For Love of Baby: Services for the Childbearing Year: VBAC Facts

The baby is born full term, when he is ready. The labor contractions provide him with the needed massage and hormones preparing him for life outside the womb. He emerges, taking his first breath with healthy lungs. He is immediately held and loved and nursed by his mother, still attached to his umbilical cord. His father rubs his back. The nurse gives him an Apgar of 8.

Down the hall another birth is taking place. This baby is coming two weeks early. There are no massaging contractions. This will lead to her developing respiratory distress syndrome. Her parents get only a fleeting glimpse of their new baby as she is taken away. They are told she has an Apgar of 5. Hours later the family is reunited and breastfeeding is attempted. It is a struggle that will ultimately end in formula.

Why the vast difference between these two births? The first is a vaginal birth after cesarean, the second a scheduled repeat cesarean section. Yes, these scenarios are at opposite ends of the extremes but the reality is: VBAC is safer. The benefits of VBAC far outweigh the risks in most cases.

As illustrated in the introduction, the benefits to the baby are many and include: being born when ready, a surge of hormones that help ready baby for life outside the womb, healthy lungs from being full term and massaging of contractions, higher Apgar scores, early frequent contact with mothers, increased success of breastfeeding. (2, 4, 7) The benefits to the mother are also many, such as: prevention of infection, prevention of extra blood loss, prevention of bladder, urinary tract or bowel damage, prevention of blood clots in the legs; quicker recovery; better bonding with the baby; and lower financial costs. (2, 4, 7)

What about the risk of uterine rupture during a VBAC? First, let’s define “rupture”. There are two phenomena that are commonly referred to as “uterine rupture”. The first is a complete or true rupture. It is an actual separation of the scar causing a tear through the uterine wall. The second is an incomplete rupture or a dehiscence. This is typically a benign situation, requiring no attention. (1, 2, 6) According to most studies, true rupture has an occurrence rate of less than one percent in women with a low horizontal scar, the most common kind.* (1, 2) It is worth noting that Ina Mae Gaskin, well-known midwife, reports that out of 115 VBAC attempts at “The Farm” there were no ruptures. She attributes this to not inducing or augmenting labor.(3)

If a rupture does occur this can lead to hemorrhage and shock in the mother and a risk of death to the infant. (6, 7) Dr Bruce Flamm, a leading expert in the area of VBAC, analyzed 43 reports from the years 1950-1985. During this time the risk of infant death caused by a ruptured uterus was less than one in 1,000. He reports that in three studies since that time, of over 5000 VBAC’s there was only one incident of infant death due to uterine rupture. According to these statistics then, the risk of infant mortality due to uterine rupture during an attempted VABC is the same as or less than the risk of infant mortality due to other causes. (2) There have been no reports of maternal death from a scarred uterus rupturing during labor in English literature since 1930. (6) With these findings, Dr Flamm says, “It would probably be safe to conclude that driving on a freeway is riskier than natural childbirth after cesarean section.” (2)

While driving on the freeway may be riskier than VBAC, is VBAC riskier than an elective, repeat cesarean? Today in the United States cesarean section is practically treated as casually as a teeth cleaning. The fact that it is a major abdominal surgery with the associated risks is overshadowed. However, the list of risks is long and includes: a much higher incidence of infection, hemorrhage, damage to the urinary tract/bladder or bowel and all the risks common to anesthesia use. These complications can mean longer hospital stays and thus more expense, longer recovery times and potential problems in future pregnancies. Breastfeeding is usually more difficult, recovery time is longer and there are a host of emotional issues as well. There is a slight risk of maternal death compared to none with VBAC. For the baby one of the biggest problems with a scheduled repeat cesarean is iatrogenic (Doctor-caused) prematurity. There are also breathing problems which snowball into mountains if their own. The risk of infant mortality is about the same as that for VBAC. (1, 2, 4, 7)

Many other countries recognize the value of VBAC. The United States ranks highest worldwide in cesarean section. One-third of cesareans performed annually in the US are repeat cesareans. The US is the only country where routine repeat cesarean section is “national policy”. (1) What are the roadblocks to VBAC in the US?

In 1999, ACOG (The American College of Obstetrics and Gynecology) made its recommendation, “Because uterine rupture may be catastrophic, VBAC (vaginal birth after cesarean) should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.” (8) In other words, VBAC should only be attempted in a hospital with 24-hour available physician and anesthesiologist care. This pretty much excludes every birthing location in the US. (5,8) However, ACOG provides no reason beyond “expert opinion” to give credence to their claim. In a Parentsplace column by Henci Goer, she quotes from Guide to Effective Care in Pregnancy and Childbirth, Goer refers to it as the “authority on evidence-based maternity care”, as saying:

The probability of requiring an emergency cesarean section for acute other conditions (fetal distress, cord prolapse, or antepartum hemorrhage) in any woman giving birth, is…up to 30 times as high as the risk of uterine rupture with a planned vaginal birth after cesarean. Hospitals whose capabilities are so limited that they cannot deal with problems associated with a planned vaginal birth after cesarean are also incapable of dealing with other obstetrical emergencies.”

Goer follows up with “In other words, if a hospital isn’t safe for VBAC, it isn’t safe for any woman to labor there.” (5)

By reading the bulletin in its entirety one can learn the true reason behind the recommendation: “Physicians in the United States, facing increased medical-legal pressures…Increasingly, these adverse events during trial of labor have led to malpractice suits.” Marsden Wagner, MD, MSPH, in What Every Midwife Should Know About ACOG and VBAC: Critique of ACOG Practice Bulletin No.5, July 1999, “Vaginal Birth After Previous Cesarean Section” sheds further light on this subject:

“ACOG is not a college in the sense of an institution of higher learning, nor is it a scientific body. It is a “professional organization” that in reality is one kind of trade union. Like every trade union, ACOG has two goals: promote the interests of its members, and promote a better product (in this case the well-being of women). But if there is a conflict between these two goals, the interests of the obstetricians come first…This is why ACOG recommendations cannot always be considered the gospel and the recommendations in this document are suspect. Should the United Auto Workers have the final say on standards of auto safety?” (8)

Now the basis that is given for the recommendation, “Because uterine rupture may be catastrophic…” makes more sense. Catastrophic to whom? The obstetricians.

However there are still practitioners, both midwives and doctors, out there who will support VBAC. So the first step in planning a successful VBAC is to find one of these. Some practitioners give lip service to VBAC only to back track towards the end of the pregnancy. The actual VABC rate of the practitioner and birthplace is key. * A success rate of at least 60%-70% for the practitioner is desirable. While 35% success for the birth pace is acceptable. A family can always change attendant or location if they discover their plan will not be supported. (7)

A woman in good health who follows good nutrition and exercise during her pregnancy has a better chance of a successful vaginal delivery. (1,7) Also if a rupture were to occur in an otherwise healthy mother, it would rarely pose any danger to her. (1) Cultivating a healthy mental and emotional attitude is one of the biggest factors needed for the mother. The fear of repeating her previous birth or idea that her body is incapable of laboring “correctly” are emotional humps that must be dealt with during pregnancy. Positive affirmations of her ability to birth vaginally and visualizations of a positive outcome should be practiced daily. (1,6,7) Reading many experiences of positive VBAC’s can also be invaluable. (7) The book The Vaginal Birth After Cesarean Experience compiled by Lynn Baptisti Richards is a great resource for true-life stories of VBAC. She must also do what she can to make sure there are no negative players on her team. Hiring a doula can give the emotional support the mother needs and improve the outcome of the delivery. (1,7)

During the labor it would be wise to be very careful with artificial induction or augmentation, as these have been linked to an increase in uterine rupture. (8) Also watching for signs of uterine rupture such as prolonged slowing of the fetal heart tones, excessive blood loss and abdominal pain that doesn’t go away between contractions. (7)

When weighing the risks against the benefits one can see VBAC truly is the safer option in most instances and should be the rule not the exception. When given the proper information and support a woman can have a much more fulfilling birth experience.

A baby is born. His mother pushes him into the world, just the way she has prepared for months. There are tears of joy in all her supporters’ eyes, her husband, her doula, and her midwife, as the full term, healthy baby emerges into the world. He latches onto his mother’s breast immediately. As she cradles her newborn baby in her arms, the woman reaches down and feels her scar, the tiny reminder that this birth was different than the first. This one was vaginal, a vaginal birth after cesarean.

2. Flamm, Bruce L, MD Birth After Cesarean The Medical Facts. New York: Fireside,

3. Gaskin, Ina May Ina May’s Guide to Childbirth. New York: Bantam Dell, 2003

4. Goer, Henci The Thinking Woman’s guide to a Better Birth. New York: Perigree, 1999

6.Jones, Carl The Expectant parents Guide to Preventing a Cesarean Section. New York: Bergin and Garvey, 1991

* It is important to note that the type of scar seen on the outside is not necessarily the type of scar on the uterus. This information can be found in a woman’s medical records. (6,7)

* If planning a home birth than only the attendant’s rate can be checked.

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