The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA
This brief but well-referenced post analyzes cesarean rates relative to differences in maternal diagnoses or pregnancy complexity. On average, the likelihood of cesarean delivery for an individual woman varied between 19 and 48 percent across hospitals.”
Birth attendants often claim that their high cesarean rate is due to their clientele - that they provide care for a lot of high-risk clients. This analysis shows that:
Among lower risk women, likelihood of cesarean delivery varied between 8 and 32 percent across hospitals.
Among higher risk women, likelihood of cesarean delivery varied between 56 and 92 percent across hospitals.
Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics.
This shows that practice variation in cesarean rates is real, substantive, and not just a reflection of the mother’s risk level.
Tips for Choosing a Care Provider - great overview! from Henci Goer
There are lots of good homebirth resources on the Web. My favorite place to start is:
Kate Weber Brown's Home Birth Information: http:
If you really want to learn as much as possible, get _Obstetric Myths Versus Research Realities_ by Henci Goer. (Available from The Life and Birth Bookstore, a mail-order service, a division of Cascade HealthCare Products. Customer service: 1-503-371-4445 (9am-5pm Pacific Time/ Orders: 1-80-443-9942, same hours.) She has about 40 pages of nothing but an introductory discussion of VBAC, and lots of abstracts of papers showing that VBAC is generally safer than a repeat cesarean.
Also, you might want to search the Web for the recent article from the British Medical Journal showing homebirth is as safe as hospital birth for first-time moms and significantly safer for repeat vaginal births. This article had links to several other online studies, including The Netherlands studies that might have VBAC stats.
The reason I would particularly recommend a homebirth for a VBAC is
that she'll have one-on-one care, which is most likely to notice the early
signs of any problems. Assuming you live relatively close to a hospital
and have backup arrangements, you could probably get to the hospital by
the time they could get ready for surgery anyway, in the very unlikely
case of a problem. And having the one-on-one care would give you the early
warning that you'd need to avoid serious complications.
Over the past 5 years in our area 20 of 21 women (95%) attempting home
VBAC achieved vaginal birth. Fourteen delivered at home and 7 transferred
44 successful VBACs, out of 48 attempted, plus 1 other transport (3
previous Csecs, head on peri for 3+ hrs, forceps). Have had many clients
with multiple csecs (as many as 6 previous cesareans) give birth at home,
plus clients with many repeat VBACs (a client with 2 csecs, then 7 home
VBACs and probably will have more!). I have learned a lot about birth from
these women, and patience, and faith!
All of my VBACs have been successful at home, except for two. One, who remained persistently posterior, and the other who marginally abrupted, and had a cesarean. I've worked with a mom who had a vaginal birth, then 4 cesareans, and then a tubal ligation. Got that reversed, and then had two homebirths. I love these determined, smart, well-informed ladies. VBACs are usually the cream of the crop clients, because they know what they want, and they won't give up until they get it. i always feel like I have better informed consent with them, because they have usually already researched every aspect of childbirth! I have always loved helping VBAC moms. It is one of the most rewarding parts of my practice. We have driven many miles, and into other states to help with VBACs.
My classical incision lady delivered at home last night. Her labor was
2 hr and we almost missed the birth.
An obstetrician says: From time to time ( like twice this month ) I get asked about home VBAC. I never say no but I inform women about a small ~1:1000 risk of scar dehiscence, which I assume is likely to be very adverse for the fetus, and quite possibly for them.
Those of you that practice regular home VBAC, what advice/info do you
give ? What proportion of those who initially express an interest after
counseling go on to chose home VBAC ? Status: OR
I've done 27 VBACs. One transport R/T fetal distress -> CSEC. No problem with scar.
I've found that women who have chosen a VBAC have generally educated themselves RE the issue. Above this, they have also taken the time and effort to research homebirth and find a midwife (which isn't very easy in these parts!) So, although I do cover ALL possible outcomes with those with whom I work , most consider the benefit-to-risk ratio weighs in favor of VBAC. Probably everyone that has followed the path all the way to me, has read SILENT KNIFE, and is pretty pumped up about the prospect of VBAC.
Informed consent is my midwife-middle-name. Self-acceptance of responsibility
for their choices is the recurring theme in all PN contact.
I have been attending VBAC's at home since 1982....for a total of about 45. I have a 100% success rate, even my one transport delivered vaginally.
When a potential VBAC woman comes to me, I recommend she read at least two books on VBAC. Then we discuss her particular reason for the c/s, and talk about what could have been done to avoid the c/s. We discuss risks (home vs. hospital, repeat c/s vs. vaginal birth, etc) It seems to me that, with very few exceptions, the vast majority of the women who contact me have already made their decision and are determined to have a "normal" birth. They are usually fine with taking the slightly added risk of a home VBAC over the, at least to them, very real risk of a repeat c/s.
In answer to your question.......I can't recall a woman who changed
her mind about having a home VBAC after counseling.
I was at perinatal rounds on Thursday, and a vbac with rupture of uterus was discussed. In this case there was an induction, and the original c/s was for lack of progress. The discussion was that good stats are not yet being kept, (except by some midwives, but the OB community doesn't know about our stat keeping) and the feeling was, that all ruptures seen by various OB's have been with inductions or augmentations. I know on the OB list, they state that contraindications to pitocin are contraindications to vbac, but I just don't think it is true.
When talking to midwives whose vbac attempts have led to repeat c/s for lack of progress, they state that the labour either never takes off, or gets to a point, then peters out. This is quite unlike what would happen on a pump with pit. The pit forces things, and I think there will be a call to stop inducing women who are vbac, or at least to monitor very closely and discuss risks. We'll also have to look closely at use of prostaglandins for ripening etc.
Yes, risks are discussed prior to home vbac, I also think that transport
for slow progress is much earlier than it might be otherwise. According
to Betty-Anne Daviss, who helps keep the MANA database, there are very
few ruptures and extremely few catastrophic ruptures. Far below that stated
I do home VBACS here in Texas. We have a disclosure form printed by
the Texas Department of Health outlining the incidence of rupture, etc.
So far, all but one of the families who have interviewed for a home VBAC
have gone through with it. The one who didn't discovered she had twins!
I have been successful with all of my VBACs except one who did not dilate
in her first pregnancy and repeated the problem with number two.
A very good question! I am sending you the VBAC at Home Informed Consent, that I use with my clients. I posted it several months ago and some here thought it was too (?unnecessarily) frightening. In the medical climate in which I practice, though, I prefer to be absolutely frank about the risks in writing, but then be completely supportive of a woman's desire to have a home VBAC verbally.
In my neck of the woods, the options aren't that great. The alternative is to go to one of the two small hospitals in town, which don't have 24-hour anesthesia coverage anyway, and submit to an IV, continuous EFF (no telemetry available, so this restricts to bed or bedside), and NPO while trying to have a normal labor.
So what I try to do with potential VBAC clients is to do what I do with
any homebirth client - discuss the risks both of having the baby at home
or going to the hospital to have the baby. There are clearly risks involved
in either choice, and the question becomes which set of risks is the mother
most willing to accept. Her chances of a successful VBAC are greater at
home, but there is always that remote chance of a catastrophic complication
in which loss of time in transfer may contribute to a negative outcome.
Obviously, in this culture, most women having VBACs still choose to follow
ACOG recommendations and go to the hospital, but I certainly believe it's
reasonably safe to offer home VBACs to women who feel strongly that they
want to stay at home in order to labor in a way that is more conducive
to successful vaginal birth.
Actually, scar dehiscence is almost always w/o symptoms or adverse outcome, from what I've read. I do make sure the clients read the VBAC books and risk stats. I tell them my personal experience w/ VBACs. They almost all choose home birth. I have attended home VBACs for women w/ as many as 6 previous csecs; as many as 7 VBACs p/ 2 csecs for 1 client; have 1 client w/2 successful VBACs after transporting for a primary #1 and repeat csec #2.
There is something sweeter in the eyes of a woman who's just had a wonderful
vaginal birth after having had previous cesareans.
I tell them "3 out of a thousand" (probably higher than it really is), and that we can offer no help at home but only transfer as rapidly as possible to a hospital. I pull no punches!
We have a state protocol sheet we must discuss with them. It tells them the worst cases -- fetal death, loss of uterus, hemorrhaging mom etc. Our state board does not consider VBAC to be a (necessarily) high risk condition.... Our professional organization is more strict -- requiring that parents read and sign these informed consent forms/protocol sheets.
Most who are looking at home VBAC have already done their homework though by the time they consult a midwife and are comfortable with the odds. They often remind US that the incidence of rupture without prior cesarean is approximately the same as with low segment cesarean. (The popular press has spread that information pretty thoroughly). They are pretty sure of their wishes by the time they see us...
I try to talk them out of it; just to make sure no-one thinks that I talked them INTO it[Grin]!
Haven't assisted in more than a few, but they are extremely rewarding... I was initially quite skeptical of the safety of home vbac (you know how I like to see proof!)... and took a lot of convincing, but have come around to regard it as "reasonably" safe -- using appropriate screening and precautions, of course.
I'm guessing about half of those who call one of us for initial consultation
go on to attempt home VBAC....
i probably already posted about this, but will say it again, as i was pretty much shocked by the experience...
The one uterine rupture i've seen was a woman with 1 previous low-transverse
section who came in laboring on her own -- strong ctx, 3 cm, variable decels,
pea soup mec, and the variables just kept getting worse and worse. When
they cut into her belly the uterus was completely open. Baby did fine,
mom did fine. No pit. AROM, but for variables at 3cm so i'm pretty sure
the process had already started. No idea why, but.... never say never.
I've seen two ruptures, both in hospital. One with a woman (G3, had had one vaginal birth) induced with oxytocin and an unfavourable cervix. Oxytocin was cranked up to max for several hours. Baby had had deep variables with good recovery for several hours, mom had an epidural, but had a "hot spot" on the lower left quadrant that the epidural wouldn't touch. Forceps birth (for the decels), baby somewhat depressed at birth.
OB examined mom after birth and found a good sized hole in her uterus...result was then general anaesthesia and laparotomy to repair (sigh...) He later as much as told the mom that he thought the induction was responsible for the rupture, but that she had insisted on having it (for post-dates), so it was (by implication) her fault.
Second one, woman came in tumultuous labour. Wanted an epidural, so
a rush to get one in. She also had a lot of lower abdo pain. Once epidural
was in, there was a sustained fetal bradycardia (I really think I see this
a lot with epidural, BTW, esp in second stage when the mother is no longer
lateral) and a rush to get the baby with forceps. In this instance, a small
rupture was found (manual exploration was done because of the pain). The
parents were asked if they planned anymore children. They responded "no"
(and because they had required assisted reproduction every time, it was
unlikely -- not impossible, I realize -- that they would become pregnant
accidentally). In this case, the mom was watched closely for bleeding and
shock, which didn't happen.
Hello to you all, i am new to this list and wanted to introduce myself.
i really want to have a natural home birth. but i have been told
c-section history i would have to go to the hospital for the birth. i am NOT happy about that at all. my DH really wants to deliver in a
hospital because of my past c-sections, but he is willing to consider my choice if i am OK medically to do so. any help and support would be
great! i look forward to sharing my experiences with you all.
If being in a hospital didn't introduce risks of its own, it would always
be safer to birth in a hospital because of the availability of more rapid
surgery, assuming your OB is actually on the premises and there's a surgical team ready to go.
In reality, hospitals do introduce risks of their own.
In reality, most OBs are home sleeping while women are laboring at the
hospital, "monitored" only by machines being watched by personnel
not necessarily trained to interpret what they're seeing.
In reality, it usually takes the OB longer to get to the hospital and
prepare to operate than it takes a woman to be transported to the hospital
from her home, by ambulance, if necessary.
A history of a previous cesarean increases your overall risks by about 3%, all other things being equal.
The likelihood that your baby will acquire an infection in the hospital
is 400% higher than at home, all other things being equal, and the
infections are more likely to be antibiotic-resistant and more virulent.
The subject of VBAC homebirth is near and dear to my heart because it
crystallizes the misperceptions about hospital "safety". There is
misperception that simply being at the hospital can eliminate the risks associated with unusual birth circumstances, such as VBAC. (Actually,
given the scandalous cesarean rate in the U.S., VBAC is one of the most usual birth circumstances.) The only advantage that is available in
the hospital that is not available in your home is surgery; if you are having surgery, the hospital is the place to be. Otherwise, you have to
weigh the added risks of being at the hospital against the added benefits, and the hospital usually comes up short.
It's probably not a good idea to be more than 30 minutes away from the
hospital during labor if you have a cesarean scar, but if you live
close enough to the hospital, laboring and birthing at home is statistically safer.
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