The VBAC/ERCS dilemma: is it vain to VBAC?

Kathie asked a very good question in the comments to my previous post:

Are VBAC moms minimizing the risks in order to have a more pleasant birth experience? Or are repeat c-section moms overestimating the risks of trying for a vaginal birth? (in general, I’m speaking to situations where there is a choice…not medically indicated repeat c-sections).

At the risk of boring you to pieces, let me tell you about my first two births. I’m not trying to hold myself up as some kind of role model necessarily, but to illustrate my thought processes that led me to my decision and the limits I put on the decision-making process.

My eldest son was born in December 1997 at a large university hospital in Jerusalem. My pregnancy had been uneventful, and I was considered a low obstetric risk (though a moderate general medical risk for non-OB related conditions). I’d gotten an epidural at 4-5cms dilation for pain relief, and was dilated to 9cm when the EFM tracing started showing late decelerations, diving deeper and wider. The midwife called the OB, who took one look at the monitor (which showed a fetal heart rate of 60 beats per minute by then) and asked her: “Does she have blood units ready?”.

To make a long story short, my epidural was topped up, I signed the consent form, we rushed to the OR down a short hallway, and 10 minutes later, I met my beautiful boy. It turned out he’d managed to wrap his umbilical cord around both his shoulders, clamping it in two places as he attempted to descend into the birth canal. He’s a bright, engaging child, though he can be very stubborn at times – and then I tell him that his orneriness manifested itself even in utero. 😀

My second son was born in March 2000. I’d decided rather early on that I wanted a VBAC, though to be honest, recovery from the C-section wasn’t all that bad. In fact, compared to the non-OB related abdominal (and non-emergency) surgery I’d gone through 13 months previous to the CS, it was a piece of cake: out of bed and walking around by the next morning (the CS occurred at 10:22 PM), the incision didn’t hurt, I had a bit of referred pain in one of my shoulders due to, most probably, air bubbles under my diaphragm that was easily alleviated with dipyrone. I was still wishing I’d gotten to push my eldest out, though. And since the reason for my CS was not likely to recur, I had the operative report which documented a transverse lower segment uterine scar, and otherwise had an uneventful pregnancy, I convinced my OB that this was a reasonable course of action. I also went on a tour of all 5 hospitals in Jerusalem and asked about their VBAC success rates, and decided to go to a slightly smaller and “crunchier” maternity hospital that had a 24/7 OB and anesthesiology staff, plus a small but decent NICU – but which had the highest VBAC success rates. I requested a low-dose “walking” epidural at 6cms, which had worn off by the second stage, and had continuous EFM and an IV line. I squatted to deliver my son like a good lil’ birther, though an episiotomy was, I believe, necessary (I was on my way to developing a rather large tear “up” into my clitoris and urethra). My son is almost 8, also a wonderful, healthy boy, though not quite as stubborn (you can see an old picture of them both in the title bar of this blog).

Looking back on my emotional state at the time, I think I did “minimize the risks in order to have a more pleasant birth experience” somewhat, but not to the point where I flat-out endangered myself or my baby. My decision to VBAC was based upon my risk factors for needing another CS (an indication for the CS that wasn’t likely to recur, a favorable uterine incision, my wish for more children after #2, overall decent health, a healthy current pregnancy with vertex presentation), along with providing for access to a surgical delivery just in case something went wrong anyway. I had also decided ahead of time that despite being emotionally invested in a VBAC, if an induction or augmentation of labor were deemed necessary, I’d forgo my VBAC plans and ask for a CS due to the increased incidence of uterine rupture.

So the answer to Kathie’s question, like a lot of things in life, is “it depends”. If a woman has access to all the medical information about her own condition and the facts about VBACs vs. repeat CS’s in general, she can make an informed decision (possibly along with her healthcare provider) to have either an elective repeat CS or a VBAC. Both have their advantages and their risks, and the equasion is not the same for every woman. That isn’t “minimizing the risks”, it’s recognizing the risks and benefits of both types of birth and how they relate to your personal situation.

I would, however, make an exception for women who choose to VBAC at home. Though uterine rupture is a relatively rare event, it still is more likely to happen in the context of a VBAC, and when it happens, you need that OB and neonatal team to pounce right on you and save you and your baby both. Dr Amy makes a very good case for homebirth carrying an excess risk of neonatal mortality even under the best of circumstances; all the more so when a woman has a VBAC, because such a woman is, even under the best of circumstances, no longer low-risk. In this, I tend to agree with the ACOG’s most recent statement about homebirth. A woman who denies this kind of risk is, in my opinion, elevating her birth experience over the baby’s (and her own) health, and is “minimizing the risks of VBAC”.

By the way, lest you think it’s just us evil mainstream people who think this way about VBACs, here’s one of the high priests of VBAC advocacy, Dr. Bruce Flamm, who thinks that even birth centers are too risky for VBAC and these women should all be referred to hospital:

Despite a high rate of vaginal births and few uterine ruptures among women attempting VBACs in birth centers, a cesarean-scarred uterus was associated with increases in complications that require hospital management. Therefore, birth centers should refer women who have undergone previous cesarean deliveries to hospitals for delivery.

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8 Responses

  1. I found your site on google blog search and read a few of your other posts. Keep up the good work. Just added your RSS feed to my feed reader. Look forward to reading more from you.

    – Sue.

  2. I agree, there is no pat answer for this question. However in the majority of cases, a vbac will be safer for mom and baby, and the recovery is generally so much easier… and I don’t think it’s vain to want to be able to get around well with your older child and newborn.

  3. I interviewed several OB’s, and NOT ONE asked my how many children I wanted to have when they proceeded to tell me that they believed it was safer for me to have an elective repeat cesarean for my second child. Why is that?

    One OB I interviewed tried to dissuade me from having a VBAC by telling me that I’d never want to have sex with my husband again, I’d never be able to laugh without pee’ing on myself, and best of all I’d bond with my baby better since his head would be more perfect and he’d be nicer looking after the birth.

    Needless to say, we agreed that we weren’t a good fit for each other. He didn’t attend either of my two subsequent OB attended in hospital VBAC’s. I hope to go on to have more of children -safely- , too.

  4. I was working at the second hospital mentioned.by estherar. And yes, we had relatively high VBAC rates. We also did a lot of C/Ss, as well as completely unmedicated births, in the regular and “homestyle” birthing rooms.

    What is important to remember is that, although we were a fairly small hospital, we had ALL the facilities necessary for every emergency. Nothing ever was more important than the safety of the mother and baby.

    Some women aren’t candidates for VBAC because of the reason for the original C/S, so if they want a very large family, they are going to be disappointed. There are doctors who believe passionately that the risks of VBAC are great enough that it isn’t feasible. IMO, if a woman badly wants a VBAC, then her doctor should be able to explain why he feels it is inappropriate, and if she’s unhappy with that explanation, she should get a second opinion from another OB. If both say the same thing, then she should think very seriously that they have a point.

  5. Sue – Thanks! 🙂

    Karen – while you’re right in principle (that many women are candidates for VBAC and have good outcomes), the good outcomes for VBAC are usually achieved by carefully vetting the VBAC candidates (there are several scoring systems being proposed for predicting who is most likely to successfully VBAC, though none have been officially accepted as far as I know), providing for a medical setup in cases of VBAC failure, and taking precautions during the event (such as cEFM and a heplock). It’s important to realize that the price of a failed VBAC , in terms of morbidity and mortality of the baby, is high.

    While I’m not sorry for the 2 VBACs I’ve had, in retrospect, I think my life would have been just as complete without a baby passing through my vagina.

    homefly – I can’t speak to your situation because you’ve shared none of the particulars of the reason for the CS nor the resources of the hospital the OB practiced with.

    I agree that the OB who made those claims about vaginal birth (less bonding w/baby, etc) sounds like a doofus I’d avoid like the plague, though.

    Antigonos – welcome!
    I actually wanted to ask you – your hospital actually had a CS technique named after it, which I always found rather amusing, being the earthy-birthy place it was (it closed down shortly after I gave birth due to financial mismanagement)…the uterus was sutured in one layer and the peritoneum was left open, right? I’ve been reading that the one-layer suturing may be a risk factor for rupture in a future VBAC. Have you encountered this in former patients who had CS’s in your hospital? (I only know of one such woman – me next door neighbor, in fact – who had 2 successful VBACs and no rupture, of course).

  6. My first CS was due to breech presentation.

    Sadly, the OB that I interviewed who said I’d bond with my baby better since he’d be better looking if born by CS was actually voted the best OB in town by the Austin Chronicle. He’s locally famous and quite popular.

    He also told me that he’s “done probably hundreds of VBAC’s and not had a problem with any of them. I’m sure yours will go just fine, but I don’t do them anymore because I just don’t have to.” It’s true. He doesn’t.

  7. You know, Dr. Amy says one thing when she’s trashing home birth and another when she’s elsewhere. Check out this link to a comment of hers on VBAC SAFETY, bemoaning the fact that ACOG’s recommendation of 24-hour staffing at hospitals forces women into UNNECESSARY repeat C-sections.

    On this blog (http://healthypolicy.typepad.com/blog/2006/01/on_the_defense_.html) another comment on C-sections: ”

    Your comment may actually prove my point. The fact is that VBACs were considered safe until a few years ago. That’s because the very small risk of uterine rupture (which has been known all along) is now deemed legally indefensible. Because of legal concerns, the VBAC rate has fallen from 28% to 9% in the last 8 years. This is probably the biggest single reason that the C-section rate is almost an outrageous 30%.

    Initially, VBACs were not allowed. Research done in the early 1980’s indicated that they were significantly safer than previously thought (because of changes in the type of incision, etc.) The VBAC rate rose precipitously and that was a good thing. Then came the lawsuits for ruptured uterus, which was always acknowledged to be a known complication.

    Actually the suits were not because of VBACs per se. The allegations were made that VBACs were unsafe unless an anesthesiologist and the attending obstetrician were physically present to perform an emergency C-section in the very unlikely event that a uterine rupture occured. In response, many hospitals (in an effort to protect themselves from legal exposure) now require the attending obstetrician to be physicially present through labor (which could last 20 hours or more). This is not feasible for the average obstetrician, so VBAC is essentially impossible in those hospitals.

    The end result is that many women who want a VBAC, even women who have had a successful VBAC in the past, cannot have one and are forced to have a medically unnecessary surgical procedure. These women are denied appropriate medical care because of legal concerns. That’s just one of the pernicious effects of defensive medicine.”
    # posted by Blogger Amy Tuteur, MD : 9:49 PM

  8. I don’t presume to speak for Dr. Amy, but there’s nothing contradictory in the things she says. You can be for VBACing in a hospital with all the necessary precautions (as am I – mind you, in Israel there is no such thing as a hospital without 24/7 anesthesia and OB coverage, even the small one I went to. OTOH, most births here are not managed by OB’s, certainly not private ones), and against being foolhardy and VBACing at home, or in a hospital without such a setup.

    The unnecessary CS’s are brought about as a result of hospitals not having the necessary setup for VBAC, not because the ACOG is wrong about the necessity of the setup.

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