Cesarean surgery is a life saving medical procedure when performed for reasons that are medically necessary. Medical necessity makes this surgery worth the risks involved. Potential risks of c-section include: infection, hemorrhage, hysterectomy, surgical mistakes, problems in future pregnancies, complications from surgery requiring re-hospitalization, prematurity, respiratory problems in baby, lacerations of baby, amongst others. C-section is the best choice for delivery only when the benefits of the surgery outweigh the potential risks.
A safe option for mother expecting a child after a cesarean is vaginal birth after cesarean (VBAC). We have all heard the “rule” once a cesarean always a cesarean, and with the classical vertical incision that was often the case. However, changes in the way a cesarean is performed with horizontal incision, and methods of stitching, vaginal birth after cesarean is now a very safe option. The risk of uterine rupture with labor after a cesarean is 0.7%, which is comparable to the risk of a mother that has never had a c-section. When comparing the risks and benefits of vaginal birth verses cesarean, you may decide that VBAC is the safest option for you. However, it may not be easy to find a provider who will help you with that choice. Currently, there are many factors that effect a provider’s choice to attend VBAC. Researching, finding a supportive care provider, and discussing the option with your care provider is well worth the time and energy. With all the media coverage of cesarean and VBAC options and hearings on the topics, we should see this option become increasingly available to women across the country.
In early March of this year the National Institutes of Health met with women’s health professionals from all over the country for a Consensus Development conference on VBAC (vaginal birth after cesarean). Click on the link to read their drafted statement in full. Currently, the cesarean rate in our country is at 32%. In Kentucky it has reached 34.6% – the 7th highest in the nation. The World Health Organization recommends the cesarean rate to be between 10-15% to remain within a safe zone. The most significant increase can be seen in women under the age of 25. This tells us that many of these surgeries are being performed on first time mothers. However, that also means that more mothers should be falling in the VBAC category and we should be seeing those rates increase. We are not. Only about 8% of women VBAC in the US.
The NIH came to the conclusion as follows (from ICAN- International Cesarean Awareness Network):
“The final statement from the NIH concludes that a VBAC is a reasonable option for most women. Over 75% of women who attempt VBAC will be successful.” says Desirre Andrews, ICAN President. “Currently less than 10% of women who have had previous cesareans deliver vaginally in subsequent pregnancies, leading to significant and preventable illness and death.”
The NIH made clear that the major driving factors behind this are non-medical reasons including but not limited to perceived convenience, insurance and liability concerns. Proper execution of the informed consent and refusal process is not routine, and would be one factor in addressing non-medical concerns.
So, it seems that some cesarean surgeries are happening without medical reasons for the procedure, posing real risks to mothers and babies across the country. It also seems that the option of a TOL (trial of labor) and VBAC should be offered to those women who fit within the safety standards for vaginal birth after c-section. As we have seen in the statistics this isn’t happening. Why? The NIH concluded one reason as follows (ICAN):
“NIH took the American Congress of Obstetricians and Gynecologists (ACOG) and anesthesiologists to task, calling on them to change the language in their official recommendations on VBAC. ICAN has understood for years that this language plays a large role in the lack of access to VBAC in the U.S.” continues Ms. Andrews. “We hope ACOG rises to the challenge and also hope they will finally be willing to work with ICAN and other advocacy organizations to improve maternal and fetal safety.”
ACOG Guidelines can be found in full online. The two questionable recommendations that are often used to determine whether or not VBAC is offered is:
- Physician immediately available throughout active labor capable of monitoring labor and performing emergency cesarean delivery.
- Availability of anesthesia and personnel for emergency cesarean delivery.
The first recommendation would mean that your doctor would need to remain at the hospital with you throughout your entire period of active labor. Much of the time, in normal labor, an obstetrician is on call for you, and will check on you a few times in labor, and come in only to deliver the baby and see to you postpartum. Laboring is typically done under labor nurse supervision in hospitals. Most mothers in hospitals spend labor with those they choose to have with them, and the labor nurse coming in to check on them periodically. So, for some practitioners/hospitals, the requirement would be more of the doctor’s time.
The second recommendation seems as though it would be routine in any hospital accepting obstetric patients. If you are there as a typical laboring woman, and for some unforeseen reason you require emergency cesarean delivery, you would hope that the personnel and anesthesia are in place quickly to see that you are taken care of and everything turns out safely. That is why one chooses a hospital for birthing. Hospitals handle emergencies right? It isn’t always the case that the personnel are present and ready for an emergency around the clock at some hospitals providing maternity services. For this reason, some decline to allow VBAC. However, one would also need to question whether that hospital would be ready for emergency in a birth that becomes one without it being anticipated.
The NIH stated that around 74% of the women attempting a TOL after cesarean will successfully VBAC. It is a reasonable choice for those women falling in the safe criteria and who hope to avoid the risks of repeat surgery.
If you are considering VBAC for your next birth, read, talk to your care provider about the options for this in the hospital they utilize, ask questions, and choose a provider and birth setting that is supportive of VBAC.
To check on the hospital in your area and their position on VBAC check ICAN online’s VBAC Policies in US Hospitals database. For Kentucky hospitals you may check the VBAC rate using the Inpatient Quality Indicator. Use what you find to discuss the option with your care provider. If you have found that the hospital your provider uses has a 0% VBAC rate and/or a formal or de facto ban on VBAC and yet the provider agrees to attend your VBAC, ask about any changes in these policies from the time these statistics and databases were compiled and how they plan to support your TOL. Also, ask about any restrictions they place on VBAC mothers during labor and delivery.
The issue of c-section and VBAC is one that is in great need of addressing in our country. VBAC is a safe option for most women who have had a prior c-section. Remember when discussing any option with your provider to consider risks, benefits, and alternatives.
The next post will discuss ways to achieve a healthy VBAC.
Many happy days to you and yours,
If you have questions about a topic surrounding VBAC and c-section, or any other topic you would like to read about here, email firstname.lastname@example.org. 🙂