Friday, July 24, 2009


What is a VBAC? Simply put, it is a vaginal birth after cesarean. I talk to a lot of pregnant women. Most of the mother's I speak with who have had previous c-sections will express some interest in a VBAC, but won't follow through. This is unfortunate, because the risks associated with VBAC's are less than those of elective repeat c-sections.

And yes, I did say elective repeat c-sections. This is what they are... elective. You don't have to have one.

Risks to the baby from elective cesarean section:

* Babies delivered by elective cesarean have an increased risk of neonatal respiratory distress syndrome (RDS), a life-threatening condition,3-7 and other respiratory problems that may require NICU care.
* Babies delivered by elective cesarean have a five-fold increase in persistent pulmonary hypertension (PPH) over those born vaginally.6
* Babies delivered by elective cesarean are at increased risk of iatrogenic (physician-caused) prematurity, usually related to failure to conform to protocols for determining gestational age prior to delivery, or errors in estimating weeks of gestation even with the use of clinical data.7,8 Prematurity can have life-long effects on health and well-being, and even mild to moderate preterm births have serious health consequences.9
* Babies delivered by elective cesarean are cut by the surgeon’s scalpel from two to six percent of the time.10 Researchers believe these risks to be under reported.

Risks to the mother from elective cesarean section:

* Up to 30% of women who have a cesarean acquire a postpartum infection. Infections are the most common maternal complication after cesarean section and account for substantial postnatal morbidity and prolonged hospital stay.11
* Other serious complications for women undergoing cesarean include massive hemorrhage,12 transfusions,13 ureter injury,14 injury to bowels,15 and incisional endometriosis.16,17
* Women who undergo cesarean report much lower levels of health and well-being at seven weeks postpartum than women who have vaginal births.18
* Women who undergo cesarean section have twice the risk of rehospitalization for reasons such as infection, gallbladder disease, surgical wound complications, cardiopulmonary conditions, thromboembolic conditions, and appendicitis. Rehospitalization has a negative social and financial effect on the family.19
* Women who undergo cesarean section report less satisfaction than women having vaginal births.20,21
* Women undergoing cesarean are at increased risk of hysterectomy in both the current and future pregnancies.22,23
* The maternal death rate is twice as high for elective cesarean as for vaginal birth.24
* In subsequent pregnancies, women with a prior cesarean have higher rates of serious placental abnormalities which endanger the life and health of the baby and the mother.25-27 Women are rarely told that a cesarean places future babies at higher risk.
* After cesarean section, women face higher rates of secondary infertility as well as higher rates of miscarriage and ectopic pregnancy.28,29

1 Harer WB Jr. Patient choice cesarean. ACOG Clinical Rev 2000; 5(2).
2 Greene MF. Vaginal delivery after cesarean section - Is the risk acceptable? N Engl J Med 2001; 345(1): 54-5.
3 Bowers SK, MacDonald HM, Shapiro ED. Prevention of iatrogenic neonatal respiratory distress syndrome: Elective repeat cesarean section and spontaneous labor. Am J Obstet Gynecol 1982;143(2):186-9.
4 Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode of delivery at term: Influence of timing of elective caesarean section. Br J Obstet Gynaecol 1995; 102:101-6.
5 Hales KA, Morgan MA, Thurnau GR. Influence of labor and route of delivery on the frequency of respiratory morbidity in term neonates. Int J Gynaecol Obstet 1993; 43(1):35-40.
6 Levine EM, Ghai V, Barton JJ, Strom CM. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 2001;97(3):439-42.
7 Parilla BV, Dooley SL, Jansen RD, and Socol ML. Iatrogenic respiratory distress syndrome following elective repeat cesarean delivery. Obstet Gynecol 1993; 81(3):392-5.
8 Hook, B et al. Neonatal morbidity after elective repeat cesarean section and trial of labor. Pediatrics 1997; 100(3):348-53.
9 Kramer MS, Demissie K, Yang H, Platt RW, Sauve R, Liston R. The contribution of mild and moderate preterm birth to infant mortality. Fetal and Infant Health Study Group of the Canadian Perinatal Surveillance System. J Amer Med Assoc 2000; 284(7):843-9.
10 Smith JF, Hernandez C, Wax JR. Fetal laceration injury at cesarean delivery. Obstet Gynecol 1997; 90(3): 344-6.
11 Henderson EJ & Love EJ. Incidence of hospital-acquired infections associated with cesarean section. J Hosp Infect 1995; 29: 245-255.
12 van Ham MA, van Dongen PW & Mulder J. Maternal consequences of caesarean section. A retrospective study of intra-operative and postoperative maternal complications of caesarean section during a 10-year period. Eur J Obstet Gynecol Reprod Biol 1997; 74: 1-6.
13 Naef RW III, Washburne JF, Martin RW et al. Hemorrhage associated with cesarean delivery: When is transfusion needed? J Perinatol 1995; 15: 32-35.
14 Eisenkop SM, Richman R, Platt LD & Paul RH. Urinary tract injury during cesarean section. Obstet Gynecol 1982; 60: 591-596.
15 Davis JD. Management of injuries to the urinary and gastrointestinal tract during cesarean section. Obstet Gynecol Clin North Am 1999; 26: 469-480.
16 Wolf Y, Haddad R, Werbin N, Skornick Y, Kaplan O. Endometriosis in abdominal scars: A diagnostic pitfall. Am Surg 1996; 62(12):1042-4.
17 Wolf GC, Singh KB. Cesarean scar endometriosis: A review. Obstet Gynecol Surv 1989; 44(2):89-95.
18 Lydon-Rochelle MT, Holt VL, Martin DP. Delivery method and self-reported postpartum general health status among primiparous women. Paediatr Perinat Epidemiol. 2001 Jul;15(3):241-2.
19 Lydon-Rochelle M, Holt VL, Martin DP, Easterling TR. Association between method of delivery and maternal rehospitalization. J Amer Med Assoc 2000; 283(18):2411-2416.
20 Fawcett J, Pollio N & Tully A. Women’s perceptions of cesarean and vaginal delivery: Another look. Res Nurs Health 1992; 15: 439-446.
21 Waldenstroem U. Experience of labor and birth in 1111 women. J Psychosom Res 1999;47: 471-482.
22 Stanco LM, Schrimmer DB, Paul RH, Mishell DR Jr. Emergency peripartum hysterectomy and associated risk factors. Am J Obstet Gynecol 1993; 168(3 Pt 1):879-83.
23 Bakshi S, Meyer BA. Indications for and outcomes of emergency peripartum hysterectomy. A five-year review. J Reprod Med 2000; 45(9):733-7.
24 Bewley S. Maternal mortality and mode of delivery. Lancet 1999; 354: 776.
25 Zaideh, SM et al. Placenta praevia and accreta: Analysis of a two-year experience. Gynecol Obstet Invest 1998; 46(2):96-8.
26 Ananth, CV et al. The association of placenta previa with history of cesarean delivery and abortion: A meta-analysis. Am J Obstet Gynecol 1997; 177(5):1071-78.
27 Miller DA, Chollet JA & Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol 1997; 177: 210-214.
28 Hemminki, E and Merilainen, J. Long-term effects of cesarean sections: Ectopic pregnancies and placental problems. Am J Obstet Gynecol 1996; 174(5):1569-74.
29 Hall MH, Campbell DM, Fraser C & Lemon J. Mode of delivery and future fertility. Brit J Obstet Gynecol 1989; 96: 1297-1303.

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The most serious risk of a VBAC is a uterine rupture. While this often sounds catastrophic, that is not always the case. Most uterine ruptures occur without symptoms and do not cause problems for the mother or baby. This mild type is usually only noticed when surgery is required for other reasons.

Researchers have shown that women attempting a VBAC and who have undergone a trial of labor have a 1.6 per thousand chance of uterine rupture or 0.16%.

A recent study, The Vermont/New Hampshire VBAC Project, reported that the overall risk of infant death from a VBAC attempt is 6 per 10,000 compared to 3 per 10,000 planned cesarean births.

The rate of uterine rupture rises when labor is induced with oxytocin, prostaglandin preparations, or misoprostol (Cytotec).

Women interested in attempting a VBAC should learn as much as possible about labor, childbirth, cesareans, informed consent and VBAC pros and cons. I also recommend looking into support groups like ICAN and getting the support of a doula or other support person with professional childbirth experience.

A VBAC can be a very emotionally charged and challenging event. But it is often an empowering and healing one as well.