The Great (internal) VBAC Debate

Before I can really talk about my struggle to decide whether or not to push for a VBAC, I have to back up and talk about Brendan and Cason’s birth, and why I ended up with a cesarean section in the first place.

I ended up having a c-section with Brendan and Cason, despite my best efforts and over 50 hours of labor. Both boys were head down, but I never dilated past a six. There were many things that upset me and that I regret about my labor and delivery, but I am so thankful that the end result was two healthy babies.

With B & C, I went to the hospital shortly after my water broke, even though I had intended to stay home for awhile first. This was because 1) my husband was pretty jumpy and wanted to head straight there and 2) when my water broke it was tinged pink with blood. That can be normal, but it also can be a sign of other problems, so when I called my doctor he said I should go ahead and come in.

My labor was going fine and I was making slow progress. The nurses kept insisting I start pitocin because I wasn’t dilating very quickly, but I kept telling them no.  They said that hospital policy meant that if I wasn’t ready to push/almost there in 24 hours, I’d be given a c-section because of risk of infection. I DID NOT want to have a c-section, so I finally caved and agreed to the pitocin. I still wasn’t making much progress, so they kept turning it up. Finally, they had it on full-blast and that made my contractions much, much worse. (Many things I’ve read said that pitocin contractions feel worse/different because they are unnatural. I believe that, but really have no idea because I never got to go deep into labor with natural contractions.) I asked them to turn it off, but nobody would. Because of that, I finally agreed to an epidural.

Up to that point, I had refused an epidural because of everything I had read about being restricted to the bed slowing down labor (gravity can’t help as much). I requested a “walking epidural” which is a smaller amount of the drug so that you can still walk/move but the pain isn’t as strong. I was told that wasn’t an option at our hospital, so I agreed to the standard epidural.

After that, labor was much easier, because I wasn’t in pain, but I also wasn’t making progress any faster. In fact, I was progressing even more slowly. Roughly 36 hours or so in (I’m ball parking that; I don’t remember exactly), I begged them to turn off my epidural and let me move around. I just knew that if I could change positions I would make more progress. Finally, one nurse, my favorite nurse there (who also happens to be married to my 3rd cousin,) said she would talk to the doctors for me. She came back and told me they had agreed to turn it off, but wanted the pitocin to remain on. I agreed, but only made it about 4 hours without the epidural. The first couple of hours were great, because the numbness had not worn all the way off yet, but I could change positions. I made another little bit of progress then. After the numbness wore completely off, I could not relax because the pitocin was still on as high as it could go, and I quit progressing. I got back on the epidural.

This entire time, the boys’ heartrates were being monitored, because I had been in labor for quite awhile and they wanted to make sure things were fine with both of them. (This is what upsets me the most. Obviously I had been allowed to labor longer than 24 hours without a cesarean section. I wish that the nurses had known my doctor would allow me to do that, because then they wouldn’t have pushed me onto the pitocin, and consequently the epidural, which, I believe, pretty much stopped my progress.) My doctor was going to let me continue to labor, but it had been 50 hours and I was just then at a six. If the boys’ heartrates had dropped, I would have been rushed in for an emergency c-section. At that point, I felt selfish continuing to labor, because it was like I was waiting for something to go wrong and then who knows what the lasting effects would have been on one or both of the boys. I was also concerned about the length of time I had all of those drugs in my body, the pitocin and the epidural. I finally requested a c-section, and my doctor said he thought that was probably the best choice at that point.

Brendan and Cason were born at 8:56 and 8:57 pm on December 18, 2012. They were both doing great and needed no NICU time, which is wonderful for twins. I absolutely hated my recovery, though I’m not sure how much of that was due to caring for two newborns. I have nothing else to compare it to.

Sooo, all of that to get to my current state of indecision.

It is standard policy at my hospital to do a repeat c-section, because of the risk of uterine rupture. No, they cannot force me to have a c-section, but they can make it difficult not to. I was told that they will keep the team needed to do an emergency c-section at the hospital the entire time I’m in labor, which costs $300+ per hour. While I am glad they would  be there if necessary (in the rare case of a uterine rupture, the baby suffers extreme brain damage or death if not out within 15-18 minutes), I’m not sure insurance will cover that cost. I could drive to another town with a different hospital, but out here that means that hospital would be smaller and less likely to be able to handle an emergency.

Here’s the thing: the chance of your uterus rupturing while attempting a vaginal birth after cesarean (VBAC) is roughly .5% to 1%, provided you have none of the factors that increase your risk. Less than a percent.
Those are some good odds. If it were just my health at stake, I would say, “Yep! VBAC no doubt. Here we go!”
But it’s not just my health. In fact, a uterine rupture could cause major health issues for me, too, but the real risk is for the baby. If I’m in that half a percent, it’s going to feel like 100% if my baby dies, or has horrible, irreversible brain damage. I can only imagine the crushing guilt if either of those things occurs.

When I look at it that way, even considering attempting a VBAC feels selfish. With a c-section, the biggest risks are for me, not the baby; the major surgery is done on me, the recovery is my issue, the baby is fine. If you are a mom, you know that you would do literally anything you can to protect your child.

Please know that this isn’t something I’m considering lightly. I’ve researched and read everything I can find, from blog posts to medical studies. The worst case scenario, the level-headed view from a practicing midwife, and a compilation of multiple medical studies, plus my doctor’s personal stories/experience and many other articles have all been taken into consideration.

The facts and statistics I’ll quote are from the last link above (the compilation of multiple medical studies, which also cites all of the original studies), in case you are interested in their origin.

You see, the risk of uterine rupture is increased by several factors, none of which apply to me.

  • I have had a single previous caesarean section, not multiple ones.
  • My caesarean section was a low transverse one (most common in the US today), meaning that my scar is of the type least likely to rupture.
  • If I (and I will) go into labor on my own, with no induction and have no augmentation of labor (aka pitocin), I would have a .44% chance of uterine rupture.
  • Some studies have shown that a VBAC attempt occurring less than 24 months after the cesarean can increase the risk of rupture. Further investigation shows, though, that “an interdelivery interval shorter than 18 months but not between 18-24 months should be considered as a risk factor for uterine rupture.” This birth will occur approximately 22 months after my cesarean, so should not increase my risk of uterine rupture.
  • My youth is on my side. “The rate of uterine rupture in women older than 30 years (1.4%) versus younger women (0.5%) differed significantly,” and I will be 24 when this baby is born.
  • This is a singleton pregnancy. Multiples can increase the risk of rupture, but I just have one baby in there this time.

There are other things that can increase the risk that I will take into consideration at the end of the pregnancy. For example, a baby larger than 8.8 pounds can increase the risk of rupture. Also, if, in an ultrasound performed within the last week before delivery, the uterine wall measures less than 2mm, the risk of uterine rupture is significantly increased. If either of these things holds true for me, I will likely opt for the repeat c-section.

That means, as things stand now, my personal risk is around .5%. I have about a 1/2 percent chance that my uterus will rupture and I will need an emergency c-section to save my child. That means I have a 99.5% chance of getting to deliver him/her naturally, which is something I desperately want. I want that experience, I want the chance for my body to do what it was created to do as opposed to another major abdominal surgery, I want the recovery time of a vaginal birth so that I can more easily care for my boys and the new baby, I want the minimal risks that come with vaginal birth as opposed to the multiple risks that come with a c-section, and I want the opportunity to have any future children (should we decide to do so) naturally. Of course, there is always the chance that, even without pitocin and an epidural, my body won’t dilate, and I will end up with a c-section again anyway.

I am also concerned about not going in to the hospital immediately upon going into labor. My original plan for trying to have a VBAC was to stay home as long as possible, until I felt I was getting close to delivery. Upon learning that the best indicator that the uterus has ruptured is a drop in fetal heartrate, and that many women don’t otherwise know it has occurred, and knowing the very short window of time in which the baby would need to be surgically removed to be alive, I’m no longer sure of this part. Uterine rupture can occur at any time during labor, and I would never be able to forgive myself if I was home laboring because of what I want and my baby died.

I think part of the reason I am so paranoid is because of my miscarriages. Yes, they were early, but the fear of something going wrong with your pregnancy never leaves you after something goes wrong once. A half of a percent looks small on paper, but if it happens to me, that’s it. Who cares what the odds were; I’ve either maimed or killed my child because of my selfish wants.

On the flip side, the risks to the mother are higher with a c-section. They are performed so often today that most people consider them routine and not a big deal, but things can and do happen. What if I opt for the repeat c-section and something terrible happens to me, and I leave my husband a widower with three young children?

There is no easy answer here, and what I plan to do still changes from moment to moment. Ask me tomorrow, and I may tell you something different, but, right this minute, I intend to go into spontaneous labor and try for a VBAC. I’ll be reading up on techniques to help with dilation (again. I did before Brendan and Cason, but who knows what else I might find) and I hope that if I remain somewhat active until the end of the pregnancy, as opposed to being on bedrest like with the twins, that my body will be in better condition to deliver naturally.

It probably goes without saying, but I am praying about this, of course, and will continue to do so. Your prayers for a healthy pregnancy and safe VBAC are greatly appreciated!