Did you know that over 90% of women who have had c-sections in the US end up with another c-section? A lot of that is patient choice, but the number is so low that end up with successful trials of labor after cesarean sections that it begs questioning. This is why we support VBAC (Vaginal Birth after C-Section) if this is what our patient wishes.
At the Kaldas Center, we seem to be noticing a pattern for the ever increasing numbers of patients who are seeking us out for consideration of a trial of labor after cesarean section (TOLAC for short).
I wish they had called it natural labor after cesarean section. Then the acronym could have been NOLAC, like no lack of effort to achieve the patient’s wishes safely! Seems that our patients and their friends are sensing that a lot of doctors may be giving lip service to the benefits of TOLAC, but that in the end almost all end up with another section.
This is unfortunate, expensive, and not good medical management. The reasons for that, when I speculate, are many and unquantifiable, but it leaves me with an uneasy feeling about how patients are being counseled and potentially feeling manipulated or scared into something they really don’t want.
Many doctors and hospitals don’t support VBAC and there are many myths surrounding the safety for mom and baby. In the last few decades, The American Congress of Obstetricians and Gynecologists (ACOG) have released studies and guidelines that deter some VBAC myths. The Kaldas Center supports VBAC because we believe the risks are much lower than originally thought.
In 2010, the ACOG released Practice Bulletin No.115 which said that VBAC are relatively safe for most women with one prior cesarean section and some women with two prior cesareans.
According to Vaginal Birth After Cesarean: New Insights, the risk of uterine rupture is much lower than originally thought. Original estimates were as high as 70%, but the latest research shows the risk to be much lower at around 1%. Earlier studies showed that risk of infant mortality as high as 25% but the same studies show the risk to be less than 10% if the uterus ruptures during labor.
TOLAC requires a great deal of commitment on the part of the OB doctor. Here I say doctor, rather than provider, because the rule is that a doctor capable of doing a cesarean must be immediately available to do that in case of uterine rupture. That is, camping out in the hospital the whole time the patient is in labor until after delivery in case the 1% happens and the uterus ruptures and the baby needs to come out fast.
Anesthesia is in house at Theda Clark 24/7 since it is a trauma center, so that is not an issue as it is at other hospitals where they may try really hard to talk people out of TOLAC. This situation can be very scary in those situations. I know, I’ve dealt with five uterine ruptures over the last 20 years caring for my OB patients.
Thankfully, all the babies were fine because of a decisive team effort in each of those situations. The rule of thumb is that the team has 30 minutes to have the baby out if uterine rupture is suspected. Well, if we did an experiment and all held our breath for 30 minutes that wouldn’t go so well. So Rami-rule at the Kaldas Center is try to make that 10 minutes. Sometimes such rapid action is not physically possible, but we think it should be tried for the sake of everybody involved.
Then there is the issue of this being a team effort. The Kaldas Center is a close knit team. We have a single philosophy on TOLAC and will support our patients in their decision to pursue a natural birth after cesarean if that is what they wish after they’ve been counseled on the risks, and potential benefits.
Yes, there are benefits. This unified philosophy and desire to champion the couple’s wishes is very important. It is at the heart of sound and supportive doctoring.
Usually, in large groups, such an approach is impossible. Say, when your own doctor is no longer on call and has to go pick up her kids or whatever, the on-call doctor may wish to avoid risk, or get home for dinner, or avoid dealing with an emergency situation that she or he is not feeling comfortable with so they come in and start scaring the patient into another cesarean. Sad to say, it happens and we’ve all heard the stories.
Not all patients are great candidates for TOLAC. If a woman had a persistent occiput posterior (sunny side up) baby the first time and pushed 4 hours and still did not get the baby out or at least low enough to help out safely with forceps or a vacuum (if that is what she wanted) then TOLAC is less likely to succeed. This doesn’t mean that it is impossible, since the baby may come down face down this time round. If the first baby was huge and a natural delivery was not possible, then if this baby is huge it is unlikely to work this time. However, the OB needs to really explore the story of that first cesarean.
I’ve had patients have “emergency” cesareans even when the head was showing already with no attempt to help the baby around the corner the rest of the way. I’ve had patients who were induced because of the OB’s vacation schedule and not even given a fair chance to get into labor before a cesarean was done. Not throwing any stones, but just to say these patients almost all went on to have a fulfilling, empowering, safe natural delivery after prior cesarean.
It all comes down to safely putting the patient’s wishes before your own convenience as an OB doc, knowing what you are doing so the doc can have a keen and accurate sense of when badness is happening to achieve the perfect baby every time. We know life is not perfect, but we can do our best to make it as perfect as possible every day.
Educate Yourself and Talk to Your Provider
We always encourage patients to educate themselves when it comes to their healthcare. Every woman deserves the best health care that’s best for her. Educate yourself on VBAC and talk with your doctor if you want a VBAC. You deserve the birth that YOU want.