Experts are urging that more women who've had a previous C-section be allowed to deliver vaginally.
When Eveline Andrews, 28, of Baytown, Texas, was in labor with her first baby three years ago, her doctor told her that she had a narrow pelvis and required a Cesarean section. But when Andrews became pregnant again about a year after giving birth, she felt strongly that she did not want surgery again. At first her obstetrician refused to agree to let her try for a vaginal birth after Cesarean (VBAC) because he felt a repeat C-section would be safer. Andrews persisted, however, and her doctor gave in—and at 40 weeks, she had an uncomplicated vaginal delivery.
A C-section is sometimes the safer delivery option for a woman who has already had one. But a panel of childbirth experts convened by the National Institutes of Health (NIH) this past March concluded that there should be fewer repeat C-sections and more VBACs. “A VBAC is a very safe option for many women who have had one previous C-section and who have been identified as low risk—and that is the majority of women,” says Nancy Petit, M.D., chief of the division of obstetrics at St. Francis Hospital in Wilmington, Del. (See “Are You Low Risk?”) The NIH panel reported that about 75 percent of women who attempt a VBAC—a process known as a trial of labor—have a vaginal birth.
However, doctors and hospitals have become increasingly reluctant to offer VBACs, and some have banned it. “The VBAC rate has dropped from about 26 to 28 percent in 1996 to about 8 percent currently,” says Petit, who served on the NIH panel. Thirty to 45 percent of OBs no longer offer VBACs, and some hospitals offer it only with strict stipulations, such as going into labor spontaneously before one’s due date. (A VBAC should never be attempted if labor has been induced.)
The disappearing option
Fear of litigation drives much of the reluctance to allow VBACs. “Lots of providers and hospitals refuse to offer women the option because they fear getting sued if something goes wrong,” says Amy Romano, C.N.M., a nurse-midwife in Connecticut and author of Lamaze International’s Science & Sensibility blog (scienceandsensibility.org). Even some midwives have stopped offering VBACs because of liability issues.
That’s because a VBAC can lead to uterine rupture, a dangerous tearing of the uterine muscle or past C-section scar. “Uterine rupture can be catastrophic for the baby and may be life-threatening to the mother,” says Marilynn Frederiksen, M.D., an associate professor of clinical obstetrics and gynecology at the Feinberg Medical School of Northwestern University and a member of the NIH panel.
However, the incidence of uterine rupture is low—less than 1 percent—and the NIH panel found that repeat C-sections expose women to greater risk of death than VBACs and pose risks to mothers and babies in future pregnancies, when the likelihood of such serious conditions as placenta previa and placenta accreta increases. “VBAC is a safe and reasonable option for most women and is in fact safer than repeat Cesarean for many,” Frederiksen says.
Making an informed choice
If you’re pregnant for the first time, consider the long-term potential repercussions of having a medically unnecessary C-section (see “Advice for First-Time Moms,”). If you’re not a first-timer, would like to try for a VBAC and are a good candidate, start researching your options early in pregnancy. If your doctor or hospital doesn’t allow VBACs, consider other providers. For example, a major medical center with a level-3 NICU (neonatal intensive-care unit) and round-the-clock staffing by anesthesiologists is more likely to offer the option than a small community hospital is.
Support and information can come from childbirth educators, doulas, midwives and women online and in other communities who have had a VBAC. “Making a choice that is not considered mainstream, even when research supports its safety, can be very difficult,” Romano says. “So the more support a woman has, the better.”
More support might have helped Jamie Smith, 36, of Port Orange, Fla., who delivered her first child vaginally and her second by C-section because the baby was large and breech. When she was pregnant with her third child, she asked her doctor to consider VBAC, but he cautioned against it, even though there were no safety issues this time around. Reluctantly, Smith gave in and delivered her daughter by C-section, but it was a decision she regrets because she wanted very badly to give birth without any interventions. “I should have been much more adamant about my desire for a VBAC,” she says.
Are you low risk?
VBAC tends to be safest for women who:
>Have had at least one vaginal delivery
>Have had only one previous C-section
>Had a low-transverse incision (a horizontal cut low in the uterus) during their previous C-section
>Have a history of low-risk pregnancies
>Are delivering only one baby who is a reasonable size and well-positioned
>Do not have certain health conditions, including high blood pressure, diabetes (pre-existing or gestational) or active genital herpes
>Have no history of uterine surgery or other uterine problems
Advice for first-time moms If you think the VBAC debate doesn’t affect you because you’re pregnant for the first time, think again. As the number of medically unnecessary C-sections rises, so do your chances of going under the knife for delivery No. 1 and having to deal with the VBAC question for delivery No. 2.
The best advice? If at all possible, avoid that first C-section. Certified nurse-midwife Amy Romano, C.N.M., says some women decide to be “conservative” during their first pregnancy and agree to interventions that may not be necessary, including C-sections. “Then in their next pregnancy, those women face risks they would not have faced if their first baby had been born vaginally,” she says.
Find out more about new medical guidelines from the American College of Obstetricians and Gynecologists (ACOG).