Here is a list of the risks and benefits of each. Talk to your doctor or midwife, and to your husband, as you decide about choosing a VBAC (vaginal birth after cesarean) or a repeat c-section.
VBAC vs. Elective Repeat Cesarean: Risks and Benefits
• Uterine rupture (less than 1%; in some studies only 5 per 1,000). In the event of a rupture, the following apply:
1. Risk of maternal death is less than 1% (about 3 in 27,000 VBAC labors)
2. Increased risk of maternal infection
3. Need for blood transfusion
4. Hysterectomy (3.4 per 10,000 VBAC labors)
• Same risks of any mother with no previous cesarean planning a vaginal delivery
• Risk of fetal death about 3 per 10,000 VBAC labors
• Some studies indicate increased risk of brachial plexus injury and intrapartum asphyxia
• Less blood loss
• Shorter hospital stay/faster recovery
• Fewer infections and fevers
• Fewer blood clots
• Lower risk of placenta problems (previa, accreta) in future pregnancies
• Significant cost savings for current and future births
• Mom participates more with baby care
• Lower risk of respiratory distress
• Benefits of labor contractions and hormones
• Mom participates more with baby care
• Shorter hospital stay
ELECTIVE REPEAT CESAREAN RISKS
• Surgical injury to bladder, uterus or other organs (2%)
• Hemorrhage (1% - 6% require a blood transfusion)
• Anesthesia complications
• Pulmonary embolism (1 to 2 per 1,000),
• Higher risk of infection compared to vaginal birth
• Scar tissue and adhesions can lead to chronic pain and bowel problems
• Increased risk of placenta previa and accreta in future pregnancies
• Increased risk for future ectopic pregnancies
• Increased risk of maternal death (2–4 per 10,000 surgeries compared to .5–1 per 10,000 for successful VBAC)
• Increased risk of uterine rupture during future pregnancies, even without labor
• 1.67 times more likely to have stroke within 3 months of birth
• 2 to 4 times more likely to have respiratory distress
• Increased incidence of asthma in childhood and adulthood
• Risk of being cut during surgery
• Higher rate of NICU admission than vaginally-born infants
• Some studies indicate higher rate of neonatal mortality
ELECTIVE REPEAT CESAREAN BENEFITS
• No labor pain or discomfort, although significant pain after surgery.
• Lower rate of infection than if cesarean was performed after the onset of labor
• Full night’s rest before birth
• Choose baby’s birthday
• Some studies indicate overall perinatal mortality similar for both elective repeat cesarean and VBAC
• Further data and research is needed, but some studies indicate there may be lower risk of brachial plexus injury, neonatal sepsis, intracranial hemorrhage, intrapartum asphyxia, and neonatal encephalopathy
VBAC vs. ERC: Risks/Benefits, Desire/Confidence
(thanks to Jackie Mysak, Birth Doula, www.yourbirthpartner.com)
Latest Medical Research indicates that VBACs after multiple c-sections have the same risks as those after only one.
Meet "Dr. T" from Atlanta Georgia.
Choosing a Primary Caregiver
One of your first goals is to find a caregiver with whom you feel comfortable and who shares your philosophy of birth. Your caregiver should respect your wishes and will agree not to override your decisions even if she or he would personally choose something else.
It is important to find a caregiver who understands and supports the kind of birth for which you are striving and is prepared to help you towards that goal. When making your first appointment, tell the receptionist that you wish for consultation rather than an examination. Once you have selected a caregiver, it may also be necessary to meet his or her partners in the event one of them attends the birth if the caregiver you are seeing is not on call.
Direct Entry Midwife (DEM)
Also called Registered Midwives (RM), Traditional Midwives or Certified Midwives (CM), they enter the field of midwifery through an apprenticeship, community-based training, or a field other than formalized nursing education. They have a long-standing commitment to women’s health care and experience-based training. Most often, DEMs provide care to women giving birth at home, though that is changing as birth centers become more popular and where DEMs are granted admitting privileges (several provinces in Canada, the UK, etc.).
Midwives are specialists in normal pregnancy and birth. Midwives view birth as a safe and normal passage in a woman’s life. They instill pride and confidence in women and consequently you are less likely to experience interventions during your pregnancy and birth. A midwife provides "continuity of caregiver" which means she supplies all your care form early pregnancy, through the birth and into the postpartum. Usually your primary midwife works with a back-up midwife who comes later in labour to join your midwife for the birth.
Certified Nurse-Midwife (CNM)
CNMs are Registered Nurses who have taken their post-baccalaureate specializing in midwifery and are unique to the US. CNMs practice in public, private, university, and military hospitals. They work in health maintenance organizations, in private practices, and in birth centers. Many nurse-midwives work in public health clinics, while others choose to provide home birth services. Nurse-midwives are also active in international health programs, working worldwide to improve the health of women and children.
CNMs practice in collaboration with physicians. The degree of collaboration in this team approach depends on the medical needs of the individual woman and the practice setting. For example, a nurse-midwife providing care for a women whose pregnancy is at low risk for complications may need no physician input. That same nurse-midwife providing care to a woman at higher risk would have more contact with the collaborating physician.
Primary Care Physician (PCP) or General Practitioner (GP)
Primary Care Physicians deliver basic or general care that is intended to be the patient’s first level of contact with the medical care system. Primary care physicians attend to the general health-care needs of the entire family. Trained in every major area of medicine, they serve as the primary source of a patient’s health care throughout life. When appropriate, PCPs refer their patients to specialists such as obstetricians or perinatologists. Primary care physicians may specialize in areas such as family practice, obstetrics, anesthesiology, or pediatrics.
An obstetrician is a physician who has successfully completed specialized education and training in the management of pregnancy, labor, and pueperium (the time-period directly following childbirth). A gynecologist is a physician who has a successfully completed specialized education and training in the health of the female reproductive system, including the diagnosis and treatment of disorders and diseases.
Typically, the education and training for both fields occurs concurrently. Thus, an obstetrician/gynecologist is a physician specialist who provides medical and surgical care to women and has particular expertise in pregnancy, childbirth, and disorders of the reproductive system. This includes preventative care, prenatal care, detection of sexually transmitted diseases, Pap test screening, and family planning.
An OB/GYN, can serve as a primary physician and often serve as consultants to other physicians. Should you select an OB as your primary caregiver, the likelihood of experiencing interventions is increased as they are trained in surgery and tend to view birth from a pathological viewpoint. The use of obstetricians for a normal low risk woman is unnecessary because of the increased chance of intervention as well as limiting the obstetrician’s availability for high risk women genuinely in need of their service.
Perinatologists are maternal fetal medicine specialists. A midwife, primary care physician or obstetrician can handle most pregnancies, as complications are rare. When complications are anticipated because of the mother’s medical history, or if they crop up during the pregnancy and threaten to affect the health of the fetus or mother, a specialist may be required. The perinatologist, a specialist in maternal-fetal health, is the person who often receives these referrals. The referrals are frequently made when the mother’s health provider wants her to receive care where there is a neonatal program.
In addition to basic obstetrics and gynecology training, the perinatologist has completed a two-year or three-year clinical and research fellowship. During this fellowship, he or she receives advanced training in comprehensive diagnostic ultrasound imaging of the fetus.
Many perinatologists also develop diagnostic skills and can perform complicated procedures when serious fetal disorders are suspected.
History and Regulations
During the past 50 years, many pregnant women have chosen obstetrics for their method of care and midwifery experienced a decline. Within the last 10 years, there has been a push to standardize the education of DEMs through certification and credentialing. Midwifery is currently experiencing an upswing in popularity.
Laws and regulations governing the practice of nurse-midwifery and midwifery are rapidly changing. Midwives are regulated on the state or provincial level in the US and Canada, thus professional practice and interaction with other health care professionals, such as physicians, can vary. New Zealand allows midwives complete autonomy, meaning that midwives do not have to have backup or work in a shared care arrangement with physicians. Find out what options are available in your area.
Once you have established who you will have as your caregiver, take your Doula to meet him or her. Everyone will be more comfortable at the birth if they have met beforehand. If at any time you become uncomfortable with your caregiver, feel free to change. It is never too late, women have been known to change during their labours! Women often feel that changing would be disloyal, but remember you are a consumer and you cannot afford to compromise your health or the health of your baby. Even if health and safety are not a risk you still have the right to a personal, satisfying birth experience. If you thought the mechanic working on your car was compromising your personal safety or simply not listening to your concerns, you wouldn’t hesitate to find a different mechanic!
You should feel free to ask any potential caregiver any questions you may think are relevant to your care, such as:
What is your training and how many births have you attended?
How do I contact you between visits if I have any concerns?
How do I contact you when I am in labour?
How much time do you normally spend with a labouring woman?
If a woman is in labour and you are not there, who provides her care?
Do you have a working relationship with another doctor/midwife if needed? Who and where? What happens in the event that you are unavailable?
Do you do prenatal checkups? How often? Do you do postpartum checkups?
Do you offer prenatal classes? Where are they held?
How will you assist me in preparing for labour?
What percentage of women receives episiotomies in your practice? How do you prevent the need for episiotomies?
What percentage of women receives cesarean sections in your practice?
How long does it take, on average, to prepare for a cesarean section?
What do you do in emergency situations?
Do you encourage family-centered maternity care? How do you see this working in practical terms?
Are medications available?
How do your services differ from that of other birth attendants?
Do you offer water births?
What is your policy on informed decision-making by the parents?
This may be copied and distributed with retained copyright. © International Cesarean Awareness Network, Inc. All Rights Reserved.
May 24, 2009
A new study entitled Neonatal Outcomes After Elective Cesarean Delivery published in the June issue of Obstetrics & Gynecology (aka “The Green Journal” published by American College of Obstetrics & Gynecology (ACOG)) concluded that:
“In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay.”
The journal article begins with the following introduction:
“In 2006, the United States cesarean delivery rate of 31.1% was at an all-time high, making cesarean delivery the most common surgical procedure performed in American women. This high rate of cesarean delivery is attributed to the rise in primary cesarean delivery rates from 14.6% in 1996 to 20.3% in 2005, an increase of 60%. With the rates of vaginal births after cesarean delivery (VBAC) at an all-time low of 7.9% in 2005, women who have a primary cesarean delivery have a greater than 90% chance of having a repeat cesarean delivery, only serving to increase the overall cesarean delivery rate. Almost one half of cesarean deliveries, a rate of 15%, are done electively, before the onset of labor.”
This study found that neonates born by intended cesarean delivery were more prone to NICU admission for:
1) hypoglycemia (low blood sugar),
2) needing higher rates of oxygen supplementation,
3) needing intubation/ventilator support
This study’s findings were consistent with the multiple studies previously done that documented respiratory morbidity in neonates born after elective repeat cesarean delivery, particularly with an increase in:
1) respiratory distress syndrome,
2) transient tachypnea of the newborn,
3) persistent pulmonary hypertension,
4) need for supplemental oxygen
5) respiratory morbidity related to failure to clear fetal lung fluid related to birth without benefit of labor
The authors write:
“While the common perception is that conditions such as transient tachypnea of the newborn are benign, self-limiting illnesses, several studies indicate that neonates with such conditions can progress to severe respiratory failure, leading to the need for extracorporeal membrane oxygenation or death.”