Birthing Beautiful Ideas

So we all know that What to Expect When You’re Expecting is the preeminent source on pregnancy and childbirth for women in the United States, right?

I mean, copies of that books are everywhere right?  So it must be “the best,” right?

Well, that’s what some clever (and aggressive) marketing would have us think.  But it’s not necessarily true.

(And for the record, WTEWYE is not the “best” book on pregnancy and childbirth, in my honest opinion.  My “best books” are listed on the right.  Read them.  Inform yourself.  Empower your birth.)

Now, I’m not here to “take down” the whole book and all of its paternalistic and even mis-informative advice.  Others have taken on that critique long before I sat down to write this  post.

But I am here to offer a “critique” of the “What to Expect” website’s advice-ish page on VBAC.  (Yes, I’m blogging about the silly things people say about VBAC uh-gain.)

Because if women are reading the “What to Expect” site when they’re trying to make a decision between VBAC and repeat cesarean, then they are gaining some seriously misleading and unhelpful information about VBAC.

Just take a look at some of the statements I found on the site:

“Forty percent of women who had a prior cesarean section do end up having a repeat.”

This is a misleading statement, though perhaps unintentionally.  Of all women with prior cesareans in the United States, less than 10% currently even attempt a VBAC.  So this means that over 90% of women will “end up having a repeat.”

But even if the author of this page meant to convey the rates of VBACs that are successful or unsuccessful (or that end in a vaginal birth or a cesarean section), this statement is still misleading.  With VBAC success rates ranging between 6o% and 80%, it seems more accurate to state that “twenty to forty percent of women who had a prior cesarean section and who attempt a VBAC do end up having a repeat.”

Even better?  How about, “Sixty to eighty percent of women who try for a VBAC do end up having a vaginal birth.”  (See how much more accurate and positive that statement is?)

*

“Causes like fetal distress, preeclampsia, a breech position, or placenta previa don’t generally spill over from pregnancy to pregnancy, nor is having had a large baby before any reason to think you’ll have one this time (especially if you kept your paws off the Krispy Kremes and kept your weight gain under control). If the reason was a chronic condition like high blood pressure or diabetes, though, you’d better steel yourself for another surgery.”

Why don’t we throw in a few fat-slurs in there and call it a day!

GOOD LORD.

I mean, I appreciate some good “girlfriend advice” as much as the next gal,* but this seems more like advice from some passive-aggressive chick who likes to put down her overweight pals with snarky comments about doughnuts.

NOT!  HELPFUL!

Why not offer some information about prenatal nutrition and its role in helping women to achieve healthy pregnancies and healthy births?  (And for what it’s worth, being classified as “overweight” or “obese” does not necessarily mean that a woman isn’t eating a good prenatal diet!!!)

And why not point women who might need to “steel themselves up for another surgery” toward some cesarean support groups such as ICAN?

Otherwise, the advice here just seems insensitive, and even a bit mean.  (Or perhaps I’m the overly insensitive type?  Perhaps.  I do love me some Krispy Kremes after all!)

*

“Remember that there’s no advantage (moral or otherwise) to a VBAC, so even if you could try for one, you’re absolutely entitled not to go for it if the risks make you uneasy.”

Okay.  You know those cartoons where the character’s face turns red and then steam starts shooting out of their ears and there are all sorts of steam engine or train whistle sound effects?

That’s exactly what was going on inside my head when I read this sentence.

A moral advantage to VBAC?  You mean the sort of advantage where St. Peter is gonna be all like, “Well, lady, you’d be getting through these here gates to heaven if you had just chosen that VBAC over your repeat cesarean.  TOO BAD YOU DIDN’T TAKE THE MORAL PATH!!!”

Jay-zus.

No!  There isn’t a moral advantage to VBAC!  And there’s no moral advantage to repeat cesarean either!  (Although there are moral advantages to making sure that women are accurately and thoroughly informed about the risks and benefits of both of these birthing options!)

Look, I agree with the end of this statement: any woman with a scarred uterus is absolutely entitled not to go for a VBAC if the risk (of uterine rupture) makes her uneasy.

But, as should be obvious, any woman with a scarred uterus is absolutely entitled not to go for a repeat cesarean if the risks make her uneasy.

Oh, and there are some “otherwise” advantages to VBAC.  In fact, there are advantages for women (e.g. a lower maternal mortality rate when compared with elective repeat cesarean) and for their babies (e.g. a significantly lower rates of respiratory morbidity and NICU admission when compared with babies born via elective repeat cesarean)!

So don’t go telling women that there are no advantages!  Exclamation point!

*

“…they might want to keep you off the meds to avoid masking the pain that could point to potential rupture.”

Well, sure, they might.  I’ve heard of some individual practitioners having a “no epidural during VBAC” policy in place.

But it should also be noted that even ACOG notes that epidurals “rarely mask the signs and symptoms of uterine rupture.”  So while there may be good reasons to approach epidurals with some level of caution in any labor, there are also good reasons for women to question those “no epidurals during VBAC” policies.

*

“Finally, if it doesn’t work out (and remember one in five births are cesarean), try to take it in stride.”

No, remember this: One in three births are cesarean.

Mmmkay.  Thanks.

*

“The happy ending — healthy you, healthy baby — is really all that matters.”

*

BLAAAARRRRRRGHHHH!  STEAM COMING OUT OF THE EARS AGAIN!!!!

I wrote about statements such as this one a long time ago.  In brief?

Healthy moms and healthy babies do matter.  They matter a whole hell of a lot.  But they’re not all that matters.

*

So in the end?  While I’m sure that the authors of WTEWYE are really, truly well-meaning individuals who just want to help out a pregnant women or two (million), I think my expectations of their advice have been tremendously lowered after reading their “lowdown on VBACs.”

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* Your Best Birth: Know All Your Options, Discover the Natural Choices, and Take Back the Birth Experience is much better at the “girlfriend advice” on pregnancy and childbirth, in my opinion.

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.

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*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.

Oftentimes when I see anything birth-related covered by the national news, I end up feeling very underwhelmed (to say the least).  One-sided coverage (mostly from ACOG’s perspective), exaggerated risks and benefits of various procedures or processes, and even a blatant lack of research on a given topic all seem to pervade the segments on pregnancy and birth that I’ve seen in recent years.

But the past week has been a relatively good week for transparent and seemingly fair (though, admittedly, not always cheery) coverage of a few birth-related issues.  And in my opinion, each of the following news pieces is worth checking out–not just for the decent news coverage but also for the helpful information.

From CNN

Senior medical correspondent and “Empowered Patient” columnist Elizabeth Cohen examines the relative risks and benefits of VBAC and cesarean section within the context of two current news stories: 1) the fact that some insurance companies have denied women health care coverage after considering their previous c-sections to be “preexisting conditions” and 2)  the story of Joy Szabo, a mother in Arizona who must travel 300 miles to the nearest “VBAC-supportive” hospital just to have her second VBAC (and who was threatened with a court-ordered cesarean by her local hospital if she attempted to have a VBAC there). 

All in all, I am impressed with Cohen’s discussion.  Could she have done a better job of reporting the risk of uterine rupture?  Sure.  (For what it’s wort, the rate of uterine rupture during a VBAC is less than 1% for most women: .4% if labor begins on its own, .9-1.1% if labor is augmented or induced with pitocin, creating a rate of approximately .7% for all VBAC attempts, induced or not.)

But Cohen does a superb job of addressing issues that are often overlooked in the coverage of cesarean sections and VBAC.  For one, she is careful to place the risk of uterine rupture alongside the risks of cesarean section.  This simple exercise in good reporting helps to dispel the illusion that VBACs are a “risky” option when compared with “easy” and “risk-free” cesareans.

In addition, Cohen points out that patient-chosen, non-necessary elective cesareans make up a very small percentage of the cesarean sections performed in the United States.  This is especially noteworthy in light of the fact that some medical professionals (though certainly not all) have often pointed to “too posh to push” cesareans as one of the primary reasons for the nation’s rising cesarean rate.  But their “mother-blaming” (in addition to being inherently misogynistic) simply doesn’t pan out when one considers the relative infrequency with which patient-chosen, non-necessary elective cesareans occur.

You can watch the following video to see more about what Cohen has to say about VBAC, c-section, the related issues:

From MSNBC

The very title of this article left me smiling: “Hospitals to crack down on induced labors.”

An even better title, however, would have been “Hospitals to crack down on UNNECESSARY and EARLY induced labors.”  Because as the article reports (and as studies have demonstrated), these inductions–especially those performed before 39 weeks–can lead not only to iatrogenic (or doctor-caused) prematurity but also increase a baby’s risk of NICU admission and increase first-time mothers’ risk of cesarean section.

So don’t worry–if you and/or your baby’s health requires an induction, hospital regulators and administrators are not going to deny you an induction.  But they may restrict your care provider’s ability to schedule convenience inductions–and that’s all with your and your baby’s health in mind.

From the BBC

And finally, this week the BBC news published an overview of maternal mortality across the world.  In their examination of the United States, they found that:

The US spends more money on mothers’ health than any other nation in the world, yet women in America are more likely to die during childbirth than they are in most other developed countries, according to the OECD and WHO.

The article points to the lack of health insurance and coverage, poverty, the staggering c-section rate, and obesity as potential contributing factors to this sad and disheartening state of affairs.  What’s more, it sheds brief light on the fact that African-American women are “three to four times more likely to die during childbirth than white American women,” even when one compares the outcomes of wealthy black women to wealthy white women.  (Notably, many people have speculated that the stress of racism has a significant effect on the disparity of maternal outcomes between black and white women in the United States.)

But what this article also illuminates is the fact that we must demand better maternity care for women in the United States (and in all countries, for that matter).  We need better prenatal care (which should include not offhand castigations about “gaining so much weight” but respectful and helpful nutritional counseling from the first trimester and beyond).  We need better labor and delivery care (with more emphasis on evidence-based maternity care and not on unnecessarily intervention-heavy birth).  We need health care coverage for all pregnant women (period).

At least that’s what the BBC article illuminated for me!

(For more on issues of maternal mortality in the United States, please see Ina May Gaskin’s Safe Motherhood Quilt Project.)

After months and months of a persistent cough, my son, M, has finally been diagnosed with bronchial asthma.  And while I’m sad that he has to deal with this condition for the next few years (or at least I hope for only a few more years), I’m also happy that he at least has options for treating his cough.

What’s more, I’m also thrilled with the way his new pediatrician handled his treatment options.  In fact, my interaction with her had me day-dreaming about what her approach to informed consent would look like if it were mapped onto the ways that OB/GYNs (and even midwifes) tend to approach the option between VBAC and repeat cesarean.

But before I recount my day-dream, I should give you a picture of what my interaction with M’s pediatrician looked like:

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Dr. S: Based on what you’re telling me, it sounds like your son probably has bronchial asthma, or what some people call “cough asthma.”  *Explains a bit about what it is.*

Me: What sorts of treatments do you recommend?

Dr. S: There are generally two options: Singulair, a medication traditionally used to treat the symptoms of asthma, or Boswellia, an herbal medication that I have also recommended to many of my patients.  From my experience, both seem to treat bronchial asthma equally well.  That being said, there have been many parents who have told me that they have preferred Boswellia since it doesn’t seem to have the same sorts of negative side effects that Singulair does.

Me: What are some of those negative side effects?

Dr. S: Mainly, some parents report that their children experience significant mood changes while taking Singulair.  And this is one of the side effects associated with the drug.

Me: Oh, okay.

Dr. S: *Explains the dosage and administration of each drug, the risks/benefits of each drug, also addresses where we could safely purchase Boswellia.*  Do you have an idea about which treatment you would like to use?

Me: My gut reaction tells me Boswellia, but would it be alright if I went home and researched it first?

Dr. S: Of course!  I actually encourage that.  Why don’t you call me in a couple of days when you make your decision, and then we can talk about how we will proceed from there.

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And then I started dreaming of what a prenatal appointment would look like if a doctor or midwife were to take the same empowering, informed-consent-supporting attitude that my son’s pediatrician took to his asthma treatment.

Dr. OB/GYN: Congratulations on your pregnancy!  Since you had a cesarean for your last birth, have you thought about what you would like for this birth?

Pregnant mama: Do you mean VBAC or a repeat cesarean?

Dr. OB/GYN: Yes!  Both are relatively safe options, although each one carries particular risks and benefits.

Pregnant mama: Can you tell me a little more about that?

Dr. OB/GYN: Of course.  The main risk associated with VBAC is that the uterine scar will begin to separate during labor.  This risk of “uterine rupture” is very small–only .7% for all VBACs, and only .4% if your labor begins on its own. 

Pregnant mama: Uterine rupture sounds very serious.  What about repeat cesarean?

Dr. OB/GYN: You’re right, uterine rupture is serious, but it is only “catastrophic” in approximately .05% of all VBACs.  So the risk itself is very, very small.  We may monitor you a bit more carefully in the hospital, but we can also take steps to make sure that you can still be upright and mobile during your labor.  And repeat cesareans, although relatively safe, also have serious risks.  For instance, each subsequent cesarean increases your risk of serious placental complications, such as placenta previa and accreta.  In addition, a recent study has shown that babies born after VBAC have lower NICU admission rates and fewer respiratory problems than babies born via elective repeat cesarean.

Now, this isn’t meant to scare you!  But it’s always good to know that there are risks associated with both options.

Pregnant mama: Do I have to decide right now?

Dr. OB/GYN: Of course not!  I encourage you to take the next few weeks to do some research on VBAC and repeat cesarean, and then we can discuss your plans during your next appointment.  (Editorial note: In a super-ideal world, the OB/GYN would also give the mom a couple of pamphlets on cesarean section and VBAC from ICAN.  A girl can dream, can’t she?)

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But I know from experience that these sorts of prenatal appoinments often look a little bit more like this.

Dr. OB/GYN: Congratulations on your pregnancy!  So, when are we going to schedule your repeat cesarean?

Pregnant mama: Well, what about VBAC?

Dr. OB/GYN: VBAC?!?!?!  Why would you ever want to do a thing like that?!?!?!  I.  DON’T.  DO.  VBACs.

As brought to my attention by the ever-trusty e-news updates from ICAN, the British Journal of Obstetrics and Gynecology has published in its September 2009 issue a systematic review and meta-analysis examining VBA2C (or vaginal birth after two cesareans).  Specifically, this review analyzes the success rates and adverse outcomes of VBA2C versus VBAC (after one cesarean) and versus repeat third cesareans.

After examining twenty studies, which combined included statistics for well over 55,000 births, the authors of this meta-analysis arrived at the following conclusions:

Main results: VBAC-2 success rate was 71.1%, uterine rupture rate 1.36%, hysterectomy rate 0.55%, blood transfusion 2.01%, neonatal unit admission rate 7.78% and perinatal asphyxial injury/death 0.09%. VBAC-2 versus VBAC-1 success rates were 4064/5666 (71.1%) versus 38 814/50 685 (76.5%) (P < 0.001); associated uterine rupture rate 1.59% versus 0.72% (P < 0.001) and hysterectomy rates were 0.56% versus 0.19% (P = 0.001) respectively. Comparing VBAC-2 versus RCS, the hysterectomy rates were 0.40% versus 0.63% (P = 0.63), transfusion 1.68% versus 1.67% (P = 0.86) and febrile morbidity 6.03% versus 6.39%, respectively (P = 0.27). Maternal morbidity of VBAC-2 was comparable to RCS. Neonatal morbidity data were too limited to draw valid conclusions, however, no significant differences were indicated in VBAC-2, VBAC-1 and RCS groups in NNU admission rates and asphyxial injury/neonatal death rates (Mantel-Haenszel). Conclusions Women requesting for a trial of vaginal delivery after two caesarean sections should be counselled appropriately considering available data of success rate 71.1%, uterine rupture rate 1.36% and of a comparative maternal morbidity with repeat CS option.

Although I do not have access to the full text of the article, I do think that the abstract linked above yields some highly significant information regarding the comparative risks of VBA1C, VBA2C, and third repeat cesareans–and especially between VBA2C and repeat third cesareans.

For one, although the uterine rupture and hysterectomy rates were found to be higher for VBA2C than for VBA1C, the success rates (or those that ended in vaginal births) were strikingly similar: 71.1% for VBA2C and 76.5% for VBA1C.

Comparing VBA2C and repeat third cesareans yields far more intriguing results (at least in my opinion).  For while the blood transfusion and febrile morbidity rates for both groups were similar, if not nearly identical, the hysterectomy rate was higher in the repeat cesarean group than in the VBA2C group.

What’s more (and this bears repeating from the above-cited paragraph), “Maternal morbidity of VBAC-2 was comparable to RCS. Neonatal morbidity data were too limited to draw valid conclusions, however, no significant differences were indicated in VBAC-2, VBAC-1 and RCS groups in NNU admission rates and asphyxial injury/neonatal death rates.”

And while it would undeniably be more helpful to analyze this data in its entirety, or as it is written in the full text of the article, the conclusion itself should serve as a fertile ground on which women and their care providers can more fruitfully discuss the benefits and risks of VBA2C (as opposed to a third cesarean).

(It should go without saying that there is a “VBAC scare tactic” post regarding VBA2C (or VBAmC) on my horizon!)

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 #8: Look, I’m  the one who has earned the medical degree and I am telling you that you cannot attempt a VBAC.  Your only choice is a repeat cesarean.  Period.

Questions to ask in response:

• I appreciate all of your hard work!  So could you please share with me your medical, evidence-based reasons for why I cannot attempt a VBAC?
• Are you suggesting that you will ignore any questions I ask you regarding my desires for this birth or about the comparative risks of VBAC and repeat cesarean?
• Does your malpractice insurance company prohibit you from attending VBACs?  Are there any other bureaucratic or administrative (i.e. non-medical) reasons that force you to deny your patients the opportunity to attempt a VBAC?
• Where is the nearest exit?

A more nuanced analysis:

It is worth noting first and foremost that VBAC has been shown to be a relatively safe option for most women who attempt it.  The medical literature consistently shows uterine rupture–the main risk specifically associated with VBAC–to occur in less than 1% of all VBAC attempts.  The American College of Obstetrics and Gynecology (or “ACOG,” OB-GYNs’ organizational body) claims that VBAC is not only “a safe option for many women” but is also a way to help reduce the United States’ skyrocketing cesarean rate.  What’s more, even though the risk of uterine rupture is lower (though not eliminated) if one chooses an elective repeat cesarean instead of a VBAC, there are still risks specifically associated with repeat cesarean that are not necessarily associated with VBAC.

Thus, there is absolutely no reason for any care provider to quash any and all discussion about VBAC by injecting the “MD trump card” into a conversation.

That being said, the reasons as to why a care provider might use the “MD trump card” are varied.

Occasionally, it might be that the care provider’s malpractice insurance refuses to cover VBACs.  And perhaps s/he then hides behind the “MD trump card” because s/he is too embarrassed or even frustrated to admit that s/he must make medical decisions not based on the evidence but based on what insurance companies dictate.  This is certainly an instance of the sorry state of the current relationship between insurance companies and medical care in the United States–especially when it comes to obstetricians.

Nonetheless, if you are a woman wanting to attempt a VBAC, and your care provider’s malpractice insurance does not cover VBACs, then it is certainly a wise idea to begin seeking a new care provider.

More often than not, however, it seems that the “MD trump card” arises after a woman has posed various questions challenging other scare tactics that the care provider might have uttered. 

To use an example, suppose that a woman’s care provider tells a her that VBAC is synonymous with placing a child in a car without a carseat or safety belt.  (I know of multiple women who have reported hearing this sort of comment during their prenatal appointments.)  But since this mom has done her research on the relative risks of VBAC and repeat cesarean, she reminds her care provider that the risk of uterine rupture is approximately .7% for all moms attempting VBAC and that the risk of catastrophic uterine rupture is approximately .04-.255%.   Perhaps she even cites this study or this study from the New England Journal of Medicine from which she discovered these statistics!  And perhaps she declares that she has made the informed decision to take on the risks (and benefits) of VBAC rather than to take on the risks of repeat cesarean!

And in response, the care provider claims that s/he is the one with the medical degree and that s/he will decide what is best for this mom and her baby.

This response is unquestionably problematic.  For one, it fails to engage the mother’s responsible decision to research her plans for her child’s birth.  And even if the care provider suspects that a patient has misinterpreted medical research, it is the care provider’s responsibility to rectify this misinterpretation.

What’s more, using the “MD trump card” often illustrates a care provider’s possible (and perhaps probable) arrogance.  For even if  some care providers do not know about the recent studies on VBAC and uterine rupture, or even if their teachers or mentors during medical school or residency explicitly (and incorrectly) taught that VBAC was inordinately dangerous, and even if they are embarrassed about being challenged by their patients, this does not mean that they should obscure their (perhaps innocent) lack of knowledge about the facts of VBAC and uterine rupture by using their medical degree to trump any questions that their patients may have.

In other words, if they don’t know the answer to the questions their patients are asking, then they should inform their patients that they need some time to perform additional research.  

If their patients cite research that differs drastically from the research with which they are familiar, then they should ask their patients for a couple of days to review that research in more detail.

These responses respect true informed consent.  These responses honor patient autonomy.  And these responses support the sort of participatory medicine that midwife Amy Romano talks about in her recent article on e-Patients.net.

For what it’s worth, my MD dad always tells me that if a doctor refuses to answer your questions, then it’s time to find a new doctor!  We should want care providers who who engage with us and who listen to us (both of which are good tools for diagnosis, I might add).

So instead of heeding entirely to your care provider’s “MD trump card” or even to well-meaning friends or family members who tell you that, “Your doctor is the one who went to medical school, so S/HE knows best,” consider taking a participatory role in your medical care.  Find a care provider who is willing to discuss VBAC and repeat cesarean with you–who is willing to offer transparent information about both options, who does not use the “MD trump card” when you ask questions, and who will support you in whichever decision you make for your baby’s birth.

You will be participating in the decisions regarding your baby’s health for the rest of his or her life.  Why not begin by finding a care provider who supports you in actively participating in the way you bring that baby into the world?

Back when I was an angsty 16-year-old, I made a habit of launching into self-righteous political tirades…oh, about forty-seven times a day with my friends and family members.  I was opening my eyes to the injustices of the world, discovering the hypocrisy of the beast that is humanity, and trying to change people’s minds the best way I knew how:

BY ATTEMPTING TO LOBOTOMIZE THEM WITH MY HOLIER-THAN-THOU, HEAVY-HANDED PROCLAMATIONS AND CASTIGATIONS.

But I’m not that girl anymore.

(Really, Mom and Dad.  I’m not.)

I’ve grown.  I’ve matured.  And I’ve learned that smacking someone upside the head with LECTURES and SPEECHES and RANTING only has the effect of beating someone further…and further…and further into the position that they already hold.

Seriously.  You can’t beat the “light” (which may or may not be your own point of view) into someone.

And so yesterday, I came across this article, “Pushing Back: Has the Natural Childbirth Movement Gone Too Far?”, and after reading it I thought to myself, “Crap.  CRAP.  Have I recently come across as one of those pro-VBAC or pro-natural childbirth folks who seems to be trying to beat my own position into others?!”

I am not that girl.  I don’t WANT to be that girl.

(If you do read the article, let’s just put aside the last few sentences in which the author casts VBAC as akin to Russian Roulette.  Let’s just put those sentences in a neat little compartment, stow them away, and remember that uterine rupture, while a real risk, only occurs in approximately .7% of all VBAC attempts, spontaneous or induced.  And that the VBAC success rate–which represents the number of VBACs that end in a vaginal birth–is a different concept entirely than the uterine rupture rate.)

Am I swinging my lecturing, heavy-handed sticks?  I hope not…

Because here’s the thing:

I don’t think that it is productive to use a “one-size-fits-all” approach when it comes to a woman’s decision between choosing a VBAC or a repeat cesarean.  And I do not take this approach.  I think that as long as a woman has access to transparent and unexaggerated evidence and information about VBAC and repeat cesarean, and as long as she has the unobstructed opportunity to reflect on what would be best for her and her family, then she has the tools to make a good decision to opt for a VBAC or a repeat cesarean. 

But I also don’t think that many women are given transparent and unexaggerated evidence and information about VBAC in the United States.  And when care providers continue to deny women the opportunity to choose a VBAC, and when more and more hospitals are instituting VBAC bans (whether formal or “de facto”), then women don’t have a real opportunity to reflect on what is best for them and their families.  Because they only have one option, and that is a repeat cesarean.  And while that may be the right option for some women, it is certainly not the option that all women would choose.

In that same vein, I don’t think that it is productive to be so vehemently pro-natural childbirth that one suggests that women should ignore everything that the medical community tells them.  Or that women who have labor interventions or pain medications during childbirth are somehow “failures.”  Or that women who choose a VBAC or a natural childbirth or breastfeeding are somehow morally better than those who choose a repeat cesarean or pain medication or formula-feeding.  In fact, I find all of these suggestions to be quite appalling.  (For what it’s worth, I don’t think that there are very many natural childbirth-supporters who truly hold these positions.  Oftentimes, I wonder if their/our passion and pride in their/our accomplishments come off as pontification and self-righteousness.  And I, for one, apologize if I’ve ever come off that way.)

But (and it’s a big but) I nonetheless encourage women TO ASK THEIR CARE PROVIDERS QUESTIONS.  Research birth.  Study birth.  Learn about birth.

I’m not at all suggesting that we should not listen to our care providers.  But we have a right and a responsibility to ask them questions about what may happen to our bodies at the time of our children’s births.  Because we’re dealing not only with our uteruses and our vaginas–which, depending on our care provider’s cesarean and episiotomy rates, may be cut unnecessarily–but also with our future reproductive health and with our children’s health and safety.

In addition, I think that we have a right and a responsibility to research the various risks and benefits of the interventions and medications that may be used during labor and delivery.  Cervidil.  Pitocin.  Epidurals.  Narcotic pain relief.  Amniotomy.  Cesarean section. Episiotomy.  And many others.

There are benefits and appropriate uses and times and places for nearly all medications and interventions during birth, but there are real risks to them as well.  And it is our responsibility as mothers to know these risks before our labors so that we can make an informed decision to use them and so that–as Nursing Birth and Henci Goer point out as their mission to educate child-bearing women–none of us ever has to say “But I didn’t know that was a risk” or “I would never have agreed to that if I knew that could happen.”

Finally, while I would never suggest that all women should attempt intervention and drug-free childbirths, I have suggested that all women should consider them.  And perhaps this came off as being too…you know…angsty-16-year-old-Kristen-y.

Nevertheless, there are practical reasons that one should research non-pharmacological comfort measures for birth.  And these extend beyond the various risks associated with pharmacological pain-relief.  For even if a mom wants to sign up for the epidural as soon as she walks through the hospital doors, she will most likely have to endure a few (and perhaps quite a few) epidural-free contractions until the anesthesiologist is prepared to administer the requested medication.  And if a mom’s partner knows how to apply counterpressure, or if she can reposition herself to relieve the pain of her contractions, or if she can make use of any one of the many, many non-pharmacological comfort measures that are available, then those moments while she waits to the epidural will be much more comfortable than they would be otherwise.

What’s more, these sorts of pain-relief options can even be helpful for a mom who is recovering from a cesarean section!  (I know that I was using my hypnobirthing visualizations in the recovery room as the spinal began to wear off and the nurse began applying manual pressure to my uterus.  OUCH!)

But as I also mentioned in one of my previous posts, I think that a birth in which the mother has researched her options and has chosen her options and owns her birth choices can be one that is utterly transformative and amazing and inspiring.  I’ve had this sort of experience.  I had it with A’s birth.  And let me tell you, one of the reasons I am so passionate about birth and birthing women now is that I want all women to experience the gift that his birth gave to me.  It was just that powerful.  Just that beautiful.

And my friend Ren said it best when she wrote (in response to Heather Armstrong’s recently-posted birth story):

Armstrong makes a big pile of money off of her blog because tons of people read it, and I couldn’t be happier for her right now, because I love that she just told all those thousands of women: YOU HAVE OPTIONS.   You should study.  You should prepare.  You should make the decisions yourself.  Your birth should be your own.  Not a doctor’s.  Not a midwife’s.  Not a doula’s.  Those people can support you and help you in many ways, but you should not turn over the birth of your child to someone else, no matter what degrees or certifications they may have.  And if you choose to have interventions (induction, drugs, whatever), you should choose them based on the research you have done for yourself. I don’t think women hear this enough.  No, I know women don’t hear this enough.  So I am grateful and glad for people like Armstrong who are saying it, loudly.

Because, as Armstrong relates and as I can personally attest, if you do the preparation work and do what you can to own your birth experience, it can be a miracle in your life.  Religious.  Spiritual.  Utterly transformative.  And not just because now you have this kid to contend with.  The kid is a separate miracle. The birth experience is something different.  Something extra.  Something for you (and hopefully your partner, as well).  If you choose to make it so.

And I hope you do.

In a non-pontificating, non-self-righteous sort of way, of course.

I have now written five posts on “VBAC scare tactics,” or “the (outrageous) statements [that] 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.“  I plan to write more–many more, in fact, because there are loads of unfounded “reasons” that OBs (and some midwives) give to women each day in order to deter these women from choosing a vaginal birth after cesarean rather than a repeat cesarean.

In each of my posts on VBAC scare tactics, I identify one particular scare tactic, supply a list of questions that a mother can ask her care provider in response to this scare tactic, and then provide an analysis and/or summary of the research that either challenges or even debunks the scare tactic and its insinuations.

Yet nowhere do tell a mother that she should leave her scare-tactic wielding care provider.

Nowhere do I tell her that should wait for labor to begin spontaneously.

And nowhere do tell a mother that she should attempt an intervention and drug-free childbirth.

And this is despite the fact that I think that these are wise and excellent choices for the vast majority of all births, and despite the fact that I think these choices give a woman the best chance of having a successful VBAC.  (And, let’s be honest, it’s also because I’m under no impression that someone is going to come across my blog and say, “Hey, that gal at Birthing Beautiful Ideas told me to do it, so by God, I’m gonna!”)

Nonetheless, despite what I think is wise and excellent and VBAC-success-producing, I also think that women should feel empowered to make their own decisions about the births of their babies.  They should be able to make their decisions autonomously, and from evidence and research that they have read and/or discovered.  And when a VBAC-supporter or natural-childbirth-supporter or anyone is too heavy-handed in his or her advice, then this heavy-handedness can diminish a woman’s sense of empowerment and autonomy.  It can even influence a woman to refrain from looking more closely at whatever it is that the advice is pertinent to.

(For what it’s worth, I think that my birth experience with A was so spectacular because I owned every decision I made about the birth, and I made those decisions from a place of empowerment and autonomy, from a place where no one ever told me categorically what I should or should not do.)

Even so, I think that it is reasonable for me to “lay my cards on the table,” so to speak, and elucidate what I think a woman should consider:

• If one’s care provider is hurling “VBAC scare tactics” left and right, then one should consider finding a new care provider.  I did.  I did it.  At nearly 37 weeks into my pregnancy no less.  And it was terrifying, and I cried for days…and I have never once regretted my decision.  Because A’s birth would have been so, so different–and certainly not so amazing and transformative–if I hadn’t reached inside myself and culled up all of my strength and stood up to an obstetrician who tried to coerce me into an unnecessary repeat cesarean.  (For those of you who do wish to transfer to a new care provider, here is good resource containing questions that you can ask when interviewing your new care provider.)

• Unless an induction is medically indicated or necessary, I think that all pregnant women should consider waiting for labor to begin spontaneously.  There are  real risks associated with inductions, whether or not the mother’s uterus is scarred.  There are also real disadvantages to induction since the mother must be hooked up to an IV and to continuous electronic fetal monitoring, thereby limiting her ability to change positions as a comfort measure and to use gravity as a way to “bring the baby down.”  What’s more, synthetic oxytocin (or pitocin) interferes with the body’s ability to release endorphins that can help to counteract the pain of labor, and it intereferes with the body’s own release of natural oxytocin, which helps to promote the mother’s bonding with the baby after birth.  So while induction may be a reasonable and even necessary way for labor to begin–even for a mom attempting VBAC, despite the extra risk that induction presents–there are numerous reasons that should give a mother pause before consenting to a non-necessary induction.

• And finally I think that all women should consider attempting an intervention-free and drug-free childbirth.  I’m certainly not saying that all women should attempt a “natural childbirth.”  But I think that all women should at least consider them.  Weigh the pros and cons of pain medications and interventions.  Or at least look at their options.  Or KNOW that there are options!   (They’re not for everyone, of course, and there are definitely, without a doubt, times and places for pain medications and medical interventions during birth–just so long as a mother can, if possible, participate in the decision to use those interventions and can make that decision from a place of empowerment and autonomy.)  But back to why women should at least consider or research a natural childbirth…  My reasons for this stretch beyond the multitude of physical and emotional benefits of a drug-free birth for both mom and baby.  They stretch far beyond the risks that accompany the various medical interventions used during labor and delivery.   For in addition to these reasons, I think that a drug-free and intervention-free birth can be one of the most amazing, inspirational, empowering, and transformative events in a mother’s life.  Especially when it is borne from a place of education and empowerment and autonomy and preparation.  And it’s not just for granola-crunchy and/or birth junkie types either–just check out Heather B. Armstrong’s most recent post about the natural birth of her second daughter over at dooce.com.  (I, like many others, have been stalking her blog every day for the past couple of weeks to get this latest installment of her birth story.)  As Ms. Armstrong so wisely says, for those of us who work toward and research about and are lucky enough to have a natural childbirth, these births have the ability to change our perspective on our entire lives.

And that’s something that every woman should know is possible.

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 #5: You know, VBACs aren’t as safe as we thought they were.  They are much more dangerous to you and your baby.  A repeat cesarean is the safer route.

Questions to ask your care provider:

• What is the difference between how safe you thought they were and how safe they now actually are?
• Was there a particular study that specifically concluded that VBACs are an unsafe option?  Or that the risk of uterine rupture for moms attempting VBAC is actually higher than was once thought?
• What are the comparative risks of VBAC and repeat cesarean?

A more nuanced analysis:

 If I were to make an educated guess, I would bet that this particular “scare tactic” can be traced back to a study published in the July, 2001 edition of the New England Journal of Medicine.  This particular study–”Risk of Uterine Rupture during Labor among Women with a Prior Cesarean Delivery” (Mona Lydon-Rochelle et al.)–did demonstrate what many VBAC supporters already knew: namely, that a trial of labor following a cesarean (or a VBAC attempt) has a higher risk of uterine rupture than does a repeat cesarean.  But it also led to what many have come to call the current “VBAC-lash”: a climate in which very few obstetricians will encourage, let alone “allow,” their patients to attempt a VBAC.

To elaborate, this particular study found that the rate of uterine rupture among women with repeat cesarean deliveries without labor was .16%, whereas the rate of uterine rupture among women all women attempting VBAC was .6%.  This is a significant difference, but it is not necessarily the sort of difference that makes VBAC an unsafe option.  (Worth noting is that there is still a risk of uterine rupture even if a woman opts for an elective repeat cesarean!)  Nonetheless, many people–physicians and media included–took the discrepancy between these numbers as an indication that elective repeat cesarean was unequivocally a safer birth choice than was VBAC.

But as Jill MacCorkle points out in her excellent critique of this study and its interpretations in an article in Mothering, the study itself has certain limitations and flaws (including the fact that it lacks an analysis of the comparative risks of repeat cesarean).  More importantly, however, the conclusions that others have drawn from the study–namely, that VBAC is “unsafe” or is “not as safe as we thought it was”–are not necessaerily supported by the data.

For one, the conclusion that the study’s authors offer is that “for women with one prior cesarean delivery, the risk of uterine rupture is higher among those whose labor is induced than among those with repeated cesarean delivery without labor.  Labor induced with a prostaglandin confers the highest risk.”

Look carefully at what the conclusion states: the uterine rupture risk of women attempting VBAC is highest among those whose labor is induced, particularly among those who labor is induced with prostaglandins (such as Cervidil).  In this respect, the “lay-person’s conclusion” about this study should not be that VBACs themselves aren’t as safe as they used to be or as safe as once thought but that induced VBACs aren’t as safe as VBAC attempts where labor begins spontaneously.  And this is well-supported by the data in this NEJM study, in which the risk of uterine rupture:

• among VBAC attempts where labor begins spontaneously was found to be .52%;
• among VBAC attempts where labor was induced with pitocin was found to be .77%;
• and among VBAC attempts where labor was induced with prostaglandins was found to be 2.45%.

Noteworthy too is that, as MacCorkle points out, the uterine rupture rates from this study did not differ significantly from previous studies on uterine rupture rates following a trial of labor (or VBAC attempt).  In fact, some of these numbers found a lower risk of uterine rupture than some other previous studies!  In this respect, the 2001 article certainly does not demonstrate that VBAC is “not as safe as we thought it was.”

Another article that the purporter of this particular “VBAC scare tactic” might be referring to is a 1996 NEJM article, “Comparison of a Trial of Labor with an Elective Second Cesarean Section” by M. J. MacMahon et al.  In this study, the authors conclude that “among pregnant women who have had a cesarean section, major maternal complications are almost twice as likely among those whose deliveries are managed with a trial of labor as among those who undergo an elective second cesarean section.”

But as Henci Goer points out in The Thinking Woman’s Guide to a Better Birth, this study too has certain limitations and flaws that may give a skewed perception of VBAC.  As she writes,

…preeminent VBAC researcher Dr. Bruce Flamm points out that the authors coded wound infections and hemorrhage requiring transfusion as “minor complications,” both of which occurred more often in the planned cesarean group (emphasis added).  If you make these major complications, the difference between the two groups disappears.  Dr. Flamm adds that even without doing this, major complication rates were quite low–a bit less than 1 percent in the planned cesarean group, a bit more than 1 percent in the labor group.

So from afar, it might be true that VBAC may not seem as safe as was once thought.  But up close–in painstaking, nuanced detail, and in light of the most transparent and thorough evidence–it turns out that they are a safe (though not risk-free) option, even when compared to the relatively safe (though certainly not risk-free) option of a repeat cesarean, and especially when allowed to begin and proceed spontaneously and without unnecessary medical intervention.

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 #3: I’ll let you attempt a “trial of labor” just as long as you go into labor before your due date.  After that, we’re scheduling a repeat cesarean.

Questions to ask your care provider:

• Does the risk of uterine rupture go up after this point in a woman’s pregnancy?
• Why can’t we extend the deadline until 42 weeks, after which point my pregnancy is truly “postdates” by ACOG’s standards?
• Instead of scheduling a cesarean, would you consider inducing labor?  (Even if your care provider refuses to induce VBAC labors with prostaglandins or pitocin–and s/he may have very good reasons for this policy–you can always ask about a non-chemical induction, such as a foley catheter induction or an amniotomy.  More on these options in a bit.)
• What happens if I refuse to schedule a repeat cesarean and wait for labor to begin spontaneously?
  

A more nuanced analysis:

It is my opinion that these “due date deadlines” for VBAC moms often demonstrate the care provider’s underlying lack of support for VBAC–especially when the deadline falls before the mother’s due date.  (For what it’s worth, I’ve heard of some care providers who state that they will only “allow” their patients to attempt a VBAC if they go into labor before 39 weeks.  As I’ll explain in a bit, this policy all but guarantees a repeat cesarean for most moms.)

First, due dates themselves are only estimates.  The very fact that these dates are estimates is represented in both acronyms that obstetricians and midwives themselves use to refer to a woman’s “due date”: ‘EDD’ (estimated due date) or ‘EDC’ (estimated date of confinement).  So it should come as no surprise to one’s care provider that the due date is not like an expiration date but is rather an educated guess about the length of gestation.

What’s more, calculating one’s due date based on one’s last missed period (or LMP) is not a foolproof or perfectly accurate way to determine when one’s baby is “due.”  For this method of estimating due dates assumes that the mother ovulated and conceived her baby exactly fourteen days after her last period began.  And if, like many women, she did not ovulate or conceive on the fourteenth day, then an estimated due date based on her LMP can be off by a couple of days, and even by a couple of weeks.

Finally, while (early) ultrasounds can offer fairly accurate due date estimates, they are not foolproof either.  In fact, ultrasounds in the late first-trimester and beyond can be “off” by as much as two or three weeks!

Accordingly, since due dates are “only” estimates–hopefully educated estimates, but estimates nonetheless–it is important to ask your care provider why this estimated date should confer so much concern upon your VBAC attempt.

What’s more, since a normal gestation can last up to 42 weeks (at least as defined by the American College of Obstetrics and Gynecology), it is even more important to keep in mind that many mothers will not go into labor spontaneously before their estimated due dates.  Some perfectly normal pregnancies–again, even within the confines of ACOG’s guidelines–will extend well past the “39 week” or “40 week” deadlines set by the care providers to which I refer in the aforementioned scare tactic.

And if these mothers follow the VBAC “guidelines” established by their care providers, then they will end up with repeat cesareans for pregnancies that are not truly “postdates” (i.e. lasting beyond 42 weeks) and that may not even be as close to the estimated due date as they think, especially if the due date is (unknowingly) inaccurate.  And this should be of special concern given the current research on the health risks posed to babies born via elective cesarean before 39 weeks.

Furthermore, it is exceedingly important to ask one’s care provider about the research that s/he is using to make his or her decision about the “VBAC deadline.”  And thus far, there is no research recommending that all VBACs take place at or before 40 weeks gestation.

It is worth noting, however, that the recent NIH Consensus Statement on VBAC does find attempting a VBAC past the estimated due date (i.e. past 40 weeks gestation) does decrease the VBAC success rate slightly.  But the VBAC success rate is vastly different from the uterine rupture rate:  the VBAC success rate represents the rate of women attempting VBAC who give birth vaginally, and the uterine rupture rate simply represents the rate of uterine ruptures following a VBAC attempt.  What’s more, there might be other factors (such as increased induction rates) that contribute to the decrease in VBAC success beyond 40 weeks.

Notably, the 2004 Landon study concludes that induction with pitocin or prostaglandins does increase the uterine rupture risk in VBAC attempts.  Accordingly, this increased risk may be one of the reasons that your care provider would choose to schedule you for a repeat cesarean rather than a chemical induction.  (Worth noting is that pitocin induction increases the uterine rupture risk to approximately .7-1.2%, as opposed to .2-.7% for spontaneous labors.  This increased risk may be acceptable for some women who agree to a pitocin induction, especially a “low-dose” induction.)

Nonetheless, instead of a pitocin induction–and instead of a repeat cesarean–you can always ask your care provider to attempt a foley catheter induction or an amniotomy to induce labor.  Neither of these forms of induction poses any additional risk specific to moms attempting VBAC. And while the amniotomy in particular has some specific disadvantages (particularly an increased risk of infection), and while neither form of induction guarantees that labor will begin, it may be worth attempting one of these forms of induction if 1) you choose to stay with your care provider, 2) s/he refuses to budge (or will only deviate slightly) from the “due date deadline,” and 3) you are committed to attempting a VBAC rather than agreeing to a repeat cesarean.

Moreover, it is entirely within your right to refuse a repeat cesarean and to await for labor to begin spontaneously.  In fact, ICAN has a tremendously helpful and well-researched resource on the disadvantages of (non-necessary) induction and the advantages of awaiting spontaneous labor in a vaginal birth after cesarean.  What’s more, in addition to citing research regarding the fetal brain development that occurs all the way through the 41st week of pregnancy, Lamaze International’s Practice Paper on Letting Labor Begin on its Own describes the many ways in which awaiting spontaneous labor is beneficial to both mother and baby.  Combined, these include the facts that:

• Studies generally show that induction increases the cesarean rate, especially for moms attempting their first VBAC.
• Studies also show that induction increases the risk of vacuum or forceps-assisted vaginal delivery, jaundice, low birth rate, and admission to the NICU.
• Chemical induction interferes with the body’s production of the hormones that help to loosen the pelvis in preparation for birth.
• Synthetic oxytocin (or pitocin) carries with it a number of risks, including (but not limited to) postpartum hemorrhage and cardiac arrhythmia in the mother and fetal bradycardia and low Apgar scores at five minutes for the baby.
• Because of the increased need for monitoring during an induction, the mother is usually confined to the bed or to the immediate area surrounding the bed, thereby making it extremely difficult for her to move to help her cope with the intensity of labor.
• Induction increases the likelihood of a mother requesting an epidural, which itself carries extra risks to both mother and baby.
• And finally, both pitocin and prostaglandin inductions increase the risk of uterine rupture for moms attempting VBAC.

Accordingly, it bears asking your care provider what would or could happen if you simply refused to undergo an induction and/or the recommended surgery–even if this would certainly become a potential uphill battle for you and your attempt to have a VBAC.

In this respect, I strongly encourage you to become familiar with ICAN’s White Papers,  particularly with the document entitled “Enforcing and Promoting Women’s Rights.”  This document explains not only the doctrine of informed consent but also the laws and ethical guidelines that should protect you and your right to attempt a VBAC.  (Yes, it can be construed as an actual right!)  It also  explains your rights and your options in regard to your care provider and in regard to the hospital at which you plan to give birth.

And from someone who has not only defended herself against the scare tactics of a VBAC-denying obstetrician but also changed care providers at nearly 37 weeks to a truly VBAC-supportive obstetrician, I know from experience that this knowledge–the knowledge of one’s rights and options–can be empowering.