VBAC on VOX

Low Birth Rates Increase to Highest Rates in 40 Years

There's a lot of other information in the article, so read carefully. Some put the blame on the economy, and while that surely shares part of the blame, I was happy to see that other causes of low birth weights were mentioned: multiple births, lack of prenatal care, and most especially, premature births caused by early, elective inductions. The article did not discuss the reasons these early inductions were done, but I find it interesting that as more and more women are being induced early -- or just having elective Cesareans before 39 weeks -- due to the worry of a "big baby" (>4,000 grams), the number of babies being born weighing less than 5.5 pounds is rising.

Maybe the March of Dimes is right when it recommends that babies should be left to gestate until they're as near term as possible.

If you're worried about a big baby, at least give yourself a chance to birth it; you might just be surprised what your body and baby can do when allowed to work together, without unnecessary interference.

You know, I've been posting all this stuff about statistics and studies and research, and I just realized: none of this is for me. All of this information is really for other people, people who don't yet know that I want a home birth or who don't take me seriously.

So, I'll only be posting studies and statistics that mean something to me. I'm no longer collecting data so that I can "prove" my decision to other people. The point is: I'm comfortable with the risks of VBAC; I'm comfortable with the risks of home birth; I'm comfortable with the risks of having a VBAC home birth. I am not comfortable with the risks of birthing in a hospital.

I will VBAC at home, and no study or statistics will change my mind.

Safety and Efficacy of Vaginal Birth After Cesarean Attempts at or Beyond 40 Weeks of Gestation (Obstetrics and Gynecology, 2005;106:700-706)

Summary: Women attempting VBAC before or at 40 weeks gestation had higher success rates (77.8%) than women past 40 weeks gestation (68.7%). Uterine rupture rates between the two groups were similar. So, VBAC after EDD (estimated due date) is just as safe as before or at EDD, though odds of success are lower.

I can't access the full text, just the abstract, so I'm wondering why the success rates differ between "at term" women and "post-dates" women. My guess is that it has nothing to do with the length of gestation but rather with how a woman's labor and delivery is managed differently once she reaches 40 weeks. Just a guess.

A small study, but interesting, nonetheless.

External Cephalic Version for Breech Presentation With or Without Spinal Analgesia in Nulliparous Women at Term

Note to self: if next babe is breech, as first was, maybe try a spinal during ECV.

VBAC Facts recently posted a written dialogue between a mom in Southern California and an OB acting as spokesman for a hospital that recently "banned" VBACs. Mom's letter is here and the OB/hospital response is here. Make sure to read the blogger's comments after the hospital letter.

If this is representative of the kinds of lies and twisted truths perpetuated by obstetricians and hospitals unsupportive of VBACs, it's no wonder the C-section rate is on the rise and VBACs are dwindling.

Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia -- no increased risk to mother or baby from home births compared to hospital births, but home births had significantly fewer interventions.

Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands -- Conclusions: The outcome of planned home births is at least as good as that of planned hospital births in women at low risk receiving midwifery care in the Netherlands. This is great, except that the Netherlands has a completely different philosophy surrounding birth than the United States. Midwifery and home births are standard choices and comprise much higher percentages of birth than in the U.S. So kind of comparing apples to oranges, but still significant, because it shows that midwifery as the standard model of care is just as good, if not better, for most women than the standard OB care common in the U.S.

American College of Nurse-Midwives Position Statement on Home Birth (December 2005)

In short, low-risk home births had outcomes quite similar to low-risk hospital births, in terms of safety. The big difference is the rate of medical interventions: women giving birth in hospitals had much higher rates of episiotomy, forceps/vacuum delivery, and cesarean surgeries than women who planned home births.

So, midwives attending home births achieved the same safety rates as doctors and midwives attending hospital births, but without all the interventions.

Outcomes of planned home births with certified professional midwives: large prospective study in North America

Objective To evaluate the safety of home births in North America involving direct entry midwives, in jurisdictions where the practice is not well integrated into the healthcare system.

Setting All home births involving certified professional midwives across the United States (98% of cohort) and Canada, 2000.

Participants All 5418 women expecting to deliver in 2000 supported by midwives with a common certification and who planned to deliver at home when labour began.

Main outcome measures Intrapartum and neonatal mortality, perinatal transfer to hospital care, medical intervention during labour, breast feeding, and maternal satisfaction.

Results 655 (12.1%) women who intended to deliver at home when labour began were transferred to hospital. Medical intervention rates included epidural (4.7%), episiotomy (2.1%), forceps (1.0%), vacuum extraction (0.6%), and caesarean section (3.7%); these rates were substantially lower than for low risk US women having hospital births. The intrapartum and neonatal mortality among women considered at low risk at start of labour, excluding deaths concerning life threatening congenital anomalies, was 1.7 deaths per 1000 planned home births, similar to risks in other studies of low risk home and hospital births in North America. No mothers died. No discrepancies were found for perinatal outcomes independently validated.

Conclusions Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.

Contrast this study with the one below.

In short, mothers with multiple VBACs have increasingly lower levels of complications while mothers with multiple elective Cesareans with no labor have increasingly higher levels of complications.

Obstetrics & Gynecology (2006;107:1226-1232)

OBJECTIVE: To estimate the magnitude of increased maternal morbidity associated with increasing number of cesarean deliveries.

METHODS: Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999–2002).

RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively.

CONCLUSION: Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.

Straight from the horse's mouth!

Obstetrics & Gynecology (February 2008;111:285-291).

OBJECTIVE: To estimate the success rates and risks of an attempted vaginal birth after cesarean delivery (VBAC) according to the number of prior successful VBACs.

METHODS: From a prospective multicenter registry collected at 19 clinical centers from 1999 to 2002, we selected women with one or more prior low transverse cesarean deliveries who attempted a VBAC in the current pregnancy. Outcomes were compared according to the number of prior VBAC attempts subsequent to the last cesarean delivery.

RESULTS: Among 13,532 women meeting eligibility criteria, VBAC success increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%, and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively (P<.001). The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52% (P=.03). The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter.

CONCLUSION: Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy.

I feel it important to note that this study does not say that VBACs are always safer than C-sections. It simply reports that once a woman has had a successful VBAC, the likelihood of she having future successful VBACs increases.

Ok, people. Prepare to be shocked. And awed. Great Britain's equivalent to the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynecologists (RCOG), issued a joint statement with the Royal College of Midwives explaining their position on home births.

Their position couldn't be any different from ACOG's.

Here's the full statement. The summary alone will blow your socks off.

Ahem. They issued a joint statement with midwives. See ACOG? Midwives are NOT the enemy.

RCOG and RCM then discuss not only the physical benefits to home birthing (due to lower levels of significant interventions like induction, augmentation, perineal trauma and surgical delivery), but acknowledge that the process of birth -- and its resulting emotional and psychological effects -- are quite important and should be considered when studying childbirth, whether in a hospital or at home.

They honestly state the risks and complications of birthing at home (all of which could also occur in a hospital). They conclude that transfer to a nearby hospital should be a backup plan, if serious complications with the mother or baby occur. They also recognize that some mothers choose to transfer for non-critical reasons, such as epidural anesthesia.

When discussing how to achieve best practices for childbirth, they state: "Both the RCM and the RCOG believe that to achieve best practice within home birth services it is necessary that organisations’ systems and structures are built to fully support this service. These will include developing a shared philosophy, fostering a service culture of reciprocal valuing of all birth environments. Comprehensive involvement by local multidisciplinary teams and users to underpin home birth practices within a clinical governance framework results in a quality service which demonstrates commitment to supporting women in their choices." (Emphasis added by me.)

They further flesh this out by placing birthing decisions into the hands of mothers and encourage care providers to give women unbiased information on the risks and benefits of home birth. They also encourage fathers to be involved in the decision-making and childbirth processes!

This next quote made me blink. Then I read it again to make sure I had read it correctly the first time: "It is acknowledged that there are no known risk assessment tools which have an effective predictive value concerning outcomes in the antenatal period and labour." Hallelujah! Finally, doctors who admit they have no way of predicting the future, especially the future of a woman's pregnancy and birth experience. When was the last time you heard ACOG admit it didn't know something?

RCOG and RCM conclude with recommendations about continuity of care, the importance of communication during the antenatal period, and the necessary service structures that should be in place to handle unexpected emergencies. They encourage employers and government entities to be supportive of home births and warn that discriminatory practices based on place of birth are harmful to both women's health and children's development.

Their conclusion? That while home births may not be suitable for every woman or preferred by most women, they are perfectly acceptable and safe for women at low risk of complications.

My only quibble with this? They don't explain what "low risk of complications" means. That simple phrase leaves an open door for unscrupulous care providers to provide biased information on the risks and benefits of both home and hospital births or to coerce a mother into a model of care she may not be comfortable with.