Time lapse between CS and VBAC significant?
Our referral hospital advises repeat CS for women who will birth
in less than 24 months from their last CS because of the increased
risk of uterine rupture.
Can you point me to the research around this issue?
I find that not all hospitals have this belief, therefore is it
In the past I have attended many successful VBAC, not all of
which came after 2 yrs from the last CS.
As it happens, I have the research at my fingertips. I've been
working on a new edition of my first book, Obstetric Myths
Versus Research Realities, this time with a co-author, Amy
Romano. (BTW, Amy has a new blog for Lamaze, Science and
Sensibility, that might interest you.) I finished the VBAC
chapter a few months ago, and I have five studies
reporting on scar rupture rates according to either interpregnancy
or interdelivery interval. Studies differed in which measure
they chose and the length of the shorter interval. Nonetheless, the
scar rupture rate with the shorter interval ranged from 1.1% to
2.8%, or a 97% to 99% likelihood of an intact
uterus. Interestingly, the studies at the two extremes both
measured the same interval: an interdelivery interval of less than
or equal to 24 months vs. greater than 24 months. This tells you
that something else is affecting rates. That something is likely to
be single- uterine suturing, induction of labor, or the two
Bujold E, Mehta SH,
Bujold C, et al. Interdelivery interval and uterine rupture. Am J
Obstet Gynecol 2002;187(5):1199-202.
Huang WH, Nakashima DK, Rumney PJ, et al.
Interdelivery interval and the success of vaginal birth after
cesarean delivery. Obstet Gynecol
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
Shipp TD, Zelop CM,
Repke JT, et al. Interdelivery interval and risk of symptomatic
uterine rupture. Obstet Gynecol
Stamilio DM, DeFranco E, Pare E, et al. Short
interpregnancy interval: risk of uterine rupture and complications
of vaginal birth after cesarean delivery. Obstet Gynecol
I eagerly await your new version of your book, I lend my copy
out to women who question the protocols that I must bring up with
them even if I don't agree. I have to obey protocol but the women
know they don't have to follow protocol themselves.
Have you got around to comparing the statistical risk of uterine
rupture in a woman in spontaneous labour, one previouse CS with
double layer closure and no other risk factors, to the risks of
booked CS to eliminate the risk of rupture?
I have four studies
of truly elective repeat cesarean in which the cumulative scar
rupture rate was 0.2 per 1000. I can't quite nail down the rate in
your optimal-for-VBAC population, but it should be 4 per 1000 or
less. Four per 1000 was the rate in the big Landon 2004 study in
women with spontaneous labor onset who labored without oxytocin
augmentation. In the birth center VBAC study, the rate in women
with one prior cesarean who had not reached 42 weeks gestation was
2 per 1000. These women, too, would have had spontaneous onset and
no augmentation. Put positively, the women you describe should have
a 99.6% to 99.8% odds of an intact uterus. Moreover, in the few
women who had the scar give way, except for rare cases, the
only adverse outcome would be an urgent repeat cesarean. Against
this, must be considered the potential harms of accumulating
cesareans for the mother, baby, and
Thank you for your
enthusiasm about the new edition.
Blanchette H, Blanchette M, McCabe J, et al. Is vaginal
birth after cesarean safe? Experience at a community hospital. Am J
Obstet Gynecol 2001;184(7):1478-84; discussion 84-7.
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.
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.
Loebel G, Zelop CM, Egan JF, et al. Maternal and neonatal
morbidity after elective repeat Cesarean delivery versus a trial of
labor after previous Cesarean delivery in a community teaching
hospital. J Matern Fetal Neonatal Med 2004;15(4):243-6.
McMahon MJ, Luther ER, Bowes WA, Jr., et al. Comparison of a
trial of labor with an elective second cesarean section. N Engl J
Spong CY, Landon MB, Gilbert S, et al. Risk of uterine
rupture and adverse perinatal outcome at term after cesarean
delivery. Obstet Gynecol 2007;110(4):801-7.
The specific woman I was after the info for had an empowering
VBAC a couple of days ago. As well as the books I have, I
downloaded as many of the above articles as I could and gave them
to the couple to read. The reading they did and the support I gave
had such a great outcome, her grin is a mile wide.
I love happy endings! :-D
I'm not a medical professional, just a mom trying her best to
avoid another c-section, and was dearly hoping for your input.
I had my first c-section for breech presentation 6/2007. Though
my current OB was initially supportive of my overarching desire to
VBAC for my last pregnancy (b. 2/2010), I started to get the "let's
go ahead and schedule that c-section) from week 33 on, despite
my adamance and with absolutely no medical reason on their part. I
had a very high leak at 39-weeks and after approx. 30 hours at home
with increasing though irregular contractions, ended up
going into the hospital due to all the OB calls/pressure, and of
course being concerned. After being there for 9 hours hooked up to
pitocin, the baby had a couple of heart decels, and it was off to
the ER for another section. I must add that the OB on call was
completely done with me by that point, and was still miffed that I
hadn't gone straight into the hospital after my leak was confirmed.
I believe I only got to around 2cm...not great progress, but then
again, my body was completely not ready at that point. Both of my
sections were terrible experiences for different reasons, with
long-term recover implications, though I was indeed blessed
with two fine babes.
I am currently 11-weeks pregnant - a bit sooner than we had
planned, but a blessing nonetheless. My current OB has said they
will "allow" me to try for VBAC if I go into spontaneous labor
before 39 weeks, otherwise it's a section. Unfortunately, because
of my previous experience, I've simply lost all trust in them,
and have been looking elsewhere. Yesterday, I visited the only
OB practice in my area that actually has delivering midwives on
staff - kind of my "last resort" - and received a call today that
they won't take me as a VBAMC due to the fact that there will be
less than 18 months spacing between my births, that the
rupture rate is a "staggering 4%", and they just won't take that
risk. I have a couple of other possibilities in the area, but
would love to know if this is indeed true. I know short
interpregnancy is a additional risk, but I can't seem to find the
data to back this up, even from ACOG's most recent VBAC bulletin. I
live in NC - as you may or may not know, we are midwifery
backwards, and section crazy.
Homebirth is of course an option, but with 2 sections and a less
than ideal spacing, it's not my "comfortable" preference. Any input
you might be able to lend would be infinitely appreciated. Would
love to have some rebuttal info out there if there is indeed some
Very best -
To begin with, as an earlier post of mine (13 May 2009) in this
thread makes clear, the risk of scar rupture is not 4%, but 1% to
3% and that it almost certainly varies depending on other factors
such as how the uterus was sutured and whether the woman was
induced or augmented. Second, what happened to your right to refuse
surgery? As your post makes clear, the new medical care providers
you consulted would force you either to agree to major surgery and
run the risks of not only that operation but the risks of
accumulating cesarean surgeries or forego hospital care. The same
goes for your current ob who will only "allow" a VBAC if you go
into labor before 39 w, a stricture for which there is no
supporting evidence of which I am aware. The best I can
do for you is give you some ammunition for securing your rights. I
hope it helps or that you can find other care. To find other care,
see if there is a chapter of
International Cesarean Awareness Network in your area, try the Birth Survey to see if anyone
local is listed, or talk to the doulas and independent childbirth
educators in your community.
From the American Congress of Obstetricians and Gynecologists'
latest VBAC guidelines (2010) (not available electronically):
"Respect for patient autonomy supports the concept that
patients should be allowed to accept increased levels of risk . . .
Respect for patient autonomy also argues that even if a center does
not offer TOLAC, such a policy cannot be used to
force women to have cesarean
delivery or to deny care to women in labor who decline to
repeat cesarean delivery."
And from more general sources:
“In order to ensure
consumers' right and ability to participate in treatment decisions,
health care professionals should:
Provide patients with easily
understood information and opportunity to decide among treatment
options consistent with the informed consent process.
Discuss all treatment options with a
patient in a culturally competent manner, including the option of
no treatment at all. . . .
Discuss all risks, benefits, and
consequences to treatment or nontreatment.
Give patients the opportunity to
refuse treatment. . .
Abide by the decisions made by their
patients . . . consistent with the informed consent
“A hospital must protect
and promote each patient’s rights. . . . The patient’s
rights include . . . being able . . . refuse treatment. . . . The
patient has the right to be free from all forms of abuse or
“You have the right to be
informed about the care you will receive. . . .
You have the right to make decisions
about your care, including refusing care.”
All Times America/New_York
Please note that this Forum is intended to help women make informed decisions about their care. The content is not a substitute for medical advice.