C-Section or VBAC?

Several hundred years ago, having a C-section meant almost certain death for the mother because there was a common belief that a uterine incision could not be sutured. As a result, C-sections were associated with excessive blood loss and infections with no good way to solve either of these problems.

As the popular story goes, the farmers had done C-sections on their cattle for years and had always sewed the cow's uterine incision up after delivery of the calf. So, doctors learned from the farmers. Doctors began doing the same with their female patients and the mortality rate for a C-section decreased. Of course, nobody today knows whether any of this is true or not, but it is a good story.

Why the increase in C-sections?

With the advent of the successful uterine suturing, the arrival of the antibiotics to treat infections, and the better availability of blood transfusions, the safety of C-sections increased. However, women who had had a C-section were told “Once a C-section always a C-section.” Because of this notion, the C-section rate remained relatively low, around 5 percent in the 70s.

As the safety of C-sections increased, the issue of risk became a smaller factor in a decision to have a C-section and convenience became a larger factor. Let’s face it. In spite of the fact that your vaginal birth is cheaper and safer than a C-section, the C-section is much more convenient. A natural, unobstructed labor and vaginal birth are time consuming. The time spent on working with women to enable natural deliveries may interfere with a doctor’s surgery schedule since gynecologists do surgeries as well as deliver babies.

There’s also long-standing convenience for the patient. It is my understanding that Lucille Ball had two C-sections, the second within a week of filming of the first “I Love Lucy” show. In this show, a bath robe and pots and pans were used to disguise her recently postpartum abdomen. So, convenience has been around for a long time and still plays a large part today in the decision to have a C-section.

When I was a resident in the late 1970s, we were still trying to avoid C-sections. My C-section rate in residency was around 10 percent. We were still doing suctions and using forceps. But we were discovering the problems with using suction and forceps, what we termed instrumented vaginal births. I quickly developed a remarkable dislike for suction-assisted vaginal birth. No matter what the advertising says about the safety or effectiveness of the suction device, there are two problems with it.

First, suction devices can cause a lot of damage to the fetal scalp. Secondly, in my experience, suction only works when you don’t need it. In other words, you simply cannot use suction before the baby really crowns. The baby's whole head needs to have passed into the birth canal, not just the scalp. And let's face it, if the baby has crowned, instrumented delivery is not needed.

Manufactures safety information usually indicates that no more than three trials of suction are permitted. However, the definition of what constitutes a trial of suction is remarkably subjective.

Forceps have been used for hundreds of years. For the most part, their use can be successful, although many residencies have some experience with fetal death associated with forceps use. I have actually heard of instances in which the baby's head was pulled off. So, this is where the issue of risk begins to get a little muddy. Certainly, C-section or a repeat C-section can be less risky than complicated instrumental deliveries using suction or forceps. Because of some of the horrific stories associated with forceps use, staff doctors and residents became wary and cautious about using forceps and found a C-section preferable to a difficult vaginal birth. As the fear of the use of suction or forceps in deliveries rose, instrumentation for vaginal birth was used less and less.

Then there’s the problem with breeches. I was trained at a time, when we still did vaginal breech births and I learned how to do them. Today, we have fewer medical staff members who are proficient in vaginal breech births. The important thing about medical training, as in any other field, is competency. Proficiency in a procedure is generally directly related to the number of procedures performed. So, there is a minimum number of times a procedure is performed in order to gain some kind of proficiency.

Without proficiency gained from performing a procedure a given number of times, necessity enters the decision whether or not to do a C-section. If the staff doesn’t know how to do a vaginal breech birth, they are certainly unable to teach the residents how to do them. The C-section rate is now approximately 33 percent. This rate is a result of several different factors. Certainly, the safety of a C-section has improved over the last 100 years. Increasingly, doctors are not trained to do vaginal breeches, and in some places, doctors don’t want to do a vaginal birth after C-section (VBAC). Some of those reasons include the resistance of insurances in covering VBACs and the American College of Obstetricians and Gynecologists (ACOG) various opinions on VBACs over the years. The VBAC Link website provides a lengthy list of questions and answers about VBACs.

I’ve often heard the saying that we don’t know where we are or where we’re going, unless we can understand where we’ve been. This is a story of how we got to where we are. So, where are we with VBACs?

The Canadian Medical Journal article reports the death rate from a VBAC as .0038 percent and the death rate from a repeat C-section as .0134 percent. Most of these death rates are very small, but they should be smaller. Death is NOT a good measure of quality care because it is neither a subtle nor a sensitive indicator of good quality care. The Centers for Disease Control and Prevention (CDC) says 80 percent of obstetric deaths should be avoidable.

Unavoidable deaths would include saddle pulmonary emboli, some heart attacks, and some ruptured congenital aneurysms. Actual illness associated with delivery would be a more sensitive measure of quality of care in birth outcomes, but the same things that make injury a more sensitive indicator of quality of care are also the measures that make it more difficult to measure because one provider’s minor injury might be another provider’s severe injury.

In the end, information on the death certificate (used in many research studies) is qualitative, not quantitative. Presently there is no way of measuring the degree of injury or the quality of care on a death certificate. The degree of injury would be more accurately reflected in the billing codes. More injury, more cost.

There are providers who complain that the quality of their care is top notch, but the patients present with factors beyond the provider’s control, putting them at higher risk which providers claim isn't their fault. If all else fails, there is the often heard excuse “Difficult case managed well” a phrase to protect providers from litigation and other responsibility for bad care and bad outcomes.

Over the past forty years, we have come to think that C-sections, are low risk procedures. In truth, according to the National National Library of Medicine article, even the planned cesarean group had increased postpartum risks, including cardiac arrest (heart attack), hematoma, hysterectomy, infection, anesthetic complications, blood clots, hemorrhaging requiring hysterectomy, and prolonged hospital stays. The vaginal delivery group had a lower risk of bleeding which required blood transfusion and overall had a lower risk for severe maternal morbidity, including postpartum heart attacks, pulmonary thrombosis, and pulmonary emboli (potentially deadly blood clots going to the lungs). The most common risk factor for C-sections is infection.

In my experience, the main problem with infection is not rupture of membranes or the length of rupture, but the number of cervical exams. Granted, the number of exams is hard to control, especially when you have nursing shift changes in which providers expect nurses to examine the cervix at least twice with each shift change.

My Recommendations

During my residency, my C-section rate was at 10.5 percent. When I arrived at my first practice after graduating from residency, the C-section rate was 15 percent. I thought that rate was too high and set about lowering it by increasing vaginal births of twins and breeches while recommending and doing VBACs if there wasn’t a recurring reason to have another C-section. With these methods, I lowered the practice's C-section rate to 10.9 percent. There were no maternal deaths and no illness resulting from the C-sections.

Although a C-section or repeat C-section, might be considered convenient for the doctor, or the patient or both, a vaginal birth or VBAC is safer and less expensive for most women and their babies. The risk to the mother and baby with a C-section are notably higher than the risks for a VBAC. For starters in bringing down the C-section rate, it’s time for insurances and federal payments for a C-section to be made comparable to the payment physicians receive for vaginal deliveries of VBACs.