Birthing Beautiful Ideas

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?)

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.

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.

In that light, one of my favorite online resources on VBAmC, Plus-Size Pregnancy, offers a tremendously helpful overview of the research on uterine rupture during a VBA2C.  Part of this overview includes not only a look at the correlation between pitocin and uterine rupture but also a critique of the studies on VBA2C that do not distinguish between between induced, augmented, and spontaneous VBA2C labors in their results.  As Kmom, the site’s author, surmises, the rate of uterine rupture among spontaneous VBA2Cs would likely be significantly lower than 1.36% if studies on VBAmC were to make these distinctions.

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.  Futhermore, 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 2004 Practice Bulletin on VBAC, only recommends VBA2Cs in cases where the mother has already given birth vaginally.  This practice bulletin cites three studies in its short section on VBA2C, all of which found the uterine rupture rate for VBA2C to range anywhere from 1% to 3.7%.  For reasons not explicitly articulated in the practice bulletin*, ACOG focuses primarily on a particular study from the American Journal of Obstetrics and Gynecology–i.e. the one with the 3.7% uterine rupture rate (Caughey et al. 1999).  They go on to claim that based on this study’s results, the risk of uterine rupture is nearly five times greater for women attempting VBA2C than for women attempting VBAC after one cesarean; but for women who have had a previous vaginal delivery before attempting a VBA2C (for instance, one vaginal birth and then two cesareans), the risk of uterine rupture is only one fourth of what it would be otherwise.

It is worth looking at this section of the practice bulletin with a critical eye, especially in light of the recent BJOG study (which, to be fair, was published five years after the ACOG practice bulletin).  One should ask why Caughey et al.’s findings differ so drastically from the more recent meta-analysis and systematic review of VBA2C.  One should ask if ACOG plans to update their practice bulletin according to the BJOG findings–especially in light of their conclusion that the maternal and neonatal morbidity rates for VBA2C and third cesareans are comparable.  (Not surprisingly, Kmom offers an excellent critique of the Caughey study on Plus-Size Pregnancy.)

Of course, if you have had a previous vaginal birth and are seeking a VBA2C-supportive care-provider, this portion of the practice bulletin should work to your advantage!  For it explicitly states that “for women with two prior cesarean deliveries, only those with prior vaginal deliveries should be considered candidates for spontaneous labor.”  At the very least, then, ACOG sanctions considering you as a candidate for VBAC.  (In my humble opinion, however, you ideally want a care provider who will do more than consider you as a candidate for birthing your baby in a way that is relatively safe, especially when compared to the option of a third cesarean!)

Finally, it is entirely within your right to insist that you would rather take on the relative risks of VBA2C than the relative risks of a third (or fourth, fifth, etc.) cesarean surgery.  While uterine rupture is a serious occurence (though one that is not always, or even often, catastrophic), the risks of cesarean surgery are also serious, and even potentially catastrophic, occurences.  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.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

*I can only guess that the writers of the practice bulletin chose to focus solely upon the third study since used Level II evidence, while the others used Level III evidence.  Updated to add: Nonetheless, it was also pointed out to me in a comment to this post that one of the authors of this study (Zelop) was also one of the authors of the practice bulletin, thereby raising suspicions of a conflict of interest in the bulletin’s reportings on uterine rupture and VBA2C.