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VBAC: A husband’s experience and lessons learned

“I have just seen so many women who have husbands who aren’t supportive because they don’t understand. My husband would love to help more men understand.”

A couple recently shared their VBA2C (vaginal birth after two cesareans) journey with me.  It touched my heart.  My the time I was done reading it, I had tears in my eyes.

So many women do not feel that VBAC is an option for them because their partner isn’t on board.  Now I know there are women who will birth how they please regardless of their partner’s feelings or thoughts, but there are many women who wish to bring their baby into the world while preserving their relationship.  And, what typically happens in these scenarios, is that the woman puts the desires of her partner above her own and she schedules a repeat cesarean.  Often, the challenge of educating and convincing their partner is just to great in the face of the conventional wisdom that states VBACs are just plain dangerous.

Just the other day, I was talking to a couple in their 40s who didn’t have children.  Yet despite the fact that they were not in the “world of childbearing,” they thought “once a cesarean, always a cesarean.”  This falsehood is so engrained in our society that even those without children know it by heart and believe it to be true.

The absence or presence of social support is a huge factor in whether a woman plans a VBAC or a repeat cesarean.  This is why it is so important for partners and people of non-childbearing age, such as the birthing woman’s parents, grandparents, and extended family, to know that the American College of OBGYNs and the National Institutes of Health say that VBAC is a safe, reasonable, and appropriate choice for most women with one prior cesarean and for some women with two prior cesareans.  When friends and family members are undereducated about VBAC, it negatively impacts the birthing mom.  Many women are simply not willing to create family drama in order to plan a VBAC.  And the seeds of resentment are planted.

And then there are men that want to support their wives, but don’t know how.  They feel trapped between a growing mistrust of their doctor and the desire for a good outcome for their wife and baby. Today I spoke with a father who said that he “felt powerless” as his wife was bullied into a cesarean. He really believed that he should be able to completely trust his wife’s OB, but as her labor progressed, he did so less and less.  And yet, he didn’t know what to do.

Men need to hear the experiences of other men as partners are such a critical part of the birthing woman’s support team.  For many women, when their partners are on board, they have the emotional sustenance required to plan a VBAC in a country where over 90% of women have a repeat cesarean and women planning VBACs are often bombarded with stories of “VBACs gone wrong.”

I hope you enjoy the words of this engineer, this military man, this caring father, as he graciously articulates his VBAC journey.

I would love to share more VBAC stories from the partner’s perspective.  You can submit your birth stories via email.

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One of the most important life choices is the freedom to choose what one wants for their own health and their body.  For my wife, it was the choice to have a VBAC after two c-sections and the need for her husband’s support to make it happen.  This is a short story about a husband’s lesson learned and incredible experience of sharing a VBAC birth with his wife.

Our first child together was a cesarean because the labor would not progress and ultra sound pictures indicated a large head.  The doctor feared complications due to the large head and the concern over my wife’s first vaginal birth 9 years earlier that resulted in a 4th degree tear.  Our going in game plan was always as natural as possible.

Before we decided to start a family, my wife relayed her desire to have a natural birth when the time came. She described the challenges in her first birth that resulted in a painful 4th degree.  She relayed that in retrospect, the 4th degree tear could have been prevented had the atmosphere of the delivery room been more supportive, more relaxed and the doctor vetted more carefully prior to delivery.

All doctors are not created equal.  A medical degree does not guarantee that two doctors will have equal outcomes. And with my wife’s first child years before I was in the picture, there was good evidence to support her claim that both support structure and doctor helped lead to a painful labor.

“I could not understand the true emotional implications”

When our son was born cesarean, there was a disappointment that only she could truly understand. I was simply happy to have a healthy son.   I remember her making a comment about cheating me out of the experience to have a natural birth, as if her body had failed what it was made to do.  I reminded her that natural or cesarean, it was all the same to me as I just wanted wife and baby to be healthy.  How this was accomplished was not important to me.  But, to my wife the cesarean felt like a violation of her choice and cheated her out of the way nature created the female physiology to behave after 9 months of baby development.

I admittedly could not understand the true emotional implications that having a cesarean had on my wife until she went through her second cesarean.  When we decided to have baby number two together, my wife’s third, our doctor immediately said that since our son was born cesarean that our next child would have to be delivered cesarean too. We argued the point and our doctor, whom we loved and took care of all the children and my wife, finally gave us the option to find another doctor because the hospital “protocol” required that under the circumstances (quoted as saying the 4th degree and then a cesarean) dictated a second cesarean regardless of how the pregnancy was to progress.  This catch-22 complicated several factors for us.

“Our doctor, whom we loved, gave us zero options”

First, our doctor, whom we loved, gave us zero options.  She was a great person, wonderful doctor, but she was strapped to the protocol of the local hospital or their medical group that tells patients what they will do as opposed to giving the patient real options and choices on their health care.  I mentioned to my wife that we could switch doctors for this pregnancy but found that it may complicate our life because we were getting good care just miles from our house with the current doctor.  In the end, we stuck with the doctor we liked.  The lesson learned was that I should have told the good doctor to either grow a pair and stand up to the hospital’s myopic protocol and allow us the opportunity to do it our way or we should have just cut ties and got a new doctor who supported our VBAC wishes.  In the end, my wife’s freedom to decide should have been more important than our comfort zone with the local doctor.

I reluctantly supported our doctor and their protocol for a second cesarean.  I could tell my wife was disappointed, but she did not fight me.  This is one of those critical marriage lessons that go both ways.  Since there was little objection, just subtle and maybe even lingering apprehension to not make the decision to switch, we stayed with the plan.  Looking back, my wife’s apprehension to switch doctors was due to lack of VBAC education and lack of support from any of her caregivers, including me.  She just couldn’t understand why she was being forced into major surgery.

Later, after our daughter was born, I realized how much the inability to have the option of a natural birth meant to my wife.  The night before the scheduled cesarean, it appeared my wife was going into natural labor.  In retrospect, considering the labor signs and the small size of the baby, there is little doubt that she could have delivered vaginally.  My wife mentioned this to me the night before the c-section when she was having contractions and said, “I can do this naturally.” My response was, “No, we already have this scheduled for a cesarean in the morning and the doctor said that they would not do it.”  This response was naive and void of any empathy or realization of what that lack of support meant to my wife.  We went into surgery and it wasn’t until she was pregnant with our third that I realized how much the second cesarean had left her with some lasting emotional stress and even low grade secret resentment toward me for not supporting her or understanding her feelings on the topic better.  Whether she’ll admit it publicly, she harbored feelings against me for not supporting her, for the medical community’s lack of birthing choices, and to the doctor who we loved but had a hard time saying no to.

“I realized I let my wife down”

When I finally realized how critically important it was to have the freedom and choice to labor naturally, without absolutes dictated by the medical community or their “legal directives,” did I realize that I let my wife down. When the clue light came on I was set on supporting her on a VBAC, but it didn’t start that way.  My awakening did not come immediately when we found out we were having a third baby.

The pregnancy of our last child coincided with the pop up surprise news that I had to leave on a one year deployment to Afghanistan. In January 2012, I found out I was leaving the first week in April for a one year deployment and days later my wife announced she was pregnant.  What great timing.  Now my wife had to be a pregnant single mom to 3 children for an entire year.  Fortunately, we found out that due to the length of the deployment I was allowed 15 days of leave any time after 90 days in theater and therefore we started planning on my arrival for leave to coincide with the birth of our new baby.

“A selfish desire to try”

My wife quickly relayed her wishes about how this pregnancy would go.  She said to me bluntly that we’re doing this naturally. I quickly shot back with absolutely not.  My engineering brain quickly argued with her that we had three data points that indicated this was not a good idea: a 4th degree tear from forceps and 2 cesareans.  I told her that I did not want to take the chance of having my wife or baby put at risk because of a selfish desire to try and prove something to me or the world that she could do this naturally.  I had read medical reports of women’s uterus rupturing and dying from bleeding after attempted VBACs.  I feared what could happen.  But, I never knew the more thorough and recent facts of what my wife wanted to do.  She knew that I was a man who required facts to make critical decisions so she turned away from this conversation and re-engaged me at a later time with literature that showed a VBAC after 2 cesareans is not as dangerous or risky as I originally thought.  She showed me numerous medical associations that supported VBACs of all types.  I did a little more research and realized that from a technical perspective; it was possible assuming the pregnancy progressed normally without anomalies.

“It was at this moment that guilt set in”

When my wife dropped this data in my lap and looked at me with a long, deep stare that pierced right through me, my awakening had begun.  I realized that she wanted to have the choice to deliver this baby naturally without anyone in the medical profession telling her no unless there was a clear smoking gun for why it wasn’t possible, like high probability of death to baby or mom.  I knew she needed my support to make this work.  I decided at that moment that I would support her wish to have our baby without surgery.  I knew if anyone could do it, she could.  And I knew that there was no reason why we shouldn’t try to do it naturally.

It was at this moment that guilt set in for not doing something about my wife’s desire to try and have our daughter (second c-section) naturally.  I could have pulled my alpha male tricks and told the hospital to pack sand and that we were going to labor naturally and they’d have to follow our wishes or put us in the parking lot.  But, I didn’t do that and I was determined to redeem myself for not understanding how she truly felt.

“The only doctor we could find was a 2.5 hour drive without traffic”

The plan was complicated.  The only doctor we could find that took our military insurance and would entertain our idea of a VBAC with my wife’s past birthing history was in Los Angeles, a 2.5 hour drive without traffic from our desert home.  The doctor seemed too good to be true.  Our doctor, Dr. W, was personable, professional, and most importantly very supportive.  There was no talking down or psychological political play to try and convince us that our decision was not wise.  I told him that if there was no real reason why the baby couldn’t come into this world naturally, then we wanted his support for a VBAC.   He said he’d support our wishes as long as mom and baby were healthy, and the American College of Obstetricians and Gynecologists (ACOG) supported VBAC.

This seemed too good to be true because our impression was that California was much more litigious than Washington State from where we had our last two children and the previous c-sections.  We assumed we would have fewer choices in California because California is a highly regulated state.  In our case, it took a very experienced doctor with the courage and trust to allow us to proceed with our desire to have a natural baby.  He was under pressure from both the hospital and his own reputation if things went badly, but he took a chance and gave us the benefit of the doubt to respect our right to choose.

“I wasn’t worried about the rocket attacks from insurgent forces, I was worried about my wife.”

While in Afghanistan, I wasn’t worried about the every 8 to 10 day rocket attacks from insurgent forces, I was worried about pregnancy issues and my active wife.  She was now a pregnant single mom, raising a teenager and two children, running 3 houses (we own two in WA State) and maintaining an aircraft.  With our son, my wife was put on bed rest at 29 weeks due to pre-term labor and in the end because the labor did not progress she had the first cesarean.  The surgery was an experience she did not ever want to repeat but ended up repeating with our daughter.  While I received the daily reports via emails, skype sessions and pictures, I prayed for her and the kids’ safety and health.  I was slated to fly home on or around the 5th of October and be present for the birth, due date October 11th.

There is no doubt that the 15% increase in grey and white hair while deployed was due to the reports of life at home.  While pregnant, my wife traveled to Florida, Georgia, and Colorado, traveled and hiked the forest on the Pacific coast with all the kids.  And at 8 months pregnant I would get pictures of her painting various rooms in the house and even using a chain saw to do yard work.  I pleaded with her to hire the labor and help as I was scared something was going to happen.  She was simply not a sit on the couch woman.  She was on the go all the time.

With our second daughter, my wife fell out of the car 10 days before the scheduled C-section and shattered her left 5th metatarsal. Ten days after breaking her foot, she had the c-section, then 2 weeks later she was in a car and we were moving from Washington State to California and into temporary housing, headed to our next California duty station.  She had a cast on her foot for 4 months. This experience was painful both emotionally and physically.  Now, 8000 miles away, I was afraid something similar might happen but even worse since I would not be there to help.

“Preparing her mind and body for a successful VBAC”

Simultaneously while my wife traveled with the kids, painted, and did yard work with chain saws, she took numerous steps to ensure that the VBAC would succeed.  Of her many objectives, one was to ensure that the baby would not be occiput posterior as her first and only vaginal birth yielded a decade earlier and a contributor to the 4th degree tear. She also contacted and connected with various people who gave her more information on how to best prepare for a VBAC.  She had chiropractic appointments to help loosen up her hips and to prepare her body for natural labor.  She read more medical data, communicated and worked with people like our doula, who volunteered her services free to military members.  The doula could be instrumental in helping many women and seems to be an underutilized service.  Our doula volunteered with Operation Special Delivery for families of deployed military members, free of charge.  Free expert doula care is something that does not exist and therefore we were fortunate to be in the right part of the country at the right time when a humble, caring and experienced woman was offering her doula services free to military spouses.  This too was a unique windfall and something that feels more like a blessing than pure luck.

Through my wife’s various connections, proactive appointments, nightly stretching rituals, she was preparing her mind and body for a successful VBAC.  People such as our doula volunteered hours talking about the game plan for VBAC day.  There was a real possibility that my leave period could have been canceled or late, because anything in the military is possible. Therefore, our doula was necessary to coach and represent my wife’s interest in the event that I couldn’t get home.  With both me and our doula in the room with my wife we were able to support her and time share in helping her along.  Fortunately, we both shared the same objectives and wanted the birthing room to be sterile of negativity and only wanted supportive hospital staff to interface with my wife.  This was a critical aspect of the successful VBAC.  The doula’s warrior like spirit and endurance meant that I had help and an advocate by my side the entire time.  By the time the baby arrived, all three of us, the doula, my wife and I had been up for almost 36 hours since we never got to sleep the night contractions started. My wife text messaged our doula when the contractions got bad and she stayed up on standby until my wife told her that we were headed into the hospital.  Our doula arrived shortly after we arrived at the hospital and stayed through the entire experience.

“What was important was her health and the baby’s, not my convenience of being home”

Thankfully, my wife’s pregnancy was just about as perfect as one could hope for.  She had terrible heart burn, the normal stuffy nose and difficulty sleeping at night, due to the physiological challenge of having a baby grow against the bladder, making nightly trips to the bathroom routine.  All this was normal and when I finally arrived in Los Angeles on October 7, we were ready to have a baby.  There were no indications that the pregnancy could not continue into normal labor.  Now, the next step was simply getting my wife into labor.  She tried acupuncture, lots of walks and when I arrived, we tried the husband-wife techniques that usually help stimulate labor.  But, after a few days home, there were no signs of labor and my wife was getting frustrated.  She so desperately wanted me to experience this with her and my window home was short.  I told her what was important was her health and the baby’s, not my convenience of being home.  The strict military protocol didn’t have flexibility in the return schedule: unless it was a major medical emergency, I was slated to leave on the 16th day after I arrived home.  So if the baby came late, then I would have very little time with the baby.  If the baby had to be delivered via yet another c-section, my wife would be in dire need of help because she’d be hard down with NO family scheduled to be around after I left. This iteration of the various scenarios had me the most concerned. I was sick to my stomach thinking about this situation; leaving my wife days after a c-section with a house full of kids was unthinkable.  I knew I’d have to come up with some creative way to get her immediate help at home.

Another scenario that had me concerned was the baby being 7-9 days late, as was the case with a friend during the same period.  The reality of me coming home and then leaving with no baby was a possibility and then having to deliver just hours or days after I left to return to Afghanistan was a horrible thought too. In this scenario, the probability of complications increased because the possibility of the baby growing too big and then again requiring a c-section increased significantly.  When my wife began to panic a little about having no signs of labor, I tried my best to reassure her that everything would work out.  In my statistically oriented mind, I knew the odds were against us.

“Contractions were coming about 4-5 minutes apart and they were getting stronger”

Lying in bed on the 8th of October, my wife was upset at the possibility of our grand plan not working out and I assured her that this baby was coming and it would come on the due date.  Early in the afternoon on October 10, my wife started to have small contractions.  By around 10 pm they were getting more significant.  Just after midnight on October 11, the baby’s due date, the contractions were coming about 4-5 minutes apart and they were getting stronger.  Then with the first real sign of labor, the bloody show, we decided to leave for the hospital, which was about a half hour drive from our hotel.

My father had flown into town a few days before I arrived from Afghanistan.  He was the cat herder; he took care of our 4 and 2 yr old.  My father at 68 years old has the amazing stamina to handle two energetic kids. We left at around 0130 in the morning on October 11 and left my father to pack up the entire little cottage we were renting at a local air force base in LA.  When we got to the hospital, my wife’s contractions became very strong and painful. I remember my wife saying labor will be hard for me because I’ve never seen her in real pain and I’m not good with seeing her in pain.  I didn’t know what she meant until she started to go into active labor.  Our doula met us at the hospital.  Between the doula and me, we helped coach my wife through 17 hours of painfully slow labor.

My wife’s labor pains came strong and painful.  She was right; I’d never seen her in that much pain before.  She had painful contractions for hours and hours.  Her first cervical check revealed she was only 1-2 centimeters.  She became frustrated again – after all that work and pain we assumed she would have been considerably further along. Since my wife had two c-sections previously, the staff was trigger happy to react to any anomalies seen in my wife or the baby.  Their threshold for pregnancy challenges was low.  If the monitors weren’t on at all times, they’d come into the room quickly and impatiently.  Our doula and I had to tell the staff to stop over-reacting.  They settled down a bit, but they reminded me that there wasn’t much wiggle room for the monitor rules.  The previous night, a woman’s uterus ruptured just after birth and she almost died in a room next to ours.  So the staff was even more on edge than usual.

Therefore, we had additional pressure to ensure my wife was relaxed but yet progressing.  After 13 hours of labor, she was exhausted and the pain was beginning to take its toll.  Her dilating slowed at around 6 centimeters.  The anesthesiologist recommended an epidural in case my wife needed a c-section.  They could put one in without administering medicine.  We did not want an epidural to prevent my wife from being able to position on all fours or sitting on the port-a-potty they brought in for her to labor on.  But, the pain was so bad, that it was preventing her from relaxing and she was simply running out of energy.

At 8 cm the epidural was in, we made the decision to administer a very low amount of pain relief, just enough to take the edge off.  This technique worked and the small amount of pain relief helped my wife regain some confidence as it reduced her pain level. They put in enough pain meds for 1 hour of relief.  The doctor said the water bag needed to be broken to further progress.  Several hours after the water broke the doctor came in and checked her.  She was 10 centimeters now, the magic number to begin the delivery.

After 15 hours of labor, the baby had to be delivered now.  The doctor recognized how tired my wife was and he ensured no more epidural medicine was administered because he needed her strength to push the baby out if we were to do this naturally.  He pulled me aside and told me the baby’s threshold heart rate was down 30%, something I had observed and was concerned about. Dr. W told me that it was time to get the baby out and it was coming out one of two ways.  He said when he comes back, we’re having the baby.  He couldn’t let the heart rate deteriorate any further and said the baby is plus 1 and not happy about being stuck in that position.

“The natural urge to push wasn’t happening”

I went immediately to my wife, who was exhausted and told her when Dr. W comes back in, it’s time to push.  I calmly gave my wife a pep talk, but she was too tired to respond and her lack of response had me worried.  But, she listened.  Both our doula and I could tell that my wife was having a hard time pushing. The pain was difficult to push through and for some reason the natural urge to push wasn’t happening like my wife envisioned it would happen.  Her body made it to 10cm, slowly, but wasn’t sure what to do now.  The natural urge to push wasn’t occurring.  But, it was time to push anyway.

I didn’t want to seem panicked, but I told my wife several times when the good doctor comes back, he’s either taking you to the OR or you’re going to have to push this baby out.  A delivery nurse came in first and she wanted to observe my wife push and immediately gave her some corrective technique.  Then Dr. W came in and did the same assessment and recognized some technique issues and then he turned into an assertive drill instructor, telling my wife to push.  Both the labor nurse and the doctor’s quick technique advice were key.

“Is that the baby’s head?”

After one of my wife’s strong pushes and while I was holding her right leg back I noticed something unusual looking next to the doctors finger that was positioned about a half inch inside my wife’s vagina. I couldn’t make out the object initially but once my tired brain thought of all the possibilities I realized that it looked like a mat of wet hair.  I asked the doctor, “Is that the baby’s head?” He said yes it is. I was filled with energy and excitement that I hoped would jump to my wife when I told her the news of what I had just witnessed.  I couldn’t believe I was staring at the top of our child’s head.  We made it I thought!  I told my wife I could see the baby’s head.   She pushed harder and after about 3-4 good pushes, our baby came right out.  It was the most amazing thing I’ve ever witnessed.

Once the baby was out, they placed her on my wife’s bare chest. After several minutes we realized that we never checked to see what the sex was.  My wife lifted her up, moved the umbilical cord and I think we were both surprised to see a little girl part.  We did not want to know the sex of the baby until he or she was born.  We assumed we were having a boy because of how strong the baby was during the pregnancy and how much the baby looked like our son from the 3-d ultra sounds.

“She felt so good that we requested to leave the hospital at the absolute minimum stay period.”

Lucy Rose was born at 7:47pm on October 11, 2012.  She was 7 pounds 1 ounce.  My wife had no tearing and her uterus showed no signs of trauma from the VBAC.  She felt so good that we requested to leave the hospital at the absolute minimum stay period.  The baby was born at 7:47 pm and we told the hospital we’d stay exactly the required 24 hour monitoring period. By 8pm, 24 hours later, we were loading up the car and heading back to our desert home, 2.5 hours from the hospital.  We arrived at our home around 11:30pm.

This was the first time I had been home since April 7th and it was so nice to be back.  No hospital nurses checking vitals every 2 hours and the comfort of our own nest.  The next 10 days at home with the baby, my wife and kids were absolutely wonderful.  Due to the natural birth, my wife was immediately mobile.  Unlike the previous two births, it was great seeing my wife smile, happy and glowing and able to move without pain.  She loathed the c-section and dreaded the possibility of having to go through that again, especially without the help of her husband.  Thankfully, we were able to have a successful VBAC preventing my wife from having to relive another c-section.

“She came in and began lecturing us on the dangers of a VBAC.”

When we arrived at the hospital, the birthing process started out badly.  The first nurse we dealt with was what I would consider bluntly, an idiot.  She came in and began lecturing us on the dangers of a VBAC.  I quickly told her to stop and leave. This same nurse came in again and tried to make more negative commentaries and this time our doula rolled in and told her to essentially shut up and do her job.  I pulled this nurse out and told her that we weren’t going to have any negativity in the room.  I told her that we weren’t 16 year old idiots; we were well informed and educated people who most likely knew more about the risks than she did.  I had thoughts of leaving the hospital due to the initial behavior of the nurses.  In all honesty the staff on duty when we arrived was absolutely horrible. They were unfriendly and unprofessional.

But at shift change, something wonderful occurred.  The next shift yielded very competent, supportive and professional nurses who understood that our path through this experience was going to be nothing but positive and supportive.  Two of our nurses were also doulas.  We had great health care providers through the rest of the stay at the hospital.  No more myopic lectures about the risks but instead an all out effort to support my wife through this delivery.  There is no way we could have made it through this experience without the help and support of true and knowledgeable nurses who understood compassion and realized that the patient is first and foremost.

“My initial thought was that this hospital was going to be a disaster but I was happy to be wrong.”

My initial thought was that this hospital was going to be a disaster but I was happy to be wrong. We fortunately experienced a well organized and supportive hospital where our experience was wonderful and our dream of a natural birth and of a successful VBAC was realized.  The ability to have a natural birth allowed my wife to function immediately after the birth, something that would be crucial when I left again for another 5 months.  My 9 days at home after Lucy was born, allowed my wife to rest and regain her strength.  Then when I left, she would be able to successfully handle the newly expanded family.  If she had had a c-section, our lives would have been even more complicated and challenging.  Alleviating this variable was crucial and it was extremely important in allowing my wife the choice and freedom to labor as she desired.

“Having hospital protocol tell you what you can do with your body is a crime.”

Having hospital protocol tell you what you can do with your body is a crime.  It was a crime with our second baby and one that I unfortunately did nothing to stop.  I was guilty of not recognizing the deep and complicatedly emotional desire and need to have that choice.  I was guilty for not carefully listening to my wife.

But, I was fortunate to have had a second opportunity to ensure she was able to have that choice.  When I saw and finally understood my wife’s deep desire and passion to have a VBAC, something that I can’t really explain, but instead felt – I knew she could in fact do it and that I needed to help pave the way to ensuring it was possible. That meant I needed to knock down the obstacles that got in our way, like doctors saying no or nurses trying to convince us that our decision was dangerous and risky.  I listened to my wife, and we thank God that we found a doctor who trusted us.

Ultimately, faith, education and research, proper planning, incredible support that we received from people like Dr. W and our doula, and the great nurses who helped make this a success were critical to the successful VBAC.   We heard it before “you’ve had one, so now you need to have them all c-section.” This we now know is myth and one myth that removes the woman’s choice to attempt a VBAC.  Our hope is that other women and couples will have the same support and success as we experienced.

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

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

“Once a cesarean, always a cesarean”

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

One might interpret this statistic to mean that planned VBACs often end in a repeat cesarean. However, VBACs are successful about 75% of the time (3-7). The VBAC rate is so low because of the women interested in VBAC, 57% are unable to find a supportive care provider or hospital (1). And I would argue further that even among the women who have a supportive care provider, those women are so bombarded by fear based misinformation masquerading as caring advice from friends and family, they have no chance.  It is shocking to learn how ill-informed both women planning VBACs and repeat cesareans are about their birth options even upon admission to the hospital.  There is a fundamental gap in our collective wisdom about post-cesarean birth options.

Cesareans make subsequent pregnancies riskier

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

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

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

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

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

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

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

Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery (8).

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

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

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

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

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

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

VBAC bans and emergency response

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

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

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

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

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

Impact of VBAC on future births

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

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

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

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

Women deserve the facts

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

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

Take home message

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

Almost half of the pregnancies in America are unintentional.

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

_________________________________________________

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The best compilation of VBAC/ERCS research to date

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

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

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

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

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

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

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

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

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

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

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

While rare for both TOL [trial of labor after cesarean] and ERCD [elective repeat cesarean delivery], maternal mortality was significantly increased for ERCD at 13.4 per 100,000 versus 3.8 per 100,000 for TOL. The rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL and ERCD. The rate of uterine rupture for all women with prior cesarean is 3 per 1,000 and the risk was significantly increased with TOL (4.7 1,000 versus 0.3 1,000 ERCD). Six percent of uterine ruptures were associated with perinatal death. Perinatal mortality was significantly increased for TOL at 1.3 per 1,000 versus 0.5 per 1,000 for ERCD… VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans… The occurrence of maternal and infant mortality for women with prior cesarean is not significantly elevated when compared with national rates overall of mortality in childbirth. The majority of women who have TOL will have a VBAC, and they and their infants will be healthy. However, there is a minority of women who will suffer serious adverse consequences of both TOL and ERCD. While TOL rates have decreased over the last decade, VBAC rates and adverse outcomes have not changed suggesting that the reduction is not reflecting improved patient selection.

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

Placenta problems in VBAMC/ after multiple repeat cesareans

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

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

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

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

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

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

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

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

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

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

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

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

Here are some stats to consider:

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

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

Read more about accreta.

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

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

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

[and]

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

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

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

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

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

Compare that to the risks in a first pregnancy:

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

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

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

Just kicking the can of risk down the road

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

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

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

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

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

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

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

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

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

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

I urge you to watch Dr. Birnbach’s presentation along with all the presentations from the 2010 NIH VBAC conference.

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

Below is Silver’s (2006) study abstract:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ACOG-logo

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.

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.

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.

Shows the rates of placenta accreta in up to six cesareans (Silver 2006).

Risk of serious complications increase with each cesarean surgery

Yesterday I shared a Canadian article, and last year a letter from two OBs opposing a hospital VBAC ban, which discuss the risks of cesarean sections including placenta accreta and hysterectomy.

Definitions

Today I want to share a study that measured the increasing risks that come with multiple cesareans, but before I do so, lets do a quick review of definitions.

Placenta accreta (March of Dimes 2005):

In a normal pregnancy, the placenta attaches itself to the uterine wall, away from the cervix.

  • Placenta accreta is a placenta that attaches itself too deeply and too firmly into the wall of the uterus.
  • Placenta increta is a placenta that attaches itself even more deeply into the uterine wall.
  • Placenta percreta is a placenta that attaches itself through the uterus, sometimes extending to nearby organs, such as the bladder.

Hysterectomy (Women’s Health 2009):

A hysterectomy (his-tur-EK-tuh-mee) is a surgery to remove a woman’s uterus or womb. The uterus is where a baby grows when a woman is pregnant. The whole uterus or just part of it may be removed. After a hysterectomy, you no longer have menstrual periods and cannot become pregnant.

Placenta previa (PubMedHealth 2011):

Placenta previa is a complication of pregnancy in which the placenta grows in the lowest part of the womb (uterus) and covers all or part of the opening to the cervix.

There are different forms of placenta previa:

  • Marginal: The placenta is next to cervix but does not cover the opening.
  • Partial: The placenta covers part of the cervical opening.
  • Complete: The placenta covers all of the cervical opening.

Increasing risks with multiple cesareans: Focusing on accreta

Today’s study is Maternal morbidity associated with multiple repeat cesarean deliveries (Silver 2006) which included over 30,000 women undergoing up to six cesareans over four years.  (Download the full text PDF.)  Silver measured the complication rates per cesarean number.  And their findings are important to every mom pregnant after a cesarean.  Keep in mind that all the cesareans included in the Silver (2006) study were schedule and performed without medical indication except for the first cesarean.  All the complications noted were a direct result of the surgery, not of any other medical complication.

Silver (2006) found:

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

Accreta was defined as the “placenta being adherent to the uterine wall without easy separation [and] included placenta accreta, increta, and percreta.”

Below are some slides from the VBAC Class I developed and teach illustrating the  rates of placenta accreta, previa, previa with accreta, and hysterectomy by number of cesareans (Silver 2006).   The number below the cesarean number indicate how many women were included in that category.

Remember as you look these over, the risk of uterine rupture in a spontaneous labor after one prior low horizontal (“bikini-cut”) cesarean is 0.4% (Landon 2004).  Risk of uterine rupture during one’s second cesarean is 0.9% (Landon 2006).

Shows the rates of placenta accreta in up to six cesareans (Silver 2006).

 Shows the rate of placenta previa by cesarean number (Silver 2006).

Accreta, previa, and cesarean hysterectomies

I was especially interested to see the relationship between previa and accreta.  Silver (2006) found that if you have previa, you are very likely to have accreta and that risk increases with each cesarean.  For example, if a woman has one cesarean and is diagnosed with previa in her next pregnancy, her risk of having accreta is 11%.  That risk jumps to 40% in the third pregnancy, 61% in the fourth pregnancy and 67% for the fifth and sixth pregnancy.

Shows the rate of placenta previa with accreta per Silver 2006.

Complications associated with accreta

Accreta is nothing to mess around with as it has a very high rate of maternal mortality (up to 7%) and morbidity including hemorrhage and hysterectomy.  Fang (2006) asserted, “abnormal adherent placentation [is] the primary indication leading to emergent peripartum hysterectomy…. As the number of prior cesarean deliveries rises, the risk of cesarean hysterectomy increases dramatically.”   In other words, all these primary cesareans and repeat cesareans are causing placentas to abnormally implant in subsequent pregnancies.  As a result, many women who have placenta accreta end up having hysterectomies as that is the best way to control the hemorrhaging that results from accreta.

Rate of hysterectomy by cesarean number (Silver 2006).

Women who had accreta also experienced the following complications:

  • 15.4% (1 in 6.5): surgical injury to bladder
  • 2.1%  (1 in 48): surgical injury to the ureters which are the tubes that connect the kidneys to the bladder and is the “most serious complication of gynecologic surgery
  • 2.1%  (1 in 48 ): blockage of an artery in the lungs (pulmonary embolism)
  • 14% (1 in 7):  mom was put on a mechanical ventilator because she couldn’t breathe effectively
  • 26.6% (1 in 3.8): mom requires advanced monitoring and care so she is admitted to the intensive care unit
  • 5.6% (1 in 17.8): mom requires another operation
  • 3.5% (1 in 28.6): endometritis, “an inflammation or irritation of the lining of the uterus”

Because the risks of cesarean are so great, Silver (2006) concluded with the following statement,

Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.

Alternatives to cesarean hysterectomy

Non-hysterectomy options were discussed in a February 2006 Healthline article by Alison Stuebe, Department of Maternal-Fetal Medicine, Brigham and Women’s Hospital, Boston, MA:

In the majority of cases, hysterectomy is the most effective way to manage the potentially fatal consequences of placenta accreta. Unfortunately, however, most cases of placenta accreta are not discovered until the last minute. And, because a hysterectomy results in infertility, some women may want to consider more conservative options.

Conservative or alternate techniques for treating placenta accreta include:

  • curettage (scraping) of the uterus;
  • surgical repair of the part of the uterus where the placenta was attached;
  • clamping the blood vessels that nourish the pelvis (to control the bleeding); and
  • using x-ray guidance to inject gelatin sponge particles or spring coils into the blood vessels that nourish the uterus (this procedure usually is not feasible in emergency situations.) This procedure requires help from interventional radiologists, doctors who specialize in advanced treatments for bleeding.

Reported success rates of these procedures vary widely. In one recent study, 31 cases of placenta accreta were managed without hysterectomy; there were no reports of infertility or maternal death.

Using ultrasound and MRI to diagnose accreta

All the statistics I have shared above are from hospital based studies where women have access to operating rooms, surgeons, and blood products.  I suspect that the likelihood of a mother dying from hemorrhage due to placenta accreta is significantly higher in an OOH (out-of-hospital) birth.  This is why I think it is completely reasonable to have an ultrasound or MRI to try to diagnose accreta when planning a OOH birth.

Although second and third trimester bleeding can be a symptom for previa, I was surprised to read on the University of Maryland Medical Center’s website, “About 7% to 30% of women with placenta previa do not experience vaginal bleeding as a symptom before delivery.”   Thus one cannot rely on bleeding during pregnancy as a reliable symptom for previa which is why ruling it out via ultrasound appears to be a effective plan. (No citation was given, so if anyone has information to affirm or refute this stat, please leave a comment.)

There appears to be some controversy about the ability to accurately diagnose accreta during pregnancy.  According to a 2011 Medscape article byDr. Robert Resnik, “the diagnosis [of placenta accreta] can be made with accuracy, by very specific ultrasound findings, about 80% of the time, and can be confirmed with MRI findings.”

However, in a 2010 article published in the Journal Watch Women’s Health, Andrew M. Kaunitz, MD states, “If ultrasound findings [while looking for accreta] are not definitive, MRI evaluation is appropriate.  Unfortunately, the diagnostic precision of these two imaging modalities for placenta accreta can be suboptimal.”

I also highly recommend you read Dwyer (2008) which provides an excellent overview and compared the accuracy of the two methods:

Sonography correctly identified the presence of placenta accreta in 14 of 15 patients (93% sensitivity) and the absence of placenta accreta in 12 of 17 patients (71% specificity). Magnetic resonance imaging correctly identified the presence of placenta accreta in 12 of 15 patients (80% sensitivity) and the absence of placenta accreta in 11 of 17 patients (65% specificity). In 7 of 32 cases, sonography and MRI had discordant diagnoses: sonography was correct in 5 cases, and MRI was correct in 2.

Because of this high rate of maternal mortality and morbidity, some doctors suggest if accreta is diagnosed via ultrasound and/or magnetic resonance imaging (MRI) during pregnancy, a cesarean hysterectomy should to performed as early as 34 – 35 weeks.  (Read Does Antenatal Diagnosis of Placenta Accreta Improve Maternal Outcomes?, The maternal outcome in placenta accreta: the significance of antenatal diagnosis and non-separation of placenta at delivery and Placenta accreta: A dreaded and increasing complication for more information on early delivery via cesarean section.)

What difference does it make if you know you have accreta before delivery?

Because accreta has a high maternal mortality and morbidity rate, a hospital plans for a birth with accreta (usually a cesarean if diagnosed before labor) very differently than a birth (cesarean or vaginal) without known accreta.

One night during my endless random reading, I stumbled across the Royal College of Obstetricians and Gynaecologists’ (the UK’s ACOG) clinical guidelines for placenta praevia, placenta praevia accreta and vasa praevia.  (Note that the Brits do spell previa/praevia differently than Americans.)  This document included a detailed description of how they recommend a hospital plan for a cesarean birth due to placenta accreta:

The six elements considered to be reflective of good care were:
1. consultant obstetrician planned and directly supervising delivery
2. consultant anaesthetist planned and directly supervising anaesthetic at delivery
3. blood and blood products available
4. multidisciplinary involvement in pre-op planning
5. discussion and consent includes possible interventions (such as hysterectomy, leaving the placenta in place, cell salvage and intervention radiology)
6. local availability of a level 2 critical care bed.

Taking this extensive preparation into account, I suspect that women fare better when accreta is diagnosed before delivery.

Evidence to suggest previa less likely to “move” in VBAC/VBAMC moms

RCOG’s clinical guidelines also included evidence that of women who were diagnosed with previa early in their pregnancy, women with a prior cesarean where less likely than an unscarred mom to have their placenta “move” enough to permit a vaginal delivery at term (50% vs. 11%).  Since the study in question included over 700 women with previa, this is a large enough study to give us good evidence.

Women with a previous caesarean section require a higher index of suspicion as there are two problems to exclude: placenta praevia and placenta accreta.  If the placenta lies anteriorly and reaches the cervical os at 20 weeks, a follow-up scan can help identify if it is implanted into the caesarean section scar.

Placental ‘apparent’ migration, owing to the development of the lower uterine segment, occurs during the second and third trimesters,52–54 but is less likely to occur if the placenta is posterior55 or if there has been a previous caesarean section.35  In one study, only five of 55 women with a placenta reaching or overlapping the cervical os at 18–23 weeks of gestation (diagnosed by TVS) had placenta praevia at birth and in all cases the edge of the placenta had overlapped 15 mm over the os at 20 weeks of gestation.56  A previous caesarean section influences this: a large retrospective review of 714 women with placenta praevia found that even with a partial ‘praevia’ at 20–23 weeks (i.e. the edge of the placenta reached the internal cervical os), the chance of persistence of the placenta praevia requiring abdominal delivery was 50% in women with a previous caesarean section compared with 11% in those with no uterine scar.53

Conversely, although significant migration to allow vaginal delivery is unlikely if the placenta substantially overlaps the internal os (by over 23 mm at 11–14 weeks of gestation in one study,54 by over 25 mm at 20–23 weeks of gestation in another52 and by over 20 mm at 26 weeks of gestation in a third study57), such migration is still possible and therefore follow-up scanning should be arranged.

I looked up source 53 and it’s Dashe (2002) which shared:  “The outcome of the study was persistent placenta previa resulting in cesarean delivery.  This diagnosis was based on clinical assessment and ultrasound at time of delivery.”  You can read Dashe in its entirety by clicking on this link and then looking for the “Article as PDF” link on the right hand side.

Considering your future fertility

Many women who don’t plan on having more children do not think these complications are applicable.  But I know many women, and I’m sure you do too, who were not planning on more children, but got pregnant nonetheless.  This is consistent with the CDC’s findings that 49% of pregnancies are unintentional.  Unless you or your partner get sterilized or practice abstinence (what fun!), the chance of you getting pregnant, and experiencing these downstream risks, are there.  It’s important when evaluating your current birth options to consider how that decision will impact the risks of your future pregnancies as well as your future delivery options.

Last updated 9/13/12.

Hospital’s Oxytocin Protocol Change Sharply Reduces Emergency C-Section Deliveries

This article published June 19, 2009 demonstrates one hospital’s experience when they changed their oxytocin (Pitocin) protocol.

I’ve included the entire article below and have emphasized what I consider to be the most interesting parts.

Hospital’s Oxytocin Protocol Change Sharply Reduces Emergency C-Section Deliveries
By Betsy Bates
Elsevier Global Medical News
Conferences in Depth

CHICAGO (EGMN) – The modification of the oxytocin infusion protocol at a large university-affiliated community hospital nearly halved the number of emergency cesarean deliveries over a 3-year period, reported Dr. Gary Ventolini.

As oxytocin utilization declined from 93.3% to 78.9%, emergency cesarean deliveries decreased from 10.9% to 5.7%, Dr. Ventolini said at the annual meeting of the American College of Obstetricians and Gynecologists.

Other birth outcomes improved as well at an 848-bed community hospital that serves as the primary teaching hospital of the Boonshoft School of Medicine at Wright State University in Dayton, Ohio.

These included significant declines in emergency vacuum and forceps deliveries and a sharp reduction in neonatal ICU team mobilization for signs of fetal distress (P = .0001 in year 3 compared with year 1).

“More and more data are showing us that we are using too much oxytocin too often,” Dr. Ventolini, professor and chair of obstetrics and gynecology at the university, said in an interview.

“Our pivotal change was to modify the oxytocin infusion from 2 by 2 units every 20 minutes to 1 by 1 unit every 30 minutes. And we see the results,” he said.

Outcomes of 14,184 births from 2005, 2006, and 2007 were retrospectively analyzed to determine any impact of the change in an oxytocin protocol implemented in 2005. Patient characteristics were similar in all three calendar years.

The most profound changes were in emergency deliveries, including caesarean deliveries, vacuum deliveries (which dropped from 9.1% to 8.5%), and forceps deliveries (which fell from 4% to 2.3%).

The overall cesarean section rate remained unchanged, as did the rates of cord prolapse, preeclampsia, and abruption.

Dr. Ventolini cited a recent article in the American Journal of Obstetrics and Gynecology that suggests guidelines for oxytocin use, including avoidance of dose increases at intervals shorter than 30 minutes in most situations (Am. J. Obstet. Gynecol. 2009;200:35.e1-.e6).

Dr. Ventolini and his associates reported no financial conflicts of interest relevant to the study.

Subject Codes:
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Elsevier Global Medical News
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June 19, 2009   10:04 AM EDT

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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.

How to present yourself

Go to your consultations like you would a job interview.  You are not hanging out with your girlfriends.  You want the care provider to perceive you as an intelligent, thorough, and reasonable woman who has done her homework, collected all the info, and would really appreciate the opportunity to VBAC/VBAMC.  Trust is fundamental here and flows both ways. If you can make a human connection with the care provider, then all the better.  Humor is an excellent way to do this.

  • Wear your most professional looking clothes.
  • Get a babysitter for your younger kids if possible so you are not distracted.
  • Bring your medical records and operative reports from your prior cesarean(s).
  • Read, be familiar with, and bring a copy of the 2010 ACOG VBAC guidelines.
  • Google the care provider, their practice, and the hospital/birth center and note any special awards or recognition they have received.  Bring this up in a complimentary way during your appointment.

Remember, a lot of care providers are concerned about being sued, so they are sizing you up as much as you are them. They want to know that you understand the risks and benefits of your options and that you have realistic expectations.  Be sure that you don’t repeat birth myths while speaking to them as that will reflect poorly on you.

Once you connect with them on a human level, and they see that you are an educated, rationale, and reasonable woman, then you can determine how willing they are to negotiate on some of their terms (if necessary.)  For example, if they require moms to stay in bed during the entire labor, ask if their hospital offers telemetry units (wireless fetal monitoring).  Some hospitals even have them in a tube top so they don’t move around as much and are less noticeable to moms.

It’s very important to not come across as angry or argumentative, because that decreases the likelihood that they will attend you.  Express your frustration, anger, and pain with support groups online.

The three types of care providers

There are three types of care providers: those that are VBAC supportive, those that are not, and those that pretend to be until the last minute.   When an care provider says that they are VBAC supportive, but every single one of their clients got risked out for VBAC, ask yourself what is more likely: For every single one of their patients to develop a medical condition that ruled out VBAC or that they really weren’t supportive in the first place? This is why it’s a huge red flag if your care provider says, “We can wait later/ until your third trimester/ 36 weeks to talk about that.”  Your care provider should be comfortable discussing their VBAC philosophy with you now.  You deserve to know if they are genuinely supportive or not so that you can hire another care provider who is more in-line with your goals if needed.  You don’t want to be in a position where you are 36 weeks and your care provider says, “Let’s schedule a cesarean at 40 weeks just in case.”  You can switch providers late in pregnancy, but it can prove difficult.  Keep in mind that you may have better luck getting names when speaking to someone face to face.  Sometimes, people don’t want to give out names to someone they don’t know over the internet.

To give you an idea of how some non-VBAC supportive care providers talk, and what you should look out for, please read:  Another VBAC Consult Misinforms, Scare tactics vs. informed consent, and Hospital VBAC turned CS due to constant scare tactics.

If your husband/partner wants more information, direct him to: A father says, Why invite the risk of VBAC?

Top 18 Questions

Here is a list of questions that are relevant to all birthing women, VBAC or not. What I’ve added is my commentary on how I think their answer reflects how supportive they really are of VBAC.

I think the most important questions relate to going overdue and suspecting a big baby.  Many women have been risked out of VBAC as a result of these two variables, so I will address those two questions first.  Then I will list the rest of the questions in the order of their importance from my perspective.

What is their philosophy on going past 40 weeks? ACOG’s latest VBAC Guidelines, Practice Bulletin No. 115, (which from here on out I will refer to as “PB115”) states that going overdue should not prevent a woman from planning a VBAC.

What is their philosophy on “big babies?” PB115 states that suspecting a big baby should not prevent a woman from planning a VBAC.  Further, ACOG Practice Bulletin No. 22, which appeared in the November 2000 issue of Obstetrics and Gynecology, found no value in inducing for “big baby” since it simply doubles the CS rate and does not prevent shoulder dystocia or reduce newborn morbidity.  Nor do they support cesarean section for suspected “big babies:”

While the risk of birth trauma with vaginal delivery is higher with increased birth weight, cesarean delivery reduces, but does not eliminate, this risk. In addition, randomized clinical trial results have not shown the clinical effectiveness of prophylactic cesarean delivery when any specific estimated fetal weight is unknown. Results from large cohort and case-control studies reveal that it is safe to allow a trial of labor for estimated fetal weight of more than 4,000 g. Nonetheless, the results of these reports, along with published cost-effectiveness data, do not support prophylactic cesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g (11 lb), although some authors agree that cesarean delivery in these situations should be considered.

How many VBACs have they attended? Word spreads fast on pro-VBAC OBs.

Of the last 10 women seeking VBAC from them, how many had a VBAC? If it’s less than 7 or 8, I would ask what happened in those 2-3 labors that ended in a cesarean.  This would give you a great idea of how they manage labors.

Do they attend VBACs with an unknown or low vertical scar? PB115 states that an unknown or low vertical scar should not prevent a woman from planning a VBAC.

Do they have any standard VBAC protocols that differ from a non-VBAC mom? If so, ask what they are.  Compromises almost always have to be made in order to birth in a hospital.  If your care provider requires an intrauterine pressure catheter, you can read more about those here.

Under what circumstances would they induce a VBAC?  It is a myth that a VBAC mom should never be induced.  Inducing a VBAC mom increases the risk of uterine rupture which should be weighted against the reason for the induction.  “Big baby” (less than 11lbs) and “over due” (meaning you are 40 weeks, 1 day) are not legitimate, medical reasons per ACOG.

However, if a medical reason for induction is present, women should be given that option rather than required to have another cesarean.  As a Southern California OB, recently shared on my FB page,

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

If I was overdue and my care provider was concerned about the baby, I personally would request a biophysical profile to check on baby and as long as baby and I are fine, I would request to wait for labor to start instead of inducing or scheduling a repeat cesarean.

However, if my provider was unwilling to wait for spontaneous labor, or if there was a medical reason for the baby to born, and it was the difference between a VBAC and a repeat cesarean, and I had a favorable Bishop’s score (download the app), I would consent to a Foley catheter or low-dose Pitocin induction (not Cytotec or Cervidil).  If I was induced with Pitocin, I would be comfortable with continuous external fetal monitoring.  My personal preference would be to have telemetry (the wireless monitors) because I need to move during labor.

What methods do they use? PB115 states “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.”

PB115 also said, “Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC [trial of labor after cesarean.]”

Landon (2004) reviews how uterine rupture rates vary by drug: 1.4% (N = 13) with any prostaglandins [such as Cytotec or Cervidil] (with or without oxytocin), 0% with prostaglandins alone, 0.9% (n = 15) with no prostaglandins (includes mechanical dilation with or without oxytocin), and 1.1% (N = 20) with oxytocin alone.  Women who were not induced or augmented had a rupture rate of 0.4%.  Overall, they found 0.7% of women experienced a true uterine rupture with an additional 0.7% experiencing a dehiscence.

Do they attend vaginal breech births? 3% of babies are breech at term, so it’s good to know what would happen if you were in that 3%.  Some hospitals do support vaginal breech birth.

Do they attend vaginal twin VBACs? PB115 states that suspecting twins should not prevent a woman from planning a VBAC.  Read stores of twin/multiples VBAC births.

How many uterine ruptures have they witnessed? This can be an indicator of their induction rates or simply how many VBACs they have attended.  It’s a numbers game.  The more births you attend, the more complications you see.

What kind of monitoring do they require? PB115 states, “Most authorities recommend continuous electronic fetal monitoring.  No data suggest that intrauterine pressure catheters or fetal scalp electrodes are superior to external forms of monitoring…”

CIMS asserts in Mother-Friendly Childbirth: Highlights of the Evidence,

Routine continuous electronic fetal monitoring (EFM), compared with intermittent auscultation, increased the likelihood of instrumental vaginal delivery and cesarean section and failed to reduce rates of low Apgar scores, stillbirth and newborn death rates, admissions to special care nursery, or the incidence of cerebral palsy.

In June 2009, ACOG released new heart rate monitoring guidelines where they affirmed,

“Since 1980, the use of EFM has grown dramatically, from being used on 45% of pregnant women in labor to 85% in 2002,” says George A. Macones, MD, who headed the development of the ACOG document. “Although EFM is the most common obstetric procedure today, unfortunately it hasn’t reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions.”

What is their CS rate? This seemingly simple statistic is actually quite complicated. If they are a perinatologist who specializes in high risk births, then a higher CS rate would make sense.

As the 2009 edition of the World Health Organization’s “Monitoring Emergency Obstetric Care: A Handbook” states,

Both very low and very high rates of caesarean section can be dangerous, but the optimum rate is unknown. Pending further research, users of this handbook might want to continue to use a range of 5–15% or set their own standards…. Earlier editions of this handbook set a minimum (5%) and a maximum (15%) acceptable level for caesarean section. Although WHO has recommended since 1985 that the rate not exceed 10–15% (125), there is no empirical evidence for an optimum percentage or range of percentages, despite a growing body of research that shows a negative effect of high rates (126-128). It should be noted that the proposed upper limit of 15% is not a target to be achieved but rather a threshold not to be exceeded. Nevertheless, the rates in most developed countries and in many urban areas of lesser-developed countries are above that threshold. Ultimately, what matters most is that all women who need caesarean sections actually receive them.

Do they perform an automatic CS if waters have been broken for more than 24 hours, even if there is no evidence of infection and mom and baby are fine? If they say yes, this could be a red flag.

Do they have a time-limit on how long your labor can be before they c-section you? Generally, as long as mom and baby are fine, labor should be permitted to continue.

Do they require epidurals for VBAC? PB115 states that pain medication “for labor may be used as part of TOLAC, and adequate pain relief may encourage more women to choose TOLAC.”  One reason that some OBs require epidurals is because if they deem a cesarean necessary, you are already numb.

Do they require an IV or heplock? IVs can restrict your movement. A heplock means they put a line in your arm, but it isn’t connected to a bag.  Heplocks & IVs can be annoying and get you into the “patient” rather than “healthy, birthing mom” mindset.

Are you permitted to move and deliver in your position of choice? Laying on your back or the “on the edge of the bed with your knees by your ears” are great for their viewing, but may not be the most effective positions for you. It’s always nice to have options other than the standard birthing position, such as those demonstrated in this chart or using items like a birth/squat bar or a birth stool (which has the same concept as the bar, but you can sit) for delivery.

Additional questions for out-of-hospital providers

I’ve collected the follow questions over the years as I saw various discussions of questions to ask an out of hospital provider.  Not all of the issues raised here are relevant to every woman, but I include them all so you can pick and choose which ones speak to you. Since OOH providers are often women and midwives, those are the terms I will use.

Her background

  • How many births has she attended?
  • How many years has she been attending births?
  • Number of births attended as primary midwife vs. doula vs. assistant?
  • What is her training?  DEM, CPM, CNM?
  • What equipment does she bring to each birth?
  • How often does she use it?
  • What is her post-partum hemorrhage protocol? Does she carry Pitocin or Methergine?
  • What is her position on ultrasounds?
    • Does she recommend them for HBAC/HBAMC?
    • How many weeks gestation?
    • Where would you have this done?
    • How does payment work?
  • Would she attend you at home as a monitrice and then transfer to hospital as a doula?

Other birth professionals

  • Does she recommend/offer concurrent care with an OB?
  • Is she required to have OB sign-off for HBAC?
  • When and how often would you meet them?
  • Does she have partners or is she a sole practitioner? What is their training/ experience?
  • Does she have assistants? What is their training/ experience?
  • How many midwives and assistants will attend your birth?
  • How many births does she attend per month?
  • How often does she miss births?  Reasons?
  • Does she have a backup midwife? What is their training/ experience?
  • Does she recommend a doula?
  • Which doulas does she work with most often?

Licensing & payment

  • Does her state offer/require licensure?
  • Is she licensed?  Why/why not?
  • Can she legally attend HBAC?
  • How would you get a birth certificate?
  • Does she carry liability/ malpractice insurance?
  • What insurance reimbursement should you expect?
  • What is her fee?  Does she offer payment plan?  What is the payment schedule?

Transport

  • What is her transport rate?
  • What’s her transfer protocol?
  • Does protocol differ for emergent v non-emergent transfer? Different hospitals?
  • What is the transport time by car and ambulance?
  • What are the most common reasons for transfer in her practice?
  • Has she experienced a cord prolapse, shoulder dystocia, placental abruption, or accreta?
  • Will/can she stay with you upon transfer?
  • Has CPS been called on past clients?
  • Does she have familiarity with the local hospitals?
  • Does she have a hospital contact that she can call in the event of an emergency transfer?
  • Do you have any particular concerns/issues from prior births?  How would she handle them?

You might have to interview several providers until you find one who is truly supportive of VBAC. If you do find such a provider, refer all your friends, VBAC or not, to this provider so that they can reap the benefit of someone who supports non-interventive birth! I really think that true change won’t occur in the medical community in terms of supporting natural non-interventive birth and VBAC until the OBs and hospitals see their revenue decrease. For this reason, we all need to support OBs, midwives, and hospitals that support VBAC.

Last updated October 11, 2013

Monterey County hospital reverses VBAC ban

This is great!  A hospital reversing their VBAC ban!  I really wish articles like this would talk less about "the experience" and more about the life-long benefits of vaginal birth for mom and baby. 

May 28, 2009

Natural birth after c-section possible at NMC again

By Leslie Griffy
lgriffy@thecalifornian.com

Monterey County women who’ve had a c-section don’t have to leave the county to give birth naturally anymore.

Natividad Medical Center announced Wednesday that so-called VBACs vaginal birth after cesarean are back.

Like hospitals throughout the country, those in the county dropped the practice of allowing women who have had cesarean sections to give birth vaginally because of a slight increase in complications for such births. Still demand for the service was there.

"This is something that I’ve heard women wanting for as long as I’ve lived here," said Judy Rasmussen, the hospital’s director of prenatal services.

Increasingly, expectant mothers are pushing for natural birth over c-sections. But many women who have had caesareans in the past were told they’d not be able to find a hospital to give birth naturally.

When Cindy Laurance gave birth to her second child in 1990, she hunted for a place to have her daughter through VBAC and ended up at Natividad, then one of the few to provide the service.

"I wanted the experience of natural birth," she said. "You are much more present when you don’t have a lot of drugs in you."

Her first born, Alex McCloskey, didn’t nurse right away because of the drugs required for the c-section, Laurance said. It was different with daughter Anna, born using VBAC. Her own healing time, Laurance said, was much quicker, and she was empowered by experiencing the birthing process.

"VBAC is a really good opportunity for women to have the experience has nature intended," Laurance said.

Natividad’s insurer, BETA Healthcare, approved the facility for the procedure. It required the hospital to have an obstetrician and anesthesiologist at the hospital 24 hours a day, as well as an operating room on standby should something go wrong, said Dr. Peter Chandler.

"You can’t wait for doctors to come in from home," Chandler said. Natividad had met those requirements for the past year.

The announcement won plaudits from the Birth Network of Monterey County, a group that aims to education families about birthing options.

"The old adage ‘Once a c-section, always a c-section’ no longer holds true," said the group’s Joy Weston.

For more information, call 831-755-4156.


I’m pregnant and want a VBAC, what do I do?

I recently received this comment.

Hi…thank you so much for your site! Very informative. I live in Glendale and I had a c-section last year with my first daughter. I went in to be induced even though I wasn’t looking forward to it. No contractions. No mucus plug. No water broken. I guess I just wasn’t ready for labor yet. They hooked me up to an epidural because they said I was going to feel immense pain so I went with it. 26 hours went by and I never dilated so they gave me a c-section at citrus valley medical center. I saw them on your list for high c-section rate. Now, I am pregnant again (a year and a month later) I really want to have a VBAC! Any suggestions? I can see that you have touched many women…any information to spare would be awesome- Rose

Rose,

There are so many women who have experienced your exact story.  They trust their OB because, hey, they didn’t go to medical school, right?  So, here is your body, so obviously not ready to birth and yet we feel like if we force your body to birth by giving you drugs, somehow this will result in a normal labor.  Did your OB discuss the risks of induction?  How it increases the likelihood that you will need a cesarean either by the induction “not working” or your labor starting and then stopping or by the induction stressing the baby resulting in a “fetal distress” diagnosis?  I’m guessing no.  Let me make one suggestion.  If you want a VBAC, don’t go back to that OB and certainly don’t go back to Citrus Valley.  With a 28.7% primary cesarean rate, a 43.3% total cesarean rate, and a sad 1.5% VBAC rate, your chances of VBACing there are zero.  Put it another way: in 2006, there were 2105 cesareans and 17 VBACs there.  And I bet that if we knew your OB’s cesarean rate, it would probably be about the same as Citrus’ total cesarean rate.  So, you need a new care provider and a new location for your birth!  YOU CAN DO THIS!

So, first things, first.  Congratulations on your pregnancy! This is such an exciting time of your life!  But know that if you want a VBAC, this is not something that is just going to fall into your lap.  Especially if you want a hospital birth, you need to become informed, empowered, and ready for (a likely) battle.  If you pick a homebirth, you can relax a bit.  But more on that later.

Here are your marching orders!

1. Read. Rikki Lake’s My Best Birth is an excellent overview of birth.  Once you read that, if you are ready for more I recommend Ina May Gaskin’s Ina May’s Guide to Childbirth, Dr. Marsden Wagner’s Born in the USA, Henci’s Goer’s The Thinking Woman’s Guide, Jennifer Block’s Pushed, Tina Cassidy’s Birth in that order.  (While I want to give you all the great books I love, I also know that a lot of women only have time to read one or two.)

Please don’t waste your money or time on The Girlfriend’s Guide or What to Expect When You Are Expecting.  I’ve read them both and was so surprised that these are some of the top selling pregnancy books in the US.  They are dumb.  And lame.  And dumb.

Let me give you a recap of What to Expect: Can I take baths?  Can I exercise?  Can I have sex while pregnant?  Yes (not to hot), yes (not to strenuous), and yes (provided you have a normal pregnancy without a history of preterm labor.)

And The Girlfriend’s Guide?  Basically tells you to go to the hospital and get your epidural.  Oh, and your body is going to hell after a baby.  After I read that book, I was truly terrified of what my post-baby body would look like.

Seriously, skip them both.  There are so many great books to read, don’t waste your time on that dribble.  And yes, your boobs and butt will sag after having a baby, but at the end of your days, I don’t think you, or your children, will care one bit about your flabby boobs.

2. Home vs hospital. I had a homebirth, I had a good outcome and it was amazing.  You can read my birth story here: My HBAC Birth story.   But homebirth comes with real risks and even though the risk of uterine rupture is low, it does and will happen.  And in about 6% of uterine ruptures, the baby will die (Guise, 2010).  Chances are, you will be fine, but those statistics represent real moms and real babies.  With what we gain in homebirth (privacy, control, peace, limited pressure, etc), the primary thing that we lose is immediate access to surgical intervention.  You can read my extended thoughts on homebirth here: Why Homebirth.

So, read, think, reflect and decide what feels best. Of course, this also depends on your health and if you would qualify for a homebirth.

Someone suggested this to me when I was early pregnant with my VBAC son and I learned a lot: Imagine for a week that you are having a hospital birth. How do you feel? Are you nervous or at peace?  Are you excited or anxious?  Now do the same with  homebirth.

Other articles you might find interesting: Homebirth vs hospital birth for the number cruncher, OB lists reasons for rising cesarean rate, and Neonatal nurse has a homebirth VBAC.

2a. Hospital birth. If you chose to birth in a hospital, find the hospital with the highest VBAC rate.  Since you are in California, you can easily do this by going here: VBAC & Cesarean Rates of California Hospitals, 2007 and be sure to read Why if your hospital “allows” VBAC isn’t enough.

I think that if you want a hospital VBAC, your best bet is Kaiser.  Just looking at their 2006 California statistics, they had a 20.8% VBAC rate, a 15% primary cesarean rate and a 22.4% total cesarean rate.  Some Kaiser locations even permit CNMs (certified nurse midwives) to manage VBAC labors.  The national VBAC rate is 10% and in California it’s 9%, so 20% is excellent.

If you have a hospital birth and good insurance, you will likely save money in comparison to a homebirth (unless you have a PPO which may pay for some of your homebirth costs or you live in a state like Florida), but take that money you save and invest it in a doula.  I strongly recommend you have a doula if you have a hospital birth.  Labor requires concentration.  Dealing with medical professionals who may think you are a bit odd for wanting a VBAC requires concentration.  Your typical laboring woman does not have enough concentration and energy to deal with both things.  Read VBACing Against the Odds and Hospital VBAC turned CS due to constant scare tactics.

Hospitals vary greatly. Here is a wonderful birth story of a woman who VBACed at a Southern California Kaiser: The Birth Story of James Liam.

2b. Home birth. If you are at home, I think a doula is something you can get if you want, but skip if you don’t feel the need.  But this is really a personal preference.  At home, you have the freedom that you just don’t have at the hospital and you need not worry about hospital personnel trying to talk to you mid-contraction.

However, with homebirth you have other issues to attend to.  The most important thing when interviewing midwives is experience.  You need to know how many births she has attended and of those, how many was she the primary midwife (the responsible person at the birth as opposed to assisting a senior midwife.)  If you have an inexperienced midwife with limited informal or formal education, you are taking on additional risk that is really unnecessary.

Additionally, you want a midwife who has enough experience to know when to go to the hospital as well as the professionalism to interface, and even take crap from, hospital employees.  You and your baby’s well being should come well before her possible discomfort.  In states where it is illegal for a midwife to attend a OOH (out-of-hospital) VBAC, your midwife is not likely to present herself as your midwife if you transfer and this is understandable.

You also want to be aware of the birth myths that are sometimes propagated amongst midwives.  It is a massive red flag if your midwife repeats any of these myths to you.

I personally think that hiring a midwife who has experience and knowledge is more important than hiring one that you “click” with.  That really should come secondary to the ability to make quick decisions regarding your health as well as the health of your baby.

3. Find a provider. After you read The Three Types of Care Providers Amongst OBs and Midwives, Questions to Ask a Provider, Scare tactics vs. informed consent aka why I started this website, you can go to Finding a VBAC Supportive OB or Midwife and start using the resources listed there to find referrals for OBs or midwives.  I think the best way to find a care provider is through word of mouth.  I have heard many ‘bait & switch’ stories at 36 weeks. A provider says everything the mom wants to hear in the interview and then did a 180 once the woman was to far along in her pregnancy to expend the effort of finding another care provider.  It’s best to hear from multiple women, if possible, how a provider is during birth. 

4. Childbirth Education.  I think Bradley classes are great because you learn a ton.  The tone of a particular class can vary greatly depending on who is teaching it. I took the Hypnobabies Home Study course with my VBAC baby and I thought it was good, but it had a completely different emphasis.  I would also encourage you to find a “Truth About VBAC” workshop in your area.

Bradley had far more information about interventions, pros, cons, physiology and anatomy.  Hypnobabies was more about relaxation, visualization, positive thinking, calm, and peace.  My VBAC labor was very manageable until the last hour or so and I attribute that to maintaining a calm and peaceful state of mind, being in the peace of my own home, and, since I was drug-free and at home, having the freedom to move into the most comfortable position at the moment however and whenever I wanted.

There are many things that I enjoyed about Hypnobabies and if it’s possible, I would suggest doing both.  Hypnobabies is very clear that they don’t want you to take any other course and that they don’t want you to be exposed to the idea that childbirth is painful.  They even discuss pain like it’s a four letter word.  Pain doesn’t have to be negative though.

5. Finding support. 92% of women in the US have a repeat cesarean (Martin, 2009).  I personally believe this is due to misinformation, unsupportive medical professionals, a lack of social support, and hospital VBAC bans.  If you plan to VBAC, you are likely to come across many women who were lead to believe by their OBs that VBACs are to dangerous, illegal, or that “no one does them.” I know women in real life who knew one person who didn’t think they were complete whack-a-dos for planning a VBAC, and that person was me.

It can be hard and it can be isolating, but you can find support, you just need to know where to look.   Go back to the Finding a VBAC Supportive OB or Midwife list of resources and go to a couple La Leche League, ICAN, or Holistic Moms meetings.

And rest assured that even if you don’t know anyone in real life who supports your decision, you can find loads of support on-line.  Please don’t feel alone.  It can be so hard when you are so excited about your upcoming VBAC and the rest of the world is looking at you like you are crazy.  But you are not.

brothers-baby-siblings

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.