The Latest Best Evidence on the Safety of VBAC

13 Dec

Henci Goer and Amy Romano have recently published their much awaited book, Optimal Care in Childbirth: The Case for a Physiologic Approach. Their research, based on the best available evidence, makes a strong case for supporting women who want to plan a VBAC.

The most valuable aspect of their book is the fact that they have selected high quality studies that truly compare the benefits and risks of elective repeat cesarean (not medically necessary) with planned VBAC. They have only included well-designed studies that took into account confounding factors, that is, factors that can lead to a misinterpretation of results.  Optimal Care in Childbirth

The authors clearly show that some studies published in respected journals may in fact reach mistaken conclusions and confirm that the current, restrictive guidelines for VBAC  are not based on sound evidence.

In the interest of clarifying some of the confusion and misinformation regarding VBAC, here are the facts regarding VBAC based on Goer’s and Romano’s research in Chapter 6 of their book.

Who Can Labor for a VBAC?

Over 95% of women with a prior cesarean can labor safely for a VBAC without any uterine scar problems.

  • Women with more than one prior cesarean
  • Women with a single layer uterine closure
  • Women with a low vertical uterine scar
  • Women with a prior pre-term cesarean.
  • Women with a short inter-delivery interval (< 18 months since the prior birth)
  • Women of older maternal age.
  • Women with an anticipated macrosomic (more than 4000g) baby
  • Women whose pregnancy is past their due date

What are the odds that a woman who wants to labor after a prior cesarean will actually have a VBAC? 

On average the VBAC rate is 74%, but care during labor makes a difference. With usual management, studies report VBAC rates in women with no prior vaginal births ranging from 61% to 72%. With physiologic care, that is, care that supports the natural unfolding of the labor process, a study reported a VBAC rate of 81%. This means that somewhere between 9 and 20 more women with no prior vaginal births will have a VBAC with physiologic care than with usual management.

Most women with a prior cesarean will give birth vaginally, including women with the following conditions:

  • More than one prior cesarean
  • Having had a prior cesarean for:
    • Dystocia (delay in progress)
    • Macrosomia, a baby weighing more than 4000g ( 8lb. 13oz)
    • Older age
    • High body mass index (BMI)
    • Longer pregnancy duration

Women are more likely to have a VBAC if:

  • They have had a prior vaginal birth either before or after the cesarean.
  • Labor begins on its own. One reason heavier women, women carrying bigger babies, and women who are past their due date are more likely to have a repeat cesarean is that they are more likely to have labor induced.
  • They are given physiologic care-supportive of the normal process of labor with minimal use of interventions.

With proper care the risk for a scar rupture can be as low as 0.5% or 1 in 200 healthy women laboring for a VBAC.

The likelihood of a symptomatic scar separation during labor is dependent on the type of care provided to women during surgery and when laboring for a VBAC. To lower the risk for a potential scar rupture:

  • Physicians should use double-, not single–layer, suturing when closing the uterine incision.
  • Avoid inducing or augmenting labor.
  • Misoprostol should not be used for inducing labor in women with a prior cesarean scar.
  • Oxytocin should not be given to induce labor with an unripe cervix.
  • Women undergoing cervical ripening before induction should be given sufficient time for this process (longer than 40 hours).
  • Labor should not be augmented unless the fetal head is engaged in the pelvis and the cervix is dilated 3 or more centimeters.
  • Allow 12 hours between doses of PGE2 (dinoprostone) for cervical ripening and induction.
  • Women with more than one prior cesarean should not be given PGE2.
  • Allow 40 minutes before increasing the oxytocin dose.

No evidence establishes benefits in VBAC labors for the following practices, but they introduce potential harms.

  • Early admission to the labor and delivery unit
  • Routine use of I.V.s
  • Use of an intra-uterine pressure catheter
  • Forbidding food and water (NPO)
  • Establishing a time limit for women to reach full dilation and complete second stage
  • Manually exploring the uterus for scar separation after a vaginal birth

However, electronic fetal monitoring is a reliable indicator of a uterine scar rupture. Over 90% of the time a uterine scar rupture is detected by abnormal fetal heart tones (bradycardia) as documented by electronic fetal monitoring.

What are the advantages for mothers of planning a VBAC?

Accumulating cesarean surgeries increases the likelihood of:

  • Placenta previa, placenta accreta, and having the two in combination
  • Severe bleeding
  • Hysterectomy
  • Maternal admission to ICU
  • Maternal need for postoperative assistance with breathing
  • Thromboembolism
  • Ileus
  • Operative injuries
  • Adhesions

In contrast, having a VBAC decreases the risk of uterine rupture in future VBACs and increases the odds of having another vaginal birth thereby avoiding the risks of additional surgery.

For babies, accumulating cesarean surgeries increases the likelihood of:

  • Preterm birth and subsequent complications
  • Breathing difficulties
  • Admission to NICU

What are the trade-offs between having a VBAC and an elective repeat cesarean?

Although the rates are low, elective repeat cesarean increases the odds of maternal mortality. Twenty-one more women per 100,000 having elective repeat cesareans die than women planning a VBAC.

The differences is small, but 4 more perinatal deaths (deaths during labor or in the days after birth) per 10,000 occur with planned VBAC than with planned repeat cesarean. However, looking at neonatal deaths (deaths in the first four weeks after birth), studies disagree. One study reported rates of 11 per 10,000 with planned VBAC versus 5 per 10,000 with planned repeat cesarean but two others reported identical or nearly identical rates of 7 to 8 per 10,000.

Goer and Romano are optimistic that women have an excellent chance of having a VBAC when given proper care.

…a woman laboring in a low-stress environment surrounded by care providers who are relaxed and confident of her ability to give birth, who make decisions collaboratively with her, and who help her deal with any fears and anxieties is more likely to do well in labor and progress to vaginal birth than a woman who feels she needs to be in defensive mode or who feels unsafe, doubtful, or frightened.

* The information provided in this blog post is based on Chapter 6, “The Case Against Elective Repeat Cesarean,” of Goer’s and Romano’s book, Optimal Care in Childbirth: The Case for a Physiologic Approach (p 95-128).


For additional evidence-based information on the impact of cesarean section see Childbirth Connection’s just published report, Vaginal or Cesarean Birth: What Is At Stake for Mothers and Babies? A Best Evidence Review.


Only Women Have the Legal Authority to Decide How, Where and With Whom They Want to Give Birth

19 Sep

With thanks to Hermine Hayes-Klein, U.S. attorney for her assistance with this article.

On September 20th over 1,000 individuals, health professionals, and birth advocates groups will be screening the one hour campaigning documentary Freedom For Birth: The Mothers’ Revolution in over fifty countries worldwide.  This global call-to-action video directed and produced by two British film makers was inspired by and reports on the ruling of the European Court of Human Rights who in December 2010 stated that childbirth is a fundamental human right. Women have the human right to choose how, where, and with whom they want to give birth. The Court held that governments cannot use the force of law to take away their options.

On May 31 and June 1, 2012, over 300 men and women gathered at The Hague University in The Hague, The Netherlands, for a conference on Human Rights in Childbirth to discuss what it means for childbirth to be a human right and what conditions are necessary that can truly give women the right to control their own bodies. The film includes interviews with over forty birth experts from four continents and with civil rights attorneys who spoke about the new context in which the violation of women’s rights in childbirth can now be framed. Human rights are universal rights.

Hermine Hayes-Klein, the American attorney who spearheaded the Human Rights in Childbirth Conference while serving as Director of the Byrkenshoek Center for Reproductive Rights in The Hague stated,

“More than anything, the film seems to be a call to women to stand up for themselves,  for their rights around birth.  It’s also a call to lawyers, and an offer from the lawyers in the movie, to help and support women in that process. It’s essentially a kind of reframing of the birth-care conversation, isn’t it—it’s no longer just about, ‘please give us evidence-based care, and ‘joint decision-making,’ but, ‘We own these bodies, these are our babies, and the provider role is simply, only, to advise and support us on our terms.”

In Ternovszky v. Hungary, the European Court  handed down a judgment in favor of Anna Ternovszky, a Hungarian mother who brought her case to the court. She wanted to give birth at home with her midwife, Dr. Ágnes Geréb, formerly an obstetrician/gynecologist, but could not do so because it was not clear whether home birth was “legal” under Hungarian law, and midwives who agreed to attend a home birth risked being convicted.  In fact  Dr. Geréb was convicted and initially sentenced to prison and later to house arrest.

The European Court of Human Rights ruled that birthing women have the right to choose the circumstances in which they give birth, including the choice for home birth, and that their government must enable that choice as legitimate. When the state prevents a woman from being free to choose the circumstances of the birth of her children it is violating her right to privacy, her right to autonomy and her right to control her own body.

The European Court’s ruling is binding on all members of the European Union. But is the ruling of the European Court useful for those concerned with women’s birth rights in the United States or indeed other countries?, the website created to facilitate and encourage the much needed revolution for birthing women suggests that the fundamental human right recognized in the Ternovszky case is relevant in any constitutional democracy with a meaningful right to privacy and right to physical autonomy. Anna Ternovszky stood up for her rights, and so those rights were enshrined in law; her example could be followed in other courts around the world.

“As a birthing woman, you have the right to meaningful choice and genuine support for your personal needs around and during childbirth.  Nobody can tell you that you “must” do anything.  Nobody can “let you” or “not let you” do anything.  Nobody can pressure or force you into a cesarean section that you do not believe is in the interest of yourself and your baby.  Nobody can cut an episiotomy if you do not consent to one.  Nobody can do anything to your body or your baby without discussing it with you first and asking for your consent.  You have the right to be the ultimate authority over everything that occurs around your body’s birth of your baby.”

The documentary producers, Toni Harman and Alex Wakeford, parents of a four year-old daughter, organized this event to be the kick-off of what they hope will be a global  “Mothers’ Revolution,” because only mothers or expectant mothers can really bring about the change.  Following the September 20th  Premier Screening,  a 20 minute version of the documentary will be available for free download from the Freedom For Birth website. The video is available with sub-titles in 17 languages.

The producers hope to keep the momentum going and ask that those hosting the attending the screenings, please take photos and post them on their Facebook pages and on Twitter to build up a global buzz:

Women and birth advocates interested in finding out more about the Human Rights in Childbirth Conference can view a webinar, visit the conference Facebook page,  or may be able to get a copy of the conference proceedings.


Women Are Poorly Informed By Their Careproviders About the Benefits of VBAC and Risks of C-Section

12 Sep

Although VBAC is encouraged by ACOG and viewed by the National Institutes of Health as a reasonable option to a repeat cesarean, less than 10% of women with a prior cesarean had a VBAC in 2010.  A study published in the September issue of the American Journal of Obstetrics and Gynecology suggests that care providers  are not educating their patients about the benefits of VBAC and women are not making an informed decision when they elect to have a repeat cesarean section.

Researchers surveyed women with one prior cesarean birth who were being admitted at St. Luke’s Roosevelt Hospital Center in New York City to have a repeat cesarean or to labor for a VBAC. Women had already made their  decision about how they wanted to give birth. The expectant mothers were surveyed between November 2010 and July 2011, after ACOG’s guidelines recommending that women receive “thorough counseling” that included the benefits and risks of VBAC.

Although the hospital has a comparatively high VBAC rate of 33%, the authors found only 13% of women who chose to have a VBAC and 4% of women who chose to have a repeat operation were aware that 60-80% of women who labor after a cesarean have a normal birth. Only one in two women who labored and one in four women who had a repeat cesarean knew that the risk of separation of the prior uterine scar was “0.5-1%.”

Of the women who had a repeat operation, more than half  did not know that recovering from a repeat cesarean was longer than after a VBAC and 46% did not know that the rate of complications increases with each successive cesarean. Only half of the women knew that there is greater risk of damage to organs, excessive bleeding, and infection with an elective repeat cesarean and two thirds were not aware that an elective repeat cesarean is associated with an increased risk of maternal death, neonatal respiratory complications and admission to a neonatal intensive care unit (NICU).

Of the women who perceived that their providers favored an elective cesarean, 86% selected to have a repeat operation. Three out of four women who felt that their providers favored a VBAC chose to labor.  Half the women who didn’t think their provider had a preference chose a repeat cesarean and half chose to labor. The researchers suggest that “provider bias may be affecting the opinion of some patients, with undue influence on a patient’s voluntary decision-making.”

The authors of the study, who hypothesized that current low VBAC rates were a result of poor patient education, concluded that despite the fact that this group of women represented “a better informed population,”  they “showed insufficiencies in the area of comprehension, a major trend in informed consent. They lacked awareness and understanding of their situation and possibilities.”

To make an informed decision about how to give birth after a prior cesarean women need complete and accurate information about the risks and benefits of both options.


Sources of reliable information on VBAC and elective repeat cesarean.

Childbirth Connection,   VBAC or Repeat Cesarean?

Lamaze Giving Birth With Confidence Blog,  A Woman’s Guide to VBAC

Queensland, Australia-Center for Mother and Babies, Vaginal Birth After Cesarean (VBAC)

Optimal Birth, British Columbia,  VBAC Brochure

Vermont/New Hampshire VBAC Project, VBAC Patient Education

Society of Obstetricians and Gynecologists of Canada, Vaginal Birth After Cesarean

Royal College of Obstetricians and Gynaecologists, U.K., Birth After Caeserean: Information For You

Power to Push Campaign, British Columbia, Vaginal Birth After Cesareanvideos and birth stories, Ten Birthing Misconceptions

Breastfeeding, Birth Practices, and Cesarean Section: Is There a Link?

10 Aug

August is the month dedicated to increasing awareness about the benefits of breastfeeding for mothers and babies and to making commitments to support, protect, and promote the best feeding option for infants. Breastfeeding provides optimal health, nutritional, immunologic and developmental benefits to newborns as well as protection from postpartum complications and future disease for mothers. In 1991 the World Health Organization and UNICEF introduced the WHO Baby-Friendly Hospital Initiative outlining Ten Steps for birth facilities and maternity care professionals to follow to ensure that mothers and babies get the best start after birth for initiating and continuing breastfeeding. Since then, evidence has been mounting showing that the likelihood of initiating and continuing breastfeeding is determined even before the baby is born.

In 2003 the WHO and UNICEF established that birth practices impact breastfeeding. New guidelines recommended that to maximize the establishment of successful breastfeeding, women in labor regardless of birth setting, should have access to the following birth care practices:

  • Care by staff trained in non-drug methods of pain relief and who do not promote the use of analgesic or anesthetic drugs unless required by a medical condition;
  • Care that minimizes routine practices and procedures that are not supported by scientific evidence including withholding nourishment, early rupture of membranes, use of IVs, routine electronic fetal monitoring, episiotomy and instrumental delivery; and
  • Care that minimizes invasive procedures such as unnecessary acceleration or induction of labor and medically unnecessary cesarean sections.

Minimizing the use of drugs and interventions reduces the odds for complications including infection, increased pain, stalled labor and abnormal fetal heart tones. Recommendations also emphasized that care givers should respect women’s choices:

  • Care should be sensitive and responsive to the specific beliefs, values, and customs of the mother’s culture, ethnicity and religion;
  • Women should have access to birth companions of their choice who provide emotional and physical support throughout labor and delivery;
  • Women should have the freedom to walk,move about, and assume the positions of their choice during labor.

Supporting women in labor with this model of care is more likely to lead to an uncomplicated vaginal birth.

In 2009 the Centers for Disease Control published the CDC Guide to Breastfeeding Interventions, confirming that hospital birth practices have a significant impact on the initiation and continuation of breastfeeding. The report states that the use of medications during labor and cesarean birth have a negative effect on breastfeeding. So does the separation of mother and baby after birth and during the hospital stay.

The CDC found that a woman’s birth experience exerts a unique influence on both breastfeeding initiation and later infant feeding behavior. Although the hospital stay is typically very short, events during this time have a long and lasting impact. Medications and procedures administered to the mother during labor affect her infant’s behavior at the time of birth, which in turn affects her infant’s ability to suckle in an organized and effective manner at the breast.

Use of analgesics, epidural anesthesia and cesarean birth have a negative effect on breastfeeding, making it more difficult for mothers to initiate nursing and establish a successful breastfeeding pattern before leaving the hospital.

Babies are more likely to be breastfed and for a longer period of time if they have early skin-to-skin contact.  With a cesarean babies are more likely to be taken to the nursery for observation and monitoring for potential problems during the first hour of life, the “golden hour” when breastfeeding is best initiated.  Babie are also more likely to spend time in a newborn nursery than rooming in with their mothers. The separation seems to have an impact on the mother’s initial ability to respond to and care for her infant. When mothers and babies are together, skin-to-skin, babies cry less, it improves the mother’s perception of her infant, and enhances her confidence in her mothering skills.

Some hospitals like San Francisco General in California, a Baby-Friendly designated facility, have established pro-breastfeeding cesarean guidelines to increase the number of mothers who successfully initiate breastfeeding. Operating room policies now include routine skin-to-skin contact as soon as possible and within 90 minutes after a cesarean delivery. Babies who experience skin-to-skin in the operating room are better able to latch on to the breast and less likely to receive formula before discharge.

Birth practices for labor, birth, and postpartum can facilitate or hinder the initiation, establishment, and continuation of breastfeeding. According to a CDC report many birth facilities have policies and practices that are not evidence-based and are known to interfere with breastfeeding. Maternity care providers have an obligation to care for women and newborns in a way that provides both with the best possible health outcomes.


UNICEF-U.K. , Care Pathways for Breastfeeding

Baby-Friendly U.S.A.

U.S. Surgeon General’s Call To Action to Support Breastfeeding

CIMS, Breastfeeding Is Priceless. A Coalition for Improving Maternity Services Fact Sheet

Sylvie Donna, A Look at the Research: The Link Between Epidural Analgesia and Breastfeeding.