Avoid a repeat C-section.
“Go for it!” is not the advice pregnant women contemplating a VBAC — or a vaginal birth after a previous C-section — are accustomed to hearing. But that’s exactly what the medical director of Christiana Care Women’s Health Ambulatory Services in Wilmington tells many of her expectant moms.
“In a well-selected patient, VBAC is very beneficial,” says Elizabeth Zadzielski, MD. Indeed, the National Institutes of Health reports that 60 to 80 percent of women who attempt a VBAC are able to successfully deliver vaginally.
“The majority of women would likely be candidates” for a VBAC, concurs Sindhu K. Srinivas, MD, director of obstetrical services at the Hospital of the University of Pennsylvania. And according to the American Congress of Obstetricians and Gynecologists, a successful VBAC has fewer complications than an elective repeat Cesarean. Given this fact, why don’t more women attempt VBACs?
“There are a lot of misconceptions out there,” says Ginnie Calabrese, co-founder of Loving Birth Services in Williamstown, NJ. Jennifer Gleeson Blue, co-leader of the Southeastern PA Chapter of the International Cesarean Awareness Network (ICAN) agrees. “Women in general are undereducated about birth, Cesareans and VBACs,” she says. “So many women are told that it’s not a good option, and they don’t question it.”
While the potential risk of attempting a VBAC is low, the consequences are fairly significant, says Dr. Srinivas. The biggest risk — at .9 percent with one prior C-section and 1.4 percent with two — is a uterine rupture, which can lead to death for mom or baby.
There are complex reasons why so many women and doctors choose the risks of a surgical birth over those of a VBAC. One is that C-section risks (infection, injury to organs, problems with the placenta in future pregnancies) primarily affect the mother and not the baby, says Dr. Srinivas.
Expectant moms are finding that many doctors shy away from the risks of VBAC — and they’re not entirely wrong. To provide VBAC opportunities, says Dr. Zadzielski, “You need to be able to act emergently.” Hospitals must have an anesthesiologist and an obstetrician available at all times in case a repeat C-section becomes necessary, which may not be possible at smaller facilities.
“It’s a risk that doctors don’t seem to want to take even if the patient is willing,” muses Malaga, NJ mom Jasmine Bohren. After having had two prior C-sections, 13 practitioners told Bohren they would not accept her as a VBAC candidate for the delivery of her third child. She eventually found a midwife and doctor to support her successful VBAC, in September 2013.
“They give you the worst statistics ever,” she says of the doctors who focused on the potentially scary outcomes of attempting a VBAC but never mentioned the risks of a third C-section. Calabrese has noticed this phenomenon, too. “We’ve become desensitized to how serious a Cesarean surgery is,” she notes.
Next page: VBAC candidate musts, how to find a VBAC provider & VBAC resources
A good VBAC candidate
Practices with doctors who will perform VBACs tend to limit candidates to women who have had only one prior C-section, says Dr. Zadzielski. Other essential VBAC criteria include:
- A transverse (horizontal) scar on the uterus
- The placenta is not near or attached to the scar.
- The placenta is not low-lying.
- The reason for the previous C-section: If it was for breech positioning, a nonreassuring heart-rate tracing or an arrest of dilation, the chances of a successful VBAC are good, says Dr. Zadzielski.
Reasons not to attempt a VBAC include:
- The placenta blocks the cervix.
- Breech positioning
- A vertical incision on the uterus
“There are a lot of clinical factors that determine the likelihood of success,” says Dr. Srinivas. It’s not a perfect science, but doctors try to use available research and patient information to inform the decision to try a VBAC.
VBAC benefits include:
- A shorter hospital stay
- Faster recovery
- No surgery
- Lower risk of infection and the need for a blood transfusion
- It may help avoid future C-sections.
Find a VBAC provider
Despite a perceived dearth of willing practitioners, “There are many, many physicians in support of VBAC,” says Kathleen McCarthy, certified nurse midwife and co-owner of The Birth Center in Wilmington, DE. She recommends choosing a provider with whom you feel safe, who supports you and hears what you say.
“Find doctors who are honest about the pros and cons,” recommends Bohren. Calabrese advises interviewing practitioners to determine whether they are “VBAC-friendly” or “VBAC-tolerant,” explaining that tolerant doctors will accept VBAC patients but VBAC-friendly doctors are more supportive of and invested in a successful vaginal delivery. “The doctor works for you,” she says. “If the provider is not serving you, find a new one!”
ICAN’s Blue notes that some providers will change course during the pregnancy, pushing for a repeat C-section after having accepted the patient to VBAC. Dr. Srinivas defends the need to shift tactics at times: “Chances of success fluctuate based on new clinical information during the pregnancy; recommendations might change.” As a result, she says, it is important to have “an open and evolving conversation through prenatal care.”
If you’d like to attempt a VBAC:
- Find a VBAC provider early in the pregnancy. Many providers who accept patients in their first trimester may be hesitant later on, says Dr. Srinivas.
- Consider hiring a doula. “Doulas increase the chances of vaginal birth,” says Calabrese.
- Take a VBAC class or a regular birth class. VBAC moms may not have even labored before.
- Talk to women who’ve had positive VBAC experiences.
Finally, “Do your research,” says Bohren. “Always double-check what your doctor tells you because it may be based on outdated opinions.”
Suzanne Koup-Larsen is a contributing writer to MetroKids.