I want a VBAC, but only if I go into labor on my own. I don’t want to be induced.” That’s based on again, the risk, the chance of success, the experience, all of those things, and those are sort of the three places that people land. That’s fine and obviously, you can switch from one group to another over the course of pregnancy based on how things are evolving, but that’s really the decision that someone is going to make. “I’m trying for a VBAC.” “I want nothing to do with VBAC,” or “I’m into it, but only if I go into labor on my own.” That’s something you want to make sure to see what your doctor thinks about that as well. Meagan: Yeah, okay. I love that so much because yeah. Like we said, there are so many reasons why like preeclampsia and all of these things, but yeah. Just wondering why you would have to be induced in order to VBAC. Cervical Exams Okay, so let’s talk about cervical exams. This is also a hot topic in our community about routine cervical exams or having a cervical exam prior to even labor beginning to determine the likelihood or the success of a VBAC. Can we talk about the evidence of cervical exams during labor in general, right? In physiological birth, everyone is like, “We just don’t want to be touched. We just want birth to happen,” but when we come to hospitals, sometimes it’s a little bit more routine where they want to know the data of what’s happening with the cervix and everything like that. What is the evidence on actually determining someone’s success rate before labor even begins based off of where they are dilated? Dr. Fox: Those are two totally separate reasons why we would check the cervix. In terms of someone in labor, there is a tremendous amount of variation in the frequency of cervical exams in labor based on the provider, based on the culture, based on the patient, and so there isn’t one way to do it, but the reason one would have their cervix checked in labor is just to assess how the labor is progressing. Everybody does it. Doctors do it. Midwives do it. Home birth attendants do it. The question is not do you check the cervix? It’s how frequently do I check the cervix and what do I do about it? That’s going to vary greatly across everything. The evidence is actually that it’s not harmful. Again, I’m not saying it’s not painful or annoying or uncomfortable certainly if you don’t have an epidural. I’m not talking about that. I’m just talking about the risk involved. There are people who say that more cervical exams increase the risk of an infection. The data on that is actually pretty weak amazingly. When we do the exams, we wear gloves. These are sterile conditions, number one. Number two, some of the data that indicates more cervical exams are associated with more infection is really just that more cervical exams are a marker for a longer labor. The longer you are in labor, the more cervical exams you are going to have and a longer labor is definitely a risk factor for infection. So it’s not exactly clear in that sense and also, if anything, if it’s ever going to be a risk, it’s only once your waters are already broken. If your waters are not broken, there is no reason to think that it should increase your risk of an infection or there is at least no good data to support that. I would say in labor, there is a lot of variation in that. Again, it’s hard to say. There isn’t one way of doing it, but the reason to do it is just to assess how labor is progressing to make decisions like do I need to get Pitocin or not? Do I need to do a C-section or not? Is this someone who I want to break their water or not? Is this someone who we can tell, ‘You know what? Just rest and I’m going to go home and come back in the morning’ or not? All of those things, when is she going to deliver? Fine. Before labor, examining someone’s cervix in the office or before we do anything in labor, the data on that is originally meant to give a prediction of when someone’s going to go into labor on their own meaning if you examine someone, the term we use which is kind of crude is “ripe”. If the cervix is ripe versus unripe– for some reason, doctors love to compare things to foods, specifically fruits. I don’t know, whatever. Maybe we grew up in a tree-based society. I’m not sure, but whatever. It’s crude, but that’s the term that is out there. The thought is if the cervix is ripe and the components of that are a little bit open, it’s short, it’s soft, it’s what we call anterior meaning in front of the head versus all the way behind the head and the head is low, the likelihood that person is going to go into labor on her own in the next week or so is higher than if her cervix is unripe. That’s why it was invented. I personally have found that to be mostly useless because okay. If someone’s chance is, let’s say 40% versus 20%, what does that mean? Nothing. You can have a very unripe cervix and go into labor that night and you could be 3 centimeters dilated and not go into labor for 2 weeks. What’s the difference if your chance is 40 versus 20%? What are you going to do about that? Nothing. In our office, in our practice, we don’t routinely check the cervix before 38 weeks and then after 38 weeks, we offer it as an option. A lot of people want to know what’s going on with their cervix. There is a lot of curiosity out there. If someone doesn’t want to know, that’s fine. We’re not going to do it. But one of the reasons it might be helpful practically might– I’m not saying definitely– let’s say someone called me at night. It’s 3:00 in the morning and they are like, “I’m having some cramping. I’m having some contractions. They’re not so bad. They’re this. They’re that. I live 2 hours away,” and I saw her that day in the office and her cervix was long and closed, I may feel differently than if I saw her and her cervix was already 4 centimeters dilated. So, okay. There is some practical information that is to be gleaned, but it’s not always that useful. When you’re inducing someone’s labor, it does give you a sense of the likelihood of success and what agent you’re going to use or not use, so that’s the reason you’ll do it either on admission to labor and delivery for induction or maybe in the office just before to sort of plan the induction because what we do is based on the cervix. For VBAC specifically, it’s not like it needs to be done, but obviously, my thoughts about someone who is trying to VBAC are going to be different if, at 38 weeks, she’s 3 centimeters dilated, the cervix is soft, and her head is low versus her cervix is long and closed and firm and the head is way up near her nose. I’m just going to think about it a little differently and then I’ going to counsel her a little bit differently and then it may be practical. It may, but it’s not usually tremendously helpful clinically is what I would say. Meagan: Okay. So for our listeners, kind of what you were saying is that you can get the information, but it doesn’t mean that you’re not going to be able to have a VBAC or you’re no longer a good candidate if at 38, we’ll say 38 weeks, you have a long, hard, posterior cervix. It doesn’t mean– you might just have different counsel or have a different discussion. Dr. Fox: Right. Yeah. Again, it might be that. It might slightly change your odds one way or another, but it’s not usually something that we use as a decision-making tool about whether you should or shouldn’t VBAC. Again, let’s say– I’ll give you an example where it might be useful. Let’s say we have a situation where someone has a prior C-section. They’re thinking about VBAC or they’re interested in it, but they have some concerns, right? Like most people, they’re interested but they have some concerns. They’re 38 weeks and let’s say the baby is measuring a little bit small and her blood pressure is a little bit high. I say, “We need to deliver you. We need to induce. We need to deliver you.” At that point, there isn’t an option of being in spontaneous labor. It’s either I induce her and if I don’t induce her, we have to do a C-section. Those are the two options on the table because waiting is not a safe option anymore. Fine. It’s possible that my counseling will be different if when I do her cervical exam, it’s long and firm and the head is high versus the head is low and the cervix is dilated and soft because I’ll tell her, “Listen, inducing your labor in one situation is likely going to take a long time. Your success rate is a little bit lower” versus “It’s going to be a shorter time, again, likely not definitively and your success rate is going to be higher.” It’s possible that she might say, “All right. I don’t want an induction if my cervix looks like this” or “I do want an induction if my cervix looks like this.” It’s part of decision-making potentially, but that’s usually if I’m about to induce her labor versus do a C-section. If she’s going home either way, if it’s just the Tuesday and it’s 38 weeks and there’s nothing wrong and I’m just sending her home and she will either come back in labor or come back in a week, then it’s not going to matter much if her cervix is open or closed on that day. It’s really if I have to make a decision about delivery that I’ll be more practical. Meagan: That’s something that I love about you is just that– Dr. Fox: Oh, all right. Meagan: I do. It’s like, “Let’s talk about this.” You offer counsel. I don’t know. You just offer more. It’s not just like, “You have.” It’s the way you talk anyway. I mean, I’ve never been a patient in your clinic so I’m talking very broadly of what I feel like I love about you, but it doesn’t seem like you’re black or white. It’s, “Hey, this is what we have. This is what we’re showing. This is where baby is or where you are and it’s no longer safe to be pregnant for you or for baby. Here are the options and based on that person as an individual, it might be different versus the lady that you had four or five years ago is now the standard for every person that walks into your clinic. Dr. Fox: Right. Right. I mean, listen. Medicine– there’s a lot of balance here. On the one hand, there is this push to be very standardized and that everybody should be the same. There are advantages to standardization. Less mistakes, it’s more clear, everybody has rules versus individualization which has its advantages as well because you can personalize medicine. You can tailor things to the individual. They are not a conflict, but there are two sides to the coin. On the one hand, you want things to be standardized and on the other hand, you want things to be individualized. One of the arts of medicine is knowing which way to lean and that’s where people differ. Experience gets involved. There is also, I would say, this idea in medicine where there are certain times where the doctor is supposed to say to the patient, “This is what you should do,” to be very directive, right? There are other times where the doctor is supposed to say, “Here is option A. Here is option B. Here is option C. Here are the pros and cons of all of those. What do you want to do?” Right? The problem is you don’t want a doctor who is always telling you what to do because that’s authoritative and it’s very– Meagan: It doesn’t feel good. Dr. Fox: Right and it’s also usually not appropriate, but you also don’t want a doctor who can’t make up his or her goddamn mind. You see the problems. When we’re training young doctors, we always talk about patient autonomy, patient autonomy, which is correct. Patients should have autonomy to make decisions for themselves, but you also have a duty as a doctor and as a professional that if you believe one option is better than the other, tell them and tell them why. If my plumber said to me, “Well, I could use the copper pipe or I could use the steel pipe. Which one do you want?” I’d be like, “I don’t know which one I want. Which one is better?” Meagan: Which one is best? Dr. Fox: Right. If he said to me, “Listen, you should absolutely have the copper pipe because they are better,” I would say, “Fine, do that.” But if he said to me, “Well, there are pluses and minuses. The copper is a little bit better but costs a lot more,” then I have to make a decision and that’s appropriate. The same is true in medicine. If I have a patient with pneumonia and I said to her, “Well, you could have antibiotics. You could not have antibiotics,” then I’m an idiot. I should be saying to her, “You have pneumonia. You need antibiotics,” because this is why I trained, why I went to medical school, to tell you, “You need antibiotics. This is the one you should have.” Fine. That’s appropriate. But in a VBAC, I don’t think it’s necessarily appropriate to say that. I say, “Okay. You have a 1% risk of uterine rupture. On the one hand, you could try a VBAC. Here are the advantages. Here are the disadvantages. Here are the risks. On the other hand, you could have a C-section. Here are the advantages. Here are the disadvantages. Here are the risks. I think they are both reasonable. Do you have a preference and which risk scares you more?” That is appropriate. I would say for people who are trying out figure out, do you have a good doctor? Do you have a good midwife? It’s not just, “Are they kind?” You want them to be kind. It’s not just, “Are they smart?” You want them to be smart. It’s not just, “Does their office run on time?” You want their office to run on time. It’s also, do you get a sense that they have a good balance between when it’s appropriate to tell you what they think is correct and when they give you options and have you participate in your healthcare decision-making? If they are always telling you what to do, it’s probably too much on one end. If they never tell you what to do, it’s probably too much on the other end. You need to strike a good balance. Getting back to what you said about the reason you love me, I definitely have situations where I tell people, “VBAC is not a good option for you. You shouldn’t do it. It’s a bad idea. I’m telling you it’s a bad idea.” Again, we’re not the police. I can’t force someone to do something. I’m not going to tie someone down and do a C-section, but I will tell them, “This is a bad idea.” I would say that’s the exception. Most of the time, it’s, “All right. Here are the options. Here’s what we are doing.” It’s not that we always tell people, “Here are your options,” and it’s sort of touchy-feely, we do that when it’s appropriate. It’s frequently appropriate, but sometimes, we have to tell people, “It’s a bad idea. This is why it’s a bad idea. You should not choose this option because of A, B, and C.” I’m very comfortable telling someone that, but I usually just don’t have to. Uterine Window, Dehiscence, and Niche Meagan: Yeah. I love that. Awesome. Well, we’re going to go into the very last topic. I know we are kind of running out of time, but this is one where we’re going to get stuff like that or we’re going to be like, “You shouldn’t do this” or the other opposite where it’s like, “We could do this. We could see how this goes.” It’s uterine rupture. We talked about uterine rupture, but more specifically to uterine window, lots of people are “diagnosed” or told that they had a uterine window maybe in their first Cesarean or multiple Cesareans later and that they shouldn’t VBAC or that they can’t VBAC or my specific provider told me that I would for sure rupture. He said those words– for sure, guaranteed. Then we have dehiscence which is chalked up into a full uterine rupture, but we know it’s not. Anyway, there is some stickiness in there. So can we talk about that? If someone was told or if it was put in an op report that they had a uterine window or a slight dehiscence, as an OB in your practice, what would you suggest or how would you counsel moving forward? Dr. Fox: Right. Right. I will give you the short answer and the long answer. The short answer is if I have someone who I think has a uterine window, I would tell them not to VBAC because I think the risk of rupture is too high. I would never tell someone, “You are for sure going to rupture,” because that is not true with anybody. Meagan: You can’t predict that. Dr. Fox: Even in the worst-case scenario. Someone who has had a prior classical C-section, they have a 10% risk for rupture. Someone who has a prior uterine rupture is not even 100%. I don’t think it’s 100%, but it’s usually too high for comfort. The problem is not so much me making the recommendation, “Don’t VBAC if you have a uterine window,” it’s how do you make that diagnosis? I think that’s part of the trickiness. Some of the confusion is that there is different terminology and some of the reason is we don’t have definitive definitions. So for example, uterine rupture is very clear. That’s when you are in labor and the entire uterus opens up internally and the baby and the placenta come out. It’s exactly what you would think a rupture is. That is pretty clear. The terms dehiscence and window are used interchangeably and what they basically mean is the muscle of the uterus is separated, but the very thinnest outside layer of the uterus, what we call the serosa, which is like a saran-wrap layer on top of the uterus did not open, so the baby did not protrude through this defect in the uterus. Meagan: It didn’t go through all of the layers. Dr. Fox: But it basically went through all of the muscular layers which is basically like one step short of a rupture. Now, we don’t know how many of those people would go on to rupture if you continued laboring then in that labor or in the next pregnancy. No one knows because no one’s really tried it. No one has really pushed that envelope because they are too afraid to. It’s hard. It’s very unusual to be diagnosed with a window on your first C-section because usually, it’s not going to happen unless you’ve already had an incision in a C-section. Usually, it’s someone who has had a C-section, then on their second C-section, when someone goes in to make the incision whether they tried to VBAC or didn’t try to VBAC, they see this and then they are talking about the next pregnancy. Most people are not going to recommend VBAC because the risk of rupture is too high in that circumstance. I fall into that camp as well. I am humble enough to say it doesn’t mean someone will rupture, but I think that risk is too high and I’m not really willing to test it out on someone because I think it’s probably not safe. Now, sometimes, someone may have been told they had a window and they really don’t. It’s hard to know. There’s another situation that is different which is when someone is not pregnant and they have an ultrasound of their uterus and they see some form of a defect in their prior C-section. So someone had one C-section, had the baby, they’re not pregnant. They come to my office and they do an ultrasound. I looked at the area of the scar and it looked like it wasn’t healed perfectly, so instead– Meagan: Properly. Dr. Fox: Well, it’s not proper or improper, it just frequently doesn’t heal to full thickness. Let’s say the uterus is a centimeter thick and I see that only half of the centimeter is closed and the other half of the centimeter is open, right? We call that sometimes a uterine niche. We sometimes call that a uterine defect. Some people call that a window, though it’s not technically a window. The question is A) What does that mean? and B) What do you do about it? The answer is nobody knows. That’s the problem. Meagan: Yeah. That’s the hard thing. Dr. Fox: Nobody knows exactly what you would do to allow VBAC, not allow VBAC, this or that, generally, what a lot of people will do is if they have only had one C-section, they’ll usually let them VBAC, but there is some data that if it’s less than 3 millimeters remaining of closed, the risk of rupture is somewhat higher. Again, that data itself is pretty weak. No one knows for sure. Should you use that? Should you not use that criteria? It’s very, very difficult and you’re going to see a lot of variation out there. In our practice, we don’t use that test so much to decide whether someone should VBAC or not after their first C-section because the data doesn’t support that. What we use it for is someone who has had multiple C-sections and they are already not planning to VBAC, but we are trying to figure out if is it safe to get pregnant at all. Do we need to fix this during pregnancy or if they get pregnant, do we need to deliver them at a different time? That’s a much more complicated discussion, but that’s how we use it practically. If someone has had one C-section, I don’t generally recommend doing that test to check the thickness and then making decisions based on that because it’s not clear that your decision-making is going to be any better with that information than without that information. So I don’t use it personally, but definitely, people will find it out there. They measure the thickness and they say it’s too thin. That data is all over the place, unfortunately. Maybe one day, we will work it out, but it hasn’t been worked out yet. Meagan: Yeah. So you can technically fix a niche? Dr. Fox: You can technically fix it, but that doesn’t necessarily mean they are safe to deliver vaginally the next time. Meagan: Because that’s a uterine procedure. Dr. Fox: Yeah. These are all new questions that are being sorted out. It may take a very long time to sort it out, but I would say for the more typical person who has had one C-section that was basically fine, it went well, and she is trying to decide to VBAC or not, the current data does not support measuring the thickness of the scar routinely either prior to pregnancy or in pregnancy and then making decisions about VBAC or not. There are people who do it and I’m not saying it’s wrong, but the data to support that is pretty weak so it’s not something that is universally recommended to do. It’s a different situation if someone had a C-section and then someone saw with their own eyes there is something wrong with this uterus or if someone has had multiple C-sections and then they see it, those are different clinical situations where it might come in handy. Meagan: Okay. Great answers. Awesome. Thank you seriously so much. It’s just such a pleasure to have you. I do. I just enjoy talking with you. I think it’s awesome and I think this community is just going to keep loving these episodes. Dr. Fox: It’s my pleasure. It’s your wonderful Salt Lake City disposition. Meagan: Yes. Next time you are in Salt Lake, come say hi. Dr. Fox: Love it. We’ll do it. I love Salt Lake City. Good stuff. Meagan: Yes. I love it here except for the cold. Dr. Fox: Except for the cold. I hear ya. I grew up in Chicago which is where my pleasant disposition comes from, but yes. It’s also cold in the winter. Meagan: That’s a whole different cold. Dr. Fox: We don’t get the skiing. We get the cold, but not the skiing so at least you get the mountains so you did it right. Meagan: Yes, we did. Awesome. Well, thank you so, so much. Dr. Fox: My pleasure. Thanks for having me. Always a pleasure. Closing Would you like to be a guest on the podcast? Tell us about your experience at thevbaclink.com/share. 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