All VBACs are not created equal

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Several weeks ago I wrote about the one size fits all approach of homebirth midwives. No matter the question, the answer is always homebirth.

Natural childbirth advocates have a one size fits all approach, too:

Personal characteristics are irrelevant. Advanced maternal age, maternal obesity, pre-existing maternal disease? It doesn’t matter because the counseling and treatment plan are always the same: you can and should have an unmedicated vaginal birth.

Medical history is irrelevant. Had a previous shoulder dystocia, C-section, postpartum hemorrhage? Who care? You can and should have an unmedicated vaginal birth.

Complications are irrelevant. Baby is breech, have gestational diabetes, colonized by group B strep? Who cares? You can and should have an unmedicated vaginal birth.

Labor complications are irrelevant. Dysfunctional labor, prolonged rupture of membranes, pushing for 4 hours? Who cares? You should still stay home because you can and should have an unmedicated vaginal birth.

In my piece about homebirth midwives, I ascribed this one size fits all approach to ignorance and dogma, and that goes for natural childbirth advocates as well. Ignorance refers not only to obstetrics, but also to basic statistics. One facet of this ignorance is the mistaken belief that statistics for a group as a whole apply equally to each individual.

Take the case of VBAC (vaginal birth after Cesarean). The overall success rate for attempted VBAC is nearly 76%. Natural childbirth advocates think that means that each individual woman’s chance of a successful VBAC is also nearly 76%. Nothing could be further from the truth. Both the chance of having a successful VBAC and the chance of a uterine rupture are modified by past medical history and factors in the current pregnancy. That was the take home message of the lecture on VBAC that I attended at the recent Harvard Medical School Review of Obstetrics .

For example:

History of a previous vaginal birth impacts the chances of successful VBAC Women who have had a previous vaginal delivery (VD) have an 86% chance of successful VBAC, and women who have had a successful VBAC in a previous pregnancy have a nearly 90% chance of having another. But for women who have never had a VD, the chance of successful VBAC is only 61%.

The reason for a previous C-section also impacts the success rate of attempted VBAC If the previous C-section was done for a non-recurring condition like breech, the chances of successful VBAC are higher than for women whose previous C-section was performed for dystocia.

The larger the baby, the lower the chance of successful VBAC Although macrosomia (baby larger than 4000 gm) in the absence of other risk factors is not an indication for repeat C-section, the size of the baby definitely affects the chance of success. For example, while a woman who had a previous C-section and no vaginal deliveries has an overall chance of successful VBAC in the range of 60+%, the chance of success drops to 38% if the baby is over 4500 gm. And if the previous C-section was done because the baby didn’t fit, the chance of a successful VBAC with a baby over 4500 gm is only 29%.

Other factors also have a large impact on success For example, if the baby’s head has not descended into the pelvis at the start of labor, the chance of successful VBAC drops to only 10%.

Maternal factors affect success The chance of successful VBAC drops as maternal age increases, and as maternal BMI (body mass index) increases. Women over age 35 and women with a BMI greater than 30 have a lower chance of successful VBAC.

The most dreaded complication of attempting a VBAC is rupture of the uterus, leading to massive hemorrhage, death of the baby and possible death of the mother. The risk of rupture also depends on the circumstances surrounding the previous C-section and characteristics of mother and baby in the current pregnancy.

Overall, elective repeat C-section is safer for the baby, and vaginal delivery is safer for the mother But those risks are not equal. The risk of death of the baby in attempted VBAC is 10X than the risk of death of the mother from a repeat C-section.

The worst situation for both mother and baby is a failed attempt at VBAC. While the overall risk of uterine rupture is 7/1000, that jumps to 23/1000 in a failed attempt. Therefore, the risk of rupture is directly dependent on the chance of success.

Other factors also affect the risk of rupture These include the type of incision on the uterus (transverse is safer than vertical), the length of time since the last pregnancy (an inter-pregnancy interval of less than 6 months triples the risk of rupture), and the timing of the previous C-section (a preterm C-section has a higher risk of rupture in a subsequent pregnancy than a term C-section).

The bottom line is that an individual woman’s chance for a successful VBAC and risk of a uterine rupture depend on her specific circumstances.

Should a woman try for a VBAC?

Natural childbirth advocates, who take a one size fits all approach to everything, will counsel every woman to attempt a VBAC and quote an overall risk of success that may not actually apply to that woman.

In contrast, obstetricians, who provide care customized to the individual woman, can offer her a realistic assessment of her chances of a successful VBAC, and a realistic assessment of the risk of a uterine rupture. Ultimately, of course, each woman has to decide for herself which risks she is willing to take, but she can only make an informed decision if she has all the information. The one size fits all approach does not allow her to make an informed decision.

Only a personalized risk assessment, based on HER history, HER medical conditions, and the size and position of HER baby will allow her to make an informed choice for VBAC or elective repeat C-section.

  • Kathy

    Homebirth midwives in WA state do not do VBACs and they absolutely take past history into consideration. I wish you would not lump all homebirth midwives in the world into one category. There is so much variety. But, by lumping them all into one category, you not only alienate anyone who wants to use a midwife or has used a midwife, but you also alienate anyone who just is sick and tired of the wars going on between women. It is fine to use solid science to make your point. But stereotyping all natural childbirth advocates and all midwives weakens your argument considerably.

    • Ash

      In Washington state? Please tell me what prohibits CPMs from TOLACs at home.

      http://apps.leg.wa.gov/RCW/default.aspx?cite=18.50&full=true#18.50.108

      Midwives’ Association of Washington State does not say that it is prohibited in their documnents.

      http://www.highlandmidwife.com/AboutUs.html

      You may be confusing Washington state’s policies about what is permitted in birth centers vs birth in a woman’s home.

      • Bombshellrisa

        The midwives always have the disclaimer that their malpractice insurance doesn’t cover VBAC and the clients’ insurance will not pay the fee for a HBAC but does NOT say that the midwife will not attend it. The client contracts for care for midwives who are known to attend (but don’t advertise the fact) HBACs are password protected.

        • Kathy

          The midwifery malpractive insurance for washington state presently excludes all VBACs. So, yes, you can possibly find a midwife to do a vbac but she won’t have malpractice insurance and therefore will not be licensed.

          see page 6

          http://www.washingtonmidwives.org/documents/MAWS-VBAC-GUIDELINE-12.26.12.pdf

          • Bombshellrisa

            The midwives listed above are all licensed in WA state. The list needs to be edited to include Sherry Dress, Elizabeth Trautman, Andrea Henderson, Linda Morgan and Beth Morrill.

          • Bombshellrisa

            http://www.midwiveswashington.com/midwife-list-wa-3/ here is the list of licensed CPMs in WA state. Most of the ones who have had disciplinary action taken have reports that can be read. HBACs, twin births and breech births are among them.

      • Kathy

        please see my comment blow to bombshellrisa. You would need to contact Highland midwife to ask her about her vbac stats. It may be that she has no malpractice insurance or that the percent refers only to breech babies.

        • Bombshellrisa

          Lorri Carr states in her contract of care that she doesn’t have malpractice insurance and that any client who chooses to retain her as a midwife understands this.

        • Ash

          Your post: “Homebirth midwives in WA state do not do VBACs.” Well, clearly some do.

    • Bombshellrisa

      Yes they do. Lorri Carr’s info sheet on her client care contract for VBACs states this: “Legal liability issues: Your midwife does not have malpractice insurance coverage for VBACs. Your insurance policy may not reimburse providers for VBAC, so you may be liable for the entire fee; this can be determined in advance.
      Informed Choice
      I have reviewed my operative report and obstetrical records with my midwives. I have read and understand the information regarding potential risks and benefits involved with vaginal birth after cesarean section, and have done my own related research. I understand that there is no malpractice insurance coverage for circumstances arising from, or in conjunction with, my decision for VBAC. I have discussed this with my care providers and have had all my questions answered and I choose to plan for an out-of-hospital VBAC.”

      • Kathy

        Well who in their right mind would use a medical provider who does not carry malpractice insurance. That’s a whole different issue. I was unaware of this. My midwife told me, in 2007, that malpractice insurance does not cover vbac and she would refer any and all risky pregnancies to an OB, as per her malpractice insurance limitations.

        • Bombshellrisa

          There are so many women here who have found out the hard way that their midwives don’t have malpractice insurance. I was a midwifery student in WA state and found out the ins and outs of how this works, no matter what the law said.

    • Bombshellrisa

      Moonrisehealth.com (Brandy Ross-Bell), CPM, ND)

      Being a Naturopathic Physician and Midwife makes Dr Ross’s care second to none.Dr Ross was the first of seven midwives to accept me as a vbac patient without hesitation or giving the impression that my birth was going to be an imposition.My family and I were so impressed with the quality of care that Dr Ross provided during my pregnancy, we decided to stay with her as our family physician.You are in a knowledgeable, professional, and truly caring set of hands when you are with Dr Ross.

      Happy Mommy
      http://onetreephotography.com/2011/05/louisas-birth-story-seattle-birth-photography/
      This is the birth photography of a VBAC Brandy Ross attended at home

      • Bombshellrisa

        Sunrisemidwifery.net “Currently, my VBAC rate is 95% (approximately 20 total VBACs).” This from Kristin Eggelston, home birth midwife in WA state

  • somethingobscure

    I appreciate having the stats and perspective this blog provides! There is so much information out there from non-medical professionals, I think this is a very important point of view.

    I’m not sure if there is a direct email or contact address for queries, but I couldn’t find one, so I’m just going to post my question here.

    I’m pregnant with my second child now. My first was a cesarean because my son had severe heart decels while I was pushing, and his heart rate wasn’t recovering quickly so a c-section was recommended. I had a midwife in a hospital, overseen by an ob, as was standard care at my hospital. I did not have an epidural, as it just never occurred to me while I was in labor. I was supposed to have intermittent fetal monitoring, but it ended up being constant from the time I first entered the hospital at 6cm because of heart decels during contractions. At +1 station, the ob attempted a vaccum extraction but after 2 attempts he only moved to +2, and after each contraction they were scrambling to find his heart beat, so based on his heart rate fluctuations they recommended a c section. I felt great about this decision, and I have no guilt/feelings of sadness/whatever that I didn’t have a vaginal birth because it was what my son needed.

    Now I’m not sure what to do. I have been cleared already as a good candidate for vbac if I choose it. I had a low transverse incision, no risk factors, age 26, previous c section was 18 months ago, due to fetal concerns not labor problems, I did fully dilate during my first labor, not a single concern that I am not a good candidate. What I have a hard time with is parsing out what is truly safest for me. And I say me because that is my biggest concern. I have one child already, and I have no intention of leaving him and potentially another child motherless because of my childbirth choices. I would be devastated if I had a still birth, but what I mean to say is that I can always try for another baby or adopt, but my babies cannot get another mother. For that reason I want to choose whatever is safest for me. You state quite plainly that vbac is safer for mothers. But what about the risks of a failed vbac or a uterine rupture? I would like to know — when all is said and done, when no pre-labor risks are present besides previous c section, which option is empirically safer, vbac or rcs?

    • anon13

      I’m not Dr. Amy, but I think you are right that a VBAC is safer for the mother. If you have your trial of labor in the hospital, any issues are found quickly and there can be a quick conversion to a c-section. Most likely, your VBAC will be fine.

      Discuss with your OB what factors contributed to your first section – nuchal cord, short cord, large head, bad position or whatever? That should make you feel more at ease with a VBAC if those are unlikely to recur.

      There is a Facebook group, VBAC and Birth after Cesarian that is evidence based if you would like more perspectives.

    • fiftyfifty1

      The biggest factor by FAR is how many babies you plan. The risk to mother goes up a lot if she has had many CS because of the risk of the placenta attaching to the scar and actually growing into the uterine muscle. When this happens, it is really risky for bleeding. If you plan just a family of 2 babies, that is not an issue, but if you are planning 4 or more, it really is an issue. 3 babies is in the gray zone.

      Keep in mind that it is really easy for anti-CS groups to twist maternal mortality stats. Yes, more women die after CS than die after vag birth, but that’s because some of these women are having CS for things like diabetes, heart disease, kidney disease, car accidents etc. These stats don’t apply to you.

  • Heather

    My CNM does home births and will not do home VBACS, breech, twins and many other higher risk births. So no, the answer is not “always homebirth” for a competent midwife. Just not true.

  • Twins+one_mom

    Yeah One size fits all, its’ not remotely realistic. My first pregnancy was a twin pregnancy. Overall the pregnancy went smoothly, no serious complications until we hit 35 weeks. My doctors were thankful, and happy that we had made this far, namely because a lot of twins have a habit of delivering early. But I didn’t have a single contraction, didn’t dilate at all.
    At 35 weeks, I developed gestational diabetes and pre-eclamsia, I started going to see my doctor every 2 days, and when He decided that it was no longer safe, we had C-section at 36 weeks a 3 days. The twins were in a breeched position and a transverse position. When the doctor told me that later, all I could think about was all the people that told me to try natural labour, that c-section was the worse way to go. No way in Hell was I going to deliver either of then. Nobody was even low enough to start the process.
    Next pregnancy, on paper I am a perfect candidate for a VBAC, I waited 3 years between pregnancies, my last c-section was not due to a “failure to progress”, but due to emergency reasons. All the doctors and nurse and any other medical professional told me that VBAC was the best choice for me. It was an ideal circumstance for a VBAC.
    Well with 5 doctors (I attended an OB clinic up here in Canada, common in rural areas here), 10 RNs, countless nurses, and several other professionals all insisting that I was okay for a VBAC, I said “okay, there a general agreement here, that this is a very real possibility for us, and that you all believe that there will be a safe, good outcome”
    Truth is that no one had to convince me, they had to convince my body and the baby, neither of which agree. Well more my body, then the baby. If all had been good, the baby mostly likely would have done her thing all fine and good, she tried to several times. But there a twist or so to my body, almost literally.My doctor explained it to me in layman terms. My pelvis is wide enough for the baby to fit through, but my uterus is too awkwardly shaped. So even time the baby went to “drop”, she bounced back up and she did do this several times. Not fun. Given enough time, I would have gone into labour, but Baby would have died in labour or already be dead by that time, and I would have serious health problems or worse. The doctors (different doctors) didn’t notice with the twins, because it was just naturally assumed that the twins didn’t have the room to “drop”, they didn’t but they were doing to either way.

    So I had a 2nd c-section at 39 weeks and 2 days. The doctor was just upsets about it, he said that he found very little scar tissue from my last c-section when he opened me up. He joked with my husband that he had a hard time finding the scar, or any scar tissue at all. Due to this he believed that I would have had a very low chance of a rupture. On paper, I looked perfect, my body had other paperwork though.
    And the doctors were realistic about this, when I didn’t go into labour before 39 weeks, they examined me, talked to each other, and came to the conclusion, I could still try, but I was very likely to end up in the OR either way or the baby could end up in trouble. It was up to me and my husband.
    My 3rd daughter is on her play-mat beside me right now, trying her hardest to roll over for the first time, she’ll be 4 months on Friday, and she’ll be meeting her paternal grandparents for the first time this weekend. It wasn’t a hard choice, risk her and me over nothing. I am never going to deliver naturally, and interventions had nothing to do with that fact, it just me, and the way my body is. I have 3 children and have never felt a contraction, and most likely never will.

    • Young CC Prof

      Yay science for giving you three healthy children without significant risk to yourself!

  • Wendy

    The point of the whole birth experience is NOT the process, but the child you hope to greet and nurture when the birth is complete, whichever way it happens. I just wish people wouldn’t worry about CS and feel inadequate or disappointed if they end up needing one.

    I had a CS after a long labor with my first, who turned out to be 10 lbs and, despite induced labor progressing well and full dilation, he never descended despite my best pushing (and I tried all kinds of positions and whatnot). I was happy with the CS because I had a beautiful son next to me and that was the only goal of the process. I had no birth plan other than a live baby and a live mom. Plus, when I saw the enormous size of his head with this cone on the middle part where he’d been trying to descend, I thought ‘AHA’ and was glad we had a convenient, safe, awesome place to do the CS.

    For my second child (3.75 years later), I was interested in the possibility of a VBAC since it had been several years, and I remembered the recovery after a CS being particularly rough (of course mine was rougher after full on labor than if it had been planned CS). My OB was totally straight up with me; he said VBAC was an option but only if several things went ‘right’ to facilitate it. Like: going into labor on my own, preferably a week early, with a baby who was smaller than my first, and no other pregnancy complications to deal with. I thought all this was unlikely to happen so we scheduled the CS—had the date and OB booked and everything.

    As it turned out, all the things the OB stated to be the preferable conditions for a VBAC came to pass, so I had a successful one, and was happy about it, too. But no more so than my first birth; I felt equally proud of each experience and equally connected to each child.

  • Christine

    I can’t speak with any kind of experience on home birth midwives, but there is DEFINITELY a one-size-fits-all approach to VBAC in “vbactivist” circles. There’s a laundry list of interventions you MUST avoid if you want a successful VBAC (ie. all interventions), no matter how innocuous. You MUST push from any position EXCEPT lithotomy. You MUST go against hospital policy by eating labor; you need your strength, and if you follow the script, you won’t need a c-section anyway. Above all, any attempt to rain on your VBAC parade is just a doctor trying to manipulate you into a c-section so he can get to his golf game, natch’.

  • Christine

    Thank you, Dr. Amy! I had my first VBAC 6 years ago, and it was with a CNM in a hospital. At the time, I had an extreme “birth junkie” mentality, and while the midwives really didn’t have any hard numbers yet. I must say that they were very patient with my naive requests, but also made it clear that we must work within the hospital guidelines. The birth was long (posterior baby, would not engage in my pelvis for anything), but free of any complications. I gave myself a congratulatory pat on the uterus for beating “the system”.

    Three years later, I had my second VBAC. Same midwife, same hospital, only I was much less of a control freak. For the first 21 hours or so, everything was moving right along, when my posterior, unengaged baby decided to turn transverse… and from there is was a shit storm of one unexpected complication after the next, including an external version, then I spiked a fever (GBS+, and had not finished the full course of IV antibiotics yet). Shoulder dystocia (ironically, he was my smallest baby), then the little scamp rotated on the dismount and came out at such an angle that I sustained a 4-degree tear, which required 2.5 hours of surgery to repair. Without pain relief. The recovery was many times worse than my c-section.

    Anyway, I became a pariah in the VBAC community because I refused to gloss over the hellishness of my 2nd VBAC.Not only do they paint all “interventions” as being roadblocks to a VBAC, they have such a single-minded focus on vaginal birth being the ultimate prize. There is no room for dissent. There are no objective discussions of statistics, only shrill histrionics. And it’s fueled by women who have been convinced (like I once was) that they have been “robbed of their birth experience” and VBAC is the only means of restitution.

  • wookie130

    Thank you for posting this. I am 35, and 21 weeks pregnant with my son. I had my first child, my daughter, at 34, via elective c-section due to marginal placenta previa. I was offered the opportunity to attempt a VBAC with this baby, but I’ve declined, due to concerns I have about my age, the fact that this will be our last child, and also how closely spaced together kids will be. I just told my OB that I’d prefer they “leave my vagina out of this”, as I’d prefer going with another elective c-section, and I couldn’t possibly be more at peace with this decision.

  • carr528

    I’m so thankful for my midwife when I was pregnant with my second. As we got closer to my due date, she took the time to talk to me about my options for a VBAC or RCS. She was very honest, and I felt like I had all of the information I needed. Ultimately, I chose a RCS, but it was completely my choice, and I never felt bullied into either choice.

  • guest

    This was my problem with my first, one size fits all due to breech, at the hospital, the bullying and harassment i put up with was disgusting and certainly came close to pushing me towards the homebirth mentality, fortunately i finally had an OB who spoke to and treated me as an individual (i was never anti csec but avoid if possible) and i was happy to trust him with what did end up being a VD of my son (yes still breech)
    similar story with my second, i ended up catching him UNASSISTED in the hospital, due to the fact i couldnt be close to pushing if i was only 6cm 20min prior on admission (yes emergency button pushed and hubby chasing someone down as soon as i got pushy feelings), this despite being under the care of the head of MFM at that hospital for my pregnancy (he was awesome but unfortunately for me not required for my delivery)
    this time i HAVE gone with a homebirth midwife, but it is one who is collaborating with an OB who ill have seen half a doz times by the time i go, and plan on going to the hospital for delivery since she has the ability to stay as my main provider there, she doesnt come anywhere near what you describe as the problems with many HB midwives and i will happily promote her over what ive now termed ‘cattle class’ to any friends who get pregnant

    • Karen in SC

      I’m glad you had two healthy babies and congrats on the third!

      But tell me, what would you have done had the vaginal breech ended in tragedy? Thanked the doctor for treating you as an individual while he or she went against the usual standard of care? Granted being at a hospital allows better monitoring and possible conversion to an emergent c-section, but I believe the breech study that was being conducted in the PNW was halted due to a loss and it become unethical to continue.

      Every so often, Captain Obvious lists summaries of malpractice awards from an OB journal. Many are for failure to perform c-sections in time.

      • guest

        The whole thing is about one size fits all, and that was my issue with it, for me it was just fortunate that all things lined up and my risks were as low as you can get, but also why i was in the hospital, constant monitors, an OB who knew how do do breech. the breech trial was also one size fits all and why it was so dangerous, many things would have ruled out VD for me, but when i was in the ideal for a successful birth i wanted to try and everything was continually assessed as i laboured
        in fact ive been asked many times by others who dont know anything to do with breech, whether i wished my first had been the size of my second (much smaller) so it would have been easier, i have to say no, as that would have greatly increased the danger and i would have csec for sure.
        Any good OB or midwife should treat every patient as an individual without compromising care, rather they should be enhancing it by doing so

    • Guesteleh

      I have a lot of sympathy for people who get crappy maternity care from OBs. I was so unhappy with my OB that I switched doctors 28 weeks into my pregnancy. And the antepartum care in the hospital sucked. But going to a homebirth in response is like having a bad dental experience and then letting your neighbor pull your tooth with pliers and no painkillers or antibiotics. Why trade mediocre care for dangerous care? Especially someone like you who is at higher risk for a catastrophic uterine rupture that can kill you and your baby?

      • guest

        why do you consider me at higher risk of uterine rupture??
        and its exactly BECAUSE of mediocre care i have chosen this route, plus we do plan to get to the hospital to deliver.
        labour and birth is nothing like getting a tooth pulled, plus my midwife is fully trained (i have no doubt more so than some of the midwives involved in my care previously) and registered, and can and does work in a hospital setting, painkillers is a no go for me anyway so no care there and if needed my OB will prescribe any antibiotics needed. one of the things my midwife questioned me about was my edd to avoid booking someone due any time around one of her regular trips to an outlying hospital. hardly dangerous care

  • Mac Sherbert

    Thank you for this post. I found this site when I was pregnant with my second child. I was interested in VBAC, but could not find anything on the internet other than butterflies and rainbows about how wonderful they were. My OB gave me a pamphlet, but it was basic and just didn’t satisfy my need for real numbers on rupture.

    I was a good candidate for VBAC and my doctor was completely ok with it and even offered a “soft” induction. My body was showing all the signs of impending labor, but it just would not start. (I was miserable!) I declined and schedule a repeat c-section at 40 weeks 3 days. Now the NCB crowd would say I could have waited longer, but no this baby was conceived using fertility treatments the due was not an estimate! In the end, I’m 100% sure the RCS was the best choice for us. The baby was 9 lbs. plus and it seems labor never started because the baby was to big for my pelvis…not dropping.

    If a woman, wants a VBAC and is a good candidate and knows the risks I see no problem with it. However, it’s like all things be prepared for things to not go as planned.

    While in a sense I understand the argument for VBACs because a woman wants a larger family…In another it doesn’t. Why risk this baby for the possibility of more babies? I had no trouble conceiving my first baby, but ended up with secondary infertility. I wanted three children, but I was lucky to get two.

  • KarenJJ

    If the only tool you have is a hammer, then everything looks like a nail.

  • Sue

    Thanks for the article. This is the way normal health care professionals discuss an area of practice.

  • SF Mom & Psychologist

    Completely OT, but I’m looking for support and resources for a loss mom. My good friend lost her sweet baby girl this morning. The baby was only six days old and born (at 34 weeks) with some very serious problems. She had amazing medical care and fought hard but did not make it. I’ll wait and see how my friend is doing, but any advice, resources, etc. that people can share would be helpful in the event that she wants to find support beyond friends and family. We all feel unbearably sad.

    • Anj Fabian

      Pediatric hospitals have loss/grief groups and are your best bet for finding one closely matched to her needs.

    • Gene

      Contact “now I lay me down to sleep”. They are an organization that will provide free photography services for young babies that die. Beautiful pics to remember her daughter by. They’ve worked with some of my patients before.

    • anion

      Oh, how awful. I’m so sorry.

  • Ellen Mary

    Is there a benefit beyond waiting 9 months? So if a woman decides to wait 18 months or 24 months, would the risk of rupture further decrease?

    I want another pregnancy, and I do want another vaginal delivery. However in a sense, next time it would be like doubling down: now it isn’t enough to just go to the hospital, if I truly want the safest situation for my baby (and for me, psychologically) I have to sign up for the most invasive delivery the hospital has to offer. :*( Something I truly do not want. One compromise is to go to a Regional Trauma Center for delivery, but there are costs & convenience issues there.

    Also given that I won’t be forced into sterilization or hormonal contraception by my births, and I remain opposed on a religious level, that increases the risks further because I will be relying on strict NFP, which still carries a chance of landing me in a 3rd C situation, with even higher maternal age.

    • Ellen Mary

      What I mean is: how can we really expect a mother, in her 9th month of pregnancy with a wanted child, to confidently choose an option she is told is less safe for her baby? I just don’t know if I could, even though by SNMs calculator my chance of VBAC success is over 80% . . .

      • Young CC Prof

        Because, for a pregnant woman who has been medically evaluated and declared a good candidate, delivering in a hospital with the ability to do a STAT c-section if rupture occurs, on CEFM, with IV and epidural pre-placed, the difference in risk is pretty small.

        And because no one really puts safety first in every decision that they make, there is room in life for other considerations.

  • Ducky

    Great post, thank you. I would love to see more posts like this on risk factors! The facts really help to put the debate into context.

  • snm rose

    Have you seen this calculator? The clinical site I’m at (CNM student) uses this in counseling women about VBAC risks & benefits. It helps them outline areas of high risk, potential modifiable factors, and create a discussion about whether or not she would like to try a TOLAC based on these risks/benefits: https://mfmu.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbirth.html There’s also another link at the bottom that takes into account factors at admission for labor. FTR, they still provide care to women who choose an ERCD, which IMHO is the way it should be. We still provide care based on YOUR choice, not based on what we want you to do because it affects our income…

    • Karen in SC

      Does it cover all the factors discussed in the post above? If not, it’s not perfect. Hopefully it’s just a starting point.

      • snm rose

        Obviously it does not cover every potential factor ever, but of the factors Dr. Amy listed, the only one it doesn’t cover is macrosomic baby and my guess for that would be that’s because you can’t certainly diagnosis that until a baby is born. It’s definitely a starting point and never used as “your chance is 90% so you must vbac” or “your chance is 60% so you must ercd.”

        • Haelmoon

          I use that at work. I use it when women are not sure which option they prefer so that they can have a more personalized risk. I explain the limitations. If often results in women wanting a VBAC if they have a spontaneous labour, and an ERCS if there is an indication for delivery (the choice then is between an induction or a c-section). I never use it to convince a woman not to have an ERCS. I do use it for women who are clinically poor choices for VBAC (low chance of a success or higher clinical risk for complications in labour or difficulties performing an emergency c-section – like obese women). It is an objective way to show their low chance of success that does not seem to be me not wanting to attend their VBAC.

    • Box of Salt

      It’s also posted by another commenter below.

  • http://Www.awaitingjuno.blogspot.com/ Mrs. W

    Note: even if the woman is a “good candidate” for a VBACS, her preference should be taken into account…I’ve heard of women (in Canada, of course where the national animal is a Beaver for a reason) being pressured into VBACs they don’t really want.

    • Renee Martin

      It happens here too. VBAC pushers only tell about the places that don’t do them, but no one mentions the ones that push them on those that do not want them.

  • Adelaide GP

    I don’t understand what gives TFB legitimacy to run paid VBAC workshops? I thought she was a doula, ie support person, which is separate to someone qualified to give obstetric advice. Isn’t it against some sort of health policy to be paid when you are in no way qualified to teach in an area? I suspect the answer is no, but I think its ironic that TFB fancies herself to be a public health scholar when these workshops would likely pose a threat to public health as she is peddling dangerous misinformation. She also cannot claim her public health qualification translates to legitimacy in delivering individual VBAC advice. I did a grad dip in public health but this knowledge only indirectly helps my GP work. Maybe provides a bit of insight into population screening and counselling about what screening vs diagnostic tests mean, but I wouldnt say it directly helps me with clinical care. It’s a separate albeit complementary academic discipline to the clinical sciences.

    • Amy Tuteur, MD

      Asking a doula for medical advice is like asking cleaning woman for architecture advice. Just because she takes care of a building doesn’t mean she knows how to build it. Just because a doula takes care of women in labor doesn’t mean she knows anything about childbirth.

      • Renee Martin

        Oh Dr Amy, cleaning ladies ARE skilled medical professionals!!! /snark

        We have a “MW” here in town that spent some years on the OB floor getting blankets, fetching drinks, and of course cleaning the rooms and stocking needed items, etc.

        She decided this was enough experience to be a “MW’, since she saw so many laboring women. She actually tells victims, er, clients, that she has been part of the OB team that delivered a thousand babies. She puts herself out as an expert because of this. I am pretty sure she has already killed a baby.

        Im sure you thought that was funny to reference cleaning ladies, but its only funny when its not true.

        • http://kumquatwriter.wordpress.com/ Kumquatwriter

          She delivered both of my close friends babies. Friend stopped speaking to me when I suggested the mw might not be the safest choice ever.

          • Amazed

            I think I’ve read something on her but I thought she was a town legend… Silly me.

          • RN who has seen too much

            LOL. we live in the same city and we have a mutual friend ;). I think I know who you are talking about!

          • http://kumquatwriter.wordpress.com/ Kumquatwriter

            Possibly but this friend lives 2 hours from here, on the coast. I miss her friendship :(

        • attitude devant

          Don’t EVEN get me started. When she all started claiming all this experience, we all called her on it, but she said “Oh I was observing all those deliveries.” Uh-huh. She even sets herself up as a ‘breech expert.’

      • Adelaide GP

        Definitely. The lack of insight and hubris is at an almost delusional intensity!

  • gtrslinger
    • Captain Obvious

      A) ultrasounds can be off a pound in either direction, and rarely 1 1/2, yet 2 pounds off. I sometimes perform ultrasounds on pretermers or suspected LGA babies that deliver within 24 hours. Usually birth weight and sono weight are within 1/2 pound. Rarely 1 pound off. Never been 2 pounds off. TFB has some anecdotal, less than 5%, bad estimates and professes that ALL women should know that ultrasounds are horrible at estimating EFW. In fact, there are MOSTLY pretty dang close.
      B) ACOG does suggest ECS if EFW greater than 5000g, or 4500g if diabetic. Perinatologists often concurr if AC greatly larger than HC even if less than 4500g, consider elective CS.
      C) with all the factors needed to consider a VBAC, you cannot guarantee willingness to feel comfortable with a VBAC until the patient is term. How can you know the term facts at 8 weeks gestation Gina? If the baby is average size or smaller, cervix is favorable and the patient goes into labor spontaneously than she is a fair candidate. If the baby is LGA, cervix is closed and your at 40 weeks with no signs of labor, consider repeat CS. But Gina can tell a patient at the onset of prenatal care how this will be at term?

      • Young CC Prof

        Yup, that’s what reality-based people know. Conditions change, and a VBAC that looked like a good bet at a patient’s first prenatal visit now looks like a pipe dream. Like that skiing trip you tentatively planned last summer, you should probably check the snow reports a couple weeks in advance.

        • Captain Obvious

          Gina, ACOG also recommends VBACs to be performed in a hospital that has immediate access to an OR with 24/7 staffing. If Gina is going to quote ACOG, than quote all of ACOGs statements and quote them correctly.

          • Sue

            Yep – funny how ACOG might be an authority when you agree, but an arrogant paternalistic bunch of greedly golfers when you don’t.

      • Haelmoon

        I look at the individual parameters of the fetal biometry too. If the abdominal circumference is greater that the 90%tile, it is unlikely that we are underestimating the weight significantly. If the femur length is long, but the abdominal circumference is normal, I generally see that we are over estimating the weight. That is because the calculation we use squares the femur length. When I including this in my discussion, I am rarely wrong in identifying macrosomic babies. There is some evidence that the babies with the big bellies are those that have the higher risk for shoulder dystocia. I discuss the limitations of ultrasound, but that does not make it a useless tool. It all depends on how you use it.

        It also depends on who is doing the scan.

        • Young CC Prof

          Yes! Individual parameters! Those specific measurements are more accurate than estimated fetal weight, right? Since weight is a formula based on those, and babies come in different shapes.

        • meglo91

          Interesting. The docs were worried that my daughter would be macrosomic based on her ginormous belly (95th percentile). But she was born at 38 weeks at 7 lbs 12 ozs — long and skinny with a small head and a round, but manageable, belly.

          • Captain Obvious

            7# 4 ounces is roughly the 50% for 40 weeks. So 7# 12 at 38 weeks is actually near the nintieth percentile.

          • The Bofa on the Sofa

            7# 4 ounces is roughly the 50% for 40 weeks.

            Interesting. I’ve always used as my guideline 7 1/2 pounds at 40 weeks, and adjust by a half a pound a week from there as the average, with a standard deviation of probably ± 1.

            So average at 38 wks would be 6.5 lbs, so 7 3/4 would be a tad above the high end.

            I never had any actual basis for my weight estimator, but looking at the chart, it’s pretty dang close (even the standard deviation is not bad – looks more like 13 – 14 oz, but hey, close enough)

          • atheist mommy/Oma

            Wow, my youngest was estimated to be a minimum of 10lbs at 37 weeks. It did end up being very accurate. I had a c-section the day after that ultrasound and she was 10lbs 3oz.

          • meglo91

            Whoa, that’s nuts. How old are those charts? Have babies gotten significantly bigger over the last few decades? Because it seems like everyone I know has 9 pounders. Babies that are 7.5 lbs are on the small side of the spectrum among the folks I know. Do I just know people with enormous babies? Thanks Captain Obvious!

          • Young CC Prof

            I think the average weight of full term babies used to be 7 pounds and is now 8 pounds.

            It seems to be caused by, on the plus side, less smoking and fewer teen moms, on the minus side, more GD and/or overweight moms.

      • Jessica S.

        It’s funny, my son’s EFW at 36 wks was 8lbs and it was only laypeople who commented on how “wildly off” US estimates could be. All the professionals said it was pretty darn accurate, with a half to three-quarters of a pound +/-. Our last US, exactly a week before he arrived (via CS) estimated him at 9lbs 10oz. He was 10lbs 10oz at birth. I’m sold on the accuracy! Or at the very least, I’m sold on listening to professional opinions. ;)

        • Captain Obvious

          It’s funny how the crunchy are all up in arms about how “wildly off” ultrasounds are (and they can be occasionally), but how they ignore the rate of Homebirth morbidity and mortality that occurs (more than hospital birth). Even though the significance of Homebirth injury is hugely more important than EFW, you wouldn’t know that by what significance they argue.

        • Dr Kitty

          My daughter’s EFW at 38weeks was 7lbs. Her birthweight was 6lbs 3oz. But she inherited her daddy’s big head and long legs, so I’m happy the US did what it was supposed to.

        • Amy M

          They estimated one of my twins pretty much dead on (“about 5lbs”) and were off on the other by 1/2lb. The u/s tech suggested they were both about 5lbs, and one was 4.5lbs at birth at 36wk. At their size, it was a big difference, but considering she was trying to sort whose legs and arms were whose, at 35+ wks gestation, I thought it was a reasonable estimate. The smaller one wasn’t smaller enough to trigger any alarms about TTTS at any point, so all good.

    • MichelleJo

      My daughter had EFW of 7lb 2 oz at 5 PM and a birthweight of 8lb 2oz at midnight, seven hours later. But I don’t rant about EFW s meaning nothing because 1) a small percentage may be way off, 2) 8lb could have been mistaken for 7lb somewhere along the line, especially as the 2 oz bit was right. And lastly, the EFW and BW were done by the NHS ;-). With another baby, it was out by only a few ounces, which is not really out because nobody in the medical community considers EFW to be bang on. It is known to be an approximation.

      • The Bofa on the Sofa

        I guess I don’t get it. EVERY measurement comes with an uncertainty, and in something like this, a standard deviation is going to be completely meaningful.

        So not only is it not surprising that the measurement is off by some amount, if we have an idea of the standard deviation, we have a pretty good idea of exactly how many will be how far off.

        This garbage about US weight estimates being off is a complete and utter strawman. The people who do the measurements and those who actually use them know damn well there is an uncertainty to it.

        The key is that the uncertainty means that it can be off in either direction. If the baby’s weight can just as well be high as it can be low, then it doesn’t do any good to say, “Yeah, the baby measured X, but that doesn’t matter because it could be smaller than that” It could also be larger than that.

        • Young CC Prof

          Exactly. It’s not a freaking digital scale. But when they say your baby is unusually large, it almost certainly is. And sure, there’s always some story about your friend’s cousin’s wife who was told her baby was ten pounds and the baby popped out only seven and a half. Sure it’s happened occasionally, most likely due to user error on the part of the person performing the ultrasound.

          But people win the lottery every single day. Is that a good strategy to pay the rent? Nope. The good strategy is to assume that your baby’s weight is within about half a pound of the estimate, and to play lottery for fun only.

          • The Bofa on the Sofa

            It’s not a freaking digital scale.

            And shoot, even a digital scale has an uncertainty to it. It’s a smaller uncertainty than an US estimate, but uncertainty nonetheless.

            And sure, there’s always some story about your friend’s cousin’s wife who was told her baby was ten pounds and the baby popped out only seven and a half. Sure it’s happened occasionally

            And given that we know the statistics, we have a pretty good idea at exactly how often constitutes “occasionally.” 1 in a hundred? I mean, if the standard deviation is 1 lb on the estimate, that means that 5% will be more than 2 lbs lighter than the estimated. If you know 20 people who’ve had it done, chances are 1 will be that far off.

            Moreover, given that you only hear about the extreme variations, it might sound more common, but remember, most people who are estimated within a half a pound aren’t running around talking about it.

            It’s total straw, that’s all that’s to it.

          • http://kumquatwriter.wordpress.com/ Kumquatwriter

            My father’s brother’s nephew’s cousin’s former roommate totally had a 7 lb baby when the doctor said it would be 10 lbs omg!

          • AmyP

            For real, a woman I know unexpectedly had an 11 pound baby. Her OB must have freaked.

  • gtrslingr

    Don’t know if anyone saw this discussion on feminist breederhttps://m.facebook.com/thefeministbreeder/posts/10152015076547727?comment_id=30942572&offset=0&total_comments=112&notif_t=feed_comment_reply

    I am Meagan Tubb BTW.

    • Luba Petrusha

      Link is all screwed up.

  • Jessica S.

    Excellent! I’ll be meeting with an OB at the hospital, in a month or so, to assess a repeat CS (my family physician is providing my prenatal care, but she doesn’t deliver babies). I’m not sure what they’ll recommend; my only concern is not wanting to be induced again, in order to try, only to end up with another CS. But if this babe is large like the first (almost 4800 gm), it looks like I’m already well below 50% chance. Plus, I’ll be 37 when I deliver. The way I see it, I want a CS on the books on or near my due date and if I spontaneously go into labor beforehand, then what the hell – we can try, as long as they think it’s safe. Otherwise, just use the escape hatch, please! :)

  • Fertile Myrtle

    The prospect of an HBAC is unsettling. Is it possible that women are choosing HBAC’s in some areas due to hospitals or providers not allowing/attending VBAC’s? In that way the “one size fits all” approach of not allowing VBAC’s might be encouraging more HBAC’s, which is unfortunate.

    • Young CC Prof

      Sometimes it’s because the only nearby hospital doesn’t have the resources to offer safe VBAC. Sometimes, more frighteningly, it’s because a doctor told the woman she specifically was a poor candidate. Sometimes it’s just because she wants a home birth and doesn’t comprehend the difference between HBAC and hospital VBAC, or between HBAC and “low risk home birth.”

      • Jessica S.

        Great response. Strikes me that the fact a hospital needs to be equipped to handle a VBAC should be the first sign that it’s not a easy-breezy procedure. Also, I’m grateful I live in an area rich in medical resources. (Seattle, WA) I know a lot women don’t have the same access.

    • Renee Martin

      I think this is mostly an excuse for two reasons.

      First off, areas where there are VBAC accessible hospitals all over, moms STILL choose HBAC! When they cannot use the excuse that no one offers them, they move the goal posts, and say that they don’t want monitoring, that home will give them better odds, that OBs are impersonal. Whatever.
      Its always something for those that want HB. Moms not so dedicated will just find the closest, friendliest place, and go with it.

      Second- If you want a VBAC, and are a decent candidate, you can get one, but it may take some extra efforts because most places that do not offer them have legitimate reasons.

      Like other types of medicine and special procedures that require extra resources, many smaller, understaffed, or rural, hospitals simply don’t have the ability to do them. You don’t go to your local small hospital for heart surgery, you choose certain places for cancer surgeries even if it requires travel, and moms with complicated pregnancies choose places with high level NICU’s/

      Joy may have been annoying, but she DID do what she needed to get the VBAC she wanted. I can respect this. She travelled a little, like so many people do.

      If VBAC activists really want to help, they could help find the nearest VBAC offering hospitals and help moms arrange for the care they want. They could help find local docs to do the prenatal, and plan for the other hospital to do the delivery. They could offer financial assistance for those that cannot afford to travel, or for moms to stay in the area of the other hospital for a few weeks.

      If there is a will there is a way. But the way is not bashing OBs and hospitals. Or staying home.

      • SNM1

        I agree to some extent with you, but I do think that a refusal on the part of some hospitals and MDs to attend VBACs does contribute to some women having a HbAC. I am part of a forum where women are constantly looking for a VBAC friendly doc/hospital because they can’t find one within a reasonable distance. And when a woman who lives close to a large city and can’t find a provider/hospital for her TOLAC it is sad. It should be about informed choice. Women are not one-size fits all. My sister had a section for previa. She has no comorbidities and no contraindications for a TOLAC. However, her dr has told her that she has to go into labor on her own before 39 weeks if she wants a VBAC… That isn’t evidenced based and there is no current reasoning for the claim. I would understand this statement if it was more based on the decreased chance of success with a post dates pregnancy, but at 39 weeks? It just doesn’t make sense! And this is at a VBAC friendly facility! So I can see how women would get frustrated and do a home birth in this situation. And this scares me because as a future CNM it is my personal belief that a VBAC should take place in a hospital where emergencies can be dealt with immediately, not at home! The number of high risk women giving birth at home scares me and I believe that we must work on changing the system altogether to make it safer (more VBAC friendly hospitals and providers and more stringent guidelines on who are appropriate candidates for home birth). I think that the majority of moms value their babies safety over their own desires and are just looking for providers who will support them in TRYING to have the birth experience they want. Yes, there are those who are just looking for a reason to say they were forced into a home birth by “the man” but I think that isn’t the case for the majority.

        • Sue

          I clearly don’t know the precise circumstances, but an entire institution has to be set up and prepared for VBAC, not just the obstetrics provider.

          • Anj Fabian

            An OB can be just as pro VBAC as can be, but can they magic up a fully staffed VBAC on demand?

          • Karen in SC

            Jeevan’s hospital in India can do c-sections, but doesn’t have a blood bank. There is always a delay when relatives (!) have to arrange for blood and go get it.

            See The Learner in the blog roll.

          • The Bofa on the Sofa

            Yeah, I actually have no idea what our OB thought about VBACS (although I suspect she had no interest in doing them). All we know is that the hospital did not provide adequate staffing to allow it to be done safely, so her view on it is irrelevant.

  • anonymous

    Small grammatical error:

    “Medical history is irrelevant. Had a previous shoulder dystocia, C-section, postpartum hemorrhage? Who care?”

    Should probably read:

    “Medical history is irrelevant. Had a previous shoulder dystocia, C-section, postpartum hemorrhage? Who cares?”

  • The Computer Ate My Nym

    Dumb question of the day…breech tends not to recur, but dystocia does? Does anyone know why that would be?

    • attitude devant

      Are you talking about shoulder dystocia? “Dystocia” is a broad term….

      • Deborah

        Dystocia just means “getting stuck”. Labor dystocia would more properly be called “head dystocia” because even the head isn’t coming.

    • Young CC Prof

      Shoulder dystocia is caused by things like a big baby, a baby with a big abdominal circumference, and sometimes the shape of the mother’s body.

      Breech is kinda random, AND, it can be diagnosed before labor or at the onset of labor. Shoulder dystocia, when it happens it’s already an emergency.

      • The Computer Ate My Nym

        Oh, duh! If the first c-section was done for breech and you know the second one is cephalic then there’s no recurrent indication. I was thinking so hard about whether uterine shape could influence risk of breech that I ignored the obvious!

        • Young CC Prof

          Apparently uterine shape can influence the risk. My OB thought that my baby was breech because I had a couple strategically placed fibroids that caused him to get stuck and not be able to turn. But yeah, the difference is that babies don’t suddenly become breech in the middle of labor.

          Unless of course you are a DEM who can’t tell a baby’s head from, well, you know.

  • attitude devant

    So, I have been puzzling over the general silence about the truly horrible death rate for HBAC as reported int the MANA study. Why does no one comment on this?

    • The Computer Ate My Nym

      If MANA were a mainstream medical organization, they’d probably look at the data and say that at least HBAC and breech should be considered too dangerous for home birth based on the available data. The very fact that they didn’t immediately issue a statement that new data shows HBAC is dangerous and not recommended says to me that they have no interest in protecting their patients.

    • moto_librarian

      Well, there is a lot at stake, right? I mean Jen Kamel has a whole cottage industry going with her VBAC facts site, workshops, etc. She describes her HBAC as a “glorious” accomplishment. We wouldn’t want to ruin that gravy train, now would we?

      • attitude devant

        I looked at the vbac facts website. Who IS this woman???? She talks about the ‘VBAC community’ — is that some kind of joke? You have to have an advocacy group for VBAC? I always think of Joy Szabo, who used to show up here and complain about access to VBAC as if it was the obstetrician’s fault that the rural Arizona hospitals didn’t have enough resources to staff an OR 24/7. And her top post is full of straw men—surely no one actually thinks that vbac is illegal?

    • Young CC Prof

      I saw ICAN sharing the study and claiming it proved HBAC was safe! It really is like a cult. Everyone says that the data proves one thing when it absolutely totally proves the opposite. And no one questions it. And if they do they get voted off the island.

  • mom of 2

    OB’s: is it known whether the risk of rupture is lower if you’ve already had a VBAC?

    Also, does pit actually increase the risk of rupture? Or is it that if you need pit due to inadequate contractions, you were more likely to rupture anyway?

    I ask as someone who had an easy VBAC, but my doc opted to induce with pit right at 39 weeks because of 2 vessel cord. Was that a reasonable choice? And is my chance of rupture still 7 in 1000 the next time? I know I’m a good candidate for another VBAC but its still a tough choice.

    • attitude devant

      Your risk of rupture is probably lower this time around, but not zero. And yes your doctor was correct because the risk of stillbirth from the cord anomaly (actually a true variation of normal, albeit one with some real risks) outweighed the risks associated with induction.

  • Are you nuts

    I think people who choose a home VBAC don’t understand what “rupture” means. Rupture is a somewhat sanitized word but thinking about the reality of what a rupture is, it’s terrifying. If a rupture happened at home, what are the odds of a good outcome?

    • Young CC Prof

      The odds of saving the baby appear to be around zero. Far less than 50%, anyway.

      • Anj Fabian

        The odds of the baby surviving are very low. Jeevan has had babies survive OOH ruptures, but they are always described as “very ill”. It appears to be pure luck if a UR doesn’t kill a baby in an OOH situation.

        • fiftyfifty1

          I love Jeevan.

          • AmyP

            I hope they work out the blood bank issue…It sounds like a huge obstacle to good care.

    • http://Www.awaitingjuno.blogspot.com/ Mrs. W

      depends on how you define “good outcome”….

  • lawyer jane

    I can’t fathom why anyone would try for a VBAC unless they wanted to have more children. The risks and benefits seem clear.

    • Young CC Prof

      That’s kind of how it looks to me, too. Certainly it’s the only compelling medical reason in terms of Seriously Bad Stuff.

      Of course, if you had a fairly easy VB with #1, c/s for nonrecurring complication with #2, and want to avoid surgery with #3 so you can get back to chasing after Thing 1 and Thing 2 faster, that’s not a bad idea at all.

      • The Bofa on the Sofa

        In that case, take the extra day in the hospital with nurses to help as a reprieve.

        • Wren

          An extra day or two in hospital wouldn’t have come close to covering the difference in recovery between my c-section and my vbac. It was a non-recurring reason (breech), I was right at 39 weeks and my second was relatively small (6lb 6oz). I have never doubted that my in hospital vbac beat a second c-section in my case. Being able to actively play with my 20 month old when I got home was a good thing for us.

    • Trixie

      Because if you’re a good candidate, in a hospital with CEFM and immediate access to surgery, the risks are pretty close, and some people find cesarean section to be less desirable than vaginal birth for various reasons. For me, the recovery was much easier, light years easier, than my c/s.

      • Susan

        I don’t think it’s always that clear either. I am supportive of intelligent well chosen highly monitored VBACs, supportive of breastfeeding and unmedicated births for those who want them. I am just not supportive of people defining their own personal choices as being morally superior or conferring some special secret unicorn dust no one else has.

    • KT

      I am on pregnancy #2. #1 was an emergency c/s. PROM, I wasn’t actually going into labor, baby was going having heart rate decels down into the 80s during my not terribly progressive contractions that lasted 5 minutes each and also during the pitocin-induced contractions at a quite low dose. Spoke with my OB who said I wasn’t progressing and she’d let me try laboring a little longer but it was likely either a c-section now or later. Since I wasn’t really in a labor pattern of any sort and they gave me terbutaline to stop the impact of the pitocin so my baby would stop having decels, my c-section was really closer in impact on me to a scheduled c-section than an emergency one. It wasn’t a terrible recovery. There was meconium in the remaining fluid when the c-section was performed, so I was very grateful for the decision that we made.

      I’m hoping to try for a VBAC this time, but only with the approval of my OB and in a hospital setting following their protocol. I hope to have 3-4 children. Also as a random benefit, I hope to be able to lift my toddler before 2 weeks after delivery. I do realize that some vaginal births make lifting a toddler just as difficult as some c-sections, but I’m hoping for the best while planning for the worst.

      Maybe I’ve been reading the wrong sources (it is incredibly difficult, I’ve found, to find non-biased information in layman’s terms on a VBAC and I haven’t had time to dig through any of ACOG’s information in detail, just overviews), but I don’t think OBs would allow VBACs if they were really so unsafe that RCS-es were a no-brainer.

    • OBPI Mama

      I can… recovery sucked for me and scar tissue got worse each c/s… recovery-wise: especially because I had lots of other little children to care for. I am not a good candidate for vbacs (previous shoulder dystocia) and so I would never choose that route, but definitely understand and support good candidates who want to try.

  • http://www.pcosra.com/ PCOSRa

    Is this VBAC Success calculator reasonably accurate?
    https://mfmu.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbirth.html

    • The Computer Ate My Nym

      I don’t know, but when I put my data in it returned the answer “dream on sucker!” (Ok, what it really said was 32% chance of success, but that’s without having the information that the scar on my uterus looks keloid like, which must take the odds down.)

    • Angela

      Interesting. It isn’t clear to me if you’re is supposed to enter your pre-pregnancy weight/BMI or include weight gained in pregnancy. Trying it both ways, I seem to have about a 64%-70% chance of success with my first TOLAC in 7ish weeks.

    • expat

      It doesn’t have gd or history of macrosomic babies in the calculation

      • The Computer Ate My Nym

        Nor a number of other factors like pre-eclampsia history, maternal comorbidity, etc. I think this calculator gives a best-case scenario: it can tell you that your probability of success is no higher than (number), but not really that it is not lower than that number.

    • Dr Kitty

      Up to a point.
      Not for me.
      It gives me a success estimate of 78%.

      But it doesn’t ask questions like
      “Cervical endometriosis?”
      “Metal in spine and pelvis?”
      “Grossly abnormal pelvic shape?”
      “Did your first baby engage in your pelvis?”

      Never mind
      “Do you want a VBAC?”

      If my OB thought my chances of a successful VB was 10%, and that was before all the fun stuff with the cervical scarring and endometriosis developed! I’d

      • Dr Kitty


        I’d put money on my VBAC actual chance of success being “when hell freezes over”… Not that I would ever even be interested in a TOLAC.

    • snm rose

      I just posted this above, but I’m doing a clinical rotation at a very academic institution and it’s policy that they use this calculator to calculate a woman’s chance at her 1st OB appt. So I would say, it’s not 100% obviously, but it’s used here for counseling purposes. It doesn’t take everything into account, but it considers the most popular risk factors for success or failure of a TOLAC. So that’s why it doesn’t ask those random “cervical endometriosis” etc questions. It’s a quick way to get an estimate and it builds another part of helping a woman decide if she would like a TOLAC. Obviously if she came in and we knew she had a history of a grossly abnl pelvic shape, we would calculate this and then tell her that was baseline, but given X, Y, and Z, your chances are actually much lower than that, but we don’t have the data to calculate your chances. How many studies do you think have been done on metal in spine & pelvis and how it corresponds to VBAC success or failure? Answer: probably not many.

      • Dr Kitty

        That’s my point.
        The calculator is a rough guide, which will still need to be modified for each individual patient.
        BUT what you GET is
        “My OB says my chance of success is 25% with a 2% chance of rupture and she won’t support my VBAC! But the calculator says my chance is 80% and we all knower the rate of rupture is 0.5%…so I’ll HBAC and ignore her fear mongering!Positive comments only please!”

        Conveniently forgetting whatever risk factor the OB had taken into account (uterine anomaly, previous myomectomy, EFW 5500g, persistent OT position or whatever) when calculating the individual woman’s risk.

        My OB is old. He does vaginal breeches, VBACs, vaginal twins, rotational forceps and is very, very skilled. If the most he could say about my chance of a VB was “Well, you could always give it a go…but I think the odds are about 10% you end up with a VB, and probably an instrumental if that”

        • Dr Kitty

          So yeah.
          His ONLY reason why I should attempt a vaginal delivery was “As long as you’re sure you won’t regret not trying”.
          Which, IMHO is not a great reason to risk my child’s brain function.
          Oh, and if I had agreed to a VB?
          It would have been CEFM and epidural on arrival, because anything else in his words “just wouldn’t be sensible, given we’ll probably end up in theatre”.

          I trust his judgement. He’s been doing this since before I was born, and if that was how he felt for the first pregnancy, and before he sorted out the cervical endometriosis, I doubt VBAC would even come up in discussion.

          Which is why the calculator, for me, is worse than useless.

    • guest

      My first post – this is a subject much on my mind… The calculator gave me a 76 per cent chance of VBAC. But a pro-VBAC OB I saw prior to this pregnancy told me that my best case odds – if baby was in a good position and not too big – are about 50 per cent. I find the odds around VBAC don’t seem to match the stats – unless everyone is choosing ERC. VBAC is promoted and encouraged as a safe option here in Australia, but – as an example – the percentage of successful VBACs are 14 per cent at my local (large, tertiary) hospital and significantly less than that at the private hospital I am actually booked into. (Figures are from 2007-10 but newer ones weren’t available last I checked).

      • Young CC Prof

        The USA numbers are that about 75% of attempted VBACs are successful, but most women with a history of cesarian delivery are simply scheduling RCS, so the total VBAC rate is quite low.

      • araikwao

        Yes, I believe rates vary by institution. I’m also in Aus,and had a vbac at a decent-sized tertiary hospital. My obstetrician’s MW thought the rate was about 70% there,but maybe 80% at the private hospital he also did deliveries at. I’m surprised your tertiary hosp would have such a low rate.

        • guest

          I might have been unclear – that figure for my local public hospital was for total VBAC rate – not successful VBACs as a percentage of all VBAC attempts. My local hospital’s total VBAC rate is close to overall Australian figures. 84 per cent of women with a history of caesarean have a repeat caesarean, according to Australia’s Mothers and Babies 2011 (health department report at http://www.aihw.gov.au/publication-detail/?id=60129545702). It’s a surprising figure, I think.

          • araikwao

            Oh, now I’m with you! No wonder the MW who did our hospital tour was falling all over herself in excitement when she heard I was planning a vbac, saying “I wish more women would do that”.

          • Young CC Prof

            The question is, why? I’m not saying the VBAC rate is too low or too high or anything else, but of the large numbers of women who schedule RCS, I’d like to know how it breaks down by reason. I can think of 3 basic reasons.

            1) Medical indication, like the doctor said VBAC was unlikely to succeed or too risky, and/or specific indication for c-section with this pregnancy, like breech or multiples.

            2) No conveniently located hospital offered VBAC

            3) VBAC was an option but the mother was not interested in a trial of labor, essentially maternal request.

            Primary MRCS is pretty unusual, but I suspect maternal request repeat c-section works out to a not insignificant portion of total births.

  • OttawaAlison

    According to the vbac calculator my chance of success is about 30% so ya, I don’t see the value of having a TOL with the odds stacked against me if I have another baby.

  • amazonmom

    I love this post! I regularly use your posts on VBAC to educate friends who are getting false info from the homebirthers. Most of the time they end up choosing the hospital for their VBAC so I think it’s been worth it. With a baby that would have been 4500+ grams and without the head engaged any lingering doubt that my planned RCS was the right choice is gone!

  • Monica

    So you mean any schmuck off the street can’t tell whether or not a woman can have a vbac? I’m shocked! I mean surely a birth educator can know just from one line of my doctor said I can’t have a vbac because my baby is too big.

    It’s not a wonder my doctor was so quick to say when I signed up for my c-section that I would be a perfect candidate to attempt a vbac. I had already birthed 2 babies vaginally without any problems and my c-section was due to breech. In my final pregnancy as we got closer to my due date I had plenty of frank conversations about my options for delivery. Given my history of quick labors and being GBS positive my doctor wanted to induce me. She was going to start by breaking my water, which she had a lot of confidence would work. Considering that was what got things moving with my oldest two vaginal deliveries and I had been contracting for weeks. But she did say they might have to use a little pitocin. She explained the possible complications from that and we went along with that plan. My daughter had her own plan of course and decided to come the night before my scheduled induction, but you wouldn’t believe the grief I got from a self proclaimed birth advocate when she heard my doctor was going to induce me for a vbac. It was actually comical to me that this possible not even high school graduate actually thought I would listen to her over my own doctor when it came to my medical care. Not only did she have the education and experience to back up what she was telling me, but my doctor had my medical history as well. So yeah, who do you think I’m going to listen to? A faux doula who may or may not have completed the 12th grade or my experienced OBGYN who had intimate knowledge of my medical history and body. Yeah guess what I’ll take my doctor’s advice any day ;).

  • Amy Tuteur, MD

    The New York Times reports that homebirth is not safe:

    http://well.blogs.nytimes.com/2014/04/08/hospitals-safer-than-homes-for-births/

    • stenvenywrites

      “Over all, babies delivered by midwives at home had nearly four
      times the risk for death compared with those delivered by hospital-based
      midwives, with the risk highest if the birth was the woman’s first.

      When a birth was handled by others — policemen, taxi drivers and
      so on — the death rate was four times that of hospital births.”

      So does this imply that homebirth midwives have roughly the same mortality rates as taxi drivers? If so, why do CPMs bother with their cute little credentialing process, when they could just apply for a medallion? And why do pregnant women hire CPMs when they could just call a cab? Taxi drivers aren’t lobbying for insurance reimbursement, and they carry exactly the same amount of malpractice insurance as CPMs. Even better, when you tell one to take you to a hospital, he won’t argue with you.

      • Young CC Prof

        Actually, I think we should make a picture meme for this fact.

      • DaisyGrrl

        I don’t know about your city, but taxi medallions are expensive here. Much easier to make a pretty website declaring oneself a midwife.

      • The Bofa on the Sofa

        I’m not sure. If you read it carefully, you can see that the HB rate was compared to hospital midwives, which are low-risk pregnancies. OTOH, the taxi driver deliveries might be compared to the overall hospital rate, which is higher (because it includes high risk).

        I almost think that has to be the answer, but I am happy to get clarification. So maybe the relative numbers are something like

        1 Hospital with a midwife (low risk only)
        2 Hospital with a doctor (includes high risk cases)
        2 OOH birth center with a midwife
        4 HB with a midwife
        8 Cab driver

        • Young CC Prof

          Just checked CDC Wonder. You’re right. OOH Other Midwife, 1.37 per thousand (Neonatal deaths, 37+ weeks, 2500+grams.)

          OOH Other attendant, 2.59 per thousand. Of course, this includes deliberate unassisted births, and births that took place out of the hospital because reaching the hospital was impossible at that moment. And it’s a random risk profile, rather than an allegedly low risk profile.

          • Young CC Prof

            By the way, if you look that up, do NOT then sort by “cause of death.” I just did that and I wish I could unsee that list. Some were birth related, but quite a few were NOT.

          • Jessica S.

            :/ I guess any death that isn’t birth related would probably be traumatic or something.

          • Young CC Prof

            The summary is “lousy parenting.”

          • fiftyfifty1

            I saw one of these during training. Teenager with hidden pregnancy. Final outcome not pretty….

  • almostfearless

    Which is why I won’t be trying to a VBA2C… both of my babies didn’t move down at all (10% chance of success, wow) and I had pre-e both times. Oh and I’m AMA. Yeah forget it.

  • Amy M

    I don’t understand this: “The worst situation for both mother and baby is a failed attempt at VBAC.
    While the overall risk of uterine rupture is 7/1000, that jumps to
    23/1000 in a failed attempt. Therefore, the risk of rupture is directly
    dependent on the chance of success.”

    What is the definition of a failed attempt in this context? A trial of labor, with a subsequent decision to section? Does that mean the rupture is more likely during the section? Or during a future pregnancy after a failed VBAC? Or is the 7/1000 risk the overall risk for the entire population of pregnant women compared to women undergoing TOLAC but getting nowhere? I’m confused about exactly at what point and which population has the 23/1000 risk of rupture. Sorry, I’m not trying to be obtuse here, I just didn’t understand this part.

    • Hannah

      I was wondering about that. Surely, by definition, a rupture would be a failed attempt at VBAC, so obviously the cohort of failed VBACs would contain more ruptures regardless of whether individual factors that increase risk of VBAC failure also increase risk of rupture.

      • http://www.antigonos.blogspot.com/ Antigonos CNM

        There are various reasons why an attempted VBAC winds up being a repeat C/S, such as failure to progress, dysfunctional labor, etc. Uterine rupture is an extremely serious COMPLICATION of a failed attempt to VBAC rather than the cause of the failed attempt. But as the numbers show, the chances of an unusual event are greatly increased by having a prior scar on the uterus [BTW, the scar almost always is fine -- the uterine tissue tears away from the scar, which is like gristle]

        Uterine rupture can happen to anyone — and not even in labor — but it is rare. I once took care of a rabbi’s wife who had had 8 children vaginally without complication and suffered a uterine rupture in her 7th month of her ninth pregnancy, “out of the blue”, and had to have a hysterectomy [and well over 2 dozen units of blood and blood products afterward].

        • fiftyfifty1

          wow!

        • Amy M

          So you are saying that failed VBAC due to some reason is more likely to have the complication of rupture (23/1000) during the TOL, vs. 7/1000 during labor of the population of women who haven’t had a previous Csection? If the failed VBAC gets to the OR for Csection, is the rupture more likely during the Csection? Or once they get sectioned w/no rupture, they are out of the woods until the next pregnancy, and then have the same odds if they attempt labor again?

    • Angela

      I didn’t understand that part either. Dr. Amy, can you please clarify?

  • expat

    This is a nice counterpoint to TFB’s, “I teach VBAC workshops where I tell women that the risks of home birth after 2 cesareans and macrosomic babies are totally low risk and doctors just don’t like to do them because malpractice fears and golf and stuff.” What was her risk factor per Dr. Amy’s numbers? 30% chance of success? Compared to 80% for the general population? Considering that failure at home means a 1/50 risk of death, I’d say she dodged a bullet.

    • The Bofa on the Sofa

      risks of home birth after 2 cesareans and macrosomic babies are totally low risk and doctors just don’t like to do them because malpractice fears

      I don’t think she doesn’t understand how malpractice works.

      • attitude devant

        Yeah. TFB ought to remember how much fun it was to be sued in federal court and face possible financial ruin. Then maybe she’ll get what it’s like to face a big malpractice suit.

        • The Bofa on the Sofa

          No one ever gets sued for a good outcome.

  • Ash
    • Trixie

      So, Dr. Grünebaum and the other authors basically demonstrated that you’re just as safe having the taxi driver deliver your baby as you are a CPM? Taxi drivers probably work out to be a bit cheaper, as well.

      • The Bofa on the Sofa

        I found that odd that the similar death rates were not pointed out. I was wondering if I read that right – did it just say that the risk with a cab driver is the same as a midwife? Seems so…

        • Trixie

          It said “nearly” a 4 times increased risk with home birth midwives, and 4 times increased risk with others such as taxi drivers. So the improved safety of having home birth midwife training amounts to a rounding error vs. your average person off the street. At least, that’s how I read it.

          • Young CC Prof

            Some of that could be the fact that inadvertent out-of-hospital births tend to be precipitous labor. Which can have complications of its own, especially for the mother, but by definition does NOT involve, for example, arrested labor.

          • The Bofa on the Sofa

            I sure as hell hope so, because if there isn’t more to it, that is pretty damning information against midwives. Then again, if it is true, it would be a great means to an end of the CPM – call your local congresscritter and tell them that a CPM is no better than a cab driver, and watch how fast they go down.

          • Trixie

            True. But still, as a sound bite, a pretty good takeaway.

    • http://www.antigonos.blogspot.com/ Antigonos CNM

      My personal feeling is that it is more than just atmosphere, although atmosphere helps. Most hospitals staff for the minimum, not the maximum. One nurse, or one midwife, covering two or more patients, cannot give really comprehensive care and support to each patient. That has been the ratio in too many places I have worked. It needs to be one-on-one.

  • Trixie

    Small typo: need an S on the end of “care” in the fourth paragraph.

  • AlexisRT

    To be fair, OBs who refuse to do VBACs ever are also practicing one size fits all medicine. There may be reasons (liability) but it isn’t about the personal risks vs benefits to the patient.

    I chose an RCS after considering all the factors in my situation.

    Pro-VBAC:
    1) My section had been an emergent, pre-labor CS for fetal distress in the context of severe preeclampsia. Considered unlikely to recur.
    2) No surgery.

    Anti-VBAC:
    1) Chronic hypertensive on medication. (I run above 160/100 unmedicated, so I remained medicated for pregnancy.) This introduced an entire set of new rules about delivery timing and potentially moving my delivery up if my blood pressure rose above 140/90 after 37 weeks (I believe ACOG released new guidance shortly after this pregnancy, but at the time they were doing 39 if BP was controlled). This was a MAJOR con and frankly logistical pluses of scheduling were dwarfed by this one. My OB was (pleasantly) surprised I did not need delivery earlier than anticipated.
    2) At most, I planned on 3 children.

    Neutral:
    High BMI; lower chance of VBAC success, but also difficulty with surgery. I viewed this as choose your poison.

    Nonetheless I had people tell me that VBAC was absolutely the correct choice. I don’t think they weighed the evidence correctly. I also don’t think that, if I had gone into labor spontaneously before 39 weeks, that I would have been wrong to allow it to progress. It just didn’t seem that planning on it was wise. (In the end, I did not have a single contraction prior to my C section and my final cervical check was as unpromising as could be, so I have no what-might-have-beens about it.)

    I do believe the consequences of multiple CS should be weighed… IF a woman anticipates that 4 or more children are a likely scenario. It typically doesn’t come into play, but I know a few women who rationally weighed it more heavily. I think concerns about accreta may be overly weighted in discussions when we’re talking about women who only plan on 2 children. Or, I know someone who had 2 unmedicated vaginal deliveries and then #3 was breech; choosing a VBAC for #4 was pretty straightforward for her.

    • attitude devant

      I actually don’t know any physicians who refuse to do VBACs. If they feel that their hospitals are not properly staffed for VBACs then I’d listen to that concern and take it seriously.

      • The Bofa on the Sofa

        Our OB “refused” to do a VBACs because the hospital was not properly staffed in anesthesia to do them with adequate safety backups.

        She did not tell us we couldn’t do a VBACS, only that we would need to go to a hospital that could do it safely, which was an hour away, where she didn’t have privileges.

        I’d like to hear the counter-argument to her justification based on “personal factors.” “I don’t care, you have to do it anyway, even though I can still sue you if something goes wrong”?

      • Guest

        There are definitely practices that strongly discourage VBACs if not outright refuse to attend them. There are hospitals with vbac bans. The argument used against vbac bans is that if they are unprepared for *that* type of obstetric emergency then they are unprepared for other types of obstetric emergencies. From my understanding, this is mainly an issue in more rural areas with hospitals too small to justify staff being in house 24/7.

      • R T

        My Perinatalogist will not do VBACs. His hospital allows them and is very adequately staffed and has a level III NICU. He personally just does not support them. Actually no one in his practice will do them. They will refer you to other doctors who do VBACs in the same hospital. When I had my csection he said I would be a candidate for VBAC, but made it clear it wouldn’t be with him!

      • Medwife

        My hospital has banned them, over the objections of the OBs delivering there.

    • Amy Tuteur, MD

      Obstetricians don’t decide not to do VBACs. Their hospitals and insurance companies decide for them without taking their opinions into account.

      • Guest

        Many providers do screen and offer VBAC’s to appropriate candidates, however there are physicians who do not offer VBAC’s. Just experiencing one uterine rupture is enough to make a provider stop offering VBAC’s and as long as they are up front with patients about what services they will or will not offer, I find that is perfectly justified.

        Would add to the list of factors associated with likelihood of successful VBAC: postdates. TOLAC success begins to decrease around 39 weeks and substantially so after 40-41 weeks. Another reason postdates HBAC stories are something nightmares are made of.

      • AlexisRT

        While that may be the case for many it is not the case for all. I even know someone who was told by her NHS consultant that he “did not do” VBACs. When I enquired into the availability of VBAC in my area, I was told that “Dr X will, but Dr. Y doesn’t o them.” By the practice. I also encountered varying attitudes within the group I eventually chose. The doctors were hospital employees.

    • Erica

      This was very similar to my thought process for my RCS.

      My first section was a semi-emergent, pre-labor section for impending pre-e (not sure that it was officially diagnosed, but I did have rapid swelling, off and on high bp (getting higher as I went), and a +2 protein on a urine dipstick). I had gestational diabetes and was pregnant with twins. Never had contractions, or any dilation, completely unfavorable cervix at that point (35w3d). For my second pregnancy, my doctor was completely willing to allow me to VBAC if I chose.

      For me:

      1) The second pregnancy was definitely going to be my last. I opted for a tubal ligation during the surgery.
      2) I didn’t have a proven pelvis, and while that’s the “same” as a first pregnancy, I already knew what c-section recovery was like.
      3) I could plan my dates so my out of town mother could come help me during recovery (that didn’t exactly work out, as my father got sick just before my delivery, so I ended up on my own anyway).
      4) Added bonus, I got an extra two weeks on paid disability before I had to return to work.

    • Trixie

      I’m pretty glad I chose a VBAC, in the hospital, but I think it made total sense to choose RCS in your situation.
      My prior c/s was for malposition, I had 2 years between pregnancies, under 35, normal BMI, good health, average size 7 lb baby, roomy pelvis, baby engaged, etc. I went into labor at 41 weeks and a day, and they were about to get pretty touchy if I went beyond that (I did have an NST the day before). So I was a good candidate, and I still would have been nuts to do it at home.
      Also, the hospital was super nice about it. All the nurses and doctors were really supportive.

    • Young CC Prof

      Yes, it is definitely a personal tradeoff kind of thing!

      For me, I’d be a pretty good candidate with my next baby (if there is a next baby) since my c/s was for the nonrecurring complication of breech position. However, I want at most two children, so future fertility issues from many uterine surgeries isn’t an issue. Therefore, scheduled RCS and VBAC (in the hospital on CEFM) would both be reasonable choices medically.

      I would most likely just schedule RCS at 39 weeks. My first c/s wasn’t too bad physically, and emotionally a small risk to the baby seems far worse than the risk of surgery to me. Of course, another woman in similar circumstances might want to attempt VBAC, and that wouldn’t be wrong.

      Of course, if you’re pregnant with your third and last baby after 2 c-sections for failure to progress, and you’re still bound and determined to have your trial of labor, that’s pretty silly IMHO.

    • Are you nuts

      I’m not an OB so I don’t know for sure, but I would guess the main driver behind not doing VBACs would be lawsuits.

  • moto_librarian

    I know two people who experienced ruptures during VBAC attempts. One was in a hospital, and she and her daughter both survived (although it was definitely life-threatening for both of them); the other was at home with a CNM who transferred at the first sign of a problem but it was already too late. Her son died. I have seen their experiences completely marginalized by the NCB community. They have been accused of “fearmongering” for providing information on what can happen when a VBAC attempt fails. The idea that a c-section is still correlated with “failure” of a woman’s body is both paternalistic and biologically essentialist.