Article, November 1998
Safety Considerations When
Planning a
VBAC at Home
Nicette Jukelevics, MA, ICCE
The author is not aware of any published studies on the safety of
home VBACs However, the author is aware that some women do have home
VBACs whether it is legal or not in their local community. In the
interest of safety for mothers and babies, the author wishes to provide
the following information.
Current evidence indicates that routine repeat Caesareans are no
longer the safest option for women with one or more low segment uterine
incisions.
Worldwide studies confirm that the risk of a symptomatic low-segment
uterine rupture that requires emergency medical interventions is less
than 1%. That means that 99% of women labouring for a VBAC will have
a safe birth.
Many women who have had an oppressively painful birth experience
or an emotionally traumatic labour that led to a Caesarean birth lose
trust in the established medical system. When planning a VBAC, in
consideration of the low risk of a uterine rupture, some women may
choose to labour at home as long as possible or labour and give birth
at home.
By avoiding conventional hospital births women hope to avoid medical
interventions they feel will complicate labour and increase their
risk for another Caesarean. By labouring at home women can avoid interventions
and protocols that have been associated with an increased risk for
Caesarean: failed oxytocin inductions, use of epidural analgesia for
labour, and formal admission to the labour and delivery unit before
active labour has been established. When protocols call for continuous
electronic monitoring, routine use of I.V. fluids, restriction of
liquids, or restriction of movement during labour women may feel psychologically
fettered and not in control of their labour.
Labouring for a VBAC in a hospital setting assumes that the facility
is equipped to respond to a medical emergency rapidly 24 hours a day.
If planning to labour at home, women should take the following information
into consideration.
What is a Complete Uterine Rupture?
In the very rare event that a uterine rupture may occur, expectant
mothers with one or more prior low-segment scars who choose to labour
at home need to think about the possibility of transfer to a medical
facility.
A symptomatic uterine rupture is a tear through the thickness of
the uterine wall. It is a potentially life threatening condition for
both the mother and/or the infant and requires immediate surgical
intervention. Uterine ruptures have also occurred in women who have
never had a Caesarean. Rarely, they have also occurred in women with
a prior Caesarean scar, but at a different location of the uterine
wall and the prior scar remained intact.
What are the Symptoms of a Uterine Rupture?
Research studies indicate that it is not always possible to detect
a uterine rupture in labour until it has actually occurred. A uterine
rupture can occur suddenly. The symptoms that indicate a uterine rupture
may have occurred vary and are inconsistent. The sole consistent association
with a uterine rupture reported in the medical literature is abnormal
foetal heart tones-variable decelerations or bradycardia (slow heart
rate) detected with electronic foetal monitoring.
The following symptoms may or may not be present when a uterine
rupture occurs.
- Vaginal bleeding
- Sharp pain in between contractions
- Uterine atony (soft uterus)
- Decrease in the strength or frequency of contractions
- Abdominal pain tenderness
- Recession of the foetal head (in second stage)
- Bulging under the pubic bone
- Sudden onset of pain at the sight of the previous scar
When a uterine rupture occurs there is not necessarily a loss of
uterine tone or amplitude of contractions. Labor often continues.
Medical studies show that using intrauterine pressure catheters to
anticipate uterine ruptures is not a useful diagnosis of an impeding
rupture.
Response to a Uterine Rupture
In the United States, the American College of Obstetricians and Gynaecologist
(ACOG) has established that as with any other labours, a hospital
should be able to respond to a medical emergency within 30 minutes
of the diagnosis. That means a surgical team ready to respond, an
anaesthesiologist, and operation room must be available in 30 minutes
or less. The Society of Obstetricians and Gynaecologists of Canada
(SOGC) has established similar guidelines.
A retrospective study in a US teaching hospital however established
that if the response time to a uterine rupture was 17 minutes or less
that foetal distress was noted babies had better neonatal outcomes.
(Leung, et al, 1993).
What is a Dehiscence or a Window?
The terms, uterine dehiscence, window, incomplete or asymptomatic
separation, and silent rupture describe a partial separation of the
uterine wall. The risk of a dehiscence with a low transverse uterine
scar is approximately 1-2%. A dehiscence causes no symptoms and is
not correlated with any increase in risk for rupture.
A dehiscence may be present in women who have elective repeat Caesareans,
prior to the onset of labour, in women who have a natural birth after
a prior Caesarean and in women who have a Caesarean after labour has
started. A dehiscence will usually heal on its own and requires no
medical treatment.
Medical Interventions Do Not Necessarily Reduce the Chance for
a VBAC.
Ironically the majority of the studies with high VBAC rates have
included routine electronic monitoring, use of I.V. fluids, and some
included traditional epidural analgesia. However, because the medical
staff was conducting a research study they may have been more patient
in allowing women a longer time to complete their labours. They were
also probably more dedicated and committed to having women avoid an
unnecessary Caesarean for "failure to progress."
Questions an Expectant Mother May Want to Ask of the Birth Attendant
These are some of the issues women may want to discuss with their
birth attendant.
- Prior experience with VBAC
- Ability to detect uterine rupture
- Availability of emergency medical response
- Travel time to nearest hospital
- Staff privileges of attendant at nearest hospital
- Does birth attendant have immediate means of communication with
nearest hospital
Mothers may also want to find out about any published data on the
safety of home VBAC's in their own community.
The authors of A Guide to Effective Care in Pregnancy and Childbirth
state, "Outcomes of pregnancy and childbirth depend to a large extent
on the social policies and health care organizations of the country
in which the woman lives. Her health, her use of and response to health
services, and her ability to follow the advice that she is offered
are affected by her own social circumstances and by the wider social,
financial, and health care policies. " (p.12)
If some women are having illegal VBACs at home, one should ask what
factors have driven them to abandon the established health care system,
and what if anything-medical societies and health care policy makers
can do to reduce their risks.
Childbirth deeply affects a woman physically, emotionally, and spiritually.
Her perceptions of her experience of birth has a long term impact
on her self-esteem and her family. Women can make the best decisions
for themselves when they participate fully in the care provided by
their birth attendants.
References:
ACOG Practice Patterns 1995. Vaginal Delivery After Previous Caesarean
Birth. American College of Obstetricians and Gynaecologist, 409 12th
Street, S.W., Washington, DC 20024-2188.
Enkin, M., Keirse, M.J.N., Renfrew, M., and Neilson, J. (1995). A
Guide to Effective Care in Pregnancy and Childbirth. Oxford University
Press.
Flamm, B. L. and Quilligan, E.J. Editors (1995) Caesarean Section:
Guidelines for Appropriate Utilisation. Springer-Verlag: New York.
Leung, Anna, S. et al, (1993). American Journal of Obstetrics and
Gynaecology, 169, 945-50.
Copyright, Nicette Jukelevics, MA, ICCE 1998
Nicette Jukelevics is a childbirth educator of twenty years who teaches,
writes and speaks about Caesarean and VBAC issues. She is the co-author
with Ruth Ancheta of the VBAC Source Book and Teaching Kit (forthcoming).
She can be reached at Centre For Family, 24050 Madison St., Suite
200, Torrance, California, USA. E-mail at Center4fam@aol.com. She
is currently constructing her vbac.com site soon to be available on
the Internet.
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