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Normal Birth Forum Featuring Henci Goer
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Posted By HGOER on 3/17/2007 11:47:35 AM
Subject: RE: VBAC at Home
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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

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