A Plea for VBAC Education

The United States has the highest rate of cesarean sections in the world, accounting for 30% of all births in the early 1990's. This rate has increased tremendously since 1970, where only 5.5% of all births were cesarean. Much of this increase is due to repeat cesareans, following the 1916 rule of "once a cesarean, always a cesarean." Procedures have changed a lot since then, most notably the use of low horizontal incisions versus the higher classical vertical incisions.

The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP) would like to the reduce the number of repeat C-sections by encouraging mothers with a previous C-section to undergo a trial of labor, otherwise known as a vaginal birth after cesarean (VBAC).

There are a number of benefits to delivery by VBAC rather than repeat cesarean:

• Lower risk of infection. It is obvious that surgically opening up the abdomen will expose it to more germs through the air and imperfectly sterilized medical equipment, as compared to a natural birth.
• Less uterine scarring. Multiple uterine scars increase the probability of placenta accreta, where the placenta adheres to the uterus more than normal, causing hemorrhage during birth, possibly leading to maternal death.
• Decreased pain, increased mobility and faster recovery. The cesarean section is a major surgery requiring bed rest, pain medication, and restricted activities for months. A VBAC mother can resume normal activities in a day or so.
• The ultimate feminine experience. Natural birth is perhaps the most intense physical and emotional experience that a woman can have: the coaching, the breathing, the concentration, the squeezing, the pain; the relief of birth, the tears of joy when hearing the newborn's first cry, and immediate bonding between the mother and the newborn.
• Lower cost. A vaginal birth costs about half ($2500) of a cesarean birth ($5000). This is obviously of interest to the insurance companies and HMO's, who are obsessed with reducing medical costs.

However, VBACs are not without their risks, the most significant being uterine rupture.

Much of the medical literature says that the occurrence of uterine rupture is "very rare." The same literature acknowledges the rate of uterine rupture in VBAC deliveries to be 0.7%, or 1 in 140. When you take into account uterine dehiscence, the probability of uterine scar separation goes up to 1 in 70. This starts to get scary. You'd easily be a millionaire if the chances of winning the lottery were 1 in 70.

Of course, some uterine scar separations are "without incident." In a uterine dehiscence, the scar stretches perhaps to the point of translucency, but does not rip. This normally does not cause a problem. A uterine rupture, on the other hand, is a bursting of the uterus, exposing the fetus to the hostile environment of the interabdominal cavity.

The exact mechanism for the cause of the resultant fetal distress due to uterine rupture is not known, but a frequent consequence is oxygen deprivation to the fetus. Irreversible brain damage results from greater than seven minutes of oxygen deprivation, with outcomes running the gamut: learning disabilities, cerebral palsy, a state of permanent vegetation, or death.

On the maternal side, a uterine rupture could cause internal hemorrhage, which, if not rapidly diagnosed, could lead to death in minutes.

The good news is that a uterine rupture can have minimal maternal and fetal consequences if the VBAC delivery is appropriately managed. ACOG says, "plans for appropriate management, rapid diagnosis, and immediate intervention should be in place prior to undertaking a trial of labor." This means that the fetal heart rate should be monitored continuously, especially during second stage of labor. Virtually all uterine ruptures coincide with a sharp drop in fetal heart rate. Recession of the fetal head and bulging of the abdomen are the most accurate signs of uterine rupture. Other symptoms, such as acute abdominal pain and vaginal bleeding reinforce such a diagnosis. Upon recognition of such ominous signs, immediate surgery should be undertaken to assure a good maternal and perinatal outcome.

Unfortunately, the word is not out to the whole obstetric community. A comprehensive survey of obstetric textbooks at Stanford's Lane Medical Library shows that very few cover the management of VBACs, with Flamm's 1980 book, Birth After Cesarean, being one notable exception. ACOG has a 1994 committee opinion about VBACs and a 1994 book, Precis V: An Update in Obstetrics and Gynecology, which have a few paragraphs about VBACs. Most of the other textbooks merely refer the reader to the ACOG opinion paper. All the detailed and useful information lies in more inaccessible journals such as the International Journal of Gynecology and Obstetrics and the American Journal of Obstetrics and Gynecology. I doubt that most practicing obstetricians keep abreast on these journals.

We probably know a lot more about this subject than many practicing obstetricians. This knowledge was accumulated over the last year and a half since the difficult birth of our daughter, Catherine Grace. She was born after a uterine rupture, causing oxygen deprivation that resulted in extensive damage to her brain, including the brain stem. Her blood pH was 6.6, a level described by one of the nurses as "incompatible with life." She was put on a ventilator and heavily sedated to control seizures. She died after suffering three months of feeding intolerance and spastic quadriplegia. The cost for her care approached $200,000.

The delivery was performed at Stanford University Hospital, a tertiary care institution that is equipped to handle high-risk deliveries. During the second stage of labor, the fetal heart rate dropped drastically, the crowning fetal head receded, my wife Rita felt near-coincident acute abdominal pain, and her abdomen bulged asymmetrically. About a half hour later, our [former] obstetrician performed an emergency cesarean and was shocked to find the fetus's head and shoulders protruding into the abdomen. Until this point, she was clueless that a uterine rupture had occurred.

One might make the point that this was a rare emergency condition, and that the probability always exists that complications will occur. However, without complications, nearly anyone can assist a delivery; it is up to the professional obstetrician to recognize the problem cases and take appropriate action.

Our plea in this essay is to educate the obstetricians about appropriate management of VBACs before undertaking one. Completion of a certified course in VBAC management should be mandatory to perform a VBAC delivery. Obstetric textbooks and courses should be updated to include VBACs and uterine ruptures. An operating room should be on standby readiness for each VBAC delivery in case an emergency C-section is required.

We would like our daughter's life not to have been sacrificed in vain. It is our hope that obstetricians around the world will learn from our case, so that future VBAC mothers can be assured that they are in the hands of a competent professional.