Natural Birth is the Key to C-section Prevention and VBAC Success

The greatest concern for women who have had a previous cesarean is the risk of uterine rupture during a vaginal birth. Uterine rupture is very serious and can be life threatening to the mother and baby. Just stating that risk would make most mothers choose a repeat c-section on the spot, however when a mother is in possession of all the facts, weighing the risks and benefits becomes much easier to choose a VBAC.

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.

Why should I avoid a c-section

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.

WHAT IS A DOULA?

Doula is a Greek word for servant. The definition has been adapted to mean a woman serving a woman in childbirth.

Doulas are trained to provide continuous physical, emotional, and informational support to you and your partner before, during and after childbirth. They assist you during labor with relaxation, breathing, message, verbal encouragement and other comfort measures. They also work with your partner, encouraging his involvement and creating an atmosphere of teamwork and trust.

A doula does not offer medical assessments, advice or treatment. They provide continuous personal support for you and your partner during your birth experience.

I want you to have the best birth experience possible, that's why being a doula is my passion...

Inductions

If a woman is trying to avoid an epidural and allows herself to be induced when there is no pending emergency she will find it nearly impossible. The way doctors induce is aggressive, it is so common to use the epidural with inductions that they don't take any thought for trying to keep the induction as close to a natural simulation as possible. I have known midwives to use pitocin this way with success at giving women a pretty natural experience without drugs, but women should not count on the prudent use of the drug. The standard induction makes the contractions harder and faster than a natural labor progression would be.

An induction stacks the deck against natural birth and one medical intervention inevitable leads to another and another. The induction makes the continuous EFM a necessity to safeguard the baby, which causes unmanageable pain and stress for the mother. The EFM is very physically uncomfortable because of the placement of the EFM around the abdomen a very sensitive area during labor, but it is even more upsetting to the labor process because it limits the mother's mobility so much so that the mother has no physical pain relief at her disposal. She can't really move very easily and usually ends up in bed on her back so the nurses can adjust the straps just right to get a good reading on the EFM, in order to prevent fetal distress. The constant interruptions to adjust the EFM straps disrupt the woman’s concentration and relaxation which is essential to the progress of natural birth.

Women who are induced are also seldom allowed to use the shower or birthing tub to get relief from the pain (except with some midwifes who provide continuous labor support and supervision). It is my opinion that if you are induced you will not likely be able to cope with labor naturally and will just feel like you failed in the end. What you need to know is that failure in natural birth is most often related to medical intervention and not the mother's ability. A women's best chance at having a natural drug free birth is for a women to go into labor naturally, be free from as many medical tools and interventions as absolutely possible, and have natural birth support from a wise woman who knows natural birth well, like a doula or midwife.

Cesarean Birth

The best policy on Cesarean birth is prevention. I believe that American women would be best served by the Midwifery model for maternity care then the heavily medicalized version we have subscribed to over the past century. Most American women don't realize how different our maternity system is here compared to other modern countries who keep their cesarean rates under 10%.

Our current system has resulted in a cesarean rate of 29.1% (Centers for Disease Control and Prevention, 2005) and an increasing number of women who are traumatized by their birth experience. Hospitals have not made birth safer for mothers or babies. We've been trying to fix a broken system for half a century.

The fix is in. As long as doctors and the powerful money behind our current model reject the midwifery model for maternity care and continue to treat pregnancy as an illness rather than the inherently natural condition it is the system will continue to fail American women. A mother astutely observes that, "There are many rackets in America but the one I find most offensive is "Medicalized Childbirth". The money that is made by the medical community from complicated birth and cesarean sections fuels the miss use of these interventions and women and babies reap the consequences. Before you just accept these medical interventions as necessary research the connection between common medical interventions and cesarean rates in the U.S. Remember when it comes to caesareans prevention is key, and yes in large part they can be prevented.

For those who have already suffered the consequence and who are told that they cannot have a natural birth after a cesarean I would say find another doctor there are doctors who are willing to do this and women are having successful VBAC’s every day. (See my article on VBAC’s to learn more about this issue) For example, a mother I know had a c-section with her first baby because she was told that her pelvis was too small to birth her 9 lb. baby boy. After the birth of her son by cesarean her doctor told her she would not be able to have a baby vaginally, but because this mother had friends in the natural birth community she sought another opinion. The doctor she found was known for his positive position on VBAC’s, he asked her if they had ever done an official measurement of her pelvis which they had not, he measured her and found that her pelvis was perfectly ample and that she would be able to have her next baby naturally. Since then she has naturally birthed five healthy babies with no complications. This is just one story of many like it that should convince women to question what their doctors say and make sure they are receiving the best medical advice.