VBAC scare tactics (1): VBAC = uterine rupture = catastrophic outcome
I began writing this post a couple of days ago and, after noticing that it had the potential to become ten pages long, I soon realized that I had a “blog series” on my hands. Accordingly, this post will be the first in a series of questions, concerns, and information that VBAC moms should have on hand if and when they encounter “VBAC scare tactics” from their care providers.
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Many women who want to have a vaginal birth after cesarean (or VBAC, pronounced “vee-back”) in this country have faced some sort of opposition from their care providers when they have expressed their desire to VBAC.
Sometimes this opposition is blatant (e.g. “I don’t do VBACs. Why would you ever want to risk having your uterus explode and ending up with a dead baby?”). (More on why this is an outrageous statement in a bit.)
Sometimes this opposition becomes obvious only at the end of the third trimester (e.g. “Oh, it looks like your cervix isn’t dilating, so you probably won’t go into labor on your own. Let’s schedule you for a c-section.”) (Many VBAC-ing moms refer to this tactic as a “bait-and-switch” since it involves a supposedly VBAC-supportive care provider rescinding this support once the actual VBAC is imminent.)
Sometimes even a care provider’s “support” of VBAC is instead a conditional, half-hearted, or perhaps sneakily-disguised opposition to VBAC (e.g. “You can only have a VBAC if you deliver before 39 weeks/are dilating and effacing well before your due date/didn’t have a cesarean for failure to progress/etc.”).
These “scare tactics” (as many VBAC-ing moms have come to call them) are often misleading, exaggerated efforts by OBs (and yes, even midwives) to discourage women from VBAC and to encourage them to “choose” a repeat cesarean. (Of course, it’s not really a choice if your provider won’t even “let” you VBAC, is it?)
And if you find yourself up against a barrage of scare tactics–as I once did–it can be exceedingly difficult to stake your claim and argue against the doctor (again, or midwife) who may or may not have your and your baby’s health prioritized higher than medico-legal concerns and who may or may not be hurling phrases like “catastrophic uterine rupture” and “dead baby” your way.
If you do find yourself facing such scare tactics, and if you do want to have a VBAC, there are some questions that your care provider should be able to answer when s/he hurls those scary and/or outrageous comments and standards your way. And if s/he refuses to or even cannot answer these questions, then you might want to consider finding an alternative care provider–one who is making medical decisions based on research, evidence, and even respect for your patient autonomy and not on fear, willful ignorance, or even convenience.
Before continuing, I should add the following disclaimer: Namely, I do not intend to suggest that I am overwhelmingly “anti-OB.” However, I do think that there are a great many OB/GYNs (and midwives, for that matter) who, for whatever reason, mislead their VBAC patients by misrepresenting the facts about VBAC, exaggerating its risks, downplaying the risks of repeat cesarean, and seemingly making up reasons to exclude their patients from being “acceptable” VBAC candidates. These actions are inexcusable, not only because they can undermine maternal and neonatal health but also because they undermine a mother’s autonomy over her body. Nonetheless, I also know that there are some OB/GYNs who not only practice evidence-based medicine in regard to VBACs but also who wholeheartedly support (and even encourage) a woman’s right to choose a vaginal birth after a previous cesarean. And I know this because one such OB attended the beautiful, triumphant birth of my second son.
Scare tactic #1: Why would you want to risk a VBAC only to have a ruptured uterus and a dead baby?
Questions to ask in response:
- What is the rate of uterine rupture for a mom attempting VBAC?
- How many uterine ruptures have catastrophic outcomes (i.e. how many result in either the death of the baby or a baby suffering severe injury)?
- What is the risk of VBAC compared to repeat cesarean?
- Or even, Do cesareans ever contribute to the death of the mother or the baby?
A more nuanced analysis: And another disclaimer, for that matter.
First, I do not–I repeat, I do not–want to obscure the fact that uterine rupture is a real risk, that it affects real mothers and babies (and not just “statistics”), and that moms attempting VBACs do face a higher risk of uterine rupture than do moms without scarred uteruses. (For what it’s worth, these are all reasons to reduce the primary cesarean rate in this country.)
Nonetheless, the “why do you want to risk a dead baby” statement presents not only an exaggerated conception of uterine rupture but also a misleading dichotomy between “risky VBACs” and “risk-free cesareans.”
For one, neither VBACs nor c-sections are risk-free.
The main risk associated with VBACs is uterine rupture, in which the cesarean scar on the uterus separates during or before labor begins. According to the 2004 Landon study, for women who have a low transverse (or horizontal) incision*, the risk of uterine rupture is approximately .7%. This rate is slightly lower when the labor begins spontaneously, and slightly higher when the labor is induced or augmented with pitocin.
Accordingly, while the risk of uterine rupture is increased for moms laboring with prior cesarean scars, over 99% of women who attempt a VBAC will not experience uterine rupture.
Moreover–and again, this is not to undermine the gravity of uterine rupture and its potentially catastrophic consequences–a recent evidence report on vaginal birth after cesarean found that “6% of uterine ruptures were associated with perinatal death.” At this rate, then, the fetal/neonatal mortality rate for VBAC moms (and specific to the risks associated with VBAC) is approximately .04%.
In other words, 99.96% of women attempting VBAC will not lose their babies because of uterine rupture.
Notably, there are other risks besides death associated with uterine rupture, both for moms and their babies, and these can also be serious. But with an overall uterine rupture rate at less than 1% for most moms attempting VBAC, it does not seem prudent–or even accurate–to characterize VBAC as a choice that warrants a threat about “ending up with a dead baby.”
What’s more, there are many serious risks and complications associated with repeat cesarean section. These include anything from injury to the bladder and other organs, an increased risk of placenta previa, placenta accreta, and placenta percreta in future pregnancies, maternal hemorrhage, and even death. In fact, the maternal mortality rate associated with planned elective repeat cesarean section (about 13.4 per 100,000 births) is over three times higher than the maternal mortality rate associated with a VBAC (about 3.8 per 100,000 births), regardless of whether that VBAC attempt ended in a vaginal birth.
So you might even consider asking your care provider this question: Why would I risk tripling my risk of death by choosing a repeat cesarean?
In sum, while the choice to have a VBAC or a repeat cesarean is not always an easy choice, and while many women can reasonably choose either option, all women should still have this option. Moreover, they should be able to make this choice without it being overshadowed by the insinuation that they are putting their babies at unnecessary and extraordinary risk either way.
But if your care provider refuses to budge on his or her evaluation of the risks of VBAC–or even if s/he begins to budge a bit–you can always point them towards this recent study on “Neonatal Outcomes after Elective Cesarean Delivery.” And then ask: Why shouldn’t I strive to have the healthiest baby possible?
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*Most women who have had cesareans in the United States in the past few decades will have had low-transverse incisions. Only your surgical records can confirm this for you, however. (Notably, there are some women with external vertical scars who nonetheless have transverse or horizontal scars on their uterus.)
Great blog as always!
I know many many women who have had c-sections, but I have never once heard that any of them have lost a baby due to being born by c-section.
My 2nd. baby did go into respiratory distress, so I know that those risks do exist, but I am positive the fetal mortality rate is small.
I think most c-section moms that choose a repeat cesarean are mostly scared that they will be in that 1% of women that do rupture. I have met a mom online that lost a baby during a rupture. She was able to go on and have another baby via c-section (which I had previously been unaware was possible to have another baby after a rupture). I have to admit that was enough to solidify my decision for a repeat c-section with my babies (after having had a thin uterus with my 2nd. baby and c-section).
First, Morgan, thanks so much for reading and commenting! I want to add that I hope I didn’t come off as insinuating that *every* mom who has the opportunity to VBAC *should*. It’s obviously an extremely personal choice, and one that should be made from the background of the best, most transparent evidence and support.
I agree with you that many c-section moms who *choose* a repeat cesarean do so after weighing the risks of VBAC against the risks of repeat cesarean and choosing the risks of the latter. On the other hand, I know some VBAC moms who don’t want to take on the risks of RCS (one such mom knew of another woman who died from surgical complications during the cesarean), and therefore choose the former option! And that’s why I actually think that *either* option (i.e. VBAC or RCS) can be a good choice for a mom and her family, depending on their circumstances, desires, and beliefs.
I guess my main issue is that not every mom who *has* a repeat cesarean actually has the opportunity to *choose* a repeat cesarean. And that’s why I think it’s important for moms who are considering VBAC to know what sorts of questions to ask their care providers when discussing VBAC vs. repeat cesarean so as not to be “bullied” in one direction.
I suffered the loss of my baby and had a hysterectomy due to uterine rupture with attempted VBAC enhanced by pitosin. Think very carefully before attempting VBAC.
You make a good point about statistics being real people. When the odds are 1,000,000 to 1 and you’re the one it’s 100% happening to you. I ahould have phrased my VBAC comment to say don’t let anyone talk you into something you don’t want or feel unsure of. I was very opposed to the PIT but was encouraged by my physician to use it. (safe & prgressive, enhancing) My uterus literally blew apart and my full-term, beautiful baby girl died five days after she was born due to lack of life support in the womb from the rupture. I lost multiple units of blood and nearly died myself and my opportunity to ever have another baby died that day, as well. It was a life-shattering event. My story is a pregnant mom’s worse nightmare. I had one vaginal delivery and followed it with a section five years later for a breech baby. This event was my 3rd pregnancy 8 years later and I opted for a VBAC. In hindsight, I would not have chosen the route I was encouraged to take. But hindsight is always 20/20.
You make an especially good point here–that no one should be talked into doing something that they don’t want or feel unsure of. And this goes for VBAC or repeat cesarean or ANY other intervention that a mom faces in the course of the birth of her child.
It seems that it ultimately comes down to a matter of *true* informed consent and whether or not a mother has been informed of *all* of the risks of any procedure or intervention that is proposed to her. It’s also important, I think, that none of the risks or benefits have been exaggerated or misrepresented. And especially when it comes to birth, I think that this often happens.
You are right–it is a pregnant mom’s worst nightmare, and I am so sorry that you had to experience that nightmare. And while not every VBAC-supporter might agree with me here, I think that moms who are considering VBAC should hear *real* stories about what *can* go wrong, either with VBAC OR with repeat cesarean. The risks are all real, and they affect real people, and as I say time and time again, it’s important to remember that behind the statistics, however miniscule they may be, are these *real* people like you.
My first two children were born by Csection due to pregnancy-induced hypertension.
My third child I tried to have a VBAC. I was using a very respectable high risk OBGYN practice, and the senior dr did not want me to try a VBAC after 2 csections, but the younger doctors felt it would be OK.
While I was in labor, my uterus began to rupture (they called it a catastrophic rupture). Although, thank God, both my daughter and I survived, they ended up having to do an emergency csection and an emergency hysterectomy, so I am now unable to have anymore children.
The nurses told me I almost died; they said my BP went so low they thought they would lose me (I remember waking up in recovery, feeling that my entire body was extremely tense and I couldn’t untense it….and the nurse seemed very distraught and anxious.)
Thank God my daughter is 100% fine (she is now 11 years old), but I will never forget that experience as long as I live. I should have gone with what the senior dr felt.
@Annette – I am so sorry that your birth experience ended up being so horrific, and I am sorry to hear of the loss of your uterus and your fertility. Even though the risk of uterine rupture following a VBA2C is still relatively low (1.3%, and higher when the labor is induced or augmented), it is still a risk that affects real women and real babies. With that in mind, I am so glad that both you and your daughter are healthy today.
That being said, even repeat cesarean section carries with it serious risks. In fact, elective cesarean section is associated with a maternal mortality rate that is three times higher than the maternal mortality rate for those attempting VBAC. Serious risks are involved in either birthing option, as rare as those risks may be.
The best that any of us can do is to be as informed as we can about the risks and benefits of all of our options, to hear the opinions our of care providers, and to make our own decision: one that best fits our values and preferences. Very rarely, the outcomes will be bad–with VBACs and with repeat cesareans. And again, I am sorry that you were one of the women who experienced one of these rare outcomes.
But most of the time, the outcomes will be good–with VBACs and with repeat cesareans. This isn’t not meant to obscure the risks inherent to both, but it is meant to point out that neither birthing option is so inherently risky that it should be foregone for the other.
Warmly,
Kristen (Birthing Beautiful Ideas)
My wife and I just experienced a rupture during labor. We had a successful VBAC with our last child, so thought this labor would be like last. Boy were we wrong.
Thankfully, the baby is fine, and my wife is expected to make a full recovery. But the doctor cautioned us strongly against having more children.
My suggestion, based on my own experience, is this: a VBAC is great if you have labor on your own, but don’t let them induce you. Our doctor said it was a really, really low dose. He said it should be fine. But it wasn’t, and labor was harder and slower because she was stuck in bed, couldn’t walk around or get in a warm bath. Ultimately, allowing them to use Pitocin put us on a path to rupture.
If I had it to do again, we would have had a c-section after we spent the night after water breaking with no labor. The Pitocin was a bad idea that I wish the doctor had never had. My wife just wanted to listen to the doctor, a mistake that could have cost us so much more than it did.
David, I am very sorry to hear of your and your wife’s recent experience with uterine rupture. That being said, I am very heartened to hear that both your wife and your new baby are healthy–what a blessing.
I agree that women should be informed completely accurately and transparently about the evidence which shows that pitocin induction and augmentation do increase the risk of uterine rupture. The overall risk with an induction or augmentation (1.1% and .9%, respectively) are still slight enough that some women may be willing to take on the extra risk. But for a care provider to say, “no, it should be fine” without fully conveying that there is still an extra risk…well, that’s just infuriating to me. It undermines a woman’s right to informed consent and refusal, and as it did in your wife’s case, it puts women at extra risk.
I know I am late coming to the game, but here it goes.
The author is correct that the rates of uterine rupture and other complication associated with birth, whether VBAC or C-section, represent real mothers. However, those who commented, “X happened to me and I had a bad outcome,” or “I know many who have had Y and never had a bad outcome,” these are ANECDOTES. They are NOT statistically significant, unless of course the second commenter is talk about many hundreds of births. If you had a bad outcome and fell within that .4% then that’s horrible and I’m sorry you have suffered. But is misguided to tell people that they should ignore the scientific evidence because you had a bad outcome.
If a study states that eye color correlation with intelligence, but I say that all the blue eyed people I know are more intelligent than those with brown eyes, then my contribution is not helpful. I have provided no unbiased data to refute the study, only revealed my own ignorance.
Posting birth stories in the appropriate forum is great, but adding them to post on scientific evidence as a way to refute said scientific studies is ignorant and unproductive.
Meghan, the people who posted their birth stories are not ignorant and nobody is forcing anybody to ignore the scientific evidence because they had a bad outcome. Personally, I want to know the statistics AND the stories – ideally from all the possible outcomes of all the possible choices. Most people, not all, make decisions based both on facts AND emotion, myself included. My thinking is this – give me the facts, and then help me imagine living with each possible outcome good and bad (hence reading some birth stories), revisit the facts, repeat a few more times and then go with what feels right. (I’m doing this right now with decision about whether to try for another baby after early onset preeclampsia, VBAC is a second layer of the decision-making). Anyway, I want to thank both the author of this piece and the people who shared their stories. It’s all been helpful!
PS – BirthingBeautifulIdeas, can or have you ever written about VBAC after a classical incision? I think I’ve read the risk of rupture is 4-7%. It seems most docs wouldn’t do it, and I probably wouldn’t want to anyway but honestly, I like to research things to death before I make a final decision and I don’t find much about VBACs and classical incisions on the web.
Jill, I am so, so saddedened to hear of your loss.
I agree that all women should think carefully about their birth choices, whether they opt for a VBAC or a repeat cesarean. Each one carries with it risks that are potentially devastating, and it is important to remember that the cesarean and VBAC moms who suffer these risks are real people and not mere statistics. .04% is an extremely small percentage, but it is a number that represents flesh and blood loss that should be seriously remembered and considered.