VBAC is Safer!

[CTRedSoxMom]

The Advantages of Vaginal Birth for Cesarean Veterans

Many women prefer vaginal birth because they recover more quickly and with less pain than they do from a cesarean. In addition, each C-section increases the risk of complications (such as heavy bleeding, infection and infertility) in the next pregnancy, so women who want more than two or three children often hope to avoid the operation. And every time you cut into the uterus the chances increase of developing life-threatening placental abnormalities that can cause hemorrhaging during childbirth.

There are also some smaller benefits for mother and child. "We think there are some physiological things that happen to the baby who is delivered vaginally," says Dr. Caughey of UCSF. "It's a better transition in utero to ex utero. For example, it is better for the baby's respiratory system. We think it may be a better transition to breastfeeding."

And then there's the ultimate high many women experience when pushing out a baby, an event some consider life's most joyful rite of passage. "Women can feel a lot of glory when they deliver vaginally," says Dr. Lanner-Cusin of Alta Bates Summit. "Many women want to have accomplished a vaginal birth and they want to experience that feeling. I would never think less of anyone who wants a C-section but I think women looking for that glory should be able to try to deliver vaginally if the circumstances are right."

VBAC Risks Are Real But Very Low

Besides the typical complications that can arise in childbirth, the only significant risk with VBAC is the stresses of birth putting so much pressure on the old scar that the uterus ruptures. In very rare cases, uterine rupture can cause dangerous blood loss in the mother and brain damage or death in the baby. The risk for uterine rupture is real but it occurs in only 0.5 percent of cases.

This percentage is a baseline figure, explains Dr. Caughey of UCSF. "The risk increases to 1 to 2 percent if the mother has had more than one C-section with no previous vaginal birth," he says. "If the VBAC patient is induced with Pitocin, it also increases two to four fold to 1 to 2 percent. Studies have also suggested that there's an increased risk for women who become pregnant and labor for VBAC within less than 24 months after prior cesarean, or whose prior incision was closed with a single layer of sutures as opposed to two layers. On the other hand, a woman with a prior vaginal birth has 3 to 5 times lower risk of a uterine rupture."

Many hospitals strive to reduce the risk. In 2000, Dr. Elliott Main, chairman of Obstetrics & Gynecology at San Francisco's California Pacific Medical Center stopped allowing VBAC patients at CPMC to be induced with oxytocin (Pitocin). Main explains that oxytocin spurs strong contractions of the uterus, which puts a lot of pressure on the incision scar. Ever since he developed the policy the hospital hasn't had a single uterine rupture.

UCSF, on the other hand, does occasionally use oxytocin, Foley bulb or AROM to induce VBAC patients. "You have to consider the risk and the benefit," Caughey says. "If we are doing a VBAC for a woman who lives in Northern California, say three to four hours away, we will do an induction at 39 to 40 weeks of gestation as opposed to have her either stay in San Francisco for weeks on end or risk going into labor too close to home and not be able to make it down to UCSF in time."

When Dr. Weiss sees a cesarean veteran at Kaiser San Francisco, she and her patient thoroughly discuss all of these risks. "We look at the medical history to determine together if VBAC is a good option," she says. "We talk about her chances for success based on the reason behind her prior C-section. Was the past cesarean because the baby was breech? Was it because of a dropping heart rate? If a woman has already had two previous C-sections it is not recommended that she try for a vaginal delivery. The best candidate for a VBAC is someone who has had only one prior C-section or a C-section as well as a prior vaginal delivery."

But while doctors ask endless questions to determine if their patients are strong VBAC candidates, women really have only one main question for their doctors: Is VBAC safe?

"Safe is a tricky word," says Dr. Caughey. "There's always a small risk. The way we think about childbirth in the United States is with absolutely no tolerance for risk--and this has led to some problems such as our country's high cesarean rate. It really depends on how you view risk. I wouldn't consider a VBAC particularly risky but someone else might. For example, the risk of severe injury or death of a child in the setting of VBAC is similar to the risk of being pregnant for an additional week past your due date. I'm also more optimistic about VBACs at my own institution because all of the providers are in house on the labor floor 24/7."

Monica Cornish is fully aware of the risks. "I was feeling gung ho about it until I brought it up with my sister, who had a VBAC six years ago with no complications," she says. "But since her VBAC, my sister has known of three people who ruptured with catastrophic consequences. With two of them the babies died and in the third case the mother died. Although the risks are rare, they are real and it made me question whether or not it was worth it. I do question myself and whether these reasons are selfish given the risks, even though they are small. The trauma of losing the baby or leaving my toddler without a mother just because I want to avoid pain and have a certain experience seems somewhat trivial and shallow. "

Stories of uterine rupture passed down by friends of friends can easily scare off VBAC candidates, but Cornish pressed her obstetrician for more information and realized that the risks were lower than they seemed. Now she's feeling confident about her choice. "Sutter has a good track record since they implemented their VBAC policy," she says. "No ruptures at all. They only allow good candidates (no serious problems getting the baby out the first time around, no more than one C-section, only use Pitocin to augment not induce) and have a lot of medical back up in case something goes wrong. My OB's personal opinion is not to push things too hard. If labor stalls, it's for a reason, so she's not going to let things go for as long as she would a regular birth. By choosing a conservative VBAC route the risks are not much higher than with any other birth."

[shorty969]

Apr. 28, 2009 at 10:30 AM

i really liked your post...it was really interesting to read

[CTRedSoxMom]

Apr. 28, 2009 at 3:31 PM

Thank you Shorty969

(Original Poster)