Why I Want To VBAC
My friend Desiree inspired me to do this one. I have talked about how I am going to VBAC and all the logistics and preparation and details involved but I haven’t talked about why I want to. I think for a lot of women it is easier to schedule an elective repeat cesarean section (ERCS). Many OB’s do not support VBAC or hospitals have VBAC bans or people have misinformation that does not make VBAC seem like a safe and healthy option.
I know I am certainly one of those women that it would be easier for. It would probably be easier to go ahead and schedule my ERCS now. I was told after Graham was born that due to the inverted t incision scar on my uterus that there was an up to 15% chance of uterine rupture and that it would be best to schedule an ERCS at 36 weeks to avoid any labor. At first, even though I was devastated, it didn’t sound too bad. I didn’t have Graham until 41 weeks 1 day. Having my next baby at 36 weeks kind of sounded great compared to going past 41 weeks. Plus, we had a really hard long labor, 52 hours total, so the thought of skipping all that and just having the baby sounded pretty tempting. That’s how I rationalized it all in my head, to make myself feel better about having had the first c section and about having to have the inverted t incision. I thought, ‘well, at least I don’t have to be pregnant forever and I don’t have to labor just to end up with another c section and I can plan everything.’ But it never really set in and it never really felt right to me. So I started researching.
I already knew that VBAC was a safe and healthy option for moms with bikini cut scars so I didn’t really start out researching VBAC safety as a whole. I started with the inverted t incision because that put me in a whole different category of risk according to the doctors. I looked for the studies that backed up the 15% claim of rate of uterine rupture in a subsequent trial of labor (TOL) and couldn’t find anything. I did find the most commonly quoted rates of 4-9%. So I started thinking that at least that meant there was a 91-96% chance that no rupture would occur. That was motivating. The I found my friend Jessica, another inverted t incision mom. She had started a Yahoo group, Life After Inv T, on her own webiste, Jessica’s Haven, she shared her birth story of a VBAC after inverted t incision. It was the first I had ever heard of this and I was so excited. I didn’t even know it was possible then I realized, she had two other moms stories on her site too. This gave me confidence to start really looking at VBAC as a viable option for me.
One reference that Jessica made as far as determining the safety of VBAC after an inverted t incision was the Landon Study 2004. The Landon Study found a rupture rate of 1.9% for inverted t incision type scars. I was floored. This was the largest VBAC study ever done and the rate was more than half to almost four times less than the smallest rate quotes I had found previously. At this point I got angry. I got angry at all the information I was given after my first c section. I was angry at the suggestion that I purposely deliver a preterm baby when I have always known that it is better for babies to initiate labor, letting us know they are ready to be born. I was angry at the thought of having to endure another c section, not just for my own sake but my baby’s sake. I realized that ERCS tend to be easier on both mom and baby but what if I want a third child? A fourth? Each c section a woman has increases risks of complications. And what about the issues that area associated with babies that are born by c section? They weren’t risk free either were they? My brain was racing and I was again on a quest to learn more.
I have read the Landon Study many many times. I gave my Korean OB a copy of it the first time I met him, in case he had never heard of it. I highlighted all the parts that pertained to me and any other information I thought should be discussed. He was very welcoming of that information and asked me to be sure to bring him anything else I come across that my help me have a better birth or for him to be a better doctor. I really appreciated that support. I found a post on a message board the other day that kind of breaks the Landon Study down a little bit. I am including that information here because there are several points that I want to touch on that really define why I want to VBAC. I am going to bold these points and I am going to italicize any of my own commentary.
The 2004 Landon study in the NEJM (12/2004) is a very good source for UR information. It included nearly 18,000 that had a TOL (trial of labor which may or may not lead to a successful VBAC). The overall rate of UR was 0.7% which translates into 124 uterine ruptures in that group of nearly 18,000. Only 2 of the babies died following a uterine rupture. Keep in mind, the group included women having a TOL after 1, 2, 3 and 4 c-sections. It also included women who classical, invert T and J incision as well as the low tranverse incision (which is most common and considered the safest for a TOL). About 25% of the women in the TOL group had their labors induced (with prostoglandins or pitocin) and/or augmented with pitocin which also increases risk of uterine rupture. About 25% of the women in the TOL group were less than 2 years from their previous c-section. Clearly, there were many other potential risk factors that could come into play here with the risk of UR.
According to this study :
The absolute risk of neontal death is 0.08% with a TOL vs 0.05% in an ERCS; stated otherwise, the risk of neonatal death is 1 in 1250 babies with a TOL vs 1 in 2000 with an ERCS . Babies can die in both a TOL and an ERCS. The difference between the two is very very small as you can see. TOL and ERCS both have risks. There are risks associated with vaginal birth in an unscarred uterus. There are risks associated with getting in a car and driving to work and leaving your house with the oven on and with pretty much everything else we choose to do in life. At least these are calculated risks with firm data to give us an idea of what we are dealing with.
The absolute risk of the mother’s death was 0.04% with an ERCS cs 0.02% with a TOL; stated otherwise, 1 in 2500 mothers will die due to an ERCS vs 1 in 5000 mothers will die with a TOL) Again, very small increase in risks here. Even though the risk of maternal death doubles for an ERCS, it is still under a half of a percent. Compared to the risk of fetal death, the mother’s risk is lower so one could say that VBAC is safer for the mom than it is for the baby but I am not sure that is very accurate since again, all of these numbers are under 1% total. And even if I sound cold or strange, I think for me I have to consider Graham, the child that I already have living here now. While the baby growing in my belly is very important to me, I could not imagine dying and leaving Graham to grow up without a mother. If I were basing my decision on the risk of fetal death vs maternal death, I would choose to lower the risk of maternal death. I have not based my decision to VBAC on comparing these two risks, however, and again, since all the risks are so very low, it’s not really important that I compare them that way. Some people may, but I’m not.
This study also separated out the number of women and the number of UR based on incision type:
- Low transverse incision (n=14,483): 105 ruptures (0.7%)
- Low vertical incision (n=102): 2 ruptures (2.0%)
- Unknown type of incision (n=3206): 15 ruptures (0.5%)
- Classical, inverted T or J incision (n=105): 2 ruptures (1.9%) I can’t really say anything. It’s right there to see. It’s not 15% or 4-9%, it’s 1.9% and I believe this.
- Unclassified (n=2)
It also separated out the number of women based on rates/types of induction:
- Spontaneous labor (n=6682): 24 ruptures (0.4%)
- Augmented labor (n=6009): 52 ruptures (0.9%)
- Induced labor (n=4708): 48 ruptures (1.0%)
- With any prostaglandins, with or without oxytocin (n=926): 13 ruptures (1.4%)
- With prostaglandins alone (n=227): 0 ruptures
- With no prostaglandins (n=1691): 15 ruptures (0.9%)
- With oxytocin alone (n=1864): 20 ruptures (1.1%)
- Not classified (n=496): 0 ruptures
Augmenting and inducing does raise UR (uterine rupture) rates. The numbers are still very small but in the absence of a valid medical reason to augment or induce, I would not do it. I feel that way about unscarred uteri though. Elective induction causes problems whether it’s for a first timer, a VBACer or anyone else.
A Breakdown of the number of previous cesareans (obtained from a subsequent study by Landon in Obstetrics and Gynecology 7/2006) (the women who had more than 1 c-section were grouped together and had a UR risk of 0.9% while the women who had 1 VBAC had a risk of 0.7%):
• 16,915 (94.5%) had 1 prior cesarean
• 871 (4.9%) had 2 cesareans
• 84 (0.5) had 3 cesareans
• 20 (0.1%) with 4 cesareans
8 women had an unknown prior # of c-sections
Risks of choosing a a TOL (trial of labor) vs an ERCS (elective repeat c-section):
•More likely to suffer a uterine rupture – the rupture rate in the TOL group was 0.7%; there were no ruptures in the ERCS group, however, women who presented in early labor and did not have a documented intention to labor were excluded so it is possible that women went into labor before their scheduled c-section and ruptured but were excluded from this study’s data
•1.4 times more like to have a uterine dehisence (typically a benign, thin area in the uterus)
•1.7 times more likely to need a tranfusion
•1.6 times more likely to develop endometriosis
•1.3 times more like to have another adverse event such as (broad ligament hematoma, cystotomy, bowel injury, ureteral injury)
•1.6 times more likely for the baby to die (doesn’t sound like that big of a difference right? Remember that babies only die in about 2-10% of uterine ruptures according to many studies AND babies do die after c-sections.
Risks of choosing an ERCS over a TOL:
•1.5 times more likely to need a hysterectomy I could have lost my uterus the first time, it was T’d secondary to difficult delivery of the head and once removed for cleaning and stitching it was found to be extremely large. So large in fact that they couldn’t get it back in. And it wouldn’t contract. I remember the slight panic in the room in those minutes. Luckily with a few shots of pitocin straight into my shoulder, it contracted and they got it back in. I’d kinda like to avoid that drama this time around. I’d like to have another baby, maybe two after this one.
•2.5 times more likely to have a thromboembolic disease (deep venous thrombosis or pulmonary embolism) I have a blood clotting disorder, prothrombin gene mutation. I am already higher risk for developing a DVT or PE. I do not know the stats but factored in with the risks of developing these issues just by having an ERCS, it is very motivating for me to stay off the operating table. PE is the number one cause of death in pregnant women. So while the data shows a higher rate of death for the ERCS group at 0.04%, mine risk is going to be higher than that, even though I don’t know what the numbers are. It would be pretty hard to find information on risk of death by PE during an ERCS for a woman with PGM. That’s a mouthful.
•2 times more likely for mother to die
Risks of a successful VBAC delivery (remember that TOL can end in repeat c-sections) vs an ERCS:
• 1.2 times more likely to need a transfusion My doc said I could be a little higher risk on this one as my placenta is anterior and if I have any detachment issues after the birth. I am A+ which is an extremely common blood type in Korea and I am delivering at a University hospital in Seoul with plenty of blood in the bank. I feel ok with this.
Risks of an ERCS vs a succcessful VBAC:
•3 times more likely for mother to need a hysterectomy See above. The above stats were for ERCS vs TOL (VBAC attempt whether successful or not). This stat here is for ERCS vs successful VBAC.
•5 times more likely to have a thromboembolic disease (deep venous thrombosis or pulmonary embolism) See above. The above stats were for ERCS vs TOL (VBAC attempt whether successful or not). This stat here is for ERCS vs successful VBAC.
•1.5 times more likely to develop endometriosis
•4 times more likely for mother to die
2 things this study does not address regarding newborns is the incidence of respiratory distress in babies born by elective repeat cesarean which can be quite serious. It also does not address the number of babies that have brain damage as a result of a UR. I want to say the chance of brain damage is about 10-15% when you have a UR but I’d have to double check that. Obviously, UR is very rare but it does happen. When it does happen, UR rarely results in fetal death or brain damage though that too can happen. Babies are usually okay after UR. As far as the mother goes, it doesn’t address the decrease in hospitals stay, post partum surgical infection, etc.
Overall, I feel as if the medical data on the safety of VBAC, fetal death, maternal death, and other complications assure me that VBAC really is the best option. Medical reasons aside, there are emotional reasons as to why I want to VBAC. HERE is the linkt to a fantastic video of a woman and her three births. The first two were c sections and the third was an HBA2C (homebirth after 2 cesareans). Bring tissues.
I just feel like i owe it to my baby to birth it in a natural and peaceful way. I owe it to the baby to come into the world, straight my arms and not into the hands of rough strangers. I want the experience but mostly I want the baby to have the experience. Graham and I were separated the first three hours of his life, that is heartbreaking! Part of giving my baby the peaceful birth is to also birth it without drugs as well. I don’t want the baby to be groggy and disoriented at birth or to have latch or suck issues which is very common with c/s babies, including my first baby. I want immediate skin to skin contact with my baby after it’s born, not for it to go to a warming table where it is suctioned and scrubbed and roughed up so it will cry. None of that is necessary, what’s necessary is the skin to skin contact, with me, with my body heat and my scent and my touch.
I truly believe that how we birth matters. I realize there are women who have c sections and they are happy about them and they had no bad outcomes and their babies were fine after them and emotionally they are happy they had their c sections. I also believe that a lot of women who have an unplanned c section the first time do have some emotional baggage as a result. I think that many women who go on to have ERCS rather than VBAC still think about VBAC and ‘what if’ really aren’t that happy that they had c sections and wonder if they really were necessary or not. I am not a woman who escaped my c section unscathed. II did have a lot of emotional baggage as a result. It’s already been proven that c section moms have a higher rate of postpartum depression and I can attest to that one personally. For me, ultimately, I just believe that I can birth. Even though it didn’t quite work out that way the first time, it doesn’t stop me from believing it or believing that birthing the baby myself is the best option for both me and the baby. I know that I could end up with a repeat c section and I am mentally prepared for that outcomes but it won’t be because I didn’t do the work or set myself up for the best possible scenario. It will be because it truly was necessary and that will be enough for me.
I am really looking forward to my labor. I am looking forward to the contractions and finding my rhythm with them, going off to labor land and having a pretty low intervention peaceful birth. I am looking forward to it because at one point in time I thought I’d never get to do that again but I am getting that chance and I am thankful for it. It seems so far away right now but I bet it will all be in here in no time.