Trying for a VBAC
"With my first pregnancy, I read all the books and wanted to experience a natural birth process, but then I didn't have a choice," says East Greenwich, Rhode Island, mom Sonia Millsom, whose first child, Anita, 5, was in a breech position and had to be delivered by c-section. "But with my second pregnancy, I did have a choice, and I wanted to try a vaginal birth."
Many moms who have an unplanned c-section share Millsom's disappointment over not experiencing a vaginal birth, and when they become pregnant again, this feeling often drives some of them to attempt what is known as a VBAC (vaginal birth after cesarean). It wasn't common in the United States prior to 1980. However, when studies showed that the rate of emergency c-section wasn't any higher for those giving birth by VBAC than it was for those having second vaginal births, the popularity of VBAC rose quickly, hitting an all-time high in 1991.
Unfortunately, this drastic increase in the number of VBACs led to less effective screening to determine which women were truly eligible for vaginal birth; serious complications, such as uterine rupture (a tearing of the incision from the previous cesarean), began to occur more often. According to Roger Freeman, MD, director of obstetrics and gynecology at Long Beach Memorial Medical Center, in California, this documented rise in the rate of rupture over the last decade has made doctors more hesitant about VBACs. In 2002, for example, the number of VBACs dropped from 55 percent to nearly 13 percent of all births. Today's attitude toward VBAC seems to be cautiously optimistic. So while fewer VBACs are being performed, they are much safer, and doctors are now evaluating patients more carefully.
Can You Have a VBAC?
For women who've been screened properly and deemed fit for a VBAC, the success rate is between 60 and 80 percent, according to the American College of Obstetricians and Gynecologists (ACOG). There are several medical factors that physicians consider when assessing your situation.
What type of incision was made on your uterus during your previous c-section?
This is the key factor in deciding if you can deliver vaginally. There are three types of incisions used during c-sections: low transverse (a side-to-side cut made on the lower part of the uterus), which is the most widely used; low vertical (an up-and-down incision made in the lower part of the uterus); and high vertical or "classical" (an up-and-down cut made in the upper part of the uterus), which was once commonly used but is now reserved for extreme emergencies.
Though every incision leaves a scar, certain uterine scars are more likely to rupture during a VBAC. Classical incisions are most likely to rupture, so women with these are advised not to attempt a VBAC. The best VBAC candidates are those with low transverse incisions.
What was the reason for your previous c-section?
This can tell your doctor a lot about your chances of delivering vaginally. If your c-section was due to something physicians wouldn't expect to repeat, such as the fact that baby was breech or his heartbeat was irregular, then you have a good chance of having a successful VBAC without complications, says Iffath Hoskins, MD, chair of obstetrics and gynecology at Lutheran Medical Center, in Brooklyn, New York. However, if you had a c-section because your cervix did not dilate adequately or the baby's head did not descend, or both, your chance of a successful VBAC is somewhat lower. Likewise, according to research Dr. Hoskins has conducted, the further along a woman was during her first labor when she needed a c-section, the less likely she'll have a successful vaginal birth in her second labor. In addition, if you're carrying a larger baby, your doctor may determine that a VBAC is too risky.
Are both you and your unborn baby healthy?
If the fetus's health is unstable or if there are complications, such as your child being in a breech position, you can't have a VBAC. Your health is also considered, because conditions such as diabetes and high blood pressure can make VBAC riskier. If problems arise during labor, a c-section can still be performed quickly and safely. In fact, ACOG guidelines state that a physician capable of performing a c-section should be present during every VBAC delivery. For this reason, home births aren't recommended for moms-to-be attempting a VBAC.
Too many c-sections?
ACOG's latest guidelines say that VBAC is a safe option for women who have had only one cesarean, provided their doctor feels they're good candidates. Even if you wanted to try a VBAC after having two c-sections, it might be hard to find a doctor to do it.
What type of labor do you want?
Recent studies have shown that the rate of uterine rupture is lower when labor begins spontaneously; also, the use of prostaglandin gel (applied to the cervix to encourage dilation) can increase your risk of rupture. For this reason, doctors will usually not induce labor for a VBAC.
Weighing the Risks
Having a VBAC increases a woman's risk of complications, including uterine rupture, endometritis (a temporary inflammation or irritation of the uterine lining), and a variety of newborn injuries caused by the uterine rupture. The good news is that these complications are relatively rare. In fact, past research from Ohio State University Medical Center (the largest study ever done on the safety of VBAC) found that the current risk of developing a serious complication during a VBAC is about 1 in 2,000.
However, keep in mind that not every VBAC attempt is successful. Kate Kelly, mom to three boys in Pelham, New York, tried a VBAC with her second child. "Nothing bad happened -- it was just a replay of the first birth," she says. "I dilated quickly, contractions were strong, and everything was great until it was time to push. Only this time, there was a frame of reference, so when my doctor said, 'This just isn't going to happen,' I was like, 'Fine.'"
Of course, you have to be prepared for the fact that if you can't follow through with the VBAC, like Kelly, you'll have to endure the painful recovery that follows a c-section -- after you just withstood hours of labor. In addition, a failed VBAC attempt leads to a higher risk of a post-operative infection compared with the risk for women who deliver by scheduled cesarean, says Dr. Hoskins. For many expectant moms, these negative aspects are enough reason to opt for a scheduled cesarean.
On the flip side, repeat c-sections also carry certain risks, such as placenta accreta, in which the placenta adheres abnormally to the uterine wall. And, of course, a c-section involves major abdominal surgery, which makes you susceptible to the associated risks, such as bleeding, infection, or blood clots in your legs or lungs. With a vaginal birth, you'll spend less time in the hospital, and your recovery period will be two weeks as opposed to six weeks or longer.
"I was able to hold my daughter much sooner than I could hold my firstborn, and because I wasn't in a drug-addled haze, I was able to call my family and rejoice in the birth right away," says Eileen Glanton, of Glenside, Pennsylvania. Moreover, this desire to bounce back quickly affects a mom's decision to opt for a VBAC. "I wanted to care for my baby as soon as possible and be able to care for my other two kids as well," says Elain Cox, of Sammamish, Washington.
Preparing for a VBAC
You're having your second baby, "but it's like you're going into delivery for the first time," says Millsom, mom to 5-year-old Anita and 4-year-old Veronica. So if you're considering a vaginal birth after a c-section (VBAC), follow the experts' advice: Take childbirth classes that address VBAC, and read as much about the process as possible. Many moms planning to attempt a VBAC also enlist the help of a midwife or doula to guide them through labor. Regardless of your approach, focus on the fundamental goal. Dr. Hoskins reminds all her VBAC patients about what really matters: "A successful birth means a healthy mother and a healthy baby, regardless of the route of delivery."
Copyright © 2007. Used with permission from the October 2007 issue of American Baby magazine.
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