O Say Can You “C”: Discussing Cesarean Prevention and VBAC’s

Medical technology is an amazing thing.  Cesareans save many women and babies, and I am so thankful that they are available. However, it is clear that something isn’t right in American obstetric care.  The World Health Organization states that an acceptable cesarean rate to ensure the best outcomes for mothers and babies is between 5 and 15% and that rates above 15% seem to do more harm than good (Althabe and Belizan 2006).  Currently, Louisiana leads the United States with a cesarean rate of just over 40%, more than 3 times the recommended rate.  The US rate is hovering around 30%. April is Cesarean Awareness Month, the perfect time to discuss this important issue.

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Why are cesareans a big deal? After all, it’s just another way to have a baby, right? C-sections have become so common, that we often forget that they are a major abdominal surgery and carry physical and emotional risks.  Many mothers also feel a sense of deep sadness and disappointment when they do not have a vaginal birth.  I know that after my cesarean, I felt as if my body was broken and had let me down.  Mothers are often told, “At least you have a healthy baby,” which undermines their feelings. Often, the emotional scars take much longer to heal than the physical one.

So, what can you do to prevent a cesarean?  The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFN) recently released a joint Obstetric Care Consensus statement: Safe Prevention of the Primary Cesarean. The statement outlines several practices that are recommended to lower the cesarean rate and provide the best outcomes for mothers and babies. These guidelines should be discussed with your care provider early in your pregnancy.  A few of them are listed below:

  • Slow progression during early labor, defined as 0-6 cm, is not an indication for a cesarean.  As long as mom and baby are doing well, it is normal for early labor to last more than 20 hours in first time mothers and more than 14 hours in mothers with previous children.
  • Once active labor begins (usually around 6 cm dilation) and if a mother’s water is broken, failure to progress is defined as no change after 4 hours of contractions or no change after 6 hours of Pitocin.  This standard allows for much more time than the previous definition.
  • It is normal for the pushing stage to last at least 3 hours in first time moms and 2 hours in mothers who have had previous children.  An additional hour can be expected if the mother has epidural anesthesia.
  • Variable fetal heart rate decelerations are often a response to repetitive cord compression and not necessarily a reason for cesarean. The statement outlines other options for treating this if it becomes necessary.
  • Induction of labor can increase the risk of cesarean and should not be done before 41 weeks unless medically necessary.  It is normal for an induction to last for 24 hours after Pitocin administration and water has been broken before considering a cesarean.
  • Ultrasounds done late in pregnancy are associated with an increase in cesareans but do not improve outcomes.  Macrosomia (aka “big baby”) is not a reason for cesarean.
  • Continuous labor support, such as a doula, is one of the most effective ways to decrease the cesarean rate and is often underutilized.

If you’ve already had a cesarean and are pregnant again, you face the tough and very personal decision of whether to have a vaginal birth after cesarean (VBAC) or a repeat cesarean.  The old saying, “once a cesarean, always a cesarean,” is no longer true. It is important to research the benefits and trade offs of each option to determine which is best for you.  I recommend finding a care provider with a proven history of supporting VBAC to discuss both options.  Unfortunately, many providers will not allow mothers to have a VBAC and may not fully discuss the pros and cons of each.

Why consider a VBAC? ACOG says that VBAC is a “safe and appropriate choice for most women”.  Of those women who attempt a VBAC, around 75% are successful.  Some benefits include faster recovery time and lower risk of infection. The National Institute of Health also says that “there is emerging evidence of serious harms relating to multiple cesareans.” These risks include placenta accreta, hysterectomy, blood transfusion, and dense adhesions which are scar tissue that causes pain and difficulty with future surgeries.  These risks increase with each subsequent cesarean.  For these reasons, many women decide to pursue VBAC as an alternative to repeat cesarean.

As with all births, VBAC does carry risks.  The most commonly noted concern is uterine rupture which occurs when the previous cesarean scar separates.  While very rare, it can be a serious complication.  Studies have shown that the risk of uterine rupture is less than 1% and decreases with each successful VBAC.  Of that 1%, about 6% result in infant death. When uterine rupture occurs, immediate cesarean is required for the safety of mother and baby.

Why might you choose a repeat cesarean? Some women prefer the convenience of being able to plan the date and time of their babies’ births.  They may also be nervous about the thought of undergoing labor and more comfortable with the cesarean process because they have done it before. If you have a classical style scar instead of the more common low transverse scar, your risk of uterine rupture may be higher.  Many care providers prefer to perform a repeat cesarean in this case.

There are many resources available to moms who have had a cesarean and who may be considering a VBAC.

  • International Cesarean Awareness Network (ICAN) – The Baton Rouge chapter has a private Facebook pages for moms who have had cesareans and also meets monthly. The national ICAN website also has statistics and resources.
  • VBACFacts.com includes a compilation of relevant studies and data discussing common myths and the most up-to-date research.
  • ACOG Practice Bulletin discussing VBAC

For more information about cesarean prevention and VBAC, join ICAN of Baton Rouge for a panel discussion with OBs from Associates in Women’s Health to be held Thursday, April 3rd at 6:30 pm at Woman’s Hospital in Baton Rouge. To sign up, visit the Facebook event.

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