Patients coming in to their first pregnancy visit will read in our “Frequently Asked Questions” document that our doctors do not recommend or offer vaginal delivery after C-section, also known as “VBAC” (Pronounced “Vee-back”). Although this is offered by some doctors in the community, we feel that it is important for you to understand our reasoning and at times can recommend another group who may feel differently if a patient feels strongly about attempting VBAC.
We understand that very few patients wanted to have a C-section when it occurred the first time, and it can be a very disappointing time and can be attached to a whole bunch of emotions about losing an experience that we really longed for, and sometimes even felt was necessary to be a complete woman or mother. For many women vaginal delivery is almost a rite of passage and taking away the possibility that this will ever happen can be heartbreaking. While understanding that fully, we also know that most women agree that the primary goal in pregnancy is to have a healthy baby, and the decision about whether or not to have a C-section must always have that goal in the forefront, eclipsing all others.
Sometimes the decision to have that first C-section is relatively easy, like when the baby is in acute distress. While still disappointing, we find much less emotional aftermath in that kind of situation than in cases when something happened that the patient can imagine was at least partly under her control. If the baby just would not come out after a prolonged labor and a C-section was the result, we can torture ourselves with ideas like “maybe I could have pushed harder”, “maybe I should have waited longer”, or if the baby was too big or was breech “may I should have gained less weight or not done (enter any activity) that could have cause the baby not to turn”.
It is amazing how our brains can play these tricks on us, and not surprising how strongly we might feel about making this right next time, and achieving or goal with the next pregnancy to compensate for whatever we feel that we lost the first time. In many instances I have found that a strong desire for VBAC is coming from this type of emotional place, which can feel so strong that it surpasses our real goal of putting the baby first.
Granted, few people want a C-section. It is a fairly major surgery, it hurts afterwards for a couple of weeks, and goes against some of our strongest desires to let things happen naturally, let the baby come when she wants to, and to be a “real woman” by having the experience of labor and delivering a baby vaginally. For many of us these are all strongly imprinted ideas that go beyond our culture and back to a very primal level. It’s good to keep in mind that currently in countries where C-sections are not available (and in the relatively recent past in our own country), obstetric disasters are common; mothers and babies are permanently damaged or die regularly, and “letting things happen naturally” is proven to be not always such a good idea. (There is a prior blog on this topic, at the following link: http://cwccblog.com/a-world-with-no-c-sections/).
After we have had one C-section for whatever reason, as much as we might grieve about that reality, there is a scar on the uterus itself which is always a weak point, and that scar can cause major issues in future labors if labor is allowed to take place. Generally C-sections are done though a horizontal incision low on the uterus, which we call a “low transverse” C-section. (Sometimes the incision on the skin may be vertical, but the incision on the uterus is almost always horizontal). Rarely a C-section is done through a vertical uterine incision (the skin incision in this case may be horizontal, so you can’t judge by the skin) which is called a “classical” C-section since that is how they all used to be done in the old days. Very preterm babies or babies in unusual positions such as being sideways may occasionally be delivered by a classical C-section, but at CWCC that represents less than 1% of C-sections.
When we are in labor, the uterine muscle (which in pregnancy is the largest muscle in our body) contracts forcefully every 2-3 minutes for hours. Each time the uterus contracts, it puts strain on that old scar. Just like a seam in a piece of clothing is a potential weak point under stress, the old scar is always a weak point even years after healing, and can occasionally by torn open by the pressures of labor. When that happens, it is called a uterine rupture, and the baby and/or cord and placenta can be partially or completely expelled from the uterus into the abdominal cavity. The result is a complete or partial loss of oxygen for the baby, and a true emergency which requires intervention within minutes to resolve without the risk of permanent injury to the baby. If a significant uterine rupture occurs in a major hospital and is recognized immediately, with an operating room and anesthesia immediately available and a doctor standing right at the bedside, it can still be impossible to get the baby delivered in a safe timeframe to avoid the possibility of permanent neurologic damage to the baby, or worse.
Obviously in reality all of those factors are not always in place, and even a small delay in recognition or lack of immediate availability of resources can use up precious seconds. If oxygen is completely cut off, which can occur in some uterine ruptures, we only have about 4 minutes to get the baby delivered before acid levels rise in the baby’s bloodstream which can cause brain damage and not too long after that, death. While most cases of uterine rupture still allow some degree of oxygenation to the baby, it is limited at best and time to delivery is critical. Countless cases exist of fetal brain damage and death from uterine rupture; this is not a hypothetical issue, it is a very real one. A further issue is that a ruptured uterus is very damaged and sometimes cannot be repaired. Dramatic blood loss can occur sometimes resulting in maternal death and frequently in the need for hysterectomy, as well as the need for massive blood transfusions which can cause other issues.
That being said, the risk of uterine rupture with VBAC is not high. With one low transverse incision, the risk of uterine rupture is about 1%, and approximately doubles for each additional C-section. For a classical C-section the risk is probably about 10%, although VBAC is never recommended in these cases so data is limited. Proponents of VBAC stress that 99 percent of attempted VBACs do not result in rupture and they are correct. The problem is that we cannot predict who that 1% will be, and as mothers ourselves we feel that the bottom line is that we go to great lengths to protect ourselves and our children from things that have a much lower risk than 1%, when the outcome is potentially disastrous. Think about vaccinations for example, or getting routine pap smears, or wearing seat belts, or childproofing our doors and cupboards, or not letting our kids walk to the park alone. We could ignore all of those things and 99% of the time we would be fine, but we do them because the possible outcome that we are trying to avoid is so serious.
When it comes down to it when choosing VBAC vs. a scheduled repeat C-section, I ask patients to consider only one question, which is “what is the safest thing for the baby?” If that is the only consideration, then the answer is clear. Of course we would not put a mother at significant risk in order to reduce a small risk to the baby, since there are two patients involved. Luckily in this country at the Woman’s Hospital of Texas and with your well trained CWCC doctors, the risk to the mother of repeat C-section is very minimal. While each successive C-section has a slightly higher risk of bleeding, adhesion formation, and placental issues such as placenta accreta (where the placenta grows into the old C-section scar and often requires hysterectomy to remove), the vast majority of repeat C-sections are completely uneventful. While having 4 or more C-sections can start to significantly increase surgical risk, in reality we rarely come across a patient who wants more than 3 for obvious reasons, and we have done up to 5 C-sections without incident in patients who request this.
Our goal at CWCC is to reduce the risk of the first C-section as much as safely possible, so that the decision about VBAC is less common. But once a C-section has occurred, we always ask ourselves “what is best for the baby?” and recommend repeat C-section, as this is always what we would choose for ourselves and for our own family members.
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