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VBAC scare tactics (3): An early eviction date

July 9, 2009

This post is part of a continuing series on “VBAC scare tactics” and the questions that VBAC moms can ask their care provider when confronted with these scare tactics.  I encourage all mothers who read these posts take the information contained herein as a springboard from which they can 1) continue their research on VBAC, 2) maintain a communicative relationship with their care providers, and 3) find a care provider who best supports the mother’s interests and plans for the birth of her child.

(To read my disclaimers about “why I am not anti-OB” and “why I take the gravity of uterine rupture seriously,” please see my posts on VBAC scare tactics (1) and (2).)

Scare tactic #3: I’ll let you attempt a “trial of labor” just as long as you go into labor before your due date.  After that, we’re scheduling a repeat cesarean.

Questions to ask your care provider:

  • Does the risk of uterine rupture go up after this point in a woman’s pregnancy?
  • Why can’t we extend the deadline until 42 weeks, after which point my pregnancy is truly “postdates” by ACOG’s standards?
  • Instead of scheduling a cesarean, would you consider inducing labor?  (Even if your care provider refuses to induce VBAC labors with prostaglandins or pitocin–and s/he may have very good reasons for this policy–you can always ask about a non-chemical induction, such as a foley catheter induction or an amniotomy.  More on these options in a bit.)
  • What happens if I refuse to schedule a repeat cesarean and wait for labor to begin spontaneously?

A more nuanced analysis:

It is my opinion that these “due date deadlines” for VBAC moms often demonstrate the care provider’s underlying lack of support for VBAC–especially when the deadline falls before the mother’s due date.  (For what it’s worth, I’ve heard of some care providers who state that they will only “allow” their patients to attempt a VBAC if they go into labor before 39 weeks.  As I’ll explain in a bit, this policy all but guarantees a repeat cesarean for most moms.)

First, due dates themselves are only estimates.  The very fact that these dates are estimates is represented in both acronyms that obstetricians and midwives use to refer to a woman’s “due date”: ‘EDD’ (estimated due date) or ‘EDC’ (estimated date of confinement).  So it should come as no surprise to one’s care provider that the due date is not like an expiration date but is rather an educated guess about the length of gestation.

There are also inherent flaws in the current method that OBs and midwives use to calculate one’s due date.  I encourage readers to research the difference between Naegele’s Rule–the due date predictor most widely used–and the Mittendorf Rule–a more recent due date predictor that takes into consideration the differences that a mother’s race, age, number of previous births, and other factors can have on the length of gestation.  For instance, Mittendorf and his fellow researchers found that white women pregnant with singletons averaged a seven-day-longer gestation than what Naegele’s Rule predicts. (American Journal of Obstetrics and Gynecology, 1993, Vol. 168)

Accordingly, since due dates are “only” estimates–hopefully educated estimates, but estimates nonetheless–it is important to ask your care provider why this estimated date should confer so much concern upon your VBAC attempt.

What’s more, since a normal gestation can last up to 42 weeks (at least as defined by the American College of Obstetrics and Gynecology), it is even more important to keep in mind that many mothers will not go into labor spontaneously before their estimated due dates.  Some perfectly normal pregnancies–again, at least within the confines of ACOG–will extend well past the “39 week” or “40 week” deadlines set by the care providers to which I refer in the aforementioned scare tactic.

And if these mothers follow the VBAC “guidelines” established by their care providers, then they will end up with repeat cesareans for pregnancies that are not truly “postdates” (i.e. lasting beyond 42 weeks) and that may not even be as close to the estimated due date as they think, especially if the due date is (unknowingly) inaccurate.  And this should be of special concern given the current research on the health risks posed to babies born via elective cesarean before 39 weeks.

Furthermore, it is exceedingly important to ask one’s care provider about the research that s/he is using to make his or her decision about the “VBAC deadline.”  Three studies performed on this very topic all conclude that awaiting spontaneous labor past the estimated due date (i.e. past 40 weeks gestation) does not significantly increase the risk of uterine rupture.  Two of these studies do conclude that the VBAC success rate decreases after 40 weeks, but this is vastly different from the uterine rupture rate:  the VBAC success rate represents the rate of women attempting VBAC who give birth vaginally, and the uterine rupture rate simply represents the rate of uterine ruptures following a VBAC attempt.

Notably, one of the above-referenced studies–and various others, including the 2004 Landon study—conclude that induction with pitocin or prostaglandins does increase the uterine rupture risk in VBAC attempts.  Accordingly, this increased risk may be one of the reasons that your care provider would choose to schedule you for a repeat cesarean rather than a chemical induction.  (Worth noting is that pitocin induction increases the uterine rupture risk to approximately .7-1.2%, as opposed to .2-.7% for spontaneous labors.  This increased risk may be acceptable for some women who agree to a pitocin induction, especially a “low-dose” induction.)

(Worth noting is that ICAN has a tremendously helpful and well-researched resource on the advantages of awaiting spontaneous labor in a vaginal birth after cesarean.)

Nonetheless, instead of a pitocin induction–and instead of a repeat cesarean–you can always ask your care provider to attempt a foley catheter induction or an amniotomy to induce labor.  Neither of these forms of induction poses any additional risk specific to moms attempting VBAC. And while the amniotomy in particular has some specific disadvantages (particularly an increased risk of infection), and while neither form of induction guarantees that labor will begin, it may be worth attempting one of these forms of induction if 1) you choose to stay with your care provider, 2) s/he refuses to budge (or will only deviate slightly) from the “due date deadline,” and 3) you are committed to attempting a VBAC rather than agreeing to a repeat cesarean.

Moreover, it is entirely within your right to refuse a repeat cesarean and to await for labor to begin spontaneously.  And this is why it bears asking your care provider what would or could happen if you simply refused to undergo the recommended surgery–even if this would certainly become a potential uphill battle for you and your attempt to have a VBAC.

In this respect, I strongly encourage you to become familiar with ICAN’s White Pages,  particularly with the document entitled “Enforcing and Promoting Women’s Rights.”  This document explains not only the doctrine of informed consent but also the laws and ethical guidelines that should protect you and your right to attempt a VBAC.  (Yes, it can be construed as an actual right!)  It also  explains your rights and your options in regard to your care provider and in regard to the hospital at which you plan to give birth.

And from someone who has not only defended herself against the scare tactics of a VBAC-denying obstetrician but also changed care providers at nearly 37 weeks to a truly VBAC-supportive obstetrician, I know from experience that this knowledge–the knowledge of one’s rights and options–can be empowering.


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