VBAC vs. Elective Cesearen: Pros and Cons

There is apparently quite a bit of concern regarding mine and Scott's decision to pursue a Vaginal Birth After Cesarean (VBAC). So I would like to shed some light on some of the facts that we have discovered concerning VBAC and Elective C-sections.

The 1995 American College of Obstetricians and Gynecologist (ACOG), which is the leading governing and research body for OB-GYNs recommended "limiting repeat cesarean births to those that were medically necessary. Obstetricians should counsel and encourage women to try to give birth vaginally." It continued to say that vaginal births (after cesarean) "would lead to shorter hospital stays, fewer transfusion, fewer post-partum fevers and a savings of more than four-thousand dollars per birth." It also stated that "not only would this course of action (VBAC) be better for women it would also not cause any greater risk for their babies." They concluded by recommending that "women with 2 or more previous cesareans with no contraindication who want VBAC should not be discouraged from trying for a vaginal birth, that women with large babies should not be automatically exempted from trying a VBAC and that VBACs should not be limited to the largest hospitals."
Between '95 and '98 VBACs were encouraged and done at most hospitals, even the Dr's at our clinic on Kodiak fondly remember doing VBAC on the island. So what changed? Several things, the 2 changes that I find most compelling are the induction rate and societal changes. Prior to '98 little was known about the risk of using induction medication on VBAC patients therefore more VBAC patients were being induced as the use of induction medication also increased. We now know that using induction medication on a VBAC patient increases their risk of uterine rupture. Therefore, dr's willing to attend VBACs today do not consider induction an option until after 6cm dilation and most not even then. Another theory for the change in recommendations is that societal changes in the '90s led to increases in malpractice lawsuits which caused a shift in the recommendations.

The '99 ACOG bulletin withdrawals the recommendation that repeat cesarean section only be done when medically necessary and strongly urges that physicians capable of performing an emergency C-section be "immediately available". Since most hospitals do not have the capability to have round the clock staff they have developed policies that do not allow women to have VBAC's at their hospital. Some smaller hospitals however interpret this recommendation to allow VBAC by having staff on call so that the decision to incision time is 30mins just as they would in the case of a 1st time pregnancy in need of an emergency section. It is my feeling that any hospital that cannot offer emergency surgery to laboring VBAC patients is therefore unable to provide any other form of emergency surgery, as the decision to incision time would also be approximately 30min. The ACOG bulletin also does not provide research supporting their change in policy and since it is my understanding that the uterine rupture rate has not significantly changed it is understandable how people jump to the conclusion that the changes were made not for the benefit of the patient but for the benefit of the Drs. due to increases in malpractice suits. A few of the Drs I have talked to have stated that they feel another shift is coming and they are hopeful that ACOG will once again add in recommendations for allowing multiply cesarean VBACs. For the most recent ACOG recommendation you can visit consensus.nih.gov/2010/vbac.htm

Here is a pros and cons list concerning VBACs:
PROS:
-VBAC is safe (the consent form that must be signed for the Dr and Hospital clearly states that the patient must be made aware that VBAC is safer than elective C-section, no consent form or information form is given stating the risk of elective C-section).
-Elective repeat cesarean poses greater risks to the mother's life and health than does vaginal birth. It poses hazards to the baby as well, especially with succeeding pregnancies and more than one cesarean.
- Most women, including women whose prior cesarean was for lack of progress or who are believed to be carrying a big baby, will birth vaginally if allowed to labor.
CONS:
- While the healed uterine scar is tough it is widely excepted that a form of uterine rupture (symptomatic scar separation) will occur in 1% of VBAC patient that have had 1 prior c-section, it is my understanding that this type of separation occurs most commonly in the first couple hours of labor. Another form of uterine rupture (spontaneous scar separation) is the most common type of rupture and occurs most likely between 36 and 39 weeks, I am not sure at what percent this form of rupture occurs while I have asked several Drs they have not been able to give me an answer other than the 1% mentioned above. Also, while they quote the same percentage of risk they do not ask the patient to take any special precautions such as limiting activities or bed rest, since it is unknown what causes it. Uterine rupture means that the scar will open up enough for the umbilical cord or the baby to pass through the opening or for bleeding to occur (if left unattended or not caught fast enough this may lead to the death of the mother or baby) However, when a c-section is done promptly few babies and even fewer moms will be injured.
-The perinatal mortality rate (deaths around the time of birth) in 29 studies have found that 3 out of 10,000 deaths occur for both VBAC labors and planned cesareans.

Pros and Cons for Elective Cesarean
Pros:
Since there is no labor, there is no chance of symptomatic scar separation, at least not during labor, prelabor cesareans have lower infection and other complication rates than cesareans done in labor.
Cons:
Compared with vaginal birth, c-section substantially increases the risk of infection, injury to other organs, hemorrhage, and anesthesia complications. The complications, in turn, increase the risk of prolonged hospitalization, hysterectomy and maternal death. Repeat c-sections are more technically difficult to perform because of scar tissue. For this reason, injury to other organs is more common, Scar tissue formation can cause chronic pain and bowel problems. Elective cesarean also increases the baby's risk for poor condition at birth, breathing difficulties and jaundice. Each successive cesarean greatly increases the risk of developing placenta previa and/or placenta accreta in subsequent pregnancies. Both of these complications pose life-threatening risks to mother and baby. Cesareans also increase the odds of infertility and ectopic pregnancy, another life-threatening danger, in subsequent pregnancies. Women with multiple prior cesareans have a slightly increased risk of symptomatic scar separation during VBAC.

Closing note: I am not anti-Cesarean. Despite how it sounds I am completely open to allowing the Drs to perform a c-section if it becomes medically necessary. Since I am considered a higher risk I will be under greater supervision and monitoring so that should a c-section need to be done it will be done at the 1st signs of possible danger. However, as I have stated many times in this post all the research agrees that a VBAC is safer than a repeat elective cesarean.

Most of my information has come from the several Drs we have spoken with, Guide to Childbirth by Ina May and The Thinking Woman's Guide to a Better Birth by Henci Goer as well as the NIH website and ACOG VBAC statements.