13 Myths About Vaginal Birth After Cesarean

Many women believe that the only safe choice after a cesarean is another cesarean. Social pressure plays a huge role in a woman’s decision making process and the prevailing American conventional wisdom is greatly influenced by persistent and pervasive myths about vaginal birth after cesarean (VBAC). The result is a 86% repeat cesarean rate in America among women with one prior cesarean (1) despite the fact that most women are candidates for VBAC and most VBACs are successful.  Let’s draw a clear line between myth and fact.

fact-myth-street-sign-square

According to the National Institutes of Health (NIH), “VBAC is a reasonable and safe choice for the majority of women with prior cesarean.” (2) The American College of Obstetricians & Gynecologists (ACOG) concurred when they said “most” women with one prior cesarean and “some” women with two prior cesareans are candidates for VBAC. (3)

Power to Push VBAC Booklet

BC Women’s Cesarean Task Force Power to Push 2010 VBAC Booklet

Myth:  VBAC after one cesarean has a 60-70% risk of uterine rupture.

The risk of uterine rupture after one low transverse (bikini) cut cesarean is about 0.5% – 1% depending on factors. (2) (Keep in mind that this refers to the incision on the uterus, not on the abdomen.) First time moms are at risk for complications that are equally serious to uterine rupture and occur at a similar rate such as placental abruption, (4) cord prolapse, (5) and shoulder dystocia. (6)

Myth: Hospitals ban VBAC because it’s such a serious and unusual complication that they cannot manage it appropriately.

Hospitals with labor and delivery units have protocols in place to respond to obstetrical emergencies. The guidelines used to manage the complications from first time moms and repeat cesarean moms are also used to address uterine rupture in VBAC moms.

Myth: To expedite an emergency cesarean, epidurals are required in VBAC moms. VBAC moms can’t have epidurals because it will obscure the pain of uterine rupture.

Per ACOG, epidurals may be used in a VBAC (3) and evidence suggests that epidurals do not mask uterine rupture-related pain. (7, 8) Additionally, only 26% of women who experience a uterine rupture report abdominal pain, so it is an inconsistent and unreliable symptom. (9)

Myth: There is a 25% chance that either baby or mom will die during a VBAC.

pb115-VBAC-Aug-2010-1

ACOG 2010 VBAC Guidelines

The risk of maternal mortality is very low whether a woman plans a TOLAC (0.0038%) or an elective repeat cesarean (0.0134%). (2) Limited evidence suggests that there is a 2.8 – 6.2% risk of infant mortality after a uterine rupture with many factors contributing to this range. (2, 10)

The most serious cesarean-related complications become more likely as an individual woman has more cesareans. (11) These complications include placental abnormalities such as placenta accreta which carries an up to 7% maternal mortality rate (12) and a 71% hysterectomy rate. (13) After two cesareans, the risk of accreta is 0.57%, (11) similar to the risk of uterine rupture after one cesarean.

Myth: I can’t have a VBAC in my state because it’s illegal.

VBAC is legal throughout America and in some states, it’s legal for a midwife to attend an out-of-hospital VBAC.

Farah Diaz-Tello of the National Advocates for Pregnant Women clarifies, “I have never heard of a situation in which a physician has lost their license for adhering to a woman’s wishes after providing them will full informed consent, and attending them in a manner that is consistent with the standard of care. Even physicians who have been found liable for medical malpractice do not automatically lose their license.”

Myth: VBACs can’t, or shouldn’t, be induced.

VBAC_WebImage

NIH 2010 VBAC Conference

When a mom or baby develops a complication that requires the baby be born sooner rather than later, but not necessarily in the next ten minutes, induction can make the difference between a VBAC and a repeat cesarean. This is why ACOG maintains that medically indicated Pitocin and/or Foley catheter induction “remains an option” during a VBAC. (3, 14)

Myth: Hospitals ban VBAC because they can’t meet ACOG’s “immediately available” requirement.

Some hospitals interpret ACOG’s “immediately available” recommendation to be a mandate that an anesthesiologist must be in the hospital 24/7. Some hospitals that cannot provide that level of coverage have banned VBAC. However, “immediately available” does not have a standard definition and various hospitals implement the guideline in different ways. (15)

Myth: Hospitals that do not have 24/7 anesthesia coverage ban VBAC.

There are motivated hospitals that offer VBAC without 24/7 anesthesia. The rural hospitals that serve the Navajo Nation in New Mexico are an example and they report a 38% VBAC rate. (16) The American VBAC rate after one cesarean is 14%. That drops down to 4% after two or more cesareans. (1)

ACOG's VBAC FAQ

ACOG’s 2011 VBAC FAQ

Myth: The evidence shows that 24/7 anesthesia coverage creates a safer environment for VBAC.

ACOG confirms that the data is not available: “Although there is reason to think that more rapid availability of cesarean delivery may provide an incremental benefit in safety, comparative data … are not available.” (3, 15) In the absence of empirical evidence, the “immediately available” recommendation is based on the lowest level of evidence which is “consensus opinion.” (3) Hospitals without 24/7 anesthesia implement a variety of policies to make VBAC safer including fire drills and cesarean under local anesthesia. (15)

Myth:  If your hospital doesn’t offer VBAC, you have to have a repeat cesarean.

As Howard Minkoff MD said at the 2010 NIH VBAC Conference, “Autonomy is an unrestricted negative right which means a woman, a person, anybody, has a right to refuse any surgery at any time.” (16) ACOG affirms that “restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will.” (3)

There are real risks and benefits to VBAC and elective repeat cesarean section.  Make the right decision for yourself: understand your options, discern truth from fiction, know your legal rights, and get down to the facts.

References

1. Curtin, S. C., Gregory, K. D., Korst, L. M., & Uddin, S. F. (2015). Maternal Morbidity for Vaginal and Cesarean Deliveries, According to Previous Cesarean History: New Data From the Birth Certificate, 2013. National Vital Statistics Reports, 64(4). Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_04.pdf

2. Guise, J.-M.; Eden, K.; Emeis, C.; Denman, M. A.; Marshall, N.; Fu, R. (.; Janik, R.; Nygren, P.; Walker, M.; McDonagh, M. Vaginal Birth After Cesarean: New Insights; Agency for Healthcare Research and Quality (US): Rockville (MD), 2010. http://www.ncbi.nlm.nih.gov/books/NBK44571/

3. American College of Obstetricians and Gynecologists. Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology 2010, 116 (2), 450-463, http://www.acog.org/Resources_And_Publications/Practice_Bulletins/Committee_on_Practice_Bulletins_–_Obstetrics/Vaginal_Birth_After_Previous_Cesarean_Delivery.

4. Deering, S. H.; Smith, C. V. Abruptio Placentae, 2013. Medscape. http://emedicine.medscape.com/article/252810-overview#a0199.

5. Beall, M. H.; Chelmow, D. Umbilical Cord Complications, 2012. Medscape. http://emedicine.medscape.com/article/262470-overview#a30.

6. Allen, R. H.; Chelmow, D. Shoulder Dystocia, 2011. Medscape. http://emedicine.medscape.com/article/1602970-overview#a03.

7. Johnson, C.; Oriol, N. The role of epidural anesthesia in trial of labor. Reg Anesth., Nov-Dec 1990, 304-308.

8. Kamel, J. Can you feel a uterine rupture with an epidural?, 2012. VBAC Facts. http://vbacfacts.com/2012/06/22/can-you-feel-a-uterine-rupture-with-an-epidural/.

9. Nahum, G. G. Uterine Rupture in Pregnancy , 2012. Medscape Reference. http://emedicine.medscape.com/article/275854-overview#aw2aab6b6.

10. Kamel, J. Confusing fact: Only 6% of uterine rutpures are catastrophic, 2012. VBAC Facts. http://vbacfacts.com/2012/04/03/confusing-fact-only-6-of-uterine-ruptures-are-catastrophic/.

11. Silver, R. M.; Landon, M. B.; Rouse, D. J.; Leveno, K. J. Maternal Morbidity Associated with Multiple Repeat Cesarean Deliveries. Obstetrics & Gynecology 2006, 107, 1226-1232. http://journals.lww.com/greenjournal/fulltext/2006/06000/maternal_morbidity_associated_with_multiple_repeat.4.aspx

12. American College of Obstetricians and Gynecologists. Placenta accreta. Committee Opinion No. 529. Obstet Gynecol 2012, 201-211. http://www.acog.org/~/media/Committee%20Opinions/Committee%20on%20Obstetric%20Practice/co529.pdf?dmc=1&ts=20120623T1523006523

13. Shellhaas, C. S.; Gilbert, S.; Landon, M. B.; Varner, M. W.; Leveno, K. J.; Hauth, J. C.; Spong, C. Y.; Caritis, S. N.; Wapner, R. J.; Sorokin, Y.; Miodovnik, M.; O’Sullivan, M. J.; Sibai, B. M.; Langer, O.; Gabbe, S. The frequency and complication rates of hysterectomy accompanying cesarean delivery. Obstet Gynecol 2009, 114 (2, Part 1), 224-229. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2771379/

14. Kamel, J. Myth: VBACs should never be induced, 2012. VBAC Facts. http://vbacfacts.com/2012/05/27/myth-vbacs-should-never-be-induced/.

15. Birnbach, D. J. Impact of Anesthesiologists on the Incidence of Vaginal Birth After Cesarean in the United States: Role of Anesthesia Availability, Productivity, Guidelines, and Patient Safety (video), 2010. Vimeo. http://vimeo.com/10808838.

16. National Institutes of Health. NIH VBAC Conference, Day 2, #04 – Discussion, 2010. Vimeo. http://vimeo.com/10898005.

17. Office of Statewide Health Planning and Development. Utilization Rates* for Selected Medical Procedures in California Hospitals, 2011. http://oshpd.ca.gov/HID/Products/PatDischargeData/ResearchReports/Hospipqualind/vol-util_indicatorsrpt/ (accessed June 12, 2013).

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168 thoughts on “13 Myths About Vaginal Birth After Cesarean

  1. KIMBERLY

    I’m afraid about going plan have 1st time with vbac Since I had 4 CSections I believe Drs. Are banned on vbac only accepts CSections repeat. I’m looks for lists whoever Drs. Accepts vbac from 4th CSections.

    Reply
    1. Jen Kamel Post author

      Kimberly,

      It can be very tough to find a provider who attends VBAC after multiple cesareans. I outline various ways to find supportive providers in your area here. What city/country are you from? I can also post a request on my Facebook page though people may be more likely to share in a face-to-face conversation.

      Best,

      Jen

      Reply
  2. Gabor Sz.

    I’d like to share an encouraging story. Apologies for the volume.

    Our first born was an emergency C-sect 21 months before, due to pre-eclampsia on g. week #34. My wife (35) preferred a VBAC for baby #2 (also a girl) due January 2016.

    Towards the end uninterrupted pregnancy, at the very end of g. week #39 the amnion must have ruptured somewhere high and the fluid broke. Contractions only began 5-6 hours later. From then on, with a frequency of 5 minutes, contractions repeated for 12 hours. In the last 2-3 hours of labor the amniotic sac was broken behind the cervix manually with a use of an artery forceps to let the remainder of the amniotic fluid leave and help the baby slide closer to the birth canal. Also, my wife was given an infusion of oxytocin to help the contractions be stronger and longer lasting. Also, the frequency of the contractions got higher.

    In the meantime, taking a shower, surviving the pain of a contraction on an giant inflated ball or taking a shower on that ball was allowed, in fact encouraged despite of previous warnings that a TOLAC can strictly only happen in a lying position, for its entire duration in that very hospital – the reasons behind I think was the need for constant baby heart rate monitoring – but anyway, this rule was not that strict for us on this occasion. Warm water – not sitting in a bath which can be harmful to the baby but having a long shower proved to be a good pain killer.

    All went well, the baby heart rate was normal. My wife was asked several times as she stared to train for the pushing phase, the movements during the peak of the contractions on whether she can feel any unusual pain on that area where the scar is – which could be hard to tell from the whole pain women experience – since the whole pelvic area: bones, muscles were dilating that time, causing a pain which could be felt even at the waist area. The main thing was to be able to concentrate on if it hurt specifically between the contraction caused pains.

    The unpleasant part was not to be allowed to consume any food or drinks, even a quarter of a gulp was allowed seldom. All due to the risk of a potential emergency caesarian and the inevitable narcosis after birth which was needed to let the doctor touch the scar on the uterus from the inside to check for any ruptures.

    At the end, all went okay and our second daughter was born the VBAC way. She and her mother are both healthy.

    The team around her was obviously a key to the success – the doctor who allowed the use of oxytocin – he would tell us monitoring was okay and he could have intervened and fixed the damage in time if needed. If there is a higher risk for a uterine rupture during a VBAC, an operation always carries more risk alone, specially if it’s a repeated caesarian. 10 days before the birth, the scar was examined via ultrasound and was found to be thick enough (5mm) to let my wife a TOLAC.

    The success of VBAC mainly because of the rules was not for granted. We tried to gather as much information as we could previously. It only added to the confusion that each doctor had a slightly different opinion and attitude. Exceeding the terminus, inducing the birth was not going to be allowed, my wife would have been forced in the hospital right before the due date for up to a week and it would have ended with a programmed caesarean had nothing started the natural way. The induction was disallowed even by the first team (night shift) which before the one which actually was on site when the baby was born. Reasons were that oxytocin could cause a lot more tension on the scar of the previous c-sect. Statistically, a uterine rupture is slightly more likely for a VBAC than a first vaginal birth, but eg. This article tells you it’s a mountain made out of a molehill: http://midwifethinking.com/2011/02/23/vbac-making-a-mountain-out-of-a-molehill/.

    Narcosis was not a real factor jeopardizing initial breast-feeding. A couple of hours later mother was allowed to feed the baby. The real hazard is if the narcosis took longer or the baby could suck down the milk to 0 – which is not an issue since a newborn has a stomach as big as a cherry’s core. Officially, you should not breast-feed the baby for 4-6 hours, but since the colostrum already collects long before birth in the breast, for a newborn who can sip only a bit then fall asleep, materials used for anesthesia is not problem. Half an hour after the examination in narcosis, the mother was already awake and was allowed to be with the baby.

    Three days later, they were out of hospital.

    Lessons learned: we should have studied which doctor would enable the VBAC the most flexible way – not of course at any cost. Since we only started to look for a pre-arranged doctor who would be on hand when it was needed regardless of hospital schedules. We were lucky to have the best doctor around on his schedule that time.

    So you’ve got to learn the hospital protocol beforehand and choose a doctor or even another hospital if you can to make sure your desire on a VBAC is supported. Worst case scenario would have been a programmed caesarean, when the mother cannot even start the labor which is told to be needed for both mother and baby, physically and emotionally in a healthy way. If you can choose at least let the contractions start and you can still opt for a c-sect if needed.

    All of this happened in a hospital of a small town just outside of Budapest, Hungary, Central Europe.

    Reply
  3. Sarah

    I had an emergency c-section with my first after the baby went into distress. I’m going for a VBAC this time around. My dr says she’s supportive however as we get closer she’s insisting on a scheduled C-sect at 40 weeks. She feels the risk is too high to carry past 40 weeks. Any advance on how to politely refuse? I feel like if I refuse a scheduled c section I’ll be left without care and then will need to just show up to the hospital once I’m in advanced labor. However, since we have no idea when labor will begin, I feel it’s taking a huge risk to just sit it out without medical care. Any insight would be greatly appreciated!

    Reply
    1. Jen Kamel Post author

      Hi Sarah,

      I am so sorry that you are in this situation, but you are certainly not alone.

      I shared your story here and a lot of women had some great advice.

      A lot of women feel like you: they don’t want a surgical birth just because they are pregnant after 40 weeks. And ACOG says being pregnant after 40 weeks is not a reason to have a cesarean. It’s never to late to switch providers if you feel that your provider will not respect your wishes.

      Best,

      Jen

      Reply
  4. Tiffany C

    I live in Davenport, Ia. I currently had 3 c sections against my will because these doctors refuse to do a vbac. First one in 2005 was an emergency c-section understandable. 2nd 2006 my second dr didn’t want to do vbac and at that time I didn’t know he was practicing without a license and being sued. 3rd new Dr 2013 just simply refused to do a vbac. Now I’m pregnant and long for a vbac I refuse to take no as an answer as I do have rights and have researched. I just found out that my Dr now doesn’t want to do a vbac after its been discussed since my first appt but the catch I go to The Group so its a group of different Dr’s I see and none of them have said anything until I met this new one on Friday now she wants me to go to IA City which is 45 min away. I’m at witts end. At the end of the day I’m thinking the one taking a risk they’re still getting paid for it so why does it matter but 1 thing I do know is I will not have another c-section. I feel like I’m so alone. I just want to scream cuss the whole 9 but I stand by my decision.

    Reply
    1. Jen Kamel Post author

      Tiffany,

      I hear you and I’m sorry that VBAC wasn’t an option for you after one or two cesareans. Now you have three and the options are even slimmer.

      I also hear that if you drive 45 minutes, you might have a supportive provider? That is definitely something to consider. I would meet with that provider and see what they have to say.

      For many women, they have to drive many hours, or even fly, in order to have a supportive provider at their birth.

      Best of luck!

      Jen

      Reply

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