TOLAC and VBAC
In a time when vaginal birth is out of whack
Erin wrote this week with questions about VBAC. That's Vaginal Birth After Cesarean. It sounds like Erin did everything in her power to avoid having a cesarean section with her first baby. She wasn't induced until two weeks after her due date, used a cervical ripener, pitocin, rupture of membranes and eventually an epidural. Still, she just didn't dilate and eventually, her baby quit being a good sport with contractions and Erin ended up in the operating room. Here she is, pregnant with number two and she wants to avoid a repeat cesarean. There are a couple of pieces of information missing from her email that might shed some light on why she had the first cesarean: Her weight and her baby's weight. I don't know Erin. She might be skinny as a rail. Obese women, however, and those who gain a lot of weight with pregnancy, have way more cesarean sections. Women with really big babies also have more cesarean sections. If Erin's babies are just too big to make it into the birth canal, she can contract all day and won't dilate. If she's got too much fat in the pelvis and the baby can't descend past it, she's not going to dilate adequately. Like I said, Erin might be a slender woman who just wouldn't dilate. It's uncommon but not unheard of. Stuff happens.
Erin wants a TOLAC (trial of labor after cesarean) and hopefully a VBAC. Yeah, good luck with that, Erin. Unfortunately, we're birthing in a time when VBACs are as unpopular in the medical community as venerable disease. More than 90% of women who've had a cesarean section will have repeat cesarean sections with subsequent babies. It used to be, just 10 years ago that VBACs were encouraged by obstetricians and as many as 28% of women successfully delivered their babies vaginally, even after having had a cesarean. Nowadays? Not so much. Most obstetricians discourage VBACs and many hospitals won't allow them to be performed at their facilities. Why? Because of a .08% chance of uterine rupture occurring with labor after having had a cesarean.
Uterine rupture is scary stuff. The uterine scar made by the previous c-section breaks causing massive maternal hemorrhage and a good chance of both maternal and fetal death. Like I said, scary stuff. That said .08% translates to 1.6 per thousand chance of that happening. Not exactly a common event. Regardless, the American College of Obstetrics and Gynecology say that doctors and hospitals can't do VBACS unless an anesthesiologist or certified registered nurse anesthetist is on premises 24/7 along with the obstetrician ready to do an emergency cesarean section during the entire labor.
Most OB/GYNs don't stand at their patient's bedside for their entire labor. They hang out at their office, home, or kid's soccer games and come in periodically to see how things are going. When the labor nurse needs them, they get there quickly (usually within less than 20 minutes) but it's hard to run a busy OB practice from a labor room. Bedside care during labor is the nurse's job. Some hospitals can't afford 24-hour anesthesia services. Therefore, they don't do VBACs. Insurance companies won't cover hospitals that can't comply with these standards. No insurance? No VBAC.
Cesareans aren't without their own risks including hemorrhage, infection, and other complications. It's no slam-dunk for babies either. Recent studies show a greater chance of both maternal and fetal illness and death from cesareans. We've certainly gotten good at them and can avoid most complications, especially considering our current 30% cesarean rate but still, stuff happens. Healthy People 2010, a collaborative effort of federal and state government health officials, as part of an overall nationwide health improvement initiative has established target rates for cesarean sections: 15 % first-time C-section rate and 63% for subsequent deliveries. That's a goal of a 37% VBAC rate by 2010. Yeah, good luck. This is a rock and a hard place. If doctors and hospitals can't comply with ACOGs standards for immediate emergency cesareans, that's not gonna happen. It's a very complicated issue.
So, what can Erin do to have a VBAC? First, make sure your doctor/midwife and hospital even do them. If your doc says, "yeah, well, we'll see," don't count on his support. Find a supportive practitioner. Then, make sure you don't gain too much weight (25-35 pounds on average), stay healthy by exercising and eating right and try to wait for spontaneous (not induced) labor. Then, hope for the best. If you end up with a VBAC, good for you. If not, well, dang.
Good luck, Erin. I really hope you'll be one of the women who helps us achieve the 2010 Healthy People goal and that you have a wonderful birth and a very healthy baby.
Got a question for Jeanne? E-mail it to firstname.lastname@example.org and it may be answered in a future blog post.
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