After giving birth to her first two children naturally, Hila Mizrahi of Aventura needed an emergency Cesarean section to deliver her son, Ariel, 2.
"His heart rate had dropped, and we didn’t know why," Mizrahi said. It turned out the baby’s position in the womb was affecting his blood flow, and a vaginal birth would have been difficult.
When Mizrahi became pregnant with her fourth child, she wanted to try to deliver naturally again, a process called Vaginal Birth After Cesarean, or VBAC.
She’d heard from friends that many Ob/Gyns wouldn’t even try a VBAC. There were risks -- uterine rupture, and situations that could deprive the baby of oxygen or blood. But Mizrahi was a good candidate for a VBAC, and on April 20, her physician, Dr. Nigel Spier, delivered baby Shira without complications at Memorial Regional Hospital in Hollywood.
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Before 1970, the standard practice was once a Cesarean, always a Cesarean. During the 1970s, as women achieved successful VBACs, it became more popular - up to 28 percent in 1996, according to the American Congress of Obstetricians and Gynecologists. By 2006, the VBAC rate had fallen to 8.5 percent, due to hospital and insurer restrictions, and to hesitancy by physicians and patients when evaluating the risk. In August 2010, ACOG relaxed its restrictions on VBACs, making more women eligible.
But that doesn’t mean physicians are lining up to do them.
Risks of complications, restrictions by birthing facilities and hospitals and South Florida’s litigious climate have resulted in a cautious stance from the medical community.
Still, women who are interested in VBACs can find physicians willing to do them. They just need to do their homework when evaluating the risks, and choosing a doctor and birthing facility, said Dr. Christ-Ann Magloire of Serenity Holistic Ob/Gyn in North Miami Beach.
Magloire said that about 10 percent of her deliveries, roughly two of 20 each month, are VBACs. Magloire is affiliated with Memorial Medical Center Miramar and West, North Shore Medical Center and Jackson North Medical Center.
Even before ACOG relaxed its restrictions, Magloire, who began practicing medicine in Boston, said she worked in a culture where VBACs were more common. "I was VBACing in residency. It was not a foreign or dangerous thing to do. You have to believe that a woman was born to birth, that her uterus is equipped to handle it," she said. "I believe that a woman is
supposed to birth naturally; that a C-section doesn’t prevent that."
What are the benefits of a VBAC?
A VBAC avoids major abdominal surgery, lowers a woman's risk of hemorrhage and infection, and shortens postpartum recovery, according to ACOG.
What are the risks?
Risks include uterine infection or rupture, and a failed VBAC requires an emergency C-section, which is more dangerous than a scheduled one. VBACs are successful 60 to 80 percent of the time, according to ACOG.
Who is eligible for a VBAC?
Women with one previous C-section and a low-transverse "bikini cut" incision are still considered the best candidates, but now, "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 trial of labor after Cesarean," according to Dr. Jeffrey Ecker of
Massachusetts General Hospital in Boston, who co-wrote the guidelines.
What adds to the risk?
• If your first C-section was because of a problem that exists in the current pregnancy, that raises risk. If the C-section was because of a mechanical issue not present in current pregnancy, you’re a better candidate.
• The time between a C-section and current pregnancy doesn’t affect outcome, but should be at least a year.
• Induction raises risk of uterine rupture, so if you’re going to try VBAC, labor should start naturally.
When evaluating a patient who wants a VBAC, Magloire said several factors are considered. She looks at the notes of the physician from previous births, to see if anything was noted that may rule out the woman as a candidate for natural birth.
She looks at the number of C-sections a woman has had, and the length of time since the previous birth. The type of cut made in a previous C-section also can send the risk up or down. "But how do you quantify risk? My biggest job is to inform, to manage the risk," she said.
What should I ask my doctor if I want a VBAC?
Women seeking a VBAC should discuss it at their first prenatal visit. Ask the doctor:
• Under what conditions will he/she perform a VBAC?
• How many has he/she performed?
• How will he/she evaluate whether you are a good candidate?
• What are the risks to you?
• What are the risks to the baby?
Spier said women should look for a doctor "who has experience and an established protocol for performing VBAC, and who will be accessible and available during labor, in case of an emergency." Also important is a Level 2 or Level 3 facility with 24-hour in-house anesthesia, a neonatal intensive care, established critical care protocols and a multidisciplinary approach to managing obstetrical emergencies such as uterine rupture and post-partum hemorrhage, he said.
Dr. Rene Paez, an Ob/Gyn with South Miami Hospital, said women should make sure that the physicians who cover for your doctor also are experienced with VBACs. "Patients could potentially run into a problem if their physician, who is in his or her own practice, is out, and the covering physician either will not do one or isn’t experienced in the procedure."
Why are some doctors reluctant to perform VBACs?
"Physicians are still very reluctant to offer VBACs because of the litigious environment that exists in Florida," Spier said.
"Many physicians will not offer VBAC as an option to their patients if there is a chance they could get sued, even if they followed the guidelines and took every necessary precaution."
What should I look for in a birthing facility for a VBAC?
A birthing center or home birth is not the appropriate setting for a VBAC, Spier said. "If the uterus ruptures, there is only a very short window of time in which to act and perform an emergency Cesarean delivery, if there is any chance for a good outcome for the infant," he said. "In addition, during the time it takes for transfer to a hospital, the mother risks life-threatening internal hemorrhage from the ruptured uterus."
The hospital needs to have around-the-clock anesthesia and C-section coverage with a dedicated operating room, Paez said.
"Some facilities have to call in a C-section team, and time is crucial," he said. "The physician always needs to be in-house when a VBAC is scheduled."
Magloire said that when something goes wrong in a VBAC, it usually happens to the baby because of oxygen- or blood deprivation, she said. "That’s why ACOG prefers a Level 3 NICU," she said.