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Nervous about planning a VBAC

Isha recently left this comment:

I am pregnant and plan on having a VBAC. I am due January 30,2011, as the day gets closer, I get more nervous about it. I hope I am making the right choice in having the VBAC.

Hi Isha!

I too wondered if it was unreasonable to plan a VBAC and that is when I started researching.  I found that learning more about the risks and benefits of VBAC vs. repeat cesarean gave me a lot of peace.  Check out the Quick Facts page for a brief overview and for more information, check out the information made available by the 2010 National Institutes of Health VBAC Conference.

There is about a 0.4% risk of having a uterine rupture with one prior low transverse cesarean in a spontaneous labor (meaning you weren’t induced or given pitocin or other similar drugs during your labor) (Landon, 2004).  One would think that with all the hoopla about uterine rupture, that this rate would be significantly higher than other obstetrical complications.  So I was really surprised to learn that uterine rupture occurs at a similar rate to other obstetrical complications such as post partum hemorrhage, cord prolapse or placental abruption!  And when we look at infant outcomes, there is about a 6% chance of infant death or oxygen deprivation after an uterine rupture (Landon, 2004) compared to the 12% risk of infant death after a placental abruption (Ananth, 1999).

Yet how many of us as first time moms worried our entire pregnancies about any of those complications? How many of us considered an elective primary cesarean in an attempt to circumvent them? How many of us were offered, or even strongly pressured, to consider an elective cesarean by our friends, family, or OB?  How many of us where made to feel selfish over our desire to plan a vaginal birth?

Yet moms planning a VBAC are often made to feel that having a repeat cesarean is the most prudent, conservative choice whereas only selfish women who wish to experience vaginal birth plan a VBAC.  Only people who do not understand the statistics would make such a bold claim.

Just looking at the risks of VBAC isn’t enough when considering your options.  One must also consider the risks of a repeat cesarean.  Women planning an elective primary or repeat cesarean are probably never provided with a Cesarean Consent Form as comprehensive as this one.

I also suggest reading Another VBAC Consult Misinforms and Scare Tactics vs. Informed Consent for more discussion on how women are subtley, and sometimes not so subtley, coerced into repeat cesareans by their care providers.  Additionally, check out VBAC Ban Rationale is Irrational for why the much often quoted “24/7 anesthesia requirement” doesn’t make laboring women or hospitals safer.

Most people are not aware of these facts and thus rely on the conventional wisdom and persistent rumor that VBAC is so risky and cesareans are so safe. Neither are true. Both have risks and benefits.

But when comparing the risks and benefits, both the American College of Obstetricians and Gynecologists (2010) and the National Institutes of Health (2010) have deemed VBAC a “reasonable option” for “most women” with one prior cesarean and “some women” with two prior cesareans.  Most people don’t know that either.

I hope this information gives you some peace.  While it’s not terribly soothing to learn that there are major, rare complications that can occur with either option, it’s also good to know that VBAC is not an excessively risky choice.

Warmly,

Jen

_________________________________

American College of Obstetricians and Gynecologists. (2010, July 21). Ob-Gyns Issue Less Restrictive VBAC Guidelines. Retrieved July 21, 2010, from ACOG: http://www.acog.org/from_home/publications/press_releases/nr07-21-10-1.cfm

American College of Obstetricians and Gynecologists. (2010). ACOG Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Washington DC.

Ananth, C. V., Berkowitz, G. S., Savitz, D. A., & Lapinski, R. H. (1999). Placental abruption and adverse perinatal outcomes. JAMA , 282 (17), 1646-1651.

Goer, H. (n.d.). When Research is Flawed: The Safety of Planned Vaginal Birth After Cesarean. Retrieved August 23, 2010, from Lamaze International: http://www.lamaze.org/Research/WhenResearchisFlawed/VBACLandon/tabid/175/Default.aspx

Landon, M. B., Hauth, J. C., & Leveno, K. J. (2004). Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery. The New England Journal of Medicine, 351, 2581-2589.

National Institutes of Health. (2010, June). Final Statement. Retrieved from NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights: http://consensus.nih.gov/2010/vbacstatement.htm

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13 comments to Nervous about planning a VBAC

  • Zsuzsi

    Isha-
    Interestingly enough, I am due only a couple days ahead of you. I am due on January 28th, 2011. I too am concerned about VBAC – but after reading Jen’s response, I quickly realized that in order for me to feel more confident, I just need to do more research. I am also going to attend one of the ICAN support groups in my area. I hope that you continue to take the steps you need to feel comfortable with your decision.

    Take care-
    Zsuzsi

  • I was wondering about the statistic you mentioned at the top of your reply. “There is about a 0.4% risk of having a uterine rupture with one prior low transverse cesarean in a spontaneous labor (meaning you weren’t induced or given pitocin or other similar drugs during your labor) (Landon, 2004).”

    With my first delivery, I was determined to have a natural, no drugs birth but it ended up being the complete opposite. After 20 hrs of labor I was only 2 cm dilated, the baby hadn’t dropped and also about 10 hrs before delivery my water broke and there was meconium. I still wanted a natural birth so we waited as much as possible and I was even put on a drip to strengthen contractions. I remained at the same dilation and we had to have a cesarean. The baby was getting stressed and the heart rate was rising.

    So we did, I did ask my doc whether I could have a VBAC and he said if no complications in next birth yes.

    In your quote you say that the risk of rupture is 0.4% if there was no other intervention (so I guess if it was immediate emergency to get the baby out or selective Cesarean). Which means in my case the risk would be higher. Is that right?

  • Kari

    Hi,
    What is your definition of spontaneous labor? For example, my water broke, but I didn’t go into active labor right away and was given patocin, which allowed me to get to 9.5cm dilation with in hours. Would this still be considered spontaneous?

    My little man was face up and wouldn’t turn, at the end of the day we did c-section. At the time my doctor said I should be able to go natural in future births, but receiving all of the facts now, it doesn’t seem that way.

    Thanks for all your information. I feel so much more informed and able to discuss it better w/ my doctor and husband going forward.

    Thanks,
    Kari

    • Jen Kamel

      Hi Kari!

      I’m not a medical professional, but my understanding is that when your water breaks it can take several hours for contractions to start. How long a medical provider waits until they use pitocin, if at all, varies from practice to practice.

      When a labor starts spontaneously (without being induced), but then something like pitocin is administered, that is called augmenting a labor.

      Warmly,

      Jen

  • doro

    I really learnt a lot from your research. i had my first daughter vaginally, it was a long labour lasting 48 hours,i was induced ,she weighed 8.3lbs.
    my second daughters labour was different, her water broke, and i went to the hospital early, after 11 hours i was only 4 cm and the nurse said my baby had turned to a breech position. i had to have an emergency Caesarean .
    My third baby, had no problems, but the hospital wont let me have a VBAC, even though i changed hospitals. They all said the same thing, i eventually had to have an over medicated elective Caesarean, my son suffered a lot in the hospital. he was placed on i.v and was given so many injections that i knew nothing of. i eventually left the hospital after i realized they had read a false blood level on a faulty machine, and caused my little boy a lot of distress.
    Now am pregnant for my fourth child, i live in Nigeria, i do not know what kind of care i can recieve. we do not have an active midwifery organisation, and most hospitals would not allow a VBAC. Am secretly planning an home birth, your research gave me plenty comfort.

  • Alverna

    I am strongly considering a VBAC. Everyone else is saying once a cesarean always a cesarean but I want to challenge my gynae next week when I see him for my appointment. My son did not engage at 39 weeks that was the reason for the first cesarean. I will be giving birth in October 2011. I am doing all the research that I can possibly do and I want to thank everyone for the wonderful support that you are giving us mothers who are considering a VBAC.

    My mom is a midwife and she says as long as this baby engage she does not see any reason why I wont be able to deliver vaginally.

    Thank you again and I will let you know how it went.

    Alverna

  • Cheryl

    I was wondering if you have any statistics on VBAC risks with 2 prior c-sections. I had a c-section the first time because of concerns related to high blood pressure and gestational diabetes. My dr told me that my incision was low and transverse, and that a vbac would be an option for the next delivery, but I moved out of state and the dr I had last time would not allow it and actually told me that there wasn’t one in the region that would. (I did not have HBP or GD) That was a little over 3 years ago. My dr did tell me after the c-section that she was able to make the incision along my previous scar so that I would still only have one scar.

    This time, I was able to find a dr (in the same city) that will let me try a VBAC as long as everything continues to go well. Apparently even the clinic I used last time has started allowing some VBACs as well. My current dr said that he would not induce labor under any circumstances and doesn’t want me to go past 41 weeks. I think that’s wise and am agreeable to that. No HBP or GD this time either!! But I did hit the magic age of 35 at the end of April which immediately bumped my pregnancy into a high risk category. I’m currently 36 weeks (due July 9) and feel like a VBAC is the right option for me. But I have some family and friends that are concerned and I know I would benefit from their support. So if you have some information that could help me help them feel better about it, I’d appreciate it.

  • Hello Ladies! I am a Certified Professional Midwife in southern Calif. My birth center, AquaNatal, specializes in assisting women to have safe VBACs in our deep warm built-in tubs from Waterbirth International. If you are in the area I hope you will stop by.

  • Colleen Tatum

    I am looking for the risks to fetus if a uterine rupture occurs, i have found data that suggests the risk of rupture if the first csection is less than 18 months jumps to almost 5%
    But even if that occurs what are the risks to the baby? My ob said baby could suffocate, is that true, how long do you have etc? I can’t find info on fetal survival after rupture and what would be the cause of death or injury to baby if it does occur?

    • Jen Kamel

      Hi Colleen,

      I’m sorry it has taken me so long to reply to your comment. It is frankly really hard to keep on top of all the comments I receive!

      The studies on uterine rupture by birth interval are small and don’t control for important factors like induction and augmentation which we know increases the rate of rupture. So in studies like this that have reported high rates of rupture, we don’t know if that rate is due to short birth intervals or induction/augmentation or simply due to the wonky numbers that small population samples occasionally yield. Read more here.

      As a result of this inconclusive evidence, some OBs require 18 -24 months from cesarean to subsequent delivery whereas others don’t. So, if you have a small birth interval, it might be worth your while to interview other care providers in your area.

      As your OB said, uterine rupture impacts baby by interrupting the blood flow to and through the placenta, and thus oxygen supply. The evidence strength on rupture-related perinatal mortality (infant death within 28 days of birth) is low and you can read more about this here. The evidence on the rate of rupture-related oxygen deprivation and brain damage is even more inconclusive as reported by the 2010 National Institutes of Health VBAC Conference. You can review all the documents and presentations related to that conference here.

      I do cover this topic and so much more in the 6 hour class I teach which is offer via an on-line webinar and in a city near you.

      Hope this helps!

      Best,

      Jen

  • Dawn Orvis

    I want to urge any woman who is considering a VBAC to go for it! I successfully VBAC’d on 9/15/11 – a 7lb baby girl. My first child was posterior and almost 9lbs, resulting in an emergency c-section. It didn’t help that I had gained almost 75lbs through my pregnancy. I am 5’4″ and got pregnant when I was already overweight (165lbs). The docs said I had “a small pelvis.” Ladies, that is balony. Do not listen to them if they tell you that. There is no way they can tell how big your pelvis will get in labor.

    A few words of advice:
    1) Be as active as possible throughout your pregnancy. This keeps your weight down and also your baby’s weight (which helps to make sure the baby can fit through the birth canal). I walked several miles a day up until I delivered. Take the steps instead of the elevator, etc. You will thank yourself. Trust me. Plus it really speeds recovery. I was only in the hospital for 36 hours from the time I set foot in L&D. I was able to leave the hospital a full day early. As a bonus, my daughter is 5 months old today and I am 11 lbs lighter than I was when I got pregnant!
    2) Go to http://www.spinningbabies.com and follow the advice to make sure your baby is in the optimal position prior to labor. Just say NO to a posterior baby! :)
    3) Stick to your guns. They wanted to schedule me for a C because I was a week overdue. My OB said ok to VBAC with the stipulation that I didn’t get induced with Pitocin. If you are under Pit, the risks of uterine tear greatly increase (and so do the chances you will sue your doctor, which is why they don’t want to let you go VBAC in the first place). I put the C off and did lots of nipple stimulation, sex & pelvic exercises to get the labor hormones going so I would go into spontaneous labor. It worked. My water broke on its own.

    My water broke around 7pm. I ate a big bowl of cereal for strength and waited a bit longer. Went to the hospital around 8:00pm and by 2:00am I was pushing. At 4:30, Natalie was born. I pushed for a long time, but that was because she was turning and trying to find her way out. Once she got into optimal position, she was out 10 minutes later.

    I can’t stress enough how physical activity will help you successfully VBAC. It will also give you the strength & stamina you will need to push if your baby is not in optimal position.

    Good luck to you all! And trust in yourself & your body. Women were made to have babies and anyone who tells you a C is necessary because of a small pelvis should only say that if you have had Polio. Otherwise, I guarantee you are big enough to vaginally deliver. Even if you are only 4ft tall!

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