Some of the questions I get asked most frequently by clients preparing for a VBAC are the same as the questions before a first-time birth: How can I handle the pain of labor? Which interventions should I accept, and what are the pros and cons of the interventions I might be offered? How will I know when and how to push? How can I prevent tearing? Can I do it? All of these questions are, of course, individual both to you and to this specific birth. But I will share some thoughts that may be helpful in addressing these questions, alongside the advice that your medical provider will be able to offer in light of your specific medical history and risk factors.

Can I do it?

Let’s start with the last question from my list above: can I do it? I believe that for the majority of people contemplating a VBAC, especially those with an otherwise low-risk pregnancy, the answer is yes, you can do it! Labor is undoubtedly a challenge, but we often find unexpected depths to our strength when we are challenged the most. Having a supportive team around you, which may include a VBAC-supportive provider, a doula you have a good rapport with, and a loving partner, will help tremendously, but you are the one who is going to have to do the hard work and you are the one whose body, mind, and spirit have been preparing for this hard work. However, it is also really important to know that “doing it” doesn’t always mean having a specific mode of birth. A vaginal birth is not a trophy. Whatever happens in labor, whatever medical decisions may be made, you can draw on your strength and your support team to lovingly and courageously give birth to your child. To learn more about choosing and preparing for a VBAC, two excellent sites are VBAC Facts and the International Cesarean Awareness Network (ICAN).

How to handle the pain of labor?

If you experienced labor before, you know that it hurts. If you haven’t experienced labor before, you have probably heard a lot about the pain of labor and you may be wondering just how much it hurts. I’m going to be very honest with you when I say that for many, it hurts even more than they thought it would. I’m also going to be very honest when I say that this pain is temporary, and you can get through it. You may choose to use medical pain relief, and there is no less honor in your birth if you do. But for those who want to experience fully all of the sensations of labor and birth, or if you have to wait for a period of time before you can have medication, the following tips may be helpful. My advice is generally to try whatever you, your doula, or your provider thinks might help, and to stick with whatever you find helpful for as long as you find it helpful. As your labor progresses, something that felt good at an earlier stage may no longer helpful or even feel annoying; that’s the time to stop doing it and try something else.

Here is a good toolbox of non-medical techniques that may help with labor pain:

• Breathing, prayer, and meditation techniques described in my earlier post about VBACs
• Movement and changing positions, using the bed, birth balls, and pillows creatively to support you in different positions. (A doula can help you find and get into different positions you may find helpful. Even with the continuous fetal monitoring that is often required in a VBAC labor, movement and position changes are still possible, you just might need your doula or nurse to help readjust the monitoring sensors after you change positions.)
• Hot water: If you are lucky enough to be offered a deep pool to labor in, go for it! If not, a bath or even a folding chair in the shower is a great option. The water should feel warm but not hot enough to turn your skin red or overheat you. Make sure you have someone present who can help you get in and out of the pool or tub. It might also feel good for that person to stay with you and fan your face while you are in the hot water.
• Massage (You may want to pack a tool like a tennis ball or rolling pin for your partner or doula to massage you with.)
• Counter-pressure on your lower back or hips (especially helpful with back labor, when you feel the contraction pain in your back)
• Ice packs or hot packs (These are good items to pack in your hospital bag, but know that some hospital policies will not allow them to heat things up for you.)
• Squeezing a comb in the palm of your hand
• If you have any other tips you have tried or heard about, please share them in the comments!

What about interventions in labor?

Interventions are a whole big topic for another blog post (or really several blog posts), and it’s really impossible to offer generic advice about this. What I will say is that you should value your intuition about this, and to know that there are no right or wrong answers. If your provider is offering an intervention, ask questions until you understand the answers about why this intervention is being recommended, what benefits and risks it might carry, what it is likely to feel like, and what alternatives might be available. If you are somebody who likes to research all the possibilities ahead of time, Evidence Based Birth is a good source of unbiased, accessible information. I will say that sometimes what we learn can be surprising. For instance, many people hoping for a VBAC are afraid that having an intervention like an induction will result in a “cascade of interventions” ultimately resulting in another Caesarean; however, in cases where a pregnancy is high risk or has continued beyond the date that a provider feels is safe, offering an induction instead of a scheduled Caesarean may be the most VBAC-friendly option. Try to keep an open mind, but don’t be afraid to speak up for what is important to you.

One intervention that is often considered standard protocol for hospital-based VBAC labors is continuous fetal monitoring. The Evidence Based Birth factsheet on fetal monitoring gives a helpful overview, although the factsheet does not focus specifically on VBAC labors. Providers, and sometimes parents, usually say that they feel better being able to see how the baby is responding to labor. This can provide an early warning in case there is an emergency, and it may be reassuring to hear your baby’s heart beat, particularly if you have anxieties about the outcome of the birth. However, it can also feel intrusive and limiting to have to accommodate the monitoring equipment while you are in labor. The most common type of monitor consists of two ultrasound sensors that are held on with belts strapped across your belly (pictured above). One registers the fetal heart beat, and the other senses pressure changes in your uterus to show when you are having a contraction. These are both connected by wires to a machine that records and graphs the two readings. You can still move around, as long as you stay within the cords’ reach of the monitoring station, but the belts and sensors may slip and the hospital staff may ask you to go back into a certain position to ensure that the monitor continues to pick up the baby’s heartbeat. This can be annoying, particularly if you find that movement and position changes are helping you cope with labor. It may be worth asking if there is another type of monitor available. Options that are sometimes available include a box that connects to the sensors and wireless transmits a signal to the monitoring station (allowing you greater range of movement but still subject to the sensors slipping) and a different type of pad that actually sticks to your skin and transmits wirelessly. It may even be possible to get in the bath with these types of monitoring; your nurse will explain what you can and can’t do while wearing these types of monitors, if they are available. Sometimes, an internal fetal monitor and/or intrauterine pressure catheter may be recommended. These are inserted through your vagina. Once inserted, they are less likely to slip and may give a more accurate reading, and as long as you are otherwise mobile (not having an epidural), you can still move around and change positions to some extent. Some people are not comfortable with having these devices inserted internally, so if these are recommended you might want to ask the questions I suggested for any intervention: why this intervention is being recommended, what benefits and risks it might carry, what it is likely to feel like, and what alternatives might be available.

How will I push the baby out?

For anyone who has not given birth vaginally before, the idea of pushing a baby out can be difficult to imagine and the subject of many questions and fears. Here, is in many aspects of birth, your body will probably surprise you with how it knows what to do when the time comes, but this doesn’t necessarily mean that it will be easy. At some point, the painful contractions will likely begin to be replaced or accompanied by a feeling of pressure. Often this pressure will feel like you need to poop. A phrase that will usually get a labor and delivery nurse running to check you is “I feel like I need to go to the bathroom but I can’t.” If you have an epidural, it is possible that you won’t feel this pressure or urge to push so much, although often the hospital staff will turn down the strength of medication when you are approaching this stage so that you will be able to feel the urge to push. How you will push is up to you and may come instinctively. When you feel the urge to push, with a contraction, you will probably bear down instinctively (much like going to the bathroom). Using your breath and your body’s natural urges, you can push slowly and with control; this may help your perineum to stretch gradually and reduce the likelihood of tearing. Sometimes the hospital staff will suggest a more forceful method in which you hold your breath and bear down for a count of ten. This may be helpful, especially if you have an epidural, but it can also be more stressful and exhausting, and may contribute to the baby coming out more quickly without giving your perineum time to stretch. You don’t have to lie on your back like you’ve probably seen in the movies, although some providers may ask you to because it is more convenient for them to see what is going on this way. Since other positions, such as squatting, lying on your side, or even standing can be more comfortable and effective for pushing, you may want to ask your provider about how they will support you to find your own best position for pushing. Although some tearing can occur from pushing, you can lessen the likelihood and extent of tearing by practicing the slower, more controlled form of pushing that may be more instinctive, and asking your provider to apply warm compresses around your perineum as the baby crowns (as the head emerges). Some people also practice perineal massage and stretching before birth to try to help with this. There isn’t a lot of evidence that this actually prevents tearing, but it doesn’t seem to do any harm either, so if this is something you would like to try and it feels right to you, that’s fine. Some people preparing for a VBAC are really worried about tearing. If this is you, you might like to check out the Evidence Based Birth webinar on preventing tearing.

I hope that helps to answer some of your questions about VBAC labor. As you see, many of these are really the same questions that anybody preparing for a vaginal birth might have, although depending on the reasons and circumstances surrounding your previous Caesarean experience, you may have some particular concerns about different aspects of your birth. What other questions do you have? Leave them in the comments and I will take them up in a future post!