Previous Post: Infant Mortality in the US…are we really on top?   Next Post: Dealing With Nausea or Morning Sickness in Pregnancy

Where can I find information to help decide whether or not to pursue VBAC?

A friend recently asked me to pass along some information to help a friend of hers decide whether or not to pursue VBAC.  This was my answer to her:

That can be a tough decision for many women!

The reason for her previous cesarean is important to consider in assessing her odds of having a vaginal birth this time around.  If it was for twins, breech or fetal distress; then it had nothing to do with her ability to birth vaginally, and she is a good candidate for a VBAC (assuming a low transverse incision).  If she had her cesarean for “failure to progress” (FTP) at a low dialation, many women think they are not good candidates for VBAC, but actually, the research shows that they are MORE likely to successfully VBAC than a woman who had a cesarean for FTP at a high dialation…simply because the cesarean was probably called before there was even a chance to find out if her body could do it!  Not to say that a woman who had FTP at a high dialation can’t have a VBAC…one of my clients pushed for 3 hrs with her first baby and then had a cesarean, only to have a VBAC with a baby that was 11 oz bigger than her first baby–and no tearing as well. 

There are very few women who are not good candidates for VBAC–just women with specific medical conditions that make labor dangerous, and a VERY small percentage of the population that have malfomed pelvises.

If she is a Christian, she might be interested in the VBAC_HOPE discussion group.

A great website that deals with the research is VBAC Facts  The author of this site is not afraid to challenge false statements made not just by the medical community, but also the “natural birth” community.  She also offers an on-line class about VBAC which your friend might find helpful in making her decision.

For books, I reccommend The Thinking Woman’s Guide to a Better Birth by Henci Goer, A Good Birth, A Safe Birth by Diana Korte & Roberta M. Scaer (these are good for any pregnant woman) and The VBAC Companion by Diana Korte.  For something that isn’t so much “research” but more “emotional support,” Ina May’s Guide to Childbirth by Ina May Gaskin is good.  I also always throw in that I like anything by Dr. Sears, but he doesn’t have anything that really sites research, or is specifically geared to VBAC.

Regarding your friend’s OB…considering that some OB’s will tell women the risk of rupture is 5 or even 20%, I suppose supplying the “1%” stat is good.  But the true rate of rupture is somewhere below 0.5%  This rupture rate includes labors that include Pitocin for augmentation, so it stands to reason that the rupture rate would be lower if Pitocin is not used–in fact, I’ve heard anectodal evidence of care providers who never use Pitocin on VBAC clients, and have rupture rates much below 0.5%  Not all ruptures are “catastrophic.”  In fact, the research that provided the 0.5% figure includes asymptomatic ruptures that were discovered AFTER vaginal birth by manual exploration of the uterus–a practice that has been discreditted.  Only about 1 in 10 ruptures (or about 1 in 2000 attempted VBAC’s) result in damage to the baby due to the rupture, only about 1 in 20,000 VBAC labors result in a baby that dies due to a rupture.

Some questions that are definitely good to ask when considering a care provider for VBAC are:

• What percentage of the care provider’s clients with previous cesareans attempt VBAC (the lower the number is, the more likely it is that the care provider steers clients toward elective repeat…hard to say what a good number is though.  Most surveys indicate that at least half of women with previous cesareans are interested in VBAC, so I’d say that at least 30-40% might be a good minimum).
• What percentage of the care provider’s clients who attempt VBAC have vaginal births?  Research indicates that up to 80% of women who attempt VBAC can have vaginal births–perhaps more.  But outside of midwives, it is hard to find care providers with that high of a vaginal birth rate.  Again…over 50% would be a “minimum” I’d look for.
• How does the care provider feel about going past the due date?  There is no research to support not allowing a woman attempting VBAC to go past her due date–but many care providers do insist on induction or elective cesarean at 40 weeks.
• If labor needs to be induced, what method will be used?  If the care provider mentions prostaglandins, Cervidil, Prepidil (gel), or particularly Cytotec/misoprostol…RUN.  These all significantly raise the risk of rupture.  Pitocin raises the risk of rupture to 1.7%…which some women are okay with, others not.  Raising the Pitocin dosing slowly and in small increments will result in less risk of rupture than using a “high dose” protocol (”high dose” is raising the drip rate about every 15 to 20 minutes, often doubling the dose at each raise.  The package insert reccommends raising the dose in small increments every 30-60 minutes…and interestingly, this is considered “low dose” even though it is the standard package reccommendation!)
• What routine testing is done in late pregnancy?  If it isn’t mentioned, specifically as about ultrasound to estimate fetal weight.  These ultrasounds are notoriously inaccurrate–I had a client whose baby was 2.5 lbs smaller than was predicted to be by an ultrasound done just one week prior to the birth.  If a large baby is predicted it may cause the care provider to be unwilling to continue with VBAC plans, even in the absense of VBAC it has been shown to lead to the care provider being more quick to move to cesarean, and often undermines the mother’s confidence.  To quote one of my clients who pushed out a 9 lb 11 oz baby without a single tear “If I’d have known she was going to be that big, I could have never birthed her vaginally.  I wouldn’t have pushed as hard as I did because I would have been afraid of tearing from stem to stern.”
• What procedures are routine following a vaginal birth?  If the care provider mentions checking the uterus for rupture (which unfortunately is still routine in some areas), she should know that this is VERY painful, and does not provide any benefits.  It does increase the odds of having a post-partum uterine infection.

And that…LOL…is my $.02 worth.

Yes, I should have mentioned ICAN, I’m not sure why I didn’t…hmmm….  What other resources do you think are important to a woman considering VBAC?

Tags: chose care provider, uterine rupture, VBAC