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13 Myths About VBAC

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 90% repeat cesarean rate in America (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.

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) 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. (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 a 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 is 10%. (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.

 DSC_0111 head Jennifer Kamel is the Founder & Director of VBAC Facts whose mission is to close the gap between what the best practice guidelines from ACOG and the NIH say about VBAC and repeat cesarean and what people generally believe.  While making information relative to post-cesarean birth options easily accessible to the people who seek it, VBAC Facts strives to create a deep understanding of  “the why” by providing political and historical context of the current VBAC climate as well as medical and scientific context for understanding obstetrical risk and evaluating birth-related research. VBAC Facts is an advocate for accurate and fair information and does not promote a specific mode of delivery, type of health care professional, or birth location. Ms. Kamel presents her class “The Truth About VBAC: History, Politics, & Stats” throughout the United States. Provider approved by the California Board of Registered Nursing, Continuing Education Provider #16238.

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1. National Center for Health Statistics. User Guide to the 2012 Natality Public Use File. Hyattsville, Maryland : National Center for Health Statistics, 2013. ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2012.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.ahrq.gov/clinic/tp/vbacuptp.htm

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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117 comments to 13 Myths About VBAC

  • Paula

    Hi! I have had 2 c-sections, I agree that it is possible to have a VBAC but I also think that it is horrible for us, women who have never had a natural childbirth, to feel guilty about our C-sections, as if we were absolutely responsible for what happened. And, most of the time, we feel guilty because many women support natural birth. Even though it is important to support it, they shouldn’t make us feel guilty for the very simple fact that we couldn´t have a natural childbirth

    • Jen Kamel

      I absolutely agree with you Paula.

    • Hi Paula, I read your post with interest because it shows to me yet again, the impact a positive or negative birth experience has on women. Childbirth shapes how we feel about ourselves as a woman and mothers and impacts on our relationship with our children, partners, family and society as a whole – it’s as profound as that! Caesarean section can be a life saving operation and I am sure that your doctors offered for the very best clinical reasons for you and your baby’s wellbeing. You have no reason to feel guilt therefore and I hope you made a good recovery. The evidence strongly supports normal birth and VBAC; to ignore this evidence, we do so at our peril.

  • Sally Green

    I was a VBAC and am glad I didn’t cave in to the myths. It was amazing to experience that primal urge to push, just incredible. No judging; do what’s best for you! But I wouldn’t be afraid to be a VBAC if the doc thinks it’s fine.

  • Brenda Dotson

    I had my first child c-section due to her being breach. I then had 3 more children all VBAC without any issues. I never even considered having scheduled C sections for my other children. And I’m so glad my husband and I got to have the experience of labor.

  • Dr. OB

    Jennifer,

    What is your source of these “myths”. I do not know one OB around who has ever, for example, quoted a uterine rupture rate of 60%. It is insulting to imply that we as a Profession are behaving in such an un-ethical manner on any scale. It is not an “us vs. them” problem as you and your sites imply. I really do think that you are NOT being fair to the vast majority of OB/GYN’s that absolutely support “natural birth” which, unfortunately, does not always go so naturally.

    OB/GYN

    • Jen Kamel

      Some of these myths (such as the 60% uterine rupture statistic) are directly from the mouths of OB/GYNs who, apparently, do not know better. However, they absolutely do not represent all doctors as I personally know many wonderful, ethical doctors. It’s unfortunate that many take the “us vs. them” mentality. I do not and the practitioners, including OBs, who have taken my seminar can attest to that.

      Just like when people “shop doctors” when they need knee surgery – because we acknowledge that not all doctors are equal – I encourage women do to the same if they want to plan a VBAC as philosophies, protocols, and knowledge can vary greatly between practitioners.

      Best,

      Jen

      • Jen, as an independent midwife, practising in the UK, I can add a whole list of stuff and nonsense, lies and shroud waving statements that pregnant women I have worked with, have be subjected to. And often coming from midwives, I hasten to add!

  • Marlene

    I never believed any of these… except that VBACs USUALY should not be augmented or induced. I read uterine rupture was 12 times higher when VBACs were induced, but I forget where I read that; could have been the NIH 1982 study on C/S safety.

  • The surgical birth rate is so very high now that more and more women are dying!! This is real. Not to mention that the mothers and babies have serious breastfeeding problems and often quit.

  • Lea

    My first was a c-section. Then I had six children VBAC. I never had any problems. Of course I was warned each time of the risk but didn’t seem risky to me. I also breastfed them all. Did have some difficulty with the first. It was all worth it!

  • JudyC

    It is such a shame that so many women are denied a chance at VBAC. I had two CS which I hated and that turned me into a passionate midwife. I have attended so many VBAC over the years, at home an in hospital as well as several HBA2C. So far no trouble with any. If a woman wants it she should be given every opportunity to labour and birth normally as there is enough science out in the big wide world to prove it safer.

  • I’ve been told outright by the ONLY hospital within an hour of my home that I will “absolutely not be allowed to deliver there” if I choose a VBAC! I’m devastated! Is there anything I can do to legally fight this without being a total jerk?

    I want the right to choose. I was forced into a c-section first time. The second time I was coerced into a repeat cesarean. This will be my third baby. If at any time during my pregnancy or labor, it becomes obvious to my doctor that a repeat cesarean is medically necessary, then I will have no issue agreeing to one, however, I’d at least like the option to discuss VBAC until that point. Being told that it’s absolutely not an option seems illegal and unethical to me. With my second, I fully believe my body would’ve been successful in a VBAC situation. Because my OB/GYN had a patient coming to her office within a few hours, she coerced me into a repeat cesarean even though my water ruptured spontaneously and labor was progressing normally, confirmed in hospital by OB and EFM. Needless to say, I was devastated at being denied that right to choose.

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