Vaginal Birth After Caesarean

  • VBAC in general
  • Monitoring women with a prior caesarean
  • VBAC and induction
  • VBAC after two caesareans?
  • Links to other sources of information

General

Vaginal Birth After Caesarean is usually abbreviated to ‘VBAC’, pronounced ‘Vee-back’


Last night while working nights I delivered a woman in the front of a Ford Corsa in the car park. Lovely normal delivery, physiological third stage. Absolutely beautiful. When it was all over I read her notes as there was no time before. She was a previous section. Had she come in earlier she would have had a drip put up, bloods taken and actively managed. Just goes to show, doesn’t it? It was when the placenta was still in situ an hour after delivery and she was rhesus neg, I had visions of the docs coming down and whipping her off to theatre and me getting a blasting for not using syntometrine. Fortunately she was as determined as I was that that wasn’t going to happen and she pushed it out beautifully.

This has happened a few times, not in the car park, but women with previous sections wanting a ‘normal’ delivery and being told what will happen to them when they go into labour. Some of them decide to stay at home rather than have a drip put up, almost compulsory epidural and CEFM (Continuous electronic foetal monitoring) and come in almost fully dilated and have nice normal deliveries. Others are so frightened by the doctors that they rush in at the merest hint of a contraction in case their uterus ruptures.

I was on such a high until a brick wall rose up to smack me in the face at 06.00 this morning. God I love this job.

Gail, midwife


I was on night duty – the woman deliberately left it to the last minute before coming in to the delivery suite; previous section for big babe. Nobody would “allow” her to even try for a normal birth. I just had enough time to listen in with my Pinards when the baby’s head was on the perineum. Beautiful birth – 4.6Kg!! Mum was ecstatic ………….. then came all the “what ifs”, “she was lucky”, “total disregard for her baby’s well-being”, etc., etc.. from some of my colleagues. Mum KNEW she could birth her baby. It was lovely – I look back on this with a huge grin on my face. Obstetrician’s comment, “You were very lucky, THIS TIME”. I was furious. Couldn’t he have said, “Well Done – you did it all by yourself. Proved us ALL wrong.”

Brenda, Midwife


Obstetrician’s comment, “You were very lucky, THIS TIME”.

Perhaps the response could be: Luck had nothing to do with it. She made an informed decision that she was not willing to run the risk of unnecessary intervention and repeat her previous experience – and she was proven to be right.

Beverley


Regarding rates of rupture the most up to date info I could find is in the Guide to Effective Care (Enkin et al, 1995) which has a chapter on VBAC. Very briefly they state – the rate of rupture for a lower segment incision is about 0.5% and most of these will be “silent” or “incomplete” which may only be discovered incidentally at the time of repeat C/S. More dangerous “explosive” ruptures are most likely in women who have had a classical mid-line incision, and the rate of rupture of classical scars is about 2.2%.

Andrea.


ECPC (Effective Care in Pregnancy and Childbirth, eds. Enkin, Keirse, Renfrew & Neilsen) differentiate between dehiscence and wound rupture. They say that dehiscences (in developed countries) are:

‘usually slight, often representing so-called ‘windows’ in the uterus and carry no sequelae. Indeed the prospective studies found evidence of dehiscence in 0.5 – 2.0% of women undergoing planned CS before labour had even started. The corresponding figure amongst women undergoing a trial of labour (successful or unsuccessful) was little different (0.5 – 3.3%) although because of lack of randomisation, the two figures are nt directly comparable. The important point is that serious wound dehiscence is a rare complication during labour after CS’

They go on to say that maternal morbidity was less in the labour groups than inthose undergoing elective CS. The most important point is contained in chapter 38, section 6. I quote:

‘Excluding symptomless wound breakdown, the rate of reported uterine rupture ranges from 0.9 – 0.22% for women with a singleton vertex presentation who had undergone a trial of labour after a previous transverse LSCS. To put these rates into perspective, the probability of requiring an emergency CS for other acute conditions (fetal distress, cord prolapse or antepartum haemorrhage) in any woman giving birth is approximately 2.7%, or 30 times as high as the risk of uterine rupture with a trial of labour’

‘The degree of opposition to vaginal birth after CS, in North America in particular, is difficult to explain, considering the evidence that trials of labour are both safe and effective. Two national consensus statements and two national professional bodies in Canada and the USA have recommended policies of trial of labour after previous CS.’


Caroline Spear at marco@gmys-spear.freeserv is a leading member of the Caesarian section support gropup in UK and has a mine of info on the subject including a copy of Murray Enkins chapter on VBAC, published in the third edition of ECPC, August 2000


If a woman with a past caesarean has not been induced or had her labour augmented with oxytocin, then her risk of symptomatic uterine rupture would be less than 1 in 200. Still not something to dismiss lightly, but there are plenty of other emergency situations that are more likely to arise in an otherwise normal labour.

True rupture occurs in between 0.3 and 0.7% of VBAC labours, depending on which study you look at [1, 2]. The working estimate that many people use is 0.5%. Dehiscences are thought to occur in around 1.1% of VBAC labours.

The chances of any mother needing an emergency caesarean for any acute conditions apart from uterine rupture, such as fetal distress, cord prolapse or antepartum haemorrhage, is approximately 2.7% according to ECPC [3].

Now consider the mother’s chances of needing an *immediate* emergency caesarean. She increases her risk from around 2.7% to around 3.2%, but she is still more than five times more likely to need a true emergency caesarean for other reasons, than for uterine rupture.

‘Relative risks of uterine rupture’ is an article on the Midwife Archives which aims to put these risks into perspective alongside other risks of childbirth and everyday life. I suspect that some of the statistics included are contentious, but it is certainly food for thought:

http://www.gentlebirth.org/archives/vbacrisk.html

I was at least able to get the woman up on all fours.

Well done! I bet she will appreciate the fact that you treated her as a woman giving birth, and not as a walking caesarean scar.

I wholeheartedly and absolutely support the right of mothers to make their own choices in childbirth, regardless of their obstetric history, but I do feel that mothers attempting VBAC need to be aware of the possible complications – and of course, mothers having a c/s need to be aware of the risks of that option too. They need accurate information to help them decide what the pros and cons are for their family, not shroud waving over one particular issue.

My own page on VBAC, with discussion of risks of rupture etc, is at: http://www.homebirth.org.uk/vbac.htm

Angela


I have a nice little story about VBAC in a medical unit.

This spontaneously labouring woman had been given two lots of Morphine over 8 hours or so ( given in early, early labour) and was 5cm when I took over her care. Contractions had been 2 strong in 10, then went to 1 in 10. CEFM was generally reassuring with very occasional brief early decelerations. She was re-examined by the registrar at the usual 4 hourly interval – she had remained the same ‘despite good contractions’. The reg couldn’t understand her lack of progress, even though I reiterated that the contractions had been affected by the Morphine, but was not prepared to give Syntocinon (obviously not).

So said to her she would discuss with her senior registrar – but suggested C/S (immediately this had the effect of making the woman less confident in her ability to birth this baby). This lady had said to me that it was her last baby and she wanted a normal birth. She was sore as Morphine was wearing off, didn’t want an Epidural – realised that it and the Morphine were making for a long labour, didn’t like Entonox.

I discussed her options at length, but she had given up and felt a C/S was for the best as she felt exhausted – I felt I’d let her down. Meanwhile the last lady to have had a C/S was having some problem and the anaesthetist was tied up so we couldn’t go to theatre.

An hour later, with contractions picking up, the reg burst into the room and announced theatre was now ready. I felt this woman was cracking on in labour.

The reg re-examined to make further decisions – she had progressed 2cm but it was OP – she advised an epidural and would send in the anaesthetist (again putting doubt in her mind in her abilities). She had the first baby, which had been OP, vaginally with no help. She decided she would try a change of position, went onto hands and knees and had a desire to push soon after. She birthed her baby in that position before the anaesthetist could get his hands on her (babe birthed in OA position).

She was understandably shocked – as only an hour and a half earlier she had been ready to go for C/S. Next day when I saw her on the ward she was glad she had done it herself.

For me there were other issues – like the Reg taking over and advising C/S and Epidural right over my head, as if I weren’t in the room to do my job. These are things that happen to you and relieve you of confidence in your ability to help women – how to be an advocate in such a situation – this again comes back to Tikki’s question. I think you must be strong willed to be able to challenge protocols – and some of us aren’t that confident in ourselves or our skills because of where we work. For me, this next year will be the decider – If I can’t get work in a midwifery led unit, or get the courage up to go independent, then I will leave the profession that I love and work somewhere else instead.

Cheryl


One woman I know had a c/s for a breech first baby. Part of the ‘sales pitch’ for the elective caesarean was that, if she had a c/s for this baby,there was no reason why she could not have ‘normal’ births for her subsequent children. Her second baby was born after a 6-hour labour, during which she was flat on her back and strapped to monitors throughout. The mother does not consider this to have been a ‘normal’ birth because of the CEFM and subsequent restrictions on her position.

She is currently expecting her third and told the consultant she was considering home birth. Consultant has tried to dissuade her and said she would have to have continuous monitoring throughout any labour because of her scar. The woman now feels she was misled when she agreed to the original caesarean, as it has effectively ruled out her chances of ever having a truly ‘normal’ birth; the spectre of uterine rupture will always be there, even if she does labour with intermittent monitoring, at home, or on the moon. As Margaret Jowitt said once before, a woman with a prior caesarean has *already* had medical intervention in all of her future labours.

Incidentally, the woman in question said to the consultant that, since she’d already had one VBAC with no intervention (apart from CEFM), surely her scar had been well and truly tested and proven to be sound. Would she not be considered lower-risk now? The consultant said that no, in fact he considered her to be *higher* risk after one VBAC as there was a chance that the labour could have weakened the scar.

Any thoughts? Was he just being awkward and trying to dissuade her from home birth, or could there be something to this?

Angela


Triplet VBAC!

This study looked at vaginal birth of triplets. One set of triplets was born vaginally to a mother with a past caesarean.

Preliminary experience with a prospective protocol for planned vaginal
delivery of triplet gestations.
AUTHORS: Alamia V Jr; Royek AB; Jaekle RK; Meyer BA
SOURCE: Am J Obstet Gynecol 1998 Nov;179(5):1133-5
CITATION IDS: PMID: 9822488 UI: 99039941


Monitoring women with a prior Caesarean

I’ve been reading up on VBACs and all the studies I can find suggest that the most common sign of uterine rupture is changes in the fetal heart rate pattern, such as ‘prolonged fetal heart rate decelerations’, ‘variable decelerations’ and ‘fetal bradycardia’. Apparently this is much more common than pain or bleeding.

Those in favour of continuous monitoring for women having a VBAC say that you can only reliably detect these changes with CEFM. Is this correct or can intermittent monitoring with sonicaid/pinard be as helpful? I imagine that part of the concern is that these changes could be sudden and if you were only monitoring every 15 mins you might be too late, but what do you all think?


The difference between continuous and intermittent fetal monitoring is that with CEFM you can see the relationship between changes in the fetal heartrate and contractions more clearly. Also, the baseline variability (normally 5-15bpm) is visible. Variability refers to the amount that the heartrate varies around the baseline. eg a baseline of 120 would actually have a range of say 115-125bpm. Also, for legal purposes, CEFM gives you a printout of the fetal heart trace that in our hospital is kept for 25 years.

Kirsten Blacker


I understand that the first indication that scar dehiscence is occurring may be an increase in the maternal pulse. This is because serous fluid leaks down into the peritoneal cavity which results in the increase. Alterations in the fetal heart rate do not necessarily follow immediately, so the maternal pulse is an extremely important marker.

Lorna Davies


How does everybody feel about intermittently monitoring a labouring woman who has had a previous c/s 16 months previously? This situation came up yesterday at work. I had been intermittently monitoring for about 2 hours and another midwife took over while I had a break and she thought I should be continuously monitoring. The midwife-in-charge agreed, said it was in the protocol and said there was ‘a realistic risk’ of a uterine rupture in this situation. What really annoyed me was a midwife who qualified 1 year ago already seeming VERY defensive and obstetrically-minded when she said ‘it’s just to cover yourself’ and ‘how would you feel if the baby died from a uterine rupture?’. Am I being TOO relaxed about monitoring?

I was at least able to get the woman up on all fours. Any insights and, hopefully, reassurance would be gratefully received. I had to go home before this woman delivered so I don’t yet know how she did but I will find out today. Fingers crossed!

Sarah


Interesting posts about monitoring and VBAC. Just 2 weeks ago I had a case of a woman who had had two previous sections for breeches and was hoping for a normal vaginal birth this time. The woman wished to have the baby in Portsmouth which has quite a reputation for being a high tech, ‘if it moves, monitor it’ unit.

I discussed the case with the Obstetrician, and explained that unless I had reason to believe, from intermittent monitoring, that there was reason to be concerned about the fetus, I would not be doing any CTG. I explained that I did not think that fetal distress was the first sign of scar problems I felt that changes in the woman’s demeanour and importantly changes in the woman’s pulse rate would be what I would be looking out for,I planned to intermittantly auscultate the FH with either my hand held doppler or my Pinards.

I shared with the consultant Murray Enkin’s chapter from the new ECPC (Effective Care in Pregnancy and Childbirth) which I had had emailed from Canada, and she accepted my views and more or less said that if women could have constant observation from a midwife who knew them, constant CTG would be less important.

In the event we went into Portsmouth in labour which was at 42 weeks and after a dose of castor oil. The Midwifery and Medical staff were lovely, supportive helpful and interested. They relieved me for breaks, for meals and did not in any way alter my care, taking the woman’s pulse frequently for me and continuing my observations.

As it turned out the labour did not progress well. The membranes ruptured spontaneously at about 6cms. We got to 8 and five hours later there was an oedematous cervix, less dilated than previously, and the contractions, which had been good, started to space out. Mother and fetus in excellent condition, so to theatre for a CS under spinal, no hurry, no hassle, baby straight to mum and dad and good outcome.

So no, I do not believe that routinely all cases of VBAC require continuous CTG and I therefore do not do this.

In sisterhood,
Mary Cronk


Of course there is a risk of scar dehiscence with a previous scar, but I think that hospitals and obstetricians go for overkill. The highest risks of scar dehiscence are with the use of prostaglandons and oxytocics to drive labour on artificially. I seem to recall that with a spontaneous natural onset of labour which is allowed to proceed without intervention the risk of scar dehiscence is low (I seem to recall less than 1%, correct me if I’m wrong).

The problem is that most studies looking at scar dehiscence do not seem to say how labour was managed for the participants ie did they undergo routine ARM (artificial rupture of membranes) or other interventions of questionable value?

It seems daft to continuously monitor every single woman with a previous LSCS. How can a woman be active in labour and adopt different positions with a monitor attached to her?

Jade


Speaking as a mother who successfully had a VBAC, your intermittent monitoring must have shown the mother your faith in her ability to labour successfully.

When you approach a VBAC, it feels a bit as if you are being set up as a failure from the outset. It’s refreshing to have someone look after you, who gives you back the confidence you are so sadly lacking when faced with the constant barrage of “risks” and “complications”. I had to employ independent midwives to achieve this. Please don’t change your practice; let it be available on the NHS!

Do you think the new qual. midwife just didn’t have the experience in VBACs to allow her to feel confident in ignoring protocols?

Tikki


How does everybody feel about intermittently monitoring a labouring woman who has had a previous c/s 16 months previously?

It depends how intermittant the monitoring is! Also what the reason for section was. However, at the end of the day working for someone else we do have a responsibility to both the woman and the trust we work for (yes, I know most of you won’t like that) and if it is an obstetric unit the limitations placed on us are much much tighter than those working independently.

But, if your main concern is ‘getting the woman on all fours’ then a ctg machine doesn’t prevent this – no it isn’t as easy- wires are a pain, and yes the woman can mobilise- again a bit of a pain, but no impossible.

Tizzy


Whether to accept continuous monitoring or not in a VBAC labour is a difficult decision. There are other signs of uterine rupture apart from foetal heart tracings. However, one of the problems with uterine rupture is that women seem to experience very different symptoms before the rupture is discovered. Sometimes there is pain or bleeding, but certainly not always. One woman who emailed me said that she felt just ‘jolts’, but no pain. Some midwives suggest that there will be changes in the mother’s pulse rate, but I’ve not been able to find any research on this and, since (fortunately) most midwives will encounter very few cases of uterine rupture in their careers, it’s hard to speculate about general trends based on a relatively small number of cases.

What the research does tell us, however, is that the first sign of uterine rupture is often variations in the baby’s heart rate. This can happen quickly, and if the baby’s heart is being monitored every 15 minutes or so with a Sonicaid, the early warning signs might be missed. If the baby’s heart rate changes soon after one monitoring, it may not be noticed until the next check, 10-15 minutes later. The studies mention the early signs being ‘prolonged fetal heart rate decelerations’, ‘variable decelerations’ and ‘fetal bradycardia’ [1,2]. Here’s a quote from [3]:

“Bleeding and pain were unlikely findings with a uterine scar separation (3.4% and 7.6%, respectively). The most common manifestation of a scar separation was a prolonged fetal heart rate deceleration leading to operative intervention (70.3%).”

On the other hand, all the cases I’ve read of uterine ruptures have occurred when CEFM was in place, but the early signs were not acted upon. It is quite possible that an attentive midwife monitoring intermittently, giving you one-to-one care and who knew what to look out for, would react more quickly to any signs of problems than a midwife who was reassured by the presence of the magic monitor and was perhaps not having to give you so much personal attention. If the midwife is monitoring you intermittently (esp. with a Pinard stethoscope rather than a Sonicaid), then she will have her hands on your tummy and will probably be more tuned in to your general condition, than if you are being monitored continuously.

However, the bottom line is that continuous monitoring can give useful information in VBAC cases – it’s just whether the price is worth paying. What a pity few hospitals get mobile monitors sorted out.

You might also find that the hospital staff are concerned about progress in labour. This is another tricky one. Normally I would be the first to say that labouring against the clock is a recipe for disaster. However, in VBAC labours there is more justification for it. The majority of ruptures seem to occur when labour is not progressing well, despite there being strong contractions – the uterus is working hard but things aren’t moving, and as you can imagine that puts the scar under great stress. There are a couple of studies which found that rupture was significantly more likely 2-3 hours after the ‘partographic alert line’ was crossed (whatever that means). Looking on the bright side, if you factor out the labours which did not progress well, the risk of rupture in labours which do proceed faster must be significantly lower than the figures given for labours overall.

Oh dear – I hope I don’t sound like an apologist for interventionist obstetrics here. I’m just trying to explain why it might be worrying if a VBAC labour doesn’t progress smoothly. It’s not just that caregivers have no confidence in the mother – there is an evidence-based rationale for this. On the other hand, I’ve often read birth stories from VBAC mums who emphasise that, since their confidence in their ability to give birth is often low, feeling happy with the environment, free to move, and feeling that you can progress at your own rate is vitally important.

Personally I feel that you cannot manage every labour on a worst-case basis, because if you do that then overall, mothers and babies are going to come off badly. VBAC mothers are not just walking scarred uteruses, and it’s important to remember that even with two past caesareans, you are more likely to have a straightforward vaginal birth than not. In fact, looking at most of the studies I’ve read, a mum with a prior caesarean has about the same or better chances of having a vaginal birth than a first-time mum with no shadows cast by her obstetric history – in many cases first-time mums have a c/s rate of over 20% whereas the rate of vaginal births among mothers who attempt VBAC is over 80% in many studies.

Angela Horn (not a midwife, just a mum!)
Homebirth Reference Site
http://www.homebirth.org.uk

REFS

[1] The effect of uterine rupture on fetal heart rate patterns.
J Nurse Midwifery 1999 Jan-Feb;44(1):40-6
Menihan CA

[2] Uterine rupture in women attempting a vaginal birth following prior
cesarean birth.
Menihan CA
J Perinatol 1998 Nov-Dec;18(6 Pt 1):440-3
Department of OB/GYN, Women and Infants Hospital, Brown University School of
Medicine, Providence, RI 02905, USA.

[3] Uterine rupture during trial of labor after previous cesarean section.
Am J Obstet Gynecol 1991 Oct;165(4 Pt 1):996-1001
Farmer RM, Kirschbaum T, Potter D, Strong TH, Medearis AL Department of Obstetrics and Gynecology, University of Southern California, Los Angeles 90033.


CEFM is no guarantee that signs of uterine rupture will be noted. I’ve read four or five accounts of uterine rupture in VBAC attempts recently, and in each of them, CEFM was used but the early warning signs were apparently not recognised or just ignored. In each case, it was highly likely that one-to-one care from a competent midwife using intermittent monitoring would have detected a problem earlier.

See http://birthstories.com/stories/626.htm where Kim, the mother, says:

” during labor my I suffered pain on my left side and no one could put two and two together and figure out that my uterus was ripping. When I finally reached a 10 and was attempting to push the pain become so bad I couldn’t push anymore. Then at the time my doctor walked in, my daughter’s heart stopped”

Her baby survived but has cerebral palsy.

If any of you had a VBAC mother who was having severe one-sided pain, would you not have had suspicions?

Or how about the story of Catherine Grace’s birth, where her mother was induced. The monitor was showing signs of worrying heart-rate variations for over five hours before the birth. The obstetrician was pushing on the mother’s abdomen to ‘help’ her. The mother complained of abnormal pain unlike that of contractions. The father pointed out a strange asymmetrical bulge in the mother’s abdomen, but the ob wasn’t worried. Ob proceeded to have two attempts at Ventouse delivery, before going for a c/s. The baby died several months later.

http://www.worldserver.com/turk/birthing/CatherineGrace.html

L. was induced with Prostin after a prior caesarean.

“my waters broke. Within 10 minutes of this happening my son Stephen’s heart rate was fluctuating, I had no unusual pain, no bleeding and no shock, just three very large jolts in my belly. I was made to wait approximately one hour before they could get Stephen out as there was no anesthetist available. When the surgery finally took place, on opening my up they found Stephen in the Abdominal Cavity, the placenta was completely detached, and my Uterus was in total shreds”

The point of this is that CEFM is not like a magic elastoplast on the uterus. I would suggest it’s more important that the attending midwife knows that there are many signs of uterine rupture to look out for, and that an emergency plan is in place.

Angela Horn

References

[1] Vause and Macintosh
Use of prostaglandins to induce labour in women with a caesarean section scar
BMJ 1999;318:1056-1058 ( 17 April )

[2] Miller DA; Diaz FG; Paul RH.
Vaginal birth after cesarean: a 10-year experience.
Obstet Gynecol 1994 Aug; 84:255-8
Over 17,000 women having VBACs, the uterine dehiscence rate was 1.1% and symptomatic rupture occured in 0.7% of labours.

[3] Effective Care in Pregnancy and Childbirth, Chapter 38, section 6.
eds. Enkin, Keirse,Renfrew & Neilsen
“To put these rates into perspective, the probability of requiring an emergency CS for other acute conditions (fetal distress, cord prolapse or antepartum haemorrhage) in any woman giving birth is approximately 2.7%”


I agree with you about looking out for other signs of uterine rupture. When intermittently monitoring I think you have more time to look at the whole picture and be observant for those signs (which, thankfully, I’ve never had to deal with). With continuous monitoring, all attention is focused on the CTG and not the woman. People think they can see things on the CTG that aren’t really there.

This woman’s previous labour had been induced for pre-eclampsia (no problems in this pregnancy) but she had laboured well then and then had a c/s for ‘delay in 2nd stage’ and op (occiput posterior) position. Therefore my concern was to keep her mobile to get this baby in a more optimal position.

My acid test always seems to be ‘would I do this if she was labouring at home?’ I can understand the caution from other staff but this was a spontaneous labour and she had laboured well in the past. Everybody seemed to assume she would ultimately present problems. When I came back from my break, she had also had a Venflon sited and blood taken for full blood count and group and save.

…..

Just to let everybody know, the woman who had had a previous c/s did deliver normally over an intact perineum, 18 minutes after I had left!! She had been showing signs of 2nd stage for most of the evening but I was just stepping back and not interfering and knew she would show me when she was ready to deliver. I’m really pleased for her, just upset I missed it! You win some, you lose some, I suppose! Hope that cheers some of us up!

Sarah


Cherie Blair’s VBAC

What a joy to hear that Leo Blair was accorded the privilege of a VBAC. (and to such an elderly mother too!!!!!)

I am almost 47 and my 2nd child, now almost 22 was born by LSCS (lower-segment caesarean section) due to an abruptio placentae and undiagnosed breech presentation. I was in transition at surgery and denied the strong urge to push. Daughter had very bruised ankles and was physiologically jaundiced for many weeks post delivery.

3rd baby was SVD (spontaneous vertex delivery) 19 years ago, but not after a long struggle with the obstetrician who wanted to induce me, give me an epidural (so that he could feel inside my uterus for dehiscence), etc. My compromise was to agree to the induction. Babe born with apgars of 9 & 9 after a 45 minute labour, whilst doctor attempting to apply FSE (foetal scalp electrode) due to 2nd stage dips (in baby’s heart rate) – fool!

Anyway, even though I am to be a granny in September, the whole point of this is to relate that, having had 2 lovely spontaneous deliveries and a section, I know what I would opt for any day – a normal delivery!!!!! If I could deliver a baby tomorrow, I wouldn’t hesitate to opt for a normal delivery.If a section is unavoidable, so be it, and I am so sorry if I am upsetting anybody with a less than optimal prospect – but why CHOOSE to have a section?

Elaine


After Cherie Blair had her fourth baby by VBAC:

Article in The Times, 20 May 2000, by Dr Thomas Stuttaford

Dr Stuttaford apparently wrote his article before finding out that Mrs Blair was not in fact having an elective repeat caesarean. The article pooh-poohs the idea of a VBA, and includes a description of what happens during the operation, diagram of the operating theatre.

This is the same doctor who once wrote that his wife had a caesarean, and for the next baby ‘without my knowledge of course’ asked her obstetrician about the possibility of a VBAC… Dr Stuttaford was glad to hear that the obstetrician told her that everyone had a right to choose how they wanted to die, but he didn’t want her to do it in his hospital… and not to be so silly, of course she would be having all her future babies by caesarean. Dr S. went on to imply that his wife was a silly cow and thank God her obstetrician was more sensible!!!

I particularly love his use of the dreaded A-word:

Some doctors might have been tempted to **allow** Mrs Blair to start in labour and to see how labour progressed. ”

How kind of some of them to ALLOW a mother to decide whether or not to undergo major surgery… even if Dr Stuttaford does think they would be misguided.

Angela


VBAC and Induction

Regarding a woman who had a C/S, followed by 2 VBACs and is now overdue with her 4th baby. Her midwife is unhappy to perform a stretch and sweep as has had a C/S, but in the same breath is talking about induction in hospital as if it is safer. Which is the lesser of 2 evils? *And*, at what point do you treat a woman who’s had a C/S as a “normal” labouring woman, after 1 VBAC, after 2, or never?


Once a woman has had a C/S then there will always be a scar on her uterus. Personally I would think that a stretch and sweep by the midwife would be a less risky option than a full induction in a hospital, assuming that induction means ARM, synto. I don’t know where this woman is planning to birth, but perhaps a compromise could be a stretch and sweep followed by some fetal monitoring, which I assume is what she would have during a hospital induction. This might reassure everyone, and minimise the intervention.

Kirsten Blacker


I am not a midwife, but a mother who has had a home birth after a caesarean operation for pre-eclampsia, and am expecting again so planning another home birth.

I saw a confidential study carried out in one of the three large maternity units in Dublin, Ireland. It concerned over 60,000 pregnancies with an incidence of 13 womb ruptures. IN 11 CASES, INDUCTION OR AUGMENTATION HAD BEEN USED. (THE OTHER 2 WERE “HIGH” PARITY – 4 AND 6) Conclusion: DO NOT INDUCE A SCARRED UTERUS!!!!!

Also, in Marie O’Connor’s study of intentional homebirth in Ireland (1992), over 20% of the women had pregnancies of longer than 42 weeks – with no ill-effects. What is the rush??

Monica O’Connor
Home Birth Association of Ireland


Foley bulb catheter induction, which is almost eqivalent to a lonnnnng, slow, stretch and sweep, is known to be the safest method of inducing a VBAC.

Angela C
(DEM Apprentice midwife in the US)

American Journal of Obstetrics and Gynecology, January 2000,
in two parts, part 2, volume 182, number one

UTERINE RUPTURE DURING INDUCED TRIALS OF LABOUR IN WOMEN WITH A PREVIOUS CESAREAN DELIVERY

D. Ravasiax S. Woodx J. Pollard University of Calgary, Foothills Hospital, Calgary, AB, Canada

OBJECTIVE: To determine the rate of uterine rupture during induced trials of labour (TOL) after previous cesarean delivery compared to spontaneous TOL.

STUDY DESIGN: Rates of uterine rupture were determined for all inductions in women with a prior cesarean section and for each mode of induction, including prostaglandin E2 gel (PGE2), intracervical Foley catheter, artificial rupture of membranes (ARM) and oxytocin. Comparisons were made with Fishers’s exact test.

RESULTS: Between 1992 and 1998, there were 2119 TOL, 575 of which were induced (27%). The overall rate of uterine rupture was 15/2119 (0.71%). The uterine rupture rate with induced TOL (8/575, 1.4%) was significantly higher than with spontaneous TOL (7/1544, 0.45%), p=0.036. The relative risk of uterine rupture with induction was 3.09 (95% CI 1.12 to 8.42). Uterine rupture rates by method of induction (alone or in combination with another) are shown in the table below and are compared with uterine rupture during spontaneous TOL.

Induction Method Number of Ruptures Number of women Rupture rate p-value
PGE2 5 172 2.9% 0.004
ARM 2 130 1.5% 0.15
Foley 1 130 0.76% 0.47
Oxytocin 5 427 1.2% 0.15
Spontaneous TOL 7 1544 0.45%

The relative risk of uterine rupture with PGE2 use versus spontaneous TOL was 6.41 (95% CI 2.06 – 19.98). The relative risk for Foley catheter induction compared with spontaneous TOL was 1.70 (95% CI 0.21 to 13.69).

CONCLUSIONS:
(1) The rate of uterine rupture with induced TOL is significantly higher than with spontaneous TOL.
(2) PGE2 exposure during TOL is associated with more than a 6-fold increase in uterine rupture when compared to spontaneous TOL.
(3) Foley catheter induction is associated with the lowest rupture rate in the induced TOL group and is comparable to spontaneous TOL.


As for the woman being 4 days over she should leave well alone. She is best not induced at all. I wonder if the midwife thinks her scar is not going to stand up to a sweep what hope does she give it in labour – well that’s another issue altogether. I have had clients who were booked for home vbac going 14 days overdue and still having a normal birth.

If the woman is under pressure to get into labour and can’t withstand it then she could start trying some of the more gentle ‘home remedies’ to get things going in the right direction.

Elaine.



I am a second year pre-reg student. Last week one of the women on the unit was having her second child, the first was born by caesarean section as it was breech. She was this time trying for a normal delivery. She progressed to about 5cm where she stuck. Syntocinon was then put up to encourage her contractions. Well to cut a long story short her uterus ruptured and the baby was born by c/s. The apgars on the baby were 0/2/3. My thoughts on this are surely if the cervix was not dilating naturally then why interfere with something so delicate as a trial of scar? Was this just ‘bad luck’ or should we really not be using syntocinon on trial of scars? As I haven’t done my abnormal block yet I am unsure of when you can use syntocinon and when not. I just seem to see syntocinon going up all the time as the woman isn’t having the magic 5 :10 contractions. Where I used to work as an auxillary before starting my training they didn’t use syntocinon but they still seemed to deliver normally without the midwife interfering.

Nikki


My understanding is that one of the contraindications to Syntocinon is a previous CS (or any uterine surgery). If this is as I believe, the woman could be entitled to huge damages and I hope she sues the pants off them.

Lesley


I’m surprised that a woman having a ‘trial of scar’ should be given syntocinon – well perhaps I shouldn’t be that surprised, considering the gung-ho attitude to synto that seems to exist in some units – it’s dangerous stuff, known to cause overstimulation of the uterus and fetal distress – & overstimulation of the uterus can in turn cause scar/uterine rupture…

I know it’s really hard when you’re a student but if ever you’re not happy about using synto say so (after turning it off)

I’m sure Midirs (www.midirs.org) have a search on it

Max

 


If you are concerned about the gung-ho use of synto to promote a 5:10 rate of contractions, I suggest you go to the information leaflet in the box and have a look at what the manufacturers suggest the rate of contractions should be when using their product. It provides extremely interesting reading.

Lorna



I am just comming up to term with my fourth child and I would like to know more on the subject before I need to go and discuss induction. I do not mind the prostaglandin being used as I see this as just a softening agent for the cervix, but it concerns me that due to the fact that this is my fourth child and my last was born by section. I am concerned about being offered synto drip. They already know that I do not want the drip due to the fact that I will not be strapped to the bed and monitored throughout my labour, as I like to be very mobile. Could anyone give me any more info on this?


Prostaglandins should not be used for women who have a scar from a previous section, because they break down scar tissue, increasing the risk of scar dehiscence or rupture.

Lorna


Where I work policy is that we can use synto on a scarred uterus, but NOt prostaglandin. Bears thinking about

Kirsten



There is a lot of evidence that both syntocinon *and* prostaglandins must only be used with extreme care in VBAC labours. Both have been implicated in scar ruptures.

There are summaries of a number of papers on this, with references, on my website’s VBAC pages, at www.homebirth.org.uk/vbac.htm. The VBAC and Induction page can be reached directly atwww.homebirth.org.uk/vbacinduction.htm

The paper below by Rosen et al reassured obstetricians that no link was found between induction of labour and uterine rupture in VBAC candidates. It has since been used by many as the justification for asserting that there is no link between oxytocin induction or acceleration and uterine rupture. However, it was a meta-analysis published in 1991 and the component studies must therefore be older. There are a number of more recent studies which raise new questions about the safety of induction of labour in mothers attempting VBAC.

Vaginal birth after cesarean: a meta-analysis of morbidity and mortality.
Obstet Gynecol 1991 Mar;77(3):465-70
Rosen MG, Dickinson JC, Westhoff CL
Department of Obstetrics and Gynecology, Sloane Hospital for Women, Presbyterian Hospital, New York, New York.

The authors looked at 31 studies giving a total of 11,417 attempts at VBAC. They found that:

  • Maternal febrile morbidity was significantly lower after a trial of labor than after an elective repeat cesarean
  • The intended birth route made no difference in the rates of uterine dehiscence or rupture. This means that the rate of uterine ruptures found in mothers attempting VBAC was no different to that for mothers undergoing elective repeat caesareans.
  • The use of oxytocin was not associated with an increased risk of either rupture or dehiscence.
  • The presence of a recurrent indication for the previous cesarean was not associated with an increased risk of either rupture or dehiscence. This suggests that a mother whose first c/s was for suspected cephalopelvic disproportion (ie baby might be too big to come through the pelvis), was not at any extra risk even if her next baby appeared big too.
  • The presence of an unknown uterine scar was unassociated with dehiscence or rupture. Thus it appeared to make no difference if doctors did not know whether the mother had a classical scar or a low transverse scar.
  • After excluding babies dead before labour started, those with deformities incompatible with life, and babies of extremely low birthweight, there was no difference in perinatal death rates between babies born after VBAC attempts and those born after elective repeat caesareans.
  • More babies had low 5-minute Apgar scores (6 or lower) after VBAC attempts, but the researchers were unable to exclude very low birth weight fetuses or those with congenital anomalies from this analysis.

The authors conclude: “Our findings argue for trials of labor for more women after a cesarean birth.”

Medline abstract: http://130.14.32.45/cgi-bin/VERSION_A/IGM-client?427+records+1

However, more recent studies have reached different conclusions:

This paper, published in 1999, is among the most recent of the VBAC studies and we can assume that the researchers will have been familiar with previous research on the matter. Its findings are worrying.

Uterine rupture during induced or augmented labor in gravid women with one prior cesarean delivery.
Am J Obstet Gynecol 1999 Oct;181(4):882-6
Zelop CM, Shipp TD, Repke JT, Cohen A, Caughey AB, Lieberman E
Department of Obstetrics and Gynecology, Massachusetts General Hospital, the Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Harvard Medical School, and the Department of Obtetrics and Gynecology, University of Nebras.

The study looked at 2774 women attempting VBAC at term, after 1 prior cesarean delivery and no other births. It compared the rates of uterine rupture associated with spontaneous labour, oxytocin induction or acceleration, and prostaglandin E2 gel induction. The analysis controlled for other factors which might confuse the result, such as birth weight, use of epidural, duration of labour, maternal age, year of delivery, and years since last birth.

Of 2774 women in the analysis, 2214 had spontaneous onset of labor and 560 women had labor induced with oxytocin or prostaglandin E(2) gel. 1072 women had their labours accelerated (‘augmented’) with oxytocin.

The overall rate of rupture among all patients with induction of labor was 2.3%, in comparison with 0.7% among women with spontaneous labor. Among 1072 patients receiving oxytocin augmentation, the rate of uterine rupture was 1.0%, in comparison with 0.4% in nonaugmented, spontaneously laboring patients.

After adjusting for birth weight, use of epidural, duration of labor, maternal age, year of delivery, and years since last birth, induction with oxytocin was associated with a 4.6-fold increased risk of uterine rupture compared with no oxytocin use. Acceleration with oxytocin made uterine rupture was 2.3 times more likely, and use of prostaglandin E(2) gel made rupture 3.2 times more likely. These differences did not qualify as statistically significant though, because of the small numbers involved.

CONCLUSION: “Induction of labor with oxytocin is associated with an increased rate of uterine rupture in gravid women with 1 prior uterine scar in comparison with the rate in spontaneously laboring women. Although the rate of uterine rupture was not statistically increased during oxytocin augmentation, use of oxytocin in such cases should proceed with caution.”

—-

See also the study by Ravasiax et al above, which is the most recent of the VBAC induction studies.

Prostaglandins

The prostaglandin gel most commonly used to induce labour is Prostaglandin E2, also known as dinoprostone, or Prepidil. Apart from the studies mentioned above, there are a few others listed on the site. Several studies looking specifically at the use of PE2 have maintained that it is safe for VBAC labours, including one by Bruce Flamm below. However, there are other disturbing reports of individual cases where PE2 seems to have played a role in uterine ruptures.

Prostaglandin E2 for cervical ripening: a multicenter study of patients with prior cesarean delivery.

 

Am J Perinatol 1997 Mar;14(3):157-60
Flamm BL, Anton D, Goings JR, Newman J
Department of Obstetrics and Gynecology, Kaiser Permanente Medical Centers, Los Angeles, Riverside, CA 92505, USA.

5022 women attempted VBAC at California hospitals after prior cesareans. Of these patients, 453 (9%) were treated with PGE2 gel. There were no significant differences between the rates of uterine rupture in the two groups, and “indicators of maternal and perinatal morbidity were not significantly higher in the prostaglandin treated group”.

The use of PGE2 gel for cervical ripening appears to be relatively safe in patients with prior cesarean delivery.

——-

It is important to differentiate between prostaglandin induction using PE2 and that using Prostaglandin E1, otherwise known as Misoprostol. There is considerable evidence that this drug is unsafe for VBAC labours, eg:

Disruption of prior uterine incision following misoprostol for labor induction in women with previous cesarean delivery
Obstet Gynecol 1998 May;91(5 Pt 2):828-30
Wing DA, Lovett K, Paul RH
Department of Obstetrics-Gynecology, University of Southern California School of Medicine, Los Angeles, USA

Researchers planned to compare misoprostol to oxytocin for induction of labour in mothers attempting a VBAC. After two uterine ruptures among just seventeen mothers receiving misoprostol, the trial was stopped on safety grounds. They concluded: “When misoprostol is used in women with previous cesareans, there is a high frequency of disruption of prior uterine incisions.

and also:

Uterine rupture associated with the use of misoprostol in the gravid patient with a previous cesarean section
Am J Obstet Gynecol 1999 Jun;180(6 Pt 1):1535-42
Plaut MM, Schwartz ML, Lubarsky S
Department of Obstetrics, Northwest Permanente PC, British Columbia, Canada.

Out of 89 women attempting VBAC whose labours were induced with misoprostol, 5 suffered uterine ruptures. However, among 423 women attempting VBAC who did not receive misoprostol, only one suffered a rupture. The rupture rate for VBAC candidates after misoprostol induction was therefore 5.6%, compared to 0.2% otherwise.

CONCLUSION: Misoprostol may increase the risk of uterine rupture in the patient with a scarred uterus. Carefully controlled studies of the risks and benefits of misoprostol are necessary before its widespread use in this setting.


VBAC after two caesareans?

I wonder what your views are on vaginal birth after caesarean after 2 caesareans. I am pregnant for a third time and I am dreading the thought of having another caesarean. My first caesarean was for fetal distress (passing meconium, dipping heart-rate etc). My second was for failure to progress (I think it was just taking too long for everybody else).

I feel now that they were both due in the most part to my absolute fear and terror of the birthing process and lack of attention by a midwife during the labour process.

I don’t want to go to hospital as I feel that this was definitely part of the problem for me. I am considering a home birth and wondered what the radical midwives thought of this idea.

Berndette


VBAC after two previous c/s is not so uncommon – there are several women on the HBAC list below who have done it, for example, and several studies showing that the majority of women attempting VBAC after two past c/s will be successful. For example, in this study the chance of a successful VBAC after 2 c/s was 70%:

Obstet Gynecol 1990 Nov;76(5 Pt 1):865-9
Vaginal birth after cesarean: a meta-analysis of indicators for success.
By Rosen MG, Dickinson JC

The new (August 2000) edition of ‘A Guide to Effective Care in Preg & Childbirth’ (ECPC) by Enkin, Keirse et al says a woman with two or more previous caesareans should be treated just like a woman with one previous caesarean when approaching VBAC.


Update

Bernadette did go on to have a vaginal birth at home after her two prior sections, and she’s written a very detailed and moving account of it. She was greatly helped by ARM members along the way!

Her birth story is at www.homebirth.org.uk/bernadette.htm

Home Birth after Caesarean

I had a c.sec on my second pregnancy (a planned home birth) for pre-eclampsia.

Of course, I was told (in the hospital) that I would never be a candidate for home birth but just 20 months later I had the fabulously empowering experience of a home birth. I am so grateful that my independent midwife was prepared to study with me to see just what, and how big, the risks were. (It was her first VBAC).

I guess if we had had to go to hospital it would have taken 40-60 mins.

I am quite certain that in hospital I would have been over-monitored and not allowed to relax into my labour. Some of our closest hospitals now have c.sec. rates of 20-25%.

Monica O’Connor Home Birth Association of Ireland hba@iol.ie


There is a dedicated ome birth after caesarean (HBAC) webring at www.geocities.com/Heartland/Garden/2269/hbacring.html

There is a mailing list at for people considering home VBAC at http://www.egroups.com/group/hbac. Most members of the list are American and it seems to focus on emotional support for people planning home VBACs, but there is lots of information too and frequent discussion of how to find a suitable midwife.

Links to other sources of information:

Birthrites: Healing After Caesarean Inc.
(www.birthrites.edsite.com.au)

Vaginal Birth After Cesarean: A Primer for Success
Detailed article from Mothering magazine, on VBAC and preparing for one.

VBAC Reference Pages
(www.vbac.org.uk)

Twin VBAC – VBAC with twins is still an option
(www.homebirth.org.uk/vbactwins.htm)

ICAN – International Caesarean Awareness Network
www.efn.org/~djz/birth/add1095/ican.html

VBAC information for parents and midwives, in Midwife Archives at Gentlebirth.org
www.gentlebirth.org/archives/icanvbac.html

VBAC.com – a new US site which promises a “woman-centered, evidence based, resource”.
(www.vbac.com)

VBAC articles at Childbirth.org
www.childbirth.org/section/VBACindex.html

VBAC Information and Support in the UK
This page lists contact details but does not contain any articles.
www.hants.gov.uk/cousin/cousinweb/vbac.html


AH updated 17 August 2000

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