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VBAC scare tactics (5): VBACs aren't as safe as we thought they were

August 4, 2009

Many women who want to have a vaginal birth after cesarean (or VBAC, pronounced “vee-back”) in the U.S. have faced some sort of opposition from their care providers when they have expressed their desire to VBAC.  Oftentimes, this opposition comes in the form of ” VBAC scare tactics.”

The (outrageous) statements are often misleading, exaggerated efforts by OBs (and yes, even midwives) to discourage women from VBAC and to encourage them to “choose” a repeat cesarean.  (Of course, it’s not really a choice if your provider won’t even “let” you VBAC, is it?)

And if you find yourself up against a barrage of scare tactics–as I once did–it can be exceedingly difficult to stake your claim and argue against the doctor (again, or midwife) who may or may not have your and your baby’s health prioritized higher than medico-legal concerns and who may or may not be hurling phrases like “catastrophic uterine rupture” and “dead baby” your way.

If you do find yourself facing such scare tactics, and if you do want to have a VBAC, there are some questions that your care provider should be able to answer when s/he hurls those scary and/or outrageous comments and standards your way.  And if s/he refuses to or even cannot answer these questions, then you might want to consider finding an alternative care provider–one who is making medical decisions based on research, evidence, and even respect for your patient autonomy and not on fear, willful ignorance, or even convenience.

I encourage all mothers who read this post (and others in my “VBAC Scare Tactics Series”) to  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 #5: You know, VBACs aren’t as safe as we thought they were.  They are much more dangerous to you and your baby.  A repeat cesarean is the safer route.

 

Questions to ask your care provider:

  • What is the difference between how safe you thought they were and how safe they now actually are?
  • Was there a particular study that specifically concluded that VBACs are an unsafe option?  Or that the risk of uterine rupture for moms attempting VBAC is actually higher than was once thought?
  • What are the comparative risks of VBAC and repeat cesarean?

 

A more nuanced analysis:

 If I were to make an educated guess, I would bet that this particular “scare tactic” can be traced back to a study published in the July, 2001 edition of the New England Journal of Medicine.  This particular study–“Risk of Uterine Rupture during Labor among Women with a Prior Cesarean Delivery” (Mona Lydon-Rochelle et al.)–did demonstrate what many VBAC supporters already knew: namely, that a trial of labor following a cesarean (or a VBAC attempt) has a higher risk of uterine rupture than does a repeat cesarean.  But it also led to what many have come to call the current “VBAC-lash”: a climate in which very few obstetricians will encourage, let alone “allow,” their patients to attempt a VBAC.

To elaborate, this particular study found that the rate of uterine rupture among women with repeat cesarean deliveries without labor was .16%, whereas the rate of uterine rupture among women all women attempting VBAC was .6%.  This is a significant difference, but it is not necessarily the sort of difference that makes VBAC an unsafe option.  (Worth noting is that there is still a risk of uterine rupture even if a woman opts for an elective repeat cesarean!)  Nonetheless, many people–physicians and media included–took the discrepancy between these numbers as an indication that elective repeat cesarean was unequivocally a safer birth choice than was VBAC.

But as Jill MacCorkle points out in her excellent critique of this study and its interpretations in an article in Mothering, the study itself has certain limitations and flaws (including the fact that it lacks an analysis of the comparative risks of repeat cesarean).  More importantly, however, the conclusions that others have drawn from the study–namely, that VBAC is “unsafe” or is “not as safe as we thought it was”–are not necessaerily supported by the data.

For one, the conclusion that the study’s authors offer is that “for women with one prior cesarean delivery, the risk of uterine rupture is higher among those whose labor is induced than among those with repeated cesarean delivery without labor.  Labor induced with a prostaglandin confers the highest risk.”

Look carefully at what the conclusion states: the uterine rupture risk of women attempting VBAC is highest among those whose labor is induced, particularly among those who labor is induced with prostaglandins (such as Cervidil).  In this respect, the “lay-person’s conclusion” about this study should not be that VBACs themselves aren’t as safe as they used to be or as safe as once thought but that induced VBACs aren’t as safe as VBAC attempts where labor begins spontaneously.  And this is well-supported by the data in this NEJM study, in which the risk of uterine rupture:

  • among VBAC attempts where labor begins spontaneously was found to be .52%;
  • among VBAC attempts where labor was induced with pitocin was found to be .77%;
  • and among VBAC attempts where labor was induced with prostaglandins was found to be 2.45%.

Noteworthy too is that, as MacCorkle points out, the uterine rupture rates from this study did not differ significantly from previous studies on uterine rupture rates following a trial of labor (or VBAC attempt).  In fact, some of these numbers found a lower risk of uterine rupture than some other previous studies!  In this respect, the 2001 article certainly does not demonstrate that VBAC is “not as safe as we thought it was.”

Another article that the purporter of this particular “VBAC scare tactic” might be referring to is a 1996 NEJM article, “Comparison of a Trial of Labor with an Elective Second Cesarean Section” by M. J. MacMahon et al.  In this study, the authors conclude that “among pregnant women who have had a cesarean section, major maternal complications are almost twice as likely among those whose deliveries are managed with a trial of labor as among those who undergo an elective second cesarean section.”

But as Henci Goer points out in The Thinking Woman’s Guide to a Better Birth, this study too has certain limitations and flaws that may give a skewed perception of VBAC.  As she writes,

…preeminent VBAC researcher Dr. Bruce Flamm points out that the authors coded wound infections and hemorrhage requiring transfusion as “minor complications,” both of which occurred more often in the planned cesarean group (emphasis added).  If you make these major complications, the difference between the two groups disappears.  Dr. Flamm adds that even without doing this, major complication rates were quite low–a bit less than 1 percent in the planned cesarean group, a bit more than 1 percent in the labor group.

So from afar, it might be true that VBAC may not seem as safe as was once thought.  But up close–in painstaking, nuanced detail, and in light of the most transparent and thorough evidence–it turns out that they are a safe (though not risk-free) option, even when compared to the relatively safe (though certainly not risk-free) option of a repeat cesarean, and especially when allowed to begin and proceed spontaneously and without unnecessary medical intervention.

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