The Rules About VBAC (Part 1): A Deep Dive into US VBAC Guidelines with Jen Kamel

Jen Kamel: Hello, and welcome to The VBAC Facts® Podcast. I'm Jen Kamel VBAC Facts® founder and CEO. Since 2007, our focus has been to provide accurate and objective information on vaginal birth after cesarean and repeat cesarean to parents, professionals, policy makers, and the court so all decisions can be informed, ethical, and just.

Understanding ACOG and Its Influence

Jen Kamel: Today we'll be talking about ACOG's VBAC guidelines. And who is ACOG? Why does this matter to you? ACOG is the American College of Obstetricians and Gynecologists, and what they say about VBAC is relevant to you if you are someone birthing in the U. S., or works in health care at all because ACOG's guidelines influence VBAC hospital policy, as well as the individual policies of obstetricians.

And because there is so much misinformation and confusion surrounding ACOG's guidelines, I find it especially helpful to quote directly from their guidelines. So I'm going to be doing that today. And I really want you to compare and contrast what it is that you think ACOG says, what you have heard ACOG says, and what ACOG actually says.

Jen Kamel: I have ACOG's guidelines right here, and I'm really excited to share some of this with you because I think you will be very much surprised. This is ACOG's most recent guidelines published in 2019, number 205. If you have heard that ACOG isn't supportive of VBAC, if you have heard ACOG has narrow guidelines about VBAC, then this is an episode you need to listen to.

Decoding ACOG's VBAC Guidelines

Jen Kamel: So I think just their beginning couple sentences are so enlightening and help us really set the tone for what ACOG really intends in terms of VBAC access. So they start with, "Trial of labor after cesarean delivery, TOLAC, refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery regardless of the outcome. Now pause, and I'm going to be doing that a lot.

Alternative Language for TOLAC

Jen Kamel: Rather than the term TOLAC, which I know many clinicians use, I know a lot of medical research uses, I really love a couple alternatives. First is the term LAC. Labor after cesarean. And I heard that for the first time from Melissa Cheyney, and I think it is such an excellent alternative to the acronym TOLAC, because LAC stands for labor after cesarean, and it focuses on what we all have control over, right? That choice to labor after a cesarean. We don't have control over the outcomes.

An alternative to LAC is planned VBAC. And again, both LAC and planned VBAC focus more on the choice at hand, and that is whether to labor or not. And it isn't a trial. It isn't a try. It isn't something you are attempting. You are choosing to labor after a cesarean. And I love how that language focuses on agency.

Okay, so that's just the first sentence in. "This method provides women who desire a vaginal delivery the possibility of achieving that goal of vaginal birth after cesarean delivery, VBAC. In addition to fulfilling a patient's preference for vaginal delivery at an individual level, VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies, as well as a decrease in the overall cesarean delivery rate at the population level.

However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor, i. e. VBAC, and elective repeat cesarean delivery." Pause.

That statement it is true for anyone laboring, right? So if you are a first time parent, cesarean during labor is going to have a higher complication rate of someone who has a vaginal birth versus someone who plans a scheduled cesarean before labor. I just want to be clear that the higher rate of complications associated with cesarean during labor is not unique to birth after cesarean. That is something that we see across the board. And I think that's something that's so important to point out, because sometimes I see that held up as a reason to not labor after a cesarean. But if that was true, then we could say the same thing about someone who is pregnant without a prior cesarean.

Assessing VBAC Candidacy

Jen Kamel: "Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC." So I always argue, who is the appropriate candidate for TOLAC? The person who reviews the risks and benefits and makes an informed decision. And we'll see later on in ACOG's guidelines how they say there are no universal mandates for who is or is not a VBAC candidate.

I like to say, and I know this might sound really radical, but everyone is a candidate for VBAC. Every single person with a prior cesarean is a candidate for VBAC and how they decide whether they want to have a VBAC is looking at the risks and benefits in front of them and making an informed decision.

So I think that whole concept of VBAC candidacy is really sticky because there is this idea that someone else makes that decision for the birthing parent. When in reality the clinician talks about risks and benefits, the clinician provides a recommendation, and then the patient makes an informed decision, and the clinician should support that informed decision.

So this idea that there is a checklist of who is a VBAC candidate and who is not, that is false and that's actually in ACOG's VBAC guidelines. So if you are shocked already, buckle up because it's only begun. "So thus, the purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and to provide practical guidelines for counseling and management of patients vaginally after a previous cesarean delivery."

One very important thing to talk about anytime we look at ACOG's guidelines is to consider the level of evidence available for each of their recommendations.

Levels of Evidence in ACOG Guidelines

Jen Kamel: And that's actually at the very end of any of their committee opinions and they break out all of their recommendations by the level of evidence available to support each individual statement .

So level A means that there is good and consistent evidence supporting that statement. Level B means there is limited or inconsistent evidence. And level C means there is no hard evidence supporting that recommendation. So that's very important whenever you're looking through ACOG's guidelines to not only read the entire narrative, but also to go into the back and compare and contrast what are the levels of evidence available for each of their recommendations.

And I think it's fascinating to see when we look at all of their recommendations here, only three are associated with level A evidence. And so let me just read those to you. The first is "Most women with one previous cesarean delivery with a low transverse incision are candidates for, and should be counseled about and offered TOLAC."

The second one, "Misoprostol should not be used for cervical ripening or labor induction in patients at term who have had a cesarean delivery or major uterine surgery." So misoprostol is Cytotec. And then the third, "Epidural analgesia for labor may be used as part of a TOLAC." I mean, all of these could be a whole long conversation, right?

But I want to just briefly touch on the epidural because there are some clinicians who say, well, I really want my patient to have an epidural on board because in the event of an emergency, we can quickly change over to a cesarean delivery. Or people say, well, I don't want my clients to have an epidural because that can inhibit pain in the event of a uterine rupture and can delay diagnosis.

Okay, so both of those are problematic because the reality is in a true emergency situation the fastest way to perform a cesarean is with general anesthesia, because when you have a situation where seconds count, you're not going to fiddle around with a spinal, you're not going to fiddle around with topping off an epidural, you're going to go straight to general.

So that's number one. Number two is we know from the research that epidurals do not inhibit the symptom of abdominal pain in the setting of a uterine rupture. So there should not be concern about an epidural delaying diagnosis of uterine rupture because that is not what we see in the research.

So of all of this entire guidelines, we have three Level A evidence recommendations. So that's important to keep in mind.

Health Advantages of VBAC

Jen Kamel: So when ACOG talks about the risks and benefits of VBAC they say, "In addition to providing an option for those who want to experience a vaginal birth, VBAC is associated with several potential health advantages for women. For example, women who achieve VBAC avoid major abdominal surgery and have lower rates of hemorrhage, blood clots and infection and a shorter recovery period than women who have an elective repeat cesarean delivery. Additionally, for those considering future pregnancies, VBAC may decrease the risk of maternal consequences related to multiple cesarean deliveries, such as hysterectomy, bowel or bladder injury, transfusion," so that's a blood transfusion If someone loses too much blood, hemorrhages too much, and they need to have some blood replaced, "infection and abnormal placentation," such as placenta previa and placenta accreta.

So placenta previa is when in a subsequent pregnancy, the placenta lies. Let me put this paper down so I can show you. So let's say this is the bottom of the uterus, so we've got the cervical opening here, and the placenta is lying right here over the cervical opening or maybe close to the cervical opening. So clearly if we have a complete placenta previa and the baby's up here, The baby can't go through the cervical opening, right? Because the placenta is in the way. So that's placenta previa. Placenta accreta is when you have the placenta have an abnormally deep attachment either in or through the uterine wall. So both of those are indications for a repeat cesarean.

They say, "However, elective repeat cesarean delivery and TOLAC are associated with maternal and neonatal risk. "The risk of either approach includes maternal hemorrhage, infection, operative injury," so that includes things like injury to the bladder, the bowel, the ureters. The ureters are these little tubes that connect your kidney to your bladder. "Blood clots, hysterectomy, and death. Most maternal morbidity related to TOLAC occurs when repeat cesarean becomes necessary."

"Thus, VBAC is associated with fewer complications than elective repeat cesarean delivery, whereas failed TOLAC is associated with more complications." Now remember what we said before, this is that same trend that we see regardless if someone has a prior cesarean or not. Right? So we're going to see the highest rates of complication when someone is in labor and they need a cesarean delivery versus someone who has a vaginal birth, those births tend to have the lowest rates of complications.

Understanding Uterine Rupture and Dehiscence

Jen Kamel: "Uterine rupture or dehiscence associated with TOLAC results in the most significant increase in the likelihood of additional maternal and neonatal morbidity. So it should be noted that the terms uterine rupture and uterine dehiscence are not consistently distinguished from each other in the literature and often are used interchangeably."

Such an important point and I often see conversations that are not super clear on this issue of uterine rupture versus uterine dehiscence. So let me break it down for you. First, uterine rupture is when we have a full thickness opening through the uterine wall. The pregnant uterus has the myometrium, the uterine muscle, and the serosa, which is the outer layer of the uterus. When both of those layers open up, that is when we have a uterine rupture. Now in 95 percent of the cases, in someone who has a prior cesarean, that uterine rupture occurs along the prior scar line.

A uterine dehiscence is when the inner layer, that myometrium, the uterine muscle, separates, but the outer layer, the serosa, stays intact. So that is what you would also hear be described as a uterine window, a incomplete uterine rupture, there's a lot of different terms.

These are words that all describe these same events, which is why it's especially confusing for not only parents, but for professionals because we hear all these words and we think, "well, certainly an incomplete rupture is different than a uterine dehiscence, which is different than a uterine window." They're all the same thing, which is why when you read anything that I write, if you come to any of our trainings, you will see that we only use two phrases, unless we are citing a piece of research. We use uterine rupture and we use uterine dehiscence.

Uterine rupture is where we see higher rates of perinatal mortality and morbidity and we see higher rates of maternal morbidity. It is very rare for the laboring woman or parent to die as a result of uterine rupture.

When we look at medical research, one of the most important things, and I have a whole checklist up on the website on how I personally go through and qualify research on VBAC.

Evaluating Medical Research on VBAC

Jen Kamel: If you are someone who is online talking about medical research, or if you are just looking at it for yourself or for your clients, it's really important to know, how do you qualify medical research relative to VBAC?

So one of the questions I ask is how do they define uterine rupture? And you can find that in the methods section of any piece of research on VBAC. And you're looking for something that uses that same language when I was talking about the difference between a uterine rupture and a uterine dehiscence. You are looking for a definition that says uterine rupture is described as a full thickness opening through the uterine wall, or all layers of the uterus open, or something to that effect where it's very clear they are making a clear distinction between rupture and dehiscence.

In studies that do not do that, we come into this problem where they are categorizing dehiscences as ruptures and then reporting that rate as a uterine rupture number, and that's giving us an inflated rate of uterine rupture.

Now, the challenge is, is that while we have those types of studies in the universe, we also have studies that actually make that clear distinction. And so when you go online and people are saying things like, "Oh, well, you know, I've heard the rate of rupture is 0. 4%, but I've also heard that so many studies or all studies combine rupture and dehiscence. So really that 0. 4 percent reflects both rupture and dehiscence. So the rate of actual rupture is a lot smaller." That is false. That is false. Okay, so, again, this is why it's so important when we're talking about VBAC and we're talking about research and we're talking about where you're getting your information to be very clear that you are just looking at studies that are measuring uterine rupture and we're talking on a case by case basis. So all the studies that I cite at VBAC Facts have passed this criteria that I go through and one of those most important criteria is how they define uterine rupture because that is a critical number for us to have a handle on.

So ACOG also says, "Furthermore, the reported incidence of uterine rupture varies in part because some studies have grouped true catastrophic uterine rupture together with asymptomatic scar dehiscence."

Exactly. And "asymptomatic scar dehiscence" really important to here, because scar dehiscence is asymptomatic. So you won't see that show up on the heart rate strip. You will not see fetal heart rate abnormalities. You will not see bleeding. You will not see other symptoms that you will see associated with uterine rupture.

"Additionally, early case series did not stratify rupture rates by the type of prior classical or by the type of prior cesarean incision." Yes, "i. e. by the type of prior classical incision, such as low transverse versus classical."

That is another question that I ask. Do they control for scar type? Is this particular study that I'm reading, is it clearly delineating between a low transverse uterine rupture versus a classical uterine rupture?

There's so much good stuff in here. Look at how far we are in the podcast and we're on page two.

Looking at Table 1 and Table 2, where they have composite maternal and neonatal morbidity, looking at elective repeat cesarean section, so that's a cesarean section that happens in the absence of labor, it happens before labor begins, and a TOLAC, aka a planned VBAC or labor after cesarean. And we can see when we compare both of these outcomes, and remember TOLAC always includes those who labored and had a VBAC and those who labored and had a repeat cesarean.

So when we look at this chart, we can see rates of infectious morbidity, surgical injury, blood transfusion, hysterectomy, uterine rupture, and maternal death. So infectious injury is slightly higher with TOLAC. Surgical injury is higher with TOLAC. Blood transfusion is slightly higher. Hysterectomy is pretty similar. Uterine rupture, of course, is higher in TOLAC, right? But also it's not zero in those who have elective repeat cesarean deliveries. And maternal death, I have an Instagram post on this topic and it gets so much traction because people get fired up.

So in both of these elective repeat cesarean and TOLAC, the risk of maternal mortality is very, very low, right? For elective repeat cesarean, it's 0. 0096 percent versus TOLAC, it's 0. 0019%. Okay, both very low. It's very unlikely that the birthing parent, will die as a result of either planning a elective repeat cesarean or a TOLAC. The risk of maternal mortality is five times higher with an elective repeat cesarean delivery. And so that right there is the difference between absolute risk versus relative risk, which is how those two risks compare. So absolute risk is that number 0. 0096 percent versus 0. 0019%. Versus relative risk: elective repeat cesarean maternal death is five times higher than during a TOLAC.

That's an important concept to understand when you're looking at medical research, because the questions I'm always asking are, "What is the absolute risk?" And then also "What is the relative risk?" So relative risk, significantly higher, absolute risk, incredibly low with both.

Okay. So I'm sitting here doing this editing and I just can't help myself. And you know, if you are just listening to the audio podcast, you probably wouldn't even notice, but see those on YouTube are going to see, "Hey, there's Jen with like a different hairstyle and different clothes." And as I'm editing this, I just felt compelled to add that when we look at these charts on ACOG's guidelines, they're referring to outcomes in the present birth. And that is something that is very important to consider. But it is not the complete picture.

And later on in the podcast, I'll refer to the very important discussion of considering how many children someone ultimately wants to have. How many children they're open to having. And I really wish there was more emphasis in ACOG's guidelines about that future risk because I was just talking with a labor and delivery nurse the other day, who said every single day on her floor, they have someone with accreta. Every single day. And so placenta accreta, I referenced it earlier, it's when the placenta abnormally attaches to and through the uterine wall. And it is associated with significant rates of maternal morbidity and mortality, and it's even higher if that accreta is not detected prenatally and someone is birthing at a community hospital. So, looking at not only the risks and benefits in the current pregnancy, but also the risks and benefits in future deliveries is really important.

I really want to make sure that especially birthing parents who are listening to this podcast know that these two charts in ACOG's guidelines on maternal mortality and morbidity and neonatal mortality and morbidity are not the complete picture because yes, what is happening in the current pregnancy is an important piece of the whole decision making puzzle, but it is not the only piece.

And so we have to remember that increasing risk of complications that are associated with multiple prior cesareans, including placenta accreta, placenta previa, hysterectomy, blood transfusions, blood clots, surgical time, all of these things increase at a statistically significant rate. And that's really important to keep in mind. Okay, back to the podcast.

"Composite neonatal morbidity and mortality." I have a whole blog post about this and I will probably turn that into a podcast just because there is so much to say on that one topic, so I am not going to cover that in detail right now.

ACOG says "about the stratification of candidates. "Most published series," meaning studies, "examining women attempting TOLAC have demonstrated a vaginal delivery rate of 60 to 80 percent. However, the likelihood of achieving a VBAC for an individual varies based on her demographic and obstetric characteristics.

For example, women whose first cesarean delivery was performed because of arrest of labor disorder, or less likely to succeed in their attempted VBAC than those whose first cesarean delivery was for non-reassuring indication." Okay. A comment about that many people who have their cesarean for arrest of labor which is also called failure to progress, do not meet the definition for the failure to progress diagnosis. And that was per a particular study, I'll put it in the show notes. One of the criteria someone must meet in order to satisfy the FTP criteria is that they must be at least six centimeters.

And this particular study, when they looked at all these people who had their cesarean for FTP, approximately 50 percent were not six centimeters. So they did not even meet the criteria for the FTP diagnosis.

However, when those people who had their prior cesarean for FTP then go to the VBAC calculator, say, and plug in that they had their cesarean for FTP, the VBAC calculator generates incredibly low VBAC odds. And then they think, Oh, I have really low odds of having a VBAC. Why even try?

Critical question. If you or a client had a cesarean for FTP, look at their operative report, look at their medical records, look at the criteria for FTP, which we have up at vbacfacts.com/calculator and compare and contrast. Were they six centimeters? Did they meet the other criteria to meet the FTP diagnosis? If not, it does not matter what their medical records say. If they did not meet the criteria for that diagnosis, they should not consider themselves as having a prior FTP diagnosis, and they should not check that box in the VBAC calculator. Because that will substantially ding predicted odds and the feedback calculator is problematic and you know, the reality is this could be like a 30 hour podcast, right? This episode right here because there is so much to say on every single line, but we're just going to go through it briefly. And as we go through in future episodes of the podcast, I'll dive more deeply into these various topics because there is so much to say.

Speaking of which, let's jump to when ACOG talks about the role of vaginal birth after cesarean delivery prediction models, aka the VBAC calculator.

VBAC Calculators and Prediction Models

Jen Kamel: ACOG says "the probability that a woman attempting TOLAC will achieve VBAC depends on her individual combination of factors." Pause again. "Individual combination of factors."

I have so many people who ask me, "This is the scenario in my prior birth. How likely is it that I will have a VBAC?" Here's what I say. There are so many factors that go into how an individual birth plays out. Change up one of those factors and your birth can play out totally differently. For example, in your prior labor, the baby was posterior.

This pregnancy, you go into labor, baby is not posterior. That could make the difference. Maybe you were not, quote, allowed to move around during labor. Maybe you were induced. There are so many things. And the reality is we can plug your numbers into a VBAC calculator.

We can look at all the research that says, oh, if you had your C section for breech, your VBAC odds are this versus FTP, your VBAC odds are this. But let me tell you something. For you personally, the VBAC odds are either a hundred percent, you're either gonna have a VBAC, or it's zero percent, you're gonna have a repeat cesarean.

At the end of the day, you don't have 75 percent of a VBAC. You know what I mean? So we can look at these studies and they can be helpful in terms of giving you an idea of what your odds are, or for your clients what their odds are, but at the end of the day, It's either you have a VBAC or you don't.

So you know me, I am a huge numbers person. I want to have everything charted out. I love my spreadsheets. I love all my stuff. But the reality is it's either going to happen or it's not. So I love using evidence as a guide, but it is not predictive. And that's exactly what ACOG is saying here. "Several investigators have attempted to create scoring systems to assist in the prediction of VBAC, but most have had methodological, limitations and have not been used widely."

So methodologic limitations refers to the fact that there are issues with how those VBAC calculators were created. And in fact, when we look at some of those VBAC calculators, we can see that while they were accurate or true for the specific population in the study in which those calculators were developed. When those calculators were applied to other populations, they did not accurately predict. And again, I talk about this more at vbacfacts.com/calculator. Check it out to learn more.

So, they say, "However, one model was developed specifically for women undergoing TOLAC at term with one prior low transverse cesarean delivery incision, singleton pregnancy," so only one baby, "and cephalic fetal presentation," meaning the baby was head down, so the baby was not breech.

"...this model uses information that is available at the first prenatal visit to generate the predicted probability that a VBAC will be achieved if TOLAC is undertaken. Predicted probability for VBAC is based on a multivariable logistic regression model that includes maternal age, BMI, race, prior vaginal delivery, history of a VBAC, and indication for prior cesarean delivery."

Pause. So much to say about this. BMI. We know from medical research that provider bias slash provider preference impacts the choices that parents make. And so if parents perceive that their provider is leaning towards repeat cesarean or leaning towards VBAC, the person is more likely to make the choice that is in line with their perceived preference of their provider.

So with BMI, we see quite a bit of bias slash preference about how people labor and, and how people give birth. And so parents tend to follow that lead. So if you are someone in a larger body and your provider says, "You know, I really think it's better for you to do a repeat cesarean," parents are more likely to make that choice and we see that in the research. The challenge with that is we have that dynamic playing, and then we have research that gobbles up that dynamic and then serves it forth to the rest of us as science. That's how bias gets baked into medicine. And we know from one piece of research that they said , even among the parents who were good VBAC candidates, I think they said less than 30 percent actually chose a VBAC.

It might've been 10%. It was very low and it was shocking because here is a group of people who were otherwise good candidates, had larger bodies, and yet they were far less likely to actually plan a VBAC. Same thing with race. We see lower VBAC odds associated with race, specifically people who are Black.

Then that is sucked up in the VBAC calculator as quote science, that for whatever reason Black people have lower VBAC odds. It's served up as science in the VBAC calculator. It's served up as science in medical research that finds lower VBAC rates. Race was recently removed from the VBAC calculator, but we know it takes about 20 years for new evidence to make its way into clinical practice. So there may very well still be providers out there who believe being Black, being Latinx, being non white is associated with lower VBAC odds.

This is why it's important for you to know the facts. This is why it's important for you to know what ACOG says, and this is why it's important for you to be listening to the podcast now. Because this is the kind of information that's going to help you, your clients, and your patients to more successfully navigate this complicated health care system.

Okay, we're quite a bit into the podcast and we've gone through three pages. Let's just see how this goes. So a prior vaginal delivery, absolutely. Someone who has a prior vaginal delivery has higher VBAC odds .

This is really a critical statement. And I actually use this statement in a lot of my trainings because I think people are shocked when they hear it. So many people think ACOG is not supportive of VBAC, ACOG is really strict. But let's also remember that ACOG is providing recommendations. They're not providing mandates. Right? And so it's interesting when people say, "Well, we have to do X, Y, Z because ACOG says," but then also at the same time, they're sort of ignoring the things that they really don't want to do that ACOG recommends. So have your ears perk up when someone says, "Oh, we can't, or we must do X, Y, Z because of ACOG."

The reality is, many hospitals pick and choose what they want to quote, follow and what they want to dismiss. Because the reality is if all hospitals honored what ACOG says, all hospitals with labor and delivery units would be offering VBAC throughout the U S. Are you surprised? It's true.

Let me read you the statement.:" The preponderance of evidence. suggests that most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about and offered TOLAC."

However, how many people labor after a cesarean? When we look at the research, nationwide research, 80 percent of people with a prior cesarean, one prior cesarean Schedule an elective repeat cesarean section. 20 percent labor, between 14 and 16 percent actually have a VBAC.

So there's a massive disconnect there, right? Between what ACOG says and what is actually happening. Because the reality is that should be like 80 percent of people should be laboring because everyone should have access to this option. No one should be told routinely, you need a repeat cesarean just because they have had a prior cesarean. There are absolutely reasons to have a repeat cesarean, scheduled or otherwise, but having a prior cesarean is not one of those reasons.

Who is Not a VBAC Candidate?

Jen Kamel: "Conversely, those at high risk of uterine rupture, such as those with a previous classical or T incision, prior uterine rupture, or extensive transfundal uterine surgery, or those in whom vaginal delivery is otherwise contraindicated, such as those with placenta previa, are not generally candidates for planned TOLAC."

Another key phrase, "are not generally candidates." That is very different than "are not allowed to plan a VBAC," "is contraindicated for planning a VBAC" because that's the language that I hear used. "People with a prior classical cesarean are not allowed to plan a VBAC." That is not what ACOG says here.

Okay, that phrase, "not generally candidates." Key. Key. Okay, let's continue. "However, individual circumstances must be considered in all cases. For example, if a patient who may not otherwise be a candidate for TOLAC presents in active labor, the patient and her obstetrician or other obstetric care provider may judge it best to proceed with TOLAC."

Right there. So this scenario that we hear about, about people being admitted to the hospital and maybe their hospital has a VBAC ban or their provider doesn't support VBAC or whatever, and they're rushed down to have a repeat cesarean because you're not quote, allowed to have a VBAC here, that is out of line with what ACOG says.

Because ACOG is very clear, "not generally candidates, Individual circumstances must be considered." And even in cases where someone who might not otherwise be a candidate presents in labor, they might decide, hey, I actually want to continue laboring.

And I think it's important here, the phrasing. "The patient and her obstetric care provider may judge it best." So let's be very clear here. Informed consent is not the same as shared decision making. So in this scenario, it would ideally would progress like this. The person is admitted to the hospital. They might not otherwise be a candidate for VBAC. The clinician says, okay, so here are the risks and benefits of proceeding with labor. The patient makes the decision. The provider supports that informed decision. And then they proceed. That is what it looks like.

Another key phrase, "good candidates for planned TOLAC are those women in whom the balance of risks as low as possible and chances of success as high as possible are acceptable to the patient and obstetrician or other obstetric care provider." Again, acknowledging that while we have this research as guidelines, that the findings of research on a large group of people doesn't necessarily translate to the outcomes for an individual person. So the research that we have available is a guideline, but it's not predictive, and it's not going to tell us for an individual person, "this is how their labor is going to play out."

Someone who had their prior cesarean for breech, whose VBAC odds are about 80%, they might end up with a repeat cesarean for whatever reason. So remember, guidelines... they give us an idea, but it's not predictive.

"However, the balance of risks and benefits appropriate for one patient may be unacceptable for another." And this is why it is so important for parents and professionals to have access to accurate information that they can confidently communicate to clients so clients can make truly informed decisions. Because there is no right way to birth and how people distill, you know, we have all this information that kind of filters through our individual personal filters and results in us making a decision.

But that decision that might be totally right for me, I might feel completely comfortable with a specific set of risks and benefits and circumstances. Someone else might feel totally different. And that's why it's so important to get accurate information to people. And that's why those of us who are out educating people about VBAC, why it is so important for us to have our facts straight because people listen to us. And with that comes a responsibility of sharing accurate information.

"Delivery decisions made during the first pregnancy after a cesarean delivery will likely affect plans in future pregnancies." Exactly. Because one of the things that we see is that once someone has two prior cesareans, their odds of laboring after a cesarean drop off considerably.

The latest nationwide research says about 7 percent of people labor after two or more cesareans. The latest research that we have out of California that just looks at people who had two prior cesareans found that less than 3 percent actually labored.

So when we look at 20 percent who labor after one cesarean, and that drops down to 3 percent after two cesareans, this is why it is so important for people to have access to VBAC after one cesarean, because not only do their risks increase in future pregnancies, regardless of mode of delivery, because we have those increasing risks of placental abnormalities like previa and accreta. We also see with multiple prior cesareans, with each prior cesarean, the risk of things like hysterectomy, ICU admission, surgical complications and injuries, hemorrhage. Those all dramatically increase at a statistically significant rate. And statistically significant is a phrase that you're going to hear a lot here on The VBAC Facts® Podcast, and what that refers to is that we see a connection between a specific variable and a specific outcome. So in this situation, the variable is multiple prior cesareans and the outcome are things like hysterectomy, excessive bleeding, blood transfusions, placental abnormalities, ICU admission, etc. So we can see in the research that there is a connection between those two things.

"Therefore, decisions regarding TOLAC should ideally consider the possibility of future pregnancies." Another critical question to ask, if you are a birth professional, you should be asking your client who is coming to you pregnant after one or more cesareans. "What are your intentions in terms of the size of your family?"

That completely changes the conversation, right? If someone has two or three prior cesareans and they are open to as many children as God gives them, they might be pregnant six, seven more times. So we've got to look at what are the risks and benefits of having a vaginal birth after three cesareans and then potentially having vaginal birth for the remainder of those pregnancies versus having that fourth c section and then having c sections for the remainder of those pregnancies. And I am shocked how many parents are pregnant after a cesarean and their clinician or other professionals in their life never asked this question of them. And this is why if you are a parent listening to this podcast, it's important for you to have that conversation with your provider if they don't bring it up.

"Although there is no universally agreed upon discriminatory point, evidence suggests that women with at least a 60 to 70 percent likelihood of achieving a VBAC who attempt a TOLAC experience the same or less maternal morbidity than women who have an elective repeat cesarean delivery. Conversely, women who have a lower than 60 percent probability of achieving a VBAC who attempt TOLAC are more likely to experience morbidity than women who have an elective repeat cesarean section. Similarly, because neonatal morbidity" so again, morbidity is just another word for a complication, right? It's a fancy word for complication. So, "...neonatal morbidity is higher in the setting of failed TOLAC than in VBAC, women with higher chances of achieving VBAC have lower risks of neonatal morbidity.

For example, one study demonstrated that composite neonatal morbidity was similar between women who attempted TOLAC and women who had an elective repeat cesarean delivery if the probability of achieving VBAC was 70 percent or greater. However, a predicted success rate of less than 70 percent is not a contraindication to TOLAC."

So important. It's because ACOG refers to all of these odds, you know, 60%, 70 percent that some clinicians lean into the VBAC calculator because they say, okay, well, ACOG says that about 60 to 70% is the cutoff for higher rates of morbidity. So I'm going to pull out the VBAC calculator and I'm going to look and I'm going to see, okay, how does my client in front of me line up relative to that 60 to 70%? And if they're higher, great, that provider may be more likely to encourage a planned VBAC. But if they're lower, that provider might say, um, I think you should have a repeat cesarean.

It's really important for us all to hear that a predicted success rate of less than 70 percent is not a contraindication to TOLAC. Another reason it's not a contraindication is because we know from these VBAC calculators, I've included this in the article we have at vbacfacts.com/calculator, we have had a couple studies that have demonstrated that the VBAC calculator under predicts VBAC odds.

And so the particular study that I'm thinking about had people into three different categories. High predicted VBAC odds, moderate, and then low. And then it published the rate of VBAC odds associated with each category. And in each category, the actual VBAC rate was significantly higher than the predicted VBAC rate. And so that's one of the reasons why a low VBAC rate generated by the VBAC calculator should not be a contraindication.

Okay, "More than one previous cesarean delivery." I have a whole article up on these topics up at vbacfacts.com/vba2c. And then we also have another one at vbacfacts.com/vba3c. And that talks about three or more cesareans versus the other one is two prior cesareans. So I'm not going to go into too much detail on this here, but I just want to share a few key points.

One. Having two prior cesareans is not a contraindication. People should absolutely have access to VBAC. If you want to provide your clients with accurate information, you can go to that article and we even have a continuing education training available within VBAC Facts® Professional Membership that goes into more detail and nuance, which is really important when you're talking about providing your clients with accurate information and fielding those questions that parents ask. So, highly recommend you check out that training.

The other thing I really want to say here is that so many people believe ACOG says after three prior cesareans, you are not quote allowed to plan a VBAC. And ACOG absolutely does not say that. They do not say those words and we can go back to what ACOG said earlier about there being no universal mandates.

So again, it all goes down to the fact that everyone is a VBAC candidate. Everyone should have the right to evaluate the risks and benefits for themselves and make an informed decision. That's really what it comes down to.

Let's talk about big babies, because that is a reason that I see so many people being, quote, risked out for VBAC. And there's a lot of conversation here, a lot of narrative here, but I just want to jump to the bottom line. "Suspected macrosomia alone should not preclude offering TOLAC."

Bottom line, I go through the research and "The Truth About VBAC™ for Families", as well as "The Truth About VBAC™ for Professionals", which is available within VBAC Facts® Professional Membership. If you want to learn more about that, if you want to go through the research with me, highly recommend you sign up for those courses because I go through it all there.

"Gestation beyond 40 weeks." Again, ACOG says, "Thus, although the likelihood of success may be lower in more advanced gestations, gestational age greater than 40 weeks alone should not preclude TOLAC."

I recently, a professional member asked in our group, "Hey, um, so one of my clients," she's a doula, "one of my clients, their OB says that the risk of uterine rupture increases every week they're pregnant beyond 40 weeks." Okay, so that's not true and there's not research to support that. So really key, again, for people to know what ACOG says.

Okay, a previous low vertical incision. So a low vertical incision is a up and down, so vertical is up and down incision in the lower uterine segment as opposed to the fundus, that's the upper uterine segment. So the lower uterine segment, an up and down incision, that is not a contraindication to VBAC.

This is what ACOG says, "Recognizing the limitations of available data," meaning we don't have a lot of research on this topic, "the obstetrician and or other obstetric care provider and patient may choose to proceed with TOLAC in the presence of a documented prior low vertical uterine incision."

So, this is another topic that I'm glad we're talking about right now. Limited evidence does not mean you are not allowed. Limited evidence means for the birthing parent: you get to accept the fact that this is a level of unknown risk and like in any choice regarding childbirth or pregnancy, you get to make that decision and you get to hold the responsibility for the outcome because no one can guarantee you an outcome.

Even if you are someone who had your c section for breech and you have really high VBAC odds, no one can guarantee you the outcome. So, important concept to understand. Limited evidence means unknown risk, which means people still have the right to make their own medical decisions.

"Unknown type of prior uterine incision, the type of uterine incision performed at the time of a prior cesarean delivery cannot be confirmed in some patients. Although some have questioned the safety of offering TOLAC under these circumstances, two case series, both from large tertiary care facilities," tertiary means a very large, well resourced hospital, "reported rates of VBAC success and uterine rupture similar to those with documented prior low transverse uterine incisions," and that's probably because the bulk of those unknown incisions were low transverse uterine incisions. That is the most common type of uterine incision, and odds are if someone has an unknown uterine incision, that's what they have. And of course, there is a chance that someone could have a prior classical, classical being a vertical up and down incision in the uterine fundus, so the upper part of the uterus.

"Additionally, in one study evaluating risk factors for uterine rupture, no significant association was found with the presence of an unknown scar. The absence of an association may result from the fact that most cesarean incisions are low transverse and the uterine scar type often can be inferred based on the indication for the prior cesarean delivery. Therefore, women with one previous cesarean delivery with an unknown uterine scar may be candidates for TOLAC unless there is a high clinical suspicion of a previous classical uterine incision such as a cesarean delivery performed in an extremely preterm gestational age."

So, remember, ACOG is clear, "not generally a candidate" does not mean not allowed, right? So if there is a high suspicion of a previous classical incision, that is an opportunity for a conversation. We actually have articles on special scars up on the VBAC Facts® website, and we also have a training on classical, T/J, and low vertical scars up on Professional Membership. So if you're interested in learning more about that, highly recommend you check that out.

"Twin gestation studies," it says, "women with one previous cesarean delivery with a low transverse incision who are otherwise appropriate candidates for twin vaginal delivery are considered candidates for TOLAC. I mean, that's just the bottom line."

So obesity have a whole section on that. I just want to jump to the main point. "Women who have a BMI of 30 or greater may be candidates for TOLAC depending on their other characteristics, such as having had a prior vaginal delivery and their care should be individualized." So that means that a practice should not say, if you have a BMI of X, you are not a candidate for VBAC. This is a situation for individualized care.

Induction and Augmentation After Cesarean

Jen Kamel: Oh, induction and augmentation. This is something I see all the time. K. This is what I need to have everyone hear. Induction is an option after a cesarean. Induction is an option after a cesarean. I feel like we should all say that five times fast. Because I see even physicians on social media, talking about how you cannot be induced after a cesarean So let's talk about what that means.

If you say someone cannot be induced after a VBAC, what you're saying is, if a medical indication presents, say they have preeclampsia, right? And it's not at a stage where they need to be delivered right now in the next five minutes, because that is an emergency c section. But say the clinician and the patient have a conversation. It's still early in the process. "You know what, let's have an induction and see how things play out." if that induction was not an option, the only option that person would have would be to have a c section.

Informed consent means in this particular situation: here are the risks and benefits of induction, here are the risks and benefits of having a c section now or having a c section in a week. And then here are the risks and benefits of you remaining pregnant with preeclampsia. That's informed decision making. You're looking at each option and you're talking about the risks and benefits, and then the patient makes an informed decision. So there's a whole lot here. We actually have a whole training on VBAC induction within VBAC Facts® Professional Membership. It is fascinating all the factors at play.

It's also fascinating that over in Europe, they use oral Cytotec. I know, people in the U. S. here are curling their toes because in the U. S., and as we saw in ACOG's guidelines, Cytotec is a contraindication for term induction with a live fetus. So Cytotec can be used when we have a fetal demise in the second trimester.

So unfortunately we're at time, so we're going to go ahead and wrap it up for today, but we are not done with ACOG's VBAC guidelines. Join us in our next episode where we talk about external cephalic version, epidurals, diagnosing uterine rupture, VBAC after uterine rupture, VBAC in rural hospitals and who makes the ultimate decision about planning a VBAC versus elective repeat cesarean. You may be surprised what ACOG actually says.

Until next time, I'm Jen Kamel, founder and CEO of VBAC Facts®, and don't forget what we're about. Since 2007, our focus has been on providing accurate and objective information on vaginal birth after cesarean and repeat cesarean to parents, professionals, policymakers, and the court, so all decisions can be informed, ethical, and just. Join us next time, and until then, take care.