Interview with Dr. Jean-Gilles Tchabo
In my last post (which you can read here), I talked
about my experience approaching the delivery of my second child, after having an emergency c-section for my first.
The OB/GYN I chose for my second pregnancy, Dr. Jean-Gilles Tchabo, encourages vaginal deliveries after cesarean sections (VBACs) as an option for women in my situation. In the last post we dispelled some of the myths about VBACs, and today, we delve deeper into the topic as I pose a couple of reader questions about VBACs and repeat c-sections to Dr. Tchabo.
We had a reader ask us a question about the use of pharmaceuticals like Pitocin and Cervidil to induce labor for a VBAC and whether using those methods are riskier than waiting for labor to start naturally or doing things like membrane sweeps or a foley bulb.
The most important thing is that the woman’s body is ready for labor. If you try to induce labor at 38 or 39 weeks when the conditions aren’t right, for example, the cervix is closed and posterior, the baby isn’t engaged) then induction is more likely to fail and the woman will wind up with a repeat c-section. Artificially inducing labor before the body is ready is taxing on the body and the uterus. The issue with using pharmaceuticals to induce with a woman trying for a VBAC is that it can be hard to control labor if something does go wrong. The half-life of Pitocin is very short, about 25 minutes, so if something happens and we need to stop the Pitocin we can and we can move quickly. The half-life of cervadil, however, is much longer, in the range of six hours. So if we need to induce a woman for a VBAC, we prefer to do things like strip the membranes or use a foley bulb (If we need to we can just take the foley bulb out and that is that). The ideal situation is that the woman goes into labor naturally between 39 and 41 weeks.
Another reader wanted to know what evidence there is for time limits on labor and gestation. I’m thinking this goes back to the question about the restrictions put on VBACs by hospitals and practices.
So long as there are no conditions that contraindicate labor I don’t really use “failure to progress” as a good enough reason for a c-section. If the baby isn’t in distress, the mother is doing well, she’s dilating and contracting and labor stalls, you can sometimes wait an hour or two and see how things go. Usually with enough time and comfort measures labor will usually pick back up on it’s own.
In terms of gestation the recommendation is that women should deliver between 39 and 42 weeks and I think that is a good guideline. Before 39 weeks the baby may have complications and the cervix may not be ready for induction. Before 39 weeks the baby may need to spend some time in the nursery or NICU. But studies have shown again and again that after 42 weeks the placenta starts to be compromised. If at 42 weeks labor hasn’t started on it’s own and the body doesn’t show signs of being ready then we go ahead and have a repeat c-section. But this isn’t a conversation you should be having with the patient at 41 or 42 weeks. This is a conversation that needs to happen well before then so that it’s not a surprise to them.
In my case, I was convinced I wasn’t going to need a c-section as there have been big babies in my family and none of my female relatives have needed a c-section, so when my son was born just shy of 8lbs but a c-section was required I was totally not expecting it. My daughter measured larger than my son, so we took a VBAC off the table for my second delivery.
Yes, and this is the thing people say all the time, “I had a 9 or 10lb baby vaginally so everyone else should be able to do it.” This is not the case. There are a number of factors that go into whether or not a woman can have a successful vaginal birth. Some women appear tiny and can have a 10lb baby without a problem. Other women can’t have a 7lb baby vaginally. It’s not necessarily the weight, but it’s the proportions of the baby’s body to the mother’s. What we really worry about are the head and the shoulders. You can have a 7lb baby but if the shoulders are too wide for the mother’s pelvis the baby won’t fit. I don’t like it when I hear people say that they had a big baby so other women should be able to, too, it’s just not the case.
Some women who have had multiple c-sections have reported that they’ve found it difficult to find a provider willing to attempt a VBAC after they’ve had more than one c-section. For example, if they’ve had two previous c-sections and are pregnant with their third and would like to try for a VBAC there aren’t a lot of doctors willing to take that on. Why is that?
Ideally you want to avoid the primary c-section in the first place, and if at all possible if you can have a VBAC with the second baby it improves your chances of a successful VBAC with subsequent pregnancies. But when you have multiple c-sections, the scar tissue can weaken and become very thin from being cut repeatedly. That weakened scar can cause very serious complications, that’s when you start to really worry about uterine rupture and placenta ascreta. Those are two complications that can lead to the death of the mother, the baby or both. So in cases where a woman has had more than one c-section we default to another c-section as a delivery method.
Right now we don’t have a good way to measure the scar tissue from the previous c-section. We can use ultrasound, but that is not as accurate as we’d like. Hopefully as technology improves we will have better ways to measure the thickness of the scar tissue and that may mean that some women who have had multiple c-sections can safely try for a VBAC, but until then our priority is always a safe mother and baby.
The last thing anyone wants is for baby or mother to die or suffer permanent damage. Things such as a uterine rupture or placenta ascretia can lead to death, disability, intensive care and sometimes a historectomy, which would remove the woman’s ability to have future children and we want to avoid all of that. The risks of those complications go up when a woman has had multiple c-sections and is attempting a VBAC.
Now, there are exceptions to this. If, say, the mother has had a long break between pregnancies. For example if she has had two previous c-sections and is pregnant again three, four or five years later, then we can be relatively confident that the scar as healed completely and properly and we may consider a VBAC for the third pregnancy.
But I mentioned this before, one of the biggest things we look for with a VBAC is the time between pregnancies. If a mother comes to our practice and has had a previous c-section with a very short break between pregnancies, say four to six months, then that is not a good situation. The scar hasn’t healed and the mother is at higher risk for serious complications. The scar needs at least 15-24 months to fully heal.
* And although we say it often, Julia and I need to say it again here: Never, ever, take medical advice from strangers on the internet, including from us! Talk to your real-world physician before you make any medical decisions for yourself or your child. SERIOUSLY!*
Disclosure: Dr. Tchabo delivered Leslie’s first baby and she used his practice for her second pregnancy although he did not deliver her second child. She received no compensation or special consideration for this series. This series ran several months after Leslie delivered her second child.