Monday, April 7, 2014

MANA Study Part 4: Vaginal Birth After Cesarean



You are reading Part 4 of my MANA study series. Click to view:

MANA Study Part 1: Intrapartum Mortality Rates

MANA Study Part 2: Neonatal Mortality Rates

MANA Study Part 3: Total Mortality Rates

MANA Study Part 4: Vaginal Birth after Cesarean (currently reading)

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For today's post I am discussing VBAC, HBAC and the MANA study outcomes for HBACs. Let's first lay out the different acronyms:

VBAC -- Vaginal Birth After Cesarean
HBAC -- Home Birth After Cesarean
TOLAC -- Trial Of Labor After Cesarean
ERCD -- Elective Repeat Cesarean Delivery
RCS -- Repeat Cesarean Section

TOLAC refers to all women who have had a previous cesarean section (or more than one) who attempt a vaginal birth. The outcome for TOLAC may be vaginal birth (VBAC) or it may be repeat cesarean section. TOLAC therefore includes outcomes for both.

ERCD refers to all women who decided to forgo an attempt at vaginal birth. ERCD is a bit of a deceiving term. While a cesarean section in this group is labeled as “elective” it also includes women who medically needed cesarean sections for reasons aside from having a previous cesarean section (which would mean it is not actually an elective cesarean section). Because women with chronic illnesses, or other such medical contraindications for TOLAC, are lumped into the ERCD group, the risks of ERCD may be overestimated.


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I'm briefly going to discuss various aspects surrounding VBAC before discussing the startling increased risk for babies born at home to mothers attempting a HBAC.



Why VBAC?

Because cesarean section is a major abdominal surgery, with risks that increase with each cesarean section (6), an attempt to have a VBAC is an option many women consider. When TOLAC ends in vaginal birth, it is associated with the least amount of complications.(4) According to ACOG, "Most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about VBAC and offered TOLAC."(4)


Vaginal Delivery Rate for TOLAC

According to ACOG, 60-80% of women who attempt a VBAC will deliver their baby vaginally.(4) A study by Guise J-M, et al. has it narrowed down further, stating that 74% of women attempting VBAC will deliver vaginally.(2)


Risk of Uterine Rupture

The risk of uterine rupture is often the primary concern for women with a previous cesarean section. The rate of uterine rupture for a woman with one or more prior cesarean sections is 0.5% to 2%.(3, 4) For a woman with one low transverse scar who spontaneously goes into labor on her own has a risk closer to 0.5% of uterine rupture (0.5% = 5 per 1000 = 1 per 200).(2, 3, 4)

The uterine rupture risk of “1 in 200” is the statistic most commonly quoted but as you can see, it is not all-encompassing. Not every woman facing an attempted VBAC or HBAC will have a 1 in 200 chance of uterine rupture, rather the 1 in 200 chance of uterine rupture is the lower threshold. While induction may increase risk of rupture, it is not true that use of induction agents is the only thing that may increase risk of rupture. Location of scar noticeably impacts the risk of uterine rupture. (4) Other factors, such as number of previous cesarean sections, gestational age and size of fetus, may affect the likelihood to rupture though the data is insufficient. (3) As ACOG recommends, “Assessment of individual risks and the likelihood of VBAC is, therefore, important in determining who are appropriate candidates for TOLAC.” (4)


Determining Uterine Rupture and Taking Action

"As stated in a prior VBAC evidence report, and echoed in studies contained in this report, there is no single sign for the occurrence of uterine rupture; however, fetal heart tracing abnormalities, particularly fetal bradycardia (reported in 33 to 100 percent of all studies) is the most frequently reported sign of uterine rupture. Other signs reported in uterine rupture studies in descending order are maternal vaginal bleeding, maternal pain, and uterine contraction disturbances." - Guise J-M, et al. (2)

It makes sense then, considering fetal heart tracing abnormalities are the most frequently reported sign of uterine rupture, that it is recommended for women who are attempting VBAC to have continuous electronic fetal monitoring (cEFM) (4, 5) -- as opposed to intermittent electronic fetal monitoring (iEFM) or using a non-tracing monitoring device such as a handheld Doppler or fetoscope. It is rare (or perhaps completely unheard of) for cEFM or iEFM to be used at a home birth.

"Delivery of the fetus within 10-37 minutes of uterine rupture is necessary to prevent serious fetal morbidity and mortality." -Nahum GG, et al.(3) (my emphasis) The studies that assessed time from uterine rupture to delivery used fetal bradycardias as the sign of uterine rupture. Other studies have shown that even when cesarean sections take place under 18 minutes after prolonged decelerations have been identified, serious neonatal morbidity occurred, such as HIE.(2, 3) 

Decision-to-incision time is therefore critically important to consider for mothers attempting an HBAC (which is true for any woman attempting an out-of-hospital birth). Keep in mind, a hospital must do its own monitoring/assessment before performing a cesarean section. Getting dressed, out of the house and into a car (or waiting for an ambulance), travel time (traffic considerations where applicable), and hospital protocol will all affect how long it can take a mother to have a cesarean section.


Comparing Rates: VBAC versus ERCD

The mortality rates (for babies) are as follows: 

Hospital TOLAC mortality rate2 = 1.3/1000 

Hospital ERCD mortality rate2 = 0.5/1000 

As you can see, the risk to the baby is significantly greater for those attempting VBAC. However, a mother with a previous cesarean section has more to consider. Mortality risk is higher for the baby, but what about risks for the mother’s health? According to ACOG, "at an individual level VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies." (4) The maternal mortality risks are as follows:

Hospital TOLAC maternal mortality rate2 = 3.8/100,000 

Hospital ERCD maternal mortality rate2 = 13.4/100,000

Since maternal deaths are so rare, they are measured per 100,000, whereas infant deaths are measured per 1,000. The risk of death for a baby born to a mother attempting a VBAC is an increase of 0.08%; the risk of death for a mother who attempts a VBAC is a decrease of 0.0096%. In other words, there are approximately an additional 9-10 deaths per 100,000 for women who choose ERCD and there are approximately an additional 80 deaths per 100,000 for babies whose mothers choose VBAC in a hospital setting.

For maternal complications for term deliveries, there was no evidence for statistical difference in rates for hysterectomy rates, blood transfusion rates and infection rates for TOLAC vs ERCD. (2) However, these risks (and others), increase with each cesarean section.(6)

For complications and morbidity for term babies (premature babies are likelier to face neonatal complications, i.e. respiratory issues, which is why we are looking at term babies only) born to mothers with a previous cesarean section, the evidence is lacking due to multiple factors (i.e. differing or lack of definitions). Studies suggest that ERCD increases TTN (transient tachypnea of the newborn) and TOLAC increases HIE (hypoxic ischemic encephalopathy) but the quality and amount of data we currently have is not sufficient.(2) For babies needing bag and mask ventilation, the difference is statistically significant:

Hospital TOLAC infants requiring bag-and-mask ventilation2 = 54/1000 

Hospital ERCD infants requiring bag-and-mask ventilation2 = 25/1000 

Please note: There are other possible complications for both babies and mothers, however, due to various factors, it is hard to nail down precise risk levels, especially for term deliveries. In general, the risks of TOLAC primarily affect the baby; the risks of ERCD primarily affect the mother. 

Remember, “TOLAC” includes women who attempted VBAC that ended with a vaginal delivery and also those who needed repeat cesarean sections. TOLAC that ends with repeat cesarean delivery is more likely to cause complications than ERCD; TOLAC that ends in vaginal delivery is less likely to cause complications than ERCD. (4)


Repeat Cesarean Sections and Future Pregnancies

A primary concern for repeat cesarean sections is the potential impact on future pregnancies. With each cesarean section, the risks increase. According to Silver RM, et al., "The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries." (6) These risks should not be taken lightly as certain complications, such as placenta accreta, can have life-threatening consequences. Because of the increase risk to women who have had cesarean sections, the American College of Obstetrics and Gynecologists and the Society for Maternal-Fetal Medicine recently published a joint paper to emphasize the importance of working to safely reducing the primary cesarean rate.


Comparing Rates: Home versus Hospital 

Finally, let's discuss risk between home and hospital for women who have had a previous cesarean section. We are looking at total mortality rates for each: intrapartum (during labor and delivery) + early neonatal (live birth through the first 6 days) + late neonatal (days 7 through 27):

MANA study TOLAC mortality rate1 = 4.75/1000 

Hospital TOLAC mortality rate2 = 1.3/1000 

Hospital ERCD mortality rate2 = 0.5/1000 

As you can see, the risk of death for attempted HBACs for babies has a nearly four-fold increase compared to VBACs attempted in a hospital; HBACs are nine and a half times more likely to end in death of a baby compared to ERCD. (Worried about the sample size? Do birth centers have better outcomes? Read this.)

There were 1052 HBAC babies in the MANA study and 5 of those babies died. According to the hospital rates, 2 babies at most should have died in the MANA study. In other words, at least 3 babies in the home birth group died preventable deaths. 

Some of the studies used for the hospital mortality rates actually include antepartum stillbirths (when a baby dies before the onset of labor). If we look at intrapartum mortality rates only (death during labor and delivery), in the MANA study there were 3 deaths out of 1052 that occurred after the onset of labor but before delivery, compared to the hospital TOLAC mortality rate which is 0.1-0.4/1000. Which means, comparing home TOLAC to hospital TOLAC, a baby is 7 to 27 times more likely to die at home. 

13% of the women who were attempting HBACs in the MANA study had repeat cesarean sections (approximately 136 women). We, unfortunately, do not know if any - or how many - of these women had uterine ruptures because the authors don’t provide any information on whether uterine rupture was the cause. The omission of this critical piece of information is a serious flaw because many women considering HBAC are concerned specifically with uterine rupture.

Coincidentally, the MANA study infant mortality rate for HBAC mothers is consistent with the risk of uterine rupture (5 babies out of 1052 died in the MANA study; risk of uterine rupture is 5 per 1000). It is possible that all 5 deaths were due, directly or indirectly, to uterine rupture. If the mother/parents of those 5 babies declined an autopsy to confirm exact cause of death, it would be listed as "unknown." If an autopsy was performed on any of the 5 babies, it may have been listed as something else as the direct cause of death - for example, uterine rupture could have caused the placenta to detach from the uterine wall and therefore, cause of death could technically be listed as "placental abruption" even though the uterine rupture was the underlying cause of death.

The MANA study authors also neglected to specify neonatal morbidity for high risk pregnancies. We have no idea how many HBAC attempts in the MANA study ended with babies who had respiratory issues, NICU stays, hypoxic events, or other neonatal complications. This is another serious flaw. HBAC-related neonatal morbidity is important for women to consider when deciding between locations.


My Thoughts… 

Because of the increase risks associated with cesarean section (especially multiple cesarean sections), if I were faced with deciding between attempting VBAC or choosing RCS, I feel I would lean toward attempting a VBAC. I would absolutely do so in a hospital and would want cEFM. I would want to have a frank, honest conversation with my care provider regarding my personal risk factors - which of course may change throughout the course of pregnancy. I also would want to discuss our hospital policies, procedures and capabilities.

This is no surprise to regular readers to hear that I would not consider HBAC. It saddens me greatly to hear that some women feel forced into choosing between HBAC or ERCD because of VBAC bans at certain hospitals. I can only hope that in time, with the good fight that many are fighting, more hospitals will lift their bans on VBACs. Our care as pregnant women should be recommended on an individual level, with careful consideration.


Discussion

I thought it would be interesting and enlightening to discuss benefits and risks in a Q&A with two women, bringing two different perspectives. First, I'd like to introduce the women who participated in the discussion with me: Anna Gregory* and Barbara Herrera. Barb is a CPM/LM (Certified Professional Midwife and Licensed Midwife), Monitrice, Doula, and blogger at The Navelgazing Midwife. Barbara is an HBAC supporter and when she was a practicing midwife, she attended HBACs. Anna is an HBAC mother and former HBAC supporter. Her first baby was born via cesarean section due to breech presentation. For the birth of her second child, she hired an HBAC-experienced certified nurse midwife (CNM). Tragically, her birth ended in uterine rupture, hospital transfer, repeat cesarean and a stillborn baby.

As I said, two different perspectives.

Our conversation took place over the course of a few days. This is not the full conversation as I, of course, needed to trim it down. There are breaks in the conversation (where I wrote an asterisk), when conversations dwindled for a moment (I think you’ll understand why). Here we go…

Dani: “Let's start off with benefits of VBAC.... when a VBAC attempt ends with vaginal delivery, it is associated with the least amount of complications. What are other potential benefits from VBAC (physical health, mental health or otherwise)?

Anna: “I know one big draw for me was that having another (young) child at home, I really wanted a faster recovery so I could still pick her up and snuggle so that she didn't feel supplanted by the new arrival. I didn't want to be away from her for any length of time, either. I wanted to deliver naturally, I wanted to prove to myself I could do it. I had a horrible c-section experience with my first and I thought HBAC would be better for my baby and for me than an RCS. And also, with a VBAC/HBAC, I hoped I would have more control over the birthing process and be able to bond immediately with my baby instead of being separated during recovery like I had been with my daughter.”

Barb: “Emotionally, some women feel resolved about their previous cesareans. They feel a sense of closure about it. There are physical benefits, the healing time is less (unless there is extensive tearing, which I have seen twice in VBACs). One of the things I'm working on right now is how important is "the experience"... and whether that should have a place in deciding where and how to deliver. The decision to VBAC and HBAC is driven much of the time by emotions.”

Dani: For those who do pursue VBAC/HBAC, what do you think consists of good support (before, during and after birth)?

Anna: “Having a discussion about the options rather than just assuming one way is better - or not - is important. Honest discussion of the benefits and risks for both modes of delivery. Statistics are objective - I get it - but I always say that 0.5% sounds minuscule whereas 1 in 200 does not.  Subsuming yourself in VBAC “success” stories online does not help a mom make good decisions and can compound a sense of failure if it doesn’t work out.

I think OBs need to explain why they need to monitor VBAC labors so carefully in terms of explaining how hard it is to detect rupture. It’s hard to look at a list of “this is what MUST be done” if you’re trying for a VBAC, instead of offering an explanation.  I would also suggest asking the doctor about his or her experience with rupture and also whether there is a staffed OR open 24/7 in the hospital and sufficient blood supplies in event of a rupture.”

Barb: “I think finding a provider who is sympathetic to a VBAC mom is important. That's a given with home birth midwives and most CNMs. A provider that believes in VBAC is essential. How many women get the bait and switch in the last few weeks? A good support from family is crucial, too, especially the partner.”

Anna: “And I think all providers should walk clients through a VBAC risk form gently, without just giving it to them to read and sign. It's the whole idea of what "informed consent" really means. Being open to questions and making sure the mother has the right questions in mind.”

Barb: “The Informed Consent isn't as big of a deal to most women. They don't WANT to know the down and dirty as much as they want the "joyous" aspects. That's in my experience, anyway.”

Anna: “That was me, Barb. I signed that form without reading it and taking it seriously because I knew the form to be "just a tool of scaremongering." I wish I had read it. I wish I had absorbed that it said there was more risk associated with homebirth than hospital birth. I wish I didn't have the whole line of "birth is risky anywhere" running through my head.”

Barb: “Would you have believed your midwife had she said homebirth was more dangerous? Or would you have stuck to your VBAC desires as the ultimate goal?”

Anna: “I wish she had known - and told me - that I did have various risk factors - under 24 months between deliveries, single layer of sutures and a 9lb baby - and I wish she’d told me that a VBAC in a hospital setting would, therefore, probably be wiser.  I wish she had told me there might not be time to transport in event of a rupture. I would have taken her advice seriously. By her own admission my midwife finds it very hard to say “no” to a woman wanting an HBAC – although after my rupture she was no longer willing to attend HBAC deliveries. When my OB identified my first baby was breech I was upset by it, but I never questioned the need for a section. It made sense to me. I never understood that statistically, repeat cesarean section was safer for babies. And I knew I was only going to have 2 children.”

Barb: “I would think it's common knowledge about repeat cesarean section being safer, even than TOLAC. But I might be wrong. So, how do we get women to pay attention to the Informed Consent without them thinking it's scaremongering? That seems like an important question. How do we bridge the reality with the wishes?”

Anna: “I do not think, Barb, that the vast majority of women who choose TOLAC know that the mortality rate for babies is higher for VBACs than it is for repeat cesarean section.
I think Dani's point in this post about monitoring is important - for example. I didn't know it would be so hard to detect rupture. Increased risk of rupture factors, too, those should be discussed - macrosomia, singles sutures (possibly), time between c-sections, etc. -- based on one study my various risk factors actually gave me a 5.6% chance of rupture (9lb 2oz babe, 22 months between sections, single suture closure, over 40 weeks gestation). My midwife thought my baby was about the same as our first child (7.5lbs). If I'd had a late ultrasound we probably would have known he was bigger and that would likely have changed my choice. I also didn't know my placenta was right where my scar was. My midwife told me her only regret was that she didn't arrange for an OB consult after she discovered I'd had single sutures.

And I did not understand that 15 minutes to the hospital would likely mean they wouldn't be able to section me in time. I thought if something went wrong - we'd transfer fast, I'd have a section and all would be well.” 

Barb: “Yes, transport time needs to be discussed more.”

Dani: “Agreed. Transport time and a very clear plan for transfer should be laid out. What do you both think constitutes a midwife as being experienced and competent for being the primary midwife for HBAC moms?”

Anna: “I think that second question is easier for me, because I know what my criteria were. I looked for 1. a CNM, 2. a CNM with hospital experience, 3. someone who had a good record of transferring at the first sign of trouble and 4. someone who'd attended several HBACs before. In retrospect, I wish I had also asked her what the signs of rupture were and whether she had ever seen one.”

Barb: “I think if a midwife is aware that she needs to do more fetal heart tone (FHTs) listening and can verbalize what the signs of uterine rupture are, she can be a decent midwife to attend an HBAC. Thing is, many HBAC moms don't want to be treated any different than other moms. Listening to FHTs a lot might hamper their experience.”

Anna: “My midwife did listen after every contraction. The contraction before I ruptured was 133 - next contraction was a 60.”

Barb: “Wow... did she call 911 right then? Or did she change your position a couple times.”

Anna: “Yes - 911 immediately. Then I started vomiting violently and my contractions completely stopped.”

Barb (looking at Anna’s records from her birth): “Wow... a note that you only lived 10 min away from the hospital.”

Anna: “Yes.”

Dani: “From when the 911 call was made to delivery, how much time passed?”

Anna: “It took me 25 minutes to get there with me yelling at EMS the whole way. Our son died before we reached the hospital. When the doctor couldn’t find a heartbeat, there was little urgency to do a section - they still didn't know I had ruptured until my BP tanked. Initially - believe it or not - they talked about inducing to try for a vaginal birth. They took forever to start an IV. And later a spinal wouldn't take - the OB thinks it was probably due to the blood loss.”

Dani: “I cannot imagine what you were thinking during the transfer time.”

Anna: “I wasn't thinking, I was screaming. And there was nothing they could do to get him out.”

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Dani: “When TOLAC becomes a repeat cesarean section, or worse, uterine rupture, how is that for women to emotionally cope with? These are important things to consider as well, I’d think, so women don’t feel blindsided or alone if they are in the (approximately) 25% that end up with repeat cesarean.”

Barb: “Then women crash! They feel doubly bad about their bodies and their experiences.”

Anna:  “It's so heartbreaking to me to see moms on VBAC support boards come back and say they're traumatized because of a failed VBAC attempt to that they don't feel they can bond with their baby. And I also see, time and time again, women who do have a VBAC and expect SUCH a better experience that they're then deeply disappointed and depressed - that may be from the complications of a vaginal birth - tearing for example - or that they expected delivering a baby to be so much easier physically and mentally than a c-section when - frankly - giving birth and taking care of a newborn can be just plain hard one way or another.

At the moment, when someone googles "uterine rupture" or goes to a VBAC support forum she most likely will only see positive stories that are very real - or dry, medical technicalities that might sound a bit scary but are de-humanized. The rupture moms rarely share their stories. They're embarrassed, they feel like failures and when they do speak out they're often told they're fearmongering.”

Barb: “Do women with uterine rupture feel defective? (In general.)”

Anna: “Yes. The worst feeling in the world is that your own body let you down. Again, particularly if you're imbued with the idea to "trust birth" and trust your body. My inability to birth my baby killed him. He was perfect. And I felt him crawl up out of my uterus. There was nothing at all I could do to comfort him as I felt him struggling.”

Barb: “I am so, so sorry. I can't imagine your pain.”

Dani: “I’m so sorry, Anna. I’m so, so sorry.”

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Dani: “Barb, Anna’s midwife added a brief comment and I’d like to hear your thoughts on what she said: "It's a tough one because you want women to have a choice and so many practices are not attending VBACs any longer which leaves many women "forced" into having a repeat section. However, ACOG has recently updated their recommendations for labor and hopefully, as an organization, they will continue to support VBAC as a safer choice for women rather than a repeat cesarean section. I am a firm believer in a women's choice but as Anna knows - I'll never attend another HBAC again. Just isn't worth the risk to the baby or the woman should the uterus rupture. "

Barb: “I've often said, "Midwives are a product of our experiences" - I can imagine why she would never attend another HBAC again, but there is the issue of informed consent and a woman's choice to birth how and where she wants to. So we have to make it the safest for her wherever she chooses to birth. I've also said, "How informed is informed consent?" Meaning, does a woman really know what she's getting into when she signs the IC form? We like to think so, but we hear about the regrets afterwards, the women saying they didn't really understand what was being said (Anna said that herself). I don't know how to make sure women know what the risks are while allowing them autonomy to choose how and where to birth. Is it scaremongering to drill in the risks?”

Dani: “I think we all agree that attempting VBAC in a hospital setting is a reasonable, safe option and hopefully, a woman wanting a VBAC isn't faced with a hospital ban. What are your thoughts on hospital bans?”

Anna: “If a hospital isn't equipped to handle VBAC (ie. a 24/7 staffed OR) they should be allowed a VBAC ban. I hate that option might be taken off the table for women who want to VBAC but our onus should be on making sure that doesn't have to happen - particularly in rural areas and OBs should be able to collaborate to facilitate care in a VBAC “friendly” hospital.”

Barb: “I think VBAC bans are bad news for women because that pressures them to birth out of hospital, if not even unassisted. Of course, the ideal is to have all hospitals 24-hour ready for complications, but a uterine rupture isn't any different than a cord prolapse or postpartum hemorrhage when it comes to needing immediate care and they don't ban all women from birthing in smaller hospitals. Yes, there are two patients at play, but I think if they are able to handle most emergencies, they should be able to do VBACs as well. Expecting women to travel for a VBAC isn't fair. I think if you want to give Informed Consent about the abilities of the hospitals, that's fine, but out and out bans? I disagree.”

Dani: “I agree with Barb. I don't like the idea of bans and I, too, fear it pushes women away from hospitals into riskier situations. I don't like the idea of anything like that being banned.... not home birth, not hospital VBACs, not elective 38 week inductions, etc... I don't have to agree or support the choices of all women but I think they deserve the options. Those options, though, should come with very clear informed consent.
The relationship between a home birth midwife and client is very different than the typical care provider / patient relationship. It is much more intimate. Home birth mothers trust their midwives implicitly. This is why ethics for midwives should trump philosophy – and that isn’t always the case. Typically, a woman chooses home birth because she sees it as a reasonable, safe choice -- even for high risk situations or "variations of normal." She wants to avoid unnecessary interventions but is not opposed to necessary interventions. If a home birth midwife insists on a transfer or referral or intervention, the client is more than likely going to heed the advice of the midwife. Of course there are some that would refuse hospital at all costs.... but that’s not the norm… home birth mothers are typically women wanting an alternative, but still safe choice. Women who, in the end, would do anything for their baby to arrive healthy and safe.

Clearly, with HBAC, it’s absolutely not just as safe as hospital birth and women deserve to know this. Hospital data and home birth anecdotes were all we had until now (because of the MANA study). And now we know that HBAC has a very significant increase risk for babies.

Barb, if you could write a conclusion here, what would it be?”

Barb: “Informed Consent has to change. The truths about uterine rupture need to be highlighted and understood so women can make choices that are based on fact instead of rumor and hearsay. I agree that home birth midwives have a greater burden with telling women about the risks, especially since they are greater in home births anyway. Women do trust their home birth midwives implicitly and that trust needs to be balanced with the midwife not being afraid to tell the client the truth about risks. When a midwife is afraid of "pulling the dead baby card," bad things happen. We've seen that over and over. A midwife sometimes has to say things that are scary or that the client doesn't want to hear, but she needs to do it anyway. I would also concur about women telling their uterine rupture birth stories needing compassion not ostracization. They are telling a birth story! They deserve to be heard, not shuffled off into the dark corners of the Internet. I intend to offer a place for women to speak their truths without recrimination. I hope it's healing for them to be in a place of light.

Thank you, Danielle, for writing this. I hope it's also a healing piece for the uterine rupture women. Even though I've never seen a VBAC uterine rupture, I am listening to these stories and am much more aware of what can happen to women during TOLAC attempting VBAC/HBAC. I am still pro-HBAC, but am much more cautious about it than I was. It must be done with true Informed Consent, not the minimal consent so often offered now. I hope when that happens, women can make the decision that is best for them and their babies. I also hope that hospitals will become more VBAC-friendly so women don’t feel compelled to deliver at home or unassisted. Yes, it's important to remember the possibilities of uterine rupture, but allowing a woman to birth as naturally as possible in the hospital, even if she has to have continuous fetal monitoring, would go a long way to helping women feel comfortable in there. Women deserve to have their "experience" honored as much as their safety. When there is balance, we might actually find the place where women's needs are being met just as much as protecting the lives of both mother and baby. Both are equally important.”

Anna: “”Thank you, Barb.”

Dani: “Very well said, Barb. Anna, what about you? How would you conclude this? And also, what would you say to a mother considering HBAC?”

Anna: “I think this would be the place where I would urge some kindness: if a rupture mom is brave enough to share her story, please know that she is not doing it as a fearmongerer, she's doing it as a woman who sees the need to balance the stories of "healing VBACs" with those that are traumatic: both happen. We're so guilty of being defensive and jumping to conclusions instead of listening and expressing sympathy. I support VBAC in an appropriate hospital environment and I hope hospitals and OBs continue along the track I see, more and more, of supporting VBAC. But a woman who chooses to weigh the risks and opts for ERCD shouldn't have her choice belittled. A woman who ruptures and returns to a support board to tell her story shouldn't be told that just because she was on the wrong side of the statistics, that her story is sad but doesn't deserve to be told as much as VBAC success stories. She shouldn't be told "I'm sorry for your loss, but maybe the best place for you to share your story is a baby loss forum - we're a VBAC support group, not a VBAC loss group."

To mothers considering HBAC, I'd say I understand why you think it might be a lovely thing to do, but here's the harsh reality: HBAC is an enormous gamble. And the stakes are about as high as you can imagine. A hospital OR will be too far away if you're one of the unlucky ones, and you and your family will live with your choice to homebirth forever. You will ask yourself every day if that birth experience you craved, killed your baby, or left him brain damaged. There is no recovery from that. Talk to your provider about your desire for a VBAC. Give them a chance to work with you on your birth experience. Understand that there is something much worse than hospital VBAC or an ERCS, and that something worse could be death. Is it really worth it?”

*



If you'd like to read Anna's full story and read the stories of other moms bravely sharing their uterine rupture stories, please visit the blog: Navelgazing Midwife

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In order to provide the most accurate information possible to my readers, I asked for my piece to be reviewed. I want to extend a special thank you to Dr. Martha Reilly, MD and Professor Brooke Orosz, PhD for taking the time to do so. I appreciate your time and expertise very much!

Thank you, Barb Herrera, for your time, honesty and genuine desire to be a part of this. Thank you, also, for offering up your blog as a safe space for women who have experienced uterine rupture to share their stories... they deserve to be told by the mothers and deserve to be heard by all of us!

Thank you, Anna. Thank you for being so brave and for sharing your story. I know what you do – all the hard work – to honor your son and to help protect other mothers from enduring the heartbreak you and your family have endured. You are amazing and I am honored to call you my friend.




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References

1. Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D. and Vedam, S. (2014), "Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009." Journal of Midwifery & Women’s Health, 59: 17–27. doi: 10.1111/jmwh.12172 (Click Here)

2. Guise J-M, Eden K, Emeis C, Denman MA, Marshall N, Fu R, Janik R, Nygren P, Walker M, McDonagh M. "Vaginal Birth After Cesarean: New Insights." Evidence Report/Technology Assessment No.191. (Prepared by the Oregon Health & Science University Evidence-based Practice Center under Contract No. 290-2007-10057-I). AHRQ Publication No. 10-E003. Rockville, MD: Agency for Healthcare Research and Quality. March 2010. (Click Here)

3. Nahum GG, et al. "Uterine Rupture in Pregnancy." Medscape. July 2012. (Click Here)

4. The American College of Obstetricians and Gynecologists. "Vaginal birth after previous cesarean delivery." Practice Bulletin No. 115. Obstet Gynecol 2010;116:450–63. (Click Here)

5. Bailey RE. "Intrapartum Fetal Monitoring." Am Fam Physician. 2009 Dec 15;80(12):1388-1396. (Click Here)

6. Silver RM, et al. "Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries" Obstetrics & Gynecology. June 2006. Volume 107, Issue 6, pp 1226-1232. doi: 10.1097/01.AOG.0000219750.79480.84 (Click Here)



MANA Study Part 1: Intrapartum Mortality Rates

MANA Study Part 2: Neonatal Mortality Rates

MANA Study Part 3: Total Mortality Rates

MANA Study Part 4: Vaginal Birth After Cesarean


*The name Anna Gregory is a pseudonym in order to protect the identity of this mother for career-related reasons.


21 comments:

  1. This was a tremendous post. The factual information about VBACs was presented very well, and the ensuing conversation was enlightening. Anna, I am so very sorry for the loss of your son. Barb, I appreciate your perspective, but I remain very bothered by the culture surrounding birth. We know that childbirth remains a leading cause of death for both women and their babies in the developing world, yet there is this obsession with avoiding the very interventions that save lives in the developed world. Why is this? I am disturbed by the number of midwives that are uncomfortable with truly talking about the risks of HBAC with their patients. "If I don't attend this woman doing a HBAC, she will do it on her own with no help" seems like an empty excuse to me. I truly believe that very few women would choose to HBAC if no provider would agree to preside over it. I agree that women have the ultimate choice over how they give birth, but that does not mean that we should expect a provider to participate in an activity that is both risky and (likely) out of their scope of practice. Knowing that CEFM is one of the best ways to detect a uterine rupture early, it seems unconscionable that any ethical midwife would want to preside over HBAC given their reliance on handheld dopplers.

    I have seen the way that loss mothers are treated by their former "friends" in the natural childbirth world, and it is vile. It turns into the most horrid iteration of the "mean girls" phenomenon that you have ever seen. Any attempt to share the bad side of something like HBAC is cast as "fearmongering." Well, Anna has told us just how much there is to lose when no one is allowed to talk about the dangers of HBAC. It is unconscionable.

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  2. A 2004 study was published in the Green Journal that concluded that VBAC was too risky for birth centers. This conclusion was drawn from data collected in the first Birth Center Study. Authors included nurse-midwives Kitty Ernst, Judith Rooks and Susan Stapleton

    http://journals.lww.com/greenjournal/Fulltext/2004/1100/Results_of_the_National_Study_of_Vaginal_Birth.9.aspx

    I have to wonder why this study is disregarded among midwives promoting OOH birth?

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    Replies
    1. Because they want to continue to be able to take on HBAC clients. They oppose true informed consent because it may scare women away from OOH births.

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  3. This piece is amazing, I can't praise it enough. Thanks to everyone involved for speaking out.

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  4. In a perfect world, more hospitals would offer VBACs, but we have to deal with reality. And in the United States, there are a couple of issues that impact the availability of VBACs. The first is liability. I have asked this question in other conversations about c-sections and not gotten a response, so I will ask it here as well: Can anyone find a case in which a family successfully sued a doctor for an unnecessary c-section? I have seen plenty of lawsuits with astronomical payouts in which babies suffered injury or death because a c-section was not performed quickly enough, yet I know of no cases in which a jury provided compensation when a healthy infant was delivered. Yet no one in the NCB community is willing to address the consequences of liability for doctors, CNMs, and hospitals. Lay midwives aren't required to carry insurance and are usually indemnity proof because they lack assets, so they don't have to worry about financial consequences for their actions, but other medical professionals do. You can't talk about why some hospitals don't offer VBACs without addressing this issue.

    The other issue is that the United States is a large country with a huge rural population. Smaller hospitals have limited resources. They often do not have 24 hour obstetric anesthesia, an empty OR dedicated for OB emergencies, etc. These are all things that ACOG recommends be available for VBAC attempts. Instead of pressuring all hospitals to offer VBACs, why can't we focus on helping women who are good candidates for TOLAC to find a tertiary care center where they can deliver safely?

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  5. I had a uterine rupture in 2010. Back then, I was only dimly aware of UR. When it happened to me, I felt like I was the only one.

    I later learned the hard way how certain VBAC supporters try to silence and dismiss UR survivors. We don't fit the accepted narrative of glowing, happy mothers "healed" by their second birth. We weren't healed. We were traumatized. That's not supposed to happen.

    Thank you for letting Anna share her story, and thank you to Barb for allowing us to share our stories. Women cannot make an educated choice about the risks, and how to mitigate them, if they only hear one side.

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  6. My one beef with your analysis is that you're overestimating the maternal risk of Cesarean based on the very stat that you criticize.

    At the top of the post, you clarify:

    "ERCD refers to all women who decided to forgo an attempt at vaginal birth. ERCD is a bit of a deceiving term. While a cesarean section in this group is labeled as “elective” it also includes women who medically needed cesarean sections for reasons aside from having a previous cesarean section (which would mean it is not actually an elective cesarean section). Because women with chronic illnesses, or other such medical contraindications for TOLAC, are lumped into the ERCD group, the risks of ERCD tend to be overestimated."

    But then you continue to roll with the 13.4/100k maternal mortality risk for ERCD vs. the 3.8/100k risk of VBAC and take that as proof that Cesarean is significantly more dangerous for mothers. That's as disingenuous a conclusion as MANA comparing low-risk homebirth deliveries to all-risk hospital deliveries.

    To accurately assess the comparative risk to mom of VBAC v. ERCD, we need a bucket for women who were good candidates for TOLAC - likely to have a successful VBAC - and who chose ERCD anyway, and to compare the mortality rate in that group to the VBAC group. Does such a stat exist?

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  7. What's commendable about this post is that it does not present this issue in the black-and-white, "I'm right, you're wrong" fashion that really stifles any true conversation surrounding home birth and midwives.

    There is so much gray area, and emotion involved in making decisions about home birth. You've presented a very complex topic and revealed many aspects of the decision to 1) want a VBAC at home from a mother's perspective, and 2) want to provide this option to women from a midwife's perspective.

    Also, this post reveals the shifts in perspectives regarding HBAC when the outcomes are not what was intended. And the death of baby and injury to the mother's body are very real and serious consequences.

    Any way - thank you for your bravery in being willing to take on this subject via the high road - and not elevating the conversation to a human and compassionate level.

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  8. Edit: please strike "not" from the final sentence. Thank you.

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  9. Thank you, thank you, thank you for posting this. I am currently 19 weeks pregnant with my second and leaning towards attempting a VBAC. As far as I know I'm a fairly good candidate and one of the 3 delivering OBs at my practice has tentatively agreed. However I've been having a terrible time finding balanced VBAC information that would help me really understand the risks and benefits in layman's terms. This post helps me clarify questions for my provider at my next appointment as well as gives me things to discuss with my husband. It's all a lot to ponder.

    And Anna, I am so very, very sorry for your loss. Thank you so much for being willing to share your story.

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  10. Thank you so much for this piece. Your work on this is thorough and honest and will help alot of people.

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  11. This is an excellent post! The conversation at the end was particularly affecting and effective. Well done and I hope it gets shared on a lot of the VBAC support pages so those women can have a balanced and non-sensationalized view of the pros and cons of the choice to VBAC.

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  12. The best proof of just how truthful and effective this post is was helpfully provided by Jen Camel of VBACFacts, or Jen Camel of VBACLies, as it happens. She tried to shred it apart, got called out for her lies, lack of credentials and lack of integrity, she pulled her post down like the coward she is.

    Well done, Dani. Keep doing what you do with the class you do it and let the bullies dig holes for themselves. One day, Jen and fellow bullies might even dig holes bigger than their enormous heads, who knows.

    Your faithful Amazed here.

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  13. I think Barb's comment about care providers doing a "bait and switch" during the last few weeks is so unfair. Is that the new way of criticizing risking someone out of a vbac?

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    Replies
    1. I am quite stunned at how many women think they are being reasonable by demanding a VBAC, as long as they are low risk. Then, suddenly, when they aren't, they start singing 'la-la-la, I can't hear you" and refuse to accept that things changed and they are no longer proper candidates.

      I find it horrible of any type of provider, blogger, or whatever, to endorse the line of thinking that it must have been the doctor's evil plan all along. Any type, Barb included.

      Once again, Amazed here

      Delete
  14. Barb's comparison of UR after a c-section to cord prolapse, etc is a little disingenuous. A cord prolapse can happen during any delivery. You can't be "risked out", so the hospital will do their best to deal with it. But you can predict that certain patients will have a higher risk of UR because of their previous c-section and so you can determine ahead of time not to take that risk.

    ReplyDelete
    Replies
    1. Rupture has a much higher mortality rate for baby than cord prolapse or abruption, too.

      Delete
  15. Hi, husband here (2 kids both rcs) trying to learn about the safest way to birth, so excuse me if i step on any opinons along the way as it appears everyone has opinions. however...

    reading this article and comparing it to http://www.skepticalob.com/2014/04/surprise-induction-lowers-the-risk-of-c-section.html the safest option is to schedule a c section and go to the hospital for the pitocin and EFM, but with your research you conclude:

    "Because of the increase risks associated with cesarean section (especially multiple cesarean sections), if I were faced with deciding between attempting VBAC or choosing RCS, I feel I would lean toward attempting a VBAC"

    but the study shows this:

    Hospital TOLAC mortality rate2 = 1.3/1000
    Hospital ERCD mortality rate2 = 0.5/1000

    Homebirth is not an option as too many things can go wrong. we are done having children with this being our third. my wife has talked about wanting to do the vbac, but since this is our last child it seems like the only reason to try a vbac is if we were having more kids (and we're not) or for sentimental reasons (i see a lot of stories about women feeling "broken" because they did not have a natural childbirth and she has not had one)

    I'm not trying to being a jerk and i want to support my wife, but having 3x the risk just to say she has a natural childbirth seems like a risk nobody would take and just the thought of her risking our child for something like this really makes me feel angry. doctors have spent a lot of time and money learning and studying and I see all these posts about not trusting them because of bait and switch, I mean seriously, we pay them a lot of money to not take their medical advice? it would be like me not taking my tax lawyer's advice for my business.

    In any case, this will be our last child. It seems like pitocin and a c section is the safest route to go with. So if you were knowing that this was your last child, would that change your advice about doing the vbac?



    ReplyDelete
    Replies
    1. Hi there,

      So you said "the safest option is to schedule a c section and go to the hospital for the pitocin and EFM"

      If someone chooses a scheduled c-section, they would not have pitocin. They would not go into labor. They would go in for their c-section.

      As far as what to choose between repeat cesarean section versus attempt VBAC.... It all depends on your wife's personal health history and her current health. When TOLAC ends in VBAC, it is associated with the least amount of complications (which is why I said I would likely choose to attempt VBAC if faced with the decision.... depending on circumstances). But not everyone that attempts a VBAC, will end up having a VBAC. Some who attempt VBAC will end up having a cesarean section. It's why an honest discussion needs to be had with the primary care giver. Her chance of successfully having a VBAC will depend on her own personal risk factors...... no one online, no VBAC pamphlet, no article will be able to answer the question for you. The only person that will be able to answer the question of "should your wife attempt VBAC" is her care giver... b/c the care giver will be able to help her understand why she is or is not a good candidate for attempting VBAC. If the care giver is not helping her understand, then she/you should ask for an explanation.

      It's important for women to understand whether or not she is a good candidate. Only a qualified, professional OB or CNM will be able to determine this with her health history and current pregnancy info. When TOLAC ends in repeat cesarean, it's associated with more risks than just choosing cesarean upfront. But when TOLAC ends in VBAC, it's associated with less complications.

      I feel like I'm talking in circles! Hope this helps...

      Delete
  16. This article was a very emotional one. I have so much sympathy for Anna to have gone through what she went through. After reading the first part of the article, I have a question. I have had a c-section and then went on to have a successful VBAC with my second child. I have read before that there are different types of uterine ruptures. I have read that some uterine ruptures are classified as catastrophic or full-thickness tears leading to death or injury or sterilization, such as what Anna had. I have also read that some uterine ruptures are not catastrophic but classified as incomplete and are asymptomatic and require no emergency surgery and cause no harm because they are only the equivalent of a small tear. Have you come across this information as well Dani? Because if you have, I wonder if you had any incite as to how many uterine ruptures are catastrophic and how many are incomplete or if they are all lumped together in that 0.5%. I read an article once that talked about this and the person said that if he were getting on a plane and the flight attendant told everyone boarding that the plane had a 1 in 200 chance of crashing, he would not fly. And I agree. If I had thought that my chances of having a catastrophic rupture were so high, resulting in an emergency surgery where anesthesia probably hasn't begun to work or, worse, resulting in the death of my child, I would probably just have opted for the repeat c-section.

    ReplyDelete
  17. Thank you so much for sharing the honest views. I'm very sorry your loss Anna.

    ReplyDelete

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