One of the most controversial topics in Obstetrics is VBAC* (Vaginal Birth After Cesarean Section). Before the 1970’s, the rule of thumb was “Once a C-section, always a C-section.” When a C-section is performed, an incision is cut in the lower part of the uterus. It is sutured back together after the baby is delivered, but it is always weaker than the surrounding tissue. The concern for allowing someone to labor after a C-section is that the uterine scar might break open due to the force of the contractions. Studies in the late seventies showed that the actual occurrence of rupture was low and it was safe to consider VBAC in the appropriate candidates. With increasing C-section rates, the opportunity for VBAC increased until the mid-90’s when the VBAC rate peaked at 28%. However, with increased number of VBAC, we saw increased complications. A lot of women were getting VBACs who were not ideal candidates and at that point the dangers of induction with VBAC were not fully realized. VBAC also became a huge malpractice issue, with multimillion dollar lawsuits being handed out like candy.  The rate has continued to decline, with many physicians and hospitals no longer offering VBAC at all.

Over time, with a perpetually increasing primary C-section rate and a decreasing VBAC rate, the overall C-section rate has continued to climb at an alarming pace. The current national rate is 31%. It is truly unacceptable that 1/3 of all babies will be delivered by C-section in this country. Obviously both physicians and patients need to do what they can to reduce the primary C-section rate, but it is time to further evaluate our attitudes about VBAC.

In 2010, the National Institute of Health convened a conference to address the rising C-section rate in this country. They attempted to analyze the data and issue a newer set of recommendations to further improve patient access to VBAC. The difficulty with VBAC is that the data obtained in most studies is not of the highest quality. But based on the best available information ACOG has issued a new set of standards. The new guidelines and several journal articles this year are advocating a “common sense” approach.

So what’s the big deal with C-section anyway?
Surgery is not benign. While a commonly performed surgery, the risks of C-section are real and begin to increase exponentially with each subsequent C-section. When you have 4 or more C-sections, your chance of severe hemorrhage and complication can approach 10%, much riskier than a VBAC would have been after that first C-section. If VBACs are not available in a given region, then once a women has had one C-section, she is essentially limited in the number of children she can safely birth. There are many families whose quivers are not full at 4 children, and they desire more. Additionally, most women do not really know how many children they will want later in life. Studies show that of women who have a tubal ligation in their twenties, up to 20% of them will regret it.

A successful VBAC has the lowest risk of complication and is the best possible outcome. A planned repeat C-section is the next best, with an unsuccessful VBAC (a repeat C-section after someone has been in labor) having the highest risk of complications. A successful VBAC has many benefits for the mother including a shorter recovery time and more immediate bonding and breastfeeding with her baby. The problem is that no one can accurately predict who is going to have a successful VBAC.

The worst outcome of a VBAC is uterine rupture and it happens .5 – 1.0% of the time. This can result in serious complications for the mom including hysterectomy, hemorrhage or bladder damage. The baby can suffer neurological injury or death. The best available data shows the rate of fetal death to be 1/1000.

Best Candidates:
Prior vaginal delivery
Spontaneous labor
Non recurrent indication (cause of 1st C-section is not present in this pregnancy)

Women with spontaneous labor and a non-recurring indication have the best chance of a successful VBAC, 60-80%.

Risk factors for unsuccessful VBAC:

Maternal age >35
Maternal obesity
Fetal weight > 4000 g (8#7oz)
Pregnancy exceeding 40 weeks
Less than 18 months since last cesarean section
Induction of labor

While not deal-breakers, these risk factors make success less likely and should be considered.  A failed VBAC has the highest risk of complications, so depending on your risk factors, a repeat c-section may be the wiser choice.

Not all of these factors will be known early in the pregnancy. One option I like to use for VBAC is the ‘watch and wait.’ If a woman is a good candidate and desires to VBAC, we see how her pregnancy progresses. If she develops preeclampsia at 35 weeks and her body shows no sign of being ready for labor, then we will proceed with a repeat C-section, as induction does increase the risk of rupture. A women who’s first C-section was for breech but then has an uncomplicated second pregnancy, and goes into spontaneous labor should have a great chance for a successful VBAC.

Not Candidates:
3 or more previous C-sections
Previous classical C-section (uterine incision made in a vertical rather horizontal manner)
History of uterine rupture

I realize that this is a lot of information to process. Deciding whether to VBAC or have a repeat C-section is not always  straight forward and should be carefully considered by you and your provider. If you have a desire for more than 3 kids or have a strong desire to experience a vaginal delivery then you should more strongly consider VBAC. If you feel your family is complete with 2 kids and you are not comf0rtable with the risks of VBAC, then a repeat C-section may be your best option.

Sources:

National Institutes of Health. NIH Consensus Development Conference: vaginal birth after cesarean: new insights. Consensus Development Conference statement. Bethesda (MD): NIH; 2010. Available at: http://consensus.nih.gov/2010/images/vbac/vbac_statement.pdf.

Vaginal birth after previous cesarean delivery. Practice BulletinNo. 115. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2010;116:450–63.

*For all the sticklers out there, I do realize the better term is TOLAC (trial of labor after cesarean section), but since there are aleady TMA (too many acronyms) in my post I just stuck with VBAC.

The cesarean section rate in the US has reached an all time high. What is most concerning with the recent statistics is that primary (first) cesarean rate is now 30%. With the VBAC (vaginal birth after cesarean section) rate also declining, this increasing primary cesarean rate places our country on course for an overall rate that could soon reach 50%, which seems absurd.

The reasons for this have been examined by government analysts, insurance companies and patient advocacy groups alike. Doctors blame lawyers and increasing malpractice litigation, while insurance groups blame “greedy” doctors who get paid more for cesarean section.  While patients are left on the sidelines asking, “What’s really going on, and what can I do to help reduce my risk of a cesarean section?”

In the midst of the rhetoric, some helpful ideas have emerged such as making public each hospital and physician’s personal cesarean section rate, so patient’s can be aware of true outliers of the norm. Additionally ACOG has recently adopted more evidence based guidelines for interpreting fetal heart rate tracings, which can help physicians make decisions based on these guidelines and not make decisions out of fear of lawsuit.  The NIH has also revised its VBAC guidelines, to once again encourage this practice.

The decision to perform a cesarean section is never one I take lightly, but after these new statistics came out, it has caused me to search for even more ways to help bring my rate down. Certain risk factors for cesarean section such as maternal age >35,  twins and placenta previa are not preventable.  However, there are some patient risk factors that are modifiable.

Obesity
The biggest risk factor for cesarean section is actually something that is best addressed before pregnancy: obesity.

The adult obesity rate in the US is rising at a startling rate. Approximately 30% of reproductive age women are obese, defined as a BMI of 30 or greater. Obesity doubles your risk of cesarean section, and also doubles the complication rate of cesarean section. Additionally, it increases your risk for other pregnancy complications such as pre-eclampsia, gestational diabetes, and blood clots. The risk is even higher if you are both vertically challenged and overweight.

If you do enter pregnancy in the overweight range, limiting weight gain and daily exercise are your best tools to help avoid further complications.

Smoking
Ten percent of women still continue to smoke during pregnancy, with this number approaching 17% among teenagers. In addition to risks of preterm labor and still birth, smoking also increases the risk of placental abruption which then increases the risk of cesarean section.

Staying Active

Excess weight gain in pregnancy, even in normal weight women, has also been shown to increase the risk of cesarean section.  Making wise food choices and continuing a doctor approved exercise regime can help prevent gestational diabetes and excess weight gain in pregnancy.

Limit Elective Inductions
With first pregnancies especially, one of the biggest set ups for unnecessary cesarean sections is unnecessary inductions. Induction increases the rate of cesarean section by 15% in women having their first baby. In subsequent pregnancies the risk is much lower at 1%. There are medical reasons for inductions such as high blood pressure or diabetes. However, swollen ankles, back pain and misery are not good enough reasons to put yourself at an increased risk for the complications that can occur with cesarean section.

Be Open to Forceps/ Vacuum
On nearly every birth plan I read, the patient will write something like, “prefer to have cesarean section rather than forceps.” In actuality, judicious use of vacuum and forceps is key to help reducing the cesarean section rate.  I try to explain to patients that the true risks of vacuum and forceps when performed properly can be lower than those of cesarean section. The decision as to which is safer is determined by how deep the baby’s head is in the birth canal. When the head is near crowning and there is need for urgent delivery, usually a vacuum or forceps is the best option for both mother and baby.

Finding a Doctor you Trust
If you are looking for a competent, patient and caring physician (I think these are the top three qualities an OB/GYN should have) talk to a labor and delivery nurse at your local hospital for a recommendation.  Once you find a physician that you can trust and with whom you feel comfortable, talk to them about your thoughts on cesarean section and ask them for additional ways that you can reduce your risk.

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Yes, there is much that needs to be done to reduce the cesarean section rates in the US. Just as there is not one specific cause, there is also not one specific answer. The medical community will continue to look for ways to safely reduce this rate. Hopefully these tips will help you as the patient, make proactive decisions for a healthier pregnancy and delivery.

(All patients examples are either used with the patient’s permission or are a fictitious conglomerate of multiple  patient encounters.)

beep…… beep……beep…..

The fetal heart rate is in the 60’s. I recognize the cadence of tones, without having to look at the monitor. The nurse looks at me anxiously, waiting for instruction on what to do next. Glancing past her, I see she has all the supplies in the room to prepare for a cesarean section.

This is the patient’s third pregnancy. The first two pregnancies culminated in beautiful ‘Kodak moment’ vaginal deliveries. However, this labor was not going quite as dictated by the birth plan…

Earlier that day, she had started her labor with a bradycardia, where the baby’s heart rate had dropped to the 70′s for several minutes.  Luckily, it resolved nicely when we changed mom’s position. The baby’s heart rate becam reassuring, showing signs of adequate oxygen and health.  Her labor had progressed quite well until 8 cm at which point the baby’s heart rate tracing began to have late decelerations, which can be an indication of poor oxygenation. We rolled her onto her left side and applied oxygen, but despite our efforts, the decels worsened. With the next cervical exam, there was only a small amount of cervix remaining (“anterior lip”).  The cervix is essentially like a very tight turtle neck that the baby’s head has to squeeze through as it passes through the birth canal, with only the strength of the uterine contractions and gravity to help it escape. I placed her in ‘knee- chest’ position, hoping that gravity and physics might help dissolve the anterior lip of the cervix.  I rechecked her and found that my attempts to convince her cervix to dilate were not working.

Time. How much time do I have to get this baby out? Assessing a baby during labor is like taking care of someone in the ICU with only one vital sign. No physical exam, no pulse OX, no stethoscope, just a 1 lead EKG to make your diagnosis. In obstetrics, we have only the fetal heart rate tracing and can infer limited information from it. There are a number of fetal heart rate patterns that can tell us the baby is healthy. Most of the “bad” patterns are not very accurate. Around  97%of the time even though the tracing looks “bad” the baby is still OK… but there’s no way to know for sure. Studies suggest that it takes up to 30 minutes of decreased oxygenation to lead to brain damage.

I look to my patient, knowing that she wants a vaginal delivery very strongly but she also has put her trust in me to help her have a safe delivery and a healthy child. I look at the clock, and see the pattern has been questionable for about 20 minutes.  I need this baby out in 10 minutes or less.

Do I take her to the OR? Do I try to have her push?

If she pushes through the lip, I’m the hero for helping her achieving the much desired vaginal delivery. If it doesn’t work, we may have to rush the delivery and do a stat c-section.

I search the fetal heart rate tracing for one sign of reassurance. Come on give me something I can hang my hat on: an acceleration or some variability. I know the patient can do this vaginally if only we could buy her some time. The tracing, however gives me no reassurance.

Let’s try to push one time, I tell the patient. If you can’t bring the baby close enough to deliver were going back for a cesarean section.

The OR team begins to set up. I position her at the angle I think gives her the best shot at pushing past the anterior lip of the cervix.

With the push, the multiparous cervix dissolves and I  feel the baby entering deeper into the birth canal.Yes, I think internally, this is going to work. As  the contraction finishes, the head retreates back up into the pelvis and the cervix reappears. Crap.

beep…… beep……beep…..

The fetal heart rate is in the 60’s. I recognize the cadence of tones, without having to look at the monitor. I meet the nurses anxious gaze. The art of obstetrics has failed me and now the science of it is pounding in my ear drum telling me that time is up.  I have to call a stat section or the risk to harm to the baby will quickly climb above the risk of cesarean section to the mom.

The moment I call it, the room becomes well-oiled chaos. As we sprint to the OR, I wonder to myself if maybe we should have tried one more push? But on arrival to the OR the nurse rechecks the heart beat, finding it still in the 60s.

Moments later I pull a screaming healthy baby girl through a low transverse uterine incision. The cord had been wrapped tightly around the shoulders, preventing her descent.  The baby comes out screaming, filling her lungs with much needed oxygen and quickly turning a healthy shade of pink.  The mom cries gentle tears of relief.

Later in the waiting room, I let the family know mom and baby are fine.

I await their reaction.

The dad thanks me, with tears in his eyes.

These are the hardest calls to make. I had mere moments to decide the fate of this precious woman and her child. In this situation, the safest thing for the mother was a vaginal delivery whereas the safest thing for the baby was a cesarean section. I try my best to use the science available to balance the pendulum of mother’s and baby’s safety to achieve a  healthy delivery for both.  In the end, that’s what matters most.

Photo credit to: www.amandamcnealphotography.com