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?’”

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Comment by vanessa belling ducos on May 11, 2009 at 8:40am
i am on my 3 child firs one was vag 2 way c/s i am going with a midwife this time
hoping to have a vbac but dont know if its safe i had a hard time healing from the c/s i was in bed for 8 week took me a long tome to feel like my self

for the ladys that have dun vbac do i have any thing to be scared off
o ya i live in a area that will not do vbac so i have to drive 45 m a way to some were that will let me have it :)
Comment by Linda Llone Hinchliffe on May 7, 2009 at 2:33am
I am a 43 year old mum of 9 - ranging from 22 yrs old to 6 months.

My obstretic history is as follows:

1986 - C/S for PET
1988 - C/S for fetal distress
1990 - Hosp VBA2C
1993 - C/S for alledged cord prolapse (sued the hospital over this...)
2000 - Hosp VBA3C (booked HB, transfer for high BP in labour)
2002 - HWBA3C
2004 - HWBA3C (filmed for Home Birth Diaries)
2007 - HWBA3C (filmed for Home Grown Babies)
2008 - Hosp WBA3C (filmed) booked HB transfer in labour for High BP, ended up with retained placenta.

I fought 'tooth & nail' for my VBA2C - ending up travelling across london to have him under the excellent care of Prof Wendy Savage, after that I knew I could do it and when I ended up with a 3rd C/S for 'doubious' reasons I sued the hospital concerned and won...

After that the CMW's have been brilliant, however my last baby was a hospital birth without my CMW...I got a hospital based M/W who was horrid - thankfully for Hugo arrived within an hour of her taking over my care (2 hrs 52 mins recorded for labour) however my 3rd stage was 1 hr 20 mins which I still feel that her treatment of me was the cause of some(or all) of the problems....

If there is a next time (who knows !!) I will stick to my HWB with my lovely CMW and will try and keep calmer so my BP stays low.
Comment by Sizzly M. Acevedo on May 6, 2009 at 5:37am
I had a c-section with my first. Its been 7 yrs going on 8. I will have a homebirth and here in Florida the midwives are allowed to do VBACs as long as they have a backup doctor to sign off and once they have had a successful VBAC they are no longer needing a sign off.
Comment by Sarah Kent on May 4, 2009 at 12:19pm
I'm a VBAC/HBAC-er in the UK. my VBAC changed my life and I totally agree with the fact I would not be the person I am today had it not been for my c-section - as much as I hated it and as much as I know it *was* completely avoidable I know it has made me a stronger and better woman today. It took me a good 6 years of psycologically torturing myself over it to come to that conclusion but I'm glad I came to it!!! I certainly would not have had my twins at home had it not been for the fact I had had the awful experience of a c/s first! Bizzare as it sounds it is true!
Comment by liz creditor on May 2, 2009 at 10:09pm
I agree 100%. I would not be the childbirth educator that I am today with my primary c-section. I had two hospital vbacs so I have never done a homebirth but I wish I had...
Comment by Heather Barrett on May 2, 2009 at 9:53pm
Two homebirths later, I'm quite certain I would have avoided a c/s had I stayed home with my first, as well, Liz. The only benefit I see is that I'm now an advocate for other women, which I would not have been had I had the birth I wanted. It's a small blessing in a very sad reality.
Comment by liz creditor on May 2, 2009 at 9:47pm
If your going to have a vbac, dont bother with an OB. Use a midwife. If I had used a midwife with my first, I might never have had a c-section to begin with....
Comment by Ashley Wegner on May 1, 2009 at 4:39pm
I had a similar problem to the one the woman in this article had. I could only find 1 doctor who'd allow VBAC at the hospital that I go to. It's probably because her husband is also the only neonatologist in the county!

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