Myth: Risk of uterine rupture doesn’t change much after a cesarean

Myth: Risk of uterine rupture doesn’t change much after a cesarean

1/18/12 – The difference in uterine rupture (UR) rates between unscarred and scarred uteri is significant: 1 in 14,286 in an unscarred uterus and 1 in 156 in a scarred uterus.  Another way to express this is: 0.7 in 10,000 (0.007%) in an unscarred uterus and 64 in 10,000 (0.64%) in a scarred uterus.  This 91 times greater risk does not mean that the risk of UR is so large in a scarred mom, it’s that it’s so very, very small in an unscarred mom.

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I came across a couple different bits of (mis)information the past day that have really concerned me. In both situations, people, one of whom is a certified professional midwife (CPM), give false information regarding how a cesarean affects one’s risk of uterine rupture in future pregnancies.

First, a women with a prior cesarean asks for uterine rupture rates after a cesarean, “preferable one with stats” on Facebook. One woman gives this reply:

… almost all cases the risk of rupture is less than one percent, even after multiple sections, or special scars such as an inverted T. The risk is roughly double what it is for an unscarred uterus, but considering the tiny numbers it doesn’t really make a difference, especially since the vast majority of ruptures are not catastrophic in nature, something that is not differentiated in study results.

(There are several things that are false in this statement, but I’ll save those for another post.) Then later in the day, I came across this comment from a CPM’s website:

Will you do a vaginal birth after cesarean?
Yes. Studies have shown that there isn’t much of a difference in uterine rupture rates in someone that has had a previous cesarean and someone who has never had one. A lot of my clients are VBAC’s or attempted VBAC’s. I am completely comfortable with this.

Both of these representations of uterine rupture after a cesarean are erroneous. It’s especially disturbing that a midwife who is counseling VBAC moms and attending their births at home, is giving her clients grossly incorrect information. The risk of a uterine rupture does much more than double after a cesarean as the risk in an unscarred uterus is infinitesimal in comparison to a scarred uterus.

Comparing the risk of uterine rupture: Prior cesarean vs. no prior cesarean

I started looking around and quickly found Uterine rupture in the Netherlands: a nationwide population-based cohort study (Zwart, 2009) which contains the data I needed to compare the rates of rupture in unscarred vs. scarred uteri. You can read the study in its entirety here.

This study included 358,874 total deliveries, making it “the largest prospective report of uterine rupture in women without a previous cesarean in a Western country.” It also differentiates between uterine rupture and dehiscence which is really important because we want to measure the rate of complete rupture. (Remember how the lady from Facebook made the statement, ” the vast majority of ruptures are not catastrophic in nature, something that is not differentiated in study results.” That portion of her statement was also false.)

Zwart (2009) looked at 25,989 deliveries after a cesarean and found 183 ruptures giving us a 0.64% uterine rupture rate or 64 per 10,000 deliveries. 72% of those ruptures occurred in spontaneous labors. Of the 183 ruptures, 7.7% resulted in infant deaths representing 14 babies dying. This gives us a rate of infant mortality due to uterine rupture after a cesarean of 0.05% or 5 in 10,000 deliveries.

Zwart also looked at 332,885 deliveries with no prior cesarean resulting in 25 ruptures giving us a 0.007% uterine rupture rate or .7 per 10,000 deliveries. 56% of ruptures occurred in spontaneous labors. Of the 25 ruptures, 24% resulted in infant deaths representing 6 babies dying. This gives us a rate of infant mortality due to uterine rupture in an unscarred uterus of 0.0018% or 0.18 in 10,000 deliveries.

This study found that the risk of uterine rupture is 91 times greater in a woman with a prior cesarean vs. a woman without a prior cesarean. Not double, not similar, but 91 times greater.

It is important to note that, “severe maternal and neonatal morbidity and mortality were clearly more often observed among women with an unscarred uterine rupture as compared to uterine scar rupture.” Meaning, if an unscarred mom ruptures, her baby is more likely to die than a scarred mom. We see this when we compare the 24% of unscarred ruptures that resulted in an infant death vs. the 7.7% of scarred ruptures that resulted in an infant death which represents a 3 fold greater risk.

However, due to the fact that uterine rupture occurs more frequently in a scarred uterus, the risk of infant mortality due to uterine rupture after a previous cesarean was 27.8 times greater than the risk of infant mortality after a rupture in an unscarred uterus.

In other words, while ruptures in unscarred uteri are more deadly to infants, more infants die due to ruptures in scarred uteri because they occur more frequently.

OBs are often vilified (rightfully so) for giving women inflated rates of uterine rupture and I’ve documented several examples here: Another VBAC Consult Misinforms, Scare tactics vs. informed consent, Hospital VBAC turned CS due to constant scare tactics, and A father says, Why invite the risk of VBAC?.

As a result, 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.

It’s unfortunate when a woman chooses a mode of delivery based on false information. Whether it’s a a woman deciding to have a repeat cesarean due to the exaggerated risk of uterine rupture provided by her OB or a woman deciding to have a (home) VBAC due to her midwife playing down and underestimating the risk of uterine rupture. It is just as bad to minimize the risk of uterine rupture as it is to inflate the risk.

While the risk of rupture in a spontaneous labor after one prior low transverse cesarean is comparable to other obstetrical emergencies, it is important for women weighting their post-cesarean birth options to know that their risk increased substantially due to their prior cesarean. It is important for them to understand the risks and benefits of VBAC vs. repeat cesarean. It is important for them to have access to accurate information and be able to differentiate between a midwife’s/blogger’s/doula’s/birth advocate’s/person on Facebook’s hopeful opinion vs. documented statistics.

I implore those who interact with, and have impact on, women weighing their birth options: do not pass along information, no matter how great it sounds, if you don’t have a well-designed scientific study supporting it. If you hear a statistic you would love to use and share, just ask the person who gave you this information,”What is the source?” and use the citation anytime you quote the statistic. But if the person doesn’t have a well-designed scientific study, be wary and don’t use the stat. This way, we can reduce the rumor and increase the amount of good information on the Internet. I know, a lofty goal.

Read more birth myths debunked including Lightning strikes, shark bites, and uterine rupture and Myth: Unscarred mom induced (with Pit) as likely as VBAC mom to rupture.

Resources Cited

Zwart, J. J., Richters, J. M., Ory, F., de Vries, J., Bloemenkamp, K., & van Roosmalen, J. (2009, July). Uterine rupture in the Netherlands: a nationwide population-based cohort study. BJOG: An International Journal of Obstetrics and Gynaecology, 116(8), pp. 1069-1080. Retrieved January 15, 2012, from http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02136.x/full

What do you think?
Leave a comment.

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health. Created By: Jen Kamel | Copyright 2017 VBAC Facts | Terms of Use | Privacy Policy

 

Two-Thirds of OB-GYN Guidelines Have No Basis in Science

Two-Thirds of OB-GYN Guidelines Have No Basis in Science

PushNews from The Big Push for Midwives Campaign
CONTACT: Katherine Prown, (414) 550-8025, katie@pushformidwives.org
FOR IMMEDIATE RELEASE: August 15, 2011
Study: Two-Thirds of OB-GYN Clinical Guidelines Have No Basis in Science
Majority of ACOG Recommendations for Patient Care Found to Be Based on Opinion and Inconsistent Evidence
WASHINGTON, D.C. (August 15, 2011)—A study published this month in Obstetrics & Gynecology, the journal of the American College of Obstetricians and Gynecologists, found that barely one-third of the organization’s clinical guidelines for OB/GYN practice meet the Level A standard of “good and consistent scientific evidence.” The authors of the study found instead that the majority of ACOG recommendations for patient care rank at Levels B and C, based on research that relies on “limited or inconsistent evidence” and on “expert opinion,” both of which are known to be inadequate predictors of safety or efficacy.

“The fact that so few of the guidelines that govern routine OB/GYN care in this country are supported by solid scientific evidence—and worse, are far more likely to be based on anecdote and opinion—is a sobering reminder that our maternity care system is in urgent need of reform,” said Katherine Prown, PhD, Campaign Manager of The Big Push for Midwives. “As the authors of the study remind us, guidelines are only as good as the evidence that supports them.”

ACOG Practice Bulletin No. 22 on the management of fetal macrosomia—infants weighing roughly 8 ½ lbs or more at birth—illustrates the possible risks to mothers and babies of relying on unscientific clinical guidelines. The only Level A evidence-based recommendation on the delivery of large-sized babies the Bulletin makes is to caution providers that the methods for detection are imprecise and unreliable. Yet at the same time, the Bulletin makes a Level C opinion-based recommendation that, despite the lack of a reliable diagnosis, women with “suspected” large babies should be offered potentially unnecessary cesarean sections as a precaution, putting mothers at risk of surgical complications and babies at risk of being born too early.

“It’s no wonder that the cesarean rate is going through the roof and women are seeking alternatives to hospital-based OB/GYN care in unprecedented numbers,” said Susan M. Jenkins, Legal Counsel of The Big Push for Midwives. “ACOG’s very own recommendations give its members permission to follow opinion-based practice guidelines that have far more to do with avoiding litigation than with adhering to scientific, evidence-based principles about what’s best for mothers and babies.”

The Big Push for Midwives Campaign represents tens of thousands of grassroots advocates in the United States who support expanding access to Certified Professional Midwives and out-of-hospital maternity care. The mission of The Big Push for Midwives is to educate state and national policymakers and the general public about the reduced costs and improved outcomes associated with out-of-hospital maternity care and to advocate for expanding access to the services of Certified Professional Midwives, who are specially trained to provide it.

Media inquiries: Katherine Prown (414) 550-8025, katie@pushformidwives.org

What do you think?
Leave a comment.

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health. Created By: Jen Kamel | Copyright 2017 VBAC Facts | Terms of Use | Privacy Policy

 

VBAC Ban Rationale is Irrational

VBAC Ban Rationale is Irrational

Virginia of Hagerstown, Maryland left me this comment in response to the article Why if your hospital “allows” VBAC isn’t enough:

my hospital says that they will do a vbac but they aren’t set up for it because the labor side is far away from the c-section side so if i try to do a vbac and end up having a c section it will take a lot longer to get me to surgery. do you think this is a legitimate reason to consider not having a vbac? im too close to my due date (7 days left) to change hospitals or doctors although i am beginning to wish i would have. ..
-NERVOUS in hagerstown maryland

Hi Virginia,

The short answer is: No, that is not a legitimate reason to deny you a VBAC.

The reality is, you are less likely to experience an uterine rupture than a complication that has absolutely nothing to do with your prior uterine surgery.

Since obstetrical complications arise during labor in women with no history of uterine surgery that require immediate surgical delivery, or more commonly in women with multiple prior repeat cesareans, how can a hospital claim that they are fit to attend those births, but not yours?

Any birth (VBAC or not) could end in a medically necessary cesarean and any hospital (urban or rural) set up for birth should have a plan detailing how they will respond to those inevitabilities.

I have also often wondered how often women with true obstetrical complications requiring immediate cesareans or even car accident victims requiring surgery, have been unable to receive that care due to otherwise healthy moms and healthy babies undergoing  scheduled elective repeat cesareans occupying the operating rooms?  With 92% of American women having repeat cesareans (Martin, 2006), I’m sure it’s happened, especially in smaller hospitals.

The ability of rural hospitals to safely attend VBACs, as well as a specific plan that they could implement, was extensively discussed at the March 2010 National Institutes of Health VBAC conference.  One doctor spoke during the public comment period and stated that her rural hospital  – without 24/7 anesthesia – 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.)

As David J. Birnbach, M.D., M.P.H (2010), who presented on the impact of anesthesiologists on the incidence of VBAC asserted:

Lack of immediate available of anesthesia may not always be a key factor in outcome [during a uterine rupture], especially in cases where the obstetrician is not present. Many cases of uterine rupture can be stabilized while the anesthesiologists becomes available, and examples have been suggested of ways to reduce the risk associated with such a crisis. These include antepartum [prenatal] consultation of VBAC patients with the anesthesia departments, development of cesarean delivery under local anesthesia protocols, finding methods of improving communication on labor and delivery suites, practice “fire-drills,” and development of protocols matching resources to risk.

I urge you to watch Dr. Birnbach’s presentation along with all the presentations from the 2010 NIH VBAC conference.  The American Association of Justice article entitled “When every minute counts,” also discusses improving response times.

These drills would also be helpful to the women who have other obstetrical emergencies including placenta previa, placenta accreta, and other complications that are more common in women with multiple prior cesareans.

Additionally, as I argued here:

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.

I highly recommend you read the Final Statement produced by the conference as it was the catalyst for the subsequent revision of ACOG’s (2010) VBAC guidelines in the Practice Bulletin No. 115 where they affirmed:

Women and their physicians may still make a plan for a TOLAC in situations where there may not be “immediately available” staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk.

This is a huge change.

The term “immediately available,” first introduced in the 1999 Practice Bulletin No. 5 and then reiterated in the 2004 Practice Bulletin No. 45, was the reason why many hospitals ultimately banned VBAC.  Hopefully the removal of that recommendation in this new Practice Bulletin will result in the reversal of VBAC bans and an overall greater support for VBA1C and VBA2C.  ACOG acknowledged that their prior recommendation was resulting in way to many cesareans and the increasing risks that multiple cesareans bring are significant and unacceptable.  (Please read the risks of multiple cesareans detailed by Silver 2006 in Another VBAC Consult Misinforms.)

The removal of the “immediately available” recommendation is supported by the NIH (2010) Final Statement which found it, if implemented in all hospitals, to be an impossible standard that could result in the closing of many Labor & Delivery units:

Would provision of an anesthesiologist standing by waiting for an emergency at every hospital that practices obstetric care increase patient safety?  In truth, that person would need to be doing nothing else clinically, so even being in the hospital might not qualify for “immediately available.”  Looking at the numbers of anesthesia staff currently available, the minimum requirement to provide immediate anesthesia [per the recommendation of the American Congress of Obstetricians and Gynecologist] care for all deliveries would be to have all deliveries accomplished at facilities with greater than 1,500 deliveries annually.  This would require that approximately three-quarters of all obstetric programs nationwide be closed (Birnbach, 2010).

I am excited and hopeful to see the ripple effects of this new Practice Bulletin especially for women in rural areas.  Hopefully the option of VBAC will become a reality for more women.

Resources Cited

American College of Obstetricians and Gynecologists. (2010, July 21). Ob-Gyns Issue Less Restrictive VBAC Guidelines. Retrieved July 21, 2010, from ACOG: http://www.acog.org/from_home/publications/press_releases/nr07-21-10-1.cfm

Birnbach, D. J. (2010). Impact of anesthesiologists on the incidence of vaginal birth after cesarean in the United States: Role of anesthesia availability, productivity, guidelines, and patient saftey. Vaginal birth after cesarean: New Insights. Programs and Abstracts (pp. 85-87). Bethesda: National Institutes of Health.

Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., & Kirmeyer, S. (2006). Births: Final Data for 2004. National Vital Statistics Reports , 55 (1), 1-102.

National Institutes of Health. (2010, June). Final Statement. Retrieved from NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights: http://consensus.nih.gov/2010/vbacstatement.htm

National Institutes of Health. (2010, March 8-10). NIH VBAC Conference: Program & Abstracts. Retrieved from NIH Consensus Development Program: http://consensus.nih.gov/2010/vbacabstracts.htm

What do you think?
Leave a comment.

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health. Created By: Jen Kamel | Copyright 2017 VBAC Facts | Terms of Use | Privacy Policy

 

ACOG issues less restrictive VBAC guidelines

ACOG issues less restrictive VBAC guidelines

Wow, Practice Bulletin No. 115, replacing No. 45 is a breath of fresh air.  No. 45 included the infamous “immediately available” phrase resulting in a fire of VBAC bans to rage around the country, but primarily in rural areas.  Surely No. 115 is in response to the NIH’s March 2010 VBAC conference and the VBAC Statement it produced.

In short, VBAC is a “safe and appropriate choice for most women” with one prior 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 (ACOG, 2010).

What follows is a brief overview of these new guidelines.

They express support for VBAC after one and two prior cesareans:

Attempting a VBAC is a safe and appropriate choice for most women who have had a prior cesarean delivery including for some women who have had two previous cesareans.

They express support for VBAC with twins or unknown scars:

The College guidelines now clearly say that women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a TOLAC.

They say a Pitocin induction remains an option:

Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC [trial of labor after cesarean…Misoprostol [Cytotec] should not be used for third trimester cervical ripening or labor induction in patients who have had a cesarean delivery or major uterine surgery.

They detail the risks that can come with multiple cesareans which are often not listed in your standard “informed consent” document:

[VBAC] may also help women avoid the possible future risks of having multiple cesareans such as hysterectomy, bowel and bladder injury, transfusion, infection, and abnormal placenta conditions (placenta previa and placenta accreta).

But what will have the most impact on the most women is the lifting of the “immediately available” recommendation turned requirement as suggested by the NIH VBAC Conference:

The [American] College [of Obstetricians and Gynecologists] maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available.

They acknowledged how the phrase “immediately available” in their last recommendation were used to support VBAC bans:

“Given the onerous medical liability climate for ob-gyns, interpretation of The College’s earlier guidelines led many hospitals to refuse allowing VBACs altogether,” said Dr. Waldman. “Our primary goal is to promote the safest environment for labor and delivery, not to restrict women’s access to VBAC.”

And they now support hospitals who do not meet the “immediately available” standard attending VBACs:

Women and their physicians may still make a plan for a TOLAC in situations where there may not be “immediately available” staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk.

Finally, they assert how women should not be force to have a repeat cesarean against their will and that women should be referred out to VBAC supportive practitioners if their current care provider would rather not attend a VBAC:

The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient’s desire to undergo VBAC, it is appropriate to refer her to another physician or center.

Removing the “immediately available” standard while supporting VBAC with twins, after two prior cesareans, and with unknown scars is a huge step in the right direction.  It seems that the option of VBAC is now available to hundreds of thousands of women, many of whom, up to this point, were left with no choice at all.

Read the whole press release dated July 21, 2010: Ob-Gyns Issue Less Restrictive VBAC Guidelines.

Download the PDF: Practice Bulletin #115, “Vaginal Birth after Previous Cesarean Delivery,” is published in the August 2010 issue of Obstetrics & Gynecology.

The College maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available. “Given the onerous medical liability climate for ob-gyns, interpretation of The College’s earlier guidelines led many hospitals to refuse allowing VBACs altogether,” said Dr. Waldman. “Our primary goal is to promote the safest environment for labor and delivery, not to restrict women’s access to VBAC.” Women and their physicians may still make a plan for a TOLAC in situations where there may not be “immediately available” staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk. “It is absolutely critical that a woman and her physician discuss VBAC early in the prenatal care period so that logistical plans can be made well in advance,” said Dr. Grobman. And those hospitals that lack “immediately available” staff should develop a clear process for gathering them quickly and all hospitals should have a plan in place for managing emergency uterine ruptures, however rarely they may occur, Dr. Grobman added. The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient’s desire to undergo VBAC, it is appropriate to refer her to another physician or center.

What do you think?
Leave a comment.

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health. Created By: Jen Kamel | Copyright 2017 VBAC Facts | Terms of Use | Privacy Policy

 

Interview with Dr. Fischbein: An Inside Look at Hospitals and VBAC Bans

Interview with Dr. Fischbein: An Inside Look at Hospitals and VBAC Bans

Stand and Deliver recently conducted an excellent interview with Dr. Stuart Fischbein, a Southern California VBAC and breech supportive OB.  It’s an excellent read and I’m including my favorite parts below.  You can read the entire article here: Stand and Deliver: Interview with Dr. Stuart J. Fischbein.

First, let’s do  quick review of ACOG’s Practice Bulletin #54, published in July 2004 and the reason why some American hospitals have banned VBAC, recommends, “a physician [be] immediately available throughout active [VBAC] labor who is capable of monitoring labor and performing an emergency cesarean delivery.”

Now that we are all on the same page, here are excerpts from Dr. Fischebin’s interview:

Don’t hospitals ban VBAC because it is dangerous?

They ban VBACs under the guise of patient safety. But patient safety is a euphemism for “we don’t have a good evidence-based reason to do it, other than we don’t want to get sued, it’s more expedient, and we make more money from c-sections—the hospital does, not necessarily the physician, but the hospital does—so we’re going to ban it because it’s easier for us, and we’re going to say it’s for patient safety because of the risk of rupturing the uterus.” But you know what? That risk should be something that the patient decides. Patients have a right to be given informed consent, free from misinformation or coercion, free from skewing information that benefits the practitioner or the hospital. And they have the right to consent or refuse to accept the treatment that’s offered. That right is frequently being denied.

What role does malpractice insurance play in VBAC availability?

The reason that a lot of hospitals ban VBACs anyway [despite meeting ACOG’s “immediately available” recommendation] —and this isn’t very well known to most people—is because their insurance carrier will tell them that if they allow VBACs, their premium will be much higher. Rather than pay higher premiums, they just ban VBACs and do so under the guise of patient safety. The hospital lawyers, the insurance company lawyers, the insurance company executives, and the hospital administrators are making decisions for patients and then lying about why they’re doing it.

Aren’t uterine ruptures the primary reason for repeat cesareans in women with a prior cesarean?

Most emergency c-sections, the ones that occur suddenly, have nothing to do with a uterine rupture.  They are for placental abruption, prolapsed cord, or prolonged fetal heart rate decelerations.  Far more often, it’s something unrelated to the VBAC that causes an emergency.  And somehow the hospital can manage to take care of those situations. If hospitals can take care of those things, why can they not take care of VBACs?

ACOG’s latest VBAC recommendation was based on consensus opinion, not scientific evidence.  Doesn’t that matter to hospitals when implementing VBAC bans?

Ultimately it won’t matter to the hospital. It’s not about evidence-based medicine. It’s very clear to me in discussing this with the committees that they don’t care. They’re being told by the risk managers, the lawyers, and the insurance companies that they cannot do VBACs. And that’s the final word. The anesthesia departments are also often behind VBAC bans. They talk about patient safety, but really it is that reimbursement is so bad and they don’t want to have to sit around in the hospital all day long and they are fearful of being sued.

Do hospital administrators impact how an OB counsels a woman on VBAC?

I’m supposed to tell patients that they have to go elsewhere if they want a VBAC, that they can’t stay in their own community, that they have to drive 50 miles. … I’m not supposed to tell them that they have the option of showing up in labor and refusing surgery. The hospital actually put in writing that I should avoid telling them that. They’re telling me to skew my counseling, and they have no shame in doing so.

How do OBs feel about working in hospitals with VBAC/breech bans?

For physicians who are not really committed to doing VBACs or breeches, it’s a lot easier to do a section. You get paid about the same. With a section, you can do the surgery at 7:30 am and you’re in the office by 9 am. If you have a breech or a VBAC, you have to cancel your day or spend the night at the hospital. It’s a lot more work, and you don’t get paid any more for it. So you really have to be either dedicated or crazy or somewhere in between. You have to keep your ethical feet well-grounded.

How do VBAC bans impact hospital revenues?

For hospitals, it’s easy. Does a hospital make more money off a practice that has a 5% c-section rate or a 25% c-section rate? That’s an easy question. Although they will never admit that; [the official reason for VBAC bans] will always be patient safety. Clearly, there’s no incentive for them to offer a VBAC to anybody.

How do VBAC bans impact women seeking VBAC?

A successful VBAC occurs about 73% of the time. If a hospital bans VBAC, they’re basically telling 73% of women that they have to undergo a surgical procedure that carries more morbidity than if they had a vaginal birth.

How could tort reform impact VBAC supportive OBs and birthing women?

[With] tort reform, you might be able to make changes by improving competition. If you get rid of some of the restrictions on businesses, you might see more competition start up. You might see more birth centers open, or birth centers that actually have operating rooms, little maternity hospitals. Just like we’ve seen specialty surgery centers open up recently. For years hospitals tried to squelch these things because they know they can’t compete with them. Some day, maybe the major hospital model will go out of business. And would that be so terrible? We have specialty hospitals that do heart surgeries, gastric bypass, or plastic surgery. Why not specialty hospitals that just do maternity? Run by doctors and midwives. 

What do you think?
Leave a comment.

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health. Created By: Jen Kamel | Copyright 2017 VBAC Facts | Terms of Use | Privacy Policy

 

AAFP National VBAC Guidelines

AAFP National VBAC Guidelines

Update: In May 2014, the AAFP released new guidelines.

This is a great piece for deciding between VBAC and repeat cesarean.  Those who wish to VBAC, but have husbands, family, and/or friends who don’t understand why, might find this document very useful.

I have found that people who are anti-VBAC really seem impressed by what doctors and medical organizations have to say, so I’m thinking they will find this document compelling.

Plus, VBAC has this reputation of being “risky” and repeat cesareans are thought of as the “conservative approach,” and this document challenges both lines of thinking.

Why not write a sweet little note like, “I know you are concerned about me choosing the VBAC, so I thought you would find this interesting,” and mail them a copy.  That way, they can read it, think it over, and you can chat about it later.

No one wants to see a loved one hurt or die, and since most believe that a repeat cesarean is the most conservative approach, they tend to lean in that direction.  However, once they understand that real, but small, risks are present with VBAC and repeat cesarean, and that the risks of VBAC go down with each VBAC whereas the risks of cesareans go up with each surgery, hopefully they will respect your decision.

I recommend bringing this document with you when you go to interview OBs about VBAC.  They might be unfamiliar with the data, and they too might be persuaded by a document written by a medical organization.  If your OB is anti-VBAC, this might be a good document to mail them once you have found a truly supportive OB or midwife.

I’ve included the entire text below because when I searched on Google for VBAC vs. Repeat Cesarean, it wasn’t on the first page of results, so I’d like to bring more attention to it.

Please note, they refer to VBAC as TOLAC (Trial of Labor After Cesarean.)

You can view and print the document in PDF format here: Trial of Labor After Cesarean: A Shared Patient-Physician Decision Tool.

******************************************************************

In March 2005, the American Academy of
Family Physicians published an evidence based
clinical practice guideline on TOLAC
(Trial of Labor After Cesarean; formerly called
Trial of Labor Versus Elective Repeat Cesarean
Section for the Woman With a Previous
Cesarean Section).
The AAFP guideline
recommends offering a trial of labor to women
who have had one previous cesarean delivery
with a low transverse incision. The guideline
also recommends that physicians and other
maternity care professionals explore the risks
and benefits associated with a trial of labor with
each woman who is a candidate for TOLAC.
The following shared patient-physician decision
tool can be used to initiate the conversation
about the potential risks and benefits of TOLAC.
It is important to note that this piece is not
a patient education handout. It is not meant
to be used as a standalone tool. Physicians
should go through each section with the
TOLAC candidate and explain how each factor
may (or may not) affect her. After answering
any questions the patient may have, the
physician can give the annotated handout to
the patient so she and her partner can review
it as they consider their options.
To read the AAFP’s TOLAC Guideline, visit
http://www.aafp.org/tolac.

Patient name: ____________________________________________________
Physician: _______________________________________________________
________________________________________________________________
________________________________________________________________

Trial of Labor After Cesarean:
Deciding What’s Right for You
and Your Baby

Women who have had a baby by cesarean section (C-section)
may have a choice about how to have their next
baby. They may choose to have another C-section. This
is called an “elective repeat cesarean delivery” (ERCD for
short). Or they may decide to try having the baby vaginally.
This is called a “trial of labor after cesarean” (TOLAC). When
a woman tries a trial of labor and is able to deliver vaginally,
this is called a “vaginal birth after cesarean” (VBAC).

If you’re reading this handout, it’s because your doctor
has decided that you have a choice between a planned
C-section and a trial of labor. To help you understand the
risks and benefits of each, you doctor will go through
this handout with you. He or she will explain how the
factors below apply to you. Be sure to ask your doctor any
questions you have. It’s important that you understand all
of the issues before you make a decision.

If I try labor, how likely am I to have my baby vaginally?
Because every situation is different, no one can tell if you
will be able to give birth vaginally. However, you should
know that about 76 out of 100 women who try a trial of
labor deliver their babies vaginally.

What happens to women who try labor but can’t
deliver vaginally?
Some women who try a trial of labor are not able to deliver
vaginally and end up having an unplanned C-section. You
should know that most of the babies born by unplanned
C-section are healthy and do not have long-term problems
from the C-section.

Is it is safer trying labor or having a planned C-section?
You already know that having a baby—whether vaginally or
by C-section—has some risks. The risks are generally small
whether you choose a trial of labor or planned C-section.
Studies have shown that there is no difference between
the two when it comes to the woman’s risk of death or
hysterectomy. There are, however, a few other risks to
consider. These are explained below.

Infection. Of women who choose a trial of labor,
7 out of 100 will get an infection. By comparison,
9 or 10 out of 100 women who choose planned
C-section will get an infection. This means that women
who choose C-section have a slightly higher risk of
infection (2% to 3% higher) than women who choose a trial
of labor.

Uterine rupture. A C-section leaves a scar on the
uterus. During a trial of labor, the scar can break open.
Usually this doesn’t affect you or the baby. In rare cases,
however, it can pose serious risks to you or your baby.
This is called symptomatic uterine rupture and it occurs
in 2.7 out of 1,000 women, or about ¼ of 1%, who try a
trial of labor.

Infant death. Sometimes—but not always—uterine rupture
results in the death of the baby. The chance of
this is about 15 in 100,000, or about 1/100th of 1%, in
women who try a trial of labor. There is no good data
about the risk of infant death for women who choose
elective repeat C-section.

What factors affect my chances of delivering
vaginally?
Doctors have studied thousands of women who have
attempted a trial of labor. They found that the following
factors affect a woman’s chance of delivering vaginally.
Your doctor will tell you how these factors apply to you.
You might want to ask your doctor to put a checkmark
next to the factors that may affect you and to cross out
the ones that probably won’t.

Factors that increase the likelihood of a
vaginal birth after C-section (VBAC)

• Being younger than 40 years old. If you’re under 40,
you are 2½ times more likely to have a VBAC.
My age: _________
Other notes: ________________________________
__________________________________________
__________________________________________
__________________________________________

• Having a vaginal birth before. If you’ve ever had a
baby vaginally, you’re more likely to be able to deliver
that way again.
I had a baby vaginally, but it was before I had a
C-section. You are 1½ to 2 times more likely to
deliver vaginally again.
I had a baby vaginally after I had a baby by
C-section. You are 3 to 8 times more likely to
have a VBAC.
Notes about your previous delivery or deliveries:
__________________________________________
__________________________________________
__________________________________________
Other notes: ________________________________
__________________________________________
__________________________________________
__________________________________________

• Having favorable cervical factors during labor. This
means that your cervix is dilated (open) and effaced
(thinned out) enough to deliver vaginally. If you’re well
dilated and effaced, you are 1½ to 5 times more likely
to have a VBAC. If you’ve had a vaginal birth before,
your cervix may open and thin out more quickly than if
you haven’t. If you haven’t had a vaginal birth, it’s hard
to tell how well dilated and effaced your cervix will
become during labor.
I have had a previous vaginal birth.
Other notes: ________________________________
__________________________________________
__________________________________________

• If the reason you needed a C-section before isn’t
a factor this time. You might have needed a
C-section because of infection, difficult labor, breech
presentation, or concerns about the baby’s size or
heart rate. If you don’t have the same problem this
time, you are 2 times more likely to have a VBAC.
Reason for my previous C-section: ______________
__________________________________________
__________________________________________
__________________________________________
Other notes: ________________________________
__________________________________________
__________________________________________
__________________________________________
Factors that decrease the likelihood
of a VBAC

• Having had more than one C-section. If you have had
two or more C-sections, you’re 60% less likely to have
a VBAC.
Number of C-sections I’ve had: _________
Other notes: ________________________________
__________________________________________
__________________________________________
__________________________________________

 

• Going into labor after 40 weeks. After this time, you
are 20% to 30% less likely to have a VBAC.
My baby’s current gestational age: ________
My previous child(ren)’s gestational age(s) at birth:
__________________________________________
__________________________________________
__________________________________________
Other notes: ________________________________
__________________________________________
__________________________________________
__________________________________________

RISK OF SYMPTOMATIC UTERINE
RUPTURE IN ALL WOMEN
For all women . . . . . . . . . . . . . . Less than 1 birth per 1,000
For women who have
not had a C-section . . . . . . . . . Less than 1 birth per 1,000
For women who have an
elective repeat C-section . . . . About 1 birth per 1,000
For women who have a trial
of labor after C-section . . . . . . 2 to 4 births per 1,000
(800) 274-2237 • www.aafp.org

• Trying to deliver a baby that is 8 pounds, 13 ounces
(4,000 grams) or larger. If your baby weighs this much
(or more), you are 40% less likely to have a VBAC.
My baby’s current estimated weight: ____________
My previous child(ren)’s weight(s) at birth: _______
Other notes: ________________________________
__________________________________________

• Using medicines to induce or augment labor. If you
need medicine to start or help your labor, you are 50%
less likely to have a VBAC.
Notes: _____________________________________
__________________________________________

What if I have other concerns?
In addition to thinking about your health and that of your
baby, you’re probably dealing with emotional issues
and practical concerns about the birth. Some common
concerns are listed below. When you read through this
list, you may want to put a checkmark next to the issues
you really care about and cross out those that aren’t
as important to you. Talk with your doctor about your
concerns. These issues haven’t been studied like the ones
above, but your doctor may be able to give you some
insight into how they might affect you.

Recovery time. If you deliver vaginally, you’ll probably
spend less time in the hospital and be back on your
feet more quickly. Some women think this is important
because they’ll be caring for the new baby and their older
children too.

Involvement in the delivery. For some women, having a
baby vaginally is more emotionally satisfying than having
a C-section. You get to hold your baby sooner, which
may help with bonding and even with breastfeeding. Your
partner may feel more involved in a vaginal birth too.

Future childbearing. Doctors typically don’t want women
to have more than two or three C-sections. So, you’re more
likely to be able to have more children if you have a vaginal
birth instead of another C-section.

Planned versus unplanned delivery date. Because
it’s better to go into labor on your own when you’re
planning a trial of labor, you probably won’t be able to
be induced. Not knowing when you will go into labor can
be stressful. It can also be a problem if you can’t arrange
for someone to watch your other child or children at a
moment’s notice. For these reasons, some women prefer
to plan on a C-section.

Pain during labor and delivery. If you had an especially
difficult and painful labor before, you may fear going
through it again. For this reason, some women prefer to
have another C-section and avoid labor. It’s important to
remember, though, that there are ways to manage the pain
if you decide on a trial of labor.

How do I make this choice?
You and your partner should work with your doctor to
decide whether the benefits of a trial of labor outweigh
the risks.

If you decide to try labor, you and your doctor will talk
about what to do if it looks like your labor is running into
complications. It’s best to have a plan before you begin your
labor so that you don’t have to make decisions during labor.

Resources Cited

1. Wall E, Roberts R, Deutchman M, Hueston W, Atwood LA, Ireland B.
Trial of labor after cesarean (TOLAC), formerly trial of labor versus
elective repeat cesarean section for the woman with a previous
cesarean section. Leawood, Kan.: American Academy of Family
Physicians; March 2005.
2. Guise J-M, McDonagh M, Hashima J, Kraemer DF, Eden KB,
Berlin M, et al. Vaginal Birth After Cesarean (VBAC). Evidence
Report/Technology Assessment No. 71. Rockville, Md.: Agency for
Healthcare Research and Quality; March 2003. AHRQ Publication
No. 03-E018.
3. Gardeil F, Daly S, Turner MJ. Uterine rupture in pregnancy reviewed.
Eur J Obstet Gynecol Reprod Biol 1994;56:107-10.
4. Miller DA, Goodwin TM, Gherman RB, Paul RH. Intrapartum rupture
of the unscarred uterus. Obstet Gynecol 1997;89:671-3.
5. Kieser KE, Baskett TF. A 10-year population based study of uterine
rupture. Obstet Gynecol 2002;100:749-53.

What do you think?
Leave a comment.

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health. Created By: Jen Kamel | Copyright 2017 VBAC Facts | Terms of Use | Privacy Policy