A Critique of A VBAC Primer

By Jessica Tiderman

My assignment was to choose one article that you disagree with or feel contains information that might be harmful, inaccurate, controversial or unnecessarily frightening for pregnant women.  It sort of turned into a rant.  ;-)

Article:  A VBAC Primer: Technical Issues for Midwives
By Heidi Rinehart, MD

The first problem that I have with this article is its age.  This article was published in Spring, 2001.  A publication like Midwifery Today should have articles like this updated every 5 years or whenever new studies come out with evidence supporting or refuting the thesis.  In the time since this article was published there have been a variety of studies and an update to the ACOG Practice Bulletin that she referred to.

In this article, Rinehart claims that women who have had a classical, T- or J-incision on the uterus from their cesarean should not be allowed to VBAC.  My first problem with this statement is that very few women have an upright T incision, many more have an Inverted T which is an entirely different incision altogether.  Her inaccurate terminology makes me wonder how well she researched the unusual cesarean incisions (Special Scars) before writing this article. She also didn’t quote any stats on what the possible risk of rupture is for those incisions or what it was expected to be at that time.  In a study published in 2004, Landon et al found a uterine rupture rate of 1.9% for women with a Classical, Inverted T or J scar.  Rinehart presents this information in a way that would be very frightening to any midwife or mother who did not have knowledge of the Landon study or of the many women who have VBAC’d on these scars without incident.

In the section titled “Types of Uterine Incisions” I believe her description of how the uterine scars heal is inaccurate, I don’t know of very many old episiotomy scars that just sprang “open during the most gentle birth.”  Most episiotomy and cesarean scars heal very well with little remaining scar tissue.  Further, she uses a lot of technical terms in this section that make things sound unnecessarily scary.

According to Gretchen Humpries article The Suture Debate, the single layer of sutures is less likely to become infected, become inflamed, hemorrhage, and/or cause endometritis. Therefore by Rinehart’s own logic this would make them less likely to rupture.

I do believe she is correct in theorizing that the state of health of the mother at the time of the previous cesarean is more of an indication of rupture than her state of health during the current pregnancy.

In the section titled “Risks of VBAC”, she states that “a separation of the uterine scar can result in death or neurologic injury for the baby (estimated at 30%)”.  At the NIH VBAC conference in 2010 Dr. Landon stated that the current estimate for catastrophic rupture is only 6%.  She also states that “women with two previous cesareans have a three- to five-fold greater risk (between 1.7 and 3.7 percent of all labors) of uterine rupture than women with one previous cesarean.”  It was also stated at the NIH VBAC conference that risk of rupture for a VBA2C was only slightly higher than a VBAC at 0.9%.

She does also point out that inductions and interventions do increase the risk of rupture, but to me it seems like she emphasizes the possible risks more than the causes and how to lower the risks.

She recommends that home birth midwives have the mother get “an ultrasound early in the third trimester to rule out a placenta that is overlying the previous scar.”  I believe this would be less than helpful.  Scars cannot always been seen on accurately on ultrasound if at all.  Having this ultrasound opens the mother and baby to new risks as well.  If the ultrasound tech decides there is not enough fluid, is too much fluid, baby is too big, baby is too small, etc.  What then?  Not to mention the unknown risk of ultrasound exposure.

Ultimately, I feel she does little to reassure midwives or mothers that VBACs at home are safe unless the mother has only had one cesarean and it was a low transverse incision.