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Jun112012

HBACs

After some long and deep thinking about this topic over the last couple of years, I’ve come to the conclusion that Vaginal Birth After Cesareans (VBACs) should be permitted to birth at home (a Home Birth After Cesarean – HBAC). I’ve been vocal about my belief that homebirth midwives need more education and skills training and have intimated that breeches and twins should not be born at home, but this is the first time I’ve spoken clearly about my feelings about HBACs.

As I considered this, I re-read the entire National Institutes of Health VBAC Summit’s recommendations a couple of times, read statistics in a variety of journals and then read both pro and anti sites regarding both VBAC (at all) and HBACs. I also tapped into my own cesarean and VBAC experiences as a doula and homebirth midwife, but tried to take the hard data at least as valuable, if not more so, than mine. In my ponderings, I’ve also put myself in the place of a birthing woman; what would I do if I were considering a VBAC/HBAC? Also, I’ve taken my own daughter’s situation… a primary cesarean, wanting a VBAC… and wondered how I would counsel her. I honestly feel I am infinitely more conservative with her life than I ever was with my own.

While I acknowledge there is risk in VBAC and surely more risk in HBAC, I feel that weighing the risks between a possible rupture versus the risks that can and do occur during and after a cesarean can lead a woman to, with true Informed Consent, to choose to VBAC/HBAC. And in some ways, having an HBAC can be even safer (safer being relative) than a VBAC in the hospital because women are able to be mobile and not be induced or augmented. Of course, women having an HBAC do not have continuous fetal monitoring so there is the argument that early signs of rupture can be missed in a homebirth. I’ll accept that and women choosing HBAC will have to, too. Women at home, however, are able to feel the rupture when an epidural’d woman would not. Not that all ruptures can be felt.

The great majority of ruptures are slow, not the catastrophic ones usually thought of when discussing this topic. While time is of the essence, there can be enough time to transfer to the hospital if a non-catastrophic rupture begins. (Catastrophic meaning sudden and imminently life-threatening… not that a uterine rupture isn’t a horrible event all on its own.)

In my opinion, the ideal HBAC client looks like this:

  • has had a previous vaginal birth
  • has had only one previous cesarean
  • has had at least two years between pregnancies (not births)
  • does not have insulin resistance issues or gestational diabetes mellitus
  • has not had a previous baby over 9 pounds
  • is not expected to deliver a baby over 9 pounds
  • does not go over 41 weeks 3 days (Seems arbitrary, I know, but will explain below.)
  • has a midwife who is highly educated and amply skilled
  • is within 15 minutes of a hospital, 15 minutes car driving, not ambulance driving (ambulances coming to the home and then getting to the hospital can take 15 minutes or more)

But, ideal is probably pretty rare.

I’ve written that the safest place for birth is in the hospital. Ample staff, access to technology, an operating room and blood products are in hospitals, not at home. So, if one is wanting the safest (with regards to the mother’s and baby’s lives) place for any birth, the hospital wins, hands down. But, there are trade-offs and they do not always have anything to do with “the experience.” At home, technology isn’t foisted on women and babies, technology that can hinder labors and cause more problems than they solve (induction and augmentation as one huge example). Women are also treated as human beings and while this might seem “experience-y,” civility can help women relax and allow their labors unfold as well as trust the provider more and, therefore, be more inclined to share worries or concerns about what is happening in the labor.

Regarding delivering before 41 weeks 3 days as the ideal time frame, if a woman is wanting a VBAC, this timeline allows hospital interactions if the birth doesn't happen before then. That labor might begin after that and an HBAC happening, that's certainly true, but I am inclined to want to offer the mom every opportunity for a VBAC and, to me, that includes the hospital "interventions." Again, it does seem awful arbitrary, but just how I feel.

This is, in no way, meant as The End of the VBAC/HBAC discussion, but a beginning. Women must play out every scenario, discuss every concern with their partners and providers (ideally, a medical and midwifery provider in order to get a balanced perspective) and ultimately decide, for themselves, if the (extremely) minimal risk of a catastrophic rupture is worth staying at home. Remembering that uterine ruptures also happen before labor even begins can help them consider the risks.

In this discussion on my Navelgazing Midwife Facebook Page, women have shared their stories of uterine rupture and fetal death, so acknowledging that possible reality is crucial. Weighing each location’s pluses and minuses is vital. The only two uterine ruptures I've had with clients have been with women having their first babies and the women were induced/augmented with pitocin. I've known of other ruptures, but have no experience with any catastrophic ruptures. But, even so, I absolutely understand the risks. (I have seen a maternal death, so totally get risks in birth.)

For me, I would, with the above ideal situations, attempt an HBAC. Even though my daughter hasn’t had a previous vaginal birth or a baby under 9 pounds, I believe that, with care, she could attempt an HBAC next time. That, above everything else I’ve said, speaks volumes. (Not that she would want or try to HBAC; she isn’t pregnant, so moot at the moment.)

I look forward to thoughts and concerns, though I did try to address most of them.  

References (5)

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    - Navelgazing Midwife Blog - HBACs
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    Wonderful Webpage, Stick to the useful job. Thanks.

Reader Comments (23)

Okay, not only 15 minutes from the hospital but a hospital that has a 24hour 7days a week anesthesiologist on site - that is, a place that is set up for VBACs and ready for what might happen anyway. Just being near one doesn't mean it is one that is ready for a VBAC emergency.

June 11, 2012 | Unregistered CommenterEthel

I have no idea why women would want to risk it at all. Yeah the risk of rupture is low but come on! When it happens it needs to be taken care of now not after a rush transfer from your home. By the time you get to the hospital and into the or to get things taken care of the baby is likely dead and you are bleeding out. Why would you mess around with something like that?

"At home, technology isn’t foisted on women and babies, technology that can hinder labors and cause more problems than they solve (induction and augmentation as one huge example)."

I highly doubt that hospitals are foisting technology onto anyone. They are trying to use the tools they have to get the best outcome possible. The studies have shown that induction and augmentation are actually useful and do help more women get a vaginal birth that they want. Why should we allow labor to stall so that the mom becomes exhausted and ends up not being able to push efficiently enough? You claim to have become a reformed home birther but I am not seeing this with this post. You are bringing out all the misinformation that the people obsessed with having a home birth at all costs bring out and not actually really truly looking at the research.

I am never going to understand the obsession with having a vaginal birth. All four of my kids were csection babies. I could have attempted a vbac, but with with my history of large babies that was not something I was prepared to attempt. Call me a wuss if you like but the idea of pushing out an 11 pound baby with a giant head was not something that appealed to me. I am glad that I picked the option that was safe for my children and safe for me too.

June 11, 2012 | Unregistered CommenterAwesomemom

You're right... with a hospital with immediate C/s capabilities.

Awesomemom: I don't think I've ever said I was a "reformed" homebirth midwife. I still believe in homebirth and haven't changed that at all. There are limitations to that, but I still believe homebirth to be a safe and sane option.

If you'd have seen the hospital births I have, you would see that, indeed, pitocin is foisted on women. I've seen it used far more often than a piddly labor and even with piddly labors, other things/positions would have kicked things into higher gear... less technology sometimes/often works, too.

I do NOT believe I am just stating the VBAC party line. Far from it. I am acknowledging that hospital birth is the ultimate safety for mom and baby; that isn't often said. I do believe, as I said, however, that homebirth should be an option for VBAC women.

Didn't expect my opinion to be lauded.

June 11, 2012 | Registered CommenterNavelgazing Midwife

As a doula (and former apprentice midwife) I see births including VBACs, in the hospital and at home. It is not uncommon for doctors in the hospital to want women attempting VBACs to have continuous monitoring, an IUPC, and progress under very stringent guidelines or they push pit. They often use these to negotiate "allowing" a woman a TOLAC. I would call that foisting technology onto a woman.

June 11, 2012 | Unregistered CommenterRachel

Interesting... My midwife (and the hospital she practices at) sort of specializes in VBACs. It's a big thing they promote there. I've never had VBAC so I can't speak from experience, but it was not my impression that technology is foisted on anyone. I'm betting they'd want to monito more regularly, (I don't remember being monitored more than every couple hours) but I doubt they'd push for an epidural. Mayb a heplock in case you need blood (does a heplock work for blood?) but I'd been dreading a heplock and ended up needing one (strep b +) and even with my needle issues I really didn't notice it once things got going. I realize not every hospital is like that, but at that hospital I dont see how the comforts of home would outweigh the peace of mind of being in a hospital? But homebirth is already outside my risk threshold so I guess I'm a little biased. :-)

June 11, 2012 | Unregistered CommenterMeagan

Here's what I find confusing: You have decided that you support home birth for VBAC in limited circumstances, but you do not support home birth for breech or twins. You also talk a lot about the need for adequate training for midwives. Perhaps as a layperson I just have a very poor understanding of where the various risks in birth come from, but it seems to me that in all of these situations, you have the possibility of something going very wrong very quickly, but with twins and breech, the skill of the attendant has a lot more to do with the outcome, whereas with VBAC, it's mostly luck (assuming no pit). Either there is a rupture or there isn't. I don't understand where you see midwife skill coming into play here. Or is it just a numbers game? That a higher percentage of breech births will result in head entrapment than VBACs will result in uterine rupture?

June 11, 2012 | Unregistered Commenterchingona

I appreciate your blog and your perspective, I however have to disagree with HBAC. While I do think that your ideal circumstances would provide an added layer of safety, I still see issues with training and oversight that preclude this as being a topic we could call "safe".

One of the largest issues that is present in homebirth currently is the apparent willingness of midwives to accept women who should be risked out of homebirth. There are so many stories out there of HBA2C and HBA3C that while don't all end in catastrophe do show that without oversight it can't be guaranteed that women are appropriately risked out nor that precautionary measures are taken. For instance in your ideal situation I would say that a sonogram should be on the check list, it is important to know in VBAC that the baby is positioned well, an approximate (while imperfect) weight, and that placenta accreta or previa is not detected - though accreta is not often detected until labor. Many midwives don't require/recommend/encourage sonograms and again there has to be the oversight to ensure precautions are taken, a woman is told why a sonogram is more strongly recommended and is clearly able to make informed choice.

Midwifes have to be trained and aware of how to spot a rupture and FAST. In a whole lot of those stories where rupture does occur it is not quickly identified and acted upon in the home setting which can turn a non-catastrophic event into a catastrophic event.

Also, without adequate communication between the hospital, an OB and the midwife while 15 or even 5 minutes to a hospital may seem fast enough, if the midwife cannot adequately inform the hospital of the situation prior to arrival, does not have well documented, complete and understandable patient notes, or have an OB back up that is on call and affiliated with the hospital that has done per-registration for the mother the hospital may not be adequately staffed or prepared for the transfer and care of that patient. This affects everything from OR and staff scheduling, to blood products and is something that should be considered. A whole lot of hospitals won't do a TOL with VBAC unless they have 2 ORs fully staffed and operational because they can't guarantee that another emergency won't happen that occupies the OR. From walking in the door there is a whole lot of delay at the hospital and without communication and continuity of care that can not be mitigated.

Just the fifteen minute drive is too long for a mom to bleed internally and a baby to go without oxygen. Even with everything ready at the hospital (let's pretend that midwives have an OB backing them and the hospital is on notice about the HBAC occurring and aware of the possible transfer) I think that the 15 minutes is actually very misleading because even best case scenario if oxygen to the baby is compromised for fifteen minutes we are still talking brain damage and we all can see it is not realistic to expect that a hospital will perform a c-section within 5 minutes of walking into the door as our current homebirth setting happens in the majority of cases.

Even in the best case scenario, the mom has to accept that the risks of VBAC at home may well include loss of life for herself and child and I think that if midwives honestly set down patients and sincerely said "the safest place for you to deliver is in a hospital" without a but, or other mitigating statement that most women wouldn't choose that risk. And most midwifes would NEVER make that statement.

We also can't forget that a woman who has had only a c-section and one pregnancy still has what is considered an unproven pelvis. We also must consider that with subsequent pregnancies after c-sections the risk of a complication related to a prior c-section still increases and compounds, so the first HBA1C isn't the most risky it is each and every after that where risk increases. We must also consider when we make these endorsements that a large issue happening with homebirth is the midwife accepting risk that shouldn't be accepted and where rules can be bent they are and will be bent per the impression of that midwife. Without regulation, training and oversight that bending of risk and wide ranging midwifes views on what informed consent entails, what actual risks are, or what is acceptable standard of care and action can and will be deadly.

June 11, 2012 | Unregistered CommenterCourtney

As an anesthesiologist I feel the need to clear up your misconception about the "connection" between a woman with an epidural and a delay in diagnosis of uterine rupture.

That is very old thinking.

The first sign of uterine rupture is often fetal heart rate abnormalities NOT pain, NOT uterine tenderness, NOT maternal tachycardia. Pain, uterine tenderness and maternal tachycardia have low sensitivity for lower uterine scar dehiscence or rupture.

I refer you to a study by Johnson and Orieol which reviewed 14 studies of VBACs that included 10 967 patients. (Reg Anesth 1990, 15:304-8). 5 of 14 patients with an epi who ruptured had abdo pain. 4 of 23 patients without an epi who ruptured had abdo pain. The most common symptom of UR was an FHR abnormality. An epidural did not delay diagnosis.

Given that symptoms of UR that can be easily be determined at home (pain, uterine tenderness, maternal tachycardia) are non-specific and, in fact, not commonly the first signs, and that the first sign (FHR abnormalities) are not easily picked up at home with intermittent doppler auscultation (which will miss changes in variability), and further that the consequences of uternine rupture for both mom and baby can be devastating, I believe encouraging HBACs is irresponsible.

There is simply no way to get a uterine rupture from home to the hospital quickly enough to allow intervention that would reduce maternal and fetal morbidity and mortality.

June 11, 2012 | Unregistered Commentertheadequatemother

As a mother who had had a VBAC both in the hospital and at home, I thank you for your support of HBACs. Given the choice again I will still choose HBAC and it's bc of people like you who will support me that I have that opportunity to make my own choices in birth.

June 11, 2012 | Unregistered CommenterALW

chingona says:
"... whereas with VBAC, it's mostly luck (assuming no pit). Either there is a rupture or there isn't. I don't understand where you see midwife skill coming into play here."

Besides my belief that midwives need more education and skills training in general, it requires a midwife who adheres to the appropriate standards of listening to the baby... not being laxidasical... so if there are fetal heart tone changes they are caught earlier rather than later.

Skill also refers to the midwife recognizing the difference between normal birth and abnormal descriptions from mom. An example: I had a mom I was monitricing for and when I went to her house, she was having pain in her scar, during contractions especially. While that *can* be a normal part of a VBAC labor, it can also NOT be normal and I took no chances and took her in right away even though the baby sounded fine. She didn't rupture, but had a great VBAC. I erred on the side of caution and believe ALL midwives/monitrices/doulas should do the same.

June 12, 2012 | Registered CommenterNavelgazing Midwife

I know arguments can get heated, but I always enjoy a good debate and I also find it satisfying to hear how much people care about these topics. People obviously care hugely about mothers and babies, even apart from those in their immediate family.

In my view HBACS are a little dangerous. CEMACE reckons 1 woman died in the UK between 2006-2008 from uterine rupture, which is one too many but still a tiny risk for VBAC.

The risk of having a baby die is about 10 per 10,000. This is a bit higher than for a planned repeat CS, which is about 1 per 10,000 (NICE intrapartum guidelines). These are not brilliants stats but elective cesareans carry their own risks, and there are things like infection risks and damage to the mother to think about.

Sorry to be a bit boring but every woman has to research their own options and choose a way of doing things with a care provider they trust. We should provide as much information as possible and then let people make their decisions as adults. If we enforce any one line of care we get into dodgy moral ground.

June 12, 2012 | Unregistered CommenterEllie

So because most ruptures are not catastrophic, there would be time to go to the hospital if the midwife is skilled enough to pick up the signs? But with, say, head entrapment, there simply is no time to transfer? Is that the distinction?

June 12, 2012 | Unregistered Commenterchingona

I'm a longtime fan of your site, and only a very occasional commenter =) But on this one I had to weigh in!! I'm Canadian, and have had 2 VBACs. I have 4 kids; primary C/S, adoption, hospital VBAC, and hospital VBAC. With my 4th baby I wanted an HBAC, and here were a few of my reasonings;

-safety; it being my second VBAC my uterine rupture rate dropped from 0.4% to 0.2%. 0.4% is considered a low rate of occurance in obstetrics for any emergency, and 0.2% even lower. The percentage of catastrophic ruptures is only 5%, according to the Cochrane Review. 5% of 0.4% is pretty small.

-also; prolapsed cord is a comparable obstetrical emergency requiring prompt surgery and whose risk lies with the baby, similar to VBAC (VBAC risk is also maternal but lies mostly with the baby), and prolapsed cord happens in 0.6% of births. If we consider all low risk births to be safe enough to deliver at home with a 0.6% risk of prolapsed cord, it follows that it is reasonable to deliver at home with a 0.4% or a 0.2% risk of uterine rupture (only 5% of which are catastrophic).

-I live in BC, Canada, and the BC College of Midwives considers HBAC to be within the midwifery scope of care and that midwives in our province act within their licensure by attending HBACs (despite this it is difficult to find a registered midwife who will attend an HBAC, which was frustrating for me).

-There is much about physiological birth that we have yet to understand and discover. The physiological process of birth is optimized in a home environment. The benefits are many.

-My first VBAC was 10 lbs 2 oz. Why disqualify me from having a 9 lb HBAC the next time? That seems unfair. Perhaps I would volunteer that my kind of situation could be a possible exemption from your 9 lb rule? =P

-On the other hand, hospitals in Canada are much more open to VBAC than ones in the U.S. and women here have the right to informed refusal of any intervention, so the hospital environment is not so inhosiptable as some hospital environments I have heard about in the U.S. Thus, when I developed IDDM (gestational) although I was disappointed, I was still able to have a midwife attended water birth in hospital, with my 3 older kids watching and with intermittant monitoring (chosen explicitly by me) and no saline lock or IV (also chosen explicitly by me), with the lights low, and no separation or disturbance after the birth. So my hospital option wasn't so bad, comparatively speaking. That birth was beautiful, and my daughter was exactly 9 lbs.

-I still felt that I should have had the option of a home birth even with IDDM. My blood sugars were very well controlled with insulin and diet and exercise, I am a healthy weight, and research shows that good glycemic control is correlated with fewer health problems for baby after the birth (particularly blood sugar regulation problems). Women in Holland have the option to have midwife attended home births even in 'high risk' situations; refusals are simply documented and midwives are thus legally protected. This is to me a better example of emancipation of choice for women (and obviously I mean well informed choice). Anyways, this is a side issue. I delivered in hospital, and that was fine.

-My final point has to do with response times. The gold standard in obstetrics for responding to an emergency is 30 minutes from recognition of emergency to commencing surgery. In an integrated system such as the one we have in Canada, home births which take place within 30 minutes of the hospital lose none or very little time in an emergency. Proximity to an operating room DOES NOT GUARANTEE IMMEDIATE ACCESS TO IT. Where I live, a home birth midwife who discovers an emergency is developing at a home birth, phones ahead to the maternity ward and gets the ball rolling for surgery before they even begin transporting. This means that the OR staff is assembled or very close to, and the OR is ready by the time the transfer arrives. Thus, outcomes in urban areas are the same for home and hospital in my area.

Rural areas have longer response times for everything, and rural hospitals take longer to assemble operating room staff as well (if they offer OR services). Home births in rural areas are still safe but parents who choose them need to be very well informed.

-I think my main issue with the VBAC/HBAC discussion is when VBAC is considered 'dangerous' at all. Birth is not risk free, and VBAC birth is safe, particularly if undisturbed, spontaneous, and well supported.

That is my $0.02 on a topic I feel very passionate about, and consider myself to be pretty well informed on. =) Thanks for listening. =)

June 17, 2012 | Unregistered CommenterMelissa Vose

Can anyone tell me how likely you are to rupture before going into labour? It was my understanding that once you've had one caesarean, you're at risk of a rupture even if you plan another elective caesarean at term. Just having once had a caesarean puts you at risk for all future pregnancies; it's not as if planning another one magically eliminates all possibility of rupture.

In the UK, my local hospital had a 78% success rate for VBACs, but I'm pretty sure they discouraged HBACs.

June 17, 2012 | Unregistered CommenterTam

I really appreciate your post here... I'm 28 weeks and planning an HBAC. I hate when people talk about wanting a homebirth for the "experience." if I truly felt safe in a hospital setting, I would, without doubt, be there. Every woman who is planning an HBAC has a story (and they are often more than willing to share)... So it's nice to see someone writing and acknowledging that although a hospital is the safest place for a woman to birth should something go wrong, there are pros to being at home that go beyond the "experience" of childbirth. I find that midwives and obs have blindly followed their own ethos without regard to their client's need for informed consent, making information gathering and synthesis more complicated than it should be.

And it does say volumes that you would support your own daughter's choice in an HBAC.

June 17, 2012 | Unregistered CommenterChristian

@Tam-- this states that there is a 26/100,000 chance of uterine rupture for a rcs. I haven't had time to check the sources, by they are listed if you'd like.

http://givingbirthwithconfidence.org/2-2/a-womans-guide-to-vbac/weighing-the-pros-and-cons/

June 17, 2012 | Unregistered CommenterChristian

Barbara, more please!
I'm enjoying your posts but need them in larger quantities ;) Sorry to be cheeky, i'm off bike touring in 2 weeks and will have limited access to blogs i think so i'm asking nicely if you have anything interesting brewing you could post it before then. Feel free to ignore me if you're busy :) Also, do you have any brilliant, engaging m/w book recommendations I could take on a 4/5 day plane journey from New Zealand to Slovenia? My longest stop in the airport (not getting a hotel as i'm too cheap) is 30 hours so they would have to be really fantastic books to keep my occupied. Thanks for any help.
Keep it coming! x

June 17, 2012 | Unregistered CommenterEllie

Comment from Jen "VBACFacts" Kamel:

Melissa, <<The percentage of catastrophic ruptures is only 5%, according to the Cochrane Review. 5% of 0.4% is pretty small.>>

The use of the word "catastrophic" in relation to rupture has been used to describe a couple different events - a complete rupture (as opposed to a dehiscence) or infant death due to rupture. This unclear language has resulted in a lot of confusion.

At the 2010 National Institutes of Health VBAC Conference, the following statistic was shared: "6% of uterine ruptures are catastrophic." But what they meant was, "6% of uterine ruptures result in an infant death."

I write more about uterine rupture versus dehiscence and the 6% statistic here: http://vbacfacts.com/2012/04/03/confusing-fact-only-6-of-uterine-ruptures-are-catastrophic/.

Uterine rupture - an opening through the complete thickness of the uterus - happens about 0.4% of the time in non-induced/augmented TOLAC after one prior low transverse incision per Landon (2004).

June 18, 2012 | Registered CommenterNavelgazing Midwife

Ellie: Wonderful, sweet comment. :)

I've been writing a chapter for a pregnancy book, so have been expending my writing energy there. Just finished today, though, so we'll see what I can do to help you along. ;)

I also just got an advanced copy of Heart & Hands to review, so am working through that, too. Not sure if my review is what they were expecting, but it will be different than the usual obsequious accolades of other midwives. Not horrid (yet), but certainly parts to point out as not so wonderful.

Speaking of, I keep forgetting to post that Dr. Biter settled with the Medical Board. It'll be a few months before we learn the details, but he won't be losing his license (as far as we can tell).

(Doesn't this sound like a newsy email? Filling in your need? *laughingwink*)

How long are you biking for? Where? While I admire you, I could never imagine doing that. Good on you.

I'll keep you in mind as I write. *hugs*

June 18, 2012 | Registered CommenterNavelgazing Midwife

Jen "VBACFacts" Kamel says:

chingona says:
"... whereas with VBAC, it's mostly luck (assuming no pit). Either there is a rupture or there isn't. I don't understand where you see midwife skill coming into play here."

There are many variables that impact how quickly a mom can transfer from a home birth to the hospital in the event of an obstetrical emergency such as uterine rupture. The skills of the midwife present are an integral part of that process. As I write here http://vbacfacts.com/hbac:

"How a complication plays out depends on many variables: the type and severity of complication, how quickly it is diagnosed (based on the skills and experience of your care provider), if it is something that can be managed at home (based on the skills, experience, and supplies of your care provider), if not, how quickly can you get to the hospital (based on the distance, driving conditions, etc), and how quickly the hospital personnel can respond to your complication. Does your home-based care provider have a good professional relationship with the hospital? Can s/he call ahead, inform them of your transfer, and have them ready the OR (if necessary)?"

It is phenomenal that Canada has an integrated system where home birth midwives can call ahead to the hospital and give them a heads up regarding a transfer.

While the 30 minute "decision to incision" is the standard in many areas, research on infant blood gases has shown if the baby isn't delivered (almost always by cesarean) within 16 - 17 minutes of a uterine rupture, there can be serious brain damage or death to baby. You can watch a presentation from the 2010 National Institutes of Health VBAC Conference that goes over the research here: "The Immediately Available Physician Standard" by Howard Minkoff, M.D. http://vimeo.com/10809456. Or read his presentation abstract here: http://consensus.nih.gov/2010/vbacabstracts.htm.

You can read more about the 2010 NIH VBAC Conference here: http://vbacfacts.com/2012/04/11/best-compilation-of-vbac-research-to-date/

June 18, 2012 | Registered CommenterNavelgazing Midwife

Jen "VBACFacts" says:

Tam, <<Can anyone tell me how likely you are to rupture before going into labour?>>

Per Zwart (2009), 16% (1 in 6.25) of unscarred ruptures (women without prior cesareans) and 9% (1 in 11) of scar ruptures (women with prior cesareans) happen before the onset of labor. They found a scar rupture rate of 0.64% (1 in 156) (including non-induced/augmented, induced, and augmented labors.) This gives us a 0.0576% (1 in 1736) risk of a scar rupture before labor.

Zwart (2009) differentiated between uterine rupture and dehiscence and included 97% of births (358,874 total deliveries) in The Netherlands between August 1, 2004 and August 1, 2006, making it “the largest prospective report of uterine rupture in women without a previous cesarean in a Western country.” Of the 208 scarred and unscarred uterine ruptures, 130 (62.5%) occurred during spontaneous labor reflecting 72% of scarred ruptures and 56% of unscarred ruptures. That is because the one factor that increases our risk the most is our prior cesarean. You can read the full text of the study here: http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02136.x/full. I have written extensively about Zwart here: http://vbacfacts.com/2012/01/16/myth-unscarred-mom-induced-as-likely-as-vbac-mom-to-rupture-2/ and here: http://vbacfacts.com/2012/01/16/myth-risk-of-uterine-rupture-doesnt-change-much-after-a-cesarean/.

June 18, 2012 | Registered CommenterNavelgazing Midwife

@NGM, thanks for pointing this out; The use of the word "catastrophic" in relation to rupture has been used to describe a couple different events - a complete rupture (as opposed to a dehiscence) or infant death due to rupture. This unclear language has resulted in a lot of confusion.

At the 2010 National Institutes of Health VBAC Conference, the following statistic was shared: "6% of uterine ruptures are catastrophic." But what they meant was, "6% of uterine ruptures result in an infant death."

this is important to know. Statistics and data on birth need this type of extrapolation for us to really understand them!! Do you know the morbidity rates for VBAC babies? That might be more informative, although I imagine we need to refine the definition of catastrophic.

The more I learn about birth related research and data the more complex I realize it really is. There are just so many variables. But I have to say that for myself, even 50% 0f 0.4% is low.

June 19, 2012 | Unregistered CommenterMelissa Vose

Ah I see, can I ask what book? That's interesting. Ha, yes, good comment and I've been enjoying your posts, breech is a difficult one. It's such a fine line between having faith in women's ability to give birth normally without forgetting that nature can actually be pretty cruel..

Biking: the idea is to go from Slovenia to Turkey, get a plane over the Stans as we're wusses, and then cycle from India to China and down South, possibly to Malaysia. I really want to see Korea but I don't know if we'll be able to, kind of in the wrong direction!

I could never imagine practising as an independent midwife where you are so the admiration is mutual, you're very brave! And also, I haven't done it yet, I'm just talking/writing about it so you should see how far we get first!

June 21, 2012 | Unregistered CommenterEllie

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