VBAC vs. Planned Cesarean
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.