Many women long for natural birth and feel that there c-section stole something from them but even if you aren't that mom and you are at peace with your previous c-section you may want to consider the risks of having multiple c-sections. American College of Obstetricians and Gynecologists (ACOG) stated that VBAC is safer than a repeat cesarean, and VBAC with more than one previous cesarean does not pose any increased risk.
The most serious cesarean-related complications become more likely as an individual woman has more cesareans. These complications include placental abnormalities such as placenta accreta which carries a 7% maternal mortality rate and a 71% hysterectomy rate. Just how serious are the risks of uterine rupture and how do they compare to the risks of multiple c-sections? The risk of uterine rupture with a low transverse incision (think bikini scar on your uterus) during a vaginal delivery is .2 to 1.5%, which is approximately 1 chance in 500.
To put this risk in an everyday perspective, perfectly healthy laboring moms are at risk for complications that are equally serious to uterine rupture and occur at a similar rate such as placental abruption, cord prolapse, and shoulder dystocia. After two cesareans, the risk of life threatening accreta is 0.57%, similar to the risk of uterine rupture after one cesarean. When taken together the facts show that that the old adage, "once a c-section, always a c-section" may have done more harm than good.
A midwife I worked with once told me that "worry is the work of pregnancy." Every mother worries about the possible scenarios of labor and birth that may cause harm to her baby. Mothers who have the additional consideration of the risks of VBAC vs. multiple c-sections may wonder how every ordinary labor complication or intervention might affect the success of their VBAC. What if I have to be induced? What if I need an epidural? Will a VBAC limit my natural birth options?
What if my baby is big?
Every baby is different, and every labor is different. I participated in a VBAC for a woman who had a prior C-section because the baby wouldn't fit through her pelvis. The baby delivered vaginally, weighed 2 pounds more, and fit just fine! ACOG states that the effects [or difficulties] of labor with a baby more than 8 ¾ lbs have not been substantiated. There is not evidence that a large baby requires a cesarean. The pelvis and the baby’s head are not rigid structures and both mold and change shape to allow birth. During labor there are certain techniques that a woman can use to help open up the pelvis, thus allowing the birth of a large baby. For example, squatting increases the outlet of the pelvis by 10%.
Inductions
Some studies have shown an increase in the rates of uterine rupture in women who undergo labor induction or augmentation. However ACOG attributes these findings to the reasons for and methods used in the administering of induction drugs. The overwhelming evidence shows that the most successful VBACs are the result of natural labor in which medical interventions are only used when absolutely necessary. Therefore planned inductions for non-medical reasons could complicate VBACs and the best way to prevent an increased risk is to practice natural birth basics in achieving your vaginal birth. A mom or baby who in those rare cases develops a complication that requires the baby be born sooner rather than later, but not necessarily in the next ten minutes, should rest assured that their doctor is able to use induction drugs prudently and that these drugs can still make the difference between a VBAC and a repeat cesarean. This is why ACOG maintains that medically indicated Pitocin and/or Foley catheter induction “remains an option” during a VBAC.
Epidurals
Some erroneous reports assert that epidurals are required in VBAC moms to expedite an emergency cesarean if the need arises while other reports state the opposite, that VBAC moms can’t have epidurals because it will obscure the pain of uterine rupture. Neither is true. C-sections are meant to be a last resort when unavoidable emergency complications arise. Hospitals equipped for these emergency can perform c-sections quickly and safely. The ways in which epidurals can complicate a VBAC do not differ from the way in which they complicate every labor. Epidurals complicate vaginal birth in many ways, they restrict movement for the mother and baby which can lead to malpresentation of the infant, uneven dilation, failure to progress, and fetal distress. All of these complications increase the chances of c-section but none of them have been proven to increase the risk of uterine rupture or obscure the pain of uterine rupture.
Continuous electronic fetal monitoring
Continuous electronic fetal monitoring is not necessary during a drug free natural VBAC. Regular intermittent monitoring is sufficient to monitor a VBAC. This is important to understand because continuous electronic fetal monitoring is known to increase the risk of c-section because it reduces movement and thwarts natural pain coping. Mothers who choose VBAC should not feel pressured to be continuously monitored, should not have their movement restricted, and should insist on natural coping techniques for natural birth.
Where I deliver my baby
VBACs can limit your choices of delivery location. Most birth centers will not deliver VBACs, many home birth midwives will not attend a VBAC at home, and some hospitals don't allow VBACs. This has prompted some to believe that VBACs are such a serious and unusual complication that medical professionals cannot manage it appropriately. This is not true. Policies developed to answer defensive medicine protocols have made it burdensome for some hospitals to facilitate VBACs. Some hospitals apply the ACOG’s “immediately available” recommendation as an absolute mandate that an anesthesiologist must be in the hospital 24/7. Some hospitals that cannot provide that level of coverage have banned VBAC. However, “immediately available” does not have a standard definition and various hospitals implement the guideline in different ways. There are motivated hospitals that offer VBAC without 24/7 anesthesia. The rural hospitals that serve the Navajo Nation in New Mexico are an example and they report a 38% VBAC rate. The American VBAC rate is 10%. ACOG affirms that “restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will.”
Your health care provider
Talk to your health care provider early in your pregnancy to make sure VBACs are allowed where he or she does deliveries. If not, you may need to change providers or hospitals if you want to pursue VBAC. Your health care provider will review the details of your previous c-section to determine if you are a good candidate for a VBAC. VBAC eligibility depends on many factors, including the type of uterine incision that was used for your prior C-section. A low transverse incision is strongest and least likely to open during another labor. It is also the most common incision. 90% of women who have undergone cesarean deliveries are candidates for VBAC.
With a national cesarean rate of nearly 34% percent, it would be easy to assume that surgical delivery of a baby is a piece of cake. While the surgical technique has been perfected over recent decades, Cesarean delivery is not a benign procedure it is surgery and is accompanied by serious risks; wound infection, wound dehiscence, and injury to internal structures like accidental cut in the bowel or bladder. New mothers want to be the best mothers they can be when they take home their bundle of joy, and recovery from labor and delivery is already a challenge, but adding the increased and prolonged pain from a c-section recovery is disheartening and often leads to higher incidence of serious postpartum depression, delayed skin-to-skin contact between mother and baby after birth, delayed breastfeeding, and higher incidents of breast feeding difficulties.
Natural birth is the answer
The bottom line on c-sections and VBACs is simply that natural birth is the best way to avoid a c-section and the best way to safeguard against VBAC complications. The best way to ensure a safe and healthy labor for you and birth for your baby is to avoid any medical interventions, including pain medications, inductions, continuous electronic fetal monitoring, and cervical exams for dilation. Hire a doula and build a supportive, calm, and permissive environment to labor in. Having a support person who is trained and experienced in birth will make all the difference to your ability to cope during labor which is key to avoiding unnecessary medical interventions and complications.
The bottom line on c-sections and VBACs is simply that natural birth is the best way to avoid a c-section and the best way to safeguard against VBAC complications. The best way to ensure a safe and healthy labor for you and birth for your baby is to avoid any medical interventions, including pain medications, inductions, continuous electronic fetal monitoring, and cervical exams for dilation. Hire a doula and build a supportive, calm, and permissive environment to labor in. Having a support person who is trained and experienced in birth will make all the difference to your ability to cope during labor which is key to avoiding unnecessary medical interventions and complications.
