Category Archives: VBAC

VBAC Ban Rationale is Irrational

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

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

Hi Virginia,

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

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

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

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

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

The ability of rural hospitals to safely attend VBACs, as well as a specific plan that they could implement, was extensively discussed at the March 2010 National Institutes of Health VBAC conference.  One doctor spoke during the public comment period and stated that her rural hospital  – without 24/7 anesthesia – had a VBAC rate of over 30%!  It turns out, if a hospital is supportive of VBAC and motivated, they can absolutely offer VBAC safely.  (I also welcome you to read the commentary of two obstetricians and one certified nurse midwife who argued against the VBAC ban instated at their local rural hospital.)

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

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

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

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

Additionally, as I argued here:

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

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

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

This is a huge change.

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

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

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

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

______________________________________________

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

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

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

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

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

ACOG issues less restrictive VBAC guidelines

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

In short, VBAC is a “safe and appropriate choice for most women” with one prior cesarean and for “some women” with two prior cesareans.  Being pregnant with twins, going over 40 weeks, having an unknown or low vertical scar, or suspecting a “big baby” should not prevent a woman from planning a VBAC (ACOG, 2010).

What follows is a brief overview of these new guidelines.

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

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

They express support for VBAC with twins or unknown scars:

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

They say a Pitocin induction remains an option:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Portraying OBs as the bad guys?

Miriam left this comment in response to the article entitled, Hospital VBAC turned CS due to constant scare tactics:

Many of the stories on this website point to the ob/gyns as the bad guys.  While I believe there may be some doctors that use tactics and lies, it is overlooked that the doctors are just as misinformed and scared as the patients!

I would like to add a little clarity based on my experience as a patient who has had 2 c-sections.  I had a section 5 years ago due to “failure to progress”.  (5 minutes after the consent, while the doctor was prepping for surgery, my body signaled the progress I had been “failing” to reach with the most incredible urge to push.  However, I thought he knew best and stupidly agreed to continue with the c section.)  I have regretted it ever since.   However, I believe that the doctor truly was concerned and I trusted it, despite the fact that I personally believe I could have delivered vaginally.

The reason I believe some doctors’ concerns are sincere if not valid is because of the education, both formal and informal, they have received.  My ob/gyn was a specialist in many fields of womens’s medicine and so I trusted that.  Little did I know I was signing on an expert in surgery.   A doctor’s entire training revolves around how to interfere with something very natural… childbirth.  They are taught about evey possible bad case scenario, so they are prepared, so they are trained in intervention.

Then they go into the field and begin to learn the hospital and insurance policies that insist the doctor use these scare tactics becase they have been bitten so badly financially by unsatisfied women who sue them into making this policies in the first place.   The problem is the high costs associated with lawsuits and therefore, the rest of the vbacs suffer.  In my case, I was not ever “allowed” a second c-section because the hospital had lost a single lawsuit against a woman who hemmoraged during her vbac.  It was my “bad guy” doctor that has to pay the high cost of mal-practice to the point that, combined with the overhead of his office, he had to deliver 150 before he began to make any money.  So out of fear he falls back on his training which tells him that women need help to get a baby into the world.

Instead of blame (another product of fear) we should look to ourselves and educate each other about how to accept disappointment and best of all, how to avoid it by educating ourselves.  We can have more confidence for it’s own sake instead of walking into birth/labor with the attitude of going to war with our practitioners.

Miriam,

I agree with a lot of what you said.   I share these stories for a multitude of reasons, none of which include the desire to portray OBs as “bad guys.”

I want women to understand that there are OBs who practice in this manner.  I want to share with women the various tactics that these type of OBs use in order to passively, or actively, encourage a woman to have a repeat cesarean.  I want women to know that if they encounter these tactics from their OB that they have options.  They can find another care provider that supports VBAC.  There are absolutely wonderful OBs out there.  I had the opportunity to hear many speak at the NIH VBAC Conference this past March.

You said, “Instead of blame (another product of fear) we should look to ourselves and educate each other.”  I agree.  Yet there are many women who say, “Why do I need to educate myself?  I didn’t go to medical school.  That is why I hire my OB.  To advise me.” Being an informed patient is important regardless.

It’s not until they read a birth story like this do they see how wildly the “standard of care” can vary depending on who you hire as your care provider.  That is why I share stories like this.  To illustrate how bad the care can be to encourage women to become active participants in their care rather than passive patients along for the ride.

You talk about OBs being “misinformed and scared.”  You stated, “Then they go into the field and begin to learn the hospital and insurance policies that insist the doctor use these scare tactics because they have been bitten so badly financially by unsatisfied women who sue them into making this policies in the first place.”

OBs who have been sued over VBACs have a higher propensity to not attend VBACs in the future, but is it ethical for a doctor to encourage a women to have a repeat cesarean solely because they have been sued?

I think the most ethical thing an OB can do is be honest with the patient about their fears and refer them to a care provider who is supportive of VBAC.  Unfortunately, what some of these OBs do is either lie to the patient about the risks of VBAC vs. repeat cesarean (read Another VBAC Consult Misinforms and Scare Tactics vs. Informed Consent for more) or act like they will give the patient a trial of labor only to pull the plug with some bogus reason in the last weeks of pregnancy or even in labor.

If an OB doesn’t want to attend VBACs, they should be upfront with the patient so they have the opportunity to find a provider who is supportive.

Warmly,

Jen

Another VBAC consult misinforms

At the NIH VBAC Conference, I was happy to hear the draft Consensus Statement acknowledge that there were non-medical factors that affect women’s access to VBAC:

We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL [trial of labor after cesarean]. . . We are concerned that medico-legal considerations add to, as well as exacerbate, these barriers.

Many women assume that their local hospital has banned VBAC, or their OB doesn’t attend them, because VBAC is excessively dangerous.  Most women are unaware of the many non-medical factors that play into VBAC accessibility.

What disappointed me, however, was the panel’s surprise at the misinformation and bait & switch tactics to which many women are subjected.  I think when you are a VBAC supportive practitioner, it may be hard to believe that your colleagues practice in a manner like I describe below.

To give you an idea of the kind of advice that many, many moms seeking VBAC receive, here are excerpts of an email from Brooke Addley of northeastern Pennsylvania.  She decided to ask her OB about VBAC at her annual exam in March 2010.  This is what happened:

Once I brought the subject up stating that I really would not be open to a c-section unless it was medically necessary he said “they are all medically necessary” and then went on to mention that just within this last month there were two major ruptures at the local hospital.  From there he just talked about the risk of VBAC and how catastrophic it could be if there was a rupture.

A uterine rupture can be catastrophic, but it is rare and the incidence of uterine rupture is comparable to other obstetrical emergencies such as placental abruption which has a worldwide rate of 1%.  As Mona Lydon-Rochelle PhD, MPH, MS, CNM said at the NIH VBAC conference, “There is a major misperception that TOLAC [trial of labor after cesarean] is extremely risky” and George Macones MD who stated in terms of VBAC, “Your risk is really, really quite low.”  Additionally, the risk of infant death during a VBAC attempt is “similar to the risk” of infant death during the labor of a first time mom (Smith, 2002).

One of the factors discussed at the NIH VBAC conference is that a practitioner is less likely to offer VBAC if they have experienced a uterine rupture, particularly if there is a bad outcome.  However, that ethically should not interfere with him providing his client with accurate information on the rate of uterine rupture as well as studies that substantiate the rate provided.

When I cited the low rate of uterine rupture [of 0.5% – 2% after one prior low transverse cesarean] he said “that information is incorrect and the rate is actually higher.”  Yet when I asked him to lead me in the direction of the study or studies where he found that out he said there isn’t any because many women have repeat [cesareans] and once in the OR it is discovered that they have a thin window in their uterus and if they labored/pushed it would have ruptured for sure.

The rate of rupture in a spontaneous labor after one prior low transverse incision is 0.4% (Landon, 2004). So not only did he give her an inaccurate picture about the rate of rupture, but he led her to believe that there are no studies on VBAC.  (I always wonder in situations like these: Is the OB really actively trying to mislead the patient or is he really so misinformed?)  This OB should read the NIH VBAC conference Program & Abstracts, or my VBAC Class bibliography, to see that in fact there are many studies on VBAC.

Then the OB gives her inaccurate information on VBAC success rates:

I asked the VBAC success rate and he said that most fail.

VBACs have a success rate of about 75% which has been the conclusion of many studies  (Coassolo, 2005; Huang, 2002; Landon, 2005; Landon, 2006; Macones, 2005).  Success rates vary based on a variety of factors, but to say that ‘most fail’ is absolutely false.  What this OB should say is, “Most women who attempt a VBAC with me as their care provider fail,” which is probably 100% true.

And then the OB gives her the line that many women fall for:

He did however say that although he really does not recommend it . . . he would allow me to try.

And there is the hook.  So many women are satisfied to simply be given the opportunity to VBAC.  Unfortunately, from what this OB has said already, I do not believe Brooke would have a genuine opportunity to VBAC.  Surely this OB would come up with some “valid medical reason” that she needs a cesarean sometime during her pregnancy or labor.  Here come the requirements to be granted a trail of labor:

…yet there are many things that would have to be taken into consideration, including my unproven pelvis. He mentioned that in the hospital I would have to have continuous monitoring and 18 hours after my water broke, if I was not progressing, they would want to use Pitocin to advance the labor.  He also mentioned that he does not allow any woman under his care to go past 40 weeks.

The unproven pelvis standard is bizarre.  Don’t all women pregnant with their first child have an unproven pelvis?  Do we offer them all of them an elective primary cesarean to prevent a “failed vaginal delivery?”

No stereotypical VBAC consult full of misinformation is complete without a healthy helping of repeat cesarean risk minimization:

He did not mention risks to repeat c-sections.  When I brought it up he said there aren’t any except the obvious risks that come with any surgery.

False, false, false.  According to Silver (2006), a four year study of up to six repeat cesareans in 30,000 women:

Increased risks of placenta accreta, hysterectomy, transfusion of 4 units or more of packed red blood cells, [bladder injury], bowel injury, urethral injury, ileus [absence of muscular contractions of the intestine which normally move the food through the system], ICU admission, and longer operative time were seen with an increasing number of cesarean deliveries…. After the first cesarean, increased risk of placenta previa, need for postoperative (maternal) ventilator support, and more hospital days were seen with increasing number of cesarean deliveries…Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.

It is quite typical for a woman to receive inflated rates of uterine rupture while the practitioner minimizes the risks of repeat cesarean.  This OB goes one step further and claims there are no risks at all besides the general risks associated with surgery.

It is no wonder that most women ‘chose’ repeat cesareans and only 45% of American women are interested in the option of a VBAC (Declercq, 2006).  What kind of choice is it when you make major medical decisions without even a fraction of accurate information?

There is much discussion and debate about what constitutes informed consent.  However, there is no debate that informed consent fundamentally consists of understanding the risks and benefits of your options.  When a woman only hears the (inflated) risks of option one and the (inaccurate) nonexistent risks of option two, it is clear that her practitioner is trying to influence her final decision by skewing the information provided.

Finally, the OB suggests that the desire to have a vaginal birth and avoid medically unnecessary surgery warrants psychological help:

I flat out said to him that I just cannot have another c-section [without medical indication] and he told me that I need to see a therapist, [that] it’s not that big of a deal and it is the safest way to go!

It might be helpful for this OB, and others who think like him, to learn more about how women are impacted by their cesareans.  Cesareans performed on otherwise healthy babies and healthy moms are absolutely a big deal to many women.  Even when cesareans are medically indicated, there are women who still mourn the loss of a vaginal birth even as they celebrate their healthy baby and the technology that made their entrance into the world safe.  Read American Women Speak About VBAC for more personal stories.

Then the OB makes it sound like he’s the only game in town:

Oh and then at the very end he said I could always go with another provider but he is pretty much the most open to VBAC.  I flat out told him that he is not VBAC friendly at all and that if he is the most open in town I have quite the battle ahead of me.

The emotional fallout of the appointment:

The entire visit I just had to hold back tears and once I hit the street I lost it.  I just want to hit my head against a wall!! I’m just sad, sad that it has to be this way – sad that, as much as I want to have another baby, I dread getting pregnant.  Sad that women are told this shit and forced to believe it.  I’m just in such a funk now…..just a sad, sad funk.

But it’s not just Brooke.

Michelle was told by her OB that uterine rupture rates increase with each VBAC which contradicts a 2008 study that concluded the risk of uterine rupture drops 50% after the first VBAC (Mercer, 2008).  One of the women who attended the VBAC class this past Sunday said that her OB quoted a uterine rupture rate of 6-10% after one prior low transverse cesarean. Sarah was quoted a rate of 10% “after the first section.”  Karla was also quoted 10% and called “selfish” by her OB who was “appalled that [she] would risk the life of [her] baby.”  Once again, the correct rate for uterine rupture in a spontaneous labor after one prior low transverse cesarean is 0.4% (Landon, 2004) and these women are quoted rates 15 – 25 times higher.

Another way doctors lie is by circumventing the risk of VBAC issue entirely.  A friend told me that her doctor said her medical insurance wouldn’t pay for a VBAC.  So believing her doctor and thinking she didn’t have any other option, she had a scheduled repeat cesarean. Turns out, my friend had the same medical insurance as me and that same insurance reimbursed me for my homebirth VBAC.

And who can forget the irate mom who left a comment on the VBACfacts Facebook fan page expressing her disbelief that any “selfish idiot” would pursue a VBAC.  Her OB told her that there was a 10% infant and maternal mortality rate with trials of labor after cesarean.  When I emailed her with the correct rates of 0.02% for maternal mortality and 0.05% for infant death or brain damage (Landon, 2004) and requested she forward any studies supporting a 10% mortality rate, she didn’t reply.

VBAC consults that misinform are all to common and help contribute to the 90% repeat cesarean rate in American (Hamilton, 2009).  If you are a VBAC supportive practitioner, and would like to make it easier for women in your community to find you, please read: How to best connect moms with VBAC supportive practitioners?

Learn more about finding a supportive care provider:

______________________________________________________

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

Declercq, E. R., & Sakala, C. (2006). Listening to Mothers II: Reports of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection.

Hamilton, B. E., Martin, J. A., & Ventura, S. J. (2009, March 18). Births: Preliminary Data for 2007. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_12.pdf

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

Landon, M. B., Hauth, J. C., & Leveno, K. J. (2004). Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery. The New England Journal of Medicine , 351, 2581-2589.

Landon, M. B., Leindecker, S., Spong, C., Hauth, J., Bloom, S., Varner, M., et al. (2005). The MFMU Cesarean Registry: Factors affecting the success of trial of labor after previous cesarean delivery. American Journal of Obstetrics and Gynecology , 193, 1016-1023.

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

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

Mercer, B. M., Gilbert, S., Landon, M. B., & Spong, C. Y. (2008). Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstetrics & Gynecology , 11, 285-91.

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

Smith, G. C., Pell, J. P., Cameron, A. D., & Dobbie, R. (2002). Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. Journal of the American Medical Association , 287 (20), 2684-2690.

American Women Speak About VBAC

I’m here at the NIH VBAC conference and my brain is swimming!  I want to write a separate article later on the conference itself, but for now I want to share with you a piece I put together for the benefit of the panel who will be writing the Consensus Statement.

I received many requests to share it online, not only from conference attendees but by the women themselves who contributed their stories for this piece.  You can download a PDF copy of this document here.

I’m especially excited that I had the opportunity to share the comments provided by Wendy S. from California, Kristen K. of Nebraska, and Rachel R. of Oregon during the public discussion time which you can view via the Day 2 Webcast.  (You can also view the Day 1 Webcast, download a PDF of the Program and Abstracts, as well as pre-order the consensus statement.  The more people who order the consensus statement, the more powerful the message that people are interested in the option of VBAC.)

While the contributors gave permission for their full names to be used on the  handout I distributed at the NIH, not everyone is comfortable with their name on the internet.

American Women Speak About VBAC

In an effort to bring the consumer perspective to the 2010 NIH VBAC Conference,  Jennifer Kamel, Founder of VBAC Facts, asked women across America, “Why is the option of VBAC important to you?”  This is what they said.

Alabama – To avoid not being able to carry your baby because he’s dead from the placental abruption (or uterine rupture) as a result of those damn previous cesareans. – Amanda M.

Arizona – VBAC is important to me because I don’t want to continue to have increased risks with each major surgery. – Amanda McM.

Arkansas – Personally, VBAC is stellar important to me because I wanted to give birth to my babies, not have them cut out and handed to me.  On a soul-deep level, I believe it was necessary to validate my purpose in existing.  – Jer W.

California – It is important to me because I have the right to experience the complex passage of vaginal birth and the positive cascade of effects for mom and baby.  I want the right to experience VBAC without driving 90 minutes or more with traffic. Successful or not, VBAC empowers women for choice and a chance to fill an emotional void that is unmatched.  The whole “readily available” lawyer talk certainly is not protecting our other high risk patients.  – Wendy S., L&D RN

Because when a woman experiences a VBAC, she reclaims her body and gets to see that she is in fact perfectly capable of giving birth without surgery.  She is no longer broken.  Her body and spirit heal. – Layla M.

To me it is like saying someone should be required to have open heart surgery, even though a laparoscope would be safer, just because doctors/ hospitals/ insurance companies, prefer it that way.  It is so much bigger than our desires to experience a vaginal birth or even to be some kind of hippie earth mother. It is about our right to safe and respectful medical care. Courtney Stange-Tregear

I wanted a VBAC to heal my raw emotions and psychological trauma caused by not having a vaginal birth the first time and because I believe it’s safer. Unfortunately, I had to travel 3 hours to get to the closest facility that allowed VBACs. But having the chance to VBAC was great! – Andrea O.

Because I love women and love babies and have spent 20 years investigating what affords the best possible beginning for them both and that is a vaginal birth. – Joni Nichols BS MS CCE CD(DONA) (CBI)

It is wrong that I have to travel to another county and fight for a normal, safe, healthy birth for my baby.  Hospitals and doctors need to get their priorities straight and practice true informed consent. – Kathleen S.

My VBAC proved to me that I was not as broken as I felt after receiving so many labels [FTP, etc] regarding my cesarean. – Alexandra R.

Colorado – VBAC allowed me to trust in my body and let it do what it needed to do.  My midwife and her assistant viewed my “long labor” as simply a variation of normal.  I was finally able to deliver my 10 lb baby, with a nuchal hand, in an amazing waterbirth.  My body is amazing and strong and did not let me down. Jill K., Ph.D. (Clinical Psychologist and Professor)

Connecticut – Without VBAC, women have no choice and are forced into dangerous births. – Danielle M.

Florida – VBAC matters because it is lifelong; it is forever; it is not short term.  The effects of a VBAC never wear off. – Shannon M.

My VBAC offered me a better recovery without worrying about an incision site. – Meredith S., HBA2C mom

Hawaii – The fact that the possibility of a malpractice suit dictates what most obstetricians offer and results in them pushing the birth option that is more likely to end in a mother’s death is totally incomprehensible to me. Evidence-based care is what our standard should be.  Every single obstetrician should be pushing the safest option for mother and baby, not the safest option for avoiding a lawsuit. – Naomi S.

Idaho – My VBAC was validation of my womanhood. It has made me a better mother and spouse. – Bonnie M.

Indiana – I wanted to have a large family and I think VBAC is the best option instead of repeat c-sections!!  I have had 6 VBACs so far and hope to be able to have as many more! – Stacy G.

Kentucky – Because having my baby cut out of my abdomen was very traumatic for me.  The bonding was more difficult [than my three previous vaginal births] and PPD followed. – Denise H.

Massachusetts – When my son was born by (unnecessary) cesarean, I felt like someone had deflated my belly and handed me a baby. He was mine, but a part of me felt like they could have handed me any baby. But when I look at my daughter’s head and stroke it while I am nursing her, I can say I gave birth to that head. I gave birth to that head! This is my baby. And no one can take that away from me. – Catie Ladd

Michigan – There are all sorts of “soft” reasons why VBAC is great but when it really comes down to the bottom line, what keeps me working for ICAN, what brings tears to my eyes, is the fact that women and babies are dying who shouldn’t, because VBAC is no longer a real option for most women in the U.S. – Gretchen Humphries, MS DVM

Mississippi. After my first baby’s labor ended with a cesarean, I felt that I really hadn’t been given a chance.  I felt bullied and pushed into a cesarean I didn’t want because it was more convenient for the doctor than letting me continue at a ‘slower than normal’ dilation rate. – Nancy W.

Nebraska – If VBAC was not an option, my daughter would have been an only child.  I could never willingly conceive knowing my child would be cut out of me via a completely unnecessary surgery. – Kristen K.

New Jersey – VBAC is certainly safe for both mom and baby as long as the original incision in the uterus was a low segment transverse incision. Evidence based medicine reports approximately 75% of women can successfully VBAC. As long as the mom is aware of the risks (minimal) and the benefits (MANY) they should have the right to VBAC. – JoAnn McQueen Yates, CNM

New York – Because I didn’t want to go through surgery if it wasn’t necessary.   Doctors take little stock in the emotional and psychological factors of giving birth – it’s not just about pushing out a baby!! – Carrie Moyer Howe

Ohio – Delivering vaginally for me was a “rite of passage.” I was finally able to cast off the numerous doubts and my sense of failure I experienced. I really was “adequate.” – Ellen B., Nurse Manager & VBAC mom X2

Oregon – After my c-section with my daughter, laughing was extremely painful for weeks.  I would think, how awful that during a time that should be filled with joy, I’m unable to laugh.  – Rachel R., HBAC mom

I think it’s important for the operating room space and staff to be available for a true emergency cesarean, rather than have me taking up their space and time for convenience. – Rebecca C.

Pennsylvania – If I had to plan a pregnancy to end in surgery, I would not have another child, period.  – Judy P., DVM, PhD (molecular biology)

VBAC is important to me because it has the capacity of healing my broken Self. – Monica R., PhD.

South Carolina – VBAC is a natural conclusion to a natural process.  Not to mention, how many babies with true emergencies, would be saved by not having operating rooms tied up with elective cesareans? – Raechel Fredrickson

West Virginia – Aside from the fact that offering VBACs is practicing Evidence Based Medicine and should be offered without question, I would like for other women to experience the joy and self-assurance that comes from working with her body as well as the indescribable feeling of pulling her fresh, warm baby up to her chest as I experienced with my HBA3C. – Teresa S.

Finding VBAC statistics for your hospital and state

Update 3/25/16: Another excellent resource for California residents is California Quality Care.

Update 4/11/12: Since I wrote this article, the brilliant Jill Arnold from the Unnecesarean started a new website where she shares cesarean rates by hospital: CesareanRates.com.  I would recommend checking this resource first before trying out the strategies I describe below.

__________________________________

Jeri left this comment at I’m pregnant and want a VBAC, what do I do?:

I want to plan for a VBAC I am not pregnant as of yet but will be ttc in 2 months. I am from La Crosse WI area and they have two hospitals Gunderson Lutheran and Franciscan Skemp..when I called them to get there statistics about VBACs they told me they didn’t have any. So how should I choose which hospital to go to for the better chance of succeeding with my VBAC. I also do not have any doulas in the area is it necessary to have a doula for a successful VBAC? Any thoughts or suggestions would be great. Thank you.

Hi Jeri!

It’s ironic that the person you spoke with at the hospital said that they didn’t have any VBAC statistics, because when I googled “Gundersen Lutheran VBAC,” I found a page entitled “Births by Cesarean and Vaginal Births After Cesarean” on Gundersen Lutheran’s very own website where they state:

A vaginal delivery is the preferred, naturally-designed way to have a baby but when needed, delivery by Cesarean section is a second option. At Gundersen Lutheran, efforts are made to choose a vaginal birth, even after a previous C-section unless there are reasons that would put mother or baby at risk.

“Generally, successful VBAC is associated with shorter maternal hospitalizations, less blood loss and fewer transfusions, fewer infections, and fewer thromboembolic events than cesarean delivery.” [ACOG Practice Bulletin #54 2004)

AIMS
1. To have a cesarean section rate below the national rate
2. To have a VBAC rate higher than the national rate

They have succeeded in their goals as Gundersen Lutheran boasted a 27.3% VBAC rate in 2006.  That is exceptional considering that the national average is 9.2% (CDC 2006) and the Wisconsin state average is 12% (Wisconsin: Infant Births and Deaths 2006).

Ted Peck, M.D. is named “activity leader” on that page so I would contact him and ask for the top three VBAC doctors at Gunderson Lutheran.  I would also check out the resources here for additional referrals and to see if any of the names overlap.  Keep in mind that just because the hospital has a great VBAC rate doesn’t mean that all the OBs are supportive of VBAC.  You will still want to ask the same questions and interview a couple different doctors, just like you would get more than one quote if you wanted work done on your house.  You are the consumer, you have the power to chose who you will hire!  It’s important for you to understand the risks and benefits of VBAC vs. repeat cesarean to you, your baby, as well as your future children and health, but be on the look out for scare tactics masquerading as informed consent.

I also googled “Franciscan Skemp VBAC” and was directed to ICAN’s VBAC Hospital Policy Information where Franciscan Skemp is listed as a de facto VBAC ban hospital.  This means that while there is no formal ban in place, the hospital does not attend VBACs.  They could give you a whole list of reasons like, “Our OBs don’t want to do them” or “Our anesthesiologists don’t want to sit in the hospital during a VBAC labor,” but Dr. Stuart Fischbein gives us another perspective:

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

(To read more of this interview with Dr. Fischbein, please go to: An Inside Look at Hospitals & VBAC Bans.)

If I was unable to easily find this information by googling, I would have gone to Wisconsin’s Department of Health Services and just start searching for VBAC, birth, cesarean, and hospital statistics to see what I could find.  Sometimes this data is so deep within a website, it can be tricky to locate.  You could also call the Department of Health Services and ask them if they maintain hospital birth statistics.  The state of California maintains this data, but I don’t know if all states do and if they make that information available to the public.

In terms of a doula, yes, I think it’s very important for any woman laboring in a hospital, especially women seeking a VBAC, to have a doula.  (Here is more information on what a doula is and the many benefits of having one: DONA’s Birth Doula FAQs.)  Some practices are not supportive of doulas, even going so far as to post a sign in the waiting room detailing their anti-doula policy.  Switch providers immediately if you read a similar sign or if you discover that your provider is not doula friendly.  A great way to find out is to ask your OB or midwife if they have any doulas they can recommend.  Their response will quickly tell you if this care provider and you have the same vision for your birth.

I went to findadoula.com, and found there was one doula listed for La Cross, WI:

Renee Plunkett

Telephone: 608-786-4466

Location: West Salem Wisconsin United States

I also cover the following geographic areas:
La Crosse, WI

Hopefully you two will be a good fit and if not, the list of resources I provide for finding a supportive OB or midwife can also be used for finding a doula.  I would add DONA and toLabor (formally ALACE) which are Doula credentialing organizations as additional resources.  DONA lists 64 birth doulas and toLabor lists 10 birth doulas in Wisconsin.

You can find more VBAC statistics by going to the The Birth Survey’s State Resources page which provides links to each state’s birth statistics.

For Wisconsin, we have Wisconsin: Infant Births and Deaths, 2006 where we are given the following statistics on page 30:

Delivery Method Number Percentage
Vaginal (no previous C-section) 52,713 72.9%
Primary C-Section 10,342 14.3%
Repeat C-Section 7,418 10.3%
VBAC 1,017 1.4%
Forceps 812 1.1%
Other 0 0.0%
Total Births 72,302 100%

We can determine the VBAC rate by adding the number of Repeat C-Sections (7,418) and VBACs (1,017) together to get a total number of births after cesarean in 2006 (8,435).

By dividing the total number of VBACs (1,017) by the number of births after cesarean (8,435), and multiplying that number by 100, we get the VBAC rate of 12.06%.  This means that 87.9% of women in Wisconsin have repeat cesareans.

Here’s hoping you are in that 12%!

Warmly,

Jen from vbacfacts.com

Response to OB: Scare tactics vs. informed consent aka why I started this website

I receive this comment on the post Hospital VBAC turned CS due to constant scare tactics:

I am very disheartened by the tone of this website. I am a board certified Ob/gyn and a very strong advocate for VBACs, IF a patient chooses one within the hospital guidelines. I DO believe and say to my patients my goal is “a healthy mom and a healthy baby” because I truly believe this statement. You would not believe the number of patients who believe that I want to do XYZ to go home to my family, go shopping or improve my golf game. A vaginal delivery is easier for me in the long run because I have less paper work, less rounding and have avoided performing a major surgery on a patient. I have no desire to perform a patient’s 6th c-section!

But each patient who chooses a VBAC has to realize there ARE risks associated with the procedure. I would be committing malpractice if I did not inform each patient of the risks and benefits of both options. The risk of uterine rupture is [less] than 1 percent, but if it happens to my patient she will be upset that I did not inform her of the risks. The “seeds of doubt” you discuss are all things that I have told patients considering a VBAC. I prefer to stretch the informed consent process over the entire course of the prenatal visits versus just one 5 or 10 minute conversation. If I have discussed all the options ahead of a patient’s actual labor, if I come in and say that I need to perform a repeat c-section for XYZ reason, I am not having that discussion for the first time in the LDR, but rather we have discussed the possibility months ago. I use my prenatal visits to build a repoir [sic] with my patients and to educate her/her family about the scenarios we may face in the delivery room.

In an ideal world, every patient would be presented with the option to have a VBAC if she desires. Unfortunately due to the malpractice climate some doctors and hospitals no longer feel comfortable giving patients this choice. The rhetoric in this article does nothing healthy to advance the cause  of ensuring this happens. It only serves to create mistrust between patients and doctors who are true advocates for patients.

Dear VBAC Supportive OB/GYN,

I’m very happy that you left this comment and hope that you stick around and read some more.  We need more OBs who are supportive of VBAC and vaginal birth.  (I’m curious about your hospital’s guidelines.  Would you share?)

The unfortunate reality is that there is a huge segment of OBs who perform surgery under the guise of maternal/fetal health when in reality it is for their personal convenience.  I have had the opportunity to hear that directly from OBs.  Often the “healthy mom/healthy baby” reason is used in the midst of a repeat cesarean recommendation and I believe that is true in the birth story featured in Hospital VBAC turned CS due to constant scare tactics.

If you look over on the category list and click on ‘uterine rupture’ you will see that it is a common topic on this site.  I cite specific rates as well as sources so people can independently verify what I write.  I absolutely agree that women need to understand the risks of VBAC, but they need the accurate numbers, not some inflated risk provided by an unsupportive OB and not some understated risk provided by well-meaning, but misinformed, birth advocates.  (Check out my article Lightning strikes, shark bites & uterine rupture for more on this.)

Here’s how I make the distinction between informed consent and scare tactics.

Informed consent is understanding the risks and benefits of VBAC vs. repeat cesarean.

Scare tactics are just talking about the risks of VBAC without mentioning the risks of a repeat cesarean.

Informed consent includes accurate statistics.  Women write me all the time telling me that their OB quoted a uterine rupture rate of 5% or 10% or even 25%!  A woman just recently contacted me and said that women seeking VBACs are “selfish, unbelievable IDIOTs.”  Naturally she would say this as her OB told her that she and her baby had a 10% chance of dying if she attempted a trial of labor after cesarean.

If the doctor tells you there is a 10% chance of you and your baby dieing [sic] and you do this any way…you are a selfish, unbelievable IDIOT…I have two perfect babies and I wouldn’t have my 1st if it wasn’t for a c-section…why on earth would I risk the life of my 2nd child to say I had a ‘v-back’…do you psychos want a metal [sic]…go away and get off your freakin’ soap boxes…you are all scary and creapy [sic]!

This is why I started the website.  Women are lied to all the time.  They contact me either via angry emails like the one above or really sad depressed emails because they were fed these falsehoods, consented to surgery, and then learned the truth.

So, this is how I responded:

I completely understand why you were happy to have a repeat cesarean given that you were told the risk of mortality was 10%. I’m sorry to tell you that you have been misled. The risk of maternal mortality with repeat cesarean and VBAC is very low, but the risk is higher with a repeat cesarean: 0.04% vs. 0.02% per a National Institute of Health Study of 18,000 women. (Landon 2004: http://content.nejm.org/cgi/content/abstract/351/25/2581) This is 500 times smaller than the risk you were quoted of 10% maternal mortality. That same study found the rate of infant death to be 0.01% and they did a review of 880 uterine ruptures in a 20 year period resulting in 40 infant deaths in 91,039 VBACs which is a rate of 0.04%. They found the combined risk of infant death or brain damage to be 0.05% or 1 in every 2000 VBAC labors which is a 200 times smaller than the risk you quoted of 10%. If you or your OB have a large VBAC study showing a 10% mortality rate, please email me.

Needless to say, she did not respond as there is not one large VBAC study showing maternal or infant mortality rates anywhere near 10%.  This woman was lied to.  Why do you suppose her OB would tell her that?

Informed consent also includes asking how many more children the woman wishes to have.  We know that the risk of uterine rupture, uterine dehiscence and other peripartum complications decrease after the first VBAC, (Mercer 2008) whereas the risk of “placenta accreta, hysterectomy, transfusion of 4 units or more of packed red blood cells, [bladder injury], bowel injury, urethral injury, ileus [absence of muscular contractions of the intestine which normally move the food through the system], ICU admission, and longer operative time were seen with an increasing number of cesarean deliveries.  [In addition] after the first cesarean, increased risk of placenta previa, need for postoperative (maternal) ventilator support, and more hospital days were seen with increasing number of cesarean deliveries.” (Silver 2006)

How many VBAC consent forms include the risks of cesarean?  Not just the risks to mom and baby in the current pregnancy but the downstream consequences for future pregnancies?  I’ve never seen it.  Does your VBAC consent form include this information?

It’s one thing to understand the risks of VBAC, but they must be countered with the risks of repeat cesarean, otherwise the patient is left with the false notion that repeat cesareans are risk free.  This does not benefit the patient and I believe it’s only because women haven’t started suing over complications resulting from repeat cesareans that this erroneous philosophy on informed consent continues to thrive.

Informed consent is putting the risk of uterine rupture into perspective by comparing the risk to other obstetric complications as Larry Leeman MD MPH and Eve Espey MD MPH do when expressing their concern over the rising cesarean rates in Native American populations due to hospital VBAC bans.  They say:

Should you offer vaginal birth after cesarean delivery at your facility?

Should your referral facility be offering VBAC?

Let’s put some of the above issues into perspective.

What are just a few of the risks that you should currently handle very well:

[Note from me: I used the chart they provided here and combined it with uterine rupture & infant mortality/morbidity stats for use in the VBAC Class I teach.]

Slide 103

Taken on their own individual merit, most of the above common urgencies and emergencies occur more frequently than 0.5 percent. Taken as an aggregate, the risks above far outweigh the risks of VBAC. Now seeing the above risks, if you feel you need to re-evaluate offering obstetric intrapartum care because the above risks, then please contact me as soon as possible.

Scare tactics are simply saying, “VBAC is dangerous” or “Is it worth your baby’s life?”

Informed consent is having a thoughtful thorough conversation where you ascertain if this is the first time the woman has heard about the risks of uterine rupture, or if she is an informed patient who is well aware of her risks, benefits, and options.

I do believe that coming back to the risks of VBAC again and again during a pregnancy conveys to the patient that you really think this is a considerable risk, and not one worth undertaking.

Lisa Allee, CNM, wrote this in response to a hospital that instituted a VBAC ban.  The hospital said that their ban wouldn’t impact many since only 2 patients a year perused VBAC after the VBAC counsel.  She recommended:

Re-evaluate how VBAC counseling is done. To provide true informed consent the numbers need to be presented clearly. The data consistently shows a uterine rupture rate of 0.5-3%–it is important to explain that this means 97-99.5 women out of 100 will not have a uterine rupture and out of the few that do, not all will have problems. It is, of course, important to discuss the risk of uterine rupture to mother and baby, but to put it in this perspective of being rare and review the high-quality, careful care we provide to women who are VBACing to help prevent problems. It is also very important to review the differences in postpartum morbidity and risk between a vaginal birth and cesarean delivery, (be sure to include the oft ignored higher rates of breastfeeding and orgasm difficulties post cesarean delivery.) If, in contrast, providers only make a recommendation of repeat cesarean delivery and an institution has a policy that only allows for repeat cesarean delivery, then they have effectively negated a woman’s right to make an informed decision in a situation where there is a choice.

And she suggests that women be given an accurate picture of what a cesarean is like:

Review the postpartum morbidity and risk differences for women post vaginal birth vs. post cesarean delivery. This will help to dispel the delusion that a woman who has had a cesarean delivery is walking out of the hospital “healthy” and bring a more accurate sense of respect for what is really happening for that woman. She has just had major abdominal surgery and is in recovery from that surgery. She is in pain and is at risk for a number of post-surgical complications. Her future pregnancies have also now taken on a longer list of potential risks. Along with all this she is also a new mother with a newborn to care for and feed every 1-2 hours with an abdominal incision that she is fully aware of each time she moves. This human perspective of the implications of a cesarean delivery might help providers to be concerned with their personal and institutional cesarean delivery rates.

I did not get the feel from the birth story relayed in Hospital VBAC turned CS due to constant scare tactics that the OB was really supportive of VBAC, did you?  Would you classify this OB as a “true advocate for patients?”

  • OB only talks about the risks of VBAC.
  • OB required a VBAC consent form that only lists the risks of VBAC.
  • OB wants to schedule a cesarean at 38 weeks.
  • OB “did not seem very please” when the patient expressed her desire to VBAC.
  • OB began NST at 37 weeks.  Patient lists no reason for this.
  • OB does not put the process and significance of dilation into context.  Patient seems to believe that no dilation at 37 weeks and no change till 40 weeks is a bad sign.  Patient does not understand that dilation is not a hard sign of labor.
  • OB tries to scare patient by telling her that her baby was big and it “could be a very hard delivery” for her.  It is this scare tactic, and the subsequent recommendation for cesarean based on suspected macrosomia  that convinces patient to schedule a cesarean.  Baby ends up weighing 7lbs 2oz.  ACOG does not recommend cesarean for suspected imagemacrosomia unless the baby is 11lbs (ACOG’s Practice Bulletin No. 22 on Guidelines for Fetal Macrosomia published in the November 2000 issue of Obstetrics and Gynecology).
  • OB makes a “threatening call” to patient upon her spontaneous labor and lies by saying that if patient doesn’t have the “C-sec at the decided time, [OB] was not going to be available for the entire week and that some random doctor from the hospital” would perform her surgery.
  • OB gets caught in this lie when the nurse tells patient that OB “has asked to be informed about your progress [and] will continue to be there for you.”
  • OB then has a colleague tell patient that “she was sure it was going to be a very tough delivery” because of “baby’s head was big” and would weight “at least 8 lbs.”
  • OB who said she wouldn’t be available after 11:45am, suddenly becomes available and is present to perform the surgery.

You stated in your comment that my article “only serves to create mistrust between patients and doctors who are true advocates for patients.”

Here is my sole goal with that article and this website: To implore women to put as much effort into interviewing and hiring an OB as they would for someone to install a pool.  Educate yourself.  Get referrals.  Ask questions.  Don’t just stay with your current GYN because they do a great pap smear and you enjoy the small talk.  Hire someone who has a birth philosophy similar to yours.  Hire someone who is supportive of vaginal birth!  And look for the red flags!  There were so many in this woman’s story.  I know we disagree on that.  Maybe that is because you are a VBAC supportive OB who doesn’t see stories just like this one every day.

While there are OBs who are truly supportive of VBAC, I personally know three, most are not.  Most behave exactly like this OB.  And I don’t believe for a second that this OB ever intended to give this patient a genuine opportunity to VBAC. I really wish the OB would have just said that upfront to the patient so she could have had the opportunity to hire a truly supportive practitioner.  At the very least, this OB can post a sign in their waiting room, like this one above from a Provo, Utah practice, so women know their birth philosophy as soon as they walk in the door.  As unappealing as it is, this practice is providing their patients with informed consent on the type of birth they provide.  What is shocking to me, is that there are enough patients who are so ill-informed that they would continue care with a practice like this.

And this site will be there for the women who had cesareans under the care of OBs, like this Provo practice, to provide them with accurate, easily verifiable information for them to make an informed decision on what kind of birth they want the next time.

Warmly,

Jen

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

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

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

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

Don’t hospitals ban VBAC because it is dangerous?

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

What role does malpractice insurance play in VBAC availability?

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

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

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

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

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

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

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

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

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

How do VBAC bans impact hospital revenues?

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

How do VBAC bans impact women seeking VBAC?

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

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

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

Want a VBAC? Ask your care provider these questions.

While there are care providers who may mislead you about your risks, benefits, and options, this article is written assuming that you are meeting with an ethical care provider who supports the option of VBAC.  Read more on how to find a providers like this.

If you are a good candidate for VBAC, the single most important decision you can make that will have the greatest impact on your chances of VBAC success is who you hire to attend your birth.   This is why it’s important to interview several care providers and ask specific questions.

You will often receive different information when speaking to the doctor or midwife directly than you would from the people who answer their phones.  When calling their office, be sure to state that you want to have a consultation.  Ideally, you want to meet in an office, not in an exam room.

Questions You Should Ask

The key to all of these questions is that they are open ended.

The trick is to ask the question and then sit back and really listen.

What is your philosophy on planned VBACs?

What is your philosophy on planned VBACs going past 40 weeks?

What is your philosophy on suspected “big babies” (macrosomia) among planned VBACs?

How many VBACs have you attended?

Of the last 10 planned VBACs you attended, how many had a VBAC?

What is your philosophy on inducing VBACs?

What is your philosophy on monitoring planned VBACs?

Does your hospital have telemetry (wireless monitoring)? How often is it used?

What is your philosophy on waters being broken for more than 24 hours?

How long do you think it’s safe for VBACs to  labor?

What is your philosophy on epidurals in planned VBACs?

What are your standing orders for planned VBACs and do they differ from your standing orders for first time parents?

How does your on-call schedule work?

What is your cesarean rate?

What are your thoughts on movement during labor and delivery positions?

What is your philosophy on IV or saline lock?

Do you offer family-friendly cesareans?

Special Circumstances

In the event that the baby isn’t head down, do you manually turn babies? (This is called an external cephalic version or ECV.)

Do you attend vaginal breech births? If not, can you refer me to a provider who does?

Do you attend vaginal twin VBACs?

Do you attend VBAC after 2 cesareans?

Do you attend VBACs with a classical (high vertical), T, or J scar?

Do you attend VBACs with a low vertical or unknown scar?


Ok, you have your list of questions… what now?

Knowing what questions to ask is just one part of the process. How to do you know what answers to look for?

Well, that’s the next step.

In order to know how the answers you receive line up with the evidence, you have to actually know what the evidence says.

And most parents and professionals don’t have the time or interest to dive into the research. Or the process feels overwhelming so they don’t take the first step.

But it doesn’t have to be that way.

In my online trainings for parents and professionals, I’ve done all the work for you. I translate the evidence on each question so you know how to decode the provider’s response as well as red flags to avoid.

Click here to learn more and get started.

Is VBAC Illegal? Is homebirth illegal?

This post was originally published June 14, 2008.  It has since been updated to include more information on the technicalities of homebirth.

I have incredible software on this website called StatCounter and through that I’m able to see what search engine queries bring people to the site.

I’ve noticed more queries asking if VBAC is illegal.

VBAC is not illegal anywhere in the USA.

It is legal to have a hospital VBAC in all 50 states.

It is legal to have a out-of-hospital VBAC in all 50 states.

If someone has told you that VBAC is illegal, they are either misinformed or are outright lying to you.  Ask them to show you the law.  This is something you should be able to easily look up through a google search.  You won’t find it because it doesn’t exist.

Linda Bennett, a retired midwife, clarifies the issue:

I also think it is important for women to know that OOH (out-of-hospital) VBAC whether home or boat or rv in the parking lot of the hospital or motel or unlicensed birthing center is also legal everywhere.

What may not be “allowed” by state regulation or law varies from state to state but if restrictions are present, it is in the form of restrictions on the license or practice of the practitioner IF she is a midwife (MDs can do what they want, although their peers may give them other headaches for attending an OOH birth).

Birth Centers with a license from their state often have restrictions specified in the law or their regulations (force of law) which mean they could lose their license if…and then VBAC.. breech.. multiples.. may be specified along with other restrictive language decided by their state regulatory board.

And I know what I am speaking about, because the small group of midwives I originally worked with in Santa Cruz took our arrests to California’s State Supreme Court over the licensing issue!

So when you hear the term “it is illegal to VBAC,” it is referring to the fact that it is illegal for a non-doctor to attend homebirths.  The physical act of giving birth in your home is not illegal.  If you are planning a hospital birth, and you don’t make it it the hospital in time and end up giving birth in your bathtub, you did not do anything illegal.

Gretchen Humphries, Advocacy Director, ICAN, explains:

[If] there aren’t laws specifically naming midwives as illegal… it leaves the impression that they aren’t illegal — which isn’t true.  They are illegal because they are practicing Medicine without a license.  They aren’t illegal because they ARE midwives, they are illegal because they AREN’T doctors.  Unless there is legal language making them legal, they aren’t.  Now, fortunately, this is pretty irrelevant in most states, still…..

Some states, like New Jersey, permit midwives to attend homebirths, but not homebirth VBACs (HBACs).

In other states, like California, homebirth and HBAC are legal for midwives to attend though you technically need to use your right of informed refusal to have a HBAC. 

Some states have legislation prohibiting homebirths or birth center births with midwives, and in those states HBAC would also be considered illegal for them to attend. 

Then there are states that permit some midwives, but not others, to attend homebirth.  Iowa and North Carolina permit certified nurse midwives (CNMs) to attend homebirths, but not certified professional midwives (CPMs.)  There is currently a bill providing for licensure of CPMs in Iowa.  Learn more about House Study Bill 229 at Friends of Iowa Midwives.

So why would someone tell you that VBAC is illegal?  Three reasons.  First, it ends the conversation.  One might be apt to debate or look for another care provider if they are told “our hospital doesn’t permit them” or “this OB doesn’t attend them.”  But if you are told it’s illegal, well, most women would just resign themselves to a scheduled repeat cesarean since many women do not want a OOH VBAC.  Linda Bennett gives us the second reason, “It is often convenient ‘shorthand’ to speak of ‘illegal’ HBACs but I find this convenience to serve the purposes of the doctors who oppose any OOH births. The HBAC is not illegal.”  Third, to say something is illegal makes it sound really dangerous, risky, and against the common good.  So by continuing the myth that homebirth is illegal, it’s feeding into the “homebirth is for wackos” machine, when it reality, it is perfectly legal for your OB to deliver your baby at home.  What stops them is a mix malpractice insurance pressures, pressure from other doctors, and the real belief that many OB have that birth is a dangerous event.

So, what do you do if you live in an “illegal” state?  There is hope, as Gretchen explains:

In a state where there is no Midwifery Practice Act, you’ll need to depend on your midwives to know what the “climate” for them is like — mine practice openly, advertise widely, go with all their transports, etc. But they ain’t legal.

So, look around.   You may find that you have options you didn’t even know about.

Ready to plan your VBAC?  Start here: I’m pregnant and want a VBAC, what do I do?.

Coping with miscarriage II

Of all the people coming to this site, it is the women who come searching for information on miscarriage and grief that just really break my heart.  There are so many of us, so I wanted to bring attention to what Candice wrote as well as my response.

Candice left this comment:

My husband and I tried to conceive for over two years. We were so excited when we found out on Oct. 21st that I was pregnant. It was amazing how I could have felt so connected so quickly. Obviously, as soon as we found out we told all out family and friends. I began spotting on December 11th and my husband immediately took me to the ER. I knew right away that something was wrong. My husband, trying to convince me and him, continued to comfort me and tell me everything was going to be fine. They did an ultrasound and determined that the baby had stopped growing at 8.5 weeks. At 8.2 weeks, I was told the heartbeat was at 171. It absolutely hurt me more than words can say because it just seemed more real once I knew there was a heartbeat. I couldn’t and still don’t understand why this happened to us. I, like you, still get upset from time to time but try to “cover up” how I really feel for friends and family, even my husband at times. I just feel that he wouldn’t understand and I feel myself trying to pull away from him and I don’t want this to happen. He is my best friend and he has been there for me through everything and I know he wants to be there for me now, I just don’t want him to know how this has truly affected me. We do want to try again but I am so worried that it will happen to us again, that I am beginning to shut down. How do you overcome something like this? My mother-in-law had a miscarriage before she had my husband and she understands but to others it just like “ok, you had a miscarriage, get over it”. I feel so alone even when I am in a crowded room of family members. Thank you for sharing this piece with others. Although, I cried through the entire thing, I really did need to read that. I am very sorry for your loss.

Candice,

Please know that I’m speaking from the heart and from someone who has been there. Don’t turn away from your husband. He is your partner and it is very likely that he is hurting to. My husband deeply mourned our miscarriage. Men mourn differently than women. Please do not let this divide you. Comfort each other. If he was hurting as deeply as you are, wouldn’t you want him to tell you? Be honest with him about your feelings and fears.

Please be patient with yourself. It has hardly been a month from when you miscarried to when you left this comment. It could take several months for you to get to a place where you can think of it and not cry. And that is ok and completely normal.

Do you have any close friends who you can share this time with? If not, family or even a message board might help you feel less alone during this time. I think if you start to share just a bit amongst friends, you would be surprised how many women have experienced miscarriage. I know, a lot of people don’t understand why it’s “such a big deal.” But, honestly, I didn’t either before I experienced it. I could think about how much it could hurt, but I never knew what it felt like in my heart. Since they haven’t been there, they don’t understand.

When you get pregnant again, you might not feel that excited. You might feel a mixture of subdued happiness and fear. I know I tried to maintain some emotional distance, as much as possible, for the first three months. It is horribly scary to think that it could happen again. There are women all around us who have experienced multiple miscarriages and are still living life through their pain. I would look at women shopping at the store, walking down the street and think that some of those women had to experience miscarriage and that we all shared this pain. It gave me some peace.

This might seem out of left field, but have you looked into a local Holistic Moms or ICAN chapter? I’m certain that you would find others who have not only experienced miscarriage, but could provide you with loads of compassion.

I’m sending you a huge hug Candice. Please go to your husband, hug him, and let him comfort you. This is what we committed to when we married – for better or for worse. This is a hard time. You will survive it. I know it doesn’t feel that way now. You might feel like you will never be happy again. The only thing that will make this better is time. Please stay in touch and let me know how you are doing. I’m wishing you peace.

Warmly,

Jen

AAFP National VBAC Guidelines

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

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

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

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

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

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

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

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

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

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

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

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

Patient name: ____________________________________________________
Physician: _______________________________________________________
________________________________________________________________
________________________________________________________________

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

Uterine rupture risk drops significantly after first VBAC

As we know, the risks of cesareans increase with each surgery which is why family size should be considered when evaluating your post-cesarean birth options. Couple that fact with the results of Mercer (2008) which found that successful VBAC also provides a level of protection to future deliveries.

Mercer found that not only do the risks of uterine rupture, uterine dehiscence and other peripartum complications decrease after the first VBAC, but “VBAC success increased with increasing number of prior VBACs” to rates over 90% for women with two or more prior VBACs.  They also found that while two or more VBACs did not decrease the risk of rupture further (so a scarred mom’s risk of rupture never goes down to the risk of an unscarred mom), it’s important to note that the risk of rupture did not increase with subsequent VBACs as women are sometimes told in an effort to obtain their consent for a repeat cesarean.

 

Mercer, B. M., Gilbert, S., Landon, M. B., & Spong, C. Y. (2008). Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstetrics & Gynecology , 11, 285-91. Retrieved from http://journals.lww.com/greenjournal/Fulltext/2008/02000/Labor_Outcomes_With_Increasing_Number_of_Prior.6.aspx

 

Neonatal nurse has a homebirth VBAC

This is a great birth story, published with permission, of a woman who had a cesarean for “small pelvis” and then VBACed a larger baby at home!  Since she is a neonatal nurse, it’s interesting to read why she chose HBAC and how she thinks her birth would have gone differently had she labored in a hospital.


I just wanted to let everyone know that I gave birth to a healthy baby girl Wednesday June 11th. I had a C/S with my son 2 years ago.

He was 8lbs 2oz and I was told that my pelvis wasn’t big enough to birth an 8lb baby. Well my VBAC baby was 9lbs 2 oz. Exactly a pound bigger than they told me. I knew I wasn’t broken.

I chose to have a homebirth  because I felt I would always have to fight for what I wanted in the
hospital. My labor went great. Started around 3am contractions coming 10 minutes apart. Then progressed to 3-5 min apart at around 6:30am.

My midwife got there around 7:30am. Later I wanted to go into the birthing tub to try to get through the contractions. My midwife wanted to check to see how far I was. 4cm and 100% effaced. She told me to try to hold off on the tub because it would be better when I am
further in labor. I then took a hot shower.

For me the contractions were more bearable standing up. When one would come on I would bend my knees and lean over onto either the couch, my bed or my husband. The worse position for me to labor on was my back and my side.

After the shower I asked if I could go into the tub again. She checked me and I was 6cm with a bulging bag. I did go into the tub which for me didn’t make much difference in the contractions. But at that point I stayed in there for quite a while because it took too much energy for me to
move.

For me the worse part was going from 6 cm to complete. I thought it would have been the pushing part but it wasn’t. In the tub I did feel like pushing a little bit. We couldn’t tell if my water had broken since I was in the tub. I decided to get checked in the tub to see if the water had indeed broken and plus since I was feeling “pushy.” Still at 6cm but the bag was bulging more.

They think that was why I was feeling like I had to push. They let me push a couple of pushes to see if that would break my water but it didn’t. Then they told me not to push and just try to breath through the contractions. My water still wasn’t breaking and it was the hardest thing trying not to push when that overwhelming feeling was there. They gave me the option of breaking my water and felt that once they did that the baby’s head would apply to the cervix and help with dilation. I agreed. They broke the water and sure enough baby’s head came right
down and I was 8-9cm.

The pushing feeling let up and I labored more for a while. I then started feeling pushy again and they decided to check to make sure I was fully dilated before I fully pushed. I just had an anterior lip. Again they told me not to push so that the anterior lip would pull back over the baby’s head and not swell. I was dying to push but breathed through each contraction for an hour or two. (I lost all sense of time so I don’t know exactly how long it was.)

The best position for me was on my hands and knees but they said that with the anterior lip that the position was actually making it worse. They wanted me to lie on my back to help take pressure off the cervix to facilitate it moving around the baby’s head.

Lying on my back was so unbearable but I did it to help with the dilation. The midwife decided to try to help push the cervix over the head. She told me to push while she held it out of the way. Finally her head came down and I could fully push to my heart’s desire. That felt great.

They asked if I wanted to go back to the hands and knees position since the cervix isn’t an issue now but I said I just could not bear to move to another position. Then the “ring of fire came” Boy did that burn.

Finally her head came out and, surprise, so did a hand. They said that her hand was across her face. They pulled the hand out along with the head and since one shoulder was in and one was out she was having a little bit of trouble maneuvering.

They wanted me to flip to my hands and knees to open up the pelvis more. I thought they were crazy. Me trying to flip over with a head hanging out. I knew that I just had to do it as quickly as I could or it wouldn’t have gotten done. My husband said he had never seen me move so quickly in my life. I pushed a little more and she was out!

Amazingly I had no tears. Personally I thought that was pretty amazing to have my first full term vaginal birth of 9lbs 2oz with no tears what-so-ever!

So to all of those women who have been told that you would have died in childbirth because you couldn’t push out your own baby YOU CAN! I am proof that I delivered a baby 1 pound bigger than what they said.

I am a nurse who works in labor & delivery so I see all of the unnecessary interventions that they do.

I was pondering about my birth. If I would have chosen a hospital birth I probably would have ended up with another c/s or an episiotomy. There were times during my birth where I thought, “Am I crazy? I can’t deal with this pain!” The midwives and doula helped me through the intense contractions.

If I was at the hospital they would have bullied me into an epidural and therefore I wouldn’t have been able to move around to get her to come down. Also I wouldn’t have been able to feeling the progression of her head coming down when I pushed.

With my son I pushed and couldn’t really feel any progress so mentally I was losing hope. With this birth it didn’t feel like I pushed for an hour because I could feel the accomplishment of her
coming down. I see this happen all of the time at the hospital.

If a mom isn’t pushing quick enough for the doctor or they think the head is too big then they will automatically do an episiotomy. They probably would have done that and it just shows that it would have been for nothing and I would have had a longer recovery time.

So therefore I am grateful that I found homebirth and such wonderful midwives. I hope this inspires all of you who are having the normal feelings of “what if I can’t do it.” Good luck
to your future births, You CAN do it!

Celebrity VBAC: Kate Winslet

The March 2004 issue of Gotham Magazine contained a great interview with Kate Winslet where she discusses the births of her two children: one an emergency cesarean and the other a VBAC.  It goes to show what incredible healing can occur for some women when they VBAC.

G: So, did vou do the delivery au naturel or did vou get the drugs?

KW: Well, here’s the tiling. I’ve never talked about this. I’ve actually gone to great pains to cover it up. But Mia was an emergency C-section. I just said that I had a natural birth because I was so completely traumatized by the fact that I hadn’t given birth. I felt like a complete failure. My whole life, I’d been told I had great childbearing hips. There’s this thing amongst women in the world that if you can handle childbirth, you can handle anything. I had never handled childbirth, and I felt like, in some way that I couldn’t join that “powerful women’s club.” So it was an amazing feeling having Joe naturally, vaginally. Fourteen hours with no drugs at all, but then I had to have an epidural because I was so tired. I honestly thought I’d never be able to do it. It was an incredible birth. It laid all the ghosts to rest. It was really triumphant.

Two Doctors Encourage Native American Women to VBAC!

Here is another response to the statement dated December 2007 from Hastings Indian Medical Center explaining why they no longer offer VBAC.

Wow is this article amazing for being published in the post-2004 “anti-VBAC per ACOG” era, by two MDs no less! If your OB gives you the third degree about VBAC, you might want to give him a copy of this article. The tide against VBAC might be turning!

Dated February 2008, not only does it openly and explicitly encourage VBAC, but it also:

  • declares VBAC as the “safest option”
  • encourages efforts to “minimize the primary cesarean delivery rate”
  • asserts that cesareans increase the risk of “placenta accreta, increta and percreta” which “may be particularly difficult to address in a rural community hospital setting”
  • puts the high cesarean rate squarely on the shoulders of OBs: “Physician specific practices influence cesarean delivery rates”
  • notes that OB attitudes towards cesareans is the “largest stumbling block” in lowering the rate
  • concludes that, “An important ingredient in reducing cesarean delivery, either in nulliparous or parous women, is to place value on vaginal delivery”
  • supports “labor management strategies to reduce cesarean rates in the Native American population in the Oklahoma Area and nationwide”
  • questions why smaller hospitals state they can’t accommodate VBAC, yet offer maternity services, when there are other emergencies that occur during non-VBAC labors at a greater rate than uterine rupture
  • encourages hospitals to revaluate their policies and support VBAC
  • asserts that VBAC is successful 75% of the time
  • reaffirms that spontaneous VBAC labors are more successful (80.6%) than VBAC labors that are induced (67.4%) or augmented (73.9%)
  • reaffirms that women who are more than 4 centimeters dilated upon admission have greater VBAC success (83.8% vs. 66.8%)
  • found VBAC success can be had among women with “larger babies” (over 4000 grams or 8 lb, 12 oz) (62%) and women who are ‘overdue’ as defined as 41 weeks or more (64.8%).  I would personally take these odds over the 0% chance of VBAC success if you have a scheduled repeat cesarean!

Maybe the pendulum is finally swinging the other way and this will be the beginning of VBAC support for all women.

The emphasis below is mine.  Note that VBAC is referred to as ‘trial of labor after cesarean’ or TOLAC.

Leeman, Larry, MD, MPH and Eve Espey, MD, MPH. “Concern for rising Cesarean rates in Native American populations.” CCC Corner 6.2 (February 2008)

Concern for rising Cesarean rates in Native American populations

By Larry Leeman MD, MPH and Eve Espey MD, MPH

Editorial Note : The following is in response to a Point / Counterpoint discussion of trial of labor after cesarean (TOLAC) in rural hospitals, December CCC Corner*

We appreciate the willingness to engage in discussion about trial of labor after cesarean (TOLAC) availability and the approach to cesarean delivery at W. W. Hastings Hospital. Every facility faces unique factors in the decision to offer TOLAC services. However, we fear that the high total cesarean rate and lack of TOLAC services will ultimately result in worse perinatal outcomes considered from a population level.

Not only is vaginal birth after cesarean (VBAC) highly desired by many women, but it is preferable to a repeat cesarean delivery in certain women, including those with a single cesarean delivery who have had a successful vaginal birth before or after their cesarean delivery. Evidence suggests that such women should be encouraged to have a TOLAC particularly if they plan to have additional children. Given these data, anesthesia staff should be strongly encouraged to change their policy and offer 1 VBAC services in accordance with guidelines similar to those developed in the Northern New England Perinatal Quality Improvement Network (NNEPQIN). Ethically, it is difficult to justify withholding TOLAC when it is the safest option. If services were offered to this group of women, obstetrical and anesthesia staff could develop greater comfort with TOLAC and expand the local eligibility criteria.

Annual cesarean rates at some Indian Health facilities in Oklahoma are > 37% and short term rates over 40%, hence are above the recently published 2006 national rates for the total U.S population (31.1%), the Oklahoma state population (33.3%), and the US Native American population (27.5%) 2 We note that the Native American cesarean rate increased 1.5% from 2005 to 2006, almost double the 0.8% increase for the total US population. The rising cesarean rate is likely a reflection of both rising primary cesarean delivery rates and decreased vaginal birth after cesarean delivery.

Given the limited availability of TOLAC services for women in the Oklahoma service area, efforts should be made to minimize the primary cesarean delivery rate. The decision to lower the threshold for primary cesarean delivery as evidenced by an acceptance of the high rate and an unwillingness to look at physician specific factors will result in higher adverse outcomes in future pregnancies 3, particularly when combined with the lack of TOLAC services. Women in the Hastings area with primary cesareans can be anticipated to have cesareans in all future births placing them at increased risk for placenta accreta, increta and percreta 5. These complications of abnormal placentation may be particularly difficult to address in a rural community hospital setting.

Although Healthy People 2010 does not include a recommendation for the total cesarean rate due to varying patient factors, it recommends that efforts be made to decrease the primary cesarean rate to 15% in women who are giving birth for the first time 6. ACOG similarly recommends that comparative cesarean delivery rates for populations, hospitals, or physicians should be based on the subgroup of nulliparous women with term singleton vertex gestations 7. We would be interested in seeing the rate for this population at those affected facilities in Oklahoma Area.

We worked in at the Gallup Indian Medical Center (GIMC) and Zuni-Ramah Hospitals in the 1990s and continue to work with Native populations in Albuquerque and New Mexico. Our study of the population based CS rate in Zuni-Ramah in the 1990s demonstrated a 7.3% cesarean rate despite an incidence of diabetes and hypertensive disorders well above national rates 8. Physician specific practices influence cesarean delivery rates 9. We believe that the cesarean delivery review initiated at GIMC in the early 1990s was important in identifying factors in patient management that can result in a high cesarean rate.

An important ingredient in reducing cesarean delivery, either in nulliparous or parous women, is to place value on vaginal delivery. The attitude that “None of the physicians in our department are concerned with our cesarean delivery rate” may prove the largest stumbling block in developing strategies more consistent with national goals.

We suggest that the maternity care providers in Hastings present the evidence for improved maternal outcomes in women with prior vaginal delivery to their anesthesia colleagues and make TOLAC available at least for this group of women. Addressing the high total (and presumably) primary cesarean rates will require analysis of the indications and physician specific patterns. Given the increasing evidence for adverse outcomes with multiple repeat cesareans and the limited ability of community hospitals to address problems with placenta accreta, increta and percreta, we support labor management strategies to reduce cesarean rates in the Native American population in the Oklahoma Area and nationwide.

OB/GYN CCC Editorial comment:

An argument for better teamwork: Trial of labor after cesarean in Indian Country

First, I want to thank the leaders of the Indian Health Midwives listserv for raising these important issues, as this discussion was originally begun in the Midwives Corner feature. Though the current discussion revolves around Indian Health facilities, it is reflective of most small rural hospitals and increasingly some larger urban facilities.

Next, the availability of the trial of labor after cesarean option is really a ‘systems’ issue not just a problem confined to midwives or physicians. To decrease the long term morbidity and mortality associated with cesarean rates that now exceed 40%, we need to approach this issue systematically. Specifically, how can we engage our Indian Health administrative staff to foster an environment whereby anesthesia, pediatric, and nursing services work together with the provider staff to decrease excess morbidity in Native women.

Should you offer vaginal birth after cesarean delivery at your facility?

Should your referral facility be offering VBAC?

Let’s put some of the above issues into perspective.

What are just a few of the risks that you should currently handle very well:

Incidence per 100
Shoulder dystocia 0.2 -3.0
Cord Prolapse 0.14 – 0.62
Abruptio placenta, overall 0.4 – 1.3
Abruptio placenta, severe – stillbirth 0.12
Placenta previa, third trimester 0.1 to 0.4
Placenta accreta, overall 0.18
Placenta accreta / previa unscarred 1 – 5
Placenta accreta / previa with 1 Ces Del. 11 to 25
Placenta accreta / previa with 2 Ces 35 to 47
Placenta accreta / previa with > 3 Ces 50 to 67
Post partum hemorrhage 1 – 5
Trauma 7

In all but one of the above cases the incidence of these obstetric emergencies is actually increasing each year.

If you can’t provide VBAC because of the 0.5% risk of uterine rupture, then should your facility be offering intrapartum care at all? [emphasis theirs]

If you work at a facility that can not develop a rapid response for a clinical issue like symptomatic uterine rupture in a VBAC setting, which happens ~0.5 percent of the time, then your facility, should re-evaluate its ability to manage obstetric intrapartum care.

Taken on their own individual merit, most of the above common urgencies and emergencies occur more frequently than 0.5 percent. Taken as an aggregate, the risks above far outweigh the risks of VBAC. Now seeing the above risks, if you feel you need to re-evaluate offering obstetric intrapartum care because the above risks, then please contact me as soon as possible.

For those facilities that feel they are able to continue to offer obstetric intrapartum care within the risk environment above, then I would suggest a program of emergency obstetric drills, pan-ALSO** certification for all nurses and providers, and an ongoing quality assurance.

Each of the last three national Indian Women’s Health and MCH Conferences has devoted significant blocks of lecture time and workshops to improve systems of care and specific content updates. (Link to Meeting Lecture notes below)

Lastly, there seems to be some confusion as some providers at times combine the risk of a TOLAC sequela vs the relative success of a vaginal birth in TOLAC. These are two separate issues that need to be discussed with our patients separately for a fully informed consent.

1.) Success of vaginal delivery

Overall the rate of successful vaginal delivery in TOLAC is actually quite high, often in the range of 75% in the general population, and much higher success rate in the AI/AN population at 85-90% over the years.

A previous successful VBAC is probably the best predictor of future success; about 90 percent of such women deliver vaginally with trial of labor. By comparison, women delivered abdominally for dystocia are least successful, although approximately two-thirds are delivered vaginally.

Among the previous dystocia group, the success rate is higher if cesarean delivery was performed in the latent phase of labor and lower if performed after full dilatation. Within the former group, 79% of women who originally had surgery while still in the latent phase of labor had a successful trial of labor, compared with 61% of patients who had an arrest of dilation in the active phase of labor and 65% of those who had an arrest of descent. (Duff et al Obstet Gynecol 1988 Mar;71 (3 Pt 1):380-4.)

Multivariate logistic regression analysis identified as predictive of TOL success: previous vaginal delivery (OR 3.9; 95% CI 3.6-4.3), previous indication not being dystocia (CPD/FTP) (OR 1.7; 95% CI 1.5-1.8), spontaneous labor (OR 1.6; 95% CI 1.5-1.8), birth weight <4000 g (OR 2.0; 95% CI 1.8-2.3), and Caucasian race (OR 1.8, 95% CI 1.6-1.9) (all P < .001).

The overall TOL success rate in obese women (BMI > or = 30) was lower (68.4%) than in nonobese women (79.6%) (P < .001), and when combined with induction and lack of previous vaginal delivery, successful VBAC occurred in only 44.2% of cases. (Landon et al The MFMU Cesarean Registry: factors affecting the success of trial of labor after previous cesarean delivery. Am J Obstet Gynecol. 2005 Sep;193(3 Pt 2):1016-23. )

The combination of previous cesarean for dystocia, no previous vaginal delivery, and induced labor had a particularly poor prognosis in the Flamm system, e. g., fewer than 50 percent of such women achieved a successful TOL.

A decision analysis model favored TOL if the chance of success was >50 percent and if the desire for additional pregnancies was 10 to 20 percent. (Mankuta et al Am J Obstet Gynecol 2003 Sep;189(3):714-9.)

Trial of labor success rates: obstetrical and historical factors

Characteristic VBAC success, percent Odds ratio (95% CI)
Previous CD indication
Dystocia 63.5 0.34 (0.30-0.37)
NRFWB [nonreassuring fetal well-being] 72.6 0.51 (0.45-0.58)
Other 77.5 0.67 (0.58-0.76)
Malpresentation* 83.8 1.0
Previous vaginal delivery
Yes* 86.6 1.0
No 60.9 0.24 (0.22-0.26)
Previous VBAC
Yes* 86.6 1.0
No 64.4 0.21 (0.19-0.23)
Labor type
Induction 67.4 0.50 (0.45-0.55)
Augmented 73.9 0.68 (0.62-0.75)
Spontaneous 80.6 1.0
Admit cervical dilation
< 4 66.8 0.39 (0.36-0.42)
≥ 4* 83.8 1.0
Birth weight (g)
< 2500 (5.5 lbs) 77.2 1.14 (0.89-1.47)
2500-3999* (5.5 lbs – 8.8 lbs) 74.9 1.0
≥ 4000 (over 8.8 lbs) 62.0 0.55 (0.49-0.61)
Gestational age (week/day)
37 0/7-40 6/7* 75.0 1.0
≥ 41 64.8 0.61 (0.55-0.68)

All overall P values are <.001; for categorical characteristics, only the comparison of birth weight <2500 g to 2500 to 3999 is not significant (P=.33).
CI: confidence interval; CD: cesarean delivery; VBAC: vaginal birth after CD; NRFWB: nonreassuring fetal well-being.
* Women with this characteristic served as the reference group.
Modified from: Landon, MB, Leindecker, S, Spong, CY, et al. Am J Obstet Gynecol 2005; 193:1016.

Flamm scoring system tool

Variable Point value
Age under 40 years 2
Vaginal birth history
Before and after 1st cesarean 4
After 1st cesarean 2
Before 1st cesarean 1
None 0
Reason other than FTP for 1st cesarean 1
Cervical effacement at admission
> 75 percent 2
25 percent – 75 percent 1
< 25 percent
Cervical dilation 4 cm or more at admission 1
Score (percent) VBAC successful
0 to 2 49
3 60
4 67
5 77
6 89
7 93
8 to 10 95

FTP: failure to progress.
Data from: Flamm, BL, Geiger, AM. Obstet Gynecol 1997; 90:907.

2.) Risks:

Numerous risk factors have been cited for uterine rupture during labor in women with a previous CD. However, these risk factors are not consistent across studies, which are generally hampered by small numbers of patients with uterine rupture. Unfortunately, no single factor or combination of risk factors is sufficiently reliable to be clinically useful for prediction of uterine rupture.

Purported risk factors include maternal age greater than 30 years, induction of labor, more than one prior CD, postpartum fever, interdelivery interval less than 18 to 24 months, dysfunctional labor, and one layer uterine closure. Within this framework of incomplete data the New England Perinatal Quality Improvement Network (NNEPQIN) has developed a system to appropriately manage the risks.

Low Risk Patient:

  • 1 prior low transverse cesarean delivery
  • Spontaneous onset labor
  • No need for augmentation
  • No repetitive FHR abnormalities
  • Patients with a prior successful VBAC are especially low risk.
    (However, their risk status escalates the same as other low risk patients)

Medium Risk Patient:

  • Induction of labor
  • Pitocin augmentation
  • 2 or more prior low transverse cesarean deliveries*
  • < 18 months between prior cesarean delivery and current delivery

High Risk Patient:

  • Repetitive non-reassuring FHR abnormalities not responsive to clinical intervention. /li>
  • Bleeding suggestive of abruption
  • 2 hours without cervical change in the active phase despite adequate labor

* NB: ‘Two prior uterine scars and no vaginal deliveries’ is listed as a circumstance under which trial of labor should not be attempted by the American College of Obstetricians and Gynecologists ACOG Practice Bulletin No. 54, ‘Vaginal birth after previous cesarean delivery’.

Here is a suggested management system per NNEPQIN

Low risk

Notify Pediatrics, Anesthesia, and operating room crew of admission
OB/GYN on campus during active phase
Perinatal Guidelines of Care, ACOG, observed

Medium risk

Notify Pediatrics, Anesthesia, and operating room crew of admission
Operating room on campus in active phase or other plan if crew is busy

High risk

OB/GYN, Anesthesia, and Pediatrics available
No other acute care responsibilities
Rapid decision to incision

Please see the Midwives Corner and Oklahoma Perspective, below, for further discussion on this topic. A complete discussion of risk, benefits, and systems issues is available in the Perinatology Corner module: Vaginal Birth after cesarean http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/VB01.cfm

Other Resources:

Vaginal birth after cesarean (VBAC) in rural hospitals Counterpoint: David Gahn, M.D.

http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#MidWives

New England Perinatal Quality Improvement Network (NNEPQIN)

http://www.nnepqin.org/

Indian Health Meeting lecture notes

http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm

OB Emergency Drills in Indian Country

http://www.ihs.gov/medicalprograms/mch/F/documents/OBEmergDrills.ppt

2007 Indian Health Data Summary (Deliveries, VBAC rates, etc…)

http://www.ihs.gov/MedicalPrograms/MCH/F/documents/DataTally81107.doc

** ALSO = Advanced Life Support in Obstetrics

http://www.aafp.org/online/en/home/cme/aafpcourses/clinicalcourses/also.html

Leeman and Espey References:

1 Cahill AG, Stamilio DM, ADibo AO, Pelpert JF, et al. Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery? Am J Obstet Gynecol 2006; 195:1143-7.

2 Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2006. National vital statistics reports; vol 56 no 7. Hyattsville, MD: National Center for Health Statistics. 2007.

3 Kennare R, Tucker G, Heard A, Chan A. Risks of adverse outcomes in the next birth after a first cesarean delivery. Obstet Gynecol 2007; 109:270-6.

4 Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006;107:1226–32.

5 Getahun D, Oyelese Y, Salihu HM, Ananth CV. Previous cesarean delivery and risks of placenta previa and placental abruption. Obstet Gynecol 2006;107:771–8.

6 U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000.

7 American College of Obstetricians and Gynecologists, Task Force on Cesarean Delivery Rates. Evaluation of cesarean delivery. Washington, DC: American College of Obstetricians and Gynecologists, 2000.

8 Leeman L, Leeman R. A Native American community with 7% cesarean delivery rate: Case mix analysis, risk factors and operative indications. Ann Fam Med. 2003;1:36-43.

9 Luthy DA, Malmgren JA, Zingheim RW, Leininger C. Physician contribution to a cesarean delivery risk model. Am J Obstet Gynecol. 2003;188:1579-85

Cahill AG, Stamilio DM, ADibo AO, Pelpert JF, et al. Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery? Am J Obstet Gynecol 2006; 195:1143-7.

The Three Types of Care Providers Amongst OBs and Midwives

Care providers, OBs and midwives, can be broken down into three categories:

1. The ones who tell you outright they don’t to VBACs.  While this is annoying, it is more honorable than the second type of care provider because at least they don’t…

2a. … tell you they are supportive, but then put so many qualifications on their support that it’s almost impossible to have a successful VBAC with them.  I call this a “circus act VBAC.”  They want you to think that if you just jump through all these hoops, you will VBAC.  But what you don’t know as a typical pregnant woman who trusts her OB is, it’s almost impossible to meet the standard they require and, one way or another, you end up with a another surgery.

  • if your baby is less than X pounds
  • if you consent to an IV
  • if you consent to an epidural
  • if you consent to continuous external, or internal, fetal monitoring
  • if you stay in bed the whole time
  • if you come to the hospital as soon as labor begins
  • if you have the baby within X hours of labor starting
  • if you have the baby within X hours of your water breaking
  • if you agree to have a cesarean scheduled at X weeks “just in case” you don’t go into labor
  • if you agree to be induced at X weeks
  • if you go into labor by X weeks and if you don’t, you agree to have another cesarean or be induced
  • it goes on, and on, and on…

2b. Or they tell you that they are supportive, but as your due date gets closer, they start focusing more and more on the risks of VBAC.  Of course, they minimize, or don’t even mention, the risks of having a repeat cesarean.  It eventually becomes clear to you that they will find some excuse either during your labor, or before labor begins, to give you a cesarean.  At which point, how can you trust their medical opinion?  But, they have strung you along for so long – usually this starts in the last couple months of your pregnancy – that you feel stuck and you think that it’s to late to find another provider.  Sometimes it is, and sometimes it isn’t.  It never hurts to check out other providers, regardless of how far along you are.  When you have a provider like this, what do you have to lose?

3.  The smallest group of care providers out there are the ones who are truly supportive of VBAC.  You can find care providers by going here and interview them using the questions here.

A Rural Hospital Defends its VBAC Ban

I love reading why hospitals ban VBAC.  There are opportunities to learn about how that particular hospital operates, specific insurance issues they face, internal politics, and personal philosophies.  And it’s always interesting to see things from the OBs perspective.

It’s very telling that when they offered VBAC, only 2 women per year opted for VBAC after being “counseled by a physician.”  Most women who have been “counseled by a physician” on VBAC vs repeat CS can tell you how that conversation goes.  It typically leaves the woman with the impression that VBACs are dangerous and repeat cesareans are not.  Women are lead to believe that if you VBAC, you are putting yourself and your baby at risk, and if you have a repeat cesarean, you and your baby will be fine.

Since their VBAC ban, they “recommend a repeat cesarean delivery and tell patients of our policy.  We occasionally have a patient that refuses a recommended c/s (breech, previous c/s, macrosomia, history of shoulder dystocia with permanent injury) and we have them sign a consent form and take care of her very well.  This is all well within the standard of care.”  I wonder how much that “occasional” patient must fight in order to have a VBAC.  If it’s like most hospitals, very hard.

“On a similar topic, we don’t offer women elective primary cesarean delivery even if the patient should decide this is her preferred method of delivery.  In this case, we do refuse to allow women to give birth the way they choose.”  I would hope that if I came in and asked them to remove one of my lungs, without any medical reason, they should deny me as well.  Should they be congratulated for not performing major abdominal surgery without a valid medical reason?

“None of the physicians in our department are concerned with our cesarean delivery rate.  One quote I heard is, ‘My cesarean delivery rate is 100% for everyone who needs a cesarean delivery.'”  And everyone who has had a prior cesarean “needs” another one, right?

Be sure to read the two responses to this piece supporting VBAC and denouncing this VBAC ban.  The first by two MDs and the second by a CNM.

Gahn, David, M.D.. “Vaginal birth after cesarean (VBAC) in rural hospitals.” CCC Corner 5.11 (December 2007)

Vaginal birth after cesarean (VBAC) in rural hospitals

Counterpoint: David Gahn, M.D.

At Hastings Indian Medical Center, the Ob/Gyn Department decided to stop offering VBAC’s routinely. None of the physicians or midwives is “anti-TOLAC/VBAC” but we considered several factors:

1) Our anesthesia department refuses to participate in a management plan to facilitate VBAC despite any data we may present.  If we request them to be in house during a VBAC, they will refuse.  Then I have to document in the chart that I requested anesthesia and they would not come in.  That is a terrible way to do business.  Our anesthesia department does provide excellent care to our laboring patients and are pros at emergent cesarean deliveries.  They are skilled professionals, but the department is not staffed well enough to provide a CRNA or anesthesiologist dedicated solely to L&D.

2) Even though our Med Staff Rules and Regulations require on call personnel to able to present themselves within 20 minutes, this is not reliable.  Also, we have only one OR crew and only one anesthesia person available in the evening.  We have a protocol for an emergency c/s when the OR crew is already operating, but nothing is workable to do a cesarean hysterectomy with no anesthesia or OR crew.  If you have ever done an emergent c/s under local with a CNM and an L&D nurse, you will appreciate this.

3) We also considered the local standard of practice. The one insurance company that covers physicians in the entire state of Oklahoma will not cover a physician who performs TOLAC/VBAC’s.  Therefore, there are no physicians other than federally employed physicians and Oklahoma University in Oklahoma City 3 hours away (they are self-insured) who will allow TOLAC.  While this doesn’t apply to the Federal Tort Claims Act, it does apply to the physician tort database, our licensing authorities, the physician’s reputation, and the hospitals reputation.  (Tort claims are printed in our local newspaper.)

4) In order for us to offer TOLAC, all 6 of our Ob/Gyn’s need to be on board with the plan and they are not, mainly because anesthesia is not in house.  There is data that supports VBAC without anesthesia present in the hospital, but you don’t know our anesthesia department or how busy we are in the evenings.

5)  Unfortunately, the national data on c/s rates is usually 2-3 years behind, and our hospital has matched those rates.  We deliver about 975 babies per year, and our c/s rate to date for CY 2007 is 37%.  Should we be ashamed of the number or proud of the good outcomes? The balance between risks and benefits in this regard in tenuous.

6) I propose that every time a healthy mom walks out of the hospital with a healthy baby, we have succeeded in our mission.  Is our cesarean delivery rate too high?  Until I see the definition of “too high”, I’ll argue with you.  I disagree with the argument that our rate is what it is because we take care of higher risk patients.  I don’t think that is a reason.  We do have a high teen pregnancy rate, diabetes, massive obesity, hypertension, etc., but we haven’t studied it that closely. We would love to decrease the c/s rate, but obstetrics is a treacherous business and each physician is held responsible for the health of patients, mom and baby. We have to face reality – if a patient does not have a perfect baby, the physician will suffer a tort claim. (And I do mean suffer.)

7) We can’t and don’t force women to have repeat cesarean deliveries, for that would be assault.  We do recommend a repeat cesarean delivery and tell patients of our policy.  We occasionally have a patient that refuses a recommended c/s (breech, previous c/s, macrosomia, history of shoulder dystocia with permanent injury) and we have them sign a consent form and take care of her very well.  This is all well within the standard of care.

On a similar topic, we don’t offer women elective primary cesarean delivery even if the patient should decide this is her preferred method of delivery.  In this case, we do refuse to allow women to give birth the way they choose.

8 ) When we did offer TOLAC, we had about 2 per year.  We take this to mean that the others, after being counseled by a physician, opted for repeat c/s.  Considering this, our c/s rate would not appreciably change if we offered VBACs.

9) Please don’t condemn us for a policy that does not recommend VBAC’s. Recognize that the data and ACOG support both options, and also recognize that the data has to be applied to the hospital.  Because of the number of deliveries we perform, we have reliable data on post-operative infections (half the national average), TTN, transfusions, IUFD’s, etc.  Also know that we have excellent collaboration between our 6 physicians, 7 midwives, and 1 nurse practitioner.  We don’t make policies like this lightly and we examine the data carefully and applied it to our current practice.

So the bottom line is we might be more aggressive with TOLAC/VBACs if we had additional support.  None of the physicians in our department are concerned with our cesarean delivery rate.  One quote I heard is, “My cesarean delivery rate is 100% for everyone who needs a cesarean delivery.”  While this a bit crass, it is germane – the decision to perform a c/s rests solely with the physician charged with the care of the patient and the patient.  I would love for our cesarean delivery rate to be 15%, but not at the expensive of a single injured child or mother. I fully support TOLAC in the right environment. That environment does not exist at Hastings Indian Medical Center. David.Gahn@ihs.gov

Consumers Question a VBAC Ban

A mom in Southern California sent me this letter that she sent to her local hospital.  With her permission, I’m sharing it here.  The hospital did respond to her in writing, which you can read here.

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

February 18, 2008

Dear _________,

I am a mother of a toddler who was born by cesarean. I recently moved to the area and was disappointed to learn that in 2003, [Hospital] system banned vaginal birth after cesareans (VBACs). According to [a local newspaper] article that covered the decision,

The American College of Obstetricians and Gynecologists recommended in 1999 that physicians, including an anesthesiologist, be ‘immediately available’ 24 hours a day at any facility that sanctions a so-called VBAC […] [Hospital] cannot meet the staffing standard…. ‘Very few hospitals outside of universities are going to be offering this.’ The prime concern is that during labor a woman’s uterus can rupture along her existing C-section scar line. Critics are quick to note what several sources report — that such tears happen less than 1 percent of the time. […] ‘The problem is when things go awry, things change immediately and that could be a dramatic outcome for the mother or the baby.

Recent research shows the risk of uterine rupture among women with one prior low uterine segment cesarean in spontaneous, naturally occurring labors to be about 0.5%.

I have several concerns about this situation that I hope you will address:

  • Women go to hospitals to give birth because they often feel that a hospital is best equipped to handle birth emergencies. According to the [Hospital] website, the hospital handles 2400 births a year. I am concerned that if [Hospital] can’t meet the staffing standard for VBACs, that means the hospital doesn’t have the ability to perform an emergency cesarean 24 hours a day/seven days a week. If the hospital cannot accommodate a medical emergency such as uterine rupture, how can they respond and treat other real, but rare, labor emergencies such as cord prolapse (approximately 0.14-0.62% of births) or placental abruption (approximately 0.65% of births), both of which require the baby to be born ASAP usually by immediate cesarean sections?
  • The cesarean rate in this country has risen well above the World Health Organization’s recommended rate of 10-15%. According to [a newspaper] article from 2003, at that time approximately 28% of births at [Hospital] were cesareans. Add to that the approximately 4% that were VBACs but are now required repeat cesareans and you get a 32% cesarean section rate — more than twice that recommended by the WHO. Healthy People 2010 recommends a reduction in cesarean births in the US to 15% by 2010. I am concerned that the cesarean rate in [our city] is so high, because cesareans are not risk-free operations, and I would like to know what the hospital is doing to address the over use of cesareans.
  • I am concerned that [Hospital] is understating the risks of primary or subsequent cesarean surgeries yet exaggerating the risks of VBAC. Cesareans pose serious risks to mothers, including two to four times a greater chance of maternal death, increased risk of emergency hysterectomy, injury to blood vessels and other organs, chronic pain due to internal scar tissue, increased chance of re-hospitalization and complications involving the placenta in subsequent pregnancies. Cesareans also pose risks to the infant, including an increased risk of respiratory distress syndrome, prematurity, the development of childhood asthma, and a 1-9% chance the baby will be cut during surgery. The recovery from a cesarean is much longer than for a vaginal birth, involving more pain, more difficulty establishing breastfeeding, and a longer hospital stay.

I understand that having an anesthesiologist at the hospital at all times is expensive, and cannot be billed to a patient’s insurance unless he or she ends up being needed. However, I am concerned that emergency anesthesia should be available at all times if [Hospital] is going to be a safe place for women to be in labor and deliver babies.

As suggested by the 2003 article, I understand that fear of litigation drives a decision to ban VBAC in many hospitals. However, many hospitals have women who want to attempt a VBAC sign a form stating that they understand the risks of VBAC. Could [Hospital] do this?

Giving birth is a life-changing event in the life of a woman. She needs to be able to work with her care provider to make decisions that are best for her so that she will feel good about the experience for the rest of her life. With the exception of the VBAC ban, I have heard good things about the birth centers in the [Hospital] system. I hope that you will re-examine this policy and give women who have had a previous cesarean and are candidates for VBAC the chance to choose between VBAC and repeat cesarean. Thank you for taking the time to consider my request. I would like to follow up with you with a phone conversation next week and I look forward to hearing your thoughts on this matter.

Sincerely,

___________________

Finding a VBAC Supportive OB or Midwife

When looking for a VBAC supportive provider, the absolute best place to start is locally. Attend a local ICAN chapter meeting or connect with them online. Chat with doulas, childbirth educators, and nurses who work in your community. They have the unique experience of observing providers over long periods of time, so they can give you the inside scoop. I also think it’s worth your time to call your local hospital and talk to the L&D nurse manager. As them who attends VBAC.

Here are some additional resources:

Note that some of the groups are not explicitly about childbirth. However, there is a tremendous amount of overlap between say, those who homeschool, plan homebirths and those who plan VBACs.

Also, those who have unmedicated births, or VBAC, or homebirth, are more likely to breastfeed beyond the first year, which is called ‘extended breastfeeding,’ and go to La Leche League meetings. They are also more likely to seek out fellow crunchy moms at Holistic Moms groups or attachment parenting groups.

You might have never considered yourself ‘crunchy’ because you think that only hippies are crunchy, but rest assured, VBACs, homebirth, homeschooling, and extended breastfeeding are things that appeal to the super liberals, the super conservatives, and everyone in between. No matter where you are on the political spectrum, you will find someone just like you in these groups.

Also keep in mind that there are traveling midwives, so if there are no care providers in your area, this is an option. Check out the ICAN email support group for referrals.

Once you have found a provider, you are going to want to ask a ton of questions. Call and make an appointment to discuss VBAC. Don’t go in for an exam and try to have an intelligent conversation while sitting on an exam table wearing a thin paper gown. This is not a position of power. Remember, you are hiring someone to support you with your VBAC.

Please interview at least as many vendors as you would to paint your house or install your air conditioning. This is a huge decision and you will be very happy if you take the extra time to screen your care provider.

Since finding a VBAC supportive care provider can be a lengthy process, I would recommend starting your search before you even become pregnant. That way you won’t feel like you are on a timetable or be fighting morning sickness and exhaustion. And won’t it feel nice to have all your ducks in a row so when that little plus sign appears, you feel excited and supported? But, if you are already pregnant and looking, it’s not too late. Take the time to find a provider, you won’t regret it!

When I Had My Miscarriage

I had completely forgotten that I wrote this piece until a month ago.

I was with a dear friend who is getting married and we were visiting with her mom.  We were talking about birth and her mom asked me, “You had a miscarriage, didn’t you?”

The question kind of caught me off guard.  Funny how even though it had been 18 months, the pain was still faintly there.  During that time, I had my sweet VBAC baby, but when I think of that miscarriage… it still makes me sad.

My friend’s mom, a psychologist, knowing that I have this blog, encouraged me so share something I wrote after the miscarriage and a recent post on the ICAN email list reminded me again tonight.  My friend’s mom said, correctly, that people don’t talk about miscarriage much and that many women, in trying to find a way to cope, are left feeling alone.

I shared with her how months after my miscarriage, I was out with my in-laws and just broke down crying in the middle of lunch.  It’s hard because unless someone has experienced a miscarriage, they just don’t understand.  And this makes perfect sense.  While you may look ‘normal’ and ‘all better’ from the outside, you’re not.  Grief takes a long time to work through you.  It’s weird how this little bundle of cells, this little baby in the making, who I just became aware of two weeks prior, become so utterly important to me so quickly.

Other people want you to move on because they care about you and, I’m sure partly, because they don’t know how to make you feel better, or feel awkward in the presence of your grief.  So not only are you dealing with your extreme sadness, but you are uniquely aware of how uncomfortable other people are with your miscarriage, so you are simultaneously downplaying your feelings and/or trying helping them cope so they will feel comfortable around you.

My miscarriage was on September 13, 2006.  I will always remember that date because of 9/11 then my husband’s birthday is 9/12.  This is bittersweet.

I wrote this on December 20, 2006 while working on our annual Christmas letter.  After I was done, and looked at my pain as it spilled out all over the page, I thought it probably wouldn’t make for good Christmas letter material.  On one hand, I wanted to be ‘real’ rather than the ‘Our life is just great here are the hundred reasons why’ material that usually makes up Christmas letters, but I didn’t know how to temper my pain.  Just saying, ‘I had a miscarriage’ seemed to short, to fleeting, but at the same time… I wasn’t ready to deal with everyone’s’ response.  My friends and a few family members knew, but most people didn’t.  Frankly I feel really uncomfortable when people feel sorry for me.  I want to say, “It’s ok,” but it’s not… where do you go from there?  Obviously, I didn’t include my ‘manifesto of pain’ in our Christmas letter.  I included the typical happy stuff and left it at that.

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

In September 2006, after many months of hoping, I was pregnant.  And for two weeks, I smiled with each wave of nausea and dreamed of my daughter being a sister and eagerly awaited May 3, 2007 when our next baby would be born.  But it was not to be.  On the second day of our big Washington trip, my miscarriage began.

I never really understood how painful an early miscarriage could be.  I only knew for two weeks that I was pregnant.  How attached could I be?  It was amazing how painful this experience has been.  I sit here three months later, and I still cry.  I don’t cry everyday.  I try not to cry in front of my daughter.  It is because of her that I have been able to go on without completely breaking down.  Her presence requires me to move forward with each popsicle on a towel in the living room and each pair of pee soaked Tinkerbell underwear.

When I was pregnant with my daughter, I had no idea what I was in for.  I was working – conflicted on whether I would/should/could quit once she was born.  I was selfish.  I really thought I lived a busy life.  I really thought I had a full schedule.  I thought I understood stress, exhaustion, and hard work.  I was all the things people are before they become parents.  And while I was excited to have a baby, I could not possibly comprehend how she would impact my life and how much I would love her – desperately, deeply, completely.  How I would do anything for this little girl.

So when I was pregnant this time, I knew all this.  I knew how much work it would be, how hard it would be, and how much I would love this child.  And I was so excited for my daughter to have a sibling.  I’m also more settled in my life now than I was when I was pregnant the first time.   We were so excited about this baby.  (My daughter has told us that she wants a baby brother.  It now breaks my heart to hear this request.)

So when I started spotting five days before that day in Seattle, I was at my parents’ house.  After several years of charting my cycle (daily cervical fluid, cervical position, and when I’m really motivated, waking temperature), I learned how my cervix feels before I start my period… and that is how it felt that day.  Even my lay knowledge told me that something was wrong.  My uterus preparing to empty doesn’t seem compatible with a pregnancy.

I went to urgent care and the MD there told me everything was fine.  He told me to stop feeling my cervix, that I would get an infection.  He sent me home with a condescending pat on the back, completely dismissing what I was saying about the state of my cervix.

I continued with our plans for that day – meeting friends at Disneyland – but did so with a heavy heart.  I certainly hoped that the MD was right, but my instinct told me differently.  And for the next five days, I tried to curb my enthusiasm, which was hard.  We went out to dinner that weekend, as planned, with my in-laws and told them that we were pregnant.  I really tried to tell myself that the doctor was the expert, not me.  I should listen to the experts.  Everything will be fine.

So when I woke up that morning in Seattle, a thousand miles from home, and saw bright red blood, I tried to justify it every way I could.  “I spotted last time and everything was fine.”  “It’s not that much blood.”  But this was more than just spotting.  Even though I had to put on a maxi-pad to cope with the bleeding, I was still trying to justify and deny what was happening.  My husband and I were at breakfast, a couple hours or so after we woke up, and the bleeding was intensifying, not decreasing.  It was surreal.  We decided to go to the emergency room.  I got up from our table and walked into the lobby.  I asked the front desk clerk where the closest hospital was and requested that she call a taxi.  I asked if the hospital was a good one.  I really thought, “I’m going to feel so dumb when we get there and they tell us that it’s fine.”  When the cab driver asked if I was ok, I meekly said, “I think I’m having a miscarriage.”

The people working that day at Virginia Mason ER were amazing.  I was wondering how we would be received based on my experience just a few days before.  They saw us almost immediately.  The nurses were so nice, gentle, respectful and the MD was very candid when he told us that he and his wife had experienced this as well.

No medical speak.  Just three human beings connected through pain.

I thought I saw a heartbeat on the ultrasound monitor and for 30 minutes I really had hope.  Long story short – there was no baby.  I will never forget my husband’s face.  The doctor came in the room to tell me and my husband was just outside the door watching our daughter as she ran around in the hall.  The doctor said development had stopped “some time ago.”  My husband heard what the doctor said and we made eye contact.  Thankfully, I didn’t need a D&C as my uterus was already almost completely empty.

We left the hospital a few hours later and I will never forget how physically weak I felt.  How emotionally numb I was.  I sensed the profound sadness deep inside my heart, but it felt far away.  It was as if I looked through frosted glass and could see my fuzzy, deformed, vaguely familiar pain. That was the part of me that didn’t want to deal with it.  I didn’t want to deal with what this all meant and ruining our much anticipated family vacation where we would attend a family wedding that weekend.  (Thankfully no one but my parents knew I was pregnant.  I don’t think I could have gone if I was receiving continual condolences and sad sideways glances.)

We walked down the beautiful hill towards our hotel and contemplated, “What next?”  I certainly didn’t want to go back to the hotel.  And do what?  Cry?  Lay in bed and look at the ceiling as our 2 1/2 year old lost her mind trapped in a hotel room?  Wow, sounds like a great time.  No, I didn’t want to do that.  I wanted to walk.  So, we did.

Slowly, gently planting one foot firmly before picking up the other, holding my husband’s hand as he pushed our sweet girl all bundled up in her stroller.  We walked by beautiful window displays.  We walked to Pike’s Place.  We spent several hours there.  Slowly walking.  It was a crisp day.  It was nice to wear a jacket.

After we got back to the hotel, my husband took our daughter to the pool at the hotel.  I laid in bed and looked at the ceiling.  Looked out the window.  Looked at the TV.  And I cried.  I cried loudly.  It was the first time I could really let loose and let it out.  I didn’t want to upset our daughter, so I had tried to keep everything ‘under control.’

So with each wail, I tried to push the pain out up and out of my mouth.  Hoping that if I just got all the pain out, I could feel better.  I wasn’t going to let this ruin our vacation.  We had plans to go to the zoo, the Children’s Museum, the Space Needle… and damn it, I was going to have a good time.  And I would smile.  Even though my sadness, I would enjoy my family.  So after that cry, I put it in the back of my mind – to deal with later.  Later, after I stopped thinking I’d get pregnant again as soon as possible, after we got home and I saw my friends with their sad faces.  Later when I could face my pain.  And, when we got back, I did cry a lot.

Even now, there are times that I cry.  It’s hard how the pain doesn’t miraculously disappear.  It just goes beneath the surface.  I hate the phrase, ‘Move on.’  Only people who have never experienced a great loss would have such a cavalier attitude towards grief.  As if once all your pain goes away, once you ‘move on,’ then you are ‘all better.’  What does that mean?

You don’t think about it?  You don’t cry?  You are never sad again?  Please.  The pain never goes away – it just isn’t so raw anymore.  The jagged edges of my pain are worn away and I don’t think about it all the time.  But just because I’m still sad sometimes, doesn’t mean I’m not still doing laundry, potty-training, and enjoying my life.  It just means I’m still sad.  It means I wish I was writing you 5-months pregnant, but I’m not.  And that sucks.  And it’s quite all right, thank you very much, if I’m ‘still’ sad about it.

A friend of mine who has experienced miscarriage twice told me that it was totally weird – no one will mention it to you.  People will act like it never happened.  And being on the other side of it, I know what it feels like to not want to upset someone.  To not know how to bring it up or what to say.  To simply be uncomfortable in the presence of someone else’s massive loss.  But now being the one ‘it’ happened to – it’s weird.  I’d talk about it if someone asked me.  But no one does.

I share this personal pain because I hope that someone else will find comfort, knowledge or understanding.  I don’t pretend to presume that I could have this power.  I just know how much strength I have gained from my brave friends who have shared their pain with me.  If it wasn’t for these friends, this could have been a very lonely, isolating event but instead I learned to share a quiet, communal understanding with women who have walked this painful well-worn road before me.