The Delivery Decision

February 9, 2017 Susana G. Gonzalez, MD

delivery-options

Crystal McAuley, 34, had a simple wish for her second delivery. She wanted to be able to pick up her 18-month-old son, Fitzgerald, when she came home with her newborn this past February.

Because Crystal’s first delivery had been via emergency cesarean section, she had two options this time: have a planned C-section or attempt a vaginal birth after cesarean (VBAC). Both have risks, and the decision wasn’t an easy one for Crystal and her husband, Simon, 42, who live in Napa and work in the wine industry.

The primary risk with VBAC is uterine rupture, where the scar from the prior cesarean separates; it happens in less than 1 percent of cases, but it’s a serious complication when it does. Yet Crystal knew that another C-section would mean a lengthy recovery, during which she wouldn’t be able to lift anything weighing more than a few pounds, including Fitzgerald. “I didn’t think I could go home and not pick up my son,” she says.

Susana G. Gonzalez, MD, an OB/GYN with St. Joseph Health Medical Group in Napa, California, says she hears this motivation often, especially since women considering VBACs likely have other children at home. “They’re not only going to be taking care of a little newborn but perhaps a toddler as well,” she says. The estimated recovery time for a C-section is eight weeks; for a vaginal birth, it’s just six, because a C-section is a surgical procedure, whereas a VBAC is not, Dr. Gonzalez explains.

Other women are motivated by the desire to experience a vaginal birth.

Not all VBAC attempts are successful, but most are. An “unsuccessful” VBAC means the baby was ultimately delivered via C-section for any number of reasons — not that a uterine rupture occurred. According to the National Institutes of Health, the average success rate is 74 percent.  Among women who attempted a VBAC at the Queen in 2015, it’s 77 percent.

THE COMPLEXITIES OF VBAC
VBACs provide a faster recovery and a reasonably high rate of success. So why aren’t they universal?

First, it’s not possible for all deliveries. According to R. Bruce Scarborough, MD, an OB/GYN with St. Joseph Health Medical Group (who performed the first VBAC in Napa County), a lot depends on the circumstances of the woman’s first C-section. If the mom didn’t dilate or the baby’s head didn’t descend, it could be that the shape of the pelvis wasn’t conducive to vaginal delivery. If a C-section was necessary because of a breech position, fetal distress or something else unrelated to anatomy, the mom is a better candidate for a VBAC.

The type of incision is important, too. “We don’t recommend vaginal birth for women who’ve had vertical incisions,” Dr. Gonzalez says. “They’ve had to have a transverse incision.” Transverse incisions are low, horizontal incisions. They are the most common type of incision for C-sections.

“We evaluate what their chances will be to have a vaginal birth and counsel them in that regard,” Dr. Gonzalez says. “We want them to go in with their eyes open and be well-informed.”

Second, not all hospitals offer VBACs. The American College of Obstetricians and Gynecologists states that VBACs should only be attempted in facilities equipped with a surgical team “immediately available” to provide emergency C-sections.3 “Many facilities can’t offer that or don’t want the liability associated with it,” Dr. Gonzalez says. “We are very supportive of it and we are the only hospital in the valley that will offer it. We actually will offer [VBACs] for patients who’ve had two C-sections in the past.”

Thirdly, some women prefer the convenience of a scheduled C-section, so they can plan ahead for child care and time off work. “I’m all about choices, and informing parents about what to expect,” Dr. Scarborough says. “We do everything we can to support our mothers.”

KEEPING HER OPTIONS OPEN
Crystal’s first obstetrician was in St. Helena, but when she became pregnant the second time, she learned they didn’t offer VBACs. So she met with the OB team at Queen of the Valley Medical Associates (now St. Joseph Health Medical Group). They outlined all her options and the various considerations. They told her she didn’t have to decide right then — or even before she began labor. “That is inevitably why we switched practices,” she says.“We wanted to have that option.”

And indeed, Crystal says she deliberated. “I flip-flopped back and forth between the planned cesarean and the VBAC throughout the entire pregnancy,” she says. “When we ended up being 10 days early and labor was progressing naturally, that’s really when I said, ‘I want to try for it’.”

FEELING THE DIFFERENCES
Once Crystal’s active labor began, she and Simon made their way to the Maternity Center at Queen of the Valley Medical Center. For Simon, the hospital’s location was ideal, convenient to grocery stores and restaurants to quickly get what he needed for Crystal or their toddler. He also made use of the shower and the sleeper chair in their private room. “I managed to catch a few winks,” he says. The couple also took advantage of the hospital Wi-Fi to stream their preferred entertainment. “We turned the lights down in the room while I labored, and we had music on,” Crystal says. “It was a very pleasant experience.”

After 28 hours of labor, Crystal began to feel the pressure of the baby pushing, which she hadn’t experienced before. “With my first one we didn’t make it that far,” she says.

Dr. Gonzalez coached her through the pushing and within a half-hour, the McAuleys’ second son, Franklin, was born.

“I could not have asked for a better scenario,” Crystal says. “[Dr. Gonzalez’s] demeanor and the way she approached everything was very calm and no-nonsense. She made me feel safe and secure.”

Just hours after delivery, Crystal was stunned that she could stand up and even take a shower. “After a C-section you cannot stand up unassisted,” she explains. “It was the most amazing shower I’ve ever had in my life!”

And when Crystal returned home, her wish became a reality: “I was able to walk through my front door, pick up my son, and hold onto him while we introduced him to the baby.”

Queen of the Valley Medical Center’s recently expanded facility offers comfort and convenience for moms and babies. In addition to VBAC, the center offers Certified Nurse Anesthetists available 24/7, two Operating/Cesearean Rooms, 10 large private mother/baby suites with sleeper chairs, the opportunity to try a Jacuzzi® birthing tub and a full-time lactation consultant. For more information, visit thequeen.org/maternity

This information is not intended as a substitute for professional medical care. Always follow your health care professional's instructions.

 

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