The Deal With VBAC
Statistics:
According to Childbirth Connections:
The national U.S. cesarean section rate was 4.5% and near this optimal range [of less than 15%] in 1965 when it was first measured (Taffel et al. 1987). Since then, large groups of healthy, low-risk American women who have received care that enhanced their bodies’ innate capacity for giving birth have achieved 4% to 6% cesarean section rates and good overall birth outcomes (Johnson and Daviss 2005, Stapleton et al. 2013). However, the national cesarean section rate is much higher. After steeply increasing over more than a decade, it leveled off at 32.8% in 2010 and 2011 (Hamilton et al. 2012). So, about one mother in three now gives birth by cesarean section.
Why Do Cesareans Happen?:
There are several reasons that are often given for why the US cesarean rate is so high- these reasons usually serve to blame mothers for having cesareans. Often quoted among the reason is maternal request for cesarean, aging and unhealthy maternal population and a fear of liability.
Interestingly, when Childbirth Connections explored these ‘reasons’, they discovered that only 1% of women who had a primary cesarean (that is, a cesarean for the first time) selected that mode of birth understanding that there was no medical reason for it. So 99% of women having a cesarean for the first time were told they or their baby had a condition that medically necessitated a cesarean. Childbirth Connections also found that cesareans have risen in all maternal age groups, not just in the older mothers. This means that in 2011 doctors were claiming that nearly 1/3 of birthing women were unable to deliver their babies vaginally although 94.5% of women delivered vaginally in 1965.
Birth experts actually name many real reasons that cesareans have risen so sharply in the last 40 years. They include: low priority of enhancing women’s own abilities to give birth, side effects of common labor interventions, refusal to offer the informed choice of vaginal birth, casual attitudes about surgery, variation in professional practice style, limited awareness of harms that are more likely with cesarean section, and incentives to practice in a manner that is efficient for providers.
The bottom line for mothers to understand is that there are two basic reasons that cesareans happen- for medical reasons or for other reasons. Childbirth Connections shares that there are many reasons that fall into the ‘other’ category most of them caused by physicians’ practice style and preferences rather than actual medical need.
Medical Indications for Cesarean:
So an important question that women need to understand is: what’s a legitimate reason for a cesarean? How do I know when a surgery is really necessary or when it’s simply someone else’s preference?
Here are some legitimate reasons women need a cesarean:
- · placenta previa- the placenta partially or completely covers the cervix
- · placenta abruption- the placenta completely separates from the uterine wall
- · uterine rupture- the uterus tears during pregnancy or labor
- · cord prolapse- the umbilical cord exits the uterus before the baby
- · fetal distress- the baby’s heart rate begins to fail during pregnancy or labor
- · uncontrolled preeclampsia- a condition in which the mother’s organ systems begin to fail
- · birth defect- a birth defect that may endanger the baby’s life should vaginal birth be attempted
- · active genital herpes- to protect the baby from transmission a cesarean will be offered
Here are some reasons women might need a cesarean:
- · multiple births- twins and, occasionally, higher-order multiples can be delivered vaginally in a hospital if the baby lowest in the pelvis is in a vertex position.
- · breech position- while many care providers are competent and comfortable delivering breech presentation babies, some have neither the experience nor the confidence to handle this variation of birth. Some practitioners are confident to deliver multiples vaginally even if the first baby is breech.
- · gestational diabetes/big baby/cephalopelvic disproportion (CPD)- Gestational diabetes is not necessarily an indicator for cesarean in itself- the concern is the possible result of a larger than average baby due to the condition. ACOG is very clear about the standards by which babies should be called ‘big’. According to ACOG, babies do not reach this distinction until they are 9 lbs 15 oz. Although there is difficulty estimating fetal weight by ultrasound during the latter part of pregnancy, unless a baby is measuring above 9 lbs 15 oz, there is no indication for a cesarean. Even with a weight estimate above 9 lbs 15 oz (understanding the difficulty of ascertaining fetal weight at this age), a Trial of Labor (TOL) is reasonable. CPD is difficult to diagnosis prior to a TOL. Unless the mother has pelvic bone deformations caused by disease (like rickets) or fracture, it is very difficult to make this diagnosis prior to labor.
- · failure to progress/maternal exhaustion: these are perhaps the most subjective reasons used for a cesarean. As there are normal lulls during labor for many women and as hospitals often create difficulties by limiting nutrition and movement, it would be very difficult to know in a hospital setting if a labor is lasting longer than it ‘ought’. There is also the difficulty in knowing how long a particular labor ‘should’ last. One complication of labor that can happen is maternal exhaustion. This occurs when mothers simply do not have the energy to continue the labor process and contractions become inefficient. Many times, maternal exhaustion can be treated with mild augmentation instead of cesarean.
Birth Choices After a Cesarean:
If a woman has had a cesarean before, what are her birth choices during a subsequent pregnancy?
ACOG’s 2010 Practice Bulletin 115 makes the following important recommendations (from VBACFacts.com):
· Attempting a VBAC is a safe and appropriate choice for most women who have had a prior cesarean delivery including for some women who have had two previous cesareans.
· The College guidelines now clearly say that women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a TOLAC.
· The [American] College [of Obstetricians and Gynecologists] maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available.
· Women and their physicians may still make a plan for a TOLAC in situations where there may not be “immediately available” staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk.
The recommendations concerning VBAC above are important for several reasons- they maintain that VBAC is “safe and reasonable” and that repeat cesarean is not the only birth option for women following one or two cesareans. They also maintain that women and their care providers may “plan for a TOLAC in situations where there may not be “immediately available” staff to handle emergencies”. Thus, Home Birth After Cesarean is a safe and reasonable choice.
Concerns About Cesarean Birth After Cesarean (CBAC):
The reasonable nature of VBAC is good news for birthing women as repeated cesareans carry genuine and progressive amounts of medical risk. According to the International Cesarean Awareness Network (ICAN) the relative risk between repeated cesareans and repeated VBACs looks like this:
This means that repeated cesareans are progressively more risky and more likely to result in harm to the mother or the baby when repeated VBACs are progressively safer and less likely to result in harm to the mother or the baby.
As a policy, care providers are ethically required to offer services that ‘do no harm’ to their clients. VBAC- because of its standard as a “safe and reasonable” option for birthing women- should always be the preferred method of birth.
Concerns About Vaginal Birth After Cesarean (VBAC):
So why then is it so difficult for women to access VBAC? There are several reasons for this:
· In 2004, ACOG made a recommendation that VBAC should be performed in hospitals where anesthesia services were “immediately available”. Since there was no unified definition as to what this meant, hospitals interpreted this guideline in the strictest possible sense and almost all US hospitals ceased offering VBAC as an option to women.
· The ‘marketing of risk’ is of concern per Jen Kamel of VBACFacts.com. When the above poster from ICAN is considered, we can see that repeated cesarean has much higher risks associated with that mode of birth than VBAC does, VBAC and cesarean birth are not spoken of in a way that realistically shares the relative risk of these birth modes.
For all the inappropriate promotion of cesarean as normative, VBAC does, indeed, have its own set of risks that should be honestly considered and weighed by each individual woman.
VBAC does include** a 1 in 115 chance of uterine rupture (uterine tissue tearing), 1 in 435 chance of a necessary hysterectomy and a 1 in 53 chance of a blood transfusion. These are real risks that should be considered especially by the mother planning to birth away from emergency medical care should it be necessary.
**It should be noted that these figures are from hospitals births with no distinction according to augmentation, nutrition, etc. Homebirth VBAC may prove to be even safer than hospital VBAC, but we simply do not have studies to bear that out.
Pregnancy/Midwifery Care After Cesarean:
State law may determine if a midwife may assist a woman to birth her children at home after a cesarean. This regulation was introduced after women were inappropriately induced using cytotec in the hospital and suffered uterine ruptures. Legislation followed poor hospital practice and home birthing women and their midwives now have to handle the situation.
If a woman’s previous VBAC(s) were for issues that are unlikely to be repeated (fetal distress, placenta previa, etc.) pregnancy care may proceed as usual. Due to the increased likelihood of placental attachment abnormalities, the midwife may want to recommend an ultrasound during the second trimester to confirm placental health and placement.
Clients will need careful review of their risk and benefits of vaginal birth after cesarean at home, including an emergency plan in the unlikely event of a rupture.
Special care should be given to the client to encourage her confidence in her body’s ability to birth her child vaginally, especially if she has never had a vaginal birth before. Midwives may also want to be sure that all support people are truly on board with a home, VBAC and have adequately addressed any fear or uncertainty.
Prostaglandins of any kind have been found to be inappropriate for induction for VBAC, but small amounts of oxytocin have been found to be acceptable by not increasing the risk of uterine rupture. In a homebirth setting, artificial oxytocin is unlikely to be available, but, should induction be necessary, the midwife may consider oxytocin producing activities (nipple stimulation, orgasm) an appropriate method of induction. The midwife may want to avoid herbal induction due to the possibility of overstressing the uterus.
During first and second stage, the midwife should be watchful for abnormal, sharp pain in the client’s abdomen that may indicate a rupture. The midwife will also want to pay close attention to fetal heart rate throughout first and second stage since sudden fetal brachycardia is often an indication of rupture.
Should the placenta fail to deliver normally in their stage, the midwife may consider transfer instead of manual removal due to the possibility of abnormal placental adhesion to the uterine wall.
Bibliography:
http://www.bellybelly.com.au/birth/small-pelvis-big-baby-cpd
http://americanpregnancy.org/labornbirth/reasonsforacesarean.html
https://www.childbirthconnection.org/article.asp?ClickedLink=274&ck=10168&area=27
http://vbacfacts.com/2010/07/21/acog-issues-less-restrictive-vbac-guidelines/
http://www.guideline.gov/syntheses/synthesis.aspx?id=25231
http://www.aafp.org/afp/2001/0115/p302.html
http://www.herpes.com/pregnancy.shtml
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