I'm afraid I have bad news, at least from the research standpoint. The sole study of out-of-hospital VBAC of which I am aware concluded that VBAC should take place in hospitals despite achieving extraordinarily high VBAC rates and extraordinarily low uterine scar rupture rates. Here is the reference and the PubMed abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed:

Lieberman E, Ernst EK, Rooks JP, et al. Results of the national study of vaginal birth after cesarean in birth centers. Obstet Gynecol 2004;104(5 Pt 1):933-42.

OBJECTIVE: Some women wish to avoid a repeat cesarean delivery and believe that a midwife-supported vaginal birth after cesarean (VBAC) in a nonhospital setting represents their best chance to do so; there is a small, persistent demand for out-of-hospital VBACs. We conducted a study to obtain the data necessary to formulate an evidence-based policy on this practice. METHODS: We prospectively collected data on pregnancy outcomes of 1,913 women intending to attempt VBACs in 41 participating birth centers between 1990 and 2000. RESULTS: A total of 1,453 of the 1,913 women presented to the birth center in labor. Twenty-four percent of them were transferred to hospitals during labor; 87% of these had vaginal births. There were 6 uterine ruptures (0.4%), 1 hysterectomy (0.1%), 15 infants with 5-minute Apgar scores less than 7 (1.0%), and 7 fetal/neonatal deaths (0.5%). Most fetal deaths (5/7) occurred in women who did not have uterine ruptures. Half of uterine ruptures and 57% of perinatal deaths involved the 10% of women with more than 1 previous cesarean delivery or who had reached a gestational age of 42 weeks. Rates of uterine rupture and fetal/neonatal death were 0.2% each in women with neither of these risks. CONCLUSION: Despite a high rate of vaginal births and few uterine ruptures among women attempting VBACs in birth centers, a cesarean-scarred uterus was associated with increases in complications that require hospital management. Therefore, birth centers should refer women who have undergone previous cesarean deliveries to hospitals for delivery. Hospitals should increase access to in-hospital care provided by midwife/obstetrician teams during VBACs. LEVEL OF EVIDENCE: III.

Personally, I think this is a Pilate-like washing of hands because, of course, hospitals in the U.S. are not giving women access to VBAC at all, let alone access to midwife-attended VBACs. The VBAC rate in the U.S. is currently less than 10%, and, according to Listening to Mothers II (http://www.childbirthconnection.org/article.asp?ClickedLink=748&ck=10396&area=27), over half the women giving birth in 2005 who wanted a VBAC were denied this option.

VBAC denial forces women to agree to major surgery in order to receive medical care, because, of course, labor is what happens at the end of pregnancy unless it is prevented. This is a clear violation of the medical and ethical right to informed refusal. It is also a violation of human rights in that the supposed reason for enforced cesarean surgery is that VBAC is too dangerous for the baby. Even if that were the case, which it is not, human rights principles hold that no one can be forced to undergo any invasive procedure, let alone major surgery, in order to benefit another person. That principle holds even if there is a 100% chance that the beneficiary will die, which is far from the case with VBAC. Even where VBAC is allowed, it amounts to what I call “Cinderella VBACs”:  “You can have a VBAC IF the baby isn’t too big and IF you go into labor by your due date and IF you progress in labor at a rapid enough pace and IF . . . .“ You get the picture. I don’t know how accessible hospital VBAC is in Australia, but it looks from your post that things are pretty much the way they are here.

I also have a critique of the premises and conclusion of this study under "When Research is Flawed" on the Lamaze Normal Birth website at http://www.lamaze.org/Research/WhenResearchisFlawed/VBACLieberman/tabid/176/Default.aspx. Worthy of note is that lack of access to timely cesarean after uterine scar rupture was NOT the issue.

At any rate, I do have something that might prove helpful that isn’t research. I am aware that the state of Vermont permits home birth for VBACs because I met a midwife who was instrumental in lobbying for this at the Coalition for Improving Maternity Services conference last week. Here is some information on that: http://vtprofessionals.org/opr1/midwives/forms/midwiferule.pdf. You’ll find what you are looking for on p 10 under “Previous Cesarean Delivery.” I found it by searching on the terms “home” “VBAC” “Vermont.” I tell you this because you might find other useful tidbits by doing the same, such as someone you could contact directly. I wish I could remember the midwife's name so that I could put you in contact with her. 

-- Henci

On this note, I would like to know as a childbirth educator who supports homebirth and supports VBACs-- something that I really don't know and have been asked in class-- how long does it take for a rupture to result in a baby's death?  As one class participant noted, " If you have a VBAC at home and rupture-- you're basically screwed, right?"  I did not have the necessary information to answer the question-- instead emphasizing the tremendous obstacles women have getting a hospital VBAC and the risks of cesarean surgery.  Can you answer this question?

Thanks,

Shayna

Unfortunately, the answer to your question is, "It depends." Should all hell break loose, and you have less than 10 minutes to get the baby out, then, yes, you are screwed. But you are almost certainly also screwed if you are already in the hospital. Hospitals, even tertiary care centers, can't operate that fast, you should excuse the pun.

Does that mean that all women should schedule repeat surgery to avoid this rare scenario? Nope. Repeat cesarean surgery carries risks that threaten the life and well-being of women and babies as well and that, moreover, escalate with accumulating cesareans.

Fortunately, in most cases, it is clear that something is going/has gone wrong, but there is time, including time to move into the hospital, provided the home is within reasonable distance, and the hospital is prepared to whisk the woman into surgery prep and then surgery when she arrives.

This brings up another problem whether the woman is choosing to birth in or out of a hospital: staff not believing the mother. I am aware of more than one case where tragedy ensued because nurses didn't take the laboring woman seriously when she said something was wrong or that she was experiencing unusual pain. This includes one specifically relevant to your couples. The woman came into the emergency room from a planned home VBAC, told staff she was having a scar rupture, was patronized ("There, there, Dear, labor hurts you know), and was admitted the labor ward where nothing was done for some hours. Her baby was alive when she arrived but not when they finally operated.

As things stand, few women wanting VBACs have access to an optimal situation. Most have no hospital option; they must choose between repeat surgery and the risks that entails in the short- and long-term or home birth, in some cases with no qualified birth attendant. Some can get a VBAC in the hospital but only under restrictions that make it almost impossible to achieve that goal, not to mention giving birth under the aegis of the same system that led to having a preventable cesarean in the first place. Again, home birth is the only viable alternative, although it has the drawback of possibly not getting a needed cesarean quickly enough. In an ideal world, women planning VBAC would have access to competent, supportive care wherever they chose to birth and to competent, supportive back-up should they choose to birth in birth centers or at home.

-- Henci     

Henci,

Thanks for your as-usual excellent responses.  Your analysis of the problem has been similar to my own line of thinking-- somethine along the lines of "you have a 1 in 6500 chance of losing your VBAC baby (and that's hospital statistics based upon .5% rupture rate and 5% of ruptures resulting in baby dying-- this is the stat I found)  OR a 1 in 5000 chance of the woman herself dying due to a planned cesarean (according to "Guide to Effective Care in Childbirth")  -- and as Bruce Flamm writes, while the loss of a baby is sad, the loss of a healthy mother is fairly inexcusable-- ie.  it is preferable to risk the life of the baby than that of the mother from an ethical standpoint-- a painful dilemma that all are put in due to the first cesarean.

In any case, my devil's advocate question is-- why are so many women dying in cesareans actually?  I live in NYC, and would LOVE to have disclosure about our local hospitals-- some of the fancy ones like NYU and Cornell who do almost 40% c/s and have high volume-- does it not make sense that they should be losing a couple of women each year?  But you never hear anything about it.  And the hospitals are not required to disclose.

My point is that how can we really prove that "top" OB care can't use interventions in a less risky way?  It's so hard for anyone to believe (even me to some extent) that a woman at a renowned medical center with a prominent OB practice has the same risks of dying from a c/s as a woman who gets her care from an inner city clinic, does not receive personal care by anyone who remembers her, and then has a c/s.  One of the stats that I am thinking of that kind of backs this up is the fact that while Hispanic and Black women have less interventions used on them, they have much higher maternal mortality rates.

Are the old 1 in 5000 for c/s and 1 in 20,000 mortality rates for NSVD equally applicable to everyone regardless of culture or economic echelon or medical care-- I want to understand those statistics and their application better.  It seems maternal mortality is so poorly understood and studied.

Thanks,

Shayna

To begin with, I have some different stats on perinatal deaths from scar rupture and maternal deaths from cesarean surgery. “Step 6” of the CIMS systematic review, Evidence Basis for the Ten Steps of Mother-Friendly Care, downloadable for free at http://www.ingentaconnect.com/content/lamaze/jpe/2007/00000016/a00101s1;jsessionid=2o3j1upnso1ko.henrietta, reported a range of 1 to 4 per 10,000 excess perinatal deaths in women planning VBACs versus women planning repeat surgery. These numbers come from some systematic reviews and some big, recent studies. Converting to your way of reporting, this would be a range of 1 in 10,000 to 1 in 2500.

As for maternal deaths associated with repeat cesarean surgery, a large U.S. study reported a rate of 60 per 100,000, or 1 in 1666 in a population delivering between 1999 and 2002 (Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006;107(6):1226-32.). The hospitals involved in the study were university-associated centers, so presumably the care was top-notch. Compare this with the overall U.S. maternal death rate in 1999 associated with vaginal birth: 13 per 100,000 or 1 in 7692 (Chang J, Elam-Evans LD, Berg CJ, et al. Pregnancy-related mortality surveillance--United States, 1991--1999. MMWR Surveill Summ 2003;52(2):1-8.). Bear in mind, too, that the maternal mortality rate in all vaginal births would include women who were very sick, and because the cesarean study only included women having cesarean deliveries, it would miss some deaths related to prior cesarean surgery such as deaths from ectopic pregnancy early on. It would also miss cesarean-related deaths occurring months or years later such as deaths from bowel torsion caused by cesarean adhesions.

The thing is that no matter how skilled the surgeon or how prepared the institution to handle an emergency, any surgery carries risks and accumulating cesarean surgeries increases those risks.

-- Henci