April is Cesarean Awareness Month

April is Cesarean Awareness Month — a time to learn about and share important information about how to avoid a first-time cesarean, discover your options for VBAC, and find resources for support in healing from a cesarean. Where to start? ICAN - the International Cesarean Awareness Network — is an excellent place to find several resources related to cesarean, including educational white papers, ways to get involved with advocacy, and links to your nearest ICAN chapter where you can find local resources and information about hospitals and caregivers in your area, as well as connect with other women living near you who have experienced cesarean and VBAC.

What are your favorite resources for cesarean? Please share them in the comments!

Cesarean Awareness Month: A Woman’s Guide to VBAC

April is Cesarean Awareness Month. While it can be a life-saving procedure for mom and baby, a cesarean is often prescribed when vaginal birth is a safe and sound option. Be aware that you have options, that you have a right to ask questions, and a right to know your risks. Educating yourself about birth is your best and first defense against an unnecessary cesarean. 

Throughout the month, Giving Birth with Confidence has posted cesarean resources for moms. We encourage you to comment with your experience as well as any questions. For more information be sure to check out the International Cesarean Awareness Network Blog.

 

A Woman’s Guide to VBAC

In June 2010, a National Institutes of Health (NIH) panel published a Consensus Development Conference Statement on vaginal birth after cesarean (VBAC).

In addition to examining the current evidence related to VBAC and offering recommendations for future research on this topic, the NIH panel concluded that VBAC was a “reasonable option” for most women with a previous cesarean section. The statement has not changed as of the time of this post.

Even with all that is included in the NIH Statement on VBAC, it might be difficult for many of us to wade through the information in it and figure out what it means for us and our particular birth options and unique circumstances.

This is where A Woman’s Guide to VBAC comes into play.

group of maternity care experts and VBAC advocates came together to create A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations, a free online resource guide that addresses the most common and pressing questions women may have about their birth choices in what could be called the “post-NIH-Consensus-Recommendations Era.” We hope the Guide gives you the tools you need to empower yourself to advocate for you, your baby, and your birth choices!

 

Sections in A Woman’s Guide to VBAC:

 

This guide is dedicated to all of us who are maternity care consumers, whether we are currently pregnant, have been pregnant, or simply work and advocate on behalf of pregnant women.
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What is a National Institutes of Health Consensus Development Statement?

This statement is the product of an NIH Consensus Development Conference. These two-and-a-half day conferences — which are free and open to the public — are organized by the NIH to address issues in medicine that are both controversial and pertinent to health care providers and the general public.

During the NIH Consensus Development Conference on VBAC, an independent panel listened to presentations given by invited expert speakers.  The panel also heard input from members of the general public during Q&A sessions. Finally, drawing upon the conference proceedings and upon a systematic review of the evidence on VBAC, the panel drafted their statement on VBAC.

Like all Consensus Development Statements, the statement on VBAC is not legally binding. It does not create practice guidelines, nor does it establish any health policies. Nonetheless, it is still an exceedingly important document. In fact, because of the high-quality evidence that the NIH panel uses to create consensus development statements, the NIH claims that it is “reasonable to expect that the panel will be able to give clinical guidance” to care providers.

Cesarean Awareness Month: Making Your Cesarean Mother-Baby Friendly

April is Cesarean Awareness Month. What should you be aware of? Be aware that a cesarean, while it can be a life-saving procedure for mom and baby, is often prescribed when vaginal birth is a safe and sound option. Be aware that you have options, that you have a right to ask questions, and a right to know your risks. Educating yourself about birth is your best and first defense against an unnecessary cesarean. 

Throughout the month, Giving Birth with Confidence will be posting cesarean resources for moms. We encourage you to add comments with your experience as well as any questions — we will tag cesarean questions and answer them in a subsequent post. For more information and stories this month, check out the International Cesarean Awareness Network Blog.

Making Your Cesarean Mother-Baby Friendly

By Sharon Muza, CD(DONA), BDT(DONA), LCCE, FACCE

You may find yourself headed for a cesarean birth, even when that was not what you planned.  A cesarean might have been in the cards all along for a variety of reasons, or  this change in plans might occur before labor begins, or during labor, when you, your partner and health care providers feel that a cesarean is now the best option.

As a long time birth doula and Lamaze certified CBE, I always encourage my clients and students to plan for a potential cesarean, even though many mothers feel like that outcome is unlikely.  Current cesarean rates in theUnited States tell us that more than 1 in 3 women will give birth by cesarean this year.  Having a simple plan with some wishes that continue to honor the birth of your baby, can go a long way toward making the experience a positive one.

Here are my top tips to make your cesarean birth as mother-baby friendly as possible. Discuss these items in advance with your health care provider to see what is possible in your situation and in your place of birth.

1. If you know you are going to have a cesarean, without an opportunity to labor, discuss with your provider if there is any risk in letting the baby pick his/her birth date and you heading to the hospital when your water breaks or gentle contractions start.  There are many benefits to your body, your baby and future labors if you allow your baby to initiate labor.  There are certain situations that may preclude this from being an option available to you, like placenta previa, where the placenta covers the cervical opening.

2. When the decision is made to have a cesarean, and if time allows, take a moment to talk to your baby.  Let him or her know what will be happening, that you have confidence in your team and your baby and that you will soon be holding him or her in your arms.

3. Walk into the operating room if possible.  It is very empowering to move to the OR under your own steam, if you and the baby are stable.  If you have been laboring without an epidural or the cesarean is planned, anesthesia is usually done in the OR, so you should be able to walk there on your own.

4. Ask for two support people in the operating room with you.  Your partner can be one, of course, and then your doula, family or friend may also be included.  Having two people in the OR means that your partner can go over to greet your baby at the warmer, and you can still have support with you right by your head. If your baby needs immediate transfer to a special care nursery, your partner can go with the baby, without worrying about leaving you alone.

5. Bring in music of your choice that can be played during the birth.  A CD or even an mp3 or smartphone placed on the pillow near your head playing softly can help you remain relaxed and positive.

6. Ask that everyone in the room take a moment to introduce themselves before the surgery begins.  There are several more people than you might expect in the OR during a cesarean birth, and everyone may look the same, all gowned and masked.  It can feel a little more personal to hear the staff introduce themselves and state their job…”I am Mary and I am the baby nurse…” can help you to feel like it is not such an impersonal procedure.

7. If you were waiting to discover the sex of the baby at birth, you can still do that.  The staff and surgeons do not need to announce “boy or girl” but leave that to be discovered by you and your partner.

8. Ask if it is possible to delay cord clamping for even a very short amount of time, if baby is stable.  Even 30 seconds of continued pulsing can provide benefit to your baby.

9. Sometimes, women may feel a bit nauseous during the surgery.  It may be a result of the procedure, or nerves, or unfamiliar sights, sounds and smells.  Consider bringing a little cotton ball or gauze pad with some peppermint oil dabbed on it, in a Ziploc bag.  Peppermint oil can reduced the nauseous feeling and help you to not vomit.  There is medication that can be given to you during the operation, but it may also make you sleepy, so if you can avoid it, that is great.

10. Talk to your baby after s/he has been born.  Ask your partner to tell you what is going on, and what your baby looks like; “Oh, honey, he has the same long fingers as you do…” Talk or sing to your baby, so that your little one can hear your voice as it makes the transition to the outside world.  When your baby is brought over to you, you and your partner can sing happy birthday or a special song that you may have been singing to your baby during pregnancy.

11. Ask that all possible newborn procedures be delayed until after you have returned to your room with your baby and had a chance to breastfeed.  Unless it is critical to have the weight of the baby immediately, this measurement and other procedures, (Vitamin K, eye antibiotic medication, dressing, etc.) may be able to wait until you and your baby have had a good snuggle and a breastfeeding session back in your room.

12. Ask if it is possible to get skin to skin with your baby in the OR, while your incision is being closed.  Prepare for this in advance by having removed or unsnapped your gown, and having just a warm blanket on top of you, ready for the baby.  While the baby may not be able to breastfeed in the OR, while you are on the table, you can certainly have the closeness and skin-to-skin snuggles.  You will always need some support during this time, so make sure that partner knows to keep their hands on the baby for safety.  If you are unable or prefer not to have skin-to-skin in the OR, consider letting your partner have some skin-to-skin time with the baby while sitting next to you.  Wearing a shirt that opens in the front, or even a t-shirt that has been cut a little down the neck will make it easier to slip your naked little one inside their OR gown or scrubs.

13. Ask that your uterus not be exteriorized during the procedure.  Exteriorizing your uterus is when the surgeon moves the uterus out of your body and onto the sterile field for examination and repair.  Studies show that postpartum pain after the surgery is greater when this has occurred and offers no benefits over doing the repair “in situ” (in position).

14. Ask that your uterus be double-layer sutured.  While current research is not clear that this provides any advantage over single-layer suturing, should you wish to attempt a vaginal birth after a cesarean with a subsequent pregnancy, some physicians are more comfortable and supportive of this VBAC attempt if there has been double layer suturing during the repair.

15. When you return to your room and get a chance to spend those first minutes really holding your baby and initiating breastfeeding, try and keep visitors and guests away for just a little bit, so you and your baby can get a chance to get acquainted on the outside.  This time is precious and the fewer distractions the better, to help you and your baby connect and bond.

A cesarean birth, whether expected or unplanned, offers unique challenges and circumstances for you and your baby.  It is helpful to recognize that a cesarean birth is still a birth, and you can prepare in advance by including plans for a birth on your terms, even when it occurs in the operating room.

 

Sharon Muza, CD(DONA), BDT(DONA), LCCE, FACCE is a birth doula, doula trainer and Lamaze certified childbirth educator in Seattle, WA.  Sharon is also the co-leader of the Seattle chapter of the International Cesarean Awareness Network, (ICAN.)  Sharon can be reached through her website, www.newmoonbirth.com, if you would like more information or need some support in planning your birth.

Cesarean Awareness Month: A Woman’s Guide to VBAC

April is Cesarean Awareness Month. What should you be aware of? Be aware that a cesarean, while it can be a life-saving procedure for mom and baby, is often prescribed when vaginal birth is a safe and sound option. Be aware that you have options, that you have a right to ask questions, and a right to know your risks. Educating yourself about birth is your best and first defense against an unnecessary cesarean. 

Throughout the month, Giving Birth with Confidence will be posting cesarean resources for moms. We encourage you to add comments with your experience as well as any questions — we will tag cesarean questions and answer them in a subsequent post. For more information and stories this month, check out theInternational Cesarean Awareness Network Blog.

Nearly two years ago, Lamaze published A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations, a guide for women seeking to understand the information, risks, and statistics behind vaginal birth after cesarean. The guide has been an invaluable springboard for women to research their decision on VBAC. We invite you to read the following introduction, click through to each section of the guide, and post your own thoughts, comments, and questions on VBAC. 

A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations

In June 2010, a National Institutes of Health (NIH) panel published a Consensus Development Conference Statement on vaginal birth after cesarean (VBAC).

In addition to examining the current evidence related to VBAC and offering recommendations for future research on this topic, the NIH panel concluded that VBAC was a “reasonable option” for most women with a previous cesarean section.

In the context of a current birth climate that can be somewhat hostile toward VBAC, this was an exciting moment for many birth advocates, maternity care providers, and mothers!

But even with all that is included in the NIH Statement on VBAC, it might be difficult for many of us to wade through the information in it and figure out what it means for us and our particular birth options and unique circumstances.

This is where A Woman’s Guide to VBAC comes into play.

group of maternity care experts and VBAC advocates came together to create A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations, a free online resource guide that addresses the most common and pressing questions women may have about their birth choices in what could be called the “post-NIH-Consensus-Recommendations Era.” We hope the guide gives you the tools you need to empower yourself to advocate for you, your baby, and your birth choices!

Sections in A Woman’s Guide to VBAC:

 

The Inspiration for this Project

The concept for this guide was borne out of many things: the timeliness of the NIH panel’s statement on VBAC, the importance of the statement itself, and our personal interest in advocating for women seeking vaginal birth after cesarean.

But we would be remiss if we didn’t acknowledge another source of inspiration for this project: namely, the heartfelt and heartening consumer participation in the NIH Consensus Development Conference on Vaginal Birth After Cesarean.

As women who were lucky enough to attend the NIH Consensus Conference on VBAC in person (Kristen) or view the entire proceedings in real time by webcast (Amy), we can say with some certainty that consumers — that is, the mothers, doulas, midwives, nurses, doctors, and other birth advocates who traveled from near and far and volunteered their time to attend — played a big role in this conference!

We listened, we read, we talked with one another, we got the word out to women who couldn’t participate in the meeting, and we asked some of the most incisive questions of the entire conference proceedings.

Quite simply, we made a difference.

This guide is dedicated to those consumers—and to all of us who are maternity care consumers, whether we are currently pregnant, have been pregnant, or simply work and advocate on behalf of pregnant women.

What exactly is a National Institutes of Health Consensus Development Statement?

This statement is the product of an NIH Consensus Development Conference. These two-and-a-half day conferences—which are free and open to the public—are organized by the NIH to address issues in medicine that are both controversial and pertinent to health care providers and the general public.

During the NIH Consensus Development Conference on VBAC, an independent panel listened to presentations given by invited expert speakers.  The panel also heard input from members of the general public during Q&A sessions. Finally, drawing upon the conference proceedings and upon a systematic review of the evidence on VBAC, the panel drafted their statement on VBAC.

Like all Consensus Development Statements, the statement on VBAC is not legally binding. It does not create practice guidelines, nor does it establish any health policies. Nonetheless, it is still an exceedingly important document. In fact, because of the high-quality evidence that the NIH panel uses to create consensus development statements, the NIH claims that it is “reasonable to expect that the panel will be able to give clinical guidance” to care providers.


The “Big Baby” Issue – Answers by Henci Goer

Another enlightening answer by obstetrical expert Henci Goer from last week’s Q&A session on the Lamaze Facebook page. For more answers from Henci, visit her forum on the Lamaze website

Q

More and more we hear about “big baby” as a justification for induction or c-section. I was one of those mothers myself before becoming more educated in my options. However, my second baby was 11lbs. at birth. What do you feel are the things to consider when you may be genetically prone to growing a “big baby”? Do you feel the position of the baby is more important than the baby’s size when it comes to birthing a “big baby”?

A

Unfavorable position is clearly the bigger problem because it affects babies of all sizes, but while, logically, size has to be an issue as well, there are no neat cut-off points. Here is what the research tells us about big babies that can inform strategies for maximizing safe, healthy birth:

  • High BMI women tend to have bigger babies. Take home message: losing weight sensibly before pregnancy might be beneficial.
  • Eating a healthy diet and exercising regularly optimizes sugar metabolism. Take home message: this, too, could optimize fetal weight.
  • When obstetricians wrongly believe (based on sonographic weight estimates) that the baby will be big, women are much more likely to have a cesarean than when the baby actually is big, but the doctor didn’t suspect it and vice versa. Take home message: I’m not sure that refusing a weight estimate will help because, as this makes clear, it is a matter of what the obstetrician believes. I think it would be more useful for women to explore early on how her care provider feels about women’s ability to birth bigger babies and how he or she handles that situation. Specifically . . .
  • Inducing labor for “suspected macrosomia (baby predicted to weigh 8 lb 13 oz or more)” increases cesarean surgery rates without reducing incidence of shoulder dystocia (the head is born but the shoulders hang up behind the pubic bone) or delivery injury rates. Take home message: await spontaneous labor onset.
  • Planning cesarean surgery exposes women to the serious potential harms of major surgery. The best way of determining whether the baby is too big to come out is to go through labor and see. Take home message: don’t plan surgery.
  • Labor with a big baby is likely to take longer, at least partly because the cervix may have to open further to pass a bigger head. (The “10 cm diameter” definition of full dilation is actually not really 10 cm. For the last few cm of dilation, clinicians measure, not the diameter, but how much rim is left. This means that the true diameter might be a cm or two bigger.) Take home message: find a care provider willing to be patient with a longer labor and who has no preset time limits for making progress.
  • Epidurals, confining women to bed, pushing while reclining or semi-reclining can all impede progress. Take home message: choose a place of birth that allows freedom of movement and plan alternative means of coping with labor pain so as to bypass or delay an epidural. Also, hire a doula. Doulas can help with strategies to promote good progress and increase comfort as well as with emotional support should labor progress slowly.
  • The best “first response” to shoulder dystocia is assuming a hands-and-knees position: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=9610468. Take home message: either plan to give birth in this position or have a plan with the care provider to turn to this position should the shoulders hang up. (With today’s modern “light” epidurals, it should be possible to turn to all fours with assistance even with an epidural in place.)

 

A Woman’s Guide to VBAC: Weighing the Pros and Cons

Weighing the Pros and Cons of Planned Vaginal Birth after Cesarean and Repeat Cesarean Section

This article is part of A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations, a collection of resources that address the most common and pressing questions women may have about their birth choices. View all sections in the guide, including a link to the authors, on the index page.

 

By Allison Shorten

The decision to plan a vaginal birth after cesarean (VBAC) or a repeat cesarean section (RCS) is a very individual one. There are different risks and benefits for mothers and babies. It is important to weigh these risks and benefits while taking into account each woman’s unique values, needs, expectations,
past experiences, and desired level of involvement in this decision-making process.

The following summary table compares the various risks and benefits of planned VBAC and planned repeat cesarean section.  This is a list of complications that are often talked about when women are thinking about planned VBAC or planned RCS. In a group of 100,000 women who plan a VBAC, there will be some who experience problems. If those same 100,000 women all planned repeat cesarean surgery, there would also be some who experience problems. There is no certain way to predict what the birth will be like no matter which option is chosen. That is why it is important to think about all of the things that are important to you in making any healthcare decision.

For many of the complications listed, the number of women who experience them during VBAC or RCS is still relatively small in number. It is always important to discuss any questions or concerns about options for birth with a trusted pregnancy care provider who can provide more detailed information and meet your individual decision making needs.

 

 

Information in these tables has been collated from the Final Statement of the National Institutes of Health (NIH) Consensus Conference on VBAC held in Washington on March 12, 2010. The other main source of information is the evidence-based report that informed the NIH conference panel (Guise et al 2010). The following list of resources may also be helpful to you if you need further information.

Additional Reading

A Woman’s Guide to VBAC: Discussing Your Options

 

This article is part of A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations, a collection of resources that address the most common and pressing questions women may have about their birth choices. View all sections in the guide, including a link to the authors, on theindex page.

By Jill Arnold

 

Talking to your care provider about VBAC can be a sensitive issue. Members of the American Congress of Obstetricians and Gynecologists have confirmed that concern over liability is a main reason they do not offer trial of labor to their patients. Some evidence even shows that younger obstetric providers are less willing and interested in allowing their patients to labor.

In addition, care providers, even those who are supportive of VBAC, can feel torn between their unease about what they can and/or want to discuss with their patients and their ethical obligation to deal honestly and openly with patients at all times. Women report feeling strongly influenced by their care providers’ recommendations, even though recommendations are likely to be influenced by the care provider’s fear of being sued (“defensive medicine”), rather than what is in the best interest of the woman or her baby.

In the United States, many women’s choices for care provider and birth setting are limited by finances and/or insurance and Medicaid requirements. Regardless of insurance status, all patients have the right to make informed decisions about their care.

 

Ask Questions

From choosing a care provider to talking about specifics of labor, asking questions is the best way to learn about your care provider and develop a relationship with them (or find someone better). Typical prenatal visits with a doctor are shorter than 10 minutes, so make a list of any questions before your appointment and write down notes on what you will research later. Please do not worry about your questions seeming annoying or time-consuming: you have a right to ask these questions in order to help you make informed decisions about your and your baby’s care. If your care provider shows a pattern of not wanting to answer questions, you have the right to switch to one that listens to your concerns.

If you are seeking midwifery care, especially in an out-of-hospital setting, your prenatal visits are likely to be significantly longer and more focused around your specific concerns and questions. Prenatal visits in a birth center practice are typically at least 30 minutes long and with a home birth midwife are typically one hour long, providing ample time to ask questions about risks and benefits, back-up plans, under what conditions you might be “risked out” of their care, etc. Depending on the midwife’s arrangements for collaboration with and referral to obstetricians, you may or may not have an opportunity to ask questions ahead of time of the doctors who might assume your care in labor.

 

Shop Around

Perhaps you’ve found a care provider who says they attend VBAC, but you recognize a large disparity between what they say and what you read in the NIH VBAC Conference Panel Statement. You can ask them about the gap between evidence and their practice or philosophy to try to clear up any misunderstandings. If their reasons are not satisfactory, it might be a sign to move on. There is no obligation to that care provider to stay in their care. If you feel it would be in your best interest to search for another care provider at any point in your pregnancy, it is up to you to be proactive. If this feels overwhelming, enlist the support of a partner, family member or friend to help make calls, set up appointments and get details squared away with your insurance company.

 

The “Immediately Available” Standard for VBAC

 

This article is part of A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations, a collection of resources that address the most common and pressing questions women may have about their birth choices. View all sections in the guide, including a link to the authors, on theindex page.

 

By Hilary Gerber and Amy Romano

 

Vaginal births after prior cesareans (VBAC s) were not always as uncommon as they are now. The frequency of attempted VBACs in the United States in recent decades has been associated with reactions to statements published by two major medical organizations:  the American Congress of Obstetricians and Gynecologists (ACOG), and the National Institutes of Health (NIH). The most significant impact on VBAC access came with ACOG’s so-called “immediately available” standard.

 

What Is the “Immediately Available” Standard and What Was its Immediate Effect?

In 1999, three years after a widely publicized but also widely criticized study was published (MacMahon et al., 1996), ACOG changed their practice bulletin on VBAC to include the recommendation that “ VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.” (ACOG, 1999) This practice bulletin also recommended that a physician “capable of monitoring labor and performing an emergency cesarean delivery” be “immediately available throughout active labor,” and that anesthesia and personnel for an emergency cesarean be “available.” The “[i]nability to perform emergency cesarean delivery because of unavailable surgeon, anesthesia, sufficient staff or facility” was considered to be a contraindication for VBAC.

These recommendations were given a Level C rating, which means they were based on consensus and expert opinion, not research. The recommendation that “most women” who were good candidates for VBACs “should be counseled about VBAC and offered a trial of labor,” on the other hand, was a Level A recommendation, which means it is “based on good and consistent scientific evidence.”

Unfortunately, the lower rated recommendation for immediately available emergency surgery was interpreted by many institutions to mean 24 hour in-house obstetrics and anesthesia must be present to allow a trial of labor after cesarean, and has prevented the higher rated recommendation to offer VBAC to eligible patients from being actualized.(Guise J-M et al., 2010) This has led to serious barriers to planned VBAC for women who are good candidates and desire a chance at vaginal birth.

This “immediately available” standard was not explained in any more detail in ACOG’s practice bulletin on vaginal delivery after cesarean, but it was expanded on in a later ACOG committee opinion on anesthesia and obstetrics as “a local decision based on each institution’s available resources and geographic location.” (American College of Obstetricians and Gynecologists and American Society of Anesthesiologists, 2009) Even though this explanation clearly allows for a very flexible definition of “immediately available” that takes into account individual hospital characteristics, the reaction of many smaller, more geographically remote hospitals was to ban VBACs if they could not provide in-house anesthesia and continuous supervision by an ob/gyn. One study of hospitals in a large geographic region noted that more than 30% of institutions that previously offered VBAC before the change in the guidelines were no longer allowing them.(Roberts et al., 2007) In a 2006 survey of women who gave birth in U.S. hospitals, 57% of mothers who had a prior cesarean and wanted to try for a VBAC were refused the chance, and 68% reported it was due to the unwillingness of their provider or hospital, and only 20% said there was a medical reason given. (Declercq et al., 2006)

 

What Did the NIH Consensus Panel Recommend Regarding the Immediately Available Standard?

When the NIH Consensus Panel looked at the “immediately available” standard, the evidence was mixed when discussing the relationship between “decision to incision”, or time between signs that a cesarean section may be necessary (in the case of uterine rupture, that would usually be fetal heart rate decelerations) and performing the cesarean section. Two large studies that examine how that response time may influence poor fetal outcomes were included in this evidence report. All of the research was done in hospitals with in-house anesthesia and obstetrics, and there were still occasional fetal deaths, and no consistent evidence that a quicker response or in house anesthesia made could prevent the extremely rare fetal death. The NIH Consensus Panel concluded that the evidence on response time was “insufficient”, but they did suggest that fetal bradycardia, or slow heart rate, should indicate a “prompt delivery”. No studies compared in-house obstetrics and anesthesia to on call obstetrics and anesthesia.

In addition, Anne Lyerly, a prominent obstetrician and bioethicist who has written as a member of the Obstetrics and Gynecology Risk Group in ACOG’s journal Obstetrics and Gynecology, testified at the 2010 NIH VBAC Consensus Development Conference. She argued that the absolute risk for fetal death for both VBAC attempts and a first time (also known as primary) vaginal delivery are practically identical. (See Putting Uterine Rupture into Perspective in this Guide). She warns that distorting risk and limiting informed choice in this manner “can lead to care that is neither evidence-based nor patient-centered, often to the detriment of both women and infants.” (Lyerly et al., 2007)

 

ACOG’s Response and New Guidelines

In the wake of the NIH Consensus Conference, the Editor-in-Chief of Obstetrics & Gynecology, ACOG’s peer-reviewed journal, devoted his editorial to calling for reconsideration of the immediate availability standard. Consumer advocates also waged a campaign to convince ACOG to revisit the standard. And indeed, in July 2010, ACOG released an updated version of their practice bulletin on VBAC (American Congress of Obstetrics and Gynecologists, 2010).  Although the bulletin still recommends that VBACs occur in facilities capable of providing immediately available emergency care, the following caveats were added to this recommendation: 

When resources for immediate cesarean delivery are not available, the College recommends that health care providers and patients considering [trial of labor after cesarean] discuss the hospital’s resources and availability of obstetric, pediatric, anesthetic, and operating room staffs. Respect for patient autonomy supports that patients should be allowed to accept increased levels of risk, however, patients should be clearly informed of such potential increase in risk and management alternatives.

Although it is still too early to tell whether or not these new guidelines have made any significant changes in VBAC availability throughout the United States, the changes themselves are significant in their own right.  To clarify, women can now challenge hospitals and/or care providers who have instituted VBAC bans by referring to ACOG’s own claims about respect for patient autonomy and responsibility. For it is a woman’s responsibility to be apprised of the potential increase in risk, but it is also her right to take on such risks as she sees fit.

Despite these very important changes, women will still face hospitals and providers that refuse to “offer” VBAC because of inability to intervene “immediately” should an urgent complication develop in a VBAC labor. Other sections of this guide offer suggestions for putting the risks of VBAC into perspective and taking action at the community level to improve access to VBAC.

 

Additional Reading

 

References

1. American College of Obstetricians and Gynecologists and American Society of Anesthesiologists (2009). ACOG committee opinion No. 433: optimal goals for anesthesia care in obstetrics. Obstet.Gynecol., 113, 1197-1199.

2. American College of Obstetricians and Gynecologists (1999). Practice Bulletin #5. “Vaginal Birth after Previous Cesarean Section”

3. American Congress of Obstetricians and Gynecologists (2010).  Practice Bulletin #115.  “Vaginal Birth after Previous Cesarean Delivery.”

4. Declercq, E., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to Mothers II: Report of the Second National Survey of Women’s Childbearing Experiences New York: Childbirth Connection.

5. Guise J-M, Eden K, Emeis C, Denman MA, Marshall N, Fu R et al. (2010). Vaginal Birth After Cesarean: New Insights (Rep. No. 191). Rockville, MD: Agency for Healthcare Research and Quality.

6. Lyerly, A. D., Mitchell, L. M., Armstrong, E. M., Harris, L. H., Kukla, R., Kuppermann, M. et al. (2007). Risks, values, and decision making surrounding pregnancy. Obstet.Gynecol., 109, 979-984.

7. McMahon, M. J., Luther, E. R., Bowes, W. A., Jr., & Olshan, A. F. (1996). Comparison of a trial of labor with an elective second cesarean section. N.Engl.J.Med., 335, 689-695.

8. Roberts, R. G., Deutchman, M., King, V. J., Fryer, G. E., & Miyoshi, T. J. (2007). Changing policies on vaginal birth after cesarean: impact on access. Birth, 34, 316-322.

Are You an “Ideal” Candidate for VBAC? What Are Your Choices if Not?

This article is part of A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations, a collection of resources that address the most common and pressing questions women may have about their birth choices. View all sections in the guide, including a link to the authors, on theindex page.

By Desirre Andrews

For a woman with a previous cesarean, answering these questions is a critical step to deciding between a repeat cesarean (RCS) and a vaginal birth after cesarean (VBAC).

According to the NIH VBAC Consensus Statement, an estimated 74% of women that plan a VBAC will have a successful VBAC. The success rates vary between 54%-94% depending on a several factors, including induction or augmentation of labor, pregnancy length, vaginal birth history, reason for prior cesarean, cervical readiness, race and ethnicity, health of the mother, socioeconomic status, region, marital status and type of hospital.

The following factors are based upon current evidence and point to higher rates of successful VBAC*:

Before labor:

  • A previous vaginal delivery (before or after a cesarean delivery)
  • Nonrecurring reason for cesarean delivery (such as malposition, breech, multiples, fetal distress, placenta previa)
  • Previous delivery of a baby weighing less than 4000 grams (8 lb and 13 oz)

Start of and during labor:

  • Spontaneous labor (no induction or augmentation)
  • Pregnancy length of 40 weeks or less
  • Greater cervical dilation at admission
  • Greater cervical dilation at rupture of membranes
  • Cervical effacement that reaches 75-90% upon admission
  • A single, vertex position baby (head down)
  • The baby’s head being engaged or lower in the pelvis
  • A higher Bishop score (a scoring system to estimate the success of induction)

While the medical factors listed above define an “ideal” candidate, you do not need to fit into all the areas to be a good candidate, and most women do not fit into all the categories.

Non-medical factors that can greatly influence success regardless of medical factors:

  • Care provider perception and tolerance of risk
  • Care provider preference
  • Patient preference
  • Patient perception of safety
  • How informed consent is given
  • Location and number of births per year at hospital
  • Hospital policy regarding VBAC
  • Health insurance status
  • Professional association guidelines

These non-medical factors often have the greatest impact on whether or not you are considered a good candidate and in fact give birth vaginally. Before or during labor, non-medical factors are often used to persuade a woman she is not a good candidate, even if she does fit many of the medical criteria for VBAC.

In addition to considering who is likely to have a vaginal birth, looking at uterine rupture risk also plays a part in identifying candidacy for a VBAC. These factors may lower the risk of uterine rupture:

  • A prior vaginal delivery
  • Allowing for spontaneous labor
  • A low transverse uterine scar type
  • 18 months or greater between pregnancies
  • A woman in a healthy weight range
  • A hospital that has a medium to high number of births each year

Avoiding induction is a key component in preventing uterine rupture and achieving successful VBAC.

There is no way to be certain whether or not someone will have a successful VBAC. The NIH Statement could not define the ideal candidate for VBAC because all the evidence is based on large groups of women and should not be used to predict an individual’s chance of successful VBAC. Based on the evidence, the NIH Statement concluded that a planned VBAC is a reasonable option for many pregnant women with one prior low transverse uterine incision. Vaginal birth after multiple cesareans (VBAmC) and other special situations were not addressed in this consensus statement, but there is some evidence, albeit weaker quality evidence, that shows VBAC in these situations may be a safe choice for most women as well. A subsequent Practice Bulletin from the American Congress of Obstetricians and Gynecologists states that none of the following factors, in and of itself, indicates that a woman is a poor candidate for VBAC:

  • history of two or more prior low-transverse incision cesareans
  • twins in the current pregnancy
  • gestation beyond 40 weeks
  • suspected macrosomia (big baby)
  • prior low vertical incision
  • unknown prior scar, unless there is a high suspicion that the prior scar is a classical incision.

There may be other factors specific to your own situation that, combined with one of these factors, changes whether you are a good candidate for planned VBAC.

Providing complete and easily understood informed consent for both VBAC and RCS, lowering barriers to VBAC access, increasing care provider risk tolerance and perception of safety, using a shared decision making process and, whenever possible, honoring the woman’s preference will make a marked difference in whether or not any individual will have a VBAC.

To maximize your chances of a successful VBAC, it is vital that you are assessed individually and not compared to a large group of women. To the best of your ability, use a care provider willing to partner with you, and choose a birth setting that offers individualized care. Ultimately your desire for a VBAC and your care provider’s desire to support you fully weigh heavily on your chance of success.

*The available evidence stated is only for planned VBACs taking place in hospitals and does not include out of hospital VBACs.

A Woman’s Guide to VBAC: Putting Uterine Rupture into Perspective

 

This article is part of A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations, a collection of resources that address the most common and pressing questions women may have about their birth choices. View all sections in the guide, including a link to the authors, on the index page.

By Janelle Komorowski

In recent years, it has become harder to find physicians and hospitals willing to allow women to attempt a vaginal birth after cesarean (VBAC), also called a trial of labor after cesarean (TOLAC). The biggest risk attempting a VBAC is that the uterine scar may separate during labor. This is called a uterine rupture.

Although uterine rupture is not common, it can be very serious for both the mother and baby. Most hospitals in the United States now require that anesthesia, an operating room, and a surgeon be immediately available when a woman is attempting a VBAC.

Although this sounds like a good policy, it has caused some hospitals to stop allowing VBACs because they do not have adequate staff. The National Institutes of Health (NIH) VBAC Consensus Statement raises an important question: how often does uterine rupture happen, compared with other emergencies during labor?

Every labor carries a small risk of an unexpected emergency happening, so should a surgeon, anesthesia, and operating room have to be immediately available for all labors? Or should planned VBACs be treated like other labors, where the physician is nearby, but does not have to remain inside the hospital during the entire labor?

Since hospitals don’t require a surgeon and anesthesiologist to be present during every labor, the NIH is asking whether the risk of VBAC has been emphasized more than other childbirth emergencies. These emergencies include placental abruption, where the placenta separates from the uterus before the baby is born; cord prolapse, where the umbilical cord is coming out in front of the baby’s head; and shoulder dystocia, where the baby is stuck because its shoulders are too wide to fit through the pelvis.

To understand how often such emergencies happen during labor or birth, let’s look at the following table:

Table 1.
Uterine Rupture1 Placental Abruption2 Umbilical Cord Prolapse3 Shoulder Dystocia4
7-8 out of every 1000 VBAC attempts 11-13 out of every 1000 labors 14-62 out of every 1000 labors 6-14 out of every 1000 labors

The next table shows the risk of a baby dying as a result of one of these emergencies:

Table 2.
Uterine Rupture Placental Abruption Umbilical Cord Prolapse Shoulder Dystocia
6 out of every 100 uterine ruptures will result in a baby’s death 1.25 out of every 750 placental abruptions will result in a baby’s death 91 out of every 1000 babies with cord prolapsed will die 1 out of every 1000 babies with shoulder dystocia will die

The truth is, in a low-risk woman, the risk of the uterus rupturing is about the same as the risk of any serious birth emergency happening. To be considered low risk, you should have:

  • One horizontal scar on your uterus (the scar on your skin may be vertical or horizontal)
  • A labor that starts on its own
  • No use of pitocin during labor, or prostaglandin to soften the cervix
  • At least 18 months since the cesarean birth

What are the risks of a planned repeat c-section compared to a planned VBAC? We don’t have a lot of evidence to help us decide, but the risks seem to be different for the mother than the baby. About 13 out of every 100,000 women who have a cesarean birth will die from surgery complications. Only 4 out of every 100,000 women who attempt a VBAC will die as a result.

A repeat cesarean birth may be safer for baby. NIH figures show that 50 babies out of every 100,000 born by c-section will die. 130 out of every 100,000 babies born to mothers having a trial of labor will die. However, these numbers come from studies that included all women who had a trial of labor, even if they were high risk, had prostaglandins to soften the cervix, or pitocin during labor. In other words, these numbers do not distinguish lower-risk from higher-risk VBAC attempts.

We know that softening the cervix with prostaglandins or using pitocin during labor increases the risk of uterine rupture. If a woman does not receive prostaglandins or pitocin, the risk of her baby dying during a trial of labor is probably lower.

Worth noting is that most babies who are born after a uterine rupture do not have serious long-term problems if the baby is delivered immediately after the rupture.

The NIH is encouraging doctors and hospitals to find ways to make VBAC more available for women. One of the ways this can be done is to recognize that the absolute risks of VBAC are about the same as the risk of any other serious complication during labor and birth. Understanding these risks can help you plan a safe VBAC for your next birth.

 

References

1. National Institutes of Health. NIH Consensus Development Conference: Vaginal Birth After Cesarean: New Insights, draft statement. March 8–10, 2010. Retrieved 05/12/10 from: http://consensus.nih.gov/2010/images/vbac/vbac_statement.pdf

2. Ananth CV, Wilcox AJ. Placental abruption and perinatal mortality in the United States. American Journal of Epidemiology Vol. 153, No. 4 : 332-337.

3. Murphy DJ, Mackenzie IZ. The mortality and morbidity associated with umbilical cord prolapse. British Journal of Obstetrics and Gynaecology. 1995 Oct;102(10):826-30.

4. Mackenzkie IZ, Shah M, Lean K, DuttonS, Newdick H, Tucker DE. Management of shoulder dystocia: trends in incidence and maternal and neonatal morbidity. Obstetrics and Gynecology. 2007 Nov;110(5):1059-68.

5. Vaginal Birth After Cesarean: New Insights, Structured Abstract. March 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/tp/vbacuptp.htm

 

Additional Reading