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 Find out what other moms-to-be are asking. Join in the discussion with Henci Goer, an expert in obstetric research. If you would like to contact Henci outside of the Ask Henci forum, send an email to Goersitemail@aol.com.
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Topic: Can we talk for a moment about VBAC? |
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Posted By on 06 Jul 2005 05:56 PM
I'm a little confused about what you are asking, but perhaps this will help: The likelihood of uterine rupture in a woman who has never had a cesarean is 0.01% or 1 in 10,000 (Rageth 1999). The chances of uterine rupture in women having trial of labor after one cesarean are about 0.5% or 5 per 1,000, provided no oxytocin is used to induce labor or stimulate stronger contractions (Rageth 1999; Landon 2004). Landon et al. found that when oxytocin was used, the chance of rupture increased to 1% or 10 per 1,000.
The legal issue about VBAC denial, though, is not about safety or the lack thereof, although, as a side note, any hospital refusing VBAC on grounds that it cannot handle an obstetric emergency is saying that it isn't safe for any woman to labor there. The issue is about violation of a person's right to refuse surgery, a right guaranteed them in an American College of Obstetricians and Gynecologists' "Committee Opinion" (see below). Doctors argue that they have the right to refuse to perform a "procedure," but labor isn't a procedure. Labor is what happens at the end of pregnancy. Refusal of VBAC forces a woman to agree to major surgery in order to obtain medical care. Cesarean surgery, on the other hand, is a procedure, and thus the ACOG Committee Opinion--not to mention medical and human rights principles apply. (For more information on this issue see my article on my own website Rebuttal to Rationales for Denial of VBAC.)
I hope this helps. If you need more, please feel free to write me again.
-- Henci
P.S. I am aware that the International Cesarean Awareness Network has the ideal test case: a woman in the rural mid-West who had had four vaginal births followed by a cesarean for breech who was denied a VBAC for the next baby. Although wanting an obstetrician and a hospital birth for her baby, faced with having to agree to surgery in order to obtain it, she chose to have a home birth with no professional attendant. Her baby was recently born safely at home. I know this woman is willing to go public because she and ICAN were trying to get press coverage of her story.
Landon MB, Hauth JC, Leveno KJ et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004; 351 (25):2581-9.
Rageth JC, Juzi C, Grossenbacher H. Delivery after previous cesarean: a risk evaluation. Swiss Working Group of Obstetric and Gynecologic Institutions. Obstet Gynecol 1999; 93 (3):332-7.
ACOG. Informed refusal. Committee Opinion No 237, June 2000.
"Once a patient has been informed of the material risks and benefits involved with a treatment, test, or procedure, that patient has the right to exercise full autonomy in deciding whether to undergo the treatment, test, or procedure or whether to make a choice among a variety of treatments, tests, or procedures. In the exercise of that autonomy, the informed patient also has the right to refuse to undergo any of these treatments, tests, or procedures. . . . Performing an operative procedure on a patient without the patient's permission can constitute 'battery' under common law. In most circumstances this is a criminal act. . . . Such a refusal [of consent] may be based on religious beliefs, personal preference, or comfort.”
By: Henci Goer |
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RE: Can we talk for a moment about VBAC? |
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Archived User
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| 29 Jul 2005 11:11 PM |
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I'm glad your client has resolved this in a way that feels right for her. My best wishes for a smooth, easy birth.
-- Henci By: Henci Goer |
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Archived User
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| 29 Jul 2005 04:30 PM |
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Much happier update: My client has decided to pursue what she really wants, which is a HBAC. She has chosen a care provider who has a high success rate and comfort level with VBAC and a lot of experience as well. Both are feeling confident at this point. And I am thrilled!!!
Now I am looking forward to February!
Delilah By: delilahdr1 |
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Archived User
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| 13 Jul 2005 02:22 PM |
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Update on my client:
I spent several hours in email, and then 3.5 hours at my client's house on Monday. She is seeing her old OB (the one whose backup OB was on call and sectioned her before) for her first prenatal appointment and to interview her with regard to VBAC today. However, I believe she is going to take in the hospital stats (which showed that in 2002 this particular hospital had under 6% VBAC and 36% cesarean rates) and discuss the care provider's VBAC protocols, and I hope and pray that she will then interview some of the care providers I gave her the contact information for. I will keep you posted.
Delilah
By: delilahdr1 |
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Archived User
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| 11 Jul 2005 07:46 PM |
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I went to the URL you included in your post to see what Stillerman said in context. Here is a slightly longer version:
"In the majority of instances, the uterine scar from a previous C-section is very tough and able to withstand the contractions of an arduous labor. The rate of uterine rupture occurs less than two percent during a VBAC, the same degree as in repeated C-sections. "
Well, now I know why you were having problems formulating your question. Not only is she unclear, but she got it wrong. The probability of the scar giving way and causing problems during a planned VBAC varies according to any number of factors, but for the most common case: one prior cesarean with a transverse uterine incision, the odds, as I wrote earlier, are half a percent, not 2%--provided the woman is not induced with oxytocin, prostaglandin E2, or misoprostol (Cytotec) or given oxytocin to augment labor.
Stillerman is also incorrect when she states that the odds of the scar rupturing are the same as with planned repeat cesarean. They aren't. According to Lydon-Rochelle (Lydon-Rochelle, M., et al. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 2001;345(1):3-8.), the odds of the scar giving way during elective cesarean section are 1.6 per 1,000 vs. 5.2 per 1,000 in women having VBACs with spontaneous labor onset. That is a difference of 3.6 per 1,000 favoring repeat cesarean.
However, the issue is not so simple as comparing scar rupture rates. For one thing, the concern is not that the scar gives way, but whether the baby experiences irremediable harm as a result. Here the differential is much smaller: 2 infant deaths per 10,000, much less than the excess number of pregnancies lost as a result of amniocentesis (60 per 10,000). For another thing, while the risk of harm from rupture may be higher in VBAC, there are other equally serious harms to baby and mother that are more common with cesarean section and especially with accumulating cesarean scars.
-- Henci
P.S. Click on Lydon-Rochelle et al. 2001 for more details on this study. By: Henci Goer |
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Archived User
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| 11 Jul 2005 02:35 PM |
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Thanks, and my apologies for not asking a clearer question. I guess I'm trying to clarify a statement from "V-Back" to the Dark Ages, by Elaine Stillerman (found at: http://www.massagetoday.com/columnists/stillerman in April 2005) that states, "The rate of uterine rupture occurs less than two percent during a VBAC, the same degree as in repeated C-sections." So, is this to say that the risk of uterine rupture in VBAC (1.5%) is comparable to the rate of a uterine rupture in a repeat cesarean? Because if that's the case, then the medical explanation for VBAC bans as a result of higher risk is moot. Thanks,
Morissa
By: Morissa |
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Archived User
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| 06 Jul 2005 10:56 PM |
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I'm a little confused about what you are asking, but perhaps this will help: The likelihood of uterine rupture in a woman who has never had a cesarean is 0.01% or 1 in 10,000 (Rageth 1999). The chances of uterine rupture in women having trial of labor after one cesarean are about 0.5% or 5 per 1,000, provided no oxytocin is used to induce labor or stimulate stronger contractions (Rageth 1999; Landon 2004). Landon et al. found that when oxytocin was used, the chance of rupture increased to 1% or 10 per 1,000.
The legal issue about VBAC denial, though, is not about safety or the lack thereof, although, as a side note, any hospital refusing VBAC on grounds that it cannot handle an obstetric emergency is saying that it isn't safe for any woman to labor there. The issue is about violation of a person's right to refuse surgery, a right guaranteed them in an American College of Obstetricians and Gynecologists' "Committee Opinion" (see below). Doctors argue that they have the right to refuse to perform a "procedure," but labor isn't a procedure. Labor is what happens at the end of pregnancy. Refusal of VBAC forces a woman to agree to major surgery in order to obtain medical care. Cesarean surgery, on the other hand, is a procedure, and thus the ACOG Committee Opinion--not to mention medical and human rights principles apply. (For more information on this issue see my article on my own website Rebuttal to Rationales for Denial of VBAC.)
I hope this helps. If you need more, please feel free to write me again.
-- Henci
P.S. I am aware that the International Cesarean Awareness Network has the ideal test case: a woman in the rural mid-West who had had four vaginal births followed by a cesarean for breech who was denied a VBAC for the next baby. Although wanting an obstetrician and a hospital birth for her baby, faced with having to agree to surgery in order to obtain it, she chose to have a home birth with no professional attendant. Her baby was recently born safely at home. I know this woman is willing to go public because she and ICAN were trying to get press coverage of her story.
Landon MB, Hauth JC, Leveno KJ et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004; 351 (25):2581-9.
Rageth JC, Juzi C, Grossenbacher H. Delivery after previous cesarean: a risk evaluation. Swiss Working Group of Obstetric and Gynecologic Institutions. Obstet Gynecol 1999; 93 (3):332-7.
ACOG. Informed refusal. Committee Opinion No 237, June 2000.
"Once a patient has been informed of the material risks and benefits involved with a treatment, test, or procedure, that patient has the right to exercise full autonomy in deciding whether to undergo the treatment, test, or procedure or whether to make a choice among a variety of treatments, tests, or procedures. In the exercise of that autonomy, the informed patient also has the right to refuse to undergo any of these treatments, tests, or procedures. . . . Performing an operative procedure on a patient without the patient's permission can constitute 'battery' under common law. In most circumstances this is a criminal act. . . . Such a refusal [of consent] may be based on religious beliefs, personal preference, or comfort.”
By: Henci Goer |
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Archived User
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| 05 Jul 2005 01:56 PM |
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| I am a law student intern at National Advocates for Pregant Women, and we are working to develop legal challenges against hospitals refusing to allow VBAC. I was wondering if you could clarify a statistic for me: is the risk of uterine rupture 1.5% for women with previous cesareans in a VBAC and also 1.5% for women who have never had cesarean and are vaginally delivering? Or is the 1.5% both for women with previous cesareans in vaginal birth and in repeat cesarean? By: Morissa |
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Archived User
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| 01 Jul 2005 10:15 PM |
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Wow, I am feeling mighty special today, having two of the biggest inspirations in the normal birth movement responding to my post- thank you, Henci and Barbara! I love Gentle Birth Choices. I have the video, and in fact already let this client borrow it. And my lending copy of TTWGTABB is loaned out, but when I get it back, Henci, this client will be getting to borrow it too- with sticky notes marked on important pages! I quote from TTWGTABB and hold the book up and suggest everyone go get a copy, in all my childbirth classes, when we are discussing the common hospital practices in our area.
Becky is wonderful, and is on the list I gave my client of out of hospital providers for her to interview. (She has done VBAC's in the past, it is somewhat up in the air whether she is doing them right now, but I would definitely consider her opinion a good one if she recommended another care provider.) Her reputation is extremely good. I know several people who have used her for their births, and one person who was previously in business with her and all recommend her for a good birth experience. Allen is a long way away from my client, though... about an hour's drive with no traffic.
I know Judith's name but have not met her. I will add her to the list I have given my client.
Also on my list for out of hospital/birth center include Family Centered Maternity Care, Molly Germash at the birth center in Grand Prairie (I have heard her name mentioned with regard to VBAC's a LOT- many doulas swear by her for VBAC), and Dinah Waranch at the Lovers Lane birth center. I have found three, maybe four potential hospital providers for her to interview as well. And she emailed me and said she had made an appointment with her previous care provider for the 18th so she wanted to meet with me before that - I'm like 'acck!' but didn't say that.... it was her doctor's backup that she had the c/s with, not her doctor, but there's nothing to guarantee her doctor's backup being on call again, so I hope that she reconsiders once we discuss her options with a little more clarity. I think it is unlikely that she will have anything but an ERCS if she goes back to that practice...
And I LOVE the MaternityWise site, Henci, I'm always happy to refer people to it. I have bought hard copies of most of their publications, and in fact, I might have the c/s one. I need to rummage through my files and check, maybe I can lend her that too. Otherwise, she can always go to the website= although, she doesn't spend much time online... (I can't imagine! LOL)
Thank you both for the suggestions!
Delilah By: delilahdr1 |
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Archived User
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| 01 Jul 2005 09:27 PM |
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I would also contact at least one CNM in the Dallas area who knows who the mother-friendly physicians are. You can call Becky Burpo, CNM, out in Allen, Texas. She runs the Allen Birthing Center at: 214-904-0577
You could also call Judith Harper Graham, CNM of Amazing Beginnings Birth Services.
214-938-2885 www.AmazingBeginnings.com
Even if neither of these midwives are not able to attend a VBAC, they will certainly know who is. By: Barbara |
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Archived User
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| 01 Jul 2005 03:12 PM |
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You and your client have my sympathy. It's dark days out there. It boggles the mind that women are being forced to agree to major surgery in order to obtain medical care, and so few people think this enormous violation of medical rights is a problem. But I digress . . .
Send your client to the Maternity Center Assoc. website to read Should I choose VBAC or repeat c-section? I think she will find everything she needs there, including info from up-to-date research, issues to consider in order to make an informed choice, and how to maximize her chances of having a safe, satisfying birth whether she decides to plan VBAC or repeat cesarean.
-- Henci By: Henci Goer |
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Archived User
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| 01 Jul 2005 11:35 AM |
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I have a client who had what potentially was a "failure to be patient" cesarean last year. She is pregnant again and wants to VBAC, but her confidence was very shaken. They sold her the old "your baby was just too big" (9 lbs 1 oz, I think?) and that wasn't the only "fudging" of the truth that I witnessed - did I mention that they told her it was never going to happen and the baby would never fit, right at shift change on the Saturday morning of the holiday weekend? Yeah, someone wanted to go home...
Anyway! I think we have a lot of work to do, we meaning her, but I would like to help in any way I can. Reading TTWGTABB is number one on my recommended list for her, I've already given her the ICAN website (unfortunately there are no local chapters here in Dallas anymore), and I have found some care providers who will take VBAC's... although hospital birth in my area is nowhere even remotely Mother/Baby friendly, no matter who your provider is. Most providers won't even offer TOL anymore, though, so at least I found a few who would. I put her in touch with some midwives who offer VBAC's at out of hospital birth (birth centers and home). I believe there were at one time, some Birthing from Within classes being offered- I think she might find that very valuable and am going to suggest it, if they are still going on.
As her doula and her friend, is there anything else you would suggest that I can do, resource-wise, to help her regain her shattered confidence in normal birth? And is there a good list of questions to ask when interviewing a provider specifically with regard to VBAC, that I could direct her to? BTW, I don't think there are any area hospital providers here who won't insist on CEFM with a VBAC, IF they will take a VBAC at all. And CEFM starts us the road to more interventions... sigh.
Delilah By: delilahdr1 |
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