Myth: VBACs should never be induced
Note: Since this article was published, ACOG released new VBAC guidelines in 2017 and 2018. Both maintain that LAC (labor after cesarean) induction remains an option.
Many of the comments left at the Forced Cesarean story questioned the safety of LAC induction. Many people believe that is it excessively dangerous and that planned VBACs should never been induced or augmented. This is simply not true.
Spontaneous labor is always preferable to induced or augmented labor. But there are situations that can necessitate the immediate birth of a baby. If a vaginal delivery is still an option, then birthing parents should have a choice: induction/ augmentation or repeat cesarean.
Of course, reviewing the risks and benefits of available options, including doing nothing, is essential. Some might be more comfortable with a cesarean whereas others might want to give a slow Pitocin and/or Foley catheter induction a go.
ACOG’s stance on LAC induction
Let’s start with ACOG’s VBAC recommendations where they assert:
Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC … However, the potential increased risk of uterine rupture associated with any induction, and the potential decreased possibility of achieving VBAC, should be discussed… Misoprostol should not be used for third trimester cervical ripening or labor induction in patients who have had a cesarean delivery or major uterine surgery.
While LAC induction does carry additional risks, the birthing parent still has the right to choose induction. As with all medical decisions, the provider is there to advise the parent and make a recommendation. The parent takes that information and makes an informed decision. Then, ideally, the provider supports that informed decision.
As ACOG (2010) states:
Respect for patient autonomy supports the concept that patients should be allowed to accept increased levels of risk, however, patients should be clearly informed of such potential increase in risk and management alternatives.
Medical reasons for induction
There are many situations where induction can be an option. ACOG’s recommendations on induction lists the following reasons:
- Abruptio placentae
- Fetal demise
- Gestational hypertension
- Preeclampsia, eclampsia
- Premature rupture of membranes
- Postterm pregnancy [which ACOG defines as after 42 weeks]
- Maternal medical conditions (eg, diabetes, mellitus, renal disease, chronic pulmonary disease, chronic hypertension, antiphospholipid syndrome)
- Fetal compromise (eg, severe fetal growth restriction, isoimmunization, oligohydramnios)
Uterine rupture risk of induced LACs
The elevated risk of uterine rupture associated with LAC induction has been documented in several studies. Landon (2004) reported a 0.4% rate of uterine rupture among those laboring spontaneously after one prior low transverse cesarean. That increased 2.5 times for induced labors (1.0%) and 2.25 times for augmented labors (0.9%). This increased risk was highly significant (P<0.001).
Landon further broke out uterine rupture rates by induction method:
- 1.4% with any prostaglandins (with or without oxytocin)
- 0% with prostaglandins alone
- 0.9% with no prostaglandins (includes mechanical dilation with a foley catheter with or without oxytocin), and
- 1.1% with oxytocin alone.
Taking all labor types into consideration, Landon reported a 0.7% rate of uterine rupture among those laboring after a cesarean with an additional 0.7% experiencing a uterine dehiscence.
ACOG also referenced a 2001 study of over 20,000 LACs which reported the following uterine rupture rates:
- 0.52% for spontaneous labor,
- 0.77% for labor induced without prostaglandins, and
- 2.24% for prostaglandin induced labor.
While some argue that induction is overused in America, which is tied to unnecessary emergency cesareans, it’s important not to cloud inductions that fall outside of current guidelines versus medically indicated inductions.
A low-dose Pitocin and/or foley catheter induction “remains an option” in women laboring after a cesarean per ACOG and I think that is a good thing.
What do you think?
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What do you think? Leave a comment.
As a nationally recognized maternal health advocate and Founder of VBAC Facts®, Jen helps perinatal professionals, and cesarean parents, achieve clarity on vaginal birth after cesarean (VBAC) through her educational courses for parents, online membership for professionals, continuing education trainings, and consulting services. She speaks at conferences across the country, presents Grand Rounds at hospitals, advises advocates seeking legislative change in their state, and serves as a expert witness in legal proceedings. She envisions a time when every pregnant person seeking VBAC has access to unbiased information, respectful providers, and community support, so they can plan the birth of their choosing in the setting they desire.