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Vaginal Birth After Cesarean: Yes, You Can

Once upon a time, the prevailing wisdom was “once a cesarean, always a cesarean.” Thankfully, those days are long gone, but the rate of successful VBACs (vaginal birth after cesarean) still differs widely from one hospital to the next. That’s why it’s so important to choose the right hospital for your special delivery.

A passionate advocate for lowering cesarean rates, Marin General Hospital OB/GYN Dr. Lizellen La Follette talks about the hospital’s pro-woman, patient-centric approach to labor and delivery. The key is letting you take your time while nature takes its course. Listen and learn why Marin General Hospital made the California Maternal Quality Care Collaborative’s C-section Honor Roll for their exceptionally low cesarean rate.
Vaginal Birth After Cesarean: Yes, You Can
Featuring:
Lizellen La Follette, MD
Lizellen La Follette, MD graduated from Case Western Reserve
University. After an internship at Case Western School of Medicine,
Dr. LaFollette spent her residency training from 1988-1992 at Case
Western Reserve, MetroHealth Medical Center. Dr. La Follette is
certified by the American Board of Obstetrics and Gynecology. In 2015
she co-authored a 14-year VBAC study with the Main Director of the CA
Maternal Quality Care Collaborative, and presented that at the 2015
National American College of Obstetricians and Gynecologists
Convention. This 25-year, deep-rooted history in VBAC makes her an
expert leader in this procedure.


Transcription:

Bill Klaproth (Host): Is it possible to deliver your next baby vaginally if you had a C-section before? What are the risks and what do you need to know? Here to talk with us about vaginal birth after a C-section, or VBAC, is Dr. Lizellen La Follette, a board-certified OB / GYN at Marin General Hospital. Dr. La Follette, thank you for your time. So VBAC, why is it important for a woman to know about this?

Dr. Lizellen La Follette, MD (Guest): So the most important thing about a vaginal birth after cesarean is that most women can actually succeed in having a vaginal birth after either one or two C-sections. Marin General has been a leader in vaginal birth after cesarean since the 1990's and excels at this success. One of the things I learned when I did a fourteen-year study of VBACs at Marin General was a lot depends on the provider commitment. We have that commitment at Marin General and that is probably the most important success factor for a VBAC.

Bill: So how would a woman know if a VBAC is right for her?

Dr. La Follette: So first you need to educate yourself as a woman with a prior C-section. Most women with one or even two prior low-transfer C-sections are candidates. That means the C-section incision is in the lower part of the uterus, and that is the safest part and is the one factor that we need to be able to succeed for a vaginal birth after cesarean.

Bill: So Dr. La Follette, are most women then a good candidate for a VBAC?

Dr. La Follette: Since most women have a low-transfer C-section, that means most women are a candidate for a vaginal birth after cesarean. But one of the things we've learned in California hospitals and in the country is that the hospital and the attitude of the providers in the hospital often allow certain practices to happen regardless of what you would call inherent risk. Marin General has specialized in making sure that first mom has a normal birth, so that actually is very important, so it's one of the hospital measures that we've been excelling in for many years with a low primary C-section rate. But also we know that we make a difference trying a vaginal birth after cesarean because we as providers, and anesthesiologists, and as a hospital are fully committed to allowing women to have a vaginal birth.

Bill: And a vaginal birth is much more beneficial for a woman than a C-section, obviously you don't have to do surgery, but are there other reasons that every woman should consider a VBAC after having a C-section?

Dr. La Follette: I think that's probably the best question. I think everyone should consider a vaginal birth after cesarean because the data shows that it is safer, it's less bleeding, it's less surgery, it's less infection, and it's a much quicker recovery. What's really interesting, and this is why women need to educate themselves, is it is really dependent on who your provider is. If they are committed to allowing you more time, to allowing you the opportunity to have a vaginal birth after cesarean, my fourteen-year study and the country's success has been the same. 75% to 78% of women will succeed in having a vaginal birth. That's not everybody, but that is three quarters of the majority.

Bill: Dr. La Follette, those are really good numbers, but it sounds like then some providers just prefer or default to doing a C-section.

Dr. La Follette: I think one of the problems with obstetrics, and what we're starting to learn, is that in 2011 there was a very large study that showed that the timeframe that we allow a woman to go and deliver a baby, in other words the time of labor progress, were artificially shortened in the past, and then people- women needed more time in labor. In 2011 there was a very large study that looked at all this California data to show that for most women, active labor is not until six centimeters. So if you're doing a C-section before six centimeters, they haven't even given the pelvis a try, because they're not in active labor yet. So number one is giving women more time. The second is allowing women to stay home, get labor support, get in the tub, get in the shower, because if they're too early, they think their labor has started, and then you start doing what I call meddlesome obstetrics. "Oh you're only one centimeter, we'll bring you in and we'll do-" No, you're not in labor yet. You're too early, go home, you are more comfortable at home. But that takes time, and everyone needs to be on the same page, that we are going to labor on, and stay home if we can. Once that happens, then you start to give women the chance to get into active labor and their chance of succeeding in the vaginal birth is much higher. That's one of the things that Marin General has been so recognized for. We have a very low primary C-section rate. Luckily the California Maternal Quality Care Initiative started to actually look at these numbers and recognize that the hospital should not make a difference about whether or not you're having a C-section. It should really be maternal education, obstetric education, and not whether or not you are in this zip code or another zip code.

Bill: Well speaking of Marin, Dr. La Follette, can you tell us about Marin being named to the C-section Honor Roll for the second year in a row? What is that and what does that mean?

Dr. La Follette: So the California Maternal Quality Care Collaborative created an honor roll of hospitals that have a primary C-section rate. So really the first C-section rate that's under 23.9%. And what they're looking at is what they call the low-risk mom, or first-time mom, whose baby is head down, who have one baby, not multiple, and who are full-term. Which for us now full-term is considered to be close to be thirty-nine weeks rather than thirty-seven. And so when you look at those women, this is their first chance to have a birth, and if you're able to make sure that most of those women deliver vaginally, we know for the country as well as for Marin General that the next babies will be delivered vaginally and safely. We also know that the next baby if you have a C-section, for 90% of the hospitals in the country, are born by C-section, and that we know isn't safe, it leads to hemorrhage, it leads to maternal death, and it's one of the things that we're trying to make different. So one of the things Marin General has been committed to is allowing women the time so that their first baby can be delivered vaginally, and that that primary C-section rate is under 23.9%. In fact, I've looked at Marin General's numbers for the last twenty-five years, and we've had a primary C-section rate that has been as low as 17% or 18% and sometimes as high as 22%, but for the most part, it has been very low and very safe, and it's one of the reasons why Marin General is excellent in delivering obstetrical care.

Bill: So what you're saying then is it's really important for an expectant mother to look for a hospital with a low C-section rate.

Dr. La Follette: That's exactly right, and I think one of the things we all need to understand is that if you're going through your first experience as a pregnant mom, you need to educate yourself about where you're going to be, who's going to be taking care of you, and what are the risks and benefits of delivering in one place or another. One of the things we all learn is that sometimes we fall in love with a certain campus or a certain site that looks terrific, and that might not be the best place. If you actually dig into the information, find out do they provide or give you more care? Are they committed to a vaginal birth after cesarean? Are they committed to giving you more time as a first-time mom and won't do meddlesome obstetrics? Those are hugely important factors, and for all of us in obstetrics, we need to know our own statistics. I have kept my statistics as well as Marin General's statistics for twenty-five years, so I can tell you exactly what my numbers are. We have an obligation to the consumer to be able to tell them, "What's my VBAC rate? What's my C-section rate? What's my vaginal instrumentation rate?" Those are important factors for women to understand.

Bill: And it sounds like those are really good questions that a woman should ask their primary care physician or their OB / GYN.

Dr. La Follette: I think in OB, we have fifteen visits to see you, which is probably more than we need, but that's an opportunity to ask these questions. Asking before your pregnant, you might not remember the answers, but once you are actually growing a human, you will be very committed to understanding where you're going to deliver, how you're going to deliver, and who's going to be with you during that delivery. And we're colleagues together in practice; the patient, and the physician, and the provider. We need to work together to understand the risks and the benefits of a safe delivery, and the factor of time.

Bill: Such great information, Dr. La Follette. Thank you so much for your time today, we really appreciate it. To learn more about the family birth center at Marin General Hospital, visit www.BirthMarin.org. That's www.BirthMarin.org. This is The Healing Podcast brought to you by Marin General Hospital. I'm Bill Klaproth, thanks for listening.