VBACs, TOLACs, & ERCs

VBAC: Vaginal Birth After Cesarean
TOLAC: Trial Of Labor After Cesarean
ERC: Elective Repeat Cesarean

My next birth is something that I have thought about every day since Quinn was born. When I went in for my six week check up, the doctor who performed my c-section said I had a small pelvis and guessed that if I were to attempt a VBAC, I would have a 13% chance of succeeding. Those aren't good odds. At the time, Kelly and I just accepted it and decided that I would just deliver the rest of our children via cesarean. I never thought that I wouldn't be able to deliver babies normally, but at least I could have babies, right? I'm still one of the lucky ones. I kind of went back and forth, maybe I would attempt it, maybe I wouldn't. I think that at that time, the only reason I was considering attempting another normal birth was based on how much I hated recovering from a c-section. It seriously sucks.  The first few days of Quinn's life, I couldn't get up when she cried without someone helping me. I'm her mom, I'm supposed to be able to get to her when she needs me.

Well, Quinn got older and we had always said that once she was a year old, we were going to start trying for baby #2. She turned six months old, and I realized that I was getting so close to her turning a year old and I was starting to freak out. I was going to have to get pregnant again so soon! I finally confessed my fears to Kelly and he was like "Uhhh.. we don't have to have another baby until you want to." So then I felt relieved and kind of dumb, haha. Nobody is making me have more children right this minute. I also realized that I needed to find out as much as I could about all of these birthing options.

I had to have a wellness check up or whatever those appointments are called where they do a pelvic exam every year. I questioned the doctor at the time on his opinions about VBACs. He told me he generally didn't have a problem with them, but then when I told him that I was told that I have a small pelvis, he made it sound like I wouldn't be a good candidate. He said good candidates are usually those who had to have a c-section because of a breech baby, or a cord prolapse. After that appointment I decided I needed to find out all that I could about my chances of birthing normally.

Why is the VBAC rate so low? It's only around 8% of women who have had prior c-sections that choose to do VBACs. ERCs are basically considered benign by the general public and some doctors and they really aren't. I'll get into that later. The American Congress of Obstetricians and Gynecologists (ACOG) says: "Attempting a VBAC is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans." If it's safe, why is nobody doing it? There are some guidelines in place from ACOG that say that facilities had to be completely prepared in case of an obstetrical emergency. Not all hospitals have an anesthesiologist on the floor 24/7, so they don't allow VBACs. I'm not sure whether the interpretation of the hospitals just varies on this one.

60-80% of women who attempt to VBAC will be successful. I don't think that this means the other 20-40% of failed attempts die or lose their baby, because uterine ruptures occur .5-1% of the time. I'm guessing this means that their labor stalls or something happens where the doctors decide that it's no longer save to continue laboring, and they perform a c-section. TOLACs have a maternal mortality rate of 3.8/100,000 births.

First of all, the biggest risk people talk about with TOLACs is uterine rupture. You could have a uterine rupture, and your baby will suffer severe brain damage or die. How is uterine rupture detected? Signs include: fetal bradycardia, increased contractions, new onset of uterine pain. The most common sign is the fetal heart rate abnormality. Once the uterine rupture occurs, I found two different statistics on this, you either have 16-17 minutes or 10-37 minutes to get that baby out before it gets serious brain damage or dies. I'm guessing that they don't take the time to give moms a spinal before that emergency c-section. Knowing how bad the incision hurts the day after getting it, I can't imagine getting one without being numbed. My friend had to have one and she said they strapped her to the table. Awful. I found these statistics from the 2010 NIH VBAC Conference: of women who have uterine ruptures, 6.2% (1 in 16) result in infant deaths. Mothers who deliver at term, 2.8% (1 in 36) result in infant deaths. So I'm not sure what the difference is, maybe in the first statistic, mothers were induced? In the second one, the moms were maybe allowed to go into labor on their own? I don't know.

Like I said earlier, ERCs are generally considered to be harmless by most people. They aren't. ERCs have a maternal mortality rate of 13.4/100,000. There are quite a few risks involved, but perhaps the biggest one is the risk of placenta accreta. I had never heard of this until a few months ago. This condition occurs when the placenta attaches to the uterus right where the scar tissue is. The placenta can't get proper oxygen from the scar tissue, so it burrows deeper into the uterine wall until it finds oxygen. In some cases, if even goes through the uterine wall. Once baby is born, the placenta fails to detach properly, part or all of it remains attached after delivery and severe hemmorhaging occurs. 90% of patients with this condition require blood transfusion. 40% require more than 10 units of packed red blood cells. This condition is generally detected during pregnancy. This condition has a 7% maternal mortality rate or 1 in 533, (I found two statistics for this one too). It has a 71% hysterectomy rate. I was surprised when I read the hysterectomy statistic though because from what I read on ACOG's website, almost every time they have to do a cesarean hysterectomy in order to save the mom's life. In some cases, if the mother wants more children they may attempt to remove the placenta surgically, but that comes with a lot more risks. ACOG says that the occurrence of placenta accreta has been rising with the higher c-section rate. Of 39,244 women who had c-sections, 186 of them had cesarean hysterectomies. I found two statistics for the chances of this occurring: after 2 ERCs it's either .57% or 5.77% I found those on two different websites so I'm not sure. The first one definitely sounds better though. This risk goes up with each ERC, so family size is definitely something to take into consideration.

Why don't doctors talk about this? All they ever tell you is that you shouldn't VBAC, because your uterus could rupture. I think that doctors like to be in control. If they can go in, get that baby out and sew you back up nice and tight, then they have done their job. Healthy mom, healthy baby for the time being. If they have to sit back and let your body do it's thing, it's hard for them to know exactly what's going on.

A successful VBAC has fewer complications than an ERC, but a failed TOLAC that ends in an emergency c-section has more complications than an ERC.

Fun stuff.

They told me I have a small pelvis. Quinn's head was stuck in me and the doctor had a hard time getting her out. So what is the deal with cephalopelvic disproportion? Basically that means that the baby's head is too big for the mom's pelvis. At first I had a hard time finding out much about this subject. What I did find is that this is actually pretty rare in the US these days. It usually happens because of malnutrition in the mothers that leads to bone structure abnormalities. The only thing I could find that made sense to me, is that the baby being positioned incorrectly can lead to the pelvis failing to make room for baby's head to pass through. During labor, the body releases hormones to relax the ligaments of the pelvis allowing it to expand. There is no way to know whether my pelvis would have expanded more if I had been allowed to go into labor on my own. But I do know that Quinn was posterior, or sunny side up. I definitely think it is possible that this is why my pelvis didn't spread far enough. She was correctly positioned before my labor started, but at some point she got stuck the wrong way.

ACOG says: "The chance of having a cesarean delivery is greatly increased for first-time mothers who have labor induction, especially if the cervix is not ready for labor." Well, my cervix certainly was not ready for labor. I was at a 0 and very hard. I had high blood pressure at the end of my pregnancy, and after refusing to take the prescribed beta-blockers, they wanted to induce me. I understand why they wanted to, I had really bad anxiety with each doctor visit during the last weeks of my pregnancy. I had never had a baby before, so I was kind of freaking out! Plus, since my blood pressure was rising, I felt like I had to stay calm or else I would get a bad reading!! So of course I couldn't stay calm. They got two really high readings on two different days, so they worried and induced me. They said I might have a seizure. A few hours after I had settled into my hospital room, my blood pressure went back down to a safer range. I really believe there was no medical need for me to be induced. Baby was fine, I was fine. So right now, my I strongly feel that I have a good chance of being able to birth babies normally. I think that I will probably have high blood pressure again towards the end of my next pregnancy (my mom always had this happen, and she delivered four healthy babies normally), and I will have to just either learn to calm down or put my foot down and tell my doctor that I don't need medication for it, and I don't need to be induced. I think that when my body starts to go into labor, we will check and see that the baby is positioned properly, and if he/she is, then we will go ahead and let me labor. I plan on hiring a doula for my next birth, statistically, births that are coached by a doula are much shorter. I would definitely need time to be on my side.

Something else that bothers me, a lot of doctors tend to scoff at things that midwives do. There are seriously so many things that can be done when a baby is turned the wrong way. Why don't doctors do that?! They want you to be lying on the bed when you push your baby out, because it's easier for them to catch the baby. Squatting can increase pelvis size by up to 30%. That's significant. Somewhere along the way, a lot of invaluable birthing knowledge has been forgotten, and now some women are paying for it with their lives. The US is now ranked 50th in the world for their maternal mortality rate. For every 100,000 births, 21 women die here in the US. We should be better than that.

I know that interventions save moms and babies. I am very thankful for modern medicine. I also know that interventions occur unnecessarily all too often, causing problems that could have been avoided.

I know that I am one of the lucky ones. My baby is here, I get to hold and nurse her. I thank God every day for that blessing.

Most of the information for this post comes from ACOG's website. I initially began researching on www.vbacfacts.com and then I checked ACOG to back up most of the stats I found.