Category Archives: Pain

VBAC vs. Repeat Cesarean by the American Academy of Family Physicians

This is a great piece for deciding between VBAC and repeat cesarean.  Those who wish to VBAC, but have husbands, family, and/or friends who don’t understand why, might find this document very useful.  I have found that people who are anti-VBAC really seem impressed by what doctors and medical organizations have to say, so I’m thinking they will find this document compelling.  Plus, VBAC has this reputation of being “risky” and repeat cesareans are thought of as the “conservative approach,” and this document challenges both lines of thinking.  Why not write a sweet little note like, “I know you are concerned about me choosing the VBAC, so I thought you would find this interesting,” and mail them a copy.  That way, they can read it, think it over, and you can chat about it later.  No one wants to see a loved one hurt or die, and since most believe that a repeat cesarean is the most conservative approach, they tend to lean in that direction.  However, once they understand that real, but small, risks are present with VBAC and repeat cesarean, and that the risks of VBAC go down with each VBAC whereas the risks of cesareans go up with each surgery, hopefully they will respect your decision.

I recommend bringing this document with you when you go to interview OBs about VBAC.  They might be unfamiliar with the data, and they too might be persuaded by a document written by a medical organization.  If your OB is anti-VBAC, this might be a good document to mail them once you have found a truly supportive OB or midwife.

I’ve included the entire text below because when I searched on Google for VBAC vs. Repeat Cesarean, it wasn’t on the first page of results, so I’d like to bring more attention to it.

Please note, they refer to VBAC as TOLAC (Trial of Labor After Cesarean.)

You can view and print the document in PDF format here: Trial of Labor After Cesarean: A Shared Patient-Physician Decision Tool

******************************************************************

In March 2005, the American Academy of
Family Physicians published an evidence based
clinical practice guideline on TOLAC
(Trial of Labor After Cesarean; formerly called
Trial of Labor Versus Elective Repeat Cesarean
Section for the Woman With a Previous
Cesarean Section).
The AAFP guideline
recommends offering a trial of labor to women
who have had one previous cesarean delivery
with a low transverse incision. The guideline
also recommends that physicians and other
maternity care professionals explore the risks
and benefits associated with a trial of labor with
each woman who is a candidate for TOLAC.
The following shared patient-physician decision
tool can be used to initiate the conversation
about the potential risks and benefits of TOLAC.
It is important to note that this piece is not
a patient education handout. It is not meant
to be used as a standalone tool. Physicians
should go through each section with the
TOLAC candidate and explain how each factor
may (or may not) affect her. After answering
any questions the patient may have, the
physician can give the annotated handout to
the patient so she and her partner can review
it as they consider their options.
To read the AAFP’s TOLAC Guideline, visit
http://www.aafp.org/tolac.

Patient name: ____________________________________________________
Physician: _______________________________________________________
________________________________________________________________
________________________________________________________________

Trial of Labor After Cesarean:
Deciding What’s Right for You
and Your Baby

Women who have had a baby by cesarean section (C-section)
may have a choice about how to have their next
baby. They may choose to have another C-section. This
is called an “elective repeat cesarean delivery” (ERCD for
short). Or they may decide to try having the baby vaginally.
This is called a “trial of labor after cesarean” (TOLAC). When
a woman tries a trial of labor and is able to deliver vaginally,
this is called a “vaginal birth after cesarean” (VBAC).

If you’re reading this handout, it’s because your doctor
has decided that you have a choice between a planned
C-section and a trial of labor. To help you understand the
risks and benefits of each, you doctor will go through
this handout with you. He or she will explain how the
factors below apply to you. Be sure to ask your doctor any
questions you have. It’s important that you understand all
of the issues before you make a decision.

If I try labor, how likely am I to have my baby vaginally?
Because every situation is different, no one can tell if you
will be able to give birth vaginally. However, you should
know that about 76 out of 100 women who try a trial of
labor deliver their babies vaginally.

What happens to women who try labor but can’t
deliver vaginally?
Some women who try a trial of labor are not able to deliver
vaginally and end up having an unplanned C-section. You
should know that most of the babies born by unplanned
C-section are healthy and do not have long-term problems
from the C-section.

Is it is safer trying labor or having a planned C-section?
You already know that having a baby—whether vaginally or
by C-section—has some risks. The risks are generally small
whether you choose a trial of labor or planned C-section.
Studies have shown that there is no difference between
the two when it comes to the woman’s risk of death or
hysterectomy. There are, however, a few other risks to
consider. These are explained below.

Infection. Of women who choose a trial of labor,
7 out of 100 will get an infection. By comparison,
9 or 10 out of 100 women who choose planned
C-section will get an infection. This means that women
who choose C-section have a slightly higher risk of
infection (2% to 3% higher) than women who choose a trial
of labor.

Uterine rupture. A C-section leaves a scar on the
uterus. During a trial of labor, the scar can break open.
Usually this doesn’t affect you or the baby. In rare cases,
however, it can pose serious risks to you or your baby.
This is called symptomatic uterine rupture and it occurs
in 2.7 out of 1,000 women, or about ¼ of 1%, who try a
trial of labor.

Infant death. Sometimes—but not always—uterine rupture
results in the death of the baby. The chance of
this is about 15 in 100,000, or about 1/100th of 1%, in
women who try a trial of labor. There is no good data
about the risk of infant death for women who choose
elective repeat C-section.

What factors affect my chances of delivering
vaginally?
Doctors have studied thousands of women who have
attempted a trial of labor. They found that the following
factors affect a woman’s chance of delivering vaginally.
Your doctor will tell you how these factors apply to you.
You might want to ask your doctor to put a checkmark
next to the factors that may affect you and to cross out
the ones that probably won’t.

Factors that increase the likelihood of a
vaginal birth after C-section (VBAC)

• Being younger than 40 years old. If you’re under 40,
you are 2½ times more likely to have a VBAC.
My age: _________
Other notes: ________________________________
__________________________________________
__________________________________________
__________________________________________

• Having a vaginal birth before. If you’ve ever had a
baby vaginally, you’re more likely to be able to deliver
that way again.
I had a baby vaginally, but it was before I had a
C-section. You are 1½ to 2 times more likely to
deliver vaginally again.
I had a baby vaginally after I had a baby by
C-section. You are 3 to 8 times more likely to
have a VBAC.
Notes about your previous delivery or deliveries:
__________________________________________
__________________________________________
__________________________________________
Other notes: ________________________________
__________________________________________
__________________________________________
__________________________________________

• Having favorable cervical factors during labor. This
means that your cervix is dilated (open) and effaced
(thinned out) enough to deliver vaginally. If you’re well
dilated and effaced, you are 1½ to 5 times more likely
to have a VBAC. If you’ve had a vaginal birth before,
your cervix may open and thin out more quickly than if
you haven’t. If you haven’t had a vaginal birth, it’s hard
to tell how well dilated and effaced your cervix will
become during labor.
I have had a previous vaginal birth.
Other notes: ________________________________
__________________________________________
__________________________________________

• If the reason you needed a C-section before isn’t
a factor this time. You might have needed a
C-section because of infection, difficult labor, breech
presentation, or concerns about the baby’s size or
heart rate. If you don’t have the same problem this
time, you are 2 times more likely to have a VBAC.
Reason for my previous C-section: ______________
__________________________________________
__________________________________________
__________________________________________
Other notes: ________________________________
__________________________________________
__________________________________________
__________________________________________

Factors that decrease the likelihood
of a VBAC

• Having had more than one C-section. If you have had
two or more C-sections, you’re 60% less likely to have
a VBAC.
Number of C-sections I’ve had: _________
Other notes: ________________________________
__________________________________________
__________________________________________
__________________________________________

• Going into labor after 40 weeks. After this time, you
are 20% to 30% less likely to have a VBAC.
My baby’s current gestational age: ________
My previous child(ren)’s gestational age(s) at birth:
__________________________________________
__________________________________________
__________________________________________
Other notes: ________________________________
__________________________________________
__________________________________________
__________________________________________

RISK OF SYMPTOMATIC UTERINE
RUPTURE IN ALL WOMEN
For all women . . . . . . . . . . . . . . Less than 1 birth per 1,000
For women who have
not had a C-section . . . . . . . . . Less than 1 birth per 1,000
For women who have an
elective repeat C-section . . . . About 1 birth per 1,000
For women who have a trial
of labor after C-section . . . . . . 2 to 4 births per 1,000
(800) 274-2237 • www.aafp.org

• Trying to deliver a baby that is 8 pounds, 13 ounces
(4,000 grams) or larger. If your baby weighs this much
(or more), you are 40% less likely to have a VBAC.
My baby’s current estimated weight: ____________
My previous child(ren)’s weight(s) at birth: _______
Other notes: ________________________________
__________________________________________

• Using medicines to induce or augment labor. If you
need medicine to start or help your labor, you are 50%
less likely to have a VBAC.
Notes: _____________________________________
__________________________________________

What if I have other concerns?
In addition to thinking about your health and that of your
baby, you’re probably dealing with emotional issues
and practical concerns about the birth. Some common
concerns are listed below. When you read through this
list, you may want to put a checkmark next to the issues
you really care about and cross out those that aren’t
as important to you. Talk with your doctor about your
concerns. These issues haven’t been studied like the ones
above, but your doctor may be able to give you some
insight into how they might affect you.

Recovery time. If you deliver vaginally, you’ll probably
spend less time in the hospital and be back on your
feet more quickly. Some women think this is important
because they’ll be caring for the new baby and their older
children too.

Involvement in the delivery. For some women, having a
baby vaginally is more emotionally satisfying than having
a C-section. You get to hold your baby sooner, which
may help with bonding and even with breastfeeding. Your
partner may feel more involved in a vaginal birth too.

Future childbearing. Doctors typically don’t want women
to have more than two or three C-sections. So, you’re more
likely to be able to have more children if you have a vaginal
birth instead of another C-section.

Planned versus unplanned delivery date. Because
it’s better to go into labor on your own when you’re
planning a trial of labor, you probably won’t be able to
be induced. Not knowing when you will go into labor can
be stressful. It can also be a problem if you can’t arrange
for someone to watch your other child or children at a
moment’s notice. For these reasons, some women prefer
to plan on a C-section.

Pain during labor and delivery. If you had an especially
difficult and painful labor before, you may fear going
through it again. For this reason, some women prefer to
have another C-section and avoid labor. It’s important to
remember, though, that there are ways to manage the pain
if you decide on a trial of labor.

How do I make this choice?
You and your partner should work with your doctor to
decide whether the benefits of a trial of labor outweigh
the risks.

If you decide to try labor, you and your doctor will talk
about what to do if it looks like your labor is running into
complications. It’s best to have a plan before you begin your
labor so that you don’t have to make decisions during labor.
References

1. Wall E, Roberts R, Deutchman M, Hueston W, Atwood LA, Ireland B.
Trial of labor after cesarean (TOLAC), formerly trial of labor versus
elective repeat cesarean section for the woman with a previous
cesarean section. Leawood, Kan.: American Academy of Family
Physicians; March 2005.
2. Guise J-M, McDonagh M, Hashima J, Kraemer DF, Eden KB,
Berlin M, et al. Vaginal Birth After Cesarean (VBAC). Evidence
Report/Technology Assessment No. 71. Rockville, Md.: Agency for
Healthcare Research and Quality; March 2003. AHRQ Publication
No. 03-E018.
3. Gardeil F, Daly S, Turner MJ. Uterine rupture in pregnancy reviewed.
Eur J Obstet Gynecol Reprod Biol 1994;56:107-10.
4. Miller DA, Goodwin TM, Gherman RB, Paul RH. Intrapartum rupture
of the unscarred uterus. Obstet Gynecol 1997;89:671-3.
5. Kieser KE, Baskett TF. A 10-year population based study of uterine
rupture. Obstet Gynecol 2002;100:749-53.

Cesarean Risks: Adhesions

This is a comprehensive article on adhesions which is a fancy word for scar tissue.  I think the most relevant points of this whole discussion are:

  1. Adhesions “develop in 93% of people who have undergone pelvic surgery” and “they are especially common after cesarean sections.”
  2. You get more adhesions with each cesarean.
  3. Adhesions can cause:
    • Pelvic or Abdominal Pain
    • Bowel Obstruction
    • Infertility
  4. Adhesions impact future cesareans by making the surgery longer which can put your baby at risk in an emergency situation (emphasis mine):
    • “If you have had a cesarean section and are pregnant or planning to have another child, these adhesions could complicate matters. If you are having another c-section, your health care provider will have to separate and cut through all of your adhesions before she can begin the c-section. For women who have had more than three cesareans, this could take ten minutes to an hour or more. In an emergency, this could place your baby at risk.
  5. Adhesions “shouldn’t pose a problem” for VBAC:
    • “If you elect to have a vaginal birth after a cesarean , or VBAC, adhesions shouldn’t pose much of a problem, unless you have had multiple cesarean sections. Typically, women who have only had one cesarean section can deliver vaginally without any difficulties. There is a chance that the scar tissue covering the incision in your uterus could rupture. This can be very dangerous, as it can cause massive bleeding or cut off your baby’s oxygen supply. However, the risk of uterine rupture during a VBAC is very low, typically occurring in less than 1 out of every 1,000 births.”

To read the whole article, go here: C-Sections and Adhesions

Cesarean Risks: Overview

We all know the primary risk of VBAC – uterine rupture.  And when your typical VBACing mom meets with an OB, she must sign a “VBAC consent form” acknowledging that she understands this risk.  However, I find it ironic that women signing up for a repeat cesarean are not required by their OB to sign a “Repeat Cesarean Section consent form” as a matter of course during prenatal exams since there are risks associated with cesarean section.   But since this does not happen, and most OBs breeze over the risks if they even bother to mention them, expectant moms are lead to believe that VBACs are risky and cesareans are not.

What most moms signing up for cesareans don’t know, is that this decision not only introduces risks that can impact them or their baby immediately, but this decision also impacts their future fertility as well as future cesarean deliveries and babies.  And some of these complications increase with each surgery.  As they say, “Clearly, all the risks of primary cesarean delivery are only increased for repeat cesareans, and increase even more with third, fourth, and higher-order cesarean deliveries.”

This is a great article detailing the risks of cesareans, but I’ll just list the risks below.  If you wish to read more in detail, you can go here: Risks Associated With Cesarean Delivery

Short-term Risks of Cesarean Delivery

  • Maternal Death (yeap, that is the first one they list)
  • Thromboembolism – which is define as “blockage of a blood vessel by a clot that can travel in the bloodstream to the heart, lungs or brain and cause serious damage.”  If the clot goes to your brain, that’s a stroke.  It goes to your heart, that is a heart attack.  If the clot goes to your lungs, that’s a pulmonary embolism.  None of these things are good.
  • Hemorrhage – “The risk of hemorrhage requiring blood transfusion increases substantially with increasing number of prior cesarean deliveries.”
  • Infection – “most common complications of cesarean delivery” affecting 85% of women who labored prior and 4-5% of women with intact membranes.  “Wound infections may occur in 2.5% to 16% of cesareans.”
  • Incidental Surgical Injuries – typically the bladder, bowel or ureters which, if not corrected soon, can cause other complications such as sepsis (major, serious infection), renal (kidney) failure, or fistula formation. 
  • Extended hospitalization– some people view their stay at the hospital as a vacation, me, I like my vacations pain free and with better food, but to each their own!
  • Emergency Hysterectomy – This unfortunately happened to this woman.  “. . . those who did have a hysterectomy were 13 times more likely to have been delivered by cesarean section.”
  • Pain – This little word is so powerful.  Pain is such an easy thing to overlook or to say, yeah, that’s obvious, but when you are trying to care for a newborn, or a newborn and an older child, the risk of pain is huge.  And pain for some women can go on for months.  It took me 18 months for my scar to not be oddly numb, yet sensitive. From the article, emphasis mine:
    • “A study of 242 primiparous women reported that all those who underwent cesarean deliveries (both planned and unplanned) required narcotic pain medications compared with 11% of those who delivered vaginally.Having to relieve pain with narcotic pain medications can have a significant impact on initial bonding between the mother and the newborn and on breastfeeding success rates, as well as maternal functioning postpartum; in addition, the risk for postpartum depression may be greater.”
  • Poor Birth Experience – “more likely to report dissatisfaction with their birth experience compared with those who delivered vaginally . . . less early contact with their newborns . . . significantly longer time before their first contact with their baby . . . more likely to cite a poorer score for their initial contact with their baby.”

Long-term Risks of Cesarean Delivery

  • Readmission to the Hospital – ” . . . postpartum readmission to the hospital was significantly greater for those who delivered by cesarean delivery.”
  • Pain – ” . . . more likely to report pain to be a problem in the first 2 months after delivery.”  A survey of 1500 women who had cesareans in the past 24 months said, “incisional pain was a major problem 25% of the time, and a major or minor problem 83% of the time” and at 6 months postpartum, 7% of CS moms reported incisional pain compared with 2% of vaginal birth moms who reported perineal pain.
  • Adhesion Formation – “. . . is common and significantly contributes to the risk of complications at future deliveries . . . reported increased risk of ectopic pregnancy among women with prior cesarean deliveries.”
  • Infertility/Subfertility – “. . . more likely to be unable to conceive a pregnancy for more than 1 year”

Risks for the Newborn of Cesarean Delivery

  • Neonatal death (they listed this first)
  • Respiratory difficulties – “. . . probably result from a failure of the mechanisms to resorb fetal lung fluid that are typically triggered during vaginal birth . . .3 times more common after elective cesarean delivery than after vaginal delivery”
  • Asthma – “. . . those delivered either by planned or unplanned cesarean were approximately 30% more likely than those delivered vaginally to have been admitted to the hospital for asthma during childhood”
  • Iatrogenic Prematurity – This means that the baby was premature because the cesarean occurred before the baby was ready to be born.  This typically happens with scheduled cesareans.
  • Trauma – Meaning the baby is accidentally cut by the surgeon
  • Failure to breastfeed

Risks of Cesarean Delivery to Future Pregnancies

  • Uterine Rupture – For more stats on this go here.
    • A population-based study of more than 255,000 women in Switzerland found that the incidence of uterine rupture for a woman with no previous cesarean delivery was 0.007%. That incidence rose to 0.192% for a woman with a prior cesarean delivery who planned a repeat cesarean delivery, and rose even higher to 0.397% for women who planned a trial of labor after a prior cesarean delivery. 
  • Abnormal Placentation – This means that your placenta either implants over the opening of the cervix (placenta previa) which means you have to have another cesarean or that your placenta grows through the uterine wall (placenta accreata) which can mean the placenta needs to be manually or surgically removed and puts you at a greater risk of post-partum hemorrhage.
    • . . . women with at least 1 prior cesarean delivery had approximately 3 times the risk of having a placenta previa at the time of delivery compared with women with no prior cesarean deliveries, and this risk increased substantially with increasing numbers of prior cesarean deliveries — reaching nearly 45 times the risk for women with 4 or more prior cesarean deliveries.
  • Hysterectomy – “As the number of prior cesarean deliveries rises, the risk of cesarean hysterectomy increases dramatically.”

As I’ve said before:

VBACs have risks.

Cesareans have risks.

Please understand all the information before making a decision.

Learn more here: Elective Cesarean Surgery Versus Planned Vaginal Birth: What Are the Consequences?