Speaker 1: The information in this podcast is provided for education and
Speaker 1: research information only. It is not a substitute for professional
Speaker 1: health advice.
Speaker 2: Welcome everyone, I'm Rigid Maloney, and today I've got a
Speaker 2: bit of a different format for you. Every now and then,
Speaker 2: we're going to add in what we're going to call
Speaker 2: the quick Kick. Now, this is where Pat and I
Speaker 2: have chosen snippets from our entire catalog that we may
Speaker 2: not have dedicated an episode to yet, but they answer
Speaker 2: a commonly asked question that need an immediate answer. So
Speaker 2: we're starting off with one that we often get asked,
Speaker 2: and that is who makes a good v back candidate.
Speaker 3: So if you've press play on this quick kick, you've
Speaker 3: possibly had a.
Speaker 2: Previous caesarean section to birth your baby, and your thoughts
Speaker 2: are now turning to how you're going to birth the
Speaker 2: next baby.
Speaker 3: I want to start first with a quick definition.
Speaker 2: A V stands for vaginal birth after cesarean, and another
Speaker 2: term you might hear is TOLAK, which stands for.
Speaker 3: Trial of labor after cesarean.
Speaker 2: Feedback has its own set of considerations which Pat and
Speaker 2: I talk about, using a patient's story as an example.
Speaker 2: The full episode is number thirty four which will be
Speaker 2: linked in the show notes. But for this quick kick,
Speaker 2: we've honed in to one of the most important questions
Speaker 2: to ask if you're thinking about a vaginal birth after cesarean.
Speaker 2: That is, am I a good candidate for a feedback?
Speaker 2: In this nippet, Doctor Pat starts off by talking about
Speaker 2: assessment of your previous birth in history, and then the
Speaker 2: important complications or issues that might arise during pregnancy that
Speaker 2: change the answer to this question as you get closer
Speaker 2: to your baby's birth.
Speaker 3: Let's get quick on the kick.
Speaker 1: So who's a good candidate?
Speaker 4: I think the first thing that we should talk about
Speaker 4: is that you have to want it.
Speaker 1: Yeah, yeah, so Lucy wanted it. Yes, she really wanted it.
Speaker 1: Whereas you know, if you are ambivalent, yeah, really, or
Speaker 1: you really don't care.
Speaker 2: And that's okay too, It's really, it's really okay.
Speaker 4: Absolutely, it's got to be discussed in a judgment free zone.
Speaker 4: And these days you might only be having two babies.
Speaker 4: And if you just say, look, if my patients say
Speaker 4: to me, look, the first one was born by caesarian.
Speaker 1: Section, and they'll just give me another of those.
Speaker 4: Yeah, And I'm sure a planned section is going to
Speaker 4: be nicer than the emergency section I had last time anyway.
Speaker 2: And can I tell everybody a planed section is just
Speaker 2: so much.
Speaker 1: It's really nice. Yeah, it's not such a say this
Speaker 1: every day. It's not such a bad baby to all
Speaker 1: come in on.
Speaker 2: If that's your option, yeah, yeah.
Speaker 4: So that is not that is not not a problem.
Speaker 4: And if that's what the woman and her partner want,
Speaker 4: then decision mate.
Speaker 1: That's fine. So I think feedbacks are number one for
Speaker 1: people who.
Speaker 2: Want them and the people that want them. Like for myself,
Speaker 2: it was a deep psychological need to have a vaginal birth.
Speaker 2: It took me years and years to work with my
Speaker 2: mindset after my babies to accept the fact that I
Speaker 2: didn't have vaginal births.
Speaker 1: Yeah, so that's a thing.
Speaker 4: Okay, some people are very fixed on that, and there
Speaker 4: are other people for whom it's not such a strong,
Speaker 4: deep need, but it's a strong preference, yeah, and rather that.
Speaker 1: And there are a.
Speaker 4: Good number of people who don't mind, yeah, or don't
Speaker 4: or really aren't fast at all, And it's not part
Speaker 4: of what they would look at when they're looking back
Speaker 4: on that birth and saying do they feel good about
Speaker 4: it psychologically or not? If they honestly don't mind. So
Speaker 4: those people might just elect to have another section.
Speaker 1: For the people who prefer it or really really want it.
Speaker 1: The discussion should start early.
Speaker 4: Yeah, so moving on to who's moving on to more
Speaker 4: of who's a good candidate?
Speaker 2: I read on I thought a reputable website until I
Speaker 2: talk to you about it, which said ninety percent of
Speaker 2: women are good candidates for feedback.
Speaker 1: That's got to be overstating it.
Speaker 2: Yeah. Yeah, it wasn't a reputable.
Speaker 1: It's got to be overstating it.
Speaker 2: Yeah, it's so tricky. I mean it was a pregnancy association,
Speaker 2: and I thought I will Yeah.
Speaker 4: Look, you know, it depends the definition of good candidate.
Speaker 4: Ninety percent of people may tick someone's technical boxes about
Speaker 4: what you have to have, what has to be there
Speaker 4: for the v back to be safe. But I look
Speaker 4: at more than that about a good candidate. And one
Speaker 4: thing you've got to look at is the circumstances of
Speaker 4: the first berth.
Speaker 1: Yeah.
Speaker 2: Yeah, so Lucy had a breach.
Speaker 4: Yeah right, so she's she had a breach in her
Speaker 4: first pregnancy. Babies in a breach position and the vast
Speaker 4: majority of obstrations, including myself, would have delivered that baby
Speaker 4: by section.
Speaker 1: Yeah, but what that.
Speaker 4: Tells us though, if we do a Caesar for that
Speaker 4: woman because the baby's reach. For all, we know that
Speaker 4: woman labors like a.
Speaker 2: Complete champion, Yes, and she never win, just.
Speaker 4: That she didn't go into labor or certainly didn't get
Speaker 4: to advance. So in some ways that you know, in
Speaker 4: many ways, that's a good start. Yeah, let's say we've got,
Speaker 4: for argument's sake, another patient who is a very small,
Speaker 4: very short petiitue woman with a very tall husband, who
Speaker 4: made a very big baby and obstructed at four centimeters
Speaker 4: in that inner first labor, couldn't get beyond four centimeters,
Speaker 4: did decease, the baby came out four kilos. So she's
Speaker 4: another baby with the same partner. I'm nervous ready, Yes, okay,
Speaker 4: I'm thinking not a great candidate. That'll probably happen again.
Speaker 4: And there are two ways we can go with that.
Speaker 4: We could we could decide not to do it, not
Speaker 4: to do the feedback and just do a book section,
Speaker 4: or we could say, let's see how you go. But
Speaker 4: you're really going to have to progress very nicely in
Speaker 4: that labor. And you know the art of this is
Speaker 4: working out which way to go.
Speaker 2: Yeah, and experience, I would imagine, and yeah, that's.
Speaker 1: Right, because there isn't a strict rule book about things
Speaker 1: like that.
Speaker 2: No, And are there any other things that you would say, Okay,
Speaker 2: well that makes somebody not a good candidate.
Speaker 4: Yeah, I think if Well, it's my belief that if
Speaker 4: you've had more than one previous section, that you shouldn't have.
Speaker 2: I know, I remember when we had when we were
Speaker 2: pregnant with that, you know, our third, your first, my third,
Speaker 2: and I was trying to convince.
Speaker 1: You, but I want to have so that is in
Speaker 1: my fear. That's that's a problem.
Speaker 4: There are some people out there who believe that the
Speaker 4: numbers are okay for two previous sections, and virtually no
Speaker 4: one thinks that the numbers are okay for three previous sections.
Speaker 1: Yeah.
Speaker 4: Yeah, I think that it doesn't come up that often.
Speaker 4: But if we look at two previous sections, it's my
Speaker 4: view that that's significantly the risk is significantly higher than
Speaker 4: for one. And I don't think in twenty twenty, when
Speaker 4: we expect very very good outcomes from the childbirth, that
Speaker 4: that's one we.
Speaker 1: Can live with.
Speaker 2: I'm very pleased that I had a plan section in
Speaker 2: the end, only because the obstrition. It wasn't people didn't
Speaker 2: deliver the baby'sus.
Speaker 1: I was there holding your hand.
Speaker 2: The obstrition at my obstrition was saying, look, you know,
Speaker 2: I don't remember her saying. Was I'm not sure what
Speaker 2: to s what to what here? So things had thinned
Speaker 2: and yeah, So.
Speaker 4: If you've had multiple previous caesarian sections, the lower segment
Speaker 4: of the uterus gets.
Speaker 2: Very thin and two long labors, so.
Speaker 4: We worry about the ability of that tissue to withstand
Speaker 4: the forces of a subsequent tum labor. If you've had
Speaker 4: one previous caesarean section, the lower segment of the uterus
Speaker 4: will be a little thinner, but not so that it
Speaker 4: adds a huge amount of extra risk.
Speaker 2: What about the woman that's a vaginal birth, a cesarian birth,
Speaker 2: because perhaps the baby was in breach. What sort of
Speaker 2: candidate is she?
Speaker 1: Perfect?
Speaker 4: Okay, okay, because we know that we know she can
Speaker 4: have a baby vaginally. Yes, so if she has another baby,
Speaker 4: you're roughly the same size, she say, an ideal feedback candidate. Okay,
Speaker 4: and yeah, that happens from time to time, vaginal birth,
Speaker 4: the first caesar for the second for breach, or twins
Speaker 4: or previa and then back to vaginal again.
Speaker 2: Yep, And I think, can things happen like I remember
Speaker 2: Lucy was telling me on the phone. I'm not sure
Speaker 2: we talked about it during our interview just then, but
Speaker 2: she was saying that you would check in every single
Speaker 2: appointment and say, yes, we're still on track for a fback,
Speaker 2: and things happen within a pregnancy that can change it absolutely.
Speaker 1: So that sounds like me. I definitely would return to
Speaker 1: it each.
Speaker 4: Anti natal visit in a fairly methodical way, and in
Speaker 4: my mind, I'm thinking, yes, we still meet the sort
Speaker 4: of requirements. Okay, So the things that might arise during
Speaker 4: the pregnancy that would really make us rethink the plan
Speaker 4: for a feedback might be complications, and those might be
Speaker 4: things like a.
Speaker 1: Baby that was really too big.
Speaker 4: Yeah, a consistent, reliable ultrasound evidence that the baby.
Speaker 1: Was very big.
Speaker 2: Yeah, And can we just recap what's a very big baby? Again?
Speaker 4: Well, if for in a vback situation, I would start
Speaker 4: to get a little concerned about a baby in the
Speaker 4: top ten percent. Yeah, okay, because it seems it sort
Speaker 4: of stands to reason that that baby might be slightly
Speaker 4: harder to get out and might and might put more
Speaker 4: forces on the scar from the previous section.
Speaker 2: Yea.
Speaker 4: Then other things that are potentially a complication and might
Speaker 4: just add one risk on top of another significant diabetes
Speaker 4: insulin dependent you know, preclams here, things that those are
Speaker 4: things that might arise during the pregnancy. And then things
Speaker 4: that we would know right at the start that might
Speaker 4: just make us think this isn't a goer.
Speaker 1: Would be placenta previous twins, Yeah.
Speaker 2: Yeah, wow, vback with twins that would be risky, risky
Speaker 2: yeah yeah. And what about Like my problem really was
Speaker 2: that I just did not go into spontaneous labor. I
Speaker 2: avoided the I was a terrible patient pat I avoided
Speaker 2: the healthcare people and got to forty two weeks.
Speaker 4: So yeah, well, so the perfect time I think to
Speaker 4: labor with her with her vback is spontaneous labor term.
Speaker 4: So let's break that down a little bit. Spontaneous labor
Speaker 4: is definitely preference because if the patient wants are feedback
Speaker 4: and there's some reason to induce, then our options are
Speaker 4: quite limited.
Speaker 2: In terms of how to induce.
Speaker 4: Yeah. Right, So with the vback, patient by definition has
Speaker 4: got a scar on the uterus from the previous previous pregnancy,
Speaker 4: and if she suddenly needs to be induced for whatever reason,
Speaker 4: the toolkits at a little lean that pross and jelly
Speaker 4: that we put in the vagina to mature the cervix.
Speaker 2: Can't use that pretty much.
Speaker 1: Can't use that. It's not thought to be safe in
Speaker 1: the way that it.
Speaker 4: Can overstimulate the uterus. The drip that we might run
Speaker 4: during an induction to get those contractions up and cooking.
Speaker 4: Most of us don't use those that drip. For some
Speaker 4: people consider it to be acceptable as long as we're
Speaker 4: using the drip just to tip somebody in, but not
Speaker 4: to whoop them along as as I usually put it.
Speaker 1: So there's risks there. So the best induction, of course,
Speaker 1: is the one you don't do it all.
Speaker 2: Yeah.
Speaker 1: Yeah.
Speaker 4: And if the patient comes into spontaneous labor term fantastic.
Speaker 2: Yeah.
Speaker 1: Out post dates two problems.
Speaker 4: There's some issue that that woman's not coming into labor
Speaker 4: and that might need effort to get her into labor, including.
Speaker 1: The use of drugs that we should be using for
Speaker 1: a VBAC. And secondly, the baby's getting.
Speaker 2: Bigger all that time, all the time. Yeah, I definitely.
Speaker 2: I think that's why my babies were so big. You
Speaker 2: know they had the two oldest boys had two more
Speaker 2: weeks of cooking.
Speaker 1: Well, that's right.
Speaker 4: So there is a tide, you know, the perfect time
Speaker 4: in the tide for a v back, and if you
Speaker 4: happen to labor at that time, fantastic.
Speaker 2: Yeah, it's a very big pressure if you're wanting a
Speaker 2: v back and you're not going to spontaneous labor, you're
Speaker 2: doing everything and nothing nothing works.
Speaker 1: Yeah.
Speaker 4: Sometimes if someone's very keen and we're up to post dates,
Speaker 4: the sort of turn plus seven days, turn plus ten days.
Speaker 4: Wherever your institutions post dates cut off, is.
Speaker 1: It is possible to come in and break the waters. Yes,
Speaker 1: that's safe.
Speaker 2: Yeah.
Speaker 1: What it does do is set the timer tick.
Speaker 2: Yes.
Speaker 4: Yeah, So if we do that first thing in the morning,
Speaker 4: then we're either going to come into nice, strong, natural
Speaker 4: labor and have that baby vaginally, or we're getting a
Speaker 4: section at some point, because you know, the timer will
Speaker 4: start to tack when the water's broken.
Speaker 2: Thanks for listening. Now head over to the floor episode
Speaker 2: if you want to hear one of our beautiful patients, Lucy,
Speaker 2: describe her successful vback she had for her second baby,
Speaker 2: and in this full episode, we also explore the additional
Speaker 2: monitoring that you might need during a vback, what questions
Speaker 2: to ask your care provider, what pain relief options are
Speaker 2: available if needed in a vback, and how to set
Speaker 2: yourself up to feel satisfied with your birth really no
Speaker 2: matter how your baby is born. I hope you like
Speaker 2: this format and if you have an idea for a
Speaker 2: quick kick something you might think that is a common
Speaker 2: question that others might have as well, send us a
Speaker 2: DM on Instagram at the Kick Pregnancy podcast and we'll
Speaker 2: put it on the list. In the meantime, we hope
Speaker 2: this has helped answer your question who makes a good
Speaker 2: v back candidate? Thanks for listening, Bye for now.