A Walk Through on VBACs and Why Hospitals Can’t Always Offer Them

A Walk Through on VBACs and Why Hospitals Can’t Always Offer Them July 2, 2014

Vaginal Births After Cesarean (aka VBAC) have become a bit of a hot topic since our local hospitals stopped providing this service. Some people are angry, some people are thankful, others don’t tend to care since we haven’t personally had a c-section. After hearing the debates and seeing the petitions, I decided it was time to go on an information hunt and figure out what all the controversy was about. But first, you should probably be aware of birth my philosophy.

I believe we live in a fallen world. I believe that what used to be perfect is now flawed. What comes naturally isn’t the standard for perfection anymore (ex: we are naturally sinful). Because we live in a fallen world, birth is painful and women and babies sometimes die during the process. Observed preferences about labor and delivery are a luxury. They are an opinion of what would be ideal, which is lovely, except that not every one has ideal labors and deliveries. I believe that in a fallen world, a successful labor and delivery should be defined as having a baby born into this world alive and healthy to a thriving mother. I think every baby born is a gift from God and no mother can give birth except through Christ’s strength. As Christian women, there is no ” I can” without it being immediately followed with “do all things through Christ.” (Philippians 4:13) Furthermore, as Christian women, we should not get worked up because things didn’t go the way we wanted them to. It’s ok to have preferences, it is not good to be angry or bitter when what we wanted doesn’t happen or when someone messes up. Everything happens for a reason and God is in control of it. I’ve heard stories about doctors, nurses and midwives who screwed up, and I have seen parents who continue to replay the incident in their head often or who speak unkindly about whatever the perceived wrong was or are just plain angry. If this sounds like you or your spouse, I strongly suggest reading How to Be Free from Bitterness by Jim Wilson, which is available online for free HERE.  If that doesn’t sound like you or your spouse, it’s worth reading through anyway. The Bible does not address birthing methods directly, but it does say to obtain understanding (Proverbs 4:7) and to love your neighbor (Matthew 22:39). Gossiping, badmouthing, spreading malicious rumors about your neighbor (be it a friend, an acquaintance, a midwife, a doctor or a hospital) is in direct rebellion against this commandment warranting repentance and restitution. Unless sharing some unsavory fact would serve a direct, productive, God glorifying purpose, you should not be saying it at all. Do not harbor offenses in your heart (1 Timothy 3:10-12, Ephesians 4:31-5:2).

What I am saying here is not intended to be preached from the pulpit, thankfully, I have no authority outside my own family. What I am sharing  is simply my attempted at gaining knowledge, wisdom and understanding (Proverbs 4:1-9). I do not expect everyone to agree with me or decide to make a personal crusade out of my ideas, it is our responsibility as Christians to form an honest opinion, but it is not my intention to be abrasive in sharing it. The verse that serves as a tagline for this blog is intentional. I do not think I am God, I’m but mere breath.

All that being said, let’s get down to business:

Q: What is a VBAC?

A: VBAC stands for vaginal birth after cesarean.

Q: What are the benefits of having a VBAC compared to another c-section?

A: As quoted from WebMD:

  • Avoiding another scar on your uterus. This is important if you are planning on a future pregnancy. The more scars you have on your uterus, the greater the chance of problems with a later pregnancy.
  • Less pain after delivery.
  • Fewer days in the hospital and a shorter recovery at home.
  • A lower risk of infection.
  • A more active role for you and your birthing partner in the birth of your child. (Personally, I disagree with this, a father who is determined to be active during the birth process will find a way despite level of inconvenience.) 

Q: What are the risks associated with a VBAC?

A: “Whether you deliver vaginally or by cesarean section, you are unlikely to have serious complications. Overall, a routine vaginal delivery is less risky than a routine cesarean, which is a major surgery. But a pregnant woman who has a cesarean scar on the uterus has a slight risk of the scar breaking open during labor. This is called uterine rupture.

Although rare, uterine rupture can be life-threatening for both mother and baby. So women with risk factors for uterine rupture should not attempt a vaginal birth after cesarean (VBAC).

Risks of VBAC

The risks of VBAC include:

  • Problems during labor that result in a cesarean delivery. This occurs with about 20 to 40 out of 100 women who try VBAC. But it doesn’t happen with 60 to 80 out of 100 women who try VBAC.1
  • Rupture of the scar on the uterus, which is rare but can be deadly to the mother and baby. A vertical incision used in a past C-section, use of certain medicines to start (induce) labor, and many scars on the uterus from past C-sections or other surgeries are some of the things that can increase the chance of a rupture.
  • The chance of infection. Women who have a trial of labor and end up having a C-section have a higher risk of infection. This means that the risk of infection is lower after vaginal births and after planned cesareans.3

Risks of any cesarean

The risks of cesarean delivery include:

Future risks. If you are planning to get pregnant again, it’s important to think about scarring. After you have two C-section scars, each added scar in the uterus raises the risk of placenta problems in a later pregnancy. These problems includeplacenta previa and placenta accreta, which raise the risk of problems for the baby and your risk of needing a hysterectomy to stop bleeding.4

For more information about cesarean risks, see the topic Cesarean Section.” –WebMD

Q: What factors into VBAC success rates:

A: WebMD answers, “Pregnancy, labor, and delivery are different for every woman and difficult to predict. Even if your first pregnancy required a cesarean, the next one may not. The likelihood of a successful vaginal birth after cesarean (VBAC) is influenced by various factors. Usually a combination of factors affects how well or poorly a trial of labor goes.

Your chances of a successful VBAC are best when:1

  • Your previous cesarean was not done for stalled labor.
  • You do not have the same condition that led to a previous cesarean (such as abreech, or feet-down, fetus).
  • You have had a vaginal delivery or a successful VBAC before.
  • Your labor starts on its own, and your cervix dilates well.
  • You are younger than 35.2

Your chances of a successful VBAC are lower when:1

  • Your previous cesarean was because of difficult labor, which is called dystocia. This is especially true if you were fully dilated when you had a cesarean sectionfor dystocia.
  • You are obese.
  • You are older than 35.2
  • Your fetus is very large [estimated as bigger than 9 lb (4082 g)].
  • You are beyond 40 weeks of pregnancy.”

——-> Which bring us to HOME vs HOSPITAL VBACS:

I am relatively neutral on the home vs hospital debate for normal, uncomplicated (aka routine) deliveries. If you have a wise, experienced, God fearing midwife, pros and cons really come down to preferences, geographical resources and who your put your faith in. Of course, I also advocate taking great care in finding a wise, experienced, God fearing OB if you are planning a hospital birth. We put our faith in God, not in midwives or doctors. The reason the debate of home vs hospital is heightened in regard to VBACs seem to come down to what is known as Availability.  I found this talk an extremely informative overview on why the standards of availability are what they are in the medical community today. I highly recommend taking the 20 minutes to listen to this video before proceeding in the discussion:

Diagnosing a uterine rupture is a novel in of itself, but essentially, there is no way to predict a uterine rupture. Symptoms include:

  • Clinically significant uterine bleeding
  • Fetal distress  (which is what that doppler they strap on to your stomach in a hospital is used to detect)
  • Protrusion or expulsion of the fetus and/or placenta into the abdominal cavity.

“From the time of diagnosis to delivery, generally only 10-37 minutes are available before clinically significant fetal morbidity becomes inevitable. Fetal morbidity occurs as a result of catastrophic hemorrhage, fetal anoxia, or both.” Which is why hospitals have a list of requirements they want to fulfill before they can accommodate VBAC attempts. Everyone is concerned about the rising rate of c-sections and maternal and infant mortality in the US and a lot of hospitals want to be able to offer more VBACs. The American Congress of Obstetricians and Gynecologists even revised their list of guidelines to make it easier for mothers to try for vaginal births after a Cesarian.  “During his inaugural address at the Annual Clinical Meeting (ACM) in May (2010), ACOG President Richard N. Waldman, MD, said a new sense of urgency must be placed on reducing the rate of cesarean deliveries and asked Fellows to “recommit to do everything in our power to reduce the cesarean rate.” 

When I called, Kati Haeder, who was the director of the Family Birth Center at my local hospital, she was happy to help me understand why Gritman is unable to accommodate VBAC’s, “We would love to be able to provide this service for our patients, absolutely. It is an issue of resources. We need to be able to follow ACOG guidelines which means that you have a designated surgery crew, which includes; anesthesia, circulator, scrub tech. The surgeon needs to be in house, as well, for the entire time the patient is in active labor, which means that we are unable to provide any other surgical services to anyone else in the community…. So, for example, if someone came in and needed an emergency appendectomy, they would have to be transferred out because we wouldn’t be able to operate on them if we had a VBAC here in labor… It’s very unfortunate that we had to come to this decision, but we have to think of the entire community, not just our VBAC population.”

In our town, if a woman wants to try for a successful hospital VBAC, she’d have to move to a bigger town for her third trimester so she’d be near a hospital that was equipped to performed them spontaneously. Inductions greatly increase the risk of a c-section because of the stress it places on the uterus (I’ve experienced a pitocin induced labor and I can assure you, forced contractions are nothing like spontaneously occurring ones!), so scheduling an induction at a bigger hospital farther away isn’t a good idea if you are trying for a VBAC. Essentially, if you live in a smaller town, VBACs have to be done at home.

For mothers who are considering attempting a VBAC at home, the question they should ask is, if a uterine rupture does occur, can I get to the hospital and my baby out in under 10 minutes? To answer this question, we have to know what resources are available to us. In Moscow, ID, we have a volunteer EMT department. What does this mean? As their website explains, our EMTs aren’t waiting by the station phone for your 911 call. They are in class, they are at work, they are at home asleep. Which is great in theory economically speaking, but  thinking practically, this means the fastest way to get to the hospital is to drive yourself. Usually, your neighbor will get you to the emergency room considerably faster than our ambulance company can. Incidentally, I am not trying to bash our volunteer department. There are some wonderful men and women in that team and I admire their sacrifice and skill they provide the community. Continuing on, after you asses how long it takes you to get into emergency surgery, you have to factor in the availability of medical personnel to help you (as outlined in the video above). So let’s imagine best-case actions in an unfortunate scenario: your uterus ruptures at home, your husband  or midwife speeds you to the hospital and you get there in under 5 minutes. They get you on a gurney and race you to the operating room. The staff is already there and even scrubbed in….because they already have a car accident victim on the table.  The next closest operating room is a helicopter ride away. Your baby probably won’t make it. Alternately, you get rushed to the hospital on time, and someone even calls ahead to tell them to assemble the surgery team. You make it to the hospital on time, but the surgery team takes too long to get there.  I know these are unpleasant situations to think on but we know that we live in a fallen world. We know these scenarios happen all the time. They happen to our neighbors, they happen to our friends, they happen to us.

It is my understanding that routine vaginal births are less risky than c-sections (special circumstances aside), but if a woman has had a c-section before, they will never have a routine vaginal birth — and that is not a failure or a shortcoming or something to be sad about. By the grace of God, she probably could have a complication-free vaginal birth, however as long as there is that scar on your uterus, the risks simply aren’t the same as a mother who has a no scar.  Again, remember that having a c-section isn’t a defeat. In some cases, having a c-section is the heroic and winning action. Where a newborn baby emerges from does not change the fact that a person is being born. Birth is a time for rejoicing! We are to praise God for our new little person. We’ve brought a soul into the world and it’s glorious!

Gritman encourages anyone with questions to go ahead and give the Birth Center director, Alyssa Martsching a call (since this article was written, Ms. Haeder is no longer the director)  so she can answer them. When I called, she seemed like a very nice lady who earnestly wants to be able to offer VBACs, but simply doesn’t have the tools she needs to do so. Only Jesus can make wine from water. For the rest of us,  getting annoyed or signing petitions won’t change anything. If we lived in a bigger city, finding a hospital that was able to offer this service would be easier, but as it stands, some of us live in a small town with a small hospital and a limited number of medically trained professionals to help us and limited operating room space.

I originally wrote the bulk of this post over a year ago, but was unsatisfied with my conclusions. More often than not, when I’ve asked women why they want a VBAC, their response can be boiled down to either fear, pride, or selfishness. They “don’t think doctor’s have their best interests in mind.” They want to “experience a real birth” or “c-sections are too expensive”. The volume of their collective voices tested my patience and my graciousness.  Now, I am going to ignore the last two arguments because, as a Christian, I believe them to be the weakest. Instead I’d like to focus solely on the most relevant one: Doctors don’t always have a patients best interest in mind. Yes. Sadly, this is true. But you know what, some midwives have ulterior motives too. Our actions should not be dictated by the other guy’s sins. We are responsible before God for our own actions, not theirs. Ultimately, I think the question boils down to weighing the risks. There are risks to having a cesarean, but there are also risks to having a vaginal birth. Cesarians sound wise until the mama has a blood clotting disorder and bleeds out on the table. VBACs sound wise until a placental abruption occurs. So what do we do with this? Is a VBAC safer than another cesarean? When there is life threatening risks on both sides, where do you step?

Personally, I don’t think VBACs should even become a public debate. There should be no sides to take.  The correct answer differs depending on each individual situation.   There are too many variables to be able to say yay or nay for everyone. I think sometimes VBACs are the very best option. Other times I find them incredibly foolish. It is essential to study the risks before deciding which method you want to try. It is important to examine our motives (why do or don’t you want a VBAC). This is why we must faithfully petition our Heavenly Father to guide us as we seek out what is the best decision for our own, unique situation. Let us lift up this subject in prayer:

Lord, God of Abraham, Issac and Jacob. You, who open and close our wombs. The God who hardens and softens our hearts. We call out to You today. We acknowledge how often we take our eyes off of You and are distracted by voices that fail to speak Your truth is love. We see our failure to come to You with our questions. We know that we have foolishly relied on fallible sources for information. We recognize that we have based too many of our decisions on our fears of things that can kill our bodies and have ignored that which will kill our souls. Father, we repent of these sins. We cry out to You to wash us of our uncleanness. Please open our eyes to Your ways and our ears to Your wisdom. We know that You are righteous, Lord, help us to believe that in our hearts. We know You have almighty power over our souls, our bodies and our lives. You have numbered the hairs on our heads. You know us better than we do. You are our salvation. We know that all life comes from Your hands, but we know that You are too vast, too loving and too kind for us to fully comprehend. We pray now that You would take this discussion from us. Allow us to feel Holy Spirit to navigating us through this subject of labor and deliveries. Help us to see it through Your eyes. Give us grace and humility to love one another, not merely in spite of, but because of our differences. We know that You are good and merciful. Help us to trust you with our fertility, our pregnancies, our labors, and the lives of our children and ourselves. Thank you for relieving us of the horrible burden of self-reliance. Thank you for delighting in and caring for us better than we could ourselves. Hear our prayers and do not turn Your face from us. We belong to You. In the name of the Father, the Son and the Holy Spirit, Amen.

A Walk Through on VBACs

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