TOLAC discussion

Because of the type of incision made during c-sections performed a generation ago, for women of my mom's generation, it was "once a c-section, always a c-section." I still encounter this assumption among older women (and men) who learn that I had a c-section with Oliver. They want to know my c-section date instead of my due date. I end up with a lot of explaining to do.

Thanks to a change in the way a c-section is performed, which automatically makes a future vaginal labor a safer and thus more realistic possibility, (the incision is now made horizontally across the uterus instead of vertically, which would likely cause a uterine rupture during a future trial of labor) as well as a better understanding in the medical community of the risks and benefits of vaginal births after cesareans, vaginal births for women who've had a previous c-section are now a supported option. (Not all doctors want to or are allowed to perform them, but that's a different matter.) Thus, many people nowadays have heard the term VBAC, (vaginal birth after cesarean) but the more accurate term is TOLAC(trial of labor after cesarean).

Even though my former OB estimated my chances at a successful VBAC as 50/50, when I became pregnant with my second child, it was really important to me to find an OB who was allowed to perform VBACs and would discuss my delivery options with me. (This was the case with my former OB, but I moved and needed to find someone closer to my new home.) I wanted to make the best decision for myself, even if that decision was to be a planned, repeat c-section.

It was a frustrating process in the beginning, as I had to start with a list of in-network providers from my insurance company and literally start calling around. The midwife I see for preventative care was clearly out, as was virtually every midwife, so luckily I was never interested in a home birth or birth center delivery. My only real option was under the care of a obstetrician, but I discovered that many simply will not (or cannot) consider TOLACs, no matter what my medical history. (Based on a variety of factors, some women are better "candidates" for a successful VBAC than others.)

I eventually found a new OB, whose mentor during residency happened to be my former OB, and whose practice is housed in the hospital less than two miles from my house where I plan to deliver. Even though I still had no idea whether I actually wanted to pursue a TOLAC, at least my more limited options going into this second pregnancy remained open.

Some people (again, older generation) don't understand why having the choice is such a big deal. Why don't people listen to doctors anymore and just do what they say, I was asked? I do trust doctors and rely on their medical advice that's based on years of education and training. But in medicine, even with hard data, there's not always a right or wrong answer. There are different risks and benefits associated with every course of action and patients need to take the information from their doctors and decide what's best for them. Sometimes the decision is simple, like deciding between a prevenative measure versus a wait-and-see approach for a non-life-treatening or non-debilitating condition, while others, like cancer treatments, could make patients decide between a comfortable end of life or a risky treatment with little chance of success.

In my case, I am listening to my doctor. She would have told me if she thought there were too many risks associated with a TOLAC. Instead, in her medical opinion, it would be fine for me to have a c-section (after 39 weeks), schedule a c-section, but see if I go into labor, or pursue a TOLAC, even if the result is hours of pushing and then an unplanned c-section. The risks of surgery, the risks of labor, the benefits to the baby of laboring, the benefits of waiting for the baby/my body to induce labor - they're all a wash. She's very supportive of TOLACs, even when the result will most likely be a c-section and she concurs with my concern about the risks of repeat c-sections, given that Chris and I possibly want to have more kids. Instead, I've got to decide between the 50/50 odds of delivering vaginally and avoiding the pain, recovery and complications of surgery, the likely scenario of having a labor similar to Oliver's (hours of pushing, but unable to deliver the baby, resulting in an unplanned c-section) or planning for a c-section, knowing that while it's still surgery, the complications and recovery time are reduced. There are a myriad of other factors - personal, medical and logistical - that point me simultanously at all three options. Right now I'm in an indecisive, wait-and-see mode and hoping I come to terms with not the right decision, because there is none, but the better decision.