LOUISVILLE When Ann Grider, MD, joined Women First of Louisville in 1998, the pendulum had gone from the long-time assumption in medicine of “Once a C-section, always a C-section to the 1990’s, when women practically had to beg for a repeat C-section once they’d had a C-section,” Grider says. “Today women have more choices for vaginal birth after cesarean. It’s good to give them a full picture of their options and risks so they can make informed decisions.”
According to the American College of Obstetricians and Gynecologists (ACOG), in 1970 about 5% of babies in the United States were delivered by cesarean section. By 1988, that number had climbed to nearly 25%. Today about one third of births happen by C-section, making it one of our nation’s most common operating room procedures.
Various technical, professional, and legal factors likely contributed to this increase. Yet, despite increased risk for childbirth-related complications when a woman has multiple C-sections, rates for vaginal birth after cesarean section (VBAC) are low—just 13.3% in 2018. One contributing factor for the low rate might be that smaller or rural hospitals may lack specialized facilities or staff to perform an emergency C-section should it become necessary during an attempted VBAC. In circumstances like this, a repeat C-section is generally a safer choice.
Grider explains that a successful VBAC and planned repeat C-section delivery generally have comparable risks. However, in a situation when an attempted VBAC fails and a repeat C-section becomes necessary, the risks for both mom and baby go up.
“The safety of our moms and babies must always come first,” Grider says.
Women First focuses on maximizing safety and minimizing potential VBAC risks. The practice has an 85–90% VBAC success rate in patients who have a trial of labor after a C-section. The national success rate, as recently reported by the National Institutes of Health, is 75%.
Grider credits their success to three factors:
The practice delivers exclusively at Baptist Health Louisville. Working with one hospital offers certain advantages, such as 24/7 access to anesthesiologists, laborists, and a Level II neonatal intensive care nursery with neonatal staffing.
The team is highly selective in approving VBAC candidates. They thoroughly assess each candidate’s delivery history, including scar-related risk factors and whether her previous cesarean was done for reasons that could tend to recur.
They work closely with approved VBAC candidates to help them develop personalized birth plans.
Personal Birthing Plans Are Key
Women First considers a personalized birthing plan a critical element of a successful VBAC delivery. Each patient’s plan reflects the birthing process and experience she expects for herself and her baby. It also includes key information about mom’s overall health, risk factors, and cesarean history.
Some of the plan’s components can be confusing or sensitive. Weight, for instance, is a significant VBAC risk factor and can also be a personal worry for many moms. Grider suggests patients use an online risk calculator to help gather data-driven answers to their questions.
“This useful tool provides specific numbers that can help women see potential risks in an objective way,” says Grider.
Plans typically help prepare patients for what to expect during trial of labor after cesarean (TOLAC). This acronym is a general term that describes a patient’s journey through pregnancy to VBAC.
One part of that journey may include the steps to take once labor begins. Although labor induction is not prohibited in VBACs, it may increase the risks of complications. One of the biggest predictors of VBAC success is spontaneous labor. For this reason, Women First takes a “cautionary stance” and does not aggressively induce labor in patients attempting a VBAC.
“We work with VBAC patients to select a day near their projected due date. If labor does not spontaneously begin by that point, we often recommend moving forward with a C-section,” says Grider.
By the time a patient arrives at labor and delivery, Women First makes sure she has:
Discussed her birth plan in detail with her physicians, her partner or husband, and others who may be part of her delivery.
Understood that changes in her birth plan—up to and including the need for a repeat C-section—may become necessary.
Plan changes are driven by the safety and well-being of mom and baby. Grider and her colleagues strive to make every woman’s birth experience reflect her plan, yet that is not always possible.
“Sometimes our expectations and the pictures we create in our minds can become a source of disappointment,” she says. “The reality is babies don’t always cooperate with anyone’s expectations.”
While Grider rarely has to act outside a patient’s wishes, she says being prepared for such a situation speaks to the importance of building trust. “It is my job to help a mom understand why her birth plan may not be the safest for her or her baby.”
“I’ve never had a mom go against my medical advice in an emergency situation when I’ve had to make the call to change a VBAC birth plan,” says Grider.
VBAC Is a “Reasonable Option”
In 2010, the NIH described VBAC as a “reasonable option” for many women. Updated practice guidelines released by ACOG echoed a similar conclusion.
One significant benefit of VBAC is a faster recovery time compared to what is typical following a C-section.
Vaginal deliveries have lower rates of infection than C-section procedures. They typically carry less risk for bleeding and blood clots, and are also less likely to require blood transfusion or admission to an intensive care unit.
VBAC complications can happen, yet they are generally not life-threatening. The Centers for Disease Control and Prevention reported in 2018 that women who deliver vaginally after a previous cesarean are less likely to experience birth-related morbidity than women who have repeat cesareans.
These findings underscore the importance of lowering our nation’s high incidence of cesarean sections.
A two-part goal from the Office of Disease Prevention and Health Promotion seeks to reduce cesarean births among low-risk women with no prior births and among low-risk women with a prior cesarean birth.
A Healthy People 2020 goal strives to increase VBAC to 18.3% among women with a previous cesarean delivery.
Procedures like VBAC reflect Women First’s ongoing commitment to meet each woman’s health needs with highly personalized, innovative care. Innovation is nothing new for the practice, which was the Louisville area’s first all-woman-run obstetrics and gynecology office.
The practice currently includes 11 physicians board-certified in OB-GYN, eleven nurse practitioners and physician assistants, plus additional clinical and support members. Their services range from annual health exams and screenings to advanced contraception and pregnancy care, plus numerous specialized diagnostic and surgical procedures.
Grider and her partners believe there are always valid reasons to reassess past customs or practices and question whether there are better ways to work toward positive outcomes.
“There is no single right answer for every patient. Whether or not a patient decides on VBAC is dependent on her history, risk factors, and personal desires,” she says. “Our ultimate aims are, and should always be, to reduce risks and make deliveries as safe as possible for babies and moms.”