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.
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.
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%
Risk of blood transfusion: 4.05%
Risk of placenta accreta: 0.24%
| 2nd C-section | 1st 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)
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/
http://www.bellybelly.com.au/
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