VBACS

Throughout the 1900's, doctors often stated "once a cesarean, always a cesarean." They weren't necessarily recommending cesareans, but moreso observing a pattern. They were also warning practicioners not to perform a cesarean if possible in the first place because it most often leads to repeat cesareans. This approach has changed over the years and VBAC'S (Vaginal Birth After Cesarean) are now more common. Research has shown that 70% of women who have had a previous cesarean could safely have a VBAC for a future pregnancy. However, the VBAC rate in the U.S. in 2001 was only 16.5%, and in 2002 only 12.6%. This rate has fallen by 55% since 1996!

Both the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists agree that babies and mothers are healthier, have fewer complications, and return home sooner after a vaginal birth as compared to cesarean birth.Just because a woman has already had a cesarean does not mean she cannot have subsequent vaginal births. Several studies have established that it if a woman had a low transverse incision in the uterus , she can safely give birth vaginally in subsequent pregnancies.

Advantages of VBAC over planned elective cesarean include:

• Babies are born when they are ready and are at a reduced risk of being born prematurely (when compared to babies born by elective cesarean without spontaneous onset of labor).
• Babies receive catecholamines during the vaginal birth process, increasing their alertness immediately after the birth and decreasing the risk of respiratory problems.
• Babies born vaginally are significantly more likely to breastfeed.
• When born vaginally, babies have higher APGAR scores when compared to babies born by elective cesarean with no spontaneous onset of labor.
• The risk of infection for the mother decreases to 2-4%
• The inherent risks of surgery associated with cesarean birth are decreased or eliminated.
• The risk of maternal death is lower

Risks of VBAC:
As with any birth, there are risks associated with VBAC. The risks that usually cause the most concern are uterine rupture or scar dehiscence (the scar separating during labor). Many women plan repeat cesareans as a result of the fear of this risk.

1. Uterine rupture- many doctors refuse to perform VBACS for this reason alone.
   -Uterine rupture rates are low (less than 1%) in VBAC labors that begin spontaneously. When no medication has been used to start or speed up labor, the rupture rate is between 0.09-0.8% for women with a horizontal scar. The rate of uterine rupture for vertical incisions has not been well evaluated but it is believed to be about 2.2%. This means that for more than 99% of women having a vaginal bith with one baby that is in a head-down position, after a previous cesarean, they will not experience a uterine rupture.
   -The danger lies in when a mother is induced. In the late 1990s severals studies showed a rise in the incidence of ruptured uteri in women whose labors were induced with synthetic prostaglandins (Cytotec, Prepidil, Cervidil). One report documented a rupture rate 28 x higher than that of VBAC without induction.

-While a rupture is very rare, it is important for women considering a VBAC to be aware of the things they can do, and avoid, to reduce the risks associated with VBAC and reduce the likelihood of uterine rupture.

   2. Scar dehiscence
      -Occurs in 1-2% of VBAC'S, regardless of whether the scar is horizontal or vertical. It does not have any symptoms and is harmless to the mother and her baby.

Other things to consider:

• Use of pain medication
• there is still a question on whether or not it is safe to use epidurals for pain management in women planning a VBAC. There are some authors who believe that the pain that may result from a uterine rupture will be masked by the epidural, but this doesn't appear to be supported by evidence.
• Epidurals are associated with a significantly increased use of oxtocic drugs. Epidurals, depending on when they are administered and the type of labor the mother is experiencing, have a tendency to slow labor down. As a result, caregivers may suggest oxytocics (syntocinon or pitocin) to speed things up. As already mentioned above, oxtocics may increase the risk of uterine rupture. If a mother is not expected to adhere to time limits during labor then the use of an epidural is unlikely to have an effect on the risk of uterine rupture. However, in most cases, once an epidural is sited, active management will be used and time limits are a part of that management style.
• Manual exploration of the uterus
• Many caregivers will perform a manual exploration of the uterus after the baby is born when a mother is planning a VBAC. This is done to determine whether or not there has been scar dehiscence. There haven't been any studies carried out to determine any benefit in this procedure. It also carries numerous risks including infection and potentional for converting a dehiscence into a larger rupture. The procedure itself is also very painful for the mother if she has not had an epidural or general anesthesia. In their chapter on VBAC, the authors of Effective Care in Pregnancy and Childbirth state, "the wisdome of this approach [performing manual exploration] should be seriously  challenged."

For more information, check out the following links:

http://www.vbac.com/for-you-and-your-partner-things-to-think-about/

http://www.askdrsears.com/topics/pregnancy-childbirth/pregnancy-concerns/vaginal-birth-after-cesarean/questions-you-may-have

http://www.dangersofcesareanbirth.com/

http://vbacfacts.com/quick-facts/

http://vbacfacts.com/2009/01/15/im-pregnant-and-want-a-vbac-what-do-i-do/

Watch the video for VBAC tips from a Certified Nurse Midwife (CNM)