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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?

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Posted in Home and VBAC/Cesarean 9 years, 8 months ago at 10:50 am.

9 comments

9 Replies

  1. Yes, I’m glad you mentioned ICAN!

    “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. ”
    What do you mean here? How would they check inside? I don’t think I have heard of this before.
    Thanks

  2. What an excellent post – I’m going to link you up, if you don’t mind!

    I especially like the way you break down what risk of uterine rupture actually means. It sounds so terrifying,and I can understand women reacting in fear to the term without knowing all the facts. I don’t mean to suggest it’s not something to take seriously and consider, but looking at the real statistics, as well as pointing out that many ruptures are not catastrophic, helps put things in perspective.

    An additional suggestion to the assessment of her previous c-section: I would add that she should find out if her doctor used double-layer sutures to stitch up the incision.

    As far as additional resources, along with ICAN, I would steer women to the great, relatively new site by Ricki & Abby, http://mybestbirth.com, as well as their book, “Your Best Birth”. It’s so well put together and accessible, yet also thorough. I like Henci Goer’s, but it can be a bit dense – not that *I* mind, but sometimes it feels like a bit much to ask women to slog through if they are just wanting to get a sense of what they’re dealing with. I think of it now as a good introduction, and if they want to go further and read something more substantial, Goer would be the best next step. “Pushed” by Jennifer Block as well, though that goes more into the political situation than it does offer practical information for pregnant women.

    Cheers!

  3. To clarify: In that last paragraph, I meant to say ” I think of “Your Best Birth” now as a good introduction, and if they want to go further . . . “

  4. I think you covered all the bases!

    I had “FTP” and “CPD” after pushing for four hours. I went on to vaginally birth my next baby in 1/4 the time who was a solid 1 lb. 4 oz. bigger than his brother! Anything is possible!

  5. Naomi–Manually checking for a rupture means putting a hand into the uterus and feeling around for a rupture. I’ve heard doulas from Alabama talking about seeing it done, and I’ve seen it mentioned in VBAC studies, so I assume it is done elsewhere as well.

    I’ve had two doula clients who had a similar thing happen to them, although not with VBAC. One was a first time mom who’d had a velatamous insertation on her cord, and the OB pulled on the cord (because the placenta will not come out unless you pull on the cord, don’ cha’ know?), detaching it from the placenta. The OB then proceded to stick her hand into this unmedicated mom’s uterus to grab the placenta, nearly causing her to levitate off the bed. This mom then proceded to have a lot of clotting issues over the next few hours (perhaps because her placenta was abruptly ripped off her uterus rather than waiting for it to detach on its own???), which resulted in the OB manually extracting clots over, and over, and over.

    More recently, I had a 2nd time mom who seemed to be doing just fine after her birth, and the OB palpatated her fundus to feel for clots “in the top of the uterus” she said, and then she stuck her hand into my client “to check in the bottom of the uterus,” and from the reaction of the mom, I think this OB also stuck her hand into the mom’s uterus. I’ve never seen this done to check for clots as a “routine”–which seemed to be what was happening here.

    Dou-la-la and Jill–Thank you!

  6. As a VBA2C Mom, the Landon study was critical in making an informed decision on VBAC-ing:

    It found that those who’d had multiple C-sections were no more likely to have a uterine tear, or rupture, than those who’d had only one C-section. Ruptures occurred in nine of 975 women with multiple previous C-sections, or 0.9%, and 115 of 16,915 women with just one prior C-section, or 0.7%. Women with multiple C-sections were more likely to need a blood transfusion or a hysterectomy if they tried for a VBAC, but their actual risk was just 3.2% and 0.6% respectively.

    http://www.usatoday.com/news/health/2006-06-29-vbac_x.htm

    And being at the top of the risk class, I have never had my uterus palpated internally :O I think I’d have kicked any doctor trying to do that.

  7. Carrie Aug 22nd 2009

    As a recent HBAC mom, I began my VBAC journey in southern California at an ICAN meeting so I have to say that’s at the top of my list of how to have a successful VBAC – finding an ICAN support group. Meeting other women in person was crucial for me. When we relocated to Pennsylvania at 34 weeks, there was not a local ICAN chapter here, but through the ICAN website, I found Jenn here who was a wonderful support to me during what turned out to be a tough last few weeks of my pregnancy. My baby was 9 lbs. 4 oz., had a head circumference of 14.5 inches at 41 weeks 4 days, and was delivered vaginally.

    Because ICAN was so important to me in my VBAC journey, I have started a chapter here in the Lehigh Valley – ICAN of Lehigh Valley. Monthly meetings will be starting this September – if anyone is interested in helping with this chapter, attending a meeting or needs VBAC support, please contact me at icanoflehighvalley@yahoo.com.

  8. Wow Carrie, that is great that you are right on that! I keep telling myself I have to give you Erica’s contact info…I’ll pass a copy of your comment on to her.

    I would encourage you to get a website of some sort up–even if it is on Facebook. Once you do, let me know, and I’ll definitely post a link to it in my “Resources” section.


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