Vaginal Birth After Cesarean Section
If you are considering attempting a Vaginal Birth After Cesarean Section, also known as a VBAC, we at the Tepeyac Family Center want to assist you in any way we can to make the best decision for both you and your baby. We are very supportive of VBAC because it can be quite a rewarding birth experience. If you are successful at having a vaginal delivery, you will probably recover faster, lose less blood, and avoid the risks of major surgery. However, we want to be aware of both the pros and cons of the VBAC procedure, and of a recent study that is less supportive of VBAC than the previous literature has been.
Recently, the New England Journal of Medicine published an article, which analyzed over 20,000 patients who delivered a child vaginally after having had one previous cesarean. The results were rather astounding, and as a result, this may change the way both you and we approach labor after having undergone a cesarean.
1.9 patients per 1000 who did not labor at all experienced uterine rupture. Spontaneous labor was associated with a tripling of the risk when compared to women who underwent a scheduled repeat cesarean. Induction of labor with pitocin was associated with 5 times the risk, and if prostaglandin's were used, the risk skyrocketed to over 15 times that of someone who did not labor.
We realize that if a woman has already successfully undergone a VBAC, the likelihood of her success is higher than if she has not yet delivered vaginally. However, uterine rupture is still more likely than if she had not undergone a cesarean.
Previous studies have shown there to be a further increase if the woman has had more than one cesarean. If the incision on the uterus runs vertically, known as a "classical" incision, the risk of rupture is increased so much that these women are not even candidates for VBAC.
The obvious question then becomes "What is the significance of uterine rupture?" That is a very good question because the range of effects to the mother and child vary from a mild separation which is totally a symptomatic and simply noted at cesarean, to hemorrhage requiring hysterectomy and / or blood transfusion, to a catastrophe in which the mother, the child, or both, die. Granted, these disastrous outcomes are rare, but they do happen. The biggest difficulty is that they are not always predictable.
So what does this mean to you? We will continue to offer VBAC to our patients, but we will be more selective in our choice of candidates. Each case will be considered individually. As always, we want you to have the very best birth experience which is safe for you and your particular circumstances. We encourage you to take an active role in this very important decision. We also realize it is the mother who ultimately decides what risks she is willing to undertake for herself and her child. We ask you to pray that God enlighten your mind and give you the graces necessary for you to experience the birth He wants for you.
From our perspective, we are looking for VBAC candidates who have an excellent chance of succeeding with a minimum of intervention. This means, for example, that we prefer you to be delivered by your due date; go into labor on your own (no pitocin inductions, although augmentation may by considered); have a reasonable estimated fetal weight; and continue to make good progress once in labor. If any of these conditions is not met, then the rupture rate may represent too high of a risk for you to undertake.
We understand this may be a difficult decision for you. Please feel free to ask any further questions you have in order to make an informed choice about trying a VBAC or scheduling a repeat cesarean.