Talk About Tuesday- VBAC vs Cesarean

*If you are interested in seeing what everyone else is talking about today or want to join us, please visit Lara at The Lazy Organizer.


I know I have already blogged about VBACs vrs Cesareans when I first began my research. My VBAC plans were side railed a little when it was discovered at my 20 week ultrasound that I had a low lying placenta and therefore possible placenta previa. I didn't stop my research however, because it is possible for a low lying placenta in early pregnancy can move on it's own as baby grows. Also, I had volunteered to give the monthly topic of discussion for my local breastfeeding group and I choose this same topic.

Here is what I had to say:

CESAREANS

Paraphrased from The Thinking Woman’s Guide to a Better Birth: The goal is not to be needlessly alarming. I would rather you be uncomfortable rather than ignorant. I don’t want you to have cause to say “But I didn’t know THAT was an option” or “I never would have agreed if I had known THAT could happen”. The important thing is that how we birth our babies is a conscious CHOICE and not one we felt pressured into making.

WHY ARE CESAREANS USED?
Theory: to remove a baby from the mother when a vaginal birth cannot happen or would endanger the health of mother or child

Practice: are often used before the possibility of a vaginal birth has been completely ruled out

In the US, some hospitals perform c-sections on as many as 1/3 their maternity patients and in a few hospitals that number is closer to 1/2 .

In the US, C-section is the most common major surgery procedure performed.

Cesareans are a wonder of modern medicine. They do indeed accomplish what they set out to do: deliver a baby that might not otherwise have survived or would have survived with severely compromised health. BUT, as a routine method for birthing babies, cesareans are not quite as effective. Despite escalating rates (5% in 1970 to 25% in late 90’s) birth outcomes have not improved- mortality rates have not gone down, general health of mothers and newborns has not changed.

Obstetricians once viewed cesareans as more dangerous than vaginal birth. However, improvements in surgical and anesthetic techniques have changed that perception and consequently, the c-section frequency. By rescuing mother and baby from the supposed rigors and hazards of labor, c-sections reinforce the obstetric belief in the superiority of technology over nature.

It is not just drs who are to blame for the increasing c-section rates. The litigation conscious society we live in has also helped the c-section rates to soar. It is not difficult to understand why the slightest sign of fetal distress may cause drs to head straight for the operating room in an effort to cover their butts. BUT we as mothers have to cover OURS as well!

Most cesareans are done for reasons that depend on a judgment call.

WHEN C-SECTIONS ARE NECESSARY
Placentia Previa-vaginal birth would tear the placenta, depriving baby of oxygen and nourishment, vaginal birth may be possible if the placenta previa is only partial, meaning only partially over the cervix
Prolapsed umbilical cord-when the cord comes out before the baby there is a danger that the baby’s oxygen will be cut off

WHEN C-SECTIONS MAY BE NECESSARY
Active herpes at time of labor-amount and location should be considered because they can be covered with bandages and a vaginal birth possible
Transverse lie- baby is positioned sideways and unless the baby can be moved into a viable birthing position, a vaginal birth is not possible
Cephalopelvic disproportion-baby’s head is too large to pass through the pelvis. Although drs often schedule c-sections for suspected CD, this condition is actually rare and can only be accurately determined when in labor
Decision to end pregnancy early- if the baby has a medical condition that can be better treated outside the womb
Severe pre-eclampsia or uncontrolled diabetes- each situation in these cases needs to be assessed individually

WHEN C-SECTIONS ARE UNNECESSARY
Failure to progress- does too long of a labor indicate a true risk to the health of mother and baby or does it simply mean labor is not adhering to a pre-determined time table
Fetal distress- a “longer” and “difficult” labor raises fear that a baby’s health may be compromised. Many experts believe this is done too frequently without good medical cause. Electronic fetal monitors especially when used continuously during labor are a main culprit in causing drs to incorrectly believe an infant is in distress
Breech position- 4 to 5 % of all c-sections are for this reason. Sometimes is even scheduled before a women goes into labor. But breech does not have to mean a c-section. There are doctors and midwives who are skilled in this type of delivery although they are hard to find. And as more and more breech babies are delivered via c-section the fear is that drs will become less skilled in this type of delivery.
Twins- studies have not shown c-section delivery to be statistically safer for twins although there may be good reasons to deliver twins via c-section (one or both in distress, very underweight or other health issues that need to be addressed) Vaginal delivery of twins is rapidly turning into another “lost art” delivery like breech babies.
Large baby- many drs will schedule a c-section because the baby looks too big for them. This is not a valid reason as true CD is rare and can only be determined in labor.
Health problems in mother-hypertension, diabetes and other conditions do NOT necessarily mean a c-setion but many drs schedule them “just to be safe”
Convenience-some women request a c-section even when there is no medical reason. Maybe to ensure the baby is born at a specific convenient time or too avoid labor all together. Some women and their drs may believe that they are too small to deliver vaginally but this is RARELY true.
Previous c-section- “Once a C-section, Always a C-section” Vaginal birth after Cesarean (VBAC) is a subject of ongoing debate. Previous c-sections are one of the primary causes of current high cesarean rates. A repeat c-section is not always medically indicated, but it is commonplace.

It is important to remember that c-sections are major surgery and carry with them all the potential complications and discomforts of surgery. Babies born vaginally are immediately more alert and better functioning which makes breastfeeding easier. This is also true of babies who experience labor even if a c-section is the end result.


ELECTIVE REPEAT C-SECTION: JUST SAY NO!
Unfortunately, typical obstetricians are all too ready to grant requests for C-section without giving you the information you need to make an informed decision, much less helping you over come the psychological obstacles that may prevent you from making the best choice for you and your baby.

“Once a Cesarean, Always a Cesarean”
The reason behind this outdated cliché is that a woman who had undergone a previous c-section had a scarred, weakened uterus that could more easily rupture during the stress of another labor and delivery. C-section surgery has changed and improved over the years. Once upon a time a woman was cut vertically from the naval to the pubic bone and now the cut is a lower, horizontal “bikini cut” only 3-4 inches wide. This is much more stable for future deliveries. For most women, a vaginal birth, even after a previous cesarean, is a realistic possibility.

WHY VBAC?
SIMPLE: a vaginal birth is SAFER than surgery. 1 in 1000 death rate for a c-section is a 2 to 4 times higher rate than a vaginal birth.
Most women want a trauma free birth experience and post-partum period. Women want to feel in control of their experience and a vaginal delivery is the best way to do this.
Two most important ingredients in a woman’s decision about VBAC vrs repeat c-section is her knowledge about VBAC and her doctor’s attitude. DON’T rely on your doctor to give you all your VBAC knowledge. Take charge, educate yourself and then ask your doctor questions you may have.
Women who would rather have a VBAC believe vaginal birth is better for their child and their own bodies and health. They also have an intense desire to avoid repeat surgery that is unnecessary.

*Worldwide, 1 in 3 women will not even consider a VBAC

HOW EFFECTIVE IS VBAC?
The success of a VBAC is greatly influenced by environment. Women who have had a previous c-section are generally treated as high risk and therefore usually require efm and iv lines as precautionary measures. These and other routine procedures tend to necessitate chemical inductions, pain relief, and then ultimately another cesarean.

While there is physician support for optional c-sections, when a woman expresses a preference for VBAC, some physicians are not so obliging and will try to discourage it.
Carefully research practitioner and facility you plan on using. Aim for a practitioner with a 70% success rate with VBAC and feels you are a good candidate. Also check the other staff at the facility. You want/need them to also be encouraging about your VBAC.
VBAC is a terrific example of how and when one on one woman to woman support by a doula is the number one aide to a smooth delivery. Even a friend, who is a mother and understands your want for a vbac, who can speak on your behalf can help.

Several studies have found that when doctors genuinely encouraged women to have VBACs, most of then did, and when they said nothing or acted neutral, most women didn’t. And when they discouraged VBAC in women who wanted to try it, NONE of the women did.

Roughly 3 out of 4 women, if given the chance, will have a successful VBAC.

IS VBAC SAFE?
The main concern with VBAC is uterine rupture. Uterine rupture evokes a terrifying image of the uterus tearing in two. Typically it happens slowly, not all at once, and is accompanied by noticeable symptoms. Attempting a VBAC has a 99.8% chance of birthing WITHOUT a rupture. In addition, MOST studies show no woman or baby has died from an uterine rupture, no matter the type of previous c-section incision. However, women HAVE died from complications of cesareans and the death rate is higher in repeat c-sections. Uterine rupture can happen to any woman in any pregnancy, even before labor, although this is very rare.

FACTORS THAT DO NOT EXCLUDE VBAC:
*While cited as reasons for not trying labor, they are not always valid
Prior c-section for poor progress/failure to progress/ labor dystocia/ cephalopelvic disproportion
Suspected large baby
Type of uterine scar not known *unless the surgery was from many years ago or preformed in another part of the world (such as South America) the chances of the scar being anything but the “bikini cut” is minimal.
Low vertical uterine scar
More than one prior c-section
Twins
Breeches

THE LOADED LANGUAGE OF VBACS:
“successful VBAC” implies that a labor that ends in a repeat cesarean is a “failure”
“attempted VBAC” suggests that labor is not the norm and vaginal birth is doubtful, as does “trial of labor”
“uterine rupture” is a term that creates so vivid an image that it’s a wonder any woman tries VBAC after hearing it.

WHEN IS VBAC UNSAFE?
This is a subject of controversy in the medical world.
-the classic cesarean (vertical) incision (strongly recommended against)
-health condition such as placenta previa and abrupto placenta
-if a baby is clearly in distress, a c-section will be done, regardless of a mother’s previous birth history.

One common reason for an elective repeat c-section is body size. Many petite women and their drs are convinced that they can not handle a vaginal birth. There is NO EVIDENCE to back this up. Small women can give birth to very large babies even if they have had a previous c-section. Many small women are also given an elective repeat c-section for CD which can not be diagnosed until labor.

FACTORS THAT EXCLUDE VBAC:
Vertical/classical uterine scar or extensive prior uterine surgery – while no longer the norm, the classical incision can be used with placenta previa, breech babies and sometimes emergency c-sections

VBAC FEARS
Some common fears women having about VBACs include:
-my scar will rupture and my baby will die
-my body can’t handle labor and give birth like other women
-my baby is too big for me to give birth to vaginally
-I fear the unknown of another labor, where as a c-section is already “known” to me
-I can’t take the pain of labor without medication
-I will get my hopes up only to be disappointed again
-what happened to necessitate my previous c-section will happen again

MANAGE YOUR VBAC FEARS
-appreciate that you did your best with your previous birth
-get to know other women who have had VBACs
-understand that it is normal to worry that you will fail where other women have succeeded but that it is not necessarily correct that you will fail.
-read and re read VBAC stories
-practice visualizations and affirmations of a successful VBAC

ADVANTAGES FOR BABIES BORN BY VBAC
They are born when they are ready, not prematurely by surgery. Babies born by c-section have lower birth weights and have completed fewer weeks of gestation because the repeat c-section is done early hoping you won’t go into spontaneous labor. These problems of course are less frequent with a c-section that is preformed after a trial of labor. Babies that are born through the birth canal have the benefit of a surge of hormones called catecholamines (like adrenaline), have healthier lungs, have higher APGAR scores, enjoy early, frequent contact with mom and are much more likely to be breastfed.

ADVANTAGES FOR VBAC MOMS
The risk of infection after birth drops from as high as 35% down to 2-4%. The surgical hazards obviously decrease; such as extra blood loss, need for blood transfusions, urinary tract damage, placental disorders. The recovery is quicker, sometimes by months. There is no such thing as VBAC depression, unlike with a cesarean. They feel more attached to the baby sooner.

Note: The amount of blood loss in a c-section birth is quite higher than a vaginal birth. In fact, what is considered normal in the operating room while conducting a c-section is considered a hemorrhage when giving birth vaginally.

Vaginal birth after Cesarean (VBAC) should be a non-issue by now. The official guidelines of both the ACOG (American College of Obstetricians and Gynecologists) and the SOGC (Society of Obstetricians and Gynecologists of Canada) is that in the absence of a specific reason for cesarean section, the routine policy for women with prior cesareans should be labor.

SOGC policy states:
Provided there are no contraindications, a woman with 1 previous transverse low-segment Caesarean section should be offered a trial of labour (TOL) with appropriate discussion of maternal and perinatal risks and benefits. The process of informed consent with
appropriate documentation should be an important part of the birth plan in a woman with a previous Caesarean section.

In Canada, a concerted effort to persuade obstetricians to follow their own professional organization’s VBAC guidelines had only a slight effect. They argued that women preferred repeat cesareans and their preference should be respected.

Women chose repeat c-sections for such reasons as wanting the convenience of scheduling the delivery, knowing what to expect, fearing the pain of labour or believing that VBAC is riskier for women. The first three reasons are hardly indications for major abdominal surgery, and the last isn’t true. VBAC is safer for the mother.

THE BOTTOM LINE: PROS AND CONS OF VBAC VRS ELECTIVE REPEAT C-SECTION
VBAC PROS- The consensus of research is that VBAC is safe.
Elective repeat c-sections pose greater risks to the mother’s life and health than a vaginal birth. It also poses hazards to the baby as well, especially with succeeding pregnancies and more than one c-section
Most women, including women whose prior cesarean was for lack of progress or who are believed to be carrying a big baby, will birth vaginally if allowed to labor.

VBAC CONS- The healed uterine scar is tough, but in a few women, the scar will open enough for the umbilical cord or the baby to pass through of for bleeding to occur. The number usually quoted for women with one prior c-section is less than 1 %. Even when this does occur however, few babies will be harmed if an emergency c-section is performed promptly.

ELECTIVE REPEAT C-SECTION PROS- No labor means no chance of symptomatic scar separation (at least during labor). Pre-labor c-sections have lower infection and other complication rates than c-sections done in labor

ELECTIVE REPEAT C-SECTION CONS- Compared to vaginal birth, higher risk of infection, injury to other organs, hemorrhage and anesthesia complications
These complications can result in prolonged hospital stay, hysterectomy and death
Repeat c-sections are technically more difficult because of scar tissue
Scar tissue formation can cause chronic pain and bowel problems
Increased risk for poor condition of baby at birth, breathing difficulties and jaundice
Each successive c-section greatly increases the risk of developing placenta problems.
Placenta problems pose life-threatening risks to both mother and baby
C-sections also increase the odds of infertility and ectopic pregnancy (also life-threatening)
Women with multiple prior c-sections have a slightly increased risk of symptomatic scar separation during VBACs



FACTORS THAT PROMOTE SAFE VAGINAL BIRTH
*if you experience continuous abdominal pain or vaginal bleeding that is more than streaking or spotting (bleeding which looks like the start of your period), get to a hospital immediately for further evaluation

Have a confident dr/midwife with a high vbac rate
Commit to a vaginal birth- if in the heat of labor you don’t care how the baby gets out, you just want it out, the dr may take this as a sign that you now want your repeat c-section
Give birth in or near a facility capable of performing a c-section within 20 minutes of making the decision and that can care for a possible distressed baby
Avoid induction of labor
Refuse oxytocin to strengthen labor before active labor (3-5cms dilation and regular,painful contractions)
Avoid an epidural
While it is best to avoid these, know that prostaglandin gel to ripen the cervix for induction, oxytocin to induce or strengthen labor, and epidural anesthesia CAN be used in VBAC labors
No arbitrary limits should be set on labor
Consider having continuous electronic fetal monitoring (EFM) as abnormal fetal heart rate is the most common indication of uterine scar problems requiring intervention
limit vaginal exams and avoid having membranes ruptured and internal fetal monitoring as they all can increase the likelihood of infection

FACTORS THAT PROMOTE A POSITIVE BIRTH EXPERIENCE
Use a midwife
Take care of emotional issues and fears surrounding labor
Hire professional support
Plan on having an epidural if you are worried about pain
Have realistic expectations
Take an active role in planning a VBAC that will meet your emotional and physical needs and barring an emergency in making decisions during labor and birth
Refuse the routine use of intrauterine pressure catheter or manual exploration of the scar after birth
Refuse a routine IV and insist on being allowed to drink clear liquids

PLAN A SUCCESSFUL VBAC
Take responsibility for what happens to you, don’t expect your doctor to educate you. Educate yourself and then ask your doctor questions.
Have your VBAC at the safest place for you.
Avoid people who will discourage you from a VBAC.
Eat well and exercise regularly.
Always know your options.

IF YOU HAVE A PLANNED REPEAT C-SECTION
Choose a doctor with lots of cesarean experience.
Find a doctor and hospital that are prepared to perform the surgery only AFTER you have gone into labor.
Have every step of the c-section and preparation explained to you (again).
Arrange for regional anesthesia.
Review the possibility of a blood transfusion with your doctor.
Make sure you can have your partner and/or labor assistant in the OR.
Request to hold your baby as soon as possible and to have the baby examined near you.
Arrange to feed the baby as soon as possible, especially if breastfeeding (and make it perfectly clear that NO formula is to be given if that is your wish).
Plan to have daily help both at the hospital and at home.
Consider ways to cope with post surgical pain and discomfort.
Women who seek a VBAC or vaginal birth after Caesarean are under great pressure to “perform,” meaning that their labors have to be near perfect to avoid a repeat surgery, which is a lofty goal indeed for more reasons than we could ever fit in this article. VBAC also stands for very beautiful and courageous. Indeed.

I closed by reading an open letter to Christina Agueilera written by Jennifer Block, author of Pushed: The Painful Truth About Childbirth and Modern Maternity Care.

In my own personal situation, my ultrasound last week showed that the placenta has moved so I am hoping my doctor is agreable to me going for a vbac. I see him later this week and I am anxious to see what he has to say. Of course now that the placenta previa seems to no longer be a concern, I wonder if my failed 1 hr glucose test and the resulting longer one I had to take will now become an obstacle in my path to a successful VBAC.