second time around

If you’ve had a Cesarean, you may or may not be eligible for a vaginal birth.

By Karen Young Kreeger

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Kathy Gray Farthing’s first two babies were born via Cesarean section. With small children at home to care for, Farthing hoped to deliver her third baby vaginally so she could avoid a long recovery. Like many women today, she succeeded. She also enjoyed an unexpected payoff. “Having a VBAC [vaginal birth after Cesarean] was one of the most gratifying experiences of my life,” recalls Farthing, a graphic designer/illustrator, childbirth educator and doula in Alliance, Ohio. “I went into it for practical reasons and came out with much more.”
    Women didn’t always have the choice. Before the late 1970s, the conventional thinking was “once a C-section, always a C-section.” But thanks mostly to improved surgical techniques, 60 percent to 80 percent of women who now undergo a trial of labor succeed in having a VBAC. Because not everyone tries, however, only 23 percent of all women who gave birth after a Cesarean in 1999 did so vaginally. Still, that’s up from about 19 percent in 1989. Credit a groundswell of interest in alternatives to the “once a C-section” sentiment and the desire to reverse a skyrocketing Cesarean rate.
    What went up appears to be going down, however: That 1999 VBAC figure is 5 percent lower than the 1996 high of 28 percent. Some doctors and their patients returned to the old mindset because of a few high-profile medical-malpractice lawsuits resulting from VBACs and because many doctors became concerned that the positive outcomes achieved at university hospitals might not be equaled in the smaller hospitals, where more women were having VBACs.
    “The recent decrease in VBAC attempts may be due to a greater awareness of the potential for complications — especially in smaller hospitals — as well as an increase in elective C-sections for convenience and other reasons,” says VBAC expert Bruce Flamm, M.D., clinical professor of obstetrics and gynecology at the University of California, Irvine, Medical School.

Pros and cons of VBAC
The fact is, for most women who have had a low-transverse C-section — the so-called horizontal “bikini cut” incision made in the lower abdomen — VBAC’s benefits outweigh its risks. Those benefits are physical and psychological: faster recovery, less blood loss, lower chance of infection and, for women like Farthing, a sense of achievement.
    Women who have given birth vaginally at least once or who had a C-section for a nonrecurring reason, such as a breech presentation, have the best chances of success. And receiving either an epidural anesthetic or Pitocin, which can intensify contractions, during a VBAC doesn’t make a woman an unsuitable candidate.
    Experts also say there is no evidence that VBACs cause physical problems years down the road. “I am unaware of any association between VBAC and uterine prolapse and urinary or fecal incontinence,” says Fredric David Frigoletto Jr., M.D., chief of obstetrics at Massachusetts General

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