Moms who have had or are interested in knowing about VBACs - Vaginal Birth After Cesarean

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Latest Activity: Dec 3, 2013

VBAC Article from TIME Magazine

Read Pamela Paul's fantastic article for Time Magazine: The Trouble with Repeat Cesareans.

For many pregnant women in America, it is easier today to walk into a hospital and request major abdominal surgery than it is to give birth as nature intended. Jessica Barton knows this all too well. At 33, the curriculum developer in Santa Barbara, Calif., is expecting her second child in June. But since her first child ended up being delivered by cesarean section, she can’t find an obstetrician in her county who will let her even try to push this go-round. And she could locate only one doctor in nearby Ventura County who allows the option of vaginal birth after cesarean (VBAC). But what if he’s not on call the day she goes into labor? That’s why, in order to give birth the old-fashioned way, Barton is planning to go to UCLA Medical Center in Los Angeles. “One of my biggest worries is the 100-mile drive to the hospital,” she says. “It can take from 2 to 3 1/2 hours. I know it will be uncomfortable, and I worry about waiting too long and giving birth in the car.”

Much ado has been made recently of women who choose to have cesareans, but little attention has been paid to the vast number of moms who are forced to have them. More than 9 out of 10 births following a C-section are now surgical deliveries, proving that “once a cesarean, always a cesarean”–an axiom thought to be outmoded in the 1990s–is alive and kicking. Indeed, the International Cesarean Awareness Network (ICAN), a grass-roots group, recently called 2,850 hospitals that have labor and delivery wards and found that 28% of them don’t allow VBACs, up from 10% in its previous survey, in 2004. ICAN’s latest findings note that another 21% of hospitals have what it calls “de facto bans,” i.e., the hospitals have no official policies against VBAC, but no obstetricians will perform them.

Why the VBAC-lash? Not so long ago, doctors were actually encouraging women to have VBACs, which cost less than cesareans and allow mothers to heal more quickly. The risk of uterine rupture during VBAC is real–and can be fatal to both mom and baby–but rupture occurs in just 0.7% of cases. That’s not an insignificant statistic, but the number of catastrophic cases is low; only 1 in 2,000 babies die or suffer brain damage as a result of oxygen deprivation.
After 1980, when the National Institutes of Health (NIH) held a conference on skyrocketing cesarean rates, more women began having VBACs. By 1996, they accounted for 28% of births among C-section veterans, and in 2000, the Federal Government issued its Healthy People 2010 report proposing a target VBAC rate of 37%. Yet as of 2006, only about 8% of births were VBACs, and the numbers continue to fall–even though 73% of women who go this route successfully deliver without needing an emergency cesarean.

So what happened? In 1999, after several high-profile cases in which women undergoing VBAC ruptured their uterus, the American College of Obstetricians and Gynecologists (ACOG) changed its guidelines from stipulating that surgeons and anesthesiologists should be “readily available” during a VBAC to “immediately available.” “Our goal wasn’t to narrow the scope of patients who would be eligible, but to make it safe,” says Dr. Carolyn Zelop, co-author of ACOG’s most recent VBAC guidelines.

But many interpreted the revision to mean that surgical staff must be present the entire time a VBAC patient is in labor. While major medical centers and hospitals with residents are staffed to provide this level of round-the-clock care, smaller hospitals typically rely on anesthesiologists on call. Among obstetricians, many solo practitioners are unable to stay for what could end up being a 24-hour delivery; others calculate the loss of unseen patients during that time and instead opt to do hour-long cesareans, which are now the most commonly performed surgeries on women in the U.S.

Some doctors, however, argue that any facility ill equipped for VBACs shouldn’t do labor and delivery at all. “How can a hospital say it can handle an emergency C-section due to fetal distress yet not be able to do a VBAC?” asks Dr. Mark Landon, a maternal-fetal-medicine specialist at the Ohio State University Medical Center and lead investigator of the NIH’s largest prospective VBAC study.

Part of the answer has to do with malpractice insurance. Following a few major lawsuits stemming from VBAC cases, many insurers started jacking up the price of malpractice coverage for ob-gyns who perform such births. In a 2006 ACOG survey of 10,659 ob-gyns nationwide, 26% said they had given up on VBACs because insurance was unaffordable or unavailable; 33% said they had dropped VBACs out of fear of litigation. “It’s a numbers thing,” says Dr. Shelley Binkley, an ob-gyn in private practice in Colorado Springs who stopped offering VBACs in 2003. “You don’t get sued for doing a C-section. You get sued for not doing a C-section.”
Of course, the alternative to a VBAC isn’t risk-free either. With each repeat cesarean, a mother’s risk of heavy bleeding, infection and infertility, among other complications, goes up. Perhaps most alarming, repeat C-sections increase a woman’s chances of developing life-threatening placental abnormalities that can cause hemorrhaging during childbirth. The rate of placenta accreta–in which the placenta attaches abnormally to the uterine wall–has increased thirtyfold in the past 30 years. “The problem is only beginning to mushroom,” says ACOG’s Zelop.

“The decline in VBACs is driven both by patient preference and by provider preference,” says Dr. Hyagriv Simhan, medical director of the maternal-fetal-medicine department of Magee-Womens Hospital of the University of Pittsburgh Medical Center. But while many obstetricians say fewer patients are requesting VBACs, others counter that the medical profession has been too discouraging of them. Dr. Stuart Fischbein, an ob-gyn whose Camarillo, Calif., hospital won’t allow the procedure, is concerned that women are getting “skewed” information about the risks of a VBAC “that leads them down the path that the doctor or hospital wants them to follow, as opposed to medical information that helps them make the best decision.” According to a nationwide survey by Childbirth Connection, a 91-year-old maternal-care advocacy group based in New York City, 57% of C-section veterans who gave birth in 2005 were interested in a VBAC but were denied the option of having one.

Zelop is among those who worry that “the pendulum has swung too far the other way,” but, she says, “I don’t know whether we can get back to a higher number of VBACs, because doctors are afraid and hospitals are afraid.” So how to reverse the trend? For one thing, patients and doctors need to be as aware of the risks of multiple cesareans as they are of those of VBACs. That is certain to be on the agenda when the NIH holds its first conference on VBACs next year. But Zelop fears that the obstetrical C-change may come too late: “When the problems with multiple C-sections start to mount, we’re going to look back and say, ‘Oh, does anyone still know how to do VBAC?’”

Discussion Forum

VBAC preparation

Started by Nicole A. Tucker, Lic. LCC Jun 26, 2013. 0 Replies

EPO/Borage oil = same as Prostaglandin induction?

Started by Marci For Birth Choice. Last reply by Marci For Birth Choice Dec 27, 2011. 2 Replies

Comment Wall


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Comment by Christine Dayton on May 23, 2009 at 10:45am
Thanks for the suggestions ladies. I do plan to talk to my OB about trying a foley cath for induction before resorting to medical intervention so we'll see what he says on Tuesday. He was willing to try and strip my membranes last week but couldn't because I wasn't dilated. I realize that things could happen for me very quickly and I very well may go into labor in the next day or two so I'm still looking at the hospital visit on Tuesday as my "backup plan" and trying hard to trust in my body and my baby to do the work and start the process before we get to Tuesday. I do realize I'm really lucky to have a great OB also - he's not been pushy about anything but has always been honest about what he thinks is best for me and my baby. He's the only truly vbac friendly doctor in this area, which is why I drive about an hour each way to see him. I've got alot of respect for him so I'm sure he'll help me make good decisions, should the time come to make those decisions.
Comment by Errin Woodward on May 23, 2009 at 8:53am
I just wanted to add that just because you are not dilated or effaced doesn't mean labor isn't coming soon. As far as I know, especially with the 2nd or more birth, you can go from nothing to labor much more quickly.

I don't know if you have tried membrane stripping but you might want to to do that before an actual induction. They can accidentally break your water doing this though.

I have had several babies at 42 weeks exactly, but I have never gone over. I'm sure it's a hard decision but pitocin + vbac is not a good combination. It's a hard situation to be in. Good luck.
Comment by Cherylyn on May 23, 2009 at 8:12am
I'm sorry to hog the comments, but I thought of something else worth mentioning. It might be better to at least try to induce, even if you do end up with a repeat c-section. The process of labor massages the baby's body and helps prepare the lungs for birth and breathing. If you induce and labor as much as possible it will likely improve your baby's chances of breathing normally after birth and not needing to go to the NICU.
Comment by Cherylyn on May 23, 2009 at 8:02am
You could also ask to try prostaglandin gel along with the cervical balloon, and that could help get things going. I think you chose a good OB who's allowed you to wait this long to see if you would have spontaneous labor. Not all OB's would be willing to do that, and most would have been scheduling the c-section before you go this far.
Comment by Cherylyn on May 23, 2009 at 7:57am
Christine, that's a really tough situation to be in, and I really feel for you. I understand how you feel about interventions, but you make a really good point about the risks of going past 42 weeks. I just finished reading the book Your Best Birth, and they discuss just about every issue in there. The section about inducing mentions the myths and truths about it, and being 2 weeks past due is a valid reason to try to induce. One thing you can ask for, if you don't want pitocin, is to see if your OB would be willing to try a cervical balloon first. It requires no medication and they just insert a little balloon into your cervix and slowly inflate it, and it can help open up the cervix. If that doesn't work, you can try cervadil or pitocin before deciding on a repeat c-section, depending on what your OB is open to. Good luck!
Comment by Christine Dayton on May 23, 2009 at 2:54am
I'm currently 42 weeks pregnant and have tried several natural labor inducing techniques - none of which have worked so far. As of last Monday I wasn't even dialated and was just barely effaced. I've had no real indication that things have changed since then other than one day of a little bit of bloody show and possibly a very small piece of mucus plug. It's frustrating to think that this far along my body isn't ready for labor though. I'm actually facing intervention in the coming days (repeat c section or pitocin induction) because my OB isn't comfortable letting me go to much further. I don't like being on a time clock and it's hard to continue to feel in control when being pressured like this. At the same time, I know there are risks with post date pregnancies after 42 weeks so I am inclined to listen to my OB.
Comment by irene cockerham on May 17, 2009 at 8:17pm
Just watched the Business of being born. Great Movie
Comment by Cherylyn on May 17, 2009 at 8:09pm
Labor induction techniques (including acupressure) don't work unless your body is ready for it. Also, a long labor is not uncommon for a first-time vaginal birth. Keep in mind that even though it was your second baby, it was the first one to pave the way through the birth canal, and that can take some time! I know we as women tend to analyze everything about our birth experiences, and sometimes harbor negative feelings about them. Be grateful for your healthy babies and that everything worked out. I've had experiences (having birthed 4 babies) ranging from complete medication to no medication at all, from feeling completely helpless to feeling in control and at peace. I'm also planning a home birth for the first time and I feel confident and peaceful about that decision. I'm so happy for you!
Comment by Dixon Doula on May 17, 2009 at 7:56pm
With my daughter, I didn't get a chance to feed her for 5-6 hours after birth. My husband had to stop the nurses from giving her a bottle. We had a hard time the first week. While in the hospital, they kept trying to give her a bottle because it took so long for my milk to come in. Luckily, my husband stayed in the room with me and went with her every time they took her out. It was at the end of day 6 that my milk came in, and all problems went away, but the hospital didn't make it easy. With my son, who was a VBAC, nursed with the cord still attached, was never taken from the room, and my milk came in on day two. Although I was able to bond well, and nurse well, after my c-section, it was much harder to get started. All I can say is, just keep trying and it will come with the right support and encouragement.
Comment by Laura Garcia on May 17, 2009 at 7:05pm
I had a c section in '05 because my son was breech, my obgyn didn't careto find out his position until 36 weeks, at that point it was to late for him to turn. I was devastated. In '08 I gave birth VBAC to my daughter with a mid wife in a hospital. I ended up with pitocin and and an epidural after 3o hours of labor. I may have brought this on myself, I had acupressure done to bring about labor, instead of letting nature run it's course. I was just so fearful of another c-section. My daughter ended up in the nicu, because of dusky spells. After seeing the film, I'm convinced it was the drugs. She came home with me as scheduled, but I did have some postpartum depression, also probably from the drugs. I am currently pregnant , and due in Oct. I have a wonderful midwife and am planning a homebirth. I've prayed alot and have faith in God that He is in control. Everything seems to be falling into place. Our pediatrician even offered to come to our house when the baby is born. I'm still breastfeeding my daughter and did my son for 2 years. I'd love to share birth and baby stories. God Bless.

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