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.