Vaginal Birth After Cesarean (VBAC)

“Birth is not only about making babies. Birth is about making mothers — strong, competent, capable mothers who trust themselves and know their inner strength.”

— Barbara Katz Rothman

 
 
 

After a steady decline in Cesarean section rates and a correlative rise in vaginal births after C-section (VBACs) in the late 80s through the 90s, the U.S. now suffers an extreme reversal of these trends. Following a recommendation of the  American College of Obstetricians and Gynecologists 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 is in spite of 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%. Without induction or augmentation of labor, the incidence of uterine rupture decreased to 0.4–0.9%, especially when removing prostaglandins including misoprostol, better known as Cytotec. 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. The neonatal mortality rate for uterine rupture with term babies is 2.8% of all uterine ruptures (Guise 2010).

Given the growing body of evidence regarding the safety of VBAC over repeat C-section, we believe that VBAC at home (HBAC) is a reasonable option for many women. We’ll look closely with you at the entire clinical picture to determine together if HBAC is a safe alternative to hospital VBAC. As with any other possible complication of birth, a trained midwife will be alert and able to recognize the early warning signs of rupture in most cases and facilitate transport to the nearest hospital. We encourage all women considering VBAC to research the literature, talk with a midwife, and meet with an obstetrician to make an informed choice, regardless of where you want it to occur.

The reasons cited for a C-section are many — some of which are absolutely valid and some of which beg further scrutiny. Sometimes the exact medical care used to ensure a safe delivery is what leads to the need for a C-section: Induction of labor, artificially breaking the bag of waters, epidurals, and continuous electronic fetal monitoring all can lead to circumstances that necessitate a C-section. An often-cited reason for a C-section is macrosomia, a baby that’s too big. In women without diabetes, a trial of labor is the only way to know if a baby is “too big” — it’s impossible to know beforehand. Macrosomia is not a justification for a repeat C-section either. According to the American College of Obstetricians and Gynecologists, “Suspected macrosomia alone should not preclude VBAC.”

In 2017 the U.S. C-section rate was 32%. Although our nation has more than doubled the C-section rate in 30 years, we have not lowered infant mortality and morbidity rates. Research (Eugene Declerq et. al., 2006) concludes that the rise in C-sections is based solely on physician discretion, not on maternal choice or an increase in complicated pregnancies, as is often stated. In addition, elective repeat C-sections carry added risk to the mother. For every C-section a woman has, the likelihood increases of abnormal and life-threatening placental implantation. This in turn places her at significantly higher risk of postpartum hemorrhage, hysterectomy, and death. Each C-section also increases the chance of abdominal adhesions that can lead to lifelong chronic pain, bladder dysfunction, and bowel obstruction.

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Every woman and baby have a right to a vaginal birth. When that isn’t possible for one birth, it does not mean it will be so for the next. Obstetricians who offer labor after C-section (LAC) have a success rate of 50%–75%. According to MANA, the success rate is 86% in births attended by a Certified Professional Midwife. We believe this difference is due in large part to a midwife's strong belief in a woman's ability to birth naturally. While obstetricians might “let you try,” midwives assume you can. Furthermore, a homebirth is much less likely to result in any interventions that often lead to a repeat C-section. We inherently trust in birth and choose not to intervene unless necessary. Carefully monitoring mom and baby provides the information needed to proceed confidently with birth at home or determine if hospital transfer is necessary.

Nothing is 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. Women who ultimately must birth again via C-section are comforted having a trusted and skilled midwife by their side, and know they have truly given it their all. We are 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.

 
 
 

 

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