Tuesday, May 17, 2011

Vaginal Birth After Cesarean (VBAC)

Having discussed cesarean sections in some detail, we come to a topic very close to my heart. C-sections have become common enough (30% of all births in the United States), that it is not at all shocking to meet a mother who has had at least one c-section. Indeed, c-section is so high in the consciousness of many of us who have given birth, especially those of us who have had c-sections, that it is sometimes hard to believe there are women who have not gone through it. A couple of months ago, I was telling a friend of mine about attending another friend's birth and how exciting it had been. She asked, "Oh, did she get her VBAC?!" In fact, both of her births had been vaginal, but because this friend I was speaking with had had a c-section, and I had had a c-section, and several other of our friends had had c-sections, she had forgotten that this particular woman had not!

Because most of the women I know who have had c-sections had not planned or wanted to give birth in that fashion, VBAC is also very high in our consciousness. For my friends with one child (so far), whose long labors or other circumstances led to unplanned, emergency, or unwanted-but-scheduled c-sections, my "achievement" of a successful VBAC is something I'm very happy to talk to them about and that I am often asked about. This post, then, is not so much about numbers and stats, although I will put some for everyone's own edification. This post is about why I wanted a vaginal birth and how that can still happen even if you've had a c-section (or two!) in the past.

I hope this is post is informational, emotional, and meaningful, and I hope that if you are on the fence about whether to consider or attempt a VBAC, this post helps you decide.

Let's start with some basics. In almost all cases (except for those in which c-section is necessary to save the life of mother and/or baby), vaginal birth is safer than c-section for both mother and baby. I listed some of the risks of cesarean section in the previous post. Certainly, there are risks associated with vaginal birth, as well, but these are typically less severe or less common than any of the complications or risks associated with cesarean birth.

Additionally, the recovery from a vaginal birth is generally considerably shorter, easier, and less painful than recovery from a c-section. Most women are up and about after just a few days following a vaginal birth. The typical hospital stay is 24 to 48 hours following a vaginal birth, compared to 72 to 96 hours following a c-section. Yes, there may be pain from vaginal or perineal tears or episiotomy upon sitting or using the bathroom. The abdominal area may be tender. There may be painful uterine cramping (as there would be following a c-section anyway). But because you have not experienced major surgery from which your body is attempting to recover, you will likely be surprised at the ease with which you are able to recover from the vaginal birth as compared with the c-section.

In July 2010, the American Congress of Obstetricians and Gynecologists (ACOG) issued a practice bulletin stating a desire for less restrictive guidelines for VBAC. VBAC is considered safer than cesarean delivery in most cases for women with one or two previous cesarean births. ACOG recommends allowing women a Trial of Labor after Cesarean (TOLAC) in most cases, if desired.

The most common risk cited in argument against VBAC is the possibility of uterine rupture, in which the uterine wall opens up during labor. This can be, but is not always, a catastrophic emergency, sometimes resulting in emergency hysterectomy. However, uterine rupture does not always lead to hysterectomy or even future infertility, although it does require emergency intervention in the OR. Most importantly, the chance of uterine rupture is less than 1% of all VBACs! Most major risks associated with repeat cesarean are statistically higher than the risk of uterine rupture during a trial of labor.

I mentioned in my previous post that I am most concerned with the non-medical risks of cesarean section delivery. These are mostly the emotional consequences of not experiencing the desired birth scenario. Many women feel that their bodies have failed them, or that they have missed out on something very special. These feelings can lead to postpartum depression and/or delayed bonding with the new baby. In addition, depending on the environment in which the c-section is performed, there is often a delayed initiation of breastfeeding. Plus, the pain and long recovery time associated with c-section can interfere with breastfeeding as well, sometimes leading to formula supplementation and/or breastfeeding cessation. This, in turn, can lead to further emotional consequences for the mother and continue the disruption of the bonding process between mother and baby.

I know this because I went through it, and I have spoken with many other women who have experienced these same feelings. (That's not to say every woman who has a c-section feels this way, or that every woman who has had a c-section has any difficulties with breastfeeding, or that any woman that does not breastfeed or stops breastfeeding experiences these feelings of betrayal, failure, guilt, or anger.)

I think it's pretty obvious, then, why a woman who has experienced an unwanted c-section would want to attempt a VBAC should she decide to have another baby. Having a VBAC can be incredibly healing. It's a way of saying, "Yes, my body can do this."

Approximately 60 to 80% of attempted VBACs result in a vaginal birth. This means your "odds" of success are quite good.

You are a good candidate for VBAC if:

  • You have had one or two previous cesarean deliveries using a low transverse (bikini) incision. If you are not sure what kind of incision you had, you should ask your doctor. The vast majority of c-sections performed these days utilize a low transverse incision.
  • You have a healthy pregnancy.
  • You do not have any conditions that would render vaginal birth unsafe, such as placenta previa, placental abruption, prolapsed cord, breech baby.
In other words, you are a good candidate for VBAC if you would be a good candidate for vaginal birth anyway. The only real difference is that it is more risky to attempt a VBAC if induction is necessary due to an emergency situation such as preeclampsia. These risks would have to be discussed with your care provider.

You may hear that delivering a second (or third) child is easier than the first. This is generally true if you have labored in the past or experienced a previous vaginal delivery. If your c-section was scheduled before you went into labor, and you have never experienced labor and cervical dilation, then you should expect your trial of labor to be like a "first birth". If you have been through labor, and especially if you dilated fully or at least past 6cm, your trial of labor will likely be faster and easier than your first labor.

For example, in my case, I had labored for more than 24 hours, reached full dilation, and had pushed for two hours before the c-section was performed. Thus, my second labor, my VBAC, went very quickly and smoothly, as I had been through an almost complete labor process in the past. If I had not had that previous labor, it is entirely possible that the induction attempt would have failed and I would have had a second c-section. I say this only to make it clear that every case is different, and you will have to discuss with your care provider any concerns you have about your particular experience. (I don't say doctor, because you may decide to deliver with a midwife, or at home or at a birth center, rather than in a hospital setting.)

The ways to increase your chances of a successful VBAC are essentially the same as those that would be more likely to ensure a successful and healthy vaginal birth in any case. First, choose a care provider who is VBAC-friendly, natural-birth friendly, and will listen to your desires. You can usually find such a person by talking with friends who have had VBACs, attending an ICAN meeting, and doing your own research. Then, during labor, avoid medical interventions as much as possible. Go for as "natural" a birth as you can. Stay mobile. Change positions. Don't be tied to the "flat-on-your-back-with-your-legs-in-the-air" birthing position. You can give birth squatting, on hands and knees, sitting on the toilet (yes, I know someone who did this...twice), reclining, or any way that feels comfortable.

As a final thought, since this has been on my mind recently, what with my upcoming second VBAC attempt (I'm due in September), if your trial of labor does result in a repeat cesarean section, it may be very hard to process. I can't speak to those feelings, and I won't pretend to try. But I know a few women who have not been able to deliver vaginally despite one or more VBAC attempts, and I know it can be devastating. I think it can be helpful to make the operating room environment as comfortable as possible, to insist on holding your newborn absolutely as soon as possible after delivery, to initiate breastfeeding within that ever-so-important first hour, and to know that you selected a care provider with your best interests, and the best interests of your baby, at heart.

Finally, ICAN - the International Cesarean Awareness Network - is an excellent informational and supportive group for women who have experienced (or wish to avoid) a c-section, who are interested in VBAC, or who need help healing emotionally and physically after an unwanted cesarean. I urge you to find a local chapter if you are considering VBAC. The support of women who know exactly what you've been through is invaluable.

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