TOLAC is a medical abbreviation for Trial Of Labor After Cesarean, which is a planned vaginal birth after a cesarean (VBAC). If the TOLAC is successful, it results in a vaginal birth, otherwise, another cesarean delivery is needed. A birth is officially considered a VBAC once the TOLAC results in a vaginal delivery.

Is attempting a VBAC risky?

The biggest risk of attempting a VBAC is uterine rupture. What this means is that the scar of the uterus from a previous C-section can open (rupture). The umbilical cord or even parts of the baby can protrude from the area which, as you can imagine, is problematic. Often times, these ruptures can be asymptomatic. Before attempting a VBAC, the OB may evaluate the type of previous incision and use a sonogram to determine scar thickness. OBs may take into account the age of the mother along with the type and thickness of the scar when talking about doing a VBAC.

The risk of uterine rupture is higher if you attempt VBAC less than 18 months after your previous delivery.

Can a home birth VBAC be done?

A VBAC at home is labeled HBAC (Home Birth After A Cesarean) and can absolutely be done. There are arguments on both sides about this, but the number of HBACs is increasing, mostly due to the restrictions on VBACs in the hospital. In one study from 2004-2009, the success rate of a HBAC was much higher than the hospital VBAC, but not without some issues. I welcome you to read over the study here. As of now, there are no known scientific data to show whether HBAC carries more risk than home birth for those without a prior Cesarean. As with all

What would disqualify a person for a VBAC?

Since uterine rupture is the biggest risk for attempting a VBAC, prior uterine surgeries, such as fibroid removal would likely disqualify a person. If you have had a prior uterine rupture then you also not be a candidate. Many OBs will not consider a VBAC if you have had more than two prior cesarean births.

Induction and VBAC

While the risk of uterine rupture is greater, VBACs and inductions can be used together. Induction does need to be much slower. Pitocin is used for induction and creates contractions. The higher amount of Pitocin given, the more intense and frequent the contraction. If you have a uterus with a scar, jiggling it too much and too fast will create an environment for rupture.

Think about your uterus as a bag of water. If you have a bag of water and that plastic bag is intact, you can jiggle it all day long and the risk of it breaking is pretty low. But you have a plastic bag that has a rip in it, but the rip is covered with duct tape, the risk of it breaking from jiggling is greater. Therefore when jiggling the bag of water with a taped up rip, you must jiggle slower as to not break the bag.

Why finding an OB that supports a VBAC can be challenging

To summarize all of this, many OBs and hospitals find VBACs an unnecessary risk. There is far less risk, in their eyes, to simply doing a routine C-section. There are some that flat refuse. One of my first doula clients that had to have a cesarean birth found herself pregnant again (yay!), but she was in a new state and they simply refused any other possibility other than a repeat C-section. I was shocked at this, but I know it happens.

“The World Health Organization (WHO) recommends an ideal C-section rate of 10 to 15 percent of all births. The current rate in the US is 31.5 percent — about one in three babies.” Full article here.

“According to the American College of Obstetricians and Gynecologists, a mother’s uterus has less than a 1 percent chance of rupturing at the site of a C-section scar if she attempts a vaginal birth. That risk increases to a little less than two percent after two or more C-sections.” Putting those stats in perspective, that is one or two births per 100 that end in uterine rupture. When put that way, OBs become restrictive when talking about VBACs.

As with all things, do your research. Talk to a potential OB, talk to a potential midwife. If one person says no and you are not at any risk for a VBAC, you can always find someone else if that is the route you wish to take. At any point during your pregnancy, you can change doctors, change midwives and hospitals. You are never locked in.

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What is an umbilical cord?

The umbilical cord is the vital connection between the fetus and the placenta. Umbilical cord development begins around week 3 with the formation of the connecting stalk (pre-umbilical cord where embryo is connected to what will become the fetal portion of the placenta). By week 7, the umbilical cord has fully formed.

By the end of the first trimester, the umbilical cord is comprised of are two arteries and a vein. It is surrounded by a j gelatinous substance call Wharton’s Jelly. The umbilical vein carries oxygenated blood with nutrients from the placenta to the fetus and the umbilical arteries transporting deoxygenated blood with waste products from the fetus to the placenta.

What does Wharton’s Jelly do?

A thick, gelatinous substance made primarily of collagen, its main job is to provide cushioning and protection for the umbilical cord’s three blood vessels by preventing the cord from becoming compressed or bent. Wharton’s jelly also supports the umbilical vessels’ ability to deliver oxygen, blood sugar, and amino acids to a developing fetus. [Miraclecord News]

What’s does this have to do with an umbilical cord knot?

Occasionally the cord can knot and happens naturally as baby moves around. It can also happen during delivery as baby twists and turns towards the exit. Usually not posing a threat, these knots often unknot on their own. Wharton’s jelly prevents small knots from getting tight.

Sometimes; however, the knot gets very tight, and healthcare providers call this a true knot. Unlike a small knot that loosens easily, a true knot is so tight that it can block oxygen and nutrients from reaching the fetus. It can cause complications during pregnancy and delivery because it deprives the fetus of vital nutrients and oxygen. These true knots comprise less than 1% of all pregnancies.

How to know if I have a true knot?

Its important to monitor movement especially in the last trimester. If baby is moving significantly less, then this is something you want to bring up to you midwife or OB. True knots can be diagnosed through ultrasound. Since you can’t unknot the knot, your health care provider will monitor you and baby much closer and more often. An elective cesarean plan may be brought up if baby is in increasing distress. Labor can also tighten a true knot and can become an emergency if baby is in distress.

Are there risk factors for umbilical knots?

These true knots are rare. Small knots, like the one above, is rarely a cause for concern. The concern comes in when they become tight, potentially cutting off oxygen to the baby. According to the Cleveland Clinic, these are some risk factors:

• The fetus is small for its gestational age.
• The umbilical cord is very long.
• You’re carrying monoamniotic twins (identical twins that share an amniotic sac).
• You have too much amniotic fluid (polyhydramnios).
• You’ve had two or more pregnancies (multiparity).
• You’re older than 35.

To sum up

Know you body and your baby. Heading into the third trimester, if movement of baby has reduced, inform your healthcare provider. Most knots are nothing to be too concerned about and change with baby’s movement. Wharton’s Jelly keeps the cord well lubricated so the knot doesn’t become tight. Enjoy your pregnancy, there will be plenty of skinned knees to worry about later.

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What does U.F.O. stand for? Simply put, it means upright, forward and open. When having your body in this UFO position there is an astounding 28% more space in your pelvis that when you are lying on your back. Holy Cow Batman!

Why does it seem everyone lies on their back to give birth?

You see it in the movies–woman lying on her back in extreme pain, grunting, groaning, sweating, holding their breath, pushing. We are inundated with images of birth this way in books, television, movies and many birth photos you see online. Unless there is a medical reason or your body simply wants to, birthing on your back is just plain difficult.

Why is it difficult? For one thing, you are pushing uphill. For another you are closing off space.

Our coccyx bone usually tucks right into the pelvis, as your baby’s head descends it pushes the coccyx out of the way. If there is something blocking this move (like a bed if you’re lying on your back) it slows baby’s descent and makes life much harder for you both! —birth-ed

What are some upright positions for labor?

Glad you asked! Upright can include most anything that is not lying flat. It can be on a birth ball, swaying or holding onto your birth partner, in a shower chair, on the toilet, squatting, using a birth bar and even in a sideline position on the bed.

Ok, I get upright, but what is forward in the UFO acronym?

Leaning forward into your bump, either by leaning onto your partner, using a wall to lean on or using a birth ball helps open up the pelvis and encourages baby to move into positions easier for birth. No need to complicate it, your body instinctively knows the best position to be in, trust your own body.

The open part is easy.

If you are upright and leaning forward, you will be open. These positions (squatting, leaning over something, on all fours, kneeling) all help by reducing the length of the birth canal. A shorter birth canal means the baby has a shorter distance to go to get to the outside world.

I will be getting an epidural, do I have a choice of labor and birth positions?

You will be happy to know that giving birth on your back does not need to be your destiny when receiving an epidural. There is something know as a walking epidural. These are not “all-numbing” like the standard epidural, but it still provides effective pain relief. Contrary to it’s name, you are not going to go walk around, but you will have more range of motion than the standard epidural. This will allow you to move into different positions (with assistance) in the bed.

If you opt or need the standard epidural, blotting out all sensation, you are still not destined to a flat back delivery. The sideline delivery can work very well to keep you open. Including a peanut ball between your legs while on your side can be very useful.

I will go into the different epidural options and your range of motion in a subsequent blog post. In the meantime, keep on with UFO!!

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Celebrating pregnancy and motherhood

This is a time to celebrate motherhood and pregnancy. You will not be pregnant forever, although it may seem like it! Even if you have additional children, this moment, with this child is unique and deserves a portrait. Love yourself and those big ankles.  Love that big tummy. Photograph them for all time.

One of my favorite quotes

“To be Pregnant is to be vitally alive, thoroughly woman and distressingly inhabited. Soul and spirit are stretched – along with body – making pregnancy a time of transition, growth and profound beginnings.” –Anne Christian Buchanan

The Popularity of the Maternity Portrait

The importance of maternity portraits has led to their popularity. As a result of women becoming more empowered, the desire to document these moments has risen. Look at birth photography. That genre is still in its infancy really.

Pregnancy has been part of art for centuries, but mostly pregnancy is part of a story being told. “Among the oldest surviving examples of the depiction of pregnancy are prehistoric figurines found across much of Eurasia and collectively known as Venus Figurines“.

To read more about the history of pregnancy portraits, click here. If you are ready to celebrate with a maternity portrait, contact me today.

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