VBAC Primer

iStock_000023917518SmallIn 1985 the World Health Organization stated that, “There is no justification for any region to have CS [Cesarean section] rates higher than 10-15%.” In 2010, WHO set out to review both the underuse (under 10%) and the overuse (over 15%) of cesareans worldwide.

Looking at data for 2008, the 2010 WHO report found that 54 countries had cesarean rates below 10%; 69 countries had cesarean rates above 15%; and, just 14 countries had rates in the suggested 10 to 15% range. Worldwide, medically unnecessary cesareans use a disproportionate share of global economic resources. According to the report, 6.2 million unnecessary cesareans were performed worldwide in 2008 at a cost of approximately $432 million.

Brazil has the highest cesarean rate in the world at 45.9% and Chad has the lowest, 0.4%. The countries within the recommended range of cesareans (10 to 15%) are the Philippines, Vietnam, United Arab Emirates, Cape Verde, Kazakhstan, Kuwait, Guatemala, Republic of Moldova, Montenegro, Namibia, Saudi Arabia, Honduras, Netherlands, Armenia, Ukraine, and the Syrian Arab Republic.

The United States has the 15th highest cesarean rate in the world, at 30.3%. WHO estimates that the cost of the 673,047 unnecessary US cesareans in 2008 was $687,167,996. According to the CDC the US rate has increased again and is now at 32%. New Jersey has the highest cesarean rate in the US at 38.3% and Utah has the lowest at 22.2%.

VAGINAL BIRTHS AFTER CESAREANS (VBACs)

Newborn baby girlSince the 1960s, studies have suggested that repeat cesareans—which contribute significantly to the overall cesarean rate—are not always necessary. In 1980, the National Institutes of Health (NIH) Consensus Development Conference Panel questioned the necessity of routine repeat cesarean deliveries. As a result of this statement and citizen advocacy, VBACs increased in the 1980s and through the mid to late nineties. However, since 1997, a decline in VBACS has contributed to the overall increase in cesarean delivery. In the chart below, notice the parallels between increased cesareans and decreased VBACs.

vbac_fig_1The decline in VBACs that started in the late 1990s was precipitated by 1999 guidelines released by the American College of Obstetricians and Gynecologists (ACOG) directing that VBACS only take place in facilities where emergency cesarean deliveries can be immediately performed. Evidence to support this guideline (consensus and expert opinion) was rated as Level C by ACOG and yet it had far reaching effects.

A 2007 study showed that in the years following these guidelines, the availability of VBAC services significantly decreased, especially among smaller or more isolated  hospitals. Thirty percent of hospitals stopped offering trial of labor all together because they could not provide immediate surgical and anesthesia services and this is not expected to change. There are currently too few anesthesia providers to ensure “immediate” anesthesia availability for all hospitals providing childbirth services and these shortages are expected to increase in the future.

Nonetheless, in 2010, a National Institute of Health (NIH) synthesis of the published literature on VBAC concluded that, “…VBAC is a reasonable and safe choice for the majority of women with prior cesareans. Moreover, there is emerging evidence of serious harms related to multiple cesareans.”

A TRIAL OF LABOR AND FEAR OF LIABILITY

7.4.2001 Russia, St.-Petersurg.The VBAC success rate is impressive—for 60 to 80% of women with previous cesareans, a trial of labor is successful. And, according to the NIH, “…the vaginal delivery rate after trial of labor has remained constant at approximately 74%.” However, few hospitals offer a trial of labor. A 2012 study, for example, found that 44% of California hospitals do not offer a trial of labor.

Even though a trial of labor is highly likely to be successful, access to it is limited because of liability concerns related to the fear of uterine rupture, an extremely rare complication that occurs in less than 1% of births. The words “uterine rupture” evoke terrifying images of the uterus tearing in two. In truth, the uterus typically tears slowly, not all at once, and is accompanied by noticeable symptoms. Uterine rupture can happen to any woman in any pregnancy. It can even happen before labor begins, although this is not common.

Uterine ruptures, of course, are more common in trials of labor than in elective cesarean surgery, but there is no way to predict them. Here are some possible risk factors:

  • Women with a classical and low vertical uterine scar have more risk of uterine rupture than women with a low transverse uterine incision.
  • Induction of labor has been associated with uterine rupture, even in vaginal births. One side effect of the induction drug, Cytotec, for example, is uterine rupture.
  • More than one cesarean
  • Unfavorable cervix status at the time of admission.
  • Obesity
  • Pregnancy interval of less than 18 months
  • Single layer closure for the initial cesarean
  • A previous vaginal birth decreases the risk of uterine rupture.

No woman has died from a uterine rupture.The risk of maternal death related to elective cesarean delivery is higher than for trial of labor because, ultimately, vaginal birth is safer than surgery.

A 2009 ACOG survey showed that 30% of obstetricians stopped offering trials of labors and VBACs because of fears of litigation. Risk of liability is among the primary reasons for performing a cesarean. Studies have also shown than even modest improvements in the medical-legal climate (caps on noneconomic damages and reductions in physician malpractice premiums) could result in more VBACs and fewer cesareans.

BENEFITS OF LABOR

iStock_000032385654SmallResearch has shown that going into labor, even if it later leads to a cesarean is beneficial to the baby. Hormones that come into play only after labor has begun improve the baby’s respiratory system and state of alertness at birth. Overall, the major benefit of trial of labor is the 74 percent likelihood of VBAC success and the avoidance of the health risks associated with multiple cesarean deliveries.

HOW TO INCREASE VBAC SUCCESS

Current statistics show that the success of a VBAC is strongly influenced by environment. Though the overall VBAC rate is currently only 10 to 20%, Certified Nurse-Midwives (CNMS) have a successful VBAC rate of 68.9% overall. In some practices, the rate is as high as 80 to 90%.

If you would like to try VBAC, your best bet is to carefully research the practitioner and facility you want to use. Select a practitioner with at least a 70% success rate with VBACs, one who feels that you are a good candidate and who will actively encourage you through the rough spots of labor and delivery.

When you tour the facility you are considering, listen carefully to your intuition about the place. Aside from asking about their success rate with VBACs, talk to the staff and listen for encouragement about VBAC. If you don’t feel that the staff is enthusiastic about this concept, consider using another facility, Chose a doula with VBAC experience.

Learn all that you can about VBACs, and consider joining a support group of the International Cesarean Awareness Network (ICAN).

RESOURCES

Here are some helpful resources. Many of the VBAC books are from the 1980s during the first wave of VBAC advocacy.

International Cesarean Awareness Network (ICAN)

NIH Consensus Development Conference on Vaginal Births After Cesarean: New Insights. (2010)

Cut, Stapled, and Mended: When One Women Reclaimed Her Body and Gave Birth on Her Own Terms After Cesarean by Roanna Rosewood. Roanna is the co-founder and host of BirthPlanRadio.com, and the executive action chair of Human Rights in Childbirth

VBACFacts, Jennifer Kamel’s advocacy website.

The Business of Baby by Jennifer Margulis

Silent Knife by Lois Estner and Nancy Wainer Cohen

The Vaginal Birth After Cesarean Experience by Lynn Baptisti Richards

Birthing from Within by Pam England. Pam created this birthing method from her own cesarean experience and subsequent VBAC.

The Thinking Woman’s Guide to a Better Birth by Henci Goer

Ina May’s Guide to Childbirth by Ina May Gaskin

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PEGGY-headshotPeggy O’Mara is the editor and publisher of peggyomara.com.  She was the editor and publisher of Mothering Magazine from 1980 to 2011 and founded Mothering.com in 1995. The author of Having a Baby Naturally; Natural Family Living; The Way Back Home; and A Quiet Place, Peggy has conducted workshops at Omega Institute, Esalen, La Leche League, and Bioneers. She is the mother of four and grandmother of two.

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About Peggy O'Mara

Editor and Publisher of peggyomara.com. Longtime natural living advocate, award winning writer, and independent thinker.

15 thoughts on “VBAC Primer

  1. Rosanne Gephart

    This is from a year ago, but the problems have not changed. Any hospital that can give pitocin in labor should be able to support women who want to labor naturally! Having “rules” for interventions makes since, but at least allow women the option of not having the intervention!

    Reply
  2. Jacqueline Levine

    We are at the point where ACOG itself, along with the Society for Maternal and Fetal Medicine, has issued new guidelines not just for avoiding the primary section…which is , of course, the driving force behind the CS rate, but new guidelines for assessing labor progress…and I give both studies to all my clients so they may see the very words docs say to each other, though rarely to “us”. I do not assume that you don’t know this but perhaps to make it easy for all, here’s the cite for the section guideline info:
    Practice Bulletin #115, “Vaginal Birth After Previous Cesarean Delivery,” is published in the August 2010 issue of Obstetrics & Gynecology.

    And here’s the info about new guidelines for assessment of labor progress:
    New Guidelines Advise Longer Labor Time to Avoid Cesarean Laurie Barclay, MD Clinical Context Obstet Gynecol. 2014;123:693-711.

    These and other new articles, plus a letter from the president of ACOG itself to his “colleagues”, recognize and assert that current practices are not in the best health interests of mothers/babies, and that docs should change their old ways accordingly. Any hope for that any time soon? We’re overdue in this country for some really good optimal maternity care, no?

    Reply
    • Peggy O'MaraPeggy O'Mara Post author

      Thanks for the update, Jacqueline. It just makes me so mad that they created the problem in the first place and now are credited with trying to fix it.

      Reply
  3. Jacqueline Levine

    Peggy, I fear that even the new guides are mostly ignored. The answer is to arm each and every woman we see with the very evidence I mentioned. if, well before her labor, we give each birthing woman the best-evidence info in her hands to see and read, and then explain her legal rights to get only best-evidence care and nothing less, we will begin to change things one woman at-a-time. But if we don’t show the evidence, it’s the docs word against ours. With the info in their hands they can ask their docs beforehand if the doc uses the new ACOG protocols. After all, they are paying for only best-evidence care, right? Here’s a specific bit from just one study about the changed assessments that women should look out for:
    Failure to Progress: Old and New Definitions OLD DEFINITION:Failure to progress A somewhat vague term that can mean the lack of progressive cervical dilation, the lack of descent of the baby’s head, or both* NEW DEFINITION: This term is not used. Instead, the ((OB) authors state “Adequate time for normal latent and active phases of the first stage, and for the second stage, should be allowed as long as the maternal and fetal conditions permit.”**
    OLD DEFINITION: Active labor When the cervix is between 3-4 cm dilated; this is when you should see the beginning of a rapid increase in cervical dilation*NEW DEFINITION: Women may not reach active labor until 6 cm dilation. Experienced moms will have a faster speeding-up of labor at that point than first-time moms**
    Arrest of the first stage of labor OLD DEFINITION:1 stage arrest is diagnosed when a woman is in active labor (3-4 cm) and she has contractions with no change in dilation for more than 2 hours* NEW DEFINITION: 1st stage arrest can be diagnosed ONLY if a woman has reached 6 cm and the water has broken, AND if there has been no cervical change for 4 or more hours of adequate contractions or 6 or more hours of inadequate contractions. If the mom is still <6 cm, then she needs additional time and interventions before an arrest of labor can be diagnosed, because she is still in early labor**

    Reply
    • Peggy O'MaraPeggy O'Mara Post author

      I agree that evidence based information is the best tool for women, but if a woman has to convince her birth provider about the evidence then I think she’s with the wrong provider. We also need to make sure she gets to the providers who already have the best records of supporting successful VBACs.

      Reply
  4. Jacqueline Levine

    Yes, that’s the problem, indeed. But, it turns out that, regardless of whether a caregiver uses only Level A best-evidence care, or just ignores it and uses “routine” or Level B or C care, if a woman knows what BE care is because we show it to her, AND if she know her rights, she may confidently refuse routine IV or induction before her body is ready, or may insist on TOL whether or not her caregiver is on her side. That’s the real triumph…when women know their rights and demand that docs respect their genuine health status and the genuine health status of their babe, and get care based on that. It’s a tough slog, but we must teach both things…what EB care is and a patients right to demand it, Then no one will say…oh failure to progress…C-section for you!” without being challenged about it. When docs figure out that you won’t be bullied, they really do back off, but the confidence to insist on good care is based on knowledge. If you don’t know what good care is, you can’t ask for it. We are in a unique position to teach and give the studies and build confidence before the day of labor. Then prepared women get the EB care they are entitled to. it works! But we must give our time before labor. It’s too late in the LDR to “protect” a woman from bad care. so just show her what it is and she can avoid it!

    Reply
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  6. Sophia

    As a student midwife in the UK it is always encouraging to hear continuing support for VBACs and to know that there is sound research to back it up. Thank you

    Reply
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