Interview with Dr. Jean-Giles Tchabo
When I was in labor with my first baby, my regular OB had to leave and I was terrified. I trusted my OB and didn’t know this new doctor that was coming on rotation, and I didn’t want a random doctor making medical decisions that could mean life or death for my baby and I.
The hospital staff reassured me that the physician coming on rotation, Dr. Jean-Giles Tchabo, was “the best,” and had trained every doctor at the hospital. If I wanted a vaginal delivery, they said, this doctor was the one who was going to make sure I got it. I thought they were trying to placate me until my husband confirmed it by looking him up online on his phone.
But what we want and what is medically essential are sometimes different things. As I’ve written before, I ended up needing an emergency c-section and it was a fairly traumatic experience. However, I’ve reviewed my medical files and I’m confident that Dr. Tchabo’s decision was in the best interests of myself and my son.
For my recent pregnancy with my daughter, I followed Dr. Tchabo to his own practice, and found that they encourage vaginal deliveries after cesarean section (VBAC), which something that not all practice or hospitals allow. So prior to my delivery, I decided to sit down with him and ask some questions about VBACs and repeat c-sections. Here’s what he had to say:
Something I loved when I first came to your practice was that everyone immediately assumed that I was going to have a vaginal birth after cesarean section (VBAC) and I know that’s something that a lot of women don’t get. Why do you default to a VBAC until proven otherwise?
Dr. Tchabo: When I was in training, the rule used to be “once a c-section, always a c-section,” but then in the 1970s in Los Angeles things started to slowly change. Because second labors tend to progress much faster than first labors [Dr. Joseph Collea] noticed that some women would make it to the hospital either very close to delivery or would deliver before the operating room could be prepped. Most of those women went on to have successful vaginal deliveries, so we started to wonder if maybe the rule was wrong.
Now we know that at about 70% of women that have c-sections don’t have them because there’s a physical abnormality with the mother or the baby that prevents a vaginal delivery, but because something goes wrong in labor. Either labor stalls, the baby goes into distress or is malpositioned, and that necessitates a c-section. For those women, most are good candidates to have a VBAC, and a VBAC is almost always preferable to another c-section in terms of recovery for the mother.
Lots of women come into my practice and believe that because they’ve had one previous c-section they need to have another, some of them are afraid to try, some are scared of child birth because an emergency c-section is not a good experience. They don’t teach us how to talk to patients in medical school, you know how to treat the problem, but not when the patient is afraid of treatment. So you have to talk to them, figure out where the fear is coming from and figure out if the fear is legitimate or if it is something you can talk them through.
Why do you feel so many hospitals and OB/GYNs are reluctant to support VBACs?
Dr. Tchabo: Everybody gets cold feet. A VBAC carries more risk than an uncomplicated vaginal delivery, so
hospitals and large practices institute policies that either prohibit them restrict women. They say “OK you can have a VBAC but you have to go into labor on your own, or before 40 weeks or you can only
labor for so long.” This all has to do with risk and concern that something will go catastrophically wrong [like a uterine rupture]. There is a risk that something can go wrong during a VBAC, and the woman has to know that risk is there, but that is why you look at a number of different factors before you endorse a VBAC.
The megagroup [practices] that have become normal now with five and nine doctors have also made it hard [to encourage VBACs]. It’s hard to get four doctors in the same room to agree on a plan of care for a patient. What is a low risk for one doctor is an unacceptable risk to another. So you can have one OB that sees a woman through her pregnancy, but when she goes into labor another doctor is on call, so he looks at her notes and says, “this is too risky for me, we’re going to do another c-section,” and the woman is caught in the middle.
You’ve mentioned that most women that have had one previous cesarean section can go on to have a successful VBAC, what are some of the things that would make you recommend a repeat c-section?
Dr. Tchabo: So long as there are no conditions that contraindicate labor. There are a number of factors, including whether or not there was a physical abnormality with the mother or child that prevented vaginal birth, for example, if the head or shoulders are too big to safely pass through the mother’s pelvis. The length of time between the previous c-section is also a factor, if pregnancies are too close together the risk goes up for something catastrophic happening like uterine rupture. The type of scar and thickness of the scar tissue are also things we have to considered before considering a mother a good candidate for a VBAC.
Our goal is always a safe mother and a safe baby and doctors must do their homework to ensure that happens. Always, the reasons why the first c-section was performed, the type of incision, the space between pregnancies and the thickness of the previous scar must be considered to make sure everyone is safe.
Together, Dr. Tchabo and I decided we would schedule a c-section for the birth of my daughter, as the same scenario that led to the first c-section would present itself again with the second delivery. More on that coming up – tune in tomorrow for part two, where Dr. Tchabo answers reader questions and discusses repeat c-sections.
* And although we say it often, Julia and I need to say it again here: Never, ever, take medical advice from strangers on the internet, including from us! Talk to your real-world physician before you make any medical decisions for yourself or your child. SERIOUSLY!*
Disclosure: Dr. Tchabo delivered Leslie’s first baby and she used his practice for her second pregnancy although he did not deliver her second child. She received no compensation or special consideration for this series. This series ran several months after Leslie delivered her second child.