Category Archives: VBAC

Why I’m feeling conflicted about AB 1306: CNM Physician Supervision vs. Home VBAC Hurdle

Update September 2, 2016

This bill was not passed.

Update August 25, 2016 1:32pm

The Senate floor vote for this bill has been postponed until Monday.


Update August 25, 2016 9:57am

For those of you watching this issue closely, this bill will be up for a Senate floor vote today. You can watch the California Senate live here.


Update August 24, 2016 10:06pm

The Senate floor vote for AB 1306 is scheduled to happen tomorrow, August 25th. (Click here to see the current status of the bill.)

The California capital opens at 9am, so if you haven’t already called your state Senator to tell them how you feel about AB 1306, tomorrow is the time.

All you have to say is, “I’m calling to voice my support of [or opposition to] AB 1306.”

Click here to receive a reminder email tomorrow at 9am.

All my thoughts on AB 1306 can be found below.


Update August 24, 2016 11:06am 

I have thought about AB 1306 for so many hours since I initially opposed it last Friday and I’m feeling really conflicted about it.  Let me share with you why.

Removing physician supervision will improve the ability of CNMs to practice autonomously including offering VBAC in the hospital setting (where hospital policy permits) and in birth centers (provided the CNM opts to offer VBAC). This could be a good thing for VBAC families and a great thing for all the other people CNMs serve.

And so it’s really tough because it could negatively impact the small number of women who plan home VBACs by requiring them to have a VBAC consult with an OB.

So, what is the right decision?

Support this bill so CNMs can have a greater reach?

Or oppose this bill because of this requirement?

My mission is to increase access to VBAC in all birth settings. Is it enough that this may increase hospital VBAC access – where most women birth – as well as birth center VBAC while possibly making home VBAC harder to achieve?

Here is the specific language from AB 1306 (Sec 6, 2746.5(B)):

If a woman wants a home VBAC and she ‘still desires to be a client of the certified nurse-midwife, the certified nurse-midwife shall provide the woman with a referral for an examination by a physician and surgeon trained in obstetrics and gynecology. A certified nurse-midwife may assist the woman in pregnancy and childbirth only if an examination by a physician and surgeon trained in obstetrics and gynecology is obtained and, based upon review of the client’s medical file, the certified nurse-midwife determines that the risk factors presented by the woman’s condition do not increase the woman’s risk beyond that of a normal, low-risk pregnancy and birth. The certified nurse-midwife may continue care of the client during a reasonable interval between the referral and the initial appointment with the physician and surgeon.’

This is why I’m conflicted:

44% of CA hospitals outright ban it. They do not “allow” their physicians to attend VBAC. What happens if those hospitals decide, they will not “allow” their physicians to even consult with families seeking out-of-hospital (OOH) VBAC? Or physicians say that their malpractice insurance will not “allow” them to consult with OOH VBAC families? Where does that leave OOH VBAC families?

Right now, the VBAC rate in the state of California is only 9%. This bill could increase VBAC access in birth centers and hospitals assuming that hospital policy “allows” CNMs to attend VBAC.

As it stands, 91% of California families have repeat cesareans and the overwhelming majority of those are due to VBAC bans, misinformation and being unable to find a supportive provider.

But here’s the tough part: OBs who are staunch supporters of VBAC have told me that they would never have a consultation with a woman planning a home VBAC because they don’t, in any way, want to be connected with something that could be construed as validating, okaying, or approving home VBAC.

Even though the legislation isn’t asking OBs to approve of home VBAC, that is what OBs see. And the overwhelming majority of OBs – who support hospital VBAC and may even philosophically agree with OOH VBAC – would not participate in VBAC consults for women planning home VBACs.

This is mitigated a bit by the fact that women can have these consults via a chart review and Skype. So regardless of where they live in the state, they could reach the handful of OBs willing to participate in a VBAC consult.

But having the VBAC consult in the legislation means that as OB allies die, or as hospital policies tighten, or malpractice insurance fears increase, the legislation holds firm. That is not a good thing. It leaves women standing out in the cold on their own. And forces them to go back to the hospital system, where, as we see from the current California VBAC rates, they will likely acquiesce to a cesarean or be forced into a cesarean per hospital policy that is presented as equivalent to law unless CNMs are able to measurably increase VBAC access in the hospital setting.

CNMs can tell families that the prior cesarean is “unlikely to impact this pregnancy” and then talk about the unlikely though possibly dire consequences if a uterine rupture occurs out of the hospital. And talk about transfer protocols as you would with any other patient. Women don’t need to talk to an OB in order to get that information.

So while this bill does include home VBAC in the language, access to home VBAC is assuming that the pregnant person can find a OB who is willing to provide them with this consult. While the option is there, the ability to exercise that option is based on the kindness and ethics of a few OBs. And when they are gone, or the climate changes, women bare the brunt of their absence.

A VBAC consult does not make pregnancies safer. It will not improve outcomes. It only undermines the professional training of CNMs and the autonomy of patients.

And all the while, this bill also removes physician supervision from CNMs. And that is a very good thing.

So, do we say to home VBAC families, “Best of luck to you?” and, “Removing physician supervision for CNMs is worth this trade?” and then hope and pray that these women can find an OB willing to provide them with this consult?

I’m sharing with you the pros and cons as I see them so you can make your own decision.

It’s not too late to contact your state Senator and tell them, “I’m calling to voice my support of [or opposition to] AB 1306.”

Does your state require families planning home VBACs to have a consultation with an obstetrician? If yes, I’d like to ask you a few short questions.


Update Friday August 19, 2016 10:21pm

Thank you to those that contacted your Assembly Member today! The deadline to amend the bill to exclude the VBAC consult was Friday.

The next step is to oppose the Senate floor vote which is expected to happen next week (the week of Aug 22nd).

Please contact your state Senator on Monday, August 22nd, and tell them, “I’m calling to voice my opposition to AB 1306.” That’s it.

If you click the yellow button below, I’ll send you a reminder email Monday morning when the capital opens at 9am.

Be notified when legislation threatens VBAC access!


August 18, 2016 by Jen Kamel

Yesterday I was in Sacramento attending the Midwifery Advisory Council meeting at the California Medical Board.

At that meeting, I learned about a piece of legislation that will decrease VBAC access in California.

TODAY IS THE LAST DAY TO VOICE YOUR OPINION!

If access to midwifery care for women who have had a prior cesarean section is important to you, then please register your opposition to AB 1306 unless amended to exclude VBAC consult with your Assembly Member or with it’s author – Assembly Member Autumn Burke.

AB 1306 would remove physician supervision for Certified Nurse Midwives (CNMs).

This is a good thing.

But here’s the bad part: it puts into statute (law) a requirement that any woman seeking to deliver with a CNM outside a hospital AND who has had a prior cesarean delivery must first have a consultation with a physician (AB1306 Sec 6, 2746.5(B)).

Be notified when legislation threatens VBAC access!

It is this requirement for consultation that is at issue for the following reasons:

• All women are capable of determining for themselves and their families, together with their midwife or health care provider, what measure of risk is appropriate for them. Requiring a physician consultation before they are able to continue midwifery care undermines patient autonomy.

• Certified Nurse Midwives (CNMs) are highly trained health care professionals. They are quite able to determine, together with their client, when a particular woman would benefit from a consultation with a physician.

Requiring a physician consultation for every woman with a prior cesarean delivery does nothing to increase her safety in the current pregnancy. There is no way for a physician (or anyone else) to predict which pregnant woman is going to have difficulty with her current birth because she had a cesarean delivery in a prior pregnancy.

Requiring a physician consultation puts an increased burden on women. It may delay prenatal care, a known risk factor for prematurity, low birth weight and poor outcomes. It is costly and time consuming in the absence of evidence for benefit.

While collaboration between care providers is the ideal, in many areas of California midwife/physician collaboration is not possible because there are no physicians willing to form this relationship. This reduces access to midwifery care and in many instances it also reduces access to successful vaginal birth after a prior cesarean.

Putting precise wording, regarding any medical condition, into statute disallows health care providers the use of the most recent research when helping clients make decisions regarding their care. Putting into law, the requirement for a physician consultation when a woman has had a prior cesarean delivery, will not allow women and their midwives to take into account the growing body of evidence surrounding the practice of a trial of labor after a previous cesarean (TOLAC), prior to determining the need for a physician consultation.

I fully support CNMs and the important care that they provide to California families. But this bill is problematic because of how it will impact VBAC access for those who want an out-of-hospital VBAC with a CNM.

Once again, call your Assembly Member or AB 1306’s author – Assembly Member Autumn Burke – TODAY and say, “I’m calling to voice my opposition to AB 1306 unless amended to exclude VBAC consult.” That’s it.

If you want to say more, you can add, “…because it restricts a woman’s right to choose her care provider and mode of delivery.”

I already called my Assembly Member and it took me exactly 36 seconds.

I hope you do the same.

If you live outside of California, please leave a comment on the author’s Facebook page so others who are learning about the bill realize the implications it will have on VBAC access unless amended.

Be notified when legislation threatens VBAC access!

When you are the statistic: Uterine rupture loss

Above: “I donated my wedding dress to be made into gowns for deceased infants to be buried in. I had pictures done in my dress before I donated it. This is one of my favorites.” – Kaila Flory

Kaila Flory lost her baby to a uterine rupture eight months ago. She recently reached out to me and gave me permission to share her story and pictures of her son Beau.  She is currently raising money to purchase Cuddle Cots in Beau’s memory. Cuddle Cots are refrigerated bassinets that enable loss parents to spend more time with their child. While t-shirt sales end on April 22, 2016 at midnight EST, you can donate anytime. Even just $10 will get her closer to her goal. Buy a t-shirt and/or donate here.  Connect with her Facebook page here

Women who have had uterine ruptures and lost their babies have endured some of our greatest fears. But they are part of our community as well. When the VBAC Facts Community, a Facebook group, was open to the public, we welcomed and embraced the parents who joined us after their loss. Often they felt like they were no longer part of the birth community. They didn’t know where they fit in. They felt isolated and yet they wanted to share their story. We had many loss moms as members and many parents who were planning VBACs wanted to hear their stories.

What follows is Kaila’s story.

Kaila’s Flory’s first son was born by cesarean after being induced for intrauterine growth restriction. When she was 38 weeks and a few days pregnant with her second son, 26-year-old Kaila started having cramps around 1 a.m. “Luckily I had stayed with my dad, so I was not alone with my 3 year old. My husband was at Basic Training. Then a contraction came. Ok, I thought, this is real. It’s time. Then another came. It had only been like a minute or 2. Then severe pain came over my abdomen, and my face and limbs went numb.”

Her father called the paramedics and she was rushed to the hospital, where a STAT c-section was ordered. She nearly bled to death.

Beau-&-Kaila

“This is the only photo I have of myself holding him. I requested people to not take my photo, but I am so glad my best friend took this with her phone. THIS is what raw, real pain looks like. This is why I want people to have Infant Loss Awareness.”

She says:

While I wholeheartedly believe that women should be given the option for VBACs, I also believe women need to consider their child’s health as the most important in this situation. I would have loved to have 3 weeks of pain just to have my son in my arms. I know it is not my fault, and that they do not, normally, schedule a c-section until 39 weeks, but part of me still feels guilty.

When Kaila contacted me, my heart broke. I emailed her back:

Kaila,

Thank you so much for sharing your story with me and I am so sorry about your loss.

I want you to know that I hear you. I really hear you.

I talk quite a bit about how these small numbers represent real women and real babies and it doesn’t matter how small the risk is, if it happens to you, if you are that number, it’s devastating.

The difficulty is that there are serious risks both ways. With VBAC, we have uterine rupture. With repeat cesareans, we have accreta.

Accreta results in more maternal deaths, more maternal complications and comparable infant deaths and complications to uterine rupture. Accreta requires a more sophisticated response of which many hospitals are unable to offer which results in more deaths and complications. Many women are never told about the risks of accreta which prohibits them from making an informed decision. [View my sources and read more about accreta here.]

I discuss uterine rupture and accreta extensively in my workshops including how often it happens, variables that can impact the rate, and outcomes for mother and baby because there is so much confusion about where the risk lies and what could happen.

The other difficulty is that no can predict how an individual birth will play out. Will you be the one to have a uterine rupture? An accreta? And in either of these situations, will you be the one to lose your baby? Or will you have a safe VBAC or repeat cesarean with a healthy mom and baby? There are no guarantees in life and no crystal balls.

Some women who lose their babies to uterine rupture say, “Don’t plan VBACs.”

Some women who lose their babies to accreta say, “I wish I had access to VBAC.”

So the question is, if there are serious complications either way, who should make the decision on how to birth?

It always comes down to the mother.

Given the small chance of a bad outcome, women should have the option to decide what set of risks and benefits are tolerable to them. They should not be forced into cesareans or mislead into VBACs. This needs to be their decision based on information. Part of the reason why I started VBAC Facts is that I, as a consumer, wanted more information and it wasn’t easy for me to find.

To bring it full circle, I hear you.

Have you had the opportunity to connect with other loss moms? I have compiled a resource page here.

I know it may ring hollow, but you are not to blame. Sometimes things happen that we cannot predict and that are outside of our control and I’m so very sorry you were the statistic.

I’ll keep you in my heart Kaila. <3

Warmly,

Jen

Kaila replied:

I will be honest with you, my doctor did not mention accreta once. Wow that is scary too. 🙁 I don’t wish that or a rupture on anyone. Thank you so much for responding to me. And thank you for advising women on what to do after a C-section. If you ever want to use my story, please let me know. I would be happy to share it for statistic purposes. Thanks so much! 🙂

So I’m sharing Kaila’s story today. As I said in my email to her, I talk about the risks of uterine rupture and accreta in my workshops because they are both real risks on either side of the equation. Sadly, a small number of people will experience this reality, and they deserve our support and compassion.

I do hope you will support Kaila’s Cuddle Cots fundraiser. Even just $10 will get her closer to her goal. Donate here. Connect with her Facebook page here.

Learn more about Infant Loss Awareness here.

Calling women who plan home VBACs “stupid” misses the point

I’m in an online group for labor & delivery nurses where the discussion of vaginal birth after cesarean (VBAC) at home came up. While some understood the massive VBAC barriers many women face, others simply said, “Find a hospital that supports VBAC.”

I left a late-night comment stating that “finding another hospital that supports VBAC” is just not a reality in many areas of the country. It’s literally not possible. Not even in the highly populated state of California. (Barger, 2013)

I also suggested rather than calling women stupid or debating the validity of the decision to have a home VBAC​, we should consider why women make this decision.

First, it is not one they take lightly.  Every parent wants a safe, healthy birth for themselves and their baby. It takes more research, work, and energy to plan a home VBAC—and it usually means thousands of out-of-pocket dollars up front. It is most certainly not the easy way out.

Women choose out-of-hospital birth due to disrespectful and abusive care, including obstetric violence and forced/coerced cesareans, delivered by hospitals. Parents also choose out-of-hospital VBAC due to VBAC bans and restrictive VBAC policies (i.e., repeat CS scheduled at 39 weeks, labor can only last 12 hours, baby must weigh less than _____, no induction/ augmentation, etc.).

These are serious issues:

Disrespectful care.

Abusive care.

Obstetric violence.

Forced/coerced cesareans.

VBAC bans.

Restrictive VBAC policies.

And this isn’t a comprehensive list of why women choose home VBAC, but it’s the ones that many nurses, providers, and administrators have control over.

In my comment on the nurses’ group, I posted the link to my California Medical Board testimony addressing these barriers and the resulting importance of access to out-of-hospital VBAC.​

We shouldn’t be asking why women are so stupid and reckless.  We should be asking:

“What can we do to make women feel safe coming to our hospital to give birth?”

And:

“How can we increase access to VBAC in all hospital settings?”

I also suggested that coming from a place of judgment on this option may very well color the tone of their communication. Even if they’re not using the words “stupid” or “reckless,” parents will pick up on what’s not being said. That’s not good for the provider-patient relationship. People want to be heard, understood, and respected. All of us.

It’s important to hear parents when they talk about their past hospital experiences, without being defensive.

Hear them and see it as an opportunity to make a change. Consider, how can you make a difference in your practice and facility?

If this were any other business, we would probably say that this is a services and marketing problem.

If you have a restaurant, and you start to lose customers to a competitor, you figure out why your customers are leaving and appeal to that.

You don’t slam the other restaurant.

You don’t call your customers stupid because someone else is offering a product that they like better.

Even if you would never personally eat there, that other restaurant is offering something that people want. And they are leaving your restaurant to get it.

So, find out what that thing is and change it.

Yes, I said all that in this nurses’ group.  The next morning, I checked to see how my comments were taken, because I know from experience that not everyone wants to hear or acknowledge the realities I outlined.

I smiled to see that the conversation had remained respectful, even from some folks who disagreed with me.  There was no name calling. No personal attacks.  My comments even had a couple likes!

It is possible to disagree without being disagreeable. And I think it’s so important to consider that many women around the country do not have access to respectful care in a facility that supports VBAC.

What are some other reasons that women choose out-of-hospital birth? Leave your comment below.

Learn more:

Askins, L., & Pascucci, C. (n.d.). Retrieved from Exposing the Silence Project: http://www.exposingthesilenceproject.com/

Barger, M. K., Dunn, T. J., Bearman, S., DeLain, M., & Gates, E. (2013). A survey of access to trial of labor in California hospitals in 2012. BMC Pregnancy Childbirth. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636061/pdf/1471-2393-13-83.pdf

Kamel, J. (2014, Dec 17). What I told the California Medical Board about home VBAC. Retrieved from VBAC Facts: http://vbacfacts.com/2014/12/17/what-i-told-medical-board-home-vbac-part-1/

Kamel, J. (2016, Jan 6). “No one can force you to have a cesarean” is false. Retrieved from VBAC Facts: http://vbacfacts.com/2016/01/06/no-force-cesarean-false/

Pascucci, C. (2014, Feb 17). Home Birth vs. Hospital Birth: YOU’RE MISSING THE POINT, PEOPLE. Retrieved from Improving Birth: http://improvingbirth.org/2014/02/versus/

 

“Hospitals offering VBAC are required to have 24/7 anesthesia” is false

In 2010, I was sitting next to an OB/GYN during a lunch break at the National Institutes of Health VBAC Conference. She was telling me about how she had worked at a rural hospital, without 24/7 anesthesia, that offered vaginal birth after cesarean (VBAC).

I asked her what they did in the event of an emergency. “I perform an emergency cesarean under local anesthetic,” she plainly stated. She explained how you inject the anesthetic along the intended incision line, cut and then inject the next layer and cut, all the way down until you get to the baby.

It certainly wasn’t ideal, but it was how her small facility was able to support VBAC while responding to those uncommon, but inevitable, complications that require immediate surgical delivery.

CLICK to share on Facebook.

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They had everything a hospital needs to offer VBAC: a supportive policy, supportive providers, and motivation to make VBAC available at their hospital.

From a public health standpoint, it’s to our benefit to offer VBAC because repeat cesareans increase the rate of accreta in future pregnancies as well as hysterectomy and excessive bleeding.

And rural hospitals are NOT capable of managing an accreta because it requires far more than (local) anesthesia and a surgeon. (Read more on how morbidity, mortality, and ideal response differs between uterine rupture & accreta.)

When I hear of smaller, rural hospitals telling women that they can’t offer VBAC because “ACOG requires” 24/7 anesthesia, I think of that OB/GYN and ACOG’s (2010) guidelines which state

Women and their physicians may still make a plan for a TOLAC [trial of labor after cesarean] 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.

So, yes, it is possible and reasonable to offer VBAC without 24/7 anesthesia.

It is ideal? No.

But do you know what else is not ideal?

It’s not ideal to have VBAC bans mandating repeat cesareans that expose women to the increasing risks of surgical birth across the board as a matter of policy—risks that can be far more serious and life-threatening than the risks of VBAC.

It’s not ideal to have any vaginal delivery at a hospital that doesn’t offer 24/7 anesthesia, because any woman giving birth may require emergency surgery.

It’s not ideal to have a cesarean (scheduled or emergency) at a hospital that doesn’t have a blood bank.

It’s not ideal nor realistic to have every pregnant woman drive hours in labor to larger hospitals that offer blood banks, 24/7 anesthesia, and various obstetric sub-specialties for planned VBAC.

It’s not ideal to have state troopers attending roadside births for some of those women.

And it’s deadly for rural hospitals to be managing a surprise accreta.

So, we have to come up with better options.

We can’t continue to pretend that banning VBAC is in the best interest of families.  It does not serve our communities in the long run because it simply exposes the ones we love to a more serious complication in future pregnancies.

Learning how to perform a cesarean under local anesthetic makes hospitals—regardless of geography—safer places to give birth. It enables them to perform cesareans more quickly when they don’t have an anesthesiologist in the hospital but the baby needs to be born NOW.

This could make a huge difference in the outcomes for any laboring mom—VBAC or non-VBAC—as well as her baby.

Learn more about VBAC barriers and watch me debunk the four reasons why hospitals ban VBAC in my workshop, “The Truth About VBAC.”

Does your rural hospital offer VBAC or not?

Does your urban or suburban hospital offer VBAC or not?

Leave a comment below!

References

American College of Obstetricians and Gynecologists. (2010). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology, 116 (2), 450-463,http://m.acog.org/Resources_And_Publications/Practice_Bulletins/Committee_on_Practice_Bulletins_Obstetrics/Vaginal_Birth_After_Previous_Cesarean_Delivery

Kamel, J. (2015, April 2). Too Bad We Can’t Just “Ban” Accreta – The Downstream Consequences of VBAC Bans. Retrieved from Science & Sensibility: http://www.scienceandsensibility.org/placenta-accreta-vbac-ban/

Kamel, J. (2010, July 22). VBAC ban rationale is irrational. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/22/vbac-ban-rationale-is-irrational/

Komorowski, J. (2010, Oct 11). A Woman’s Guide to VBAC: Putting Uterine Rupture into Perspective. Retrieved from Giving Birth with Confidence: http://www.givingbirthwithconfidence.org/p/bl/ar/blogaid=181

“No one can force you to have a cesarean” is false

Update: Since this article was originally published, it has been updated with several new resources (listed at the bottom) as well as a video.

 

hospital-bed

 

“No one can force you to have a cesarean.” I see this all the time in message boards.

Don’t worry about

… the VBAC ban

…your unsupportive provider

… your provider’s 40 week deadline

… [insert other VBAC barrier here]

no one can force you to have a cesarean.

That’s just not true.

Let’s start with what is ethical and legal: Yes, no one can legally force you to have a cesarean.

ACOG even says in their latest VBAC guidelines that “restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will.” So even if your facility has a VBAC ban, they still cannot force you to have surgery… legally or ethically.

But then you have reality: It happens all the time, but it may look different than you expect.

It’s often NOT a woman screaming “I do not consent” as she is wheeled into the OR, though that has happened.

It’s through lies. It’s through fear.

“The risk of uterine rupture is 25%.”

“Do you want a healthy baby or a birth experience?”

“Planning a VBAC is like running across a busy freeway.”

Hospital policy and provider preference are presented as superseding the woman’s right to decline surgery.

“No one attends VBAC here.”

“It’s against our policy.”

“We don’t allow VBACs.”

Or unreasonable timelines are assigned giving the woman the illusion of choice.

“You have to go into labor by 39 weeks.”

“Your labor can’t be longer than 12 hours.”

“You have to dilate at least 1 centimeter per hour.”

Or it can be a slow process where a seemingly once supportive provider quietly withdraws support exchanging words of encouragement with caution. Dr. Brad Bootstaylor, an Atlanta based OBGYN, describes how this can unfold at 4:00 in this video after a woman describes her experience:

Or, if the birthing parents don’t listen, it can escalate to calling social services, ordering a psychiatric evaluation, or even getting a court order for a forced cesarean.

It can be as simple as, “Your baby is distress.” How do you know if this is true or not? Are you willing to take that risk?

Some people suggest that parents should learn how to interpret fetal heart tones so they can evaluate their baby’s status. But I think this is a wholly unreasonable expectation for non-medical professionals, especially when one is in labor. It is as much an art as it is a science.

In short, coercion frequently isn’t by physical force. It’s through manipulation. This is why it’s worth your time and effort to search for a supportive provider who you trust to attend your birth.

Don’t just think, “Well, I can hire anyone and simply refuse.”

Sometimes it’s not that simple as Rinat Dray, was forced to have a cesarean, and Kimberly Turbin, who received a 12-cut episiotomy while yelling “Do not cut me,” know all too well.

And this is why understanding the complete picture is important. It’s not enough to ponder how things are “supposed to be” or how we want them to be, but how they actually are. The difference between perception and reality is huge. Learn more in my online workshop, “The Truth About VBAC.”

Have you seen a situation like described above play out? Share it in the comment section.

Continue the conversation & share on Facebook here:

There is a huge difference between what is legal, what is ethical, and what actually happens. #forcedcesareans #ethicalvsreality #vbacfacts

Posted by www.VBACFACTS.com on Wednesday, January 6, 2016

 

Learn more:

ACLU. (n.d.). Coercive and punitive governmental responses womens conduct during pregnancy. Retrieved from ACLU: https://www.aclu.org/coercive-and-punitive-governmental-responses-womens-conduct-during-pregnancy

Cantor, J. D. (2012, Jun 14). Court-Ordered Care — A Complication of Pregnancy to Avoid. New England Journal of Medicine, 366, 2237-2240. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMp1203742?

Hartocollis, A. (2014, May 16). Mother accuses doctors of forcing a c-section and files suit. Retrieved from The New York Times: http://nytimes.com/2014/05/17/nyregion/mother-accuses-doctors-of-forcing-a-c-section-and-files-suit.html?referrer=&_r=0

Human Rights in Childbirth. (2015, Jan 14). Rinat Dray is not alone, Part 1. Retrieved from Human Rights in Childbirth: http://www.humanrightsinchildbirth.org/amicusbriefpart1/

International Cesarean Awareness Network. (n.d.). Your right to refuse: What to do if your hospital has “banned” VBAC. Retrieved from Feminist Women’s Health Center: http://www.fwhc.org/health/pdf_about_vbac.pdf

Jacobson, J. (2014, Jul 25). Florida hospital demands woman undergo forced c-section. Retrieved from RH Reality Check: http://rhrealitycheck.org/article/2014/07/25/florida-hospital-demands-woman-undergo-forced-c-section/

Kamel, J. (2012, Mar 2). Options for a mom who will be ‘forced’ to have a cesarean. Retrieved from VBAC Facts: http://vbacfacts.com/2012/03/02/options-mom-forced-repeat-cs/

Maryland Families for Safe Birth. (2015, Jan 28). The truth about VBAC: Maryland families need access. Retrieved from YouTube: https://youtu.be/C5nymk3IGqE

Paltrow, L. M., & Flavin, J. (2013, April). Arrests of and forced interventions on pregnant women in the United States, 1973-2005: Implications for women’s legal status and public health. Journal of Health Politics, Policy and Law, 38(2), 299-343. Retrieved from http://jhppl.dukejournals.org/content/early/2013/01/15/03616878-1966324.full.pdf+html

Pascucci, C. (2015, Jun 4). Press Release: Woman charges OB with assault & battery for forced episiotomy. Retrieved from Improving Birth: http://improvingbirth.org/2015/06/preview-woman-charges-ob-with-assault-battery-for-forced-episiotomy/

Shoulder pain is a symptom of uterine rupture

I’ve written before about the symptoms of uterine rupture as well as how having an epidural does not interfere with the diagnosis of uterine rupture.

The focus of this Quick Fact is how shoulder pain can be a symptom of uterine rupture.

How can an uterine rupture cause shoulder pain?

Image Source: http://wesleytodd.blogspot.com/2013/10/ablation-for-recurring-af-i.html

Image Source: http://wesleytodd.blogspot.com/2013/10/ablation-for-recurring-af-i.html

Internal bleeding from uterine rupture can cause referred pain through the phrenic nerve which can present in the shoulder.

Shoulder pain is sometimes not included in lists of uterine rupture symptoms, but I have seen it cited multiple places (see below) and have had conversations with OBs, nurses, and anesthesiologists who have experienced uterine ruptures with shoulder pain.

I’m also aware of two cases where the uterine rupture diagnosis was delayed because staff was not familiar with the incidence of referred pain.

Anyone who works with birthing women should be aware of the symptoms of uterine rupture including referred pain.

Please note that not every uterine rupture causes shoulder pain and not all shoulder pain is a symptom of uterine rupture.

Where can you learn more?

I discuss uterine rupture – factors, symptoms, rates, and outcomes – at great lengths in my online workshop, “The Truth About VBAC: History, Politics, & Stats

The following quotes addressing shoulder pain & uterine rupture are from case studies and textbooks. Want more? Google uterine rupture referred pain or uterine rupture shoulder pain.

“APH [brisk antepartum haemorrhage], as in this case, often indicates uterine rupture and may occur in association with shoulder tip pain due to haemoperitoneum.” (Navaratnam, 2011)

“Management of uterine rupture depends on prompt detection and diagnosis. The classic signs (sudden tearing uterine pain, vaginal haemorrhage, cessation of uterine contractions, regression of the fetus) have been shown to be unreliable and frequently absent but any of the following should alert suspicion… Chest or shoulder tip pain and sudden shortness of breath.” (Payne, 2015)

“Signs and symptoms of uterine rupture may include… referred pain in the shoulder (with epidural anesthesia)” (Murry, 2007 p.283)

“Jaw, neck, or shoulder pain can be referred pain from a uterine rupture.” (Murry, 2007, p.76)

“Shoulder pain (Kehr’s sign) is a valuable sign of intraperitoneal blood in subdiaphragmatic region. Even a small amount of blood can cause this symptom, but it is important to realize that it may be 24 h or longer after the bleeding has occurred before blood will track up under the diaphragm, and some cases of acute massive intraperitoneal bleeding may not initially have shoulder pain.” (Augustin, 2014, p. 512)

“Shoulder tip pain may be experienced if significant haemoperitoneum is present, due to irritation of the diaphragm (i.e. referred pain through phrenic nerve).” (Baker, 2015, p.373)

References

Augustin, G. (2014). Acute abdomen during pregnancy. Switzerland: Springer International Publishing. Retrieved from https://books.google.com/books?id=mq8pBAAAQBAJ

Baker, P. N., McEwan, A. S., Arulkumaran, S., Datta, S. T., Mahmood, T. A., Reid, F., . . . Aiken, C. (2015). Obstetrics: Prepare for the MRCOG: Key articles from the Obstetrics, Gynaecology & Reproductive Medicine journal. Elsevier Ltd. Retrieved from https://books.google.com/books?id=DcqqCgAAQBAJ

Murray, M. (2007). Antepartal and intrapartal fetal monitor. New York, NY: Springer Publishing Company, LLC. Retrieved from https://books.google.com/books?id=_4jYJUGG56cC

Murray, M., & Huelsmann, G. (2008). Labor and delivery nursing: Guide to evidence-based practice. New York, NY: Springer Publishing Company. Retrieved from https://books.google.com/books?id=q22jEEZo7rwC

Navaratnam, K., Ulaganathan, P., Akhtar, M. A., Sharma, S. D., & Davies, M. G. (2011). Posterior uterine rupture causing fetal expulsion into the abdominal cavity: A rare case of neonatal survival. Case Reports in Obstetrics and Gynecology, 2011. Retrieved from http://www.hindawi.com/journals/criog/2011/426127/

Payne, J. (Ed.). (2015, Mar 17). Uterine rupture. Retrieved from Patient: http://patient.info/doctor/Uterine-Rupture

Applying medical research to clincial realities

Isabel recently asked over on Uterine rupture rates after 40 weeks:

“I wonder however if there are studies that compare the method of induction. My Doula said that the increase rates of uterine/ scar rupture was due to using high dosages of Pitocin, but now the induction uses lower dosages and administered at longer intervals. Do you know something about this?
Thank you”

 

Isabel,

Great question.

A few factors to consider:

1. Induction protocols can vary by provider, including some providers who don’t induced planned VBACs at all.
2. Induction guidelines can vary by hospital.
3. Women can react to the same drug/dose differently.
4. Some studies do compare the uterine rupture rates among spontaneous, induced, and augmented planned VBACs.

Medical studies on induction are only relevant to your situation if your provider follows the same protocol outlined in the study. However induction protocols are often not spelled out in detail unless that is the focus of the study.

When reading medical research, make special note of the sample size. We need ample participants in order to accurately capture and report the incidence of uncommon events such as uterine rupture. I typically like to see at least 3,000.  

Also remember that it’s ideal to have a experimental group (who receives the induction protocol) and a control group (who does not receive the induction protocol) in order to measure the difference in outcomes, such as fetal distress, uterine rupture, hemorrhage, cesarean hysterectomy, etc. Ideally, we would have a couple thousand, at least, in the experimental and control group.

In terms of the trend that induction now uses lower dosages and is administered at longer intervals, that may be true in some practices, but I would always confirm and not assume.

Anecdotally, I have heard a wide range of induction protocols reported just as research has identified similar variations among cesarean and episiotomy rates that are not linked to medical indication. This California Healthcare Foundation infographic clearly illustrates how hospitals differ:

Tale of Two Births

CLICK to share on Facebook

In terms of specific studies comparing the method of induction, the first resource that comes to mind is the Guise 2010 Evidence Report.

Search for the word Cytotec and there is a discussion comparing rates of rupture by Pitocin, prostaglandins, and Cytotec.

Pitocin is associated with the lowest rate of rupture among the chemical agents which is likely why ACOG (2010) recommends Pitocin and/or Foley catheter induction in planned VBACs when a medical indication presents. (Learn more about what the Pitocin insert actually says.)

There may be more recent studies out there. Google Scholar is a good place to start. You can often obtain the full texts of medical studies at your local library, university, or graduate school.

Also, if you subscribe to Evidence Based Birth’s newsletter, she will email you a crash course on how to find good evidence.

I hope this helps!

Jen

What is the induction protocol at your facility? Does it differ for those with a prior cesarean? Let me know in the comment section.

____________________

American College of Obstetricians and Gynecologists. (2010). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology, 116 (2), 450-463, http://dhmh.maryland.gov/midwives/Documents/ACOG%20VBAC.pdf

California Healthcare Foundation. (2014, Nov). A Tale of Two Births: High- and Low-Performing Hospitals on Maternity Measures in California. Retrieved from California Healthcare Foundation: http://www.chcf.org/publications/2014/11/tale-two-births

Guise, J.-M., Eden, K., Emeis, C., Denman, M., Marshall, N., Fu, R., . . . McDonagh, M. (2010). Vaginal Birth After Cesarean: New Insights. Rockville (MD): Agency for Healthcare Research and Quality (US). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK44571/

Friedman, A. M., Ananth, C. V., Prendergast, E., Alton, M. E., & Wright, J. D. (2015). Variation in and factors associated with use of episiotomy. JAMA, 313(2), 197-199. Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=2089343

Kozhimannil, K. B., Arcaya, M. C., & Subramanian, S. V. (2014). Maternal Clinical Diagnoses and Hospital Variation in the Risk of Cesarean Delivery: Analyses of a National US Hospital Discharge Database. PLoS Med, 11(10). Retrieved from http://journals.plos.org/plosmedicine/article?id=10.1371%2Fjournal.pmed.1001745

New Research on Home Birth with an Obstetrician

male-doctor-thumbs-up-squareOver the last five years Dr. Stuart Fischbein, a Southern California obstetrician, has attended 135 home births. These deliveries included VBACs, vaginal breech and vaginal twin deliveries.

A summary of these births has been recently published.

Here are some highlights along with a few additional resources I compiled where you can learn more.

On patient selection:

“This model was not limited by strict protocols and allowed for guidelines to be merely guidelines. Women over 35, VBAC, breech and twin pregnancies were not excluded from this series simply because those labels existed. Each client was evaluated on her own merits and the comfort of the practitioner.”

On informed choice and the limitations of hospital birth:

“Home birth is not for everyone but informed choice is. The patronizing statement, “home delivery is for pizza”, is unprofessional and has no place in the legitimate discussion. Some suggest making hospital birth more homelike. While this may be a beginning and deserves investigation, it fails to recognize the difficult balance between honoring normal undisturbed mammalian birth and the reality of the hospital model’s legal and economic concerns and policies.”

On collaborative care:

“Pregnant women deserve to know that midwifery style care, both in and out of hospital, is a reasonable choice. A collaborative model between obstetrician and midwife can provide better results than what is occurring today.”

On lost skills:

“It would be wise to put the constructive energy of our profession towards the training of future practitioners in the skills that make obstetricians truly specialists such as breech, twin and operative vaginal deliveries.”

On the growth of home birth:

“Home birth will continue to grow as educated women realize that the current hospital model has many flaws.”

On our ethical obligation to provide a smooth home to hospital transfer:

“Cooperation, respect and smooth transition from home to hospital honors the pregnant woman and is our ethical obligation.”

_____________

California Healthcare Foundation. (2014, Nov). A Tale of Two Births: High- and Low-Performing Hospitals on Maternity Measures in California. Retrieved from California Healthcare Foundation: http://www.chcf.org/publications/2014/11/tale-two-births

Fischbein SJ (2015) “Home Birth” with an Obstetrician: A Series of 135 Out of Hospital Births. Obstet Gynecol Int J 2(4): 00046. DOI: 10.15406/ogij.2015.02.00046. Retrieved from Obstetrics & Gynecology International Journal: http://medcraveonline.com/OGIJ/OGIJ-02-00046.pdf

Johnson, N. (2010, Sept 11). For-profit hospitals performing more C-sections. Retrieved from California Watch: http://californiawatch.org/health-and-welfare/profit-hospitals-performing-more-c-sections-4069

Kennedy, M. (Director). (2015). Heads Up! The Disappearing Art of Vaginal Breech Delivery [Motion Picture]. Retrieved from http://www.informedpregnancy.com/#!heads-up/cef1

Klagholz, J., & Strunk, A. (2012). Overview of the 2012 ACOG Survey on Professional Liability. Retrieved from The American Congress of Obstetricians and Gynecologists: http://www.acog.org/-/media/Departments/Professional-Liability/2012PLSurveyNational.pdf

What I told the California Medical Board about home VBAC

california state seal

A little backstory

Back in October, I attended my first Interested Parties Meeting held by the Medical Board of California regarding new midwifery regulations as required by AB1308. (Read more about AB1308 here and here.)

Up for discussion was which conditions or histories among women seeking a home birth with a Licensed Midwife (LM) should be required to obtain physician approval.

A prior cesarean was on the list of over 60 conditions or histories and home VBAC was the one subject that generated the most comment and discussion that day.

What does AB1308 mean in terms of home VBAC in California?

There has been a lot of confusion regarding what AB1308 means in terms of home VBAC in California. In an effort to clear things up, Constance Rock-Stillman, LM, CPM, President, California Association of Midwives said this on January 23, 2014:

AB 1308 went into effect on 1/1/14, but there is nothing in the new legislation that says LMs cannot do VBACs.

LMs can do VBACs.

We just need to define in our regulations what preexisting conditions will require physician consultation. [Which is what the October 15 and December 15th Interested Party meetings were about.]

Until the new regulations are written LMs should continue to follow their current regulations which only require LMs to provide certain disclosures and informed consent to clients.

Please let the community know that if they want to have a say in whether or not VBACs with California LMs require a physician consultation, they should come to the Interested Parties meeting that the medical board will be holding and tell the board how they feel about it.

The medical board is a consumer protection agency, so they need to hear what consumers want to be protected from.

We will let you know as soon as the meeting is scheduled.

[Ms. Rock-Stillman responds when questioned by those who have not been involved it the creation of this legislation yet insist this legislation removes the option of home VBAC entirely:]

I’m in my third year as president of the California Association of Midwives, and I’m a practicing Licensed Midwife.

I have been at every Midwifery Advisory Counsel meeting and at the Capitol 30 times last year.

I’ve spoken in legislative committee hearings.

I’ve sat in weekly meetings with CAM’s legal counsel who worked side-by-side with us on the legislation.

I’ve been in Assemblywoman Susan Bonilla’s boardroom with ACOG and at every one of the public events where Susan Bonilla promised that the LMs would still be able to do VBACs.

So I think I qualify as a knowledgeable stakeholder in this issue.

Yes, we intentionally left VBAC out of the list of prohibited conditions, so at this point there is no question as to whether or not we can do VBACs. The only part that’s in question is whether or not all VBACs will require physician consultation.

Regulations that clarify under what circumstances physician consultation will be required will be written by the California Medical Board.  This is a process that takes time. Maybe even a year or more.

The regulations that will be adopted will be based on evidence and input from all the stakeholders.

This is why I think it’s so important that midwives and consumers be at the meetings to insure their voices get heard.

At the last Interested Parties meeting that the medical board held, I asked what we were suppose to do until the new regulations are written and we were told that we should follow our current regulations and our community standards until new regulations are adopted.

Why I attended

My intention in attending the October 15, 2014 meeting was to amplify the voice of the consumer.  I think sometimes it’s difficult for OBs who attend VBACs, or for those who live in communities where they have access to hospitals that attend VBAC, to understand that not everyone lives in that world.

Some live in a world where if they want a VBAC in a hospital with a supportive midwife or doctor who takes their insurance, that means driving over 50 miles each way for prenatal care and delivery while they literally drive by other facilities that offer labor and delivery, but ban VBAC.

Or it means acquiescing to a unnecessary repeat cesarean whose risks compound with every surgery. Or it means planning an unassisted birth which comes with its own set of risks. This is a tremendous burden.

As VBAC and repeat cesarean both carry risks and benefits, and women are the ones who bear and endure those risks, they should be the ones who choose which mode of delivery is acceptable to them.

I celebrate when women have access to supportive hospital-based practitioners.  But the reality is, many women do not enjoy that privilege and yet they still wish to avoid the serious complications that come with each cesarean surgery.

Who else was at the meeting?

Other people in the room included the Senior Staff Counsel of the Medical Board, an OB-GYN representing ACOG, an ACOG lobbyist, Constance Rock-Stillman along with many other CAM representatives and midwives, California Families for Access to Midwives, a few other consumers, and me.

Senior Staff Counsel was tasked with writing these regulations and as the meeting progressed, items were reworded or removed from the list.

My statement

Only having five minutes to speak means that as soon as you take your seat, adjust the microphone, and look into the eyes of Medical Board, you have to establish yourself as a credible source.

And then you start to speak. You have to be clear and concise with an unwavering voice. The Medical Board is your captive audience and you need to use every second weaving the facts with the personal experiences of mothers, midwives, and doctors so you can convey the whole story.

Often Medical Boards are not well versed on Licensed Midwives, home birth, and the politics of VBAC, so there is a lot of education that has to quickly happen in a few short minutes. You must maximize your time and, while talking at a normal pace, swiftly move from fact to fact continually highlighting yet another piece of evidence that supports your case.

Those that sit on Medical Boards often have access to whatever medical care they need. So sharing the challenges real families throughout the state face when trying to obtain a VBAC is crucial.

With all those factors in mind, I focused on the importance of VBAC access, the politics of hospital VBAC, and the public health implications if families can’t access VBAC.

Throughout my entire presentation, I emphasized how increasing VBAC access was aligned with the mission of the Medical Board: to protect consumers.

It was quite challenging to adequately convey these key points in such a brief format. But as I looked into the eyes of each board member during my presentation, I felt heard. I knew they were receiving the message I intended and that all the hard work that went into preparing for that day made a difference.

Legislative consulting is yet another way that I serve the mission of VBAC Facts. To schedule a legislative consulting call, please click here.

You need to talk to the doctor/midwife face-to-face

Trying to find a VBAC supportive health care provider can be (very, very) difficult process.  Understandably, some women choose to call various providers rather than meet with them face to face. This woman’s experience illustrates the pitfalls of this method.

While VBAC is not a household term, it should be a familiar one among an OB’s front office staff.  Perhaps this will prompt more providers to have a quick discussion with their staff about VBAC and maybe even pass out a copy of the Quick Facts page (high res PDF) so that everyone who interacts with patients has a basic working knowledge of the topic.

Of course, this is the experience of one mom at one OB’s office and certainly doesn’t reflect on all the dedicated and intelligent individuals who work at OB’s offices throughout the world… simply this one.

For tips on interviewing care providers, including how to present yourself and specific questions to ask, go here.

________________________

Well, GREAT little anecdote for you all… In my search for an OB who will at least consider a VBA2C I ended up talking to a lady office assistant via phone yesterday. It went as follows:

Click to share on Facebook

Click to share on Facebook

Me: “Hi! *general convo* Is the doctor VBAC friendly?”

Lady: “Is she friendly?”

M: “No, will she consider a VBAC?”

L: “Um, what’s a VBAC?”

*I hear another nurse in the background, say ‘Yes, we do VBAC’*

M: “Wait, did she say you guys will do a VBAC?”

*Nurse in the background says to lady on the phone, ‘Wait, has she had a c-section?’*

L: “Um, have you had a c-section?”

M: “Yes, of course.”

L: “Oh, the other nurse said if you’ve had a c-section we can’t give you a VBAC.”

M: “Ok, I think you need to know, VBAC stands for Vaginal Birth After Cesarean. It would be impossible to have a VBAC without previously having had a c-section.”

L: “Oh! I didn’t know that!”

*general pleasantries and I hung up*

______________________

When you called your local health providers, what information did the front office staff share with you?  One mom said, “We’ve done surveys in Orlando by calling all the OB offices in town (I know, huuuge undertaking, right?!). We have been told vbac is illegal, that there is a 50% chance a baby will die, and all kinds of other outrageous statements, all from the person *answering the phone*.”

Resources for processing traumatic births and losses

A dear woman contacted me.  15 months after her cesarean, it was still hard for her to read my posts without crying.  This simply broke my heart.  She is not alone.  There are many women who carry the grief and pain of their traumatic vaginal or cesarean births or the loss of their baby.  Every. Day.

So I asked on Facebook for resources for women who are in the midst of the processing and grieving.  Here is the list.  If you know of more, whether they are on-line or in person groups, for free or a fee, please leave a comment.

None of these groups or individuals have been checked out or endorsed by VBAC Facts.  This is simply a list of resources for you to check out.

It saddens me to say this but there are individuals and groups who find and share the stories of loss moms in order to berate them.  Please be careful when sharing information on the internet as anything you post on-line can be easily shared with others outside your closed/private internet group.  There is no such thing as privacy on the internet.  Being anonymous and not providing your home address or identifying information are ways to get around this.

_____________________

Stillbirthday has a comprehensive list of immediate resources (like crisis hotlines, books, and websites) and long term resources (like workshops and retreats.)

There are support groups for women who have experienced uterine rupture. Here is a list: http://www.honoredbabies.org/resource-center/grief-support.htm

I know there is one local to me (Renfrew county, Ontario, Canada) but it’s not available through the Internet.

Solace for Mothers

Barbara-ann Horner: I volunteer for Postpartum Support International and most moms who call experience a traumatic birth message me i can find more resources or chat if you’d like

ICAN, the International Cesarean Awareness Network, is awesome. You can go to their website ican-online.org and there’s a ton of info and local support groups to join. I joined one after experiencing a very traumatic cesarean section and it’s been so helpful in the healing process.

The Dunamas Center does a lot of work with birth trauma.

Merrell Holliman-Carlson: I am a leader of the Ocala Birth Network, we have a FB page and also monthly meetings, we are in Marion County, FL but have several online members who are out of state, we provide information and resources for expectant moms as well as a ‘safe’ outlet for traumatized moms. A lot of us have dealt with unnecesareans and bad inductions, some have VBAC’d and others hope to. You are MORE than welcome!

http://www.humanizebirth.org/ has some resources and you can contact the ladies running the page and have our story added to the campaign as well, there is also a facebook page and group for women to share their stories and talk to others who have been through traumatic birth events as well

BEBA clinic (Ray Castelino)

Babycenter has a “Disappointing Birth Experiences” board….

Online, I recently found the Birth Trauma Association. They’re wonderful! They also have a group on Facebook.

Jamie Bodily: I offer individual sessions in the St. Louis area but no group at this point.

I know Nancy Wainer offers group workshops in the Massachusetts  area. Janel Mirendah also works in group or individually on birth trauma, she did a workshop when she came to do a screening of The Other Side of the Glass.

Yes, Mother to Mother! “Mother to Mother – Postpartum Depression Support St. Louis.  Mother to Mother provides telephone support and encouragement to women with postpartum adjustment disorder (PPAD). Mother to Mother is the only service of its kind in the St. Louis metropolitan area. We serve all women in the state of Missouri and parts of Illinois, free of charge.”

@backline is a great resource. They have a free talkline for birth or miscarriage trauma.

Birthing From Within Birth Story. Listening is amazing.

Birthtalk in Australia!!! They do free group sessions in Australia (Queensland) & personal sessions (also via Skype for international). They are the best

There’s a Birth Crisis group, as well as a CBAC group out there, I know both those group owners and they work hard to keep it safe.

A lady I know who had a stillbirth at 36 weeks is on a site called www.facesofloss.com. “Faces of Loss, Faces of Hope: Putting a face on miscarriage, stillbirth and infant loss.”

Geneviève Prono: I have been helping women heal from a traumatic and difficult birth and prepare for another birth, for twenty years. I do in person and group sessions by skype and am currently writing a book and putting some programs in place. The site in French (apparently google translates it) www.chrysalidefrance.com. What brought me to this three c-sections followed by three VBACs.

Tiffany Hoffman: I do individual birth trauma resolution as well as those who have had difficult or disappointing birth experiences. I have also created a birth trauma workshop, so that women who don’t live here can travel for a weekend intensive to start the healing process. They also learn several ways to continue processing their experience and feelings on their own. My website is www.sacredbirthspace.com

Linda Llone Hinchliffe: Our Birth Choices group offer emotional support to anyone who needs it…

Birth Matters of Fort Wayne, IN offers a Traumatic Birth Healing/Healing for Birth class several times a year. From personal experience – it’s just what my husband and I needed.

There’s a group in Virginia called Mothers Healing Together.

Lexi Abeln: I facilitate a free support group in Camp Hill, PA called Birthlight.

Birth after Caesarean Support and Information Group in Townsville, Queensland, Australia

Canaustralia.net — Empowering birthing women to make informed decisions about childbirth after caesarean

There’s a yoga studio local to me in Pittsburgh, PA that does a traumatic birth workshop.

Precious sleeping angles – group on Facebook

Stillbirth support – group on Facebook

Resources for men

Grieving fathers – group on Facebook

You can also following the two threads I posted on my Facebook profile page and fan page about this for more information or to contact the individuals above who offer counseling.

Do you have a resource you would like to add to the list? Please include it in the comments.

Induction is wrong, wrong, wrong… wait, what?

I hear all the time how induction in VBAC is contraindicated. This is false. This is the kind of misinformation that materializes when we demonize all induction rather than specifying that elective inductions are not worth the increased risks.

It’s important to use clear, specific language when we talk about birth because there is a lot of confusion among moms, advocates, doulas, and health care providers about VBAC and induction. When I point out the lack of clarity many people have on the topic to “anti-induction advocates” (for the lack of a better term), they respond with the fact that their focus is warning moms about elective inductions, which is absolutely needed. And they genuinely believe that people are aware of the distinction between elective and medically-indicated inductions. However, that has not been my experience, in fact it’s been quite the opposite.  There are many people who don’t understand the why, when, and how of inducing VBACs and that is impacting the abilities of women to make informed decisions and exercise their right of patient autonomy.

First, you can induce VBACs

To be clear, medically indicated induction in a VBAC is not contraindicated! Yet, many, many, many people persist that it is citing ACOG (1) and the Pitocin insert (2). ACOG clearly says in their latest VBAC guidelines (3) that “induction remains an option” in a mom planning a VBAC via Pitocin or Foley catheter. The Pitocin drug insert (2) does state, “Except in unusual circumstances, oxytocin [Pitocin] should not be administered in the following conditions” and then lists “previous major surgery on the cervix or uterus including cesarean section.” However, despite conventional wisdom, a prior cesarean is not listed under the contraindications section.  Further, the drug insert recognizes the value of individualized care:

The decision [to use Pitocin in a woman with a prior cesarean] can be made only by carefully weighing the potential benefits which oxytocin can provide in a given case against rare but definite potential for the drug to produce hypertonicity or tetanic spasm.

This is in line with ACOG’s latest VBAC recommendations (3) where they say, “Respect for patient autonomy supports the concept that patients should be allowed to accept increased levels of risk…” So this is information a woman can use to make an informed decision if she is faced with a medical condition that requires sooner rather than later delivery of her baby, but not necessarily in the next 15 minutes.  To induce, have a cesarean, or wait for spontaneous labor when facing a true medical issue is a decision for the mom to make in conjunction with her supportive heath care provider based on the evidence of her risks, benefits, and options.

My point is, if you just read bits and pieces of the insert, or a few key quotes from an anti-induction article, you are going to miss the full story; much like how reading the full text of a study gives you context and details that you lack by just reading the abstract.  Read my article (4) for more information on inducing VBACs.

Yet, misinformation persists

Ok, so now you know that induction remains an option per the Pitocin insert, ACOG, and respect for patient autonomy.  Now check out these quotes, from the last couple days, from six different people. If I were to keep a list of comments like these, just referring to induction and VBAC for a month, I would literally have dozens if not hundreds.  Misinformation is rampant:

“pitocin is CONTRAINDICATED for vbac bc the risk of uterine rupture”

“I thought it was unsafe to use pitocin with a vbac.”

“vbac should never be induced!”

“It is unsafe for prev surgical births. It says so in the PDR, or at least it did.”

“Not supposed to induce with a VBAC.”

“Never never never have an induction, especially with any kind of vbac!! Oh my goodness. it drastically raises your chances of uterine rupture!! Holy toledo. If you don’t know the risks involved with inductions, especially in vbacs, don’t offer the advice! Smh. Pitocin is completely contraindicated for vbacs, I’m pretty sure it even says that on the insert.”

“Are you actually trying to argue that induction of labour on a VBAC is OK???WOW…that is not evidence based AT ALL. Every study that has been done comparing the two shows a clear rise in risk associated with induction of labour and rupture. I am ALL for choice no matter the case, but I think every women has a right to INFORMED choice and you clearly are not. UNLIKE.”

Note the tone of these comments.  There is no room for negotiation.  Do you get the sense that they are just referring to elective inductions or all inductions? The message I get from these comments is loud and clear: these individuals believe that VBACs should not be induced. Period.

“Well, I would choose an induction…”

What is especially ironic is that some women who speak this way in public, privately share with me, that they themselves would opt for an induction over a repeat cesarean. Though do you see room for that option in any of the comments above?  They preserve that choice for themselves and yet pound the party line that all induction is always wrong and publicly deny that option to other women… for what purpose?  To maintain ad nauseam that induction is an evil, evil thing? Yes, apparently that is the case.

The last person’s comment was in response to me sharing my article (4) and saying that induction with medical indication does and should remain an option for moms planing VBACs.  Her reply equates my actions of sharing this reality with advocating against informed choice. How is keeping women in the dark about their options supporting the notion of informed consent? That faulty logic deserves a capitalized “WOW” with excessive exclamation points.

This is not the first person to say something like this to me. People so staunchly (and incorrectly) maintain that VBACs should never be induced because they have been indoctrinated to believe that induction is always wrong, it always introduces more risks.

More risk than what?

But the key question is: More risk than what? That is always what women should ask.

More risk than having a fetal demise before labor, partial placental abruption, or serious uterine infection and remaining pregnant? OK, so let’s say that is the truth.

Then any time any scarred woman has any of those medical conditions as well as those listed in my article (4), and they agree that remaining pregnant has higher risks that delivering the baby, they should have a cesarean, right? Even if vaginal birth remains an option, albeit via an induced labor?  Even if baby needs to be born sooner rather than later, but not necessarily in the next 15 minutes?  Those moms shouldn’t have a choice, they shouldn’t have a say, they should just go straight to cesarean?  How is that preserving choice for women?

Don’t misrepresent the facts

That is what these (extreme) “induction is wrong” proponents don’t understand. Induction has its place, as does every other medical intervention, and if you want to go straight to cesarean, rather than having a medically-indicated induction, fine.

But don’t misrepresent the truth to other women.

Don’t misrepresent what ACOG (1) or the Pitocin insert (2) says.

Don’t misrepresent the risks of Pitocin by listing a mish-mash of complications with no rates.  (How are women to understand the risks if you don’t tell them how frequently those emergencies occur?)

Don’t say things that can be disproved with a single mouse click like inducing VBACs is against evidence based medicine.

Don’t undermine a woman’s legal right to autonomy (5) by perpetuating the myth, that all induction, including when medically indicated, is wrong, wrong, wrong.

Don’t dictate specific actions while withholding facts that would enable women to make their own decisions, even if they are different that what you would prefer.

Medically indicated induction = choice

People don’t appreciate that standing for medically indicated induction is standing for women to have a choice: induction vs. repeat cesarean. Without induction, there is no choice when a valid medical reason presents. By eliminating the option of induction, women are mandated to the increasing risks (6) of repeat cesarean. And yet people who persist in their agenda say things like this to me (naturally, the following was asserted after I shared my article (4) and they didn’t read it),

Does inducing a VBAC increase the chance of rupture??? YES. Does a women, and should a women have the right to choose that irregardless of that FACT??? YES. Is the most important thing informed consent?? I believe it is.

Clear language provides clarity

So if people think that, then they should use clear, unambiguous language like, “Induction remains an option when a medical indication presents” or “Elective induction isn’t worth the increased risks” rather than flat out declaring “pitocin is contraindicated” (false) and claiming that induction in a VBAC is not evidenced based (false) as this very commenter did earlier in the thread. If someone maintains that it should be a woman’s choice, then they should share substantiated facts, context, statistics, and references, not erroneous blanket statements.

Women can make informed decisions only when they are informed

To provide information supports choice and informed consent. To dictate a specific action while misrepresenting the evidence eliminates choice and prohibits informed consent . I do not dictate to other women what they should do (7).

If you read my article (4), you will see that I list the reasons for medically indicated induction as well as provide an extensive review of studies illustrating the increased risk of uterine rupture. I do this rather than simply saying, “the risk of rupture is higher and thus you shouldn’t do it” because providing facts with context puts the choice in the hands of the mom, rather than me (or anyone else) dictating to her what she should do.

Some women will accept that higher rate of rupture in order to have a vaginal birth. Others will choose to accept the risks of a repeat cesarean section. Those are choices for women to make for themselves based on facts, not on misrepresentations of what other women (incorrectly) think is contraindicated.

“Induction is wrong” & patient autonomy

People who advocate that “induction is always wrong” don’t understand the implications of their assertions. By arguing against inductions, which in the minds of many include medically indicated inductions since no distinction is made, they are effectively advocating for more cesareans and against informed consent and patient autonomy. The mission of VBAC Facts is to make hard-to-find, interesting, and pertinent information relative to post-cesarean birth options easily accessible to the people who seek it. I advocate for informed consent and patient autonomy and that is why I share evidence (4) rather than dictating what others should do. I only hope that this reasoning and evidence based position spreads because there are far to many people out there who persist in the inaccurate philosophy that inductions in a VBAC are always wrong even in the face of a valid medical reason. This does not support choice, women, or birth.

I profusely apologize for the excessive underlining in this article, but I think you will agree, that it was absolutely necessary.

Sources

1. Kamel, J. (2010, Jul 21). ACOG issues less restrictive VBAC guidelines. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/21/acog-issues-less-restrictive-vbac-guidelines/

2. JHP Pharmaceuticals LLC. (2012, Sept). Pitocin official FDA information, side effects and uses. Retrieved from Drugs.com: http://www.drugs.com/pro/pitocin.html

3. American College of Obstetricians and Gynecologists. (2010). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology , 116 (2), 450-463. Retrieved from Our Bodies Our Blog: http://www.ourbodiesourblog.org/wp-content/uploads/2010/07/ACOG_guidelines_vbac_2010.pdf

4. Kamel, J. (2012, May 27). Myth: VBACs should never be induced. Retrieved from VBAC Facts: http://vbacfacts.com/2012/05/27/myth-vbacs-should-never-be-induced/

5. Kamel, J. (n.d.). Legal stuff. Retrieved from VBAC Facts: http://vbacfacts.com/category/vbac/legal-stuff

6. Kamel, J. (2012, Dec 9). Why cesareans are a big deal to you, your wife, and your daughter. Retrieved from VBAC Facts: http://vbacfacts.com/2012/12/09/why-cesareans-are-a-big-deal-to-you-your-wife-and-your-daughter/

7. Kamel, J. (2012, Dec 7). Some people think I’m anti-this/ pro-that: My advocacy style. Retrieved from VBAC Facts: http://vbacfacts.com/2012/12/07/some-people-think-im-anti-thispro-that-my-advocacy-style/

 

Why cesareans are a big deal to you, your wife, and your daughter

surgery-surgical-instrumentsI hear a lot, “What’s the big deal about cesareans? What difference does it really make if you have a cesarean?” Of course, if a cesarean is medically necessary, then the benefits outweigh the risks. But in the absence of a medical reason, the risks of cesareans must be carefully considered.

“Once a cesarean, always a cesarean”

If a woman has a cesarean, she is very likely to only have cesareans for future births. This is because while 45% of American women are interested in the option of VBAC (1), 92% have a repeat cesarean (2). Let me say that another way. Only 8% of women with a prior cesarean successfully VBAC.

One might interpret this statistic to mean that planned VBACs often end in a repeat cesarean. However, VBACs are successful about 75% of the time (3-7). The VBAC rate is so low because of the women interested in VBAC, 57% are unable to find a supportive care provider or hospital (1). And I would argue further that even among the women who have a supportive care provider, 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 repeat cesareans are about their birth options even upon admission to the hospital.  There is a fundamental gap in our collective wisdom about post-cesarean birth options.

Cesareans make subsequent pregnancies riskier

What’s the big deal, right? Who cares if you have a cesarean without a medical reason?

Forget about the immediate risks to mom and baby that cesareans impose. Just set that all aside for a moment.  Much of the risk associated with cesareans is delayed.  Most people are not aware of the long term issues that can come with cesareans and how these complications impact the safety of future pregnancies, deliveries, and children.

It is a well-established fact that the more cesareans a woman has, the more risky subsequent pregnancies and labors are regardless if the mom plans a VBAC or a repeat cesarean.  This was discussed at great lengths during the 2010 National Institutes of Health VBAC conference and was one of the reasons why ACOG released their less restrictive VBAC guidelines later that same year.

Many moms chose repeat cesareans because they believe cesareans are the prudent, safest choice. The fact that cesareans, of which over 1,000,000 occur in the USA each year, increases the complication rates of future pregnancies is often not disclosed to women during their VBAC consult.

A four year study looking at up to six cesareans in 30,000 women reported a startling number of complications that increased at a statistically significant rate as the prior number of cesareans increased:

The risks of placenta accreta [which has a maternal mortality of 7% and hysterectomy risk of 71%], cystotomy [surgical incision of the urinary bladder], bowel injury, ureteral injury [damage to the ureters – the tubes that connect the kidneys to the bladder in which urine flows – is one of the most serious complications of gynecologic surgery], and ileus [disruption of the normal propulsive gastrointestinal motor activity which can lead to bowel (intestinal) obstructions], the need for postoperative ventilation [this means mom can’t breathe on her own after the surgery], intensive care unit admission [mom is having major complications], hysterectomy, and blood transfusion requiring 4 or more units [mom hemorrhaged], and the duration of operative time [primarily due to adhesions] and hospital stay significantly increased with increasing number of cesarean deliveries (8).

Because the growing likelihood of serious complications that comes with each subsequent cesarean surgery, including uterine rupture, this study concluded,

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 (8).

This is because the risks of placenta accreta and previa in particular increase at a very high rate after multiple cesareans (9).

The largest prospective report of uterine rupture in women without a previous cesarean in a Western country,” concurred:

Ultimately, the best prevention [of uterine rupture] is primary prevention, i.e. reducing the primary caesarean delivery rate. The obstetrician who decides to perform a caesarean has a joint responsibility for the late consequences of that decision, including uterine rupture (10).

“Well, I just plan on having two kids…”

Unfortunately, many women don’t think about these future risks until they are pregnant again. And we all know the great difference between intended and actual family size.

According to the CDC, 49% of American pregnancies are unintentional (11). Thus, these theoretical risks quickly and suddenly become a reality for hundreds of thousands of American women every year. How women birth their current baby has real and well-documented implications and risks for their future pregnancies, children, and health.

VBAC bans and emergency response

In light of these increasing risks, VBAC bans do not make moms safer (12). Hospitals are either prepared for obstetrical complications, like uterine rupture in moms who plan VBACs and placenta accreta, previa, and cesarean hysterectomies among moms who plan repeat cesareans, or they are not. It is hard to understand how hospitals can claim that they are simultaneously capable of an adequate response to cesarean-related complications and yet they are unable or ill-equipped to respond to complications related to vaginal birth after cesarean.  Especially in light of the fact that we know motivated hospitals currently offer VBAC even in the absence of 24/7 anesthesia (13).

A recent Wall Street Journal article discusses how hospitals are trying to create a standard response to obstetrical emergencies:

The CDC is funding programs in a number of states to establish guidelines and protocols for improving safety and preventing injury.  And obstetrics teams are holding drills to train doctors and nurses to rapidly respond to maternal complications. They are using simulated emergencies that include fake blood, robots that mimic physiologic states, and actresses standing in as patients (14).

Because hospitals vary so greatly in their ability to coordinate a expeditious response to urgent situations,

Vivian von Gruenigen, system medical director for women’s health services at Summa Health System in Akron, Ohio, advises that pregnant women discuss personal risks with their doctor and ask hospitals what kind of training delivery teams have to respond in an emergency. ‘People think pregnancy is benign in nature but that isn’t always the case, and women need to be their own advocates,’ Dr. von Gruenigen says.

Impact of VBAC on future births

Counter the increasing risks that come with cesareans to the downstream implications for VBAC. After the first successful VBAC, the future risk of uterine rupture, uterine dehiscence, and other labor related complications significantly decrease (15). Thus, family size must be considered as VBAC is often the safer choice for women planning large families.

Bottom line? I defer to two medical professionals and researchers:

“There is a major misperception that TOLAC [trial of labor after cesarean] is extremely risky” – Mona Lydon-Rochelle PhD, MPH, MS, CNM (16-17).

In terms of VBAC, “your risk is really, really quite low” – George Macones MD, MSCE (16-17).

Women deserve the facts

Women are entitled to accurate, honest data explained in a clear, easy to understand format (18). They don’t deserve to have the risks exaggerated by an OB who wishes to coerce them into a repeat cesarean nor do they deserve to have risks sugar-coated or minimized by a midwife or birth advocate who may not understand the facts or whose zealous desire for everyone to VBAC clouds their judgement (19-20).

If you would like to get the opinions of actual VBAC supportive medical professionals who support a woman’s right to informed consent, there are several obstetricians and midwives who you can talk to on the VBAC Facts Community.

Take home message

Cesareans are not benign and the more you have, the more risky your future pregnancies become regardless of your preferred mode of delivery.

Almost half of the pregnancies in America are unintentional.

If hospitals can attend to cesarean-related complications, they can attend to VBAC-related complications.

_________________________________________________

1. Declercq, E. R., & Sakala, C. (2006). Listening to Mothers II: Reports of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection. Retrieved from Childbirth Connection: http://www.childbirthconnection.org/article.asp?ck=10068

2. Osterman, M. J., Martin, J. A., Mathews, T. J., & Hamilton, B. E. (2011, July 27). Expanded Data From the New Birth Certificate, 2008. Retrieved from CDC: National Vital Statistics Reports: http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_07.pdf

3. Coassolo, K. M., Stamilio, D. M., Pare, E., Peipert, J. F., Stevens, E., Nelson, D., et al. (2005). Safety and Efficacy of Vaginal Birth After Cesarean Attempts at or Beyond 40 Weeks Gestation. Obstetrics & Gynecology, 106, 700-6.

4. Huang, W. H., Nakashima, D. K., Rumney, P. J., Keegan, K. A., & Chan, K. (2002). Interdelivery Interval and the Success of Vaginal Birth After Cesarean Delivery. Obstetrics & Gynecology, 99, 41-44.

5. 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.

6. Landon, M. B., Spong, C. Y., & Tom, E. (2006). Risk of Uterine Rupture With a Trial of Labor in Women with Multiple and Single Prior Cesarean Delivery. Obstetrics & Gynecology, 108, 12-20.

7. Macones, G. A., Cahill, A., Pare, E., Stamilio, D. M., Ratcliffe, S., Stevens, E., et al. (2005). Obstetric outcomes in women with two prior cesarean deliveries: Is vaginal birth after cesarean delivery a viable option? American Journal of Obstetrics and Gynecology, 192, 1223-9.

8. Silver, R. M., Landon, M. B., Rouse, D. J., & Leveno, K. J. (2006). Maternal Morbidity Associated with Multiple Repeat Cesarean Deliveries. Obstetrics & Gynecology, 107, 1226-32.

9. Kamel, J. (2012, Mar 30). Placenta problems in VBAMC/ after multiple repeat cesareans. Retrieved from VBAC Facts: http://vbacfacts.com/2012/03/30/placenta-problems-in-vbamc-after-multiple-repeat-cesareans/

10. 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

11. National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. (2012, Apr 4). Unintended Pregnancy Prevention. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/index.htm

12. Kamel, J. (2012, Mar 27). Just kicking the can of risk down the road. Retrieved from VBAC Facts: http://vbacfacts.com/2012/03/27/just-kicking-the-can-of-risk-down-the-road/

13. Kamel, J. (2010, July 22). VBAC ban rationale is irrational. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/22/vbac-ban-rationale-is-irrational/

14.  Landro, L. (2012, Dec 10). Steep Rise Of Complications In Childbirth Spurs Action. Retrieved from Wall Street Journal: http://online.wsj.com/article/SB10001424127887324339204578171531475181260.html?mod=rss_Health

15. Mercer BM, Gilbert S, Landon MB. et al. Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstet Gynecol. 2008 Feb;111(2):285-291. Retrieved from: http://journals.lww.com/greenjournal/Fulltext/2008/02000/Labor_Outcomes_With_Increasing_Number_of_Prior.6.aspx

16. NIH Consensus Development Conference. (2010). Vaginal Birth After Cesarean: New Insights. Bethesda, Maryland. Retrieved from http://consensus.nih.gov/2010/vbac.htm

17. Kamel, J. (2012, Apr 11). The best compilation of VBAC research to date. Retrieved from VBAC Facts: http://vbacfacts.com/2012/04/11/best-compilation-of-vbac-research-to-date/

18. Kamel, J. (2012, Dec 7). Some people think I’m anti-this/ pro-that: My advocacy style. Retrieved from VBAC Facts: http://vbacfacts.com/2012/12/07/some-people-think-im-anti-thispro-that-my-advocacy-style/

19. Kamel, J. (n.d.). Birth myths. Retrieved from VBAC Facts: http://vbacfacts.com/category/vbac/birth-myths

20. Kamel, J. (n.d.). Scare tactics. Retrieved from VBAC Facts: http://vbacfacts.com/category/vbac/scare-tactics/

When all people can see is black or white

The way I do things

VBAC Facts communicates differently than many others who speak or write about birth. Rather than advocating for a specific decision, I advocate for access to information. Specifically, the mission of VBAC Facts is to close the gap between what the best practice guidelines from ACOG and the NIH say about VBAC and repeat cesarean and what people generally believe.

In meeting this goal, VBAC Facts makes hard-to-find, interesting, and pertinent information relative to post-cesarean birth options easily accessible to the people who seek it. VBAC Facts does not advocate for a specific mode of delivery, birth attendant or birth location. Because of this stance, sometimes people are a little confused. They are accustomed to outspoken advocates (arguing for either the pro or con) urging them to have a certain type of birth at a prescribed location with a specific type of birth attendant – or none at all.

VBAC Facts is occasionally labeled as pro-this/ anti-that because I periodically will not agree with someone. If someone supplies incorrect statistics, uses faulty logic, or uses the dreaded terms “always/never,” I pipe up and give my perspective and a source corroborating my stance.  You may (or may not) be surprised how often this interjection is interpreted as anti- or pro-[insert method of birth, place of birth or type of birth attendant here.]

Perhaps people interpret my realistic/ practical approach to things as anti-_________.  I like to debunk myths. I like to question the conventional wisdom. This can frustrate people because these myths give them (misplaced) confidence. Conventional wisdom can be confused for evidence because “everyone knows _____ is true.”

I acknowledge the various risks and benefits that come with our birth choices. I do this because I think that women are intelligent enough to hear “these are the risks and benefits of XYZ” rather me dictating “make XYZ choice.”

I also tend to avoid the often hollow sounding, “It will all be fine” or “I had a VBAC, so should every woman!”  To some people, that comes off as anti-this/pro-that… but for me, it’s a fair look at our choices.

I think sometimes people start to look at a specific mode of birth/ birth location/ type of birth attendant with rose-colored glasses.  They try to minimize the risks associated with their “choice of choice” in an attempt to advocate for others to make similar decisions whether that is VBAC, repeat cesarean, home or hospital birth.  (Everyone has an agenda!!)

But minimizing risks deprives women of their right to informed consent and that is really no different than individuals who exaggerate risk. I don’t advocate for women to birth a certain way in a certain location.

A big part of my philosophy is based on the fact that I have a website and a large readership.  I don’t want anyone to ever come back to me after a bad outcome and say, “You misled me.”  I feel an obligation to be honest and truthful about the pros and cons of options as well as the quality and quantity of research available to us.  Women often feel misled by their HCPs [health care providers].  I don’t want to be part of that misinformation machine.

My mission is simple: to make hard-to-find, interesting, and pertinent information relative to post-cesarean birth options easily accessible to the people who seek it.

I do this because I think the information speaks for itself.  It doesn’t need a cheerleader!  It doesn’t need someone to stretch the truth!  Just someone to say, “Read this!”

My tips for birth advocates

Someone recently posted in a group asking how they can get involved with birth advocacy. Other members and myself directed them to a variety of organizations like ICAN, Improving Birth, the National Advocates for Pregnant Women, the ACLU, and Human Rights in Childbirth.

There are many roads to the same destination. You can advocate right now by going on message boards and simply pointing people to accurate information when they ask questions. Sometimes all they need is to see a little bit that suggests what they have accepted as “truth” is the opposite of what major medical organizations, public health professionals, and medical researchers support and recommend.

Take home message

I have said many times, “Birth is not one size fits all.” As ACOG says, two women can look at the exact same information and make very different choices. There is not a Right or Wrong decision for all women, just a right or wrong decision for a specific woman. That is her decision to make based on information, not bullying or hysteria.

 

Evening primrose oil: “Don’t use it if you are pregnant?”

Many moms and midwives use evening primrose oil (EPO) for cervical ripening. So I was absolutely shocked at the complete lack of evidence on the effectiveness and safety of EPO use among pregnant women.

There are only two studies that examine the oral use EPO and its ability to ripen the cervix during pregnancy.  There are no studies on the vaginal use of EPO. In short, there is insufficient clinical evidence documenting the risks and benefits of EPO and without that information,  the question is, should pregnant women take it?

The available evidence on EPO

Paula Senner gives an excellent review of the first study (Dove 1999) in her Quantitative Research Proposal entitled, “Oral Evening Primrose Oil as a Cervical Ripening Agent in Low Risk Nulliparous Women” (emphasis mine),

The study group consisted of 54 women who took oral evening primrose oil in their pregnancy (500 mg three times a day starting at 37 weeks gestation for the first week of treatment, followed by 500 mg once a day until labor ensued), and the control group was composed of 54 women who did not take anything. Antepartum and intrapartum records of all women were reviewed focusing on the above identified criteria.

Results showed no significant differences between the evening primrose oil group and the control group on age, Apgar score, or days of gestation (P>.05)… This retrospective chart review showed no benefit from taking oral evening primrose oil for the purpose of reducing adverse labor outcomes or for reduction of length of labor.

The study’s abstract gives us more details on the its findings (emphasis mine):

Findings suggest that the oral administration of evening primrose oil from the 37th gestational week until birth does not shorten gestation or decrease the overall length of labor. Further, the use of orally administered evening primrose oil may be associated with an increase in the incidence of prolonged rupture of membranes, oxytocin [Pitocin] augmentation, arrest of descent, and vacuum extraction.

The second study found that while women who took EPO experienced a greater degree of cervical ripening, that did not result in a shorter pregnancy or labor: “There was no significant difference in the interval from onset or end of treatment to onset of labor between the two groups” (Ty-Torredes, 2006).

So one study on oral EPO found that it doesn’t work as we thought it did and it offers considerable risks.  The other study found that it does result in some cervical ripening, but that did not translate into shorter pregnancies or labors.

As a result, a December 2009 article published in the American Family Physician recommended,

The use of evening primrose oil during pregnancy is not supported in the literature and should be avoided.

Medline Plus, a website published by the US National Library of Medicine and the National Institutes of Health, published an April 2012 article on EPO.  Medline echoes the sentiments of the American Family Physician article when it said there was,

insufficient evidence to rate effectiveness for [EPO during pregnancy and] research to date suggests that taking evening primrose oil doesn’t seem to shorten labor, prevent high blood pressure (pre-eclampsia), or prevent late deliveries in pregnant women… [Further,] taking evening primrose oil is POSSIBLY UNSAFE [their emphasis] during pregnancy.  It might increase the chance of having complications. Don’t use it if you are pregnant [emphasis mine.]

Bleeding issues could complicate cesareans

Research on the use of EPO for other aliments among non-pregnant people has suggested there could be a possible association between the use of EPO and bleeding problems during surgery.

As a result, Medline recommends that people don’t use it at least 2 weeks before a scheduled surgery.

This poses a special problem for women using EPO during the last weeks of pregnancy. Since we cannot predict who will have a vaginal birth and who will have a cesarean, it is important to consider that EPO could contribute to hemorrhage during a cesarean and possibly even during a normal vaginal delivery.

We just don’t know because there is a lack of data.

Dosages and mode of delivery

Another hole in the research and our knowledge relates to dosage.

I see women reporting an incredible range of dosages on the internet. What is safe?

There are no clinical studies documenting how much women should take. Maybe X dose of EPO is good, but Y dose introduces XYZ risks.

How long should women take EPO? The last month of pregnancy? The last two weeks?  (Remember, we just read how there is a possible bleeding issue.)

Should they take it twice a day or once a day? Does the body absorb or metabolize EPO differently if it is administrated vaginally or orally?

We just don’t know the answers to these questions.

What about our bodies’ innate ability to birth?

It comes down to the fundamental question: Do our bodies need something to help us go into labor?

Many natural birth advocates reject the routine use of Pitocin augmentation during labor because they say our bodies know how to birth. Yet it’s often women from this same mindset that use EPO.

Either pregnant people as a whole need something to help them go into labor – whether that is EPO or Pitocin – or they don’t.

Are we less leery of EPO because it comes from a flower? Because it’s not produced by “big pharma?”

Because midwives suggest it more than OBs?

Because we can purchase it over the counter? Because it’s a pill, not an injection? Because we can administer it to ourselves in the comfort of our home?

Because it is used so routinely that no one questions it? Or is it simply because we all assume since everyone takes it, the evidence must be on the side of EPO?

On (the lack of) evidence: Holding ourselves to the same standard

When I have shared the lack of evidence on EPO’s ability to ripen cervi or prepare a woman’s body for labor, sometimes women reply with “But there is no evidence to suggest it won’t help either.”

American OBs used this same rationale when they induced scarred moms with Cytotec in the 1990s. There were no published medical studies on Cytotec induction in scarred women, so we didn’t know the risks and benefits. But people used it because we knew it caused uterine contractions. What can go wrong, right?

But the problem is, when there is a lack of clinical evidence on large populations of women, we are sometimes surprised with dire outcomes that no one could have predicted as was the case of Cytotec.

We cannot look back at that period and think, “How could they have done that” when we are now doing the same thing with EPO: using a chemical without evidence of its benefits and harms.

Some rail against “the medical system” because Pitocin/ultrasound/etc hasn’t been “proven safe,” yet we use EPO with no evidence that it does what we think it does, no evidence that it is safe, and the limited evidence we do have says that it’s associated with a variety of complications.

As Hilary Gerber D.O. aka Mom’s Tin Foil Hat says,

As someone who spent many years in the natural supplements industry, I agree that we need to hold natural products to the same scrutiny.

Also, most EPO is extracted with solvents like hexane. I am much more supportive of natural products or interventions that have been used in that form or method for generations (e.g. sexual intercourse at term, ingesting a substance that is a common food item, etc) than a chemically extracted, concentrated, unstudied substance.

Anecdote vs. evidence

OBs who used Cytotec on women with a prior cesarean in the 1990s inevitably would have said, “I haven’t had a bad outcome yet,” and I suspect that many people who use EPO now would say the same thing.

When we have one woman who used EPO and had an arrest of descent, do care providers recognize that this could be as a result of the EPO?

When we have one women who used EPO and it worked as expected, how can we determine her labor progressed because of the EPO?

When you have a small sample size, it’s hard to make a connection.  It’s even more difficult to connect EPO to it’s possible list of complications when not many care providers are aware of the lack of evidence on EPO and the findings of this one lone study.

Is our limited experience, with relatively few patients, without meticulous record keeping that can detect patterns across groups of patients, sufficient evidence?  I don’t think so.

We would likely need thousands of women in order to create a sample size powerful enough to detect – or rule out – common and more rare EPO complications in addition to answering the many questions I posed above.

Take away message

I’m not saying to use EPO or not.

I’m simply pointing out how little we know about this commonly used substance and questioning if that should make a difference in how we view and/or use it.

There is limited evidence on EPO’s ability to ripen the cervix and aid with labor.  We have two studies on the oral use of EPO that looked at this question and none on the vaginal use of EPO among pregnant women.

One study found that EPO doesn’t ripen the cervix and poses considerable risk.  Another study found that EPO does ripen the cervix but those women did not go into labor sooner than the women that didn’t take EPO.

We have no evidence on an appropriate or safe dosage (if that exists).

We have no evidence on the risks and benefits of oral vs vaginal administration.

In order to make the association between EPO and complications, care providers need to be aware of the complications with which EPO may be associated.

We need more large studies to confirm or refute the notion that EPO = ripen cervix = shorter pregnancies. Without that information, we are using a product that we know very little about.

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Bayles, B., & Usatine, R. (2009, Dec 15). Evening Primrose Oil. American Family Physician, 80(12), 1405-1408. Retrieved from http://www.aafp.org/afp/2009/1215/p1405.html

Dove, D., & Johnson, P. (1999, May-Jun). Oral evening primrose oil: its effect on length of pregnancy and selected intrapartum outcomes in low-risk nulliparous women. Journal of Nurse-Midwifery, 44(3), 320-4. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10380450

Gerber, H. (2012, November 13). Facebook comments on evening primrose oil.

McFarlin, B. L., Gibson, M. H., O’Rear, J., & Harman, P. (1999, May-Jun). A national survey of herbal preparation use by nurse-midwives for labor stimulation. Review of the literature and recommendations for practice. Journal of Nurse Midwifery, 44(3), 205-16. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10380441

Medline Plus. (2012, Apr 10). Evening primrose oil. Retrieved from Medline Plus: A service of the U.S. National Library of Medicine & National Institutes of Health: http://www.nlm.nih.gov/medlineplus/druginfo/natural/1006.html

Senner, Paula. (2003, December). Oral Evening Primrose Oil as a Cervical Ripening Agent in Low Risk Nulliparous Women. Retrieved from Frontier School of Midwifery and Family Nursing, Philadelphia University: http://www.instituteofmidwifery.org/MSFinalProj.nsf/a9ee58d7a82396768525684f0056be8d/f44c26c0836acbb585256dd1006b2a22?OpenDocument

Ty-Torredes, K. A. (2006). The effect of oral evening primrose oil on bishop score and cervical length among term gravidas. AJOG, 195(6), S30. Retrieved from http://www.ajog.org/article/S0002-9378%2806%2901323-8/fulltext

Wagner, Marsden. (1999). Misoprostol (Cytotec) for Labor Induction: A Cautionary Tale. Retrieved from Midwifery Today: http://www.midwiferytoday.com/articles/cytotecwagner.asp

Thoughts on VBA3+C (VBAC after three or more prior cesareans)

Note regarding “TOLAC.”  When reading from medical texts, remember that you are no longer in the land of emotion and warm fuzzies.  Rather, envision that you have been transported to another world, a clinical world, where terms like TOLAC/TOLAMC, or trial of labor after (multiple) cesareans, are used.  I don’t think that most care providers understand the emotional sting that many women seeking VBAC associate with the term TOLAC.  It’s important for women to understand the language care providers use so that they can translate TOLAC into “planning a VBAC” and not feel slighted.  You might want to read this article which describes what the term TOLAC means, how it’s used in medical research, and why it’s not synonymous with VBAC.

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A mom recently asked, “Does anyone have some facts on VBA3C?”

I provided this collection of info…

Who makes a good VBAC/VBAMC candidate?

ACOG’s 2010 VBAC recommendations affirm that VBA2C (vaginal birth after two cesareans) is reasonable in “some” women.  But they remain silent on VBAMC (VBAC after multiple cesareans.)

Some have interpreted that silence to mean that ACOG does not recommend VBAMC, yet ACOG is clear that women shouldn’t be forced to have cesareans.

Between what they say about VBA2C and who is a good VBAC candidate, we might be able to discern who might be a good VBAMC candidate.

A couple things to keep in mind while reading…

Reason for prior cesarean/history of vaginal birth.  Research has shown that women who have had cesareans for malpresentation (breech, transverse lie, etc) and/or a history of a prior vaginal delivery would have the highest VBAMC success rates.

Scar type.  Low transverse incisions (also called bikini cuts) carry the lowest risk of rupture in comparison to classical, high vertical and T/J incisions.  With the likely increased risk of uterine rupture in a VBAMC, having low transverse scars is a way to minimize that risk as much as possible.

What does ACOG say about VBAC?

In ACOG’s 2010 VBAC guidelines, it describes the qualities of a good VBAC candidate:

The preponderance of evidence suggests that most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about VBAC and offered TOLAC.  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.  Individual circumstances must be considered in all cases, and if, for example, a patient who may not otherwise be a candidate for TOLAC presents in advanced labor, the patient and her health care providers may judge it best to proceed with TOLAC.

What does ACOG say about VBA2C?

In those same guidelines, ACOG specifically addresses VBA2C:

Given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC, and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC.  Data regarding the risk for women undergoing TOLAC with more than two previous cesarean deliveries are limited (69).

The power of context and training

How a provider approaches VBAMC depends a lot on their training as well as the support of their hospital administration. In the video below, Dr. Craig Klose discusses the merits of vaginal birth after cesarean and the various factors that may impede women obtaining VBAC.

One thing that stood out to me was Dr. Klose’s comments on VBAC after multiple prior low transverse cesareans (TLC). To sum, he says that he was taught that multiple LTCs were “no biggie” and he has attended up to VBA5C. This is the power of training and context!

ACOG guidelines, your legal rights, and “forced” cesareans

As attorney Lisa Pratt asserts, “ACOG guidelines are just that, guidelines, they are not law; while it is nice when they put out a guideline that supports your factual situation, falling outside of their recommendation does not mean you must consent to something you do not want.”  You can read in the article, “VBAC bans, exercising your rights, and when to contact an attorney.”

Further, ACOG’s 2010 VBAC guidelines also says that women cannot be forced to have cesareans even if there is a VBAC ban in place:

Respect for patient autonomy also argues that even if a center does not offer TOLAC, such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery.

You may also wish to review your options when encountering a VBAC ban and the story of a mom seeking VBA2C who was threatened with a “forced” cesarean when her OB group withdrew support at 38 weeks.

Making a plan and moving forward

Your best bet is to review your medical records with several VBAC supportive care providers and get their opinion.  Obtain a copy of your medical records and operative reports from each prior cesarean, get the names of VBAC supportive providers, and ask the right questions.

If you want to get up to speed quick on VBAC, repeat cesarean, hospital birth, home birth, and VBAC bans, the best way is via my online program, “The Truth About VBAC.”

Emotional healing from traumatic births

When I posted this on Facebook, I was surprise how many women felt alone with their emotions. I decided to share this via the website so women will know they are not alone on this journey.

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Here at VBAC Facts, I focus primarily on facts, research, and logic. But as any mom preparing for birth can tell you, information is only part of the equation. Knowing the facts is important, but it’s not the whole enchilada.

Many women are carrying the emotional baggage of their traumatic vaginal or cesarean births. How we feel about our past pregnancies and deliveries influences our outlook for our future labors. This unprocessed anger and disappointment can negatively impact how future births unfold.

I interact with post-cesarean women on a daily basis and can personally attest to how important this work is. Women often feel betrayed and lied to by the medical establishment while simultaneously wondering if their bodies are broken and incapable of birth. Without trust in our care providers and confidence in our bodies, how can we birth?

At the 2012 VBAC Summit, Christy Farr of Seeds and Weeds Coaching offered practical and easy first steps for identifying and rectifying these emotional roadblocks.

For women who care to dig a little deeper, working within a compassionate, direct, and supportive framework like Christy’s can help free them from their past and pave the way to an unhindered birth.

Connect with Christy via her website or Facebook.

Get a flavor for how Christy communicates via her session, “Towards Healing: Unpacking the Baggage of a Traumatic Birth” which is available for download.

VBAC bans, exercising your rights, and when to contact an attorney

legal-gavel-booksA mom recently left this comment and I thought many other women likely have the same question. Keep in mind that this article does discuss America law which may not be applicable to other countries.

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Jen,

First thank you for your site!

I’m under the care of an OB who practices at a hospital that does not “allow VBACs” but has stated the only way to deliver at said hospital is to show up in labor & pushing.

Quoting from your site quoting the ACOG bulletin:

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.

If a patient (Me 3 prior sections), presents one’s self in labor at said hospital and declines a section, the hospital then has to heed the wishes of the patient? Am I understanding this correctly? Does the hospital have the right to stop contractions and section the patient? This is what I’m hearing in my birthing community and I really cannot believe a hospital would/could do that.

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Hi Thia!

Many women believe that all one must do to prevent an unwanted cesarean is declare, “I do not consent!” While technically true, you are entitled to control what happens to your body, the reality is, it often doesn’t play out that way. A hospital does not have a legal right to perform a cesarean on you without your consent. However, it still happens either by coercion or lies and even more rarely, by court order.

I think part of the problem is, many women are not familiar with ACOG’s guidelines. As a result, they don’t understand what ACOG recommends and discourages. (For example, many women believe that VBACs should never be induced. That is false.) Women frequently take their OB’s word as the truth. However, ACOG’s recommendations are often obscured by unsupportive care providers to mimic what the care provider wants the mom to think ACOG says. In other words, unsupportive care providers want moms to think that their options are limited per ACOG and that is just not the case.

The fact that you are doing your research gives you a massive advantage over women who just take their OB’s word for it. I highly recommend you review the article I wrote about a mom who was threatened with a forced cesarean after her OB withdrew support of her planned VBA2C at 37 weeks. It includes legal and media contacts. Through the help of the ACLU, ACLU Women’s Rights Project, National Birth Policy Coalition, and National Advocates for Pregnant Women, the mom was granted a trial of labor. I use the (demonized) term TOL because the mom ultimately did have a medically necessary cesarean during labor due to a placental abruption. However, the mom was still happy that she had the opportunity to labor.

That is as much as I can say as a non-attorney. I consulted with the brilliant Lisa Pratt who is an attorney specializing in the legal issues that uniquely affect women during pregnancy and childbirth. She said,

This answer is true for all women, not just this one. If she needs legal advice specific for her situation then she should consult an attorney. You have the right to refuse any treatment you do not want. I am sure that what she is hearing is the same horror stories that we hear of a mom being harassed by the doctor and staff to consent to a c/s or threatening to seek a court order or call CPS. I know this is a scary thought to have to deal with any of these scenarios, but fear of something happening should not keep you from exerting your legal rights, unless you really are okay with what you are consenting to. You cannot assume that the staff is not going to honor your refusal. They are people just like us, some are jerks and some are ethical and will follow your refusal, but you won’t know what you are dealing with until you are in the moment. ACOG guidelines are just that, guidelines, they are not law; while it is nice when they put out a guideline that supports your factual situation, falling outside of their recommendation does not mean you must consent to something you do not want.

You can learn more about Lisa, and schedule a phone consultation if you have further questions, via her website.

Lisa presented at the 2012 VBAC Summit in Miami. Her session, “A Legal Guide to VBAC,” is available for download.

Warmly,

Jen

Does the term “TOLAC” tweak you?

On the acronym TOLAC (trial of labor after cesarean)….

Some studies break out statistics in four ways.

1. ERCS/D (elective repeat cesarean section/ delivery)
2. VBAC (vaginal birth after cesarean)
3. CBAC (cesarean birth after cesarean aka cesarean after planned VBAC)
4. TOLAC (VBAC + CBAC stats)

Because we are unable to predict who will have a VBAC or CBAC, the TOLAC stat enables us to review outcomes from a variety of angles:

  • TOLAC vs. ERCS
  • VBAC vs. ERCS
  • CBAC vs. ERCS

Some women find the TOLAC acronym offensive, because it implies “trying,” so practitioners sensitive to this may way to use the phrase “planning a VBAC.”   Understanding that TOLAC isn’t a dig at moms, but just a straightforward, objective term that care providers use, can (hopefully) take the sting out of the word.

Remember, your care provider is not your girlfriend.  They use clinical terms because that is the language of their world. They speak like clinicians because they are clinicians. All that said, providers who are aware of how the term TOLAC is received by some women use the term “planned VBAC.”

So moms, you use the language that works for you! Just remember that TOLAC is really more of a clinical term and when your provider uses it, it doesn’t necessarily mean that they are a jerk.  They just may have forgotten to code switch from clinical to sensitive language.

Moms don’t typically say, “I’m so excited for my TOLAC!” However, if you do, you might make your provider laugh and connect with them on a human level.

Two points for the person who knows how this picture is relevant…

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New VBAC documentary “Trial of Labor”

trial-of-labor-documentary

I’m so excited for the latest VBAC documentary, “Trial of Labor,” to come out!

One of the filmmakers, Robert Humphreys, attended a class I taught in Los Angeles in March 2010 so I feel a special connection to this project which has ICAN’s stamp of approval.

There is still time for you to help bring this important movie and topic to the public.  Mr. Humphreys, together with Dr. Elliot Berlin, a popular Los Angeles chiropractor, are looking to raise the last of the funds required to complete this movie.  You can contribute as little as a dollar.  As I write this, they have raised over half of their goal.  This pledge drive will continue until Friday August 24, 2012 12:00am EDT.

We need to counter the incorrect conventional wisdom that VBACs are excessively risky and cesareans are the only prudent choice.  We need to clarify that both VBACs and cesareans have REAL benefits and REAL risks.   We need to reinforce the idea that it should be up to each mom to evaluate those risks and benefits to herself, her baby, as well as her future fertility, pregnancies, mode of delivery options, and long term health.  We need to share the American Congress of Obstetricians and Gynecologists’ latest VBAC guidelines as well as the documents and lectures from the 2010 National Institutes of Health VBAC Conference.  It’s only through education will women be able to make an informed choice.

You can also help spread the word by liking the “Trial of Labor” fan page on Facebook and blogging about the movie!

False comparison: Fatal car accidents and VBAC

RETRACTION/ CORRECTION: I originally posted this article challenging the thought that you are more likely to die in a fatal car accident than during a VBAC.  I tried to crunch the numbers in the way that I felt most accurate.  However, it has been bugging me ever since because there is no accurate way to compare these two events and I should have emphasized that more. We can accurately and fairly compare the risks of VBAC to the risks of a repeat cesarean or the risks of a first time time mom.  However, it is a misleading to compare the risks of birth to non-birth events because they are to different.  While I did discuss this at great length at the end of this article, the title I originally chose (Myth: Mom more likely to die in car accident than VBAC) just continued to feed this false comparison.  I have since updated the article and title.  I apologize for any confusion I caused.

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On fatal car accident statistics: There are many, many variables that factor into an individual’s risk of dying in a car accident.  The most accurate way to calculate your risk is by miles driven.  To learn more, please refer to the National Motorists Association’s document “Understanding Highway Crash Data.” I use the figures below in order to get an average rate for the purpose of discussion.

On terminology: Read why I use the term TOLAC.

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Prepare yourself for yet another installation to the Birth Myth series.  I’ve heard this sentiment many times over the years and I’m sure you have too.   The well-meaning people who share this “statistic” simply desire to give moms seeking information on VBAC some encouragement:

If your husband is worried about you dying during a VBAC, tell him you are four times more likely to die in a car accident on your way home from work today.  Sorry if that sounds morbid, but the odds of the mother dying in a VBAC are truly minuscule.

Another article (filled with inaccurate statements, contradictions, and oodles of statistics without sources) recently making the rounds on Facebook says one of the risks of hospital birth is the 1:10,000 risk of a fatal car accident on the way to the hospital.

While these statements are very comforting, as birth myths tend to be, they are false comparisons.  We can accurately and fairly compare the risks of a TOLAC to the risks of a repeat cesarean or the risks of a first time time.  However, it is a misleading to compare the risks of birth to non-birth events.

Comparing unlike risks

Many birth advocates try to weigh the event of uterine rupture against other life events in an attempt to give context, but this is a misleading and inaccurate comparison.  Andrew Pleasant in his article entitled, Communicating statistics and risk, explains:

Try not to compare unlike risks.  For instance, the all-too-often-used comparison ‘you’re more likely to be hit by a bus / have a road accident than to…’ will generally fail to inform people about the risks they are facing because the situations being compared are so different.  When people assess risks and make decisions, they usually consider how much control they have over the risk.  Driving is a voluntary risk that people feel (correctly or not) that they can control.  This is distinctly different from an invisible contamination of a food product or being bitten by a malaria-carrying mosquito.

Comparing the risk of a non-communicable disease, for example diabetes or heart disease, to a communicable disease like HIV/AIDS or leprosy, is similarly inappropriate.  The mechanisms of the diseases are different, and the varying social and cultural views of each makes the comparison a risky communication strategy.

Take away message: Compare different risks sparingly and with great caution because you cannot control how your audiences will interpret your use of metaphor.

Comparing lifetime/annual risk to your risk of something happening over a day (or two)

Your annual or lifetime risk of something happening will often be higher than your risk of a birth related complication.  But this is because the annual risk of something measures your risk for 365 days.  The lifetime risk of something is often based on 80 years.  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 day over 365 days or 80 years is unfair and confusing.

Look at something like your lifetime risk of breast cancer which is often quoted as 1 in 8.  So one could easily say, “Hey, I have a greater risk of breast cancer over my lifetime than I do have a uterine rupture!”  But, let’s look at this a bit more:

Again, I refer to Andrew Pleasant’s article, Communicating statistics and risk:

An oft-reported estimate is the lifetime breast cancer rate among women. This rate varies around the world from roughly three per cent to over 14 per cent.

In the United States, 12.7 per cent of women will develop breast cancer at some point in their lives. This statistic is often reported as, “one in eight women will get breast cancer”. But many readers will not understand their actual risk from this. For example, over 80 per cent of American women mistakenly believe that one in eight women will be diagnosed with breast cancer each year.

Using the statistic ‘one in eight’ makes a strong headline but can dramatically misrepresent individual breast cancer risk.

Throughout her life, a woman’s actual risk of breast cancer varies for many reasons, and is rarely ever actually one in eight. For instance, in the United States 0.43 per cent of women aged 30–39 (1 in 233) are diagnosed with breast cancer. In women aged 60–69, the rate is 3.65 per cent (1 in 27).

Journalists may report only the aggregate lifetime risk of one in eight because they are short of space. But such reporting incorrectly assumes that readers are uninterested in, or can’t comprehend, the underlying statistics. It is critically important to find a way, through words or graphics, to report as complete a picture as possible.

Take away message: Be extra careful to ensure your readers understand that a general population estimate of risk, exposure or probability may not accurately describe individual situations. Also, provide the important information that explains variation in individual risk. This might include age, diet, literacy level, location, education level, income, race and ethnicity, and a host of other genetic and lifestyle factors.

To compare events that are so different like the risk of a fatal car accident and the risk of TOL maternal mortality is inaccurate and doesn’t help moms understand their options.  Your risk of a car accident depends on how much you drive, when you drive, if you are distracted or on medication, etc, etc, etc.  The variables that impact your risk of dying during a  TOLAC are very different.  However, one way these two events are similar:  Sometimes we can make all the “right” or “wrong” decisions and the element of luck will sway us towards a good or bad outcome.

The problems with birth myths and false comparisons

False comparisons and birth myths like this are shared with the best of intentions.  So often the risks of VBAC are exaggerated for reasons having nothing to do with the health of baby and mom.  Birth advocates share these myths (which they believe to be true) as a way of boosting the morale of moms seeking VBAC as these moms are constantly faced with a barrage of unsupportive comments from family, friends, and even care providers.

The problem is, women make plans to have (home) VBAC/VBAMC based on these myths.  They make these plans because birth myths make the risk of VBAC, uterine rupture, infant death, and maternal death look practically non-existent.  That is dangerous.

Perpetuating these myths impedes a mom’s ability to provide true informed consent.  If a mom thinks her risk of uterine rupture is similar to a unscarred mom or a unscarred, induced mom, or less than her risk of getting struck by lighting or bitten by a shark, she does not have accurate picture of the risk.  And if she doesn’t understand the risks and benefits of her options, she is unable to give informed consent or make an informed decision.

Birth advocates get all up in arms about the mom who plans an elective, primary cesarean section without “doing her research.”  Or the mom who consents to an induction at 38 weeks because her OB “said it was for the best.”  Or when an OB coerces a mom into a repeat cesarean by saying the risk of uterine rupture is 15%.  Shouldn’t we be just as frustrated when moms plan (home) VBACs based on misrepresentations of the truth?  Shouldn’t we hold ourselves to the same standard that we expect from others?

The second problem with perpetuating these false comparisons and myths is that once women learn the true risks, they seem gigantic in comparison to the minuscule risk they had once accepted.  Now VBAC seems excessively risky and some loose confidence in their birth plans.  Birth advocates do not support moms by knowingly perpetuating these myths.  The reality is, the risks of VBAC are low.  We don’t need to exaggerate or minimize the benefits or risks of VBAC.  If we just provided women with accurate information from the get go, they would be able to make a true, informed decision.

The third problem is that we really look dumb when we say stuff like this.  If we want to be taken seriously, we really need to double check what we pass on.  I encourage you to ask for a source when someone says something that sounds to good to be true or just plain fishy.  (And hold me to the same standard!)  I often ask people for a source for their assertions… with varying results.

Sometimes people have a credible source available and share it with me.  I learn more and it’s all good.  Other times, people get angry.  They think I’m challenging them or trying to argue with them.  But the truth is, I’m just trying to learn. What I have found is, when people get angry, it’s sometimes because they don’t have a source and they are insulted that I didn’t accept their statement at face value.  They have just accepted what a trusted person told them as the truth and expect me to do the same.

Doesn’t it strike you as odd that some people encourage the continual questioning OBs and the medical system, yet expect you to accept what they say as The Truth no questions asked?   “Question everyone but me.”  Why?  Why is it when we question an OB, that’s a good thing, yet when we hold our birthy friends and colleagues to the same standard, that is being argumentative?  I say, ask for the source.  From everyone.

Take away messages

It is inaccurate and misleading to compare two events that are as different as a fatal car accident and TOL maternal mortality.  Period.

Let’s stop this false comparison and bring us back to what we should be comparing TOLAC/VBAC to: the risks of a repeat cesarean.

When women plan a VBAC based on false information,  their confidence can be shattered when they learn that the risk of uterine rupture and maternal death are much higher than they were lead to believe.

When women plan a VBAC based on false information, they are deprived of their right to informed consent.

While the risk of scar rupture is very different than the risk of a fatal car accident, it is similar to other serious obstetrical emergencies such as placental abruption, cord prolapse, and postpartum hemorrhage.

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Guise J-M, Eden K, Emeis C, Denman MA, Marshall N, Fu R, Janik R, Nygren P, Walker M, McDonagh M. Vaginal Birth After Cesarean: New Insights. Evidence Report/Technology Assessment No.191. (Prepared by the Oregon Health & Science University Evidence-based Practice Center under Contract No. 290-2007-10057-I). AHRQ Publication No. 10-E003. Rockville, MD: Agency for Healthcare Research and Quality. March 2010.   http://www.ahrq.gov/downloads/pub/evidence/pdf/vbacup/vbacup.pdf

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For those who are interested in the reasoning and mathematics from the original article:

But, if we were going to compare the unlike risks of a fatal car accident and TOLAC, this is how I would do it: compare the daily risks of the events.

Maternal death and TOL

Per the report presented at the 2010 NIH VBAC conference entitled Vaginal Birth After Cesarean: New Insights (Guise, 2010):

Overall rates of maternal harms were low for both TOL [trial of labor] and ERCD [elective repeat cesarean delivery]. While rare for both TOL and ERCD, maternal mortality was significantly increased for ERCD at 13.4 per 100,000 versus 3.8 per 100,000 for TOL . . . 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).

Put another way, there is a 0.0038% (1 in 26,316) risk of maternal death during a trial of labor.  For a mom to die is very rare.

Risk of a fatal car accident

Of the 311,000,000 people living in the US (US Census, 2012), about 40,000 die annually (Beck, 2006) from car accidents in the United States which gives us a annual rate of 0.0129% (1 in 7,752).  (But remember, this is a very rough representation of the risk due to all the factors I previously mentioned.)

Many women look at this number and say, “See, you are more likely to die in a car accident than during a TOL.”

But remember, 0.0129% (1 in 7,752) is the annual rate of Americans dying due to car accidents.

To compare something like your annual risk of a fatal car accident to your risk of dying during a TOL is an unfair and inaccurate comparison.   It would be more accurate (though still a false comparison) to compare your daily risk of a fatal car accident (because most people travel in a car every day) to the risk of maternal death during a TOL because you are not in labor every day for a year.  Let me explain.

Comparing TOL maternal mortality to fatal car accidents

Often this false comparison is expressed as, “You are more likely to have a fatal car accident on the way to the hospital than have a uterine rupture or die during a VBAC.”  But the risk of a fatal car accident on the day you drive to the hospital is not 1 in 7,752.  That is your risk over a year.  We have to estimate your risk on that day you drive to the hospital by dividing 0.0129% by 365 days which equals 0.00003534% or 1 in 2,829,458.

No matter what stat we use from any study, the risk of maternal mortality during a TOL is much greater.  (But remember, this is a false comparison anyways!)

Guise’s data pegs the risk at 0.0038% or 1 in 26,316 which is 107.5 times greater than the risk of a fatal car accident as you drive to the hospital in labor.  This does not mean that the risk of dying during a TOL is so large, but rather our daily risk of a fatal car accident is so small that it’s literally theoretical.  (Read Kim James’ “Understanding obstetrical risk” for more.)

What about the risk of uterine rupture?

Using the 0.47% (1 in 213 TOLs) risk of scar rupture (Guise, 2010), the risk of a fatal car accident is 13,283 times smaller.

Why don’t we spread the risk of rupture/maternal mortality across the entire pregnancy?

After I initially published this article, someone left this great comment on Facebook:

I get this, but I also get why using annual stats of car accidents would be accurate when you are looking at uterine rupture rates themselves and not just during TOL, since a risk of rupture exists throughout pregnancy and not just during labor and mom would be pregnant for approximately 10 months or more.

I wondered about the best way to crunch the numbers because these events are so different and thus so difficult to compare.  In the end, it is a false comparison, but here was my original thinking….

Most Americans are in a car everyday, so they have that risk – no matter how small – every day unless they are not in a car in which case their risk is zero.  The risk is primarily associated with being in a car.

The risk of uterine rupture and maternal mortality is primarily associated with being in labor, so we can’t spread the risk of rupture/maternal mortality across the whole pregnancy because the risk of rupture/maternal mortality is not the same from conception to delivery.

One study examined 97% of births that occurred in the The Netherlands from 1st August 2004 until 1st August 2006 and found that 9% (1 in 11) of scar ruptures happened before the onset of labor. When we take 9% of the overall rate of scar rupture 0.64% (1 in 156) (including non-induced/augmented, induced, and augmented labors), we get a 0.0576% (1 in 1736) risk of pre-labor scar rupture and a 0.5824% (1 in 172) risk of rupture during labor (Zwart 1009). Since the risk of rupture is not the same over the entire pregnancy and labor, we cannot accurately calculate a daily risk of rupture.

In other words, the risk of rupture is rare before labor (0.0576% or 1 in 1736) and then becomes uncommon when labor begins (0.5824% or 1 in 172).  Even though we could go into labor anytime during pregnancy, the risk before we go into labor is so small in comparison to the risk when we actually go into labor.

Can you feel a uterine rupture with an epidural?

woman-laboring-hospitalSome care providers discourage epidurals in VBAC moms fearing that it will mask the symptoms of uterine rupture (namely abdominal pain) and delay diagnosis resulting in a poor outcome for baby and to a lesser extent, mom  Other care providers suggest or even require VBAC moms to have an epidural so that a cesarean can quickly take place if needed.  Which philosophy does the evidence support?

Review of 14 VBAC studies

I recently came across a study entitled “The Role of Epidural Anesthesia in Trial of Labor” (Johnson, 1990) that reviewed 14 VBAC studies.  Johnson found among scarred women who ruptured, a greater percentage of women with epidurals reported abdominal pain than women without epidurals.

  • 5 of 14 (35.7%) patients with an epidural who ruptured had abdominal pain.
  • 4 of 23 (17.4%) patients without an epidural who ruptured had abdominal pain.

Interestingly, only 22% of the women who ruptured in that study reported abdominal pain and Johnson concluded, “Thus abdominal pain is an unreliable sign of complete uterine rupture.”  But is it?  69% of women in Zwart (2009) reported abdominal pain. (I write about Zwart here and here.)

One difference between the studies is Zwart included significantly more scarred moms than Johnson: 26,000 versus 10,976.  The second different is that Zwart also included 332,000 unscarred women representing 93% of the sample population.

Unscarred moms, uterine rupture, and abdominal pain

I’m curious if the reason why Zwart reported such a high level of abdominal pain was because it included so many unscarred moms.  I wonder if unscarred moms are more likely to report pain and if so, why would that be.  Zwart combines the symptoms for scarred and unscarred rupture into one chart.  If they broke that chart out by scarred vs. unscarred rupture symptoms, would we see any major differences? Generally, unscarred rupture does more damage to the uterus and is more likely to result in an infant death (Zwart, 2009), so maybe because there is more damage, women report more abdominal pain?

Most common UR symptom: fetal heart tone abnormalities

I checked out  eMedicine’s article “Uterine Rupture in Pregnancy” and was fascinated to learn that several studies concur with Johnson.  They also found that abdominal pain is reported at a much lower rate than fetal distress/ abnormal fetal heart tones:

…sudden or atypical maternal abdominal pain occurs more rarely than do decelerations or bradycardia. In 9 studies from 1980-2002, abdominal pain occurred in 13-60% of cases of uterine rupture. In a review of 10,967 patients undergoing a TOL, only 22% of complete uterine ruptures presented with abdominal pain and 76% presented with signs of fetal distress diagnosed by continuous electronic fetal monitoring. [This is the Jonhson study.]

Moreover, in a study by Bujold and Gauthier, abdominal pain was the first sign of rupture in only 5% of patients and occurred in women who developed uterine rupture without epidural analgesia but not in women who received an epidural block.  (Bujold E, Gauthier RJ. Neonatal morbidity associated with uterine rupture: what are the risk factors?. Am J Obstet Gynecol. Feb 2002;186(2):311-4).  Thus, abdominal pain is an unreliable and uncommon sign of uterine rupture. Initial concerns that epidural anesthesia might mask the pain caused by uterine rupture have not been verified and there have been no reports of epidural anesthesia delaying the diagnosis of uterine rupture.

A 2012 study out of the UK (Fitzpatrick, 2012) also reported that 76% of uterine ruptures were accompanied by fetal heart rate abnormalities in comparison to 49% reporting abdominal pain.

ACOG’s stance on epidurals

It’s important to note that ACOG does support the use of epidurals in VBACs:

Epidural analgesia for labor may be used as part of TOLAC, and adequate pain relief may encourage more women to choose TOLAC (109, 110). No high quality evidence suggests that epidural analgesia is a causal risk factor for an unsuccessful TOLAC (44, 110, 111). In addition, effective regional analgesia should not be expected to mask signs and symptoms of uterine rupture, particularly because the most common sign of rupture is fetal heart tracing abnormalities (24, 112).

Remember that fetal heart tracing abnormalities were detected in 76% of the ruptures in Johnson ad 67% of the ruptures in Zwart.

I couldn’t find any mention of epidurals masking rupture pain in the Guise 2010 Evidence Report, but found that the Johnson study was excluded from their report because “No full-text paper, opinion or letter with no data.”  Interesting.

Uterine rupture symptoms

A list of uterine rupture symptoms and their frequency per Medscape’s article on uterine rupture.

  • “80% Prolonged deceleration in fetal heart rate or bradycardia
  • 54% Abnormal pattern in fetal heart rate
  • 40% Uterine hyper-stimulation
  • 37% Vaginal bleeding
  • 26% Abdominal pain
  • 4% Loss of intrauterine pressure or cessation of contractions”

A couple notes.  One, abdominal pain is not a consistent or reliable symptom of UR.  Two, there is a level of interpretation that goes into diagnosing abnormal fetal heart tones even among people who have extensive medical training.

Additional symptoms that I have collected from other sources include:

  • Baby’s head moves back up birth canal
  • Bulge in the abdomen or under the pubic bone (where the baby may be coming through the tear in the uterus)
  • Uterus becomes soft
  • Shoulder pain

Risks and benefits of epidurals

As with every option available to you regarding birth, it’s always good to be knowledgeable on the risks and benefits of epidurals so you can make an informed choice.  Three excellent resources are this article by Sarah Buckley MD, the PubMed Health Epidural Fact Sheet and this review of epidural research by the Cochrane Library.

Take home message

The limited information available tells us that epidurals do not mask abdominal pain from uterine rupture.

The most common symptom of uterine rupture is fetal distress diagnosed by fetal heart rate abnormalities.

Epidurals may be used during a trial of labor after cesarean per ACOG.

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As always, if you can offer further research or perspective on this topic, please leave a comment.  Our knowledge is constantly growing and we can only work with the best information available to us now.  Who knows what future research will tell us?

Myth: Two numbers less than 1% are similar

I have often heard, “If two numbers are less than 1%, they are similar.”  Typically
this is expressed while comparing the risks of rupture in an unscarred versus scarred uterus.   But is this true?  How different can two numbers less than 1% be?calculator-983900_1920

Two numbers less than 1% are no more similar than two numbers greater than 1%

Just because two numbers are less than 1%, that doesn’t make them any more similar than two numbers greater than 1%.  A 2% risk of something happening is very different than an 89% risk.  While they are both greater than 1%, they represent drastically different levels of risk.

2% = 1 in 50 risk

89% = 1 in 1.12 risk

89% represents a 44 times greater risk than 2%.

What about numbers less than 1%?

It might seem rational that since numbers less than 1% are so small, that there wouldn’t be as much of a difference between them.  But numbers less than 1% work in the same way as those greater than 1%.   Let’s run a few and measure the difference.

1 in 100 represents 1%.

1 in 1,000, is the same as 0.1%, and is 10 times smaller than 1%.

1 in 10,000, is the same as 0.01%, and is 100 times smaller than 1%.

1 in 100,000, is the same as 0.001%, and is 1,000 times smaller than 1%.

1 in 1,000,000, is the same as 0.0001%, and is 10,000 times smaller than 1%.

Comparing small risks

According to Zwart* (2009), the risk of uterine rupture in:

– an unscarred mom is 1 in 14,286 (0.007% or 0.7 in 10,000) and

– a scarred mom is 1 in 156 (0.64% or 64 in 10,000).

(Both statistics include non-induced/augmented, induced, and augmented labors.)  Even though both numbers are less than zero, they represent very different levels of risk.  In fact, the risk of rupture in an unscarred mom is 91 times smaller than a scarred mom.  It’s not that the risk of rupture is excessively high in a scarred mom, but that it is so very, very, very low in an unscarred mom.

Using the language from Kim James’ handout Understanding Obstetrical Risk, the risk of rupture in an unscarred mom would be described as “very rare” whereas the risk of rupture in a scarred mom would be described as “uncommon.”

Take away messages

Just because two numbers are less than 1% does not mean that they are similar.  Numbers below 1% represent just as much of a range as numbers greater than 1%.

While the risk of scar rupture is very different than the risk of unscarred rupture, it is similar to other serious obstetrical emergencies such as placental abruption, cord prolapse, and postpartum hemorrhage.
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* Zwart (2009) differentiated between uterine rupture and dehiscence, featured 358,874 total deliveries, 25,989 of which were trials of labor after a cesarean.  Zwart included 97% of births in The Netherlands between August 1, 2004 and August 1, 2006, making it “the largest prospective report of uterine rupture in women without a previous cesarean in a Western country.”

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

Myth: VBACs should never be induced

Note: When I refer to a spontaneous labor, I mean a non-induced/augmented labor. Also, given that the risk of rupture increases with induction, a hospital is the best location for an induction.

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Many of the comments left at the Forced Cesarean mom story questioned the safety of inducing a VBAC mom. Many people believe that is it excessively dangerous and that VBACs should never been induced or augmented. This is just not the case.

Spontaneous labor is always preferable to induced or augmented labor but there are medical conditions that can necessitate the immediate birth of a baby. It’s nice for those women for whom vaginal birth is still an option to have a choice: gentle induction/ augmentation or repeat cesarean. Of course, reviewing the risks and benefits of available options, including doing nothing, is essential. Some women might be more comfortable scheduling a cesarean whereas others might want to give a gentle Pitocin and/or Foley catheter induction a go.

ACOG’s stance on inducing VBACs

The latest 2010 VBAC Practice Bulletin No. 115 produced by the American Congress of Obstetricians & Gynecologists (ACOG) asserts:

Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC [trial of labor after cesarean]… However, the potential increased risk of uterine rupture associated with any induction, and the potential decreased possibility of achieving VBAC, should be discussed… 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.

Stuart Fischbein MD, a vaginal breech/twins and VBAC supportive Southern California OB, recently shared this on my Facebook page,

According to ACOG, prior low transverse c/section is not a contraindication to induction (other than the use of Misoprostol [Cytotec]) so a Foley balloon or Pitocin may be used safely in these women. The problem arises when a practitioner does not believe in doing inductions on women with prior c/section. Despite the evidence and the ACOG clinical guideline the reality is that many doctors will just not want to deal with it.

“Many doctors will just not want to deal with it” for a variety of reasons including experiencing a recent uterine rupture or lawsuit and pressure from hospital administrators or other OBs in their practice. It’s good to know from the beginning if your care provider is open to a gentle VBAC induction and under what conditions they would recommend induction. (See below for the Mayo Clinic’s reasons for induction.) This is why I suggest asking care providers when you first meet with them: “Under what circumstances would you induce a VBAC?” and “What induction methods do you use?”

Medical reasons for induction

While many women are induced for non-medical reasons, such as being pregnant for 40 weeks and one day, there are many medical conditions where induction is a reasonable option. According to the Mayo Clinic’s article Inducing labor: when to wait, when to induce dated July 23, 2011:

Your health care provider might recommend inducing labor for various reasons, primarily when there’s concern for your health or your baby’s health. For example:

  • You’re approaching two weeks beyond your due date, and labor hasn’t started naturally
  • Your water has broken, but you’re not having contractions
  • There’s an infection in your uterus
  • Your baby has stopped growing at the expected pace
  • There’s not enough amniotic fluid surrounding the baby (oligohydramnios)
  • Your placenta has begun to deteriorate
  • The placenta peels away from the inner wall of the uterus before delivery — either partially or completely (placental abruption)
  • You have a medical condition that might put you or your baby at risk, such as high blood pressure or diabetes

ACOG’s 2009 recommendations on induction lists the following reasons:

  • Abruptio placentae [placental abruption]
  • Chorioamnionitis [infection in your uterus]
  • Fetal demise [baby has passed away]
  • Gestational hypertension
  • Preeclampsia, eclampsia
  • Premature rupture of membranes
  • Postterm pregnancy [after 42 weeks]
  • Maternal medical conditions (eg, diabetes, mellitus, renal [kidney] disease, chronic pulmonary disease, chronic hypertension, antiphospholipid syndrome)
  • Fetal compromise (eg, severe fetal growth restriction, isoimmunization, oligohydramnios)

Big babies & going overdue

ACOG’s latest VBAC Pratice Bulletin No. 115 states that going over 40 weeks or suspecting a “big baby” should not prevent a woman from planning a VBAC. I suggest asking your care provider at your first appointment about what they would recommend doing if you go past 40 weeks, past 42 weeks, or if they believe your baby is large. They may suggest a cesarean, a gentle induction, or they be open to waiting for spontaneous labor. Then you decide how you feel about their answer. If you decide that their answer is not a good fit for you, you can weigh that against the responses of other VBAC supportive care providers in your area.

Uterine rupture rates in induced/augmented labors

There are two primary factors when looking at uterine rupture during an induction: the drug and the dose. Keep in mind that while the risk of rupture generally increases as the dosage increases, two women can respond very differently to the same dose of the same drug. According to JHP Pharmaceuticals, LLC, the manufacturer of Pitocin,

Oxytocin has specific receptors in the myometrium and the receptor concentration increases greatly during pregnancy, reaching a maximum in early labor at term. The response to a given dose of oxytocin is very individualized and depends on the sensitivity of the uterus, which is determined by the oxytocin receptor concentration.

Additionally, they assert that Pitocin should not be used for induction without medical indication:

Elective induction of labor is defined as the initiation of labor in a pregnant individual who has no medical indications for induction. Since the available data are inadequate to evaluate the benefits-to-risks considerations, Pitocin is not indicated for elective induction of labor.

Many women point to the fact that the Pitocin drug insert states, “Except in unusual circumstances, oxytocin should not be administered in the following conditions” and then lists “previous major surgery on the cervix or uterus including cesarean section.” However, a prior cesarean is not listed under contraindications and the drug insert is clear:

The decision [to use Pitocin in a woman with a prior cesarean] can be made only by carefully weighing the potential benefits which oxytocin can provide in a given case against rare but definite potential for the drug to produce hypertonicity or tetanic spasm.

The elevated risk of rupture due to induction has been documented in several studies. Landon (2004) found that spontaneous labors had a 0.4% rate of rupture. That increased 2.5 times for induced labors (1.0%) and 2.25 times for augmented labors (0.9%).

Landon further broke out rupture rates by type of induction:

  • 1.4% (N = 13) with any prostaglandins (with or without oxytocin)
  • 0% with prostaglandins alone
  • 0.9% (n = 15) with no prostaglandins (includes mechanical dilation with a foley catheter with or without oxytocin), and
  • 1.1% (N = 20) with oxytocin alone.

Overall, they found 0.7% of women experienced an uterine rupture with an additional 0.7% experiencing a dehiscence.

Landon (2004) did a great job in providing rates of rupture per drug, but we don’t know the dose used in the induced/ augmented labors that ruptured versus those that didn’t rupture.

ACOG quotes a couple studies in their 2010 VBAC Practice Bulletin (emphasis mine):

One study of 20,095 women who had undergone prior cesarean delivery (81) found a rate of uterine rupture of 0.52% for spontaneous labor, 0.77% for labor induced without prostaglandins, and 2.24% for prostaglandin induced labor. This study was limited by reliance on the International Classification of Diseases, 9th Revision coding for diagnosis of uterine rupture and the inability to determine whether prostaglandin use itself or the context of its use (eg, unfavorable cervix, need for multiple induction agents) was associated with uterine rupture.

In a multicenter study of 33,699 women undergoing TOLAC, augmentation or induction of labor also was associated with an increased risk of uterine rupture compared with spontaneous labor (0.4 % for spontaneous labor, 0.9% for augmented labor, 1.1% for oxytocin alone, and 1.4% for induction with prostaglandins with or without oxytocin) (4). A secondary analysis of 11,778 women from this study with one prior low transverse cesarean delivery showed an increase in uterine rupture only in women undergoing induction who had no prior vaginal delivery (1.5% versus 0.8%, P=.02). Additionally, uterine rupture was no more likely to occur when labor induction was initiated with an unfavorable cervix than with a favorable cervix (91). Another secondary analysis examined the association between maximum oxytocin dose and the risk of uterine rupture (94). They noted a dose response effect with increasing risk of uterine rupture with higher maximum doses of oxytocin. Because studies have not identified a clear threshold for rupture, an upper limit for oxytocin dosing with TOLAC has not been established.

Induced labor is less likely to result in VBAC than spontaneous labor (44, 47, 92, 99). There is some evidence that this is the case regardless of whether the cervix is favorable or unfavorable, although an unfavorable cervix decreases the chance of success to the greatest extent (91, 100, 101). These factors may affect patient and health care provider decisions as they consider the risks and benefits of TOLAC associated with labor induction.

Given the lack of compelling data suggesting increased risk with mechanical dilation and transcervical catheters, such interventions may be an option for TOLAC candidates with an unfavorable cervix.

The Guise 2010 Evidence Report is another excellent resource that reviewed VBAC research published to date. It talks extensively about uterine rupture in induced births on pages 58 – 69 and concluded (emphasis mine):

The strength of evidence on the risk of uterine rupture with pharmacologic IOL [induction of labor] methods was low due to lack of precision in estimates and inconsistency in findings. The overall risk of rupture with any IOL method at term was 1.5 percent [1 in 67] and 1.0 percent [1 in 100] when any GA [gestational age] is considered. Among women with GA greater than 40 weeks, the rate was highest at 3.2 percent [1 in 31]. Evaluation of the evidence on specific methods of IOL reveal that the lowest rate occurs with oxytocin [Pitocin] at 1.1 percent [1 in 91], then PGE2 [prostaglandin E2] at 2 percent [1 in 50], and the highest rate with misoprostol [Cytotec] at 6 percent [1 in 17]. These findings should be interpreted with caution as there was imprecision and inconsistency in the results among these studies. The risk of uterine rupture with mechanical methods of IOL is understudied. Other harms were inadequately reported to make conclusions. Relative to women with spontaneous labor, there was no increase in risk of rupture among those induced at term. However, the available evidence on women with induced labor after 40 weeks GA indicates an increased risk compared with spontaneous labor (risk difference 1.8 percent; 95 percent CI: 0.1 to 3.5 percent). The NNH [number needed to harm] in this group is 56 (for every 56 women greater than 40 weeks GA with IOL during a TOL [trial of labor], one additional rupture will occur compared with having spontaneous labor).

So the bottom line is: more large, good quality studies that control for induction are needed.

What is too risky?

As ACOG (2010) states in their latest Practice Bulletin:

Respect for patient autonomy supports the concept that patients should be allowed to accept increased levels of risk, however, patients should be clearly informed of such potential increase in risk and management alternatives.

I agree and believe that each individual woman has the right to informed consent and, together with her care provider, can make the best decision for her individual situation. I think it’s hard to argue that women seeking VBA2C, home birth, or unassisted birth should have the right to accept the elevated levels of risk that come with those decisions and yet say that the elevated risk that comes with induced VBACs is unacceptable.

Keep in mind that while the risk of rupture is higher in an induced VBAC, the risk is similar to the risk of rupture in a VBA2C (0.9% per Landon 2006). So it’s hard for one to support VBA2C and yet demonize a VBA1C induced for medical indication by saying the risk of rupture is to high.

It is also important to note that 90 out of 91 Pitocin induced TOLACs do not rupture (Landon, 2004 & Guise, 2010). So while the risk is generally higher in induced/ augmented labors, the overall risk is still low and occurs at a rate comparable to other obstetrical emergencies.

Myth: Most ruptures occur in induced/augmented labors

It’s imperative that women seeking VBAC understand that the single factor that increases their risk of uterine rupture the most is their prior cesarean section. And while having your labor induced/augmented does increase your risk of rupture, please do not believe the myth that a spontaneous labor provides complete protection from uterine rupture.

To disprove this myth, I direct you to “the largest prospective report of uterine rupture in women without a previous cesarean in a Western country” which found that most ruptures occur in spontaneous labors (Zwart, 2009). Zwart differentiated between uterine rupture and dehiscence and found (emphasis mine):

of the 208 scarred and unscarred uterine ruptures, 130 (62.5%) occurred during spontaneous labor reflecting 72% of scarred ruptures and 56% of unscarred ruptures.

It is interesting to note that 16% of unscarred ruptures (representing 4 unscarred women) and 9% of scarred ruptures (representing 16 scarred women) happened before the onset of labor (Zwart, 2009).

What I would do

If there was a medical reason for my baby to born (as detailed by the Mayo Clinic above), and it was the difference between a VBAC and a repeat cesarean, and I had a favorable Bishop’s score (download the app), I would consent to a foley catheter and/or low-dose Pitocin induction (not Cytotec or Cervidil).

If I was induced or augmented with Pitocin, I would be comfortable with continuous external fetal monitoring. Some hospitals do offer telemetry which is wireless monitoring giving you more freedom of movement. I’ve even seen telemetry in tube tops (naturally I can’t find a link to it now, if you have a link, can you leave a comment?) and units that can be worn in birth tubs. It’s good to call the hospital beforehand to determine what kind of telemetry monitoring units they offer and to confirm that it’s not lost in a closet.

Final thoughts

There is no doubt that Pitocin is overused in America and often results in unnecessary emergency cesareans. However, it’s important not to cloud the two issues: medically unnecessary inductions and inductions with medical indication. There are situations where induction/ augmentation are reasonable and can give the mom one last option before having a cesarean. Thankfully, a low-dose Pitocin and/or foley catheter induction “remains an option” in women planning a VBAC according to ACOG. I think that is a good thing.

Further reading

The best compilation of VBAC/ERCS research to date

“There is a major misperception that TOLAC [trial of labor after cesarean] is extremely risky” – Mona Lydon-Rochelle PhD, MPH, MS, CNM, March 2010

In terms of VBAC, “your risk is really, really quite low” – George Macones MD, MSCE, March 2010

Both Drs. Macones and Lyndon-Rochelle are medical professionals and researchers who made these statements at the 2010 NIH [National Institutes of Health] VBAC Conference. Now you may think, “Wait a sec. Everything I’ve heard from my family, friends, and medical provider is how risky VBAC is and how cesareans are the conservative, prudent, and safest choice.” Why the discrepancy between the statements of these two prominent care provider researchers and the conventional wisdom prevalent in America?

It’s likely that your family, friends, and even your medical provider are not familiar with the latest and best compilation of VBAC research that was released in March 2010. It’s also possible that they are not familiar with the latest VBAC recommendations published in July 2010 by the American Congress of Obstetricians and Gynecologists (ACOG). Additionally, there are often legal and non-medical factors at play that influence how care providers counsel women on VBAC, including pressure from hospital administrators.

When I come across any VBAC study, I always wonder if it made the cut to be included in the 400 page Guise 2010 Evidence Report that was the basis for the 2010 NIH VBAC Conference. Guise 2010 reviewed each published VBAC study, performed a quality assessment, and assembled an excellent review of the VBAC literature to date:

Quality assessment is an assessment of a study’s internal validity (the study’s ability to measure what it intends to measure). If a study is not conducted properly, the results that they produce are unlikely to represent the truth and thus are worthless (the old adage garbage in garbage out). If however, a study is structurally and analytically sound, then the results are valuable. A systematic review, is intended to evaluate the entire literature and distill those studies which are of the highest possible quality and therefore likely to be sound and defensible to affect practice.

Guise focused on these key questions: “1) a chain of evidence about factors that may influence VBAC, 2) maternal and infant benefits and harms of attempting a VBAC versus an elective repeat cesarean delivery (ERCD), and 3) factors that may influence maternal and infant outcomes.” Ultimately, this 400 page document was distilled into the 48 page VBAC Final Statement produced by the NIH VBAC Conference.

This is wonderful because people who want the big picture, can read the VBAC Final Statement whereas those who want to know the exact figures, how studies were included/excluded, and the strength of the data available, can read the Guise 2010 Evidence Report.

You can get a feel for the topics presented at the NIH VBAC Conference by reading the Programs & Abstracts document. If you want more detail, you can watch the individual presentations. I was there for the three day conference and it was eye opening. I wish more medical professionals and moms were aware of this information as they are excellent resources for anyone looking to learn more about VBAC.

Everyone wants to know the bottom line: what is the risk of death or major injury to mom and baby. Here is an overview of maternal and infant mortality and morbidity per Guise (2010). It’s important to remember that the quality of data relating to perinatal mortality was low to moderate due to the high range of rates reported by the strongest studies conducted thus far. Guise reports the high end of the range when they discuss perinatal mortality which was 6% for all gestational ages and 2.8% when limited to term studies. This is a long way of saying, we still don’t have a good picture of how many babies die due to uterine rupture.

It’s also important to remember that the statistics shared in Guise (2010) are for all VBACs. They include all scar types, women who have had multiple prior cesareans, induced/augmented labors, etc. It would have been helpful if they had broke out the data in these ways as we know we can reduce the risk of rupture (and thus perinatal mortality) through spontaneous labor.

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… The occurrence of maternal and infant mortality for women with prior cesarean is not significantly elevated when compared with national rates overall of mortality in childbirth. The majority of women who have TOL will have a VBAC, and they and their infants will be healthy. However, there is a minority of women who will suffer serious adverse consequences of both TOL and ERCD. While TOL rates have decreased over the last decade, VBAC rates and adverse outcomes have not changed suggesting that the reduction is not reflecting improved patient selection.

Women are entitled to accurate, honest, and high quality data. They don’t deserve to have the risks exaggerated by an OB who wishes to coerce them into a repeat cesarean nor do they deserve to have risks sugar-coated or minimized by a midwife or birth advocate who may not understand the risk or whose zealous desire for everyone to VBAC clouds their judgement. Sometimes it can be hard to find good data on VBAC which is why I’m so thankful for the 2010 NIH VBAC Conference and all the excellent data that became available to the public as a result. There are real risks and benefits to VBAC and repeat cesarean and once women have access to good data, they can individually choose which set of risks and benefits they want. I think the links I have provided above represents the best data we have to date.

Confusing fact: Only 6% of uterine ruptures are catastrophic

It is important to note that the information shared in Guise (2010), the 400 page Evidence Report on which the 2010 NIH VBAC Conference was based, collected the best data we have available on trial of labor after cesarean.  That said, they reported, “Overall, the strength of evidence on perinatal mortality was low to moderate” due to the wide range of perinatal mortality rates reported by the studies included in the report.  Bottom line: We still don’t have an accurate idea of how deadly uterine rupture is to babies.  This is a topic on which Guise recommended future researchers focus.  I highly recommend that anyone interested in TOLAC (trial of labor after cesarean), especially those who blog or share information on social networking sites, review this very important document as it is a fascinating analysis of the best research we have to date on TOLAC.


How many times have you heard, “Only 6% of uterine ruptures are catastrophic” or “Uterine rupture not only happens less that one percent of the time, but the vast majority of ruptures are non-catastrophic?” But what does that mean? Does that mean only 6% of uterine ruptures are “complete” ruptures? Result in maternal death? Infant death? Serious injury to mom or baby? This article will explain to you the difference between uterine rupture and uterine dehiscence as well as explain the source and meaning of the 6% statistic.

Distinguishing between uterine rupture and uterine dehiscence

First, it’s important to understand what a uterine rupture is and how that differs from a uterine dehiscence. Uterine rupture, also called true, complete, or even (to further add to the confusion) catastrophic rupture, is a opening through all the layers of the uterus. Per a Medscape article on Uterine Rupture in Pregnancy:

Uterine rupture is defined as a full-thickness separation of the uterine wall and the overlying serosa. Uterine rupture is associated with (1) clinically significant uterine bleeding; (2) fetal distress; (3) expulsion or protrusion of the fetus, placenta, or both into the abdominal cavity; and (4) the need for prompt cesarean delivery and uterine repair or hysterectomy.

Whereas a uterine dehiscence, also called a incomplete rupture or a uterine window, is not a full-thickness separation. It’s often asymptomatic, does not pose any risk to mom or baby, and does not require repair. Again, I refer to Medscape:

Uterine scar dehiscence is a more common event that seldom results in major maternal or fetal complications. By definition, uterine scar dehiscence constitutes separation of a preexisting scar that does not disrupt the overlying visceral peritoneum (uterine serosa) and that does not significantly bleed from its edges. In addition, the fetus, placenta, and umbilical cord must be contained within the uterine cavity, without a need for cesarean delivery due to fetal distress.

When reading medical studies, look for how they define uterine rupture in the “Methods” section. While some medical studies combine the statistics for rupture and dehiscence, ultimately reporting an inflated rate of rupture, other studies distinguish between the two events.

So, what does the 6% statistic mean and where did it come from?

The statistic “Only 6% of uterine ruptures are catastrophic” is from the Evidence Report (Guise 2010) which was the basis of the 2010 NIH VBAC Conference and it refers to the rate of infant death due to uterine rupture. Here is the exact quote:

The overall risk of perinatal death due to uterine rupture was 6.2 percent. The two studies of women delivering at term that reported perinatal death rates report that 0 to 2.8 percent of all uterine ruptures resulted in a perinatal death (Guise 2010).

In other words, of the women who had uterine ruptures, 6.2% (1 in 16) resulted in infant deaths. When we limited the data to women delivering at term, as opposed to babies of all gestational ages, the risk was as high as 2.8 (1 in 36)%.

When we look at the overall risk of an infant death during a trial of labor after cesarean, the NIH reported the rate of 0.13%, which works out to be one infant death per 769 trials of labor.

The source of the confusion

The problem with this statistic is that some people have misinterpreted it to mean that only 6% of ruptures are true, complete uterine ruptures. In other words, if we take the 0.4% (1 in 240) uterine rupture rate (Landon, 2004), they believe that only 6% of those ruptures or 0.024% (1 in 4166) are true, complete ruptures. This is false. The 0.4% uterine rupture statistic measured true, complete, uterine ruptures in spontaneous labors after one prior low, transverse (“bikini cut”) cesarean.

So how many dehiscences did Landon (2004) detect? Landon reported a 0.7% uterine rupture rate and a 0.7% dehiscence rate. (Note that these statistics include a variety of scar types as well spontaneous, augmented, and induced labors.) So Landon found that dehiscence occurs at the same rate as uterine rupture.

I think the best way to avoid confusion is to use very clear language: 6.2% (1 in 16) of uterine ruptures result in an infant death. Put another way, for every 16 uterine ruptures, there will be one baby that dies.

Elapsed time and infant death

What determines if a baby dies or has brain damage? Some research on infant cord blood gases has suggested that if the baby isn’t delivered (almost always by CS) within 16 – 17 minutes of a uterine rupture, there can be serious brain damage or death to baby. You can watch a presentation from the 2010 NIH VBAC Conference entitled “The Immediately Available Physician Standard” by Howard Minkoff, M.D. for more information or read his presentation abstract.

Now you know the difference between uterine rupture, uterine dehiscence and the meaning of the 6% statistic. It’s helpful to understand the terminology used in relation to uterine rupture otherwise it can be very confusing as you wade your way through the statistics! It’s also very important for people to use specific words whose definitions are clear instead of words such as “catastrophic” that could mean multiple things.

Afterward – The big picture

The following are excerpts from the Evidence Report (Guise 2010) , the 400 page evidence report assembled for the 2010 NIH VBAC Conference. The limitation of Guise (2010) is that these stats are for all VBACs – all scar types, multiple prior cesareans, induced/augmented labors, etc. It would have been helpful if they had broke out the data in these ways.

While rare for both TOL [trial of labor] 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 death due to UR from term studies was 2.8%. “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… The occurrence of maternal and infant mortality for women with prior cesarean is not significantly elevated when compared with national rates overall of mortality in childbirth. The majority of women who have TOL will have a VBAC, and they and their infants will be healthy. However, there is a minority of women who will suffer serious adverse consequences of both TOL and ERCD. While TOL rates have decreased over the last decade, VBAC rates and adverse outcomes have not changed suggesting that the reduction is not reflecting improved patient selection.

A systematic review strives to be patient-centered and to provide both patients and clinicians with meaningful numbers or estimates so they can make informed decisions. Often, however, the data do not allow a direct estimate to calculate the numbers that people desire such as the number of cesareans needed to avoid one uterine rupture related death. The assumptions that are required to make such estimates from the available data introduce additional uncertainty that cannot be quantified. If we make a simplistic assumption that 6 percent of all uterine ruptures result in perinatal death (as found from the summary estimate), the range of estimated numbers of cesareans needed to be performed to prevent one uterine rupture related perinatal death would be 2,400 from the largest study,204 and 3,900-6,100 from the other three studies of uterine rupture for TOL and ERCD.10, 97, 205 Taken in aggregate, the evidence suggests that the approximate risks and benefits that would be expected for a hypothetical group of 100,000 women at term gestational age (GA) who plan VBAC rather than ERCD include: 10 fewer maternal deaths, 650 additional uterine ruptures, and 50 additional neonatal deaths. Additionally, it is important to consider the morbidity in future pregnancies that would be averted from multiple cesareans particularly in association with placental abnormalities.

Placenta problems in VBAMC/ after multiple repeat cesareans

I thought that I would take the data from the Silver (2006) that I’ve previously discussed and share it in a different way that would be helpful to women with multiple prior cesareans.  (You might find it worthwhile to read this article specifically, where you can view the data below in graphs, as well as other articles on placental abnormalities first.)  Remember that accreta is when the placenta abnormality deeply attaches into the uterus requiring surgical removal.  There is a 7% maternal mortality rate with accreta as well as a high rate of hemorrhage and hysterectomy.   One of the factors that determines your risk of accreta or previa is your number of prior cesareans.

Whether a mom has a repeat cesarean or a VBA1C, her risk of accreta (including increta and percreta) and previa in that pregnancy are:

risk of accreta: 0.31% (1 in 323)
risk of previa: 1.3% (1 in 77)
risk of accreta if previa is present: 11% (1 in 9)

Whether a mom plans a third cesarean or a VBA2C, her risk of accreta and previa in that pregnancy are:<

risk of accreta: 0.57% (1 in 175)
risk of previa: 1.14% (1 in 88)
risk of accreta if previa is present: 40% (1 in 2.5)

If a mom plans a fourth cesarean or a VBA3C, the risk during that pregnancy increases to:

risk of accreta: 2.13% (1 in 47)
risk of previa: 2.27% (1 in 44)
risk of accreta if previa is present: 61% (1 in 1.6)

The jump in risk from two prior cesareans to three prior cesareans is pretty huge…

If mom plans a fifth cesarean or a VBA4C, the risk during that pregnancy increases to:

risk of accreta: 2.33% (1 in 43)
risk of previa: 2.3% (1 in 43)
risk of accreta if previa is present: 67% (1 in 1.5)

If mom plans a sixth cesarean or a VBA5c, the risk during that pregnancy increases to:

risk of accreta: 6.74% (1 in 15)
risk of previa: 3.4% (1 in 29)
risk of accreta if previa is present: 67% (1 in 1.5)

Here are some stats to consider:

Silver (2006) found the following rates of accreta (including increta and percreta), during the first, second, third, fourth, fifth, and sixth cesareans: 0.24%, 0.31%, 0.57%, 2.13%, 2.33%, 6.74%.  (View a graph of this data.)

In other words, your risk of placenta accreta increases from first to sixth cesarean delivery:
1 in 417,
1 in 323,
1 in 175,
1 in 47,
1 in 43,
1 in 15.

Read more about accreta.

The studies that have been conducted (that I’m aware of) on uterine rupture in VBAMC are kind of small (including hundreds, not thousands of women).  So I don’t think we have an accurate idea of VBA3C rupture risk.  This site is a great resource.

Update:  When I posted a link to this article on Facebook, a mom left this comment:

Thank you for posting. My friend had 2 previous c-sections, and with her 3rd pregnancy had the bad luck of having both placenta accreta and placenta previa (both risks of repeat c-section). Her pregnancy was awful..lots of bleeding, hospitalizations, steriods and other drugs to help hold onto the pregnancy and bedrest at 20 weeks. They couldn’t do cerclage because of the placenta previa). In the end she had a healthy baby, but a 5 hour c-section surgery where she lost a lot of blood and needed a blood transfusion of 6 units of blood. She had to have a hysterectomy and also they removed part of her bladder because her placenta had embedded so far it was attached to her bladder! She was pissed that her doctor never warned her of the risks of repeat c-sections. She is 39 years old.

[and]

yes, you can share my comment. again, my friend ultimately is ok bec she was planning on having her tubes tied after this 3rd unplanned pregnancy — but she was upset initially bec her OB never shared with her any of these risks of repeat c-section…and she said “had I known, I would have really pushed for a vbac with #2”

These are the complication rates that Silver 2006 found in 30,000
women during multiple cesareans.The rates quoted were what he found during the third CS but, I think
the accreta and previa rates illustrate the risks that are present
during a third pregnancy after two prior CS.In other words, whether a mom has a third CS or a VBA2C, her risk of
accreta and previa in that third pregnancy are:

risk of accreta: 0.57% (1 in 175)
risk of previa: 1.14% (1 in 88)
risk of accreta *if* previa is present: 40% (1 in 2.5)

If she has a third CS and becomes pregnant again, the risk during that
fourth pregnancy increases to:

risk of accreta: 2.13% (1 in 47)
risk of previa: 2.27% (1 in 44)
risk of accreta *if* previa is present: 61% (1 in 1.6)

Compare that to the risks in a first pregnancy:

risk of accreta: 0.24% (1 in 417)
risk of previa: 6.4% (1 in 16) [yes, that figure is correct, previa was the reason for many of these women’s primary CS]
risk of accreta *if* previa is present: 3% (1 in 33)

That means the risk of accreta increases 887% from the first pregnancy – a huge jump.

So, if it was me, getting that ultrasound and knowing I didn’t have these complications would give me huge peace of mind.

Just kicking the can of risk down the road

This is why cesareans should not be casual or performed for the convenience of anyone.  They should be reserved for real medical reasons so that the benefits of having the cesarean outweigh the risks.  And there are real risks to cesareans, but since the ones list below are future risks, they may seem less real.  Per a November 2011 study published in the Journal of Maternal-Fetal and Neonatal Medicine:

If primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually. The rise in these complications will lag behind the rise in cesareans by approximately 6 years.

Placenta previa and accreta are nothing to mess around with.  Accreta in particular has a very high maternal mortality rate and many mothers end up having cesarean hysterectomies.   I write more about accreta here.

Many women do not think these complications are applicable to them as they don’t plan on more children after their two cesareans.  But I know many women, and I’m sure you do too, who were not planning on more children, but got pregnant nonetheless.  Unless you or your partner get sterilized or practice abstinence (what fun!), the chance of you getting pregnant is there.

By performing routine scheduled repeat cesareans, we do reduce the risk of uterine rupture in the current pregnancy, but we are also increasing the risks of accreta, previa, maternal death as well as uterine rupture in future pregnancies.  In addition, another large study found

[t]he risks of placenta accreta, cystotomy [surgical incision of the urinary bladder], bowel injury, ureteral [ureters are muscular ducts that propel urine from the kidneys to the urinary bladder] injury, and ileus [disruption of the normal propulsive gastrointestinal motor activity], the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries.

And this is especially relevant in rural hospitals which institute VBAC bans because they don’t offer 24/7 anesthesia.  Even though the “immediately available” clause was removed in the latest (2010) ACOG VBAC Practice Bulletin, many of these bans still stand.

However, in order to rapidly respond to the potentially sudden diagnosis of accreta, previa, or abruption, the hospital will have to enact many of the same ideas provided at the 2010 NIH VBAC Conference on how a hospital without 24/7 anesthesia can safely offer VBAC and respond to uterine rupture.  So why not just institute those ideas from the get-go and offer VBAC to those who want it?  (I know, I know: medico-legal reasons, which the NIH also addressed, but that is another post.)  From VBAC Ban Rationale is Irrational:

 As David J. Birnbach, M.D., M.P.H (2010), who presented on the impact of anesthesiologists on the incidence of VBAC [at the 2010 NIH VBAC Conference] 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.

Read more about the how the risk of serious complications increase with each cesarean surgery.

Below is Silver’s (2006) study abstract:

J Matern Fetal Neonatal Med. 2011 Nov;24(11):1341-6. Epub 2011 Mar 7.

The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality.

Solheim KN, Esakoff TF, Little SE, Cheng YW, Sparks TN, Caughey AB. Source Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA. Abstract

OBJECTIVE: The overall annual incidence rate of caesarean delivery in the United States has been steadily rising since 1996, reaching 32.9% in 2009. Primary cesareans often lead to repeat cesareans, which may lead to placenta previa and placenta accreta. This study’s goal was to forecast the effect of rising primary and secondary cesarean rates on annual incidence of placenta previa, placenta accreta, and maternal mortality.

METHODS: A decision-analytic model was built using TreeAge Pro software to estimate the future annual incidence of placenta previa, placenta accreta, and maternal mortality using data on national birthing order trends and cesarean and vaginal birth after cesarean rates. Baseline assumptions were derived from the literature, including the likelihood of previa and accreta among women with multiple previous cesarean deliveries.

RESULTS: If primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually. The rise in these complications will lag behind the rise in cesareans by approximately 6 years.

CONCLUSIONS: If cesarean rates continue to increase, the annual incidence of placenta previa, placenta accreta, and maternal death will also rise substantially.

http://www.ncbi.nlm.nih.gov/pubmed/21381881

What can you do when your hospital bans VBAC?

Amber recently left this comment on the Quick Facts page:

i am pregnant for the second time my first child was delivered by c-section my goal is to have my second child natural but the obgyns in my area will not allow someone who has had a c-section to have a natural birth they said it is hospital policy what would you recommend?

And here is what people recommended: 

1. Let hospital administrators and the board of directors know.

Mamas that are passing on a hospital because of their VBAC policy, need to then write the hospital administrators and the boards of directors to tell them that they birthed at XXX Hospital instead of theirs because of their VBAC policy. Hospitals need to hear that they are losing births (aka $$$) because of their policies.

2. Find an ICAN chapter near you.

She needs to get in touch with her closest local ICAN chapter TODAY. They will know details on the exact situation in her area. She should not put stock in what one person tells her- there is a lot of misinformation and myth out there. She can find both a local chapter and information about fighting a VBAC ban at www.ican-online.org

3. Sign a waiver and exercise your legal right to refuse surgery.

I had a VBAC at a hospital where no doctor staff supported it but low and behold all the nurses were amazing! I went in at 5 cm and 3 hours later baby was in my arms. Strong support is a must – I had a midwife, my husband, mom and sister. Stay focused. Don’t sign anything- except the refusal of c/section form- get in there and push your baby out!

and . . .

I would encourage her to ask to see this policy & ask if she would be allowed to sign a waiver. Ask friends if anyone they know has VBAC’d there or at another area facility. I had an experience in my last VBAC where I was told of a “policy” that didn’t really exist except in that person’s mind.

and . . .

Under the right to informed decision making she has the right to say “no thank you”. Absent a court order for a cesarean they cant force her. I’m not a huge fan of the “show up pushing” crowd, but it may appeal to her. Or she could labor in a nearby hotel with a midwife or montrice to monitor the baby and then go in to the hospital at the last minute. Again, not a fan but we’re looking at options here.

and . . .

Regarding stories of VBAC-ban hospitals. I don’t have experience myself, as my VBAC was done with a CNM at a supportive facility – but I’ve attended a VBAC at a local hospital with a VBAC ban. Mama had a RCS [repeat cesarean section] scheduled (though she didn’t intend on going in) but went into spontaneous labor 6 days prior. She labored at home several hours until contractions were about 3 minutes apart. When we arrived and they realized she had a previous c/s, they began calling in a team to prep the OR.

The mama was beyond calm – and in the middle of labor – requested to speak with the staff. The nurses (there were maybe 4 in there?), the attending OB, and the anesthesiologist (who had already been paged for the spinal for surgery) were in her room (ready to wheel her to the OR). Between contractions, she quickly and quietly explained that she was aware it wasn’t typical policy to attend a VBAC, but she was there and it was their legal duty to treat her and she was exercising her legal right to refuse unnecessary surgery.

The nurses looked shocked, the anesthesiologist said something about he was clearly not needed, and the OB (who I swear was VBAC accepting but just was staffed at a VBAC-ban hospital) told her that she was correct, they had to treat her and couldn’t force her to do anything unless her baby was in danger but she’d need to sign quite a bit of paperwork documenting the situation. He had the most odd grin/smirk on his face while he said that as if to somehow thank her for having the nerve to stand up for herself. He left the room and we didn’t see him again until she was crowning.

I in no way, shape, or form feel that that scenario is typical of a VBAC-ban situation, but it was certainly enjoyable and entertaining to have experienced that with my client.

and . . .

I just refused the c-section at a VBAC ban hospital. With my first, I pushed for 4 hours, and he didn’t get past the 0 station (he was presenting transverse) — We lived too far away from the hospital for a homebirth at our own home, but I hired the homebirth midwife for concurrent care. She was going to monitor us at a hotel near the hospital for labor, but thankfully everything went so fast we just met her at the hospital. She served as doula there. I found out from an OB nurse that one of the OBs did support a woman’s right to refuse (though not enthusiastically). I knew I needed care I could trust, so that the only c-section I got was medically necessary. You can read where my midwife tells our story here.

You have every right to refuse an unnecessary c-section, I’d just HIGHLY recommend laboring out of the hospital, and having a doula or knowledgeable advocate with you!

and . . .

This is my advice for VBACing at a banned hospital –

– Sign your informed refusal ahead of time, and be aware that when presented with the risks of VBAC, it will majorly underplay RCS risks; it might be a good idea not to bring your husband to this appointment if he’s feeling nervous about VBAC. [Or have your husband read this article beforehand.]

– Don’t let them give you a late term ultrasound for anything other than a medical problem (in other words — refuse the late ultrasound for size)

– Plan to labor out of the hospital; use a monitrice if you are nervous about that, or a good doula

– Have a smart advocate with you at the hospital so you don’t have to fight any battles yourself and can just focus on laboring

– Get good prenatal care — I did acupuncture and chiropractic, and both of those people had offered to help me in labor if I needed; having that support and belief was very empowering, because my OB absolutely didn’t think we “could” VBAC

– Own your decision; don’t be wishy-washy… be stubborn… this is YOUR BODY. I had a personal mantra that I repeated to myself over and over, “I will only have a medically necessary c-section.”

– Learn ways to get through labor naturally; I really liked the strategies in “Birthing from Within” — even more than hypno or Bradley techniques

– Show up in advanced labor (I was complete when we got to the hospital)

– Know your personal hang-ups — I pushed for 4 hours with my son and am SO GLAD that I labored down in a small bathroom until my urge to push was really strong and spontaneous; I am so glad I wasn’t on the bed pushing for a long time, because this would have brought back too many bad memories and made me feel panicky, tired, and out of control. When I got on the bed to push, I was practically crowning. THAT was very empowering for a “failure to descend” mama

To bottom line – do what you have to to get the care you need, even with limited options; own your body and decision, and give yourself every advantage and tool that you can to help ensure success.

and a VBAC supportive OB who worked in a VBAC ban hospital says:

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.

4. Ask a different person at the hospital.

Remember that not everyone is knowledgeable about VBAC or a specific hospital’s VBAC policy, even if they work at that hospital.

I have heard an OB tell a mother that her only option was repeat cesarean because the hospital didn’t allow VBAC. The director of Maternal Child Health said it absolutely wasn’t true and gave her the names of VBAC friendly providers.

5. Find another hospital via the VBAC Policies by US Hospitals database compiled by ICAN.

Remember you are buying a service. Why pay for something you don’t want. Shop elsewhere.

6. Find another provider and ask these questions.

7. Birth in another city, county, or state.

Know what you’re comfortable with, hire a doula as well as a midwife or doctor especially if you have a hospital birth, and do your research so you know your rights and options. I’m currently about to “relocate” to Seattle at 37 weeks, from Juneau, AK where there is a hospital VBAC ban at our one hospital in town so I can try to have a VBAC in a more supportive environment. I didn’t think I wanted to fight the VBAC ban while in labor, I’d rather do my political activism in a clearer state of mind! It has been a stressful journey but I know I’m doing what’s right for me so I’m feeling really good about things now. I know this isn’t an option for many and a few women since the beginning of 2011 have refused repeat c/s at our hospital. Good luck!

and . . .

Go somewhere else. . . I traveled 40 mins for my vbac in 2010 because the 6 hospitals around here wouldn’t let them either.

and . . .

I even know a family who crossed state lines to have her baby the way she desired because her states laws wouldn’t allow her.

Joy Szabo said

I found a sane doctor 5 hours away. I got slightly famous for it, too.

and I’ve heard of women traveling to Mexico to VBAC at Plenitude with Dr. José Luis.

8. Consider a homebirth.

Fighting the hospital system while trying to push out a baby is not a simple task. Yes, a support team can be a big help. Personally, I felt more comfortable staying home than going to the hospital with my boxing gloves. It’s a personal choice and she’ll have to see what she’s most comfortable with. At the end of the day, I played out both options in my mind and went with the one that I felt most at peace with.

and. . .

Hello, my personal story in a nutshell… iatrogenically necessitated c/s with my first. For #2, it was a last minute change of plans… I’m a physician and I discovered through the grapevine that OB was planning to resection me without medical indication so #2 turned into planned HBAC. Homebirth VBAC successful with my second. The second was so beautiful, so peaceful, so uncomplicated!

9. Connect with resources for more ideas.

Stratton, B. (2006). 50 Ways to Protest a VBAC Denial. Retrieved from Midwifery Today: http://www.midwiferytoday.com/articles/50ways_vbac.asp

A good closing thought:

The term “will not allow” always bothers me. Perhaps they “won’t attend a VBAC” but they definitely can not stop you. Stand up for your rights. Show them the ACOG recommendation which is to allow a trial of labor! Seek out support. Call every OB you can think of. Look into a midwife. Hire a doula. You can do this.

Do you have more ideas?

Did you deliver at a VBAC ban hospital?

What was your strategy?

Are you a health care provider at a VBAC ban hospital and have some insight?

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.

________________________________________

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.

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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

rutpures in scarred uteri

Myth: Induced unscarred mom as likely as VBAC mom to rupture

Update 1/20/12 – Someone who believed this birth myth to be true, told me that the source of this information was an OB from St. Louis who presented at the 2011 ICAN conference. I contacted ICAN and they said that the person must be referring to Dr. George Macones. Yet, no one on the ICAN Board, who were seated at the front table during his presentation, remembers him saying that induced, unscarred women have the same risk of uterine rupture as a VBAC mom. And I would think that if he gave a stat like, everyone would have remembered because it is quite a remarkable statement as you will see shortly. While many women repeat, believe, and defend this statement, no one has supplied one study to me to support it.

Update 1/21/12 – Ruth S Beattie Dicken, the Speaker Chair of the 2011 ICAN conference contacted me via Facebook and said, ” Dr Macones did not say that. Nor did any other OB. I sat in on every session with OB speakers.”

Update 1/21/12: The difference in uterine rupture (UR) rates between unscarred, induced uteri and scarred uteri is significant: 2.2 per 10,000 in an unscarred, induced uterus and 64 in 10,000 in a scarred uterus. But it’s not 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, even when she is induced.

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OBs are often vilified (rightfully so) for giving women inflated rates of uterine rupture and I’ve documented several examples over the years: 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?. But the midwife (or OB, but it’s generally a midwife) who gives false information that minimizes the risk of rupture is just as harmful to the VBAC mom. Since I wrote Lightning strikes, shark bites, and uterine rupture, I’ve been making mental notes of other birth myths that seem to be forwarded from woman to woman, without anyone asking, “That’s a great statistic! What’s the source?”

There is one that I hear quite often:

A woman without a prior cesarean whose labor is induced is just as likely as a VBAC mom to experience an uterine rupture.

Recently, I heard it again and I really wanted to know if there was some study that demonstrated this. It’s a logical conclusion that inducing an uscarred woman would increase her risk of rupture as uterine rupture is listed as a risk for Pitocin and prostaglandins (such as Cytotec and Cervidil) but how much does induction increase the risk of uterine rupture in an unscarred uterus? And does the rate of rupture increase so much that it is the same as the risk of rupture in a VBAC mom? I had unsuccessfully looked for that information in the past, so I went to my Facebook page and asked if anyone had a source.

Several women responded who had heard this information, two of which from their midwives which is really frightening. Unfortunately, no one who responded could cite where they heard this information. So I started looking and found Uterine rupture in the Netherlands: a nationwide population-based cohort study (Zwart, 2009).

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. You can read the study in its entirety here.

The role of induction in scarred and unscarred uterine rupture

Zwart utilized multiple methods of induction: cervical prostaglandins (sulproston, dinoproston, and misoprostol aka Cytotec), oxytocin (Pitocin) and mechanical dilatation. Prostaglandin “dosages ranged from 0.5 to 2.0 mg with a minimal interval of 4 h in between,” but they do not provide the dosages of the women who ruptured.

Of the 208 scarred and unscarred uterine ruptures, 130 (62.5%) occurred during spontaneous labor reflecting 72% of scarred ruptures and 56% of unscarred ruptures. 28 (13.5%) ruptures occurred during cervical prostaglandin induction. 22 (10.6%) ruptures occurred during oxytocin (Pitocin) induction.

It seems that there were women who were induced with prostaglandins and Pitocin as measured in Table 5. But there is no measure for women who ruptured and were induced with both prostaglandins and Pitocin in any of the uterine rupture tables.

There is no mention of Bishop’s score, but they did provide the “reasons for induction with prostaglandins [in scarred women which] included (nearly) post-term pregnancy (n = 10), intra uterine fetal death/ multiple congenital abnormalities (n = 5), elective (n = 3), pregnancy induced hypertension (n = 2), intra uterine growth restriction (n = 1) and prelabour rupture of membranes (n = 1).”

Interestingly, this Netherlands-based study found “there was a trend towards more liberal use of prostaglandins for induction of labour in low-volume hospitals as compared to middle- and high-volume hospitals (24.4% versus 13.0% of cases, P = 0.29).”

It’s also interesting that there were no maternal deaths even though “18 [unscarred] women (72%), rupture occurred outside office hours.”

The risk of uterine rupture in an induced labor without a prior cesarean

The study found, ” In 11 women [without a prior cesarean who experienced a uterine rupture], labour was induced, in all but one with prostaglandins.” Said in another way, 40% of the unscarred women who ruptured were induced with prostaglandins versus only 12.1% of scarred moms who ruptured.

So Zwart found that it’s not the Pitocin that causes the ruptures in unscarred moms, it’s the prostaglandins. This is logical because prostaglandins are harder to control. If the uterus is hyper-stimulating due to prostaglandins, they continue to work on the uterus even after they have been removed from the cervix. Pitocin, on the other hand, has a short half-life so the body responds quicker to the drip being turned off in the event of uterine hyper-stimulation.

While we know that there are 332,885 unscarred women included in this study, we don’t know the number or percentage of unscarred women who were induced. We need this information in order to calculate the rate of uterine rupture in induced, unscarred women.

So I did a little looking and I found Verhoeven (2009) which states ” In The Netherlands induction rates have remained stable over the last decades at approximately 15%.” Since the induction rate has been stable, and this study included 97% of births in The Netherlands between August 1, 2004 and August 1, 2006, I feel comfortable using this 15% rate of induction to calculate the rate of uterine rupture in induced, unscarred women.

So when we take 15% of the 332,885 unscarred women in the study, we get 49,933 induced, unscarred women.

Dividing the 11 ruptures that occurred in induced, unscarred women by 49,933 total induced, unscarred women, we get the following uterine rupture rate in induced, unscarred women: 0.022% or 2.2 per 10,000 deliveries.

Now let’s look at the rate of uterine rupture in women with a prior cesarean: “25,989 trials of labor were attempted in the Netherlands during the study [resulting in 183 ruptures.] The risk of uterine rupture would then be 0.64%” or 64 in 10,000 deliveries. This rate includes ruptures in induced and spontaneous labors, but we do know that 72% of those ruptures occurred during spontaneous labors.

In other words, a woman with a prior cesarean section has a uterine rupture risk 29 times greater than the risk of uterine rupture due to induction in a woman without a prior cesarean, 0.64% vs. 0.022%.

Another way to look at the data is: you would need to induce 4,546 women without a prior cesarean in order to get one uterine rupture due to induction.

While I hadn’t seen the numbers until now, I was always very skeptical when I heard this rumor. I’m glad to finally have hard numbers to share.

How does induction affect the rate of uterine rupture in an unscarred woman?

Next, since I had all the data available, I wanted to calculate how induction affects the rate of uterine rupture in an unscarred woman. Remember that 10 of the 11 ruptures in induced, unscarred women occurred during the use of prostaglandins and we don’t have information on the dosage in those labors.

We already established that the rate of rupture in an induced, unscarred labor was 0.022% or 2.2 per 10,000 deliveries.

The remaining 14 ruptures of the 25 total ruptures occurred during spontaneous labor.

14 spontaneous ruptures among 282,952 spontaneous labors in unscarred women, gives us a 0.0049% uterine rupture rate or .49 per 10,000 deliveries.

As I suspected, an unscarred woman induced with prostaglandins has a greater risk of uterine rupture than an unscarred woman in a spontaneous labor, but now we have exact figures: 0.022% vs. 0.0049%. Prostaglandin induction in an unscarred woman increases her risk of uterine rupture almost 5 times, but the overall risk is still extremely low.

Moving forward

It was interesting to note that among women with a prior cesarean, 72% of ruptures occurred during spontaneous labor. The scar itself, that prior cesarean surgery, is what increases the risk of uterine rupture the most. With this in mind, the researchers state:

With 29% of all previous caesareans being performed for breech presentation, we clearly show the negative side effects and long-term adverse consequences of routinely performing elective caesarean for breech delivery . . . the only means of reducing the incidence of uterine rupture is to minimise the number of inductions of labor and to closely monitor women with a uterine scar. . . Ultimately, the best prevention [of uterine rupture] is primary preventions, i.e. reducing the primary cesarean delivery rate. The obstetrician who decides to perform a caesarean has a joint responsibility for the late consequences of that decision, including uterine rupture.

This is why more hospitals offering breech vaginal birth and VBAC, such as Portland, OR based Oregon Health & Science University (OHSU), is so important. Read more about OHSU’s mission to reduce the cesarean rate.

As I say in Myth: Risk of uterine rupture doesn’t change much after a cesarean:

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.

I use the data in this same study to debunk the myth: the risk of uterine rupture is roughly double, or not much different, from an unscarred uterus. . . more dangerous information from what should be trusted sources.

Read more birth myths debunked including Lightning strikes, shark bites, and uterine rupture and Myth: Risk of uterine rupture doesn’t change much after a cesarean.

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Notes: This study found that there were 183 ruptures after a prior cesarean and states in the abstract that this reflects a rate of 0.051% or 5.1 per 10,000 deliveries. But the problem is, they divided the number of uterine ruptures after a cesarean by the total number of women (with a prior cesarean and without.) It’s only towards the end of the study do they state the risk of uterine rupture in a woman after a prior cesarean is 0.64%. So, this is a little confusing and is another example of why reading the entire study, rather than just the abstract, is so important.

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Verhoeven, C., Oudenaarden, A., Hermus, M., Porath, M. M., Oei, S. G., & Mol, B. (2009). Validation of models that predict Cesarean section after induction of labor. Ultrasound in Obstetrics & Gynecology, 34, pp. 316-321. Retrieved January 15, 2012, from http://onlinelibrary.wiley.com/doi/10.1002/uog.7315/pdf

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

entirety

Do intrauterine pressure catheters make VBAC safer?

A mom planning a VBA1C (vaginal birth after one cesarean) at a Southern California Kaiser recently emailed me. She discovered while interviewing her care provider and asking how they treat VBAC labors differently than non-VBAC labors (an excellent question), that they require intrauterine pressure catheters (IUPC) in all VBAC labors. She wanted to know what I thought of their policy.

As I read more and more about IUPCs, I was increasingly curious why they would be required.  The evidence for their ability to predict uterine rupture is lacking and as a result major OB/GYN associations do not endorse their use in VBAC labors.  Below you will find the recommendations of the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG aka Canada’s ACOG), abstracts of the studies they reference, as well as questions to ask your care provider if they require IUPCs.  As I find more info, I’ll update this page.

What is an IUPC?

WebMD describes it as “a small catheter that is placed along side the baby [that] measures the strength and duration of contractions.”

In order for the IUPC to be inserted next to the baby in the uterus, the fetal membranes must be ruptured and the cervix dilated to at least 1-2cm (UptoDate, 2011).  I suspect that this greatly, if not entirely, limits mom’s ability to move during labor depending on the policies of the hospital and care provider. This also increases the risk of infection and puts mom on the clock in terms of how long her care provider/hospital permits her to labor once her water has been broken.

Do professional obstetrical associations recommend IUPCs in VBACs?

While trying to find if IUPCs were helpful in labor, particularly in diagnosing uterine ruptures, the National Guideline Clearinghouse (2011) gave me a good starting point:

With regard to intrauterine pressure catheters, RCOG notes that their routine use in the early detection of uterine scar rupture is not recommended. ACOG similarly states that no data suggest that intrauterine pressure catheters are superior to external forms of monitoring, and there is evidence that their use does not assist in the diagnosis of uterine rupture.

What does ACOG say about IUPCs?

As I was interested in the exact language used in ACOG’s (2010) VBAC guidelines, I looked it up and found this:

No data suggest that intrauterine pressure catheters or fetal scalp electrodes are superior to external forms of monitoring, and there is evidence that the use of intrauterine pressure catheters does not assist in the diagnosis of uterine rupture.

What IUPC VBAC studies does ACOG reference?

ACOG cites only two studies in that paragraph. The first was published 18 years before ACOG’s recommendations where released and the second, 21 years before. If these are the best studies ACOG can find, then I’m left thinking that there are not many high quality studies on IUPC through 2010.

The first study cited was Devoe (1992) which concluded (emphasis mine),

Though intrauterine monitoring was brief, this model allows a unique view of ‘controlled’ uterine rupture. Spontaneous uterine rupture may evolve more gradually; however, neither catheter type [fluid-filled or solid] would be likely to aid its early recognition.

The second study was Rodriguez (1989) which found (emphasis mine):

The usefulness of the intrauterine pressure catheter in the diagnosis of uterine rupture was assessed by review of 76 cases of uterine rupture, 39 of which were monitored with an intrauterine pressure catheter. The classic description of a loss of intrauterine pressure or cessation of labor was not observed in any of the patients. However, an increase in baseline intrauterine pressure was observed in four patients with an intrauterine pressure catheter. The increase in pressure was associated with severe variable decelerations such that by itself the intrauterine pressure catheter added little to the diagnosis of uterine rupture.

What does RCOG say about IUPCs?

Then I looked up RCOG’s (2007) VBAC guidelines and it stated (emphasis mine):

The routine use of intrauterine pressure catheters in the early detection of uterine scar rupture is not recommended. Observational studies, with varying methodology and case mix, have shown that intrauterine pressure catheters may not always be reliable and are unlikely to add significant additional ability to predict uterine rupture over clinical and CTG surveillance. Intrauterine catheter insertion may also be associated with risk. Some clinicians may prefer to use intrauterine pressure catheters in special circumstances (such as in women who are obese, to limit the risk of uterine hyperstimulation); this should be a consultant-led decision.

What IUPC VBAC studies does RCOG reference?

RCOG cites four studies in that paragraph. Again, it’s surprising that these studies were published 15 – 25 years before the 2007 RCOG guidelines.

First, Arulkumaran (1992) which I found so interesting, I included the entire abstract (emphasis mine):

To evaluate the symptoms and signs of scar rupture with special reference to intrauterine pressure measurement a retrospective analysis of labour records of those women who had trial of labour with a previous Caesarean scar in the National University Hospital over a period of 6 years (1985-1990) was carried out. Known symptoms and signs associated with scar rupture, cardiotocographic tracings and fetal and maternal outcome in these patients were studied. Of the 1,018 women with previous Caesarean scar (4.2% of our pregnant population at term) 722 (70.9%) had trial of labour; 70% delivered vaginally. There were 4 (0.55%) incomplete and 5 (0.69%) complete scar ruptures. All 9 women had an oxytocin infusion; 3 were diagnosed postdelivery (all 3 had complete ruptures); 3 of the 6 who had rupture prior to delivery had sudden reduction in uterine activity, 1 had scar pain and prolonged bradycardia and 2 had no symptoms or signs. Continuous cardiotocography with intrauterine pressure measurements may help to identify scar rupture early and may be of value especially in those who have an oxytocin infusion.

Second, Beckley(1991) whose abstract doesn’t give us much information:

A series of 12 trials of scar associated with scar rupture is reviewed. Uterine activity patterns were assessable in 10 of them. Clinical features and characteristics of the intrauterine pressure waveform and uterine activity are discussed in relation to the integrity of the scar.

The third study RCOG cited was Rodriguez (1989) which ACOG also cited and I previously shared.

Fourth, Madanes (1982) whose abstract also is lacking any conclusions or major findings:

A case of uterine perforation by an intrauterine pressure catheter is described. Five similar cases from the literature are reviewed. A revision of the pressure catheter insertion technique is discussed.

Do IUPCs pose any risks to the baby?

I was very disappointed in the overall lack of published research on IUPCs in VBACs. I was further disappointed that there was very little discussion on the specific risks of IUPCs to mom or baby and at what rate these complications occur. I found Wilmink (2008) which discusses the IUPC related complications in two labors resulting in one infant death:

CASES: We describe the placement of an IUPC during induction of labor with oxytocin in two cases, one presenting with a singleton pregnancy and the other a twin pregnancy. After introduction of the IUPC, both cases were complicated by blood loss and signs of fetal distress on cardiotocography. An emergency cesarean section was performed in both cases. In the first case, extramembranous placement of the IUPC was observed, whereas in the second case, the IUPC had lacerated an arteriovenous anastomosis in the membranes, resulting in perinatal [infant] death. CONCLUSION: Placement of an intrauterine pressure catheter instead of external tocodynamometry has a small risk for serious fetal complications.

It would be helpful to have a large scale study on IUPCs conducted so we know how frequently complications like this occur.  It’s very difficult to weigh the pros and cons of IUPCs if we don’t fully understand the risks that they pose.  Is it worth mandating the use of IUPCs in VBAC labors if it means that the misplacement of the IUPC could sever the blood, and thus oxygen, supply to baby?

If your care provider requires IUPCs, what questions should you ask?

I posted on my Facebook page requesting the opinion of various midwives and OB/GYNs I know on the use of IUPCs in VBAC labors. Barbara Herrera provided this excellent list of questions:

  1. How will you know if there is a UR [uterine rupture]? What signs are you looking for?
  2. What is the process you go through to know it is a UR and not the IUPC misplacement or falling out?
  3. Who puts the IUPC in? The RN? Or you (the doc)? Who has more experience putting it in?
  4. How do we assure its proper placement?
  5. Will I be able to move about the bed and beside the bed once the IUPC is placed?
  6. If the IUPC registers something is amiss, as long as the FHR [fetal heart rate] is still okay, can I trust those around me not to freak out until we know if it is dislodged or misplaced? (Most women are much more able to move around with the IUPC than the external monitors.)
  7. Will using the IUPC mean I am going to have pitocin augmentation at some point?

The take away message

In light of the fact that

  • ACOG and RCOG do not recommend the use of IUPCs in VBACs as
  • IUPCs have not been proven effective in predicting uterine rupture and as
  • IUPCs can pose risks to babies (including blood loss and signs of fetal distress resulting in emergency cesareans and infant death) at a rate that we do not yet know while
  • requiring the (premature) breaking of fetal membranes (“breaking your water”),
  • increasing the risk of infection, and
  • possibly restricting mom to bed for her labor,

I can’t imagine why any hospital or OB would require their use.*

Elizabeth Allemann, MD left this comment on my Facebook page which I think summed up the issue well:

If a woman has decided to labor and birth with a uterine scar, she’s made her decision. If she wants to be successful, she’ll need what every woman needs to give birth: privacy, love, good nutrition, time, patience, touch, and care by a team that trusts her to give birth. And she’ll need that even more because she’s been scarred–in her heart and soul, not just on her uterus. And we need things to come down and out. An IUPC isn’t going to give her any of that. It’s a sad state of affairs when we can’t provide any of that in the hospital (generally) for any women and we end up forcing women to birth at home, just to get a chance to birth at all. Not that there’s anything wrong with home birth, but if a woman wants to give birth in the hospital, we should be able to provide that for her without a Niagara Falls of interventions waiting to pounce on her.

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* I had a conversation with a friend who teaches Bradley childbirth classes recently. She said that OBs/hospitals use IUPCs because then they can show that they “did everything” to protect the mom from uterine rupture and in the event that a UR did occur and they were taken to court, they could bring that information with them. But I responded with the fact that IUPCs have not been proven effective in predicting UR and ACOG/RCOG don’t recommend their use, so I don’t believe that would be a strong enough argument hold up in court.  I’m not an attorney, so I could be completely wrong, but that is what makes sense to my non-legal mind.

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American College of Obstetricians and Gynecologists (ACOG). Vaginal birth after previous cesarean delivery. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2010 Aug. 14 p. (ACOG practice bulletin; no. 115).

Arulkumaran S, Chua S, Ratnam SS. Symptoms and signs with scar rupture: value of uterine activity measurements. Aust N Z J Obstet Gynaecol 1992;32:208–12.

Beckley S, Gee H, Newton JR. Scar rupture in labour after previous lower uterine segment caesarean section: the role of uterine activity measurement. Br J Obstet Gynaecol 1991;98: 265–9.

Devoe LD, Croom CS, Youssef AA, Murray C. The prediction of “controlled” uterine rupture by the use of intrauterine pressure catheters. Obstet Gynecol 1992; 80:626-9. (Level II-2)

Lucidi RS, Chez RA, Creasy RK. The clinical use of intrauterine pressure catheters. J Matern Fetal Med. 2001 Dec;10(6):420-2. Review. PubMed PMID: 11798454.

Madanes AE, David D, Cetrulo C. Major complications associated with intrauterine pressure monitoring. Obstet Gynecol 1982;59: 389–91.

National Guideline Clearinghouse (NGC). Guideline synthesis: Vaginal birth after cesarean (VBAC). In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): 2011 Jan. [cited YYYY Mon DD]. Available: http://www.guideline.gov.

Royal College of Obstetricians and Gynaecologists (RCOG). Birth after previous caesarean birth. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2007 Feb. 17 p. (Green-top guideline; no. 45).

Rodriguez MH, Masaki DI, Phelan JP, Diaz FG. Uterine rupture: are intrauterine pressure catheters useful in the diagnosis? Am J Obstet Gynecol 1989; 161:666-9. (Level III)

Wilmink FA, Wilms FF, Heydanus R, Mol BW, Papatsonis DN. Fetal complications after placement of an intrauterine pressure catheter: a report of two cases and review of the literature. J Matern Fetal Neonatal Med. 2008 Dec;21(12):880-3.

Contra Costa Regional Medical Center Supports VBAC & Wins Award

Below I’ve included an article from MartinezPatch and I highlighted some sections.  This hospital boasts a 90% VBAC success rate.  That is huge!

As I shared in A father asks “Why invite the risk of VBAC?:

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.

It just goes to show that if a hospital is willing to make the effort, they can offer VBAC safely and with “no long-term complications among patients who attempt a VBAC birth or to their babies.”  Kudos Contra Costa!

Contra Costa Regional Medical Center Wins Award for Perinatal Program

County hospital receives top honors for its program to reduce repeat cesarean sections.

December 20, 2011

Contra Costa Regional Medical Center (CCRMC) in Martinez has been honored for its perinatal program that helps more women who have had a cesarean delivery avoid the surgery with their next pregnancy.

CCRMC received the award earlier this month from the California Association of Public Hospitals and Health Systems and its quality improvement affiliate, the California Health Care Safety Net Institute. The award is given to a public hospital program that best represents an innovative approach to improving health care.

Historically, most medical providers advised women who have had a C-section not to attempt a non-surgical delivery because of the slight risk of a tear in the uterine wall during labor that can be dangerous to the mother and baby. However, in recent years established medical science has recognized that a vaginal birth after a cesarean (VBAC) is possible and preferable whenever it can be achieved safely, according to Judith Bliss, MD, chair of CCRMC’s Obstetrics and Gynecology Department.

“A non-surgical delivery carries less risk to mom and baby and allows them to bond more quickly.  The key is being able to offer this option to women who’ve had a cesarean while ensuring the safest outcome possible,” Dr. Bliss said. “It’s a great joy to be able to offer many women this choice when they thought the option didn’t exist.”

The 166-bed county hospital is part of Contra Costa Health Services and about 15 percent of all babies born in Contra Costa County are delivered there. CCRMC’s perinatal unit was able to provide previous C-section patients with the VBAC option by developing a specific set of interventions, known as a “bundle,” to ensure staff could respond quickly to any complications that might occur during labor or delivery. The interventions include the ability to perform an emergency C-section, which should be started immediately in the unlikely event that a uterine rupture should occur.

Since initiating the program in October 2009, CCRMC has had significant success in reducing the percentage of repeat C-sections among eligible patients. This year, the average vaginal delivery rate for VBAC patients at CCRMC has averaged close to 90 percent through September; the national success rate for VBAC births ranges from 60 – 80 percent.   CCRMC’s success rate has been attained with no long-term complications among patients who attempt a VBAC birth or to their babies, noted Dr. Bliss, who heads the team for the VBAC project.

CCRMC developed the VBAC program in close collaboration with the Institute for Healthcare Improvement, a not-for-profit organization based in Cambridge, Massachusetts that works with health care providers and leaders throughout the world to achieve safe and effective health care.  “At a time when many providers have shied away from offering women the VBAC option because of the challenges involved, it’s very gratifying to see this hospital make such a strong commitment to doing what it takes to give patients this opportunity,” said Peter Cherouny, MD, chair of the Perinatal Improvement Community with IHI. “They’re clearly putting their patients first and doing what’s best for both mother and child.”

“We know that there are times that we have no choice but to perform a C-section,” Dr. Bliss said. “But today women have the option of having a non-surgical delivery knowing every step has been taken to assure their safety and their baby’s. To see mom and newborn together right after the birth – skin-to-skin, breastfeeding, with their families nearby – lets us know that our efforts and our vigilance are paying off.

Go here to see a video about CCRMC’s award-winning “Vaginal Birth after Cesarean (VBAC) Improvement Project.”

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 parents.

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

A reader asks, Am I making the right choice?

Isha recently left this comment:

I am pregnant and plan on having a VBAC. As my due date gets closer, I get more nervous about it. I hope I am making the right choice in having the VBAC.

Hi Isha!

I too wondered if it was unreasonable to plan a VBAC and that is when I started researching.  I found that learning more about the risks and benefits of VBAC vs. repeat cesarean gave me a lot of peace.  Check out the Quick Facts page for a brief overview and for more information, check out the information made available by the 2010 National Institutes of Health VBAC Conference.

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.

So I was really surprised to learn that uterine rupture occurs at a similar rate to other obstetrical complications such as shoulder dystocia, 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 of us as first time moms worried our entire pregnancies about any of those complications? How many of us considered an elective primary cesarean in an attempt to circumvent them? How many of us were offered, or even strongly pressured, to consider an elective cesarean by our friends, family, or OB?  How many of us where made to feel selfish over our desire to plan a vaginal birth?

Yet 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.

Just looking at the risks of VBAC isn’t enough when considering your options.  One must also consider the risks of a repeat cesarean.

I also suggest reading Another VBAC Consult Misinforms and Scare Tactics vs. Informed Consent for more discussion on how women are subtley, and sometimes not so subtley, coerced into repeat cesareans by their care providers.  Additionally, check out VBAC Ban Rationale is Irrational for why the much often quoted “24/7 anesthesia requirement” doesn’t make laboring women or hospitals safer.

Most people are not aware of these facts and thus rely on the conventional wisdom and persistent rumor that VBAC is so risky and cesareans are so safe. Neither are true. Both have risks and benefits.

But when comparing the risks and benefits, both the American College of Obstetricians and Gynecologists (2010) and the National Institutes of Health (2010) have deemed VBAC a “reasonable option” for “most women” with one prior cesarean and “some women” with two prior cesareans.  Most people don’t know that either.

I hope this information gives you some peace.  While it’s not terribly soothing to learn that there are major, rare complications that can occur with either option, it’s also good to know that VBAC is not an excessively risky choice.

Warmly,

Jen

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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

American College of Obstetricians and Gynecologists. (2010). ACOG Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Washington DC.

Ananth, C. V., Berkowitz, G. S., Savitz, D. A., & Lapinski, R. H. (1999). Placental abruption and adverse perinatal outcomes. JAMA , 282 (17), 1646-1651.

Goer, H. (n.d.). When Research is Flawed: The Safety of Planned Vaginal Birth After Cesarean. Retrieved August 23, 2010, from Lamaze International: http://www.lamaze.org/Research/WhenResearchisFlawed/VBACLandon/tabid/175/Default.aspx

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.

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