Midwifery, Pregnancy & Birth :: VBAC
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outdated notion, right?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.