I’m going to get a bit political today. If you’re not into that, skip this post. There is so much going on about healthcare reform in the media and I can’t help but notice there isn’t much mention of improving the sorry state of pregnancy-related care and maternal/fetal outcomes. No one is talking about the continued restriction of valid childbirth options for women with a history of c-section. Yes, I’m talking about VBAC.
VBAC, short for vaginal birth after cesarean, is a valid healthcare option for pregnant women in low risk categories. According to Childbirth Connection.org:
“If you do not have a clear and compelling need for a cesarean in the present pregnancy, having a VBAC rather than a repeat c-section is likely to be:
- safer for you in this pregnancy
- far safer for you and your babies in any future pregnancies”
Most OB’s and hospitals that refuse to support VBAC do so citing concerns about uterine rupture. And while this is a possibility, educating women about risks and benefits is vital to informed consent of patients. To be vital, informed consent requires patients (in this case women) the option of informed refusal. It is the right of every person to make healthcare decisions personally. Each pregnant woman, therefore, should also have the same right to choose what she will and will not accept as part of her individualized care. She can choose to accept or refuse induction, epidural, ultrasound, fetal monitoring, IV. She has the right to change her mind, even during labor.
Let’s look at the risks associated with uterine rupture during VBAC (from this article at ChildbirthConnection.org):
“What is the added likelihood that the scar will give way (uterine rupture) during a VBAC labor?
Best research suggests that an extra 27 women experience a ruptured uterus in every 10,000 VBAC labors, compared with planned c-section deliveries. Thus, nearly 400 women would need to experience surgical birth to prevent one instance of uterine rupture during VBAC labors. While the scar giving way usually requires an urgent cesarean, loss of the baby is much less common (see next paragraph).
Added likelihood for a woman with a known low-transverse (horizontal) scar: MODERATE for scar rupture compared with planned repeat c-section.”
“What is the added likelihood that the baby will die as a result of the scar giving way (uterine rupture) during a VBAC labor?
Best research suggests that about 1.4 extra babies die due to problems with the scar in every 10,000 VBAC labors, compared with planned c-section deliveries. Thus, over 7,000 women would need to experience risks of surgical birth to prevent the death of 1 baby from scar problems during VBAC.
Added likelihood for a woman with a known low-transverse (horizontal) scar: LOW for death of the baby around the time of birth compared with repeat c-section.”
To fully understand the risks associated with VBAC and make an informed decision women must also comprehend the risks to mother and baby for repeat cesarean birth. (From this article at ChildbirthConnection.org)
“Extra risks associated with cesarean section: Current research suggests that cesarean section has the following disadvantages in comparison with vaginal birth:
Physical problems in mothers: Compared with vaginal birth, cesarean section increases a woman’s risk for a number of physical problems. These range from less common but potentially life-threatening problems, including hemorrhage (severe bleeding), blood clots, and bowel obstruction, to much more common concerns such as longer-lasting and more severe pain and infection. Even after recovery from surgery, scarring and adhesion tissue increase risk for ongoing pelvic pain and for twisted bowel.Hospitalization of mothers: If a woman has a cesarean, she is more likely to stay in the hospital longer and is at greater risk of being re-hospitalized.
Emotional well-being of mothers: A woman who has a cesarean section may be at greater risk for poorer overall mental health and some emotional problems. She is also more likely to rate her birth experience poorer than a woman who has had a vaginal birth. {Note: This risk is reduced somewhat for planned cesarean birth.}
Early contact with, feelings toward babies: A woman who has a cesarean usually has less early contact with her baby and is more likely to have initial negative feelings about her baby.
Breastfeeding: Recovery from surgery poses challenges for getting breastfeeding under way, and a baby who was born by cesarean is less likely to be breastfed and get the benefits of breastfeeding.
Health of babies: Babies born by cesarean are more likely to:
- be cut during the surgery (usually minor)
- have breathing difficulties around the time of birth
- experience asthma in childhood and in adulthood.
Future reproductive problems for mothers: A cesarean section in this pregnancy puts a woman at risk for future reproductive problems in comparison with a woman who has a vaginal birth. These problems may involve serious complications and medical emergencies. The likelihood of experiencing some of these conditions goes up sharply as the number of previous cesareans increases. These problems include:
- ectopic pregnancy: pregnancies that develop outside her uterus or within the scar
- reduced fertility, due to either less ability to become pregnant again or less desire to do so
- placenta previa: the placenta attaches near or over the opening to her cervix
- placenta accreta: the placenta grows through the lining of the uterus and into or through the muscle of the uterus
- placental abruption: the placenta detaches from the uterus before the baby is born
- rupture of the uterus: the uterine scar gives way during pregnancy or labor.
Concerns about babies in future pregnancies: A cesarean section in this pregnancy can affect the babies of future pregnancies. Studies have found that they are more likely to:
- be born too early (preterm)
- weigh less than they should (low birthweight)
- have a physical abnormality or injury to their brain or spinal cord
- die before or shortly after the birth”
When women are fully informed of the risks associated with repeat cesarean and VBAC, they should each have the opportunity to choose which risks they are willing to take. When a doctor refuses to “allow” his patients to attempt VBAC, s/he is taking away a fundamental right of women to determine the direction of their healthcare.
According to ACOG’s Committee Opinion #321 from November 2005, respecting patient’s autonomous decision making is a fundamental ethical obligation:
“Requiring informed consent is an expression of respect for the patient as a person; it particularly respects a patient’s moral right to bodily integrity, to self-determination regarding sexuality and reproductive capacities, and to the support of the patient’s freedom within caring relationships.”
“The ethical requirement for informed consent need not conflict with physicians’ overall ethical obligation to a principle of beneficence; that is, every effort should be made to incorporate a commitment to informed consent within a commitment to provide medical benefit to patients and thus respect them as whole and embodied persons.”
“[Even if] a woman’s autonomous decision [seems] not to promote beneficence-based obligations (of the woman or the physician) to the fetus, … the obstetrician must respect the patient’s autonomy, continue to care for the pregnant woman, and not intervene against the atient’s wishes, regardless of the consequences.“(emphasis mine)
“The obstetrician must keep in mind that medical knowledge has limitations and medical judgment is fallible” and should therefore take great care “to present a balanced evaluation of the expected outcomes for both [the woman and the fetus].”
So how can it be true that women have the right to make autonomous choices regarding their healthcare, including care during pregnancy and childbirth, yet doctors choose to ignore and even ban valid healthcare options for these same women?
This is about women’s rights. A woman doesn’t stop having the right to bodily integrity because she is pregnant. She maintains the right to independent thinking, personal preference, and choice throughout the 40+ weeks gestation. Choosing to bring a child into the world doesn’t limit my right to individualized care or informed consent. In fact, choosing to bring a life through my body has made me more focused on what is appropriate and acceptable risk to me and my baby- and this is a very personal choice.
I should always have the final say about what is ok and not ok for my body, and any baby residing within it. And that’s what I teach my girls.
Who does your body belong to?
Thank you. But you need not apologize for getting political. VBAC issues are intensely political, personal, emotional, etc. and they need desperately to be talked about.
Great post with tons of great information! I’m working on getting info out to the OBs/hospitals and general public in my area about VBAC. I attempted a VBAC a year ago and feel that I was not fully supported and was given the “sure, you can VBAC…if you do this..this..this..and this” all of which did not make for a “natural birth”. I look forward to following your future posts!
Brandi
Karen,
I couldn’t agree with you more. It seems that amidst all the flurry with Health Care Reform, Women’s health has been cast aside. The only issue addressed is abortion and legislation is even trying to limit and/or do away with that!
VBAC is just one area in which women are continuously having their rights ignored. Until US health care comes to understand that woman’s health does not lend itself to the mechanized, scientific procedures preferred (As evidenced by the number of labor inductions, cesareans, and hysterectomies) in our “privatized” commercial health care system and return to sound practices that promote natural health, we will continue to see the rises in maternal and infant mortality, women will continue to lose their uteruses and we will all continue to be the hormonal, confused messes that these procedures, performed excessively and often unnecessarily, produce.
A friendly business associate of mine had a C/S five years ago during the birth of her one (and only, by choice) child.
Ever since her recovery from the C/S she has struggled with abdominal pain. She’s been worked up by urologists, OB/GYNs, gastroenterologists, pain specialists, and even a psychiatrist. Recently, she underwent laparoscopic abdominal exploratory surgery. This revealed both endometriosis (expected) and the fact that her bladder had been sutured to her uterus during the C/S (surprise!).
Medically justified though her C/S might have been, this is NOT a surgery one should undergo unnecessarily without careful consideration. (Though malpractice of this nature is, I sincerely hope, very rare.)
Another interesting fact is that the risk for uterine rupture is comparable to the risk of a miscarriage after an amniocentesis and you don’t see people stopping those anytime soon.
it all starts with the clock in the hospital. Not giving you enough time to birth, scaring women with doctor lingo and stressing them out so their labor comes to a complete halt. and then the inductions which don’t give you or the baby a break and time to breath as does natural labor. Then comes epidurals to numb the body because the fake hormones they pump your body slow your labor and do not break the brain blood barrier so you are not benefiting from them. Then comes the fetal distress which leads to emergency c section. Which leads us right into the VBAC discussion.
Another interesting point to notice is that electronic fetal monitoring constant or intermittent is not effective as we think it is. World Health Organization recommends intermittent Doppler monitoring.
I honestly think ACOG (American College of Obstetrics and Gynegology) is the real reason we are decades behind in this field because of their backwards thinking. They set the tone for cesareans and wrote papers and guidelines that hospitals will follow.
I’ve been reading Pushed by Jennifer Block, Childbirth Without Fear by Grantly Dick-Read and Hypnobirthing the Mongan Method by Marie Mongan.
Claire, you couldn’t be more spot on! All of the unneccessary interventions just scare women into cesarean. You would’ve never needed it had they never intervened and let your body birth and prepare the way it needs to. I don’t know if you saw the documentary “The Business of Being Born”, its by Ricki Lake and was very informative and amazing.
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