VBAC after Cesarean for Arrest of Descent or Cephalo-Pelvic Disproportion – written by Pamela Vireday
A cesarean for “Arrest of Descent” means a cesarean done after a woman has dilated fully and pushed for a while without the baby descending. The amount of pushing time required for the diagnosis varies from source to source but is usually at least 1-3 hours.
When a woman has a cesarean for Arrest of Descent, she is often told something is wrong with her pelvis. She might be told she has:
- A “flat” sacrum
- A “prominent” sacrum
- A pubic arch that is “too narrow”
- Ischial spines that are “too prominent”
- A pelvis that is “too small”
- “Too much soft tissue” (fat) lining the vagina/pelvis
- A pelvis that is the “wrong shape”
- A baby that was “too big” for her pelvis
- “Cephalo-Pelvic Disproportion” (baby too big and pelvis too small, causing baby to not fit)
Often women who have been told these things are strongly discouraged from tryingfor a Vaginal Birth After Cesarean (VBAC). There are documented cases where women have been told their pelvis is too flat or too small to have a VBAC, that they have “soft tissue dystocia” (a.k.a. “fat vagina“), that their pelvis is the wrong shape, or that since they couldn’t push out a baby before, chances are they never will be able to because CPD is a recurring condition:
Yesterday, at my appt, while speaking with one of the midwives – she asked if I wanted her honest opinion & that if I was unable to push out a 7 and 1/2 pound baby and 2nd babies are normally larger then she didn’t think it would be successful.
The bottom line is that providers that are not truly VBAC-supportive often make women believe that something is wrong with their bodies and that they have little chance of having a vaginal birth, implying it’s better just to schedule a repeat cesarean. Then the care providers conveniently have fewer VBAC labors to attend.
And a new study just out confirms that many women with a prior cesarean for Arrest of Descent do indeed go on to have a VBAC and should not be discouraged from trying.
New Study on VBAC after Arrest of Descent
A recent American study (Fox 2018) shows that VBAC after prior Arrest of Descent is often successful.
In the study, one hundred women who had one prior cesarean for Arrest of Descent had a “Trial Of Labor After Cesarean” (TOLAC or TOL). A whopping 84% ended up having a VBAC. This is an excellent rate and better on average than many VBAC studies.
The authors concluded (my emphasis):
This suggests that arrest of descent is mostly dependent on factors unique to each pregnancy and not due to an inadequate pelvis or recurring conditions. Women with a prior CD [Cesarean Delivery] for arrest of descent should not be discouraged from attempting TOLAC in a subsequent pregnancy due to concerns about the likelihood of success.
The fact that the authors state this so strongly in an obstetrics journal is a big deal because it goes against what is commonly taught to many OBs, so let’s reemphasize those points:
- Arrest of Descent is NOT usually due to an inadequate pelvis
- “CPD” is not necessarily a recurring condition
- Women with this history should not be discouraged from trying for a VBAC
Other Similar Studies
Was this study just a fluke? What do other studies on Arrest of Descent say?
There are only a couple of studies that specifically use the term “VBAC after Arrest of Descent” so you have widen the search a bit. Other search terms to consider include “CPD + cesarean,” “cesareans after full dilation,” or “cesareans done during second stage of labor” (pushing), or “prolonged second stage,” or similar terms. Carefully vetted, these are essentially Arrest of Descent cesareans too.
If you just look at studies that examine VBAC after a cesarean for CPD, research reviews show that about two-thirds of women will have a VBAC. This rate is lower than for those whose first cesarean was for breech or fetal distress, but is still a very good rate. If all those women had been discouraged from VBAC or pressured into repeat cesareans, two-thirds of them would have had unnecessary cesareans!
There is very little data on women who have had more than one cesarean for CPD. However, one 1989 study did contain some data on women like this. If you crunch the data in the full text of the study, women with 2 prior cesareans for CPD had a 56% VBAC rate. So although we don’t have a lot of data on this, what we do have suggests that even among women with more than one cesarean for CPD, more than half will have a VBAC.
The doctors who like to discourage VBAC cite a discouraging 1997 study that found a low VBAC rate (13%) in women who had reached full dilation and pushed in their previous labor. However, the rest of the research is much more encouraging.
In one Californian study from 2015, 54% of women with no prior vaginal birth and a prior cesarean during pushing stage went on to have a VBAC. In other words, they were just as likely to have a VBAC as not.
Similarly, a Danish study found a 59% VBAC rate in women whose cesareans occurred at 9-10 cm of dilation (9 cm often represents a fully dilated woman with a cervical lip, likely due to fetal malposition). Again, more than half had a VBAC and avoided the risks of additional surgery.
But some studies have results even better than that. In a New York study, 74.5% of women with prior pushing-stage cesareans went on to have a VBAC, some of them with forceps help, which suggests that fetal malpositions were an issue for quite a few.
Echoing those numbers is a Canadian study that found a 75% VBAC rate in those with a prior second stage dystocia cesarean. A very small, older Irish study found a 73% VBAC rate in those with a prior cesarean in the second stage.
Similarly, an older Dutch study found an 80% VBAC rate in those with a prior Arrest of Descent cesarean. This echoes our current Fox 2018 study that found an 84% VBAC rate after prior Arrest of Descent.
In summary, the majority of the research clearly supports the idea that women with a prior cesarean that occurred after full dilation and pushing can be offered a “trial of labor after cesarean” and will have a quite reasonable chance for a VBAC.
In the end, the decision whether to go for a VBAC is the mother’s, but she should be reassured that she is just as likely to have a VBAC as not, and in many practices, especially with proactive care regarding fetal position, her chances are even better.
The Importance of Fetal Position
So what causes Arrest of Descent? Why does it happen in some births but not others in the same mother? The answer is usually fetal position.
In Arrest of Descent/CPD cesareans, the problem is usually the BABY’S POSITION, not the mother’s pelvis.
If the baby is not well-positioned, labor tends to be slow and extra painful. It often slows or stalls between 4-7 cm of dilation. Often the mother eventually dilates fully but there is little or no progress during pushing. Fetal distress may occur.
Some providers become impatient and intervene with procedures (like breaking the waters) which may do more harm than good. Frequently, they are too quick to move to surgery when more patience might see the position resolve or the baby be born just fine in the “less-optimal” position. Recent research suggests that more than three-fourths of women with prolonged pushing stages (more than 3 hours) will deliver vaginally if just given a little more time.
What kind of fetal positions can cause problems? Read here for illustrations and specifics of the different fetal positions. The Spinning Babies website also has many helpful articles and illustrations on fetal position and how to help create maximum room in the pelvis. In the meantime, below is a brief introduction of the most common fetal malpositions.
Keep in mind that Presentation refers to which part of the baby is presenting first, and Position refers to how the baby is oriented in the mother’s body in a head-down position. Also keep in mind that when describing fetal position, obstetric texts reference the back of the baby’s head (the occiput) and which way the occiput is oriented in relationship to the mother. Most laypeople find it easier to understand by thinking of which way the baby is looking, so I use both in my descriptions.
Both the Spinning Babies website and The Labor Progress Handbook by Penny Simkin et al. have many ideas for various ways to help malpositioned babies resolve their position, and for creating more space in the pelvis. We will discuss this further in future posts.
|Occiput Anterior or OA|
The easiest fetal position for labor and birth is usually Occiput Anterior. This is abbreviated OA and means the baby is head-down with the back of the baby’s head against the mother’s front; in other words, the baby is looking towards the mother’s back. This position is considered the norm and the vast majority of babies will be born in this position.
Direct OA is when the baby is looking directly back at the mother’s sacrum. LOA is when the baby is mostly facing the mother’s back but his back is a bit towards the left side; ROA is the same but a bit towards the right side.
Ideally, the baby’s chin is tipped towards its chest so the smallest possible diameter of its head presents. If the baby’s head is not well-flexed, the presenting diameter is a bit larger. If the baby’s head is tipped to one side or the other, it can be even larger. More on that below.
|Illustration by Gail Tully, Spinning Babies|
One of the most common fetal positions that can cause problems during labor is the Occiput Posterior position. This is abbreviated OP; the back of baby’s head is against your back and baby is looking at your tummy. If the baby is directly facing your back, that’s direct OP; if it’s a little to the right or left, then that’s ROP or LOP.
Although many babies enter labor in less-ideal positions like OP, only about 5% stay posterior all through labor and deliver that way. Babies that come out in the OP position are sometimes called “Stargazers” or “Sunny Side Up.”
By itself, an OP position does not have to mean a cesarean, since most OP babies turn during labor and become OA before birth. The labor may be a little longer and more painful but it often proceeds just fine with a little patience. However, babies that are persistently posterior all the way through labor and birth have a high rate of problems.
Research clearly shows that persistent posterior babies have higher rates of cesareans for CPD or Arrest of Descent. This is because the presenting head diameter of a baby in OP position is larger than the baby in an OA position. In addition, the back of the baby’s head is against the mother’s back and that makes for a more painful labor, with lots of back labor and a slower dilation. This in turn often means lots of interventions from care providers that may make the situation worse, like breaking the waters, which takes away the cushion for baby to turn more easily and may lead to fetal distress.
However, OP babies do not always end with cesareans. With time and patience, an OP baby with a flexed head (chin to chest) can often be born vaginally. Alternatively, a vaginal birth may be possible if the care provider is patient and allows extra time for the baby’s head to mold enough to descend into the pelvis. When it hits the pelvic floor, it often then rotates from OP to OA on the perineum and may be born quickly. Often an OP baby can be helped to rotate to OA through manual rotation, an instrumental delivery, or maternal postural changes like the all-fours position.
But because of the impatience of many providers, the fetal distress that can occur, and the extra-painful, longer labors associated with OP babies, many persistent OP babies end up being born by cesarean.
If a baby’s head is deflexed (not chin to chest), this can cause problems as well. A deflexed head makes the baby’s presenting head diameter larger. This means the baby may not fit through very well, or the baby needs extra time for its head to mold enough to get through. OA babies with mildly deflexed heads experience longer labors, but with a little patience, are usually able to be born vaginally.
However, significant problems can occur if deflexion is extreme. Extreme examples of deflexed heads include a brow (forehead first) or face (face-first) presentation. Although vaginal births of brow and face presentations have been documented, most often they end in cesarean these days unless the baby’s position can be resolved. Fortunately, brow and face presentations are quite rare.
Deflexed babies in an OP position are fairly common and result in many long, difficult labors. OP babies already start out with a larger presenting head diameter; when they also have deflexed heads (known as a “military” position), this makes the head diameter even larger. Big OP babies often have deflexed heads, making their head diameters even larger. These babies often have extremely long and hard labors, and many end in cesareans. Turn the baby around and/or tip its chin towards its chest so that the head is flexed and the baby would likely fit much better; many cesareans could be avoided.