FAQ

Note 7/25/10 – This page contains a lot of detail.  If you are looking for an overview of VBAC vs. repeat cesarean, please visit the Quick Facts page.  After you read that, if you want more information, come back here.

“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

There is so much information out there about VBACs – I won’t regurgitate it all here.  Rather, I’ll give a brief overview.  If you would like to learn more, I offer a 5 hour on-line class.  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:

• VBAC parents “have been erroneously told that they are in a very high-risk group.”
• “the chance that a VBAC candidate will require emergency surgery is, for all practical purposes, no higher than that of any other pregnant woman”
• “the risk of VBAC is not substantially greater than the risk of any type of childbirth.”
• “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.”

The National Institutes of Health (2010) asserts, “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 majority of women who have TOL [trial of labor] 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 ERCS.”

Please read these articles for further analysis:

• Two Doctors Respond to the Hastings Indian Medical Center VBAC Ban and Encourage Native American Women to VBAC!
• A Midwife Responds to the Hastings Indian Medical Center VBAC Ban
• Interview with Dr. Fischbein – An Inside Look at Hospitals & VBAC Bans
• Scare Tactics vs. Informed Consent
• VBAC Ban Rationale is Irrational
• More on VBAC Bans

Comparing the Risks: VBAC versus Repeat Cesarean Section

Childbirth Connection summaries the risks of VBAC vs ERCS (elective repeat cesarean section), in its article Options: VBAC or Repeat C-Section:

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.

Here are the conclusions of a handful of medical studies:

Landon (2004), a study of 18,000 women, found, “A trial of labor after prior cesarean delivery is associated with a greater perinatal risk than is elective repeated cesarean delivery without labor, although absolute risks are low.”

Fang (2006) which was a overview of the VBAC research to date concluded, “Because repeat cesarean deliveries are performed largely to benefit the neonate, clinicians may often overlook maternal complications resulting in significant morbidity and even mortality as a result of repeated surgeries….. Because neither VBAC nor ERCD [elective repeat cesarean delivery] is without maternal and neonatal risks, VBAC should remain a viable option for clinicians and patients in the new millennium. Vaginal birth should not become a relic of the 20th century!”

Mankuta (2003) “favors a trial of labor if it has a chance of success of 50% or above and if the wish for additional pregnancies after a cesarean section is estimated at near 10% to 20% or above because the delayed risks from a repeated cesarean section are greater than its immediate benefit.”

Rageth (1999), a study of 29,000 women, confirmed,“A history of cesarean delivery significantly elevates the risks for mother and child in future deliveries.  Nonetheless, a trial of labor after previous cesarean is safe.  Induction of labor, epidural anesthesia, failure to progress, and abnormal fetal heart rate pattern are all associated with failure of a trial of labor and uterine rupture.”

Silver (2006) was a four year study of 30,000 women undergoing up to six repeat cesareans determined, “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.”

Mercer (2008), a study of 13,532 women found, “ An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy.”

Here are a couple quotes from the March 2010 National Institutes of Health VBAC Conference:

• “There is a major misperception that TOLAC [trial of labor after cesarean] is extremely risky” – Mona Lydon-Rochelle PhD, MPH, MS, CNM
• In terms of VBAC, “your risk is really, really quite low.” – George Macones MD

Further reading:

• The best compilation of VBAC/ERCS research to date (where I provide links to the various documents and videos of lectures presented at the 2010 NIH VBAC Conference)
• Just kicking the can of risk down the road
• Placenta problems in VBAMC/ after multiple repeat cesareans
• Risk of serious complications increase with each surgery

Factors for rupture

There are a few things to consider in terms of VBAC – type of scar, labor induction (drug type and dosage), and uterine rupture vs. dehiscence.

40% of American births are induced or have their labor augmented through the use of drugs to stimulate contractions and ripen the cervix.  These women are at an increased risk of rupture including women who have unscarred uteri.  (However, don’t believe the myth that a first time induced mom has the same risk of rupture as a VBAC mom.)  However, there are medical conditions that necessitate the immediate birth of baby, and for moms whom vaginal birth is still an option, it’s nice for them to have a choice: repeat cesarean or a gentle induction with Pitocin and/or a Foley catheter.  Read more on inducing VBACs.

Older studies often did not distinguish between uterine rupture and uterine dehiscence which gave the medical community, and public at large an inflated, inaccurate estimate of risk.  Fortunately, modern studies often do distinguish between these two events.  Nevertheless, it’s always good to read the  “Methods” section of a study to verify how that study defined rupture versus dehiscence.  Along the same lines, ever hear that “only” 6% of ruptures are catastrophic?  Read more.

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 eliminating the risk of 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.

For more articles on uterine rupture, please click here.

Infant Outcomes

In terms of infant outcomes, I again refer to the Landon (2004) 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.

However this rate is inflated as Landon (2004) included women who had pre-labor stillbirths in this statistic.  In other words, women whose babies passed away before labor, had VBACs rather than repeat cesareans, and so those deaths were counted towards the 0.05% statistic.  Please read Henci Goer’s analysis for more information.

In Table 6 entitled “Perinatal Outcomes After Uterine Rupture in Term Pregnancies” Landon (2004) stated that from 114 ruptures at term, 7 (6.2%) babies had hypoxic-ischemic encephalopathy (oxygen deprivation), 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.

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.

For more articles on infant outcomes, please click here.

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.

Henci Goer’s analysis found that the increased rate of endometritis was likely not related to a trail of labor after cesarean:

The two groups of women studied were dissimilar, making interpretation of the results problematic. The authors emphasized that the women planning VBAC were significantly more likely to have had a prior vaginal birth, which is known to be associated with a higher VBAC success rate and better outcomes. However, they report but do not emphasize many other differences between the VBAC and ERC groups. For instance, women planning VBAC were more likely to smoke, have public insurance (Medicaid), have a preterm birth, and deliver a low birth-weight baby. It is unknown whether or how these variables might affect outcomes. The researchers took care to exclude the preterm births from the analysis of neonatal outcomes, but their analysis of maternal outcomes included these births. This might account for this study’s findings related to postpartum endometritis (infection of the womb). Unlike previous studies comparing VBAC and ERC, this study found a significantly higher rate of endometritis in women electing VBACs. Some common risk factors for endometritis are also known to cause preterm birth. Since 14 percent of the women planning VBAC in this study were preterm, it is possible that much of the excess risk for postpartum endometritis reported in this study could have been prevented by excluding preterm births in the analysis of maternal outcomes.

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%.)

Please note that the rates reported for endometritis and blood transfusion were likely under-reported in the repeat cesarean group.  As Landon (2004) states in the body of their analysis, “The exclusion from the study of women who presented in early labor and subsequently underwent repeated cesarean delivery probably lowered the risk of these complications [endometritis and blood transfusion] in the group of women undergoing elective repeat cesarean section.”  This demonstrates how important it is to read the entire study and not just the abstract.

For more articles on maternal outcomes, please click here.

Symptoms of Rupture

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

• Excessive vaginal bleeding
• Extreme pain between contractions ((may or may not be felt through epidural, though it usually is because of it’s severity)
• Contractions that slow down or become less intense
• Abdominal pain or tenderness
• Baby’s head moves back up birth canal
• Bulge in the abdomen or under the pubic bone (where the baby may be coming through the tear in the uterus)
• Sharp onset of pain at the site of previous scar
• Uterus becomes soft
• Shoulder pain
• Heart decals in baby

 Zwart (2009), which included 358,874 total deliveries making it “the largest prospective report of uterine rupture in women without a previous cesarean in a Western country,” gives us more details.

Clinical symptoms that led to the diagnosis of uterine rupture included abdominal pain (69%), abnormal fetal heart rate pattern (67%), vaginal bleeding (27%), hypertonia (20%) and acute absence of contractions (14%). Among 162 women with complete reporting of all five mentioned symptoms, 91 women (56%) presented with a combination of symptoms, the most frequently encountered combination being abdominal pain and abnormal fetal heart rate pattern (Table 3).

You can read the full article and view Table 3 here.

Many rupture stories include the laboring woman knowing or feeling 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 normal, listen to you.

Risks of Cesarean

It’s amazing how many OBs will deny a woman the opportunity to VBAC due to their concern over uterine rupture and yet, they are remiss in listing all the risks involved with a cesarean? (Please read Another VBAC Consult Misinforms for specific examples from multiple women.)  Please read this excellent cesarean section consent form created by the Coalition for Improving Maternity Services dated February 2010.

For more articles on cesareans, please click here.

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.

If a hospital 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?

I always thought the ability to treat the very rare complications that require immediate surgical intervention was one of the main benefits of hospitals in terms of birth.  If hospitals eliminate their ability to rapidly respond to a medical emergency requiring a surgical birth, I wonder how is laboring at a hospital like that significantly different than laboring at home?

Please click here to read more on hospital VBAC bans and VBAC in rural hospitals.

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

Has been moved here.

American College of Obstetricians and Gynecologists: VBAC Practice Bulletins

• 2010 ACOG Practice Bulletin, No. 115
• 2004 ACOG Practice Bulletin, No. 54
• Vaginal Birth After Cesarean in California: Before and After a Change in Guidelines, 2006
• 1999 ACOG Practice Bulletin, No. 5 – Summary
• 1999 ACOG Practice Bulletin, No. 5 – Full Text
• Critique of ACOG Anti-VBAC Practice Bulletin No. 5, July 1999
• 1995 ACOG VBAC Guidelines

Last revised: September 22, 2010

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