Vaginal Birth After Cesarean

 

Vaginal Birth After Cesarean (VBAC)

VBAC is currently a controversial and highly charged topic in maternity care in the US.  It has been made this way by the huge increase in the rate of cesarean sections over the past 40 years, the disempowerment of birthing mothers and families, the very significant health effects of c-sections, the overbearing effects of malpractice insurance and risk management practices, policy changes by ACOG and AMA recommendations, the well-grounded evidence of the risks of c-section and the benefits of vaginal birth, and the increasing desire of mothers to birth their babies vaginally.

 

Successful VBAC at home

The likelihood of having a successful VBAC at home (often called HBAC) is high and most homebirth providersscreen potential VBAC mothers for risk factors.  It is more successful than in the hospital because the midwifery model is supportive of the physiological processes that promote vaginal, healthy births: care is one-on-one and supportive;  medications that cause fetal distress or uterine stress/tearing are not used; fetal well-being is carefully monitored; and midwives are trained to immediately identify uterine tearing.  Additionally, midwives are very interested in helping women birth vaginally as this is better for mother and baby and we have no financial incentive to use repeat c-section.

 

Avoiding a primary or repeat c-section promotes:

Lower rate of maternal death (4/10,000 with c-section, 0.5/10,000 with vaginal birth)

Lower rate of immediate maternal complications such as infection, hemorrhage, blood clots, and side effects of anesthesia

Less postpartum discomfort and faster recovery

Significantly lower rate of future maternal complications such as placenta accreta, placenta previa, and future c-sections

Lower rate of injuries to the baby

Lower rate of premature babies, babies with breathing problems, and babies needing NICU admission

Less separation of mothers from their babies

Shorter hospital stays for mother and baby

Significantly reduced health care costs

Increased maternal satisfaction and control in decision-making

 

Strong predictors of VBAC/HBAC success:

One low transverse c-section with double-layer closure

Prior vaginal delivery

One or more prior VBACs

Spontaneous labor with VBAC, with no induction or augmentation (especially with Pitocin and Cytotec)

When the cause of the prior c-section was a condition not likely to occur again (i.e. breech, twins, placenta previa)

Maternal age <40

Natural drug-free birth

Favorable cervix

Strong maternal desire for vaginal birth

>18-24 months since prior c-section

Close monitoring of labor, contractions, and reports of abdominal pain

 

Risks of VBAC

The risk of potential uterine rupture is the main concern with VBAC.  Uterine rupture causing the death of the baby or mother or a hysterectomy is rare in the absence of uterine stimulating drugs (such as Cervidil, Pitocin and Cytotec).  In fact, a woman with one c-section has a risk of uterine rupture less than 1%.  This statistic is derived primarily from VBACs attempted in hospitals where induction and/or augmentation of labor with the above mentioned drugs which cause excessive uterine stress and with epidurals which mask symptoms of uterine rupture and cause fetal distress.  Induction and augmentation of labor should NEVER be done during VBAC because they increase stress on the uterine scar, inhibits the normal ability of the uterus to adapt to fetal distress, causes strong and uncontrollable uterine contractions, and reduces the mother's ability to feel pain and move normally.

The above statistic of 1% rupture rate also includes uterine scar separation (dehiscence or pseudo-rupture).  This occurs when the scar thins and/or opens, leaving only the outside lining of the uterus intact.  Separation is not usually a problem in labor as it is not accompanied by fetal distress or maternal bleeding.  It is often not even diagnosed unless the doctor inserts his hand into the uterus via the vagina to feel for it (this is only done in emergencies or on medicated women as it is VERY painful).

It is also important to know that over half of all ruptures occur in women who have not had a previous c-section.  This means the ruptures are being provoked by the drugs for induction and augmentation of labor!  So the real risk of uterine rupture with VBAC is much less than 1% when done in a healthy, supportive, and non-interventive environment.  Recent statistics from out-of-hospital births are proving this.

Another significant risk in VBAC is abnormal placental attachment and, therefore, detachment after the birth of the baby.  Abnormal placentation often cause maternal hemorrhage.  It attaches abnormally due to the presence of the scar tissue from the prior c-section.  The rates have skyrocketed with the rate of c-section.

 

Factors associated with decreased rate of successful VBAC:

More than one prior c-section

C-section sutured in a single-layer closure or in a classical incision

maternal age >40

Labor induction or augmentation

Epidural anesthesia

Continuous fetal monitoring

Obesity or poor health

History of pelvic injury or rickets

Fetal macrosomia (large baby) >4 kg/8lb14oz

Unsupportive provider or restrictive protocols in hospital

 

Considerations for VBAC and location of birth

There are many factors that come into the decision to homebirth.  HBAC brings many of them into greater relief.

"Status of the scar": before HBAC, it is important to know that the scar is in good condition and has healed well.  If you experienced an infection in the wound after surgery, a c-section before 26 weeks gestation, or a single-layer closure, your scar likely weaker.  If you had a recent c-section, the scar may not have had enough time to heal completely.  Some providers insist on a term ultrasound to assess the scar's thickness.

Labor status: If you labor is long or abnormal or the baby is malpositioned, a hospital transfer is likely.  If the placenta detaches abnormally and you hemorrhage, emergency treatment and transport is needed.

Time and distance from home to hospital:  Morbidity and mortality are increased when c-section is delayed with a true uterine rupture.  Ideally the nearest hospital with emergency c-section capability is less than 20 minutes away, even though a healthy outcome for mother and baby is not assured with it that close.  Traffic, road conditions, and weather should also be considered.

Liability and insurance issues: Your midwife may not have malpractice insurance that covers VBAC.  This is very common, actually.  Your insurance company may not pay your midwife for attending your VBAC so you may have to pay all the midwifery fees.