Will VBACs make a comeback?
The New York Times wrote a fascinating story looking at the rise and fall of VBACs — or vaginal births after Caesarean section — and how the government would like to bring them back into practice more frequently. It examined the successes at a Navajo hospital in Arizona, where they have lowered their number of Cesareans and increased their number of VBACs, even though the national numbers are just the opposite.
Here is the gist of The New York Time’s very long, but very interesting, story:
In the beginning there used to be a saying “once a Caesarean, always a Caesarean.”
Doctors feared the Caesarean scars on the uterus could rupture during subsequent labors so women were always forced to have Caesareans after their first one.
However in 1980 a panel declared it was safe for many women to deliver vaginally after having a C-section and the VBAC became very popular.
By 1996 VBACs reached their high of 28.3 percent.
Then there were some problems. Ruptures, deaths and of course lawsuits lead to stricter guidelines to perform VBACs and the rate has now dropped to below 10 percent.
So why is that bad? Here’s what the New York Times’ article explains:
“The national Caesarean rate, 31.8 percent, has been rising steadily for the last 11 years and is fed by repeat patients. Critics say that doctors are performing too many Caesareans, needlessly exposing women and infants to surgical risks and running up several billion dollars a year in excess bills, precisely the kind of overuse that a health care overhaul is supposed to address.”
“Even the American College of Obstetricians and Gynecologists has acknowledged that the operation is overused. Though there is no consensus on what the rate should be, government health agencies and the World Health Organization have suggested 15 percent as a goal in low-risk women.”
“ ‘VBAC’ has become a battle cry, with fierce advocates on both sides—women who insist that they should not be forced into surgery versus doctors and hospitals who insist on repeat Caesareans, citing the risks of labor and concerns about liability and insurance. ”
With that background information, then the article looks at the Tuba City Regional Health Care Corporation. It’s a hospital run by the Navajo Nation in Arizona and many believe is a model of what obstetric care should be like across the nation.
The hospital’s overall Cesarean rate is 13.5 percent which is less than half the national rate of 31.8 percent in 2007.
And last year the hospital had 32 percent of women who previously had Cesareans deliver vaginally. (Remember the national average is below 10 percent.)
Nurse-midwives deliver most of the babies born vaginally. It is believed that the C-section rate is lower because the midwives are trained to coach women through labor and will wait longer to recommend a C-section. Also the midwives are less likely to induce before due dates which can also lead to a C-Section.
(For comparison sake, midwives attend to only 10 percent of vaginal births nationally.)
Besides just the midwives, changes in insurance practices could also help increase VBACs, according to the article.
“Changes in malpractice insurance would also help, so that obstetricians would feel less pressure to perform Caesareans. (The hospital and doctors in Tuba City are insured by the federal government, and therefore insurance companies cannot threaten to increase their premiums or withdraw coverage if they allow vaginal births after Caesarean.) Patients, too, would have to adjust their attitudes about birth and medical care during pregnancy and labor.”
So what do you think? Did you have a VBAC? Would you have chosen a VBAC if you could? Did you feel pressured to have a C-section from your doctor or insurance company?
Do you think it is an important goal to reduce the number of C-section and increase VBACs? Would you be afraid to deliver vaginally after a C-section?
Would this story help you want to have a midwife attend your birth? Would it increase your confidence in asking for a VBAC?
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243 comments Add your comment
Theresa Walsh Giarrusso
March 12th, 2010
3:06 pm
Hey guys — gWinnett is out today so we’ve been at a jumpy place burning off some energy!! Also getting ready for Lilina’s 3rd birthday party — will show photos of Cinderella cake I’m getting ready to decorate!!!! New blog — nothing sexy but very important —- Consumer Product Safety Commission has issued an official warning on slings and has illustrations to show correct way to use them — also new Cadmium jewelry warnings – check out the photos to make sure your kid’s not wearing deadly jewelry!!! (awesome!)
http://blogs.ajc.com/momania/2010/03/12/cpsc-issues-official-baby-sling-warning-also-update-on-more-cadmium-jewelry/
RN-OB
March 12th, 2010
3:12 pm
Wow! There are alot of emotions on this topic.
Having worked in hospital based OB for over 30 years, I have seen far more iatrogenic caused complications than natural cause complications. Not a week goes by that we don’t see several babies delivered by elective repeat (or primary) cesarean that end up in the NICU with breathing issues that causes painful procedures for the baby, disruption of bonding, breastfeeding and extreme worry for mom and dad. I had a physician tell me she would never have consented to elective cesarean if she had been informed that he might spend ANY time in the NICU caused by too early removal from her body.(elective @ 37 weeks). She was not in obstetrics and had been assured by her docotor that her baby was completely ready! I saw one last week that followed the guideline of “no elective procedures until 39 weeks without medical cause” and the baby (whose pregnancy had been dated by ultrasound very early on) was 35-36 weeks when he was pulled out of his mother’s abdomen and spent 2 days in the NICU trying to breathe.
There are risks to birth – period. It is up to the woman and her healthcare provider to discuss evidenced based information and the woman to make an INFORMED, non-fear based decision as to which risks she chooses to accept. If her doctor does not wish to offer VBACs, he/she needs to be up front and not try to use fear to coerce the woman to make a decision for surgery or pull a “bait and switch”. If I told my patients the same kind of outlandish information that some doctors tell their patients, I would have lost my nursing license years ago. (like the doctor of a friend who told her the uterine rupture rate was 40%!) .
The bottom line is we need to drastically decrease primary cesarean rate, go to a system where midwives assist healthy women to give birth and obstetrical surgeons are only used for complictions and help women to trust that their bodies work well in the vast majority of instances and we can help if they veer from normal..
If a woman receives the information and chooses to accept the risk of primary, non-medically indicated cesarean surgery, she has the right to choose it BUT her insurance company or medicaid SHOULD NOT be required to pay for it. When she has to pay $10,000-$15,000 out of pocket, I’ll bet she changes her tune.
Amy
March 12th, 2010
3:23 pm
My first child was born after I was in labor for about 14 hours and not progressing at a decent page. However, I hadn’t seen the doctor until that point and it was Easter Morning (He was on call my regular doctor was gone) and I believe he just really wanted to get home to his family. I had another cesarean delivery two years later because the doctor I had at the time (1996) pushed me in that direction. Now I am 42 and pregnant. I have always felt like I missed out by not having a vaginal birth. I would love to do it this time, but my new OB also said no! So, there is no choice but a third cesarean. Considering it has been 14 years since I last delivered, I truly thought I would at least get the choice.
momto5+1
March 12th, 2010
3:32 pm
If you are local, Amy…you do have a choice. You just need a new provider.
Elaine
March 12th, 2010
3:33 pm
Amy, if you live in the Atlanta area, you definitely have a choice. You would have to switch doctors, but it is doable.
Amy, see the first few posts on this topic...
March 12th, 2010
3:41 pm
…yes,you have choices; you are also probably considered a HIGH RISK pregnancy, especially with advanced maternal age (hope you had the amniocentesis done) along with 2 prior c/s. As both momto5 and Elaine are very attuned to this process, please just follow their advice and make an INFORMED decision NOT predicated upon the ” I have always felt like I missed out by not having a vaginal birth. I would love to do it this time” thought process.
Good luck, and good health, to you and your 3rd blessing…
Patricia
March 12th, 2010
3:45 pm
Amy, I am sorry to hear that your OB refuses to consider supporting your wish for VBAC. Can you find a more supportive care provider? I fired my OB group and transferred to a new doctor at 37+ weeks. Not the ideal situation, but I did what I had to do to be “allowed” to go into natural labor, much less attempt (and ultimately, succeed at) VBAC. See the first page of comments for Christine’s link to ICAN Atlanta for information and support. Best wishes to you!!
Robin
March 12th, 2010
6:03 pm
I had a VBAC under the watchful eye of my very helpful obstetrician – after having to expend far too much energy and time during my second pregnancy to find a doctor who would even consider it. There are scientifically-based guidelines for assessing who is a good candidate for trying a VBAC, so a blanket fear of them is unwarranted. I wanted to give birth in a hospital in case complications did arise, for my baby’s and my safety, but then I trusted my doctor not to push for unnecessary interventions. Unfortunately that trust is eroded in many doctor-patient relationships. My child and I are fine, and I had a wonderful experience and a much easier recovery than after my previous Caesarean.
Catherine S
March 12th, 2010
6:09 pm
Amy,
I have stayed out of this discussion up until this point, but feel that it is for people like you that ICAN (nternational Cesarean Awareness Network) exists!!! You DO have a choice!! There are a few doctors and several Certifieed Nurse Midwives in the Atlanta that will support your choice to VBAC, you just have to be willing to speak with a few a decide which one works the best for you. Unless you have a real underlying condition such as placenta previa, where CS is truly indicated, you have a choice. There are excellent providers that will support you in that choice and will give you real information, based on valid studies, not fear based misinformation. Even if you chose to have an elective repeat surgery, at least look into alternatives and that way, it will be YOUR EDUCATED choice, not your doctors.
catlady
March 12th, 2010
7:07 pm
Michelle–your experience may have explained mine (all 3 of mine). Thank you. All three were significantly late 1-3 weeks and good-sized (smallest one was 9 lbs. 3 oz.) babies with 24 hour labors and all kinds of troubles. Each time the doctor said, “Well, that baby is definitely post-mature! I begged for a c-section with my first (10 lbs) but the doctor “didn’t have the time–too many other babies to deliver–I’d just have to push it out!” When they pulled her out they thought her collarbone was broken, and my tailbone broke.
There are quite a few things I understand better now than I did then (I think there is a country song in there somewhere.)
j
March 12th, 2010
8:15 pm
Isn’t VBAC that ag school down in Tifton?
ktmain
March 12th, 2010
9:43 pm
Why are MEN even posting. Really have you been through 34 hours of labor pain meds free? This will be my third c-section and I WISH i would have listened to my doctor when he told me at 8weeks preg with my first he highly rec’ed a c-section bc my pelvis was so small. My delivery bc an emergency bc i listened to other people tell me my doctor only wanted to make more money… turns out he was right from the begining. Thank goodness my son was ok, however he still has a scar on his upper lip from my pelvis bone (stork bite they called it) bc i tried for so long to have a vaginal birth. Listen to your doctor – believe it or not they PROBABLY know what is best:)
obnurse
March 13th, 2010
9:00 am
Everyone keeps giving stats from NIH and other broad organizations. Why hasn’t anyone quoted ACOG or AWHONN? Those are specific to OB. You will give yourself more credence if you quote ACOG or AWHONN.
Christine
March 13th, 2010
9:58 am
The main reason NIH keeps getting mentioned is that they just held a VBAC Consensus Panel earlier this week and that is what the blog post was in response to. They actually called out ACOG for some language in their VBAC recommendations that contributed to the declining VBAC rate.
That is getting more into the politics of VBAC than the science, though. Which the NIH panel also addressed.
to ktmain...
March 13th, 2010
3:42 pm
A stork bite is a common type of birthmark seen in a newborn. It is most often temporary.
The medical term for a stork bite is nevus simplex. A stork bite is also called a salmon patch.
via: http://www.nlm.nih.gov/medlineplus/ency/article/001388.htm
It is a “birthmark” not a “birthing” mark. And plenty of c-section babies have them.
irisheyes
March 13th, 2010
7:20 pm
“I have heard time and again women say ‘my c-section baby would be dead if it weren’t for my c-section,’ and you know what, some of them are probably 100% correct. But a vast majority of them believe that that is true because their OB told them so, and once they seek out what really happened prior to them landing in the OR, they discover differently. ”
@Michelle Frank, I’m going to be very clear. I WOULD be dead. My oldest son’s head was FAR TOO LARGE to come out. I labored for over 14 hours in every position known to man, and when he was finally born, his head had not even begun to mold. He would have never made it through the birth canal. My youngest son could NOT have been born vaginally. The bones in his skull fused in utero, so his head could not have molded to come through the birth canal (he has the neurosurgery scar to prove it). So, I am one of those who are 100% correct. I’m not against VBAC’s, and I firmly believe that women should have the choice. But, there ARE medical reasons for c-sections, and to scoff at that and say “if you really knew the truth” is asinine.
Christine
March 13th, 2010
8:03 pm
But Michelle said “you know what, some of them are 100% correct”. She never said “if you really knew the truth”. She is right, there are definitely people out there who think they had emergency cesareans that either weren’t true emergencies, or were emergencies that were potentially caused by interventions in labor.
There are definitely medical reasons for cesareans. There are definitely mothers and babies that would die without them. But the cesarean rate in Atlanta is approaching *40%* which is higher than the already crazy high US national average of 31.8%. 40% of women are not having emergency cesareans. Someone has to be having the unnecessary ones.
Michelle Frank
March 13th, 2010
8:13 pm
irisheyes, Christine posted exactly what I would’ve posted myself had I gotten back here first. I wasn’t directing any tidbit of what I said exactly at YOU, so to take what I said and throw it back at ME the way you just did…now that seems asinine.
motherjanegoose
March 13th, 2010
10:05 pm
VBACS are successful for many folks and not for others.
I did not request a C section for my son but this is the way he was successfully delivered. A VBAC, for me, was a nightmare.
I AGREE that my nightmare will not happen to everyone SO to those who feel comfortable taking a chance….GO FOR IT, after all: it is your body and your baby….no matter how you deliver…you will be living the outcome…not me.
I do find it interesting that I am the ONLY one here. who has posted, living the situation of a VBAC gone wrong. Of COURSE, my opinion is skewed…I WAS THERE and experienced the trauma myself and my daughter will live with it her entire life.
Again, you should absolutely do what you think is best for you and your unborn baby….who really knows what will happen until it does…you make the choice for yourself.
Christine
March 13th, 2010
10:27 pm
You did not have a VBAC gone wrong. You had an unfortunate complication of a vaginal birth that happened to be after a cesarean.
The only risk that is specific to a VBAC is uterine rupture.
mandapanda
March 13th, 2010
10:29 pm
coming in here late…but….my first cesarean, since I’d labored for 18 hrs or more (but was induced just because I was at 41 weeks, and the pit contractions made me beg for the epidural..) on my back in the bed (the epidural ties you down)….they had me start to try to push at 9 1/2 cm w/ a lip…doc had been on call all wknd and was ready to get home… they told me that baby’s head was beginning to “swell” (though a “caput” is normal for vaginal born babies, i know now)…and that it just “wasn’t happening for me this time, we should do the c/s, baby wasn’t coming out, maybe next time”….so fearing for my baby (even though there were NO signs of fetal distress)…i consented. Next time I wanted a VBAC…i knew we wanted more and that multiple cesareans would add more risk, and I just knew I was made to birth, I was the first woman in my family to have a c/s, period….. once again though it was just taking too long for my careproviders….NO signs of fetal distress and they wheeled me to OR yelling “We do not consent to a c/s” Next birth..long story short, I had a doctor supporting me for a VBA2C…and I did go into labor, earlier than my other two, and I got to crowning (very quickly too), but…my placenta abrupted….(there is a MUCH higher risk for placental abruption in women w/ a previous c/s and that risk goes up MORE w/ yet another c/s) My baby died and I almost died. Pathology showed that the placental abruption happened an hour before my uterus ruptured….so the uterine rupture had nothing to do w/ my VBAC attempt. Funny though, how I got a Much BIGGER baby w/ a bigger head down into my pelvis that “just wouldn’t” before) More and more babies and mothers are going to be dying from all of these added risks after cesareans, …the maternal mortality rate HAS already risen, and the infant mortality is too (especially in Alabama) and it’s already much higher than many other industrialized nations. WHEN are ppl going to wake up? Mary Jane…i’m sorry your daughter was injured,.I truly am. But she sounds like she’s doing really well. My baby is dead though. And your doc shouldn’t have used the suction but let nature take it’s course. As far as the malpractice issue w/ VBACs, statistics show that it is a fear of the PERCEIVED threat of malpractice that makes doctors not do them. But actual numbers in the scheme of things is really low. And most lawsuits are truly from cases of actual malpractice..ie, inducing a VBAC which adds risk and not disclosing full consent of the risk, etc. Just my .02
mandapanda
March 13th, 2010
10:34 pm
actually a uterine rupture CAN happen on unscarred uteri (especially w/ the use of cytotec) but it’s rarer than how rare it is for VBAC. U/R can happen after a myomectomy as well, but still rare. What to me everyone SHOULD be worrying about is placental abruptions, because they can happen w/ little signs to show for it, until it’s too late. The risk rising significantly after a previous cesarean, and even MORE after multiple cesareans. Stillbirth and miscarriage risk rise as well after prior cesareans. Which is why I fight to lower the PRIMARY cesarean rate on top of fighting for the right to VBAC.
Michelle Frank
March 13th, 2010
10:37 pm
motherjane: you are doing every woman who has ever had an either necessary or unnecessary c-section a MAJOR disservice by repeatedly imploring that your baby’s Erb’s Palsey was a result of a VBAC. Your situation is just an anecdote; there is no research at all that links your daughter’s condition with VBAC. It is horribly sad, and I’m sorry that your provider lacked the necessary skills to provide you with an eventful delivery and a perfectly healthy baby. But if you would PLEASE get your facts straight…
Michelle Frank
March 13th, 2010
10:39 pm
obviously I meant *un*eventful delivery…
Christine
March 13th, 2010
10:48 pm
Mandapanda, I said that the only risk of vbac is uterine rupture – not that UR is a risk that only happens in vbac. Yes uterine rupture can happen in an unscarred uterus as well.
mandapanda
March 13th, 2010
11:09 pm
yes, sorry , was reading that wrong…thanks!
mandapanda
March 14th, 2010
12:36 am
someone mentioned amniocentesis due to maternal age…. do the research on that and be informed there also…. there is a greater risk of baby dying (miscarrying/stillbirth) from that than from uterine rupture, at least after 1 c/s, not sure multiple c’s…
mandapanda
March 14th, 2010
12:37 am
ack, if you don’t post that other long post i posted, can i have a copy of it emailed back to myself LOL
motherjanegoose
March 14th, 2010
8:16 am
mandapanda…..I cannot imagine your loss! There are certainly complications on both sides of this issue.
Causes of Erb’s Palsy ( see the link I posted at the beginning)
Erb’s palsy is the result of a nerve injury. All the arm’s nerves are connected to a group of nerves near the neck which is called the brachial plexus. The brachial plexus nerves are responsible for feeling and motion in the hand, fingers, and arm.
Erb’s palsy can be caused by several things which can happen during a difficult delivery ******.
( I BELIEVE THIS APPLIES TO MY VBAC, AS I HAD LABORED FOR OVER 24 HOURS, HAD A PREVIOUS C SECTION, A BABY OVER 8 POUNDS…verified… IN THE WOMB?)
Approximately one or two babies per thousand births will have a brachial nerve injury. The brachial nerves can be injured if the baby’s neck and head are drawn to the side when the shoulders exit the birth canal. Pulling excessively on the shoulders as the baby comes out head first can also lead to a brachial nerve injury. During a breech birth (feet first), the arms are usually raised and may be injured from excess pressure.
Larger than average babies ( my daughter was over 8 pounds and we all knew it) are especially at risk for a problem during delivery called shoulder dystocia. In shoulder dystocia, the infant’s head is delivered normally, but one shoulder becomes stuck under part of the mother’s pelvic bones. This is a difficult situation for doctors to remedy. ( does that make anyone feel better?) .
Use of forceps or a vacuum extractor should be avoided (THESE WERE USED FOR ME) if possible during delivery, because use of these methods increases the risk of shoulder dystocia. In the case of an extra large baby or a delivery which is expected to be breech, the physician should advice the mother and her family of possible problems and what may be needed to safely deliver the baby.
Statistic are wonderful but sometimes life gets in the way and then you can take the statistics and do what you please with them!
If you are determined to deliver vaginally, then you should….YES this is ONLY my opinion and I have lived with the outcome. Perhaps others will not be so unfortunate. Again, I am sharing my experience and this may not be yours…how will you know?
Christine
March 14th, 2010
8:46 am
You’re missing my point. I don’t doubt that the Erb’s Palsy was related to your delivery (and likely your doctor). My point is that it has nothing to do with a *VBAC*
You did not have a bad VBAC. You had a bad vaginal birth. That was also after a cesarean. But what happened to you could have happened with any vaginal birth and is not related to VBAC at all.
motherjanegoose
March 14th, 2010
9:08 am
i am sorry to be so ignorant Christine… but you stated::
You did not have a bad VBAC. You had a bad vaginal birth. That was also after a cesarean.
What does VBAC stand for?
Vaginal Birth After Cesarean???? What am I missing? Your sequence seems the same as mine.
YES, I had a bad vaginal birth that occurred after a cesarean. You are correct!!
Christine
March 14th, 2010
10:40 am
Your birth wasn’t bad *because it was a VBAC*
Your child’s injury was not related to VBAC. The only increased risk that vbac has is uterine rupture. You did not experience a uterine rupture, therefore the fact that your birth was after a cesarean is irrelevant.
You had a bad VB that just happened to be AC.
As Michelle pointed out, when you are telling people your story, they may come away with the impression “VBAC is dangerous”. But VBAC is no more dangerous than a regular vaginal birth, and Erb’s Palsy is not a risk of having a scar on your uterus.
Nadia74
March 14th, 2010
12:57 pm
Mother Jane, the point is that what happened with your daughter could have happened evenif she had been your first birth. The fact that you had a previous cesarean has nothing to do with the fact that she had shoulder dystocia. You would not have requested a cesarean for a first birth, right? So, if this had happened during a first birth, you would have just blamed it on an incompetent doctor/bad vaginal delivery. I understand that you wanted a cesarean at some point during your daughter’s birth, and the doctor did not do one, but again, this does not make it a VBAC gone wrong.
VBAC Mama
March 14th, 2010
1:35 pm
mandapanda – I’m so sorry for your loss. What happened to you is the stuff docs don’t like to tell us when they’re pushing c-sections (especially planned c-sections for “big babies” etc). Every c-section increases a mom’s risk of uterine rupture, placenta abruption, placenta previa and placenta accreta, all of which can be deadly for mother and baby. EVEN IF YOU PLAN A REPEAT C-SECTION, you can suffer from an abruption or rupture before your surgery date (which, for the safety of the baby, should be scheduled no earlier than 39 weeks, in absence of an urgent reason – see March of Dimes for more info). For those who think VBAC is exceptionally risky, you should know you’re at risk of rupture just by getting pregnant again! It doesn’t matter how you planned to deliver the baby if you rupture at 33 weeks.
The same medico-legal climate that makes it so difficult to find medical personnel supportive of VBAC is what contributes to the high primary c-section rate. Until docs practice evidence-based medicine over fear-based medicine, USA will continue to rank at the bottom of industrialized nations for maternal morbidity (42nd in ‘09, down from 41st in ‘07). And if more c-sections were the answer, we wouldn’t be 2nd from the BOTTOM for fetal mortality among industrized nations.
2 if by C-Section
March 15th, 2010
1:30 pm
My 1st was a necessary C-Section as she was Frank Breached (bottom down, head and feet in ribs) from 6 months and never turned. My 2nd four years later, my Dr. and I agreed I would attempt a VBAC, though he encouraged me not to. I went into labor and after several hours had only dialated about 2 cm. The Dr. told me I could continue to labor if I wanted to for a few more hours, or they could take me immediately and do a non-emergency Cesarian. He warned that if I chose to labor longer there was a high possibility I would end up with an Emergency Cesarian since I was not dialating and she had not dropped very much. I chose the C-Section immediately so I could still be awake. Had I waited and done an ER – I would have had to have been knocked out. Afterward the Dr. told me that it was good I did that because my scar was very thin and in his opinion would likely have ruptured had I not gone ahead with the C-Section.
I am all for VBACs and natural births when possible, but sometimes you do need to listen to your Dr. It helps to have an OB that you can fully trust. I knew mine had my best interests at heart, not the hospital’s, and I felt like I was able to make the choice myself, not forced into it.
VBAC Mama
March 15th, 2010
5:44 pm
2 if by C-Section – Unfortunately, there are a lot of things you were told that are wrong. First, when a baby is breech, it is safe to try to turn the baby (called external cephalic version). My doc turned my baby once during my pregnancy. I’ve known other women who had it done multiple times. If the baby remains breech, frank breech can be delivered safely. The Canadian version of ACOG recently reversed its recommendation that breech babies be delivered by c-section and now recognizes that vaginal delivery is safer (see http://ecochildsplay.com/2009/06/19/vaginal-birth-better-for-breech-babies-says-canadian-doctors/). Of course, that’s only if your provider knows how to do it. Regarding your VBAC attempt, it is unlikely you would have had to have been knocked out if you needed a c-section. If it was a concern, you could have had an epidural in place just in case. For my emergency c-section, they still had time to do a spinal, even though the baby was experiencing decels. It’s pretty rare that they need to completely knock someone out, especially when they plan ahead for it. Furthermore, your doc neglected to tell you that it is normal for a uterus to thin out during labor and they can look translucent at delivery.
You wrote, “My 2nd four years later, my Dr. and I agreed I would attempt a VBAC, though he encouraged me not to.” You later say your doc had your best interests at heart. He clearly did not support VBAC so is it any suprise that he only “let” you labor for “several hours” and then scared you into making a decision by threatening you with being knocked out? Was your baby in distress? Did anyone encourage you to get out of bed to help the baby drop? Did he discuss augmentation to help get things going?
With my successful VBAC birth, my labor stalled at 3 cm for several hours. I had been leaking amniotic fluid for hours. My doc then augmented my labor with pitocin, starting as low as possible and upping it only until my contractions became regular. I delivered 4 hours after starting pitocin, dilating the final 7 cm in that time.
I’m not trying to pick on you, but rather to point out how the same situation could have been handled differently with a TRULY supportive provider. It is hard to make an informed choice when doctors withhold pertinent information or use scare tactics to get their way.
Cassia
March 15th, 2010
9:53 pm
obnurse – Everyone keeps giving stats from NIH and other broad organizations. Why hasn’t anyone quoted ACOG or AWHONN? Those are specific to OB. You will give yourself more credence if you quote ACOG or AWHONN.
I have read the ACOG 2004 VBAC guidelines (the most recently published ones) many times and have also read a number of the studies referenced therein. The information ACOG uses to write their guidelines comes from the same source that is available to the NIH for their most recent statement (accept that NIH may be using more up to date sources since much has been learned in the last 6 years). Both groups get their statistical information from peer-reviewed studies in medical journals. Therefore, the information from *this* NIH statement (as it was directed at comparing VBAC and ERCS) is no less applicable to the field of OB than a statement from ACOG.
Cassia
March 15th, 2010
10:22 pm
Let me first clarify that I am NOT anti-cesarean. I am grateful that the procedure is available and that both mom and baby almost always survive. This was not the case until fairly recently in history, and is still not the case in some areas of the world. And there are definitely cases in which a C-section saves the life of mother, baby or both.
The real problem, to me, is the current lack of true informed consent, and of the ability to make a reasoned choice.
I have been a prospective VBAC patient twice. Both times I was required to sign a waiver stating that I understood choosing VBAC could result in uterine rupture, hysterectomy, need for transfusion, infection, and even the death of the baby. Honestly, these can be pretty scary forms. They state the horrible things that *could* happen, but they do not mention the actual risk rates nor do they put them into perspective. Frankly, I doubt those who choose an Elective Repeat C-section (ERCS) receive a similar consent sheet listing the risks of choosing a C-section. I hope they would, but I get the feeling their consent is more along the lines of the general hospital consent – basically “as in any procedure, there are many possible complications but they cannot all be listed here on this form – ask your doctor if you have any concerns.”
During my third pregnancy (second prospective VBAC) I had read enough from the medical journals to know that those things listed were all possible with ERCS as well. This was also the pregnancy in which the doctor was less supportive and kept emphasizing the risk of hysterectomy from a failed trial of labor. The doctor, however well intentioned, was misled. The risk of hysterectomy in a VBAC attempt is not any higher than the risk in a ERCS – in fact, many studies have found slightly more cases of hysterectomy in ERCSs than in VBAC attempts. But my doctor had not read those studies – he was going off of his own impressions. And he honestly thought more hysterectomies occurred in VBAC attempts.
A few months later I called a hospital in the ATL area to ask about their policy on VBACs. The nurse I spoke with said the hospital completely banned them because of the high risk of uterine rupture. During our conversation, she kept stressing “the high risk of UR.” When I finally asked her what she thought the risk was she responded, “Well, they used to say it was 40% but now they’re saying it’s even more.” She was wrong. No study has ever listed the risk as 40%. The highest I’ve ever seen was no more than 12% and that was specifically when cytotec was being used to induce (a big no-no for VBACs and dangerous for even those with no previous uterine surgery). ACOG actually listed the rate as more around 0.8% in their 2004 guidelines. Do I think she was trying to lie to me? No. I think she really believed the rupture rate was that extreme. She just didn’t have the right information.
So a major problem is that usually neither doctors (or nurses) nor patients know the real risk of the “bad outcomes,” nor are they then able to put those risks into perspective.
Cassia
March 15th, 2010
10:54 pm
So what are the real risks? Here are some comparisons, using the information provided in the NIH statement that this blog article mentions.
As a reference, these numbers are all in comparison to 100,000 women – so “2” would be 2/100,000 or 0.002%. VBAC *attempts* (includes those with uterine ruptures and those that end up with a C-section anyway) are listed as TOL, Elective C-sections are ERCS:
–Immediate risks–
Maternal mortality (death of mother): 3.8 TOL vs 13.4 ERCS overall (For perspective – the rate of motor vehicle-related mortality for men and women aged 25-44 is about 16)
Hysterectomy: 157 TOL vs 280 ERCS. Risks increase with each C-section (about 420 total with one prior C-section, 900 with two, 2410 with three, 3490 with four, and 8990 with five or more).
Need for blood transfusion: 900 TOL vs 1200 ERCS. This also increases with each prior C-section.
Deep venous thrombosis (DVT – blood clot, which can lead to stroke): 40 TOL vs 100 ERCS
Uterine rupture (UR) : 325 TOL vs 26 ERCS overall. Keep in mind that the rate of UR in women with no previous uterine surgery is about 6 (in 100,000 of course).
The ERCS UR rate is significant because it reminds us that choosing one doesn’t erase the possibility of UR. It is also important to note that most URs don’t lead to fetal death because of the ability to do an emergency C-section. Some may argue that this is taking advantage of the hospital system to make it less dangerous, but that safety net is the whole point of using a hospital in the first place. That is the same safety net that would be needed in case of a placental abruption or prolapsed cord – both of which can occur during any labor.
Birth trauma to baby (specifically brachial plexus injury): 180 TOL vs 30 ERCS. (Again, please note that choosing an ERCS doesn’t completely take away this risk and that the TOL rate is likely the same as the non-VBAC vaginal birth rate.)
Perinatal mortality (20 weeks to 28 days of life) – 130 TOL vs 50 ERCS. I’m am not yet sure how these numbers were reached specifically since it seems a lot can happen between 20 weeks gestation and 4 weeks old that had nothing to do with delivery method, but the report did mention that the TOL rate is comparable to the perinatal mortality rate in first time moms and that overall mortality (irrespective of delivery method) is 1073.
Also, it appears that ERCS may lead to increased rates of respiratory problems and possibly asthma, but this comes from studies comparing general C-sections to general vaginal births so the numbers aren’t included in this VBAC statement.
A note on perinatal mortality and URs – According to the NIH numbers, babies die in 3-6% of the URs, with those at term (not preemies) tending to be less than 3%. Extrapolating that, using 5% so as not to understate the numbers and the NIH UR rates of 325 TOL vs 26 ERCS, that would indicate a mortality rate of 16.3 TOL vs 1.3 ERCS due to UR.
What is significant about this is that while women are often told that attempting a VBAC will put their baby’s life in jeopardy because of the risk of UR, the risk of a baby dying because of a TOL UR is actually fairly comparable to the risk of a mother dying as a result of an ERCS.
I know that many doctors/nurses who practiced in the 90s (when UR became a bigger concern) seem to remember more URs than these statistics would indicate. Please remember that at that time less was known about what causes ruptures and many things that are now known to be very dangerous were used at that time without knowing the possible harm. For instance, induction using prostaglandins has now been found to increase the UR rate by up to 15 times the baseline rate. Among these is cytotec, which currently has a warning label that says it should NOT be used in pregnant women because of the risk for rupture, even in those with no prior c-section.
Cassia
March 15th, 2010
10:57 pm
–Additional long-term risks—
C-section delivery is associated with higher rates of placental abnormalities in future pregnancies, and the rates increase with each progressive C-section.
Placenta previa (where the placenta covers the cervix), for instance, has a rate of 900 after one C-section, 1700 after two, and 3000 after three or more. This may not seem like a big concern if you were planning a C-section anyway, but previas increase the risk of hemorrhaging, hysterectomy, and accreta (placenta growing into/through the uterus) – even when a C-section is done before any labor starts.
And looking at the chance of the placenta growing into/through/past the uterus alone there is a risk of 319 after one C-section, 570 after two, and 2400 after three or more. These are pretty scary risks that would occur in pregnancy (so it wouldn’t matter if the mother wanted a TOL or ERCS for that pregnancy) and most of those rates are more than the risk of UR in a TOL.
Also, a prior C-section is associated with increased risk of abruption (placenta detaching from the uterus), chronic pain, ectopic pregnancy, stillbirth, and infertility, though it is not clear if these risks increase with additional C-sections.
Other problems that do increase with each C-section include clinically significant adhesions, complications during a future repeat C-section, and bowel and ureteral (like bladder) injuries. And, ironically enough, some women also experience pelvic floor disorders even if they have had only C-sections.
The bottom line is that these future risks should also be taken into consideration if a mother would like children after the current pregnancy. According to ACOG’s 2004 VBAC guidelines this should be considered if the mother is even 10-20% certain that she would like another child after this one – so basically if she is even considering the idea.
So again, there are risks to both choices. In fact, no pregnancy is risk-free, no matter the choices made. This is the information women and their providers should have access to when faced with the VBAC vs ERCS decision.
Michelle Frank
March 16th, 2010
10:36 am
Cassia,
Amazing.
mandapanda
March 16th, 2010
3:41 pm
GOOD JOB CASSIA! And i’d go further…not just a 10-20% certainty they want more kids in the future, but….every form of birth control/sterilization has a failure rate..even tubals and vasectomies. how many of us know women w/ “v-babies” or “tubal babies” or “my birth control failed babies” etc etc…. I know this seems far-fetched…but even these women are at risk from those placental complications and uterine rupture in subsequent pregnancies…. this is why we MUST fight to get the cesarean rate down! This is a human rights issue!! women and babies are dying!
College of OBGYN: Stop forcing women to have C-sections! | Momania: A Blog for Busy Moms
July 26th, 2010
12:08 am
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