Episode 259 LIVE: Meg and Julie Answer Your Questions in The VBAC Link Community

Meagan and Julie went Live in The VBAC Link Community Facebook Group answering your questions. They recorded the conversation to share with you on the podcast today. Topics include: Risks of VBAC, Repeat Cesarean, and CBAC Cook versus Foley Catheters Cervical lips Membrane sweeps VBA2C and VBAMC CPD Thank you for sending in your questions! An educated birth is an empowered one. You’ve got this, Women of Strength! Additional Links The VBAC Link Blog: VBAC vs Repeat Cesarean Cook versus Foley Catheter Study EBB 151: Updated Evidence on the Pros and Cons of Membrane Sweeping ACOG Article: VBAC The VBAC Link Blog: VBA2C Needed Website Full Transcript under Episode Details Meagan: Hey, hey everybody! Guess what? It’s November which is one of my favorite months because it is my birthday month. I have forever and ever loved birthday months so this is going to be a great month because it is my birthday month. Today we are kicking it off with questions and answers with myself and Julie. Hey, Julie. Julie: Hey, I’m so excited to be here. Meagan: Welcome back. We’re going to get right into this review and get some of these great questions answered. We know you guys have so many questions. This review is from bunnyfolife777. It says, “So much hope.” It says, “I’m 16 weeks pregnant and shooting for my VBAC. I’ve been in The VBAC Link group on Facebook for over a year, but I’ve only just started listening to the podcast. I don’t know why I waited. I’m bawling now just two episodes in. The statistics and advice you share are golden. I’m going to listen to it again and take notes this time. I’m scared about having to advocate for myself living abroad where most doctors push for C-sections so I’m thankful I can arm myself with the knowledge through The VBAC Link. Thank you.” Oh, that makes me so happy. We’re going to be talking about statistics on this podcast episode today. Julie: You know I love a good statistic. Meagan: I know. You are the statistic junkie. Julie: I’m a nerd. Meagan: Okay, okay Julie. I love having you back on the show. It just feels so natural. Julie: It’s fun. Meagan: It is fun. It’s so fun so thank you for being willing to join me again on these random episodes. As we were saying, we are really just wanting to answer some of these questions. So yeah. What is one of the questions right here that you love that you are like, “Let’s start this off with”? Julie: Okay, so gosh. I mean, there are so many good ones. I feel like we’ve talked about a lot of these things many, many times over the years, but I feel like every time we talk about them, we get a new perspective in. There is new information and new evidence. Not everyone goes and listens to every single one of the episodes although lots of people do, but I think it’s fun to revisit some of these things. I don’t know. There are so many that stuck out to me. VBAC vs Repeat Cesarean vs CBAC One thing that we haven’t really talked about directly in this way is, is it really safer to give birth vaginally? I mean, yes. It is. We can go over that but I really like the second part of that question which is, “What if that labor doesn’t work and goes to a C-section? Is that more dangerous?” I want to talk about that because we talk about VBAC is safer than a repeat Cesarean statistically. We are talking about all of the numbers when we talk about all of the different things that could go wrong between vaginal birth and Cesarean birth then actually, for the second, whether you choose VBAC or repeat Cesarean, the statistics are actually not that much different as far as safety goes. VBAC is slightly safer overall, but there really isn’t a big enough difference to say, “You should absolutely do this.” Right? That’s where your intuition comes in. But if you want more than two kids, the more C-sections you have, the higher the chance you have of having severe complications. By the time you get to your fourth or fifth C-section, you have a 1 in 3 chance of having a major medical intervention during your Cesarean. I feel like so many times we as people educating about birth or talking about birth talk about just those two things. VBAC and repeat Cesarean, but there’s actually a third thing that’s worth talking about. That is a TOLAC– I know it’s kind of a trigger word for some, but it’s just a medical term we’re going to use here– that ends in a repeat Cesarean. Meagan: Yes, because we know that happens. Julie: We know it happens. It does happen. Meagan: It happened with me. Julie: Sometimes it’s medically necessary. Sometimes it’s not, and you just don’t know. We’ve got to put it in the order of three things. First, the safest is VBAC or a vaginal birth. Second is a scheduled C-section and the third is a VBAC attempt or a TOLAC that ends in a repeat Cesarean. We also call that a CBAC or a Cesarean birth after a Cesarean. Now, if you labor and then have to have a C-section for whatever reason, there are more risks with that including postpartum hemorrhage or bleeding, and needing a blood transfusion. Obviously, the risks to baby are pretty similar but it’s just harder to operate on a uterus that is contracting. You’re more likely to bleed because that uterus is contracting. Sometimes, if it’s an emergency situation, the providers have to do things like a special scar or a special type of incision or they have to put you under general anesthesia. That has more risks in and of itself. I feel like that’s a really valid question that she asked. What if? What if? There are always what if’s, but what is safer? Meagan: Right, right. For patients or parents that are going for a TOLAC, a trial of labor after a Cesarean, and then may require or end up going to have that Cesarean, there is also a slightly increased risk of postpartum infection. Julie: Yes. Meagan: And also some possible complications. You just touched on it a little bit, but when a uterus is already contracting– so I’m going to backpedal a little bit. When we go in for an elective Cesarean, typically we are not already in labor. We’re not already having contractions so performing a Cesarean on a contracting uterus can possibly cause some issues there as well. That is sometimes why a lot of providers don’t want an elective Cesarean to even go to 40 weeks or past. They want to have an elective earlier on. That may also help give you some understanding of why providers are saying that. But yeah, it just slightly increases in other ways. Yeah. Anyway, keep going. Julie: No, I love that. I just don’t think we’ve ever– I mean, we do in our course and things like that. We talk about it directly, but that’s something to consider. I think that’s also really important. I feel like it adds the extra layer of where you want to make sure you have a really good provider because if you have a provider who is not really supportive or who is giving you tons of red flags or who is saying that you have to induce because of a big baby– I’m surprised that big baby isn’t in some of these questions, to be honest. We can talk about that a little bit later, but it’s really important. That’s something to consider. It’s all about weighing the risks and what risks are you more comfortable with taking on? Are you more comfortable taking on the risk of going into a vaginal birth attempt– you want to try for a VBAC– and having the possibility of it ending in a repeat Cesarean? The possibility of it ending in a repeat Cesarean varies depending on where you are birthing. If it is a home birth, you have a 10% chance of it ending in a Cesarean. Statistically, nationwide, you have a 30-40% chance of it ending in a repeat Cesarean. But if you have a really good provider, there’s probably only a 10-20% chance of it ending in a repeat Cesarean. Sometimes, if you have a really bad provider, you might be looking at a 50 or 60 or 70% chance of having a repeat Cesarean. So what is an acceptable risk for one person is not for another. If that just sounds too scary for you or are risks that you are not willing to take, then maybe scheduling a repeat Cesarean is the right choice for you and that’s okay. But if you’re a diehard and want to fight the system to prove everybody wrong no matter what the costs are, then maybe you just want to have a VBAC and that’s okay. Not that that’s a bad thing, but it’s also probably not a very healthy way of thinking. I was like that. I’m like, “I’m getting my VBAC and I’m going to do everything I can to safely set up the best chances for me and my baby.” That’s why I ultimately chose an out-of-hospital birth with a really amazing provider who had tons of experience in all types of birth situations. But I don’t know. I think that’s super important and something to consider. We’re not trying to scare anyone here, but we are never going to lie to you. We’re never going to dance around the issues. We’re never going to sugarcoat things. Meagan: Yeah. Yeah. I think that was a good question. Okay, well if it really is safer to have a vaginal birth, what’s the safety here? Yeah. I really loved that question a lot. Julie: I wish I had some statistics off of the top of my head, to be honest. I’m pretty sure we wrote a blog about it. VBAC versus a repeat Cesarean. Meagan: Okay. I’m going to bounce to this next question– Julie: Wait, wait, wait, wait. Wait, wait, wait, wait. I have something. Meagan: Did you find a stat? Julie: No. Well, yes actually. I found the blog. If you guys want to know more about the blogs, I’m not going to get into it because we want to move on to all of these other questions. Our wonderful transcriber, Paige, is going to put a link to the blog in the show notes so make sure you check it out and it goes in super, really big detail about all of those statistics, and pros and cons for all of those things. I say our transcriber, but you know what I mean. I feel like it’s still us. It’s still we, right? I don’t know. I’m never going to not feel like that. Maybe one day. No, probably not. I miss it so much. Meagan: Probably not. No, probably not. Julie: Sorry, let’s go on. Cook vs Foley Catheter Meagan: No, you’re fine. So I want to talk about catheters. Not catheters to drain urine, but the catheters to help with an induction. Someone asked, “What’s the difference?” We’ll even hear in Utah a Cook versus a Foley. A Foley catheter can also be the type that actually goes into your bladder through your urethra and drains urine but there’s also a Foley catheter that can help induce labor. There’s Cook and Foley. One of the questions was, “What is the difference between the two?” Really, the only difference is that a Cook has a double-balloon and the Foley is not a double. There’s just one. If you can– I don’t even know how to give this image. How would you give this image of what a Cook catheter is like? The catheter with two balloons on it? I don’t know, like ice cream? Oh, you’re muted. Julie: I’m sitting over here dancing. Meagan: She’s dancing in this image and I’m like, “She’s saying something.” I’m thinking of a double scoop of ice cream. Julie: I’m thinking it’s kind of like a barbell. Yeah. Or like a barbell, right? If you think of a cartoon barbell with the balls on the end but much shorter. Meagan: Yeah. Both of them are inflated with saline. It’s inserted through the cervix, the balloons are inflated, and then they put pressure mechanically onto the cervix which causes pressure and dilation and effacement and things like that. Yeah. It’s been a really long time since these have been being used. We will see, once in a while, providers say that a catheter, Cook or a Foley, is a contraindication for someone who wants to have a VBAC. That is kind of hard. It’s really interesting. It’s just a balloon that goes in. There’s no medicine that is put in at all. It’s just saline and like I said, it’s a mechanical dilation. So if you are curious about methods of induction that your provider is comfortable with, I would encourage you before you get to the 37th, 38th, 39th, 40th, 41st, and 42nd week of pregnancy to discuss with your provider more about a Cook catheter and what they are comfortable with. It is really hard because sometimes, those catheters can be one of the best ways to help induce a cervix or a TOLAC for someone who is wanting to go for a VBAC because they can’t always just do other ripening aids and this can definitely help with the cervical ripening to help get to that further progress of having a baby. Julie: I love it. I think it’s silly sometimes how providers will not induce with a Foley for VBAC. I just don’t get it because there’s no solid evidence that supports not doing that. I just think– me and you, we’ve seen so many VBACs induced with that. It’s been fine and healthy. There is just not anything out there. I know every provider has their things that they will and won’t do. If you have a provider that won’t do that, then you might want to talk to another provider. Meagan: Now that we kind of know that there are two different types, let’s talk a little bit about the differences. There is a difference in what they do. Why would we even use them? Which one is better? I think that is a big question. Which one is better to use? I’m just going to tell you after some evidence that a Cook catheter for cervical ripening has greater results. What have you seen, Julie? What have you seen in the past? Julie: Honestly, I’m trying to think if I’ve ever seen anybody use the Cook catheter. I think I’ve only seen Foleys to be honest. I’m trying to think back. Maybe there has been one but I just can’t think of any. Meagan: I’ve only seen one. Yep, I’ve only seen one and it was up at the University Hospital here in Utah. They used that. She was barely half of a centimeter dilated and 30% effaced, very little. They used that for softening really, but the Cook catheter, I think, through studies has shown that it is more effective or has greater cervical ripening compared to the Foley. However, in fact, I’m going to hurry and pull this up. I’m just going to read this. It shows, “The duration from the balloon insertion to it exiting and delivery was significantly shorter using a Foley catheter.” Julie: Interesting. Meagan: Yeah. So Cook catheter has a greater result of actually ripening the cervix, but the Foley has a greater success rate overall from start to finish. I mean, I have seen so many people with Foleys. It sounds weird because sometimes, everyone is like, “You’re suggesting Pitocin?” I’m not suggesting it. I’m just saying that I have seen a Foley placed with Pitocin at 4mL, just a little bit, and it is insane sometimes how great the result is. Sometimes when the Foley comes out– maybe you’ve seen this– it’s a mechanical dilation so it kind of relaxes just a little. It’s not like we go backward. It just kind of relaxes like it’s overstretched and it relaxes. Then we have to catch up, right? But I have seen where with there is a tiny, tiny lift of Pitocin being involved– Julie: You don’t have that relaxing as much, yeah. Meagan: Yeah. I don’t see where it’s like, “Oh, you’re a 4,” and then they check and they’re like, “Well, you’re kind of a 3.” Listeners, I just want you to know that that’s a thing too. If a Foley comes out, remember that it’s a mechanical dilation in your cervix. It may be stretchy-stretchy, but you might not be a full 4 or whatever. So talking about top to bottom, Julie you just mentioned that a little bit ago. With me, do you want to talk about that? Julie: Yeah. Well, I mean, the Cook catheter has two balloons essentially that they fill up with saline. The Cook has two balloons. The Foley has one. The idea with the Cook catheter is that it puts pressure on both ends of the cervix. My gosh, I don’t know if we even said how they put it in. You insert a catheter in through the cervix and then the Cook has two balloons on either end that they inflate so it pushes to soften and open the cervix. Then, the Foley only has one balloon that they put. They insert it into the top through the cervix inside of the uterus and inflate it there with the balloon. They tape it to your leg and it pulls. Meagan: They tug it. Julie: You’ve got to tug it and it pulls down. It provides a lot of pressure so that the cervix can soften and open. All of my clients have just been pretty uncomfortable with it in. They feel some relief when it comes out because then it just falls out. It pulls out at some point. Honestly, I don’t know. This is maybe making me sound like an idiot but do they tape the Cook catheter to the leg or not? I don’t know. Meagan: I did not see it taped to the leg. Julie: I’m wondering if maybe that’s why the Foley is more successful because you’re having just one downward motion instead of two pressures going toward each other. I don’t know. I don’t know. Meagan: Yeah, maybe. It’s kind of interesting because with the Foley, every 20-30 minutes, they’re wanting you to pull on it. Julie: I don’t know if they do that with the Cook. Meagan: I don’t either because we haven’t seen enough. Julie: Yeah. Meagan: So if you’re listening today, go comment in today’s episode. If you had a Cook catheter, let us know what happened. Tell us about it. Tell us what your experience was. I think they said in the study that really, there was no significant difference in the outcomes specifically between the two having more Pitocin or the mode of delivery or anything like that. It’s just that the Cook catheter had a greater result of cervical ripening and the Foley catheter maybe shortened the duration but there wasn’t any crazy, significant difference of mode of delivery or your for sure had to use Pitocin with a Cook or anything like that. So that’s interesting. Julie: Yeah, interesting. The point is that it is safe for VBAC. This is another thing. I’m going on a teeny little soapbox that I’m going to get off really fast, but why does it take the burn of proof to show that something is or is not evidence-based or is a reasonable patient? Rely on the patient. If your provider says, “No, it’s dangerous. We can’t do Foley for a VBAC,” make them show you why. Ask them where the source is coming from. I don’t understand why we have to bring the stuff to show that it is safe. Why? It’s stupid. Meagan: I don’t know. I don’t know. Why? Julie: Why? Meagan: I mean, even the American Journal of Obstetrics and Gynecology says– Julie: Yeah, and that’s ACOG’s journey. Meagan: They say, “Foley catheter did not increase the risk of uterine rupture in TOLAC.” It says that. “Similar, uterine scar dehiscence was not associated with a Foley catheter.” I don’t ever want to make it sound like we are bashing a provider or it’s a show bashing providers, but we’re having providers tell people that they have zero option to be induced especially if there’s a medical reason. Sometimes there’s a medical reason. We’ve got preeclampsia or something is going on, but this mom wants to have a trial of labor and a VBAC, but then her cervix isn’t super great for induction. We’re being robbed of these options. They even say, “The data shows the Foley catheter is a safe tool for mechanical dilation in women undergoing a trial of labor after a Cesarean.” If your provider is saying that you’re not a candidate or it’s a contraindication for VBAC, then maybe I invite you to have a discussion with them. Right? An open discussion of, “Okay, what I have learned is that it’s not necessarily a contraindication. Is there new evidence that we’re not aware of?” Maybe there is. Maybe there’s new evidence. Julie: There’s not. Meagan: I know, but right? Maybe they have secret evidence. Julie: Give them the benefit of the doubt, right? Meagan: Is there new evidence that we’re not aware of and is there any way that we can have a conversation about it? Can we talk about this because if it is, then okay? But if not– Julie: Well, and honestly, gosh. I just think that it’s just something that they’ve heard or something that their practice does or something that the hospital says. You know, I mean, we all do it in our lives. Our mom says, “Oh, this and this. Oh, you should never cook with refined sugar. You should always use granulated sugar.” I don’t know. I’m not a baker so it’s probably not a good example. But you know, and then you go throughout your life like, “Oh, my mom says you should never cook with this type of sugar,” but that type of sugar is totally fine. Someone you trust had told you that so it’s just ingrained in your belief. I have those things. Meagan: It’s like the trans-fat argument. Julie: Yes. It’s like, my gosh. How many beliefs do we hold that maybe we know they’re just silly, but it’s just something we’ve known for so long that doing it otherwise would feel so foreign to us. There are so many things in the system like that where the providers aren’t meaning to do harm, it’s just the way that they’ve been taught. It doesn’t give them an excuse. Oh my gosh, there was a quote the other day that popped up in my feed. I was arguing online with some photographer about birth photography and I got a little heated because I was super tired because I’d been to three births in four days and I was awake for 16 hours through the night. Anyway, but a little while later, some unrelated person posted this quote in their stories and I like it because it goes along with what I was just talking about. It says, “Don’t assume malice. Assume ignorance. Life is easier. The world is kinder and you can educate. Actual malice is pretty rare, I find.” Then somebody else commented and said, “I always remember Hanlon’s Razor. Never assume malice when incompetence will suffice as an explanation. With that said, never forget Fred Clark’s lot either. Sufficiently advanced incompetence is indistinguishable from malice. There is a certain point at which ignorance becomes malice at which there is simply no way to become that ignorant except deliberately and maliciously.” I’m going to forward this to you. Meagan: I was just going to say will you forward that because that is amazing. Never just assume malice. Julie: Assume ignorance. They just don’t know. It’s okay because there are lots of things we don’t know too but when it gets to the point where you’re just completely refusing to see that there’s any other way, then that’s where it gets to be malice and aggressive. But I love a provider or a nurse when I’m in the delivery room doing peanut ball or Spinning Babies and the nurse is like, “Oh, tell me more about that.” That is a position of maybe ignorance and they want to learn and do better. They just don’t know those things. But when you have a nurse come in who says, “Oh, we don’t use the peanut ball before 7 centimeters because it doesn’t do anything,” that is a malicious form of ignorance. Meagan: Yeah. Yeah. Okay, I love that so, so much. Thank you for sharing that. Julie: You’re welcome. I’m glad I screenshotted it. Cervical Lips Meagan: Me too. Okay, one of the questions is about cervical lips. Julie: Mmm. Meagan: I know, it’s a good question. It’s hard because it happens and it’s frustrating if it doesn’t go away. Right? It’s like, if I make it to 9.5 centimeters and I have this lip that will not go away, one– why doesn’t it go away? Why does it happen? Two– how can I get it away? What are some ways? It sucks if that is the only reason why a Cesarean happens. Julie: Well, first do you want to say what a cervical lip is just in case people don’t know? Meagan: Yep, yep. Julie: Oh, me? Well, a cervical lip is just where your cervix is almost fully dilated, but there is just a little sliver of it, or part of it– so if you imagine a crescent moon shape, where part of your cervix is all the way gone behind baby’s head and there is just a little sliver of it on some part of the baby’s head coming over. Just a teeny bit. Just like a lip. Just like a little lip. Meagan: Yes. So when we have cervical lips, sometimes pressure on that part of the cervix helps it melt away and thin. We work through positions like what Julie was saying by using a peanut ball or we make you more central through a squat or sitting on the toilet. Sometimes it’s an anterior lip. Sometimes it’s way on the side. Sometimes it’s a little puffier in the back. Sometimes we will use positions to help get rid of that lip. But it’s really hard because sometimes even through positions, that lip sometimes doesn’t go away. Sometimes it can be massaged or it can be advanced. I’m happy to continue but I want to give you an opportunity to talk too. Julie: No, you’re good. Meagan: But advancing, right? Julie: The provider will hold it during a contraction and push it back. That’s really painful if you don’t have an epidural. If you have an epidural, that’s a good way to do it. The medical system is going to hate me for saying this, but I’ve also seen people push through a contraction when they have a cervical lip and it slips right over baby’s head. You don’t want to push too much with a cervical lip also because it can cause the cervix to swell if it’s a positional issue. There are a whole bunch of things you can do, but Meagan, I think you were right on track when you were talking about movement, positions, squatting, and all of those things to help put that pressure on and help straighten baby’s head out. I mean, it’s not always because of the baby’s head, but it could be. Squatting and putting that pressure down is just going to really help. Meagan: Yeah, so when a provider is holding it and helping it, I call it an advance. Advancing it over the baby’s head. Sometimes it just needs to slip over the baby’s head. It’s so stretchy. Julie: It will stay there. Meagan: Sometimes, it’s so stretchy that it will just go away. I’m always giving sound effects on this podcast. Sometimes it’s like we’re trying, trying, and trying, but then we have possible issues because then we’re swelling. We’re aggravating it. It’s tissue. It’s the cervix so it can get bogged and it can swell. So if that is happening and your provider is like, “Yes. I think through this push, I can push it. I can help advance it over this baby’s head and it’s going to go away and we’re going to have a baby,” great. It’s worth trying. But if it’s over and over and over again and we’re advancing it and it’s just not going, we are risking it to swell. So yeah. Movement. This sounds weird too. Here I am suggesting Pitocin again. Sometimes a little stronger of a contraction, just a little bit stronger of a contraction and a little bit of a lift can just put the amount of pressure on the cervix or cause the cervix to continue dilating. Then the cervix is done and you can turn the Pitocin off. That’s always an option to say, “Okay. We’ve done this, this, and this. Let’s move on.” Some providers, usually out-of-hospital providers– Julie, I don’t know if you’ve seen this– will place Arnica. Julie: Yeah. I have seen that. Meagan: If it’s starting to feel puffy or maybe have done advancing a couple of times. Julie: I love Arnica, man. It is my favorite. Arnica gel. Meagan: I love it too. Julie: Love it. Meagan: Yes. I love it. Sometimes providers will do some Arnica up there to help reduce inflammation and swelling and things like that. Cervical lips can happen for no reason really other than just it’s happening. People say, “Oh, sometimes it’s baby’s position.” Again, maybe we want more pressure. Sometimes it’s the lack of intensity. If I remember right, if you’ve ever had a LEEP procedure– Julie: Yeah, like some scarring on the cervix can cause that. Meagan: Yes. Yeah. So a LEEP procedure or maybe really bad cervical tearing or trauma to the cervix can create less elasticity. I don’t know if that’s the right word. But it can cause a cervical lip. I’ve also seen– this is more for the edema again on the Arnica– Benadryl. Providers give someone Benadryl because it’s an antihistamine for swelling. Yeah. There are so many things that you can talk to your provider about. If you have a cervical lip, oh. Go ahead. Julie: I was going to say that sometimes, just doing nothing. Meagan: Just waiting, yes. Julie: Sometimes in labor, even us as doulas, we see, “Oh, well it looks like contractions are coupling. Let’s do some abdominal lifts.” But sometimes, that’s an intervention. It just is. Spinning Babies® is an intervention. It’s a more natural intervention, but sometimes, maybe a lot of the time, you just need to leave it alone. I don’t know. I saw this post on social media the other day that was talking about, “I hate Spinning Babies® because it’s an intervention and all of these doulas and midwives are like, ‘Oh, let’s do Spinning Babies®. Let’s do Spinning Babies®.’ It’s an intervention just like Pitocin or whatever.” I don’t think it’s just like Pitocin, but it kind of takes away from the trust of the natural labor process when you’re like, “Oh, you’ve got to fix this.” It’s kind of, in a way, saying that we don’t trust the natural labor process as much. But there are some times when it is good and beneficial to do those things. There are some times when you can’t just trust the natural labor process alone, but a lot of times, you can. A lot of times, we just need to let these things be and they will resolve themselves. This is a big thing where knowing all of your options then trusting your intuition and having someone to guide you like a doula will help you know which is the right thing for you whether you want to try squatting, try different positions, try Arnica gel, or just leave it be for a little while. There’s no right answer. Meagan: There is no right answer and there are these things that we can do. Sometimes they work and sometimes they don’t, but we want you to know that there are things you can do. Sometimes those things just do nothing. Absolutely. Membrane Sweeps So let’s talk about sweeping membranes. Talking about interventions, sweeping the membranes. I’ve heard it called a sweep and a scrape. Julie: Ew. Meagan: Yeah. People say “scraping the membrane”. If you don’t know what sweeping the membranes is, it’s when a provider will insert typically their fingers inside the cervix and separate the membrane of the amniotic sac from the cervix and do a little sweep around. That releases hormones like prostaglandins and things like that. Sometimes, it’s used to induce. It’s a more gentle– I don’t know if that’s how you say it– way of inducing. One of the questions, Julie, was, “Does it work? What are the pros and cons? Should I do this?” We do have a lot of providers that will say, “Oh, we can just strip your membranes.” What do you think? What do you say? Julie: Evidence Based Birth® used to have a great article on this. The one thing that I– okay, I love Evidence Based Birth®. Meagan: I think she still does. Julie: This is the thing though, they took away all of their articles and replaced them with just their podcast transcripts. I wish that they would have their regular blog articles still instead of just having the podcast and the transcripts which makes me a little bit sad because then you have to read through the whole thing in order to find what you are looking for. But I do love me some Evidence Based Birth®. Listen, Evidence Based Birth® does say that there is research that shows that starting regular membrane sweeps at 37 weeks of pregnancy and doing them, I think it’s twice a week until delivery can shorten your pregnancy by one to two days. Personally, for me, that’s not enough evidence to want to do them because you are getting 10+ cervical membrane sweeps. That is a lot for just a one or two-day shorter pregnancy. But for some people, that might be worth it to them. It’s just one of those things where there is that evidence that shows, but this is the thing. Doing one membrane sweep at 40 weeks is not going to shorten your pregnancy by one or two days. It’s not going to shorten your pregnancy at all. This is what the studies show. There might be some anecdotal things or your water might break prematurely and that might kickstart labor, but the one-off or the one or two membrane sweeps here and there is not statistically proven to shorten that. You have to start super early. Another thing I want to say– Meagan: Two days to have to avoid going in or having it massaged or swept twice a week? Julie: Yeah, one to two days. It would cause you so much pain and cramping and it would make you miserable. Meagan: That’s the thing I wanted to say. Sometimes cervical sweeps or membrane sweeps can actually promote prodromal labor. Julie: Yeah. Meagan: Right? We’re up there and we’re disrupting the cervix and making it think that we need to start contracting, but our body is not really ready to labor so we’re contracting, contracting, contracting, and getting exhausted, but labor is not happening. Then the next day, we’re sweeping again or we’re contracting again, but then really, we don’t have a baby for 2-3 weeks. Right? We’re exhausted when labor starts. Julie: Yeah. Meagan: Like you said, they can hurt. If our cervix is posterior, especially at 37 weeks, it’s a lot more likely for our cervix to be posterior than it is anterior, they have to go in, back, and around to get to the cervix and sweep. It’s not just in and out. That can cause a lot of discomfort that’s really unnecessary. One of the questions is, “Does it possibly increase infection?” We are inserting something into the cervix and sweeping around, maybe yeah. Julie: Well, here’s the thing though. I’m just skimming through this podcast article on Evidence Based Birth®’s website. If you want to find it, it’s super easy. Just Google “Evidence Based Birth® Membrane Sweeping” and it will pop up right there for you. Meagan: They give you updated evidence on it. Don’t they have it updated? It was in 2020. Julie: Yeah. It’s in 2020 for sure. They break it down. There are 44 studies that they look at. Some of them show no difference. Some of them show 9% increase in artificial rupture of membranes. Premature and accidental. There are a whole bunch of varying interpretations here, but none of them are too conclusive as far as it causing that significant of a difference in when labor will start. Yes. Go and read it if you’re curious. It’s really good. Or you can listen to it, I guess as well. There is great stuff there. Meagan: Yeah. It’s Episode 151 on Evidence Based Birth®. Yeah. Julie: Yeah. Meagan: Yeah. So I think just closing out this question as a whole, it’s a personal preference. If you want to try something to encourage labor to begin on more of a natural basis, then it could be worth it. But for my personal suggestion to my doula clients and what I would do– again, I’m me. I’m not you. If I was being faced with a medical reason to induce or a concern, but I was going to be induced anyway, I would maybe try it. Does that make sense? If I was already going to be induced for a medical reason, then I would probably try it. Julie: One or two days might be beneficial for you at that point. Meagan: One or two days might be beneficial. If I can avoid going in and being hooked up to a Pit drip, then that might be better for me. That’s one of my things. If I was facing an actual induction, I maybe would try it. For my actual birth, my midwife wanted to. She said, “Hey, why don’t you come in and we’ll strip your membranes?” I said, “Nope.” I didn’t feel like I needed it. I don’t know if it would weaken my membranes or accidentally rupture my membranes because that is a possible consequence. We can induce infection. We can accidentally break our water. We can weaken it as we separate it. So those types of things, for me, were not worth it. I was good to just keep going as I was. Julie: Yeah. VBA2C Meagan: Okay. What are some other questions? I know we have a couple more before we end. Julie: There’s one about VBAC after two C-sections I know. Meagan: Oh yeah. Yes. Julie: Let’s talk about that one. “Why do so many providers not support VBAC after two C-sections? What does the evidence say?” Meagan: Mhmm. Well, the evidence says that it is reasonable. Julie: Yeah. It is. Even ACOG says that it’s reasonable. Meagan: Yep. Yep. Yep. Julie: I feel like this goes back to what we were talking to about before with that quote. I feel like most providers have just been told that it is not safe, so they say that it’s not safe, so they don’t do it and they don’t support it. They throw around terms like, “Oh, it doubles your chance of uterine rupture. 50% chance of uterine rupture,” and things like that, right? We have the system that is just content on not wanting to have or support any evidence that will go contrary to the things that they’ve been taught. You see with the ARRIVE trial. We have been throwing evidence at providers that so many things reduce your chances of C-section for years. Right? Like waiting for labor to start on its own, laboring at home as long as possible, avoiding Pitocin, avoiding elective inductions, and all of those things. We’ve been throwing these things at providers for years about nice, safe, non-medical ways to avoid Cesareans and providers weren’t interested in it all. Then all of a sudden, the ARRIVE trial comes out and they’re like, “Oh, inducing at 39 weeks decreases Cesarean rates,” which, it doesn’t by the way. As soon as providers are shown something that reinforces things they already know and do, they’re like, “Oh, yeah. That’s something I can get behind. I can do this because I already do this all of the time anyways. I already schedule inductions. I already do Pitocin. I already do these surgeries.” So when they’re shown something that will reinforce their beliefs and things that they already know how to do, they’re on board with it. But my gosh, you try and show them these nonmedical ways of improving birth outcomes and nobody wants to buy it because they’re like, “Oh well, that’s just–”. It’s not how they’ve been trained. Meagan: It’s not how they’ve been trained and sometimes they’ve seen a scary outcome. Julie: Yeah, of course. Meagan: Studies do say that women requesting for a trial of labor, a VBAC and having a VBAC, should absolutely be counseled and absolutely be offered an opportunity because we know that the success rate is as high of 71%, if not higher. 71% or higher, right? The uterine rupture rate is not much higher and if you compare VBAC after two Cesareans, maternal morbidity is really comparable to a repeat Cesarean. It’s low. It’s overall safe and reasonable to have a vaginal birth after two Cesareans. Julie: The risks to baby are similar. The risks to mom are actually higher in a repeat Cesarean like increased blood loss, pulmonary embolism, and maternal death is still incredibly low. Maternal death is incredibly low. We’re talking about .000-something-percent, but when you’re looking at it against VBAC, it’s 10 times more likely for a mother to die during a Cesarean birth during a vaginal birth. I don’t want to scare you because 10 times more likely sounds like a super scary number like, “Oh, you’re twice as likely to have a stillbirth after you’re 41 weeks,” but it’s an incredibly small increase and incredibly small risk already. It’s the same thing with this. It’s an incredibly small risk but we don’t talk about those things. Meagan: It’s even harder to find evidence for vaginal birth after three or more Cesareans. That’s where we don’t have a lot of information. Most providers out there, to be honest, if you’ve had three Cesareans, it’s going to be harder to find someone that will allow you to give birth vaginally. It’s so hard. But it still doesn’t mean that you’re absolutely not a candidate or that it is a ginormous risk that completely risks everybody out. People do it and again, we were talking about it earlier. If it’s a risk that you are willing to take and it’s a comfortable risk for you, then that says something. Yeah. VBAC after two Cesareans is totally reasonable and totally possible. We’ve got lots of stories on the podcast. I’m living and walking proof. Julie: And lots of stories of VBAC after three or four Cesareans too. Meagan: Three or four, yeah. Yeah. It’s totally possible. If a provider is trying to tell you that your risk of rupture really is 50-60%, then that is one– not a provider that you should probably be going to for a VBAC, but two– something that probably needs to be changed because maybe they just are really uneducated on the evidence. We’re looking at just barely over 1%. It’s really low. Julie: And not even that, there are several different studies. ACOG sites two studies in their practice bulletin and one of the studies shows no difference in rupture rates between VBAC and VBAC after two C-sections. The other one shows a slightly higher increase. I don’t remember what the numbers are off of the top of my head, but VBAC Link does have a blog on VBAC after two C-sections. You can probably just Google “VBA2C” and it will pull up in the first or second search results, but I’m sure that Paige will probably also link it in the show notes for us. So take a look at those statistics because even ACOG says that and if ACOG says something, why are we not behind that evidence that ACOG published? Meagan: I know. It’s so funny because ACOG goes through a lot to publish these things, these articles and journals, but then we’re not having providers– I’m going to say midwives too. We have midwives that don’t follow these practices. We have providers that don’t follow it. The evidence is there. They’re showing that it’s there. Why aren’t we doing it? CPD I know we’re almost out of time, but I just really want to talk about CPD a little bit because lately in our inbox, we have been seeing a lot of people being told that they hear the stories. They see the stories and they wish they could, but they were diagnosed with CPD and they can’t. They can’t get a baby out of their pelvis. For those who don’t know what CPD is, it’s cephalopelvic disproportion. It’s just pretty much saying that your pelvis is too small. Yeah. Julie and I personally have both been diagnosed. Julie: Told that, yeah, in our op reports. Here’s the thing about CPD. It’s incredibly rare. It’s incredibly rare and most of the time comes from growing up incredibly malnourished like in third-world countries so your bones grow in a deformed way or after a traumatic pelvic injury. It’s very rare for a true CPD diagnosis to come from a normal, healthy person. You can’t even diagnose it without pelvic imagery exam, like an actual scan. It’s not even an x-ray. If you go, “My doctor gave me an x-ray and told me my pelvis is too small.” First of all, that’s not the right way to diagnose it. Second of all, pelvises– your body is so pumped full of hormones that our pelvises expand. They literally move around as baby is coming down. Babies’ heads overlap, the skulls and these bones in their heads overlap and squish together and smoosh together to come out of that pelvis. Your pelvis is opening in ways that it doesn’t normally and babies’ heads are smooshing together in ways that they never will again, so how are you even supposed to tell how much a pelvis is going to open and expand and how much a baby’s head is going to smoosh together? I will die on that hill. Man, I will die on that hill. No. You were diagnosed with CPD and that’s bull crap. That diagnosis was bull crap and unless you grew up in Africa or in these poor countries. All of these African women are still having babies. Sorry, that probably sounded a little bit bad. I didn’t mean to say it like that. These women are still having babies even though they were malnourished. You have to have a severe, severe deformity from malnourishment. Rickets is the disease that comes along usually wth CPD or a traumatic pelvic injury like maybe you got in a car accident. Meagan: Thrown off a horse. Julie: Or got kicked hard in there somewhere sometime by something. I don’t know. But it’s just not as common as people are saying. It’s not. Meagan: Right. Yeah. It’s just overused. So if you have been told that, I hope that through the evidence– we’re going to have links here in the show notes to all of these studies and things. I hope you know that your pelvis is perfect. Julie: Your pelvis is perfect. Let’s make a shirt. “My pelvis is perfect.” Make it a shirt. Do it. “My pelvis is perfect. Hashtag why we VBAC.” Meagan: Right. Okay, well thank you for being here. Thanks everybody for submitting your questions. We’re going to keep doing these. We’re going to bring the questions and answers. We’re going to talk about them. We’re going to talk about some of the statistics and the evidence behind some of this. So yeah. Make sure to watch out on our Instagram if you haven’t followed us on Instagram, and I’ll make sure to let you know when the next Q&A with Julie and I will be. Julie: If you’re in Utah looking for a birth photographer, come and find me. My Instagram is @juliefrancombirth or you can find me at www.juliefrancom.com . I would love to support you and I would love it even more if Meagan and I could support you. So reach out, we’ll give you a deal. We’ll hook you up because we love being in the birth space together. Meagan: Yes, we do. We just got our first one the other day and it was awesome. Julie: It was awesome. Closing Would you like to be a guest on the podcast? Tell us about your experience at thevbaclink.com/share. For more information on all things VBAC including online and in-person VBAC classes, The VBAC Link blog, and Meagan’s bio, head over to thevbaclink.com . Congratulations on starting your journey of learning and discovery with The VBAC Link. 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