Let me see if I have understood you. I think you are saying that Australia's independent midwives keep collective track of their statistics and that among home birth clients who plan VBAC and who are still eligible for home birth at the time labor begins, 97% have a vaginal birth. Is that correct? If it is, it would be good to know how many women planning home VBAC we are talking about, what percentage have prior vaginal births, and over what time period.

I would like to take a look at Cronk's VBAC guidelines and her sources for the usefulness of maternal pulse for signaling scar problems. Rather than my searching for this on the website, save me time by sending the link or links to these specific pages. The way to do this (hopefully your posting screen is like mine) is to highlight a word or words and click on the taskbar icon with the green circle and the chain link under it. It will ask you to type or paste in the URL and will create a link between the highlighted words and the address of the URL.

As for who is "suitable" for VBAC, that isn't a word I would use. I think that we are talking about a scale. At one end are ideal candidates such as Robin. At the other are women for whom planned VBAC would almost certainly end in disaster. One I can think of off the top of my head is a woman with a complete placenta previa (placenta overlaying the cervical opening). In between are individual women with individual variables that affect their likelihood of VBAC and their likelihood of scar rupture. Clouding the issue is the degree to which provider management and philosophy impinge on those variables, which means that whatever the rates reported in the research, we do not know the true rates under ideal conditions. For example, women who have had a prior cesarean for labor dystocia are less likely to have a VBAC than women who had a cesarean for a nonrepeating reason, but they are also less likely to be given as long a time to labor in the VBAC labor than women whose prior cesarean was for a nonrepeating reason. For another, almost all studies show that inducing labor in general and with an unripe cervix in particular increases the risk of scar rupture compared with spontaneous onset. Your extremely high HBAC rate is yet another indicator of the impact of care practices and philosophy. In almost all cases, it can be demonstrated that planning VBAC is the better option and that planning VBAC with an enthusiastic provider who knows how to care for women optimally is the best option. I would recommend that women who may be at higher risk for scar rupture or other severe complications of prior c/sec, for example, women with single-layer suturing or women with multiple prior c/secs, who are at greater risk for placenta accreta (placenta grows into the uterine muscle and sometimes through it and invades other organs), give birth in a setting that can deal  24/7 with need for an urgent cesarean and a baby in trouble. I believe, though, that once a woman has accurate, unbiased information, only she can or should decide if she is a suitable candidate for planned vaginal birth--and that includes women with relative or even absolute contraindications. 

I agree with you that women planning VBAC should avoid epidurals. They slow labor and interfere with mobility and pushing, which could lead to a preventable cesarean; they can cause a drop in fetal heart rate, which is also a symptom of scar rupture and could lead to an unnecessary cesarean; and they pretty much guarantee need for oxytocin to augment labor, which several studies show increases risk of scar rupture. I would not, however, call them "contraindicated," with its implication that women should not be allowed to have them. As with VBAC itself, I want the woman to make an informed choice, understanding the potential benefits and harms of all her labor coping options. For some women, the benefits would outweigh any risks.

-- Henci