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 Seaason Violi-Whitney on June 29, 2009 at 12:05am
i have 4 beautiful babies, and 3 of them where VBACs, my 1st was a 10lb bruiser, he got stuck coming out ((shoulder dystocia)) so i had an emergency Csection, and after that i swore black and blue that i would never do that by choice again, it was horrible, if at all possible, i will chose natural each time...
the Drs & midwives in my area prefer natural, and will always let a woman try a natural labour if that is what she wants, inessthere is high risk..
Comment by Cherylyn on June 1, 2009 at 11:37am
Yay for Leah! Sometimes you have to do a lot of research and legwork to get what you want, but I'm sure it's worth it :)
Comment by leah walz on June 1, 2009 at 9:12am
Thanks Kimberly for your help. I have been able to find a couple midwives in my area now. Talked to one says she is open to helping me. Gonna talk to another one that is a bit closer too.
Comment by Kimberly James on May 28, 2009 at 5:44pm
I think the risk of rupture rises with subsequent c/s, but I don't know that to be true after 2 c/s. In looking for consent forms, I've noticed some (both for HBAmC and VBAmc) some stipulations like "has only had 1 prior c/s" some even require previous vaginal birth.

But, LEAH, you're right - it gets harder to find a provider after multiple cesareans. I strongly recommend: (lots of VBAmC success stories out there thanks to this organization's support and advocacy) (excellent evidence based information that is VERY helpful for finding out risks/benefits of certain decisions)
Comment by Kimberly James on May 28, 2009 at 5:38pm
Denise, you just need to go to L&D at your hospital or call them to ask about their protocol. If I remember correctly, at ours:
* no eating during labor
* heplock
* continuous EFM
* deemed high risk once you reach active labor

Some docs require "delivery" in the OR
Comment by leah walz on May 28, 2009 at 2:06pm
Cherylnn, Thanks again for your help! much appreciated! Sorry if
I seem dumb on the issue haven't really read much about it yet. but I will! Haven't had anyone to really talk to about this. most people I know have had sections that I'm close to. Beside my mom who not want to talk about it. Sister no longer with us. So thanks again! :)
Comment by Cherylyn on May 28, 2009 at 1:20pm
Leah, in the book Your Best Birth, they talk about the "Honeymoon Vagina" on page 151. It basically says that the vagina was designed to stretch and snap back. Think about how proud a man would be to "have an organ that can expand dramatically and then shrink back to its former puny size". They also say that the majority of men can't tell a difference between a vagina that's never given birth versus one that has. Obstetricians can tell, because they're trained for it. I seriously doubt childbirth has any negative effects on the vagina. Pelvic exams are uncomfortable and painful for everyone in varying degrees, and some doctors are more gentle than others. The book actually says that there's more to be concerned about the pelvic floor than the vagina, which is why kegels can be so helpful, and avoiding episiotomy is important. The pelvic floor stretches regardless, whether you have a vaginal delivery or a c-section.
Comment by leah walz on May 28, 2009 at 1:02pm
Cherylynn, thanks for the encouragement! I have been looking on the net to try & find a midwife for a home birth so far not a whole lot around me. I live in MN. but not by any big cities or even by a hospital able to take me "if" something went wrong. About the small pelvis, I'm 5' 2" but not really petite. not to give to much info on personal stuff, but often when my hubby & I have sex we have to be careful what position we do it other wise it hurts. When I get a pelvic exam it hurts pretty bad, when I was pregnant they had a hard time even checking my cervices. I have only see one dr. so I don't know if someone else would tell me something else. has anyone else had these problems & still had natural deliver? So I have a question hope nobody thinks I really weird, but does how much your vagina go back to normal after a baby. I would figure it would differ with everyone. That is one reason my hubby doesn't know if he wants me to go natural. Although I'm wondering myself too. I have had 4 kids but have not had to worry about any of the stretching issues. I just don't want this big change & wish it was the way it used to be. Thanks so much for all your help!!
Comment by Cherylyn on May 28, 2009 at 11:32am
Leah, something you can show to your OB/midwife and hubby, is this article about how the risks to babies increase with each c-section:

Risk to Baby Rises With Repeat C-Sections
Comment by Cherylyn on May 28, 2009 at 11:27am
Leah, I've heard of women doing a VBAC after multiple cesareans, and it's definitely possible. Depending on where you live and the policies and feelings of the caregivers there, it could limit your options of where to birth your baby. I would suggest you start looking for an OB or midwife who is open to letting you try a VBAC. I really don't think that pelvis size has much to do with a woman's ability to give birth vaginally. I am 5'1" tall and usually weigh about 115-120 pounds when I'm not pregnant, and I have given birth vaginally to 4 babies so far. Three of them were over 8 pounds at birth, and the smallest was 7 lbs. 11 ozs. It always bothers me when a doctor tells a woman her body was not made for childbirth. What else was it made for? Anyway, start interviewing caregivers and find out what your options are, and don't give up! Good luck!

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