Monday, March 19, 2012

VBAC vs. Repeat C-Section -- by Abbey Robinson

I hope you enjoyed Allison's HBA3C story from last week.  I asked another friend, Abbey, who has also had a VBA3C to write a post about the safety of VBAC versus Repeat C-Section (RCS). Abbey is a doula who writes a blog dealing with vaginal births after multiple cesareans and other interesting topics.  She recently started a Facebook page as well.  She's pretty opinionated too, but VBACs are her passion. 


I've always considered myself an advocate of all things 'natural'.  A bit of a hippie in high heels, well, wedges to be exact.  I've never wanted my children to be exposed to anything artificial or harmful and have always wanted to give them a gentle start to life.  Of course, all of that starts at pregnancy and birth, so naturally I expected and planned natural births and to breastfeed my babies. 

The benefits of natural birth are far to strong to ignore...including but not limited to:
* Baby coming when ready (lower NICU rates, longer gestation means better brain development (ref 01)
* Immediate skin to skin contact (better bonding)
* Delayed cord clamping (increased levels of iron, lower risk of anemia, fewer transfusions, and fewer incidences of intraventricular hemorrhage) (ref 02)
* Immediate ability to breastfeed (ref 03)
* Faster, easier recovery
* No scarring on uterus, so no increased risk of uterine rupture or other effects on future pregnancies

For many of us, the desire to birth naturally is based largely on the emotional aspect of birth.  It's what WE as women want to be able to do.  There are FAR too many emotional benefits to natural birth to list.  The glorious hormones received after an uninterrupted birth have been talked about by advocates of natural birth for many years.  The famous French Obstetrician, Michel Odent says, "Oxytocin is the hormone of love, and to give birth without releasing this complex cocktail of love chemicals disturbs the first contact between the mother and the baby."  He says that any interruption of that process is damaging to the mother/baby bond including any induction or augmentation of labor.  Artificial oxytocin does not have the same effects as natural oxytocin.

Unfortunately my journey to birth took a very medical twist, despite having good information and support.  Fourteen years after my first pregnancy, my natural birth score card read 3 to 1.  That's right, 3 c-sections and 1 natural VBAC (Vaginal Birth After Cesarean -- I had a VBA3C).  Despite the odds, my bond with my babies was strong and I learned to advocate for my own health.  I have always thirsted for knowledge and continued researching risks/benefits of both VBAC and RCS (repeat cesarean section) since the birth of my first child in 1996.  I'm a bit of a sponge with statistics and numbers and love to share that information with others.  I want women to make truly informed decisions about the kind of birth they want, but they can only do that if they are given ALL the information.  I'm sorry if the numbers below make your head spin, but they are SO important...especially in these days where c-sections are treated like lollipops and being handed out to every woman who (thinks she) wants one.  Here's a little of what I've learned over the years.

The risks of VBAC carry the same risks as vaginal birth, but also the same benefits.  The major difference is the increased risk in uterine rupture.  Did you know that women who have never had a scarred uterus can have a uterine rupture?  According to a 12 years study in 1983, the uterine rupture rate in an unscarred uterus is 1 in 16,840 or about 0.006%.   (ref 1)  7 of the 10 cases of rupture were reported in women who either had used oxytocin or prostaglandins to augment or induce labor.

Finding the rupture rate for a scarred uterus is a little more complicated because there are so many variables that have to be considered that can increase risk of uterine rupture.

But let's keep it as simple as we can for now.  In an Australian study of over 29,000 women, the risk of uterine rupture in spontaneous labor without augmentation after one prior incision was 0.15%.  (ref 2)  Once you introduce labor augmenting and induction drugs, the risk of uterine rupture increases from 3-14 fold and jumps to 1.91%.

The conclusion of this study was NOT that women shouldn't VBAC, it was that "careful consideration should be given to the use of oxytocin for augmentation of labour or induction by any method for women with a previous caesarean" Because that's where the true risk lies.
In the summer of 2010, ACOG revised it's VBAC guidelines to say "VBAC is a safe and reasonable option for most women, including some women with multiple previous cesareans, twins and unknown uterine scars. ACOG also states that respect for patient autonomy requires that even if an institution does not offer trial of labor after cesarean (TOLAC), a cesarean cannot be forced nor can care be denied if a woman declines a repeat cesarean during labor." (ref 3)

I read a story the other day of a mother who was attempting a VBA2C.  Her OB seemed supportive up to 38 weeks and then he informed her that she would be having a RCS.  The mother printed the ACOG guidelines and when presented to her OB, he said he had never seen it.  The c-section appointment was cancelled and that mother was given more time.  I suspect there are MANY OBs, nurses, and other medical professionals who don't know about the ACOG statement... sad but true. We often hear about the risks of c-sections, and not many people I know really want to have a primary c-section but after they've had that first one, there is a belief in this area that a repeat c-section is safer than attempting a VBAC.  How true is this?

After you've had your first c-section, you have a choice to have a RCS or to VBAC.  If you are only going to have ONE more child, your risks during your second surgery still skyrocket, but after 2 c-sections, the risks are downright scary. 

Some of the risks of RCS include but are not limited to:
* Hysterectomy
* Blood transfusion
* Placenta accreta
* uterine rupture 
* additional surgery due to hemorrhage
* injury to the bladder or bowel
* thromboembolism
* excessive blood loss
* cystotomy
* bowel injury
* ureteral injury
* and ileus (bowel obstruction)
* the need for postoperative ventilation
* intensive care unit admission
* duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries (ref 5)
* lower breastfeeding rates
* immediate skin to skin more difficult
* delayed cord clamping much harder
* harder/longer recovery
* scheduled delivery means baby could be premature (higher incidences of NICU stays)

Some long term risks are:
* Scar tissue/adhesions (can cause any number of issues, pain, fertility problems, etc.)
* Endometriosis and Adenomyosis can be caused from scarring on the uterus resulting in surgery and hysterectomy years after c-section

The charts below are from ICAN.
1st C-section Risk of hysterectomy: 0.65%
Risk of blood transfusion: 4.05%
Risk of placenta accreta: 0.24%
2nd C-section1st VBAC
Risk of major complications: 4.3%Chance of successful VBAC: 63.3%
Risk of placenta accreta: 0.31%Risk of uterine rupture: 0.87%
Risk of hysterectomy: 0.42% Risk of hysterectomy: 0.23%
Risk of blood transfusion: 1.53%Risk of blood transfusion: 1.89%
Risk of dense adhesions: 21.6%
3rd C-section 2nd VBAC
Risk of major complications: 7.5%Chance of successful VBAC: 87.6%
Risk of placenta accreta: 0.57%Risk of uterine rupture: 0.45%
Risk of hysterectomy: 0.9%Risk of hysterectomy: 0.17%
Risk of blood transfusion: 2.26%Risk of blood transfusion: 1.24%
Risk of dense adhesion's: 32.2%
4th C-section 3rd VBAC
Risk of major complications: 12.5%Chance of successful VBAC: 90.9%
Risk of placenta accreta: 2.13%Risk of uterine rupture: 0.38%
Risk of hysterectomy: 2.41%Risk of hysterectomy: 0.06%
Risk of blood transfusion: 3.65%Risk of blood transfusion: 0.99%
Risk of dense adhesion's: 42.2%

5th C-section: placenta accreta: 2.33%
hysterectomy 3.49%
in the women with previa, the risk for accreta was 61% (ref 5)
6th (or more) C-section:  placenta accreta: 6.74%,
hysterectomy 8.99%,
in the women with previa, the risk for accreta was 67% (ref 5)

Additionally, the risk of accreta for women who had previa was 3%, 11%, 40% for 1st, 2nd, and 3rd c/sections.  (ref 5)


NOTE: "Major complications" include one or more of the following: uterine rupture, hysterectomy, additional surgery due to hemorrhage, injury to the bladder or bowel, thromboembolism, and/or excessive blood loss. (ref 4)

There was a study done with over 30,000 women having their 1st c/section up to their 6th (or more) c-section over a 4-year period that concluded, "Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery." (ref 5)  This study alone should deter ANYONE from wanting to have multiple c-sections.

If you want more info on the risks and benefits of VBAC and RCS, www.ICAN-online.org is a fantastic place to start.  www.VBACfacts.com is good, factual information.  www.specialscars.org is for women who have had 'different' types of uterine scars, including classical, T, inverted T, J, myomectomy or other uterine scarring. 
http://www.ncbi.nlm.nih.gov/pubmed/20716251  (ref 2)

18 comments:

apawol said...

What a great post. I love the stats too! Planing for our first VBAC after 1 previous c-section. Baby is due in July, so far so good! I needed this today, just reaffirms that I am doing to right thing for my baby and my body!

Liene said...

My VBAC resulted in our now seven week old son. Without women like you fighting to shed light on the dangerously high rate of Cesareans I would never have managed it. As it was, I had to have baby #2 in France to make it happen :) Thanks for all you do.

Thirty Little Piggies Designs said...

Was the Australian study done on those after one VERTICAL incision? or was it after one horizontal incision?

~Fort Worth Doula said...

omgoodness!! thanks little piggies!! I'll get Donna to fix that!! It's definately horizontal! But for info on stats for vertical scars...check out www.specialscars.org.
~Abbey

Thirty Little Piggies Designs said...

No problem just thought I'd point it out. Didn't want such great information to have a small error make it look wrong. I had another question. Are the statistics you quote for subsequent VBAC's? Like a women had 1 c-section then 3 vaginal births to be at her 3rd vbac. Right? If this is right do you have statistics to compare these things between a vba3c and a 4th c- section? Does that make any sense?

~Fort Worth Doula said...

There isn't enough info, but what there is shows that there isn't much difference at all in the risks of a first VBAC vs. a VBA3C (or more)but the risks of a 3rd CS (or more) are downright frightening. The stats on the 3rd VBAC vs. a 3rd c/s are above... here's a link to VBA3C http://www.ncbi.nlm.nih.gov/pubmed/20374579
((Of course, this is all contingent on variables used...mainly prostaglandins, artificial oxytocin, and other interventions))
~Abbey

~Fort Worth Doula said...

Sorry... The conclusion of that study was "Women with three or more prior caesareans who attempt VBAC have similar rates of success and risk for maternal morbidity as those with one prior caesarean, and as those delivered by elective repeat caesarean."
~Abbey

Allison said...

This info is some of what helped me make the case for vaginal birth with my 4th--I would have been at greater risk of death or other complications with an RCS than with a trial of labor. My husband likes graphs and studies :) so I showed him these--

http://consensus.nih.gov/2010/vbacstatement.htm

Scroll down under #3 to Table 1. Mortality Rates. You will see that I have a greater risk of death by motor-vehicle than in birthing my baby! But people don't tell my I'm brave for deciding to drive my car everyday. I love seeing the risks compared that way. Life is just not a risk free endeavor!

Thanks Abbey for laying out the real deal! You are an inspiration to so many of us.

ob said...

Wow, may I quote you?

~Fort Worth Doula said...

Of course!

Bevin Armstrong said...

Hello, I just happened upon your blog when i googled "vbac after 3 c-sections". I just wanted to say thank you SO much for the information. Before I began my search, I was guessing there was no hope for a vbac after I'd had 3 previous c-sections. Im looking forward to reading more of your blog tomorrow...Im exhausted at the moment. ;) Thanks again!

Lourdes Olson said...

I just had my baby on Sept 14 by VBAC. I had 3 normal deliveries years ago, then an emergency c section due to a failed inductio by a health provider who insisted baby #4 was going to be too large-I was induced at 40 weeks but she wasn't ready (and only 8.5 pounds, not much bigger than my biggest vaginal birth). Since the c section I had fertility problems for 12 years-I had 2 miscarriages and no other pregnancies despite ot using birth control, and though I would never have a baby again. My baby #5 is a miracle-she was early (32 weeks)and is in NICU, because my body refused to hold on longer, but I went into labor on my own, and had a wonderful dr who encouraged the trial of labor. With no pitocin, I delivered my baby vaginally. She is doing very well and already breathing on her own. And because I did not have a major surgery, I can see her every day.

Canned Ice said...

Hi, I really want a VBA2C, I would love it if someone with a lot of knowledge on VBAMC could please message me (not sure how this site works yet) I'm due 2 May 2013, no way my gynae will agree but would like some opinions and will look for a midwife if needed.

Brettina Mendoza said...

Appreciates the things you have shared here. My birth trauma lawyers were all happy to read what you've shared. Thanks a lot. Have a nice day!

CNJ said...

I appreciate the stats!! I have had 3 C-sections. I tried homebirth for my first which ended in an emergency section. Dr. encouraged VBAC for my second but ended in section. With my third I literally signed myself out of the hospital and went home knowing that staying would up my risk for a section. My water broke and I never went into labor was at home 5 days after my water broke with nothing happening, did what the midwife said to stimulate labor and nothing! Ended up with a 3 section. I am afraid I am pregnant with my 4th and I would be excited if I could have the baby naturally but my history is not good. I do hate all the risks of a C-section it is a bit depressing to look at in light of this being a 4th section...

mena said...

I would not attempt a VBA3C. That sounds super scary. My friend had her 5th caesarian birth 2 months ago. Didn't have any problems highlighted here.

I also have a friend whose mum died giving birth to her virginally after 2 caesarian births.

Some bodies can't handle a natural birth...

And I'm not advocating unnecessary caesarian births. I had all my kids virginally.

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Lety Murphy said...

Hi,

Do you have the exact link to the ICAN chart? I am trying to compile data for a local workshop and would love the exact link. When I was researching VBAMC in 2011 while looking to have a VBA3C I stumbled upon those stats somewhere else and now I can't find it.

Thank you

Lety Murphy
peacefulheartessence@gmail.com
peacefulheartessence.com