LADYIST IS SEX ED FOR GROWN WOMEN. OUR SEXPERTS ARE ANSWERING THE QUESTIONS THAT HEALTH CLASS NEVER FULLY EXPLAINED. WHAT DO YOU WANT TO KNOW ABOUT YOUR SEXUAL OR REPRODUCTIVE HEALTH?
One LADYist reader asked us, "What's the verdict on VBACs?"
What's a VBAC, you ask? While it might seem to be a type of artificially intelligent vacuum cleaner or a new sort of fancy air conditioner, it's an abbreviation for "vaginal birth after cesarean section."
Well, dear LADYist readers, it's a real thing. But it wasn't always.
You might have heard an old saying, "Once a cesarean, always a cesarean." New York OB-GYN Edwin Cragin coined the phrase a century ago, well before the procedure was as common as it is today.
If you're a good candidate (more on that later), most experts prefer vaginal birth over cesareans, even if you've already had a C-section for a previous birth.
Vaginal birth is just safer for both mom and baby most of the time, according to the experts. The American College of Obstetricians and Gynecologists (ACOG) says VBAC is associated with a decreased risk of maternal mortality and complications.
Vaginal birth has the added benefit of a faster healing time after delivery.
CESAREAN BIRTH: NOT A PANACEA
When a woman on the big screen is in labor, she's a screaming, sweating, mess.
You told us your true to life labor stories in a previous LADYist.
Cesarean birth is often portrayed less dramatically: a quick incision, and voilà! Baby!
We know it's a sometimes necessary and life-saving procedure. Still, popular culture usually misses a few things about cesareans.
"Really and truthfully, you're talking about something that's quick and easy for me as a surgeon, but for the patient this isn't quite so quick and easy," said Dr. David Lagrew, executive medical director for the Women and Children's Services Institute for Providence St. Joseph Health in Southern California.
Cesarean is a major abdominal surgery, with a longer recovery time and higher risks of infection and hemorrhage than vaginal birth. And the risks of serious complications for mother and baby increase with each subsequent C-section.
Lagrew thinks we might have lost sight of the risks over the years, because modern hospitals are so good at doing the procedure. We now have antibiotics, and blood transfusions can be performed on-demand, in most cases.
But experts agree that cesareans are performed far too often when they're not medically necessary.
"I'm sort of a fanatic about keeping the C-section rate low," Lagrew said.
He's not alone; the federal government set a goal of reducing the number of C-sections nationwide from the current rate of 32% of all low-risk deliveries to 23.9% by 2020. California's rate is 31%, according to the Centers for Disease Control and Prevention.
SO YOU'RE SAYING VBAC IS RECOMMENDED?
As with most things in medicine, it's not that simple. VBAC is not for everyone.
"The rate shouldn't be 100%," said Lagrew.
The American College of Obstetricians and Gynecologists suggests doctors have serious conversations with their patients about the risks of both trying for a vaginal birth (after a C-section) and planning another cesarean. That decision should be made jointly.
CALCULATE THE RISKS VS. THE BENEFITS
Just as a C-section isn't devoid of risks, neither is VBAC. Both can lead to hemorrhaging or infection.
It's rare, but for some women who opt for a vaginal birth after a cesarean, all the bearing down could cause the scar from the previous C-section to reopen. That's what doctors call (*trigger warning*) uterine rupture.
I know! That makes me want to hold my lower abdomen like my uterus is a scared puppy, too.
But if you're considering a VBAC, there's good news: Uterine rupture happens in less than 1% of deliveries.
And when it does happen, the damage can be contained, Dr. Lagrew said.
"Most of the time, it wasn't this big catastrophic event, like we had in the old days," he said.
Still, not all women are good candidates for VBAC. You've got to consider the age of the mother, her overall health, whether the original scar is with or against the muscle fibers, and many other birth factors.
Do you wish there was a tool to help you decide whether you want to try?
THERE'S AN APP FOR THAT
SPOILER ALERT! WE'RE NOT ALWAYS LISTENING TO MOMS
"A lot of women who would like the choice of [VBAC] just simply cannot find that [option] readily available," said Lagrew.
The California Health Care Foundation funds a periodic survey called Listening to Mothers in California. The 2018 edition found that about half of the women surveyed who gave birth in 2016 were interested in trying vaginal birth after a C-section, but almost half of them reported not having that option, mostly because providers and hospitals did not allow VBAC.
"You still have a lot of providers who are like, 'Why would I want to take that medical legal risk?'" said Lagrew.
More disturbing to Lagrew, other women said they were offered a chance to try, but closer to delivery, their health care team changed the plan.
"For some women, it felt sort of like a bait and switch," he said.
Only 13% of California mothers get a VBAC, according to data compiled from 332 hospitals by the California Maternal Quality Care Collaborative.
HOW TO ADVOCATE FOR YOURSELF
You should know that ACOG, the advisory organization for OB-GYNs, tells docs that "coercion is not acceptable."
If you want to try for vaginal delivery after a C-section, you've got to talk to your health care provider and know a few things about where you plan to deliver.
- Find out what your OB-GYN's philosophy is about VBAC early in your pregnancy.
- Decide early what types of things might change your mind.
- Babies don't always cooperate with delivery schedules. Know whether the other OB-GYNs in the practice are willing to let you try.
- Consider a midwife and/ or work with a doula. Women who do this are more likely to have a VBAC.
- Walk during labor. It helps things progress, and most women don't get the chance to do it in the hospital.
- If things are under control early in labor, don't go to the hospital immediately. If you're further along, you're less likely to have a cesarean when you get to the hospital.
- Know whether your delivery room allows VBAC. You can also check on YELP and Cal Hospital Compare. There's even an "honor roll" for hospitals with higher VBAC rates.
- Find backup. Organizations like ICANand the California Maternal Quality Care Collaborative, advocate for women.
DON'T TRY THIS AT HOME
ACOG does not recommend attempting a vaginal birth after cesarean at home "because of the unpredictability of complications requiring emergency medical care."
Dr. Lagrew agrees.
He says he understands why some women might want to opt for a home birth, considering how hard it can be to find a doctor who will let them attempt VBAC.
"But that doesn't mean you want to take that risk," he said. Even though the risk of complications is low, added Lagrew, it "is not zero."
(Photo by: Philippe Hughuen / AFP)