Today was a nice and boring day. Just the typical work, home, dinner, eat, play, baths and bed. Nothing crazy, nothing stressful. Just the way I like it. Of course that means I really have nothing to talk about today! Making it topic day!
So, my topic title may not make a ton of sense to all of my readers. VBAC = Vaginal Birth After C-Section; RCS = Repeat C-Section.
Once you have a c-section, you are instantly met with some BIG decisions (if you plan on having more kids of course). Do you fall in line with the theory of “once a c-section, always a c-section”, or do you fight for that VBAC. And trust me, the VBAC is just that…a fight. It’s finding a midwife/OB that is TRULY VBAC friendly, finding a hospital that is TRULY VBAC friendly, and fighting yourself every step of the way…fighting the fear of the risks, fear of the unknown, comfort of what you’ve already been though. It’s a daunting task indeed.
I was never sure that I wanted to have kids growing up. I didn’t long for the day I would be a mother. Olivia was quite the [welcomed] surprise. Then my fear of giving birth set in, instantly. I had NO desire to do it, and was absolutely scared to death at the thought. Honestly, I told myself many times “I wish I could just have a c-section and skip the whole thing”. Throughout the pregnancy, I did my research, read everything I could, talked to moms, took my childbirth preparation class, and really came around to everything. I was ready, and even excited. At around 35 weeks, Olivia still had not turned into position, and my midwife was starting to worry. She said it was pretty late in the game, and there was a good chance she wouldn’t turn. She pointed me to a website that had exercises and tips on trying to get baby to turn (www.spinningbabies.com), and we scheduled a version at the hospital, to manually turn the baby. After I did some research on the version, I knew it wasn’t for me. It’s painful, dangerous to mom and baby, has a very low success rate, is done in the hospital in case it sends mom into labor, and even if it does work, there is a good chance baby will turn back into breech position. In the end, I decided it wasn’t worth the risk, and I truly felt that a breech baby is breech for a reason, and we just can’t know what that reason is. I also would never birth a breech baby naturally (not that my midwife or hospital would have allowed it), as that is incredibly dangerous for the baby – when you deliver your baby, baby will take their first breaths shortly after their chest is delivered….so, of you are delivering head last [the hardest part of the baby to deliver], your baby is more than likely going to take their first breath(s) before their head is delivered…very dangerous. Not knowing the true repercussions of a c-section, I just gave in and prepared for it.
The surgery itself went great. My recovery was picture perfect (not EASY, but went just as it should have). In the end, I ended up having a lot of emotional issues after Olivia’s birth. I felt empty, I felt like I was ripped off from an experience that I deserved…that I had earned. It just was not the right ending to the process of pregnancy. I didn’t give birth…I had a procedure. And it was not sitting well with me. I think everybody focuses on the physical side of a c-section, and you often forget that pregnancy, labor and delivery have a very emotional aspect as well. I knew at that moment, I never wanted to do that again. I immediately started researching VBAC’s…the good, the bad, the risks, the benefits, and started preparing myself. There was no question in my mind that a VBAC was in my future.
Here is the best research and comparisons I have compiled online throughout my VBAC journey (this is going to be LONG). Both VBAC’s and RCS’ involve some increased risks to mothers. However, without a clear, compelling and well-supported need for c-section in the present pregnancy, planned vaginal birth is safer overall for you than a planned RCS. With supportive care, 75 or more out of 100 women who plan VBAC give birth vaginally. The others go on to have another c-section, primarily for reasons that are unrelated to the scar.
A planned c-section offers certain advantages over a c-section that takes place after labor is underway. A planned c-section is less likely to involve injury to other organs during surgery, to lead to infection after surgery and to take an emotional toll. Nonetheless, whether planned or unplanned, a c-section is a major surgery and involves pain, a post-operative recovery period and a greater risk for mothers in many areas.
Your plan for your family size plays a key role in deciding as well. Each additional c-section increases the amount of internal scarring and the number of uterine scars. The accumulating scar tissue makes it more and more difficult for the egg to make its proper way from the ovary into the uterus and for the placenta that nourishes the baby to grow and attach normally. These problems can pose life-threatening risks to babies and mothers. The scarring can also pose challenges for future surgical procedures, c-section or other. If a woman who has a VBAC has more children, she almost always gives birth vaginally and her uterine scar almost never gives way during future labors.
Scar-Related Situations and Their True Risks:
- Type of Uterine Scar Not Known: Many years ago, studies showed that a horizontal cut on the lower part of the uterus produced a much stronger scar than the previously used vertical incision. As a result, virtually all women who had a previous cesarean and are pregnant now have a scar that goes from side to side. Exceptions may be a past c-section for placenta previa, an emergency situation, premature birth, or breech positioning.
- Previous C-Section for Premature Birth: The lower portion of the uterus may not have developed enough at the time of the past c-section to permit a cut that goes from side to side. For this reason, doctors may make a vertical incision at the bottom of the uterus. However, the low vertical incision appears to be just as strong as a transverse incision.
- Baby Expected to be Larger Than Average: Some have thought that babies expected to weigh more than 8 pounds, 13 ounces would put extra pressure on the scar. However, studies don't show this to be the case.
- Pregnancy Goes Beyond the Due Date: Studies do not show an increase in problems with the scar in pregnancies going beyond 40 weeks.
- Twin Pregnancy: Studies haven’t shown an increase in problems with the scar during labor with twins compared with one baby. However, limited information on VBAC labors with twins is available at this time.
- Baby is in a Breech Position: Few care providers will agree to vaginal breech birth even when the mother has no c-section scar, so the question here is whether it is it safe to have a procedure in which the care provider uses hand maneuvers on the belly to try to turn the baby into a head-first position. As with twins, there is little research on this point.
Overall, less than 1 in 100 – that is 0.01% - women who labor after a c-section experience the scar giving way during labor, which generally leads to an emergency c-section. In VBAC labors, loss of the baby occurs much less frequently than scar separation and emergency c-sections. The following situations have been shown to increase risk for scar-related problems:
1. more than one prior c-section
2. uterine infection following the previous c-section
3. mother aged 30 or older
4. due date less than 18 months after the previous c-section
In some rare situations, it is thought that substantially more women, 8 to 12 out of 100, will have the scar give way. Almost all care providers, including those who usually encourage VBAC, would strongly recommend a planned RCS in the following situations:
- Certain uterine scars from a c-section that aren’t the usual horizontal cut made at the bottom of the uterus: In these rare situations, the concern is that the scar on the uterus may be weaker and more likely to give way and cause serious problems than the usual c-section scar.
- Mother had previous uterine surgery for gynecologic problems, such as for removal of fibroid tumors.
- Uterine scar opened and caused problems in a prior labor: The key point here is that the scar has caused problems before.
- Uterus does not have the usual pear shape: Examples of this are a heart-shaped uterus or a uterus that is partly divided down the middle.
- Ultrasound in late pregnancy finds that the area of the scarred uterus is unusually thin: There may be a concern if the scar is 2.5 millimeters thick or less.
Induction of labor is highly discouraged when attempting a VBAC delivery (really, induction of labor is a large factor in the high c-section rates, so should be avoided in general as much as possible). Agents used to soften and shorten the cervix may increase the likelihood that the scar will open and lead to problems in labor (some studies find a relationship, and others do not). Some researchers think these agents may soften the uterine scar as well. Using synthetic oxytocin (Pitocin) by itself to try to start labor may also increase the likelihood that the scar will give way. In this case, at most 2 women in 100 experience this problem compared to the rate of less than 1 in 100 in women not being induced. Giving Pitocin early in labor to strengthen contractions may also increase the risk of scar problems.Given the increasingly casual use of labor induction in the United States, many women have the option of waiting for labor to begin on its own, or at least waiting to induce labor until changes in the cervix signal that it is ready to open. If your caregiver recommends induction to you, it is important to consider together the risks and benefits of waiting for labor to begin on its own, inducing labor or scheduling a RCS.
If you have given birth vaginally in the past, your chances of having scar problems with a VBAC labors appear to be reduced. Also, if you have already had a vaginal birth (in addition to your c-section), you are more likely to reach a goal of VBAC than a woman who has not had a vaginal birth.
For women who have labored before, fear of another difficult labor holds many women back from attempting a VBAC. If you can identify what elements of your labor distressed you, you may be able to avoid repeating the problem. Here are some ideas:
- If you feel that you didn’t have good supportive care from your caregivers, you may wish to choose a different caregiver, birth setting or both.
- If you feel that you didn’t get the support you needed from your partner or others who were with you, hire a doula or invite a friend or relative to assist you and your partner.
- If the problem is the frustration of long, non-productive hours in labor or pushing, you can:
- know that your next labor may proceed very differently; the first is usually the longest.
- learn about factors that can interfere with labor progress (laying down consistently during labor, epidurals/medical interference, early induction, etc.) and gather ideas on how to help labor progress more smoothly. This is another reason to hire a doula as she will know these things.
- decide ahead of time on reasonable limits for the cervix to dilate fully and then for you to push the baby out. Knowing you have an end point can help you feel less anxious and more in control. If you reach this point, you can choose whether to go beyond it. Keep in mind when setting limits that women with prior c-sections tend to labor more like first-time mothers than women who have given birth vaginally.
Despite limitations of the best available research, the following conclusions seem clear:
- Scar giving way: The scar is more likely to give way during a VBAC labor than in a RCS; for most women, the added risk of the scar giving way is about 27 in every 10,000 VBAC labors.
- Death of baby: While the scar giving way poses a threat to the baby, the added risk that the baby will die from a problem with the scar during a VBAC labor, compared with women planning a RCS, is about 1.4 in every 10,000 VBAC labors.
- Hysterectomy in mother: If the scar gives way, some women have a hysterectomy. The added risk of needing a hysterectomy from this cause is about 3.4 in every 10,000 VBAC labors, when compared with women planning a RCS. However, considering risk for hysterectomy from all causes, women who plan a VBAC are not more likely to experience an unplanned hysterectomy than women planning a RCS.
- Infection: Women planning RCS’ are more likely to develop infections than women planning VBACs.
- Multiple scars in uterus: Accumulating c-section scars increase risk for experiencing a number of serious problems relating to future pregnancies and births. These include:
o scar rupture in a subsequent labor
o ectopic pregnancy: the embryo develops outside the uterus
o placenta previa: the placenta grows over the cervix, the opening to the uterus
o placental abruption: the placenta separates from the uterus before the baby is born
o placenta accreta the placenta growing abnormally into or even through the uterus.
When weighing planned VBAC versus planned c-section, the focus is often on potential problems with the uterine scar in labor or on problems associated with accumulating scars. But this results in an incomplete picture because it overlooks other risks that also differ between vaginal birth and c-section. Summarized here are some of the many extra risks associated with c-section surgery, as well as the few advantages.Most of what we know about these risks comes from studies of c-section’s in general, not planned c-section’s. Available research suggests that some of these risks may be lessened when the c-section is planned.As you consider these, keep in mind that on average, 3 out of 4 women who labor after a c-section will give birth vaginally with care that encourages and supports VBAC.
- Physical problems for mothers: Compared with vaginal birth, c-section increases a woman’s risk for a number of physical problems. These range from less common but potentially life-threatening problems, including hemorrhage (severe bleeding), blood clots and bowel obstruction, to much more common problems such as longer-lasting and more severe pain and infection. Even after recovery from surgery, scarring and adhesion tissue increase risk for ongoing pelvic pain and for twisted bowel.
- Hospital stays: If a woman has a c-section, she is more likely to stay in the hospital longer and to be re-hospitalized.
- Emotional well-being: A woman who has a c-section may be at greater risk for poorer overall mental health and some emotional problems. She is also more likely to rate her birth experience poorer than a woman who has had a vaginal birth.
- Mother-baby relationship: A woman who has a c-section is more likely to have less early contact with her baby and initial negative feelings about her baby.
- Breastfeeding: Recovery from surgery poses challenges for getting breastfeeding under way, and a baby who was born by c-section is less likely to be breastfed and get the benefits of breastfeeding.
- Impact on babies: Babies born by c-section are more likely to:
o be cut during the surgery (usually minor)
o have breathing difficulties around the time of birth
o experience asthma in childhood and in adulthood. - Impact on any future babies: A c-section increases risks for babies in future pregnancies. Some research finds that babies who develop in a scarred uterus are more likely to:
o be born too early (preterm)
o weigh less than they should (low birth weight)
o have a physical abnormality or injury to their brain or spinal cord
o die before or shortly after the birth
This is a great site that I found, which compares VBAC’s to RCS’ very in-depth http://www.childbirthconnection.org/article.asp?ClickedLink=293&ck=10212&area=27. I feel like when a mother is truly informed, has a good support system and really looks at the facts, it is clear that the risks of a RCS are far greater than the risks of a VBAC, both physically and emotionally.
I have become quite the advocate of VBAC’s, and wish with all my might that more women would seek this important option. We need more women to do it, spread the word and pave the way so that it becomes the norm rather than the "once a c-section always a c-section" notion that is still so prominent. More than that, I wish more women would go into their initial labors and/or c-sections with more knowledge about what they are getting into.
Here are a couple pictures of my ladies to end today’s novel.
