October 7, 2010

New Policy Now Supports VBAC (Vaginal Births After Cesarean)

VBACs, also known as Vaginal Birth After Cesarean, have been a hot topic over the past several months. Back in March of 2010, the NIH (National Institute of Health) held a conference Vaginal Birth After Cesarean: New Insights, which offered a substantial amount of research and evidence in support of VBAC. Recently, the American College of Obstetricians and Gynecologists (ACOG) released new guidelines for VBAC. These updated guidelines are a far departure from their previous stand. They are less restrictive, and appear to be encouraging both care providers and expectant mothers to seriously consider this option.

This pendulum shift away from the idea “Once a Cesarean Always a Cesarean” motto is partly due to the frighteningly high cesarean rate we have in the US. In 1970, the US had a 5% C-section rate. In 2007, we were at 31%. A good portion, 25% , was due to the restrictions placed on care providers and hospitals for offering VBACs. In the past, insurance, hospital policies and the threat of malpractice encouraged many doctors to dismiss VBACs as a possibility for expectant mothers. Additionally, the ACOG insisted that any care provider overseeing a VBAC have immediate medical assistance available. This protocol limited smaller hospitals that did not have a full staff of surgeons and anesthesiologist readily available. Now, ACOG is saying facilities should be “capable of emergency situations” and that they should have a clear, logistical plan in case an emergency cesarean is necessary.

The ACOG press release states ” The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC (Trial Of Labor After Cesarean). On the other hand, if, during prenatal care, a physician is uncomfortable with a patient’s desire to undergo VBAC, it is appropriate to refer her to another physician or center.”

So now that the restrictions have softened, and VBAC is a realistic option for women, it is important to look at the reasons why one may want to take this VBAC path.

Why a VBAC?
Some women feel a strong pull to having a vaginal birth experience, especially if their first birth ended up with an unexpected cesarean section. For these women, the opportunity to try for a VBAC can be emotionally rewarding. Those seeks a VBAC have already experienced this major abdominal surgery and would like to avoid the inherit risks that are associated with it as well as the recovery period.

Recently I spoke with one mother who explained her reasons for wanting a VBAC. Her first child was breech, which required a cesarean birth since her care provider did not deliver breech babies vaginally. She never had the opportunity to feel labor and wants to experience the natural labor process and birth in a different way than she did the first time. Subsequently, she explained that she did not want to deal with the recovery of a cesarean while taking care of her two 1/2 year old. She said the newborn is not the concern, her active toddler would be the challenge.

Risks vs Benefits of VBAC compared to RCD (Repeat Cesarean Delivery) (Also called ERCD- Elective Repeat Cesarean Delivery)

Who Is a Good Candidate For a VBAC

This list may help identify who would be a favorable candidate for a VBAC.

-Less than two previous cesarean deliveries
-Previous cesarean incision left a low transverse uterine scar
-No underlying health issues, diabetes, high blood pressure, herpes, placenta previa
-No additional scar tissue
-Nonrecurrent indication that was present for prior cesarean delivery
-Previous delivery of a baby weighing less than 4000 grams (8 lb. and 13 oz.)
-18 months or greater between pregnancies
-Lower maternal body mass index
-At a location where anesthesia and personnel for emergency is available or a management plan is in place for such an event.
– According to AAFP (American Academy of Family Physicians), women under 40 are more likely to have a successful VBAC
-Midwife, Gloria Lemay, explained in a recent article “Midwifery Care for the VBAC Woman,” in Midwifery Today, Issue 57, “If the [VBAC] woman has dilated past five centimeters in the first birth, I plan for it to be fairly fast, —like any second baby. If the woman has not gone into the birth process or not dilated past five the first time, that’s all right, she’ll still give birth vaginally, but we have extra midwives on call to bring fresh energy if the others get discouraged or tired.”

According to the consensus put out by the NIH (National Institute of Health), women attempt a TOLAC (Trial of Labor After Cesarean) have a 60-80% of a success VBAC. .

What to expect in a VBAC and TOLAC (trial of labor after cesarean)

Each care provider will approach the care of a VBAC mother differently. So it is important to discuss what he or she will require. Here is a basic outline of what you may expect and questions to ask your care provider.

-To lessen the risk of uterine rupture, VBAC mothers are not to be induced. However, some care providers do allow a little bit of augmentation with Pitocin
-Since a VBAC cannot be induced to start labor, some care providers do not want their VBAC patients passing the due date.
-Full time EFM (External Fetal Monitoring). Many care providers will want to have full time monitoring. Again, this is a point of discussion for your care provider.
-Some providers will ask their VBAC mothers to have the epidural catheter in place in case of the need for an emergency c-section arises.

It is exciting to see a shift in the paradigm of birthing in our country. For years, many women have wanted the opportunity for a VBAC and it has been denied, leaving them with not only a deep physical scar, but an emotional one as well. Now with the support of ACOG and NIH, more women are allowed to explore this option. My advice to mothers who want a VBAC: be your best advocate and align yourself with a care provider that truly believes in your ability to birth vaginally.

For those interested in more information including clinical studies and articles, please look at the NIH Consensus Development Conference Vaginal Birth After Cesarean: New Insights



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