Can You Really VBAC It?

Pursuing a Vaginal Birth After Cesarean By Shel Franco

I don't remember much about the birth of my first child. I don't remember what he looked like after birth. I don't remember how it felt to hold him. In fact, I didn't spend much time with him until he was six hours old. Like 20 percent of all American births, my son was delivered by Cesarean section.

And I knew from the moment I returned home, barely able to walk up my front steps, that this was not the way childbirth was meant to be.

Why VBAC?
Birth is a natural process. The overwhelming odds are that most women will have uncomplicated labors and deliveries. Yet, in these days of medical skill, Cesarean section is viewed as an equal alternative to vaginal birth. The truth is that Cesarean sections save lives, but statistics suggest many may be unnecessary.

In the United States, high Cesarean numbers cause the surgery to seem commonplace and make it easy to forget that this major abdominal surgery carries many risks. For Cindy Minear of Westminster, Calif., the decision to pursue a vaginal birth after a Cesarean was not difficult. She remembered all too well the seeping incision that needed to be re-opened and drained, and the nurses who came to her house twice a day to clean and repack the wound. "Not wanting to go through all the medical complications was the main factor in [deciding to have a VBAC]," Minear says.

According to the International Cesarean Awareness Network (ICAN), the risks of Cesarean section include:

• increased risk of maternal death;
• hemorrhage;
• infection;
• damage to internal organs;
• complications caused by anesthesia;
• adhesions;
• long-term pain;
• and bladder problems.

Women who undergo Cesarean sections may also be subject to increased risk of future reproductive problems including the risk of secondary infertility, scar tissue, uterine rupture, placenta previa and placenta accreta. Aside from physical risk, ICAN says a Cesarean delivery can increase emotional and psychological complications, such as clinical depression and difficulties with bonding, breastfeeding and family relationships.

The Risk
"[The greatest risk of vaginal birth after Cesarean is] uterine rupture, or the incision coming apart," says Cathy Hartt, a certified nurse-midwife in Galveston, Texas. "Sometimes this happens and we never know it because Mom and Baby do fine. But it is potentially life-threatening to both Mom and Baby and can occur rapidly."

Statistically speaking, rupture is rare. "Most of the large studies show this risk to be less than 1 percent," says Kathleen Gray Farthing, public relations professional for ICAN. "The risk of rupture is around the same risk or less than any birthing woman has for cord prolapse, placenta previa, placenta abruption, fetal distress and some other complications of birth."

These rates vary, particularly when certain factors are present. One of those factors is the type of surgical opening. The Cesarean can be accomplished using classical incisions or transverse incisions. Today, the classical incision, sometimes called a vertical incision, is mostly reserved for emergency situations. "[The] vertical incision scar is more likely to rupture, because it ascends into the upper segment of the uterus that is more active," says Lorrie Peck, a midwife in Edmonds, Wash.

A transverse, or horizontal, incision is most common. This cut is made in a lower, less active part of the uterus, making the scar better able to withstand rupture. "[The] risk with one prior low transverse incision [is] quoted as 0.5 to 1 percent," says Geffrey H. Klein, MD, an obstetrician and gynecologist in Webster, Texas.

In addition to the type of incision, the type of labor may also affect the risk of rupture. Labor can be spontaneous, beginning on its own, or it can be induced with the help of drugs. Some recent studies show uterine ruptures are less likely with spontaneous labor.

The Caregiver
In the United States, most women use obstetricians for care during pregnancy, labor and delivery. Board-certified obstetricians follow VBAC guidelines created by the American College of Obstetrics and Gynecology (ACOG). According to Dr. Klein, current ACOG guidelines mandate that women attempting a vaginal birth after Cesarean have no more than two prior low-transverse Cesarean deliveries, have clinically adequate pelvises and have no other uterine scar or previous rupture. The guidelines also require the immediate presence of a physician who is able to monitor and perform an emergency Cesarean delivery. As a result, anesthesia must be available, along with the personnel to administer it.

To some women's dismay, most doctors will not negotiate where these guidelines are concerned. Dr. Klein explains why doctors must comply. "It is at their patient's medical and their medicolegal peril to vary."

In order to circumvent the guidelines, some women turn to certified, licensed or lay midwives. A certified nurse midwife (CNM), under the direction of an obstetrician, will still be subject to these rules, but the requirements to VBAC with an independent midwife vary.

Peck accepts women with prior Cesareans as homebirth candidates, if they are in good overall health and have a horizontal incision scar without any evidence of separation. When there is separation or weakness at the old incision site, Peck says vaginal birth may be attempted at the hospital, but not at home.

When VBAC is the goal, using a doctor or a midwife does not matter nearly as much as the caregiver's genuine support for a vaginal birth.

The Preparation
In addition to a supportive caregiver, several factors will increase the odds for a successful vaginal birth after Cesarean.

"Be totally committed to your desire for a VBAC," Minear says. "Read as much as you can on the subject."

Some recommended books are "Silent Knife," "The VBAC Companion" and "Birth After Cesarean: The Medical Facts."

"Be informed," Hartt says. "Take childbirth education." The best classes are those that specifically address VBAC and promote birth as a natural process.

Consider hiring a doula, an experienced, knowledgeable woman who believes in your ability to give birth," Farthing says. The more support and positive influence a woman has, the greater her belief in herself and in her body's ability to birth.

VBAC is possible. I know, because three years after my Cesarean section, a vaginal birth produced my second child. To say it was worth the effort is an understatement. I will always be grateful for the way he looked, how he felt in my arms, and the woman I became the moment I pushed him into this world.

Want to read more? Should Women Having Large Babies Expect to Deliver by Cesarean? Why Hire a Doula? Could I have a VBAC? What are the risks of a VBAC?

About the Author: Shel Franco is an assistant editor for iParenting, and the mother of three.