VBAC

Vaginal Birth After Cesarean:

If you have already had a cesarean birth, there is no reason to plan for another. Vaginal birth after cesarean (VBAC) is generally safer than a repeat cesarean. VBAC may be perceived as a risk, remember, having a baby at all carries some risk. This is why Mothers are so brave. Any kind of birth requires courage and support. The main risk does not lie in uterine rupture, which is extremely rare, of most concern is the psychological and spiritual stress of not going along with the powerful medical system. Many brave families have blazed the trail. You should be able to find a midwife or doctor who is supportive. It may be challenging, but keep on trying until you feel you’ve found the one you trust.

Sofi’s Vaginal Birth after Cesarean

Exerted from The Ecology of Gentle Birth by Robin Lim
“Sofi planned a natural birth, but her baby was in a transverse position when she went into labor. With the baby lying sideways, it was necessary for Sofi to have a cesarean birth. She was fortunate, she saw her baby immediately after the surgery, and the midwife helped her to initiate breastfeeding. Three years later, when she was again pregnant Sofi at first had trouble finding someone to agree to support her in having a normal birth. Finally a friend told her about a midwife, who worked with a good back-up Obgyn doctor. After checking Sofi regularly, finding her to be in good health, the doctor and midwife agreed that she should plan for natural childbirth. Her midwife pointed out the fact that by breasfeeding her first child, Sofi had plenty of Oxytocin hormone receptors to help her future births go well. Oxytocin is monogamous with its own receptors, so the more love you give and share, the more capacity you have to LOVE!

Sofi came into the birth center 3 cm. dilated. She labored sometimes walking, sometimes on hands and knees, and if tired she would rest on her left side. Her husband was a wonderful labor support. He made sure she drank and ate well to stay hydrated and to keep up her strength. Sofi’s three-year old son played nicely with the toys at the birth center, and awaited the birth of his sibling. Sometimes he crawled into his laboring mothers arms, and shared his own special support. A few hours later, to Sofi’s surprise she was feeling like pushing. The midwife checked her and she was fully dilated. Sofi’s husband held her from behind and she began to push. As the baby’s head began to peek into view, Sofi’s husband sang the Azahn, the song of his culture. He had tears in his eyes, to witness the miracle of birth. The baby girl was 3.5 kilograms, 600 grams bigger than Sofi’s first baby. She was born totally naturally, and went right to the breast. Afterward Sofi expressed how healing it was to finally have her dream come true, a natural, normal, gentle birth.”

Women pregnant after a previous cesarean section have special needs and concerns that are social, psychological and clinical. The skillful midwife uses all of her talents—intellect, interpersonal communication, intuition and judgment—to nurture, protect and empower the pregnant women in her care.

This is the advice from an OBGYN who had her baby at home. You can read the entire article see reference 1 below.

There are three articles that have influenced my practice(See references 2, 3, 4 below).  I advise that women wait 1 full year from the Cesarean before conceiving again.  From these 3 articles it looks like the risk of rupture is 2.5-3 times higher when the birth dates are less than 18 months apart. (getting pregnant within 9 months of the Cesarean). I do not tell them “the longer, the better”.  There is no evidence to support that advice.

In terms of the risk of a repeat VBAC with a single layer closure.  The studies that I have read about risk for repeat VBAC’s (with a prior successful VBAC) is that the risk if about 1/2 of what it was for the first VBAC.  There is some risk with a repeat VBAC but it’s lower than the first one.  I would consider a woman with a successful VBAC (after single layer closure) a good candidate for another VBAC.

A home birth midwife’s VBAC protocol might include:

  • a third trimester ultrasound for placental location
  • an informed consent document for VBAC clients
  • distance to hospital constraints
  • limit on the number of previous C-sections
  • operative note confirmation of type of scar and that the scar healed without infection
  • a double-layer closure
  • a responsive back-up doctor/hospital
  • no stimulation of labor with herbs or other methods (especially Cytotec!!)
  • at least two midwives at the birth
  • an IV or Heplock in place
  • more frequent FHT assessment
  • strict progress in labor guidelines
  • no manual extraction of adherent placenta rule
  • providing EMS with a map to the house
  • alerting the back-up doctor to an upcoming VBAC (then giving him/her the “all clear” when she is safely delivered)

Single layer suture VS double layer

Your care provider may ask to see the operative report in determining if you are a good candidate for a VBAC. Some people feel that when attempting an out of hospital VBAC that a double layer suture is the safest. Nine studies including 5810 women were reviewed. Overall, the risk of uterine rupture during labor after a single-layer closure was not significantly different from that after a double-layer closure. Locked but not unlocked single-layer closures were associated with a higher uterine rupture risk than double-layer closure.5 This refers to how the incision was sutured or sewed up. When it is a single layer, then an unlocked stitch is best.

References

  1. A VBAC Primer: Technical Issues for Midwives by Heidi Rinehart, MD This article first appeared in Midwifery Today Issue 57, Spring 2001 www.midwiferytoday.com/articles/vbacprimer.asp
  2. Interdelivery interval and risk of symptomatic uterine rupture. Obstet Gynecol. 2001 Feb;97(2):175-7. http://www.ncbi.nlm.nih.gov/pubmed/11165577
  3. Risk of uterine rupture associated with an interdelivery interval between 18 and 24 months. www.ncbi.nlm.nih.gov/pubmed/20410775
  4. Short interpregnancy interval: risk of uterine rupture and complications of vaginal birth after cesarean delivery. Obstet Gynecol. 2007 Nov;110(5):1075-82. http://www.ncbi.nlm.nih.gov/pubmed/17978122
  5. Single- versus double-layer closure of the hysterotomy incision during cesarean delivery and risk of uterine rupture. www.ncbi.nlm.nih.gov/pubmed/21794864

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