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What Every Woman Should Know About Vaginal Birth After Cesarean

Over the last 20 years there has been increasing acceptance of VBAC. Study after study has proven it to be a safe alternative to repeat elective cesarean in most cases. So "once a cesarean, always a cesarean" is an outdated notion, right? Unfortunately, it's becoming quite clear that we are experiencing a VBAC-lash right here in Iowa. If you are a pregnant woman living in the Des Moines area and have had a previous cesarean section, chances are your provider will now be scheduling you for a repeat cesarean based, in part, on a July, 2001 New England Journal of Medicine (NEJM) study and recent recommendations from the American College of Obstetricians and Gynecologists (ACOG).

The NEJM study in question showed that for women undergoing a "trial of labor" after a previous cesarean, the risk for a potentially serious complication called "uterine rupture" may be greater than previously believed, particularly when labor is induced with contraction-stimulating drugs called prostaglandins (such as Pitocin or Cytotec). In general, this risk is believed to be around 1%, but is multiplied many times when these drugs are used-the uterus can contract so forcefully that it literally ruptures. Even ACOG has published a statement discouraging the use of prostaglandins for labor induction for women attempting a VBAC ("Committee Opinion" April 2002).

Because of this small risk of uterine rupture, ACOG has also issued a recommendation that VBAC should be attempted only institutions equipped to perform an immediate cesarean section. This, in effect, rules out a trial of labor in many community hospitals, with most midwives (who collaborate with OB's but usually don't have one sitting in the next room awaiting an emergency), and any out-of-hospital births. However, it is important to note that the risk of complications from elective repeat cesareans is at least as high, if not higher, than VBAC. According to one extensive review of relevant studies, "VBAC was no riskier for babies than planned cesarean." ("Is vaginal birth after cesarean risky?" Henci Goer) What's more, the odds of an amniocentesis causing a miscarriage are "more than ten times the risk of the baby dying from a VBAC-related uterine rupture. Yet obstetricians aren't lobbying for an end to amniocentesis on the grounds that it is too hazardous." (Goer).

The simple fact is that giving birth, whether vaginally or through a cesarean, carries risk. However, there are things that can be done to lower that risk. The first and foremost is not using induction drugs during a trial of labor after a previous cesarean. It seems quite clear that returning to a more cautious approach toward interventions in a VBAC is necessary in order to keep trials of labor safe for mother and child.

What's important here is that a woman's right to make an informed decision regarding her baby's birth is being eroded. Before you allow your OB to make the decision for you, do some research (VBAC.com is an excellent resource). Please don't rule out VBAC just because your doctor tells you it will be easier or safer: it's just not necessarily true. By avoiding induction drugs, in particular, your chances of having a successful vaginal birth are very good: success rates range from 60-80%. We shouldn't abandon the success of the last two decades.

A must read Newsweek Web Exclusive article by Claudia Kalb, "A Change of Delivery--More women want to be able to have a baby naturally, even if they've had Caesareans.  Research backs them up--so why won't doctors??" can be found here.  

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