VBAC vs. Planned Cesarean
For those readers who may not know, "VBAC" stands for "Vaginal Birth After Cesarean." There is quite the debate about this concept in the last few years. After many years of declining cesarean rate in America, the rate began rising as we began the new century. In 2003 it hit 27.3%, higher than it has ever been. Many major health organizations state that there is no medical justification for a rate over 15%. Much of the rising rate is blamed on a rising rate of repeat cesareans. For a while there was a push to see women attempt "VBAC," however following a very flawed report in 2001 the VBAC rate has dropped sharply.
Now a new report has come out in the New England Journal of Medicine, and most of the popular headlines are once again proclaiming that VBAC is more dangerous than planned cesarean. Here's one example of a typical article about the report.
Now here's my take on this whole thing.
The media reports a 0.7% rupture rate in the VBAC group. There is no differentiation between rupture following a natural labor or an induced/augmented labor. Likewise for the other "complications" associated with VBAC, they don't differentiate between management styles of the labor. I think that we can safely assume that when labor is induced (defined as any attempt to start or strengthen contractions prior to 4 cms dilation) or augmented (defined as use of Pitocin after 4 cms dilation), the rate of complications will go up. It would be nice to see the newborn complications and maternal complications other than rupture be reported in terms of whether labor was induced, augmented, or natural (rupture rates were reported for induction vs. non-induction in the 2001 report that led to much of the VBAC-lash, but nothing else--and no distinction between natural and augmented labor). Providing this information could help women to make informed decisions about what levels of interventions they are comfortable with.
I think something that is widely under-respected in the obstetrical community is that doing a cesarean section to birth a baby is a complication in and of itself--it is major surgery for Pete's sake! This particular report mentions that part of the picture to evaluate is how many children the woman wants to have--for a woman who wants more than one child after her initial cesarean, a repeat cesarean often will not be the wisest move due to the increased risk of infertility, tubal pregnancies, placental abnormalities, and unexplained still birth at term following cesarean birth. How many of these studies consider that about 60% of women who have 1 cesarean section will have "uterine adesions" following the surgery, and 95% of women have 2 cesareans will have them? Do they consider that about 5% of women who have adhesions will suffer chronic pain from them--that one of Dr. Kavorkian's client's only ailment was adhesions that caused her so much pain that she wanted to kill herself? Given that, I find any claim that complications are higher for the mom for vaginal birth to be ludicrious. Yes, for some individual moms cesarean birth is safer. But over all? No.
Similarly, when looking at newborn complications I rarely find a comprehensive look at things. What about allergies later in life? What about iatogenic (Dr. caused) prematurity from doing a planned cesarean too soon? When they say that babies in the VBAC group are more likely to have a drop in O2 supplied to the brain, how are they determining that? Based on fetal monitoring, which is KNOWN to be inaccurate in determining fetal distress and to be worthless in lessening the rate of cerebral palsy--which is supposedly what was being caused by the low oxygen levels? Based on cord blood testing? Are they looking at long term impact on the babies? Or are these transient cases of low oxygen levels that have no lasting impact?
All in all, I'd still say for the average woman with a previous cesarean, her best shot for having a healthy birth and healthy baby is to plan for a vaginal birth, to resist induction, and to resist many of the "standard" interventions that come with birth in America.
Now a new report has come out in the New England Journal of Medicine, and most of the popular headlines are once again proclaiming that VBAC is more dangerous than planned cesarean. Here's one example of a typical article about the report.
Now here's my take on this whole thing.
The media reports a 0.7% rupture rate in the VBAC group. There is no differentiation between rupture following a natural labor or an induced/augmented labor. Likewise for the other "complications" associated with VBAC, they don't differentiate between management styles of the labor. I think that we can safely assume that when labor is induced (defined as any attempt to start or strengthen contractions prior to 4 cms dilation) or augmented (defined as use of Pitocin after 4 cms dilation), the rate of complications will go up. It would be nice to see the newborn complications and maternal complications other than rupture be reported in terms of whether labor was induced, augmented, or natural (rupture rates were reported for induction vs. non-induction in the 2001 report that led to much of the VBAC-lash, but nothing else--and no distinction between natural and augmented labor). Providing this information could help women to make informed decisions about what levels of interventions they are comfortable with.
I think something that is widely under-respected in the obstetrical community is that doing a cesarean section to birth a baby is a complication in and of itself--it is major surgery for Pete's sake! This particular report mentions that part of the picture to evaluate is how many children the woman wants to have--for a woman who wants more than one child after her initial cesarean, a repeat cesarean often will not be the wisest move due to the increased risk of infertility, tubal pregnancies, placental abnormalities, and unexplained still birth at term following cesarean birth. How many of these studies consider that about 60% of women who have 1 cesarean section will have "uterine adesions" following the surgery, and 95% of women have 2 cesareans will have them? Do they consider that about 5% of women who have adhesions will suffer chronic pain from them--that one of Dr. Kavorkian's client's only ailment was adhesions that caused her so much pain that she wanted to kill herself? Given that, I find any claim that complications are higher for the mom for vaginal birth to be ludicrious. Yes, for some individual moms cesarean birth is safer. But over all? No.
Similarly, when looking at newborn complications I rarely find a comprehensive look at things. What about allergies later in life? What about iatogenic (Dr. caused) prematurity from doing a planned cesarean too soon? When they say that babies in the VBAC group are more likely to have a drop in O2 supplied to the brain, how are they determining that? Based on fetal monitoring, which is KNOWN to be inaccurate in determining fetal distress and to be worthless in lessening the rate of cerebral palsy--which is supposedly what was being caused by the low oxygen levels? Based on cord blood testing? Are they looking at long term impact on the babies? Or are these transient cases of low oxygen levels that have no lasting impact?
All in all, I'd still say for the average woman with a previous cesarean, her best shot for having a healthy birth and healthy baby is to plan for a vaginal birth, to resist induction, and to resist many of the "standard" interventions that come with birth in America.
posted by Jenn | 1/12/2005 10:58:00 AM
4 Comments:
I so believe in this! I am against all the unecessary inductions and C-sections being performed out there. But what can you say. It's more convenient for the Doctors and the Mothers are clueless to the risks.
Hi, You couldn't be more correct, of course. But we have to remember that to the medical establishment the birth of a baby is not "normal," only in retrospect, so it is treated like a tickign time bomb.
Like with many things, the morbidity from adhesions/infertility/chronic pain is not taken much into consideration. Sad.
The word is IATROGENIC; iat·ro·gen·ic:
Induced in a patient by a physician's activity, manner, or therapy. Used especially of an infection or other complication of treatment.
You have a good point in this article. Could the reason VBAC is risky be the same reason why OBs feel the need to intervene so much? Perhaps enabling a woman give birth the way her body was intended to, with guidance from a positive, supportive, source, instead of forcing her into a model of care that was created by a man, totally clueless about what is really necessary during any part of childbearing, would produce drastically improved results.
I think much of this, however, falls on the mothers to become better informed: to ask more questions, do more independent research, and to truly make an informed choice about her care. It also serves that she must choose a healthcare professional (yes there are drs out there who are patient centered) that support a mother's right to choose her own level of medical intervention. I am greatly blessed to have such a dr. who has told me the choice for VBAC vs. another C was my choice (previous C because of enlarged head with my son -- 110th percentile -- that would not engage in birth canal. I had previously given birth to a girl naturally, vaginally). Thus, I'm doing a great deal of research and reading about the risks and watching to see if this baby will have an enlarged head like my son. I will make this choice not my dr.
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