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Taking back your birth Labor & Delivery

Taking back your birth

Once a C-section, always a C-section, right? Not necessarily. Just because your first baby was born in an OR doesn’t mean your next one has to be.

Three years ago, while expecting my first child, I read every pregnancy book I could get my hands on to prepare myself (as much as one can) for a smooth delivery. When I went into labor one day after my due date, I was feeling confident. But after 12 hours, I was whisked away for an emergency C-section because our baby’s heart rate dropped as my labor progressed. Thankfully, our son was born beautiful and healthy—by all accounts, perfect. Still, a part of me was devastated.

I was unprepared for the physical recovery of a C-section, and I couldn’t reconcile the feelings of failure that lingered for months after his birth. Before we had even left the hospital, I was determined that my next delivery would be different.

The rise of C-sections
Cesarean deliveries account for almost a third of all births, according to the Centers for Disease Control and Prevention (CDC). They’re most commonly performed when labor has stalled, when the baby is in a position that makes vaginal delivery difficult or impossible, or when there are indications that your little one isn’t getting enough oxygen (based on a lack of movement, an abnormal heart rate or a bowel movement in utero).

Anastasia Leyden, a mom of two in Melrose, Massachusetts, had planned for an intervention-free birth but was labeled with “failure to progress” after enduring 36 hours of early labor. “The word ‘failure’ captures my dismay at opting for a C-section,” says Leyden. “I was not prepared for the very sterile and impersonal nature of the birth.”

Despite feelings of regret, when baby or mom is truly at risk, a C-section can be a lifesaving choice. Romiya Barry, a mom of two in Groton, Massachusetts, found herself facing an early induction because of potential intrauterine growth restriction. When her baby began to show signs of distress during labor, she was taken for an emergency C-section. Barry is thankful that her daughter, born six weeks premature, is alive and well. Still, she says, “I felt that everything was rushed and that there was little time for me to process it. Even though I was physically present, I missed out on my daughter’s birth. I felt robbed.”

After having a cesarean delivery, mothers often assume that any future pregnancies will end in the operating room—and many medical professionals follow that protocol. “The No. 1 reason for C-sections is a repeat C-section,” says Katherine Economy, MD, a maternal-fetal medicine specialist at Brigham and Women’s Hospital in Boston and instructor at Harvard Medical School.

However, surgery isn’t the only option. Many women are good candidates for a trial of labor after cesarean (TOLAC); that is, they can attempt to have a vaginal birth after cesarean (VBAC).

Weighing the risks
In recent years, there’s been a push from the American College of Obstetricians and Gynecologists (ACOG) to both decrease the rate of primary C-sections (the number of women having a first C-section) and increase the rate of VBACs in an effort to curb the total number of cesarean deliveries. And according to the CDC’s preliminary data on 2014 births, it’s working. Last year the overall cesarean delivery rate was 32.2 percent—a 2 percent decline from 2013 and the lowest rate since 2007.

Economy suggests that hospitals are seeing more women requesting a TOLAC largely because of increased awareness and open dialogue between patients and their health care providers.

Still, according to the latest statistics from the CDC, only 20 percent of women who previously delivered by C-section attempted a TOLAC in 2013. The rest chose to schedule a repeat C-section.

Given that the odds are in their favor—ACOG cites a 60-80 percent success rate —why aren’t more moms attempting a TOLAC? As with any pregnancy, there is always a chance that surgery will become necessary, and some women don’t want to labor only to end up in the OR again, says Cecilia Jevitt, PhD, CNM, associate professor and midwifery specialty coordinator at Yale School of Nursing.

Access also plays a huge part. Smaller hospitals or birthing centers often require repeat C-sections because they don’t have round-the-clock resources to handle an urgent surgical delivery should complications occur. Many women would rather schedule a repeat section than switch to a new provider or hospital, explains Economy.

The main TOLAC complication that worries moms and providers, though? Uterine rupture. This happens when there’s a tear in the wall of the uterus, often at the site of a scar from a previous C-section incision. “Although the risk is only about 0.5 percent to 1 percent in women who are good candidates for VBAC, it can be catastrophic when it happens,” says Economy. When the uterus ruptures, the baby is deprived of oxygen and has to be immediately delivered surgically to prevent brain damage. Mom can face significant blood loss or a hysterectomy. Uterine rupture is rare, but when it occurs, both mom’s and baby’s lives are in danger.

“No one wants harm to come to mother and baby,” says Jevitt, which is why a TOLAC should occur in a hospital equipped to handle emergency deliveries.

ACOG stresses that patient selection is key to keeping the risk of uterine rupture low and VBAC success rate high. A failed TOLAC carries a greater risk for mom and baby compared with a repeat C-section because surgical delivery after laboring can mean more bleeding and a greater risk of infection.

C-sections, like any major surgery, are not without inherent risks, but they also have long-term effects as far as future pregnancies are concerned. For example, placental abnormalities, like placenta previa (where the placenta is too close to the mother’s cervix) and placenta accreta (where the placenta attaches to the wall of the uterus), are more likely to occur. Plus, the risk increases with each additional C-section.

Is it right for you?
Choosing to try for a vaginal birth after having had a C-section is a personal decision for moms, but that doesn’t discount the importance of her support system. Jevitt suggests using a doula or midwife could also help lead to a successful VBAC. Both provide much needed personal support that can aid in avoiding unwanted interventions during labor. “Supporting a labor after a C-section requires time and patience,” she says. “The more informed a woman is and the more support she has, the better her [chances of] success.”

If you’re interested in a VBAC, talk to your doctor about your options. She can weigh in with advice specific to you. Various factors affect whether a woman is deemed a good candidate for a TOLAC: the length of time between your pregnancies, if you’ve delivered vaginally before, if you go into labor without being induced and if the reason for your last C-section will likely occur again. Body mass index (BMI), age and ethnicity also come into play.

Once you’re in the throes of labor, there will be a few differences for TOLAC moms. Economy notes that most providers will monitor the baby more closely, as fetal distress can be an early indicator of uterine rupture. They’ll also watch for “loss of station” (when baby’s head has migrated out of the pelvis) and signs of internal bleeding in the mother.

Induction isn’t always an option because it slightly increases the risk of uterine rupture, says Economy. However, some doctors may be willing to use a low dose of Pitocin in certain cases.

Your perspective and involvement can make the entire process a lot easier. “If you want a VBAC, you have to be motivated and engaged,” says Economy. “Make sure you’re a good candidate, understand the risk and that there are no guarantees, and be patient with the process.”

Ultimately, a healthy baby and mom are what matter. If it doesn’t work out, it’s not a failure. It’s just another path to bringing baby into the world. Although Leyden had hoped for a VBAC, she agreed to a second C-section after finding out her daughter was transverse (sideways) and measuring large, but she credits her VBAC prep with helping her stay calm and present during the procedure. “Whether you have a vaginal birth or an elective or emergency C-section is not a reflection on your character or abilities as a mother,” she says.

Almost 23 months after the birth of our son, we welcomed our daughter through a successful VBAC. Throughout my pregnancy, my OB was supportive, answering questions and explaining risks and benefits. During labor, my husband, a terrific nursing staff and the on-call doctor (another OB from the same practice) helped me remain calm and confident. The birth was a healing and rewarding experience that I wish any woman who desires a vaginal birth could have. But looking at my children today, no one can tell that they came into the world with such different deliveries—because they are both healthy, happy and abundantly loved.