Trialing Labor after Cesarean | Info on VBACs and why they aren't happening

A VBAC.

What does that mean? It means you’ve had two cesarean births in your history and you’re now attempting a vaginal birth. Some people may wonder… why on earth would you ever want to do that? Surely it’s easier and safer to just opt for a repeat cesarean delivery?!

Yes, but also no. As a mother who had three inductions, I do hold some space in my heart for wanting a spontaneous birth. The moment of … oh that was my water, time to go! The excitement of leaving in the night and the whirlwind of activity and excitement that happens with traveling to your birthing destination. Laboring at home <3 Ugh. How I wish I could have labored at home.

For some mothers, the desire for a vaginally delivery is exceptionally strong. Decreased healing time, no major surgery, the opportunity to immediately see and hold your delivery, the ability to even assist or your partner assist in delivery. You just have more options and a birth with greater bonding opportunities with a vaginal delivery.

But what about one after two cesareans? Here’s some quick facts on VBAC and VBA2C…

  • 90% of women who have undergone cesarean deliveries are candidates for VBAC ( 1)

  • Women requesting for a trial of vaginal delivery after two cesarean sections should be counselled appropriately considering available data of success rate 71.1%, uterine rupture rate 1.36% and of a comparative maternal morbidity with repeat CS option. ( 2)


WHY NOT VBAC?

The popularity of C-sections is deeply entwined with the popularity of VBACs, and long has been—even back to 1916. It was in that year, at a New York Association of Obstetricians & Gynecologists (ACOG) conference, physician Edward Cragin coined the phrase "Once a cesarean, always a cesarean." In that time and for much of the last century, it certainly was true. Commonly, women were cut using the classic incision, or a vertical one that left mothers at heightened risk for uterine rupture when trialing labor after cesarean.

But the practice guidelines of ACOG evolved, and the low transverse incision (bikini cut) became more common, really picking up steam in the 1970s. This low transverse incision greatly decreased the risk of uterine rupture, making VBACs much less risky. By 1996, the VBAC rate was at 28 percent, an all-time high. (3)

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Yet the VBACs that were happening were not always taking place under ideal conditions, with doctors neglecting to properly screen candidates or using cervical ripening to induce labor (OSF St Francis actually has a specific policy some cervical ripeners), which doctors now know increases the risk of uterine rupture. The rate of rupture increased largely because of those two factors. As a result, in the 1990s, ACOG issued guidelines restricting VBAC. The rate of VBAC fell dramatically while the C-section rate shot up. Around 2005, the way method of delivery was documented on birth certificates changed slightly, so data in the graph below reflects comparing apples to apples instead of apples to oranges data. Current information supports that as of 2018, the national VBAC attempt rate is 11%, with a national average total cesarean rate of 32%.

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What does all of that mean?

It’s simple. We failed mothers. We failed to manage their labors without rushing them. We introduced labor augmenting drugs to speed up the timeline of labor, and consequently, we pushed their bodies too hard. We caused uterine ruptures. We caused infections. We caused problems. And then what happened? Instead of addressing the management of care of VBAC, we told mothers to stop trialing labors after cesareans. We told them VBACs were dangerous, not that we made them dangerous.

Then comes reason number two: our physicians were afraid of retaliation. Our physicians caused harm throughout the ‘90s to mothers and families. And they started paying the price. Providers, researchers, and advocates all cite “fear of litigation” as a driving force to forgo VBACs. Obstetricians are sued more frequently than many other specialists and have to pay higher malpractice premiums. More telling is a 2015 paper in the journal Obstetrics and Gynecology that found that 42 percent of 171 Florida physicians surveyed stated litigation as the primary reason they did not do VBAC, whereas lack of experience handling uterine ruptures was the primary concern for only 11 percent of these doctors. (3) While ACOG instructs doctors who don't want or can't perform a VBAC to recommend a VBAC-interested patient to another provider who supports VBAC, only 22 percent of these doctors actually did that.

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Is VBAC worth attempting?

To me — yes. Emphatically yes. You will need to be a great candidate, which there’s a 90% chance you are. You will need a supportive provider, a hospital that allows VBACs. You will need to understand the process of birth, how it happens and what your body needs to do on it’s own. You need to know and understand the risks and be prepared additional health care providers that you’ve been counseled on your options from your primary OBGYN and would appreciate fear tactics not being used to sway your decision making in labor itself. You’ll need to believe that it’s possible for you, as it is for over 70% of women who attempt it.

VBAC isn’t “dangerous”, though it poses risks. I encourage any mother with 1-2 cesarean deliveries under her belt to discuss her options. And if your OBGYN is NOT willing to let you trial labor, ask for a second opinion.

Jen Kamel, a former commercial real estate analyst and VBAC mother who now runs the website VBAC Facts, says access to VBAC is a fundamental reproductive right. "We should be advocating for access to VBAC just as we do for any other reproductive option, from birth control on," Kamel says. "Everyone has the right to decide what happens to their body."


Brittney HogueComment