Sonoma County Medical Association
Lela Emad, MD
The rate of cesarean births in the United States continues to rise. During 2007, approximately 1.4 million women—accounting for 31.8% of all births—delivered by c-section, and the preliminary data for 2008 indicate yet another increase—to 32.3% of all births. These rates, the highest ever recorded in the U.S., exceed cesarean rates in most other industrialized countries.
Despite the prevalence of cesarean births, many expectant mothers wish to undergo a planned trial of labor after cesarean (TOLAC). If successful, TOLAC enables them to give vaginal birth after cesarean (VBAC). Yet these less invasive birthing options are rarely an option for women. Nationwide surveys have shown that since 1996, approximately one-third of U.S. hospitals and half of physicians no longer offer TOLAC.
TOLAC is associated with an increased risk of uterine rupture at the site of the previous uterine incision, increasing the risk of fetal injury, fetal death, and maternal morbidity and mortality. For this reason, the American College of Obstetricians and Gynecologists (ACOG) issued guidelines in July 2010 stating that, “The College maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available.”
Candidates for TOLAC need to be selected carefully. The odds favor a safe VBAC delivery for low-risk mothers who meet the criteria and attempt a trial of labor in a dedicated facility. Approximately 74% of women who attempt a TOLAC are successful at delivering vaginally.
Motivated mothers consistently benefit physically, mentally and emotionally from being able to choose VBAC deliveries. Even if the TOLAC is not successful and a repeat cesarean is required, many patients express increased satisfaction in having had the opportunity to make the attempt at natural childbirth.
As part of a clinical team dedicated to minimizing c-sections, I encourage women to carefully weigh the benefits and hazards associated with both cesarean and VBAC deliveries. A successful VBAC allows women to:
• Avoid major abdominal surgery.
• Speed up postpartum recuperation and return home faster from the hospital.
• Reduce risks of infection, severe bleeding and rehospitalization.
• Improve maternal-child bonding and early breastfeeding immediately following birth.
• Increase likelihood of a safe vaginal delivery in subsequent births, an important consideration for women who desire larger families.
VBAC is particularly helpful to women who plan to have additional children. These women can avoid problems associated with scarring from multiple c-sections, such as placental complications, bladder or bowel injuries, and hysterectomy.
The new ACOG guidelines mentioned above uphold the safety and appropriateness of VBAC deliveries for women who, formerly, may not have been considered good candidates. These include women who have had two prior c-sections with low-transverse uterine incisions, and women bearing twins who have had a previous cesarean with a low-transverse incision.
TOLAC and repeat c-sections both involve risks. The lowest complication rate is for women who succeed at TOLAC. The elective repeat c-section has the next lowest complication rate. The highest risk occurs when TOLAC fails and necessitates a repeat c-section. Many of these mothers will have had long labors with much higher risks of infection, bleeding and even hysterectomy.
C-sections also pose risks for newborns, including a higher incidence of respiratory problems, interference with maternal-child bonding, and possible lacerations from surgical instruments. By comparison, vaginal delivery provides a reduced risk of prematurity and more immediate opportunities for mothers to hold, breastfeed and nurture their infants.
Women and their physicians should thoroughly discuss these matters, with a clear understanding that the decision ultimately rests with the mother and her partner. As a clinician, I believe it is important for women to be able to consider their options and make informed decisions. Women with a previous c-section should meet with their physician to determine whether they are good candidates for TOLAC.
Expectant mothers desiring VBAC should consider the emergency resources and medical expertise available at the hospital they choose. At Santa Rosa Memorial Hospital, for example, an operating room is kept on standby throughout the course of active labor for any mother attempting TOLAC, and both anesthesiologists and ob-gyns are on the premises should an emergency c-section become necessary.
Out of 1,118 babies born at Santa Rosa Memorial during 2009, 102 were delivered via VBAC—nearly 1 in 10. Expectant mothers are willing to travel long distances—including from Mendocino, Lake and Solano counties—to preserve their option of avoiding unnecessary c-sections.
Women can increase their chances for successful VBAC by eating right, exercising, and maintaining proper weight and body mass index prior to and during pregnancy. Other considerations are the mother’s age, gestational age of the baby, weight and position of the baby, and time elapsed since the mother’s last pregnancy.
Expectant mothers and their physicians also should take into account the reasons a prior c-section occurred. A baby in breech position, for example, is a complication less likely to recur in subsequent pregnancies. In contrast, a woman who has experienced slow or stalled labor, or pelvic size constraints that impeded natural labor, stands a greater chance that these variables may also affect future deliveries.
Every labor is unique, as is every child. Matching up with a team of caregivers who will empower a woman to meet her birthing objectives is essential. Through education, encouragement, commitment of necessary healthcare resources and shared decision-making, physicians can present women with opportunities that help curb the rising trend of high cesarean rates.
1. Hamilton BE, et al, “Births: preliminary data for 2008,” National Vital Statistics Reports, 58;16, www.cdc.gov (6 April 2010).
2. Menacker F & Hamilton BE, “Recent trends in cesarean delivery in the United States,” National Center for Health Statistics Data Brief, No. 35 (March 2010).
3. National Institutes of Health, Vaginal Birth After Cesarean: New Insights, consensus.nih.gov (March 2010).
4. ACOG, “Ob-gyns issue less restrictive VBAC guidelines,” www.acog.org (21 July 2010).
5. ACOG, “Vaginal birth after cesarean delivery,” www.acog.org (September 2010).
6. Alvarado A, “Where to turn for more information about c-sections,” californiawatch.org (11 September 2010).
Dr. Emad, an ob-gyn in private practice in Santa Rosa, chairs the ob-gyn department at Santa Rosa Memorial Hospital.
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