Informed Consent for Homebirth VBAC
(a collaborative contribution from the San Diego County Midwives)
The United States cesarean rate is at a record high of 31.1 percent,
and the Centers for Disease Control (CDC) reports that the maternal death
rate is increasing for the first time in decades coinciding with this sharp
rise. The World Health Organization (WHO) data shows that mothers die at
a higher rate in the United States than 40 other countries. Prevailing
medical research demonstrates that in most cases, a vaginal birth is safer
and healthier for you and your baby even after a previous cesarean birth.
Besides reading available literature, you are encouraged to attend local
ICAN (International Cesarean Awareness Network) meetings to help prepare
for your birth.
Some risks of VBAC
• Uterine rupture (less than 1%) which may not be life threatening or may lead to emergency surgery, blood transfusions, hysterectomy, and/or death of mother or baby
• Repeating negative experience if cesarean becomes necessary
• Need for emergency cesarean which may have a greater risk of complications
Some benefits of VBAC
• Avoiding the risks of cesarean (as below)
• Safer and gentler birth for mother and baby in most cases
• Easier bonding and breastfeeding initiation
Some risks of elective repeat cesarean section
• Increased risk of life-threatening neonatal respiratory distress syndrome (RDS) and other respiratory problems that may require NICU care
• Five-fold increase in persistent pulmonary hypertension
• Increased risk of iatrogenic (physician-caused) prematurity
• Two to six percent chance of laceration by surgeon’s scalpel
• Up to 30% increased risk of postpartum infection
• Increased risk of massive hemorrhage, transfusions, ureter or bowel injury, incisional endometriosis
• Twice the risk of re-hospitalization for infection, gallbladder disease, surgical wound complications, cardiopulmonary conditions, thromboembolic conditions and appendicitis
• Increased risk of hysterectomy in both the current and future pregnancies
• Twice the maternal death rate for elective cesarean as for vaginal birth
• Higher rates in subsequent pregnancies of serious placental abnormalities eg placenta previa or accreta
• Higher rates of secondary infertility, miscarriage and ectopic pregnancy
Some benefits of elective repeat cesarean
• Convenience of scheduling
• Avoidance of a labor that may result in a repeat cesarean
• Decrease in the (less than 1%) risk of uterine rupture
Educational materials provided (from links at gentlebirth.org/ronnie/VBAC.html)
Statement: Elective Cesarean Sections Riskier than Vaginal Birth for Babies
and Mothers and
Rising Cesarean Rate Bad for Mothers, Top 12 Studies from 2007 - from ICAN - International Cesarean Awareness Network
The Risks of Cesarean Section (Feb., 2010) – A CIMS Fact Sheet (replaces "The Risks of Cesarean Delivery to Mother and Baby")
What Every Pregnant Woman Needs To Know About Cesarean Section & VBAC or Repeat C-Section
August, 2010 - Vaginal Birth After Previous Cesarean Delivery
The Medical Board of California’s Standards of Care for Licensed Midwives require us to inform you of the official policy statement from the American College of Obstetrics & Gynecologists (ACOG) on vaginal birth after cesarean from Practice Bulletin #54 July, 2004: Vaginal Birth After Previous Cesarean Delivery. Full text is available at http://www.acog.org/acog_districts/dist9/pb054.pdf, and summary is as follows.
The following recommendations are based on good and consistent scientific
evidence (Level A)
• Most women with one previous cesarean delivery with a low-transverse incision are candidates for a VBAC and should be counseled about VBAC and offered a trial of labor.
• Epidural anesthesia may be used for VBAC.
The following recommendations are based on limited or inconsistent scientific
evidence (Level B)
• Women with a vertical incision within the lower uterine segment that does not extend into the fundus are candidates for VBAC.
• The use of prostaglandins for cervical ripening or induction of labor in most women with a previous cesarean delivery should be discouraged.
The following recommendations are based primarily on consensus and expert
opinion (Level C)
• Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.
• After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her physician. This discussion should be documented in the medical record.
• Vaginal birth after a previous cesarean delivery is contraindicated in women with a previous classical uterine incision or extensive transfundal uterine surgery.
Client’s Right to Self Determination per article 5B of the Medical Board
of California Standards of Care for Licensed Midwives
Together with my partner, I present for midwifery care acknowledging that I have a lower uterine segment scar from one or more previous cesareans. I have received and read the above educational resources and fully researched the risks and benefits of a homebirth VBAC as well as elective repeat cesarean. I have had the opportunity to discuss the risks and benefits with our midwife and medical doctors and assume responsibility for our decision to plan a homebirth VBAC with a licensed midwife. I agree to provide her a copy of the dictated operative report for my previous cesarean, to permit increased monitoring, and upon request of the midwife, transfer to a hospital at any time if labor does not proceed in a normal manner. The midwife has explained her experience working with VBAC births and that she attends continuing education seminars, reads practice journals and stays abreast of updated practice policy statements regarding the clinical management of VBACs.
After reading this three-page document, I voluntarily waive transfer of care to a physician for a VBAC, but my midwife encourages me to maintain collaborative care with a physician to facilitate transfer if necessary. I choose to plan a homebirth with a licensed midwife unless complications arise. I understand that no guarantee can be made that a homebirth or VBAC will actually result from our attempts, but I firmly believe that our best chance for a safe and healthy birth exists by planning a homebirth.
We, ____________________________ (mother) and ____________________________
(partner), understand and willfully enter into this VBAC homebirth plan
together and have made copies of this document for our records.
_____________________________ Date____________ ____________________________ Date___________
Ronnie Falcao, LM MS, Licensed Midwife
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