At the NIH VBAC Conference, I was happy to hear the draft Consensus Statement acknowledge that there were non-medical factors that affect women’s access to VBAC:
We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL [trial of labor after cesarean]. . . We are concerned that medico-legal considerations add to, as well as exacerbate, these barriers.
Many women assume that their local hospital has banned VBAC, or their OB doesn’t attend them, because VBAC is excessively dangerous. Most women are unaware of the many non-medical factors that play into VBAC accessibility.
What disappointed me, however, was the panel’s surprise at the misinformation and bait & switch tactics to which many women are subjected. I think when you are a VBAC supportive practitioner, it may be hard to believe that your colleagues practice in a manner like I describe below.
To give you an idea of the kind of advice that many, many moms seeking VBAC receive, here are excerpts of an email from Brooke Addley of northeastern Pennsylvania. She decided to ask her OB about VBAC at her annual exam in March 2010. This is what happened:
Once I brought the subject up stating that I really would not be open to a c-section unless it was medically necessary he said “they are all medically necessary” and then went on to mention that just within this last month there were two major ruptures at the local hospital. From there he just talked about the risk of VBAC and how catastrophic it could be if there was a rupture.
A uterine rupture can be catastrophic, but it is rare and the incidence of uterine rupture is comparable to other obstetrical emergencies such as placental abruption which has a worldwide rate of 1%. As Mona Lydon-Rochelle PhD, MPH, MS, CNM said at the NIH VBAC conference, “There is a major misperception that TOLAC [trial of labor after cesarean] is extremely risky” and George Macones MD who stated in terms of VBAC, “Your risk is really, really quite low.” Additionally, the risk of infant death during a VBAC attempt is “similar to the risk” of infant death during the labor of a first time mom (Smith, 2002).
One of the factors discussed at the NIH VBAC conference is that a practitioner is less likely to offer VBAC if they have experienced a uterine rupture, particularly if there is a bad outcome. However, that ethically should not interfere with him providing his client with accurate information on the rate of uterine rupture as well as studies that substantiate the rate provided.
When I cited the low rate of uterine rupture [of 0.5% – 2% after one prior low transverse cesarean] he said “that information is incorrect and the rate is actually higher.” Yet when I asked him to lead me in the direction of the study or studies where he found that out he said there isn’t any because many women have repeat [cesareans] and once in the OR it is discovered that they have a thin window in their uterus and if they labored/pushed it would have ruptured for sure.
The rate of rupture in a spontaneous labor after one prior low transverse incision is 0.4% (Landon, 2004). So not only did he give her an inaccurate picture about the rate of rupture, but he led her to believe that there are no studies on VBAC. (I always wonder in situations like these: Is the OB really actively trying to mislead the patient or is he really so misinformed?) This OB should read the NIH VBAC conference Program & Abstracts, or my VBAC Class bibliography, to see that in fact there are many studies on VBAC.
Then the OB gives her inaccurate information on VBAC success rates:
I asked the VBAC success rate and he said that most fail.
VBACs have a success rate of about 75% which has been the conclusion of many studies (Coassolo, 2005; Huang, 2002; Landon, 2005; Landon, 2006; Macones, 2005). Success rates vary based on a variety of factors, but to say that ‘most fail’ is absolutely false. What this OB should say is, “Most women who attempt a VBAC with me as their care provider fail,” which is probably 100% true.
And then the OB gives her the line that many women fall for:
He did however say that although he really does not recommend it . . . he would allow me to try.
And there is the hook. So many women are satisfied to simply be given the opportunity to VBAC. Unfortunately, from what this OB has said already, I do not believe Brooke would have a genuine opportunity to VBAC. Surely this OB would come up with some “valid medical reason” that she needs a cesarean sometime during her pregnancy or labor. Here come the requirements to be granted a trail of labor:
…yet there are many things that would have to be taken into consideration, including my unproven pelvis. He mentioned that in the hospital I would have to have continuous monitoring and 18 hours after my water broke, if I was not progressing, they would want to use Pitocin to advance the labor. He also mentioned that he does not allow any woman under his care to go past 40 weeks.
The unproven pelvis standard is bizarre. Don’t all women pregnant with their first child have an unproven pelvis? Do we offer them all of them an elective primary cesarean to prevent a “failed vaginal delivery?”
No stereotypical VBAC consult full of misinformation is complete without a healthy helping of repeat cesarean risk minimization:
He did not mention risks to repeat c-sections. When I brought it up he said there aren’t any except the obvious risks that come with any surgery.
False, false, false. According to Silver (2006), a four year study of up to six repeat cesareans in 30,000 women:
Increased risks of placenta accreta, hysterectomy, transfusion of 4 units or more of packed red blood cells, [bladder injury], bowel injury, urethral injury, ileus [absence of muscular contractions of the intestine which normally move the food through the system], ICU admission, and longer operative time were seen with an increasing number of cesarean deliveries…. After the first cesarean, increased risk of placenta previa, need for postoperative (maternal) ventilator support, and more hospital days were seen with increasing number of cesarean deliveries…Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.
It is quite typical for a woman to receive inflated rates of uterine rupture while the practitioner minimizes the risks of repeat cesarean. This OB goes one step further and claims there are no risks at all besides the general risks associated with surgery.
It is no wonder that most women ‘chose’ repeat cesareans and only 45% of American women are interested in the option of a VBAC (Declercq, 2006). What kind of choice is it when you make major medical decisions without even a fraction of accurate information?
There is much discussion and debate about what constitutes informed consent. However, there is no debate that informed consent fundamentally consists of understanding the risks and benefits of your options. When a woman only hears the (inflated) risks of option one and the (inaccurate) nonexistent risks of option two, it is clear that her practitioner is trying to influence her final decision by skewing the information provided.
Finally, the OB suggests that the desire to have a vaginal birth and avoid medically unnecessary surgery warrants psychological help:
I flat out said to him that I just cannot have another c-section [without medical indication] and he told me that I need to see a therapist, [that] it’s not that big of a deal and it is the safest way to go!
It might be helpful for this OB, and others who think like him, to learn more about how women are impacted by their cesareans. Cesareans performed on otherwise healthy babies and healthy moms are absolutely a big deal to many women. Even when cesareans are medically indicated, there are women who still mourn the loss of a vaginal birth even as they celebrate their healthy baby and the technology that made their entrance into the world safe. Read American Women Speak About VBAC for more personal stories.
Then the OB makes it sound like he’s the only game in town:
Oh and then at the very end he said I could always go with another provider but he is pretty much the most open to VBAC. I flat out told him that he is not VBAC friendly at all and that if he is the most open in town I have quite the battle ahead of me.
The emotional fallout of the appointment:
The entire visit I just had to hold back tears and once I hit the street I lost it. I just want to hit my head against a wall!! I’m just sad, sad that it has to be this way – sad that, as much as I want to have another baby, I dread getting pregnant. Sad that women are told this shit and forced to believe it. I’m just in such a funk now…..just a sad, sad funk.
But it’s not just Brooke.
Michelle was told by her OB that uterine rupture rates increase with each VBAC which contradicts a 2008 study that concluded the risk of uterine rupture drops 50% after the first VBAC (Mercer, 2008). One of the women who attended the VBAC class this past Sunday said that her OB quoted a uterine rupture rate of 6-10% after one prior low transverse cesarean. Sarah was quoted a rate of 10% “after the first section.” Karla was also quoted 10% and called “selfish” by her OB who was “appalled that [she] would risk the life of [her] baby.” Once again, the correct rate for uterine rupture in a spontaneous labor after one prior low transverse cesarean is 0.4% (Landon, 2004) and these women are quoted rates 15 – 25 times higher.
Another way doctors lie is by circumventing the risk of VBAC issue entirely. A friend told me that her doctor said her medical insurance wouldn’t pay for a VBAC. So believing her doctor and thinking she didn’t have any other option, she had a scheduled repeat cesarean. Turns out, my friend had the same medical insurance as me and that same insurance reimbursed me for my homebirth VBAC.
And who can forget the irate mom who left a comment on the VBACfacts Facebook fan page expressing her disbelief that any “selfish idiot” would pursue a VBAC. Her OB told her that there was a 10% infant and maternal mortality rate with trials of labor after cesarean. When I emailed her with the correct rates of 0.02% for maternal mortality and 0.05% for infant death or brain damage (Landon, 2004) and requested she forward any studies supporting a 10% mortality rate, she didn’t reply.
VBAC consults that misinform are all to common and help contribute to the 90% repeat cesarean rate in American (Hamilton, 2009). If you are a VBAC supportive practitioner, and would like to make it easier for women in your community to find you, please read: How to best connect moms with VBAC supportive practitioners?
Learn more about finding a supportive care provider:
- The Three Types of Care Providers Amongst OBs and Midwives
- Questions to Ask a Provider
- Finding a VBAC Supportive OB or Midwife
- Scare tactics vs. informed consent aka why I started this website
Coassolo, K. M., Stamilio, D. M., Pare, E., Peipert, J. F., Stevens, E., Nelson, D., et al. (2005). Safety and Efficacy of Vaginal Birth After Cesarean Attempts at or Beyond 40 Weeks Gestation. Obstetrics & Gynecology , 106, 700-6.
Declercq, E. R., & Sakala, C. (2006). Listening to Mothers II: Reports of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection.
Hamilton, B. E., Martin, J. A., & Ventura, S. J. (2009, March 18). Births: Preliminary Data for 2007. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_12.pdf
Huang, W. H., Nakashima, D. K., Rumney, P. J., Keegan, K. A., & Chan, K. (2002). Interdelivery Interval and the Success of Vaginal Birth After Cesarean Delivery. Obstetrics & Gynecology , 99, 41-44.
Landon, M. B., Hauth, J. C., & Leveno, K. J. (2004). Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery. The New England Journal of Medicine , 351, 2581-2589.
Landon, M. B., Leindecker, S., Spong, C., Hauth, J., Bloom, S., Varner, M., et al. (2005). The MFMU Cesarean Registry: Factors affecting the success of trial of labor after previous cesarean delivery. American Journal of Obstetrics and Gynecology , 193, 1016-1023.
Landon, M. B., Spong, C. Y., & Tom, E. (2006). Risk of Uterine Rupture With a Trial of Labor in Women with Multiple and Single Prior Cesarean Delivery. Obstetrics & Gynecology , 108, 12-20.
Macones, G. A., Cahill, A., Pare, E., Stamilio, D. M., Ratcliffe, S., Stevens, E., et al. (2005). Obstetric outcomes in women with two prior cesarean deliveries: Is vaginal birth after cesarean delivery a viable option? American Journal of Obstetrics and Gynecology , 192, 1223-9.
Mercer, B. M., Gilbert, S., Landon, M. B., & Spong, C. Y. (2008). Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstetrics & Gynecology , 11, 285-91.
Silver, R. M., Landon, M. B., Rouse, D. J., & Leveno, K. J. (2006). Maternal Morbidity Associated with Multiple Repeat Cesarean Deliveries. Obstetrics & Gynecology , 107, 1226-32.
Smith, G. C., Pell, J. P., Cameron, A. D., & Dobbie, R. (2002). Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. Journal of the American Medical Association , 287 (20), 2684-2690.
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