Friday, February 19, 2010

Shifting the paradigm: VBAC should become the norm

For years I have believed that once a woman has a cesarean, the choice to deliver vaginally (VBAC) or have another c-section (RCS) for future deliveries should be entirely hers. I've believed that the risks, while different, carry roughly equivalent chances of worst-case outcomes. It is up to each of us to determine which set of risks we are most comfortable with, and go forward making the decision that will allow us to look back without regret. I have struggled to learn to support women who looked at all the evidence and still chose RCS- it is definitely not a choice I would not personally make- but in the end it was never my place to judge someone for making the decisions that she felt were right for her and her baby.

While I still don't feel I have any right to judge women who choose RCS, I have reached a point where I don't feel that is at odds with speaking up for VBAC. I recently read that over 50% of women would like to attempt VBAC, but nationally less than 10% actually do. Why is that? I'm sure there are a certain number of women for whom VBAC is legitimately not an option, but the majority are probably very good candidates and yet they choose (or are forced to choose) RCS. Why?

VBAC is vilified, there's no doubt of that. Lawyers like this Indiana Medical Malpractice Lawyer are all too willing to support the perception that VBAC is in and of itself a needlessly risky procedure that often results in poor outcomes for mothers and babies. There is a pervasive belief among the general public- and among juries- that a c-section represents everything possible being done to ensure a healthy and safe delivery, and I've often seen it said that OB's are never sued for the c-sections they perform, only the ones they don't.

But I don't really want to talk about medical malpractice, I want to talk about why major abdominal surgery is considered the normal way for a baby to be born, just because his mom has a scarred uterus. Recent studies are coming down in favor of VBAC as safer than RCS for moms and babies, and it is absolutely clear that RCS increases future risks for women and their subsequent babies- but even if the risks were equal, why do we believe the intervention is better than the natural process? Why are we burdening our healthcare system with the time and expense of so many cesarean sections when there is an equally safe (possibly safer) and much less invasive alternative?

It is time for this paradigm to shift. I'm not suggesting that the option of repeat cesarean be taken away, but I believe we need to change the starting point when a woman is choosing between VBAC and RCS. In today's obstetric world, RCS is the automatic assumption and women who don't have a compelling reason to attempt VBAC rarely do. It is even more rare for an OB to encourage a woman to choose VBAC. This is completely upside down! We shouldn't have to fight and change doctors and travel for hours to be "allowed" to labor and deliver our babies without being cut open. We should expect to deliver vaginally unless there is a compelling reason to do otherwise, and VBAC should be the first option offered to women with a previous cesarean.

A shift in our thinking, a return to normalzing birth... I'm not idealistic enough to think it would be easy, but I am not cynical enough to think it's impossible either. I still have hope that one day in the future, the 50+% of women who would like to have a VBAC will be supported and encouraged.


  1. My mother-in-law had her first baby by c/s in 1980. It was a classical incision and a classic FTP-type c/s - she showed up with prodromal labor that had been going on for days and insisted they keep her in the hospital (though they had sent her home twice already). The hospital was a very bad experience, and her refrain from the birth is "I never even dilated. If I hadn't had the c/s we both would have died."

    When she was expecting again in 1992, her doctor encouraged her to consider a VBAC. She wanted nothing to do with it and insisted on a scheduled RCS, but I do find it interesting how much the approach has changed. Again, she had a classical incision in 1980. Yet her doctor, in an area now renowned for elective c/s and hostility to VBAC and natural birth, was encouraging VBAC in 1992.

    I fully agree with you that those women who want a VBAC should be supported and have no difficulty finding a hospital and provider who will support that birth.

  2. I just read your birth experience with having a VBAC on baby center and I have to say THANK YOU! I needed a c-section with DD because I never dilated after they induced me. I just found out that I am pregnant with #2 and your experience made me laugh and cry and created a hope a in me. I can do! I will dilate!

  3. I cannot agree more with this post. The fact that VBAC is not the automatic standard first option is just incomprehensible to me. There is something inherently wrong with presuming that women should have further surgery/ies without being given the support and opportunity to at least attempt vaginal delivery. It's infuriating and I'm so thankful for people like you who are railing against the system and offering support to those of us who WOULD like to buck the trend.
    VBAC hopeful for May 2010