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VBAC is Safe!

This page includes research, wisdom and information that shows how safe giving birth after cesarean section really is; it also shows that VBAC births become less safe when induction drugs are involved.

For cesarean and VBAC articles and birth stories, go here.
For more medical references, see the page Induction Dangers.

Click to go to the desired section on this page:

How long must one wait after a c-section before having a VBAC?

From BIRTH AFTER CESAREAN by Bruce Flamm:
"Rumor has it that its safer to wait several years after a cesearen section before attempting a vaginal birth. There's absolutely no evidence for this belief. Studies on wound healing have shown that tissue regains the majority of its strength within a few weeks of an operation. The tissue that gives a healing wound its strength is called collagen. According to a general surgery textbook, 'Collagen content of the wound tissues rises rapidly between the sixth and the seventieth days but increase very little after the seventieth day and none at all after the forty-second day.' Since the uterine scar is almost fully healed within weeks after a cesarean section there is no reason to postpone plans for another baby."

Summary of 4 Studies on VBAC safetyby Gretchen Humphries. An excellent paper that illuminates the findings, as well as the failings, of important research documents. Included: how there is no study about the outcomes of planned home VBACs.

Women respond to the Britsh Medical Journal about VBAC (Go to the bottom of the linked page, and click on "Rapid Responses" to view the responses.) The BMJ published a news story on 7/14/01 that suggested that "once a cesarean, always a cesarean" is on the rise again. This page includes wonderful responses form mothers and midwives about how cruel the implications of this story (referenced from the damaging New England Journal of Medicine anti-VBAC paper) truly are.

About Uterine Ruptures, and the Remarkable Human Uterus Wonderful info about how rare uterine rupture is (including in vertical- "Classical" incisions), and how to strengthen the uterus during pregnancy- an already remarkably strong and adaptive muscular organ.

How likely is it that your VBAC uterus will rupture?by Eileen and Pat Sullivan. Well- you're actually a lot more likely to win at roulette or have a doctor who is an imposter than you are to have your scar rupture in childbirth.

Medical journal citations about VBAC safety- and inducted birth dangers

Vaginal Birth After Cesarean is extremely safe- as demonstrated by Swiss scientists

The following study has been broken down into lay language by Gretchen Humphries, MS, DVM.

"This study is just chock full of good stuff.

  • Huge number of TOLs (trials of labor)- over 17,000- showed that in this group, being induced reduced the VBAC success rate and increased the rupture rate.
  • Epidural also showed an increase in ruptures, probably because they tended to be augmented with pitocin, I'd bet.   
  • Also showed that even with the 0.4% rupture rate, the fetal mortality from those ruptures was extremely low (and really, isn't that what is scary about a rupture? losing the baby?)- about 0.03% of all TOLs had a fetal mortality due to rupture.  3 out of 10,000 is a lot lower than just about any other reason a baby might die during labor. 
  • And, every other peripartum (during childbirth) complication happened more often in the non-labor (elective cesarean) c-section group, including hysterectomy. 

I know its only one study, and you do have to look at the entire body of the literature but this is the one I refer to when people discount the low rupture rates found in other studies because the 'numbers are too small'.  There is nothing small about the numbers in this study, I think it's as accurate as you can get when studying something as rare as uterine rupture."

Delivery after previous cesarean: a risk evaluation. Swiss Working Group of Obstetric and Gynecologic Institutions.
Author Rageth JC; Juzi C; Grossenbacher H; Spital Limmattal, Schlieren, Switzerland.
Source Obstet Gynecol, 93(3):332-7 1999 Mar
Abstract

OBJECTIVE: To examine the risks of vaginal delivery after previous cesarean and to find criteria to help decide whether a trial of labor or an elective repeat cesarean should be preferred.

METHODS: We evaluated 29,046 deliveries after previous cesarean registered in a pooled database of 457,825 deliveries used to assess quality control in gynecology and obstetrics departments in Switzerland.

RESULTS: Among the 17,613 trial-of-labor cases logged (attempt rate 60.64%), the success rate was 73.73% (65.56% after inducing labor and 75.06% after the spontaneous onset of labor). The following complications were significantly more frequent in the previous-cesarean group: maternal febrile episodes (relative risk [RR] 2.77; 95% confidence interval [CI] 2.52, 3.05), thromboembolic events (RR 2.81; CI 2.23, 3.55), bleeding due to placenta previa during pregnancy (RR 2.06; CI 1.70, 2.49), uterine rupture (92 cases; RR 42.18; CI 31.09, 57.24), and perinatal mortality (118 cases, including six associated with uterine rupture; RR 1.33; CI 1.10, 1.62). The postcesarean group also showed a 0.28% rate of peripartum hysterectomy (81 cases; RR 6.07; CI 4.71, 7.83). There was one maternal death in the group, compared with 14 maternal deaths in the group without previous cesarean (no statistical significance). The risk of uterine rupture for patients with previous cesareans was elevated in the trial-of-labor group compared with the group without trial of labor (RR 2.07; CI 1.29, 3.30), but all other maternal risks, including peripartum hysterectomy (RR 0.36; CI 0.23, 0.56), were lower. When comparing the women having a trial of labor, the 70 with uterine rupture more often had induced labor (24.29% compared with 13.92% in the nonrupture group; P = .013), had epidural anesthesia (24.29% compared with 8.44%; P < .001), had an abnormal fetal heart rate tracing (32.86% compared with 8.53%; P < .001), and had failure to progress (21.43% compared with 7.98%; P = .001).

CONCLUSION: A history of cesarean delivery significantly elevates the risks for mother and child in future deliveries. Nonetheless, a trial of labor after previous cesarean is safe. Induction of labor, epidural anesthesia, failure to progress, and abnormal fetal heart rate pattern are all associated with failure of a trial of labor and uterine rupture.

Uterine rupture is RARE, strongly linked with induction drugs, and not all that lethal after all.

Out of 114,933 deliveries, there were 37 ruptures; half of those were because of induction drugs. Out of those 37 ruptures, only one baby died.

A 10-year population-based study of uterine rupture.

Obstet Gynecol 2001 Apr;97(4 Suppl 1):S69
Baskett TF, Kieser KE.
Dalhousie University, Halifax, Nova Scotia, Canada

Objective: To review the incidence, associated factors, and morbidity associated with uterine rupture.Methods: A 10-year (1988-1997) population-based review of 114,933 deliveries in one province.

Results: There were 39 ruptures: 16 complete and 23 dehiscence. Thirty-seven cases had undergone a previous cesarean delivery (34 lower transverse, 2 classical, 1 low vertical). Of the 114,933 deliveries, 11,585 (10%) were to women with a previous cesarean delivery. The incidence of uterine rupture in those undergoing a trial for vaginal delivery (4,516) was complete rupture (3/1000) and dehiscence (5/1000). Induction or augmentation of labor with oxytocics was associated with 50% of complete ruptures and 25% of dehiscence. There were no maternal deaths, but 33% of patients with complete ruptures required blood transfusion. There was one neonatal death attributable to uterine rupture.

Conclusion: Induction and augmentation of labor are confirmed as risk factors for uterine rupture. Fetal heart rate abnormality was the most reliable diagnostic aid. Serious maternal and perinatal morbidity was relatively low.

PMID: 11275210 [PubMed - as supplied by publisher]

Women who've had at least one vaginal birth after cesarean are far less likely to have uterine ruptures in subsequent births

Successful first vaginal birth after cesarean section: a predictor of reduced risk for uterine rupture in subsequent deliveries.

Shimonovitz S, Botosneano A, Hochner-Celnikier D Department of Obstetrics and Gynecology, Hadassah University Hospital, Mt. Scopus, Jerusalem, Israel.

BACKGROUND: Uterine rupture is a catastrophic obstetric complication, most often associated with a preexisting cesarean section scar. Although a vaginal birth after a cesarean is considered safe in modern obstetrics, it is not known whether repeated VBACs increase the risk of rupture, or whether the first VBAC proves the strength and durability of the scar, predicting further successful and less risky vaginal deliveries.

OBJECTIVES: To evaluate the effect of repeated vaginal deliveries on the risk of uterine rupture in women who have previously delivered by cesarean section.

METHODS: In this retrospective study, 26 VBAC deliveries complicated by uterine rupture were matched for age, parity, and gravidity with 66 controls who achieved VBAC without rupture. The histories, demography, pregnancy, labor and delivery records, as well as neonatal outcome were compared.

RESULTS: We found that the risk of rupture decreases dramatically in subsequent VBACs. Of the 40 cases of uterine rupture recorded during the 18 year study period, 26 occurred during VBAC deliveries. Of these, 21 were complicated first VBACs. We also found that the use of prostaglandin-estradiol, instrumental deliveries, and oxytocin had been used significantly more often during deliveries complicated with rupture than in VBAC controls.

CONCLUSIONS: Once a woman has achieved VBAC the risk of rupture falls dramatically. The use of oxytocin, PGE2 and instrumental deliveries are additional risk factors for rupture, therefore caution should be exerted regarding their application in the presence of a uterine scar, particularly in the first vaginal birth after cesarean.

PMID: 10979328, UI: 20433706
Isr Med Assoc J 2000 Jul;2(7):526-8

Effect of previous vaginal delivery on the risk of uterine rupture during a subsequent trial of labor

Zelop CM, Shipp TD, Repke JT, Cohen A, Lieberman E

Department of Obstetrics and Gynecology, Lenox Hill Hospital.

[Medline record in process]

OBJECTIVE: We examined the effect of prior vaginal delivery on the risk of uterine rupture in pregnant women undergoing a trial of labor after prior cesarean delivery.Study Design: The medical records of all pregnant women with a history of cesarean delivery who attempted a trial of labor during a 12-year period at a single center were reviewed. For the current analysis, the study population was limited to term pregnancies. The effect of previous vaginal delivery on the risk of uterine rupture during a subsequent trial of labor was evaluated. Separate analyses were performed for women with a single previous cesarean delivery and for those with >1 prior cesarean delivery. For each of these subgroups, the rate of uterine rupture among women who had >/=1 prior vaginal delivery was compared with the rate among women with no prior vaginal delivery. Logistic regression analysis was used to examine the associations with control for confounding factors.

RESULTS: Of 3783 women with 1 prior scar, 1021 (27.0%) also had >/=1 prior vaginal delivery. During a subsequent trial of labor, the rate of uterine rupture was 1.1% among pregnant women without prior vaginal delivery and 0.2% among pregnant women with prior vaginal delivery (P =.01). Logistic regression analysis controlling for duration of labor, induction, birth weight, maternal age, year of birth, epidural analgesia, and oxytocin augmentation indicated that, among women with a single scar, those with a prior vaginal delivery had a risk of uterine rupture that was one fifth that of women without a previous vaginal delivery (odds ratio, 0.2; 95% confidence interval, 0.04-0.8). In the group of 143 pregnant women with 1 previous cesarean delivery, women with a prior vaginal delivery had a somewhat lower risk of uterine rupture (3.9% vs 2.5%; adjusted odds ratio, 0.6; 95% confidence interval, 0.01-6.7). This difference was not statistically significant.

CONCLUSION: Among women with 1 prior cesarean delivery undergoing a subsequent trial of labor, those with a prior vaginal delivery were at substantially lower risk of uterine rupture than women without a previous vaginal delivery.

Uterine rupture associated with the use of Cytotec (misoprostol) for VBACs

In a retrospective (case reports, computerized search of medical records, literature review) study of 89 women who had Cytotec, there were 5 women who had ruptures- a rate of 5.6%. Of 423 similar patients who didn't get misoprostol, there was only one case of rupture- a rate of 0.2%.
-AJOG, June 1999, Part 1, Volume 180, No. 6:1535-42

For more about Cytotec dangers, go to this page.

Prostin gel significantly increases uterine rupture rates

*Note that Cytotec is not used (to the best of activists' knowledge) in Canada for labor induction. It is STILL being used in hospitals in California -- including Pomona Valley Medical Center, San Antonio Community Hospital and Doctors of Montclair Hospital.

Uterine rupture during induced trial of labor among women with previous cesarean delivery

Debra J. Ravasia, MD Stephen L. Wood, MD Jeffrey K. Pollard, MD Calgary, Alberta, Canada

Objective: This study was undertaken to compare the rates of uterine rupture during induced trials of labor after previous cesarean delivery with the rates during a spontaneous trial of labor.

Study Design: All deliveries between 1992 and 1998 among women with previous cesarean delivery were evaluated. Rates of uterine rupture were determined for spontaneous labor and different methods of induction.

Results: Of 2119 trials of labor, 575 (27%) were induced. The overall rate of uterine rupture was 0.71% (15/2119). The uterine rupture rate with induced trial of labor (8/575; 1.4%) was significantly higher than with a spontaneous trial of labor (7/1544; 0.45%; P = .0004). Uterine rupture rates associated with different methods of induction were compared with the rate seen with spontaneous labor and were as follows: prostaglandin E2 gel, 2.9% (5/172; P = .004); intracervical Foley catheter, 0.76% (1/129; P = .47); and labor induction not requiring cervical ripening, 0.74% (2/274; P = .63). The uterine rupture rate associated with inductions other than with prostaglandin E2 was 0.74% (3/474; P = .38). The relative risk of uterine rupture with prostaglandin E2 use versus spontaneous trial of labor was 6.41 (95% confidence interval, 2.06-19.98).

Conclusion: Induction of labor was associated with an increased risk of uterine rupture among women with a previous cesarean delivery, and this association was highest when prostaglandin E2 gel was used. Am J Obstet Gynecol 2000;183:1176-9.

*A Prostin information sheet with uterine rupture warnings can be read here.

Induction drugs cause uterine rupture

-In both VBAC moms and those without scarred uteruses.

"A study was done in November 2000 re uterine rupture and VBAC (American Journal of Obstetrics and Gynecology. Volume 183(5) November 2000, pp1176-1179 view study here). It shows that uterine rupture is more than 6 times more likely when induction/augmentation occurs. The only ruptures I have heard of (personally) have occurred in women being induced, and they have all had epidurals in place. Every drug will affect the risks involved, and this is where women need the information the most.

VBAC has been shown (again and again) to be safer than an elective c/section for no medical reason- except a prior caesarean birth. Safer for both mother and child. Hysterectomy is actually more likely if you have an elective c/section than a VBAC. Not the other way around, as is commonly believed. It is the induction/augmentation that increase the risks and make VBAC dangerous- risking babies and mothers, not the VBAC itself, but how it is managed.

Uterine rupture occurs in unscarred uteruses when women are induced/augmented, and then it IS usually catastrophic, as an unscarred uterus really 'ruptures' whereas a scarred uterus may just open slightly along the scar line. A study, in the British Medical Journal, about uterine rupture rates, printed in the BMJ 1996; 312: 1204 – 1205 (May 11), 'In a study of 32 cases (from 1 July 1993 – 30 June 1994) only 3 were scarred uteri (from a previous c/section).'

Women attempting to birth VBAC have been rushed and drugged through the experience; and some of the results have been disastrous. For example, read this BMJ study."

Birthing Beautifully,
Jackie Mawson.
Convenor of Birthrites: Healing After Caesarean Inc.

Uterine Rupture Risk After Prior Cesarean Not Increased After 40 Weeks' Gestation

Spontaneous labor is safe; induced labor is not, regardless of duration of pregnancy.

WESTPORT, CT (Reuters Health) Mar 13 - Among women with on previous cesarean delivery, the risk of uterine rupture during a subsequent trial of labor is not substantially increased after 40 weeks' gestation, according to a report in the March issue of Obstetrics and Gynecology.

However, the risk is increased with induction of labor regardless of gestational age. Dr. Carolyn M. Zelop, of Lenox Hill Hospital, New York, and colleagues compared outcomes in women with prior cesareans delivering at or before 40 weeks with those delivering after 40 weeks. They reviewed labor outcomes over 12 years for 2775 women "with one prior scar and no other deliveries" who had a trial of labor at term. According to the report, uterine ruptures occurred in 0.8% of women delivering at or before 40 weeks' gestation and 1.3% of women delivering after 40 weeks. Among those with spontaneous labor, the rupture rate was 0.5% at or before 40 weeks and 1.0% after 40 weeks (OR 2.1). With induced labor, the rates were 2.1% and 2.6%, respectively (OR 1.1). The overall rate of cesarean delivery was higher for women after 40 weeks' gestation compared with women at or before 40 weeks, at 35.4% and 26.7%, respectively. The rate of cesareans associated with spontaneous labor at or before 40 weeks was 25%, compared with 35.5% after 40 weeks for (OR 1.5). For induced labor, the rates of cesarean delivery were 33.8% and 43%, respectively (OR 1.5). "Because spontaneous labor after 40 weeks is associated with a cesarean rate similar to that following induced labor before 40 weeks, awaiting spontaneous labor after 40 weeks does not decrease the likelihood of successful vaginal delivery," Dr. Zelop and colleagues conclude. Obstet Gynecol 2001;97:391-393

Elective cesareans DO NOT preserve the pelvic floor

Can elective cesarean save your pelvic floor?

NO, says a recent South Australian study reported in the December 2000 edition of the British Journal of Obstetrics and Gynaecology. The 1998 South Australian Health Omnibus Survey involved a random selection of 4400 households. 3010 men and women aged 15-97 years were interviewed in their own homes, to determine, among other things, the prevalence of pelvic floor disorders, and to determine the relationship to gender, age, number of children and their mode of birth.

The prevalence of urinary incontinence (uncontrolled leakage of urine) in men was 4.4% and in women 35.3%. Urinary incontinence in women increased after pregnancy according to the number of children and age. Pregnancy (more than 20 weeks) REGARDLESS OF MODE OF BIRTH, greatly increased major pelvic floor dysfunction- defined as any type of incontinence, symptoms of prolapse or previous pelvic floor surgery. Compared with a woman with no children, pelvic floor dysfunction was more than two and a half times as common in a woman who had birthed a baby by caesarean, over three times as common in a woman birthing naturally and over four times as common in a woman who birthed with at least one forceps. The difference between caesarean and forceps was significant, but not between caesarean and a natural birth.

The investigators commented "...elective caesarean section is apparently not an effective way to reduce the prevalence of most subsequent pelvic floor disorders, except when instrumental vaginal delivery can be avoided". MacLennan AH et al. The prevalence of pelvic floor disorders and their relationship to gender age, parity and mode of delivery. BJOG 2000;107:1460-70.

Contributed by Jackie Mawson
Convenor of Birthrites: Healing After Caesarean

Comment from a professional birth attendant: "I think a lot of female incontinence is caused by peeling the bladder off the uterus during cesarean surgery and then reattaching it. This interference with the normal attachments of the bladder lead to later urinary problems. The pelvic floor has nothing to do with post-cesarean incontinence." -Gloria Lemay




 

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