On the second visit to my OBGYN, Dr K, she told me that according to a medical calculation I have a 61% chance of having a successful vaginal birth if I wanted to try labor. Sometimes referred to as TOLAC (trial of labor after cesarean) and VBAC (vaginal birth after cesarean).
I was only 12 weeks pregnant at the time. It felt super early in the pregnancy to even think about birthing plans, but she wanted to bring it up to give me plenty of time to think about it. Her job as my doctor is to share information about the risks. Both options, another c-section and VBAC, come with potential risks.
For the past 18 weeks, I’ve been trying to figure out what the risks are and what I feel most comfortable with. I’ve been trying to figure out what is the best decision for me and this baby. The most up-to-date figure I can find is from 2013, when the average success rate for women in the U.S. who attempted a trial of labor after one previous cesarean was 70%.
Most literature encourages TOLAC/VBAC, suggesting that overall it’s better for mom and baby. But most of these articles don’t talk about that calculation I mentioned. Is VBAC encouraged for all women, or just those with a certain percentage on the calculator? Would women who have 86% probability of success be encouraged to choose VBAC while someone closer to 60% might not be?
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| Unsplash: Luma Pimentel |
Calculating the Chance of Success
Let’s break down the factors that are considered in this calculation: ethnicity, age, the cause of the previous cesarean and BMI.
Ethnicity - As a white mother, I fare well in this calculation. Due to systemic racism, which results in inequitable access to and quality of care, BIPOC mothers have decreased chances of successful VBACs. Overall in our healthcare system, BIPOC mothers have much greater risk - two or three times! - of maternal mortality compared to white mothers. The Centers for Disease Control & Prevention (CDC) has written about it. Just last week, Vice President Kamala Harris announced a call to action to address the country’s high rates of maternal mortality.
Age - Younger mothers are more likely to experience success with VBACs. But how young? I know I’m now in the “Geriatric” 35+ category, but only just! Do I have the same risk as someone who is 40? 45? I’ve tried playing with the age variable on some of the online calculators I’ve found. Dropping my age to 30 hasn’t made a big difference in my potential success rate.
Cause of previous c-section - Max was a breech baby, a factor unrelated to whether or not my body can handle vaginal labor/birth. My c-section wasn’t a result of a complication that arose during labor, or because of a condition such as hypertension. If that had been the case, no doubt my risk would be higher and chance of success lower.
BMI (body mass index) - a racially problematic metric (in both creation and application) used to attempt to measure health. At the start of this pregnancy my BMI was higher than it’s ever been in my life. Mostly this is because I didn't lose all the weight I gained during my first pregnancy. Not due to a lack of trying!
It was definitely the biggest concern I had on my mind as I first entered the doctor’s office back in July. I already felt uncomfortable with the extra weight on my body since Max’s birth. Though I was giving myself time to work it off in a way that suited me and my lifestyle. I had taken up running again, hoping to do a 10 mile run in August. I was trying to reduce consumption of sweets and alcohol without setting myself strict limits.
The first trimester hit me so hard with nausea and exhaustion that I had to stop running. I was quickly concerned that I could end this pregnancy with another 20lbs of extra weight. Not that my BMI matters to me, but how I feel in my own body does: whether I have energy for the day, or feel good in my favorite clothes (or can actually fit into them!).
What does this number say about my health and ability to birth a child through my vagina? When I adjust my BMI to where it was pre-first pregnancy, using a weight that I maintained comfortably, the VBAC calculation score goes up only 4 percentage points. That’s not a huge amount. I would have to weigh 40lb less to move my success rate up to 70%, the average in the US.
After breaking it all down, I don’t feel any better about the calculation. I don’t think it’s necessarily helping me understand the risks as they pertain to me. At the end of the day, the medical profession recommends VBAC to all women knowing that 30% will require an emergency cesarean. So maybe 61% isn’t that far off what’s considered an acceptable medical risk.
The Risks to Consider
So, what are the risks associated with my two options? And how do I decide which risks to accept? Warning here, I’m going to talk about medical risks and the thought of some of this might make your guts churn.
A c-section is a major surgery. It results in scarring, can include a long recovery period (6 weeks on average), presents risk of infection, potential hemorrhage and requires a longer hospital stay.
That said, my stay in the hospital with Max was 27 hours, and Dr. K. confirmed with a planned c-section it’s likely I’d only spend 24-48 hours in hospital. Plus, I’ll have a private room that Steve can also spend the night in. With the NHS, I was in a room with 3 other new moms, divided by thin curtains, and Steve wasn’t allowed there between 9pm and 9am. It was horrible.
I recovered pretty well and quickly after my last c-section. Dr. K thinks it would be a similar experience for me a second time around. I didn’t have trouble with trapped gas, which I’ve heard can be quite painful, or infections. I heard from friends who hadn’t been able to pick up their baby for some weeks, but I was able to lift Max earlier than I had expected. I’ve never experienced labor, but from my understanding that can have lasting implications and a long challenging recovery too.
I already have a scar, and I’m not exactly bothered by it. It’s not very visible to anyone but me and Steve. So that’s not a concern, even if it was to be more pronounced after a second incision.
The risk of blood loss and hemorrhage is there both in cesarean and VBAC. In fact, I think the most horrifying risk with TOLAC is uterine rupture - where the scar from my previous surgery tears under the pressure of labor contractions. Sounds horrific, doesn’t it? It apparently only happens to 0.6% of women in TOLAC, one in every 170. The same medical article suggests the rate is much lower for “unscarred uteruses,” at one in every 8,000. Here’s where I start to get overwhelmed and confused by all the statistics. Is 1 in every 170 really that bad? Compared to 1 in 8,000 it seems like it!
If successful (61% chance) a vaginal birth will require no surgery, potentially a shorter hospital stay, and a quicker return to normal activities. But even successful labor can be hours long, painful, stressful and traumatic. Even a successful vaginal birth can result in lasting consequences, anywhere from scarring due to the need for stitches, peeing involuntarily when sneezing for the rest of your life, to prolapse of pelvic organs.
If unsuccessful during a TOLAC (the other 39% chance in my calculation), I may face greater risk due to the need for an immediate emergency c-section. When babies get stuck, or stressed and their heart rates drop, a quick decision is made to whisk you into surgery. I can imagine that mentally I would be OK to handle the c-section because I’ve been through it before. But emotionally, that sounds like an upsetting situation, to worry about the baby like that. I’d worry about Steve too, having to witness that. Emergency cesareans tend to have greater risk of surgical complications than planned cesareans and are more likely to result in lasting issues for the mom.
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| Unsplash: Kristina Tripkovic |
Upon reflection, I realize that I’m not comparing apples to apples. I’m comparing an apple to an orange, and I can only see one side of each piece of fruit. On the other side, one or both might be completely dank and green with mold.
This medical paper sums it up for me.
Because most maternal morbidity during TOLAC occurs when repeat cesarean delivery becomes necessary, VBAC is associated with fewer complications than elective repeat cesarean delivery, and failed TOLAC is associated with more complications.
You don’t know until you know. If you do have a successful labor, resulting in a VBAC, that's probably better for you than a cesarean would have been. BUT if you don't have a successful labor, it's worse. So, why try? Do I think 61% is enough of a chance? I hate decisions like this.
There’s more to this decision than medical risk and percentages, and there’s a subconscious voice inside my head telling me what I should do. I’ll talk about that in Part 2.
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