Update: In May 2014, the AAFP released new guidelines.

This is a great piece for deciding between VBAC and repeat cesarean.  Those who wish to VBAC, but have husbands, family, and/or friends who don’t understand why, might find this document very useful.

I have found that people who are anti-VBAC really seem impressed by what doctors and medical organizations have to say, so I’m thinking they will find this document compelling.

Plus, VBAC has this reputation of being “risky” and repeat cesareans are thought of as the “conservative approach,” and this document challenges both lines of thinking.

Why not write a sweet little note like, “I know you are concerned about me choosing the VBAC, so I thought you would find this interesting,” and mail them a copy.  That way, they can read it, think it over, and you can chat about it later.

No one wants to see a loved one get hurt or die, and since most believe that a repeat cesarean is the most conservative approach, they tend to lean in that direction.  However, once they understand that real, but small, risks are present with VBAC and repeat cesarean, and that the risks of VBAC go down with each VBAC whereas the risks of cesareans go up with each surgery, hopefully they will respect your decision.

I recommend bringing this document with you when you go to interview OBs about VBAC.  They might be unfamiliar with the data, and they too might be persuaded by a document written by a medical organization.  If your OB is anti-VBAC, this might be a good document to mail them once you have found a truly supportive OB or midwife.

I’ve included the entire text below because when I searched on Google for VBAC vs. Repeat Cesarean, it wasn’t on the first page of results, so I’d like to bring more attention to it.

Please note, they refer to VBAC as TOLAC (Trial of Labor After Cesarean.)

******************************************************************

In March 2005, the American Academy of Family Physicians published an evidence based clinical practice guideline on TOLAC (Trial of Labor After Cesarean; formerly called Trial of Labor Versus Elective Repeat Cesarean Section for the Woman With a Previous Cesarean Section). The AAFP guideline recommends offering a trial of labor to women who have had one previous cesarean delivery with a low transverse incision. The guideline also recommends that physicians and other maternity care professionals explore the risks and benefits associated with a trial of labor with each woman who is a candidate for TOLAC.
The following shared patient-physician decision tool can be used to initiate the conversation about the potential risks and benefits of TOLAC.  It is important to note that this piece is not a patient education handout. It is not meant to be used as a standalone tool. Physicians should go through each section with the TOLAC candidate and explain how each factor may (or may not) affect her. After answering any questions the patient may have, the physician can give the annotated handout to the patient so she and her partner can review it as they consider their options. To read the AAFP’s TOLAC Guideline, visit
http://www.aafp.org/tolac.

Patient name: ____________________________________________________
Physician: _______________________________________________________
________________________________________________________________
________________________________________________________________

Trial of Labor After Cesarean: Deciding What’s Right for You and Your Baby

Women who have had a baby by cesarean section (C-section) may have a choice about how to have their next baby. They may choose to have another C-section. This is called an “elective repeat cesarean delivery” (ERCD for short). Or they may decide to try having the baby vaginally. This is called a “trial of labor after cesarean” (TOLAC). When a woman tries a trial of labor and is able to deliver vaginally, this is called a “vaginal birth after cesarean” (VBAC).

If you’re reading this handout, it’s because your doctor has decided that you have a choice between a planned C-section and a trial of labor. To help you understand the risks and benefits of each, you doctor will go through this handout with you. He or she will explain how the factors below apply to you. Be sure to ask your doctor any questions you have. It’s important that you understand all of the issues before you make a decision.

If I try labor, how likely am I to have my baby vaginally?
Because every situation is different, no one can tell if you will be able to give birth vaginally. However, you should know that  about 76 out of 100 women who try a trial of labor deliver their babies vaginally.

What happens to women who try labor but can’t deliver vaginally?
Some women who try a trial of labor are not able to deliver vaginally and end up having an unplanned C-section. You
should know that most of the babies born by unplanned C-section are healthy and do not have long-term problems
from the C-section.

Is it is safer trying labor or having a planned C-section?
You already know that having a baby—whether vaginally or by C-section—has some risks. The risks are generally small
whether you choose a trial of labor or planned C-section. Studies have shown that there is no difference between the two when it comes to the woman’s risk of death or hysterectomy. There are, however, a few other risks to consider. These are explained below.

Infection. Of women who choose a trial of labor, 7 out of 100 will get an infection. By comparison, 9 or 10 out of 100 women who choose planned C-section will get an infection. This means that women who choose C-section have a slightly higher risk of
infection (2% to 3% higher) than women who choose a trial of labor.

Uterine rupture. A C-section leaves a scar on the uterus. During a trial of labor, the scar can break open. Usually this doesn’t affect you or the baby. In rare cases, however, it can pose serious risks to you or your baby. This is called symptomatic uterine rupture and it occurs in 2.7 out of 1,000 women, or about ¼ of 1%, who try a trial of labor.

Infant death. Sometimes—but not always—uterine rupture results in the death of the baby. The chance of this is about 15 in 100,000, or about 1/100th of 1%, in women who try a trial of labor. There is no good data about the risk of infant death for women who choose elective repeat C-section.

What factors affect my chances of delivering vaginally?
Doctors have studied thousands of women who have attempted a trial of labor. They found that the following factors affect a woman’s chance of delivering vaginally.  Your doctor will tell you how these factors apply to you. You might want to ask your doctor to put a check mark next to the factors that may affect you and to cross out the ones that probably won’t.

Factors that increase the likelihood of a vaginal birth after C-section (VBAC)
• Being younger than 40 years old. If you’re under 40, you are 2½ times more likely to have a VBAC.
My age: _________
Other notes: ____________________________________________________________________________________________________________________
__________________________________________

• Having a vaginal birth before. If you’ve ever had a baby vaginally, you’re more likely to be able to deliver that way again.
I had a baby vaginally, but it was before I had a C-section. You are 1½ to 2 times more likely to deliver vaginally again.
I had a baby vaginally after I had a baby by C-section. You are 3 to 8 times more likely to have a VBAC.
Notes about your previous delivery or deliveries:
______________________________________________________________________________________________________________________________
Other notes: ____________________________________________________________________________________________________________________
__________________________________________

• Having favorable cervical factors during labor. This means that your cervix is dilated (open) and effaced (thinned out) enough to deliver vaginally. If you’re well dilated and effaced, you are 1½ to 5 times more likely to have a VBAC. If you’ve had a vaginal birth before, your cervix may open and thin out more quickly than if you haven’t. If you haven’t had a vaginal birth, it’s hard to tell how well dilated and effaced your cervix will become during labor.  I have had a previous vaginal birth.
Other notes: ____________________________________________________________________________________________________________________

• If the reason you needed a C-section before isn’t a factor this time. You might have needed a C-section because of infection, difficult labor, breech presentation, or concerns about the baby’s size or heart rate. If you don’t have the same problem this
time, you are 2 times more likely to have a VBAC.
Reason for my previous C-section:__________________________________________________________________________________________________
__________________________________________
Other notes: ____________________________________________________________________________________________________________________
__________________________________________
Factors that decrease the likelihood of a VBAC
• Having had more than one C-section. If you have had two or more C-sections, you’re 60% less likely to have
a VBAC.
Number of C-sections I’ve had: _________
Other notes: ____________________________________________________________________________________________________________________
__________________________________________

• Going into labor after 40 weeks. After this time, you
are 20% to 30% less likely to have a VBAC.
My baby’s current gestational age: ________
My previous child(ren)’s gestational age(s) at birth: ______________________________________________________________________________________________________________________________
Other notes: ____________________________________________________________________________________________________________________
__________________________________________

RISK OF SYMPTOMATIC UTERINE RUPTURE IN ALL WOMEN
For all women . . . . . . . . . . . . . . Less than 1 birth per 1,000
For women who have not had a C-section . . . . . . . . . Less than 1 birth per 1,000
For women who have an elective repeat C-section . . . . About 1 birth per 1,000
For women who have a trial of labor after C-section . . . . . . 2 to 4 births per 1,000
(800) 274-2237 • www.aafp.org

• Trying to deliver a baby that is 8 pounds, 13 ounces (4,000 grams) or larger. If your baby weighs this much (or more), you are 40% less likely to have a VBAC.
My baby’s current estimated weight: ____________
My previous child(ren)’s weight(s) at birth: _______
Other notes: __________________________________________________________________________

• Using medicines to induce or augment labor. If you need medicine to start or help your labor, you are 50% less likely to have a VBAC.
Notes: _______________________________________________________________________________

What if I have other concerns?
In addition to thinking about your health and that of your baby, you’re probably dealing with emotional issues and practical  concerns about the birth. Some common concerns are listed below. When you read through this list, you may want to put a check mark next to the issues you really care about and cross out those that aren’t as important to you. Talk with your doctor about your concerns. These issues haven’t been studied like the ones above, but your doctor may be able to give you some
insight into how they might affect you.

Recovery time. If you deliver vaginally, you’ll probably spend less time in the hospital and be back on your feet more quickly. Some women think this is important because they’ll be caring for the new baby and their older children too.

Involvement in the delivery. For some women, having a baby vaginally is more emotionally satisfying than having a C-section. You get to hold your baby sooner, which may help with bonding and even with breastfeeding. Your partner may feel more involved in a vaginal birth too.

Future childbearing. Doctors typically don’t want women to have more than two or three C-sections. So, you’re more likely to be able to have more children if you have a vaginal birth instead of another C-section.

Planned versus unplanned delivery date. Because it’s better to go into labor on your own when you’re planning a trial of labor, you probably won’t be able to be induced. Not knowing when you will go into labor can be stressful. It can also be a problem if you can’t arrange for someone to watch your other child or children at a moment’s notice. For these reasons, some women prefer to plan on a C-section.

Pain during labor and delivery. If you had an especially difficult and painful labor before, you may fear going through it again. For this reason, some women prefer to have another C-section and avoid labor. It’s important to remember, though, that there are ways to manage the pain if you decide on a trial of labor.

How do I make this choice?
You and your partner should work with your doctor to decide whether the benefits of a trial of labor outweigh
the risks.

If you decide to try labor, you and your doctor will talk about what to do if it looks like your labor is running into complications. It’s best to have a plan before you begin your labor so that you don’t have to make decisions during labor.

Resources Cited

1. Wall E, Roberts R, Deutchman M, Hueston W, Atwood LA, Ireland B.
Trial of labor after cesarean (TOLAC), formerly trial of labor versus
elective repeat cesarean section for the woman with a previous
cesarean section. Leawood, Kan.: American Academy of Family
Physicians; March 2005.
2. Guise J-M, McDonagh M, Hashima J, Kraemer DF, Eden KB,
Berlin M, et al. Vaginal Birth After Cesarean (VBAC). Evidence
Report/Technology Assessment No. 71. Rockville, Md.: Agency for
Healthcare Research and Quality; March 2003. AHRQ Publication
No. 03-E018.
3. Gardeil F, Daly S, Turner MJ. Uterine rupture in pregnancy reviewed.
Eur J Obstet Gynecol Reprod Biol 1994;56:107-10.
4. Miller DA, Goodwin TM, Gherman RB, Paul RH. Intrapartum rupture
of the unscarred uterus. Obstet Gynecol 1997;89:671-3.
5. Kieser KE, Baskett TF. A 10-year population based study of uterine
rupture. Obstet Gynecol 2002;100:749-53.

What do you think?
Leave a comment.

What do you think? Leave a comment.

1 Comment

  1. Great find! I’m very proud of the AAFP for taking this type of stand against the ACOG. Of course, the OB approach will be to say that FPs are not well versed in the complications that can arise during VBAC, so they have no standing to make such a recommendation.

    It is interesting, though, that the ACOG is one of the few professional organizations to go against the recommendations of the WHO as well as the FIGO. The AAFP is simply voicing their unity with these international organizations who represent not just physician interests but patient interests as well.

    Reply

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Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at a hospital, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. Even more have accessed her trainings online. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is the Secretary for the California Association of Midwives and the California Association of Licensed Midwives. Her favorite flavor of ice cream is peanut butter chocolate. And mint chip. And coffee.

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Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

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