Pick your Risk: thoughts about VBAC

February 12th, 2010 § 0 comments

After posting what I did about the VBAC discussions during the workshop last week, you may be somewhat surprised about the tone I take in this post. Fasten your seat belts…

This weekend, I’ve been reading Pushed: the painful truth about childbirth and modern maternity care by Jennifer Block. Her observations on VBACs remind me of my own, while having long discussions on them with my preceptors.

In today’s world, the prevailing view is that a cesarean is almost, if not totally safe. And, in many people’s minds, even safer than vaginal birth. Midwives and homebirth advocates may sometimes sound as if we believe that vaginal birth is almost, if not totally safe, and a cesarean is one of the most dangerous thing that could befall a mother. There is another view, however—that both vaginal birth and cesarean delivery have their risks.

We confront risks daily, as we go about our lives. We make risk/benefit decisions all the time. However, often, when mothers confront the decision of how their baby will be born, they are often given a false sense of security in the form of a c-section.

Cesareans carry more than the initial risks of major (not minor) abdominal surgery, which include infection, increased blood loss (about twice that of a vaginal birth), decreased bowel and respiratory function, longer recovery time (and usually much more painful), reactions to the anesthesia, and a risk of additional surgeries. These are the initial risks to the mother, which are mentioned rarely enough. However, there are also the long-term risks that are even less often mentioned: abnormal placental implantation (risking placenta abruption, placenta acreta, percreta, increta with accompanying risk of hysterectomy), increased risk of ectopic pregnancy, adhesions (scar tissue that connects layers of tissue), infertility, and the risks and difficulty of the procedure increase with each successive section.
Then there are the risks to the baby: premature birth (if the due date was incorrectly calculated), respiratory problems, low APGAR scores, fetal injury (rare, but the baby can be nicked when the surgeon creates the incision).

Too often, mothers are given only the benefits of a c-section, without being fully informed as to the risks for now, and the risks for later (not to mention that women are rarely told how difficult it will be for them to find a supportive care provider if they ever decide they want a vaginal birth with a subsequent pregnancy!).

With VBAC come the risks of uterine rupture, of course, but only about .3% greater than with a repeat cesarean. In an out-of-hospital birth, if uterine rupture occurs, the outcome is pretty grim for mom and baby. But, on the other hand, a mother doing a VBAC in hospital is likely to encounter a set of interventions that increase the risk of uterine rupture (induction, augmentation, etc).

My take, then, on this issue is that mothers must fully inform themselves of all possible benefits and risks that accompany the various available options (in or out-of-hospital, vaginal birth, or cesarean delivery), and then take responsibility for their actions. Decide with which risk you are most comfortable, and go with it, because the truth is…we cannot eliminate risk in this world.

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