The VBAC Controversy
The c-section rate in the U.S. has risen sharply over the past few decades. In 1970 the rate was about 5% and today that rate is about 30%. Certainly there are many factors that have contributed to this startling statistic. The advent of electronic fetal monitoring, the high rate of epidural analgesia,and the medical-legal environment have all played a part in this alarming rate of operations for what has been a natural part of life for milleniums. Ther used to be the addage of " once a c-section always a c-section." This no longer holds true. In fact in a recent publication by the American College of Obstetrics and Gynecology it states that " the benefits of VBAC ( vaginal birth after cesarean ) outweigh the risks in most women with a previous low transverse cesarean delivery." ( see ACOG bulletin of 2007 ) Most women with one prior low transverse incision are good candidates for VBAC. Even women with 2 c-sections may be candidates if they have had at least one prior vaginal birth. Most studies indicate an approximately 60-80% success rate for Trial of Labor After Cesarean or TOLAC as it is sometimes referred to. I personally have experienced an 80% success rate.
Both VBAC and repeat c-sections have certain risks associated with them. The benefits of successful VBAC include a shorter and less costly hospital stay, less likelyhood of blood transfusion or maternal death, less risks of thromboemolic events such as pulmonary emboli, less rate of endometritis or infections. There is also less risks for the associated increased risks of abnormal placentation that occurs from multiple cesareans.
The main risk with VBAC is an approximaetly 4/1000 risk of uterine rupture. For that reason an obstetrician is required to be immediately available during the labor. For this reason many doctors and hospitals decline doing VBAC's. The main risk of a repeat c-section is a 4x increased risk of maternal death associated with operative dellivery over that of vaginal delivery. ( see the green journal of OB/GYN ) In addition, the more c-sections a woman has, the increased risk of abnormal placentaion known as placenta accreta. This can be life threatening, and may cause massive blood loss and even an emergency hysterctomy at the time of delivery. The more c-sections a woman has, the more likely to also have an accreta.
However despite all of this, there is less risk in a scheduled repeat c-section than if a woman has a " failed VBAC " and still has to have a c-section after laboring. The bottom line is that whether you choose to undergo a repeat c-section or a trial of labor or VBAC, is a very personal and complicated decision and requires a detailed discussion between you and your doctor. This is however, one important way to decrease the alarmingly high c-section rate in the U.S. and do so safely. Dr. Mark T. Saunders, www.drsaundersobgyn.com
Dr. Saunders is a well-respected board certified obstetrician and gynecologist that has been practicing in the American Fork area for over 16 years. He has established a new practice facility located just 1/2 bock south of the IHC American Fork Hospital.