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)