VBAC Scare Tactics (9): You Have *How Many* Scars on your Uterus?

VBAC Scare Tactics (9): You Have *How Many* Scars on your Uterus?


Many women who want to have a vaginal birth after cesarean (or VBAC, pronounced “vee-back”) in the U.S. have faced some sort of opposition from their care providers when they have expressed their desire to VBAC.  Oftentimes, this opposition comes in the form of ” VBAC scare tactics.”

The (outrageous) statements 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?)

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 insinuating that VBACs are synonymous with driving your child in a car without a car seat.

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.

I encourage all mothers who read this post (and others in my “VBAC Scare Tactics Series”) to  take the information contained herein as a springboard from which they can 1) continue their research on VBAC, 2) maintain a communicative relationship with their care providers, and 3) find a care provider who best supports the mother’s interests and plans for the birth of her child.

(To read my disclaimers about “why I am not anti-OB” and “why I take the gravity of uterine rupture seriously,” please see my posts on VBAC scare tactics (1) and (2) .)

Scare tactic #9: You’ve had more than one c-section?!  No.  No way.  You’re not going to find anyone who will attend a VBAC after multiple cesareans.  You need to schedule a repeat cesarean.

Questions to ask your care provider:

  • What reason(s) do you have for refusing to attend a VBAC after multiple cesareans?
  • Is the risk of uterine rupture increased after more than one cesarean?
  • What are the comparative risks and benefits of VBA2C and third cesareans?
  • Are there any increased cesarean risks when one has a third, fourth, etc. cesarean?
  • What is ACOG’s position on VBA2C (or VBAC after two cesareans)?
  • What does the current research say about VBA2C?

A more nuanced analysis:

It is important to realize first and foremost that many women in the United States and Canada are able to find care providers (including obstetricians) to attend VBA2Cs and even VBACs after three or four cesareans.  In fact, you can find many of their inspiring birth stories online.

This does not mean that finding a VBAmC (or VBAC after multiple cesarean)-supportive care provider will be easy in many cases.  But it is still possible.

Nonetheless, many women seeking a VBAmC encounter a specific roadblock when they are planning their child’s birth: namely, they cannot find a care provider who will agree to attend a VBAC after two or more cesareans.  And the reasons that these care providers have for denying women the opportunity to attempt a VBAmC are varied.

One reason may be that the risk of uterine rupture for a VBA2C is higher when compared with the risk for a VBAC after one cesarean.  A recent systematic review and meta-analysis of VBA2C in the British Journal of Obstetrics and Gynecology, which examined twenty studies and included combined statistics for well over 55,000 births, found the rate of uterine rupture for VBA2C to be approximately 1.36%.  This is compared with an overall uterine rupture rate of approximately .7% for women attempting a vaginal birth after one cesarean.

When examining these rates, however, one should take into account the ways in which pitocin acts as a confounding factor when assessing the uterine rupture rate among all women attempting a vaginal birth after cesarean.  Although the overall uterine rupture rate for VBACs after one cesarean is approximately .7%, this rate drops to approximately .4%when one focuses solely upon VBAC labors that begin and proceed spontaneously–that is, without pitocin augmentation or induction (which increase the uterine rupture rate to approximately .9% and 1.1%, respectively).  It seems safe to assume, then, that the uterine rupture rate would probably drop below 1.36% (at least within the BJOG meta-analysis) for VBA2Cs if one were to factor out those labors in which pitocin was administered.

What’s more, the increased rate of uterine rupture does not necessarily make VBA2C unsafe.  In fact, comparing the outcomes of VBA2Cs with third cesareans, the BJOG study also concludes that the maternal morbidity rate for the VBA2C group was similar to that of the group undergoing third cesareans.  Furthermore, although the authors note that the data regarding neonatal morbidity was “too limited to draw valid conclusions,” they also note that there were “no significant differences” in the NICU admissions rates and the asphyxial injury and neonatal death rates among the VBA2C, third cesarean, and VBAC after one cesarean groups.

In other words, when compared with the option of a third cesarean, VBA2C is comparably safe for the mother and for the baby.

It is also worth noting that the study shows not only a success rate (or rate of labors ending in vaginal birth) for VBA2C that is similar to the success rate of VBACs after one cesarean (76.5%) but also a high success rate: namely, 71.6%.  In other words, if you attempt a VBA2C you have a 71.6% chance of having a vaginal birth.   This rate is not only encouraging but also indicative of the fact that a second cesarean does not give one a “low” chance of delivering vaginally in the future.

Another reason that OB-GYNs in particular may refuse to attend VBA2Cs is that the American College of Obstetrics and Gynecology (or ACOG), in a previous 2004 Practice Bulletin on VBAC, only recommended VBA2Cs in cases where the mother had already given birth vaginally.

But in 2010, ACOG revised its recommendations on VBA2C accordingly:

Studies addressing the risks and benefits of TOLAC in women with more than one cesarean delivery have
reported a risk of uterine rupture between 0.9% and 3.7%, but have not reached consistent conclusions regarding how this risk compares with women with only one prior uterine incision.  Two large studies, with sufficient size to control for confounding variables, reported on the risks for women with two previous cesarean deliveries undergoing TOLAC. One study found no increased risk of uterine rupture (0.9% versus 0.7%) in women with one versus multiple prior cesarean deliveries (66), whereas the other noted a risk of uterine rupture that increased from 0.9% to 1.8% in women with one versus two prior cesarean deliveries. Both studies reported some increased risk in morbidity among women with more than one prior cesarean delivery, although the absolute magnitude of the difference in these risks was relatively small (eg, 2.1% versus 3.2% composite major morbidity in one study).  Additionally, the chance of achieving VBAC appears to be similar for women with one or more than one cesarean delivery. Given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC, and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC.  Data regarding the risk for women undergoing TOLAC with more than two previous cesarean deliveries are limited.

This revised recommendations are much more amenable to VBA2C than the previous recommendations.  The most current ACOG practice bulletin on VBAC acknowledges the relevant research on VBA2C, and it encourages care providers to consider women with two previous low transverse cesarean scars as VBAC candidates.  What’s more, it encourages care providers to counsel women on their options rather than to take away those options by making their birthing decisions for them.

Thus, it is certainly worth discussing these revised recommendations with your care provider if s/he is denying you the opportunity to plan a VBAC after multiple cesareans.

Finally, it is worth having a conversation with your care provider regarding the relative risks of VBA2C than the relative risks of a third (or fourth, fifth, etc.) cesarean surgery.  While uterine rupture is a serious occurrence (though one that is not always, or even often, catastrophic), the risks of cesarean surgery are also serious, and even potentially catastrophic, occurrences.  When compared with a vaginal birth, a c-section carries an increased risk of hemorrhage, blood clots, and bowel obstruction for the mother; and an increased risk of breathing difficulties around the time of birth and childhood and adulthood asthma for the baby.  What’s more, one’s risk of hysterectomy, placenta previa and placenta accreta in future pregnancies increase significantly with each subsequent cesarean section.

And avoiding these risks (and more) should give any woman grounds for contesting a repeat cesarean that she does not want.

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  1. Michelle Potter
    Michelle Potter12-07-2009

    I think this is definitely an area that deserves more study. Am I correct in assuming that no matter how a woman is giving birth this time, the more previous cesareans she’s had, the more her risk is? So a woman with two previous cesareans and one VBA2C is at less risk than a woman with three previous cesareans? If that’s correct, then it seems pretty important to determine how safe it is for a woman with a history of cesareans and plans for more kids to “switch over” to vaginal birth, and to *encourage* her to do so if possible since that would reduce her risk for next time.

    I’d be very interested in knowing what difference is made (if any) if a woman with two previous cesareans has had vaginal births *in between* the cesareans. I had an unnecessary cesarean with my first birth, then three VBACs, then a necessary cesarean with my fifth (totally unrelated to the made-up reason given for my first birth, and totally unrelated to having had a previous cesarean.) I’d think I’d be at less risk than a mom whose last two births were both cesareans, but obviously that’s just an assumption.

    • BirthingBeautifulIdeas

      Michelle, that is a fantastic question, and one that was addressed in a 2006 Green Journal article (“Maternal Morbidity Associated with Multiple Repeat Cesarean Deliveries.”) As the study’s authors conclude, each subsequent cesarean increases the risk for placenta accreta, bowel injury, ureteral injury, hysterectomy, and blood transfusion requiring four or more units (among other complications).

      In the groups they examined, placenta accreta was present in .24% of first cesareans, .31% of second, .57% of third, 2.13% of fourth, 2.33% of fifth, and 6.74% of sixth or more. The rates of hysterectomy showed similar increases, although, unless I’ve missed it, I don’t think that the study’s authors factored in how grand multiparity could have contributed to the increasing hysterectomy rates. (To do so, they probably would need to compare the outcomes of women having fifth and sixth or more vaginal births, etc.) Admittedly, the groups in the fifth and sixth or more cesarean groups were relatively small, so the data may be a bit skewed. Nonetheless, it still seems unlikely that the numbers would drop all that dramatically if one examined larger populations of women undergoing higher-order cesareans.

      So yes, these risks do increase with each c-section that a woman has.

      As far as your very interesting question re: the order of the vaginal births and cesareans, I haven’t yet seen any studies or data on that topic. I don’t even know if I can make an educated guess about what the results of such a study would be! There are some studies (including the Caughey one cited in the ACOG practice bulletin on VBAC) which suggest that having a previous vaginal birth reduces one’s risk of uterine rupture regardless of whether that birth was a VBAC or a pre-cesarean vaginal birth. So in your case, your risk of uterine rupture in subsequent births would most likely be less than 1.36%. (Although I haven’t seen anything on it yet, I’d love to know why a previous vaginal birth reduces one’s risk of uterine rupture, especially since the birth need not be a “scar-testing” VBAC!)

  2. Tweets that mention Birthing Beautiful Ideas | VBAC scare tactics (9): You have *how many* scars on your uterus? -- Topsy.com
    Tweets that mention Birthing Beautiful Ideas | VBAC scare tactics (9): You have *how many* scars on your uterus? -- Topsy.com12-08-2009

    […] This post was mentioned on Twitter by Karen Angstadt and Michelle Potter, Kristen O. Kristen O said: VBAC Scare Tactics 9: You have *how many* scars on your uterus? http://bit.ly/6mFDpR #VBA2C #VBAmC […]

  3. Gretchen Humphries
    Gretchen Humphries12-08-2009

    One of the co-authors on the Caughey et al paper was Dr. Zelop. Dr. Zelop was one of the 2 named authors of the 2004 ACOG Practice Bulletin on VBAC, the one that quotes the 3.7% rupture rate for VBA2C. There are some who believe there was some “conflict of interest” when looking at the data on VBAmC. I will also say that excessively high rupture rates in all classes of VBACs has been a consistent finding in most of the studies I’ve read that have come from Zelop et al’s research group and many of us find THAT to be the more concerning fact in all of this.

    • BirthingBeautifulIdeas

      @Gretchen Humphries, thank you for that insight! I didn’t even pick up on that while looking at the practice bulletin. Now that you mention it, I think I recall reading something about the excessively high rupture rates in Zelop’s research group. Has there been any speculation about why these rates are so excessively high?

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    […] Beautiful Ideas – VBAC Scare Tactics (9): You Have *How* Many Scars on Your Uterus?: Another post in a great series on VBAC scare tactics, this time on VBAmC (VBAC after multiple […]

  5. Eva Duhon
    Eva Duhon01-10-2011

    I have had 2 c-sections. I believe that both were unnecessary. My husband and I are TTC. I really want to VBA2C with this one. You mentioned that it’s harder to find a provider… do you know if there is a list of providers from across the nation of facilities that provide this service? I live in FL, so I’m also faced with the government issues…

    Eva Duhon

    • BirthingBeautifulIdeas

      Eva, I mentioned your situation (anonymously) on Twitter, and someone suggested that you try and contact Dr. Tate (Dr. Joseph Tate, I believe) in Atlanta. He is widely known for supporting VBAmC and may know of some doctors in surrounding states who will support one too. I’ll let you know if I hear of any other suggestions! Best of luck to you and your family.

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