Evidence-Based Medicine: VBAC vs Repeat Cesarean

“Once a c-section, always a c-section.”

Every day, across American, millions of women face this “reality.”  For the last decade, the American College of Obstetrics and Gynecology (ACOG) has supported this sentiment through its policies discouraging VBAC (vaginal birth after cesarean).  But what many women and their doctors view as an unfortunate (and unavoidable) side effect of the growing c-section rate is in fact something that 60-80% of women can avoid.

VBAC became very popular during the late 1980s and early 90s, as an attempt by women to regain their birth experience from the then all-time high cesarean rate of about 24%.  Many women were able to experience vaginal birth during this time, but obstetricians noticed a disturbing rise in the rate of uterine rupture, a phenomenon that is a life-threatening emergency to mother and baby.  It was especially prevalent among VBAC mothers, whose cesarean scars caused weak spots in the uterine wall.

Source: Childbirth Connection

Because of this troubling observation, in 1999, ACOG issued a recommendation to its members that VBAC only be attempted in a hospital where an obstetrician and anesthesiologist were consistently present.  Since women insisted on VBACs, and VBAC seemed to cause uterine rupture, the idea was to be prepared for the emergency.  But what ACOG failed to address was the relationship between the routine use of induction drugs on VBAC patients, which caused hyperstimulation (harder and more frequent than natural labor contractions), thus leading to uterine rupture along the cesarean scar.  So rather than dealing with one of the causes of the problem and discouraging unnecessary inductions (especially with off-label drugs like Cytotec), ACOG decided to instead deal with the fallout of such imprudent practices.

Source: Born in the USA (Wagner, 2008)

BUt while ACOG and its members crusaded against VBAC, striking the fear of uterine rupture into the hearts of pregnant women, they failed to educate women on the risks of the only other alternative – repeat cesarean.  By doing this, they made it impossible for the women in their care to make an informed decision as to what was best for their baby.  If you were given the choice of vaginal birth, with an “increased risk of uterine rupture,” and could lead to hysterectomy, fetal brain damage, or death, or a repeat c-section, which would you choose?  This imbalanced attitude toward educating patients persists with many obstetricians today.

The truth is, repeat cesarean has its own risks, which are frequently downplayed by ACOG and its members.

For the mother, risks of repeat cesarean include:

  • Physical problems for the mother, including hemorrhage, blood clots, and bowel obstruction (caused by scarring), infection, long-lasting pelvic pain, and twisted bowel.*
  • Longer hospital stay, with an increased risk of being re-hospitalized.*
  • Negative impact on bonding and breastfeeding due to separation during the critical first few hours after birth.*
  • Placenta Previa** – the placenta attaches near or over the opening to her cervix; this increases her risk for serious bleeding, shock, blood transfusion, blood clots, planned or emergency delivery, emergency removal of her uterus (hysterectomy), and other complications.
  • Placenta Accreta** – the placenta grows through the uterine lining and into or through the muscle of the uterus; this increases her risk for uterine rupture, serious bleeding, shock, blood transfusion, emergency surgery, emergency removal of her uterus (hysterectomy), and other complications.
  • Fertility problems**
  • Ectopic Pregnancies** – the egg implants somewhere other than the uterus.
  • Placental Abruption** – placenta detaches before birth

For the baby:

  • Breathing problems at birth*
  • Increased risk of asthma during childhood*
  • Prematurity**
  • Low birth weight**
  • Physical abnormalities or injuries to brain or spinal cord**
  • Death before or shortly after birth**

* These risks are associated with cesarean section in general, not just repeat procedures, but the overall likelihood of experiencing such complications increases with each subsequent surgery.

** These risks are more common in repeat cesareans than with vaginal births, and have been shown to increase in frequency for each subsequent surgery.

[Source: Childbirth Connection]

Last year, ACOG changed its tune, lifting the restrictive recommendation.  But a decade of anti-VBAC sentiment has left its mark.  Because of the “increased risk of uterine rupture” that ACOG has repeatedly emphasized, insurance companies have become reluctant or even unwilling to cover the procedure.  An obstetrician who would like to offer VBAC may be hesitant when faced with increased malpractice insurance costs.  In some states, home-birth midwives and alternative birth centers are forbidden to offer the option.  Some women have turned to home VBACs because they were unable to find a provider willing to offer it, and decided they’d rather take the risk of an unassisted home birth over a mandatory c-section.  It remains to be seen how the new ACOG recommendation will affect the choices of women as to how (and where) they give birth.

Let’s hope it’s for the better.

For more information on the safety of repeat cesareans and VBACs:

The Unnecesarean (blog)

Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First by Marsden Wagner (2008)

Ina May’s Guide to Childbirth by Ina May Gaskin (2003)

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Evidence-Based Medicine: Are Inductions Safe?

A couple weeks back, I researched the necessity of labor induction.  I learned that, according to the Listening to Mothers Survey from 2005, about 40% of all labors are medically induced.  I also learned that, according to birth experts Ina May Gaskin and Marsden Wagner, induction is only medically indicated in about 10% of births.  This means that about three-quarters of all women who are induced are doing so without medical indication.  If induction is perfectly safe, there would be no concern — so what does the research say?

The stats…

80% of medical inductions were done using a drug called Pitocin, a synthetic oxytocin, which causes the uterus to contract.  Other methods of induction include prostaglandin medications applied to ripen the cervix, stripping/sweeping the membranes, and “breaking the water”  (artificial rupture of membranes (AROM)).  Most mothers included in the survey were subject to 2 or more methods of induction, the most common combination being Pitocin and AROM.

Not only are many labors medically induced, but many are also augmented using the same methods listed above.  When these numbers are included, about 50% of women are given artificial oxytocin to either induce or augment labor, and 65% have their water broken.

The risks…

  • More painful labor — Common induction methods such as artificial oxytocin can lead to longer and stronger contractions that are closer together.  This means more pain for the mother during contractions, as well as a shorter period of time between contractions to recuperate.  This can quickly exhaust a laboring woman, not to mention tarnish her birth experience.  Many women whose labors are induced or augmented find an epidural to be a necessity.

“I went into labor on my own with my daughter, but was induced with my son.  With my daughter, I found that sitting in a warm bath made the pain very manageable, and I didn’t get the epidural until very late — 7 cm, I think.  With my son, I got an epidural at 3 cm — I just couldn’t stand the pain.”  — Annie, 31

  • Prematurity — Miscalculation of due dates can lead to a woman being induced before her baby is mature.  Iatrogenic (doctor-caused) prematurity is on the rise, and with it comes all the risks commonly associated with prematurity, such as breathing problems.  New research shows that the production of fetal lung proteins trigger labor — meaning that the baby triggers spontaneous labor when its lungs are ready to breathe.  Inducing without medical indication means your baby may not be totally ready to breath independently.  Labor should NEVER be induced before 39 weeks for this reason, and should ideally be around 42 weeks as long as the baby shows no signs of distress.
  • Fetal Brain Damage or Death —  The only time a fetus can get oxygen is during the rest period between contractions, so when those periods are shorter, the fetus gets less oxygen.  Lack of oxygen is associated with an increased risk of brain damage.
  • Maternal death —  According to Marsden Wagner’s book Creating Your Birth Plan, induction of labor is linked to higher rates of uterine rupture and amniotic fluid embolism (AFE), both of which are rare but usually fatal (80% of AFEs are fatal — 50% within the first hour after symptoms appear).  C-Section dramatically increases the incidence of both.  Many women who survive uterine rupture undergo hysterectomies and are unable to have any more children, and most that survive AFEs are severely brain damaged.  Fetal death is also common with both of these complications.
  • “Cascade of Interventions”A woman who is either induced or has her labor augmented artificially is at an increased risk of instrumental (forceps and vacuum-assisted) and surgical (c-section) interventions.  So even if the induction drug itself is considered safe (which Pitocin is), the risks associated with all other forms of intervention must be calculated as well.  While the more severe risks (uterine rupture, AFE, fetal brain damage) are relatively rare, the so-called “cascade of interventions” is fairly common.  A woman who is induced more than doubles her riskof having a C-Section.  A woman who goes in to be induced may find her plans for a low-intervention birth go awry very quickly.

 “I got induced at 41 weeks because they thought she was going to be too big too birth otherwise.  First came the Pitocin, then the epidural for the increased pain, which meant I was tethered to the bed with IVs, so I couldn’t move around.  Then my labor slowed down, and they broke my water to speed things up.  I went into labor thinking that I could manage an induction naturally, but instead I ended up with a C-Section because of failure to progress.”— Silvia, 26 

  • Interferes with Bonding/BreastfeedingArtificial oxytocin alters the mother’s natural hormones during and after birth, potentially affecting her ability to bond with or breastfeed her baby.  Any other interventions she experiences (such as cesarean) can also interfere.  

“When my son was born, I felt like he belonged to someone else.  I kept waiting for that overwhelming feeling of attachment I knew I was supposed to feel, but it just didn’t come — I felt like I was just going through the motions for weeks.” — Patty, 29

What is the alternative?

So if induction carries with it the risks listed above, it could be argued that elective induction is not in the best interest of the mother or baby.  So what’s the alternative?  Well, waiting.  Just remember, every day your baby “cooks,” s/he will be a little bit stronger, a little bit healthier.  As we talked about last week, babies can and have been (vaginally) born past their due dates perfectly healthy.   Trust your baby, and trust your body to go into labor on your own — it’s better for both of you!


Evidence-Based Medicine: Is Induction Necessary?

During my last month of pregnancy, I had a few “false alarms,” where I was convinced I was in labor, but it turned out I wasn’t.  I was so anxious to meet Sweet Pea, a little nervous about what labor would actually feel like, and it started to do weird things to my brain.  After our third false alarm, my husband and I finally sat down and accepted the reality that we had no control, and that Sweet Pea would come when she was ready.  We knew that every day she “cooked,” the healthier she would be.  I went to bed that night at peace, knowing that the best thing I could do for her was to be patient.  The next morning, I woke up in labor – at 39 weeks on the nose.

Many first time mothers experience the same kind of anxiety and anticipation that I did, but the weeks stretch on an on, even surpassing their due date.  And those women and their doctors are talking more and more about artificial induction, using labor-stimulating drugs like Pitocin.  A study from 2006, featured in the New England Journal of Medicine, found that 40% of low-risk, first time mothers were induced into labor.

Induction is definitely a growing trend in America.  But is this trend necessary to improve the outcomes for mothers and babies?  Are there situations where induction is medically indicated?  And how much of this trend is based on convenience — either for the mother or doctor?

When is induction medically necessary, improving the outcomes for mothers and babies?

According to Ina May Gaskin’s Birth Matters, up to 10% of all labors may call for labor induction.  She lists specific circumstances that may call for induction, such as:

  • cancer
  • hypertension
  • diabetes
  • kidney disease
  • IUGR (intrauterine growth restriction)
  • significant decrease in amniotic fluid
  • intrauterine fetal death (followed by a long (weeks, not days) wait for labor to begin)

Marsden Wagner (perinatologist, and author of Born in the USA) adds two other conditions:

  • documented placental malfunction (placenta losing its ability to nourish the fetus)
  • deteriorating preeclampsia (high blood pressure during pregnancy)

According to Gaskin and Wagner (both specialists in their fields), under these conditions, induction actually improves the outcome (as opposed to spontaneous labor).  But they both state that only about 10% of all pregnancies need to be medically induced.  And when you add up the statistics for each of the above circumstances, it comes very close to 10% of pregnancies.  But, according to Childbirth Connection‘s 2005 Listening to Mothers Survey, half of all pregnant women experience induction.  So why the major discrepancy?

You may notice that two of the most commonly-given reasons for induction — postdate (overdue) pregnancy and big babies (macrosomia) — are not listed.  This may explain the difference in recommendation versus reality.  Let’s see what the evidence says about those two reasons.

Induction Due to Post-Dates (Overdue)

This is the normal distribution for gestational age.  Notice when the largest majority of babies are born — 40-41 weeks.  And approximately the same percentage give birth between 41-42 weeks as do 39-40.   And this is all with spontaneous labor!

I think this about says it all.

Normal, low-risk pregnancies go to 40 weeks and beyond quite often.  First time mothers are especially likely,.

What about the risks of going past 42 weeks?  Isn’t there a risk to the baby?

According to Wagner, a study from 1963 found that a slight increase in the number of stillbirths after 42 weeks, with a significant increase after 43 weeks.  This study has been frequently cited as evidence to support induction before 42 weeks.  But Wagner puts the risk to the individual woman into perspective —  as it turns out, only 3 percent of pregnancies even extend beyond 42 weeks, and even after 43 weeks, only 10 percent (of that 3%) have any problems.  So as you can probably deduce, the chances of going so far past your due date that you put your baby at risk is pretty insignificant (about 0.3%).  You have a much greater chance of going into labor spontaneously before you reach 43 weeks, and an even if you don’t, there’s a good chance your baby will still be born healthy.

Another risk in induction due to postdates is the inaccuracy of EDDs (Estimated Due Dates).  Because of normal variations in the menstrual cycle length amongst average women, and the tendency to base due date on the last menstrual period (LMP), a woman’s due date could be off by 2 weeks or more.  So if a woman gets induced at 40 weeks, her baby could actually only be 38 weeks (or less), which is associated with more health problems for the baby.  This is a phenomenon called iatrogenic prematurity (essentially, doctor-caused prematurity), and is a growing portion of the increasing prematurity rates.

So, post-dates is generally NOT a medically indicated reason to be induced.

“Big Babies” or Fetal Macrosomia

First, macrosomia is defined as a baby weighing over 8 lbs 13 oz.  It legitimately effects about 10% of all pregnancies in America.

Perhaps the one of the most prominent concerns about big babies is a complication called “shoulder dystocia,” where the baby’s shoulders get stuck on the mother’s pelvic bone.  The risks of this complication include paralysis, Erb’s palsy, and fetal hypoxia (baby doesn’t get enough oxygen). Sounds scary, doesn’t it?  And if you are of the unfortunate 1% of women who experience it, it will definitely be treated as scary in the typical US hospital.

So what happens when a woman experiences shoulder dystocia?  Just think ALARMER.

  • Ask for help. This involves requesting the help of an obstetrician, anesthesia and pediatrics for subsequent resuscitation of the infant.
  • Leg hyperflexion (McRoberts’ maneuver)
  • Anterior shoulder disimpaction (suprapubic pressure)
  • Rubin maneuver
  • Manual delivery of posterior arm
  • Episiotomy (Does anybody else wonder how cutting open the perineum has any impact on a baby who is stuck on the pelvic bone?  Okay good, me either.)
  • Roll over on all fours

According to Wikipedia, the advantage to this mnemonic is that it goes from least invasive to most invasive.  That sounded all fine and good, until I got to the last method — roll over on all fours.  Wait, what??  How is rolling over on all fours less invasive than say, an episiotomy (you know, where they cut your perineum)?

Turns out “Roll over on all fours” has a name — Gaskin’s maneuver, and was discovered by midwife Ina May Gaskin (yes, the same one mentioned earlier).  This maneuver opens the pelvis (wider than lying on her back) , allowing the shoulders to slide through. Sounds pretty non-invasive.  In one study, the Gaskin maneuver had the following results:

“Half of the eighty-two babies weighed more than 4000 grams (about 8.5 pounds); 17 or 21 percent weighed more than 4500 grams (about 8 pounds, 10 ounces); thirty of the 1-minute Apgar scores were less than or equal to 6, and two were less than or equal to 3; only one of the 5-minute Apgar scores was less than or equal to 6, which is 1.2 percent; forty-nine of the women or 60 percent delivered over an intact perineum, and there were no third- or fourth-degree lacerations; one woman had postpartum hemorrhage not requiring transfusion; and one infant had a fractured humerus.

That sounds a heck of a lot better than an episiotomy to me.  So why aren’t more hospitals using this technique?  Probably the biggest reason is that movement during labor is limited by current birth practices, such as epidurals and electronic fetal monitoring, which generally require the mother to lay on her back.

Another issue with justifying induction because of macrosomia is the accuracy of the diagnosis.  Macrosomia is generally diagnosed using an ultrasound, which has been found to be inaccurate in nearly two-thirds of cases.

And according to Wagner, while macrosomia has been used to justify induction, evidence does not support this practice.  In fact, C-Section rates increase with induction due to macrosomia, with NO improvement in outcomes.  As he puts it in Born in the USA, “trying to hammer out too large a baby can harm the baby.”

Conclusion:

  • Evidence suggests that induction rates of less around 10% are essential to optimal outcomes for mothers and babies.
  • About 50% of pregnant women experience induction in the US.
  • Gestational ages range, and 42+ weeks pregnancies can still be healthy and deliver spontaneously.
  • Due dates can be up to 2 weeks off.
  • Big babies have a higher risk (1%) of developing “shoulder dystocia,” which has serious complications.
  • Diagnoses of macrosomia can be inaccurate up to two-thirds of the time.
  • If you induce due to macrosomia, you have a greater risk of undergoing a C-section

Oh, and:

  • Episiotomies widen your vagina (skin/muscle), not your pelvis (bone).  Just say “no” to episiotomy.
  • Patience is key.

With all that I’ve read, I have to say I come down on the side of “very wary” of induction.  Unless you are in the 10% whose medical condition requires it (see above), it’s probably better for you to wait until your baby is good and ready to come out.

Here are some more natural ideas for inducing labor:

  • Walk.  A lot.  — I walked more in the last month of my pregnancy than I did in the previous 8 months combined.  Which was nice, since I couldn’t walk farther than 4 feet without pain for about a week after she was born.
  • Have sex.  A lot. — As awkward as it sounds, the prostaglandins in semen help soften the cervix.  And it might sound a little dirty, but let’s admit it, that’s how we all got into this predicament to start with.
  • Start a lengthy project.  — Not only does this fill your time, but you are almost guaranteed that your baby will come before you can finish it.
  • Buy expensive concert tickets for right around your due date.  — Along the same vein, it’s likely that you won’t get a chance to use them.

HAPPY WAITING!