Long Facts

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 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.”

In other words, the decision to not offer a woman the option of VBAC is not based on medical risk to mom or baby, but rather on politics and the fear of litigation.

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

Comparing the Risks: VBAC versus Repeat Cesarean Section

I give a complete comparison in my VBAC Class and just haven’t had a chance to type it all up for the site.  Below is a brief summary and many links to excellent references.  Also, be sure to read our bibliography.

Throughout this article, I reference frequently the December 2004 VBAC study, Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery by Mark Landon MD because it is the largest 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.

When comparing the risks of VBAC vs ERCS (elective repeat cesarean section), the risks are essentially this: “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” (Options: VBAC or Repeat C-Section by the Childbirth Connection).

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 MD
• In terms of VBAC, “your risk is really, really quite low.” – George Macones MD

Further reading:

• National Institutes of Health VBAC Conference: Final Statement
• National Institutes of Health VBAC Conference: Programs & Abstracts
• The risks of cesarean surgery
• Uterine rupture is so not worth it for a VBAC

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 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.

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)

Kayani (2005) 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.”  Landon (2004) found that inducing or augmenting labor resulted in a doubling of the uterine rupture rate and Kayani (2005) 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; 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 is not fun! 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.

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) revisedits 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 hopsital VBAC bans and VBAC in rural hospitals.

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

Has been moved 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!

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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