The more comfortable doctors became with vaginal birth after cesarean (VBAC), the more risks they began to take. Before, no one ever induced a VBAC woman, and certainly no one ever used Pitocin, but now Pitocin is used frequently. There has been an increase in uterine rupture with the advent of induction and Pitocin. I find it incomprehensible that instead of understanding how obstetrical directives create problems and decrease the safety of VBAC, obstetricians in the United States believe that the danger is inherent within VBAC. It has come to my attention that recently, instead of taking the time to suture the incised uterus in layers, doctors have been taught a "short-cut" technique that uses only one layer. This method compromises the integrity of the scar and predisposes a woman to greater incidence of uterine rupture. So now doctors can tell you with a straight face that VBAC is dangerous: they are making it so.
- excerpted from "A Butcher's Dozen" by Nancy Wainer,
Midwifery Today Issue 57 (Cesarean Prevention/VBAC)
Click here to read "A Butcher's Dozen" in its entirety.
In several large studies of VBACs, the following factors were seen more frequently with uterine rupture: prostaglandin cervical ripening, Cytotec/misoprostol ripening, induction of labor, use of Pitocin, failure to progress, forceps/vacuum and epidurals. A recent study showed that rates of uterine rupture are 3.0 times higher when the trial of labor is less than 18 months after the cesarean, suggesting that good scar integrity requires adequate time for healing before the next pregnancy.
While home VBAC does create time and distance barriers to responding to a crisis, home VBAC does not introduce iatrogenic risk. The ACOG Clinical Management Guidelines and most obstetricians do not acknowledge most of the iatrogenic risks cited above, even though several retrospective studies have shown statistical significance. A recently published study actually looked at rupture rates in VBACs after one previous c-section. They found that the rupture rate was 0.4% in spontaneously laboring women, while the rate was 1.0% in oxytocin-augmented labors and 2.3% in induced labors. A growing body of retrospective studies suggests that meddlesome obstetrics increases the risk for VBACs.
Other factors may affect the rate of uterine rupture because they impair optimal healing of the uterine incision. Factors that may increase the risk of rupture but are unproven include: chorioamnionitis at the time of c-section, postoperative endometritis, diabetes mellitus and steroid use during the healing process.
- excerpted from "A VBAC Primer: Technical Issues for Midwives" by Heidi Rinehart, MD,
Midwifery Today Issue 57 (Cesarean Prevention/VBAC)
The rate of uterine rupture for repeat cesarean deliveries without labor for women having a previous c-section was 1.6 per 1,000 women. Uterine rupture was highest where prostaglandin administered to induce labor was used for the second birth -- 24.5 per 1,000 women. For women whose labor was induced without prostaglandin, the rate was 7.7 per 1,000 women. And for those with spontaneous onset of labor, the rate was 5.2 per 1,000 women.
- National Institutes of Health
Combining the results in 20 studies of Cytotec-induced labors published in peer-reviewed journals and papers presented at professional meetings -- a total of 1,958 births -- I discovered a total of two maternal deaths, 16 baby deaths, 19 uterine ruptures and two life-threatening hysterectomies.
Uterine rupture virtually never occurs in spontaneous (unaugmented) labor in women who've had no previous uterine surgery. Probably because of differing practices surrounding labor induction and augmentation, the rate of uterine rupture varies widely from hospital to hospital. Uterine rupture is less likely to happen in an out-of-hospital birth. Most midwives providing these services do not use drugs to augment labor. The complication has been reported as frequently as one in every 100 births and as rarely as one in every 11,000 births. In my own group practice at the Farm Midwifery Center in Summertown, Tenn., in approximately 2,100 births we have had no uterine ruptures.
By contrast, approximately one in 100 Cytotec-induced births in the 20 studies I looked at resulted in uterine rupture. About half occurred in women having VBAC, the others among women who had had no previous uterine surgery.
In fact, it is women who have had cesareans who are at greatest risk from Cytotec. An article published in 1999 in the American Journal of Obstetrics and Gynecology reported that uterine rupture occurred in five of 89 women with previous cesarean delivery whose labors were induced with Cytotec -- about one out of 16, a shockingly high figure, representing a more than 28-fold increase over those who did not have Cytotec induction for VBAC (vaginal birth after cesarean). One of the five ruptures also caused a baby to die.
- excerpted from "Cytotec: Dangerous experiment or panacea?" by Ina May Gaskin,
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Question of the Week: VBAC
Q: I am seeking insight about having a VBAC after four c-sections. Does anyone have experience with a situation like mine? I labored with all but one of my babies and was labeled CPD. All my labors were augmented. We are considering having another baby.
- NV, midwife
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Question of the Week Responses: T-Shaped Incision
Q: A primip transported from an attempted homebirth -- breech with legs folded "tailor style." A c-section (classical) was done because of advanced status of labor. The baby's butt and body were easily delivered through the incision, but an arm was folded over the head and jammed into the fundus. When they found it difficult to remove the arm, an extension was cut perpendicular to the classical incision. Mom now has a T-shaped cut on the uterine wall. She was told to never attempt a VBAC -- rupture "guaranteed." Any input?
- Linda, CNM
A: Rupture of the uterus is never guaranteed. It is, however, more likely with a classical incision or a "compound" incision. I believe the rate of rupture is about 2-5% for classical incisions -- far from guaranteed but a high enough rate that few providers are comfortable with doing a VBAC.
If she heals well, eats nourishing, tissue-building foods and waits a couple of years minimum before having another baby? It's her call as to what risks are acceptable to her, and her caregivers' call as to what risks they're willing to support. Most allopathic practitioners would not even consider a VBAC in that situation.
Here's how to think about a 1 in 20 risk (5%): Although it means that out of 100 people, 95 will do just fine, it also means that if you knew 20 people who tried it, one would have had the problem. Given that the complications of rupture can be extreme, this is something to seriously consider. And what kind of closure was done on the incision -- two layer or one?
Be aware that not all ruptures happen in labor... small separations may happen in late pregnancy without labor or with Braxton Hicks.
If she were to decide to labor in the future, any augmentation of a future labor (Pit, Cytotec, castor oil, evening primrose) would be foolhardy and inappropriate. Pain medication in a future labor would be out of the question as well because it would mask some of the primary symptoms of rupture. Easy access to surgical intervention would be appropriate (i.e. quick transport). It might be advisable to investigate whether an ultrasonographic evaluation of the uterine wall in late pregnancy could detect small separations of the uterine wall.
The gentlest, slowest, most low-key birth would be appropriate. The last thing you want is anything that will put the uterus into overdrive.
A fully informed decision is vital. She must read the surgical record, find out what kind of closure was done, read about healing and maximizing the strength of her tissues (regardless of what kind of birth she's going to have in the future, the uterus must strengthen so it can support pregnancy, let alone labor), wait at least two years to get pregnant again to allow for maximum healing time, investigate first whether a VBAC is something she's willing to risk, and then find out if there is a care provider who would support a VBAC in her circumstance.
And she must trust her instincts and her gut. Does she have a strong feeling that this is something her body can do? Or does she have a strong feeling that she should not risk it?
- Jen Rosenberg, doula, childbirth educator
A: A woman just had her second vaginal birth after a T-incision -- no rupture and fairly aggressive labor pattern. She had very little bleeding after and her fundus was firm immediately after birth and throughout postpartum. She did, however, have a water labor and birth for both of her vaginal deliveries. Laboring and pushing in water reduces stress on the uterine muscle, conserves the mother's strength, and usually shortens the length of labor.
- Jenny West, Albuquerque, NM
A: I once did a homebirth for a woman who could find no other birth attendant (OB or midwife) who wanted to take the risk of uterine rupture with her T-shaped uterine incisions. She had had a classical incision with one birth and a lower transverse with another. I was much younger and braver then! I read and reread Silent Knife to get my courage up. The birth went smoothly without incident. They named the baby after me, and I felt I earned it. Would I do it again? No. Fifteen years has changed my world view a bit.
A: I don't agree that uterine rupture in future VBAC attempts can be "guaranteed." There simply is not enough research on this type of scar to back such claims and not even enough data to know an accurate percentage of risk.
On the other hand, risk of rupture does seem to increase when there are classical or other scars that extend to the fundus. If single-closure incision was used, the risks may be even greater. With the current hysteria over VBAC, any provider who offers a VBAC to this lady would have little support and no defense in the event of a problem.
If the lady and provider are willing to take these risks, I would encourage a delay of pregnancy until her baby is at least 1 year old. She needs time to heal, both physically and emotionally. Have her get plenty of vitamin C & protein. Start abdominal strengthening exercises when able. Signed informed consent and emergency planning are essential. In the end, the lady has the right to choose how to have her baby, but the midwife must also claim her right to practice according to existing knowledge, availability of emergency care and personal comfort level.
- Susan Karimi
A: A T-incision carries a much greater risk of rupture because the incision compromises the active part of the uterus in labour. This is why lower-segment incision is safe because the lower part of the uterus is not as greatly involved in the contractions. As you probably know, the uterus contracts from the top, and then down.
Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!
I hear the rumor all the time that care providers are telling small women they won't be able to birth. I don't believe it for a minute. As a woman who is all of 5'1" I birthed an 8 lb. 14 oz. baby in 7 hours with no tearing. Height should not be an issue.
- Amy V. Haas, BCCE, Fairport, NY
Recently a doula client was being induced by Kaiser at 39 weeks for macrosomia and gestational diabetes. I thought she could deliver her baby with support and help. The second day of induction, in which she had been getting Cytotec, she was sectioned for macrosomia and failure to progress! I was so disgusted and angry. They of course waited until I was not there to do this and had no other reason. I tried to talk the client into going home after she was checked and found to be 2 cm dilated, still in the latent phase of labor, but she chose to stay. She was 4' 9" and kept being told that she could not deliver this baby vaginally. They did not even try or allow her to try. Needless to say, I am still upset by this and will talk to future clients about avoiding such interventions.
- Tora Spigner RN, MSN, doula, future CNM
The conventional western medical recommendation about breastfeeding and women with HIV is that they should by no means breastfeed. I have heard from an international midwife that new evidence refutes this recommendation. According to two studies done in South Africa, when HIV-positive women breastfeed exclusively there is no increased risk of transmitting HIV to their babies over formula feeding. Evidence suggests that the problem of transmission comes when mothers mix breastfeeding with fluid and/or formula feeding or with foods that could hurt the neonatal digestive system.
- Coutsoudis, Anna, et al. Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. The Lancet: (354), August 7, 1999. pp 471-476.
- Coutsoudis, Anna et al. Method of feeding and transmission of HIV-1 from mothers to children by 15 months of age: prospective cohort study from Durban, South Africa. AIDS, 15 (3) 2001. pp 379-387.
- Kuhn, et al. Helper cell responses to HIV envelope peptides in cord blood: protection against intrapartum and breast-feeding transmission. AIDS, (15) 2001, pp 1-9.
- Karen Ehrlich, CPM, LM, Felton, CA
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