I am so thankful that I live in California where it is legal for midwives to attend homebirths.  Many women around the country who live in more rural areas are faced with the choice of an unwanted repeat surgery at their single local hospital that has “banned” VBACs or in a state where it is illegal for midwives to attend homebirths or home VBACs.  I can’t imagine being faced with such a choice.

In California, you can have a home VBAC with a midwife if you exercise your right of informed refusal.  Simply write a letter stating that you understand the risks of VBAC/HBAC and then your midwife puts it in your file.  This process is even made more simple because you can use the letter I wrote below as a template.

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May 15, 2007

To Whom It May Concern:

This is a letter expressing my desire to evoke my right of informed refusal and have a homebirth midwife, L, attend my VBAC (vaginal birth after cesarean) this coming November/December 2007.

I understand the risk of uterine rupture and that I could be statistic. I also understand I have over a 99% chance of not experiencing uterine rupture.

I understand that the risk of rupture among women with one prior low uterine segment (”bikini cut”) cesarean in spontaneous, naturally occurring labors to be about 0.4%. (Landon 2004) Some studies have found the risk to be even smaller at 0.12%. (Gonen 2006)

I understand that labors induced or augmented with Pitocin or Cervidil have rupture rates two to three times higher. (Landon 2004)

I question a medical system that simultaneously discourages women from VBAC by warning them how risky VBACs are, yet voluntarily increases the risk by inducing VBAC women.

I question a medical system where obstetricians can induce VBACing women with Cytotec, with no evidence showing that it is safe, resulting in rupture rates 28 times higher than rupture rates in labors without Cytotec inductions (Plaut 1999) resulting in unnecessary and unfortunate ruptures and infant deaths.

I believe that uterine rupture will be diagnosed faster by having a midwife’s eyes, ears, and hands focused on me rather than an L&D nurse’s attention divided amongst several EFM machines.

I believe that within the midwifery model of care, a women’s experience and intuition is given more respect than a machine that goes ping.[1]

I question a medical system that does not distinguish between true uterine rupture and uterine dehiscence when discussing the risk and outcomes of uterine rupture.[2]

I question a medical system that minimizes the risks of primary or subsequent cesarean surgeries yet exaggerates the risk of VBAC. Few women who undergo an elective cesarean section understand the variety of risks or know that they have a 3.6 greater risk of dying over vaginal birth (Deneux-Tharaux 2006) or that their baby’s chances of being admitted to the NICU or developing a pulmonary disorder doubles with a cesarean section. Babies born by elective cesarean section have a 10% chance of being admitted to the NICU or a 1.6% chance of developing a pulmonary disorder. (Kolas 2006)

I question a medical system that minimizes the risk of amniocentesis yet exaggerates the risk of VBAC. The risk of miscarriage from amniocentesis is 0.5%.[3] Miscarriage is death of a baby.  Compare that to the approximate 0.5% risk of uterine rupture in a one-prior bikini cut cesarean section in an non induced/ augmented VBAC.[4] Rupture does not equal death, but miscarriage does.  Yet the March of Dimes describes the risk of miscarriage vis-à-vis aminos as “small” while the number of VBAC-friendly hospitals decrease.

I question a medical system that changes policy solely based on the non-scientific or tested recommendations provided by the professional organization ACOG.[5] ACOG has recommended that hospitals attending VBACs be “equipped to respond to emergencies with physicians immediately available to provide emergency care”[6] which has resulted in many hospitals “banning” VBACs. If hospitals cannot accommodate a medical emergency such as uterine rupture, how could they possibly respond and treat other real, but rare, labor emergencies such as cord prolapse or placental abruption, both of which require the baby being born ASAP usually by immediate cesarean sections?  How could any mother labor in confidence knowing that if something went drastically wrong, that hospital could not quickly respond?

I understand that if “things go downhill fast,” I may be out of luck. I also understand that if I or MIDWIFE sense or determine any trouble at any time I can transfer to HOSPITAL which is 4 miles from my residence.

I understand that “while ACOG has recommended in the past that the ‘decision to incision’ time be no more than 30 minutes, in one study at a university hospital in the United States, (Chauhan 1997) 52 percent of the emergency cesarean sections for fetal distress had a decision to incision time that exceeded 30 minutes.”[7]

I understand that despite the fact the USA has the best technology and spends the most money in the world on medical care, we have the second highest infant mortality rate in the developed world[8] and rank 40^th in maternal mortality rates.

I understand that the countries with the lowest infant and maternal mortality rates utilize midwives for normal, healthy pregnancies and only engage the services of an obstetrician when a pregnancy becomes high-risk. (Born in the USA by Marsden Wagner, MD)

I understand the risks of birthing in the hospital by becoming part of the “birthing machine” through submitting to hospital protocols and “standard of care” procedures that introduce more risk than benefit when routinely performed on all women regardless of medical necessity.

I would rather open myself to the risks present in homebirth in order to reap the benefits of birthing at home, than expose myself to the risks present in the hospital.

Sincerely,

VBAC Mom

[2] “To accurately asses the risk of VBAC, it is necessary to differentiate between complete or true uterine rupture and incomplete rupture, often termed occult rupture or uterine dehiscence.  True uterine rupture is often sudden and associated with pain, blood loss and fetal morbidity.  It is most commonly seen in spontaneous or traumatic rupture of the unscarred uterus.  It also has been associated with classic uterine scars, often occurring without labor.  Conversely, uterine dehiscence is partial separation of the uterine wall that is usually asymptomatic and rarely contributes to fetal or maternal morbidity.  This is often the type of separation seen in lower segment scars, and usually occurs during labor.  Often asymptomatic windows are incidentally noted at the time of repeat cesarean section.” From OB/GYN Secrets by Wilkins-Haug & Fredrickson.  Section 77 VBAC by Robert Silver MD.

[3] March of Dimes. Amniocentesis. http://search.marchofdimes.com/cgi-bin/MsmGo.exe?grab_id=0&page_id=1061&query=amniocentesis&hiword=amniocentesis%20

[4] “True uterine rupture is typically distinguished from asymptomatic scar separation (dehiscence) by the need for emergency surgery, although some reports combine these separate processes and confuse the statistics.  The rate of true uterine rupture with one prior low-transverse scar has been reported by ACOG to be between 0.2 and 1.5 percent (one of 67 to 500 women).  Other studies involving more than 130,000 women undergoing a trial of labor for VBAC report rates that average 0.6 percent (approximately one of every 170 women).”  (Toppenberg 2002)

[5] What Every Midwife Should Know About ACOG and VBAC: Critique of ACOG Practice Bulletin No. 5, July 1999, “Vaginal Birth After Previous Cesarean Section” by Marsden Wagner, MD, MSPH http://www.midwiferytoday.com/articles/acog.asp

[6] ACOG Practice Bulletin No. 5, July 1999, “Vaginal Birth After Previous Cesarean Section” “Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.”

[7] What Every Midwife Should Know About ACOG and VBAC: Critique of ACOG Practice Bulletin No. 5, July 1999, “Vaginal Birth After Previous Cesarean Section” by Marsden Wagner, MD, MSPH http://www.midwiferytoday.com/articles/acog.asp

[8] Per study by Save the Children. http://www.cnn.com/2006/HEALTH/parenting/05/08/mothers.index/index.html