The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

ICAN/VBAC/Cesarean

See also:

• Postpartum Urinary Incontinence - Not Caused by Vaginal Birth
• Microbial Colonization of Newborn Skin and Gut - Cesarean Effects
• WBAC - Water Labor and Waterbirth for VBAC
• Resolving Birth Issues
• Birth Trauma From Cesarean
• Epidurals and Other Drugs
• Lawsuits and Complaints
• Birth Stories - Cesarean/VBAC Stories

Subsections on this page:

• In The News
• Ongoing Research
• Working to Reduce the Cesarean Rate
• Elective Cesarean
• Risks of Cesareans to Mother and Subsequent Pregnancies
• Risks of Cesareans to Newborn
• DNA Changes from Cesareans
• Prohibitions Against VBAC
• Recovering from the Surgery
• Institutional Quotas for Cesareans
• VBAC Havens and Traveling Midwives
• VBAC Resources
• VBAC Guidelines (from ICAN President)
• Safety of Going Past Due Date with VBAC
• Ultrasound to Predict Dehiscence or Uterine Rupture
• Single-layer Vs. Double-layer Closure
• Uterine Rupture and Fetal Extrusion and Mitigation
• VBAC Safety/Rupture Statistics
• Size of VBAC Baby
• Marriage and Cesarean Aftermath
• Women Who've Had Cesareans Talk About What Happened
• Women Who've Had Cesareans Talk About The Aftermath
• Trouble Bonding with Cesarean Baby
• Suing After An Unnecessary Cesarean
• Women Who've Had Cesareans Talk About Avoiding Cesarean
• HBAC - Homebirth VBAC
• Avoiding a Surgical Birth
• Rapture of VBAC
• Comparing Cesarean and Vaginal Birth Morbidity and Mortality
• Relative Risks of Uterine Rupture
• VBAC and Electronic Fetal Monitoring
• Vaginal Birth after How Many Cesareans?
• OBs Discuss Cesarean for Fear of Shoulder Dystocia
• Vaginal Cesarean
• Working to Increase the Cesarean Rate
• Court-Ordered Cesarean
• Humanizing Cesarean - Planning a Surgical Birth
• Self-Cesarean

In The News

This is the link to the original story by the California Watch health and welfare section.  Where are our local reporters on this????

It is very similar to the SFGate story. Just in case anyone is interested in reading it. Maddy Oden was also interviewed for the story.

Most of you know that Maddy Oden's daughter Tatia Oden French and her baby died after being induced with Misoprostol (aka: Cytotec, "Miso") at Alta Bates in Oakland. No informed consent (about the "off label" use or the known risks) were given by the hospital staff. But, that is the "standard" of practice around here.
 

Sincerely,
Jeanne Batacan

ICAN's newly launched Hospital VBAC Policy Database is a listing of every hospital in the U.S. with information about the VBAC policy of that hospital.  The user has the ability to submit comments about a particular hospital, adding to the information available to women searching for information about specific hospitals.

The Trouble With Repeat Cesareans Time Magazine, 2/19/09] Piece on repeat cesareans, the reporter's follow-up blog post and the press release from ICAN about VBAC bans.

Ongoing Research

 Humiliation

IMPORTANT!  A surgeon performing a cesarean section may choose from among a number of different techniques.  If you're planning a cesarean, it makes sense to discuss these choices with your surgeon, and if you're not planning a cesarean, it's even more important to have discussed these issues ahead of time, in case a cesarean becomes medically necessary.

There are two significantly different techniques used to close the internal incisions - single-layer vs. double layer closure.  Single-layer closure appears to be more vulnerable to rupture in subsequent pregnancies.

There are two significantly different techniques used to close the external incision - suturing or stapling.  Yes, stapling, as in "with a staple gun".  Many people feel that the suturing facilitates better healing and leaves a scar that isn't quite so frankenstein-like as the stapled scar.

The fastest way is with a single-layer closure of the internal incisions followed by external stapling.

These are important choices.  Educate yourself and talk with your surgeon beforehand.

This raises a really significant question.  If the strength of the healed uterine scar is dependent on the quality of the suturing, why is the liability for uterine rupture assigned to the care provider with the subsequent pregnancy, rather than the original surgeon?

NO VBAC

This gentlebirth.org web page is mostly about avoiding Cesareans and planning VBACs, but there are women who cannot or choose not to plan future VBACs.  There used to be an online support group for these women called novbac, but it seems to have disappeared.  Here was their charter:

"This list's sole purpose is to support women who for whatever reason have been unable to have a VBAC after one or more c-sections. Although we do support VBAC, we feel a need to support the woman that cannot have a VBAC or has attempted a VBAC only to have a repeat c/s. This is a list to promote healing and to support our fellow mothers."

"This is a list for women who had a cesarean birth(s), who want to discuss their feelings, thoughts, and/or experiences regarding cesareans, labour, birth, HBAC, VBAC, the impact of a cesarean section on self & spouse/family, or any other topics you wish to discuss. This list is also available to women who have a possible c-section pending and want to discuss any issues that they presently coping with. "

Working to Reduce the Cesarean Rate

ICAN - International Cesarean Awareness Network - The organization that is most focused on reducing the cesarean rate.
You can read through their ICAN eNews Archive and join their online forum.

Donate to ICAN or join ICAN today to support their work and receive their excellent newsletter.

They maintain a referral service -  Professional Subscriber Network for midwives, doulas, CBEs, chiropractors, massage therapists, hypnobirth therapists......

And . . . NEW in the UK . . .  ukvbachbac - A Yahoo! Group - A UK discussion group on vbac and home vbac for interested mums, mums to be, midwives and anyone else with an interest in avoiding unnecessary c-sections. Useful information and articles can be found at caesarean.org.uk

Citizens for Midwifery – the only national consumer-based group promoting the Midwives Model of Care!

Join Citizens for Midwifery today to support the midwifery model of care and superior outcomes for mother and babies.

Vaginal Birth After Cesarean - notes from the American College of Nurse-Midwives 48th Annual Meeting from Medscape Nurses [Medscape registration is free.]

I thought this video editorial did a very good job of explaining current VBAC issues, i.e. they're not really clinical!

From Medscape Ob/Gyn & Women's Health [Medscape registration is free.]
Kaunitz on Women's Health
Trial of Labor and Vaginal Birth after Cesarean: Maintaining Access and Choice [Posted 03/27/2009]
Andrew M. Kaunitz, MD

Why does the national U.S. cesarean section rate keep going up? The page dispels two myths that continue to arise and identifies interrelated factors that are leading to record-level cesarean rates year after year.

Soaring C-Section Rate Troubles Doctors - [Forbes magazine - 7/13/07] - It includes quotes from Marsden Wagner and discusses the economic pressures contributing to this trend, the increased risks of cesarean, and an observation by another obstetrician that the overuse of this surgery runs counter to the sacred rule in medicine of “First Do No Harm.”  At the end, readers are directed to ICAN for further information.

ANACS nurses endorse the booklet "What Every Pregnant Woman Needs to Know About Cesarean Section". This evidence based material is put out by the Maternity Center Association. Nurses are encouraged to bring this to consumers attention and to help educate women about cesarean sections. Nurses and consumers can download a copy for free!

Publicized by the Association of Nurse Advocates for Childbirth Solutions (ANACS)

We don't browbeat women into having caesareans  - from the UK

Elective Cesarean Surgery Versus Planned Vaginal Birth: What Are the Consequences? and The Problem with ‘Maternal Request' Cesarean from the Lamaze Institute for Normal Birth.

NIH Cesarean Conference: Interpreting Meeting and Media Reports

Caesarean delivery in the second stage of labour - Better training in instrumental delivery may reduce rates

"Although second stage caesarean section is sometimes appropriate, many could be prevented by the attendance of a more skilled obstetrician."

Where's my midwife? is a grassroots organization seeking to increase access to midwives in hospitals, free-standing birth centers and at home through education and advocacy.

Previous cesarean delivery: understanding and satisfaction with mode of delivery in a subsequent pregnancy in patients participating in a formal vaginal birth after cesarean counseling program.
Cleary-Goldman J, Cornelisse K, Simpson LL, Robinson JN.
Am J Perinatol. 2005 May;22(4):217-21.

See also: Significance for Normal Birth from the Lamaze Institute for Normal Birth

Elective Cesarean

See also: Microbial Colonization of Newborn Skin and Gut / Cesarean Effects - Cesarean birth disrupts this crucial colonization

Elective cesarean sections are too risky, WHO study says [Jan 11, 2010]

Many women are mis-led to believe that a cesarean is the "pain-free" way to give birth.  In the landmark study, Listening to Mothers, the authors write about the "Myth of the Pain-Free Cesarean.  For women who had a cesarean, pain in the area of the surgical incision was the leading postpartum health concern, with five out of six of these mothers citing it as a problem in the first two months and one in fourteen citing it as a problem at least six months after birth."

C- Sections a Critical Factor in Preterm Birth Increase

Great response from an OB/GYN to the "Choosy Mothers Choose..." story.

Dear Editors:

Your writer glamorizes a major surgical procedure that,if performed unnecessarily, can have serious outcomes for the mother and baby. This is not a face-lift,it is major abdominal surgery that has three times the maternal death rate as vaginal birth. Are the women who elect this [usually when prodded by their doctors] made aware of that? Are they also aware that their baby may be born too soon or too small and have long-term educational problems because their brains are not fully developed? Do they understand that,after the first cesarean, the next pregnancy has twice the stillbirth rate and can have life-threatening problems with the placenta because of the uterine scar? Do they know that there is no epidemiologic evidence that cesarean prevents future urinary incontinence and in fact can make future abdominal surgery more difficult due to abdominal adhesions?

My point is that most women with normal pregnancies who agree to elective induction of labor or scheduled cesarean haven’t a clue about some of the very negative consequences of the surgery. Cesarean section is a very important and life-saving intervention in some high risk situations. However there is plenty of evidence that vaginal birth has a toning and protective effect on the baby’s brain and results in babies with less asthma,chronic lung disease, and learning disabilities.

In my opinion,if this unfortunate trend continues, our society may find out in the near future that “It’s not nice to fool Mother Nature.”

Charles Mahan, MD, FACOG
Professor,USF Chiles Center for Healthy Mothers and Babies

Vaginal birth after caesarean section versus elective repeat caesarean section: assessment of maternal downstream health outcomes.
Pare E, Quinones JN, Macones GA.
BJOG. 2006 Jan;113(1):75-85.

CONCLUSIONS: These results indicate that long term reproductive consequences of multiple caesarean sections should be considered when making policy decisions regarding the risk-benefit ratio of VBAC.

Caesarean birth triples maternal death risk

Postpartum Maternal Mortality and Cesarean Delivery.
Deneux-Tharaux C, Carmona E, Bouvier-Colle MH, Breart G.
Obstet Gynecol. 2006 Sep;108(3):541-548.

RESULTS: After adjustment for potential confounders, the risk of postpartum death was 3.6 times higher after cesarean than after vaginal delivery (odds ratio 3.64 95% confidence interval 2.15-6.19). Both prepartum and intrapartum cesarean delivery were associated with a significantly increased risk. Cesarean delivery was associated with a significantly increased risk of maternal death from complications of anesthesia, puerperal infection, and venous thromboembolism. The risk of death from postpartum hemorrhage did not differ significantly between vaginal and cesarean deliveries. CONCLUSION: Cesarean delivery is associated with an increased risk of postpartum maternal death. Knowledge of the causes of death associated with this excess risk informs contemporary discussion about cesarean delivery on request and should inform preventive strategies. LEVEL OF EVIDENCE: II-2.

Infant outcome worse with planned c-section [1/8/07] Newborns who are delivered via planned cesarean section are more likely to be transferred to the neonatal intensive care unit and to experience lung disorders compared with those delivered via planned vaginal delivery.

Planned cesarean versus planned vaginal delivery at term: comparison of newborn infant outcomes.
Kolas T, Saugstad OD, Daltveit AK, Nilsen ST, Oian P.
Am J Obstet Gynecol. 2006 Dec;195(6):1538-43.

CONCLUSION: A planned cesarean delivery doubled both the rate of transfer to the neonatal intensive care unit and the risk for pulmonary disorders, compared with a planned vaginal delivery.

Babies born by Caesarean are three times more likely to die in first month

Infant and Neonatal Mortality for Primary Cesarean and Vaginal Births to Women with "No Indicated Risk," United States, 1998-2001 Birth Cohorts.
Macdorman MF, Declercq E, Menacker F, Malloy MH.
Birth. 2006 Sep;33(3):175-182.

Results: Neonatal mortality rates were higher among infants delivered by cesarean section (1.77 per 1,000 live births) than for those delivered vaginally (0.62).

Mothers aren't behind a vogue for caesareans - [Boston Globe, 4/3/06]

Cesarean Delivery on Maternal Request - 2003 Data from the National Vital Statistics reports, Vol 54, Number 2, (116 pdf pages)
In 2003, the latest year statistics are available, there were 4,089,950 births.

In 2003 there were 51,602 VBACs.

There were 1,119,388 Cesarean surgeries.

The current rate of cesarean section, per the highest rate in the study quoted in the NIH papers, would place up to 103 women at risk of dying from or with or right after their cesarean. According to one study the worst rate of mothers dying due to cesarean deliveries was reported to be 92 per 100,000 such deliveries. ( a rate of 0 was also reported in a different study).

Some of these women had diseases such as eclampsia that killed them. Many would have died from hemorrhage, stroke, anesthesia complications, infection or a combination of these. Some of the women who died in relation to their surgeries, had undergone their Cesarean because there really was no better choice. Some who die may have elected their section for personal or quasi-medical reasons.

Patient Choice Cesarean

Look for a terrific rebuttal from Suzanne Arms at http:

Consumer Reports Questions Cesarean Frequency [12/30/05]

Risks Associated With Cesarean Delivery - [Medscape registration is free] If you're considering an elective cesarean, make sure you know the risks.

The risks associated with cesarean delivery can be divided into those that are short term, those that are longer term, and those that present risks to future pregnancies. There are also risks to the newborn that need to be considered.

As C-Sections Increase, So Do The Complications

C-section studies from BirthRites

Neonatal impact of elective repeat cesarean delivery at term: a comment on patient choice cesarean delivery.
Fogelson NS, Menard MK, Hulsey T, Ebeling M.
Am J Obstet Gynecol. 2005 May;192(5):1433-6.

"RESULTS: Neonates born by elective repeat cesarean are more frequently admitted to advanced care nurseries than infants born to mothers intending to deliver vaginally (risk ratio 3.58, 95% confidence interval 3.35-3.58). CONCLUSION: The decision to undergo scheduled cesarean delivery appears to negatively impact immediate neonatal outcomes."

Now add to the doubled risk of a NICU stay after a planned c/s the corresponding increase in the risk of interrupted mother/father/baby attachment, increased child abuse and/or neglect as a result of interrupted attachment, a significant reduction in the initiation and duration of b/f, and maternal/paternal depression/anxiety and the corresponding effects of THAT on infant growth and development, and you have a long-term ripple which is the stuff of horror movies.  Yikes.

Cesarean Voices, A web site by, for, and about cesarean born people - explores the implications of having been born non-labor cesarean, of coming into a human life here on earth without going through the heretofore universal initiation and learning experience of the journey down the birth canal.

Researchers describe the "novel clinical entity" of intrapartum elective cesarean, and find that it is more often proposed by the physician than the patient.

Intrapartum elective cesarean delivery: a previously unrecognized clinical entity.
Kalish RB, McCullough L, Gupta M, Thaler HT, Chervenak FA.
Obstet Gynecol. 2004 Jun;103(6):1137-41.

CONCLUSION: This study documents a heretofore unrecognized clinical entity: intrapartum elective cesarean delivery. Physician characteristics, as opposed to patient characteristics or intrapartum factors, are a major determinant of whether laboring patients are being offered cesarean delivery.

API's statement about the medical ethics of elective caesarean sections

Women's Health Care Professionals Issue Warning About Cesarean Section on Demand - Research shows that the risk of maternal death following cesarean section is five to seven times higher than vaginal birth. Complications during and after the surgery may include injury to the bladder, uterus and blood vessels, hemorrhage, anesthesia accidents, blood clots in the legs, pulmonary embolism, paralyzed bowel and infection.  There are serious risks also in subsequent pregnancies.

November 11, 2003 - Childbirth And Postpartum Professional Association (CAPPA) issues response to the recent ACOG Statement on Ethical Cesareans.

I am familiar with at least one fairly recent case (not my case), circa 1992, from rural north central Missouri. Obese female demands general anesthetic for elective repeat C-section. Physician agreed. Just after induction of general, patient arrested and expired about 24 hours later in ICU. Husband was in OR and refused C-section (during cardiopulmonary resuscitation), C-section not done later, fetal heart tones still present post arrest, but gone before patient death. Large settlement (about 900,000)--husband's deposition denied any memory of refusing C-section after cardiac arrest. I don't know what the indications for the section were. No one is sure why the patient died. The section was completely elective, patient was not in labor.

Physician Perspective on Elective Cesarean

High rates of caesarean delivery do not necessarily indicate better perinatal care and can be associated with harm.

Risks of Cesareans to Mother and Subsequent Pregnancies

After the afterbirth: a critical review of postpartum health relative to method of delivery.
Borders N.
J Midwifery Womens Health. 2006 Jul-Aug;51(4):242-8.J Midwifery Womens Health. 2006 Jul-Aug;51(4):242-8.

Four million women give birth each year in the United States, yet postpartum health has gone largely unaddressed by researchers, clinicians, and women themselves. In light of rising US cesarean birth rates, a critical need exists to elucidate the ramifications of cesarean birth and assisted vaginal birth on postpartum health. This literature review explores the current state of knowledge on postpartum health in general and relative to method of delivery. Randomized trials and other published reports were selected from relevant databases and hand searches. The literature indicates that postpartum morbidity is widespread and affects the majority of women regardless of method of delivery. Women who have spontaneous vaginal birth experience less short- and long-term morbidity than women who undergo assisted vaginal birth or cesarean birth. To maximize postpartum health, providers of obstetric care need to protect the perineum during vaginal birth and avoid unnecessary cesarean deliveries. Clinicians must initiate the discussion about postpartum health antenatally and encourage women to enlist needed support early in the postpartum period. Flexibility in the schedule of postpartum care is essential. More research from the United States is warranted.

Risks of adverse outcomes in the next birth after a first cesarean delivery.
Kennare R, Tucker G, Heard A, Chan A.
Obstet Gynecol. 2007 Feb;109(2 Pt 1):270-6.

CONCLUSION: Cesarean delivery is associated with increased risks for adverse obstetric and perinatal outcomes in the subsequent birth. However, some risks may be due to confounding factors related to the indication for the first cesarean. LEVEL OF EVIDENCE: II.

Risk of Placental Abnormalities Rises with History of Multiple Cesareans

CONCLUSION: A cesarean first birth is associated with increased risks of previa and abruption in the second pregnancy. There is a dose-response pattern in the risk of previa, with increasing number of prior cesarean deliveries. A short interpregnancy interval is associated with increased risks of previa and abruption.

The following information is from Volume 3, Issue 3 of Research Summaries for Normal Birth, July 2006, from the Lamaze Institute for Normal Birth:

Summary: This large retrospective cohort study examined the association between history of one or more previous cesarean surgeries and the risk of placental abruption or placenta previa in a subsequent pregnancy. Data were obtained from a Missouri state-wide dataset in which siblings were linked to one another and to their biological mothers. Missouri’s vital statistics recording system has been described as a “gold standard” for its reliability and validity in previous literature.

Risk for previa in the second birth was increased 50% among women with a previous cesarean surgery. Among women with two previous cesareans, there was a two-fold increase in the risk of previa in the third pregnancy. Risk for abruption in the subsequent pregnancy was increased 30% in both the second and third births when the prior birth was by cesarean. A pregnancy occurring within the first year after giving birth by cesarean was associated with further elevations of the risk for both previa and abruption. The researchers controlled for the effects of potential confounding factors such as maternal age, race and smoking status.

Significance for Normal Birth: This study adds to the growing body of research showing strong evidence of a dose-response relationship between cesarean surgeries and placental complications in subsequent pregnancies: the more cesareans, the more complications. The doubling of risk for placenta previa in women with two previous cesareans is particularly troubling because previa in the presence of a cesarean scar is associated with placenta accreta, a complication that results in very high maternal morbidity and mortality. The long-term reproductive risks of cesarean surgery are only beginning to be understood. As the evidence of harm accumulates, it becomes ever clearer that preventing unnecessary primary cesareans is a crucial measure for protecting the health of both mothers and babies.

Risks of Cesareans to Newborn

See also: Birth Trauma From Cesarean

The Trouble With Repeat Cesareans By Pamela Paul Thursday, Feb. 19, 2009

Neonatal Outcomes May Be Better With Vaginal Birth After Cesarean Delivery
Laurie Barclay, MD

According to a study published in the June issue of Obstetrics and Gynecology, babies born via vaginal birth after a prior cesarean section (VBAC) have lower rates of respiratory morbidity and intensive care admissions compared with babies born by repeat cesarean section.

The retrospective cohort study was comprised of 672 women with one prior c-section in a singleton pregnancy at 37 weeks or more gestation, and compared both neonatal outcomes and monetary costs of the procedures.

Researchers found that babies born via repeat c-section had higher rates of intensive care admission and higher rates of oxygen supplementation for delivery room resuscitation than those babies born by VBAC. The highest rates of resuscitation, however, were in babies born by c-section after a failed VBAC.

And while a successful VBAC is definitely less expensive than a second c-section, the highest costs were associated with a cesarean after a failed VBAC.

The study's authors suggest that these results "[argue] for greater selectivity in performing a cesarean delivery in the first place, and certainly a greater need for counseling before a primary elective cesarean delivery."

Neonatal outcomes after elective cesarean delivery.
Kamath BD, Todd JK, Glazner JE, Lezotte D, Lynch AM.
Obstet Gynecol. 2009 Jun;113(6):1231-8.

CONCLUSION: In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay. LEVEL OF EVIDENCE: II.

Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America
José Villar  a ,   Eliette Valladares b,   Daniel Wojdyla c,   Nelly Zavaleta d,   Guillermo Carroli c,   Alejandro Velazco e,   Archana Shah a,   Liana Campodónico c,   Vicente Bataglia f,   Anibal Faundes g,   Ana Langer h,   Alberto Narváez i,   Allan Donner j,   Mariana Romero k,   Sofia Reynoso l,   Karla Simônia de Pádua g,   Daniel Giordano c,   Marius Kublickas m   and   Arnaldo Acosta n,   for the WHO 2005 global survey on maternal and perinatal health research group
The Lancet 2006; 367:1819-1829

Interpretation - High rates of caesarean delivery do not necessarily indicate better perinatal care and can be associated with harm.

CDC Says Cesarean Triples Neonatal Death Risk - . . . regardless of risk factors, babies born by cesarean section face a risk of death nearly three times that of vaginally born babies.

DNA Changes from Cesareans

Here's the simplest version of the story:

Cesarean delivery can alter DNA

 . . . The researchers noted genetic mutations in babies delivered via Cesarean. . . .

The actual research:

Epigenetic modulation at birth – altered DNA-methylation in white blood cells after Caesarean section (p 1096-1099)
T Schlinzig, S Johansson, A Gunnar, TJ Ekström, M Norman
Acta Paediatr. 2009;98:1082–1084; 1096–1099.

News Stories and Reviews:

Higher DNA Methylation in Cesarean-Delivered Newborns May Be Linked to Later Disease Development [Medscape registration is free.]  "Moshe Szyf, PhD, professor in the Department of Pharmacology and Therapeutics, McGill University, Montreal, Quebec, Canada, regards this article as the first to demonstrate the effect of seemingly harmless interventions on our genome. "The DNA seems to record the changes to environments in early life. It will be interesting to see what fraction of these changes remain as a memory in our DNA for our life course," he said via email to Medscape Obstetrics & Gynecology."

C-section Births Cause Genetic Changes That May Increase Odds For Developing Diseases In Later Life - ScienceDaily (June 29, 2009) - good explanation plus excellent Related Stories

Genetic changes after Caesarean section may explain increased risk of developing disease - this is a little more technical. [from physorg.com]

Epigenetic modulation at birth - altered DNA-methylation in white blood cells after Caesarean section [ from news-medical.net]

Prohibitions Against VBAC

ICAN President's Letter to California Medical Board about VBAC - from Tonya Jamois, 4/20/05

Your Right to Refuse - What to do if your hospital has "banned" VBAC.

E-mail ICAN with the name of the hospital and your city/state.

50 Ways to Protest a VBAC Denial by Barbara Stratton

File a VBAC ban complaint
Dear Friends,
Barbara Stratton has been working hard to find a way to reverse VBAC bans both in her own state of Maryland as well as nationwide.  Please read her letter below, explaining an action many women can take that may not only help reverse their local bans, but could also have an impact across the country.
Barbara writes:
One of the most promising approaches we have to reversing hospital VBAC bans nationwide is to file complaints through the Medicaid system and then appeal any denials to the federal level. If successful, all hospitals nationwide that receive Medicaid funding (most do) would be forced to reverse their VBAC bans.
So far, I've only known of a single woman to file one of these complaints and she didn't appeal the initial denial. We need to have these complaints come in from across the country from women willing to file and then appeal any denials.
You don't have to receive, or have received Medicaid in the past in order to file a complaint. The only qualifying factor is that you live near a VBAC banning hospital and want to see that ban reversed!
Simply call the hospital and verify that they receive Medicaid funding. Then ask for the contact info for the Chief Compliance Officer for Medicaid.
I can then email you a letter template that just requires you to insert your info plus the compliance officer's info. Print it out, mail it in and you are done.
See how easy that is?
Please email me directly if you are interested.
Thanks,
Barbara Stratton
womancareadoula@comcast.net
At least 30% of births in this country are by cesarean section, including at least 20% of first births. That means there are a large number of women who would benefit from being able to give their best try at having a VBAC. Many of us can file the kind of complaint Barbara describes, which could help so many women and babies have a better birth.

Denied VBAC? - [from Robin Elise Weiss at pregnancy.about.com] - A vaginal birth after a cesarean (VBAC) is becoming more and more rare these days and doctors and lawyers fight over the risks of VBAC. For the women who have decided that they want a vaginal birth, they may be told no. Here is what they can do to try to find the birth they want.

Here's the article that was first used as the justification for ACOG's opposition to VBAC:

Risk of uterine rupture during labor among women with a prior cesarean delivery.
Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP
N Engl J Med 2001 Jul 5;345(1):3-8

Risk/benefit of Delivery Mode After C-Section Should Be Individualized (News)

Vaginal birth after a previous cesarean section (VBAC) may be the wisest choice for women planning to have two or more pregnancies. However, another cesarean may be less likely to lead to problems in women who intend to have no more than one additional pregnancy, according to researchers.

Standing up to the VBAC-lash: - A critique of the New England Journal of Medicine VBAC study and implications for the future of the medical model of childbirth by Jill MacCorkle

BMJ followup Vaginal delivery after caesarean section triples risk of uterine rupture(BMJ 2001;323:68 ( 14 July )

Women respond to the Britsh Medical Journal about VBAC

Anti-VBAC Study and Refutations

A definite yes! to the suspicions of recent backlash.

I was recently labor coaching for a hospital birth - planned to be the first VBAC after three sections. The OB was known in the community to be very supportive of natural childbirth, but even he was trying to convince my client that a VBAC after three surgeries was taking some huge risk. He asked her to sign some "backlash" forms about how dangerous VBAC is.

Then, when my client arrived at the hospital in labor, she was informed by the hospital staff that they could not support her in her choice to have a vaginal birth. Some tense discussions followed, during which it became clear that the hospital intended to get a court order to force her to delivery surgically if she didn't make that choice. (It's ludicrous to call it a "choice" at this point.)

The perinatologist said that because there were no studies showing the safety of laboring with three uterine scars, they had to assume it was not safe and that it was putting the baby at risk. She told us that there is an increase in risk for laboring with 1 vs. 2 scars, and that they had to assume the possibility that there could be an enormous increase in risk between 2 scars and 3.

She actually told us that their working assumption was that the risk of catastrophic rupture (in which the baby died) was 5%. Yes, 1 out of 20. My hope for her is that she finds herself in a position to learn more respect for women's choices in birth.

The first c-sec is the major problem.  I can't tell you how many women who had c-secs for their first baby told me it was because the baby was in distress yet it took 1-3 hours for them to go to surgery.  When a baby is in true distress they have those ladies in surgery and open within 15 minutes.  And mind you, once surgery was decided on no one checks dilation again or monitors any of the contractions.

And another problem is that they use those blasted machines to declare that a woman is in labor.  No dilation (or maybe she is dilated 1-2 cms), no effacement but the dang machine says she is in labor so some yahoo comes in after a while and does AROM, because she is not moving along.  Then augments.  All the while (which by now it could easily be 8 hours) she has been on an IV with no food. These primips now have drugs forcing the labor process and the poor gal just can't handle it anymore.  C-sec due to maternal exhaustion or fetal distress.

Best thing is to stop that first c-sec and the only way to lower those numbers is by having midwives attend them.  Our local CNMs have lowered one hospitals c-sec rate to 14%.  The hostile hospital, which abhors midwives, has a rate of 29%.  I applaud those midwives because it has been a rough row to hoe and one waited for years to get the respect due her.

Dr. Phelan has definitely changed his colors on VBAC. It is very ironic that his earlier medical research supports the safety of VBAC. In the last few years he has become a VBAC antagonist.

Not too long ago, someone posted an outrageous "VBAC consent" form filled with scare tactics and even inaccuracies. Guess who the author was? Yep- Dr. Phelan. He published this as a recommended consent form for all OB's to present to women during their pregnancies if they are considering VBAC.

He also published an article a couple years ago with a title something like: Cesarean goal rate for the year 2000: 50%. It also was an outrageous editorial.

LATimes, Sunday, January 25, 1998, Home Edition; Section: PART A; Page: A-1

Dr. Jeffrey Phelan, a noted obstetrician and fetal medicine specialist who along with Paul of County-USC helped pioneer the idea of vaginal birth for women who have had caesareans, makes no bones about rejecting the ideas he once proposed.

Phelan, co-director of maternal-fetal medicine at Pomona Valley Medical Center and an attorney, recently called for increasing the caesarean rate to 50% of all births.

Recovering from the Surgery

Painful gas

    * rocking in a rocking chair
    * drinking hot lemon water
    * walking

As your intestines begin to function again, you may have gas pains. To ease your discomfort, eat light foods that are easy to digest (toast, yogurt, soup). Get out of bed and walk around. Movement helps stimulate your digestive system.  Actually, come to think of it, so does sucking on something - a lollipop or popsicle would help, or heh, why not ask the nurses to get you a pacifier to suck on!  Seriously, that kind of sucking is what stimulates babies to move their bowels every time they nurse.  :-)

Some naturopaths are offering a treatment to soften up scars from c-sections.  Apparently they inject saline fluid into the scar area, which causes inflammation, which helps the scar tissue to heal.

Chinese medicine recommends treating cs scars w/acupuncture as they cross vital meridians and create obstruction.

The C-section scars create obstructions in key energy fields and should be treated not only via acupuncture but also with some type of topical drawing packs to get the scars to heal up with more normal tissue than scar tissue. Dr. Bob Marshall has formulated Medi-Body Packs, which work well for this purpose.  You can buy them from Premier Research Labs.

Treating all kind of scars is very effective with Myofascial Release. We must think of scars as roots that continue to grow within our body reaching and pulling our fascia in a 3D web!

I would highly recommend JBMFR (John Barnes Myofascial Release) for C-section scars. I recently came back from the Woman's Health Seminar in which we learned to do a lot of internal work to treat all kinds of issues that we females may encounter.

Cesarean Scar Care in the Post-Partum Period - sponsored by ICAN!

Presented by physical therapist Isa Herrera, MSPT, CSCS, Clinical Director of Renew Physical Therapy in NYC, this great online session will teach and guide you through the basics of cesarean scar care in the post-partum period.

This much-needed class is geared toward new moms and healthcare professionals alike who are looking to understand and implement some real-world techniques to get relief from pain, itching, burning, tingling… and also learn how to restore the abdominal muscles and posture so that you feel like yourself again.

Much of the great material to be included in this webinar is taken from Isa’s new book, Ending Female Pain, A Woman’s Manual. The book has been endorsed by filmmakers Ricki Lake and Abby Epstein, Dr. Jacques Moritz, and most recently by Jill Osborne of the IC-Network and NY Times best-selling author and gynecologist Dr. Christiane Northrup.

Highlights of this webinar include:
Understand how to locate scar adhesions and why they are so important to eliminate
Learn mobilization and massage techniques for cesareans
Restore abdominal function after cesarean with safe abdominal exercises
Learn the connection between Diastasis Recti and low back pain and pelvic pain
Learn simple yoga stretches for indirect scar mobilization during the early post-partum period

Scar Reducer™ Gel - Reduces the appearance of scar tissue and beautifies skin texture.

Complications of Cesarean Deliveries [Medscape registration is free]

Excerpt from Nursing the Caesarean Born, by Michel Odent, MD -  Midwifery Today Issue 69

Institutional Quotas for Cesareans

Feeling pressure from hospital for more c-sections, she leaves By Cheryl Welch, Staff Writer

Dr. Helen Sandland closed her Wilmington practice and is moving to Mississippi after New Hanover Regional Medical Center asked her to perform more cesarean sections on her patients.

VBAC Havens and Traveling Midwives

As VBAC access becomes more limited, some women are going to other countries to avoid a surgical birth or hiring traveling midwives to come to their home from other parts of the country.

Plenitud; embarazo, parto digno y lactancia (Plenitude; pregnancy, birth with respect and lactation)
We are in Guadalajara, Mexico and offer bilingual (Spanish/English) care for birth at a local rental home or at the birth center - a little 4 room retreat within the 18 bed hospital Valle de Atemajac. The hospital houses us but does not dictate our policy. Our primary cesarean rate is 11% and our VBAC/HBAC rate is 85%.
Email contact info is Joni Nichols - joninichols@infosel.net.mx
Phone: 011 52 333 656 82222
The ob/gyn I work with is Dr José Luis Grefnes Sanchez.

In addition to our autonomous four bed water-birthing center within a hospital (part one of the story of how we created it was just published in Midwifery Today #75; Autumn 2005) we also attend VBAC at home. Barbara Harper describes us in the newest edition of Gentle Birth Choices.

We serve families from all over the United States, Canada and Mexico.  Travel to Guadalajara is a straightforward flight from the US! There are no problems with acquiring US or Canadian passports for the babies born to families coming from these countries. Both countries have consulates in Guadalajara.   I typically offer one night's stay in my home to give visiting families a base while they check out their housing alternatives. We have a terrific bed and breakfast/kitchenette option locally with good weekly and/or monthly rates and we sometimes know of apartments or homes available for short term rental.

donna mitchell in alabama will accept VBAC moms who will come here..or may be able to travel.  heartathome@att.net

On a quiet, beautiful and secure country estate, overlooking the central valley of Costa Rica, Central America, Birth-my-baby offers two modern homes for expectant mothers to have their babies in peace and gentleness.

From Sherri Holley, CPM: "I travel all around the world for women who cannot find a  midwife to serve them. I do VBAC's, breeches, and twins. I have practiced for 30yrs and have attended over 2,000 birth as of 2008. lastfrontiermidmwife@yahoo.com

From Jane Gandy in Garland, Texas - As long as someone has been getting prenatal care somewhere, I'm fine taking them at the end. fruitofthewomb@att.net

From gail hart in Oregon, hdw4@msn.com

I don’t mind taking them at the end. Even if they haven’t had prenatal care!

It might be heresy to say this, but I think prenatal care – or lack of it – is pretty irrelevant if you are meeting a healthy mom with normal Blood pressure, at full term, with an appropriate-sized vertex baby, in good position,  with good heart-tones.

I’ve actually met a couple of women for the first time when they are in early labor.
It’s nice to have some bloodwork on them. Or at least to know their blood type.
A woman with severe anemia will show it.
An Rh negative mom is probably the only sneaker, but generally it isn’t a problem with the first pregnancy. And moms will usually know if they are rh negative if they’ve ever had a baby before.

If they PASS a very thorough prenatal/labor exam – I don’t see lack of prior care to be an impossible hurdle.

I think the biggest issue is to try to convince them to let me use eye meds for the baby (just in case)

From Suzanne Smith, CPM, in Orem, Utah, suzanne@betterbirth.com

I would accept such a client.  Of course, I would prefer for arrangements to be made early, not have her show up all of a sudden at 37 weeks, but as long as she has been getting good care and I can look at the other risk factors and find them acceptable, I have no problem with a transfer in at 37 weeks.

From Deva Burgess in California - I also have taken ladies as they were in labor.  shstamidwife@finestplanet.com

From Judi Mentzer in California - Mentzer Maternity accepts anyone who comes to our door.  Occassionally we have those who we have never seen prior to labor and may or may not have been seen by someone else. jmentzer@pa.net

We have met ladies in labor who have left others' care at the last minute.  I judge each case as it comes and handle those ladies as I handle all ladies.  If they need medical care they will be referred.  If not, they deliver.  We have had VBACs come in like that.

From Brenda Capps in southern California: I have and still do take ladies last minute. If they are sincere I will help them. BCappsmidwife@cs.com

BirthLove.com has a list of

Traveling Midwives

Ollie Anne Hamilton, Great Falls, MT, 406 453 4915, E-mail: mwinmt@birthwithlove.com
In practice since 1977, will travel to most anywhere.

Sandi Blankenship, BA, LM, Jensen Beach, FL, 772-359-1258, E-mail: sandib2@juno.com
In practice since 1997, will travel overseas to attend a birth for any woman expected to have a normal pregnancy, labor and birth, including first-time and older mothers.

Lillian Alice Sanpere, LM, CPM (I go by Alice), Tallahasee, FLorida, 850-681-6969 or 850-509-1540, E-mail: purplemidwife@yahoo.com
In practice since 1986, will travel to most anywhere, internationally, will consider suitability for homebirth on an individual basis.  Speaks fluent english, spanish and fairly good french.

Jerry Whiting, Perris, CAlifornia 92570, 951-657-7734 Home, 909-553-5344 Cell, E-mail: Jerry@homebirth-only.com will travel anywhere to attend births for VBAC's, Primip's, Twins, Breeches, The very young.  In practice since 1999, 450 home births.

donna mitchell in alabama will accept VBAC moms who will come here..or may be able to travel.  heartathome@att.net

Dismayed at the lack of VBAC-friendly institutions near you?  Don't just get mad - get active!  Get involved with ICAN and your local birth circles or midwifery support groups.  If you don't have any in  your area, start one.  If you don't do something, how will things get better for your sisters, daughters and nieces?

VBAC Resources

Expanded Acronyms

• ICAN - International Cesarean Awareness Network
• VBAC - Vaginal Birth After Cesarean
• HBAC - Home Birth After Cesarean

Online Support Groups

birthingbycesarean@yahoogroups.com - This is a list for women who had a cesarean birth(s) or to women who have a possible c-section pending and want to discuss any issues that they presently coping with.

HBAC@yahoogroups.com - This list is for people who are exploring the option of having a vbac at home.  For more information.

vbac-hope@yahoogroups.com - This is a Christian list offering support and hope for those facing all aspects of Cesarean and VBAC, including HBAC (home birth after cesarean). For more information.

ICAN homepage

Be sure to read their Focus: Sex and the Myth of Cesareans from The Clarion, Volume 33, February 22, 2006

VBAC - Excellent Patient Education from Kent Midwifery Practice in the UK (Kay Hardie and Virginia Howes)

Cesarean & VBAC from Mothering Magazine - Crucial information, to help you understand (and advocate for) your right to birth safely and without surgery.

A VBAC Primer: Technical Issues for Midwives by Heidi Rinehart, MD [Midwifery Today Issue 57, Spring 2001]

VBAC: Should you try, or avoid disappointment? by Gayle Peterson, PhD
Q: I had a cesarean for my first child. I am pregnant again and would love to give birth vaginally, but I am frightened. I'm very concerned that it might be more difficult for me emotionally if I try for a VBAC and fail, than if I just schedule a cesarean. What is the best decision for me and my family?

Can Low Glycemic Diet Increase VBAC Success?
Cohain JS.  judyslome@hotmail.com
MIDIRS Midwifery Digest 2009:19:71

Vaginal Birth After One Previous Low-Segment Caesarean Section - clinical practice guideline from the Association of Ontario Midwives [337.4KB 20/11/2006 21:25] - note that they state:

"Recognition that hospital policies perceived by a woman as restrictive may lead her to choose giving birth at home;"
"Home birth reduces the risk of iatrogenic consequences;"

The Royal College of Obstetricians and Gynaecologists Issues Practice Paper on VBAC

In this practice guideline, issued in February of 2007, the RCOG recommends the following to inform the care of women undergoing either VBAC or elective repeat cesarean section (ECRS):

• Women should be informed that, overall, the chances of successful planned VBAC are 72-76%.
• Women should be informed that attempting VBAC probably reduces the risk that the baby will have respiratory problems after birth.
• Women should be informed that elective repeat cesarean section may increase the risk of serious complications in future pregnancies.

• Women undergoing VBAC carry an additional 1% risk of either blood transfusion or endometritis.
• Women undergoing planned VBAC carry an addtional 2-3/10,000 risk of birth-related perinatal death, though the absolute risk of such birth-related perinatal loss is comparable to the risk for women having their first birth.
• Induced and/or augmented labors carry a two- to three-fold increased risk of uterine rupture and a 1.5-fold increase of cesarean section compared with spontaneous labors.

VBAC Success CD from HypnoBabies

This is taken from the Winter 2006 - Number 76 issue of Midwifery Today:

"The federal Emergency Treatment and Advanced Labor Act (EMTALA) requires hospitals to admit women in active labor and to abide by their treatment wishes until the baby and placenta are delivered. The act was originally passed to prevent hospitals from "dumping" patients who can't pay, but it's since been applied in all sorts of other ways and includes specific provisions that apply to laboring women.

The attorneys we've consulted on the VBAC ban issue have told us that hospitals are much more afraid of being found in violation of EMTALA than they are of malpractice suits because the act is routinely enforced and each violation subjects them to fines between $50,000 and $100,000.

I can't emphasize enough the importance to individuals who may find themselves in this situation of memorizing phrases such as "It's a violation of my rights under EMTALA to force me to undergo a cesarean," or "I'm invoking my right under EMTALA to refuse a, b, c." Whether the hospital in question says it bans VBACs is unimportant; according to EMTALA, you have the right to be admitted to a hospital once you're in active labor and, once admitted, you have the right to refuse any recommended treatment. You can also remind them that VBAC isn't a treatment, it's the natural culmination of a normal physiological process. Cesareans are the treatment.

Also, it's helpful to know that EMTALA begins to apply once you are anywhere within 250 feet of a hospital; you don't have to be in the emergency room. You can be standing in the hospital parking lot, and if they so much as touch you against your express consent, they are in violation of EMTALA. For anyone interested in reading more, we've compiled a legal primer on the rights of pregnant women at http://www.birthpolicy.org

Editor's Note: To learn more about this important subject, go to

Risk of Uterine Rupture With a Trial of Labor in Women With Multiple and Single Prior Cesarean Delivery.
Landon MB, Spong CY, Thom E, Hauth JC, Bloom SL, Varner MW, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, Peaceman AM, O'sullivan MJ, Sibai BM, Langer O, Thorp JM, Ramin SM, Mercer BM, Gabbe SG.
Obstet Gynecol. 2006 Jul;108(1):12-20.Obstet Gynecol. 2006 Jul;108(1):12-20.

CONCLUSION: A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation. Maternal morbidity is increased with trial of labor after multiple cesarean deliveries, compared with elective repeat cesarean delivery, but the absolute risk for complications is small. Vaginal birth after multiple cesarean deliveries should remain an option for eligible women.

Elective Cesarean Surgery Versus Planned Vaginal Birth: What Are the Consequences? - Elective or "maternal request" cesarean surgeries pose serious and life-threatening complications for mothers and babies. Despite the risk, the popularity of elective cesarean surgery continues to rise-from 2001 to 2003, the rate increased by 36 percent.

For example, following a population of 100,000 healthy, low-risk first-time mothers, through three pregnancies, comparing outcomes based on whether they have elective cesarean surgery for the first delivery or plan vaginal birth.

With elective cesarean surgery:

57 more women will die
999 more women will have a hysterectomy
135 more women will have a uterine rupture and 7 babies will die
63 more women will have a cesarean-scar ectopic pregnancy 45,900 more women will have dense adhesions (adhesions make subsequent pelvic or abdominal surgery more difficult, increase the likelihood of injuring organs or blood vessels during surgery, and can cause chronic pain and bowel obstruction)
13,500 more women will experience wound (abdominal vs. perineal) pain for 6 months or more
378 more babies will die in the womb (antepartum fetal demise) without explanation after 34 weeks of pregnancy
7,830 more babies will be born preterm (before 37 weeks completed gestation)
1,620 more babies will born weighing in the lowest 5% for their gestational age
4,244 more babies will have respiratory problems serious enough to require admission to intensive care
3,240 fewer women will have anal sphincter trauma (This assumes an anal sphincter injury rate of 1%, a rate achievable with optimal care [Albers 2005].) BUT
630 more women will have bladder injury
10,260 fewer women will have moderate to severe urinary incontinence
BUT
0 fewer women will have later-life urinary incontinence (MCA 2004)

Vaginal Delivery After Prior Cesarean Delivery May Have Low Absolute Risk  CME

VBAC info from an HMO! (circa 2001) - This is a pro-VBAC handout.

Preliminary Births for 2004: Infant and Maternal Health - The cesarean delivery rate rose 6 percent in 2004 to 29.1 percent of all births, the highest rate ever reported in the United States (2). The rate has increased by over 40 percent since 1996. For 2003–04 the primary cesarean rate rose 8 percent, and the rate of vaginal birth after cesarean delivery (VBAC) dropped 13 percent. The primary rate has climbed 41 percent and the VBAC rate has fallen 67 percent since 1996.

Battle lines drawn over C-sections (USA Today) - For some women, birth has become the latest battleground for reproductive rights. At a growing number of hospitals, women are being forced to schedule a repeat cesarean section just because they already had one. Doctors and hospitals say they fear lawsuits if they allow a patient to attempt a VBAC and something goes awry.

This news account of a sad case of uterine rupture highlights that the ruptures tend to happen in the higher-risk cases: the woman had a vertical incision from her previous surgery, which just about everyone recognizes as an absolute indication for repeat c-section; her previous surgery was for CPD, although possibly caused only by malposition of the fetal head; her labor was induced with prostaglandins; she was not monitored during labor.

The article also clarifies, "While there are clearly cases when C-sections are necessary to protect the health of mother and baby, C-sections are associated with five times more postpartum cardiac arrests, five times more wound infections and twice as many anesthetic complications than in vaginal births. C-sections cost the health-care system 65 per cent more, partly because of longer hospital stays."

The lawsuit brief is also available.  [Cojocaru (Guardian Ad Litem) v. British Columbia Women’s Hospital, 2009 BCSC 494, Date: 20090409, Docket: S032599, Registry: Vancouver (IN THE SUPREME COURT OF BRITISH COLUMBIA)] This states that, she suffered from constant pain for the half hour preceding more serious signs (of fetal distress?).

VBAC.com - A woman-centered, evidence-based resource

50 Ways to Protest VBAC Denial - by Barbara Stratton

ICAN of Tacoma offers downloads of  brochures to give to your clients, friends or family who may have had a cesarean or is trying to avoid one, wants help planning a vaginal birth after cesarean, or wants to get involved with protesting the VBAC bans.

Model predicts risk of emergency after previous cesarean

Consumer Reports Questions Cesarean Frequency [12/30/05]

The American Academy of Family Physicians Trial of Labor After Cesarean (TOLAC), Formerly Trial of Labor Versus Elective Repeat Cesarean Section for the Woman With a Previous Cesarean Section
March 2005 A Review of the Evidence and Recommendations by the American Academy of Family Physicians American

The American Academy of Family Physicians (AAFP) recently published these new recommendations regarding vaginal birth after cesarean (VBAC), which differ significantly from the current recommendations of the American College of Obstetricians and Gynecologists (ACOG).

Some of the most notable highlights are:

~ "TOLAC [Trial of Labor After Caesarian] should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes."

~ "Our recommendation significantly differs from current ACOG policy because we could find no evidence to support a different level of care for TOLAC patients. Without good-quality evidence, we believe that different levels of resources cannot be advocated because their potential for unintended harms cannot be evaluated against their purported benefits."

~ ". the ACOG policy suggests that one rare obstetrical catastrophe (e.g., uterine rupture) merits a level of resource that has not been recommended for other rare obstetrical catastrophes (e.g., shoulder dystocia, abruptio placenta, cord prolapse) that may actually be more common."

~ ". current risk management policies across the United States restricting a TOL after previous cesarean section appear to be based on malpractice concerns rather than on available statistical and scientific evidence."

ACOG currently recommends that an OB and an anesthesiologist should be "immediately available," widely interpreted as being on the premises throughout the trial of labor. ACOG recommendations were based on "expert opinion."  In contrast, the AAFP recommendations are based on a comprehensive review of published medical studies, a much higher level of evidence for such recommendations. The ACOG recommendation of having a surgical team immediately available has possibly been one of the biggest limiting factors for hospitals allowing a VBAC, leaving women with limited or no options for avoiding a repeat cesarean section.

The AAFP guidelines certainly give family practice physicians more incentive to allow their patients to have a VBAC than the ACOG policy currently gives an Ob/Gyn. It will be interesting to see how the AAFP recommendations will factor into the current climate, and how useful they may be for women and birth advocates working to change hospital policies.

Vaginal Births after C-section are safer in  Birth Centers in certain situations by Judy Slome Cohain, CNM

Vaginal birth after c-section safe after due date [Reuters - 10/3/05]

Safety and Efficacy of Vaginal Birth After Cesarean Attempts at or Beyond 40 Weeks of Gestation.
Coassolo KM, Stamilio DM, Pare E, Peipert JF, Stevens E, Nelson DB, Macones GA.
Obstet Gynecol. 2005 Oct;106(4):700-706.

CONCLUSION: Women beyond 40 weeks of gestation can safely attempt VBAC, although the risk of VBAC failure is increased. LEVEL OF EVIDENCE: II-2.

Guidelines for Vaginal Birth After Previous Caesarean Birth by Ashraf Fouda, MD, Ob/Gyn Specialist, Egypt - Domiatt General Hospital

This study by Pauline Dillard, M.S., focused on Post Traumatic Stress Disorder (PTSD) differences between women who have had cesarean sections versus those who have had natural childbirth.

Hypnosis for VBAC - from Maggie Howell of Natal Hypnotherapy in the UK
"Have you had a ceasarean and want a vaginal delivery next time?  The VBAC (vaginal birth after a c-section) is a 2 part CD which helps you overcome any trauma from your previous c section and the prepares you for a natural vaginal delivery"

Maggie sent me a review copy of this CD, and I was VERY, VERY impressed with it.  I have a background in hypnotherapy and am now a midwife, so I'm very sensitive to all the issues of hypnosis for VBAC, and I thought Maggie did an excellent job.  The guided relaxation is exquisitely sensitive to the issues of VBAC, and I would think any woman planning a VBAC would benefit tremendously from listening to this on a regular basis.  Maggie's website makes it easy to order these CDs from other countries, so don't hesitate!

Maggie's work is a gift to birthing women everywhere.

Some more resources from Henci Goer:

CIMS:  www.motherfriendly.org/resources (scroll down to the fact sheet on c/sec)

Advice for Pregnant Women about C-Section, Vaginal Birth and Vaginal Birth After Cesarean (VBAC) from Maternity Center Association

3 in 10 U.S. Mothers Gave Birth by C-Section in 2004: Sharp, Continuing Rise Defies Best Evidence and Best Practice from Maternity Center Association

www.vbac.com

my article:  "Rebuttal to rationales for denial of VBAC" http:

What Should I Know About Cesarean Section? — a new booklet to help prepare every pregnant woman to make informed decisions about this important matter

Should I choose VBAC or repeat c-section?

How can I prevent pelvic floor problems when giving birth?

Could mode of delivery influence the neonatal immune response? - Cesarean section may increase the risk of diarrhea and allergy in susceptible babies, German researchers suggest.

Caesarean section and gastrointestinal symptoms, atopic dermatitis, and sensitisation during the first year of life.
Laubereau B, Filipiak-Pittroff B, von Berg A, Grubl A, Reinhardt D, Wichmann HE, Koletzko S; GINI Study Group.
Arch Dis Child. 2004 Nov;89(11):993-7.

CONCLUSION: Caesarean delivery might be a risk factor for diarrhoea and sensitisation in infants with family history of allergy. Further research in this area seems warranted as choosing caesarean section becomes increasingly popular.

Birthing the Easy Way -Learning the Hard Way - a book written by a woman who has had 5 VBAC's

My Cesarean Poem by Barbara Stratton

Uterine rupture is more likely, but not common, after previous caesarean section
BMJ  2004;329 (3 July), doi:10.1136/bmj.329.7456.0-a

"The risk of uterine rupture during labour in women who have had a previous caesarean section is small. Reviewing 568 articles published since 1980, Guise and colleagues (p 19) found that, in women delivering vaginally after a previous surgical delivery, the risk of uterine rupture during labour was increased by 2.7 per 1000 cases, the additional risk of perinatal death was 1.4 per 10 000, and the additional risk of hysterectomy was 3.4 per 10 000. It would require 370 elective caesarean sections to avoid one symptomatic uterine rupture in women who had a previous caesarean section."

Vaginal Birth After Cesarean Birth --- California, 1996--2000  from the CDC:  "Because cesarean birth is associated with higher maternal morbidity than routine vaginal birth (2,3), two of the national health objectives for 2010 are to reduce the cesarean birth rate among women at low risk to 15% of women who are giving birth for the first time (objective no. 16-9a) and  to 63% of women with previous cesarean births (objective no. 16-9b) (4). A key strategy to reduce the repeat cesarean birth rate is to promote  vaginal birth after cesarean (VBAC) as an alternative to ERCD."

VBAC safety: A closer look at the 2002 JAMA study by Henci Goer

The Assault on Normal Birth: The OB Disinformation Campaign by Henci Goer, which starts with a focus on the NEJM's July, 2001, VBAC study and accompanying editorial.

Is vaginal birth after cesarean risky?

VBAC

Rebuttal to rationales for denial of VBAC

Levine, Audrey, 2000 - Midwives as radical educators: preserving informed choice in the midst of a VBAC-LASH available from Senior Research Papers at Seattle Midwifery School.  [I'm encouraging them to put these resources online.  You could, too.]

Caesarean Birth: Making Informed Choice - an online booklet available from Birthrites: Healing After Caesarean Inc.

Victorious Birth After Cesarean Cesarean and Traumatic Birth Support  ~A site for women who want to reclaim their birth and truly heal spiritually and emotionally after a cesarean.

HBAC FAQ - Q&A about Homebirth After Cesarean - Although this was written by a VBAC mom planning a homebirth, the safety information should easily qualm fears about VBAC'ing in a hospital!  [Homebirth advocates would say this isn't necessarily true, since many aspects of homebirth make it safer for a VBAC, but most people who worry about VBAC won't know that!]

"By their own words shall they be known" - a recent discussion among obstetricians helps birthing women understand their view of cesarean, VBAC and birth in general.

Elective repeat cesarean delivery versus trial of labor: A meta-analysis of the literature from 1989 to 1999.
Mozurkewich EL, Hutton EK
Am J Obstet Gynecol. 2000;183:1187-11

Birthrites: Healing After Caesarean - Great Australian VBAC site (used to be BACUP - Birth After Caesarean Unlimited Possibilities).  This site is amazingly affirmative.  They offer a terrific Suggested Reading List and a Birth Visualization Poster that is truly inspired!  (The poster can be ordered from a U.S. distributor, Birth With Love, either plain paper or laminated.)

They publish a quarterly journal/newsletter which is very inspiring and supportive - excellent for those in Australia and also available in other countries.  (Annual subscription $15 for the US.)

They also have a feature - 'Ask an Obstetrician' - a forum set up to answer your questions; they will be answered by a qualified Obstetrician, who is very sympathetic to the valid choice of VBAC for most women.

A Butcher’s Dozen - by Nancy Wainer - an article about 12 labors that could easily have ended as cesareans under the medical model.

What would you say are the top 5 VBAC books you would recommend someone to read?  [year 2001]

The VBAC Experience by Lynn Baptisti Richards
Natural Childbirth after Cesarean by Karis Crawford & Johanna Walters
Birthing from Within by Pam England and Rob Horowitz
Silent Knife by Nancy Wainer Cohen & Lois Estner
Natural Childbirth the Bradley Way by Susan McCutcheon

1-  Nancy Cohen's Silent Knife
2-  Nancy Cohen's other book-- Open Season (if not the above)
3-  Gentle Birth Choices by Barbara Harper (AND see the companion video!!!!)
4-  Diana Korte and Roberta Scaer's A Good Birth, a Safe Birth
5-  Susanne Arms' Immaculate Deception

All five just make you spittin' determined to get your birth as far away from the sharps as you possibly can.  I'd temper them with others like Birthing From Within, Rahima Baldwin's Special Delivery, as well as Susan McCutchen's excellent Natural Childbirth, The Bradley Way for the practical aspects of getting physically ready for natural childbirth.

Vaginal birth after cesarean - from National Guideline Clearinghouse, a public resource for evidence-based clinical practice guidelines.

They have 5 other guidelines related to VBAC and cesarean.

ICAN Reading List

"Research Shows No Evidence to Support Increasing Cesareans" by Henci Goer, BA, LCCE, printed in GENESIS - The Lamaze Advocate, Summer, 2000.  This is a very good article, similar to the one below but updated for the 2001 ACOG statements supporting a woman's right to choose a cesarean section. She quotes him, "Every other medical condition we give the patient the options to deal with it.  This is the only area where we deny the patient the choice.  It's not a matter of procedure, it's the principle of a woman's right to control her body."  As Goer astutely observes later in the article, "Contrary to Harer's statement, the 'right' to a cesarean is the sole instance where obstetricians have ever championed a woman's right to determine any aspect of her care other than, perhaps, her right to refuse an epidural."  Indeed, the issue of a woman's right to choose the circumstances of giving birth seems to disappear when the issues of VBAC and homebirth are on the table.

Cesareans: Are they really a safe option? by Henci Goer - If you watched the recent segment on Good Morning America [June, 2000] addressing the safety of cesareans and the issue of a woman's right to choose this surgical procedure, you probably ended up feeling quite confused.

[The BirthLove site is by subscription only - it's well worth the subscription fee.]

Leilah McCracken, author of  The Revolutionary Passion of Mothering offers a collection of Birth Love Columns from the weekly Online Birth Center newsletter.  Many of these are about cesarean and VBAC.  In particular:

• VBAC is Safe!
• Just Take Them Out!
• A Midwife's Courage
• Will VBAC Become a Way of the Past?
• My Passion for VBAC (or: Five VBACs later- just try to tell me I couldn’t have one!)
• Up to 90% of Brazilian Women get C-Sections

Midwifery care and out-of-hospital birth settings: how do they reduce unnecessary cesarean section births?
Sakala C
Soc Sci Med 1993 Nov;37(10):1233-50

U.S. women beginning labor with midwives and/or in out-of-hospital settings have attained cesarean section rates that are considerably lower than similar women using prevailing forms of care--physicians in hospitals.

Vaginal birth after cesarean section: the demise of routine repeat abdominal delivery.
Martin JN Jr, Morrison JC, Wiser WL
Obstet Gynecol Clin North Am 1988 Dec;15(4):719-36

Cesarean Section Homepage

Vaginal Birth After Cesarean Homepage

American College of Obstetricians and Gynecologists - Vaginal Birth After Cesarean Guidelines

Vaginal Birth After Cesarean Checklist

VBAC Handout

Robin Elise Weiss' Vaginal Birth After Cesarean FAQ

MOTHERLOVE - Childbirth Services VBAC pages

Faith Gibson's Homebirth VBAC Consent Form

The Trials of the Midwife
by Katie Granju - From Minnesota Parent, October 1997
A must-read article for anyone trying to understand why the healthcare system in the U.S. continues to snub the midwifery model, despite reduced Cesareans, proven safety, and lower costs.

I have Natural Childbirth After Cesarean by Crawford & Walters and Birth After Cesarean by Bruce Flamm. These are both excellent books. But the Vaginal Birth After Cesarean by Elizabeth Kaufman is a depressing book for women who are planning for a VBAC. This woman's point of view is that VBAC and vaginal birth are not all they are cracked up to be. It disturbed me greatly so I returned it to the book store. I got it by mistake when I was looking for Lynn Baptiste Richards Vaginal Birth After Cesarean Experience. I still can not find this book anywhere to purchase. I think the positive VBAC stories described in this book would be revealing and encouraging.

Ken Turkowski's VBAC Births and Uterine Ruptures - has an extensive bibliography and there are some useful Suggestions for VBAC Delivery.

I checked out this bibliography, and it's huge. I am not sure how unbiased it is. In particular, most of the interpretations of the studies ignore the many possible problems resulting from Cesarean sections. But it might be helpful to someone doing research.

No, it can't be unbiased.  Read his sad birth story about Catherine Grace's Birth (VBAC, induced, epidural rupture, sad) .  This is from his web page on VBAC Births and Uterine Ruptures.

The extreme poor care of the labor was this: While laboring the woman gets a constant pain even between contractions, husband and mother are questioning, hospital staff dismisses. Then husband and mother notice what seems to the father a bulge of a fetal foot sticking clearly out right through the uterus and into the abdominal wall, brings it to the staff's attention but again staff dismisses carelessly saying bulges like that are not uncommon during labor. Finally a stat cesarean is ordered when during descent the baby returns too far back into the uterus or actually abdominal wall at this point.

Ken sent me to this site-some of you may remember that Ken and I struck up a cyber acquaintance through some message boards that he posted to- and while the idea of having VBAC research all in one handy reference sounded nice, it doesn't quite pan out that way. I posted about this site earlier with the disclaimer that it was a bit biased against what they term "TOL"-trial of labor. I agree that the conclusions reached in the majority of the studies seemed to ignore the morbidity from repeat cesarean. I also resented the intro. To quote directly from the site:

The problem of VBAC is essentially one of playing the odds. If a pt chooses TOL and is successful, they win-minimal morbidity, short stay and low cost. If VBAC is not successful, they lose: repeat CS after a long labor with increased risk for high morbidity, prolonged stay and high cost. On the other hand, if they choose repeat CS they play a sure thing: low morbidity, slightly longer stay and moderate cost. I encourage counseling patients about VBAC from a perspective of what is good for the patient rather that what is good for the hospital cesarean section rate.

In short, skepticism is healthy[GRIN]

Books and Newsletters about VBACs, Unassisted Birth and Pleasurable Husband/Wife Childbirth

VBAC Abstract - Miller - Vaginal birth after cesarean: a 10-year experience

Is Homebirth Appropriate for a VBAC?

Homebirth VBACs

Are there studies which demonstrate that cont EFM is superior than intermittent monitoring in "high-risk" cases ?

Vintzileos AM, Antsaklis A, Varvarigos I, et al. A randomised trial of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation. Obstet Gynecol 1993;81:899-907.

This study is an anomaly--the only RCT, as I recall, that finds a better outcome with EFM. The biggest problem with it is a highly suspect randomization scheme. They ended up with nearly 3 times (as I recall without looking at it again) the number of patients in the EFM group as the auscultation group. The randomization was supposed to be by a coin toss, which is, of course, an inadequate method. It is all to easy for the physicians to decide that this patient "needs" EFM, and just repeat the coin toss until he gets the desired outcome. In a response in Birth somebody calculated the odds of getting such a lopsided distribution randomly, and it was literally less than one in a million. There's something rotten in Denmark with this study.

VBAC After 3 Cesareans

Informed Consent for VBAC

Getting a stubborn patient to say Yes - an article written by and for OBs about perception of VBACs and how to coerce laboring women to agree to routine treatment.

This is the actual practice of the theory expounded in "Patient Choice and the Maternal-Fetal Relationship".

Excerpt from: Patient Choice and the Maternal-Fetal Relationship
American College of Obstetricians & Gynecologists, Committee Opinion, No. 214, April 1999

Look for updates here or hereor here

Doula Recommendations for VBAC Client

These were the ideas that The Farm gave to me regarding encouraging a successful vbac.  Some are new to me, so take what you need and leave the rest:

1. Use PN6, beginning at 36 weeks, start with 1 capsule a day for 3 days, then 2 capsules for 3 days, and accelerating until you are at 6 capsules a day
2. Take Essential Balance, an herbal preparation found in the refrigerated section of the health food store, beginning at 34 weeks, has essential fatty acids which enhance prostoglandins.
3. Red raspberry tea, beginning at 20 weeks, 2 cups a day until 3rd trimester, then 3 cups a day.  Strongly recommended for all pregnant women, and used very successfully by the Amish.
4. Daily manipulation of the cervix beginning at 37 weeks, more of a wiggling than a stripping of the membranes, but leading to that. Said done by the midwives, but I would guess that we could do this.  ( I looked forward to avoid VEs, but midwife said that this was extremely effective, that they even used it with women with adhesions and fibroids near the cervix, and she felt it reduced labor as well.
5. Weight gain of about 20 lbs, with a goal of a 7 1/2 pound baby, no bigger, because much more difficult to deliver, much more likely to require interventions and exhaust mom and baby.  Specifically said that Dr. Brewer diet was too rich in calories for this purpose, and that even though they are vegetarian, they would never recommend comsuming this many calories in pregnancy to most women
6. Frequent lovemaking.

Here are some sources I found in the Midwifery Today newsletter archives.

-Rupture of the unscarred uterus occurs more often and does more harm than rupture of the scarred uterus (Martin, M et al., Vaginal birth after cesarean section: the demise of routine repeat abdominal delivery, "Ob Gyn Clin North Am, Vol 15, No. 4 1988, pp. 719-736).
-The scar that has remained intact up to the threshold of labor is very likely to remain intact through the birth (Macafee, C, Irish J. of Med Science, Vol 38, 1958, p. 81).
-The possibility of other unforeseen events occurring which may necessitate transport such as intrapartum hemorrhage, fetal distress, or cord prolapse is about 2.7 percent, roughly ten times the rate of rupture during labor (Enkin, M. et al., "Effective Care During Pregnancy and Birth, New York: Oxford U. Press, 1989).
-In her literature review, Henci Goer ("Obstetric Myths Versus Research Realities" p. 42) found reference to only 46 ruptures during 15,154 labors, a rate of 0.3 percent (benign scar separations are a more common occurrence). -thanks to Anne Frye and her book, Holistic Midwifery Volume 1, Labrys Press 1995

Dr. Osterhaus in Oregon is doing some work with scar tissue therapy, injecting water or saline into the scar and massaging it to break up the scar tissue.  This might be helpful for women with painful abdominal scars.

Cesarean Art - for all the scarred mothers

VBAC Guidelines (from ICAN President)

I talked with Dr. Flamm (author of numerous VBAC studies and the book "Birth After Cesarean: The Medical Facts") last night about an article he's letting the Clarion use. I picked his brain while we were talking about some of the topics that have recently come up on our line. From Flamm:

Rupture/Pitocin: Although there are times that judicious use of pitocin have helped some women accomplish VBAC, there is data which suggests that the risk of rupture does increase slightly with the use of pitocin (From me: nearly every incident of rupture I've heard of, Pit was used). Pitocin should only be used when necessary, not routinely.

VBAC with Low Vertical Incision: A large study is in progress right now, but available data suggests that VBAC is safe and recommended with a low, vertical.

VBAC after Multiple Cesareans: There isn't a huge amount of data, but what they have suggests that VBAC is safe with multiple cesareans, with no particular limit to the number.

VBAC with twins: Flamm's practice does VBAC with twin births as long as the presenting twin (not both!) is head down.

VBAC consent forms (see my other post) Flamm is sending me a copy of the consent form that Dr. Phelan published which is currently the "latest trend" in the OB offices. We both agreed that it was an unfair approach since risks of repeat cesarean is not included in the consent form.  [Here is an annotated version of this consent form from Birthrites: Healing After Caesarean Inc. ]

Safety of Going Past Due Date with VBAC

It seems that none of the docs in our area "allow" VBAC moms to go past their due date

She has another option. She can ask her ob to show her the research that supports performing an elective cesarean if she exceeds her due date, or, if that is the plan, inducing labor. She would also be wise to find out if this ob puts any other unreasonable restrictions on her such as estimated birth weight being over some particular limit or arbitrary time limits for making progress in labor, and if so, to ask to see the evidence that supports these. If no evidence can be provided for these restrictions, she may wish to exercise her right to informed refusal. If she would like to have the research supporting the safety of VBAC and the harms of both any individual cesarean and of accumulating cesarean surgeries, it can be downloaded free at http:
Scroll down to Step 6.

Ultrasound to Predict or Detect Dehiscence or Uterine Rupture

Ultrasonography has a high negative predictive value, meaning that for the third of women with the thickest lower uterine segments, there is a very, very low chance of rupture.  This may be a helpful technology to pursue if your OB is using the possibility of rupture as a significant factor in recommendations about your care.  However, it should be noted that even for the women with the thinnest lower uterine segments, the risk of catastrophic rupture is still very, very small and can be offset through vigilant management during labor, i.e. having a labor attendant actually present in the room with you, instead of relying on the remote monitoring common in most hospitals.

Ultrasonographic measurement of lower uterine segment to assess risk of defects of scarred uterus.
Rozenberg P, Goffinet F, Phillippe HJ, Nisand I
Lancet 1996 Feb 3;347(8997):281-4

and

Published erratum appears in J Gynecol Obstet Biol Reprod (Paris) 1997;26(8):839
[Echographic measurement of the inferior uterine segment for assessing the risk of uterine rupture]. [Article in French]
J Gynecol Obstet Biol Reprod (Paris) 1997;26(5):513-9

The research (what little there is) seems to indicate that for a very small percentage of women, the doctors were able to predict that their uteruses (uteri?) would be stable throughout labor & delivery. For all the rest of the women, they were completely unable to make a prediction. As my doctor put it, "I get no usable information from an ultrasound of the scar."  This same doctor also pointed out that about 50% of ruptures occur prior to the onset of labor. He said, "This is why I feel comfortable with a trial of labor - since you've already accepted 50% of the risk."

I just read through the Spring, 2000, edition of Birth Gazette and wanted to respond to the article, "A New VBAC Concern".

I understand the concerns about an undocumented cesaraean surgery, but it seems somewhat draconian simply to turn away all mothers in this situation.

There do exist technologies that can help to provide good information even when an operative report isn't available:

This may help only a third of women, but it seems better than nothing for those women who would otherwise be denied the opportunity to pursue a home VBAC.

Would it be able to detect whether fetal parts had started to come through the dehiscence?

While I have never actually seen a case of uterine rupture or dehiscence along a C Section scar, I am sure we could see it, especially if fetal extremities were protruding. Inspection of the uterine wall is a part of detailed exams. There is quite a bit of literature demonstrating the Dx of placental accreta, percreta, etc. So I am confident that sonography could detect a breach in the uterine wall. However, NONE of the 7 major and comprehensive textbooks on OB sonography said anything about it.

Single-layer Vs. Double-layer Closure

There are two significantly different techniques used to close the internal incisions - single-layer vs. double layer closure.  Single-layer closure appears to be more vulnerable to rupture in subsequent pregnancies.

Single vs. double layer suture - a white paper by Gretchen Humphries

ICAN Online Webinars - One Layer or Two: Much Ado About Something? presented by Presented by Gretchen Humphries

A longer, better version is in the summer '03 issue of Midwifery Today Magazine but when I search the MT website it only comes up as an article that you can purchase (not read for free online).

Uterine Rupture and Fetal Extrusion and Mitigation

See also: Uterine Rupture

A small uterine rupture won't even be detectable in most cases.  It is only a problem if the baby starts to come through the opening in the uterus so that the uterus "thinks" the baby has been born and the placenta starts to detach from the uterine wall.  This movement of the baby through the opening in the scar is call fetal extrusion.

Fetal extrusion is preventable.  If you have dedicated one-on-one care for the laboring woman, preferably by a midwife trained to look for the signs of rupture, it is possible to mitigate the results of uterine rupture by holding the baby inside the uterus while awaiting a surgical birth.  This will prevent the reduction in uterine size that precipitates placental separation or abruption.

Also, fetal extrusion is not possible as long as the baby's head is down in the pelvis, which is almost certain with upright positions.

Most cases of catastrophic uterine rupture occur with pitocin and epidural and with the woman in a reclining position so that the baby's head is not contained by the pelvic girdle.

Uterine Rupture by Debbie Miller from Birthrites: Healing After Caesarean

Uterine rupture after previous cesarean delivery: maternal and fetal consequences.
Leung AS, Leung EK, Paul RH
Am J Obstet Gynecol 1993 Oct;169(4):945-950

This article discusses the sequence of events involved in catastrophic uterine rupture.  It implies that the most serious danger is when the baby is pushed through the opening in the uterus into the abdominal cavity, precipitating placental abruption.

VBAC Safety/Rupture Statistics

Women get good news about normal delivery after C-section - By Rita Rubin, USA TODAY [2/8/04]

The risk of complications from vaginal births after C-sections - known as VBACs - is actually quite small, according to the most definitive study on the subject. Liability concerns have spurred a growing number of U.S. doctors and hospitals to ban VBACs. In 2002, only 12.6% of pregnant women with a prior cesarean section delivered vaginally. That's only one-third of the government's goal of 37% by 2010. Meanwhile, the overall C-section rate in the USA has climbed to its highest level ever - 26.1% in 2002.

Interdelivery Time Affects Uterine Rupture Risk During Trial of Labor After Prior Cesarean The risk . . .  is threefold higher if the interval since the previous delivery is 18 months or shorter, rather than 19 months or longer.

Home Safe Home: A VBAC - My Way by Rachel Gathercole, Mothering Magazine, Issue 110, January-February 2002
Although this article is about home VBAC, it has a great summary of general VBAC safety issues.

All evaluations of birth outcomes ignore statistics regarding long-term outcomes, such as differences in childhood infections and hospitalizations for breastfed vs. bottlefed babies, and how cesarean rates affect those differences.  They also ignore avenues focused on prevention of uterine rupture through upright labor positions, early detection of uterine rupture through dedicated face-to-face care in labor, and mitigation of uterine rupture through application of pressure over the rupture to prevent fetal extrusion into the abdomen.

"Dr. Dermot W. McDonald of the National Maternity Hospital in Dublin Ireland suggested that the medicolegal pressure to perform a cesarean may abate only when mothers begin suing physicians for assault, alleging that they were not given fully informed consent...

"'If one went to the extreme of giving the patient the full details of mortality and morbidity related to cesarean section, most of them would get up and go out and have their baby under a tree,' [Dr. McDonald] said." [Neel J. Medicolegal pressure, MDs' lack of patience cited in cesarean 'epidemic.' Ob.Gyn. News Vol 22 No 10]

Irish physician McDonald's remarks accord with the 1990 findings of British research statistician Marjorie Tew who concluded that the British maternity system is run by obstetricians who "withhold and pervert knowledge in order to maintain public ignorance and delusion." [Tew M. Safer childbirth? A critical history of maternity care. London: Chapman and Hall, 1990.]

VBAC, C-Section, and EFM: How Safe Are They? by Jennifer L. Griebenow

Relative Risks of Uterine Rupture - Several gems, including "The risk of cord prolapse is 1 in 37 (2.7%), or nearly ten times more likely than that of rupture. "

Anne Frye on VBAC and Uterine Rupture

The easiest introduction to the studies is basic introduction.

Uterine rupture associated with the use of misoprostol in the gravid patient with a previous cesarean section.
Plaut MM, Schwartz ML, Lubarsky SL
Am J Obstet Gynecol 1999 Jun;180(6 Pt 1):1535-1542

The uterine rupture rate for patients attempting vaginal birth after cesarean section was significantly higher in those who received misoprostol, 5.6%, than in those who did not, 0.2% (1/423, P =.0001)

There is a very interesting report on rupture of the uterus from the largest hospital in Turkey (52,000 births in 3 years -- yikes!). They had a policy of routine repeat cesarean, but many women did not seek prenatal care and simply presented themselves during labor. If a woman with a previous cesarean presented in very late labor, she could avoid a cesarean, but otherwise once a cesarean, always a cesarean. They had a rupture rate of 1/1457 (0.068%), pretty low unless you remember that most women with previous scars were sectioned upon presentation to the floor in labor (must be a really chaotic place with all those deliveries) .

Of the 40 uterine ruptures, 10 were in unscarred uteri, mostly associated with prolonged labor and pitocin augmentation, with a mean parity of 3. The 30 ruptures in scarred uteri all occured with low transverse incision, 11 had more than one cesarean. The rate of rupture in >1 cesarean was 4 times that in those with 1 cesarean, but still less than 0.5% (but their overall rupture rate was really low, compared to other authors).

Rupture of the uterus.
Saglamtas M, Vicdan K, Yalcin H, Yilmaz Z, Yesilyurt H, Gokmen O
Int J Gynaecol Obstet 1995 Apr;49(1):9-15

A little bit closer to home, some authors in LA reported on 10 years of vbac. There were 17,000 women with at least one prior cesarean, 13,500 with 1 (79%), 3,000 with 2 (17%), and 800 with 3 or more (4%) -- all of whom underwent a trial of labor. All women with previous cesarean were considered for trial of labor -- except known classical (unknown scar could TOL), previous uterine rupture, or contraindication to labor. They did a routine inspection of the scar after delivery and classified separations not requiring intervention as dehisences and anything requiring intervention as a rupture.

80% (11,000 of 13,500) of single previous cesareans underwent a TOL with an 83% success rate and rupture rate of 0.6% and a rupture-related perinatal death rate of 0.18 per 1000 trials of labor.

54% (1600 of 3000)of two previous cesarean had a TOL, with a 75% success rate and a rupture rate of 1.8% and a perinatal death rate of 0.63.

30% (240 of 800)of three or more prior cesareans had a TOL, with a success rate of 79% and a rupture rate of 1.2% and no rupture related deaths (of course, the numbers in this group are much smaller -- only n=240 who had TOL, so a larger group would be needed to really observe the risks-- although I wonder where you might find a larger group?)

Another interesting factoid is that of the total uterine ruptures in women with previous cesarean, 23% (n=22) were prior to labor onset or diagnosed immediately upon admission when fetal distress was noted. All the other 95 uterine ruptures were supposedly discovered at "non-emergency repeat cesarean". Does this mean that none of the TOLs resulted in obvious uterine rupture and fetal distress, but that when they decided to throw in the towel on the TOL, they found 95 ruptured uteruses? There were 3 rupture-related perinatal deaths in women undergoing TOL, but 5 rupture related perinatal deaths in the group that was discovered to be ruptured upon admission. They had one rupture related maternal death.

The authors conclude that a TOL is a reasonable option for 2 or more previous incisions, but is best reserved for motivated patients who understand and accept the increased risk of uterine rupture and decreased risk of success which is pretty much what we have been saying in our discussion.

Vaginal birth after cesarean: a 10-year experience.
Miller DA, Diaz FG, Paul RH
Obstet Gynecol 1994 Aug;84(2):255-8

For those of you who are really interested in this subject, Public Citizen put out a White Paper in 1994 (getting outdated, I know) called Unneccessary Cesareans: Curing a National Epidemic. They have an excellent analysis of the relative risks of TOL, failed VBAC, successful VBAC, planned repeat cesarean -- for the mother and for the baby. It cost $15 for a single state report (the national report costs $60, but only has more raw data on individual hospital cesarean rates and is unlikely to be worth the extra money) and I have found it to be an in-valuable resource in the vbac or not to vbac debate.

There is no value in treating VBAC moms with uncomplicated histories any different than any other mom. ACOG even agrees (sorry no handy references). 50% of the less than 1% of VBAC that have ruptured uteri (with low transverse scars) happen before labor and even the labor ruptures are unpredictable. The figure of 1% is probably too high and is in dispute because much of the data comes from the now out of vogue practice of manually exploring uteri after VBAC, when you might find a small window or separation that was of absolutely no consequence.

It is very clear that VBAC with a low transverse scar is very safe. If I may quote a few juicy statistics from the Public Citizen report on Cesareans:
 
 

I have not seen ANY studies which indicate a higher rate with multiple cesareans. if he has some, I'd like to see them . I don't believe the stats he was showing you. The guidelines to doctors from the American College of Obstetricians and Gynecologists state that doctors should "counsel and encourage women" with previous cesareans to plan VBAC over repeat cesareans as the safer choice. The latest edition of the VBAC guidelines also includes VBAC as safe for women with multiple cesareans.

There have been no reported MATERNAL deaths due to uterine rupture of a low transverse incision.

Although rare, there have been incidences of fetal death associated with rupture of low, transverse incision. From Flamm's book:

These papers reported on a total of 11,027 women who had attempted VBAC: 8,693, or 78.8 percent, of these women had successful vaginal births in spite of their previous cesarean operations.

As far as risks to the baby, there were two fetal deaths per ten thousand births due to low transverse uterine rupture. Thus, the risk of a baby dying because of uterine rupture appears to be less than one in one thousand. To put these numbers in perspective, remember that in the US, the perinatal mortality rate is around 1.2%. In other words, if a woman decides to have a natural birth after a previous cesarean section, she is essentially at no higher risk of losing her baby than any other woman.

Abstracts about Pit and Home VBAC

What I find very odd about all this fear about uterine rupture from VBAC is that they seem to forget that the risk of rupture is unaffected by laboring. The danger is introduced by the presence of a uterine scar, which, by the way, came from the previous surgery. In any case, the danger is very small, and attention to one's body is likely to notice it before it becomes a life-threatening problem.

If the risk of uterine rupture in subsequent pregnancies was really so high, wouldn't they be doing more to avoid those first cesareans?

When I did the state stats for the Oregon Midwifery Council a few years back the rate was as follows:
Ceserean rate for total  -- 2.8%
ceserean for mulitps -- .08%
for primes 5.8%
for vbac attempt - 11%

Once a Cesarean, Always a Controversy - VBAC article by Dr. Bruce Flamm. MD

Size of VBAC Baby

I know that we have had threads like this, before, but what is the size of the biggest baby you've ever caught? i am still reeling from the huge VBAC baby a few days ago -- 12 pounds 6 ounces. Her first was 9 pounds, and her second was 10 lb 8 ounces. We don't routinely test for GD, and this lady didn't want to be tested. We thought she was growing a smaller baby this time. She was really careful with her diet, really didn't want a big baby this time. We are usually pretty good at estimating weight. After the birth, we watched this baby carefully, and she just seemed fat. No problems whatsoever. I've had several 11 pound babies, now, one recently that was born effortlessly, and posterior. I am already impressed with the capacity of the human body to give birth, but this was really amazing. I want to know the size of the biggest VBAC baby ever delivered. Does anyone know? This baby has to be in the running----

My largest VBAC was 11-7, spontaneous rotation from OP to OA. Had c/s for cpd and sepsis of 8-7 the first time around. Actually, she was heading for OR this time too....5 hrs stuck at 6 or 7 cm, got fever, OR was busy. By the time OR was free her temp was ok and cx was 8-9 so we proceeded. NSVD VBAC w/ first degree lac.

I will not work with a care provider who would think of an untried healthy pelvis as any different in its natural ability to birth its baby than any other pelvis is. To me also size of baby is a nonissue as I do not believe that babies grow too big to fit the pelvis of the woman it is growing in. In addition to this, I have never heard of a breech baby's head not getting out of a pelvis in a natural non interfered with delivery.

Last month I beautifully homebirthed my 9 lb. 6 oz. baby girl after two unnecessary scheduled cesarean surgeries for ten and eleven pound babies! My girl sailed out of me! I know I could have birthed all of my children as nature intended. I informed myself this pregnancy and baby size became a nonissue to me.

I want to see the too big baby myth, untried pelvis myth, and breech baby indication for cesarean surgery myth debunked.

Marriage and Cesarean Aftermath

Marriage Problems after Cesarean

The Pain Continues - How A Cesarean Birth Can Affect a Marriage

C-section, VBAC, HBAC . . . Ecstasy? - "I believe  that our increasingly joyous birth experiences have been a
real blessing to him and to us as a couple. "

With VBAC births it is important for the midwife to work with the dad prenatally.  a vbac father is in a horrible position because, despite the fact that his wife had an operation and a long recovery, he still got a live wife and baby at the end of it all.  Vbac dads are often "fantasy bonded" to the medical system and terrified of childbirth in general.

the good thing is that they listen very carefully and really know when the care is better and more thorough and when the practitioner is authentically on their team.  I find that if the midwife talks to them very honestly, they can trust and be fully supportive when the birth time arrives.

Primary mode of delivery and subsequent pregnancy.
Mollison J, Porter M, Campbell D, Bhattacharya S.
BJOG. 2005 Aug;112(8):1061-5.

CONCLUSIONS: Following an initial delivery by CS, fewer women went on to have another pregnancy compared with SVD. The incidence of subsequent pregnancy is similar following instrumental and SVD.

Women Who've Had Cesareans Talk About What Happened

There's some thinking that taking large amounts of Tums may cause the baby's head to harden so that it doesn't fit into or through the pelvis.  If anyone had a cesarean for a head that wouldn't mold (sometimes called CPD, but typically showing as a stall at 6 cm), please e-mail me with information about your Tums intake during pregnancy, the official diagnosis, how far dilated you got in labor and whether your baby's head was molded much, some or not at all.  Thanks.

See also Monitoring Fetal Heart Rate/Decels about unnecessary cesarean for fetal distress

Lack of progress in labor as a reason for cesarean.
Gifford DS, Morton SC, Fiske M, Keesey J, Keeler E, Kahn KL
Obstet Gynecol 2000 Apr;95(4):589-95

Conclusion: Lack of progress in labor is a dominant reason for cesarean delivery. Many cesareans are done during the latent phase of labor, and in the second stage of labor when it is not prolonged. These practices do not conform to published diagnostic criteria for lack of progress.

10 positive things I learned from my c/s

VBAC Success - Story and Rates

Jenny's Tale - Saga of a Birth Gone Wrong
or Yes, It Can Happen To You

Jenny Strikes Back - A Set of Letters and a Meeting about the Unnecessary Cesarean

Eight Hours of Torture - Horrible Epidural Experience Ends in Cesarean

Kristi - Our Miracle Baby - Mom Ignores Medical Advice to Abort A Troubled Pregnancy and Births a Healthy Baby.  Kristi was also one of the first babies born naturally to a mother with multiple previous cesareans.

[from someone whose wife had an unnecessary cesarean]

Where fetal distress is a diagnosis without a definition, a failure to progress is a diagnosis without a prognosis: there is no meaningful link between the length of labor and the outcome although there is a statistical link between the length of labor and the chances of something else going amiss. But the two things aren't the same; until something actually goes wrong which DOES require a surgical delivery there is no reason for surgical intervention.

FTP is also a completely arbitrary diagnosis. For example, the person we are suing states in one of her affidavits that a "three minute recovery from bradycardia is significant when there has been a failure to progress," the clear implication being that my wife was suffering from a FTP. But my wife was admitted in early active labor, had dilated three centimeters or more since her admission, it was our first child, and, get this, she had been in the hospital for less than four hours before being brought to surgery. Failure to progress? Ha. And how about you?

I don't know why the medical staff wasn't able to diagnose the asynclitic head and correct it prior to the surgery, but it's hard to imagine that this could possibly have been your fault. After all, you hired them to help you.

Bingo! They are the "experts"--they should know how to help you give birth, but IMHO, "they" don't. They don't know how. It was not your fault, your problem, too big baby, baby's fault, etc.

Rupture of Membranes Causes Cord Prolapse

Mom Writes Letter to OBs Who Did Unnecessary Cesareans

I think it is better to say that we all had childbirth losses and that a loss is hard to take, no matter what it is.

You couldn't have said this any better. This is probably the most important thing I learned from the book "Ended Beginnings". We do not need to compare and measure our losses to see if we have the right to grieve (or if someone else has the right to grieve).

If a person has a feeling of loss, they HAVE lost something. Whether it is a huge loss- like that of baby whom they have already met and loved, or a "smaller" loss like a miscarriage at 6 weeks (wait- don't jump on me- I KNOW a miscarriage isn't a small loss. I've experienced that) you will still go through the same process of grieving and healing. It may not be as deep a loss, or as long a grieving period, but it is the same process.

If I had a friend who lost a uterus at age 23, I too would feel that my loss of two cesareans and a miscarriage was small in comparison. I was able to go on and have another baby and a VBAC. She won't be able to do that. And yet, I don't think that a traumatic birth experience, or even a disappointing one is a insignificant loss. And for many women it is a devastating loss. I understand what you were saying, especially out of love and concern for your friend. Acknowledging her loss doesn't diminish the losses of anyone else on this line, or yours either. Perhaps your experience will enable you to be more supportive of your friend than if you had had a normal birth.

Women Who've Had Cesareans Talk About The Aftermath

You Should Be Grateful -by Gretchen Humphries - "You should be grateful, after all, you’ve got a healthy baby". How many times have we heard those words?'

I was wondering about how physical experiences may differ between women who have had just stitches and women who have also had staples. My doctor did not use staples for my c-section but my sister did have staples and she appeared to have a longer, more uncomfortable recovery.

I had staples with both my children. A few months after surgery I felt something just wasn't right....I seemed too numb. I was told by my ob that that happens and there's nothing they can do about it. I'm 5 years past my last c/s and I still have no feeling three inches above my scar. Lovely, isn't it? Like a permanent paralysis. Bleeech.

I had staples w/ my c-section and had an unexpected allergic reaction. I spiked a high temp and the incision site became red and inflamed within a day. They were drawing vial after vial of blood running many tests trying to figure out was happening to me and I was not allowed (and I didn't know better) to nurse my baby for 24 hrs. My understanding was that the hospital didn't believe that I could be allergic to surgical steel...but when they finally removed the staples it cleared up aft only about 12 hrs. Since then I've talked to many people who say that surgical steel actually contains some amount of nickel and that I could have had the reaction to that. My first cousin also had a similar reaction when staples were used on her after knee surgery. Just in case, I'll always include in my birthplan that I want NO STAPLES!

I had stitches in my external incision. My scar, which is just above my pubic hairline, has altered the shape of my abdomen by pulling in the skin there. I have had to grapple with the pain of this visible disfigurement.

Put me on the list for this complaint as well. In my first c/section the cut was where you describe, but I'm so pudgy that I don't see it :-), but my last c/section (and by golly, I mean my last), the doc did an infraumbilical incision which is a few inches below my belly button, very visible, it split open during the healing process and now it pulls up in the middle so it looks kind of like this __/\__ I do not like it. BTW I had staples both times, 21 with my first and 22 with my second, my first incision healed pretty well, my second was awful. And I still have scars from the huge blood blisters I developed from being allergic to the plastic tape.

My scar is lower down, but it looks exactly how you describe. Sort of like an upside down tummy tuck, since it looks as if the skin was pulled UP then stitched. It is sort of weird looking. I am lucky though, because I am a bit chubby, and stretched from baby, so you can't really see it.

I have a "tuck" there, but my scar is through the TOP cm of my pubic hair, I'd rather it had be higher. The PAIN of the hair growing back is BAD!!!

Cesarean Rate - A Grand Multipara's Plea
by Leilah McCracken

To the editor of the New England Journal of Medicine:

As a mother of six- and VBAC mother of four- I have to comment on the resistance of some obstetricians to the government's mandate to lower the incidence of cesarean delivery.

Cesarean sections are painful. After my section, gas pains ripped through my abdomen. My catheter hurt me when it was inside my urethra, and left sharp pains when it was out. I was a twenty-one year-old woman who had to pee in a bag, and hold her belly together before rolling over in bed. I was helpless to care for my new baby, and I will always remember his first days of life as grotesquely uncomfortable, and full of sorrow.

Cesarean sections are dangerous. Women are up to sixteen times more likely to die after a cesarean. Cesareans cause ileus, pulmonary embolism, and Mendelson's syndrome; and the formation of adhesions and intestinal obstruction. Women can have lifelong urinary troubles when the bladder is peeled away from the uterus, and bladder injuries are common as well. Women suffer emotionally as well.

Cesarean sections often involve a violent fetal extraction; trauma felt by babies during birth makes them five times more likely to commit violent suicide later in life.

And breech babies are best born vaginally.

 There is no genuine "informed consent" for most women undergoing cesarean delivery.

 More is known about how bedridden patients give birth than how women give birth: I have given birth as a patient five times; then I gave birth as a woman. I feel I was born a woman the day I gave birth to my sixth child at home, with my midwife, her partner, and my husband attending me, in love and quiet dignity. For the first time ever, I was joyful in birth, and left alone- no needles, knives, fingers, hooks, scissors, staples, drugs, tubes, synthetic hormones, medical students, nonsense.

 It is cruel to keep childbirth lock-stepped in a model that is not based on women's bodies, but on men's idealized notions of reproductive efficiency: stations of descent, counting fingertips for dilation, obsessively monitoring a woman's "progress", adding, comparing- these things are all the medical ideal of birth- predictable, graspable, manipulatable, efficient and fast...
 But birth takes her own time. Birth comes when women feel safe to let it come, and women cannot feel safe when under the constant threat of attack by gloved hands and medical steel.

 references:
 http: (adults five times more likely to commit violent suicide after traumatic birth)
 http: (see especially the "risks and benefits" section)
 http: ( British Court of Appeals ruled that women have the absolute right to refuse intervention, including cesarean section)
 http: (emotional difficulties resulting from cesarean delivery)
 http: and
 http: (breech babies best born vaginally)

(Leilah McCracken's Web site - "The Revolutionary Passion of Mothering" - contains a number of terrific, thought-provoking articles.  She especially recommends "Rape of the Twentieth Century" wherein, "I detail my births (especially the section) and, how cruel hospital birth truly is- for Moms and babes.)"

Telling Husband About Anger from Cesarean

Trouble Bonding with Cesarean Baby

How Natural Childbirth Can Heal Birth Trauma for Older Siblings

Carol Ann's Birth - a cesarean for "failure to progress" followed by trouble bonding and breastfeeding.

Her next birth was a VBAC at home, where she tuned into her body and birthed in a gloriously simple and elegant manner.

I have a question for all you VBACs out there. I'm sure that in most cases you found your VBAC birth experience to be more fulfilling than previous c/s. I'm wondering if you found that the positive experience also affected the way you bonded with your baby? I know you love all your children equally, but did any of you feel "closer" or more "bonded" with the VBAC baby?

I definitely know that there was a difference in bonding with my cesarean baby and my homebirth VBAC! I believe it's such a trauma to your body and psyche to go through major surgery there is not much energy left to "bond" and devote to your newborn initially. We chose to keep our baby with us in our room after the cesarean, or what they call "rooming-in". As with most cesarean babies she had a lot of mucous and kept choking and after day two and being up for about 60 hours, we sent her to the nursery so we could get some sleep. Now I can tell you, my VBAC baby you could not have pried out of my arms, for any reason!

My husband even said to me after our VBAC baby was born and I wouldn't let her even whimper without attended immediately to her needs, "Gosh, our first baby cried a lot more when she was a newborn and you didn't respond like this". I really felt guilty about this. I was so in shock and trying to heal myself it was harder to have the reserves to attend to her. We all have issues that we will feel guilty about in parenting. I think it is good to keep perspective about loving our children equally but not the same. I pray that it will balance out and she will benefit in other areas of my love for her and this will make up for the initial loss of bonding. I wonder also if other parents have seen a difference in personality that they attribute to being born vaginally vs./ cesarean? I realize children are all going to have different personalities, however I wonder if certain attributes are common with cesarean born children?

Personally, the worst thing about my c/s was actually a side effect of the epidural. A recently published study from Brigham's says that 15 % of women that have epidurals develop a fever. Since the baby is in the mom, baby is born with a fever too. When a baby is born with a fever, infection is assumed. The child is sent to NICU for 3-7 days to have every orifice sampled and sent to the lab for tests. Out of this 15% of babies, less than 1% actually have an infection.

My daughter was even given 2 spinal taps, even though her fever was gone an hour after her birth. My fever didn't drop so quickly, so I didn't get to touch her until she was 3 days old. Valuable time has been stolen from me and I can never get it back. I will forever wonder what effect this has had on her ability to trust her fellow human being. She certainly bonded well with the plastic box though!

That's an absolute nightmare!! Sounds just like my first birth and also like my bestfriends sister in law who had her baby (c/s) a few days ago.I will forever feel the effects of being separated from my first baby, going home 2 days before her, not being allowed to nurse her etc., not to mention the ppd I had (and never had with subsequent pregnancies) The separation delays the bonding process and to me that's a crime.

Suing After An Unnecessary Cesarean

See also: Lawsuits and Complaints

Getting Copies of Your Birth Records

Does anyone know what I need to request to have complete information on my labor and surgery and my son's delivery/birth?

In theory, you probably have the right to a complete copy of your records. In practice, it's often difficult exercising that right. Your best bet is to get a doctor to file a request for a copy of your records and then get them from him/her. You might also contact a medical malpractice lawyer in your city for advice since they have a lot of experience getting medical records.

You can, of course, simply call up the patient representative or records department and ask them how to get a copy of your records. (It's wise not to mention the word lawsuit or express any dissatisfaction with your treatment- Getting a copy of your records is not necessarily a big deal --sometimes people who are planning both to move across the country and to have another child want to get a copy of the records before they move so that the new doctor won't have to wait....)

The hospital will probably ask you to provide them with a notarised letter requesting them to provide you with copies and they may charge you a retrieval and copying charge. Your request should specify that you want copies of ALL documents relating to both your treatment and any treatment given to your child including but not limited to FHMs tracings, L&D Notes, ante, intra and post partum progress and nursing notes, and all infant care notes and test results, etc.

Finally, once you get your records you should find someone to look them over and make sure that everything that should be there is there. Records often go amiss - especially when the patient starts looking for them. An L&D Nurses or midwife who has worked at that particular hospital are probably the best people to review your documents for completeness - as well as to read between the lines.

About Lawsuit for Unnecessary Cesarean

A Plaintiff's Verdict: Meador v. Stahler and Gheridian [1/1/07]

Cesarean Lawsuit Won by Patient

Women Who've Had Cesareans Talk About Avoiding Cesarean

Ahhh, but there ARE women like this who feel it is ecstasy to deliver their baby with an epidural. MY one SIL is exactly like that. She said it was like watching a movie!!! Like having a baby SHOULD be that way????

Also, just recently I did postpartum work for two women who felt cheated because they got to the hospital too late and couldn't get it!!!

I could strangle them both!!! They have no clue what it is like to have the labor from hell and then a c/s - well, the second one does, but I don't understand her at all!!!

I was reading on a pregnancy newsgroup the other day and a woman who just found out she was pregnant was wondering if she could have the baby via c/s because she is not sure if she can handle the pain. It's her first pregnancy. I don't mean to sound judgmental of her and her choices, but I couldn't believe it! Who on earth would choose to have a c/s just because they are afraid of labor (I could understand it if there was a medical reason)! I was so mad when I read that! If she wants a c/s so bad, I would gladly trade my c/s for her vaginal birth any day!!

I soooooo agree with you! Infact, even though my very long labor was extremely painful, I am really looking forward to my next. Even if it is MORE painful. I actually think I could handle more pain now. I feel like I'll wait until I pass out from pain before I'll agree to another c-section!!! (or if the baby was in TRUE trouble).

I'm not sure you ever get over the feeling of being robbed of the precious first moments with your child. I can never get those moments back. We can't dwell on them, but we don't forget.

My heart breaks because I know that this means, for many women, that they will never know the joy that I experienced with my earlier prior to my cesareans births. Many will never know what it means, how it feels, what it does to ones soul, body, and mind to push their child into the world.

I think that loss of initial contact with your infant is something that stays with you forever. That time is so precious and so crucial and to have that taken away from us is wrong and something that we will grieve. Even after having my HBAC and getting to hold my sweet newborn immediately, I grieved for the loss of that with my first daughter.

I think what helped me was to focus on the positives about the experience and to realize the way I have chosen to mother Hannah has made up for much of the birth trauma we both experienced. I know nursing my baby gave me confidence and belief in my body and was comforting to know that I may not have been able to "control" the birth but I could do this.

I often refer to my c-section with the analogy of having a broken bone. It is mostly healed (after my homebirth!) however, on rainy days or days when things aren't quite right, it aches.

Someone needs to tell this woman that a c/s is the beginning of days and weeks of pain, but labor is usually less than one day. When labor is over so is the pain, so you can tend to the baby. With a scheduled c/s you just postpone the pain until you have to take care of an infant while you can barely walk. Even with an episiotomy, sitting on a donut for a few days is nothing compared to the pain of trying to stand after surgery. (I would imagine.)

Maybe we can help discourage c/s by complaining about the recovery period more. I know I don't want to sound like a whiny baby. All of us survived and did walk again, but the misery of recovery should be shared just as everyone else likes to share the horrors of long labors.

SO TRUE!! Here I am, 2 months and a week after my c-section and ouch! I am amazed at how sensitive the skin is around the incision AND around on my stomach. It's still very sore. I had all that gross oozing, & blood coming out for about three weeks. I recall, you did too. I get real "jumpy" every time Scott puts his hands even NEAR the area, because I'm afraid it's going to hurt. And, the hard lumpy area that runs along the scar, doesn't seem to have gotten any softer. Not as far as I can tell. AND, even though the incision is about an inch below where the hair line starts, I have blondish hairs "down there" so there's no missing the big red line.

Having a c-section actually prolongs the pain of childbearing to weeks, months and even years. This is what we need to be telling anyone opting for a cesarean section voluntarily! What seems easier at the onset is actually much more difficult.

At one time, before I knew anything about birth, I too thought I would rather have a c-section. THEN, I saw a video of the operation and quickly changed my mind. Women need to know that childbirth doesn't have to be a horror like most of their friends tell them. Yes, it usually involves some pain, but it is over a lot quicker than if you have a c-section, and it is pain w/a purpose, not a "hurt" pain. And they need to know that much of the pain they hear about is avoidable. In fact, women who have medication often describe labor as MORE painful than women who have had natural births. This is due to interventions & being confined to bed, as well as being unprepared. I wish there were a way for us to reach many more women than we do. I never heard of ICAN before I got pregnant, and nobody could give me info on Bradley childbirth classes. I finally found a teacher and had to drive 60 miles each way. There are so many ways we can get more involved and reach out to these women - starting with the hospitals. We can volunteer our services and write letters, making it known what women want and need in birth.

I know this is going to be really hard to hear, but it has been a very big theory of mine that there are actually some women out there who want the added ATTENTION that a cesarean birth will get them. Said it would be hard, but I have been around a LONG time and have seen and heard.....

Yeah, people just think I'm crazy when I tell them I had natural childbirth. You'd think they'd be interested, but it's almost like you're a leper. I guess they don't want to feel like they're expected to do it too.

I know how irritated you are - I have women come to my class requesting cesareans also. They somehow think it is easier than a vaginal birth - I let them know differently!!! But it is really frustrating!!!

I know. I remember my own mother telling me (when I was pregnant) that she wished I could have a c/s because (in her opinion) the babies come out looking so beautiful. Can you believe it? Incidentally, I didn't get much support from her after my c/s. When I was depressed afterwards, she just thought I was being whiny.

I did not want to repeat my cesarean! I do want to repeat my natural birth!

Me too. I don't EVER want to repeat my c-s. In fact, I was so upset by my first one that I was scared to death to even get pregnant with my second. Some people (who don't understand) will think this sounds too "harsh" but if I had had to have a c-s with my second for whatever reason (the reason wouldn't even have mattered), I wouldn't have had any more kids at all. I would have had my tubes tied after my 6 weeks check up. For me, I just could not handle it emotionally. Physically I was fine but emotionally - I could not have handled having a second one. So thankfully God allowed me to have a vaginal birth with my second child and third. He knew !! Now if I had to have one (which is incredibly not likely) with baby #4, I wouldn't be having any more anyway so it wouldn't make much difference. Yes I would still be devastated but it wouldn't keep me from having future children.

All I felt after my c/s was tired and depressed. I only saw my daughter through a window once in 3 days. The rest of the time I watched videotape, with no sound, through a camcorder. The viewfinder wasn't even in color. I can't imagine how depressed I would have been without that camera. I had nothing to do with that birth. I grew a perfectly healthy baby in a perfectly healthy body, but there was no joy and no sense of accomplishment. I was too happy to hear that test after test was negative to worry about how many times and in how many places her tiny body had been jabbed. No one should have 2 spinal taps in only 3 days of life, especially when she has NEVER met her mommy.

My home VBAC has given me the confidence to birth anywhere, but I hope I never have to do it in a hospital again.

Anita Plans Homebirth after A Cesarean And a Horrible VBAC

Laura and Mike Write about Homebirth After Two Cesareans

How did you HBAC moms come to the decision to homebirth? I really really really want to have my next children at home but I am scared of uterine rupture. I think this is mainly because I know so little about it.

You are where you are right now, not where I am, or anybody else is, including your spouse, in terms of your thinking and your belief system, and your faith in your body, its ability to birth, and any physical, mental or spiritual difficulties that you might perceive with these processes.

Even though I can tell you what I think or believe or have grown to accept, telling you these things...doesn't bring you to where I am ...or to the same place as anyone else here. It is your personal journey or quest, not ours, and I hope that we all respect your need to make that journey yourself, and not be 'carried along' by anyone else's views or opinions.

I hope that you will listen to your heart, and also to the little one that is beating inside you when you are making your decisions about birth. I hope that you will learn to trust your own judgment and discernment, especially when it comes to assessing the vast amount of information that we are all firing at you. Much of what you hear here seems in contrast to what your medical & professional caregivers are telling you. I think that must feel like a horrible and confusing thing to deal with, and I hope that your own quiet sense of what is 'right' for you will help you to decide what to do.

Only you really know whether the dangers and fears that your caregivers are expressing are something that you embrace yourself.

I would like to share some thoughts for you to ponder on.

1. Can you see your childbearing capability in the perspective of your family history, and think of all the women before you, your mother(1) , your grandmothers(2), your great grandmothers(4), your great great grandmothers(8), your great great great grandmothers (16) and so on...?
2. Do you see childbirth as a process that works successfully by design (of the Creator or Mother Nature)? Do you consider it a natural process that has worked for many thousands of years before the cesarean section was invented...?
3. Do you speak to or communicate with the baby inside you? Could you trust that your baby knows instinctively when is the right time to be born and what his/her birthday should be...?
4. Do you feel that giving birth is more a medical event than a physical and spiritual event? Do the people you are choosing to support and share this experience with you, share the same views, or at least respect your views if they are different from theirs? Will your wishes, preferences and desires be treated with consideration and respect?
5. What are you most afraid of? Disobeying (your caregivers)? Going against medical advice? Disagreeing with your spouse? Putting your needs (or those of your unborn baby) first? Being responsible if something went wrong? Failing? Pain? Conflict? Do you know where your particular fears come from, and can you accept the choices you make that are because of them?

The decisions you make will be based on the information that you have, which includes the facts you choose to accept, reject, or ignore. Your decisions will be based on the beliefs you hold, and who or what you trust most, whether it be a doctor, a medical system, a spouse, a Creator, Nature, yourself or your baby. They will be dependent on the amount of responsibility you want to take, or give away, and the fears that you have.

I hope that you find the wisdom you will need to make your decisions, and peace of heart after you have done so.

My HBAC was 2 weeks ago. A year ago, I never would have considered such a thing possible.

I went through 3 care providers during this pregnancy. DH and I toured 4 hospitals and a birth center. We knew that our best bet for a safe VBAC was non-intervention. The hospitals only had births w/o epidurals by accident and the BEST VBAC rate (out of 33 hospitals in 3 counties) was 46%. The birth center was so low tech that we saw no need to go. They didn't have anything that a midwife wouldn't bring to our home.

It took us a few months to come to our decision. There were lots of little steps that got us there. We researched together and made the decision together.

When you worry about rupture, remember these facts. ACOG thinks pitocin and epidurals are safe during VBAC. The rupture risk can't be too worrisome if the docs allow these two things. Also, some insurance companies require a trial of labor. If rupture was a big worry the money hungry insurance companies wouldn't take the financial risk. Thirdly, many professional midwives practice illegally. If they were worried about rupture, they wouldn't take the risk of "getting busted" during a transfer.

The more you read about birth, the more confident you will become.

The Same Mom Raves about Her Homebirth Experience

I do not want to say this to upset those who have never or never will have a vaginal birth or VBAC. I realize this may just never be for some of us and this is okay too. We can live with this and accept this also. God and nature look after all of us!

BUT, that said, for any candidates of vaginal birth: if you can at all muster the opportunity and ability for VBAC I say go for it 100% with your colors flying!!!!

After my homebirth after two cesareans I can't wait to do it again either! This is the way we were meant to feel about procreation! Awe and wonder at the accomplishment of the act of childbirthing due to no one else but ourselves!

HBAC - Homebirth VBAC

Home Safe Home: A VBAC - My Way by Rachel Gathercole, Mothering Magazine, Issue 110, January-February 2002

In the year 2005, it is increasingly difficult in some areas of the United States for women to find a hospital that will support VBAC.  Thus, more and more women are seeking to have VBACs at home, which can be safer for a lot of reasons, including upright positions that prevent catastrophic uterine ruptures.

Unfortunately, the legal environment for midwives is not that much better than for doctors who support VBAC.  Here's one midwife's protocols re: eligibility for HBAC:

I do VBACs at home. Only if there was one section, and it's been 18 months since the last section, and they do not go past 42 weeks. They have the option of a third trimester ultrasound to evaluate placental location to r/o placental problems, though few actually do this. I do primary VBACS but prefer it if they've had one before. If there was a previous VBAC, the risk is of rupture is so small, I feel like she's about the same risk as any other client. I do listen more intently and would transfer more quickly if there were funky FHTs.

I have a birth center, but in Florida we can not by law do VBACs in birth centers, but we can at home if we get a consult. There is one doc that will do consult that reads "Have your baby at or near a medical facility". People drive hours to get his "approval". I have a very detailed informed consent that has my VBAC policy; it's based on The New Mexico Midwives VBAC consent from 1999, which was developed by their LM's profession association.

Studies Supporting Homebirth VBAC

Avoiding a Surgical Birth

When I get a VBAC client and she is endlessly self-psychoanalyzing and beating herself up for having a c-sec I usually say "Look you made TWO big mistakes!  First you were born in the wrong country and second you were born in the wrong century--if you'd been born and raised l00 years ago in France, for instance, you would have given birth vaginally."

When I teach my workshops, I tell the students there are two types of pelvises in allopathic medicine: l. contracted and 2. adequate

In midwifery, there are two types of pelvises as well: l. roomy, ample  2. you could get a pony through there!

Studies Show That Acupuncture Decreases Caesarean Rates [10/9/09]

Impact of early admission in labor on method of delivery.
Rahnama P, Ziaei S, Faghihzadeh S.
Int J Gynaecol Obstet. 2006 Mar;92(3):217-20.

CONCLUSION: Later admission in labor increases the rate of spontaneous vaginal delivery in low risk nulliparous women.

Relation between private health insurance and high rates of caesarean section in Chile: qualitative and quantitative study [from BMJ]

Cesarean Section for All Twins?  [from obgyn.net]

Epidural Ups Fever, C-section Risk

Mom with Previous Myomectomy Declines Unnecessary Cesarean

Faith Gibson's pages on Informed Consent for Special Circumstances
Here are 3 "Special Circumstances" informed consent documents for home-based care and/or refusal of customary obstetrical protocols for VBAC, Twins, Macrosomia

Active Management with Pitocin Does Not Reduce Cesarean Rate

Things You Can Do To Avoid An Unnecessary Cesarean

Fallacy of Gestational Diabetes Treatment to Improve Chances of VBAC

WHO Recommendations about Section Rates

I don't think this is necessarily a bad way to set goals. There's a fine line between goals that seem challenging and those which seem so difficult that they are ignored. Better slow change than none. If a practitioner cares enough to find out if his or her practice is supported by the science, there's always Enkin et al.

Special Questions for Women Planning VBACs

Risks to Baby from Surgical Birth

Also, anything that causes pain for the mom is likely to interfere with the establishment of breastfeeding.  A relaxed, comfortable breastfeeding relationship has lots of physical benefits and probably even more emotional ones for the baby.

Preliminary research indicates that it is the babies who start labor by producing certain hormones.  Surgically removing the baby before labor starts may interrupt a delicate hormonal process that we don't yet fully understand.

Obviously, women choose a surgical birth for their babies because they believe that the tradeoffs balance out that way.  But there
are tradeoffs - sometimes unexpected ones. 

Importance of Vaginal Birth to Baby's Psychological Development

I'd only heard this and didn't give it much stock until a child I know well happened to mention that she was having a lot of dreams about tunnels.  I asked and she said, yes, she'd been born by cesarean.  I then asked her younger sister, also born by cesarean, and she said that she also had a lot of dreams about tunnels.

I've heard there are rebirthing therapies to address these sorts of issues.

Information about Hydrocephalus and D&X

Rapture of VBAC

I was saying I'd love to have another one when Baby was only a week or two old. My SIL commented that most women immediately after a birth say "I never want another one" or they don't even want to think about it; I was the opposite; that's all I could think of; I was "high" on birth (and still am)!!

After my homebirth after two cesareans I can't wait to do it again either! This is the way we were meant to feel about procreation! Awe and wonder at the accomplishment of the act of childbirthing due to no one else but ourselves!

As horrible as my labor was, after it was all over, one of my friends said to me, "Never again, right?" I told them, "No way! I want more!" This was the next morning. Everyone there thought I was wacko. They just looked at my husband and said, "You're in trouble."

Comparing Cesarean and Vaginal Birth Morbidity and Mortality

Most C-Sections Cause Hemorrhage

So a woman can lose 750 cc of blood in a vaginal birth, and it's called a postpartum hemorrhage, but if she loses 750 cc of blood during a cesarean, it's NOT called a postpartum hemorrhage. WOW!  Tom Lehrer would be proud of this New Math. Too bad the woman's body doesn't understand New Math.

This level of intellectual dishonesty is truly beneath educated professionals.  I'm just hoping the person who gave the presentation was confused rather than dishonest.

Cesarean info from Lecture at Stanford

The presenting Stanford OB said that Stanford DOES VBACs [though I would guess the particular OB still needs to be willing] and reiterated that the main reason other hospitals are not doing them is due to ACOG's policy that "OB and the team must be IMMEDIATELY (loosely defined, but basically in-house) and not just READILY (within 30 min) available in case of uterine rupture."

He also said (loosely rephrased) that vaginal birth is still the norm in the US unlike in Brazil, where Cesarean rate is over 90%. Elective maternal request Cesareans are currently between 4-18% in US and that insurance companies are starting to reimburse for them, even though they are not medically indicated.

He also said that the people who came up with the 15% guideline for trying to lower Cesarean rates, were smoking something, and that instead of trying to follow some "arbitrary" number, OB's should have maternal and fetal interests at hand.

The overall message was that there is very little good evidence on the topic of Cesarean vs Vaginal dilemma, but most "weak" or "absent" evidence shows that Cesareans have the following downsides, as compared to vaginal birth. The following rates increase, especially after repeat Cesareans:

placental complications (previa and accreta) in subsequent pregnancies; urinary and fecal incontinence later in life (though previously Cesareans were thought to protect from them); hemorrhage and hysterectomies in subsequent pregnancies; stillbirths in subsequent pregnancies; infant respiratory and pulmonary hypertension complications; infant prematurity (he pointed out that standard deviation for Neonatal Age dating is 21 days!!!- which means, the due date accuracy can be off by that much!!!);

Also, Cesareans require longer hospital stays, loss of control by the mother, and more postoperative pain/longer recovery. Also, sexual functioning was the same between CS and vaginal births at 6 months after delivery.

Rates of breastfeeding, of course decrease.

The possible benefits of Cesareans (followed by a reminder that the evidence is weak), is less postpartum hemorrhage. But that was about it... [Ed: See the snippet above about how postpartum hemorrhage for a c-section is defined as < 1000 cc, twice the amount considered a hemorrhage with a vaginal birth.]

Mode of delivery and risk of respiratory diseases in newborns.
Levine EM, Ghai V, Barton JJ, Strom CM.
Obstet Gynecol. 2001 Mar;97(3):439-42.

CONCLUSION: The incidence of persistent pulmonary hypertension of the newborn was approximately 0.37% among neonates delivered by elective cesarean, almost fivefold higher than those delivered vaginally. The findings have implications for informed consent before cesarean and increased surveillance of neonates after cesarean.

Lets look at the rates for cesarean shall we[GRIN] Maternal morbidity rates-this is illness following the procedure- are 5 to 10 times HIGHER for cesarean than vaginal birth. Morbidity rates include but are not limited to: operative injuries, operative and post operative hemorrhage, pulmonary emboli, venous thrombosis, anesthesia complications, and infection. There have been rates as high as 50% morbidity associated with cesarean section.

On to mortality:( NIH states that mortality rates are 4 times HIGHER in cesarean deliveries than in vaginal birth and that repeat cesarean carries 2 times the risk of maternal mortality that vbac does. SO! Tell me again Obstetrical community about the "risks" of vbac being "too high"!!! Notice they DON'T tell you about the much HIGHER risks of elective repeat cesarean.

Relative Risks of Uterine Rupture

Relative Risks of Uterine Rupture - Eileen Sullivan's classic discussion of relative risk of uterine rupture is a must-read.  Here's my favorite line: You're 6 times more likely to have a doctor who is an impostor than you are to suffer a rupture.

You can read more about Eileen and her wonderful work with EFT for birthing women.  And don't miss the wonderfully affirming visual treat on her main web page!

Uterine Rupture During VBAC Trial Of Labor: Risk Factors and Fetal Response by Nancy O'Brien-Abel, RNC, MN
from Journal of Midwifery & Women's Health, Posted 08/06/2003

They wrote that once a uterine rupture occurs a window of 15 minutes is the upper limit of normal time to get the baby out before brain damage occurs (note this language.. it is get the baby out, not start the cesarean). This clearly is a standard above the one previously published by ACOG. I am hard pressed to accomplish this with in-house anesthesia coverage and a ready operating room. It is my opinion that home VBAC regardless of the number of prior cesareans is tempting fate. Perhaps one might get away with it 990+ times out of a thousand. However, when the uterine rupture does occur, if serious consequences result, the question of violation of standard medical care would be easy to substantiate.

I have to respectfully disagree with my colleague. Yes, uterine rupture is a possibility during a labor when there is a scar on the uterus. However, lots of other things can and do go wrong during labors, without warning and with potentially serious consequences (abruption, cord prolapse, shoulder dystocia, amniotic fluid embolism, etc.). All labors carry potential risks, however, based on numbers analysed by Bruce Flamm (the big promoter of VBAC), a woman attempting a VBAC actually has a 50 times greater chance (statistically) of experiencing one of the other obstetrical emergencies than she does of encountering a uterine rupture. In other words, having a scar on your uterus doesn't protect you from all the other things that might go wrong. So why is VBAC so much more dangerous? Because you knew a rupture might happen and then are responsible if it does? Hey, you know something, potentially life-threatening things might happen during any labor.

I hear you. You make salient points. I respectfully submit that we should agree to disagree on this issue. I feel that this issue is one not unlike the issue of abortion. Both side have strong beliefs that despite hours of discussion will never result in one converting to the other's opinion. It is good that we can have the debate.

VBAC and Electronic Fetal Monitoring

I agree that it is as irresponsible of us to insist that ALL births are safe and uncomplicated as it is for doctors to use scare tactics to coerce mothers to follow their protocol. There is a slight chance of rupture in VBAC moms. The risks are less than in repeat cesarean, but the incidence of rupture is around 0.5%. That isn't 0. Even more rare are fetal deaths, but there have been some. On the other hand, I have yet to receive any information that includes a maternal mortality from a VBAC rupture with a low, transverse incision. There are maternal mortalities with repeat cesareans, although that is also rare.

Constant fetal monitoring continues to be a controversial topic with VBAC- even among the experts. I just spoke with Dr. Flamm about this last week. Over the years we have had an ongoing debate about EFM and VBAC mothers. He does recommend EFM in VBAC labors. (I think he has even said constant EFM.) However, he practices with CNMs, including his wife who stated at our 1992 conference that they do not treat VBAC women in labor differently than non-VBAC mothers. They use intermittent monitoring. Although many doctors say they require constant monitoring, I have yet to act as a doula in the hospital where a mother was required to have constant monitoring unless she was put on pitocin or an epidural (which is required in most places for all mothers).

Dr. Flamm said that the most reliable method of determining a rupture in his experience was with the EFM. I asked about the asymmetric bulge, bleeding, and pain. He said those signs may or may not be present, but a DRAMATIC drop in heartones was more reliable.

It is absolutely true that the difference in attention and care given a laboring woman is very much more sporadic in the hospital than at home. It may also be true that other signs may be apparent to a more vigilant caregiver and mother.

Here is my opinion on the topic: I certainly recommend some intermittent monitoring whether by EFM or fetoscope. It may be that constant monitoring would catch a slightly greater % of a very small number, but I believe that constant EFM would greatly reduce the number of VBACs. I believe that a number of women I helped would not have had a vaginal birth if they had been confined to a monitor. I also have to look at Michel Odent's Pithiviers clinic, The Farm and other places that have absolutely outstanding statistics for vaginal birth, healthy babies, healthy moms. I know they don't require constant EFM.

It is a decision that each woman must make for herself. As we all know there are no guarantees. I don't agree with many women's choices, but I know that many doctors and other women didn't agree with my VBAC plans 10 years ago. We can only offer the information, the resources, and the data we have, and even our opinions. Then each woman needs to take responsibility for her choices.

Vaginal Birth after How Many Cesareans?

[from ob-gyn-l]

I have a new patient: G7, all sections. Would you give her a trial? We're following her for AP care, but it's been a 'given' she'll just be sectioned by our OB back-up. I've never had a patient with this many sections!

When I asked a similar question of Dr. Morrison when I rotated through Univ. of Mississippi OB service as a resident, I was told that the largest number of prior C-sections in a VBAC candidate was 13 (she had a successful VBAC). That was in 1992. At my residency, which was military (with lots of transfers of care, lack of records, etc.) we used to let patients with prior C-section and undocumented scars labor "under close observation" as long as the story of the C-section wasn't too scary ("I just didn't dilate").

I don't know if it's changing times or different practice patterns here versus there, but my feeling is that the tide is turning away from "Oh, anybody can VBAC" to "VBAC is okay in carefully selected situations." (Might have something to do with that NEJM article about VBAC that was published from here.)

I am unaware of any cases of VBAC after 7xCS. I wouldn't be too optimistic about this one either ! But I doubt there is any effective difference between 3xCS and six or seven. Therefore I'd go for a VBAC (if she's motivated enough) in hospital !

I reported on the article in Journal club during my residency. That is why I remember it. Some of the old literature is still valid and worthwhile.

OBs Discuss Cesarean for Fear of Shoulder Dystocia
- No Need for Cesarean for Fear of Shoulder Dystocia or Macrosomia

See also:  Shoulder Dystocia - Breaking the Clavicle

Can Shoulder Dystocia Be Prevented? [from obgyn.net]

It always peeves me when OBs encourage women to have sections for "big babies". Either the head will come out or it won't, but you can always do the section after you're absolutely sure the head won't come out. And if they're worried about the head coming out and then having a shoulder dystocia, well, make sure they know how to break the clavicle. It's a relatively minor injury for the baby and is said to heal well within two weeks.

And, truth be told, there is no way to predict shoulder dystocia. There are some minor statistical "associations" but they're almost insignificant. 

Macrosomia and shoulder dystocia have medical liability overtones. It is difficult to find fault with someone who views induction as a prevention for macrosomia when you have survived a difficult shoulder delivery with an unexpected large infant.

I disagree. Induction increases the c-section rate in macrosomia compared to awaiting spontaneous labor, with no compensatory benefit to infant or mother. (CA Combs et al, "Elective induction versus spontaneous labor after sonographic diagnosis of fetal macrosomia. Obstet Gynecol 1993; 81:492-6.)

And what about the patient who has the complication of the c-section that turns out to have been unnecessary in retrospect? Does that not weigh on you equally?

Yes, but again, the likelihood of a C section complication, especially if scheduled and non-laboring, is quite low.

But so is the risk of significant morbidity from shoulder dystocia.

I have scanned the articles my Sandmire; it seems that they grow them big in Green Bay. The numbers are compelling, but he seems rather cavalier about fractured clavicles, and non-permanent brachial plexus injuries. While these may be minor to us in the medical community, they are not minor to the patients.

Neither are the post-op pain, days in the hospital, expense, scarring, blood loss, and infectious complications of c-section.

I certainly can now turn to the literature to defend both my approach, and the non-C/S approach. However, as long as someone out there advocates the sections, and assuming that he or someone else would testify, I can justify performing sections on these people.

You know that I detest and protest the idea that we make a clinical decision based on a guess about what will look good in court. But as long as you're doing it, and Sandmire (and several others--see the other articles) are out there and willing to testify, you could make precisely the same argument the other way: you can justify not sectioning these people. (and they may be testifying against you if you get the uncommon serious complication from doing the section.)

Furthermore, I don't particularly wish to go to court and have my expert argue with their expert, citing articles that we both know support either side.

But this could happen either way! I'm not sure why you're not seeing that. No lawyer is going to take the case of a fractured humorous that left no residual effect 6 weeks later. So in terms of your lawsuit fears, the permanent injuries are the only ones that matter. And as these several studies show, the serious complications (which have litigation potential) of a section are very much in the same range as the permanent complications of shoulder dystocia. Thus, fear of malpractice is not a rational reason (and I'll even be nice and not mention whether it's ethical) for section here.

If you're damned if you do, and damned if you don't, then don't.

(Hey, that's kind of catchy. Maybe I should copyright it.)

In former years the ability to perform a difficult vaginal delivery was essential part of obstetric practice. In current practice one mark of a skilled obstetrician is the ability to avoid difficult vaginal delivery.

And now, in current practice, one mark of a skilled obstetrician is the ability to do a fast c-section, in time to get to dinner and/or change of shift.

Vaginal Cesarean

[from ob-gyn-l]

Vaginal Cesarean

Has anyone had or heard of a cervical extension of a low transverse incision during a Cesarean delivery, which extended into the patient's vagina?

I always caution residents when doing a C-section, during the second stage of labor, to make sure that the incision is high enough to be in the lower uterine segment, because I have seen the entire low (very low) transverse incision made entirely below the cervix, i.e. a vaginal Cesarean.

That procedure is known as a laparoelytrotomy and was described in the literature around 1900. It was originally called a Gastro- elytrotomy. It was done intentionally at that time. If you can do it, it probably is preferable to a LTCCS. After a laparoelytrotomy, there is no uterine incision or scar. A vbac is much safer the next time.

I have seen lacerations(extensions of low transverse incisions) that have gone down the vagina for 8 cm. The biggest problem is in 1st recognizing them and then in repairing them. They invariably occur in the patient with a BMI > 50. I have never had to repair one from below, although it might have been smarter to do it that way on at least one that I can remember.

I had a colleague as a resident who did a low transverse incision. In fact he did it on the vagina during a CS at complete dilatation. A laceration may occur when the incision is low and baby's extraction difficult. The bladder may be involved as well.

We had the idea of creating a procedure that saves the uterus. This woman had no scar on the uterus which avoids the questions about VBAC.

Check out Thomas GT, Gastro-elytrotomy; a substitute for cesarean section. Am J Obstet. 1871;3:125

Certainly if you have a patient who is completely dilated and the cervix is retracted up that high Laparoelytrotomy is a good way to go because it does avoid the uterine scar.

I can't buy that. Seems like a good way to injure the bladder or ureter not to mention an extension into the broad ligament at this level could be quite a problem.

Not So!! The bladder is down way below where you make your incision, because the cervix and vagina are up so high. Lateral extensions shouldn't occur They would either go on around the vagina or up or down but not laterally. Yes, I am aware that if you or I can think of it, it will happen to somebody somewhere. I have done this procedure about 25 times over the years(that I recognized). Only 3 of those were intentional.

If you have done more than 100 abdominal deliveries, I bet you have done at least 1 and never known it. When it is pulled up like this the vagina looks just like a thinned out lower uterine segment. Unless you look in the vagina and see the cervix above your incision, you won't know you did it.

There was an article about a year ago by Dr. Robert Goodlin in Obstetrics and Gynecology I think discussing an operation in which the baby was extracted through an incision in the vagina instead of the lower uterine segment. The purpose was to avoid a scar on the uterus. I forgot what he called the procedure but we did discuss this on the list some time back.

Working to Increase the Cesarean Rate

Court-Ordered Cesarean

Marlowes Challenge Court-Ordered Cesareans (1/18/04)

 http: ( British Court of Appeals ruled that women have the absolute right to refuse intervention, including cesarean section)

Preganant woman's rights get short shrift - OB and lawyer get court order to force a woman to submit to a cesarean against her will.
[July 20, 2001 at Memorial Hospital in Jacksonville, FL.  OB: Neil Sager; Lawyer: Harry Shorstein, state attorney for Duval County.]

We had a case like this in BC called "the baby R" case where the mother was forced and intimidated into having a section for a 3rd baby who was presenting frank breech.  It was a case of impoverished, single mother against rich, educated obstetrician.  A women's group took the case to court after the cesarean and after her baby was apprehended and it was all ruled unlawful so that set a precedent for women in Canada that they can't be operated on against their will.  Needless to say, when the woman had her next baby, she had it at home with local midwives.

I was recently labor coaching for a hospital birth - planned to be the first VBAC after three sections. The OB was known in the community to be very supportive of natural childbirth, but even he was trying to convince my client that a VBAC after three surgeries was taking some huge risk. He asked her to sign some "backlash" forms about how dangerous VBAC is.

Then, when my client arrived at the hospital in labor, she was informed by the hospital staff that they could not support her in her choice to have a vaginal birth. Some tense discussions followed, during which it became clear that the hospital intended to get a court order to force her to delivery surgically if she didn't make that choice. (It's ludicrous to call it a "choice" at this point.)

The perinatologist said that because there were no studies showing the safety of laboring with three uterine scars, they had to assume it was not safe and that it was putting the baby at risk. She told us that there is an increase in risk for laboring with 1 vs. 2 scars, and that they had to assume the possibility that there could be an enormous increase in risk between 2 scars and 3.

She actually told us that their working assumption was that the risk of catastrophic rupture (in which the baby died) was 5%. Yes, 1 out of 20. My hope for her is that she finds herself in a position to learn more respect for women's choices in birth.

Humanizing Cesarean - Planning a Surgical Birth

The Ideal Caesarean Birth - by Robert Oliver, M.D.

Caesarean Birthing Your Own Child - Written by Paula Beckton - For many women the thought of having a caesarean is terrifying, the knowledge that after viewing your newborn child, you may be unable to hold or even see your baby for at least an hour (sometimes longer), can be devastating. Paula Beckton experienced a ground breaking caesarean, where she helped assist in the birth of her second child Oliver and not only was he not whisked away immediately, but was placed on her chest for cuddles and mother/baby bonding. This is her story...

Father's Touch Soothes Newborns - After C-Section Birth, Newborns Find Dad's Skin Soothing When Mom Isn't Available

They studied 29 Swedish men whose wives or girlfriends had just given birth by C-section to healthy babies.
Immediately after the babies were born, the infants got five to 10 minutes of skin-to-skin contact with their mothers. Then the babies spent the next two hours with their dads. [Ed. They should also be skin-to-skin with dad to keep getting exposed to his skin flora, which is about 90% the same as mom's.  This is so much better than having the baby pick up hospital germs as basic skin flora.]

SOURCES: Erlandsson, K. Birth, June 2007; vol 34: pp 105-115. News release, Blackwell Publishing.

1. the OR does NOT have to be cool. studies have shown no improvement in Post operative infection with chilled rooms. keep it warm so the baby can greet his/her mom without being subjected to the warmer.
2. of course, she should be allowed to start labor first. Frank breech poses little prolapse threat and it is doubtful with as tense as she is that she would have a precip labor...so let nature take its course as much as possible
3. MIRROR! Let her SEE what is going on.
4. lower the drapes so she can see the baby right away
5. if the baby is crying and vigorous, all checks can be done on moms chest just as in a vaginal birth. put a little cap on it and a warmed receiving blankey and let them cuddle.
6. nursing on the OR table is difficult, but with your help and her husbands, I feel confident it can be accomplished. it should be at least attempted.
7. in absence of any difficulty, the mother and babe don't ever need to be separated. Baby can follow mom to the recovery room or better yet! how about straight to her room? If not, Dad should follow the baby and keep it from being bathed and fed, unless she plans to bottle:(
8. room in! Dad and you could take shifts if necessary to accomplish this:)
9. early discharge. the sooner she gets out, the better:)

some things I forgot.."touchy feely" things. Moms voice should be the first baby hears. Moms touch should occur as quickly as possible after birth. No "unnecessary roughness" My ped "tickles" the soles of the feet vs. slap and only suctions if the baby needs it.

The staff should let the Mom know what is going on every single step of the way. No leaving her or Dad in the dark and afraid! Anesthesia CAN and SHOULD be administered with Dad in the room. This separation is not only cruel, it is ILLEGAL! and only for the "safety" of the anesthesiologist-in case he screws up, no witnesses.

Cesarean birth CAN be "family friendly" and I think an even greater effort is called for on the part of her care providers to ensure she and the baby get off to a good start after the "insult" of surgery.

More recently, an obstetrician in the UK is espousing a similar approach to humanizing cesarean birth when vaginal birth is not an option.

Every bit as magical - [12/3/05] A British doctor is challenging convention to pioneer the 'natural' caesarean. [Ed: It is ludicrous to use the word natural with a process that must take place in an operating room and involves making a 4-inch incision in a woman's belly. They might achieve more intellectual honesty by calling this a "more humanized cesarean", as it involves some of the key elements involved in a real natural birth, i.e. "as in nature":

• umbilical cord integrity, which allows for physiological conversion from intrauterine circulation to extrauterine neonatal circulation.  This allows a natural time interval (about 5 minutes) for the baby to start getting oxygen from the lungs, instead of the umbilical cord.  Allowing this process to unfold naturally allows the baby to get oxygen from the lungs before the umbilical cord oxygen supply is cut off.  Perinatal psychologists tell us that this prevents the sense of asphyxia that results from premature cutting of the umbilical cord.
• colonization of the baby's skin and gut from maternal skin flora - babies are born sterile, and they will be healthiest if they are colonized with the skin flora from their mother's body, since they are born with antibodies to her normal bacteria.

Self-Cesarean

Mexican Indian woman performs self-Caesarean: 'If my baby was going to die, so was I' - Ines Ramirez Perez

I remember a woman did this in portland oregon on the early 1980s. it was quite a sensation.

As I remember, the story in the papers went like this: She had a history of mental illness -- had been living in public housing downtown. A few weeks before her due date she went to the hospital and demanded they do a cesarean because she was tired of being pregnant. when they refused, she went home and did it herself! She wrapped the baby in  blankets and put it in a regular backpack and went out into the streets to show her friends! . They called an ambulance. The story reported that she seemed healthy but a little pale and" in her usual state of mind". She was taken to the hospital where docs repaired her wound. they were amazed at how little blood she'd lost and how well she'd tolerated it.  Both mother and baby did well with good care.