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.

The Gentle Cesarean

For years now I've been a part of the VBAC support forum on BabyCenter, and I've read literally hundreds of women's cesarean birth stories. I've read some positive and empowering stories, and I've read some tragic ones that truly fit the term "birthrape." But I have never read one like the one Joanna Moorhead describes in this UK article titled "Every Bit as Magical." Professor Nick Fisk is pioneering a cesarean technique he calls the "skin-to-skin cesarean," a significant improvement over the clinical and reserved deliveries most c-section moms expect.

Picture this: Instead of being literally strapped to the table with her view obscured by a curtain, the mother is propped up so she can see her baby's birth. Instead of the surgery being performed as quickly as possible, the pace is slower, gentler. Instead of the baby being whisked away, he is immediately placed on his mother's chest. The cesarean is recognized and honored as what it is- this baby's birth- instead of being performed like just another surgery. How wonderful would this be for women who have to have cesareans?

Taking it a step further, how wonderful would it be if all mothers could expect to be treated like their births are amazing, magical, worthy of respect and consideration? No matter how our babies enter the world, birth remains one of the most powerful and unforgettable experiences we will ever have.

Elective cesarean: The new media darling

In case you missed it, the Today Show televised a cesarean birth. A CBS affiliate in New York is publicizing a "Growing Trend: Expectant Women Schedule C-sections." Obstetric texts are compiled to show the benefits of cesarean delivery, and then those texts are quoted and debated by women who believe cesarean delivery may truly be the best and safest way to deliver babies. Every time I see these glowing portrayals of surgical births, it makes me a little bit sad, more than a little bit frustrated, and even more it makes me angry.

I am angry that we are building a culture perceiving cesarean birth as a low-risk procedure that is safe for babies and not a big deal for mothers. I am angry that women perceive vaginal birth as something to be avoided at all costs, and I am angry at the obstetric community for doing so little to allow women the opportunity to birth in a way that is neither physically nor emotionally traumatic. I am angry because women are making birth decisions based on fear, and I'm angry because the mainstream media buys into and feeds that fear. "Don't worry, honey, you don't have to go through anything terrible to have your baby- watch this video, see how easy the c-section is? The baby is out and safe and they chose the right way to deliver. Next week: brain surgery!" What else can we trivialize?


The reality is that elective cesareans have risks, for moms and for babies. Surgical delivery is not a peaceful, gentle birth any more than vaginal delivery is a hellish squeeze through the maternal pelvis. There are grains of truth in the stereotypes, but there is also a reason birth has evolved as it has. Labor is good for babies, the squeeze through the pelvis designed to clear the lungs of amniotic fluid. There is a reason for birth, and more of us need to speak up about it. Cesarean birth is not the same, it is not safer, it is not risk-free and it is not "no big deal."

I can hear the criticism already- this post is unsupportive, I am judging mothers who have to have cesareans, I'm ignoring the fact that cesareans have saved countless women and babies. First, I'm not talking about medically necessary cesareans because clearly there are times that the risk of cesarean delivery is far less than the alternative. My purpose is also not to judge women who have made informed decisions to have elective cesareans. We absolutely need to support women in making informed choices, and that includes women who choose repeat cesareans or even primary elective cesareans. That does not mean I think we should stand silently by while a woman has a primary c-section at 38 weeks for a suspected big baby after being told horror stories about shoulder dystocia by her OB. That does not mean we have to listen quietly while someone says her c-section is better for her baby because her baby won't have to squeeze through the birth canal. That does not mean we should remain silent about the fact that pelvic floor damage is caused more often by pregnancy itself than vaginal delivery- and when it is caused by vaginal delivery it is often associated with highly interventive births, directed pushing, episiotomy. Supporting a woman in making decisions about her birth should be more than simply smiling and nodding and ignoring the stench of the bullshit that is thrown around like fact when it comes to birth.

I think it is entirely possible for women to be fully informed and educated and smart, and still value a different birth experience than I do. I can use myself as a prime example- I 100% believe that natural childbirth (the unmedicated, low-to-no-intervention kind, not just vaginal birth) is the absolute safest way to bring babies into the world. I 100% believe that for low-risk women, intervention is largely unnecessary and often adds needless risk to birth. However, I still chose epidurals with my last 2 VBACs, I still scheduled a medical induction for #3 (didn't make it that far, but I fully intended to induce if I had). After evaluating my options and researching my decisions, the benefits of those procedures outweighed the risks. Anyone else might have done the same research and made a different decision- and I would have fully supported them.

What I do not support, and what I judge, is a woman who deliberately chooses to make an uninformed decision and expects me to sing the praises of her choice. "All that matters is a healthy baby" has become the mantra, yet women are conditioned to believe intervention always equates to better outcomes, and our nation's morbidity and mortality statistics simply do not back that up. We need a big wakeup call, not just "support" that amounts to encouraging ever more uninformed decisions and greater social acceptance of high-intervention deliveries and elective cesareans as the norm. We need the media to stop glorifying elective cesarean and portraying vaginal birth as torturous hell. We need to find a way to have normal birth get the glory that's reserved for surgical delivery today. We need the mainstream media to tell women their options are not limited to either the overmedicalized horror show that passes for birth in many hospitals, or an elective cesearan.

If we don't start demanding change, the trend toward primary elective cesarean will continue. If we don't let media outlets know how unhappy we are with the way they misrepresent the realities of birth, they will continue to support and encourage us to view cesarean birth as the easy, no-muss-no-fuss way to deliver our babies. We deserve better.