Category Archives: Scare tactics

Another VBAC consult misinforms

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The emotional fallout of the appointment:

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

But it’s not just Brooke.

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

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

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

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

Learn more about finding a supportive care provider:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dear VBAC Supportive OB/GYN,

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

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

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

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

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

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

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

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

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

So, this is how I responded:

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

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

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

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

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

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

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

Should your referral facility be offering VBAC?

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

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

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

Slide 103

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Warmly,

Jen

If VBAC is reasonable, why does my OB say it is dangerous?

This is a question that I’ve heard a lot.

Here is the three second answer: VBACs got a bad rap in the 1990s before we understood the increased risk of rupture during an induced VBAC labor, especially with Cytotec.  Even if your OB is supportive, s/he may be under pressure from hospital administrators, or other OBs in their practice, who feel differently.  Finally, your OB might have experienced a recent lawsuit, uterine rupture, or other bad outcome that influences the way they counsel you.

In the 90s, babies and moms were unnecessarily injured and died when VBAC labors were induced with Cytotec resulting in a high rate of uterine rupture.  Lawsuits were lost and loads of money was paid out.  Rather than taking a step back and permitting VBACs to begin spontaneously and progress normally, which has a far lower rate of rupture than induced or augmented VBACs, doctors took two steps back and declared VBAC dangerous.  ACOG now says that Cytotec should not be used to induced VBACs.  (For a complete history of VBAC and cesareans, read A History of VBACs and Cesareans in the USA by The Well Rounded Mama as well as the recent article in Time.  For more information on the dangers of inducing labors with Cytotec (misoprostol), read Cytotec Induction and Off-Label Use by Marsden Wagner, MD, MS.)

Often OBs are under pressure from hospital administrators.  For a complete understanding on the inside workings of hospital VBAC bans and how hospitals impact how an OB counsels a woman seeking VBAC, read Interview with Dr. Fischbein – An Inside Look at Hospitals & VBAC Bans.

Finally, as was discussed at the 2010 National Institutes of Health VBAC Conference, a recent uterine rupture or lawsuit could result in an abrupt change in an OB’s VBAC policy.  Chet Edward Wells, M.D., a Professor from the Department of Obstetrics and Gynecology at University of Texas Southwestern Medical Center at Dallas, presented, “Vaginal Birth After Cesarean Section: Views From the Private Practitioner.”  It was fascinating.  You can watch his presentation here and read the abstract here.

As you can see, none of these factors have anything to do with whether you are a good candidate for VBAC or not.  I wish practitioners would be more honest about their situation and refer women out to care providers who do attend VBAC.  It does not benefit anyone to exaggerate or minimize the risks of VBAC.

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To view the differing rate of uterine rupture for spontaneous, augmented, and induced labors, read Estimates of Risks of Uterine Rupture and Comprehensive chart on uterine rupture measuring multiple variables.

Vaginal Birth After Cesarean Section: Views From the Private Practitioner

Chet Edward Wells, M.D.

Professor

Department of Obstetrics and Gynecology

University of Texas Southwestern Medical Center at Dallas