On July 31, 2012, I was interviewed by Maternally Yours, a radio program on WSLR 96.5 LPFM, a Community Radio station in Sarasota, Florida. Below are the show notes with links to more information. I went off my notes for a bit, so be sure to listen to the podcast to get the full interview. Also check out Maternally Yours’ blog post about the show.
Which women at good candidates for VBAC? Which are not?
Per the American Congress of Obstetricians and Gynecologists’ aka ACOG’s latest VBAC recommendations released in 2010, VBAC is a “safe and appropriate choice for most women” with one prior low transverse cesarean and for “some women” with two prior cesareans. Being pregnant with twins, going over 40 weeks, having an unknown or low vertical scar, or suspecting a “big baby” should not prevent a woman from planning a VBAC per ACOG.
ACOG also says,
Conversely, those at high risk for complications (eg, those with previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise contraindicated are not generally candidates for planned TOLAC [trial of labor after cesarean].
Reviewing your personal medical history with a VBAC supportive care provider is the best way to see if you are a good candidate. I recommend getting a copy of your medical record(s) and operative report(s) from your prior cesarean(s), get the names of VBAC supportive providers, and ask the right questions.
It’s really important to qualify your care provider to ensure that they are supportive of VBAC, before you get their opinion on whether you are a good candidate. There is a great range of practice styles from one care provider to another.
What are some of the risks and benefits of VBAC vs. repeat cesarean?
There are real risks and benefits to both VBAC and repeat cesarean. A mom can only make an informed choice when she is aware of the risks and benefits to herself, her baby, and her future fertility, pregnancies, and health.
According to the 2010 National Institutes of Health VBAC Conference, the risk of a mom dying during a elective repeat cesarean section (ERCS) is significantly increased in comparison to a trial of labor after cesarean (TOLAC). However, the risk is still quite low in either scenario: 13.4 maternal deaths per 100,000 ERCS vs. 3.8 maternal deaths per 100,000 TOLAC.
The NIH also found that the rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL and ERCS. The risk of uterine rupture during a TOL was 4.7 per 1,000 vs. 0.3 per 1,000 in a ERCS.
2.8% – 6.2% of uterine ruptures were associated with an infant death within 28 days of birth. However it’s important to note that “the strength of evidence on perinatal mortality [the number of babies who die during the first 28 days of life] was low to moderate” due to the wide range of rates reported by the studies included in the Guise 2010 Evidence Report. (Guise was the basis for the NIH VBAC Conference. ) The NIH identified this topic as an area for future research.
It’s important for women to understand the long term implications of multiple repeat cesareans. A 2006 study of 30,000 women (Silver, 2006) undergoing up to six total cesareans found,
The risks of placenta accreta, [surgical injury of the bladder, bowel, and ureters],… the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units,… significantly increased with increasing number of cesarean deliveries.
Unfortunately, many women don’t think about these future risks until they are pregnant again. According to the CDC, 49% of pregnancies are unintentional, so women really need to consider the fact that how they birth their current baby has implications for their future pregnancies and health.
[Dr. John Sullivan Jr. of Sarasota Memorial Hospital, another guest on the show, made mention of how I lead with maternal morality. I did so for two reasons. One, the Guise 2010 Evidence Report, when discussing the risks and benefits of VBAC versus ERCS in it’s Structured Abstract (page v), also discussed maternal mortality first. I think this is because it is one of the primary questions moms have: what is my risk of dying? Second, one of the ways that unsupportive care providers coerce women into a repeat cesarean is by misleading them on the risks of VBAC including uterine rupture and mortality rates. So, I wanted women to know from the get go what the risks were.]
If evidence shows (and ACOG supports) that most women with one or even two or more prior Cesareans should be allowed a trial of labor, why are so many hospitals and physicians still banning the practice?
This is primarily due to the 1999 and 2004 ACOG recommendation that a doctor be “immediately available” to perform a cesarean. Yet ACOG did not clarify if they meant an obstetrician or an anesthesiologist nor did they provide a standard for where the obstetrician and/or anesthesiologist should be or what they could be doing.
As a result, hospitals developed their own definitions producing differing VBAC protocols and requirements. The most severe variety was the institution of VBAC bans in one-third of all American hospitals per the International Cesarean Awareness Network’s 2009 survey. These bans disproportionally affect women living in rural areas as they may have to drive hundreds of miles in order to birth at a VBAC supportive facility. The 2010 ACOG guidelines acknowledged that the interpretation of the prior recommendations were limiting access to VBAC and clarified that was not their intention. ACOG even says,
Importantly, however, none of the principles, options, or processes outlined here should be used by centers, health care providers, or insurers to avoid appropriate efforts to provide the recommended resources to make TOLAC as safe as possible for those who choose this option. In settings where the staff needed for emergency delivery are not immediately available, the process for gathering needed staff when emergencies arise should be clear, and all centers should have a plan for managing uterine rupture. Drills or other simulation may be useful in preparing for these rare emergencies.
These same policies and procedures would also enable hospitals to respond rapidly to the increasing complications we see with multiple prior cesareans including placenta accreta. Read more here.
If women want to learn more about how hospitals without 24/7 anesthesia can provide VBAC safely, they can watch Dr. David Birnbach’s presentation from the 2010 NIH VBAC Conference or read his presentation abstract.
What can a mom do if she wants to birth at a VBAC ban hospital?
Dr. Stuart Fischbein, a Southern California OB, has talked extensively about his struggles as a VBAC supportive OB who worked at a VBAC ban hospital. For a while, he told his patients that they could just show up in labor, refuse surgery, and he would attend their VBAC. When hospital administrators got wind of this, they made him put in writing that he would not longer advise his patients of their legal right to refuse surgery.
Women have VBACed at ban hospitals. The problem is when an obstetrician is under tremendous pressure from hospital administrators to only perform repeat cesareans. So with this pressure in mind, if a mom is told her baby is in distress, how does she know if her OB is telling the truth or succumbing to the pressure of hospital administrators?
Tell us about the legality of VBAC
Hospital-based VBAC is legal in all 50 states. In some states, it is illegal for a midwife to attend a VBAC either at home or in a birth center.
What are some of the myths of VBAC?
So many persistent yet very false myths! First, women should know that you can induce a VBAC. Without medical indication, the increased risks are generally not worth it. But for those women who have a medical reason, such as preeclampsia, severe fetal growth restriction, diabetes, chronic pulmonary disease, etc, an induction can be a nice alternative to a repeat cesarean. Of course, every mom should review the risks and benefits of her options with her care provider. ACOG says that Pitocin and Foley catheter induction is acceptable in a VBAC whereas Cytotec is contraindicated due to the high rates of uterine rupture with which it is associated.
Another myth is that your risk of uterine rupture doesn’t increase much after a cesarean or that your risk is the same or similar to an mom who has never had a cesarean. One study from the Netherlands (Zwart, 2009) including over 350,000 births found the risk of uterine rupture in an unscarred uterus to be very, very small: about 1 in 14,000. That same study found risk in a scarred uterus to be about 1 in 156 (this figured included induced and augmented TOLs).
Uterine rupture in a scarred uterus occurs at a rate similar to placenta abruption, post-partrum hemorrhage, and cord prolapse. It’s not that the risk is so high in an scarred mom, it’s just that it’s so very, very, very low in an unscarred mom.
Another myth is that the risk of uterine rupture in a scarred uterus is similar to the risk in an induced, unscarred uterus. This is also false. The risk in an induced, unscarred uterus is still about 1 in 4,500. It is very rare for an unscarred uterus to rupture induced or not.
Another myth is that you can compare the risk of birth to the risk of non-birth activities like dying in a car accident or choking on a pretzel. However, you can’t accurately compare the risks of a daily activity like driving or eating because those risks are measured on a annual or lifetime basis.
Your annual or lifetime risk of something happening will often be higher than your risk of a birth related complication. This is because one’s annual risk measures their risk over the course of 365 days. A lifetime risk is often based on 80 years which is over 29,000 days. You are likely to be in active labor for one day, maybe two.
To compare the risk of something that happens over 1-2 days to the aggregate risk of something that could happen any time over 365 days or 29,000 days is unfair and confusing. I think it’s more helpful for post-cesarean women to focus on the choice they have, VBAC vs. ERCS, and compare those risks to each other. Don’t get bogged down in comparing the risks of birth to the risks of non-birth activities.
Finally, a special myth for Floridans. One mom told me that since Florida had the most lightning strikes hit the ground in the nation, she was more likely to be struck by lighting than have a uterine rupture. This is false. The National Weather Service says, based on the number of reported lightning strike deaths and injuries, your risk of being struck by lightning is about 1 in 700,000. This is a lot lower than the risk of uterine rupture in a scarred or unscarred uterus.