Spring 2010
English 302N13
Dr. Ellen Moody
Knowing the risks and success factors of a vaginal delivery after a ceasarean section can help determine the right candidate for a safe VBAC delivery. Cesarean deliveries can have a very painful recovery. This is one of the many reasons why some women still hope for a vaginal delivery after having endured a previous cesarean. One major risk involved in attempting a VBAC is the possibility of rupturing the uterus, which can be very dangerous. Some important factors can determine the amount of risk involved in attempting a VBAC. These factors plus other elements, can also help to find out the possibilities of a successful and safe vaginal delivery after a cesarean. Either way it is important to talk to the obstetrician to make a wise decision.
Lately the percentage of women having cesarean sections to deliver their babies increased rapidly for many reasons. Even thuogh a cesarean delivery sometimes is necessary, there are many advantages of having a vaginal delivery that many mothers still hope for even after a previous ceserean section. Having a VBAC (Vaginal Birth After Cesarean) can be safe and possbile when the right candidate attempts it. Knowing about the risks involved in a VBAC, like uterine rupture, and the factors that influence this outcome, as well as the elements that make a VBAC successful can help you determine if you are the right candidate for VBAC.
Over a year go I had the greatest joy of being a mother for the first time. One of my biggest dreams was being able to push my baby out. But, after twenty hours of labor, the doctor told me I had to have a cesarean section because I was not able to dilate enough. They took me to the surgical room and I panicked. Almost two years prior, my sister had a cesarean section performed during which she almost lost her life. She went into a coma for several hours adn then spent many days at ICU. They ended removing her uterus and with it her ability to have more babies. This had a deeper effect on me than what I had thought. At the surgical bed, I started to tremble so strong that my entire body hurt. I could not breath well, I had extreem nausea an dstarted vomiting all while they were in the middle of the surgery.
The moment I saw my baby, without doubt, is the highest point in my life. But the recovery from the cesarean was the most hopeless I ever felt. The trembling did not stop until an hour or two after surfery. I could not talk because my mother wuold tremelbe my tongue away if I dared speaking. I did try telling the nurses to help, but they quickly left me alone to "rest." The days after that were not any easier. I got sick and coughed a lot, definitely not good after you had your stomach cut open. I thought about how vaginal births are also less expensive (so I would have paid less or my insurance company would pay less) and less risky (well if you never had a cesarean section before). So my desire to hae a aginal delivery the next time only increased. However, because really the most important element to weigh are the mother's and the baby's safety (both), it is crucial to be well-informed abouty the possibilities as well as risks of attempting a VBAC.
One of the factors that count is the kind of uterine closure (cut) performed on the previous cesarean section. This can either be a single or double layer closure. According to the Obstetrics and Gynecology Study (2010), almost a ten year experimental study based on 288 mothers delivering babies, 13 of those cases ended in uterine rupture. Seven of them are associated with having a single layer closure of the uterus in the previous cesarean section (43-50). Therefore, based on this study, you have a better chance to have a safe VBAC if the cut of your previous cesarean was a double layer.
An other factor that may increase or decrease the risk of having a uterine rupture is the kind of incision you had on the previous cesarean section. I am referring to tthe kind of incision: is it a low horizontal or a high vertical or a T-shaped cut; according to which, the risk of uterus rupture may vary. According to Flam Lisa (2000), the risk of rupture is 1 or 2 percent if the previous incision was a low horizontal cut. But if you had a high vertical or a Tshaped cut, then the risks are higher and VBAC is usually not recommended (65-75).
According to Geddes, Jennifer Kelly (2001), the risks of having a rupture in the uterus increases when hormones are used to induce labor. They explain that these kind of hormones tend to make contractions a lot stronger, which then increases the possibilities of rupture. These hormones can be applied directly in the cervical area, like the ones called prostaglandins, which increases the chances of rupture 15 times. There are also the hormones that are applied intravenously, like oxytocin, which increase the risks of rupture 5 times (I5,18). Therefore it is safer to let labor progress naturally with out the use of hormones when attempting VBAC.
In general, there is less chance of a uterus rupture if the time between pregnancies is longer. Howard, Beth (Sept, 2001), says that "VBACs are safer when there has been more than 18 months between the c-section and the next delivery, according to a recent study from the Brigham and Women's Hospital in Boston" (p83). Thus it is much better to wait longer than 18 months for the next pregnancy for greater chances of a successful VBAC.
Other risks of attempting a vaginal birth after a previous cesarean include the chance of having a infection and in some cases even a Hysterectomy depending on the tearing of the uterus. This means that depending on the complications that may ensue from a VBAC, the doctor may need to take the uterus out. Also, depending on the rupture, if one occurs, there may exist the need for blood transfusions. According to MD Mark B. Landon, complications for a woman who had a cesarean delivery previously come from the ordeal and trauma of labor. He also emphasizes how the mother and her doctor must make an individualized decision (paral).
Besides knowing about the risks of attempting a vaginal delivery after a cesarean section, it is important to be informed about factors that can make that vaginal delivery a safe reality and a success. According to Tarkan Laurie (2003), VBAC became very popular in the 90's when woman learned it could be a safe procedure. But then in 2001 the rates of woman performing VBAC plummeted from 50% to 16.4% when reports said that having a uterine rupture increased when attempting a vaginal delivery after a cesarean. But experts concluded that since in some kinds of cases the rates of uterine rupture were low (1.5%) VBAC should not be eliminated. Then it was concluded that as time went on that doctors would be able to better predict success factors for a particular VBAC (para4,7).
More recently in 2008, new studies were able to predict some of those factors that influence the risk or safety of having a Vaginal delivery after a cesarean section. According to MD Mark B. Landon in 2008, maternal demographics race, age, and body mass are factors that impact the success rates of VBAC as demonstrated by their study based on 14,529 term pregnancies. He says, "Caucasian women had an overall 78% success rate compared to 70% in non-Caucasian women. Obese women are more likely to fail TOL (Trial of Labor), as are women older than 40"(para 2). White women may have had better diets and better (more expensive) care during their lives and now during the pregnancy. They may also get better care.
Another indicator for a safe (hence successful) vaginal delivery after a previous cesarean is the weight of the baby. Tarkan, Laurie (2003), describes that mothers who are delivering babies who weight less than eight pounds and thirteen ounces were most likely to have a successful vaginal delivery after a previous cesarean. She explains that not only the mother most likely won't be able to deliver vaginally but the risks of having a uterus rupture also increase (para 6). Don't overeat under pressure from general ideas of how much a baby should weigh. Your second pregnancy after a cesarean section is high risk; keep that in mind.
Tarkan Laurie (2003) also says, that according to a study published in Obstetrics & Gynecology, woman who did not develop, a fever during the days after the previous cesarean section were more likely to be successful. The reason for this is that "often, postpartum fever is associated with infection, and any wound infection is associated with poor healing" (para 6). If the wound in the uterus did not heal well, then the chance of uterine rupture increase postpartum fever.
Some of these factors may not be known until the moment of admission to the hospital; for example, labor status; cervical examination only takes place after admission. According to MD Mark B Lancon (2008) "An 86% VBAC success rate has been reported in women presenting with cervical dilation greater than or equal to 4 cm" compared to 67% when the dilation is less than 4cm. Also an 80.6% success rate was found among women who entered into labor spontaneously rather than being induced. Inducement by drugs constitutes an important counter-indication for a VBAC. Drugs make the labor stronger and hence rupture more common.
Knowledge is a very powerful tool in everyone's life, especially when a second life is involved. Mothers who hae the option to choose between having a repeat cesarean delivery or a vaginal birth after cesarean delivery must look at all their individual risks and safety possibilities; with the advice of a careful physician who pays attention to the particulars of your case, you can make a careful wise decision. Even when a VBAC is possible, you must look at the risks first.
It is crucial that each pregnant women inform/ herself and tall to her doctor about her decision. In my own experience, learning about these factors of risk and success, {opened my eyes to what my real goal is. Even though I thought my goal was to have a vaginal birth, my real goal was that of bringing home a baby home with myself and the baby both safe and healthy. Therefore, when the time comes I will make a decision whether to attempt a VBAC or not completely based on having that outcome, myself in safety with a healthy newborn. What good would a motherless baby do me? And one must think of the furture of a severely disabled baby too.
This article talked about the kind of closure, simple or double, as an important factor in predicting uterine rupture. This source was good in determining the closure as a risk factor. However, it did not give farther explanation of what the outcome would be in such a case.
The site presented attempting VBAC in general. He mentioed the major risk is uterine rupture and the kind of cesarean incision which increases the chance of rupture. This was a great source because it was brief and to the point, but it did not expand enough on uterine rupture.
Goodes talked about the risk factor in the ordeal of labor itself. He wrote that hormones were important. Inducing labor through hormones increases the risk of uterine rupture. He was good at exlpaining how hormones affected the uterus, and enables the reader to understand.
This writer and the site provides a study made based on 14,529 women who delivered or not vaginally after a cesarean. This source was very helpful, reliable and clear. It was used more than once in my paper to show how mother's demographics and the labor status at the moment of admission were factors that could predict the success of a vaginal delivery.
This article is about preeclampsia, and tells when VBAC is safe and episiotomies in general. Even though it is shorter compared to the other sources, it provides a lot of valuable information. I used it a couple times in my paper to show that the baby's weight is an important factor to predict success or not in a VBAC, and also about the risk of performing a VBAC when the mother developed fever after the cesarean