Category Archives: VBAC

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.

___________________________________________

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?

Amber,

First educate yourself and then you can take action. You have many options.

I suggest you review the following documents and provide a copy to your health care provider: the most recent ACOG VBAC guidelines, the National Institute of Heath’s 2010 VBAC Statement, and the article VBAC ban rationale is irrational.

Next, read through the steps of planning a VBAC and familiarize yourself with the misinformation that some OBs have used to persuade women to schedule repeat cesareans, so if you hear these same lies, you can identify them: Another VBAC Consult Misinforms, Scare tactics vs. informed consent, VBACing against the odds, and A father says, Why invite the risk of VBAC?.

Additionally, it’s important to know that there are many birth myths rampant on the internet that misrepresent the primary risk of VBAC by minimizing the risk of uterine rupture such as “the risk of uterine rupture in a VBAC mom is similar to (or double) that of an unscarred mom’s risk,” or “the risk of uterine rupture in an induced, unscarred mom is the same as a VBAC mom,” or “a VBAC mom is more likely to be bitten by a shark or struck by lightning than have an uterine rupture.” Again, all these statements are false. And if you see a blog report really low uterine rupture or mortality rates, it’s likely the result of incorrect math.

On to your question. . . Unfortunately, I don’t have any personal experience of pursuing a VBAC in a VBAC ban hospital because I planned a home VBAC in order to avoid all that (almost certain) drama in the hospital. So, I went to my Facebook peeps and got their suggestions and they did not disappoint!

Here are their ideas in their own words…

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