#273 | Special Q&A Featuring Nancy Wainer on VBAC and More

July 10, 2024

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In last week's episode (#272) you met legendary midwife-author Nancy Wainer. Well she's back today for Part II, where she joins us in a Q&A-style episode to answer our listeners' questions. Nancy experienced the first planned VBAC in the United States and she coined the acronym itself in her first book, Silent Knife, published in 1983. She has over 40 years of birth experience and has supported women through some incredible births that almost certainly would have resulted in surgery in any other environment. Today, she takes questions from our community including:

1. What are the common characteristics of women who have had successful VBACS
2. Is it still safer and healthier to have a VBAC if it has been less than 18 months since your cesarean?
3. Is a classical cesarean incision truly a contraindication to VBAC
4. How much impact does the shape of a woman's pelvis have on her labor?
5. Is there ever an indication to break a woman's bag of water in labor?

We are honored to have her wisdom and advice to share with our community and this won't be the last time you hear from her!

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View Episode Transcript

Hi ladies This message is for Nancy Wainer. The question is, what were the common characteristics that you saw among women who had successful VBAC? Thank you. Hi, Cynthia, Trisha and Nancy. I recently finished doula training and the friend asked me if it is still safer and healthier to have a VBAC just 13 months after their Syrian birth or not. What are your thoughts?

No, a man's penis changes shape in order to get the baby in. And a woman's body changes shape to get the baby out.

My question for Nancy is, is a classical incision, truly a contraindication for feedback.

Babies have been coming to the planet since the beginning of time. And if you are here, then you come from really good stock.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Hi Nancy. Welcome back to the podcast one week later. Thank you for the first episode you did with us. And as promised to our listeners, we are having you here for our own little ad hoc q&a Trisha and I do a q&a episode last Wednesday of every month and this time, we just want to give you some questions that we we actually wanted to hear your answer on on some to some of these questions. Who better to answer questions on VBAC than Nancy Wainer.

So let's jump right in.

Hi, ladies, this message is for Nancy winter. The question is, what were the common character characteristics that you saw among women who had?

That's a wonderful question, a smart smart question to ask.

It really was, Oh, my goodness gracious characteristics of women who had successful VBACs. First of all, I just want to just give it a little bit of an aside, because every one of the woman, women are successful, whether or not they have V backs or they don't, they are successful. So that's a discussion possibly for another day. But I just wanted to say that they are certainly motivated. They are extremely motivated. Many of them have been burned, they've had miserable, miserable experiences. And that's one of the things that has propelled them to look for a different kind of experience, they are more than willing to listen to all kinds of nutritional advice. And that's a loaded kind of a situation because what one person might consider healthy somebody else might not. But they're more than willing to make changes and to be extremely diligent about taking good care of themselves during the months when they are planning to become pregnant, and during the time that they are pregnant. And hopefully, the things that they learn and the things that they do will be things that they do for the rest of their lives. Another thing that is a characteristic, I don't know if this is a characteristic, but they have support, most of them, not every one of them, but they find a way to have support. And they limit their connections with people who are negative, and who are not interested in supporting this decision. I can remember one woman who had 21 People at her VBAC, and every one of those people, it was appropriate for them for to be there because they were cheering her on and they were doing anything that they could they were getting water, they were providing food, they were putting on music, they were being quiet, etcetera. But I don't know that I would necessarily ever recommend that you have 21 friends and relatives. And then there was somebody else who had one person there and that person wasn't supportive. So you can have anybody you want to but make sure that they are supportive and loving and caring and willing to go the mile with you. What are the characteristics? Let's see. They just take good care of themselves. They exercise. They might take walks. They're willing to talk to their babies. I have them talk to their babies every single day because this is a joint effort. This is not just mama but this is mama and baby. And so we talk to the babies and Every time we do a prenatal appointment, we make sure that we are including the baby asking the baby's opinion, and making sure that we are all in cahoots. And it's interesting because every now and again, we just kind of were quiet. And we get a sense that something isn't quite right. And so we need to make sure that we are taking into consideration what this baby might have to say to us. What else? I'm sure there are 1000s more, but those are the ones that come to me at the moment. Nancy, what's an example when you say something like we have to take into account what this baby has to say to us that just goes right over everyone's heads out. I mean by that? Well, for example, the one example that comes to mind very quickly is a woman who was planning to have her baby vaginally after a previous cesarean. And during the prenatal appointment, when we were listening to the baby, the baby's heartbeat was funky. I don't know how else to describe it. But it was funky. I've heard lots of babies in this baby didn't sound like any other baby I had heard. And I said to the parents, I think we need to get this checked out. That baby was telling us something. And we needed to listen to the baby. But there are other times when the mother is really terrified or really frightened with cetera. And we say, let's see what the baby has to say. And the baby will say to us, Mama, I am fine. My head is down. I'm facing back. I'm coming out. Don't you worry about it anything at all. So we just take into consideration that babies have energy, and they have personalities, and they have opinions, and they're willing to share them with us if we're willing to listen. This is one thing, Nancy, that we often suggest. And this is not actually a characteristic. But something that we do think is important for most mothers when they're choosing VBAC is to choose a different provider than the one who performed their Susteren. And that I wouldn't say that applies in 100% of cases, but probably in the vast majority, if you go back to the same provider who gave you the C section, your chances are going to be decreased. That, you know, they're going to support a vaginal birth. Absolutely, they may say they will. I always say to women, what makes you think that in the two or three years since you had your baby, this particular provider, you know, went back and took all kinds of fabulous classes about natural childbirth and about being patient, etcetera, that would allow this person to treat you differently, and to have a different outcome. So absolutely.

And not to mention that one of the biggest challenges of any second time or third time mom, is to refrain from reliving her first birth. And even when she consciously catches herself and refuses to reimagine her first birth happening all over again, for this upcoming baby. It's unconscious. And no matter what women go through the first time they think it's going to happen the next time if it was a long labor, they think they're in for another long labor if their water broke early, and they think their memories are gonna really surly if they had groupie strap or preeclampsia they imagined it'll happen again. So I'm always concerned when they even see the face of that provider who gave them the C section. If they don't have completely positive emotions around that C section. Unconsciously they're going to feel like here we go again, just by seeing the face and hearing the voice if not being in the same facility.

That's exactly right. Which is one of the reason that with some of my VBAC moms, we do a redo. And that, again is another topic for another day, but we do a redo of the C section. And so she not only has the seryan in her mind, but she also has an experience of being in a loving space, where she has redone that birth. And she can call upon that as an experience in addition to this as Aryan. So we don't deny that this is Aryan happened, because I'm sure she's learned quite a bit as a result of that. But we put into her repertoire, so to speak, a different experience that was done for me and it was so incredibly powerful that I've done that with a number of different people.

Alright, let's go to the next one. Hi, Cynthia, Trisha and Nancy. I recently finished doula training and a friend asked me if it is still safer and healthier to have a VBAC just 13 months after a cesarean birth or not. What are your thoughts? Well, I think in the best of worlds, everybody would prefer that you have a baby 18 to two years apart. However, that isn't always what happens people. Number one, get pregnant unexpectedly. Number two, I had one woman who started having babies when she was in her early 40s and didn't feel as if she could wait. So I don't have any issue with that as long as she takes really good care of herself. There comes a point I don't know who said you know, 18 months, what about 16 months? So what about you know, 15 and a half months, etc. As long as she takes really good care of herself and what we generally also know is that if the incision has held up to the point where the woman has gone into labor, chances are it has proved its integrity because it If it hadn't, she might have had some difficulty beforehand. Also, the techniques for suturing now are different than they were many, many years ago when women had a higher chance of having a uterine rupture, etc. So I don't have any issues. Just last week, right after we did the first part of this podcast, we had a woman who called who had had three previous Aryans. And she did not have a whole lot of time between the last baby and this baby. And she had a VBAC after three cesarean, so I don't worry about it, I rather have somebody who has less space, but he's healthier and more conscious than a woman who doesn't take care of herself and chooses the wrong provider and allows herself to be induced and et cetera, et cetera. So but I think also that quote, rule, not that it's a rule, but that edict about waiting 18 months to two years has more to do with the fact that when you naturally space your babies, if you're fully breastfeeding, and not introducing pacifiers, and you're not introducing solid foods, etc, and you're nursing first all the time, most babies are not born 13 months apart, I'm sure a few of them are but most of them are spaced about 18 months to two years. But I certainly personally wouldn't reject somebody because their babies were less than 18 months apart. And I've had a number of whose babies were 1314 and 15 months apart, and who wants to have a cesarean? When you've got two babies under the age of two, you know, if you can possibly avoid major surgery, go for it.

I'm always suspicious of round numbers, it's just always a little bit of a an added possibility that the numbers are made up. I mean, if they really had research behind any of this, would it really come out to this nice round number of 18 months? Or would it not have been like you said 16 months, 21 months? Or how often people say something like, oh, there's a 99% chance of this. It's like always 99 Like really, this does not sound statistically evident to me. So it's one of those things I've always been suspicious of as well, because it was always this round number of 18 months.

I would agree with it. I think it's I think it has made mainly come not from research but from the concept of natural child spacing. And this is kind of when the body is ready to most ready to carry another baby. Whether she's had a vaginal birth, or not. Either way, just as far as that whole cycle you're saying, exactly, yeah, it's like the optimal spacing, but just because it's optimal doesn't mean that it's not possible.

You reminded me of a birth the woman's name is Pam, and she became unexpectedly pregnant with her second baby after having had a cesarean. And when she gave birth to her VBAC baby. By the way, they came from California to Massachusetts to have their baby and her 15 month old was sitting on her back. She was birthing with her breasts on the bed and her bum up in the air. And her 15 month old was sitting on her back while she gave birth to the back, baby. I have a picture of that somewhere in my files. It was are you kidding? Nope. He was sitting on her back.

That's unbelievable.

That's unbelievable. Yeah, yeah. Yeah.

Even when the when the baby came out, he was still sitting on the back or just sitting on her back. I have a picture of it. Nancy has a slideshow of birth story she's attended with photos and one after the other blows the mind. Honestly, truly, Nancy, remember the one with the woman who gave birth with the dog under the bed giving birth at the same
time? Oh, yes. And she's had for previous Azeri. I know I remember she had her fifth baby at home on her bed. Right while her dog was giving birth to like six puppies underneath the bed. I thought it was exactly the number five to say it might have been you know, something it might have been if I remember I remember from that. So while she was giving birth to her fifth baby and her first vaginal birth at home, you could see this, these this dog's legs sticking out from the bed skirt. And the dog was in labor giving birth to her five puppies while the woman was in the bed, giving birth at the same time to her fifth baby. I've told that story so many times.

Yeah. Hi, y'all. I cannot tell you how much I appreciate all that you do. Y'all are always blowing my mind and helping me think about things in new ways. My question for Nancy is, is a classical incision, truly a contraindication for feedback, and if it is not, are there any special preparations that women should do if they have a history of classical incision? Thank you so much.

Well, no, it is not a problem in my eyes because what I said before it goes for this particular situation as well as if the uterus has held up to the point where you are going into labor. Chances are it has proved its integrity. We have had women who have had classical incisions we had a couple of women with y incisions, two or three women with J incisions, it sounds like an alphabet soup kind of a mix, and one person with a Z, maybe two people with disease. So the type of incision that you have isn't necessarily a contra indication. It just needs to take good care of yourself and think good thoughts and eat good food and exercise and get some rest and laugh and have wonderful calm people around you, so that you have the best possible chance. And so I would have questions to ask about why the classical incision was done and when was it done and what kind of healing took place? And was there an infection but generally speaking, I would say that a classical incision doesn't necessarily mean that you cannot have a VBAC.

Hi there. My name is Jasmine, and I absolutely love your podcast. I've been listening throughout my entire pregnancy. I'm pregnant with my first and entering the third trimester. And I have a question today regarding the shape of a woman's pelvis. I've met with a local midwife just a few times. And it seems every time we talk, she's talking about the shape of a woman's pelvis, and how it can have an impact on the labor. And she even goes as far as to say that some women have the worst type of pelvises. And there's good pelvises, and I'm having a hard time believing that a woman's anatomy is ever bad. But I'm curious what your experience has been with women who have different shapes of pelvis, and how that might impact the length of their labor or the difficulty of their labor. Thank you so much.

Well, first of all, you have the wrong midwife. So I would suggest, as Trisha mentioned, before, that you change providers, I would be interested to find out what her experience if she's a mother, what kind of birth she had. But a couple things. Number one is, you know, a man's penis changes shape in order to get the baby in. And a woman's body changes shape to get the baby out. And so that's one thing to think about. That's the way it works. And there are different shapes of noses and different shapes of ears. And so of course, there are different shapes and pelvis. But what difference does it make what the difference is that if you know, and you can do what's called an external pelvic symmetry, which I don't always do anyway, because the pelvis changes shape when the woman is in labor. But you can get an idea as to what kind of shape of the pelvis is, and then you can make suggestions during the labor. You might be better off squatting, or you might not be better off squatting, or you might be better off lying on this particular side or that particular side. But the truth of the matter is, is that babies have been coming to the planet since the beginning of time. And if you are here, then you come from really good stock. Your grandma had babies, your great grandma had babies, your great, great, great, great, great, great, great, great, great, I don't know how long this podcast is, but your great grandmother all had babies. And so you come from really good stock. And so you believe that your body is normal, you take good care of yourself. And then you are with people who believe that despite the shape of your pelvis, your baby is going to come through we had a woman who had to sis Aryans. And she was told that she had a problem with a flat pubic bone and this that and the other thing and a very prominent coccyx, etc. And she had a baby with me and one other midwife I was with. And she had a 11 pound, two ounce baby and no stitches. So the truth of the matter is, is that under the right circumstances, when you're changing position, and you're relaxed, and you're bathing and showering during labor, and you're eating and you're walking, and you're swimming, and whatever else you do, big babies can come out of what this particular person might call a miss shapen pelvis, and babies heads also mold. And so you have a baby whose head can mold really, really dramatically and you have some babies whose heads need to mold in order to come out and then you have other babies who come out in their heads or is round as a balloon and they're just perfectly fine. So I would get a different midwife because there's something going on with her where she doesn't really believe that women were designed to have birth and that at the first you know, sign that maybe the labor is slowing down a little bit or whatever. She might just say, Oh, you have a you know misshapen pelvis and we better do a C section.

Two things that I think are really important or one that the mom and baby We can be in communication with each other so that the mom can sense the ways in which she needs to move and shift and older her body movements to help her baby fit in whatever shape size pelvis she has. So that mom, that mom and baby communication that you were talking about earlier is so important, which can really be disrupted sometimes in hospital birth, especially if there's an epidural or medication on board. It's harder for that communication to happen. And the second thing is that giving the mom enough time, because, baby some babies, like you said, Some babies heads have to mold unbelievably like to fit through. And they will, if they're given enough time, but when you put a three or four hour second stage limit on a mom and she needs six or seven or eight for her baby's head to navigate its way through. She was going to be done told that her pelvis couldn't accommodate her baby.

I was not the midwife but I have a friend who's a midwife on the other coast, who was at a VBAC birth. Everybody take a breath, and Mama pushed for 11 hours and had a beautiful, healthy, fabulous baby who had a real mold and had, but everybody was fine. Now that is very unusual. It's extremely unusual. But in this particular situation, that's what needed to happen.

Nancy, I want I was was once at a home birth, where the mother pushed for 18 hours. Oh, my goodness, I it. It was amazing. To me, I was the birth assistant, I was not the head midwife, and I just kept going, or we were gonna keep going, we're gonna keep going, we're gonna keep going. And she was just calm and confident. Yes, the mothers find that baby's fine. The mothers fine, the baby's fine. 18 hours later, I've never seen a head. So molded. In my life. It was extremely dramatic. But the baby was fine, adapted perfectly after the birth, and within two or three days, the head was just back to normal. I mean, no one else would this mother have had a vaginal birth?

No, no, no, no, no, no. And if something had happened, of course, it would have been the midwives fault. And it would have been the parents fault to have made a decision to have a baby at home, when a baby may have said this already. But when a baby dies at a hospital birth, it's an act of God, when a baby dies at a home birth, it is a midwife is the midwives fault. And the parents, which is nuts, just really not so. But we're here because all of our ancestors has had their babies at home. So I don't know why I've always found it to just be such a breach, for any provider to look at a woman's body and have been have the audacity to declare whether she can give birth. I just can't I don't know if it's just me, because I know there's something to pelvis shapes. And you made such an interesting point, Nancy, that I never considered that maybe certain birthing positions would lend themselves better for some women over others that was very interesting. Just explains why we all need the freedom to move and listen to our bodies and feel where we have to allow space and turn as we need to. But just the idea of one person looking at someone and I've heard of doctors who say, Oh, no, no, your pelvis. No, no, no, you can't. It's like, where do they get off telling women that and I've never heard of the case where the obstetrician added to that comment. But then again, if we keep you off your back, your pelvis will open about 30% more. So who's to say like, there's never that comment. It's like they're just some expert in glancing at you and declaring whether you can give birth, as you said, why don't we just look at everyone's noses and say, who can breathe and who can smell and look at every other organ and go around judging who can you know, do anything with any part of their body? It's really unbelievable.

I wonder if there will ever be a study done of all of the obstetricians in the United States or anywhere? And how many of these obstetricians who are mothers themselves had natural birth? Right? Because I think the statistical chance is probably 2% or they don't they don't know what it is because those women who have had a natural birth are transformed in some way. And they want that for all of their sisters. They absolutely want other women to experience that question about breaking water during labor? Is there ever an indication that that would absolutely be necessary, or have you ever experienced needing to do that to help labor along? I've met with a midwife and she has talked about and my doula also has talked about needing to break a woman's water to help the baby. And I'm just curious why that would be if there's ever actually a need to do this. Or if the water would just eventually break on its own. They talk a lot about labor being stalled, and breaking a water might help a stalled labor. Thank you so much.

I really wanted to hear what you say to this because I am very anti-amniotomy. So let's discuss  a stalled labor. I hate to use the word stalled. But there are periods of in labor when women can rest. If things are just, you know, not progressing, then lie down and breathe and listen to music if you like and just let your body just have a little bit of time to regroup, so to speak. I rarely, rarely break water. We're just patient and many of the babies that I have attended, and I don't use the word delivered because the mother delivers her baby and should get the credit for it. But many of the babies have been born in the call where the baby is born. And that you you at that point, you do generally release the the sack. So wait a minute, just to be clear when the baby is born entirely within his or her amniotic sac out of the mom's body lying there enveloped in this water. You do agree at that point at that point. Yes, at that point, the baby needs to take a breath. Right? Yeah.

I would not call that an amniotomy at that point. No, no, no, of course not. So I have rarely decided or discussed with the mother to break the water, I usually want to keep it intact. However, I will say that as a midwife. For many decades, there were a few times when I did make the decision with the woman to release the bag of fluid. And in those situations, it really did feel like it was the right decision to make a woman named Karen. She was pushing and pushing and pushing and pushing and pushing. And there was a big bag of water in front of the baby's head, although the baby was fairly low, and pushing and pushing and pushing. And I finally said to her, Karen, I think if I release this bag, you'll have this baby very quickly. And she said no, no, no, no, no, no, no. And so she pushed and pushed and pushed and pushed. No, no, no, no, no, no, no. And finally, when she was just exhausted, she said, Okay, go ahead, and I released the bag. And within literally five minutes, the baby was crowning. Now would that have happened, if I hadn't done anything we'll never know. But in this particular situation, having been to many hundreds of births before that, I just had the sense that for whatever reason, she had grown a really, really thick, healthy water sack that wasn't about to release very easily. And so that was one of the situations. By the way with Karen. When I came to her second birth, I walked in the door, and she said break my water. And I said absolutely not. That was then this is now and we're going to wait for this one to release on its own.

I completely concur with you, Nancy, in my experience. Also, as midwife, the few times that I did it, or the mother asked for it in these scenarios, especially if she was a multiple was when it was just that four bag holding back enough pressure on the cervix to get the baby to get that cervix are kind of finished the last tiny bit of dilation and the baby to come down. And that is the only time where it ever really seems to speed up labor. But in those cases, it really does. But it's few and far between. And usually always by the mothers, you know, that's by the mother's choice, right? Just Just so I understand, Nancy, in that case with the woman, Karen, that you referenced, the baby was through the cervix at that point, the baby was about to cry. Yes, she was. So it was like this ebb and flow the baby like she would make progress. And because of the pressure of that, that water balloon is essentially drawing back. So you've attended 1000s of births and the you would say you can count on two hands, how many times you've ever done an Amjad me perhaps it's very rare, okay.

It's very rare. I will also tell you that when the mother says to me break my water, break my water, my response is oftentimes How about you break it? And she'll say, Well, I can't reach it. And I'll say, Well, if you can't reach it, then it doesn't want to be broken. And why should you reach it? But I have had two or three times with a mother herself actually has released the fluid. And when the mother intuitively feels like it's time for her to do that, but we're not talking at 4567 or eight centimeters. We're talking about toward the end of birth when the end of the labor when this baby's really truly headed Earthbound. So when my daughter was coming out of me, the amniotic sac was was coming first so it hadn't released even though she was nine and a half pounds, nothing was making that sack release, which was fine. I felt great. But I remember when I imagined she was crowning my midwife said Oh, Cynthia, do you want to reach down and just break the break the amniotic sac and I said, No. That feels weird. No. But then she did it. And I always it's funny how our brains work so hard to seek regrets to seek regrets when we give birth. And I don't like that it does that. But I always kind of wished that she hadn't because I think my daughter was on her way to being born in the call, which would have been super cool to experience. I don't really think she had to do that. But yeah, no, it's no big deal, I guess. I have a photo of a bag of water that is outside of the mother's body. And it's full, it looks like it's going to release almost any second because it is so taut. And in it, there's swirl of vernix. And as the mother is moving or pushing, the vernix is rotating and moving. And I didn't get a video of this. I wish I had but it looks like just like the universe. It's so beautiful. It's just takes your breath away like a galaxy. Exactly. exact picture.

I can picture it perfectly. I've seen it - so beautiful. Yeah, yeah. And then one woman who said to me, are you going to break my water? And I said, Absolutely not. We use the term release. Are you going to release my water? And I said, Absolutely not. Everything's going really well. And she said, Well, she said, I think this was her third baby. She said, I think with the next push, it is going to release on its own. So you had all better get out of the way. And when she started to push the next time her water released and it went all over the ceiling, it went to the other side of the room. And she said Consider yourself warned. Wonderful. It was so much fun.

Well Nancy, thank you so much for doing this with us. This is my pleasure and I'm a light mode for us as far as q&a goes those are our toughest episodes and this was just enjoyable we sat back and got to hear you answer.

I want to thank you both for what you do you know that this is my passion and my my reason to be on the planet in many respects and so I am just absolutely so appreciative grateful to both of you because for needs you thank you.

Thank you for joining us at the Down To Birth Show. You can reach us @downtobirthshow on Instagram or email us at Contact@DownToBirthShow.com. All of Cynthia’s classes and Trisha’s breastfeeding services are offered live online, serving women and couples everywhere. Please remember this information is made available to you for educational and informational purposes only. It is in no way a substitute for medical advice. For our full disclaimer visit downtobirthshow.com/disclaimer. Thanks for tuning in, and as always, hear everyone and listen to yourself.

we've had lots of dogs at birth and we had a nurse and when I asked her why she wanted to have her baby at home, she said because I they won't allow me to bring my dog to the hospital and My dog is my support. So yeah, so I always remember you saying children and animals are amazing during birth because now they are part of your birth. Yeah, I agree. Yeah.

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About Cynthia Overgard

Cynthia is a published writer, advocate, childbirth educator and postpartum support specialist in prenatal/postpartum healthcare and has served thousands of clients since 2007. 

About Trisha Ludwig

Trisha is a Yale-educated Certified Nurse Midwife and International Board Certified Lactation Counselor. She has worked in women's health for more than 15 years.

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