November 15, 2005

The CDC reports:

  • National Cesarean rate for 2014 is 32.2%
  • The rate is up from 27.6% in 2003
  • U.S. cesareans have risen 40% since 1996
  • First-time cesareans are at an historical high of 22.8%
  • VBAC rate is 22.8%
  • Since 1996, the VBAC rate in the U.S. has plummeted 67%
Couples planning a VBAC, or vaginal birth after cesarean, face a number of challenges that other birthing couples do not. To begin with, there is often significant anxiety surrounding the birth. Will the same thing happen again? What did we do wrong last time? What should we do differently this time? Add to this the responsibility of finding a VBAC friendly doctor with admitting privileges to a VBAC friendly hospital and you face a real challenge. Relax. It can be done.

Consider the following excerpt which shows that the risks associated with VBAC are significantly lower than the risks of elective repeat cesarean:

Overall, attempted vaginal birth for women with a single previous low transverse cesarean section is associated with a lower risk of complications for both mother and baby than routine repeat cesarean section. The morbidity associated with successful vaginal birth is about one-fifth that of elective cesarean. Failed trials of labor, with subsequent cesarean section, involve almost twice the morbidity of elective section, but the lower morbidity in the 80% of women who successfully give birth vaginally means that overall women who opt for a planned vaginal birth after cesarean suffer only half the morbidity of women who undergo an elective cesarean section.Uterine dehiscence (asymptomatic separations of the uterine scar) or ruptures occur in less than 2% of trials of labor, the same proportion as is seen among women who have routine repeat cesareans. Most of these are asymptomatic and of no clinical importance. Indeed, the prospective observational studies found evidence of dehiscence in 0.5-2.0% of women undergoing planned cesarean section before labor had even started. The corresponding figure for women undergoing a trial of vaginal birth (successful or unsuccessful) was little different (0.5-3.3%), although, because of lack of randomization, the two figures are not directly comparable. The important point is that serious wound dehiscence is a rare complication during labor after previous cesarean section. Excluding symptomless wound breakdown, the rate of reported uterine rupture has ranged from 0.09 to 0.8% for women with a singleton vertex presentation who underwent a planned vaginal birth after a previous transverse lower segment cesarean section. To put these rates into perspective, the probability of requiring an emergency cesarean section for acute other conditions (fetal distress, cord prolapse, or antepartum hemorrhage) in any woman giving birth, is approximately 2.7%, or up to 30 times as high as the risk of uterine rupture with a planned vaginal birth after cesarean. The extremely low level of the risk does not minimize the importance of this complication to the individual women who suffer it, but comparisons may help to put it in a more reasonable perspective. RISKS TO THE MOTHER:The rate of maternal death associated with cesarean section (approximately 4 per 10 000 births) is four times that associated with all types of vaginal birth (I per 10 000 births). The maternal death rate associated with elective repeat cesarean section (around 2 per 10 000 births), although lower than that associated with cesarean sections overall, is still twice the rate associated with all vaginal deliveries, and nearly four times the mortality rate associated with normal vaginal birth (0.5 per 10 000 births). RISKS TO THE BABY:The major hazards of cesarean section for the baby relate to the risks of respiratory distress contingent on either the cesarean birth itself or on preterm birth as a result of miscalculation of dates. Babies born by cesarean section have a higher risk of respiratory distress syndrome than babies born vaginally at the same gestational age. There is also a risk of being cut during the surgery.

How to Increase Your Odds of a Successful VBAC

There are several factors influencing the outcome of a VBAC. The most important factor is the support of the partner and labor team. Before you do anything else, assemble a team of people dedicated to helping you have a VBAC. This should include your partner, your care provider, your place of birth, and your labor support person. Your nutrition plays a critical role in the success of a VBAC. You should be getting 80 to 100 grams of good quality protein a day in addition to the rest of your foods. This information comes from Dr. Tom Brewer’s book regarding diet and pregnancy called The Brewer Pregnancy Hotline. Dr. Brewer's recommendations are 1) 80-100 g protein for a singleton pregnancy, 2) salt your food to taste 3) drink water to prevent thirst not quench it 4) restrict ONLY empty calories like candy and other junk foods This is not Atkins. Whole grain carbohydrates are a good source of Vitamin E, Vitamin B, fiber and long term energy. Fats are essential for baby’s neural development and your energy reserves. Fats and oils, interestingly enough, also help the skin to be supple. You will be able to get enough fat from the meat, fish, and dairy that you eat. It is not the amount of weight you gain, but the quality of the diet that puts the weight on. I can tell you I have followed this diet with every pregnancy. I know it works. What you put in is what you’ll get out. Being well nourished could make the difference between success and failure; labor is like running a marathon, every advantage counts. The uterus is a big muscle with big energy needs to function at its best. Check out the Brewer diet Exercise contributes to the success of every vaginal birth, but is especially important to a VBAC. Try to do something active every day unless your doctor has advised you not to. Go for a walk, ride a stationary bike, go for a bike ride, swim, take a pregnancy yoga class or pregnancy aerobics class. The possibilities are endless. Actively working your muscles will help build physical endurance and mental stamina for labor. Start doing Kegel exercises to tone and limber the perineum. Tailor sitting is another low impact stretching exercise for the pelvis and perineum. I like to tailor sit on the floor while I watch TV. Squatting is yet another great position for stretching the perineum and pelvis. Squat with your heels flat on the floor and back against your bottom. Get your bottom as close to the floor as you can. It is easiest to do this against a wall so your back stays nice and straight. Finally, believe that you will have a VBAC. We have all heard of the self-fulfilling prophesy. Usually we equate it with causing something negative to happening. It is even more powerful as a catalyst for creating something positive. Visualize this birth the way you want it to happen. What you believe about your ability to do this is crucial to your success. Maybe you won’t have your ideal birth, but keep telling yourself over and over that you are going to birth your baby the way you want to. Believe it, wholeheartedly. Building belief also reduces fear. When you are convinced you will succeed, it is hard to find room to be afraid.

Your Labor Team

It goes without saying that you and your partner must be in agreement about attempting a vaginal birth. Any dissention among the two of you will definitely undermine the success of a VBAC. To be considered mother friendly, a hospital must meet the criteria of the Coalition for Improving Maternity Services (CIMS). Included in CIMS initiative are: a VBAC rate of at least 60% with a goal of 75%, allowing constant access to professional labor support, and not routinely employing practices that are not supported by scientific evidence. Check out the mother friendly childbirth initiative on the CIMS website. Doctors must meet certain criteria in addition to the CIMS guidelines in order to claim that they are mother friendly. I asked my doctor several "what if" type questions during our interview. For example, 'What would you do if you felt I wasn't progressing quickly enough?" "What would you do if you felt the perineum wasn't stretching enough?" I like to hear the following: 'I would encourage you to walk or change positions to promote labor '(NOT 'I would start pitocin') and 'I would provide perineal support and/or perineal massage.' (NOT 'I would cut an episiotomy') I know I live in a dream world, but you really should be able to get answers close to these if you are dealing with a mother friendly doctor. Also be sure to note the sincerity of the response. Many a care provider has told the mother what she wanted to hear. Many others have patently said something akin to 'don't worry about it' or 'we'll deal with that when the time comes'. These are unacceptable answers and attitudes. Those providers are not mother friendly. Doulas and midwives are usually much more mother friendly due to their philosophy of practice. Still, make certain your doula or midwife supports and believes in VBAC. Labor is not the time to be finding out that your care providers are uncomfortable with VBAC. Lastly, make a detailed birth plan. While not every nurse or doctor is receptive to a birth plan, it will help you and your doula to formulate your plan and put your decisions in writing. Try to have your birth plan written prior to the last month of pregnancy. This will give you a few appointments to discuss it with your doctor or midwife. You will want to do this so that you will know ahead of time if there are things in your plan that either your doctor/midwife or the hospital policy objects to.