California College of Midwives

 2003 Principles of Mother-Friendly Childbirth Services

MEDICAL REFERRAL FOR Post-Cesarean labor & birth

The following were VBAC guidelines adopted in 1986 by the 
American College of Obstetricians & Gynecologists:

"The concept of routine repeat c-section should be replaced by a specific decision process between the patient and the physician [i.e. careprovider].

In the absence of a contraindication, a woman with one previous cesarean delivery with a lower uterine segment incision should be counseled and encouraged to undergo a trial of labor.

A woman who has had two or more previous sections with lower uterine segment incisions and who wishes to attempt a VBAC should not be discouraged from doing so in the absence of contraindications.

A trial of labor & delivery should occur in a hospital setting that has professional resources to respond to acute  intrapartum obstetric emergencies."

In 2002,  ACOG amended these post-cesarean trial of labor guidelines. The new guidelines require the physician to be "immediately available throughout active labor, capable of monitoring labor and performing an emergency cesarean delivery" in the hospital during labor in a mother with a previous Cesarean. 

As a result of these changes in the ACOG guidelines for post-cesarean labor, many obstetricians have chosen not to provide care to women who desire to have a vaginal birth after cesareans (VBAC). A significant number of community hospitals also no longer 'permit' a previous cesarean mother to labor normally and deliver vaginally.  

It must be noted that the outcome statistics for post-cesarean trial of labor/attempted VBAC have NOT changed at all during this time period (1986 to 2002). For the last 2 decades the uterine rupture rate has been documented by dozens of reputable studies to be stable at approximately 1%, with a low range of 0.5% to as high as 1.8%. The major point of difference between the high and low numbers is whether or not the labor was induced or augmented with prostaglandins and/or Pitocin. 

According to the New England Journal of Medicine article published in July of 2000, the risk of uterine rupture when Pitocin was used was approximately double that of spontaneous labors. When prostaglandin was also used, it resulted in a 15 times greater uterine rupture rate than that of spontaneous labor. 

While the NEJM study was useful for exposing the increased risk of using Pitocin and prostaglandins to artificially stimulate post-cesarean labor, the article was instead widely used the medical profession and the media to promote the erroneous idea the VBAC labor had suddenly been discovered to be dangerous and thus to justify a return to "once a Cesarean, always a Cesarean". 

Special Circumstances Informed Consent/
Decline of Advise for Medical Management of Labor
Relative to Post Cesarean Pregnancy (VBAC)

I have had no more than one or two cesarean sections with a lower uterine segment incision and desire a home birth with this post-cesarean pregnancy.  

In deciding to labor at home I have been informed of the following: 

I understand that the benefits include:

a-    elimination of operative and postoperative complications with successful VBAC

b-    reduction in the length of postpartum recovery

c-    easier infant care and bonding.

I understand that the risks include:

a-  The most dangerous risk is uterine rupture (UR). Although UR is rare, it can be catastrophic in a matter of minutes. I understand that although it occurs in less than 1% of appropriately attempted VBACs, when it does occur it can lead to excessive blood loss, permanent neurological damage or even death of the infant, and/or damage (such as emergency hysterectomy) or death of the mother                                                             

                                                                                        ______ parents initial here                                                                                                                                              

I understand these risks are minimized by not using drugs to induce or stimulate labor, in particular, Cytotec and Pitocin but a natural labor does not guarantee that uterine rupture will not happen.                                                      
          ______ parents initial here

I understand that in the event of a uterine rupture, prompt recognition and emergency management in a hospital can usually minimize serious results. I understand that I and my baby would be safer in an acute care hospital if a catastrophic uterine rupture were to occur.  ______ parents initial here

I understand that current medical standard of care recommends tha t VBACs occur in a hospital setting.  I understand that in having a home birth I can and will  transfer care to a hospital if any of the following occur:                                                                                    ______ parents initial here              
a-      undue uterine pain

b-      unusual bleeding

c-      unusual fetal heart rate

d-      deterioration of maternal vital signs

e-      parent's request.

I understand that my midwife has attended ______VBACs at home and has transferred care during VBAC labors________times.  

I have read a copy of the "Criteria for Midwives Attending Unusual Circumstance Births" which requires that my midwife has attended at least 75 birth as the primary midwife following licensure and has advanced training and experience in "unusual circumstances"/ moderate risk labor and birth
                                                                                                                   ______ parents initial here

I voluntarily waive/decline to transfer my care to a physician for hospital-based management of labor relative to attempted VBAC. I have instead chosen to receive maternity care from my midwife and plan a home birth unless complications arise during pregnancy or labor




Recommended but not required (available on the College of Midwives web site at

I have read current published research including but not limited to:

Vaginal Birth After Cesarean and Uterine Rupture Rates in California  for 1995 Gregory K, Korst L, Cane P, et al. Obstet Gynecol 94:985-9, 1999 

This research revesls the following statistics:

Uterine rupture ratio (RR) in a normal vaginal birth / intact uteri is 1: 14,866  *****
Maternal mortality ratio for mothers in this category is 1: 16,666  

Rupture Ratio for successful Vaginal Birth After Cesarean is 1:   1,601 *****
Maternal mortality ratio for mothers in this category is 1: 16,666

RR for elective primary Cesarean is 1:1,323
Maternal Mortality ratio is 1: 5,000

RR in unplanned primary Cesarean is 1: 802
Maternal Mortality ratio is 1: 3,025

RR for elective repeat Cesarean is 1:375
Maternal Mortality ratio is 1: 5,000

Total RR for post Cesarean trial of labor (TOL) is 1:187

RR for unsuccessful post CS labor ending in CS is 1:87 *****
Maternal Mortality ratio is 1: 3,025

Uterine Rupture During VBAC Trial Of Labor: Risk Factors and Fetal Response
Journal of Midwifery & Women's Health
Nancy O'Brien-Abel, RNC, MN

This document lists the statistics for all the various complications of post-cesarean pregnancy, labor and birth, including normal vaginal birth, elective repeat Cesarean, emergency Cesarean and the downstream or delayed complications.

The Summary states that: "A pregnant woman with a previously scarred uterus is at increased risk for complications whether she has a successful VBAC-TOL, unsuccessful VBAC-TOL or elective repeat cesarean birth. Neither elective repeat cesarean nor VBAC-TOL is risk-free. Only by eliminating primary cesarean deliveries can we hope to obviate the need for repeat cesareans or VBAC-TOL."

                                                                                                                            ______ parents initial here

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