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A father says, Why invite the risk of VBAC?

I recently had an exchange with a father that I wanted to share because I think he has the same concerns as many other fathers and mothers.

He first left a comment in response to the article I’m pregnant and want a VBAC, what do I do?

Make sure they have a surgical team ready to go 24-7 If you are attempting VBAC’S.

They have about 15 min’s to get the child out, without serious damage after complete uterine rupture. It won’t be a Bikini cut either.

I replied:

Anthony,

VBACs can absolutely be offered safely without 24/7 anesthesia present.  I had the opportunity to attend the March 2010 National Institutes of Health VBAC Conference where the ability of rural hospitals to safely attend VBACs was extensively discussed. One doctor spoke during the public comment period and stated that her rural hospital had a VBAC rate of over 30%! It turns out, if a hospital is supportive of VBAC and motivated, they can absolutely offer VBAC safely. (I also welcome you to read the commentary of two obstetricians and one certified nurse midwife who argued against the VBAC ban instated at their local rural hospital.) Read more about the policies that this hospital implemented: VBAC Ban Rationale is Irrational.

One large VBAC study found that while the risk of infant death or oxygen deprivation in VBACs was 0.05%, the maternal mortality in repeat cesareans was 0.04% (Landon, 2004). Whose lives do we save? And in fact Henci Goer’s analysis shares with us that the 0.05% rate is inaccurately elevated. In the Landon (2004) study, women whose babies had died before labor were encouraged to VBAC. Those infant deaths were included in the 0.05% figure even though their deaths could not be attributed to a labor after cesarean.

There was an entire lecture at the 2010 National Institutes of Health VBAC Conference about uterine rupture, oxygen deprivation and blood gases. You can find a summary in the Program and Abstracts.

Warmly,

Jen

Then he left a comment in response to the article A letter from a hospital explaining why they banned VBAC:

Well written letter by the physician. VBAC’s are very risky. I’ve lived through the personal horror of a catastrophe. And trust me it was catastrophic. I nearly lost my wife and full term son. My son now lives his life as a quadriplegic with Cerebral Palsy. You can’t convince me it’s worth the risk. Not for the child, not for the mother, not for the family, and not for the doctor and hospital.

Greedy insurance companies thought they could turn profits by forcing VBAC’s on mothers. The doctor’s letter is true to form and his statistics are on the money. If you care about people, mothers, babies, and family, “Don’t push for VBAC’S” do the opposite.

To which I replied:

Anthony,

I am so sorry about your son.  To describe what happened to your son as tragic is a drastic understatement.

I agree that the policies in place during the 90s when insurance companies were pushing VBAC were entirely unsafe. VBAC became required in some places and some women were not given a choice about whether or not to VBAC. This resulted in women with contra-indications to VBAC experiencing bad outcomes. Women in crowded hospitals did not receive good care and had bad outcomes. Women desiring trials of labor after cesareans were induced and had bad outcomes. And all of this resulted in VBAC getting a bad name. “Instead of blaming the overuse of induction, mandatory VBACs regardless of suitability, and mismanagement of labor, doctors began saying that it was actually VBAC that was unsafe.” You can read more on the history of VBAC here.

Fortunately, we know more now about the risks and benefits of VBAC and repeat cesareans than we did in the 90s. Like how rupture rates vary depending on the scar type (Landon, 2004), how the risks of cesareans increase with each surgery (Silver, 2006) and the risk of uterine rupture and other complications decrease after the first VBAC (Mercer, 2008). We know now that inducing increases the risk of uterine rupture (Landon, 2004), but that it is a reasonable option when there is a medical indication.  As the Guise 2010 Evidence Reports asserts,

“While rare for both TOL [trial of labor after cesarean] and ERCD [elective repeat cesarean delivery], maternal mortality was significantly increased for ERCD at 13.4 per 100,000 versus 3.8 per 100,000 for TOL. The rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL and ERCD. The rate of uterine rupture for all women with prior cesarean is 3 per 1,000 and the risk was significantly increased with TOL (4.7 1,000 versus 0.3 1,000 ERCD). Six percent of uterine ruptures were associated with perinatal death. Perinatal mortality was significantly increased for TOL at 1.3 per 1,000 versus 0.5 per 1,000 for ERCD… VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans.”

So neither option is inherently safe or risky. Both offer a different set of risks. I think it’s important for women to understand these risks when considering their options. I wrote a summary here: Nervous About Planning a VBAC.

Once again, I’m so sorry about your son and I thank you for taking the time to leave your comment.

Warmly,

Jen

To which he replied:

Your statistics mean is nowhere near the mean quoted in the doctors letter. This doctor has performed how many births? and participated in many more. He travels around the country lecturing on this subject? His mean is 2.5% not .05%. .05% is risky too. But I believe 2.5% is more likely for for complications with VBAC.

Accidental death from cesarean he pegs at .001%. That’s .00001

To which I replied:

Anthony,

His statistics are wrong. That is why I posted the letter. I wanted to illustrate how important it is to educate yourself because some OBs just don’t know and give incorrect information either because they don’t know any better or because they are actively skewing their information.  Please read my comment on the differences between an OB’s opinion and medical research.

There is not one large study on VBAC that shows a fetal mortality rate of 1 in 200 (0.5%.) Please check out my bibliography. I’ve read all these studies. If you can find a study on VBAC including over 5,000 women, controlling for scar type, induction method and dose that shows an infant mortality rate of 0.5%, I would love to see it.

Warmly,

Jen

To which he replied:

I still agree with the doctor’s letter above. Why invite the risk? and it is way way too risky. How could the liability limits of a midwife, or small hospital possibly cover such a tragedy? Should that be handled by malpractice reform? By allowing our health professionals to be unaccountable? Recovery for even economic loss is nearly impossible today. The liability is tremendous. Childbirth is already risky enough. I agree that induction may be a contributing factor and maybe more research should be done on those drugs and their use. Cervadil was used to induce my wife, and it was contra-indicated at that time in women with a scarred uterus by “the Physicians Desk Reference”; but that didn’t stop it’s use. This catastrophe didn’t happen in a busy hospital. It happened because the hospital and physicians were not prepared to deal with the profound emergency. I see no benefit to anyone, by lobbying for VBAC’S. Thanks for the reply

To which I replied:

Anthony,

There is about a 0.4% risk of having a uterine rupture with one prior low transverse cesarean in a spontaneous labor (meaning you weren’t induced or given Pitocin or other similar drugs during your labor) (Landon, 2004). One would think that with all the hoopla about uterine rupture, that this rate would be significantly higher than other obstetrical complications.

You might be surprised to learn that uterine rupture occurs at a similar rate to other obstetrical complications such as post partum hemorrhage, cord prolapse or placental abruption! And when we look at infant outcomes, there is about a 6% chance of infant death or oxygen deprivation after an uterine rupture (Landon, 2004) compared to the 12% risk of infant death after a placental abruption (Ananth, 1999).

Yet how many first time moms worry their entire pregnancies about placental abruption? How many considered an elective primary cesarean in an attempt to circumvent abruption? How many were offered, or even strongly pressured, to consider an elective cesarean by their friends, family, or OB? How many where made to feel selfish over their desire to plan a vaginal birth in the face of risks such as abruption?

And where are all the lawsuits resulting from the infant deaths as a result of placental abruption? Why aren’t people outraged that all these babies are dying as a result of selfish moms who should have been prudent and had scheduled cesareans to prevent this tragedy? We hold VBAC to such an impossible standard because the tolerance for risk has been reduced to zero.

Moms planning a VBAC are often made to feel that having a repeat cesarean is the most prudent, conservative choice whereas only selfish women who wish to experience vaginal birth plan a VBAC. Only people who do not understand the statistics would make such a bold claim.

The problem is that most people don’t understand the rate of obstetrical complications in a first time mom. Conventional wisdom and rumor does not give your average individual enough information to adequately compare the risks of a primary vaginal birth, repeat vaginal birth, primary cesarean, repeat cesarean, primary VBAC and repeat VBAC. That is why we have medical studies because even doctors, who themselves attend thousands of births over their career, do not control for variables like researchers do. Doctors focus on practicing medicine whereas researchers, who are often medical doctors who still see patients, focus on constructing studies, maintaining records, and controlling for variables. All of this enables researchers to accurately detect and measure the incidence of complications and also identify larger patterns.

One thing we have learned from medical studies is that 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). Should all first time moms have cesareans because their labor is just to risky?

Let’s not forget that while a cesarean could prevent a would-be uterine rupture, placental abruption, or cord prolapse, cesareans themselves introduce many serious risks. In the face of immediate death or damage to mom or baby, these risks are absolutely acceptable. However, when we are performing major abdominal surgery on the other 99.6% of women who will not have a uterine rupture, we are subjecting them to an unnecessary level of risk.

There are several complications that occur during a second scheduled cesarean section at a rate similar to or greater than the risk of uterine rupture during a spontaneous trial of labor after cesarean after one prior low transverse cesarean (0.4%) (Landon 2004). These complications include hysterectomy (0.42%), any blood transfusion (1.53%), a blood transfusion of four or more units (0.48%), maternal intensive care unit admission (0.57%), maternal wound infection (0.94%), and endometritis (2.56%) (Silver, 2006). And while Silver (2006) found that the maternal death rate was “only” 0.07% during a second cesarean, this is 3.5 times higher than the rate of maternal death in a trial of labor after cesarean (0.02%) and 1.4 times higher than the risk of infant death or oxygen deprivation (0.05%) (Landon, 2004.) Keep in mind that all the cesareans included in the Silver (2006) study were scheduled. All the complications noted were a direct result of the surgery, not of any other medical complication.

These are important facts for people to know before they make the judgment of which option is more “risky:” VBAC vs. repeat cesarean. It’s not enough to understand the risks of VBAC, one must also understand the risks of cesarean section. Only then can one see that neither are inherently safe or risky. They both offer a different set of risks. You can read more about the specific risks that cesareans pose in the article The risks of cesarean sections.

Cesareans also have major implications for all future pregnancies and delivery options. The risks of complications increase with each cesarean section which make subsequent pregnancies more precarious which increases the likelihood of a bad outcome for mom or baby. 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 the risks of cesarean are so great, they conclude their study with the following statement, “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.”

Additionally, scheduled cesarean section puts anyone else who experiences a medical emergency requiring surgery in danger because those operating rooms become unavailable. I wonder how often women with true obstetrical complications requiring immediate cesareans, such as your wife, or non-obstetrical emergencies such as car accident or gunshot victims, have been unable to receive that urgent, time sensitive care due to otherwise healthy moms and healthy babies undergoing scheduled elective repeat cesareans and tying up the operating rooms? With 92% of women having repeat cesareans (Martin, 2006), I’m sure it’s happened, especially in smaller hospitals, many of which only have one or two operating rooms. These routine repeat cesareans impact everyone and it’s only going to get worse.

According to the CDC (Menacker, 2010), “The number of cesarean births increased by 71% from 1996 (797,119) to 2007 (1,367,049) [and] In 2007, approximately 1.4 million women had a cesarean birth, representing 32% of all births, the highest rate ever recorded in the United States and higher than rates in most other industrialized countries.” The latest data from the CDC shows that 92% of women have a repeat cesarean (Martin, 2009).  So with 1.4 million cesareans annually, we can look forward to approximately 1 million repeat cesareans annually in the future.  With primary cesarean rates growing, our repeat cesarean rate will grow, we will witness more of the complications identified by Silver (2006), including more maternal deaths, and more cases of people who really need emergency surgery dying because operating rooms are filled with otherwise healthy moms and healthy babies undergoing scheduled cesareans.

You said, “It happened because the hospital and physicians were not prepared to deal with the profound emergency.” I would gently suggest that the problem was more with your hospital than VBAC. They induced your wife with a drug that was contraindicated in a trial of labor after cesarean and then were unprepared for an obstetrical emergency. If your wife had a placental abruption or a serious complication from a repeat cesarean, it sounds like they would have been just as unprepared. That is an entirely separate issue than whether VBACs are excessively risky.

Thank you again for your comments and I wish you the best.

Warmly,

Jen

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17 comments to A father says, Why invite the risk of VBAC?

  • Very good read Jen! I can never understand how some people don’t consider the risks of major adominal surgery when advocating c-sections. I was fortunate to have both babies vaginally, but if I had had the first via c-section and were a candidate for a VBAC, I definitely would’ve tried to have baby #2 vaginally. I know of too many women who had major complications from their c-sections–two were in ICU and nearly died.

  • Hillary Dana-Rumi

    Thank you for this very important “real” dialogue. As an unecessary C-section survivor attempting a VBAC in a few short weeks, I continue to be stunned by how uneducated people continue to be about the risks of major abdominal surgery.

    My advice to women is to educate yourself, learn what your choices are…Consider how your choices can effect your future pregnancies and deliveries..seek out the right care provider. DO NOT TAKE EVERYTHING A DOCTOR TELLS YOU AS THE ONE TRUTH!!!! Please, please get 2nd, 3rd, even 4th opinions…do your own research..ask questions until you turn purple! Hire a doula and feel good about the choices and decisions you make.

    A side note: In addition to the many possible risks I would like to add hernia. My C-section resulted in an infection of the incision which in turn resulted in 3 hernias! I discovered one and the remaining 2 were discovered during my current pregenancy. All diagnosed by a surgeon who explained the surgery weakened the facia thus causing the hernias.

  • I’m not currently pregnant so it isn’t anything I should HAVE to think about at this time, but I’m attempting to be prepared for the future, as I’m not done having kids, and I really don’t want another c-section.
    My first child was born vaginally after having my water naturally break one morning and contractions never started. They induced my contractions at 16 hours after my water had broken. the birth, though induced and with an IV I never wanted was incredible, and was absolutely everything I had hoped for!
    My second child was delivered in another hospital in another state, by c-section after they forced labor by sweeping my membranes every hour (I was technically in labor but I didn’t feel I needed to be in the hospital at that point, and after a NST they forced me in saying that I had a high fluid level and a large chance of cord prolapse if I did not admit myself at that point and my water broke at home my baby might die) Anyway, though I didn’t want to be there I felt that I would be considered a bad mom if I didn’t stay. After 12 hours of contractions THEY decided to break my water, I didn’t want them to but I had fought them and lost for the last 9 months, and I was tired, and I let them do it. 3 contractions after they broke my water my daughter’s cord prolapsed and I was rushed to an emergency c-section.
    I don’t want to ever feel the pain of someone cutting me again.. yes I felt it. I appreciate anyone out there who educates about VBAC because I want to know everything I can before getting pregnant again.
    This man probably will never see things the way you do, because he is too closely involved, but I’m so glad you put it out there!

  • Alicia

    I almost cried at how well you wrote this Jen! You are very knowledgable on this topic, and it shows! I am currently 9 weeks pregnant with my third child. My first two sons were delivered via cesarean. I was never even given the chance to experiment with my body’s birthing ability with my first child. My doctor scheduled my first c-section for reasons that always seemed irrational to me, but because I was the patient and he was the doctor, I trusted him. Then with my second pregnancy he tells me that “once a cesarean always a cesarean”, and I was so bothered to hear this. I did not know about vbac and so I went along with my doctor because I thought I had no choices. Although my babies were born healthy, I always felt cheated and felt that he had pretty much decided for me how many children I would be able to have. I knew I wanted more than 2 children. It wasn’t until this past year that I met a couple other women who are big advocates for vbac and enlisting the help and advocacy of a midwife or doula during birth. These women had 2 prior c-sections like me, but had gone on to attempt a vbac with their third child and came out successful. One of these women just delivered her 4th child by a successful vbac (that makes 2vba2c) and the other women is close to term in her 5th pregnancy and will be attempting another vbac at home with a waterbirth (this actually makes her 3vba2c). I really want to attempt a vba2c after meeting them and reading all the inspiring stories.

  • Heidi

    I found all of this quite interesting and informative. I can relate to Anthony though because we too had a devastating outcome that reads like a movie. I thought I did my homework, I thought the midwife we hired was one of if not the best we could get for our situation. First I was 42 yr old, first pregnancy we had waited more than 20 years for. We conceived because of embryo adoption, I had a frozen embryo transfer. My midwife gave me pitocin by iv in our home, she prescribed bio identical hormones during my pregnancy because she feared thyroid issues and let me labor for four days with my water being broken 48 hours by the time we got to the hospital. I had severe choreoamnioitis and our baby died only seconds before the emergency Csection. This was just barely a year ago, our lives will never be the same. Learning what we learned after all this not only about our midwife but about other risks has left us feeling stupid, embarrassed and humiliated besides all the grief issues. Our outcome was directly related to the midwife and her care and lack of care. Legally because we live in a state that does not give licensure to non nurse midwives so we can’t go after the midwife because there is no malpractice insurance. We learned she has done this before and killed another baby before ours as well but you can go online and this midwife comes up smelling like a rose. She has run to another state that doesn’t give licensure so she can practice without accountability. The North American Registry of Midwives, NARM, is hiding behind what the midwife is telling them without verification. She refuses to produce records because she has destroyed them for sure.

    So here I sit getting ready for another frozen embryo transfer because thank God I had a doctor who worked on my uterus for three hours instead of giving me a hysterectomy. I was told at my 6 week post op that if I ever did this again I would need to do a 39 week Csection. I want what is best for me and my babies but how do I trust anyone, myself included? No one knows what or how a woman’s body is going to react in any given situation but ob’s seem to make decisions based on all the fears of what could happen which is part of why we chose a home birth. We thought the worst that would happen is we would go to the hospital if our best efforts failed, we never saw death as a possible outcome. That seems seriously flawed to me know. I have commented to doctors and nurses about my reality now is that birth is risky usiness and to my amazement the response has been that actually it is quite normal and that most births are fine, it is just a small percentage that can go bad.

    Our choice at this point will be a hospital birth but with all I read it is so hard to know with all the opinions. Plus, there is this issue of feeling like I will be a bad mom for using my brain and questioning anything and therefore I feel like I will have to go along with whatever.

    I want our babies, I want them healthy, I want to walk away intact without damage. For us it is our faith that we will rely on as we are presented info and choices because no one can give guarantees. I am high risk for multiple reasons especially after this. Going through a death and my husband thought he was losing me as well changes how you view, hear, and interpret things. I appreciate this article because people can think our biggest mistake and risk we took was home birth or the midwife but what we read and learned at that time seemed to point us in the direction we chose. Surviving medical attention is a reality whether one believes it or not. Our ignorance of other truths cost us our sons life. We don’t want to make another mistake by going towards another extreme.

    Missing our baby.

    • Jen Kamel

      Heidi,

      Thank you so much for your comment. You have my greatest sympathy and I can’t begin to imagine the grief and pain you have experienced since losing your precious baby.

      Unfortunately, as you know, one of the problems with hiring a non-nurse midwife in an unlicensed state is that their education and clinical skills can vary greatly. Additionally, pregnant women don’t always know the proper questions to ask in an effort to determine the midwife’s (in)formal education and assess their clinical skills.

      It sounds like there was considerable damage to your uterus since the OB spent three hours repairing it. You may or may not find it interesting to get a copy of your medical records to review why the surgery took that long.

      I am not an obstetrician or a midwife, but as it sounds like your uterus required substantial repairs, I think a 39 week cesarean is reasonable.

      You already know what your current OB thinks. You might find it helpful to get a second opinion from another OB. Bring your medical records and make an appointment for a consultation so you aren’t sitting naked under a paper robe as you try to have this serious discussion.

      Heidi, I wish you the best and once again you have my deepest condolences.

      Warmly,

      Jen

  • Becky

    Why is your stated risk for maternal mortality during an ERCS so much higher than the numbers reported by the NIH conference, which is .013%. Again, your reported number for perinatal loss in TOLAC are also much lower than their numbers, which are .13%. Are you using numbers from one study only? Thank you for any information.

    • Jen Kamel

      Hi Becky!

      The sources for each statistic are located after each statistic. I do refer quite often to the Landon 2004 study as it is the largest study completed comparing the outcomes of VBAC and elective repeat cesarean section (ERCS.) Landon (2004) included over 18,000 women in Southern California. This is important because in order to document the occurrence of an event that happens as rarely as uterine rupture, large numbers of VBAC labors must be included in studies in order to get the most accurate measurement. Landon 2004 is the source for the rates I reported for repeat cesarean maternal mortality (0.04%) and perinatal loss or oxygen deprivation during a TOLAC (0.05%).

      While I attended the 2010 NIH VBAC Conference, I have not reviewed the 370+ page report that was presented there entitled Vaginal Birth After Cesarean: New Insights (Guise, 2010). I do plan to read it and will update the Quick Facts page as well as subsequent articles as appropriate.

      Thanks for your comment!

      Warmly,

      Jen

      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

  • SZ

    Anthony is right. It’s not worth the risk. Had I known that the statistics for hypoxic ischemic encephalopathy and perinatal death were much higher for VBAC than Csection, I would have chosen C-section. I wasn’t told and didn’t even know what hypoxic eschemic encephalopathy was until my son was born. Now he has severe cerebral palsy and will suffer the rest of his life. And people like you don’t want to accept that the risks are real so you sweep the bad stuff under the rug and just promote the good. The risks are real. Someone has to be that statistic. And people should know that when looking up info for VBACs. Thanks to articles like yours and my midwives super positive attitudes toward VBACs, I had no clue that there were very real risks involved. And that risk is cerebral palsy, blindness, deafness, mental disabilities, microcephaly, organ failure, failure to thrive, and/or death. I believe in the beauty of birth but keep in mind that not everyone will have a beautiful birth. There is a reason so many babies were still-born back in the days when there was no medical intervention.

    • Jen Kamel

      SZ,

      I am so sorry about your child. I cannot begin to imagine the mental somersaults that most take place when learning that your baby has cerebral palsy. I cannot imagine the daily struggle you have mothering your sweet child.

      Based on your comments, I gently and genuinely wonder if you have read any articles on this site including the one above. In the article above, I mentioned the 0.05% risk of infant death or oxygen deprivation during a VBAC twice (Landon, 2004). Please see the paragraphs that begin with “VBACs can absolutely be offered safely” and “Fortunately, we now more know about the risks and benefits.” That is one of the major concerns when it comes to VBAC so I would hope since I mentioned it twice during one article that I would not be perceived as “sweeping the bad stuff under the rug.”

      I talk extensively throughout the site about the risks and benefits of VBAC vs. elective repeat cesarean section (ERCS). Since I have been simultaneously accused of being anti-VBAC and a VBAC zealot by different groups, I think I’m just were I want to be: providing information that is factual and somewhat neutral. I say somewhat neutral because I do agree with the American College of Obstetricians and Gynecologists as well as the National Institutes of Health when they say that VBAC is a “reasonable choice” for “most women.” That is because they have weighed the risks and benefits of VBAC vs. repeat cesarean and understand that while a repeat cesarean is less risky for the current baby, a VBAC is less risky for the mom as well as the babies in future pregnancies. Fortunately, the risk of major complications with either mode of delivery is very low.

      I think it is a crime when people make medical decisions without proper informed consent. It is unconscionable to me that you did not know that the risk of infant death and oxygen deprivation is greater with a VBAC (0.05%) than a repeat cesarean even though the overall risk is still low (Landon, 2004). You deserved better than just some pot of gold dream.

      While I am shocked that your midwife did not properly relay the risks and benefits of VBAC vs. ERCS, I am not surprised. Many women seem to base their VBAC vs. ERCS decision solely on their practitioners preference rather than the risks and benefits of each mode of delivery. Read more here: http://vbacfacts.com/2012/02/11/study-finds-pregnant-women-with-prior-cesarean-choose-the-delivery-method-preferred-by-their-doctor/. It seems that many women are completely uninformed even as they are admitted to the hospital for their VBAC or elective repeat cesarean. That study found that “Only 13% of TOLAC [trial of labor after cesarean] patients and 4% of ERCS patients knew the chances for a successful TOLAC, while the majority in both groups stated that they ‘did not know’. The majority (64%)of ERCS patients did not know the risk of uterine rupture during TOLAC and 52% did not know which delivery mode had a faster recovery time.”

      This is a very long way of saying: You are not alone. Most women do not understand the risks and benefits of their post-cesarean birth options.

      To say that this is a shame would be a gross understatement. As I say in “Myth: Risk of uterine rupture doesn’t change much after a cesarean:”

      Women seek out midwives thinking that they will be a source of accurate information and judicious support. But what happens when your midwife tells you that your risk of uterine rupture has not increased as a result of your prior cesarean section? If you have done your homework, hopefully you find another midwife fast. I would really question the skills and knowledge of a midwife who is so unknowledgeable on the risks of VBAC and yet attends VBAC births in an out-of-hospital setting.

      But suppose your haven’t done your homework, you trust your midwife, and you move forward with your plan to have a VBAC at home based on the incorrect statistics she supplies. I can’t begin to imagine the rage I would feel if I decided to have a home VBAC based on false information provided by my care provider, and then the unimaginable happened, and I ruptured, and then I learned the truth: that my risk of uterine rupture increased 91 times as a result of my prior cesarean. I would be beyond angry. I would feel so betrayed.

      I am angry with the midwives and birth advocates who minimize the risks of uterine rupture by saying ridiculous things like you are more likely to be bitten by a shark or struck by lightning or that your risk of uterine rupture doesn’t change much after a cesarean.

      The OBs who exaggerate the risks of VBAC are equally unethical. I have written extensively about this topic here: Another VBAC Consult Misinforms, Scare tactics vs. informed consent and Hospital VBAC turned CS due to constant scare tactics.

      The bottom line is, women deserve the truth! Women should not be mislead or lied to or coerced by their care providers. Nor should they be given some rosy picture that if they choose Option A, everything with be just fine. Rather women should be active participants in their birth planning who understand the risks and benefits of each option and, together with their care provider, make a decision that is best for them based on their history and current medical condition. And it should also be made clear that there are no guarantees when it comes to birth.

      Care providers should emphasize that informed consent is much more than just understanding the risks of VBAC, one must also understand the risks of cesarean. This is why I think the whole VBAC Consent Form or Cesarean Consent Form is bunk. You can’t understand just half of the equation when consenting! One should have to sign both for either a VBAC or ERCS.

      Anyone who reads the following almost 400 page document would have a good understanding of the short-term and long-term risks and benefits of VBAC versus ERCS to mom, baby, as well future pregnancies and health. Entitled Vaginal Birth After Cesarean: New Insights, it’s the most extensive complication of VBAC literature to date and was presented during the NIH VBAC Conference of March 2010.

      As I have said many times on this site, it does not matter one bit how small the statistic is when you are the statistic.

      I am genuinely sorry you were the statistic and I am sincerely sorry for the daily struggles you and your family endure.

      Warmly,

      Jen

  • Sarah

    I strongly believe that the data in regard to the C-sections is wrong!! So many C-sections deaths go unreported. My sister worked in accounting at a hospital in Reno Nevada and she said that they always tried to cover up the deaths and blame it on something other than the C-section, like obesity. The mother was always blamed. Yet, it seems like they are more likely to automatically label big women and cut them open. Heavy mothers do tend to labor longer, but they can still deliver vaginally. Women can also die from a C-section weeks or even months after delivering. Blood clots and other problems can always strike later on. Then the death is blamed on something else. Every single C-section should be tracked. Then we will be able to get the REAL data.

  • Sarah

    The accountants in hospitals track and see deaths and cause of death. Someone is getting these records.

  • Carly

    I have been reading and researching and making phone calls for months, I live in Houston and am 4 months pregnant with our second child. Our first was a c-section. I wanted to have the first at home, but husband and family were not on board. Now I am stuck in this awkward battle, I feel in my heart that I should have this baby at home, but what if I am wrong? What if I am one of the ones who will rupture, we live twenty minutes from the nearest hospital, but the midwife I have been speaking with assures me that is not too far. Because she would be listening very closely to the baby’s heart. My husband and family are with the majority who think it is selfish to even try, that we should just go to the hospital try to have our VBAC, (even though we could not find a truly supportive provider,) and if it doesn’t work out I’ll already be there to have my 2nd c-section. What do I do? Do I trust myself or listen to my family? How can I help them understand? How do I get my husband on my side?

    Thank you for all of this wonderful information . It’s nice to see it all on one site after spending months looking through too many others that didn’t seem fact based.

    Keep us in your prayers any one who reads this please!

    • Jen Kamel

      Carly,

      Deciding where to birth is a very difficult choice especially if you do not have a hospital based provider who is supportive of VBAC. The risks of hospital birth are very different than the risks of home birth. I don’t know if you read these two articles, but I write in more detail about the risks and benefits, including the factors to consider when thinking of your distance to a hospital, here and here.

      You might also want to share the many articles I have that may be helpful to unsupportive family members.

      Best of luck with your decision and birth. Please keep me posted!

      Warmly,

      Jen

  • Carly

    Sorry, I should have mentioned. My previous c-section was not because of complications, my Dr and I had not been in aggreence almost my entire pregnancy, but because we prepaid we thought it wasn’t worth the trouble to switch Dr.s, boy were we wrong. She had a plane to catch and my natural birthing ways were getting on her and the nursing staffs nerves, after being in the hospital thirty minutes she declared that my baby’s heart rate was fluctuating too much and I needed an emergency c section. I asked for a second opinion, which I never got and told her that mine and the baby’s heart rates might be fluctuating due to her screaming in my delivery room after I for the third time refused induction. So off to surgery I went…. Oh and did I mention she had a plane to catch!? So I have no bad medical history, my baby and I were both healthy all through pregnancy, and I am not overweight. So I guess I’m saying after my research it would seem I am a good candidate for VBAC. Just scared that I might be that .05%!! Is there any way to tell by how your scar healed or if it is still sensitive that you might rupture, seems silly, but I read lots of things before visiting your site?

    • Jen Kamel

      Carly,

      To go through surgery, and the increased risks that come with repeat cesareans and VBACs, all because your OB had a flight to catch. It is a real shame. The increased risks that come with post-cesarean pregnancies are real.

      Just to clarify, the risk of uterine rupture in a non-induced/augmented VBAC after one prior low transverse (“bikini”) cut cesarean is 0.4% (1 in 240 trail of labors after a cesarean) per Landon 2004.

      There are some that believe that you can measure the thickness of your uterine scar and gauge your risk of rupture, but the studies that have been performed are not large enough to accurately measure rupture. The Guise 2010 Evidence Report does discuss uterine scar thickness, so you might be interested in reading what they had to say.

      To my knowledge, there is no way to accurately measure the strength of a scar by looking at it or performing any other test. But new information is always being discovered. Just be sure to know and read the source that people cite when they write things that seem to good to be true. If it doesn’t pass the smell test, dig deeper!!

      Warmly,

      Jen

  • [...] those women are so bombarded by fear based misinformation masquerading as caring advice from friends and family, they have no chance.  It is shocking to learn how ill-informed both women planning VBACs and [...]

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