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.

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.

Labor Induction, What's the Big Deal?

There has been a dramatic rise in the labor induction rate in the last 15 years. According to the National Center for Health Statistics, the rate of inductions was 9.5% in 1990. In 2003, the rate more than doubled to reach 20.6%. There is reason to believe that the most current labor induction rates might, in fact, be under-reported. According to a 1999 review of 7,000 consecutive inductions, published in the American Journal of Obstetrics and Gynecology, the number of labor inductions may be closer to 40% in some community hospitals. Similar findings were reported in the 2002 Listening to Mothers survey. Of the nearly 1600 mothers interviewed, 49% who gave birth vaginally reported that their medical provider attempted to induce their labor and 44% actually had their labor induced.

Research dating back to the 1980s and earlier has consistently shown induced labors more often end in cesarean section, forceps deliveries, serious infections, and greater complications for both mother and baby. Still, many physicians have not been convinced, largely due to an internal debate as to whether these eventual complications are caused by the induction or were the natural result of the immediate medical issue that prompted the induction. Though this debate seems logical it hardly holds water against findings that indicate that 18% of mothers said they were induced for a non-medical reasons and another 16% cited a non-medical reason along with a medical indication. The sharp rise in inductions also reflects the loosened definition of what constitutes a medical induction, for example women who have healthy non-complicated pregnancy are routinely being induced because doctors suspect a large baby. The difficulty in late pregnancy is accurately predicting the baby's size since ultrasound measurements are based on percentiles. These percentiles measure the "average weights" of babies; however the estimates are not always accurate.

For example, one of my doula clients had an ultrasound a couple weeks prior to her due date that estimated her baby's weight to be 8 pounds and her doctor suggested that they induce the baby the next week (pre-term) which she resisted only to have him insist they do it by her due date for sure. She called me after her appointment with her doctor very upset that an induction would thwart her natural birth. I told her that her doctor does not know the size of her baby and that he is just guessing. I reassured her that big babies can come naturally as well as little ones. She told her doctor she would wait to go into labor spontaneously, during the pushing stage of her labor, which was long (not unusual for a first time mom), she later confessed she was silently cursing me believing I had been wrong about pushing big babies out only to be surprised when her new little girl weighed in at 6 1/2 pounds! When doctors advise women to induce due to the size of the baby when there is no other medical concern it is a highly speculative “medical” opinion that does not accurately indicate a medical need.

This common reason for recommending induction is steeped in falsities, the belief that a big baby means a more dangerous and difficult labor. It is true that women who receive epidurals have a more difficult time pushing their babies out and therefore are already at higher risk of c-section and the size of the baby could further complicate the birth; but it is not equally true when speaking of natural birth moms in un-medicated labors, and yet, as with the example above, doctors still recommend the induction regardless of the mothers desire for natural birth. In my experience, as a doula, it is not necessarily a foregone conclusion that a woman with a big baby is going to as a matter of course have a more difficult or even longer labor. The things that most often contribute to long and difficult labors are the obstacles of medical intervention that cause a women to be held captive to her hospital bed stealing her mobility and therefore snatching from her the most effective means of bringing her baby into the world, the power of her own body. Women who labor lying down and immobile are not only going to experience more pain, they will have longer labors and more difficulties at the pushing stage. As a doula I have seen women push for hours only to deliver a 6 pound baby, and another will push twice and a nearly 10 pound baby charges onto the scene. I have watched this phenomenon many times and it is my opinion that the traction that large babies have in the birth canal aids them in the birthing process as long as their mothers are using movement and gravity to help them along. If you will take a look at some of the other content on my

The findings of a study, conducted in Belgium, clearly shows that inductions alone are the cause of birth complications and emergency procedures and prop up the idea that births that are allowed to proceed naturally will not become complicated. The study compared over 15,000 births occurring over one year (1996-7) in first-time mothers. All women had healthy, uncomplicated pregnancies. At their request, half had labor induced artificially shortly before their due dates. The other half went into labor naturally. The women with induced labors used significantly more pain medication and had more cesarean births due to both fetal distress and stalled labors. That group also had more forceps and vacuum births and had more babies admitted to intensive care. This most recent Belgian study is but one of several in the last five years which have attempted to address these questions by studying only clinically similar, uncomplicated pregnancies. Most have found strikingly similar results.

Another reason for a provider to advise an induction is when the mother's due date has passed. Babies who are truly post-term can have more complications. However, this diagnosis must be made based on more than simply dates, since due dates are a loose estimate of gestation. Specific testing can be done, such as a biophysical profile, which measures the amount of amniotic fluid in the uterus, the breathing movements and the baby's heart rate. This would give the provider and parents a more accurate indication of a post-term baby (and ultimately a labor that needs to be induced!) rather than looking at the due date alone.

For example, one of my doula clients delivered her baby three days past her due date but had several common complications attributed to late term delivery including no amniotic fluid, while in contrast another client delivered her baby nearly two weeks past her due date and had no late term complications. Just as there is a weak connection between baby size and labor difficulty, it is also foolish to predict complications based solely late term deliveries.

Not only are doctors inducing women routinely at only 7 days post-term (not even the full 40 weeks that used to be the standard), an even more alarming trend is on the rise, the induction of pre-term infants. Preterm births and induction of labor preterm are increasing at an alarming rate, and it is increasingly evident that even late preterm babies are less healthy and incur higher costs than infants born at full term. In November 2009, the Agency for Health Care Research (AHRQ) published Thinking About Inducing Your Labor: A Guide for Pregnant Women and a companion guide for clinicians. The two publications summarized the current clinical evidence on elective induction of labor (defined as induction without medical indication), which is on the rise and is linked with the increase in late preterm birth. While the evidence base on this issue is still being established, current research indicates cause for concern: Between 1990 and 2006, the U.S. preterm birth rate (birth at less than 37 full weeks of gestation) rose by more than 20%. It is becoming increasingly recognized that infants born late preterm are less healthy than infants born full term. Late preterm babies are more likely than full-term babies to suffer complications at birth such as respiratory distress, to require intensive and prolonged hospitalization, to die within the first year of life, and to suffer brain injury that can result in long-term neurodevelopment problems. They also incur higher medical costs.

Another disturbing trend contributing to the dangerous increase of inductions are the growing number of inductions that are scheduled purely for convenience. The last weeks of pregnancy are uncomfortable and many women simply get tired of being pregnant and ask to be induced, some schedule the induction because their doctors schedule and they want to be sure their doctor is there for the birth, working mothers often schedule inductions for the ease of working it into their schedules. It is hard to imagine that any mother would knowingly open herself and her babies up to such risks as fetal distress and emergency c-section for a scheduling conflict or the annoyance of heart burn and aching muscles, but it seems that this is happening more often and even more disturbing is that it is happening with the support of medical professionals who took an oath to “do no harm.”

It is hard for women who trust their doctors and believe they have their very best interest at heart, to believe that their doctors would recommend medical procedures for them that are not prudent or necessary. This phenomenon may be perplexing, but it may be unwise for mothers to ignore the implications of such studies. With a sharp increase in elective inductions, cesarean rates twice what they are in other industrialized nations, and only 20% of women laboring drug free American women and babies are at greater risk. We have become too dependent on our doctors to educate us rather than taking the time to research our options. Most women are unaware of the real risks of induction and the link between induction and cesarean births.

If a woman is trying to avoid medical interventions in her labor such as an epidural (read my article on epidurals) or a cesarean delivery but 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. 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 the constant interruptions to adjust the EFM straps disrupt the woman’s concentration and relaxation which is essential to the progress of natural birth. This is all significantly compounded by the 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.

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 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.