VBAC or Scheduled c-section?
May 2, 2011 8:11 AM   Subscribe

I'm expecting my second child at the end of June and need to decide whether to try for a VBAC or schedule a C-section. I hear a lot of anecdotes about why one is better than the other, but would really love some hard data to help me weigh the pros and cons.

My doc is awesome, but she hasn't been able to help me objectively weigh the pros and cons of my options to the extent I'd like. She leans toward a c-section (she opted for two herself), but has been very good about letting me make my own decisions.

On the pro-VBAC side (so far):
- I won't have to wait 6-8 weeks to lift my toddler again. That's going to be tough on both of us. Do-able thanks to family, paternity leave, and then hired help, but not fun.
- C-sections are major surgery. All things being equal, seems like something better avoided. (But all things are never equal....)
- Easier recovery? This isn't clear. I actually had a pretty easy c-section recovery last time. Never felt the need for more than ibuprophen. I was exhausted and frazzled, but I'm not sure how different that would have been if I'd been "merely" experiencing regular post-partum sleep deprivation, hormones, etc.

On the pro-scheduled-C-section side (so far):
- Easier recovery? Quite a few people, including several nurses, who have had both told me their vaginal deliveries were *awful* and they'd definitely choose a c-section again. But there's selection bias, because most of this was when I was at the hospital after my first was born, and they were probably trying to make me feel better.
- Avoids risk of uterine rupture during labor. Again I wish I had better data on this; all I know is that it's "rare but very bad". The hospital apparently had one fetal demise in the fall, and my doctor mentioned another patient who only made it because she lives around the corner from the hospital (I don't). Again, anecdotes.
- I'd be certain to have my own doctor do the surgery. As far as I can tell, she did a great job. Various nurses spontaneously complimented the incision. She has a VERY good reputation. If I was able to do a VBAC, I don't really care, but if I try for a VBAC and end up in a C-section, I'd be a little concerned about having whoever's on call. (But how often does that happen? And does it really matter?)
- Labor hurt like f*@#$!#!!!! OK, to be fair, I was induced with Pitocin, and I'm told that makes it worse. But in the hours before they could give me an epidural, I was an 8 on the pain scale, at a time when nurses said most people are around a 3-4.
- The C-section was pretty calm and easy! Maybe it was just the contrast with painful labor and the fright of declining fetal heartrate, but the OR was almost soothing. I was awake, able to follow along (though my lower half was out of view), had my husband right next to me, and could hold my baby immediately.

A few things that do NOT matter to me:
- Cost. Either way, we'll be over our out-of-pocket maximum, so there's no impact to us.
- "Naturalness." To each her own, but this doesn't matter to me at all.

A few additional things it might help to know: I'm 34, healthy, fit, no history of obstetrics problems in my family (except that my big brother was breach so both of us were c-sections). Hospital is CPMC in San Francisco.

So... please help me sort through where the odds lie in terms of risks and ease of recovery?
posted by CruiseSavvy to Health & Fitness (22 answers total) 4 users marked this as a favorite
I had a vaginal birth and while I was able to be pretty mobile almost right afterwards, I had a 2nd degree tear that didn't stop hurting for WEEKS afterwards. Sex was also not particularly fun for at least 9 months afterwards. If I had to do it a second time, I'd still go for the vaginal birth, though, hoping that baby has a smaller head than the first one. And, I'm really not keen on having my stomach cut open unless it's for a tummy tuck. :)

The thing is, the only right answer here is the one that you are most comfortable with. It sounds like you are leaning toward the repeat c-section for safety sake - great! Just plan ahead to have plenty of help around when you aren't able to pick up the toddler.

Not to be corny, but you know so well by now that the prize here is not the medal for toughing it out and doing the natural thing but that beautiful baby in your hot little hands at the end of the day - doesn't really matter how they get there!
posted by Leezie at 8:27 AM on May 2, 2011

My wife has had two scheduled-c sections and she didn't have to wait 6-8 weeks to lift our kids. If fact she was lifting them in 2-3 days. Remember these little buggers are at most weight 10 lbs.
posted by jasondigitized at 8:36 AM on May 2, 2011

Would it help if you had another doctor review your file and see if that doctor has a recommendation? That might help you come down on either side of the fence. Thought I'm sure the care you're getting at CPMC is great.

If it were me and the doctor gave me the go-ahead for the VBAC, I think I'd want to try for it since my first was a C-section and I would want to try for the experience of the vaginal birth but it sounds like that doesn't matter to you. So in your case, I'd go with the repeat C since the thought of uterine rupture is pretty compelling. You may not be able to pick up your toddler for a few weeks but you still could snuggle (carefully) while laying down and while seated so it's not like you won't have contact.
posted by otherwordlyglow at 8:37 AM on May 2, 2011

Having had both, I cannot understand why anyone would willingly choose a C-section. It's abdominal surgery! It hurts like a sonofabitch, and you have cramps and a scar and you can't take a shit and eewww.
My first kid was 9 lbs, I didn't have any painkillers and 90 minutes after delivery, I took a shower and got an adrenalin rush like I could run a marathon and climb Mt. Everest. After my C-section with a breech baby (after trying to turn her, which is like Rolfing only painful), I was out of it and not in a fun way. I had no complications, but it sucked.
posted by Ideefixe at 8:38 AM on May 2, 2011 [1 favorite]

jasondigitized - I think she's talking about the toddler she already has, who is probably much heavier.

Also I forgot to add that a scheduled C really does sound SO much better than the last minute C that could result from a failed VBAC. being prepared for it and all that would really make me feel better about doing it since my C was after 24 hours of labor and not the ideal state to start from when having surgery.
posted by otherwordlyglow at 8:40 AM on May 2, 2011

I just had a conversation with my doctor about my chances for a VBAC on Friday.

She said that a lot of her consideration when recommending a VBAC vs second c-section is why the first c-section happened. Was it something mechanical that is unlikely to repeat itself?

Further anecdata: my c-section recovery wasn't that bad. But I personally know someone who nearly died from complications of her c-section.
posted by bq at 8:48 AM on May 2, 2011

I had my first child through c-sect and my second child 2 years and 4 months later via VBAC.
I really wanted a vaginal delivery because I wanted to experience it. A personal thing of mine, I wanted to go through life knowing what it was. And I gave birth to a 10 pound baby without epidural. It's true, no body gave me a medal, but I loved the experience. The adrenalin you get is awesome.
Also, I gave birth, and while my hubby and the nurses were bathing the baby I got up on my legs, and had a shower. Then 2 days later I left the hospital with my baby wrapped around me and walking. My vagina hurt like hell for 10 days, but it was great being able to run after my then 2 year old after that.
About the risk of horrible things happening during a vbac, I just know I wasn't allowed to eat anything during labor because in case of the need for anesthesia you should have an empty stomach, and that kind of sucked. Also, during labor a doctor was ready scalpel in hand to intervene had anything gone wrong. But everything was great.
I wholeheartedly recommend it.
posted by uauage at 8:48 AM on May 2, 2011

Best answer: This might be helpful -- it's a press release detailing the current ACOG approach to VBACs and trials of labor. Notably:

"In keeping with past recommendations, most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about VBAC and offered a TOLAC. In addition, "The College guidelines now clearly say that women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a TOLAC," said Jeffrey L. Ecker, MD, from Massachusetts General Hospital in Boston and immediate past vice chair of the Committee on Practice Bulletins-Obstetrics who co-wrote the document with William A. Grobman, MD, from Northwestern University in Chicago...

"In making plans for delivery, physicians and patients should consider a woman's chance of a successful VBAC as well as the risk of complications from a trial of labor, all viewed in the context of her future reproductive plans," said Dr. Ecker. Approximately 60-80% of appropriate candidates who attempt VBAC will be successful. [Bold AND italics are mine - chesty]"

Do read the whole thing, though.
posted by chesty_a_arthur at 9:03 AM on May 2, 2011 [4 favorites]

CruiseSavvy, it's like you are reading my mind/uterus. I'm looking at the same decision with a lot of the same points. (I don't really care about the naturalness or the "experience," I want what's safest for me and my baby, I have a toddler and don't look forward to not being able to lift him for -- I was told -- four weeks.)

Another thing I'm considering, which may or may not apply to you, is that my abdominal wall is already "damaged" from the first C-section; my pelvic floor is intact. (But my C-section was scheduled because my first was undeliverably breech; I only labored for two hours and that was just coincidence that I went into labor while we were at the hospital prepping for the scheduled surgery!) I'm hesitant to add another set of potential complications with pelvic floor damage when I could localize all the "damage" in once place. ("Damage" in quotes because there's nothing WRONG with me, just whatever changes the surgery caused.)

@Ideefixe, "you have cramps and a scar and you can't take a shit"

Other than the scar, which would be hidden by all but the briefest of bikinis, I had none of this. No cramps (cramps?), no, uh, pooping problems. I had the normal uterus-shrinking cramping from breastfeeding, which happens regardless of delivery method, and I understand that pooping problems are common regardless of delivery method. (In fact, dooce wrote a HILARIOUS post about her first super-problem poop after giving vaginal birth. Which almost put me off reproducing for life.)
posted by Eyebrows McGee at 9:35 AM on May 2, 2011

I think the worst case scenario is to try a VBAC, labor for untold hours and then end up having a C-section anyway. I've had a few friends go through this and it seemed to make their recovery from the surgery MUCH more difficulty. Their bodies & minds were completely exhausted and they were depressed/regretful at expending so much energy and having it not be successful.

Just a data point but I had two C-sections (1st emergency & 2nd scheduled) and had easy recoveries for both. I wanted to try a VBAC but my doctor convinced me that the risks were less with a c-section. Also, I was very stressed out when the "doctor on call" did my emergency c-section...it was strange to have a complete stranger handle something I'd been talking about with another doctor for 10 months.
posted by victoriab at 10:11 AM on May 2, 2011

*MUCH more difficult*
posted by victoriab at 10:12 AM on May 2, 2011

I had one c-section and then two vaginal births. I was very satisfied with my VBACs, even with the last one, which was completely without pain medication (NOT MY CHOICE!). Satisfied is a good word, because of course they were not easy or "fun". I don't have any data about safety, but I do have two things to mention. First, the first weeks of breastfeeding were easier after the VBACs, simply because of the weight of the baby on your surgical area, and shifting and positioning while holding the nursing baby was easier. And, the emotional experience was better. I felt like the Queen of the World after the births. Wait, my body can do THAT? I'm da WOMAN!
posted by molasses at 10:16 AM on May 2, 2011 [1 favorite]

Best answer: Well, according to this article:
Babies delivered by elective, repeat cesarean section delivery are nearly twice as likely to be admitted to the neonatal intensive care unit (NICU) than those born vaginally after the mother has previously had a c-section, a new study finds.

These c-section babies are also more likely to have breathing problems requiring supplemental oxygen, the researchers say.

"In addition, the cost of the birth for both mother and infant was more expensive in the elective repeat c-section group compared to the vaginal birth after c-section (VBAC) group," noted Dr. Beena Kamath, the study's lead author and a clinical instructor of pediatrics at the University of Colorado School of Medicine, Denver.

The study appears in the June issue of Obstetrics & Gynecology.


Kamath's team found that 9.3 percent of the c-section babies were admitted to the NICU, but just 4.9 percent of the vaginally delivered babies were. And while 41.5 percent of the c-section babies required oxygen in the delivery room, 23.2 percent of the vaginally delivered babies did. After NICU admission, 5.8 percent of the c-section babies needed the oxygen compared to 2.4 percent of the vaginally delivered babies.
The respiratory problems might be due to c-sections before 40 weeks. The lungs are among the last to develop and a more recent study shows that c-section delivery before 40 weeks is associated with health problems in the infant. You might be able to mitigate that risk by waiting as long as possible before having the c-section.

If your OB wants to schedule you for a c-section at 38 weeks, I would look at her VERY sideways and perhaps get a second opinion.

Fetuses mature at different rates. Due dates might not be completely accurate. I would personally never have an induction or a voluntary c-section before 40 weeks. If I decided to have a c-section, I'd wait until I went into labor naturally (but that is something I need to research further).
posted by the young rope-rider at 11:31 AM on May 2, 2011 [3 favorites]

Also important--how many children do you want to have? The risk of complications increases with each c-section. This article says that most women can safely have up to three c-sections. If this is your last baby, then that's not something I'd worry about; if you're looking to have more then it would weigh more heavily.
posted by the young rope-rider at 11:36 AM on May 2, 2011

I can hook you up with a little bit of data. This is all from Jennifer Block's pushed.
- Around 0.4% of VBACs (4 in 1000) will result in uterine rupture. (Source: vbacfacts.com)
- Most ruptures are not catastrophic; I don't have a stat for that.
- vbacfacts.com says absolute risk of maternal death is 0.02% for VBAC, 0.04% for repeat C. Odds of death are low in either case.
- (again vbacfacts.com) "the risk of adverse infant outcomes during a VBAC is 0.05%," which vbacfacts.com says is slightly higher than the risk during a C-section, but they don't state the number.
- Baby’s risk of serious injury or death from a VBAC uterine rupture is 1 in 2000. (Source: Pushed by Jennifer Block, p. 87. For comparison, overall neonatal mortality in the U.S. is 4.5 in 1000.) VBACfacts cites a study that says that "Babies had a 10 times greater risk of dying for reasons other than uterine rupture [during a VBAC]."

One important point (and I'm getting this from Pushed again) is that an induction raises the chances of uterine rupture significantly. Being induced raises the chances of a uterine rupture, even in a woman with no C-section scar. If you want to VBAC, it should be without an induction, especially not involve Cytotec. (The problem is that all inducing agents can hyperstimulate the uterus, but at least they can turn off the Pitocin drip if problems arise. You can't turn off Cytotec.) More about that on vbacfacts too.

To add to the pro-VBAC side, I would note that each additional C-section increases your chances of complications by a lot. Your odds of placenta accreta are 1 in 400 for a pregnancy after one C-section, but that goes up to 1 in 50 after four C-sections. Also the risk of adhesions in your abdomen goes up, your chances of hemorrhaging go up, etc. (Source: Pushed again.) Basically, the gist is that one C-section is not that much more dangerous than one vaginal birth, but 4 C-sections is a lot more dangerous than four vaginal births. If this is your last child, that stuff doesn't matter as much, but it's worth thinking about if you plan on more children.

Disclaimer: I'm just a layperson who read some books and blogs.

Good luck with whatever you choose!
posted by mandanza at 11:36 AM on May 2, 2011 [3 favorites]

I was in much the same position as you when I was pregnant with my second child. I read up a great deal on this, and talked at great length with my OB, and a friend of a friend who is an OB. In the end I decided that I didn't really stand to gain anything much from a VBAC other than the experience of a vaginal delivery (which I would love), but I would be risking the safety of myself and my baby. I chose a scheduled c-section, and do not regret it at all.

Recovery from a scheduled c-section is generally easier than the recovery from an emergency one. I heard this, and can confirm it was true for me. The explanation I heard was that if you are already in labor when a c-section is performed, your body is already under stress, which makes recovery from any medical procedure a bit harder. Anyway, the upshot is that my second c-section was difficult. I don't want to go into gory gross detail here, but the events that transpired confirmed to my OB and me, that if I had opted for a VBAC, I would almost certainly have had a serious uterine rupture, and required an emergency c-section. This would have been scary, when you have a uterine rupture, the minutes are counting down. When you have a c-section because the baby's heartbeat is decelerating inappropriately in early labor, its not quite so time-sensitive (this was the reason for my first c-section).

I am SO GLAD I chose a scheduled c-section. I wish very much that things had been different, and I could have had a vaginal delivery for one or both of my boys, but I am OK with the outcome. The important result for me, was that I have two healthy babies, and I am healthy too. C-sections are inherently risky, but so are VBACs. Consider the statistics, but also talk with your OB about how those statistics relate to you. I am a very risk-averse person. A friend has had two VBACs, which both went great, so I am not anti-VBAC, just risk averse, and my circumstances reinforced it for me, that VBAC was not right for me.

Figure out what is right for you. I really think the most important thing is to get a sense of what your risk factors are. Assuming from your question that your doctor does perform VBACs, does your hospital of choice perform them too (not every hospital does)? What's the setup for VBACs, do they insist that you labor in the hospital, and so on.

Good luck!
posted by Joh at 1:53 PM on May 2, 2011

These two podcasts may be helpful:

Pregtastic: elective c-sections.

Pregtastic: Repeat Cesarian or VBAC?
posted by bq at 2:15 PM on May 2, 2011

It's very biased towards VBAC, but if you're interested in the medical community's historical preference for c-section then you might like the documentary The Business of Being Born. Ricky Lake (I know, but she's good in this) discusses how doctors pressure women into having c-sections because it's cheaper and faster and they don't really care about the distress it puts on both the baby and the recovering mother.

I have no dog in the c-section vs. vaginal birth fight, and I have no plans of having a baby in the near future, but the movie definitely made me rethink the relative convenience and alleged ease of c-sections.
posted by Viola at 3:24 PM on May 2, 2011 [1 favorite]

I had a c-section with first child and vaginal births with second and third. I can tell you unequivocally that recovering from a long labor and then a section is MUCH harder than recovering from a long labor ending in a vaginal birth.

C-sections are not risk free and there are possible longer term risks that people don't talk about or take into account in making the decision because you're dealing with an immediate situation but there is an increased risk of ectopic pregnancy post c-section due to scarring. If you end up with a section because you need one due to fetal distress or breach presentation that's not something to change a decision but if it's an additional factor in deciding without an overriding immediate situation it's a data point worth considering aside from all the known issues of major surgery.

Your doctor's attitude and experience with VBACs is crucial as is the policy of the hospital where you plan to deliver since many are now banning VBACs. Good luck!
posted by leslies at 5:49 AM on May 3, 2011

Disclaimer: I'm biased towards VBACs as well.

That said, chance of uterine rupture is less than 1% -- by comparison: one has the same chance of miscarriage during amniocentesis, and the same chance of having a fake doctor in the Phila area. Funny, no?

I was semi-coerced into having a c-section with my second pregnancy due to having twins. I was told the practice was in favor of VBAC for 36 weeks, and then suddenly I was scheduled to see a different doc who firmly nudged me to c-section. I was warned by other moms in my area that the docs would do this, smile and nod the whole pregnancy and then decide at the last minute against vbac. They do this just when you're sick of being pregnant and willing to agree to anything just to get to meet this kid sooner. I'm annoyed that my situation played out as predicted. I don't anticipate having anymore kids, and I do regret not having the opportunity to prove to myself that I *can* birth a baby, and not fighting the coercion -- but that's *my* idiosyncratic value ;o)

One thing I had power over, however, was the scheduling of the c-section, and I feel I messed that up. It seems docs want to schedule c-sections on the earlier side of 40 weeks (or 38 for twins) -- I REALLY feel like my twins would've benefitted from another week or two to mature in the womb. They really were a full 4 weeks behind in development compared to my first child, in terms of getting the knack of nursing, etc.
So if you decide to schedule, consider the importance (to yourself) of letting the little one go the full 40 weeks.

Another thing to consider is that the docs REALLY don't want to let you vbac if you've had 2 c-sections -- so if you plan on having more kids, having a c-section now sets a big precedence for future births.

My recovery from the second c-section was slightly slower than my recovery from the first. My older child was 7, so I wasn't picking him up.
posted by MeiraV at 10:40 AM on May 3, 2011

Response by poster: Just wanted to follow up that I opted for the scheduled c-section, at 39 weeks. The key new input was what I considered a high incidence (20-40%!!) of emergency c-sections following VBAC attempts (thanks, Chesty!). Based on my personal experience, surgery after exhaustion/labor SUCKZ.

I'm happy to report that all went well, and little Baby-Girl CruiseSavvy and I are doing great. Recovery definitely felt easier than last time.

And as for the risk of uterine rupture, while 0.4% might seem low, turns out my OB commented during surgery (she knows I like to know) that the uterine wall is pretty thin down by the incision and "it's good you didn't try to VBAC; would not have been pretty." Zoinks.
posted by CruiseSavvy at 10:48 AM on June 28, 2011 [1 favorite]

Thank you for the update! I am glad you are doing well and are happy with your decision! It sounds like it was the best decision for you and I'm glad your recovery is better this time.

One of the scary things about VBAC is that it's hard to say what the uterus is up to in there (although there are some statistics based on what kind of incision you've had previously and what kind of suturing was done).

I hope researchers keep plugging along at understanding and minimizing risk factors for uterine rupture now that "once a c-section, always a c-section" is no longer a given.
posted by the young rope-rider at 11:54 AM on June 28, 2011

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