ICAN of Nashville

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VBAC & Cesarean Facts

Q. Is the adage 'Once a cesarean, always a cesarean' true?

A: No, this is outdated medical thinking. There wasn’t enough information available 40 years ago on the risks of labor after a cesarean birth. Also most cesareans done then were classical incisions whereas now almost all cesarean incisions are low transverse or “bikini” incisions. Studies now prove that VBAC is indeed a safer alternative to a scheduled cesarean birth for mother and baby after a low transverse uterine incision from a prior cesarean delivery.

Q. My doctor told me my pelvis is too small to vaginally deliver a baby over eight pounds. Is this true?

A: No, the pelvis and the baby’s head are not fixed bone structures. During labor the pelvis opens, allowing room for the baby, whose head molds to fit. The pelvis will actually open up 33% larger than it’s pre-pregnant size with a squatting position. There are several factors that contribute to this. First a hormone called relaxin is released during the latter part of pregnancy which soften the ligaments and cartilage surrounding the pelvis. Also different positions assumed during labor will change the dimensions of the pelvis such as walking, climbing stairs and squatting. This combined with the flexibility of the baby’s head gives ample room for babies to move through the pelvis. The baby’s head is made up of five plates that are connected with soft tissues that allow it to mold during the birth process as the baby travels through the pelvis. These bones return to their pre-birth state within hours of birth. 

Q: I have had more than one cesarean. Is it possible for me to have a vaginal birth?

A: Absolutely. Studies have proven that two or more cesareans do not significantly increase the uterine rupture rate compared to having one prior cesarean in the absence of induction medication. There is a correlation however to an increase in placenta accreta with each cesarean surgery, a condition in which the placenta imbeds into the muscular layers of the uterine wall. This can cause problems with retained placenta which often results in hemorrhaging and even a hysterectomy may be needed to stop the bleeding. Another strong reason to avoid repeat cesarean births.

Q: My doctor says scheduling an induction will maximize my chances for a vaginal birth.

A: Actually the opposite is true. Inductions as well as augmentation of labor contribute to a marked increase in uterine rupture rates and thus should be avoided if possible. Induction also leads to a higher rate of cesarean section than spontaneous labor. If an induction is medically indicated, close monitoring of mother and baby is highly recommended.

Q: I can’t find a doctor willing to support a vaginal birth after cesarean.

A: Finding a doctor to be supportive can be difficult. Do not take someone’s word that there is not a doctor in your area willing to support your birth. Take the time to make an appointment and go in a see several doctors and/or midwives. Ask questions and listen to their answers.

Q: Is it true that ACOG is recommending all women have a repeat cesarean?

A: No. ACOG (American College of Obstetricians and Gynecologists) says that most women with one previous cesarean delivery are candidates for VBAC and should be counseled about VBAC and offered a “trial” of labor. However, they have revised their recommendations to include that an obstetrician be immediately available during the labor of a VBAC woman.

Q: My baby is breech. Will I have to have a cesarean?

A: Not necessarily. It depends on how your baby is positioned and the experience of your doctor/midwife. With a skilled caregiver a breech vaginal delivery can be as safe or safer to mother and baby as a cesarean birth. Turning the baby is the best way to avoid a cesarean however and there are many techniques available to turn breech babies to a vertex, or head down, position.

Q: Doesn’t a vaginal birth cause problems like pelvic floor “damage”?

A: Lead researcher Dr. Alastair MacLennan in an interview with Reuters Health states, “80% of the problems a woman having a vaginal delivery has, also happen to a woman having a Cesarean section.” Most often it is the interventions like episiotomies, vacuum and forceps deliveries that contribute to urinary and fecal incontinence, uterine prolapse, and pelvic floor damage rather than the vaginal birth itself. Women who have had cesarean deliveries also experience urinary and fecal incontinence and other concerns due to the surgery or simply as a result of the hormones of pregnancy and/or the drugs used during the delivery.

Q: Wouldn’t a cesarean be safer than a vaginal birth after a cesarean?

A: A cesarean section is major abdominal surgery with all that entails. The surgery itself, as opposed to medical problems that might lead to a cesarean increases the risk of maternal death, hysterectomy, hemorrhage, infection, blood clots, damage to blood vessels, urinary bladder and other organs, postpartum depression, post traumatic stress syndrome, and rehospitalization for complications. Potential chronic complications from scar tissue adhesions include pelvic pain, bowel problems, and pain during sexual intercourse. Scar tissue makes subsequent cesareans more difficult to perform, increasing the risk of injury to other organs as well as placenta previa, placenta accreta, infertility, ectopic pregnancy, uterine rupture in subsequent pregnancies and the risk of chronic problems from adhesions. There are also risks to the baby such as respiratory distress syndrome, prematurity, lower birth weights, jaundice, lower APGAR scores (APGAR is the means of assessing the health status of a newborn), and finally in 1 to 9 percent of cases the baby is scarred or even maimed by the scalpel.

Q: What is the real percentage risk of uterine rupture?

A: This is a difficult question because there are many factors that attribute to uterine rupture. It is widely accepted though that for a woman who has had one previous lower transverse cesarean, the risk is 0.7% or 7 in 1000 women. If a woman has had two or more prior lower transverse cesareans her risk only increases slightly. Induction or augmentation will however increase the risk dramatically from 0.7% to 5%, and with a classical or T-incision the risk is found to be between 3% and 5%.

Q: Can I have a VBAC if I have a classical incision?

A: The reason VBAC isn’t recommended with a classical incision is that it is believed that the rupture rates are higher (3-5% vs. less than 1%). However, we don’t have reliable stats since women with classical incisions aren’t allowed in VBAC studies. An interesting note is that in many VBAC studies, women with “unknown” incisions (lack of records) were allowed in the studies. Their inclusion did not affect the results (which indicates that rupture with a classical incision is lower than they estimate).

Q: When is a cesarean absolutely necessary?

• Complete placenta previa at term.
• Transverse lie
• Prolapsed cord.
• Abrupted Placenta.
• Eclampsia or severe preeclampsia with failed induction of labor.
• Large uterine tumor which blocks the cervix
• True fetal distress confirmed with a fetal scalp sampling or biophysical profile
• True cephalopelvic disproportion (CPD- baby too large for pelvis). This is extremely rare and only associated with a pelvic deformity (or an incorrectly healed pelvic break).
• Initial outbreak of active herpes at the onset of labor.
• Uterine rupture