A Response to the Statement- "My Doctor Won't Let Me Have A VBAC!"
-by "mailto:ghumphries@cablespeed.com"
A few times now, I've heard about or interacted with women who had a successful VBAC a few years ago but now are being told that "it isn't as safe as we thought" or even that they can't have another one, but rather have to schedule another cesarean. Usually, they are told something about how the rupture risk is actually higher than we thought, the hospital can't do the emergency cesarean as quickly as we think it needs to be done now, etc. These are a few things that I thought about in response to the most recent query about this on ICAN:
First, while there isn't much formal study on it, what little research there is shows that if you have 1 VBAC with no rupture, your chances of having a rupture with a subsequent VBAC are extremely low (and often associated with things like induction, etc). So, basically, you've already "proven" your scar/uterus (I hate that sort of language but that's the way an OB would view it) and have an extremely low (dare I say negligable??) chance of rupture this time around. So, from that standpoint, a VBAC this time is even safer than it was the first time, whereas the risks of another c/s are exactly the same as they've always been.
Second, your OB is right that the rate of uterine rupture is now reported higher than it used to be, that's reflected in the literature. The cause is what's up for debate- many people have noticed that the rupture rate has climbed right along with the induction rate, and there's a growing body of research that shows pitocin induction, prostaglandin use and especially cytotec all increase rupture rates SIGNIFICANTLY (go "../induction.html"). Frankly, I'm not sure why this is still debated, other than that admitting induction is a real danger to women and their babies would present a pretty dilemma to the obstetrical community- instead, they like to say that the rupture rate has always been this high, we just didn't notice or the studies were bad or something. Well, the rupture rate was not this high when VBAC first started in the U.S. and VBACs were almost never induced back then. The rupture rate remains low in many European countries, which interestingly enough have much lower induction rates too. Hmmm.
Aside about induction: The national induction rate is supposedly about 18% (I find it hard to believe that its that low but anyway...) and I'm sure that some people think that 18% just couldn't be high enough to explain a rise in rupture rates from ~0.3% to 0.8+% I was thinking about it and I'll bet you a fine chocolate that the induction rate in VBAC attempts is significantly higher, because of the way VBAC and pregnancy in general are managed.
Who are the women that end up with that primary c/secs to begin with?
-Women who didn't go into spontaneous labor at 40 weeks and had failed inductions.
-Women who had malpositioned babies that caused them to have a lot of warm-up labor, which ends up being an induction even though its called augmentation because they weren't in active labor when the interventions started.
-Women who had larger babies (especially women who's OBs thought they had larger babies) and were either induced early or had panicky OBs that intervened in ways antithetical to birthing a larger baby.
-Women who had pregnancy "complications" (dubious, in many cases) like GD or border-line PIH that triggered interventions like early induction.
-Women of size.
-Women who have a slow and easy labor pattern that "requires" augmentation.
Ok, how many of these "conditions" are likely to repeat in the next pregnancy or at least be suspected of repeating? These same women are going to hear things like "We don't want that baby getting too big/blood pressure getting too high/blood sugar out of control this time so we'll induce early to give you a better chance at a VBAC" or "you must not be able to go into labor on your own, this is the second time you've gone past 41 weeks" or "you just seem to have an inefficient uterus when it comes to going into active labor, we need to give you a little pitocin to help".
On top of that, they'll suffer suffer from a magnification of the already out-of-control fears many OBs bring to late pregnancy in a woman who has had one or more c/s already. Induction is the obstetrical panacea to all real and imaginary pregnancy complications. Unfortunately, its slowly but surely being replaced by the scheduled cesarean. Since I suspect VBACs are induced/augmented willy-nilly in the U.S., I'm not at all surprised that the rupture rate is increasing.
The number that gets thrown around with regard to the "decision to incision" time for an emergency c/s is actually 17 minutes. Its based on a very small study. Certainly not a strong enough study to warrent such a drastic change in national obstetrical practice but it does have the advantage of making it easier for the obstetrical community to get what they really want which is complete control over the process (that's why, in general, they can't give up induction unless its in favor of elective c/s). If its reasonable to require a 17 minute rule for VBACs then it ought to be reasonable to require it for all births -- because an abruption is just as catastrophic as a rupture (actually, they are much the same thing) and happens about as often. Same with cord prolapse.
The fact of the matter is, and we really don't like to think about it, if you have a catastrophic rupture (not all ruptures are catastrophic, by the way) then your baby might die no matter where you are and no matter how quickly you get to surgery. Being able to have surgery within 17 minutes might save your baby but it might not -- what it *will* do is make it harder for you to successfully sue your OB for malpractice because if he got that baby out within 17 minutes, he can say he did everything according to the latest research, according to ACOGs most recent guidelines and there's nothing more that could be done. Act of God.
The other thing the 17 minute rule does is significantly reduce the pool of women "eligable" for a VBAC and that is viewed as a good thing by the obstetrical community -- no one gets sued for the c/s they did, just the c/s they didn't do. The only thing that has changed about VBAC is how its managed and the politics surrounding it. A non-medicated VBAC now is just as safe as it was 20 years ago -- the increased risk is iatrogenic for the mom and babe and legal for the OB. There have been some spectacular lawsuits over uterine ruptures and deaths of babies and some of the very vocal early proponants of VBAC have done 180 degree turns on the issue and now recommend up to a 50% c/s rate in this country!
Sadly, I suspect the cesarean rate in N. America *will* approach that and then when mothers and babies start dying because of c/s complications, the pendulum will swing back. But really, when it comes down to it, if VBAC was safer than a repeat c/s the first time you did it, it continues to be safer now, as long as you don't increase your risks by allowing certain procedures/interventions to happen. By informing you of the all the "risk and recent findings", your OB is actually informing you of the increased risk HE is taking by attending a VBAC, especially if he plans on inducing you again.