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July 22nd, 2010
11:16 AM ET

Vaginal births after C-section usually OK, docs say

Delivering a baby vaginally after a C-section is a “safe and appropriate choice” for most women, the American College of Obstetricians and Gynecologists said Wednesday.

The practice has been discouraged by many doctors and insurers in recent years.

Under the new guidelines, women who have had two previous C-sections or are carrying twins are among those now considered appropriate candidates for a vaginal birth after Caesarean, or VBAC.   Between 60 and 80 percent of women who attempt VBAC will be sucessful, the doctors said.

The guidelines "emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy," says Dr. Richard N. Waldman, ACOG's president, in a press release.  "The current C-section rate is undeniably high and absolutely concerns us ob-gyns."

The recommendations come after years of many American hospitals and doctors insisting women who have C-sections continue to do so with subsequent births.  The rate of Caesareans has increased from 5 percent in 1970 to over 31 percent in 2007.  Waldman blames the "onerous medical liability climate" for the dramatic increase in C-sesctions.   "Our primary goal is to promote the safest environment for labor and delivery, not to restrict women's access to VBAC."

Not every woman is a candidate for a VBAC.  Women who have to have an emergency C-section after attempting a VBAC may have a higher risk of injury. At the same time, a successful VBAC has fewer complications than a repeat Caesarean.  Click here for some of the pros and cons.  Experts say if you are thinking about having a VBAC, it is important to talk with your ob/gyn early in your pregnancy.

The conflict over the policy was captured on CNN in the story of Arizona resident Joy Szabo, who wanted to deliver her fourth child by VBAC. Because the hospital in her hometown, Page, Arizona, did not allow vaginal birth after Caesarean, Szabo had to leave  her family in the last weeks of her pregnancy and move to Phoenix to be near a facility that would allow her the childbirth she wanted.  (She delivered vaginally with no complications last December.)


soundoff (169 Responses)
  1. Leo

    There are hospitals that won't ALLOW women to have vaginal births after a C-section? WON'T ALLOW?!? What kind of barbaric society are we, that we won't allow women to do what they've naturally done for tens of thousands of years? If the pregnancy is high risk, or if there's a real complication, then yes, a C-section is medically advisable... but if everything is fine, then why force the woman to undergo UNNECESSARY MAJOR SURGERY?

    Oh yeah, almost forgot... it's because the hospitals can charge more than TEN TIMES as much money for a C-section birth as for a vaginal birth. Follow the money-trail, ladies. They're using you.

    July 22, 2010 at 12:39 | Report abuse | Reply
    • ND

      My wife recently had a completely successful VBAC at home under the care of licensed midwifes after searching in vain for a hospital in the area that would allow her to even attempt one. She is young, perfectly healthy, and had no risk factors that would make a VBAC a risky proposition.

      Looking back, the staunch refusal of the hospital legal departments couldn't have been more fortuitous as it set us on the path of examining alternative methods of childbirth. The midwife model of care is absolutely amazing and such a refreshing change of pace after dealing with a medical system that treats you as a potential liability at every step instead of a person.

      Many developed countries have upwards of 70% of their births at home under midwife care and manage a significantly lower infant and mother mortality rate than our system of medical intervention. Birth is a natural process – not a medical emergency.

      July 22, 2010 at 15:48 | Report abuse |
    • Chris

      Basically, the hospitals/doctors go by the CYA policy. There's a risk of uteran rupture with a VBAC. My first child was delivered via C-section due to her being in the breach position. My second child was delivered 100% naturally–VBAC. I think they just don't want to be sued.

      July 22, 2010 at 15:48 | Report abuse |
    • poumj

      In response to Leo, who can't belive some hospitals won't allow a VBAC .... I work in a small, rural hospital, and regulations require that if VBACs are allowed, a C-section needs to able to be performed in a certain, short time frame in case things aren't going well, and an immediate C-section is needed. Smaller hospitals don't have all of the personnel immediately available in-house, and instead are "on call" from their homes after hours. Since we don't have surgery staff "immediately" available, we can't offer this because we couln't assemble personnel fast enough to meet those guidlines.

      July 22, 2010 at 16:15 | Report abuse |
    • christopher

      I'm an OB and would like to respond to Leo. By far the most common reason a hospital won't allow someone to attempt VBAC is the legal climate. There are so called "expert witnesses" willing to testify at the drop of a hat that if you would have done a c-section at a specific point in time then the mother would not have a child that now has CP. There are an equal number of trial lawyers chomping at the bit to try these cases. Why??? Consider that it is not uncommon for a malpractice case to estimate a "life plan" in excess of 20 million dollars for a child. If the trial attorney "wins" that case they take a hefty percentage of that money (how do you think John Edwards made his money?). Then you have an OB with malpractice coverage to 5 million and is on the hook for the remaining 15 million. Sound like fun to you? If you think this isn't common start asking around. Sure there are poor decisions that lead to bad outcomes but a lot of the time there are settlements for extraordinary amounts of money that absolutely have nothing to do with poor judgement and everything to do with the fact that not everyone will have a perfect outcome every time. I have to pay 50K a year malpractice insurance to practice OB because of this. So, the real reason a hospital won't ALLOW a person to VBAC has everything to do with liability. To think otherwise is ignoring the facts. I personally would love all of my patients to deliver vaginally. It's easier on them, quicker faster recovery, they are happier, etc.... But, when faced with the above I challenge you to ask yourself what you would do? Consider your family at home, your ability to provide for them, your medical school debt, and most importantly how will you feel when the uncommon patient experiences a uterine rupture and ends up with a hysterectomy and neurologically damaged child? Do you still really think it because of the money for the hospital or the money for the trial lawyers? By the way, it is essentially a wash in terms of money for the OB.

      July 22, 2010 at 18:39 | Report abuse |
    • Jeepers

      My third one was at a hospital that wouldn't allow a vbac. But honestly, after having a c-section first and a v-bac for the second...I'd have opted for the c-section anyway. The episiotomy was a bagillion times worse than either c-section. Plus, you get to opt out of labor pains, you don't do quite as much damage to your pelvic floor. It has advantages. Everything has pros and cons. If I had wanted another v-bac, I'd have gone to a bigger hospital. That's just me.

      July 22, 2010 at 21:38 | Report abuse |
    • Dr.J

      Sorry Leo, but while your arguement is filled with emotion and feminist selfrightousness it lacks an understanding of how things work in the REAL world. I am an Obstetrician. I deliver babies everyday (including by VBAC). What you may not understand Leo is that doctors and hospitals have right to say that they will provide certain services while not providering others, and this includes when it comes to VBAC'ing. Doctors have to bust their butts for 12 years of training, often times taking out $150,000 plus in loans to reach a point where they can use the knowledge that they have obtained to decide how to best care for their patient's. They then have to spend almost $100,000 annually to maintain malpractice insurance because of scumbag lawyers and a countrywide mindset that "when things go wrong sue your doctor". So why should a doctor (and the hospitals they practice at) take on the extra risk of doing VBAC's? If everything goes well with a VBAC who appreciates that? No one appreciates that, that's who! People like you will just line up and say "well of course everything went well....this is what women have been doing for thousands of years" (ignoring the fact that infant and maternal mortality rates are lower now than they ever have been). But when something goes wrong (even if the patient has consented to the VBAC and all of the risks have been spelled out to her before the VBAC) there will be a thousand and one lawyers lined up ready to sue and threaten my livelihood and what I have worked so hard to obtain (and maintain) in the process. And I have been witness to cases where doctors have been sued for "complications" spelled out in the consent forms a patient has signed because the patient then turns around and says "I did not understand what I was signing". So get off of your soap box Leo! We as a society get the medicine we deserve. Doctors and hospitals practice defensive medicine because they have to protect themselves. No one else will. Not our politicians, no our patient's and not the general public (who often times have no real understanding of the variables involved in medical decision making).

      July 22, 2010 at 23:09 | Report abuse |
    • Ituri

      They won't allow it because they allowed it in the past, and were SUED by women who suffered complications having a VBAC after having already had C-section(s) in the past. It DOES increase the risk of rupture. However, the risk is NOT so high that doctors can't still deliver perfectly normal vag inal births after C-sections. Its sad that people again and again defend our heartless medical system, all the while it becomes more and more sterilized and inhuman. I rarely go to doctors any longer, its so hard to find one that looks at you as a person.

      July 23, 2010 at 00:12 | Report abuse |
    • LocalVBACtivist

      Dr J.
      I'm sorry that you are so angry about your chosen profession. Please, do all birthing women a favor and select a new one.
      It seems from your post that you are the expert in what's best for your patients. I'm sorry, but you are not. As a physician, your job is to educate the family about their situation (notice I don't call it a condition...), present them with their options, and allow them to make a decision. You are completely entitiled to not support that decision, as long as you do so early enough in the pregnancy so that the woman has the option of seeking alternative care (and, for people who may not be aware, it is also your responsibility to then help transfer her care to a physician that will continue her care).

      I would not choose you as my physician simply because you feel you know what's best for me and my family because you've gone to medical school. Just because I haven't spent $150,000 (the total you mentioned) for my medical knowledge doesn't mean it is any less complete than yours.

      Please, put some empowerment abck into your patients and help THEM make their own medical decisions, armed with knowledge and a trusted advisor (yourself). Don't belittle us, and don't berate us.

      July 23, 2010 at 10:15 | Report abuse |
    • CJ

      Thank you for bringing out the real reason so many C-sections are done! It is all about the money and the fact that the doctor doesn't have to wait around for one to give birth (a c-section can be done in 15 minutes). I had 2 c-sections, both which were unnecessary. Also, it is a case of liability. If anything goes wrong with child or mother during vaginal birth, the doctor can be sued (and is). If I had to do over, I would have had my children at home with a midwife because giving birth at the hospital was a complete nightmare!

      July 23, 2010 at 10:17 | Report abuse |
    • AGeek

      "tens of thousands of years" o_O please go back to elementary school and learn biology. Live-bearing mammals have been around, doing the whole live birth thing, for around 125 *million* years. As a species, we've been doing C-sections (with the mother surviving!) for barely 500 years. ..and thankfully,so – due to complications with our oldest child's birth. But, to the point, you're off by about four magnitudes. Can I borrow $10? ..and by $10, I mean $100,000.

      July 23, 2010 at 15:34 | Report abuse |
    • Steve

      No, Leo, it's because of lawyers and insurance companies. The woman wants a VBAC and then sues if there's a complications. Hospitals are unwilling to take the risk. They're not forcing anyone to have a C-section. The patient is free to go to a hospital that offers it. that's the way America works. The hospital does not have any obligation to offer VBAC.

      July 23, 2010 at 16:04 | Report abuse |
    • Lisa

      To Dr. J,

      The problem with your reply is that it lacked any mention of what would be safest or best for the mother and child. Your concerns about being sued are real and valid and upsetting to me (as a non-doctor) but your lack of concern for what would be best for the woman and child is equally or more upsetting. Why did you go into medicine? Mother's have a much, much higher mortality rate when they have a c-section and your post doesn't show any concern about that fact! I would want someone else for my doctor who took things like that into consideration as well. If things aren't going right for your profession I hope you will work to make change but not punish consumers and put women's lives at increased risk to CYA.

      July 23, 2010 at 16:59 | Report abuse |
    • Todd

      This has nothing to do with hospitals making money. Most hospitals lose money on obstetric care. The unwillingness of some hospitals to allow trials of labor after previous Cesarean delivery is directly related to insurance companies. Although small, the increased risk of uterine rupture and potential for expensive litigation if it does occur is the reason most hospitals disallow VBACs. Hospitals may not be allowed by their insurance carries to allow them. One major law suit can be enough to shut down an entire labor and delivery unit. If women want VBACs then society needs to become less law-suit happy and support tort reform.

      July 25, 2010 at 17:19 | Report abuse |
    • PBD

      The choice for a hospital really isn't about whether they should offer VBACs- it's whether they should offer maternity care at all. VBAC's are safe. I've had one myself, and taken care of many women who have also had them quite successfully.I also know of one patient whose baby was dying before she could get to the hospital, and died shortly after birth. Now the chance of that is very small, but the liability for the hospital is enormous. WIth the cost of malpractice insurance and low rates of reimbursement (yes,compared to care done only for men, women are "worth" about half given the same complexity of procedures), maternity care is a losing proposition for hospitals. Both hospitals in my small city offer deliveries only because it's their civic duty and women would have to travel too far to go elsewhere. Little hospitals around us are giving up maternity care, they just can't afford it. Until something is done about liability, offering VBAC care will become as rare as hen's teeth, and maternity care less and less available.

      July 30, 2010 at 10:57 | Report abuse |
    • kait

      Dr.J.... well I would say that your mindset is in violation of the Hippocratic Oath. THAT is precisely the problem. Defensive medicine is NOT the best for the mother or baby! And that is why we have the outlandish c-section rates, traumatic births (which I'm sure most of you doctors don't see as traumatic because the experience means nothing to you and all that matters is that the mother and baby are alive – not thriving, just surviving), and an actual increase in maternal mortality recently. It's a sick system, and you're right – a lot of the fault lies with the legal and malpractice parts. Which is why you should be all for universal healthcare. But wait, you probably won't make QUITE as much money. You'll still make a lot, don't get me wrong. But maybe you'll have to forgo that vacation in Cabo. But ya know, the mothers will be happier and healthier, the babies will FOR SURE be healthier. And hey, as a bonus, you're still practicing REAL medicine – not defensive bs. Just a thought.

      July 30, 2010 at 13:28 | Report abuse |
    • jen

      The reason they were so discouraged is that there is a risk of the uterus rupturing. Small rural hospitals usually can't handle these births so they usually have to go to a larger facility. The hospital where my son was born allowed it on a case-by-case basis and all staff had to be on the floor in case they had to take the mom into surgery.

      July 30, 2010 at 20:00 | Report abuse |
    • Leslie

      Glad I had my children in a simpler time. I had my first son c-section. My next 6 children were born vaginally. No complications. I never had a doctor even suggest I have another c-section.

      July 31, 2010 at 01:23 | Report abuse |
    • SC

      Cute reasoning but dead wrong. There haven't been LAWYERS for tens of thousands of years. Want change? Lobby Congress for torte reform!

      July 31, 2010 at 15:01 | Report abuse |
    • ompath

      Thankfully, my hospital allows for vbacs.
      So scary that the money I pay for my insurance could be used to pay people who will not offer me optimal care. Where do you practice, Dr. J?

      Look into your patients' eyes when you go back to work on Monday. Are you actually helping them? Are they leaving your office feeling insecure? If I got a vibe from a doc that he/she did not have my best interest at heart, I'd probably sure their ass, too, if they messed with MY health.
      Ever consider that some of the people sued DESERVE to be sued?
      http://sutterroseville.org/health/healthinfo/index.cfm?A=C&hwid=hw200557
      I'm going vbac – but it's for my health, and recovery, and the health of the baby. The natural process of delivering a baby has benefits to the child, as well. Did you know?

      Perhaps you can just go into research. Maybe no contact with women would be a good move.

      July 31, 2010 at 22:10 | Report abuse |
  2. Erin

    Actually, the reason is that the Med Mal Insurers won't allow the VBACs. This is due to people suing doctors when something out of the doctor's control goes wrong with a VBAC when the woman is fully aware of the risks. Start blaming our society, juries and judges and not the hospitals.

    July 22, 2010 at 13:00 | Report abuse | Reply
    • Matt

      actually, stop blaming juries, judges, and society and put all the blame on the medical community. tort law in med mal cases revolves entirely around what the standard practices are in the local and national MEDICAL community. the legal system looks to what the medical community thinks is the best practice. you'll note that the article is about "new guidelines" that reverse the prior outlook on VBAC after C-section. prior to these new guidelines, the standard practice was to NOT allow VBAC after a previous C-section. if someone did not follow the standard practice and something went wrong, the legal system would place responsibility on the party not following standard practices. these new guidelines should reverse this issue to a point, but just because one group says they are ok does not mean that the practice will be adopted in the medical community. until the wider medical community accepts VBAC after C-section, don't expect hospitals to allow the practice.

      July 22, 2010 at 21:57 | Report abuse |
    • Ignorance is bliss

      Matt
      You must be an ambulance chasing attorney! Been practicing ob for awhile now and never heard of a "neighborhood/community standard committee" in any hospital that established my community's standard practice. It's a legal system term that can be challenged n changed on the stand in any court case, and it can be different at the same time when there are two ongoing cases in adjacent courtrooms depending on how good(crooked) your lawyer is.
      The trouble IS the lawyers n the more gullible juries. We(the medical professionals) get judged NOT by the jury of our peers, but by who benefits fro the ten dollar allowance of being in the jury (I.e the unemployed n the people that don't have much to lose from being there).
      Why do plane crashes get investigated by FAA n aviation experts and the medical community, despite being more educated and deal with more complex machine(human body) get judged not by our peers? Lawyers want the doctors off juries because god forbid there might be a smart person on the jury, and lawyers have the most to lose by tort reform n jury of our peers
      Trial LAWYERS are the problem, including that Edwards guy ( the democratic presidential nominee) who has more blood on his hand by restricting care and forcing many ob doctors out of the Carolina he was living in. State of ob care has deteriorated more in Carolina thanks to him than any evil ob he took to court.

      July 23, 2010 at 02:06 | Report abuse |
    • Michael

      @Matt,

      If you think medical malpractice is about "plac[ing] responsibility on the party not following standard practices," you really have no idea how the U.S. legal system actually works. My wife is a medical professional (not a doctor, but her training involved post-graduate work), and she was recently named as a defendant for malpractice. Why? Because she made a phone call.

      A patient had some testing done. The results from the lab came back normal. It turns out those results were a false negative. Anyone that knows anything about medical testing will tell you that false negatives (and false positives) are unavoidable. There is no test in existence that is 100% accurate. But this patient wasn't happy with that fact. So she sued *everyone* for malpractice and "emotional distress." Furthermore, even if the test results had correctly identified the condition, it wouldn't have made a difference: There is absolutely no treatment for this condition. My wife's only involvement with the case was that she called the patient to tell her that her lab results came back normal.

      So, yeah, if you think malpractice lawsuits are about not following standard practices, you're clearly have no idea what you're talking about.

      July 26, 2010 at 11:00 | Report abuse |
  3. Dr. Gabor

    Leo wrote:"it's because the hospitals can charge more than TEN TIMES as much money for a C-section birth as for a vaginal birth."

    Hospitals can charge a million times more, insurance companies will pay pretty much the same as for vaginal birth.

    I am an ob-gyn doc for 32 years. It isn't the money. It isn't because we can go home faster. It is the 1% complication rate what VBAC carries (rupture of the uterus). And that is a serious complication. If and when it happens, the baby has a 25% probabilitty to die.

    Due to the skyrocketing lawsuits related to vaginal birth (peeking at the 1980's), and the typical blame:"..if you would have done a C-section, this may not have happened...", doctors started to do more and more C-sections. By the 90's the rate became outrageous. That is when VBAC appeared. The only "tiny little problem" was the above mentioned complication rate. Which these days and ages are unacceptable. First ACOG pushed it, then later kind of withdrew and remained silent on it, even later articles, stats, etc. started to discourage VBAC. That is when many hospitals banned it. Of course the C-section rate started to climb again, and here we are.

    The only long term solution: a radical tort reform. Bush kept talking about it, but most people didn't even understand how a tort reform would relate to the cost of, or the nature of health care. I can only write in a short note like this, that this is a very complex issue.

    July 22, 2010 at 13:27 | Report abuse | Reply
    • Noel

      I'm sorry but your 1% is wrong. Technically it is "The risk of uterine rupture during a TOLAC is low—between 0.5% and 0.9%", from the article. Don't round it up.

      July 22, 2010 at 14:16 | Report abuse |
    • m

      But Dr. Gabor that still leaves a 75% chance of living. Seems like good odds to me.

      July 22, 2010 at 14:16 | Report abuse |
    • Marina

      Why would you want to take 25% chance? I had two kids via C-section. Fist – emergency, Second by choice. We should we thankful that current medicine offers a chance of healthy delivery of the baby.

      July 22, 2010 at 15:22 | Report abuse |
    • Pirogi

      It's not a 25% chance. IF the good doctor's statistics were correct, it would be 25% of 0.5-0.9%, which is 0.125% to 0.225% chance of fetal death for VBAC mothers. As it is, the actual risk of a brain damaged or dead baby with massive uterine rupture is 0.046%. [Landon et al. 2004. Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery. NEJM, 351:2581-2589]

      "Uterine rupture" is an imprecise term that can include dehiscence, where a previous cesarean scar opens a bit during labor without great trauma to the mother or baby. They are asymptomatic and only discovered if the mother has a repeat cesarean section for other reasons than uterine rupture. Massive ruptures are where the uterus opens enough for the mother/baby to show symptoms (blood loss, shock, blood pressure and pulse changes, fetal heart tone decelerations, etc). The rates of dehiscence vs massive rupture vary depending on the study, and the actual rate of dehiscence is unknown (since it is only detected in those mothers who go on to have a cesarean section). [Diaz et al. 2002. Uterine Rupture and Dehiscence: Ten-Year Review and Case-Control Study. South Med J. 2002;95(4)]

      While it is possible for a woman with NO prior cesarean surgery to have a uterine rupture, it is more likely that a VBAC woman will experience uterine rupture. However, there are factors that increase your odds of rupture in a VBAC, and these include a classical incision scar (vs a low segment transverse incision scar), pharmaceutical induction of labor of any kind (prostaglandins, oxytocin, cytotec/misoprostol, etc), and assisted delivery (forceps, vaccum extraction, etc). A woman who has already had one VBAC is at lower risk of rupture in subsequent VBACs.

      We can look at statistics until our keyboards stop working from all the drool, but it boils down to this: a woman attempting a VBAC is 5 to 30 times MORE LIKELY to need a true emergency cesarean section for reasons other than uterine rupture (for example, fetal distress, cord prolapse, hemorrhage before the birth, etc) than she is for a uterine rupture. [Guide to Effective Care in Pregnancy and Childbirth, 2010] Denying a woman who wants to VBAC that option is simply illogical, when you look at the numbers.

      July 22, 2010 at 16:15 | Report abuse |
    • ND

      What it boils down to is that the C-section is the safest choice for the _doctor_, regardless of the patient. A baby or mother dies during a VBAC and the family sues. It doesn't matter if the doctor was honoring the wishes of the patient – they have exposed themselves to a liability and massive judgment at the hands of a sympathetic jury because of the failed outcome.

      A baby or mother dies during a C-section and the family sues. In this case, the doctor "did everything they could", took an active medical role, followed established protocol – but unfortunately the outcome was not good. Case closed.

      Practicing medicine by "CYA" does not always lead to optimal patient care.

      July 22, 2010 at 16:36 | Report abuse |
    • derakhsh

      I'm a fellow practicing OB/GYN and until we get the LAWYERS out of medicine we'll be stuck with this kind of scenario; one where medically appropriate therapies and procedure can take away your livelihood" (emotional judgement by sympathetic juries and now you cant afford malpractice insurance thus you cant practice medicine). any one of the above people that keep quoting numbers and percentages obviously hasnt had to defend their medically appropriate plan in a court of law judged by NONE of our peers!!!! also, these number pushers will change their mind when its their loved one facing the 0.025% DYING from a VBAC. you think you're brave enough to ask your wife to go ahead with a procedure that has a 0.025% chance of death? go right on ahead and write that alimony check NOW,

      July 22, 2010 at 18:18 | Report abuse |
    • ND

      Care to support your claim that VBACs have a maternal death rate of 0.025% ?

      July 22, 2010 at 18:26 | Report abuse |
    • Ignorance is Bliss

      ND
      read Pirogi above, Landon etc etc etc,,you are so opinionated are you even in medicine? what expertise do you have other than being opinionated?

      July 22, 2010 at 18:50 | Report abuse |
    • Liutgard

      derakhsh, you have a higher chance of dying in a car accident on the way to the hospital to deliver that baby! Care to climb in the car now?

      I really hate Henny-Pennys.

      July 24, 2010 at 10:42 | Report abuse |
  4. siobahn

    I get very tired of people with no medical background making statements about how the doctors and hosptials are trying to control them, bleed them for cash, etc. If you dont want a c-section, then dont have one, but sign something that you are taking your life into your own hands and have no claim should something happen during childbirth. And if the doctor or hospital doesnt want you as a patient b/c in their view, you are exposing yourself (and them) to unnecessary risks, then that is fully within their rights.

    Childbirth is complex and can be a dangerous process- a lot of things can happen, even in the best of circumstances. Lives are at stake. The fact some women actually put their own desires for a certain type of delivery ahead of their safety and child's safety is baffles me- its just warped logic and lack of priorities for the greater purpose of bringing a child safely into this world. If your doctor says for medical reasons, its safer for you and your child to have a c-section, I cannot fathom why anyone would fight that.

    July 22, 2010 at 13:47 | Report abuse | Reply
    • derakhsh

      AMEN,
      the problem is that as a culture we've become too opinionated even on subjects we have no expertise in,, thus layfolks, questioning medical management when they cant even spell!! or for that matter extremely technical issues like engineering or plane crashes.
      the reality is if PILOT and PLANE crashes get reviewed by EXPERTS, and other similarly trained individuals, i.e pilots, aviation experts etc and the same needs to happen in medicine, JURY of our PEERS

      July 22, 2010 at 18:23 | Report abuse |
    • heather

      "I don't understand why anyone would fight that." Well, I do. I went to one hospital after I had a C-Section with my first child, and the hospital said it wasn't safe to try VBAC. I went to a different hospital (nearby) and they said it was perfectly safe to try VBAC. I stuck with the second hospital, had wonderful VBAC, no drugs, no intervention, no lawsuits, no sweat. My baby was born HEALTHIER because I had a VBAC, and I recuperated FASTER and without risk of complications from major surgery. Now, if I had been a sheep I would have simply believed what the first hospital told me: it wasn't safe. I'm glad we have choices. By the way, the least risky option would be to avoid pregnancy altogether, so if you're hell-bent on reducing risk, maybe this is the option for you.

      July 23, 2010 at 02:27 | Report abuse |
    • Rhea

      Because when a doctor offers you a C-section, STATISTICALLY there is an increased chance of a negative outcome. The "need" for a section usually happens because of other unnecessary interventions that the doctor offered. I have 5 healthy children, and was offered 4 unnecessary sections. My midwife with #5 did not offer (it would also have been unnecessary). I had the advantage of an education in biology and statistics, which allowed me to understand that the risk of death and injury for me and my children was greatly increased by a non-vaginal birth. Most women just believe the doctor when he says that the section is "best".

      July 23, 2010 at 20:47 | Report abuse |
  5. Pirogi

    It's a combination of both. We live in a sue-happy society, and there undoubtedly have been instances where an obstetrician was held liable in court for problems that were out of his control.

    BUT ... my experience with birthing women is that they are rarely able to complete a VBAC when it is attempted with an obstetrician in a hospital. Hospital policies, obstetricians who pay lipservice to VBAC but in practice rarely will consent to attend one, scare-mongering pregnant women and playing the "dead baby" card when they refuse the nonsense ... all of this contributes to our ridiculously high c-section rate in this country, a large percentage of which are repeat surgeries. Women need to reclaim their RIGHT to a peaceful, intervention-free birth with their very first baby. Research pregnancy, read about standard obstetrical practice in the US compared to other countries, find a birth provider whose words AND patient history support the wishes of the mother. Ask for statistics for the hospital and the provider. Look into midwives. Look into out of hospital birth, including birth centers and homebirth. Read about the benefits AND risks of drugs for pain relief and for induction. Don't be a victim.

    Oh, and this back-and-forth philandering by ACOG regarding VBAC is par for the course. In the mid 90's, they took the stance that a trial of labor for VBAC is a safe and reasonable option. In the early 2000's, they reversed that stance, and VBACs overnight became very hard to get. Just within the last year or two ACOG's position was that VBAC was ONLY safe if the woman had access to a fully-prepped surgery suite within 30 minutes after the decision to have a cesarean. This effectively prevented out-of-hospital birthing mothers from attempting VBAC, but it is laughable, since only a very few hospitals in the country could meet these rigid guidelines, around the clock.

    I also find it interesting that this statement was released only a month after a poorly-designed study was published railing against the safety of homebirth (in direct contradiction to many, many other well-designed studies that conclude that homebirth is safe). Obstetricians know they are losing ground with mothers and families in this country. This is a desperate attempt to discredit providers that are likely to provide women with a healing and normal experience, so that OBs and hospitals can continue to cut them open for no reason, collect outrageous fees, and then go back to their golf games.

    ACOG is no friend to mothers. It is a trade organization whose sole agenda is to protect the interests of surgical birth specialists.

    July 22, 2010 at 13:55 | Report abuse | Reply
  6. MCH2011

    This policy change is LONG overdue. What the article fails to mention, however, is that the main reason doctors and hospitals refuse to attend VBAC deliveries is that the old ACOG guidelines implied that VBACs should only be attempted in hospitals that have a physician, anesthesia, and other personnel immediately available 24 hours a day for an emergency cesarean delivery. While I am pleased that ACOG has finally woken up and changed their guidelines to be more woman friendly and evidence based, this just seems like another case of OB/Gyns cleaning up a huge mess that THEY created and expecting the public, and especially pregnant women or new moms, to be eternally grateful that they've swooped in to save the day. If we put the management of normal pregnancies in the hands of midwives, where it belongs, we never would have been in this mess to begin with.

    July 22, 2010 at 14:23 | Report abuse | Reply
  7. kristina

    I have had 4 children and each of the pregnancies were problem free. My first child was born c-section, he turned the afternoon after my last doctor's vist and went from head down to butt down. My second and third were born vbac and I had no complications. My fourth child was also born vbac but it was difficult to so. Not because of him or me but the climate of doing so had changed. . We moved from California to Nevada, in Cali, a vbac was encouraged and in Nevada, you were refused. Even with two successful vbacs and pregnancies free of complications, doctors didn't want to do it. I honestly called a 100 offices in Las Vegas and I was told no. Some told me it was the insurance, some told me that they didn't want to wait at the hospital, they just came in pulled the baby out and then went home. Then some told me that once you have a csection, you must always have one citing bogus info which I knew was wrong. I just had two kids before and I wasn't stupid. It took a call to a midwife in the area that recommended an ob/gyn and she did it case by case. She took me on. My labor was so quick that the epidural never got to take a effect. Only one hospital allowed it then too and that was 5 years ago. If you have had no problems in your pregnancy, Vbacs are so the way to go!

    July 22, 2010 at 14:33 | Report abuse | Reply
    • Diane

      I also had a csection with my first (because of positioning. I was encouraged to have a vbac with my second and third. However I moved to Kentucky with my 4th and 5th, and was refused by several doctors since I would not agree to a scheduled csection. After a lot of searching I found doctors who would deliver a vbac. When #6 came along I was back in Indiana. The climate had changed and I was again discouraged from a vbac. After searching I found a vbac friendly doctor. I encourage anyone to have a vbac if possible. They are SO much easier.

      July 22, 2010 at 14:57 | Report abuse |
  8. VBAC Survivor

    Sure glad I had my VBAC in 1998 then. It went without a hitch.

    July 22, 2010 at 14:38 | Report abuse | Reply
  9. Rose

    I wonder what this means for women like me who have no desire to VBAC. I had a csection with my first after a very horrible attempt at a vaginal delivery. My csection was fine, my attempt at the vaginal delivery was hell. No I'm not interested in a VBAC or even attempting a VBAC. I would much rather just schedule the csection and have a lot of anxiety taken off of my shoulders than to try again for a vaginal delivery.

    July 22, 2010 at 14:48 | Report abuse | Reply
    • LocalVBACtivist

      Rose- I am a huge supporter of VBAC and VBAC rights for women. However, I believe that it should be the choice of the family. Knowing the risks and benefits of both VBAC and ERCS, you make the choice that's right for you. It is much bigger than the statistics- every family needs to make the decision that is appropriate for their families. Fortuantely for you, I think that you will have an easier time finding a doctor willing to schedule a repeat cesarean for you than many mothers looking for a VBAC in a hospital setting. Best of luck to you, I'm sure you are making the best decisions for you and your family, and it's nobody else's place to judge or restrict that.

      July 23, 2010 at 09:41 | Report abuse |
  10. carol

    I had a VBAC in 1995 and 2001. My C-section was in 1985. Talked with my doctor and was told that I was welcome to try the VBAC. Everything went fine. In 2001, a new study came out and I again talked with my doctor. He explained that most of the negative results were from hospitals that did not have the facilities to handle the possible complications. In other words, the study was flawed. Again, I had no problems.

    July 22, 2010 at 15:31 | Report abuse | Reply
  11. soon to be mommy of 4

    I had an emergebcy c section with my first baby – at 10pds 7oz, just could not deliver vaginally. I had a VBAC for my second son, almost as large and delivered in 25 minutes. My Dr was well aware of my wishes and was fully on board. If your Dr insists on multiple C Sections, you can find someone else with more experience who will do it!

    July 22, 2010 at 15:40 | Report abuse | Reply
    • LocalVBACtivist

      I wish it were this easy. In some areas, especially more rural settings, there just aren't any hospitals that are willing to take on VBAC. Any because our society has set us up to think that homebirth is extremely dangerous, some women aren't comfortable with that. So what options do these women really have? Go to the hospital and be forced (errr, coerced) into a cesarean, or brave it at home with a midwife (if allowed in their state) or even go it alone?

      July 23, 2010 at 09:43 | Report abuse |
  12. Dee

    You can all state that there is a low risk unless you are in the % that the uterus ruptered and you have to live the rest of your life knowing that your once HEALTHY infant was born with cerebral palsy due to the fact that your uterus ruptured and he went without oxygen – which would have been totaly prevented with a cs. Hard to live with.

    July 22, 2010 at 15:47 | Report abuse | Reply
    • ND

      This is an incomplete assumption. One would need to weigh the risks of repeat C-section (which is major abdominal surgery) vs. VBAC to get a truly complete risk analysis. C-sections are not without major complications nor risks and should absolutely not be regarded as a safer choice without a thorough examination of each patient's individual scenario.

      This sort of fear-mongering and fixation on a very unlikely catastrophic event is a big part of the reason we have a national C-section rate approaching 30%.

      July 22, 2010 at 15:58 | Report abuse |
    • heather

      I'm really sorry if you experienced a uterine rupture. Surely, it would be very hard to live with that experience. However, I have to emphasize that the risk of rupture–in all it's possible forms–is still miniscule, really. Less that one percent. By your logic, I shouldn't be driving a car, then, since my risk of injury or death–or, God forbid, the death of my child–is far greater on the open road than the risk I will have a uterine rupture post-cesarean. Do you drive?

      July 23, 2010 at 02:39 | Report abuse |
  13. E

    I had a large first baby, He was 10lbs, but I am a tall gal at 5'10". I didn't have gestational diabetes – big babies just run in our tall family. I was told I *must* be induced at 38w to prevent him getting any larger. Predicably, the induction failed pretty miserably and a c-section resulted. I had some complications during surgery involving blood loss when an artery was accidentally cut, which made recovery difficult and the actual surgery terrifying.

    My second child was 9lbs. I wasn't offered a VBAC at all. I did have several serious surgery-related complications after birth which landed me in the hospital for a total of almost 3 weeks. Being a breastfeeding mother
    (or any mother, of course) apart from the baby that long was quite traumatic, aside from the terrible pain I was in.

    My third child was only 8lbs. Another c-section. Even VABC-friendly docs don't offer a choice after two surgical births. I had placenta previa which eventually resolved, but is much higher in women who have had prior c-sections.

    I'm pregnant with our 4th and final baby girl. I'm not a candidate for VBAC and I'm considered high-risk now as a result of the surgeries. It's ironic of course that c-sections can make subsequent births high risk, isn't it? Placenta accreta is a potential problem due to the extensive uterine scarring – and a very scary one at that. My doctor has advised that if it occurs, I will be looking at a possible hysterectomy.

    My point is this, if I had known what sort of medical complications might follow with that first c-section or the following surgeries, I probably would not have even agreed to the induction or would have requested a second opinion. My first child, while large, was also very tall and very, very, healthy. Prior to his birth, there were no indications that he was not healthy, in fact – the OB was concerned solely with his size.

    Women need to be fully informed as to what a c-section really means. A lot of them result in various post-natal complications, as mine did. There is a higher rate of maternal death than in vaginal births. While encouraging VBACS is certainly a valid goal, avoiding unnecessary first c-cections (and convenience inductions which *so* often lead to surgery) should be the first goal, particularly for women who may have later children.

    July 22, 2010 at 15:48 | Report abuse | Reply
    • Veggie1970

      Wonderful points, E. I was lucky enough to have a very supportive OB when I attempted my first VBAC (in 1998, before the last change in recommendation). My first labor was a very long (60+ hour) pitocin induction that culminated in c-section. With my second, I changed doctors, and successfully VBAC'd my son. I went on to have two more VBACs, both of those drug-free.

      I agree that avoiding the first section is key. It seems in the last few years I don't hear of many women actually going into labor. Everyone is induced on their due date, if not before. All of my VBACs followed spontaneous labor. Nothing sets the wheels of intervention in motion as frequently as forcing a women to give birth before her body is ready.

      July 22, 2010 at 16:19 | Report abuse |
  14. cait

    I had TWINS the first time by Emergency Cesarean and I felt cheated. They simply pulled the babes out and it was over! No labor, no nothing! I had my third child (but second pregnancy) by VBAC, and my doctor was all for it. They induced me 10 days early so that my probability of delivery vaginally would be very good. I must say, though, having done it both ways–its a painful process either way! God love Moms who go through all the pain to have children!!

    July 22, 2010 at 16:03 | Report abuse | Reply
    • Veggie1970

      Cait, it is painful either way. Luckily the memory dulls! My philosophy has been I'd rather have the pain before I have a newborn to care for than after.

      July 22, 2010 at 16:23 | Report abuse |
    • LocalVBACtivist

      Veggie- It's only pain if you perceive it that way. I found it to be a joyous experience and wouldn't trade it for anything in the world. Let's not be fear mongering women into thinking that a vaginal delivery is as painful as a cesarean when that's not necessarily the case.

      July 23, 2010 at 09:45 | Report abuse |
  15. HS Health Teach

    In 2004, my HUMANA HMO policy basically only gave me one realistic choice of hospital to deliver at, and that was STILL an hour and a half away from my home, and their policy was no VBAC's. It's not just the doctors' insurance policies that are the problem, but also the patients'. Incidentally, my insurance denied my request to deliver at the hospital 30 minutes closer that did allow VBAC's, because apparently they were, "looking out for my safety"... (It had a better nurse to patient ratio, so was a little higher, and I even offered to pay the difference!!! ) Dang insurance companies

    July 22, 2010 at 16:24 | Report abuse | Reply
  16. momof2li

    My son was 5 weeks early when my water broke prematurely. After 36 hours of labor, I became sick and my son went into distress. I had an emergency c-section. My daughter was supposed to be a VBAC but, during a regular visit, they noticed that she was in distress and they had to do an emergency c-section. Depending on the circimstances, trying a VBAC would be great for the mother. But, if you have a history of complications, than it really should be at the discretion of your doctor and should be discussed in detail why the doctor chose this. Commuinication is key in order for the mom to be to trust the doctor and know that you are getting 100% care.

    July 22, 2010 at 16:51 | Report abuse | Reply
    • Veggie1970

      You should always consider the advice of your doctor, but educate yourself and remember it is your body. I was in a similar situation; my water broke at 23 weeks and I was hospitalized until I went into labor spontaneously at 30 weeks. I had a vaginal delivery (my 3rd VBAC) as encouraged by my doctors. I assume that by "became sick" you mean an infection set in due to the rupture of membranes, in which case it is in the best interest for mother and baby to deliver as quickly as possible. In my case, there was no sign of infection, and the process of labor helps prepare baby's lungs for life outside the womb; she actually benefited by the vaginal delivery, despite being only 3 pounds and 10 weeks early.

      It's all about choice here. Of course there are circumstances that make VBAC unwise or impossible, but those are certainly far fewer than the current rate of repeat c-section would suggest.

      July 22, 2010 at 19:25 | Report abuse |
  17. matureprimagravida

    My first child was delivered c-section because he was in a breach position and I went into labor 3 weeks early. Two women I befriended at the Lamaze class also had c-sections at the same hospital, all within a few weeks of each other. Three years later, in 1991, I delivered my daughter by VBAC at the same hospital after being induced because she was late.

    Now some would say hooray for the hospital, yet I was not altogether happy about the way things went. The health insurance we had was an HMO affiliated with the hospital. Though no one came out and told you, it was known that the hospital was trying to make up for the inordinate amount of c-sections performed in the preceding years (as I’m sure other hospitals at the time were doing) by doing as many VBACs as possible.

    In hindsight I came to believe that there was a conspiracy of silence about the size of the baby I was carrying so that I would not consider a c-section. The only time I had any idea just how large my daughter was when she was placed on my chest after delivery! She was 9 lbs 1 oz. Given the fact that I was induced with Pitocin, had back labor the entire time and received no anesthetic relief from the epidural because the line, it turns out, had been accidentally disconnected the whole time I was in labor, I would have preferred to have skipped the whole VBAC thing. (And it was also pretty aggressive on the hospital's part, I think, as I was a already a 'mature primagravida' with my firstborn)

    July 22, 2010 at 17:44 | Report abuse | Reply
  18. derakhsh

    i AM an ob/GYN and the difference between the recommending group and I (along with most other ob/gyns) is we are PRACTICING ob/gyns. These academic ob/gyns havent delivered a baby since they finished their residency and have never had the pleasure of going thru a deposition for a VBAC gone awry are ruining the field (along with their colleagues in all branches of medicine). They dont wake up in middle of the night to deliver a baby or a distressed VBAC, they are the best examples of MONDAY MORNING QUARTERBACKING, but they do so in medicine with potentially dangerous repercussion. ALso, they NEVER EVER come to court to defend the physician that followed their advice. ACOG is a JOKE, one most Ob/Gyns have to join because of the insurance certification, FACOG status etc, not because they actually listen to them

    July 22, 2010 at 17:51 | Report abuse | Reply
    • LocalVBACtivist

      derakhsh
      I'm sorry that you have had the horrible experience of witnessing UR. I hope it will not negatively affect your future care for women who understand the risk of rupture and still feel it is in their best interest to have a TOL. Thank you for your comments, it truely helps the community understand where OBs are coming from on this.

      July 23, 2010 at 09:47 | Report abuse |
    • Liutgard

      One question: Have you ever given birth?

      July 24, 2010 at 10:50 | Report abuse |
  19. OB doc

    It is true that VBAC should be a choice for most (not all, which the article does not address) women. IF they want it. The problems will come when, as in the 90s, the pendulum swings so far in the other direction that insurance companies, etc start to preferentially cover VBACs, and women who do not want them are coerced into trying it for financial reasons. As an OB, I see plenty of women for whom the idea of an attempt at a VBAC seems ludicrous to them–they want a repeat C-section. Which, especially if they are planning to limit their family size to 2 or 3 kids, is perfectly reasonable as well. I would never tell someone who met the criteria for safe VBAC trial that they could not do it (my hospital does not do VBACs, b/c of the inhouse surgical issues cited above, but we can help patients get to other, relatively near hopsitals if needed). But by that same token, neither would I coerce someone into a VBAC if she didn't want it. C-sections have risks, so do vaginal births. Women who are informed can make choices for themselves. However, as the OB doc above pointed out, a "small" risk of catastrophic outcomes becomes the ONLY important factor when you are the one whose baby is injured or dies. It is rare, but it happens, and it is devastating. Of course most go fine–we've all admitted that the absolute risk is low. Why anyone would compound that risk by attempting VBAC at home, without access to emergency C-section if needed, is beyond me and the scope of this discussion. Like I said, it seems remote until it happens to you.

    July 22, 2010 at 17:55 | Report abuse | Reply
    • heather

      By your logic, a woman who is having her first baby should be able to tell you she wants a cesarean birth, and get it. That seems ridiculous (although I'm sure it often happens, with some "reason" given to justify it medically). From my experience, LESS is MORE in terms of medical intervention–all the way down the line. If doctors could leave laboring women alone, cut out the meds and the slicing and dicing, and practice more like MIDWIVES, healthier babies would be born and less trauma would surround the entire experience. C-Sections should be performed only as a last resort, when all else fails, which is pretty seldom the case, to be honest. These days, cesareans are proffered up as a viable ALTERNATIVE to normal birth, equated as a pros and cons issue–kind of like the difference between Wriggley's spearmint or peppermint, but this is an awful injustice to women, whether they are informed enough to know better or not. It makes me sad.

      July 23, 2010 at 02:57 | Report abuse |
    • MD

      Heather, spoken like someone who isn't an MD with actual experience taking care of patients and facing all the legal ramifications of doing so.

      July 23, 2010 at 16:11 | Report abuse |
    • OB doc

      Heather, you are right in one respect. I would in fact agree to a primary elective C-section for a woman who was well-informed, and whose reason for choosing it was based on an evaluation of the risks and benefits, not on fear or emotion. Provided, of course, that she was willing to limit family size to 2 or 3 kids. I also agree with you that unneeded interventions in labor, for women who do not need them, are wrong. The problem is that unless you are trained to know whether they are needed or not, and in what type of situation, you are simply guessing. If you end up with an emergency C-section and your baby looks great, hopefully you are overjoyed. Unfortunately, there are some women who would then hold that up as proof that their C-section was "unnecessary." Look, if all the babies born by C-section are born with depressed APGARs and brain damage, we're doing something very wrong. I still hold that when you are talking about the life of a newborn, for most people (and this certainly holds up in malpractice cases), the false positives (or number needed to treat, if you prefer) are outweighed by the babies who are saved with interventions not available 100 years ago.

      July 23, 2010 at 20:30 | Report abuse |
  20. ND

    "Why anyone would compound that risk by attempting VBAC at home, without access to emergency C-section if needed, is beyond me and the scope of this discussion."

    There are plenty of reasons, many of which I enumerated above. The main one though is hospital refusal to allow VBAC on liability grounds. If the system won't work with you... you have no choice but to work outside the system.

    In our case, we were 7 minutes away from a large regional medical center with the ability to perform an emergency C-section on short notice if the necessity arose. We were under the care of experienced, licensed midwives who had developed a personal relationship with us for the entire pregnancy and had attended over 1500 births between them. Had they even the slightest doubt or concern about my wife's wellbeing we would have been transferred to the hospital immediately.

    Contrast that with the birth of our first child, where despite laboring for 24 hours we spent literally less than 10 minutes with the OB resident on duty and even less than that with the attending who finally swooped in with the scalpel.

    Don't get me wrong, obstetrics and modern medicine are wonderful things and no doubt save lives on a daily basis. But we felt safer, more cared for, and far more at peace delivering at home than we ever did at the hospital. Birth is a natural process, not a medical emergency.

    July 22, 2010 at 18:16 | Report abuse | Reply
    • Rose

      I find it interesting how attitudes can be so different. I needed a csection and was extremely grateful to have the support of physicians and nurses there when nature wanted to kill me and my baby. Your wife needed a csection and your thoughts with number two was "lets do it at home." I'm also confused with people's attitudes of "birth is natural." So, what does that have to do with anything? I can think of a half dozen things right now that are natural and deadly: 1. Tornadoes 2. Heroin 3. Cancer 4. Hearth Attacks 5. Cyanide 6. Placental Abruptions.

      July 22, 2010 at 18:34 | Report abuse |
    • ND

      Wasn't "my thought" by a long shot – I was actually quite against it at first. The important thing in my mind is choice. Women should be able to do things the way they want to, given all of the facts and a clear understanding of the risks and benefits. Your C-section must have been different than ours if nature wanted to "kill you and your baby". My wife was regarded as an inconvenience to the hospital because she was taking too long. They like to dress it up in fancy terms like "failure to progress" and what not – but basically there was no danger to anyone at that point.

      As for "natural" things, we often find that needlessly intervening in a natural process yields unwanted results – like a 30+% C-section rate and among the worst infant and maternal mortality rates in the developed world.

      July 22, 2010 at 18:44 | Report abuse |
    • DC

      Wow, ND, you must be a nathuropath because you really don't understand the risks associated with complicated deliveries and the legal environment true medical professionals deal with these days. If a VBAC is safe for a mother most OBs would definitely opt for it...faster healing time, no surgical issues.....Most hospitals have just decided they don't want to deal with lawyers and parents who realize their bad decisions have consequences .....something wrong happens and they are looking for someone to blame.

      July 23, 2010 at 00:48 | Report abuse |
  21. Ignorance is Bliss

    ND
    Death is a natural process also, one that in the US, has been used by lawyers to line their pockets in the name of defending the unprotected! specially a YOUNG starting family with a new born or a lone father left with a small 3 year old baby when his wife, love of his life and his other baby died at the hands of the doctor that didnt really tell them the dangers of VBAC...

    I guess your children dont have vaccination either because mercury can lead to mental retardation, ha?
    all I have to say to you is UTERINE ARTERY RUPTURE and those seven minutes will be your last. People are so naive that forget that in the up until our surgical techniques and infection control methods became effective, becoming a mother was a VERY DANGEROUS endeavor. I guess C-sections saved too many people, including those that nature would have weeded out.

    July 22, 2010 at 18:36 | Report abuse | Reply
    • ND

      Fear-mongering is fun and all, but the facts at hand don't support your claims of imminent and grave danger. You go on spreading the FUD, I'll rest comfortably tonight thankful I live somewhere that allows my family to make informed, educated choices and choose the path that's best for them.

      July 22, 2010 at 18:49 | Report abuse |
    • Ignorance is Bliss

      ND
      no one said there is IMMINENT danger, the only question is whether you are willing to chance (any chance) of your baby's life and your wife's life just to say you had a VBAC? obviously it wasnt your life, it was your wife's so I see why you're so non chalant about it. If that well informed, educated choice had killed your wife and baby you'd be here singing a different tune, saying how the millions you won from the evil doctor wont bring your baby and wife back and you'd give it all back to have them back (which we know wouldnt be the truth either), and how that SMALL risk is a REAL risk and should be taken seriously.

      July 22, 2010 at 18:56 | Report abuse |
    • Pirogi

      Wow, ignorance really is bliss, apparently. ND has already stated that VBAC wasn't his idea, and he was against it initially.

      What many here are STILL failing to grasp is that how a woman births is the choice of the woman. Period, end of story, goodbye. It's not up to the husband to decide if a VBAC or a c-section is the safest choice. It's not up to the medical societies, the lawmakers, or the courts. It's not even up to the doctor. Obstetricians, like all doctors, are paid consultants, nothing more and nothing less. If a woman has been given both the risks and the benefits of VBAC and cesarean surgery, then her choice should be respected, whether her choice is to attempt a trial of labor, or to schedule repeat surgery.

      July 23, 2010 at 13:09 | Report abuse |
    • Pirogi

      I also find it interesting that you, as an obstetrician, are lauding the success of "infection control measures!" Infection control did lower the maternal mortality rate, yes, but only because obstetricians had CAUSED it to skyrocket in the first place, when they began moving women into the hospital for birth instead of the home, and didn't know to wash their hands or change their clothes in between patients. Doctors would move from patient to patient, and occasionally from cadaver to birthing mother, without gloves or hand-washing. The result was a huge increase in death from puerperal fever among women who had given birth. Then – *drumroll* – doctors swooped in to save the day, by beginning to wash their hands!! Hooray for them!!!

      Seriously, infection and certainly death from infection is nearly NEVER an issue if you keep your darn hands OUT OF THE WOMAN'S VAG!NA during the labor and birth.

      July 23, 2010 at 14:01 | Report abuse |
  22. Veggie1970

    A question for the OBs posting here...I know there is a possibility of rupture even with an unscarred uterus. How does it compare with the risks for a woman who has had a previous c-section?

    Also, is there a point where a c-section is no longer an issue? When I delivered my 4th, my c-section baby was almost 13. My doctors (I had many, my last two months were hospitalized) told me that after so much time and "proving" myself with 2 prior VBACs, they wouldn't even worry about the previous section.

    July 22, 2010 at 19:28 | Report abuse | Reply
  23. Kerry

    I had a C section in 2004 when my son was found to be breech several days after his due date (repositioning him externally was not possible). I had a VBAC in 2007 with any practitioner I saw at any appointment during the pregnancy being supportive but skeptical. I am glad I had a VBAC but was also well aware of the risks as I had a sister in law who had not only a tear in the uterus duting an attempt at a VBAC but a tear in the urinary bladder as well. Luckily both she and her son did fine after emergency surgery but people who think a VBAC is a no brainer and the best way for everyone need to consider the risks carefully

    July 22, 2010 at 20:14 | Report abuse | Reply
    • ignorance is bliss

      Kerry
      AMEN dear
      my handle was chosen for a reason. if only people KNEW all the risks, then they'd act like a doctor. unfortunately there are so many complications that can happen, and few that we havent thought about, you cant really EDUCATE or counsel people properly, and when there's a disasterous outcome, the first cry to the lawyer, "I WAS NOT INFORMED"
      LAWYERS, are the problem one, and being judged not by PEERS (other MDs) is the other,(why dont pilots get judged that way? FAA has an expert panel that evaluates the cases on by one)..

      July 22, 2010 at 20:27 | Report abuse |
    • LocalVBACtivist

      Kerry
      I just want to clarify for readers who may be less familiar with VBAC and its risks: a tear (or "rupture" as you put it) of the urinary bladder is NOT related to VBAC.

      July 23, 2010 at 09:57 | Report abuse |
    • Pirogi

      Ignorance – what is a clear choice to you (after many years of indoctrination, fear of birth, and fear of losing your expensive house in a court case), may not be as clear cut to others. It is highly elitist to assume that only your exceptionally large head can fully grasp the risks of VBAC. Ridiculous, and a stellar example of WHY our cesarean rates are astronomical in this country.

      July 23, 2010 at 13:13 | Report abuse |
    • OB doc

      Local VBACtivist:
      Of course the VBAC is related to the tear in the urinary bladder. How do you think it happened? The uterus ruptured, tearing into the bladder, which may have been in an altered anatomic state due to the previous surgery (or not). I have seen this very thing in practice. Your comment only serves to reinforce the idea that a certain segment of radical VBAC activists (the "trust birth" crowd) lack the knowledge to really know the risks.

      July 23, 2010 at 20:36 | Report abuse |
    • Liutgard

      Interesting. I actually know a woman who had a urinary tear during birth without a previous c-section. Without a uterine tear. Now how did that happen?

      July 24, 2010 at 10:57 | Report abuse |
  24. Lau89

    "Ignorance is Bliss," you really appear to be much more argumentative than you are informed. You're arguing that VBACs are the risky choice as apposed to repeated C-sections, yet repeated C-sections ALSO carry risks. Once you get to 3rd, 4th, 5th pregnancies the risks of complications from so many C-sections are GREATER than that of having a VBAC. Maybe you should educate yourself on the topic beyond reading one online article before you decide to argue about it with someone who is obviously much more informed on the topic than you.

    July 22, 2010 at 20:28 | Report abuse | Reply
    • ignorance is bliss

      Lau 89
      I AM an ob/gyn and deal with mis-informed, poor decision maker, waiting to sue people ALL the time. a large study in the British medical journal in 2004-05 compared the outcome of over 65000 deliveries, 2 deaths in over 30000 vaginals, 0 in over 35000C-sections!!! complications SURE, but DEATH is the ultimate complication and an ob/gyn doing a routine repeat c-section @ 730 in AM can manage ANY COMPLICATION better than the same ob/gyn crashing a STAT c-section on a VBAC managing the same complication. but then again, there is no law about being stupid and IGNORANCE is BLISS, so ENJOY

      July 22, 2010 at 21:00 | Report abuse |
  25. Katie

    I just delivered a baby 2 wks ago. He was an attempt at VBAC after twins delivered by C-section almost 7 years ago. He and I are both fine now, but my uterus and bladder ruptured and were undetected prior to the C-section. I'm counting my blessings everyday that we're both okay and I now question if my decision to attempt VBAC was the right one.

    July 22, 2010 at 20:42 | Report abuse | Reply
    • ignorance is bliss

      I wonder whether you really considered the possibility that THE complication could happen to you! Human nature is to be an optimist (my personal opinion), and I think most people say" hey, numbers are with me", until it happens and one becomes a statistic. you want the safest way, ask your ob/gyn whether he/she would have a VBAC and let the person that deals with pregnancy, delivery and its complications EVERYDAY, be your guiding light.
      Most people have 2-4 pregnancies per life time and even if you include all their family members and their pregnancies, a given woman doesnt have much more experince than say 100 deliveries??, that's about a 3 -5 month average per PRACTICING ob/Gyn, so once you include the EXPERIENCE factor, all else should be self explanatory

      July 22, 2010 at 21:06 | Report abuse |
    • Liutgard

      Ignorance, please tell me that you don't drive...

      July 24, 2010 at 10:59 | Report abuse |
  26. Your Mother

    Regarding attempting a VBAC at home.......there is no law against being stupid.

    July 22, 2010 at 20:54 | Report abuse | Reply
    • ignorance is bliss

      nope there isn't, but I think we should be able to stop them from procreating as a society since the society ends up bearing the cost of their stupid mistakes often,, since over the long run we want smarter people and NOT dumber ones,(please include all the adults that enjoyed childhood vaccination themselves yet deny it to their children in the "to be sterilized"group as well)

      July 22, 2010 at 21:10 | Report abuse |
    • ignorance is everywhere

      Bliss, since you're a doctor and all, what do you have to say about the Netherlands, where 70% of babies are born at home without obstetric care, and they manage to kill less mothers and babies than we do in the process? I mean, if we're going to go around sterilizing a whole group of people for being "stupid", surely we should be confident and rational in our motivation for damning them and their "ignorant" ways.

      Frankly if you're representative of the doctors I can choose from when seeking my own medical care, I just might be inclined to stay at home as well.

      July 22, 2010 at 23:03 | Report abuse |
    • Ignorance is bliss

      Ignorance is everywhere
      If I lived in Netherlands I wouldn't be bombarded by ambulance chasing dogs all nugget promising me millions because I farted n soiled my pants because I ate a burritto! Also I'm okay with home births, so long as it's informed n low risk pregnancy. But I really gave to defend the Dutch here since you want to apply their lessons to our population.
      1) they are better educated,
      2) they respect their doctors, if an md tells them to come to hospital they DO, instead of giving lectures about "what I saw on TV"
      3) they are active, healthy and not50%obese
      4) they accept nature and death, not use death as an excuse to get rich
      5) they don't do home birth WITHOUT prenatal care, they go to midwives and MDs for care and have their checkups regularly
      6) they have SMALL(1-2) kids at most, not much chance for obstetrical complications when you have so few kids
      And last but not least, if you are going to go to a doctor, might as well listen to the expert otherwise yeah you should stay home and drink off your ailment, or maybe listen to a lawyer or evils of vaccination from a nut job that we have so many of on radio n tv filling the minds of people with pure idiocy, but then again what should I expect from the under-educated masses that are so gullible they listen to health advice from an actress rather than an expert!

      July 23, 2010 at 01:41 | Report abuse |
    • Amy V. Haas, BCCE

      Have published on the subject of HBAC - from a research point of view it appears to be a viable option for low risk women. However, more research needs to be done. Midwives do need to screen carefully. If you want a copy of the publication let me know.

      July 23, 2010 at 10:32 | Report abuse |
    • OB doc

      Ignorance is everywhere;
      The Netherlands has the highest neonatal mortality rate in Europe. Look it up. They have even convened a commission to look into the reasons why.
      Blep: you clearly have no idea about what an OB doc actually does or what they make. I'm not the CEO of Halliburton, for God's sake. And I'm glad you think that 12 years of postsecondary education and missing out on countless times with my family while caring for yours deserves no respect or renumeration. I love my job and wouldn't do any other, but when I'm having a bad day, attitudes like yours make me wish I had gone into a different, less demanding field. I don't think I'm a god, but if you know so much, just stay at home.

      July 23, 2010 at 20:43 | Report abuse |
  27. Lau89

    "Ignorance is bliss," I find it hard to believe that you're an OB-GYN considering how poorly you present yourself, but okay. What worries me most is that you're responsible for the care of other people, yet think so poorly of them and don't respect your patients' rights to make informed decisions for themselves. Just because you THINK you're right doesn't make everyone else stupid. If you're a doctor, I would assume you would respect research, and there is plenty of it to support the safety of VBACS, home births, etc.

    If you're argument against VBACs is the liability faced by doctors, fine, I get it. But if you're argument is that they are unsafe, you are clearly wrong. Statistically, less than 1% does not constitute unsafe.

    July 22, 2010 at 22:07 | Report abuse | Reply
    • Ignorance is bliss

      Lau89
      If you were to build a house made of straw despite the warnings from your engineer, and then complain once the big bad wolf blows it away, you ARE stupid!!, clear n simple, no choice just pure stupidity, if you choose to go to a doctor, who has had at least 12 years of post high school education( college, med school n four years of residency) you have to give some deference to their recommendation, to think that a HS diploma or I saw a baby born on tv doesn't make one educated nor well informed. VBACs are safe the great majority of the time no doubt about it, but when the patient that was well informed n signed multiple consents suffers the consequences, you won't believe how all of a sudden they DIDNT UNDERSTAND or WERENT explained to properly comes up when they sue n threaten the livelihood of the doctor involved, and why do they change their story? MONEY, n ambulance chasing dogs that run commercials on tv promising millions if you sneezed backwards at a fair.
      So why should a doctor, risk their life's work n family's livelihood for something that really isn't even appreciated? And not even rewarded financially by health insurance companies ( the pay for vaginal and VBAC, and c-section is the same!)

      For those of you promoting relevant research n data,, consider the people that write these papers,, just ask the authors of the study when was the last time they delivered a baby, and you would be surprised that none of them PRACTICE obstetrics any longer,they just publish papers! and won't even follow their own guidelines....

      July 23, 2010 at 01:24 | Report abuse |
    • Liutgard

      Lau89, I'm a bit skeptical too- at the very least I would expect a college graduate (much less a graduate of medical school!) to have better spelling and grammatical skills. And before the 'I'm in a hurry, my time is worth too much to both checking my spelling!' excuse comes up, I would like to say that anyone with so little attention to detail should not be in a responsible profession.

      I'm beginning to wonder if I should administer a basic spelling and grammar exam to my daughter's OB. I don't want my grandkids learning any bad habits. 🙂

      July 24, 2010 at 11:06 | Report abuse |
  28. US Medical Resident

    As a resident who is not yet jaded, I find it so sad to see the fear mongering that the general public does with regard to their doctors. Many of us have worked very hard not only at trying to obtain a vast knowledge base of the medical and scientific literature, but newer doctors are coming from medical schools that place great emphasis on bed side manners and the patient doctor relationship. However, everywhere I look, it seems that the media and in particular, the government when it went on its crusade against the medical community, have pushed hard to create a general sense of distrust between the doctor and the patient. This article is yet another example. The reality is that VBAC is a hot topic because no one wants surgery and everyone wants to be natural, but there are risks associated with VBACs as there are with childbirth in general. While the risk is low on a person to person basis, when looking from a population standpoint, how many people are included in 0.25% of the population giving birth each year? It is wonderful to say this is so low and one would like to opt to take the risk, but when it happens to you, and it is personal, no patient wants to hear that the risk is so low and they are just a very unfortunate statistic. This type of ideology is a far reaching problem that faces the medical community and the patients at large in almost every aspect of care. The question is do we practice medicine in a manner geared towards the individual or the population. Lets take the mammogram as a fine example:

    The risk of breast cancer in a 40-50 year old is lower than those women over 50 in the general population. There is a chance that a mammogram could look suspicious in a woman without breast cancer, but because it looks funny to the radiologist, the patient comes in for a biopsy and then worries for 10 days until they get their biopsy results back (false positive). As we struggle with how to deal with medical management (individual or population) recommendations change. In the case of mammograms, it is now not recommended by the USPSTF (government preventative medicine body) to have annual mammograms from 40-50 years of age. Statistically, they determined that the benefits do not outweigh the risks (biopsy and mental anguish associated with a false positive). That said, what do you do when you are a 43 year old who has breast cancer? You fell through the cracks now. You would not feel better if your doctor told you that the recommendation if really for the population at large and unfortunately you were unlucky. This is the exact same problem with VBACs. What do you do about those who fall through the cracks and have serious complications associated with their VBAC?

    Moreover, to address the defensive medicine comments: it is real and it does occur. Just as anyone who works in any other field likes to check their work before they make decisions, so is it true for a doctor. Not only can we get sued if we a wrong, but more importantly, our errors (and we are human and do make errors) result in direct damage or even death to our patients. This is not acceptable. Law suits merely reinforce this concept. A great example where people think it is all about the money when it is CYA medicine: A patient comes in with a new headache that is unlike anything they have had before and though there is a greater than 90% chance that the headache is not due to a tumor or a bleed in the brain, the doctor may choose to order a CAT scan or MRI of the brain to make sure they do not miss a brain tumor or bleed. The doctor's clinical judgement says that there will be nothing wrong on the scan, but just to be sure, it is ordered anyway. This then goes back to the main issue: personal or population based medical care. It costs the system money when this CAT scan or MRI is ordered. Now the question is whether it is worth the scan not only to CYA, but to be sure that the patient is OK then these issues need to be weighed against whether the cost is OK.

    I know this is all over the place, but if there is one take home message it is you as the patient need to ask yourself:

    Do I believe in personal medical care or population based care. You then need to think about how this applies to you seeking of medical care. If you are pro-VBAC, you are for individual care and not population care. This means that cost is not important to you and you are not concerned if premiums continue to rise for everyone. This type of thinking is OK, but wanting individual care does mean higher costs.

    July 22, 2010 at 23:01 | Report abuse | Reply
    • heather

      You ask, "What do you do about those who fall through the cracks?" I say, let them fall. Let me, if that turns out to be the case. If it's true that women aged 40-50 are no longer advised to receive standard annual mammography, and I'm 43, and I have breast cancer that goes undetected, I say, those are the breaks. That's life, that's death, that's just the way it goes. If I'm a woman who seeks a VBAC (as I once did and was grateful to experience), and I rupture, I would feel all the terrible feelings associated with the experience, but that's life. And let's see...it's cheaper NOT to do so many mammograms, and it's cheaper NOT to do so many surgical births, so making these things medically mandatory would only save money, which is great for EVERYONE.

      July 23, 2010 at 03:15 | Report abuse |
    • LocalVBACtivist

      I think your logic is incorrect. VBAC, if it was embraced and supported, would lower costs to the community. Fewer surgeons, fewer surgeries, shorter hospital stays, increased success of breastfeeding, lower rates of asthma, lower change of hysterectomy and blood transfusion for the mother. These things are expensive, and are easily solved by cutting out (no pun intended) the middle man. Leave women in peace to deliver their babies the way their bodies were made to do it, and the toll on society goest down. Granted, the bigegst piece of this puzzle is lowering th primary cesarean rate through changes in education, perception and liability.
      I hope that going into your career as a physician you are able to balance what's right for the patient and what's right for yourself. It IS about the individual.

      July 23, 2010 at 10:04 | Report abuse |
    • Liutgard

      "If you are pro-VBAC, you are for individual care and not population care. This means that cost is not important to you and you are not concerned if premiums continue to rise for everyone. This type of thinking is OK, but wanting individual care does mean higher costs."

      This is the worst sort of tautology. Individual care does not mean higher costs. Individual care is absolutely necessary in maternal and infant care. Every birth is different, and every birth has to be approached with fresh eyes. It is when you demand 'population' care that you run into trouble. Treating everyone alike means that some women will be forced to meet arbitrary deadlines, and arbitrary deadlines and cookie-cutter care means more intervention (which costs more) and a higher rate of c-sections, which also cost more.

      We spend the most money per capita of any nation in the world on our health care, and we get the worst results. We have the highest maternal and infant mortality rate in the developed world. Your preferred model of care delivery DOES NOT WORK. What women need is not more rules and more scare tactics. What they need are caregivers who listen to them, who pay attention to their concerns, and support them. They do not need to be rushed, frightened, pressured.

      Birth is messy and unpredictable. If you want predictability, then lobby for laws that demand that every woman be fitted with a zipper and a stopwatch as soon as they find out they're pregnant.

      July 24, 2010 at 11:21 | Report abuse |
  29. Lau89

    U.S. Medical Resident, you address the statistical risk associated with VBACS, but you didn't even acknowledge the risks associated with repeated C-sections. The risks associated with repeated C-sections, especially 3-4 and more, are GREATER than that of VBACS.

    July 22, 2010 at 23:11 | Report abuse | Reply
  30. Deron

    My wife had a c-section due to her water breaking prematurely, she wouldn't dilate past 5 after 24 hours so she got the knife. She delivered our 11lb 2 oz 2nd child by VBAC with no issues other than needing a little bit of assistance with the vacuum clamp

    July 22, 2010 at 23:51 | Report abuse | Reply
  31. Pinkristen

    my 1st son was born vaginally in 1994. my water broke 5 wks early, so when my labor started (on its own) they put a monitor on his head. the midwife had this tiny monitor thing that stuck to my son's head! while he was still in me! that monitor thing was used to check his oxygen level or heart rate or both (it was more than 15 yrs ago so i don't remember all the details). after almost 3 hrs of pushing, out came our 6 lb son. he was fine and i was walking w/in about 1/2 hr. it was a quick and easy recovery.
    my 2nd son was growing much bigger. i TOLD the drs this and they didn't listen. i TOLD them this baby was bigger and they blew me off. the day before my water broke (on its own, about a wk early) i begged for an ultrasound to see how big he was. i had the ultrasound and the dr told me he'd be SURPRISED if the baby was any bigger than 7 lbs. i INSISTED he was at LEAST 8 lbs! i was SCARED and the dr blew it off. well, that night my water broke, i went to the hosp and the next day, after about 4 hrs of pushing and miniscule progress (the baby didn't get too far down the birth canal), i was passing out fm exhaustion and whatnot. they did an emerg c-section and the baby was 8lb,2oz!!! I TOLD THEM!!! my 3rd (and that'll definitely be my last) preg was easy breezy! i wanted to do a vbac and they told me the warnings. they told me they'd have that monitor thing on his head again to check his status. i gained only 20 lbs and he felt like the same size as my 1st baby. i couldn't wait! hubby couldn't wait. my labor started on its own a wk early and i went in to the hosp. all was going well for the 1st few hrs. good progress and whatnot. they never put the monitor thing on his head though. it was going so well that the baby's head was already crowning! even though i had the epidural though, i felt this acute pain in my right side. i told the nurse and she mockingly said: "that's labor dear". i could barely argue that this was my 3rd labor and this didn't feel right...i was in waaay too much pain to talk anymore. it was excruciating. i kept TRYING to tell them about the pain for another 20 min at which point i was screaming almost uncontrollably. FIIIIIIIINALLY the dr came in and suggested a c-section. i didn't care what they did at that point, just put a stop to the torture.
    i was rushed into the emer surgery and felt them cut me. i told them i felt it and they knocked me out. i woke up 3 hrs later and after much inquiring, the nurse finally told me my baby was ok now. WTF??? they took him out of me at 10:26 a.m. and didn't tell me what happened till about midnight. my son was sent to childrens hosp in boston and we were told he probably wouldn't make it due to the extreme lack of oxygen and for the amt of time he was oxyen deprived. at best, IF he survived, he'd be brain dead. well, a few days later he did a 180 and was breathing on his own. then he was maintaining his body temp, then he was drinking fm a bottle, ...... he was released fm the hosp a wk later and we were thrilled w/the prognosis...would most likely need coke bottle glasses; would need a wheel chair or, at best, leg braces; and would probably not speak well and/or need speech therapy for a looong time. our son just turned 2...he walks, runs, talks up a storm, and has 20/20 vision.
    we were informed, we don't regret our decision to attempt the vbac. if we were to have another child (and we won't bc i'm thoroughly done :)! ) i'd definitely schedule a c-section. but if we went back in time, and knew then what we know now, i'd still do the vbac...but i'd ask where the monitor was and i'd know not to let the nurse tell me that extreme pain was 'just labor'. i'd ask more questions about that pain. if that monitor had been in place as we'd discussed months earlier, MAYBE, just MAAAAAYBE things wouldn't have been as scary as they were.

    July 22, 2010 at 23:59 | Report abuse | Reply
    • Pinkristen

      ps: baby was 6lbs. i was right about him being small. it wasn't his size that prevented him fm actually getting out of me...it was my ruptured uterus and extreme pain that prevented him fm being pushed i think. he's fine. we're really lucky and we know it. i can only speak from my own experiences, and fm that, i think that vaginal birthing is muuuch less painful, muuuuch quicker recovery, and of course more natural.

      July 23, 2010 at 00:09 | Report abuse |
  32. ED

    I had an unplanned c-section in 1999 due to positioning. In 2002 I had a VBAC, no complications, no problems, no hassles - water broke spontaneously at 6 am, healthy baby girl born at 1:37 pm....hospital had OR and OB standing by the entire time I was in labor ready to go at the slightest hint of a problem. I thoroughly researched VBAC as soon as I found out I was pregnant the second time, talked extensively with the Family Practice doc who ultimately delivered my daughter, talked to the OB extensively, weighed the risks and options, monitored the baby's position carefully - in other words, I made an informed decision on what I felt was the best course for my child - what's right for me and my child may or may not be right for the next person.

    July 23, 2010 at 00:02 | Report abuse | Reply
  33. ann

    My 1st child was born via C-section-1986. It was assumed that my 2nd would have to be born the same way. It was commonthought that once a C section, always a C section. 1989, my 2nd wanted to be born so fast (3 hours total labor/delivery), that no one had time to prepare for a C section. In fact, the Dr. went to have coffee and said it would be all day. He was not in the room when my son was born during a natural delivery. All went well, thank goodness. The doctor apologized for not beleiving , or , encouraging, a natural birth.

    July 23, 2010 at 08:31 | Report abuse | Reply
  34. Scarlett

    In my case, I'm glad I didn't try for a VBAC. Unbeknownst to me, my first OB (who wasn't chosen by me - my Dr was on vacation and I had the on-call doc called in) made an error in my c-section. She didn't make the incision large enough and I had tearing when she pulled out my daughter. The doctor never told me what happened. My sister-in-law, a nurse in Labor and Delivery heard about it from the other nurses and told me what happened. No mention of it was made in my chart apparently because when I went to have my son a couple of years later, my OB asked if I wanted to try for a VBAC. The results could have been deadly - and my OB's practice would have been in trouble since they didn't make any notation about this complication or inform me of the error. With so many doctors covering their behinds - I don't blame any OB who wouldn't want to take chances on a VBAC.

    July 23, 2010 at 10:03 | Report abuse | Reply
  35. LocalVBACtivist

    I hope that these new guidelines will translate into a change in climate in the medical community. I also hope it empowers women to take back their rights to birth in the manner that they feel most comfortable. Without fear mongering and armed with proper knowledge, a woman will intiuitively pick what's in her family's best interest. She doesn't need a hospital or ACOG to tell her what's right. Women aren't dumb, they are just not being given complete information.

    July 23, 2010 at 10:17 | Report abuse | Reply
  36. Amy V. Haas, BCCE

    What people don't seem to realize that in 1997 a study was published in the NEJM that found inducing VBAC moms with prostoglandin gel increased the rate of uterine rupture. The study was misinterpreted by the editor of the the NEJM, and then picked up by the media. As a result ACOG changed their VBAC recommendations (please note ACOG is a medical trade union), which in turn caused hospitals and doctors to change their protocols, almost universally denying women VBAC. At the time Medscape was the only reporting service to correctly interpret and report the actual findings of the study ( inducing VBAC women is contraindicated).
    So in the mean time the medical community had to spend billions of dollars to reprove that VBAC was a good choice for the majority of women who had previously had a cesarean.
    It only took 13 years for ACOG to realize they screwed up and actually had to read the research, and reverse their recommendations back to where they used to be.
    You should all be outraged at the time and waste! Not to mention all the women who have been subjected to unnecessary surgery, and all of the moms and babies who died because of it! ( both the mothers and baby's chances of dying are 3x's higher).

    July 23, 2010 at 10:23 | Report abuse | Reply
  37. Amy V. Haas, BCCE

    Just to balance things out for the medical resident above, here is a list of the risks of a Cesarean:

    Short term risks for mother:
    – Maternal death
    – Thromboemebolism
    – Hemorrhage
    – Infection
    – Incidental surgical injuries
    – Extended hospital stay
    – Emergency hysterectomy
    – Pain
    – Poor birth experience
    Long term risks for mother:
    – adhesions
    – rehospitalization
    – risk of future c-section
    – infertility
    – placenta accretion
    – placenta previa
    – uterine rupture
    Risks for baby:
    – neonatal death
    – respiratory difficulties
    – asthma
    – iatrogenic prematurity
    – trauma
    – breastfeeding difficulties
    – dental disease
    Causes:
    – introduction of Electronic Monitor with high false positive rate
    – fear of lawsuits
    – misconception of risks by public
    – Misrepresentation of risks of vagina. Births to public causing fear
    Sources:
    – Medscape
    – Maternity Center Association

    July 23, 2010 at 10:29 | Report abuse | Reply
    • US Medical Resident

      Wonderful copy and paste. Now interpret these comments. Show some statistics. For example, show me a study that compares VTE disease mortality in the post-CSD patient in an experienced center where anticoagulation prophylaxis and early OOB activity is the standard compared with that of an at home, mid wife VBAC. All this information is wonderful that once can search out and copy and paste without an understanding of what it means or how to interpret, but you need all of the facts. That said, I am not saying VBAC is bad and CSD is good. What I am saying is that you need to talk with someone who actually knows rather than being one of those conspiracy theory people who thinks docs are out to get them!

      July 26, 2010 at 06:13 | Report abuse |
  38. amy

    It's so sad that doctors who give up most of their life (medical school, endless hours of studying, 60+ hours a week of work)to practice medicine have to deal with this. The medical field is full of complexities that our current world has created. People not in the medical field just don't understand the kind of rationale and critical thinking our providers do every minute of every day. Answers and decisions are not just black and white. Everyone who thinks they know so much about medicine I would like to see you save your own life in an emergency or even non-emergency. I appreciate and respect all medical workers and am sorry you have to deal with this type of criticsm.

    July 23, 2010 at 11:02 | Report abuse | Reply
  39. Blogrl

    America is a free country. If a doctor does not want to perform a procedure because it is more dangerous than an alternative- he or she is free to do so. Patients are free to find a doctor (or a midwife) who will do the patient's preferred procedure- and who is willing to be sued if the outcome does not turn out as expected. One cannot expect a doctor to put his or her livelihood on the line just because the patient "knows better" (apparently despite not going to medical school or having any kind of medical background). Medical malpractice suits, even when the physician did nothing wrong (and ultimately wins the case) are extremely expensive. Yes, insurance pays for litigation costs, but the physician's insurance premiums go up.

    July 23, 2010 at 12:04 | Report abuse | Reply
  40. Marie

    I feel both sympathy and anger, all at once, for OBs. They are completely right that the lawsuits and torts have become completely ridiculous and undermine what should be a wonderful and essential profession. Yet so many OBs seem to think just like the lawyers they say they hate.

    When I asked my OB - known to be VBAC-friendly - about doing a VBAC during my second pregnancy, he said, "You have to be prepared to leave your daughter without a mother." He also said I should research it. I did, and found out that his statement was wrong: the NEJM study showed I was more likely to die having a repeat C-section than having a VBAC. It also showed that, as long as you are not induced, the risk of rupture was only .4%, and only some of those lead to bad outcomes. When I sat down and did the math I found that as long as I was not induced, the risk to the baby was about 1 in 4,000 - much less than other common risks in birth, and much less than the 1 in 300 risk of the amnio I had.

    The attitude that C-sections are riskless, and VBACs are risky, is apparently common. An OB on the show Deliver Me tells a potential VBAC patient, "If you want to have no risk, have a C-section."

    I am not sure why OBs perceive C-sections as free of risk - maybe "risk" means the risk of the OB being sued? My guess is they perceive themselves as in control of a C-section, and not of a vaginal birth. Thus they think it must be safer. It's the same reason people perceive driving as safer than flying, even though the opposite is true.

    There's also a lot of confusion about whether a VBAC will be successful, especially if you got all the way to pushing before your first C-section. My OB told me the success rate in this situation - which was mine - was only about 15%. I looked this up too - I found the study he'd cited, but also found two others that put the success rate at 65%-80% even if your first baby got stuck. So I figured I might as well try - maybe baby 1 had been in a bad position and this one would be better.

    I delivered my second daughter safely by VBAC last year with only 45 minutes of pushing. The recovery was 10 times easier than it was with my first, C-section birth. I didn't feel like an invalid; I could change diapers; I could kneel on the floor; I could give the baby a bath. The scar from the C-section caused me pain on and off for 3 years. It is finally gone. And so, sadly, is my ability to believe what doctors say until I read the research myself. It shouldn't be this way.

    July 23, 2010 at 12:21 | Report abuse | Reply
  41. Joe

    Hello people am I missing something here? Last I heard a C-section is SURGERY. Any kind of surgery carries a risk. My first son had some complications due to a C-section. My second son was born at home by a midwife. I'll take the 0.5-0.9% risk of a rupture, thank you. People should just be made aware of all the risks and options and then choose for themselves.

    July 23, 2010 at 14:38 | Report abuse | Reply
  42. Kim

    I'm a former OB and newborn nurse. I completely agree with VBAC after C section if the risk factors are all right. The goal of every childbirth is healthy mom, healthy baby. But folks, let me tell you all it takes is one mother going bad really, really quickly to change your opinion. I've seen it happen. And yes, childbirth is a natural thing that women have been doing for centuries, but women used to die from simple childbirth complications. C sections have saved the lives of many moms and babies. And I've seen women in labor jeopardize their own health and that of their baby because of their insistence on following a written birth plan (the standard joke in OB is–the mom who comes in with a 10 page birth plan is the one who will need the super emergency C section). I'm also astounded at the rise in convenience C sections as well as inducements. Why isn't anyone hollering about this?

    July 23, 2010 at 16:41 | Report abuse | Reply
  43. Kim

    And one more thing-quit bashing the plaintiff attorney and calling for tort reform. Both sides of a lawsuit have a financial interest. Defense lawyers get paid win, lose or draw and it is in their interest to drag things out and run up the hourly billing fees.

    July 23, 2010 at 16:45 | Report abuse | Reply
  44. blep

    Lawyers will be out of medicine when doctors stop covering for each other when they don't follow procedures and kill people. There is a standard and it isn't just the ability to sue whenever you want. Medmal suits are rarely won and doctors who follow procedure can't be sued for a mistake, only for intential disregard for proper procedure. The amount a doctor makes for what they do does not make me shed a tear for them. $150,000.00 is a drop in the bucket to what they bring home each year. Please, stop whining and realize that you are not gods and that the patient still has a say.

    July 23, 2010 at 16:59 | Report abuse | Reply
  45. Shistar

    I've had 2 boys 1st one C-section. 2nd VBAC and i am PG w/ my 3rd. I will continue to go VBAC and if a hospital tells me no then i will simply go to another or get a midwife. I do have to agree w/ Leo that the hospitals are using ladies however this Entire System is using every single one of us. Its not just the ladies, its the men and the children as well. But thats why everyone has the right to choose. You can choose to let yourself be bullied around or simply find ppl and situations that are much more kind to u and ur loved ones.

    July 23, 2010 at 18:24 | Report abuse | Reply
  46. mom

    FYI, my brother in law is a physician, and all he makes is 150,000. So no, that's not always true. He also works 12 hour days, or more with less than one day a week off, precisely because he does care about his patients and spends time with them. Please don't generalize about a huge group of people who don't differ from any other big group of people. All doctors aren't out to get people.

    July 23, 2010 at 18:34 | Report abuse | Reply
  47. Experienced Mom

    I would take a c-section anyday over a vaginal birth/ vback. Sounds like there are several men and women previous to me who have a high tolerance for pain! Lawyers go rewrite our Constitution. Doctors keep up the hard work. Insurance providers read the Bible.

    July 23, 2010 at 19:45 | Report abuse | Reply
    • Liutgard

      You have GOT to be kidding me! C-section less painful than a vaginal birth? In what universe?

      July 24, 2010 at 11:30 | Report abuse |
  48. OB

    As for the comment that a uterine rupture does not involve the bladder, this is why it is impossible for the lay patient to understand all of the risks. Anyone (like me) who has multiple times spent hours after a uterine rupture during VBAC piecing back together or removing what is left of the uterus and bladder while transfusing her blood to keep her alive knows better than the internet reading public what the risks are. A lifetime of urinary dysfunction due to bladder injury , ICU stay, a potentially disabled child, emergency hysterectomy the list is too long to go over. Just as we are supposed to trust what a patient wants, we have to be trusted as well. When a VBAC goes well we all are happy.

    Finally, this study is moot and will change nothing. The hospital and physicians will always have the choice not to participate in VBAC. The unnecessary C Section to be prevented is the first one and that will never happen without tort reform. All you internet researchers look up what happened in Pennsylvania and just try to even find an OB after that. Lobby for tort reform and you at least will have some doctors to choose from.

    July 23, 2010 at 20:58 | Report abuse | Reply
    • Liutgard

      Bladder ruptures happen in non-remarkable vaginal births too. It's just not as fun to talk about.

      July 24, 2010 at 11:32 | Report abuse |
  49. Another OB (Gabor47 elsewhere)

    I completely agree with the poster OB. I am also an ob-gyn physician, doing it for over three decades. Doing the rapid increase of C-section rates I succeeded to keep my primary C-section rate 13.5%, below national average. Then came the oceans of repeat C-sections. Now what? Then came the VBAC. I gladly jumped on the bandwagon. 99% success rate appears to be spectacular, but that 1% can be a horrible disaster. Poster OB correctly described what happens to the mom, but forgot to mention that once a uterine rupture happens, the probability of the baby to die is around 25%. I was lucky, my patients were lucky, I never had to face a uterine rupture, but when I had to perform C-section after failed VBACs (didn't work, baby didn't come out), seeing the paper thin uterus, perhaps minutes away from rupturing scared the heck out of me. Never mind about the lawsuits (which are the sad reality of our practice), just think of the patients and the babies. Medications are being taken off the market by FDA and manufacturers with far, far lower risks than the (about) 1% uterine rupture rate with VBACs.

    People (women) out there don't grasp how high the 1% failure rate of VBACs. Since about 99% seems a spectacular success, almost everybody have a friend, a relative who had a successful VBAC, so they also become proponents. They don't realize that, if the 1% happens to them, that can turn into a lifetime of disaster. Poster OB is correct by stating that the key, the real solution to prevent the FIRST C-section. Which became such a high rate because of the fear of litigation related to regular vaginal birth. Yes, yes, yes, the long term solution to all of these indeed is a very radical tort reform. No space here to explain why. Anyone who wishes to write to me and ASK QUESTIONS (I will not answer those who wish to debate anything) can write to "docobgyn at yahoo.com" email. Make sure you put the word VBAC in the title (I delete many emails with unknown senders with unknown subjects without reading them)

    Dr. "Gabor"

    July 24, 2010 at 08:19 | Report abuse | Reply
  50. Dawn

    I had one C-Section, then two successful VBAC's. My doctor who delivered my second and third babies was terrific. He firmly believed a woman should have the opportunity to try to deliver after C-Sections. When I had my second baby I felt like I had won a race. My body did what it was made to do. I can see the caution many doctors use. But I don't believe every woman should have to continue having C-Sections.

    July 24, 2010 at 09:34 | Report abuse | Reply
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