Is VBAC high-risk?

If I've heard it once, I've heard it a thousand times:

"My OB says VBAC is too risky and I should just have another c-section"
"Why would you risk your baby's life just so you can have a birth experience?"
"I'm having a repeat c-section because the most important thing is a healthy baby"

It wasn't that long ago that once you had a c-section, all your babies would be born that way. "Once a c-section, always a c-section" was the rule, and it was arguably a good one since cesareans were performed using a classic, up-and-down incision that extended well into the contracting portion of the uterus. That type of incision has a greater risk of rupturing during subsequent labors than the low-transverse incisions typically used today. With the risk of uterine rupture following a low-transverse c-section right around one-half of one percent, vaginal birth after cesarean (VBAC) has become a real option for women hoping to avoid future cesarean deliveries. And yet, controversy still surrounds the safety of VBAC vs. choosing repeat cesarean (RCS).

What is without question is that any pregnancy following a cesarean delivery carries significantly greater risk than a pregnancy in an unscarred uterus. Among those risks are higher incidence of placenta problems including previa, accreta, and abruption; higher risk of unexplained stillbirth; greater risk of preterm labor; and not least, uterine rupture. While we most often associate uterine rupture with a VBAC trial of labor, the reality is that even prior to labor, a woman with a previous cesearean delivery has a risk of rupture twelve times greater than a woman with an unscarred uterus having a normal vaginal delivery. The risk is still incredibly small- about 0.2% prelabor rupture for women choosing RCS, 0.4% rupture in a spontaneous VBAC, somewhat higher for induced or augmented VBACs- but without that scar, the risk is only 0.013%. Whenever we talk about delivery options for pregnancies after cesarean, I think it is important to recognize that we're not comparing VBAC (or RCS) to an uncomplicated vaginal delivery. We're comparing the available options, which are VBAC and RCS, and neither option is risk-free for moms or for babies.

Risk assessment is a personal thing and it's not surprising that when we are making decisions about something vitally important- how to get our babies out of our bodies and into the world- even the smallest risks can seem enormous. When we are pregnant the first time, it's just assumed we'll deliver vaginally. Once we have the option of delivering by VBAC or RCS, once we have to choose between risks, once we are forced to decide which set of horrific outcomes we prefer to chance- well, the decision isn't always an easy one. It's made even more complicated when women who want to choose VBAC are told that it's high-risk, or it's implied that they are selfishly pursuing an "experience" at the expense of their babies' health. OBs have endless "requirements" for VBAC moms due to the perception that it is risky- limits on gestation, limits on baby's size, "requiring" epidurals, requiring induction to ensure the hospital is fully staffed, requiring VBAC moms to deliver in the OR rather than an LDR room, continuous monitoring, internal monitoring, no laboring at home... you would think a VBAC mom's uterus is a bomb waiting to explode!! But is VBAC really high-risk?

The first thing I consider is how non-VBAC, vaginally birthing moms are treated. The potential for a complication requiring a truly emergency cesarean is there in any vaginal birth! Cord prolapse and abruption occur in .18% and .4% of labors respectively but those risks are not perceived as great enough to make all laboring mothers "high risk." In a VBAC labor, adding uterine rupture to prolapse and abruption, the risk of needing a truly emergent delivery is raised from about .6% to just under 1%. Does that increase justify a high risk designation?

And what about uterine rupture? Are the consequences of rupture so severe that even a small risk of rupture makes VBAC high-risk? While somewhere between 0.4% and 0.7% of VBAC labors will result in uterine rupture- a complete breach of the uterine wall- it's important to note that even a complete rupture is not always 'catastrophic' in the way that term implies. Less than 10% of complete ruptures result in permanent damage to mother or baby. 1 in 2,000 babies will suffer brain damage or death following u/r in a VBAC attempt. Is that "high risk?" If your answer is yes, would you change your mind if I told you that 1 in 2,500 mothers will die after choosing RCS?

Identifying a rupture when it occurs should be part of the equation, and the only sign that consistently occurs in the majority (but not all) of ruptures is a prolonged period of decelerations in fetal heartrate or bradycardia. This is also a sign of fetal distress in non-VBAC labors, and seems to be identified and responded to well in both hospital and non-hospital birth settings even without use of intervention like continuous monitoring or internal monitoring. Is that high risk?

What about outcomes? Recent studies are showing that women who choose VBAC have better outcomes overall than women who choose RCS. That's not comparing successful VBACs to RCSs either, it's comparing intended VBACs, whatever the outcome, with scheduled repeat c-section. Less NICU time, less respiratory morbidity, and less time in the hospital. Three times lower rates of infant death in the first month of life. Lower maternal morbidity and mortality. And that doesn't even begin to consider the impact of this birth on future pregnancies, an area where VBAC has clear advantages. High risk?

The additional risk of a cesarean scar follows a woman throughout her reproductive life and adds risk to all her future pregnancies. Uterine rupture is a real risk that is quite dramatically increased with a previous cesarean regardless of how a woman opts to deliver her future children. Women are absolutely entitled to do their own risk assessment and if they desire a more cautious approach to monitoring, both during pregnancy and during labor, they should be able to have that. However, given the increased risk of rupture even prior to labor's onset (which no one worries about), the better outcomes provided by VBAC, and the fact that providers should be ready for an emergent situation even in non-VBAC deliveries and those emergent situations occur with at least the same frequency as u/r, I don't think VBAC in and of itself should be labeled "high-risk."

(For further reading:
http://emedicine.medscape.com/article/275854-overview
http://lib.bioinfo.pl/meid:68748
http://journals.lww.com/greenjournal/Fulltext/2009/06000/Neonatal_Outcomes_After_Elective_Cesarean_Delivery.7.aspx
http://www.truebirth.com/2008/02/new-study-looks-at-multiple-vbac-outcomes/
http://content.nejm.org/cgi/content/abstract/351/25/2581)

7 years later, it still hurts

This morning I read this blog http://omgdgms.com/2009/11/10/chop-shop/ and instantly, I was transported back to my first birth. The induction I "had" to have, the utter lack of informed consent, the complications that I now realize are incredibly common during inductions, the interventions I know I should have refused, the monitoring I should have asked for before agreeing to be induced at all. I hadn't read my birth story in a long time; I much prefer the more positive version I choose to think of to the written version I never finished. Because what happened in reality was not what my birth was supposed to have been- a few lines from my birth story:

Labor! I thought.

and both of them came into the labor room-- this was after I had said I didn't want anyone in the room except my husband and my mom

when I got back to the room we had to start pitocin

I had to be hooked up to monitors all the time

then the downward spiral began

I was stuck in bed, I couldn't do anything for myself

I was tired and scared and frustrated and hurting, and I felt alone

I found myself thinking, "Good lord, could you just keep everybody the fuck out of here???"

she and the nurses kept asking me why I was crying. I couldn't tell them

I asked for the (epidural) consent form and after going to the bathroom one last time I signed it

now I started puking my guts out too. God, it was horrible.

Oh, how I hated it.

We had internal monitors, IV antibiotics, constant checks, catheter... Pretty near every possible intervention. And still, I was no closer to giving birth.

That's where I stopped writing. After I got the epidural I was no longer in pain and I stopped vomiting, but the rest of my labor complications continued. The hours continued to pass and I have to give some credit to my OB- I asked for a c-section long before she agreed it was time to perform one, and Vince was born just before 3 a.m. so I certainly can't say it was a matter of convenience for anyone. But the induction, the labor, were so awful... I felt like I'd been completely abandonded and my wishes didn't matter at all, to anyone. At one point I locked myself in the bathroom, I just wanted to escape it all, have the chance to labor and birth my baby in peace. But I didn't get that chance.

It has been so long since my son was born that I am caught off guard when I realize how emotional I still am about it. I used to feel like a failure but I don't any more. Now I just feel sad, both for the woman I was and for every other woman who has to go through an experience like mine. When did it become okay for birth to be like this? How did we go from twilight sleep and preventative forceps deliveries to this? Is inducing and medicating and offering technology instead of comfort really the answer to a better, safer birth? We've traded one illusion of control for another, and we've convinced ourselves that we are somehow to blame when it fails. The technology is infallable, our bodies are what's broken. We failed to dilate, our babies didn't tolerate labor, we developed infection. It's not because we weren't ready for labor or pitocin-induced contractions are harder on babies or artificial rupture of membranes combined with multiple internal exams increases infection risk. No. Because those things are controllable, we are the wild cards, we are the ones who failed.

Like I said, I no longer feel like a failure. I know I am capable of giving birth, I know my faith in the process was not misplaced. I just wish I could go back in time and sit next to that woman who was me, reach out to her, hold her hand, tell her that she had options. Tell her it is okay to ask questions and even say no. And then, later, I wish I could just put my arms around her, hold her, let her cry out her perceived failures, and tell her that at some point in the future those feelings would fade, and she might even find ways to use her experiences to help other women avoid going through the same thing. I can't go back, though, and my heart aches when I remember how much it hurt to have my first birth be such a testament to the failures of modern obstetrics. It still hurts, even 7 years later.

Reducing elective induction reduces cesarean rates

I was discussing a study with my OB during one of my prenatal appointments and he said, "Just because someone says it is so, doesn't mean it is so." I sort of laughed and said "I know" because the obvious counterpoint was that just because he said it was so didn't mean it was so either. At any rate, I ran across this study this morning, and while I can't get to the full text (yet!) I am always happy to find data supporting my belief that induction is associated with cesarean delivery:

http://www.ajog.org/article/S0002-9378(09)00210-5/abstract



A total of 10,166 nulliparas and 9869 multiparas attempted vaginal deliveries. Elective inductions decreased significantly, from 4.3% to 0.8% in nulliparas and from 13% to 9.5% in multiparas. A longer time to delivery was seen for both nulliparas (5.2 hours) and multiparas (4 hours) with elective inductions. Unplanned primary cesarean delivery rates are significantly lower in spontaneously laboring women, compared with those induced. (emphasis mine)



This appears to be so much better than the review I discussed in earlier posts- a large enough study group to be statistically significant, and performed recently, in the US, so it may apply to actual obstetric practice as it exists today.

Mainstreaming midwifery

This isn't going to be a typical long blog post, more like a random thought:

Last night I started thinking about how I'd always longed to have my babies either at home or in a local birthcenter that offers midwifery care and waterbirth, but either didn't or couldn't for various reasons. I wholeheartedly believe midwifery should be the standard of care for low-risk women, and homebirth an option for women who desire it. And that got me thinking: what would need to change for midwifery care and homebirth to really become mainstream options in the US? How would it change the face of maternity care? Is it realistic to expect those kinds of changes? And how would the mainstreaming of midwifery change midwifery practice itself? Though I haven't completely thought through this subject yet, I realize the answers are not simple. I'll be exploring this more in future posts!

Why Natural Birth for Normal Women?

It's easy to find information about how modern obstetric practice has failed women. Go to just about any parenting website, and you'll find loads of articles and posts about lack of informed consent, non-evidence-based care, unnecessary intervention, outright lies being told to scare and coerce women into making birth decisions they otherwise would not make. In a less dramatic way, I believe the birth community is also failing women.

While I have always strongly desired a natural, drug-free birth, I used to be an OB believer. When I got pregnant with my first child, I dutifully went to my OB, kept all of my appointments, did everything I was supposed to. I declined induction on my due date, but when 41 weeks came and my OB said I "had" to be induced, I didn't question it. Likewise, I didn't question any of the procedures that were performed in the hospital. It was only after my c-section that I really started to learn about normal childbirth, and it was only as I planned my first VBAC that I realized how much modern obstetrics is designed to keep us in fear and make us feel like WE have failed, when in fact we were never truly given a chance to succeed. I needed an alternative, but instead of finding myself drawn further into the birth community, I've found myself deeply conflicted.

It took me a good deal of time to realize that even though my beliefs about birth were not supported by modern obstetric practice, I wasn't really far enough from the mainstream to be fully embraced by the birth community. I'm not anti-OB, I'm not anti-hospital. I don't think women should have to choose a midwife-attended homebirth to have a good birth- and, perhaps most damningly, I don't think women who choose interventions like inductions or epidurals- or even cesarean sections- have any less right to a fully informed, positive, empowering, birth experience. By and large I think the birth community gives lip service to this issue- "of course you deserve a good birth experience, dear, but how do you ever expect to have one when you make those choices?"

When I was pregnant with my 3rd baby, I went online and asked (basically) this question: "Are we doing women a disservice when we tell them natural birth is impossible to achieve in a hospital?" It seemed to me that the birth community was telling women that they should expect to be treated terribly, they should expect to have their wishes trampled, they will be forced to cede their personal power and consent to any number of invasive and potentially dangerous interventions the minute they walk through the hospital doors. Perhaps my original question was poorly phrased, but I still wonder how that message is supposed to empower women to demand better treatment for themselves. The vast majority of women give birth in the hospital, and when the people who claim they want birth to be better for everyone tell women they are going to fail, well, what kind of message is that?

The responses I got so many years ago ranged from completely dismissive to personally offensive, but they boiled down to: "Natural birth is almost always impossible to achieve in the hospital, and telling women otherwise gives them unrealistic expectations. Women need to prepare for reality." It was defeating. I felt the birth community expected its members to fit a cookie-cutter mold, just like the obstetric community did. My own options were limited to a) the hospital or b) the hospital, and while I knew I hadn't exactly asked for support in achieving another natural birth in a hospital setting (I'd already had one with my 2nd baby), I didn't expect that there would be so little support for the idea that hospital birth doesn't have to be- and should not be- the end of a woman's hope for a natural birth.

A couple years ago I was talking with a friend about our upcoming births. She was heavily leaning toward a repeat c-section, and I was heavily leaning toward a homebirth VBAC, but somehow we managed to talk about our births without judgment or defensiveness- imagine that! I mentioned something about hoping to become a childbirth educator, but not feeling like I'd really be accepted in the birth community. She said that maybe it would be good to have someone like me in the field, and I laughed and said I would call my service "Natural Birth for Normal Women." The idea has festered all these years, and is now the inspiration for my blog. This is my small way of saying it's okay when you don't fit the mold, you still deserve to have your choices respected and your birth celebrated.

And maybe in a few more years I will worry less about whether I'd be accepted, and will pursue childbirth education after all.

(I should probably give my definition of the "birth community" for the purposes of this post. I am primarily talking about anyone who actively promote non-mainstream birthing options. Yes, that includes me. :-) I should also say that while I have always felt somewhat alienated by the birth community, I am blessed to know so many women who believe so strongly in the power of women's bodies. You know who you are- and you never fail to inspire me!)

Did I really just read that?

My last post was about a study showing that labor induction at 41 weeks leads to fewer cesarean deliveries than expectant managment of labor. After I posted, a friend forwarded me a link to the full text of that study (thank you Ellie!!), which you can find here http://www.annals.org/content/151/4/252.full Her first comment was, "I think if you look at the induction studies, you'll find it is not really relevant to how induction is really used in the United States." I was intrigued...

So I started reading, and while the authors do conclude that "elective induction of labor at 41 weeks of gestation and beyond is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid" the VERY NEXT SENTENCE says "There are concerns about the translation of these findings into actual practice; thus, future studies should examine elective induction of labor in settings where most obstetric care is provided." Hmmmm... What in the world does that mean? Is this review actually providing good information to use in making decisions about induction vs expectant management, or not?

The majority of the studies in the review are rated "fair" or "poor" in quality, and the authors admit that "few (of the studies) had calculated sample sizes to determine whether the study had adequate power to address the primary study question." The largest study relevant to the primary study question was excluded from results because it was published in French and non-English-language studies were automatically excluded. Many of the studies reviewed were not from the US-- and "When we stratified the analysis by country we found that the odds of cesarean delivery were higher in women who were expectantly managed than in those with elective induction of labor in studies conducted outside the United States but were not statistically different in studies conducted in the United States."

Suddenly I was realizing that this US review, that I had seen discussed on various US websites, wasn't really saying what the summaries I'd read said it should say. Induction in the US is not like induction in other countries- just like "normal" birth in the US is not like normal birth in other countries. I was starting to feel vindicated once again in feeling that my induction had led to my c-section, and then I came across this line:

"insufficient information exists with which to draw any conclusions about the effect of elective induction specifically in nulliparous women."

Even in the studies from other countries, they are unable to say that induction is a better option than expectant management for a first-time mom, and these studies don't even begin to hold the level of detail necessary to determine the effect of induction on a first-time mom with no dilation, no effacement, a baby not engaged in her pelvis. I'll never know if I could have delivered vaginally if I'd continued to wait for labor with my first baby, but this particular study no longer makes me question my deeply held belief that spontaneous labor gives a woman the best chance possible of delivering outside the operating room.