Want to have a successful VBAC (Vaginal Birth After Cesarean) if you must have a C-section the first time around? Read on!
When it comes to giving birth, a vaginal birth is certainly preferable to a C-section. Recovery from vaginal birth is much more rapid and involves less danger to the life of the Mother and child. After all, a C-section is considered major abdominal surgery with all the inherent risks.
In addition, there is evidence that children born vaginally are healthier than those born by C-section. Vaginal birth allows the child’s sterile gut to have first exposure to beneficial flora from the Mother during delivery. This exposure helps to properly seed the intestinal tract with immune system boosting bacteria.
Birth by C-section initially seeds the child’s gut with whatever bacteria are floating around the hospital environment. This leads to a higher risk for development of auto-immune problems. These chronic issues include allergies, leukemia, type 1 diabetes, asthma and others.
Intravenous (IV) antibiotics during labor can also negatively affect the normal seeding of baby’s gut during vaginal birth. As a result, skipping the Strep B test is a good idea since women who test positive are frequently forced to have IV antibiotics. Unfortunately, this happens even though research has failed to demonstrate any benefit to antibiotic treatment during labor.
Another benefit of vaginal birth is that it involves a gradual and more tolerable increase in stress for the baby. This as opposed to a cold cut Cesarean which shocks and stresses the newborn in a very short period of time. The shock stress of a C-section potentially causes unfavorable DNA changes to the baby’s white blood cells (July 2009 Acta Pediatrica).
For these reasons, it is best to take steps to avoid C-section if at all possible. Having a natural birth at home or at a birth center and avoiding an epidural is one way to reduce C-section risk. Another is to know how to induce labor naturally if baby is late.
In addition, planning for future pregnancies to be VBAC is wise too. Planning for a natural birth with a midwife in attendance with avoidance of all drugs definitely helps skew the odds in Mom’s favor. One intervention typically leads to another, and then another. A domino effect to C-section is thus avoided by refusing all interventions unless deemed a medical emergency.
Sometimes, despite everyone’s best efforts, a C-section needs to be performed. In these situations, C-sections are indeed a life saving operation.
The fact is that life is unpredictable and a C-section is the end possibility for every pregnant woman. This is true no matter how much planning is done to prevent one! As a result, every pregnant woman needs to have a conversation with her OB about the approach to stitching up the uterus in the event an emergency C-section is necessary.
Successful VBAC and Uterine Sutures
Many parents do not realize that the doctor performing the C-section has a choice about how to stitch up the uterus following surgical birth.
Double Layer Suture
The double layer uterine closure was primarily used throughout the United States prior to the early 1990’s. The first layer of sutures pulls all the cut edges of tissue together. The second suture layer, called the “imbricating pattern”, pulls uncut tissue together on top of the first suture layer.
Single Layer Suture
The single layer uterine closure has been used since the early 1990’s in the United States. Europe also uses this technique extensively. It involves suturing the cut edges together. Then, smaller sutures are used to stop any continued bleeding or to pull together areas of tissue that aren’t well counterbalanced.
Which Type of Uterine Suture is Best for a future VBAC?
Overwhelming evidence has shown that the single layer closure involves fewer complications in the immediate post operative period.
Research has also indicated that the double layer closure involves less risk of uterine rupture and successful VBAC with future pregnancy.
In other words, each suture method has benefit as well as a downside.
In 2002, a large study was published comparing single to double layer Cesarean sutures. A significantly higher risk of uterine rupture with the single versus the double closure (3.1% vs. .5%) was identified. The study analyzed 489 women who had C-sections with the single closure and 1491 women with the double closure. Results were controlled for use of pitocin, epidurals, age, and other factors.
The study authors concluded that the single closure method involves significantly higher risk of uterine rupture if the woman attempts a VBAC with a later pregnancy.
Since this study, prominent midwives in the US community have advocated use of the double layer closure to improve the odds of women attempting VBACs. Some even believe that women who have had a single layer closure should not be allowed to plan out of hospital births or VBACS at all.
I heard a prominent US midwife interviewed on National Public Radio advocating the double layer closure. Her reason? This type of suture is a very good idea for women who desire a successful VBAC with future pregnancy.
Smaller studies have shown no difference in risk of uterine rupture between the two suture methods. But, the overwhelming results of the large study by Bujold remains a concern for many in the midwifery community. Hence the continued push for use of the double layer technique.
VBAC Conclusions
If a Mom is only going to have one child or her current pregnancy is her last, then the single layer closure is probably the best choice. This type of suture in the event of a Cesarean gives the best chances for optimal post operative recovery.
However, if Mom wants more children and wants to birth them vaginally, insisting on the double uterine closure in the event a C-section is best. This type of suture greatly improves her odds for a successful VBAC in the future. In fact, some OBs and midwives won’t even attempt a VBAC without it.
Sarah, The Healthy Home Economist
Source: The Suture Debate
I had my first child in 2007, a c-section. During labor he was discovered breech, and there was no way they would allow me to deliver vaginally. The doc even threatened us that if a baby got stuck they would end up cutting the head off, what a b*tch! I was in full blown labor, I couldn’t speak for myself and I wasn’t informed much either (didn’t know about vit. K shot or goo in the eyes). My water broke at home, so I guess I am thankful that my baby at least got some whatever bacteria I had while in labor. My recovery wasn’t too bad, but compared to my VBAC with my 2nd child, was long, lonely, and painful. After my first child I was determined to have a vbac, I found a water birth center and had superior prenatal care and the birth process lasted only 2 hours and was incredible!!! My midwives were a dream come true. I would relive the entire process all over again in a heartbeat! A vbac was such a lovely and amazing experience compared to a c-section (cold and impersonal – I hated everything about it). Thank you for posting on this topic, Sarah, may other mommies-to-be be informed!
Thank you for the information. Just a suggestion: it will be helpful if you can put an option to print each entrance of your blog. I will now print this one. I want to discuss it with the doctor who made my first C-section. Greetings from Quito- Ecuador!!!
I had 4 c-sections not because I didn’t want to try vbac but because none of the doctors where we lived (my doctor included) would touch someone doing a vbac with medicaid because of the lawsuits. lawsuit abuse is still horrible where we lived, and the sad part is that most were illegals. It was my husbands last year of medical school and we were on medicaid and I did not have much of a choice. I always wonder how it would have turned out had I been able to pick differently.
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Pregnancy Question– I had a bit high of a protein result in my urine at my midwife appointment today (still in normal range, but on the highest part of it). She said it is one of the indicators of preeclampsia. The internet searches I’m doing all show to have a low fat diet while pregnant to help with this, but I’m thinking that could end up with worse results overall. Any nutritional advice for this higher than normal protein result in my urine? I’ve gotta do it again in 2 weeks, and I’d like to ace it 😉
It’s been awhile since I was pregnant but I seem to remember that I had protein in my urine once (I ate low carb, high fat, normal protein during pregnancy) and my midwife told me to drink more water and that fixed the problem. I certainly did not consider eating lowfat as an option.
Pre-eclampsia involves a lot more than protein in the urine, so be on the lookout for an unusual amount of swelling and high blood pressure also. I agree that a low-fat, low-salt diet is not the answer for pre-eclampsia, although this is what most women are told. I’m pretty sure that this leads to worse pregnancy outcomes- weaker mothers and babies.
Thank you! I’m gonna load up on water this next time. She said it’s still in normal, but I like to do what I can to prevent it going outside of normal. Thanks
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You cited the ICAN White Paper about the single vs double layer suture debate, but I think you may have missed much of the point of the White Paper. Yes, there are some studies that show an increased risk of uterine rupture with single layer closure, but not all studies show this. The studies that show an increased risk of UR with single layer closure are not very big studies. It is clear that single layer closure often leads to less complications immediately postpartum, which in theory could actually help improve healing.
Other factors that aren’t being looked at here that may have a bigger impact on UR rates are the type of stitching, suture materials, and OB preference/technique. If an OB is particularly skilled at and used to performing single layer closures, him performing a double layer closure if that’s not what he’s used to doing may not necessarily be an improvement, ykwim?
I know first hand how scary the single vs. double layer closure debate can be. It terrified me to hear this after seeing in my operative report that my second cesarean had been finished with a single layer closure (after I had specifically requested a double layer closure because of all of the scary stuff I’d heard). It took a lot of additional researching and soul searching to figure out if this would change my future childbearing plans. I went on to birth my son- all 9 lbs 10 oz of him with both hands by his head after a 2+ day active labor- completely naturally after 2 previous cesareans and a single layer uterine incision closure.
There are enough scary stories and (often mis)information out there about VBACs. I don’t think that a single layer incision closure needs to be added to the list of scary things about VBAC. I think it’s fair enough to say that the research is inconclusive, but I don’t think it’s something that should contribute to women feeling like their uterus is a ticking time bomb.
I do agree that it’s important to discuss this with your care provider before delivering to see what kind of closure they typically perform, why, & to discuss your future childbearing plans to see if that will affect their plans for incision closure if a cesarean becomes warranted. I think it’s great that you’re bringing attention to the growing cesarean epidemic and how it can often affect a woman’s future childbearing plans. ICAN has lots of information about how to make a cesarean more family-centered should one become necessary, decreasing the chances of needing a cesarean, and birth recovery support.
The Bujold study that showed the single closure to have a significant risk for uterine rupture was very large. It was the smaller studies that did not show a correlation. As I mentioned in the conclusion , it won’t hurt and very well may help considerably a woman’s VBAC chances to request the double closure. Some midwives won’t consider a woman for a VBAC if she has had a single closure C-section so ignoring this as an issue because “its too scary” is not beneficial to the situation.
Given that prominent US midwives call for the double closure, I think it is very worthwhile for a woman to request it in the event a c-section is necessary. Having regrets after the fact is no good at all.
Quoted directly from the White Paper you reference, “Because most of the research on longer term outcomes was published in Europe, many of them in foreign languages, there was no real attempt to corroborate or refute Bujold, et al., even though some of the European studies appear to have sample sizes as large as or larger than that of the Bujold, et al. study” and “After looking at all the available information on this topic, we are left with the conclusion that it is unclear as to whether uterine rupture rates are impacted by uterine closure techniques. Out of eleven published studies which looked at uterine rupture or scar integrity, only one showed an increase in uterine rupture associated with single-layer closure.”
It is correct that some well-known US OBs and midwives will not accept VBAC clients with single layer incision closures. It’s also true that there are some US OBs and midwives who won’t accept VBACs at all because they believe the risk of UR is too much regardless of closure type. There are also prominent US OBs and midwives who don’t bat an eyelash at single layer closure, type of incision, inter-delivery intervals, or a number of other factors that other care providers won’t touch with a ten foot pole in a VBAC mom. I’m not saying the concern should be ignored or that the question of safety shouldn’t be asked. I’m just saying that the research is inconclusive and shouldn’t be used to create across-the-board recommendations for double layer suturing.
Looking at it from a practical perspective, it won’t hurt and it very well may help to have the double suturing. There is no downside to the double suture as there are NO studies at all that show it will increase risk of rupture and one large study that shows that it will significantly reduce the chance. That is enough IMO for a woman to have the conversation with her OB to ensure that the double suture is used if she intends to have more children and to attempt VBAC.
I don’t know if I’d say there’s no downside to double layer suturing. Uterine rupture is not the only concern in a pregnancy after a prior cesarean (regardless of the plans to VBAC or have a repeat cesarean). Double layer suturing does appear to have increased risk of infection and adhesions over that of single layer suturing. And again, regardless of what the studies say, I think it’s also important to take into consideration the individual OB’s technique and skill in performing a closure of any kind.
I do see your points and agree it’s certainly important to discuss this with care providers ahead of time. However, coming from someone who has been in this position before, I can’t even express how terrifying it is to read that single layer suturing=bad when that may not necessarily be the case. I had specifically requested double layer suturing after reading some articles similar to this blog post, so to find out I had single layer suturing terrified me. The fear led me to research a bit more, and after digging a bit deeper I found it’s not as cut-and-dry as single=bad, double=good. I just hope that others out there reading this who may not be able to change what’s already been done aren’t unnecessarily devastated by it like I was. I’m not saying ignore any facts; just understand that there’s lots of conflicting information on this and opinions can greatly vary from one provider to the next.
In 1973 I had a C -section..after reading an article about VBAC (it didn’t have a name back then) I found a doctor willing to let me try a vainal delivery for my second. He sent off to Europe for infromation on it because it wasen’t done here. I had 3 vaginal deliveries with no complications after the initial C section and I am so thankful for that doctor and his ability to think outside the box.
I was all set up with midwife, but I ended up in emergency C-sec with first child. My baby was 10 days past due. We didn’t know it but she pooped in the bag and ingested it. She ended up in ICU for 8 days after C-sec.
The next baby I was going to have in birth center. We found only 1 doctor that would “back” my birth. He was 3 hours away, but I never went into labor and had to go into hospital to be induced. (which ups your chance for uterine tearing with VBAC) I didn’t care I was determined to have a VBAC.
3rd baby was VBAC as well. Induced, again, with a smooth birth.
I encourage women to go for VBAC. The birth experience was so worth it.
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