Hey Laura, I need info on VBACs

A friend of mine wrote to me this week, asking me to get some info for her on VBACs (vaginal birth after cesarean). She’s watched The Business of Being Born and now needs some “solid, unemotional, unhysterical supported information on the subject” to complete her act of due diligence on researching the subject.

Her doctor refuses to “allow” a VBAC, so she’ll have to find a new care provider if she chooses this route. Her husband feels a little skittish about a VBAC, so a lot of this information is going to help him get his head around the facts about VBACs, too.

Since I want to make this write-up as useful as possible to as many people as possible, I’m not going to go into specifics pertaining to my friend’s situation. Rather, I’m going to inundate you with a bunch of links so you can do the reading in whatever area you need to!

A note of concern: This is a highly emotionally charged subject. A woman’s labor and birth story are intensely personal; the choices she made (or that were made for her) are part of the narrative that gives depth and meaning to her birth experience. When I talk about risks and benefits of C-sections vs. vaginal delivery, I want to be compassionate to others’ stories.

Ultimately, the decision rests in your hands. What is important to me, personally, is that regardless of the kind of childbirth you opt for, you make an informed decision. That’s why I have this blog, after all!

Who is a good candidate for a VBAC?
The American Pregnancy Association has a nice writeup of all the qualifying conditions for a VBAC, as well as a risk comparison between VBAC and repeat cesarean.

Here’s the American Congress of Obstetricians and Gynecologists’ (ACOG - the trade union of OBGYNs) patient education pamphlet on Trial of Labor after Cesarean Delivery (TOLAC).

For local VBAC support and first hand info from parents in your area, find your local chapter of the International Cesarean Awareness Network here. It might be a good place to get referrals to care providers who are truly supportive of VBACs.

Risks of C-section
When talking to an obstetrician who is not open to VBACs, you can often come away with the feeling that “Vaginal Birth = Risky” while “Cesarean Birth = Safe.”

Unfortunately, it is not that cut and dry. Aside from the standard complications associated with abdominal surgery, the following risks inherent with C-section should also be taken into consideration:

Dramatically increased risk of neonatal death
Neonatal death (that is, within the first 28 days) is rather rare in either case, but this CDC study finds that “regardless of risk factors, babies born by cesarean section face a risk of death nearly three times that of vaginally born babies.”  Here’s the abstract: “Cesarean deliveries with no labor complications or procedures remained at a 69 percent higher risk of neonatal mortality than planned vaginal deliveries.”

Risk to baby’s future health
Babies born by C-section experience changes to their DNA that do not occur in vaginally born babies. Scientists think these genetic changes may help explain why C-section birth is associated with an increased risk of diabetes, asthma, and other breathing problems.

Another thought as to why C-section birthed babies have a higher frequency of health problems is what kind of bacteria populates the baby’s gut. Whereas babies who are pushed through the vaginal canal receive their mother’s beneficial bacteria (such as Lactobacillus) in their mouths, noses, and on their skin, babies born directly into a hospital operating room tend to gather a high concentration of less friendly (e.g. Staphylococcus) bacteria.

Risk to mama’s health
Here’s a list of Cesarean risks (also includes risks to baby), including infection, hemorrhage, and adhesions. You can read more about pelvic adhesions and how to reduce the risk.

This study showed that long-term risks of C-section include a higher risk of future infertility and incomplete pregnancies (miscarriages, etc.), ectopic pregnancy, and placental issues (e.g. placenta previa).

Risks of VBAC
The greatest risks one runs when attempting a VBAC are simply those inherent in vaginal birth: most frequently vaginal soreness and laceration, and rarely, temporary incontinence.

Uterine Rupture
You will hear this frightening term thrown around a lot, when delving into the world of VBACs.

While uterine rupture is a serious and sometimes deadly complication, it occurs in less than 1% of VBACS and

Medical experts state that the risk of a uterine rupture with one prior low-horizontal incision is not higher than any other unforeseen complication that can occur in labor such as fetal distress, maternal hemorrhage from a premature separation of the placenta or a prolapsed umbilical cord.

(from VBAC.com’s excellent piece on uterine rupture.)

Uterine rupture is a scary word, isn’t it? Can I just quote this part of that article for you here? I think it is worth highlighting (with my own emphases).

Women who receive good prenatal care, whose care providers are trained and experienced with VBAC, and who labor in a facility that is equipped to provide immediate medical care usually have good outcomes. To date there have been no reports of maternal deaths due to uterine rupture. According to the National Institutes of Health Consensus Development Report on VBAC , while rare for both, laboring for a VBAC and elective repeat cesarean, current research shows that maternal mortality is significantly increased for elective repeat cesarean, 13.4 per 100,000, compared to 3.8 per 100,000 when laboring for a VBAC.

This is why it is so important to pay attention to the numbers. While the risks are reasonably low for both a repeat C-section and a VBAC, you are statistically more likely to die when you choose a repeat C-section than a VBAC. Similarly, with ready access to emergency care, full-term, low-risk neonates do not experience an increased rate of mortality during a uterine rupture*.

Are you or your baby very likely to die during either form of childbirth? No. I’m not trying to scare you from getting pregnant again! But these are the cold, unemotional facts you are looking for.

Improving your odds of a successful VBAC
Choose a midwifery model of care
If you are comfortable, find a VBAC-friendly midwife in a free-standing birth center or who will deliver you at home. The closer you get to the hospital, the higher your risk for a non-emergent C-section becomes. More on that here and here. Out-of-hospital births are also dramatically cheaper.

Hire a doula
Having a doula present at your birth helps shorten duration of labor, reduces requests for pain meds/epidurals, and reduces the likelihood of forceps, vacuum, or cesarean extraction. More info on the benefits of doulas here.

Avoid induction and epidurals
“Labor induction is significantly associated with a cesarean delivery among nulliparous women at term for those with and without medical or obstetric complications.” (Source.)

Because the risks of epidural anesthesia include slowing labor and an increase in the risk of fetal distress, (besides restriction of eating and movement during labor), consider natural forms of pain relief.

Consider acupuncture and/or chiropractic care
Some interesting info on how acupuncture can decrease cesarean rates. The Webster Technique of chiropractic care can be helpful in correcting malpositioning of fetuses, and it helps keep the pelvis in proper alignment during pregnancy. It does wonders for low back and hip pain, too.

New to me: Homeopathy can sometimes help turn babies!

Improving a repeat Cesarean experience
Here’s a nice list of ways to create a positive C-section experience.

After the baby is extracted, request for immediate skin-to-skin contact with yourself for 5-10 minutes, then prolonged skin-to-skin contact with Daddy until you are done with post-op. It helps the transition from the womb and helps populate the baby’s gut with friendlier bacteria.

Read up on how to protect and encourage a strong start to breastfeeding after a Cesarean.

My thoughts
****I’m not a healthcare professional. I cannot make your decision for you. Talk with a trusted OB or midwife about your specific situation before you plan your next birth!****

Statistically speaking, if you have a low-risk pregnancy, it is safer (both during the delivery and long-term) if you deliver vaginally - even after a C-section.

A uterine rupture can be fatal without an emergency C-section. But so can placental abruption, prolapsed cord, and shoulder dystocia and yet you don’t hear of OBs refusing to facilitate a vaginal delivery based on the potential risk of these unpredictable complications.  Look:

(Source: “Putting Uterine Rupture into Perspective”.)

To put the numbers into further perspective, while the generally accepted incidence (in developed countries) of uterine rupture in scarred uteri is .07%, spontaneous uterine rupture in unscarred uteri is .012%.

Fear of uterine rupture is not a rational reason to forego a vaginal birth, so long as you meet the criteria for a low-risk VBAC attempt.

Your best bet for a successful VBAC is outside of a hospital, with a midwife and a doula in attendance, within a quick transfer distance in case of an emergency. Hospitals are the best place for emergencies or surgical birth; they are quickly becoming the enemy of a natural vaginal birth with no interventions. If you choose to give birth at a hospital, make sure you factor in their C-section rate as you consider your odds for a successful VBAC.

All this dizzying discussion of risks vs. benefits aside, is a VBAC a worthwhile goal in and of itself?

I really think so. Based on my own experiences, I’m a really fervent advocate for natural, midwife-assisted, out-of-hospital births. I think the way birth is currently being done to women in the US is atrocious; the medicalization of birth strips it of its mystery and majesty and leaves many women feeling broke, bereft, and violated.

The 30% C-section rate in the US is reprehensible. The World Health Organization recommends a C-section rate of no more than 15%, with the best outcomes for mothers and babies occurring at a 5-10% C-section rate*. Yet one out of three US mamas and babies are subjected to surgical births.

And while the surgical extraction of a baby from the womb can be an amazing, life-saving medical procedure in an emergency situation, it is also an unnatural, violent, and traumatic way to begin life in the outside world. We should be actively working to reduce C-sections, and the emergencies that create them.

Imagine you have decided to conceive a child.

You can either go about it the “natural” way: which typically requires some sweating, awkward maneuvering and position changes, emotional vulnerability, and possibly a few animal noises. ;)

Or, you could choose a more sanitized, medicalized approach: glaring lights, blue surgical masks hovering around your nether regions, and lots of shiny metal equipment.

Sometimes the natural way isn’t an option, and for that, the medicalized answer to conceiving a child is truly miraculous! But not a whole lot of people request surgery over sex from the get-go.

Likewise, babies can come out much the way they are put in: with an invasion of strangers and a clamor of bright lights, or with soul-stirring intimacy (plus or minus a few animal noises!) in the arms of a trusted partner - an experience which can, more often than not, leave you in a glorious haze of endorphins for days afterward.

Which would you choose?

Further reading
If you read nothing else about VBACs, definitely read A Woman’s Guide to VBAC.

A well documented list of risks to both mother and baby, presented by VBACfacts.com. You might also glean some useful info from their Long Facts list, particularly the section on uterine rupture.

The Childbirth Connection has a nice page entitled “Best Evidence: VBAC or Repeat Cesarean?” as well as a trail of other resource links from that article. You may want to also read the “Options: VBAC or Repeat Cesarean” page.

The Coalition for Improving Maternity Services (CIMS) has an excellent pdf fact sheet here.

A very long, in-depthreview of the research on uterine rupture, from WebMD.

Although this article from VBACfacts.com comparing risks of VBAC vs. Amniocentesis dips into the realm of editorial commentary and soapboxing, I think it raises some valuable points. In particular, the language used to describe the risks of each procedure:

The March of Dimes, which quotes rates of miscarriage comparable with rates of uterine rupture in a VBAC, describes the risk of miscarriage vis-à-vis amniocentesis as “small” and “uncommon.”  And these numbers are 5 – 20 times higher than the risk of fetal death or injury from a VBAC.

ACOG themselves, describes the risk of 1 in 370, as “small” as does the American Academy of Family Physicians.  This is 5.4 times greater than the risk of fetal death or injury a VBAC.

While it is emotional, it is not hysterical. The statistics are a few years old, but the commentary is what is really worth reading here.

Here’s a lengthy systematic evidence review on VBACs prepared by the Oregon Evidence-based Practice Center at Oregon Health & Science University. I have only skimmed it, but I think chapter 3, on the VBAC attempt and success rate (and factors that influence it) will be most useful.

An easy to follow, review of VBAC research called “When is VBAC appropriate?”, published by OBGManagement.com.

Another review of VBAC literature here. One of the few reviews that distinguishes between uterine rupture rates in spontaneous vs. induced labor.

I would love to get some feedback from anyone experienced in this area. Do we have any VBAC readers out there who want to weigh in with their stories?

Hey Laura, I think... Hey Laura, I need info on VBACs

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