VAGINAL BIRTH AFTER CESAREAN SECTION (VBAC): ALL YOU NEED TO KNOW BEFORE MAKING YOUR EDUCATED CHOICE

Posted in Health by woman2womenblog

“Once a Cesarean, always a Cesarean” has been the standard recommendation for many years. But the increasingly high cesarean section (C-section) rates around the world have led doctors to reassess the risks of a cesarean section versus delivering vaginally after having a previous C-section.

Repeat C-section or VBAC? The answer is not straightforward. Both options do come with some risks, and those risks vary depending on the woman and the specific pregnancy.

Here’s what you need to know about a vaginal birth after cesarean section and what you should discuss with your doctor if you want to try delivering your next baby vaginally.

1) What is a vaginal birth after cesarean delivery (VBAC)?

If you’re pregnant again and your last baby was born via cesarean section, this time you have two choices about how to give birth:

an elective repeat caesarean section (ERCS), or
a VBAC. “VBAC” stands for “vaginal birth after cesarean” and refers to giving birth through the vagina after a woman has already had a C-section. Vaginal birth also includes deliveries assisted by forceps or ventouse.

Planning for a vaginal birth after caesarean (VBAC) or choosing an ERCS have different benefits and risks (see below).

A TOLAC (trial of labor after cesarean delivery) is the attempt to have a VBAC. If it is successful, TOLAC results in a vaginal birth. If it is not successful, you will need another cesarean delivery.

2) What are my chances of giving birth vaginally after having a C-section?

As long as you are an appropriate candidate for a VBAC, there are good chances to succeed: about 60 to 80% of women who attempt a VBAC will deliver vaginally.

There are certain factors which affect the chances of success, both related to the mother and the baby (see below). Nevertheless, it’s impossible to predict with certainty who will be able to have a vaginal delivery and who will end up with a repeat c-section.

A previous vaginal delivery, particularly previous VBAC, is the single best predictor of successful VBAC and is associated with a VBAC success rate of 85–90%.

3) Am I a good candidate for a VBAC?

Planned VBAC is appropriate for the majority of women who:

are pregnant with one fetus (as opposed to twins/multiples),
their baby is positioned head down (cephalic presentation),
have a pregnancy at term (37+0 weeks or beyond),
have had one previous lower segment caesarean delivery.

4) When is VBAC contraindicated?

Planned VBAC is strongly discouraged in the following cases:

Three or more previous caesarean deliveries. See below in case you have two previous C-sections.
The uterus has ruptured during a previous labor, as this increases considerably your risk (7 times higher) of a recurrent uterine rupture with the next pregnancy.
The previous caesarean section was “classical”. In the vast majority of women, the uterus is cut horizontally, in its lower segment. This is called a low-transverse uterine incision. Rarely, a vertical incision in the upper uterus is required, this is known as a “classical” incision. Occasionally, a J- or T-shaped cut is performed. In both cases of vertical and J/T-shaped incision there is higher risk for uterine rupture. Therefore, it is very important to know which incision was performed in your previous C-section. You should note that the type of scar on your skin does not necessarily match the one on your uterus.
A previous uterine surgery, such as fibroid removal (myomectomy), as this increases the risk of uterine rupture.
There is other pregnancy complications that requires a C-section.There are certain absolute contraindications to vaginal birth that apply irrespective of the presence or absence of a scar (e.g. placenta previa)
Breech presentation (the baby comes with buttocks and/or feet first) or other abnormal presentations.
Multiple pregnancies (twins or more).

5) What factors reduce my changes of having a successful VBAC?

In general, the chances of success are lower in the following situations:

The reason for the previous c-section is likely to be problem this time around. Let’s say that a woman who already had a vaginal delivery and then had a c-section because her baby was breech (buttocks or feet first) is much more likely to have a successful VBAC than one who had a previous c-section after achieving full dilation and pushing for three hours, which may signal a narrow basin.
Labor is induced (did not start spontaneously).
You are older than 40 years old.
You are overweight.
The baby is big (over 4,000 grams estimated weight, or 8.8 pounds).
Advanced gestational age at delivery (more than 40 weeks).
Having a short time between pregnancies (less than 19 months).
You have preeclampsia (high blood pressure) at the time of delivery.

You should discuss with your practitioner about your individual chance of success and carefully weigh the benefits and the risks.

6) What are the benefits of a VBAC?

C-section is a major abdominal surgery, and as such is associated with certain increased risks as opposed to a vaginal birth. Therefore, a successful VBAC entails:

Shorter recovery period
Less post-partum pain.
Lower risk of infection.
Less blood loss, reduced need for a blood transfusion.
Less chances of needing an emergency hysterectomy (uterine removal).
Lower likelihood of damaging other organs (bladder and bowel).
Lower risk of developing a blood clot (thrombosis) in the legs (deep vein thrombosis) or lungs (pulmonary embolism).
Reduced risk of pelvic adhesions (internal scar tissue that forms between the organs, which may be responsible for chronic pain, infertility or intestinal obstruction).
Decreased chances of breathing problems for your baby. About 4-5% of babies born by planned C-section have breathing problems, compared with 2-3% following VBAC; the risk is slightly higher if you have a planned caesarean section earlier than 39 weeks. In fact, breathing problems are quite common after caesarean delivery, but usually do not last long.
Many women would like to have the experience of vaginal birth, and when successful, VBAC allows this to happen.

If you plan to have more children, VBAC may help you avoid certain health problems linked to multiple cesarean deliveries. In fact, C-section complications, such as haemorrhage, emergency hysterectomy, bowel or bladder injury, adhesion formations are all higher with the increased number of cesarean deliveries. Moreover, every C-section you have raises your risk in future pregnancies of placenta complications, such as placenta previa (the placenta lyes low and covers the cervix) and placenta accreta (the placenta implants too deeply and doesn’t separate properly at delivery). Both conditions can result in life-threatening bleeding and a hysterectomy. If you know that you want more children, this may figure into your decision.

7) What are the risks of a VBAC?

One of the most feared complications of a VBAC is the possibility of uterine rupture, that is, the scar of the uterus tears or separates. Even if you’re a good candidate for a VBAC, there is a 0.7% risk (that is, 7 out of 1000 woman undergoing a VBAC) that your uterus will rupture at the site of your C-section incision. If this happens, it may result in severe blood loss for you, eventually life-threatening, and possibly oxygen deprivation for your baby, which may result in brain damage (in 8 out of 10,000 cases) or even death (in 2-3 out of 10,000 cases). While this risk is very small overall, it is higher as compared to a scheduled C-section.
Regardless of uterine rupture, VBAC carries in increased risk of long-term neurological damage or even death. Again, the risk is very small, but is higher in women who undergo an unsuccessful VBAC than in women who have a successful vaginal delivery or a scheduled C-section.
If you end up being unable to deliver vaginally, you could endure hours of labor only to have an unplanned C-section. This may be very frustrating for certain women, as their expectations for a vaginal birth are not fulfilled.
You may need an assisted vaginal birth using ventouse or forceps, which may lead to increased risk of having a tear involving the muscle that controls the anus or rectum (third or fourth degree tear).
You may need to have an emergency C-section during labour. This happens in 25% of women. An emergency cesarean carries more risks than a planned C-section. The most common reasons for an emergency caesarean section are if your labour slows or if there is a concern for the wellbeing of your baby.

You should note that while a successful VBAC is less risky than a scheduled repeat C-section, an unsuccessful VBAC requiring a C-section after the onset of labor carries more risk than a scheduled C-section. And the risk of complications is even higher if you end up needing an emergency cesarean.

8) Can I have a VBAC if I have two prior C-sections?

According to the American (ACOG) and British (RCOG) guidelines, women who have had two prior lower segment caesarean deliveries may be offered VBAC after careful counselling. Nonetheless, they should be aware that the risk of uterine rupture is increased up to 5 times (0,9 to 3,7%).

VBAC after 2 previous C-sections is highly controversial, and may not be acceptable for certain physicians or institutions.

9) What to expect during a VBAC

VBAC should take place in a hospital or maternity that can manage situations that threaten the life of the woman or her fetus, and should NOT be attempted at home.
You should meet all the criteria, and have none of the contraindications for VBAC above-mentioned.
Factors that may reduce or increase the likelihood of success will be thoroughly discussed, and are different for each woman and each pregnancy.
Best candidates for VBAC are those women whose labor starts spontaneously, as induced labor (started with drugs or other methods) reduces the chances of a successful vaginal delivery and carries 3 times higher risk of complications.
You will be advised to present yourself at the hospital at the earliest sign of labour for careful assessment.
Your baby’s heartbeat will be monitored continuously during labour; this is to ensure your baby’s wellbeing, since changes in the heartbeat pattern can be an early sign of problems with your previous caesarean scar.
An intravenous (IV) line is indispensable in order to promptly manage any eventual complication.
You’ll have to refrain from eating anything during labor in case you require an emergency c-section later.
You can choose various options for pain relief, including an epidural.
The following signs may be indicators of uterine rupture, and warrant an emergency C-section:
- Persistent fetal bradycardia (the baby’s heart rate drops; this is the commonest sign of uterine rupture).
- Vaginal bleeding.
- Uterine scar tenderness.
- Pain between contractions.
- Cessation of contractions.
- Pain “breaking through” the epidural analgesia, or excessive epidural requirements.
- Palpation of fetal parts outside the uterus.
- Haematuria (blood in the urine).

It is important that you understand that uterine scar rupture may be silent, and that even an emergency C-section may not prevent serious complications, both for you and your baby.

In conclusion:

Successful VBAC has the fewest complications.
The greatest risk of adverse outcomes associated with VBAC occurs when a VBAC results in an emergency caesarean section.
It is often impossible to predict who will be able to have a successful VBAC and who require a repeat C-section.
Spontaneous (not induced) VBAC has a 1:150 risk of uterine rupture.
Uterine rupture is a rare but potentially life-threatening condition, both for the mother and her baby.
Even an immediate emergency C-section may not prevent serious complications, both for the mother and her baby.
The absolute risk of severe fetal problems and death associated with VBAC are very low, but higher than for planned C-section.
Babies born via planned C-section have increased risk of neonatal respiratory problems, which are usually short-lived.
Planned C-section is associated with an increased risk of placenta praevia/accreta complicating any future pregnancies; other complications such as pelvic adhesions are higher as the number of C-sections increases.

VBACs are controversial, and it may be challenging to decide whether is the best choice for you. Find a practitioner willing to support VBAC, discuss with him/her your options. Give yourself plenty of time to inform yourself and consider carefully the pros and cons of each option.

References

The American College of Obstetricians and Gynecologists (ACOG) – Vaginal Birth After Cesarean Delivery FAQ 070, December 2017 (For patients)
ACOG Practice Bulletin Number 184 – Vaginal Birth After Cesarean Delivery, November 2017
Royal College of Obstetricians & Gynaecologists (RCOG) – Birth options after previous caesarean section – July 2016 (For patients)
Royal College of Obstetricians & Gynaecologists (RCOG) – Birth After Previous Caesarean Birth – Green-top Guideline No. 45, October 2015
National Health System (NHS) UK – Clinical Guideline for: The Management of Vaginal Birth After Caesarean (VBAC). July 2016

Photo credits

1.Parents.com; 2.EvolutionaryParenting.com; 3.goldengateobgyn.org; 4.Healthymummy.com; 5.YouTube.com; 6.Scarymummy.com; 7.geoscripts.meredith.services

23Jan2018

FACT OR MYTH? TRUTHS, HALF-TRUTHS AND MISCONCEPTIONS ABOUT THE BIRTH CONTROL PILL

Posted in Health by woman2womenblog

When introduced in the 1960s, the birth control pill became a symbol of female liberation

The contraceptive pill made its appearance more than 50 years ago. Emerging during a period of social and political upheaval, it gave women the possibility to choose how and when to have a family, and to enjoy their sexual life. Thus, it is regarded as one of the greatest scientific inventions of the 20th century and one of the utmost symbols of female liberation.

From the very beginning though, this revolutionary method of contraception has been a source of controversy: some people thought it would create “a society with unbridled sexuality likely to undermine the foundations of the family”; others feared harmful effects and the birth abnormal children.

Fifty years later, the pill remains even more controversial than before and -paradoxically enough- more and more women are “liberating” from their “liberator”: the pill’s popularity is on the decline, a trend observed in many countries. The reasons behind this shift are many, but fear of side effects seems to the most recurrent. Arguably the web and social media, with the spread of countless personal stories with dramatic headlines and numerous pill scares have influenced women’s perception on the pill’s risks. But are these fears legitimate? How dangerous is the contraceptive pill? What is true and what is false?

Let’s see what science answers to the pill’s most common assumptions…

1) The pill harms your future fertility

FALSE. All scientific evidence agrees that hormonal contraceptives do not make women sterile in the long run. Sometimes it may take three to six cycles for fertility to fully return, but within a year after going off the pill, women trying to conceive are as likely to get pregnant (80%) as those who were never on the pill. In certain cases of long-term use, there may be even increased likelihood of pregnancy within 6-12 months after discontinuing it.

Moreover, hormonal birth control may preserve fertility by offering protection against pelvic inflammatory disease, endometriosis, ectopic pregnancy, ovarian cysts, ovarian and uterine cancer (see below).

2) The pill reduces sexual desire

MOSTLY FALSE. In most cases, birth control pills don’t affect libido (sexual desire): out of 10 women taking the pill, 7 experience no change in their sex drive, 2 observe increased libido, and 1 will feel less desire.

Recently, a study provided evidence that the pill does not kill desire: contextual factors, such as the relationship with the partner, stress, fatigue, family problems, recent childbirth, have a more considerable impact on sexual drive than the type of contraception used.

3) The pill makes you fat

MOSTLY FALSE. A recent extensive review study showed no evidence that birth control pills cause weight gain in most women. Although some persons may gain some weight when they start taking it, it’s often a temporary side effect due to fluid retention, not extra fat. And, like most side effects, it usually goes away within 2 to 3 months.

A woman’s weight may fluctuate naturally due to changes in age or life circumstances. Because changes in weight are common, many times they will wrongly attribute their weight gain or loss to the use of the pill.

4) The pill increases the risk of blood clots

TRUE. From the 1960s it is known that combined contraceptives pills may increase the risk of venous thrombosis, that is, a blood clot obstructing a vein, a serious and potentially life-threatening complication. Combined contraceptives contain synthetic versions of the hormones estrogen and progesterone. It is the estrogen that is mostly associated with the formation of blood clots, but the latest years it became evident that the type of progesterone also influences the risk. Indeed, the most “modern” formulations of the combined pill – the so-called third and fourth generation – containing the synthetic progesterones gestodene, desogestrel and drospirenone are associated with higher risk of thrombosis.

The European Medicines Agency (EMA) provides the following values for the incidence (frequency) of deep vein thrombosis in 100,000 women of childbearing age:

5 to 10 in non-pregnant women who do not use oral contraceptives,
20 for women using a second generation combination pill (containing levonorgestrel),
40 among women taking third and fourth generation pill.

Factors that may increase the risk of thrombosis are smoking, high blood pressure, obesity, age over 35 years, and a family or personal history of vascular accidents.

Although these figures may look scary, they should be analyzed in perspective:

In absence of risk factors, the absolute risk of thrombosis is very low.
The mortality rate of clotting events is about 1%. Thus, the odds of dying as a result of having a clot attributable to the use of the pill would be about 2 to 4 per million women.
The risk remains considerably lower than that related to pregnancy and birth (estimated 1 in 1000- 2000 deliveries).
Indicative of this is the 1995 pill scare in the UK, when a warning was issued on the increased risk of thrombosis related to third generation pills. This led many women coming off the pill, resulting in 12,400 additional births and a 9% abortions rise in 1996.

Overall, the odds of having a thrombotic episode related to the pill are very low, in particular with combined pills containing low dose of estrogen (30 or less micrograms) and old-generation progesterone (such as levonorgestrel).

The minipill, also known as the progestin-only birth control pill, is a form of oral contraception that does not contain estrogen, and its progestin dose is lower than that in the combined formulation. Although its efficacy is slightly reduced as compared to the combined pill, the minipill does not increase the risk of venous thromboembolism or arterial thrombotic accidents (see below).

5) The pill increases the risk of heart attack and stroke

TRUE. An extensive review study looking at arterial vascular accidents attributed to the pill (myocardial infarction and ischemic stroke) showed that the overall risk of arterial thrombosis was 60% increased in women using oral contraceptive pills compared to non-users. Unlike venous thrombosis, the risk did not vary according to the type of synthetic progesterone. However, it was twice as high in women taking pills with higher doses of estrogen (the older formulations of contraceptive pills).

Therefore, the combined pill containing levonorgestrel and low dose estrogen (no more than 30 µg) is the safest oral form of hormonal contraception. The minipill may also be considered in high risk women (see above).

6) A woman should not take the pill if she smokes

TRUE. There is some evidence that smoking may decrease the effectiveness of hormonal birth control. When taking the pill, smokers experience more frequently irregular bleeding than non-smokers; this could signal that the efficacy of the pill is lowered, but more research needs to be conducted to better understand the effect of smoking on the pill’s action.

But what we do know for sure is that smokers who take combined oral contraceptives have increased risk of venous thrombosis and heart disease (see above). This risk is higher for women that smoke more than 15 cigarettes/day, are older than 35 years old or take formulations with high estrogen levels.

If you are under 35 years old and smoke, you should be extremely careful about using the pill, and the decision to take it should be individualized considering other risk factors such as personal and familiar history of high blood pressure, high cholesterol or heart disease. Smokers aged 35 or over should not take the combined contraceptive pill.

If you smoke you may opt for the mini pill, which does not seem to increase the risk of venous thromboembolism or arterial thrombotic accidents; otherwise you should discuss with your doctor about another contraceptive method, such as the intra-uterine device (IUD).

7) The pill causes mood changes and depression

DEBATABLE. Most studies have shown no effect of the pill on depression and mood changes; some studies have even found a protective effect. In 2016, an extensive review on hormonal contraception and mood changes confirmed the existing evidence, and concluded that “… negative mood changes are infrequent and combined hormonal contraception may be prescribed with confidence”.

However, a recent publication came to challenge this assertion. Danish researchers went through the health records of more than a million women using hormonal contraception. They found that those on the combined pill were 23% more likely to be prescribed an antidepressant than those not on hormonal contraception. For those on the minipill (and on other progesterone-only methods, including the hormonal IUD), the figure rose to 34%. It increased even further, to 80% more likely, for girls 15 to 19 years old on the combined pill.

There are a few important points to consider about these results:

Depression is a complex condition whose cause is still poorly understood. Several factors seem to play a role: genetic, environmental, psychological and social. Therefore, it is very difficult to evaluate the link between depression and hormonal contraception.
The Danish study does not prove that hormones are responsible for the depression – “association” does not necessarily translate into “causation”.
The risk of being diagnosed with depression peaks at two to three months of contraceptive use, but then begins to fall.
Even if these findings are confirmed, the number of affected women remains small: 2.2 out of 100 women who use hormonal birth control develop depression, compared to 1.7 out of 100 non-users.

In conclusion, the pill may have impact on some women’s emotions, but further research is needed to establish whether hormonal contraceptives are indeed the cause of depression and mood changes.

8) The pill is 100% reliable

FALSE. Theoretically, with perfect use, the pill is 99.7% effective at preventing unwanted pregnancy. However, there are many factors that may interfere with the pill’s level of effectiveness: forgetting to take it, not taking it as directed, certain medications or medical problems…Therefore, when it comes to real life, the pill is about 92% effective: about 8 in 100 women using the combined pill will get pregnant in a year.

In any case, the birth control pill remains one of the most reliable contraceptive methods.

9) If you take the pill you don’t need the condom

FALSE. A survey conducted in France showed that “…one in ten young women 15 to 20 years old is not aware that the pill does not protect against HIV and sexually transmitted infections (STI)”. As stated before, the pill is a very good at preventing unwanted pregnancy but it offers no STI protection at all. In fact, the only contraceptive method that protects against sexually transmitted infections is the condom. Read more here.

10) The pill causes cancer

TRUE AND FALSE. The pill seems to increase the risk of certain cancers, but it protects again others. Overall, with the use of oral contraceptives the risk of endometrial and ovarian cancer is reduced, whereas the risk of breast and cervical cancer appears to be increased.

The protective effect on ovarian and endometrial cancer (the lining of the uterus) has been consistently demonstrated in many studies. This effect increases with the length of time oral contraceptives are used and continues for many years after a woman stops using the pill.

Long-term use of oral contraceptives is associated with an increased risk of cervical cancer. This correlation is not completely understood, as virtually all cervical cancers are caused by certain types of human papillomavirus (HPV). It has been suggested that women who use the pill may be less likely to use condoms, therefore increasing their risk of being exposed to HPV.

An extensive analysis of more than 70 studies suggested an increased risk of breast cancer among current and recent users of hormonal contraception. The risk was highest for women who started using oral contraceptives as teenagers. However, by 10 years after cessation of use, their risk was similar to that in women who had never used it.

Since most studies so far have evaluated birth control pill older formulations with higher doses of hormones, until recently it was assumed that the newer-generation pills available now would be safer regarding breast cancer risk. Yet a new study from Denmark found that even with the current pills, hormonal contraception users experienced a 20% increase in the risk of breast cancer compared to non-users; the odds rose among women who used hormones for more than 10 years. The risk was similar in magnitude to that of older pill types.

Whether oral contraceptive use increases the risk of liver cancer is not clear: while some studies found more cases of hepatocellular carcinoma ( a type of liver cancer) in women who took the pill for more than 5 years, others did not confirm this correlation.

Hormonal contraception seems to have a protective effect on colo-rectal (bowel) cancer, but this has not been yet consistently proven.

Since the pill seems to reduce the frequency of certain cancers and increase the risk of others, an interesting question arises: Does the pill increase the overall risk of cancer? The answer is NO. A recently published study provided epidemiological data on more than 40,000 women followed for more than 40 years. The results showed that users of oral contraceptives are protected from colo-rectal, endometrial, and ovarian cancer; this beneficial effect lasts for many years after stopping the pill. An increased breast and cervical cancer risk was seen in current and recent users, which appears to be lost within approximately 5 years of stopping oral contraception, with no evidence of either cancer recurring at increased risk in ever users with time. These results are reassuring and provide strong evidence that most women do not expose themselves to long-term cancer harm if they choose to use oral contraception; indeed, many are likely to be protected.

11) The pill has many bothersome side effects

TRUE AND FALSE. Some women refuse to take the pill because they fear certain annoying symptoms. Indeed, the birth control pill is a medication, and as such, it has possible side effects.

The most common adverse reactions associated with use of combined contraceptives include changes in bleeding patterns, nausea, breast tenderness, headaches, missed periods, vaginal discharge and visual changes with contact lenses; few women may also experience changes in sexual desire and mood changes, or temporary weight gain related to fluid retention (see above). In general, these side effects are not a sign of illness, and usually stop within the first few months of using the pill.

While some women may experience bothersome symptoms, the pill provides important non-contraceptive health benefits:

Decreased risk of certain cancers (see above)
Improved bone mineral density (in older women)
Protection against pelvic inflammatory disease
Prevention of ovarian cysts
Reduction of menstrual bleeding problems
Prevention of menstrual migraines (with non-stop formulations)
Protection against iron-deficiency anemia
Reduction of ovulation pain
Treatment of acne
Treatment of bleeding from fibroids
Treatment of dysmenorrhea (painful periods)
Treatment of excess hair on face or body
Treatment of premenstrual syndrome (PMS)
Reduction of endometriosis symptoms
Reduction of polycystic ovarian syndrome symptoms
Induction of amenorrhea for lifestyle considerations (when you need to stop your period for a while; you can also advance or delay your period with the pill)

So, how dangerous is the pill?

There is no perfect contraception method. I wish there were. And it is true that hormonal contraception, like any other medication, may have annoying side effects and serious health risks. Does it mean that no one should take the pill? Of course not!

We should keep in mind that severe risks are very rare and most bothersome symptoms are short-lived; in addition, the pill offers many non-contraceptive health benefits. But when discussing about the pill’s pros and cons, sometimes we forget a very important issue: the birth control pill is one of the most effective contraceptive methods. And effective birth control prevents from unwanted pregnancy, which may have not only devastating psychological consequences, but may also lead to severe physical harm.

Therefore, the potential problems of the birth control pill should be analyzed in perspective: we shouldn’t just pay attention to downsides, forgetting to place them in context with the upsides. Every woman considering taking the pill should thoroughly discuss with her healthcare provider not only the possible risks, but also its significant benefits, which for many women will be greater than the harms.