Vaginal Birth After Cesarean (VBAC)
After a steady decline in cesarean section rates and a correlative rise in VBACs in the late 80's through the 90's, the U.S. is now suffering an extreme reversal of these trends. Following an American College of Obstetrics and Gynecology recommendation that all attempted VBACs take place in a hospital capable of performing an emergency c-section in a very short period of time, many physicians and hospitals have chosen to deny their clients the option for VBAC.
This despite the fact that numerous studies have indicated that the risk of uterine rupture during labor for women with a previous c-section is less than 1%. One factor that may prove to be significant in assessing the risk of uterine rupture is whether or not an induction occurred, particularly when prostaglandins including misoprostol, better known as Cytotec were used. While uterine rupture is a very real risk that may be life threatening for both mother and baby, it occurs in less than 1 in 100 attempted VBACs.
Given the growing body of evidence regarding the safety of VBAC over repeat c-section, I believe that VBAC at home (HBAC) is a reasonable option for many women. A close look at the entire clinical picture will help both you and myself understand if HBAC is a safe alternative to hospital VBAC. As with any other possible complication of birth, a trained midwife will be alert and capable of recognizing the early warning signs of rupture in most cases. At which point a transport to the nearest hospital with appropriate staffing will take place. I encourage all women considering a VBAC to research the literature, talk with a midwife and meet with an obstetrician to make an informed choice about VBAC, regardless of where it occurs.
Many reasons are cited for needing a c-section, some of which are absolutely valid and some which beg further scrutiny. Sometimes it is the exact medical care that was intended to get a baby born safely that can lead to the need for c-section. Induction of labor, artificially breaking the bag of waters, epidurals, and continuous electronic fetal monitoring can all lead to circumstances that necessitate a c-section.
In 2010 and 2011 the c-section rate was 32.8% in the U.S. Although we have more than doubled the c-section rate in 30 years we have not lowered the infant mortality and morbidity rates. Research by Eugene Declerq et. al. 2006 concludes that the rise in c-sections is based solely on physician discretion, and not on maternal choice or an increase in complicated pregnancies as is often stated.
Every woman and baby has a right to a vaginal birth. When this is not attainable for one birth it does not mean it will be so for the next. Obstetricians who are still offering attempts at VBAC have a success rate anywhere from 50% to 75%. According to the Midwives Alliance of North America (MANA) the CPM (Certified Professional Midwife) attended success rate is 86%. I believe this difference is due in large part to a midwife's strong belief in a woman's ability to birth naturally. While obstetricians “let you try”, midwives assume you can. Furthermore, a woman is much less likely to experience any interventions at home that would lead to a repeat c-section. I have an inherent trust in birth and choose not to intervene unless necessary. That said, careful monitoring of both mom and baby provides the necessary information to proceed confidently with any birth at home.
There is nothing more profound than witnessing the joy, relief, and fulfillment on a woman's face as she reaches for her new baby after a successful VBAC. These can be such healing moments for the entire family. And for those women who ultimately birth via c-section again, there has been comfort in knowing that with a trusted and skilled midwife by their side, they have truly given it their all. I am grateful for the many opportunities to serve VBAC women; to see their strength, courage, determination, disappointment, tears of both joy and regret, relief and rage, and to welcome the little ones who come with their own stories in their own time and on their own terms.