The Truth About VBAC

“As long as you are of legal age and able to think clearly, logically, and coherently for yourself, you should never cede that responsibility [to make your own health decisions] to anyone else - not your doctor, not your friends, not to your family, not to the heath gurus, and especially not the media.  Unlike many among the health police force, I believe that you are easily smart enough to evaluate the news.  You really have no choice.  People are finally realizing that they cannot trust the health industry machine anymore.  That means you must come to rational, intelligent decision based on the best that science has to offer”  - From Eat, Drink, & Be Merry by Dean Edell, MD

The Big Picture

VBAC has risks.

Repeat cesarean has risks.

Women die from cesareans including this mom of triplets.

Women regret their repeat cesareans.

Babies born via scheduled cesarean have more breathing problems and an increased mortality rate than babies born vaginally.

Cesareans increase the risk of hysterectomies in future pregnancies.

Women schedule repeat cesareans on the advice of their OBs only to have complications resulting in hysterectomies

Be sure to understand the risks and benefits of VBAC versus the risk and benefits of repeat cesarean.

Read a letter written by two doctors supporting VBAC and opposing a VBAC ban.

Read a letter written by a certified nurse midwife supporting VBAC and opposing a VBAC ban.

Having a repeat cesarean does not eliminate the risk of uterine rupture.

Take the time to find a VBAC supportive provider.

Having a repeat cesarean does not guarantee a good outcome for you or your baby.

Study Finds VBAC “As Safe” As Repeat Cesarean

Note: I wrote this in early 2006 before I had my VBAC at home in November 2007.

As someone who is planning a vaginal birth after cesarean (VBAC) with my next child, I am always reading the latest research studies about the risks of VBAC vs elective repeat cesarean section.

All the studies I have read thus far found uterine rupture rates, ranging from 0.5% to 0.7%, in women with one prior low uterine segment (”bikini cut”) cesarean. So you can imagine my excitement when I read Results of a Well-Defined Protocol for a Trial of Labor After Prior Cesarean Delivery published recently in Obstetrics & Gynecology. The doctors encouraged women who have had one bikini cut cesarean to undergo a trial of labor (TOL) after the spontaneous onset of labor unless cesarean section (CS) delivery was medically indicated. Unless there were maternal or fetal conditions that made delivery immediately necessary, they waited for spontaneous labor or 42 weeks.

They used Bishops scores if delivery was needed before spontaneous labor. Less than 6 (unripe) had a CS while greater than 6 (ripe) had an induction. They stated that artificial rupture of membranes (AROM) was the preferred way to induce vs. induction with pitocin. They did not use prostaglandins, Foley catheters, or Misoprostol (Cytotec). They did not induce an unripe cervix. They did use pitocin for augmentation but used a max of 20 mU/min. 60 (7.1%) women were induced with either AROM or pitocin. 128 (15.2%) were augmented with pitocin.

Of the 841 women who attempted a vaginal birth, they only had 1 uterine rupture 18 hours after vaginal delivery. That woman had an uneventful course for 16 hours when she became hypotensive and had falling hemocrit. She had a laparotomy and a 4 cm rupture was found on the left uterine wall. They did not state if the previous cesarean incision was involved in the rupture.

One woman in the CS group had a hysterectomy due to placenta accreta. One woman in the CS group and two women in the TOL group who had a repeat CS had laparotomy due to post partum hemorrhage. They stated an overall rate of major complications of 1.3% in the planned CS group and 1.8% in the TOL group. However the difference was not statistically significant (p=0.50). They also stated that all but two of the major complications in the TOL group were in women who had a repeat CS.

The median hospital stay was two days for the TOL group while in the planned CS group, the median was four days. This was statistically significant (p<0.001). The NICU admissions were 2.4% for the TOL group and 4.3% for the planned CS group. This was not statistically significant but was close (p=0.55). There were no neonatal deaths and no cases of hypoxic-ischemic encephalopathy (HIE) (which was a result in the 2005 Landon et al study). In short, they found “no difference in major or minor maternal morbidity [between TOL and CS and] no serious neonatal morbidity.”

The number that is most important to me is the rate of uterine rupture because that is one of the reasons that anti-VBAC OBs give for not permitting women a trail of labor. The rate found in this study was 0.12% which is far lower than any other study has reported. They concluded, “with our well-defined protocol, a trial of labor after cesarean seems to be as safe for the mother and infant as planned cesarean delivery, and the hospital stay is shorter.”

In the US, is it highly unusual for an OB to permit a pregnant woman to wait until 42 weeks for spontaneous labor. Given how the accuracy of due dates can vary greatly depending on when a woman ovulated the month of conception (which is why charting is so important), I would hope that more doctors would permit women to gestate in peace longer rather than inducing or scheduling a repeat, or primary, CS.

Hopefully this research will prompt more studies to focus on the risks of waiting until 42 weeks for spontaneous labor vs. the risks of inductions at 42 weeks with AROM and/or small amounts of pitocin. This would challenge the current prevalent practice of automatically scheduling a repeat cesarean at 40 weeks or even earlier.

My ultimate wish is for doctors and hospitals to become more supportive of VBACs. In an ideal world, women would become their own health advocates and educate themselves on the advantages and risks of standard medical procedures and interventions commonly performed under the “standard of care” umbrella and start taking more responsibility for their medical care rather than abdicating all decision-making to their OB. Conventional wisdom states that OBs are ultra-conservative in their decision making due to malpractice concerns. However, if we as the public stopped looking to doctors as if they were gods, and thus expecting them to literally produce miracles, and started having more realistic expectations based on our own research and knowledge, maybe doctors would not feel such pressure and would permit women a TOL rather than routinely scheduling a cesarean.

Just as important is to interview OBs and midwives and find one whose birth philosophy best matches your own because there is not one way to practice medicine. Not all OBs are anti-VBAC or routinely require an IV, continuous fetal monitoring, and laboring in bed flat on your back or routinely perform episiotomies, AROMs, and inductions. It is an art just as it is a science and we have a choice who we hire to guide us through one of the most incredible moments of our lives.

Gonen, R., MD, Nisenblat, V., MD, Barak, S., MD, Tamir, A., DSc, and Ohel, G., MD. (2006). Results of a Well-Defined Protocol for a Trial of Labor After Prior Cesarean Delivery. Obstetrics & Gynecology, 107, 240-245.

My Journey to VBAC

Note: I wrote this in 2005 before I had my VBAC at home in November 2007.

I had a cesarean section with my daughter due to her footling breech presentation after an unsuccessful external cephalic version (ECV) at 37 weeks. I did have a cesarean section scheduled at 38 weeks, but, thankfully, my water broke two days before, so I did have the benefit of laboring for a few hours. My daughter never turned head down, and I was devastated to have a surgical birth. My full birth story is available here.

I am planning on having a VBAC (vaginal birth after cesarean) with my next child. I have heavily researched the topic because I was worried about the “ban on VBACs” and wondered if I was candidate. I didn’t know about the benefits of VBAC and what I could do to make my VBAC successful. I found out that the risks are low and the old adage “Once a cesarean, always a cesarean” does not hold true today. I found it very helpful to read successful VBAC birth stories and I joined the ICAN as well as their YahooGroup. This organization is an incredible wealth of information and they will arm you with the facts backed by scientific studies. You will learn how most OBs do not practice “evidence-based medicine,” but rather “defensive medicine” which is “a deviation from sound medical practice that is induced primarily by a threat of malpractice suits.” This is shown in the growing rate of inductions and cesarean sections. online. There are also VBAC support groups present around the country.

I read The Thinking Woman’s Guide to a Better Birth by Henci Goer during my first pregnancy which is a great resource for any pregnant woman but especially for a woman seeking VBAC. (Read the Introduction and Chapter 7: The Slow Labor). Goer has another book entitled Obstetric Myths Versus Research Realities which is a compilation of medical research that question the benefits of standard interventions, such as the routine use of IVs, episiotomies, and continuous fetal monitoring. It is fascinating. (Read the Introduction or an excerpt from Chapter 14: Episiotomy.) Read A Guide to Effective Care in Pregnancy and Childbirth.

Don’t Freak, Know the Facts

Note: In this article, I reference frequently the landmark December 2004 VBAC study, Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery by Mark Landon, M.D., because it is the largest case control study completed comparing the outcomes of VBAC and elective repeat cesarean section (ERCS.)  The study included over 18,000 women in Southern California. This is important because in order to document the occurrence of an event that happens as rarely as uterine rupture, large numbers of VBACing women must be included in studies in order to get the most accurate measurement. Other studies such as Risk of Uterine Rupture During Labor Among Women With a Prior Cesarean Delivery (Lyndon-Rochelle 2001) includes large numbers of VBACing women, over 20,000, but does not compare the outcomes to cesarean section. It’s one thing to identify and quantify the risks with VBAC, but those risks must be weighed against the risks associated with surgical birth as the mother only has those two options.  In order to select the safest option for herself and her infant, she needs to understand the risks and benefits of surgery just as she understands the risks and benefits of VBAC.

There is so much information out there about VBACs - I won’t regurgitate it all here. Rather, I’ll give a brief overview on VBACs, the risks, and the ironies that exist in medicine. It is very important to base your opinions and actions on facts rather than fear. It is easy to let fear dictate your life, but that is a miserable way to live. Why not know the risk, how you can reduce the risk, and plan accordingly?

Are VBACs High Risk? Quite simply, no. Bruce Flamm, MD states in Birth After Cesarean: The Medical Facts, that VBAC parents “have been erroneously told that they are in a very high-risk group” as well as “the chance that a VBAC candidate will require emergency surgery is, for all practical purposes, no higher than that of any other pregnant woman” and “the risk of VBAC is not substantially greater than the risk of any type of childbirth.” He also states, “Midwives generally give care to low-risk or ‘normal’ pregnant women. However, VBAC mothers are not excluded. Numerous medical reports have revealed that VBAC is not associated with substantially more risk than any other childbirth.” 

Factors for rupture. There are a few things to consider in terms of VBAC - type of scar, labor induction, and types of uterine rupture. VBACs have historically received a bad rap because of the methods of incision that were originally used for cesarean sections, such as the classical and inverted T, have higher rates of rupture than the low transverse (bikini cut) method. 40% of births in American are induced and women who have been induced or have had their labor augmented through the use of drugs to stimulate contractions and ripen the cervix, experience an increased risk of rupture including women who have unscarred uteri. Studies that measure the rate of uterine rupture rarely distinguish between true uterine rupture and uterine dehiscence which gives the medical community and public at large an inflated, inaccurate estimate of risk.

To accurately asses the risk of VBAC, it is necessary to differentiate between complete or true uterine rupture and incomplete rupture, often termed occult rupture or uterine dehiscence. True uterine rupture is often sudden and associated with pain, blood loss and fetal morbidity. It is most commonly seen in spontaneous or traumatic rupture of the unscarred uterus. It also has been associated with classic uterine scars, often occurring without labor. Conversely, uterine dehiscence is partial separation of the uterine wall that is usually asymptomatic and rarely contributes to fetal or maternal morbidity. This is often the type of separation seen in lower segment scars, and usually occurs during labor. Often asymptomatic windows are incidentally noted at the time of repeat cesarean section. (From OB/GYN Secrets by Wilkins-Haug & Fredrickson. Section 77 VBAC by Robert Silver MD.)

True uterine rupture is typically distinguished from asymptomatic scar separation (dehiscence) by the need for emergency surgery, although some reports combine these separate processes and confuse the statistics. The rate of true uterine rupture with one prior low-transverse scar has been reported by ACOG to be between 0.2 and 1.5 percent (one of 67 to 500 women). Other studies involving more than 130,000 women undergoing a trial of labor for VBAC report rates that average 0.6 percent (approximately one of every 170 women). (Toppenberg 2002)

So, when you hear of uterine rupture, whether it’s a study or an individual woman, it’s important to ask what type of scare, was labor induced or augmented with drugs, and was it a true uterine rupture? It is important to have facts rather than just freak out because an OB tells you that it’s to risky.

Rates of Rupture: VBAC vs ERCS. There are a couple things to consider when looking at uterine rupture. First, understand that if you schedule an elective repeat cesarean section (ERCS), you are not protecting yourself from uterine rupture. While the rates of rupture among women who do not experience labor and opt for a ERCS are lower, they expose themselves to the additional risks associated with surgery. This is supported by Mozerkewich 2000 (VBAC 0.4% vs. ERCS 0.2%), Korst 1999 (VBAC 0.53% vs ERCS 0.28%), and Lyndon-Rochelle 2001 (VBAC 0.6% vs ERCS 0.16%).

Rates of Rupture: Spontaneous vs. Induced/Augmented Labors. When attempting to approximate your risk for uterine rupture, it’s important to differentiate between spontaneous and induced/augmented labors. Landon 2004 featured the VBAC labors of almost 18,000 women and found varying rates of rupture based on spontaneous vs. augmented vs. induced labors.

Spontaneous means that labor starts on its own. Induced means that the laboring mom is given drugs, usually Pitocin, Cyotec, and Cervidil, to start labor. Augmented means that the laboring mom is given drugs during labor, usually to speed things up or to restart a “stalled” labor. Specifically, they found the following rates of uterine rupture: 0.4% (N = 24) in spontaneous labors, 0.9% (N = 52) for augmented labors and 1.0% (N = 49) for induced labors.

They further broke out rupture rates by type of induction: 1.4% (N = 13) with any prostaglandins (with or without oxytocin), 0% with prostaglandins alone, 0.9% (n = 15) with no prostaglandins (includes mechanical dilation with or without oxytocin), and 1.1% (N = 20) with oxytocin alone. Overall, they found 0.7% of women experienced a true uterine rupture with an additional 0.7% experiencing a dehiscence. Lyndon-Rochelle 2001 found that women with spontaneous labors had a rupture rate of 5.2 per 1000 (0.52%) while labors induced without prostaglandins (7.7 per 1000, 0.77%) and labors induced with prostaglandins (24.5 per 1000, .24%) experienced rupture rates 4.7 times and 1.5 times higher respectively.

I find it bizarre that multiple studies have found drug induced labors result in more ruptures, yet OBs go on inducing. If OBs are so concerned about uterine rupture, why do they continue to induce VBACing women, especially with prostaglandins (misoprostol aka Cytotec and dinoprostone aka Cervidil), which are the most risky labor inducing agents to use in a VBAC labor?

Oxytocin (Pitocin) is widely used, so it is not surprising that this uterine stimulant has been administered in a majority of ruptures. One center found that oxytocin had been given in 77 percent of their ruptures and was typically used to stimulate labor in women with a prolonged latent phase. Misuse of oxytocin carries significant risks in any mother, and this risk may be increased during VBAC, especially at high infusion rates. ACOG guidelines and other authors indicate that oxytocin use during VBAC is acceptable. Induction of labor, regardless of the method used, is increasingly recognized as a risk factor for uterine rupture. Recent VBAC studies have shown three to five times more ruptures among induced mothers compared with those having spontaneous onset of labor. (Toppenberg 2002)

In 2005, another study concluded “in women with previous caesarean section and no vaginal deliveries, induction of labour carries a relatively high risk of uterine rupture/dehiscence despite all precautions, including intrauterine pressure monitoring.” (Kayani 2005) Landon 2004 found that inducing or augmenting labor resulted in a doubling of the uterine rupture rate and Kayani concurs a year later.

Why don’t they wait for labor to spontaneously being?  As long as mom, baby, and placenta are fine, there is no reason to be inducing.  We know from Dr. Wagner’s book “Born in the USA,” that 40% of women in the US are induced.  We know that 40% of birthing women are not “high-risk,” so why all the inductions?

It’s because most OBs do not practice evidence-based medicine and there are other factors, such as convenience, which dictate their actions. It is hard to rectify a medical community that says VBAC is to risky to permit on one hand, but electively increases that risk through induction. Baring true medical complications - baby being “to big” and going “overdue” are NOT true medical complications - a woman should wait until 42 weeks for spontaneous labor.

“Medical studies have shown that the most common reason for a baby being ‘overdue’ is not that mother nature has made a mistake but rather that we have made a mistake in calculating the due date.” (Flamm, Birth After Cesarean) Size estimates based on ultrasounds are notoriously inaccurate (see Yagel 1986, Egley 1986, and Yeh 1982) and since most women do not have 28 day cycles, due dates are pretty useless (which is why it is important to chart.) If a mom really needs to be induced, there are non-drug methods of induction that are certainly worth a try, but all induction does is increase your risk for a cesarean section. It’s just not worth the risk unless you or your baby have some medical reason that birth must happen sooner rather than later, which is rare.

As a member of ICAN, I hear story after story of women whose primary cesarean section was performed due to “big baby” and then went onto VBAC a larger baby as well as women who really trusted their OB with their first baby and agreed to an induction, without a true medical reason, only to end up with “failure to progress” and sectioned. You will know when your body and your baby are ready for labor because labor will begin. Trying to force your body to birth will result in a more painful labor and an increased likelihood that your labor will end with a surgical birth. If you think waiting for labor to start is hard, consider recovering from major abdominal surgery and caring for a newborn. Take it from me - IT SUCKS! The fact is, the medical community has completely lost faith in a woman’s ability to birth without prodding and pushing through interventions, drugs, and timelines.

Infant Outcomes. In terms of infant outcomes, I again refer to the Landon 2004 study which found:

Overall, our data suggest a risk of an adverse perinatal [pertaining to the period immediately before and after birth] outcome at term among women with a previous cesarean delivery of approximately 1 in 2000 trials of labor (0.46 per 1000), a risk that is quantitatively small but greater than associated with elective repeated cesarean delivery.

In other words, while the rate of uterine rupture in a spontaneous labor with one prior cesarean is approximately 1 in 250 (0.4%), 1 in 2000 (0.05%) VBAC babies will have a bad outcome.

In Table 6 entitled “Perinatal Outcomes After Uterine Rupture in Term Pregnancies” they stated that from 114 ruptures at term, 7 (6.2%) babies had hypoxic-ischemicencephalopathy (brain damage), 2 (1.8%) died, 46 (40.4%) were admitted to the NICU, 16 (14.0%) had 5-minute apgar scores less than or equal to 5 and 23 (33.3%) had umbilical artery blood pH less than or equal to 7.0. So, there was a “bad outcome” for VBAC babies in 1 out of 2000 trials of labor. That’s a very small number. So, the risk to your baby is low.

Lyndon-Rochelle 2001 found that while 5 out of 13,115 babies (0.04%) died as a result of uterine rupture, 100 out of 20,004 babies (0.5%) died for other reasons. The mothers of those 100 babies did not rupture. Babies had a 10 times greater risk of dying for reasons other than uterine rupture. Mozerkewich 2000 found little difference between VBAC and ERCS fetal deaths, 0.2% (38 of 19,842) vs. 0.1% (10 of 13,292).

VBAC is safe for babies and Lyndon-Rochelle suggests that babies are far less likely to die from uterine rupture than they are from other labor complications.

Maternal Outcomes. Landon 2004 found that 5.5% of women (978) who had a trial of labor had complications. The most common occurring complications were endometritis, an inflammation of the endometrial lining of the uterus, (217 women, 2.9%) and blood transfusion (304 women, 1.7%) with uterine rupture (124 women, 0.7%) and uterine dehiscence (119 women, 0.7%) tied for last. The three least common complications were maternal death (3 women, 0.02%), thromboembolic disease, including deep venous thrombosis or pulmonary embolism (7 women, 0.04%) and hysterectomy (41 women, 0.2%.) Counter this with the complications experienced by women undergoing an elective repeat cesarean. Overall complication rate was 3.6% (563 women.) Top three complications were endometritis (285 women, 1.8%), blood transfusion (158 women, 1.0%), uterine dehiscence (76 women, 0.5%.) The bottom three complications were uterine rupture (0 women), maternal death (7 women, 0.04%), and thromboembolic disease (10 women, 0.1%.)

Risks of Cesarean. How is it that when most OBs hear of a woman’s desire to VBAC, they immediately pull out the “your uterus will explode” card and yet, they are remiss in listing all the risks involved with a cesarean? As we have already established how ERCS does not protect you from rupture, I find that a little one-sided and I question any OB who will waive a 0.5% risk in your face while remaining silent on the also very real, and more frequently occurring risks, associated with cesareans. Please read Comparing the Risks: VBAC versus Repeat Cesarean Section for more information.

Banning VBACs. Based on the most recent evidence, in March 2005 the American Academy of Family Physicians (AAFP) revised its VBAC guidelines and now encourages women to consider labor after a prior cesarean and maternity care providers to support women’s choice. The AAFP found no scientific evidence that having a surgical team and anesthesia “immediately available” when a VBAC mom labors to significantly improved outcomes. The complete guidelines are available as a pdf file from the AAFP web site.

I personally would not feel safe at a hospital that does not permit VBACs, whether my uterus was scarred or not. If they cannot accommodate a medical emergency such as uterine rupture, how could they possibly respond and treat other real, but rare, labor emergencies such as cord prolapse or placental abruption, both of which require the baby being born ASAP usually by immediate cesarean sections?  We know that babies have a 10 times greater risk of dying for reasons other than uterine rupture. (Lyndon-Rochelle 2001)  How could any mother labor in confidence knowing that if something went drastically wrong, that hospital could not quickly respond? At which point, why even go to a hospital? I always thought that was the point of hospitals in terms of birth - to treat the very rare complications that require immediate surgical intervention. If hospitals eliminate their ability to rapidly respond to a medical emergency requiring a surgical birth, how is laboring at a hospital like that any different than laboring at home? People labor in the hospital for that minute “what if” chance thinking that they will be safe. Thinking that laboring at a hospital is safer than home. But if a hospital labels itself as non-VBAC friendly, they have labeled themselves unsafe for any laboring woman. Hospitals which do not permit VBACs are unsafe to all women and laboring women should avoid them. We need to send a message with our money and our babies by only laboring at VBAC-friendly hospitals or electing to birth at home.

Symptoms of Rupture. It is also important if you wish to VBAC to understand the symptoms of uterine rupture.

* Extreme pain (may or may not be felt through epidural, though it usually is because of it’s severity)
* Bulge in the abdomen (where the baby may be sticking through uterus)
* Excessive bleeding
* Shoulder pain
* Loss of baby’s station
* Cessation of labor
* Heart decels in baby

The thing that remains constant in the bulk of the rupture stories I have read is this: the laboring woman knew something was wrong, but that is not always the case. It is so important to listen to your instincts and make other people, especially medical personnel in the face of their machines saying everything is just dandy, listen to you. I know hospitals are busy and L&D nurses are busy and those EFM are so helpful in permitting them to “care” for multiple patients at one time. But it seems that as soon as that belt is ratcheted on your pulsing tummy, you, as the laboring mom, have become just a wee bit invisible. Now they have the smart machines to tell them how you are doing. And somehow, your experience, your instinct, is relegated to the opinions of a lay woman in labor, which are not held in the same regard as the long ticker tape bursting forth from the EFM. Make them listen. If your instinct is telling you something is wrong, listen. Labor is ancient. Your instincts are ancient. Tap into that and use it. Use that knowledge that has been hard-wired into our brains. There is a reason why it is there. We all have the instinct to survive and if you feel that something is wrong, really wrong, it probably is. All you have to do is read the stories of women who have experienced a rupture, only to be surrounded by medical professionals who didn’t recognize the symptoms in time to save their baby, to know that it is your obligation as a VBACing woman to know the signs. Again, you must do the research, you must know the facts. Do not rely on your OB, the hospital, the L&D nurses, or that lovely external fetal monitoring machine. The knowledge you acquire is your first line of defense and you are naive if you think otherwise. You are also naive if you think any machine can identify a rupture faster and more accurately than the careful observation of a knowledgeable human being.

Scheduling Cesareans. I personally believe that OBs like to schedule cesarean sections rather than grant a woman a trial of labor because it’s convenient, they are under the misguided notion that they are in control, and, if anything goes wrong, they have already performed the ultimate intervention, so how could anyone find fault?. I understand that it’s easier for OBs to schedule a cesarean section rather than being called in at 4am like my OB. I also know that between the OBs, anestheologists, and hospital charges from the surgery and recovery, everyone involved makes more money. My insurance was billed for over $22,000. “Financial cost (as measured by hospital charges) of cesarean delivery was 1.66 to 2.4 times greater than the cost of vaginal birth.”

But I think the tipping point is control. When a woman is in labor, no one person is in control. The human body knows how to labor. It does not require any assistance. There is little regard for the subtle, unseen hormonal and chemical changes within the laboring women’s body that guide labor and delivery. OBs try to induce labor when the body is not ready, or try to augment it when the body is moving “to slow,” and then try to reduce pain when the induced/augmented contractions are stronger and more frequent than naturally occurring contractions. The OB tries to manage the labor, but the fact is, the woman’s body is in control. The OB does not know how long this particular woman will labor. The OB does not know how quickly she will dilate. There are so many unknowns because every labor is different in terms of length, speed, pain, etc and no matter how many models and charts are created, there is no accurate way to predict. There is so much that is unknown to the OB. Compare that to a cesarean section. The OB is the one cutting, the OB is in control. There is this false sense that less can go wrong because the baby is no longer dependant on the unpredictable human body. With a few cuts, the baby is born.

The cesarean section is an incredible surgery that saves lives, but the unfortunate fact is that most cesarean sections are performed unnecessarily and expose mother and baby to an unnecessary level of risk.

Whatever you decide, I encourage you to read, learn, and base your informed decision on facts. It is also important for you to be aware of your patient rights and exercise them if necessary.

Questions to Ask: How to Find a Truly VBAC Supportive OB/Midwife

I think it’s very important to discuss the particulars of your OB/midwife’s standard protocols and birth philosophy way before you hit your 3rd trimester, preferably when you are interviewing providers. No sense wasting time with a provider who isn’t really pro-VBAC. And if your OB/midwife sounds really great at the beginning and then starts talking induction/CS as your due date looms, this is a huge red flag.

There are truly pro-VBAC professionals out there, but there are far more who will string you along until you are to tired to go through the motions of finding another provider. However, it is never to late to at least seek out a provider. Email the ICAN YahooGroup. If there is a provider out there, someone on the list will be able to point you in the right direction.

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.

  1. How many VBACs have they attended? (Word spreads fast on pro-VBAC OBs.)
  2. 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 CS. This would give you a great idea of how they operate… so to speak!)
  3. Do they have any standard VBAC protocols that differ from a non-VBAC mom? (If so, this could be a red flag, because if they start viewing you as a uterus waiting to explode, rather than a laboring mom, they may not really support VBAC.)
  4. Under what circumstances would they induce a VBAC? (This is dangerous and should not be done unless there is some serious medical condition requiring immediate birth and vaginal birth is still an option. “Big baby” and “over due” are not valid, medical reasons. Before 42 weeks, induction should not be performed. At 42 weeks, I would request a ultrasound to check on baby and as long as baby and mom are fine, I would wait for labor to start instead of inducing/CS.)
  5. If so, what methods do they use? (If they use Cytotec, find another provided FAST. According to Dr. Wagner’s “Born in the USA,” uterine rupture rates in VBACing women is 28 times higher when Cytotec is used. Gonen 2006 found that very low amounts of Pitocin were safe.)
  6. What is their philosophy on going past 40 weeks? (If they want to schedule a CS at 40 weeks, run fast. They should be fine going to 42 weeks as long as you and baby are fine.)
  7. What is their philosophy on “big babies?” (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 “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.”)
  8. Do they attend vaginal breech births? (Wouldn’t it be such a bummer to believe you are having a VBAC only to be one of the 3% of women who have breech babies at term? Find out now if this provider will support a vaginal breech birth or if they will point the way to the OR.)
  9. How many uterine ruptures have they witnessed? (This can be an indicator of their induction rates.)
  10. What kind of monitoring do they require? (For me, if it’s continuous fetal monitoring, that’s enough reason to find another provider because I’m not down for staying in bed the whole labor. I want to move! In addition, continuous fetal monitoring has greatly contributed to our rising c-section rate while not improving infant outcomes or reducing rates of cerebral palsy. I personally think that 15 minutes of monitoring per hour is reasonable.)
  11. What is their CS rate? (If it’s greater than the World Health Organization’s recommendation of 10-15%, this is a huge red flag. How can they support VBAC if they are performing unnecessary primary CSs?)
  12. 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, huge red flag. Find another provider.)
  13. Do they have a time-limit on how long your labor can be before they c-section you? (There should be no limit as long as baby and you are fine.)
  14. Do they require epidurals for VBAC? (One reason that some OBs require epidurals is because if they deem a CS necessary, you are already numb. Again, this is the attitude that you are a problem waiting to happen. The question is, is this how you wish to be perceived?)
  15. Do they require an IV or heplock? (IV restricts your movement, heplock means they put the part in your arm, but it isn’t connected to a bag. Heplock can be annoying and get you into the “patient” rather than “healthy, birthing mom” mindset.)
  16. Are you permitted to move and deliver in whatever position you want? (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 where you want to be. In addition, especially if you have a big baby, you might want to deliver on your hands and knees or on a birthing stool)

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.

Comparing the Risks: VBAC versus Repeat Cesarean Section .

Note: I wrote this May 3, 2007.

When comparing the risks of VBAC vs ERCS (elective repeat cesarean section), the risks are essentially this: the risk of a “normal” vaginal birth plus uterine rupture vs. the risks of surgery to mom and baby and future complications caused by cesarean surgery.

“Both vaginal birth after cesarean and repeat c-section involve some increased risks to mothers. However, without a clear, compelling and well-supported need for c-section in the present pregnancy, planned vaginal birth is safer overall for you than a planned repeat c-section.” From Options: VBAC or Repeat C-Section Childbirth Connection

“In fact, looking at just the excess reproductive risks: infertility, ectopic pregnancy, stillbirth, preterm labor, small for gestational age, malformation, central nervous system injury, it becomes clear that the scarred uterus and the presence of surgical adhesions make a much less hospitable environment for nurturing future babies.” From Elective Cesarean Surgery Versus Planned Vaginal Birth: What Are the Consequences published by Lamaze International

Read a lot… you can start here:

 

Key Factors in VBAC Success

In all the reading and research I have done, there are a few behaviors that continually reappear among women who achieve VBACs. This is not scientific, just anecdotal.

Philosophy:

A woman who accepts her personal responsibility in her own health care by educating herself while believing in her body’s ability to give birth.

Behaviors:

  1. Supportive husband
  2. Educated herself
  3. Supportive care provider
  4. No drugs whatsoever
  5. Refused induction
  6. Refused rupture of membranes
  7. Stayed ACTIVE and changed positions the entire labor
  8. Ate and drank as she wanted to
  9. Remained completely relaxed and therefore had plenty of energy
  10. TRUSTED HER BODY!

ACOG on VBAC

  1. 7 Responses to “The Truth About VBAC”

  2. You’ve put together a great website here! Thank you for all the hard work.

    You have a great HBAC story as well. I’m so glad it went well. I had 2 hospital births (good) followed by 2 homebirths (AWESOME), so I know how homebirth goes. ;-)

    I find that study on VBAC with limited use of induction very compelling! Such a low rupture rate. I’d love to know if that mom had Pitocin at any point. On the Pitocin issue though–while 20 mU/min is “limiting” the Pitocin as compared to other protocols that can have it over 30 mU/min (highest I’ve seen as a doula is 32 mU/min), I have to point out that it isn’t, by a long shot, “low dose.”

    The package insert for Pitocin says that 6 mU/min is equivalent to normal labor, and that levels above 10 mU/min are “rarely needed.”

    A true “low dose” protocol for Pitocin would involve following the package insert at the very least. That is, starting the dose at 0.5 to 1 mU/min, raising it in 30 to 60 minute intervals at no more than 1-2 mU/min increments. What I typically see is the dose starting at 2 mU/min and being raised 2 mU/min every 15 minutes. I have also seen it DOUBLED every 15 minutes–so by 60 minutes the mom was getting 16 mU/min–nearly 3 times the strength of natural labor! She dialated from 4-10 in 1 hr 45 minutes. When I went out to the nurses’ station to comment to the medwife that my client was having difficulty with the contractions, she said to me “this is what labor is.” I’d had 3 babies by that point–none with Pitocin–so I most certainly knew that was NOT what labor needed to be!

    Oh, and also…the regular external fetal monitor will work with a mom out of bed, she is just tethered. Regardless, I agree that constant fetal monitoring is for the birds!

    By Jenn on Mar 26, 2008

  3. i found both the bquestions in regards to VBAC were very helpful and informative!!!

    By Nadine on Mar 30, 2008

  4. Great material on VBAC. Is ther any stats on trialof labor after more than one c-section? If so can you please post and send the info to me. Thanks.

    By EveM on Jun 20, 2008

  5. The info was so informative. My first section was due to the big baby theory. My second just because i had one prior section. My third because of placenta previa so they say but the entire pregnancy they were telling me there were no problems. I could VBA2C but when the time came i was whisked to the OR so fast i had no time to react. Now with my fourth I am standing up speaking out since I have done my homework there will be a VBA3C.

    By sharee on Jul 10, 2008

  6. Very comprehensive website on VBACs … wish I had found it before attempting mine. Although I haven’t fact-checked all of your research, it sounds pretty consistent with what I’ve seen. Just wanted to provide you with another perspective. At 38 wks into my 2nd pregnancy, I spontaneously went into labor at about 4:15 in the morning. By 5 am, I was in the operating room for an emergency c-section where they discovered I had a complete uterine rupture. I had NO risk factors for rupture … I’m relatively young, low transverse scar, easy pregnancy, baby was 7 lbs 6 oz, 38 wks, no drugs whatsoever, only 1 previous pregnancy, almost 3 years prior, etc. I also had no classic symptoms of rupture when I arrived at the hospital (pain, bleeding, etc). I was just extremely lucky that a very experienced OB was attending at the hospital when I arrived (he didn’t like my baby’s heartrate tracing and sent me immediately to the operating room) … he saved both my life and that of my son.

    I know that the risk of rupture is very very low, especially given my risk factors, and if I had to do it over again, I’d still take my chances with a VBAC. But having been that “1 in a million”, I’m really glad I was so close to a major teaching hospital that specializes in high risk births.

    By Susan on Aug 5, 2008

  7. Susan, Thank you so much for posting and I’m so thankful that you and your baby survived! I can’t imagine how scary! I think the fact that you ruptured and still support VBAC speaks volumes.

    By Jennifer on Aug 5, 2008

  1. 1 Trackback(s)

  2. Jul 7, 2008: planning on VBAC here! - SheKnows Message Boards

Post a Comment

VBAC Facts is proudly powered by WordPress Entries (RSS) and Comments (RSS). Designed by Bob. © 2007-2008 VBACFacts.com