VBAC is Safe!
Compiled by LLM. BirthLove members:
view this page on the main site- click
here.
This page includes research, wisdom and information
that shows how safe giving birth after cesarean
section really is; it also shows that VBAC births
become less safe when induction drugs are involved.
Note that one must be a BirthLove member to
access certain pages linked from this page.
For cesarean and VBAC articles and birth stories,
go here.
For more medical references, see the page Induction
Dangers.
Click to go to the desired section on this
page:
How long must one
wait after a c-section before having a VBAC?
From BIRTH AFTER CESAREAN by Bruce Flamm:
"Rumor has it that its safer to wait
several years after a cesearen section before
attempting a vaginal birth. There's absolutely
no evidence for this belief. Studies on wound
healing have shown that tissue regains the majority
of its strength within a few weeks of an operation.
The tissue that gives a healing wound its strength
is called collagen. According to a general surgery
textbook, 'Collagen content of the wound tissues
rises rapidly between the sixth and the seventieth
days but increase very little after the seventieth
day and none at all after the forty-second day.'
Since the uterine scar is almost fully healed
within weeks after a cesarean section there is
no reason to postpone plans for another baby."
Summary
of 4 Studies on VBAC safety by
Gretchen Humphries. An excellent paper that illuminates
the findings, as well as the failings, of important
research documents. Included: how there is no
study about the outcomes of planned home VBACs.
Women
respond to the Britsh Medical Journal about VBAC
(Go to the bottom of the linked page, and click
on "Rapid Responses" to view the responses.)
The BMJ published a news story on 7/14/01 that
suggested that "once a cesarean, always a
cesarean" is on the rise again. This page
includes wonderful responses form mothers and
midwives about how cruel the implications of this
story (referenced from the damaging New England
Journal of Medicine anti-VBAC paper) truly are.
About
Uterine Ruptures, and the Remarkable Human Uterus
Wonderful info about how rare uterine rupture
is (including in vertical- "Classical"
incisions), and how to strengthen the uterus during
pregnancy- an already remarkably strong and adaptive
muscular organ.
How
likely is it that your VBAC uterus will rupture?
by Eileen and Pat Sullivan. Well- you're actually
a lot more likely to win at roulette or have a
doctor who is an imposter than you are to have
your scar rupture in childbirth.
Medical journal citations
about VBAC safety- and inducted birth dangers
Vaginal Birth After Cesarean
is extremely safe- as demonstrated by Swiss scientists
The following study has been broken down into
lay language by Gretchen Humphries, MS, DVM.
"This study is just chock full of good stuff.
- Huge number of TOLs (trials of labor)- over
17,000- showed that in this group, being induced
reduced the VBAC success rate and increased
the rupture rate.
- Epidural also showed an increase in ruptures,
probably because they tended to be augmented
with pitocin, I'd bet.
- Also showed that even with the 0.4% rupture
rate, the fetal mortality from those ruptures
was extremely low (and really, isn't that what
is scary about a rupture? losing the baby?)-
about 0.03% of all TOLs had a fetal mortality
due to rupture. 3 out of 10,000 is a lot
lower than just about any other reason a baby
might die during labor.
- And, every other peripartum (during
childbirth) complication happened more often
in the non-labor (elective cesarean) c-section
group, including hysterectomy.
I know its only one study, and you do have to
look at the entire body of the literature but
this is the one I refer to when people discount
the low rupture rates found in other studies because
the 'numbers are too small'. There is nothing
small about the numbers in this study, I think
it's as accurate as you can get when studying
something as rare as uterine rupture."
Delivery after previous cesarean: a risk evaluation.
Swiss Working Group of Obstetric and Gynecologic
Institutions.
Author Rageth JC; Juzi C; Grossenbacher H; Spital
Limmattal, Schlieren, Switzerland.
Source Obstet Gynecol, 93(3):332-7 1999 Mar
Abstract
OBJECTIVE: To examine the risks of vaginal delivery
after previous cesarean and to find criteria to
help decide whether a trial of labor or an elective
repeat cesarean should be preferred.
METHODS: We evaluated 29,046 deliveries after
previous cesarean registered in a pooled database
of 457,825 deliveries used to assess quality control
in gynecology and obstetrics departments in Switzerland.
RESULTS: Among the 17,613 trial-of-labor cases
logged (attempt rate 60.64%), the success rate
was 73.73% (65.56% after inducing labor and 75.06%
after the spontaneous onset of labor). The following
complications were significantly more frequent
in the previous-cesarean group: maternal febrile
episodes (relative risk [RR] 2.77; 95% confidence
interval [CI] 2.52, 3.05), thromboembolic events
(RR 2.81; CI 2.23, 3.55), bleeding due to placenta
previa during pregnancy (RR 2.06; CI 1.70, 2.49),
uterine rupture (92 cases; RR 42.18; CI 31.09,
57.24), and perinatal mortality (118 cases, including
six associated with uterine rupture; RR 1.33;
CI 1.10, 1.62). The postcesarean group also showed
a 0.28% rate of peripartum hysterectomy (81 cases;
RR 6.07; CI 4.71, 7.83). There was one maternal
death in the group, compared with 14 maternal
deaths in the group without previous cesarean
(no statistical significance). The risk of uterine
rupture for patients with previous cesareans was
elevated in the trial-of-labor group compared
with the group without trial of labor (RR 2.07;
CI 1.29, 3.30), but all other maternal risks,
including peripartum hysterectomy (RR 0.36; CI
0.23, 0.56), were lower. When comparing the women
having a trial of labor, the 70 with uterine rupture
more often had induced labor (24.29% compared
with 13.92% in the nonrupture group; P = .013),
had epidural anesthesia (24.29% compared with
8.44%; P < .001), had an abnormal fetal heart
rate tracing (32.86% compared with 8.53%; P <
.001), and had failure to progress (21.43% compared
with 7.98%; P = .001).
CONCLUSION: A history of cesarean delivery significantly
elevates the risks for mother and child in future
deliveries. Nonetheless, a trial of labor after
previous cesarean is safe. Induction of labor,
epidural anesthesia, failure to progress, and
abnormal fetal heart rate pattern are all associated
with failure of a trial of labor and uterine rupture.
Uterine rupture is
RARE, strongly linked with induction drugs, and
not all that lethal after all.
Out of 114,933 deliveries, there were 37 ruptures;
half of those were because of induction drugs.
Out of those 37 ruptures, only one baby died.
(So sorry, baby...)
A 10-year population-based study of uterine
rupture.
Obstet Gynecol 2001 Apr;97(4 Suppl 1):S69
Baskett TF, Kieser KE.
Dalhousie University, Halifax, Nova Scotia, Canada
Objective: To review the incidence, associated
factors, and morbidity associated with uterine
rupture.Methods: A 10-year (1988-1997) population-based
review of 114,933 deliveries in one province.
Results: There were 39 ruptures: 16 complete
and 23 dehiscence. Thirty-seven cases had undergone
a previous cesarean delivery (34 lower transverse,
2 classical, 1 low vertical). Of the 114,933 deliveries,
11,585 (10%) were to women with a previous cesarean
delivery. The incidence of uterine rupture in
those undergoing a trial for vaginal delivery
(4,516) was complete rupture (3/1000) and dehiscence
(5/1000). Induction or augmentation of labor with
oxytocics was associated with 50% of complete
ruptures and 25% of dehiscence. There were no
maternal deaths, but 33% of patients with complete
ruptures required blood transfusion. There was
one neonatal death attributable to uterine rupture.
Conclusion: Induction and augmentation of labor
are confirmed as risk factors for uterine rupture.
Fetal heart rate abnormality was the most reliable
diagnostic aid. Serious maternal and perinatal
morbidity was relatively low.
PMID: 11275210 [PubMed - as supplied by publisher]
Women who've had at
least one vaginal birth after cesarean are far
less likely to have uterine ruptures in subsequent
births
Successful first vaginal birth after cesarean
section: a predictor of reduced risk for uterine
rupture in subsequent deliveries.
Shimonovitz S, Botosneano A, Hochner-Celnikier
D Department of Obstetrics and Gynecology, Hadassah
University Hospital, Mt. Scopus, Jerusalem, Israel.
BACKGROUND: Uterine rupture is a catastrophic
obstetric complication, most often associated
with a preexisting cesarean section scar. Although
a vaginal birth after a cesarean is considered
safe in modern obstetrics, it is not known whether
repeated VBACs increase the risk of rupture, or
whether the first VBAC proves the strength and
durability of the scar, predicting further successful
and less risky vaginal deliveries.
OBJECTIVES: To evaluate the effect of repeated
vaginal deliveries on the risk of uterine rupture
in women who have previously delivered by cesarean
section.
METHODS: In this retrospective study, 26 VBAC
deliveries complicated by uterine rupture were
matched for age, parity, and gravidity with 66
controls who achieved VBAC without rupture. The
histories, demography, pregnancy, labor and delivery
records, as well as neonatal outcome were compared.
RESULTS: We found that the risk of rupture decreases
dramatically in subsequent VBACs. Of the 40 cases
of uterine rupture recorded during the 18 year
study period, 26 occurred during VBAC deliveries.
Of these, 21 were complicated first VBACs. We
also found that the use of prostaglandin-estradiol,
instrumental deliveries, and oxytocin had been
used significantly more often during deliveries
complicated with rupture than in VBAC controls.
CONCLUSIONS: Once a woman has achieved VBAC the
risk of rupture falls dramatically. The use of
oxytocin, PGE2 and instrumental deliveries are
additional risk factors for rupture, therefore
caution should be exerted regarding their application
in the presence of a uterine scar, particularly
in the first vaginal birth after cesarean.
PMID: 10979328, UI: 20433706
Isr Med Assoc J 2000 Jul;2(7):526-8
Effect of previous vaginal delivery on the
risk of uterine rupture during a subsequent trial
of labor
Zelop CM, Shipp TD, Repke JT, Cohen A, Lieberman
E
Department of Obstetrics and Gynecology, Lenox
Hill Hospital.
[Medline record in process]
OBJECTIVE: We examined the effect of prior vaginal
delivery on the risk of uterine rupture in pregnant
women undergoing a trial of labor after prior
cesarean delivery.Study Design: The medical records
of all pregnant women with a history of cesarean
delivery who attempted a trial of labor during
a 12-year period at a single center were reviewed.
For the current analysis, the study population
was limited to term pregnancies. The effect of
previous vaginal delivery on the risk of uterine
rupture during a subsequent trial of labor was
evaluated. Separate analyses were performed for
women with a single previous cesarean delivery
and for those with >1 prior cesarean delivery.
For each of these subgroups, the rate of uterine
rupture among women who had >/=1 prior vaginal
delivery was compared with the rate among women
with no prior vaginal delivery. Logistic regression
analysis was used to examine the associations
with control for confounding factors.
RESULTS: Of 3783 women with 1 prior scar, 1021
(27.0%) also had >/=1 prior vaginal delivery.
During a subsequent trial of labor, the rate of
uterine rupture was 1.1% among pregnant women
without prior vaginal delivery and 0.2% among
pregnant women with prior vaginal delivery (P
=.01). Logistic regression analysis controlling
for duration of labor, induction, birth weight,
maternal age, year of birth, epidural analgesia,
and oxytocin augmentation indicated that, among
women with a single scar, those with a prior vaginal
delivery had a risk of uterine rupture that was
one fifth that of women without a previous vaginal
delivery (odds ratio, 0.2; 95% confidence interval,
0.04-0.8). In the group of 143 pregnant women
with 1 previous cesarean delivery, women with
a prior vaginal delivery had a somewhat lower
risk of uterine rupture (3.9% vs 2.5%; adjusted
odds ratio, 0.6; 95% confidence interval, 0.01-6.7).
This difference was not statistically significant.
CONCLUSION: Among women with 1 prior cesarean
delivery undergoing a subsequent trial of labor,
those with a prior vaginal delivery were at substantially
lower risk of uterine rupture than women without
a previous vaginal delivery.
Uterine rupture associated
with the use of Cytotec (misoprostol) for VBACs
In a retrospective (case reports, computerized
search of medical records, literature review)
study of 89 women who had Cytotec, there were
5 women who had ruptures- a rate of 5.6%. Of 423
similar patients who didn't get misoprostol, there
was only one case of rupture- a rate of 0.2%.
-AJOG, June 1999, Part 1, Volume 180, No. 6:1535-42
For more about Cytotec dangers, go to this
page.
Prostin gel significantly
increases uterine rupture rates
*Note that Cytotec is not used (to the best
of activists' knowledge) in Canada for labor induction.
Uterine rupture during induced trial of labor
among women with previous cesarean delivery
Debra J. Ravasia, MD Stephen L. Wood, MD Jeffrey
K. Pollard, MD Calgary, Alberta, Canada
Objective: This study was undertaken to compare
the rates of uterine rupture during induced trials
of labor after previous cesarean delivery with
the rates during a spontaneous trial of labor.
Study Design: All deliveries between 1992 and
1998 among women with previous cesarean delivery
were evaluated. Rates of uterine rupture were
determined for spontaneous labor and different
methods of induction.
Results: Of 2119 trials of labor, 575 (27%) were
induced. The overall rate of uterine rupture was
0.71% (15/2119). The uterine rupture rate with
induced trial of labor (8/575; 1.4%) was significantly
higher than with a spontaneous trial of labor
(7/1544; 0.45%; P = .0004). Uterine rupture rates
associated with different methods of induction
were compared with the rate seen with spontaneous
labor and were as follows: prostaglandin E2 gel,
2.9% (5/172; P = .004); intracervical Foley catheter,
0.76% (1/129; P = .47); and labor induction not
requiring cervical ripening, 0.74% (2/274; P =
.63). The uterine rupture rate associated with
inductions other than with prostaglandin E2 was
0.74% (3/474; P = .38). The relative risk of uterine
rupture with prostaglandin E2 use versus spontaneous
trial of labor was 6.41 (95% confidence interval,
2.06-19.98).
Conclusion: Induction of labor was associated
with an increased risk of uterine rupture among
women with a previous cesarean delivery, and this
association was highest when prostaglandin E2
gel was used. Am J Obstet Gynecol 2000;183:1176-9.
*A Prostin information sheet with uterine
rupture warnings can be read here.
Induction drugs cause
uterine rupture
-In both VBAC moms and those without
scarred uteruses.
"A study was done in November 2000 re uterine
rupture and VBAC (American Journal of Obstetrics
and Gynecology. Volume 183(5) November 2000, pp1176-1179
view study here).
It shows that uterine rupture is more than 6 times
more likely when induction/augmentation occurs.
The only ruptures I have heard of (personally)
have occurred in women being induced, and they
have all had epidurals in place. Every drug will
affect the risks involved, and this is where women
need the information the most.
VBAC has been shown (again and again) to be safer
than an elective c/section for no medical reason-
except a prior caesarean birth. Safer for both
mother and child. Hysterectomy is actually more
likely if you have an elective c/section than
a VBAC. Not the other way around, as is commonly
believed. It is the induction/augmentation that
increase the risks and make VBAC dangerous- risking
babies and mothers, not the VBAC itself, but how
it is managed.
Uterine rupture occurs in unscarred uteruses
when women are induced/augmented, and then it
IS usually catastrophic, as an unscarred uterus
really 'ruptures' whereas a scarred uterus may
just open slightly along the scar line. A study,
in the British Medical Journal, about uterine
rupture rates, printed in the BMJ 1996; 312: 1204
– 1205 (May 11), 'In a study of 32 cases
(from 1 July 1993 – 30 June 1994) only 3
were scarred uteri (from a previous c/section).'
Women attempting to birth VBAC have been rushed
and drugged through the experience; and some of
the results have been disastrous. For example,
read this
BMJ study."
Birthing Beautifully,
Jackie Mawson.
Convenor of Birthrites:
Healing After Caesarean Inc.
Uterine Rupture Risk After
Prior Cesarean Not Increased After 40 Weeks'
Gestation
Spontaneous labor is safe; induced labor is
not, regardless of duration of pregnancy.
WESTPORT, CT (Reuters Health) Mar 13 - Among
women with on previous cesarean delivery, the
risk of uterine rupture during a subsequent trial
of labor is not substantially increased after
40 weeks' gestation, according to a report in
the March issue of Obstetrics and Gynecology.
However, the risk is increased with induction
of labor regardless of gestational age. Dr. Carolyn
M. Zelop, of Lenox Hill Hospital, New York, and
colleagues compared outcomes in women with prior
cesareans delivering at or before 40 weeks with
those delivering after 40 weeks. They reviewed
labor outcomes over 12 years for 2775 women "with
one prior scar and no other deliveries" who
had a trial of labor at term. According to the
report, uterine ruptures occurred in 0.8% of women
delivering at or before 40 weeks' gestation and
1.3% of women delivering after 40 weeks. Among
those with spontaneous labor, the rupture rate
was 0.5% at or before 40 weeks and 1.0% after
40 weeks (OR 2.1). With induced labor, the rates
were 2.1% and 2.6%, respectively (OR 1.1). The
overall rate of cesarean delivery was higher for
women after 40 weeks' gestation compared with
women at or before 40 weeks, at 35.4% and 26.7%,
respectively. The rate of cesareans associated
with spontaneous labor at or before 40 weeks was
25%, compared with 35.5% after 40 weeks for (OR
1.5). For induced labor, the rates of cesarean
delivery were 33.8% and 43%, respectively (OR
1.5). "Because spontaneous labor after 40
weeks is associated with a cesarean rate similar
to that following induced labor before 40 weeks,
awaiting spontaneous labor after 40 weeks does
not decrease the likelihood of successful
vaginal delivery," Dr. Zelop and colleagues
conclude. Obstet Gynecol 2001;97:391-393
Elective cesareans DO NOT
preserve the pelvic floor
Can elective cesarean save your pelvic floor?
NO, says a recent South Australian study reported
in the December 2000 edition of the British Journal
of Obstetrics and Gynaecology. The 1998 South
Australian Health Omnibus Survey involved a random
selection of 4400 households. 3010 men and women
aged 15-97 years were interviewed in their own
homes, to determine, among other things, the prevalence
of pelvic floor disorders, and to determine the
relationship to gender, age, number of children
and their mode of birth.
The prevalence of urinary incontinence (uncontrolled
leakage of urine) in men was 4.4% and in women
35.3%. Urinary incontinence in women increased
after pregnancy according to the number of children
and age. Pregnancy (more than 20 weeks) REGARDLESS
OF MODE OF BIRTH, greatly increased major pelvic
floor dysfunction- defined as any type of incontinence,
symptoms of prolapse or previous pelvic floor
surgery. Compared with a woman with no children,
pelvic floor dysfunction was more than two and
a half times as common in a woman who had birthed
a baby by caesarean, over three times as common
in a woman birthing naturally and over four times
as common in a woman who birthed with at least
one forceps. The difference between caesarean
and forceps was significant, but not between caesarean
and a natural birth.
The investigators commented "...elective
caesarean section is apparently not an effective
way to reduce the prevalence of most subsequent
pelvic floor disorders, except when instrumental
vaginal delivery can be avoided". MacLennan
AH et al. The prevalence of pelvic floor disorders
and their relationship to gender age, parity and
mode of delivery. BJOG 2000;107:1460-70.
Contributed by Jackie Mawson
Convenor of Birthrites: Healing After Caesarean
Comment from a professional birth attendant:
"I think a lot of female incontinence
is caused by peeling the bladder off the uterus
during cesarean surgery and then reattaching it.
This interference with the normal attachments
of the bladder lead to later urinary problems.
The pelvic floor has nothing to do with post-cesarean
incontinence." -Gloria
Lemay
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