This
page includes research, wisdom and information that shows how
safe giving birth after cesarean section really is; it also
shows that VBAC births become less safe when induction drugs
are involved.
For
cesarean and VBAC articles and birth stories, go
here.
For
more medical references, see the page Induction
Dangers.
Click
to go to the desired section on this page:
How
long must one wait after a c-section before having a VBAC?
From
BIRTH AFTER CESAREAN by Bruce Flamm:
"Rumor
has it that its safer to wait several years after a cesearen
section before attempting a vaginal birth. There's absolutely
no evidence for this belief. Studies on wound healing have shown
that tissue regains the majority of its strength within a few
weeks of an operation. The tissue that gives a healing wound
its strength is called collagen. According to a general surgery
textbook, 'Collagen content of the wound tissues rises rapidly
between the sixth and the seventieth days but increase very
little after the seventieth day and none at all after the forty-second
day.' Since the uterine scar is almost fully healed within weeks
after a cesarean section there is no reason to postpone plans
for another baby."
Summary
of 4 Studies on VBAC safetyby Gretchen Humphries. An
excellent paper that illuminates the findings, as well as the
failings, of important research documents. Included: how there
is no study about the outcomes of planned home VBACs.
Women
respond to the Britsh Medical Journal about VBAC (Go to
the bottom of the linked page, and click on "Rapid Responses"
to view the responses.) The BMJ published a news story on 7/14/01
that suggested that "once a cesarean, always a cesarean" is
on the rise again. This page includes wonderful responses form
mothers and midwives about how cruel the implications of this
story (referenced from the damaging New England Journal of Medicine
anti-VBAC paper) truly are.
About
Uterine Ruptures, and the Remarkable Human Uterus Wonderful
info about how rare uterine rupture is (including in vertical-
"Classical" incisions), and how to strengthen the uterus during
pregnancy- an already remarkably strong and adaptive muscular
organ.
How
likely is it that your VBAC uterus will rupture?by Eileen
and Pat Sullivan. Well- you're actually a lot more likely to
win at roulette or have a doctor who is an imposter than you
are to have your scar rupture in childbirth.
Medical
journal citations about VBAC safety- and inducted birth dangers
Vaginal
Birth After Cesarean is extremely safe- as demonstrated by Swiss
scientists
The
following study has been broken down into lay language by Gretchen
Humphries, MS, DVM.
"This
study is just chock full of good stuff.
- Huge
number of TOLs (trials of labor)- over 17,000- showed that
in this group, being induced reduced the VBAC success rate
and increased the rupture rate.
- Epidural
also showed an increase in ruptures, probably because they
tended to be augmented with pitocin, I'd bet.
- Also
showed that even with the 0.4% rupture rate, the fetal mortality
from those ruptures was extremely low (and really, isn't
that what is scary about a rupture? losing the baby?)- about
0.03% of all TOLs had a fetal mortality due to rupture.
3 out of 10,000 is a lot lower than just about any other
reason a baby might die during labor.
- And,
every other peripartum (during childbirth) complication
happened more often in the non-labor (elective cesarean)
c-section group, including hysterectomy.
I
know its only one study, and you do have to look at the entire
body of the literature but this is the one I refer to when people
discount the low rupture rates found in other studies because
the 'numbers are too small'. There is nothing small about
the numbers in this study, I think it's as accurate as you can
get when studying something as rare as uterine rupture."
Delivery
after previous cesarean: a risk evaluation. Swiss Working Group
of Obstetric and Gynecologic Institutions.
Author
Rageth JC; Juzi C; Grossenbacher H; Spital
Limmattal, Schlieren, Switzerland.
Source
Obstet Gynecol, 93(3):332-7 1999 Mar
Abstract
OBJECTIVE:
To examine the risks of vaginal delivery after previous cesarean
and to find criteria to help decide whether a trial of labor
or an elective repeat cesarean should be preferred.
METHODS:
We evaluated 29,046 deliveries after previous cesarean registered
in a pooled database of 457,825 deliveries used to assess quality
control in gynecology and obstetrics departments in Switzerland.
RESULTS:
Among the 17,613 trial-of-labor cases logged (attempt rate 60.64%),
the success rate was 73.73% (65.56% after inducing labor and
75.06% after the spontaneous onset of labor). The following
complications were significantly more frequent in the previous-cesarean
group: maternal febrile episodes (relative risk [RR] 2.77; 95%
confidence interval [CI] 2.52, 3.05), thromboembolic events
(RR 2.81; CI 2.23, 3.55), bleeding due to placenta previa during
pregnancy (RR 2.06; CI 1.70, 2.49), uterine rupture (92 cases;
RR 42.18; CI 31.09, 57.24), and perinatal mortality (118 cases,
including six associated with uterine rupture; RR 1.33; CI 1.10,
1.62). The postcesarean group also showed a 0.28% rate of peripartum
hysterectomy (81 cases; RR 6.07; CI 4.71, 7.83). There was one
maternal death in the group, compared with 14 maternal deaths
in the group without previous cesarean (no statistical significance).
The risk of uterine rupture for patients with previous cesareans
was elevated in the trial-of-labor group compared with the group
without trial of labor (RR 2.07; CI 1.29, 3.30), but all other
maternal risks, including peripartum hysterectomy (RR 0.36;
CI 0.23, 0.56), were lower. When comparing the women having
a trial of labor, the 70 with uterine rupture more often had
induced labor (24.29% compared with 13.92% in the nonrupture
group; P = .013), had epidural anesthesia (24.29% compared with
8.44%; P < .001), had an abnormal fetal heart rate tracing
(32.86% compared with 8.53%; P < .001), and had failure to
progress (21.43% compared with 7.98%; P = .001).
CONCLUSION:
A history of cesarean delivery significantly elevates the risks
for mother and child in future deliveries. Nonetheless, a trial
of labor after previous cesarean is safe. Induction of labor,
epidural anesthesia, failure to progress, and abnormal fetal
heart rate pattern are all associated with failure of a trial
of labor and uterine rupture.
Uterine
rupture is RARE, strongly linked with induction drugs, and not
all that lethal after all.
Out
of 114,933 deliveries, there were 37 ruptures; half of those
were because of induction drugs. Out of those 37 ruptures, only
one baby died.
A
10-year population-based study of uterine rupture.
Obstet
Gynecol 2001 Apr;97(4 Suppl 1):S69 Baskett
TF, Kieser KE. Dalhousie University, Halifax, Nova Scotia, Canada
Objective:
To review the incidence, associated factors, and morbidity associated
with uterine rupture.Methods: A 10-year (1988-1997) population-based
review of 114,933 deliveries in one province.
Results:
There were 39 ruptures: 16 complete and 23 dehiscence. Thirty-seven
cases had undergone a previous cesarean delivery (34 lower transverse,
2 classical, 1 low vertical). Of the 114,933 deliveries, 11,585
(10%) were to women with a previous cesarean delivery. The incidence
of uterine rupture in those undergoing a trial for vaginal delivery
(4,516) was complete rupture (3/1000) and dehiscence (5/1000).
Induction or augmentation of labor with oxytocics was associated
with 50% of complete ruptures and 25% of dehiscence. There were
no maternal deaths, but 33% of patients with complete ruptures
required blood transfusion. There was one neonatal death attributable
to uterine rupture.
Conclusion:
Induction and augmentation of labor are confirmed as risk factors
for uterine rupture. Fetal heart rate abnormality was the most
reliable diagnostic aid. Serious maternal and perinatal morbidity
was relatively low.
PMID:
11275210 [PubMed - as supplied by publisher]
Women
who've had at least one vaginal birth after cesarean are far
less likely to have uterine ruptures in subsequent births
Successful
first vaginal birth after cesarean section: a predictor of reduced
risk for uterine rupture in subsequent deliveries.
Shimonovitz
S, Botosneano A, Hochner-Celnikier D Department of Obstetrics
and Gynecology, Hadassah University Hospital, Mt. Scopus, Jerusalem,
Israel.
BACKGROUND:
Uterine rupture is a catastrophic obstetric complication, most
often associated with a preexisting cesarean section scar. Although
a vaginal birth after a cesarean is considered safe in modern
obstetrics, it is not known whether repeated VBACs increase
the risk of rupture, or whether the first VBAC proves the strength
and durability of the scar, predicting further successful and
less risky vaginal deliveries.
OBJECTIVES:
To evaluate the effect of repeated vaginal deliveries on the
risk of uterine rupture in women who have previously delivered
by cesarean section.
METHODS:
In this retrospective study, 26 VBAC deliveries complicated
by uterine rupture were matched for age, parity, and gravidity
with 66 controls who achieved VBAC without rupture. The histories,
demography, pregnancy, labor and delivery records, as well as
neonatal outcome were compared.
RESULTS:
We found that the risk of rupture decreases dramatically in
subsequent VBACs. Of the 40 cases of uterine rupture recorded
during the 18 year study period, 26 occurred during VBAC deliveries.
Of these, 21 were complicated first VBACs. We also found that
the use of prostaglandin-estradiol, instrumental deliveries,
and oxytocin had been used significantly more often during deliveries
complicated with rupture than in VBAC controls.
CONCLUSIONS:
Once a woman has achieved VBAC the risk of rupture falls dramatically.
The use of oxytocin, PGE2 and instrumental deliveries are additional
risk factors for rupture, therefore caution should be exerted
regarding their application in the presence of a uterine scar,
particularly in the first vaginal birth after cesarean.
PMID:
10979328, UI: 20433706 Isr Med Assoc J 2000 Jul;2(7):526-8
Effect
of previous vaginal delivery on the risk of uterine rupture
during a subsequent trial of labor
Zelop
CM, Shipp TD, Repke JT, Cohen A, Lieberman E
Department
of Obstetrics and Gynecology, Lenox Hill Hospital.
[Medline
record in process]
OBJECTIVE:
We examined the effect of prior vaginal delivery on the risk
of uterine rupture in pregnant women undergoing a trial of labor
after prior cesarean delivery.Study Design: The medical records
of all pregnant women with a history of cesarean delivery who
attempted a trial of labor during a 12-year period at a single
center were reviewed. For the current analysis, the study population
was limited to term pregnancies. The effect of previous vaginal
delivery on the risk of uterine rupture during a subsequent
trial of labor was evaluated. Separate analyses were performed
for women with a single previous cesarean delivery and for those
with >1 prior cesarean delivery. For each of these subgroups,
the rate of uterine rupture among women who had >/=1 prior
vaginal delivery was compared with the rate among women with
no prior vaginal delivery. Logistic regression analysis was
used to examine the associations with control for confounding
factors.
RESULTS:
Of 3783 women with 1 prior scar, 1021 (27.0%) also had >/=1
prior vaginal delivery. During a subsequent trial of labor,
the rate of uterine rupture was 1.1% among pregnant women without
prior vaginal delivery and 0.2% among pregnant women with prior
vaginal delivery (P =.01). Logistic regression analysis controlling
for duration of labor, induction, birth weight, maternal age,
year of birth, epidural analgesia, and oxytocin augmentation
indicated that, among women with a single scar, those with a
prior vaginal delivery had a risk of uterine rupture that was
one fifth that of women without a previous vaginal delivery
(odds ratio, 0.2; 95% confidence interval, 0.04-0.8). In the
group of 143 pregnant women with 1 previous cesarean delivery,
women with a prior vaginal delivery had a somewhat lower risk
of uterine rupture (3.9% vs 2.5%; adjusted odds ratio, 0.6;
95% confidence interval, 0.01-6.7). This difference was not
statistically significant.
CONCLUSION:
Among women with 1 prior cesarean delivery undergoing a subsequent
trial of labor, those with a prior vaginal delivery were at
substantially lower risk of uterine rupture than women without
a previous vaginal delivery.
Uterine
rupture associated with the use of Cytotec (misoprostol) for
VBACs
In
a retrospective (case reports, computerized search of medical
records, literature review) study of 89 women who had Cytotec,
there were 5 women who had ruptures- a rate of 5.6%. Of 423
similar patients who didn't get misoprostol, there was only
one case of rupture- a rate of 0.2%.
-AJOG, June 1999,
Part 1, Volume 180, No. 6:1535-42
For
more about Cytotec dangers, go to this
page.
Prostin
gel significantly increases uterine rupture rates
*Note
that Cytotec is not used (to the best of activists' knowledge)
in Canada for labor induction. It is STILL being used in
hospitals in California -- including Pomona Valley Medical Center,
San Antonio Community Hospital and Doctors of Montclair Hospital.
Uterine
rupture during induced trial of labor among women with previous
cesarean delivery
Debra
J. Ravasia, MD Stephen L. Wood, MD Jeffrey K. Pollard, MD Calgary,
Alberta, Canada
Objective:
This study was undertaken to compare the rates of uterine rupture
during induced trials of labor after previous cesarean delivery
with the rates during a spontaneous trial of labor.
Study
Design: All deliveries between 1992 and 1998 among women with
previous cesarean delivery were evaluated. Rates of uterine
rupture were determined for spontaneous labor and different
methods of induction.
Results:
Of 2119 trials of labor, 575 (27%) were induced. The overall
rate of uterine rupture was 0.71% (15/2119). The uterine rupture
rate with induced trial of labor (8/575; 1.4%) was significantly
higher than with a spontaneous trial of labor (7/1544; 0.45%;
P = .0004). Uterine rupture rates associated with different
methods of induction were compared with the rate seen with spontaneous
labor and were as follows: prostaglandin E2 gel, 2.9% (5/172;
P = .004); intracervical Foley catheter, 0.76% (1/129; P = .47);
and labor induction not requiring cervical ripening, 0.74% (2/274;
P = .63). The uterine rupture rate associated with inductions
other than with prostaglandin E2 was 0.74% (3/474; P = .38).
The relative risk of uterine rupture with prostaglandin E2 use
versus spontaneous trial of labor was 6.41 (95% confidence interval,
2.06-19.98).
Conclusion:
Induction of labor was associated with an increased risk of
uterine rupture among women with a previous cesarean delivery,
and this association was highest when prostaglandin E2 gel was
used. Am J Obstet Gynecol 2000;183:1176-9.
*A
Prostin information sheet with uterine rupture warnings can
be read here.
Induction
drugs cause uterine rupture
-In
both VBAC moms and those without scarred uteruses.
"A
study was done in November 2000 re uterine rupture and VBAC
(American Journal of Obstetrics and Gynecology. Volume 183(5)
November 2000, pp1176-1179 view study here).
It shows that uterine rupture is more than 6 times more likely
when induction/augmentation occurs. The only ruptures I have
heard of (personally) have occurred in women being induced,
and they have all had epidurals in place. Every drug will affect
the risks involved, and this is where women need the information
the most.
VBAC
has been shown (again and again) to be safer than an elective
c/section for no medical reason- except a prior caesarean birth.
Safer for both mother and child. Hysterectomy is actually more
likely if you have an elective c/section than a VBAC. Not the
other way around, as is commonly believed. It is the induction/augmentation
that increase the risks and make VBAC dangerous- risking babies
and mothers, not the VBAC itself, but how it is managed.
Uterine
rupture occurs in unscarred uteruses when women are induced/augmented,
and then it IS usually catastrophic, as an unscarred uterus
really 'ruptures' whereas a scarred uterus may just open slightly
along the scar line. A study, in the British Medical Journal,
about uterine rupture rates, printed in the BMJ 1996; 312: 1204
– 1205 (May 11), 'In a study of 32 cases (from 1 July
1993 – 30 June 1994) only 3 were scarred uteri (from a
previous c/section).'
Women
attempting to birth VBAC have been rushed and drugged through
the experience; and some of the results have been disastrous.
For example, read this
BMJ study."
Birthing
Beautifully, Jackie Mawson. Convenor of Birthrites:
Healing After Caesarean Inc.
Uterine
Rupture Risk After Prior Cesarean Not Increased After
40 Weeks' Gestation
Spontaneous
labor is safe; induced labor is not, regardless of duration
of pregnancy.
WESTPORT,
CT (Reuters Health) Mar 13 - Among women with on previous cesarean
delivery, the risk of uterine rupture during a subsequent trial
of labor is not substantially increased after 40 weeks' gestation,
according to a report in the March issue of Obstetrics and Gynecology.
However,
the risk is increased with induction of labor regardless of
gestational age. Dr. Carolyn M. Zelop, of Lenox Hill Hospital,
New York, and colleagues compared outcomes in women with prior
cesareans delivering at or before 40 weeks with those delivering
after 40 weeks. They reviewed labor outcomes over 12 years for
2775 women "with one prior scar and no other deliveries" who
had a trial of labor at term. According to the report, uterine
ruptures occurred in 0.8% of women delivering at or before 40
weeks' gestation and 1.3% of women delivering after 40 weeks.
Among those with spontaneous labor, the rupture rate was 0.5%
at or before 40 weeks and 1.0% after 40 weeks (OR 2.1). With
induced labor, the rates were 2.1% and 2.6%, respectively (OR
1.1). The overall rate of cesarean delivery was higher for women
after 40 weeks' gestation compared with women at or before 40
weeks, at 35.4% and 26.7%, respectively. The rate of cesareans
associated with spontaneous labor at or before 40 weeks was
25%, compared with 35.5% after 40 weeks for (OR 1.5). For induced
labor, the rates of cesarean delivery were 33.8% and 43%, respectively
(OR 1.5). "Because spontaneous labor after 40 weeks is associated
with a cesarean rate similar to that following induced labor
before 40 weeks, awaiting spontaneous labor after 40 weeks does
not decrease the likelihood of successful vaginal delivery,"
Dr. Zelop and colleagues conclude. Obstet Gynecol 2001;97:391-393
Elective
cesareans DO NOT preserve the pelvic floor
Can
elective cesarean save your pelvic floor?
NO,
says a recent South Australian study reported in the December
2000 edition of the British Journal of Obstetrics and Gynaecology.
The 1998 South Australian Health Omnibus Survey involved a random
selection of 4400 households. 3010 men and women aged 15-97
years were interviewed in their own homes, to determine, among
other things, the prevalence of pelvic floor disorders, and
to determine the relationship to gender, age, number of children
and their mode of birth.
The
prevalence of urinary incontinence (uncontrolled leakage of
urine) in men was 4.4% and in women 35.3%. Urinary incontinence
in women increased after pregnancy according to the number of
children and age. Pregnancy (more than 20 weeks) REGARDLESS
OF MODE OF BIRTH, greatly increased major pelvic floor dysfunction-
defined as any type of incontinence, symptoms of prolapse or
previous pelvic floor surgery. Compared with a woman with no
children, pelvic floor dysfunction was more than two and a half
times as common in a woman who had birthed a baby by caesarean,
over three times as common in a woman birthing naturally and
over four times as common in a woman who birthed with at least
one forceps. The difference between caesarean and forceps was
significant, but not between caesarean and a natural birth.
The
investigators commented "...elective caesarean section is apparently
not an effective way to reduce the prevalence of most subsequent
pelvic floor disorders, except when instrumental vaginal delivery
can be avoided". MacLennan AH et al. The prevalence of pelvic
floor disorders and their relationship to gender age, parity
and mode of delivery. BJOG 2000;107:1460-70.
Contributed
by Jackie Mawson Convenor of Birthrites:
Healing After Caesarean
Comment
from a professional birth attendant: "I think a lot of female
incontinence is caused by peeling the bladder off the uterus
during cesarean surgery and then reattaching it. This interference
with the normal attachments of the bladder lead to later urinary
problems. The pelvic floor has nothing to do with post-cesarean
incontinence." -Gloria
Lemay
