The ideal birthplace for the VBAC mother, especially if she feels that the initial cesarean was unnecessary, may be in the home.
Fear surrounding vaginal birth after cesarean (VBAC) is related to the high level of medical interventions common within hospital birth, all which increase the risk of uterine rupture and catastrophic outcomes. This fear is sound because medical interventions are exceptionally hard to avoid in the hospital environment. However, it is inappropriate to extrapolate that risk to VBAC women birthing at home.
The incidence of uterine rupture in physiologic birth ranges from 0.1-1.2%. This incidence is no greater than any other sudden obstetric emergency, such as placenta abruption, cord prolapse, and unexplained fetal distress. In fact, the absolute risk risk of birth-related perinatal death associated with VBAC is extremely low and comparable to the risk for nulliparous women in labor. When labor is induced or augmented, the risk for uterine rupture increases two-to-three fold and the incidence of repeat cesarean is 1.5-fold more frequent.
A father is four-times more like to become the father of twins than he is to have a wife who’s uterus ruptures in childbirth. A man is also slightly more likely to suffer breast cancer than his wife is to suffer a rupture.
The success rate of planned VBACs is currently understood to be 72-75%. Having had one or more previous vaginal births, particularly previous VBACs, is the single best predictor or successful VBAC and is associated with a planned VBAC success rate of 85-90%. Previous vaginal delivery is also independently associated with a reduced risk of uterine rupture.
The nurse-midwifery team at Believe Midwifery Services, LLC is as equipped, if not more so, than the local remote hospital to handle obstetric emergencies and to date, has a successfully assisted all their VBAC clients in a subsequent homebirth with the exception of two who self-elected a non-emergent transfer for pain management. Tertiary centers however are increasingly the recommended birth site for VBAC women because they offer the immediate availability of a surgery team.
The key to our success might be in appropriate candidate selection, avoidance of interventions such as prostaglandins and pitocin, or the continual presence of the midwifery team. However, it may simply be that our client’s believe in themselves and trust the birth process as a challenging journey worth embracing.
The American College of Nurse-Midwives strongly supports the practice of vaginal birth after cesarean (VBAC) for women who are appropriately selected, counseled and managed. This position is consistent with current research which reports that successful VBAC results in significant benefits and fewer risks for women and infants than repeat cesarean delivery (2000). ACNM (2000) further states that “midwives are qualified to manage care during pregnancy, labor and birth for women planning a vaginal birth after cesarean if appropriate arrangements for medical consultation and emergency care are in place.”
The cesarean rate has increased 50% since 1990. Care managed by obstetricians is in peril. The current cesarean epidemic has not lowered indices of maternal or perinatal morbidity. Rather it is associated with greater morbidity than vaginal birth. Lowering the primary cesarean rate has become a national priority.
The American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice however, considers a prior cesarean delivery to be an absolute contraindication to planned home birth (ACOG, 2011, Committee Opinion on Home Birth). This is also the opinion of the Royal College of Obstetricians & Gynaecologists (2015). We want you to be well-informed, and appreciate that our culture has strong opinion about where women should birth particularly when they have had a prior cesarean. Often this opinion is created with very little information. ACOGs (2004) opinion is largely expert opinion and not based on outcomes proven within evidence. Evidence has demonstrated however, that this recommendation has only led to a decline in women who plan vaginal births after cesareans, but no improvement in neonatal or maternal mortality rates (Zweifler and colleagues, 2006). It is our opinion that any birth environment, home or hospital, that is ill-equipped to manage an obstetrical emergency is a dangerous place for any woman to birth her baby, as uterine rupture in physiologic birth is no more likely than any other obstetrical emergency any maternity center may face.
Repeat Cesareans are Not Necessarily Safer
There is no evidence that a repeat cesarean is safer than VBAC. To the contrary in fact. A plethora of evidence exists regarding the risks of repeat cesarean delivery, including:
- Higher risk of infection, adhesions, intestinal obstruction, chronic pain, ectopic pregnancy and placental problems compared to mothers who have a successful VBAC.
- Increased risk of hemorrhage severe enough to require a blood transfusion due to placental problems from accumulating cesareans.
- Higher likelihood of being re-hospitialized for complications related to the surgery.
- Decreased fertility and increased risk of miscarriage in future pregnancies.
- Greater likelihood of difficulty with mother-infant attachment as well as establishing and continuing breastfeeding.
- Elevated risk for premature delivery and serious neonatal respiratory problems in baby.
The greatest risk however is in those moms who plan to birth vaginally after a prior cesarean and ultimately require a repeat cesarean section. Women should also understand that there is uncertainty about the safety and efficacy of planned VBAC in pregnancies that go beyond 42 weeks of pregnancy, or those with twins or especially large babies. There is also little to no evidence about VBAC outcomes in women over the age of 40.
Interestingly, although large babies are associated with lower likelihood of successful VBAC, 60%-90% of women still find success (VBAC, 2004). Additionally, women who await spontaneous labor after 40 weeks of labor are less likely to find success, but their risk of rupture has not demonstrated to be higher (ACOG, 2004). It would be our argument that potentially, obstetricians are simply growing inpatient and fearful which invites interventions that hinder success.
It is well known that vertical cesarean scars are believed to be contrary to a trial of labor. However, and we share this cautiously and in the interest of full disclosure, ACOG reviewed a single case series and four retrospective studies regarding low-vertical uterine incision and found these women were just as likely to have a successful VBAC as women with a previous low-transverse uterine incision (2004). They state, “Women with a vertical incision within the lower uterine segment that does not extend into the fundus are candidates for VBAC” (ACOG, 2004, p 830).
Few studies regarding twins have been completed, but in two small studies with only 45 women, the rates of successful VBAC and uterine rupture did not differ significantly between study subjects and women with singleton gestations also attempting VBAC (ACOG, 2004).
Currently more than 800 hospitals in this country will not allow a woman to attempt a vaginal birth after a prior cesarean delivery (VBAC). These bans have caused consumers and experts alike to review hospital policies regarding VBAC. The National Institutes for Health recently organized a conference and convened a panel of experts to discuss the current evidence related to VBAC. The panel drafted a statement based on scientific evidence presented in open forum and on published scientific literature.
While the cesarean section can save the life of either the woman or the child, experts agree that one in three women do not require surgery to give birth safely. A hysterectomy as well, can save a woman’s life from cancer or hemorrhage, which was why it was originally implemented. Today, approximately 89% of all hysterectomies are classified as “elective” surgery and are performed for conditions that are not life-threatening.
Mothers who have experienced a high number of cesarean sections might be interested in this study by researchers Cahill, Tuuli, Odibo, Stamilio & Macones, published in BJOG in 2010. ACOG (2004) cites a 1% to 3.7% risk of rupture in women with two prior cesarean sections. Zealot et al. (2000) demonstrated this risk may decease by as much as 40% when women with multiple cesareans have had a previous vaginal birth.
Women who have had more than two cesareans however, are not well represented within the literature. We just don’t have data here to quantify the maternal risks of uterine rupture or other maternal morbidities when women with three or more prior cesareans desire spontaneous labor. Cahill et al. (2010) studied 860 women, 89 of which had three to six previous cesarean sections individually and chose to attempt VBAC. Researchers found that while there were no uterine ruptures in any of the women with three or more prior cesareans, those who elected for repeat cesareans appeared to have a higher rate of maternal morbidity (2.2% verses 0.0%, p=0.12) when compared to those who attempted VBAC. Of those 89 women, 58% labored spontaneously. The other intriguing finding was that only 36% had a prior vaginal birth, and 91% of those successfully delivered vaginally. Of the 57 women who had no prior vaginal delivery, 74% found success. Even more astonishing is that these women, who opted for VBAC, were more likely to report tobacco or alcohol use, have diabetes, and be of black race – high risk and still demonstrating improved outcomes upon repeat cesareans. Let me be very clear though, ACOG does not recommend planned VBAC attempt in women with three or more prior cesarean deliveries. These women and their outcomes are rare, making the data available on risk estimates to inform decision making quite sparse. It should be understood that women with three or more cesarean births, no matter how they birth, have increased morbidity over other women.
NICE (2015) discusses a study by Landon et al (2006) that showed no significant difference in the rates of uterine rupture in VBAC with two or more previous cesarean births compared with a single previous cesarean birth, and states that these findings are consistent with “other observational studies,” (p 7). It is notable however, that more than have of these women had experienced a previous vaginal birth. They offer the statistics of uterine rupture with two previous cesareans as 1.36%, and ultimately state that provided the woman is fully informed of the increased risk and has undergone an individual risk assessment with her provider, then planned VBAC may be supported in women with two or more previous lower segment cesarean deliveries (NICE, 2015).
Given the significant morbidities with multiple cesareans however, including surgical morbidity and abnormal placentation in future pregnancies, it is important to consider the possibility that for women with more than two prior cesareans VBAC may be associated with less morbidity, particularly in women with a high likelihood of success. Not everything can be planned. We have little ability to quantify maternal risks of uterine rupture and other maternal morbidities when a women with three or more prior cesareans desires spontaneous labor.
Please be aware that a history of multiple cesarean sections increases risk and therefore, additional fees may apply to secure additional staff for birth attendance.
Please give appropriate consideration to the spacing between pregnancies, when planning a vaginal birth after cesarean section. The risk of uterine rupture appears to be inversely related to the length of time between deliveries (the longer the interval between deliveries, the lower the risk of rupture). Women who attempt VBAC who have interdelivery intervals of less than 24 months have a 2-3 fold increased risk of uterine rupture when compared with women who attempt VBAC more than 24 months after their last delivery (ACOG, 2004; Esposito et al, 2000).