I am sorry for the tragedy at your hospital, but appreciate the true-life illustration of the speciousness of singling out VBAC for the "cesarean immediately available" criterion in ACOG's VBAC guidelines. Other conditions occur in labor that demand immediate cesarean. Indeed, labor induction and epidural anesthesia can cause rare, life-threatening complications requiring urgent cesarean, but you do not see ACOG confining their use to hospitals capable of providing one. I have said it before and will say it again: If obstetricians declare a hospital isn't safe for a VBAC labor, they are saying it isn't safe for any woman to birth there.

-- Henci

There is a false sense of security that giving birth in a hospital can save all babies and mothers.  In the small community hospital, with limited resources, it is not possible to perform a STAT c-section during off-hours.  The anesthesiologist and OR personnel are  home in bed at night and need to be called to come to the hospital.  This can generally take 30 minutes or more.  With a uterine rupture in the hospital during off-hours, this baby, too would've died in 30 minutes.  This very scenario just occurred in our local hospital with an abruption.  Ten years ago a mother died because of this lack of 24-hour coverage.  There were signs of fetal distress while pushing, which quickly led to severe bradycardia.  It was ultimately discovered this was due to abruption. The doctor had the choice of waiting for the OR staff to get there or to try a mid-forcep delivery.  The mid-forcep delivery caused a severe uterine laceration which they attempted to repair, but she went into DIC which  eventually led to cardiac failure 8 hours later.  Many home births occur within 30 minutes of a hospital. 

I think you may be being too hard on WI ob/gyn. I'm not saying the kind of person you write about doesn't exist, but ob/gyn didn't come across at all as someone with self-interest in mind--not that concern for Jeannie and her baby's welfare makes telling a disaster story right, but it is human to try to persuade people to do what you think they should do. What is more, everything in ob/gyn's training and experience would have taught ob/gyn that doing whatever it takes is appropriate. In fact, ob/gyn seems supportive of VBAC and possibly even of home birth, but not the two in combination, which puts ob/gyn way ahead of many of his colleagues who support neither. Ob/gyn also had a tragic experience in connection with a home VBAC that would definitely color ob/gyn's feelings. Again, it doesn't make ob/gyn right to try to "scare women straight," but it doesn't make ob/gyn a bad guy either. And maybe my post gave ob/gyn food for thought on why women "choose" home VBAC.

-- Henci  

Dear OB in WI,

The horrific details you provided of one woman's birthing experience seem over the top unnecessary.  The very fact that you chose to relate this story at all causes me to wonder what types of scare tactics you employ in your practice to get women to do what you want them to as opposed to taking a strong and empowering position in their own birth experience.  But then again, you do stand to earn a lot more from repeat c-sections than you would if more women chose to birth at home.  It would be much more helpful if you stuck to evidence based research when offering your opinion. 

Namaste,

An informed and educated Mother

I agree with you that in an ideal world where women received optimal care (defined as care that uses the least intervention to achieve the best outcomes given the woman's individual circumstances), a hospital VBAC would be preferable. Unfortunately, we do not live in such a world--at least not in this country. In many cases, women cannot get a VBAC at all, which amounts to forcing them to agree to major surgery in order to obtain medical care, or they can only get what I call the "Cinderella VBAC" except without a fairy godmother to magically overcome the stepmother's obstacles: "You can have a VBAC IF you only have one prior cesarean and IF your prior cesarean wasn't for dystocia and IF the baby isn't too big and IF you go into labor by your due date and IF you progress smoothly and quickly," and, in Jeannie's case, "IF you get pregnant at a sufficient interval from the last pregnancy." You might respond that Jeannie didn't say she was denied a VBAC, only that she was "recommended" a cesarean, but you can imagine the difficulties for a woman in labor to be attended by medical staff who disapprove of what she is doing and think it is risky.

I think, too, that if you will reread my response, you will see that I did not try to talk Jeannie into (or out of) a home birth. I did for her what she was very unlikely to get from her care providers: I gave her the objective facts, to wit, that the odds were 99% that she would not experience a scar rupture and possibly better because she would not be exposed to interventions that would increase her risk.  I give Jeannie credit for understanding that 1% isn't 0% and what the possible consequences of scar rupture might be. I take my stand on the principle that women have the right to informed consent and refusal. What women almost always get from medical care providers, though, is an attempt to persuade them to do what their care provider thinks they should do. (There is data on this point, for ex., Listening to Mothers II, a survey of U.S. women giving birth in 2005, found that most women, including women who had cesareans, either did not know or got wrong four questions on cesarean complications.) I hope you will forgive me for pointing this out, but your own response of telling a story of a home VBAC gone horribly wrong falls in that category. If I had wanted to push Jeannie toward home birth, I could have told an equally terrifying story of a catastrophic outcome of an elective repeat cesarean or cited the frightening statistics on the increasing risks with accumulating cesarean scars.

As for how things went for Jeannie, we can't know that unless she chooses to post again. And in answer to your other question, some of my posters are midwives or nurses, obstetricians: not so much.

-- Henci

Jeannie and Henci,

Having submitted the above blog, I noticed that the patient has likely delivered by now.  I would be curious how things went in terms of the delivery or other feedback you recieved from providers.

Perhaps my response will be helpful to others.

Dr. OB/GYN in WI

Dear Henci and Jeannie,

I have been a practicing OB/GYN in WI now for 10 years.  I have tried to remain objective in terms of the arguments regarding home birth vs. hospital birth.  In fact, WI recently joined about half of the states in certifying Lay Midwives.  The arguments over how women birth are extremely emotional and neither 'side' will ever agree.  I believe women should be empowered to make decisions for themselves, and I think that both sides want whats best for the mother (and the child!).

I have never before "blogged" or responded online, but perhaps my two cents will be worth something to both of you.  First, I believe that you are an excellent candidate for a VBAC having had a prior C/S for breech.  Anyone who says otherwise is clearly biased and there may be other factors involved (a hospital that does not do VBAC's?).

I recently performed a repeat C/S on a patient who was having her third child.  Her first delivery was a C/S for failure to progress.  Her second delivery was a home VBAC.  During that labor, she had a rupture of the uterine scar.  She delivered a stillbirth (because of the uterine rupture) and almost bled to death by the time she reached the hospital.  I truly believe that this was a preventable death and would have played out differently in the hospital setting (because of her history of a prior C/S).  There ARE signs of uterine rupture that can be detected BEFORE such a disaster occurs that can be detected with continuous fetal monitoring during active labor.

While you can both quote statistics and try to talk yourselves into the safety of a home birth in your case, it seems clear to me that you would have less chance of a bad outcome in a hospital setting (given your prior C/S).  Consider that while <1% chance of uterine rupture sounds unlikely, if it happens, it is not going to turn out well.  As I sometimes say, "nothing is rare to the person it happens to".  Please consider delivering this one IN A HOSPITAL  with a provider who you trust and who will respect your wishes.

Thank you for listening and good luck.

Dr. OB/GYN in WI 

I have the research on the association between interdelivery interval and scar rupture to hand because I recently finished writing the chapter on VBAC for the forthcoming new edition of Obstetric Myths Vs. Research Realities. The biggest of the studies, 18,000 women with prior cesareans, reported a rate of 1.1% with interdelivery interval less than or equal to 24 months compared with an overall rate in women with one prior cesarean of 0.7%. That was without adjusting for labor management that could increase the risk of scar rupture such as inducing labor or giving oxytocin to strengthen contractions. (A different analysis of the same database found that the odds of scar rupture were 0.4% with spontaneous labor onset and no oxytocin augmentation compared with 1% with induction and 0.9% with augmentation.) In other words, you have a 99% chance of having no problems with the scar and probably even better than 99%.

-- Henci

Landon MB, Spong CY, Thom E, et al. Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. Obstet Gynecol 2006;108(1):12-20.

Hi Henci,

I am currently 5.5 months pregnant with my second baby. I had my first baby via c-section because of breech presentation December 2007 (although I was able to go into labor naturally for 11-12 hours prior to the surgery), which means my deliveries will be about 16 months apart. Due to the fact that I've been automatically labled high risk by my HMO and have been recommended for a repeat c-section, I have decided to attempt a homebirth with a very qualified midwife (over 30 yrs exp.). However, I have been reading some literature that suggests my risks for uterine rupture are increased because of the short time in between pregnancies and deliveries.

I've read several of your posts surrounding uterine rupture, but didn't see anything about pregnancy/delivery intervals. What information can you provide me? Also, what research have you seen to support having an ultrasound at 37 weeks to determine rupture risk?

I know the decision is ultimately up to me, but I'm looking for some reassurance as to whether we've made the right decision to have a homebirth. I don't see the hospital as a perfect solution either, but rather a situation in which I feel I may be forced into another c-section. Any data/advice you can offer is appreciated.

Thank you, Jeannie