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Vaginal Birth After Cesarean (VBAC) Fact Sheet
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Vaginal Birth After Cesarean (VBAC) Fact Sheet
by Nicette Jukelevics
International Journal of Childbirth Education in November 1994 (Vol. 9, No. 4)
Evidence confirming the safety of vaginal birth after cesarean (VBAC) within proper guidelines has been available for more than ten years. However, wide variations in VBAC rates, unjustified by medical factors, still exist between hospitals and physicians. These facts are presented with the hope that more women will be encouraged to avoiding unnecessary cesarean section and supported in their wish to labour and have a VBAC.
- VBAC with appropriate informed consent is the standard, of care for women with one prior low transverse uterine incision. Studies indicate that overall at least 50% and as many as 90% of women who plan a VBAC can delivery vaginally (ICEA VBAC Review 1990).
- The rate of reported uterine rupture in planned VBAC with a low transverse scar has ranged from 09% to .22%. This risk is thirty times lower than any other unpredictable childbirth emergency such as acute fetal distress, premature separation of the placenta and prolapsed umbilical cord. A 1994 study based on 5733 planned labours after one or more cesareans reported a rupture rate of .8% with no maternal deaths related to uterine rupture (Guide to Effective Care in Pregnancy and Childbirth 1992; Obstetric Gynecology 1994).
- Maternal morbidity rates are consistently and substantially lower for women who plan a VBAC - 2%-23% - than for women who have an elective repeat cesarean - 11%-38% (Guide to Effective Care in Pregnancy and Childbirth 1992).
- Any hospital that provides standard obstetric care can also provide care for women who wish to plan a VBAC. A recent study concluded that family physicians can play a major role in promoting VBAC (American Family Physician 1993).
- The National Association of Childbearing Centres of the United States (NACC) indicates that birth centres may encourage VBAC clients to tabor and deliver in their facilities provided that emergency care can be initiated within thirty minutes of recognition of a problem (NACC Committee Opinion 1989).
- In the United States, 22.6% of all births in 1992 were by cesarean section. Thirty-eight percent of all cesareans performed were elective repeat operations. The VBAC rate in 1991 was 24.2%. A national health objective for the year 2000 is a cesarean rate of 15% and a VBAC rate of 35% (Unnecessary Cesarean Sections: Curing a National Epidemic 1994).
- In 1988-89. the cesarean rate in Canada was 19.5%. Thirty-eight percent of all cesareans were repeat operations. The VBAC rate for this same period was 15.6%, a fivefold increase since 1979-80.
- In the province of Manitoba, the VBAC rate for women younger than twenty was 55.2% (Canada Health Reports 1991).
- A review of twenty-five medical reports concluded that women with two prior low transverse uterine scars who wish to plan a VBAC are not at any greater risk for a uterine rupture. The literature indicates that 60% to 75% of women with two or three prior cesareans gave birth vaginally (British Journal of Obstetrics and Gynecology 1991; American Journal of Obstetrics and Gynecology 1988 and 1989; Obstetrics and Gynecology 1990).
- A low segment vertical uterine incision does not appear to increase the risk of uterine rupture for women who plan a VBAC (American Journal of Obstetrics and Gynecology 1988; Obstetrics and Gynecology 1987 and 1988).
- VBAC is safe for non-diabetic women who are expected to give birth to infants that weigh more than 4000 grams (Obstetrics and Gynecology 1989; Journal of Reproductive Medicine 1984).
- A review of forty-two studies concluded that within appropriate e guidelines. VBAC with a breech presentation is a safe and reasonable option (Journal of Reproductive Medicine 1989; Clinical perinatology 1989: American Journal of Obstetrics and Gynecology 1989).
- External cephalic version (a method of rotating a breech presentation) is a reasonable option for women with a prior low transverse scar who wish to plan a VBAC (American Journal of Obstetrics and Gynecology 1991).
- Prostaglandin E2 in gel can safely be used for cervical ripening for women who plan a VBAC. Its use can lower the risk of a cesarean for failed induction with oxytocin (Acta Obstetrics and Gynecology of Scandinavia; American Journal of Perinatology 1992).
- Although uterine rupture in planned labor after cesarean is a rare event, when it does occur, it is often seen as an acute emergency. The most common indicators of uterine rupture are an abnormal fetal heart rate pattern or prolonged declarations with an arrest of progress in labor. Abdominal pain or vaginal bleeding are not reliable indications (American Journal of Obstetrics and Gynecology 1991, 1993 and 1992; Journal of Clinical Anesthesiology 1991).
- A vertical incision (classical/midline) in the upper segment of the uterus is a contraindication for labor (Canadian Medical Association Journal 1993).
- A Canadian study of sixteen community hospitals revealed that physicians are more likely to offer a trial of labor-38.2%-if an educationally influential opinion leader initiated practice guideline recommendations. than if the hospital audited charts of women with a prior cesarean, held departmental meetings and discussed the audit results-21.4% (Journal of the American Medical Association 1991).
- Data from North American studies indicate that 30% to 50% of women who are offered a trial of labor based on the medical benefits versus risks approach choose to have a repeat operation. A significant number of women who elect another cesarean had their initial surgery for non-progressive labor (Culture. Medicine and Psychiatry 1987; Journal of Reproductive Medicine- 1993: Women and Health 1989: American Family Physician 1993).
- A European study of over 1000 women with a prior cesarean section concluded that routine examination of the prior scar to detect dehiscence after vaginal delivery is of doubtful value (ACTA Obstetrics and Gynecology, of Scandinavia: Enkin, Kerise and Chaimers 1992).
- X-ray pelvimetry, is an unreliable indicator of the outcome of planned labor after cesarean and should be abandoned (British Journal of Obstetrics and Gynaecology 1993; 1991).
- A five-year American study concluded that nurse midwives attending women in labor with a prior cesarean had an 83% rate of vaginal delivery (Journal of Nurse Midwifery 1989).
- Data from a National Birth Center VBAC Study in progress indicate that 8616 of 189 women had a vaginal birth and 93% of these took place in the birth center setting. Forty-nine infants were "macrosomic" - more than 4000 grams: 82% of them were delivered vaginally (NACC 1994).
- VBAC is a valid option in developing countries. Maternal and fetal outcomes are not compromised when women are attended by midwives in hospitals that do not have the use of electronic fetal monitors and availability of a blood bank. However, an attending physician and a surgical team must be available as needed (International Journal of Gynaecology and Obstetrics 1991: Journal of Reproductive Medicine 1992. Australian and New Zealand Journal of Obstetrics and Gynecology 1988).
Comments:
http://www.ican-online.org/
http://www.vbac.com/
http://www.cafemom.com/group/13999
Top Ten VBAC Books To Consider Reading
The VBAC Companion by Diane Korte or Nautral Childbirth After Cesarean by Karis Crawford, Johanne C. Walters
Our Recommendations and the Reasoning Behind Them
These are our Top Ten VBAC book recommendations. Your opinions may vary! However, if you have to choose only a few books to read, these are probably among the best places to start. Many of these can be ordered through www.1cascade.com, through used book services like www.half.com, or may be available for loan through local La Leche League or ICAN chapter libraries.
The VBAC Companion and Natural Childbirth After Cesarean are both excellent introductory VBAC books, if a bit old. Silent Knife is a classic in the VBAC field, published in 1983. Although its strong tone will put off some, the tone comes from being written when VBAC was still not being 'allowed' by most doctors. Even so, the book still has much to offer years later, particularly the chapters on "Mindscapes," “Voices of the Victims,” and the birthing stories.
Birthing From Within is an excellent general pregnancy manual, with lots of birth art and exercises for working through pregnancy worries. Creating a Joyful Birth Experience is a great book for creating an empowering birth experience. It has a number of valuable writing, visualization, and art exercises for working through fears. The exercises in both books may seem a bit strange or silly at first, but many women find them very helpful in preparing for birth and dealing with fears.
Rebounding From Childbirth and Transformation Through Birth, are excellent books dealing with emotional repercussions after a difficult birth, each from a different but valuable perspective.
For technical knowledge about childbirth issues, Obstetric Myths vs. Research Realities is an excellent book. It has a particularly good section on VBAC vs. repeat cesarean, and analyzes many research studies about various obstetric procedures and their effects on birth. If you need concrete data and studies to show your doctor or loved ones, or if you are questioning the value of some routine procedures, this is an invaluable book to read. A good adjunct is The Thinking Woman’s Guide to a Better Birth.
Understanding and Teaching Optimal Foetal Positioning shows how a less-favorable baby position ends up causing many c-sections. An even better explanation of this for the layperson is Sit Up and Take Notice. The Labor Progress Handbook suggests a number of techniques to help correct baby malposition and/or move along a labor that is slow or 'stuck'. It is a good resource for you or your labor coach, doula, or midwife. The Pink Kit is a video, tape, and book set that teaches women how to “map” their own pelvic shape and learn different techniques for creating extra space for baby to fit through. If your past c-section was for "Failure to Progress," "Cephalo-Pelvic Disproportion," “fetal malposition,”or if you were told your baby was 'too big' or your pelvis 'too small', all these books are a must-read.
Finally, most VBAC moms find that they draw inspiration and encouragement from reading lots of VBAC stories. The VBAC Experience has any number of these, as does Silent Knife. Many online resources also have lots of VBAC stories to read.
What's The Big Deal With Cesareans?
http://birthamiracle.wordpress.com/2008/07/29/what-is-the-big-deal-with-cesarean-section/
(thanks mbmomof3!)
VBAC videos:
vba3c:
hba2c
http://www.youtube.com/watch?v=aQd0hPHWOlQ&feature=related
and another hba2c
http://www.youtube.com/watch?v=UlfVzq1YrRg&feature=related
twin vbac homebirth:
http://www.youtube.com/watch?v=UlfVzq1YrRg&feature=related
vbac after traumatic hospital c-section:
http://www.youtube.com/watch?v=lrgy29xbtmE&feature=related
vbac after multiple c-sections (2 or more) (including one with an inverted T incision)
http://www.youtube.com/watch?v=yK0K0HAgLDM&feature=related
hospital vbac/c-section, one moms experience and comparison:
http://www.youtube.com/watch?v=_TZyTH3-R2o&feature=related
empowering hbac:
http://www.youtube.com/watch?v=hS0rP021edU&feature=related
homebirth after 1 c-section:
http://www.youtube.com/watch?v=SxmM61JG3Q4
successful vbac after switching doctors:
Many C-Sections Can Be Avoided By Waiting Out Stalled Labor, UCSF Study Shows
Pregnant women whose labor stalls while in the active phase of childbirth can reduce health risks to themselves and their infants by waiting out the delivery process for an extra two hours, according to a new study by researchers at the University of California, San Francisco.
By doing so, obstetricians could eliminate more than 130,000 cesarean deliveries - the more dangerous and expensive surgical approach - per year in the United States, the researchers conclude.
The study examined the health outcomes of 1,014 pregnancies that involved active-phase arrest - two or more hours without cervical dilation during active labor - and found that one-third of the women achieved a normal delivery without harm to themselves or their child, with the rest proceeding with a cesarean delivery.
The findings appear in the November, 2008 issue of Obstetrics and Gynecology, the official journal of the American College of Obstetricians and Gynecologists (ACOG).
While ACOG already recommends waiting at least two hours with adequate contractions in the setting of no progress in active labor, it is routine practice in many clinical settings to proceed with a cesarean for "lack of progress" before those ACOG criteria have been met, according to Aaron Caughey, MD, PhD, an associate professor in the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, and senior author on the paper.
"One third of all first-time cesareans are performed due to active-phase arrest during labor, which contributes to approximately 400,000 surgical births per year," said Caughey, who is affiliated with the UCSF National Center of Excellence in Women's Health. "In our study, we found that just by being patient, one third of those women could have avoided the more dangerous and costly surgical approach."
The cesarean delivery rate reached an all-time high in 2006 of 31.1 percent of all deliveries, according to the UCSF study. Arrest in the active phase of labor has been previously shown to raise the risk of cesarean delivery between four- and six-fold.
"Cesarean delivery is associated with significantly increased risk of maternal hemorrhage, requiring a blood transfusion, and postpartum infection," Caughey said. "After a cesarean, women also have a higher risk in future pregnancies of experiencing abnormal placental location, surgical complications, and uterine rupture."
The ten-year study identified all women who experienced what is known as active-phase arrest during their delivery at UCSF from 1991 to 2001. The study only included women with live, singleton deliveries who were delivered full-term.
The researchers examined maternal outcomes such as maternal infection, endomyometritis, postpartum hemorrhage and the need for blood transfusions. It also examined the infant's Apgar score, rates of infection and frequency of admission to the neonatal intensive care unit, among other health indicators.
The study found an increased risk of maternal health complications in the group that underwent cesarean deliveries, including postpartum hemorrhage, severe postpartum hemorrhage and infections such as chorioamnionitis and endomyometritis, but found no significant difference in the health outcomes of the infants.
It concluded that efforts to continue with a normal delivery can reduce the maternal risks associated with cesarean delivery, without a significant difference in the health risk to the infant.
"Given the extensive data on the risk of cesarean deliveries, both during the procedure and for later births, prevention of the first cesarean delivery should be given high priority," Caughey said.
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Article adapted by Medical News Today from original press release.
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Co-authors on the paper were Dana E.M. Henry, MD; Yvonne W. Cheng, MD, MPH; Brian L. Shaffer, MD; Anjali J. Kaimal, MD; and Katherine Bianco, MD, all from the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine.
Funding for these studies came from research funds from the National Institutes of Health for Henry and Kaimal. Caughey is supported by a National Institute of Child Health and Human Development grant and the Robert Wood Johnson Foundation. The authors have no potential conflicts of interest to disclose.
UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. For further information, please visit http://www.ucsf.edu/.
http://www.medicalnewstoday.com/articles/127827.php
Things more likely to occur than Uterine Rupture
Written by Eileen Sullivan, with assistance from her husband, Patrick.
After checking, it seems I was a bit off on the frequency of deadly lightning strikes... you are more likely to suffer a rupture than to be struck and killed by lightning, by about thirty times. Then again, how many people do you know who HAVE been struck and killed by lightning? <s>
Ruptures are also more common than dying in a plane crash. Henci Goer's review of the literature on VBACs found 46 ruptures in 15,154 labors. This equates to a 0.3% rate... or 1 in 333, if you prefer. Your annual risk of dying in a plane crash is 1 in 4000, according to one source, and 1 in 700,000 according to another. I can't explain the massive discrepancy between the two figures, except to quote Mark Twain about "lies, damn lies, and statistics."
Since you asked, here are some more probability statistics for you:
Your risk of dying in a car accident, over the course of your lifetime, is between 1 in 42 and 1 in 75. This is roughly 4 to 5 times greater than the risk of uterine rupture.
You're about twice as likely to have your car stolen (that's an annual risk) than to experience a uterine rupture.
Your odds of being murdered are 1 in 140 over the course of your lifetime. That's 2 times more likely than the risk of rupture.
The annual risk of having a heart attack is 1 in 160, 2 times more likely than rupture. Your risk of dying from heart disease is roughly 1 in 6, or 55 times greater than your risk of rupture.
If you're a smoker, your risk of dying from lung cancer is 1 and a half times more likely than a VBAC mom rupturing during her labor.
You're about 17 times more likely to contract an STD this year than you are to have a uterine rupture; more likely to contract gonorrhea than to rupture, as well.
You're 13 times more likely to get food poisoning than to rupture.
You're more likely to have twins than a uterine rupture. Odds of twins: 1 in 90. That's about 3 1/2 times the likelihood of rupture.
If you ride horseback, you're 3 times more likely to die in a riding accident than you are to experience a uterine rupture.
If you ride a bike on the street, you are 4 times more likely to die in an accident (annual risk) than you are to suffer a rupture.
Having a serious fire in your home during the next year is twice as likely as experiencing a rupture.
You're ten times as likely to win at roulette as you are to have a uterine rupture.
If you flip a coin, you'll be more likely to get heads (or tails) 8 times in a row than to rupture.
The risk of cord prolapse is 1 in 37 (2.7%), or nearly ten times more likely than that of rupture.
And a final irony (heads up, those of you who want a doc to give his/her opinion on your likelihood of rupture next pregnancy!)...
You're 6 times more likely to have a doctor who is an impostor than you are to suffer a rupture. Two percent of docs are phonies (1 in 50), according to several sources I found.
So instead of worrying about rupture, why not take a few minutes to check up on your doctor's credentials? ;) It'd be a more profitable use of your time, and a substantially more likely cause for alarm.
The risk of the uterus rupturing before labour (that would be before labour or before c/s) is about 2 in 1000; the risk of uterus rupturing during spontaneous labour is I believe 3-5 in 1000. It is both the stretching of the uterus and the contractions pulling on the scar that cause risk.
The medical community has been very short sighted in terms of long term complications of c-section, and many of those risks include risks to future pregnancies. Any pregnancy after c/s carries a slightly increased risk, and it is only slightly higher if you choose to VBAC. (from VBAC moms group)
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