If you've had a Cesarean, you may or may not be eligible for a vaginal birth.
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
Hospital in Boston. And according to Deanne Williams, C.N.M., executive director of the American College of Nurse-Midwives, there is no solid evidence that having a second Cesarean will prevent such problems.
The most serious risk of VBAC is the potential for uterine rupture — a tearing at the site of the old incision. According to the American College of Obstetricians and Gynecologists, this occurs in .2 percent to 1.5 percent of women who have had a single previous low-transverse C-section. Rupture can lead to lack of oxygen and, therefore, brain damage or death for the baby, as well as severe hemorrhaging and hysterectomy for the mother. If emergency care is immediately available, however, the outcome is generally good for both mother and child.
"Neither the rupture rate nor the overall safety of VBAC has changed in the last few years," VBAC expert Flamm says. "What has changed is that women are undergoing VBACs in smaller community hospitals, where a
C-section team may not be available at a moment's notice."
Preparing for delivery
If you decide to try for a VBAC, you must be a good medical consumer. "Ask prospective caregivers what their C-section rate is, what percentage of their patients attempt a VBAC and how many actually have one," suggests Ruth Wilf, Ph.D., a certified nurse-midwife based at Pennsylvania Hospital in Philadelphia. "Most women can attempt a VBAC; if only a small percentage of a caregiver's patients tries, that's a reason to look elsewhere."
Experts also suggest taking childbirth-education classes that address VBACs, reading as much medically reliable information as possible and talking with other women who have had a VBAC — on the Internet, in classes and at meetings, such as those of the International Cesarean Awareness Network (see "VBAC Resources," below).
Make sure your doctor or midwife answers your questions completely and that you're not being pushed into something you don't want, whether it's a VBAC or a repeat C-section. While the desire to give birth "traditionally" can be strong, your safety, as well as your baby's, must be your primary concern. That's why Kristine Loosley, a marketing director at an Internet business in Cupertino, Calif., has chosen a major teaching hospital for her second attempt at a VBAC. (She is employing a doula as well for support.) Says Loosley, who also has diabetes, "I would like this delivery to be about giving birth instead of having surgery. But my baby's safety is paramount."