#317 | The Risk of Uterine Rupture: Breaking Down ACOG's VBAC Bulletin

What's the one question every woman wants to answer when considering a VBAC? Is it safe for me and my baby? In today's episode, Cynthia & Trisha break down the available data on VBAC, why we should discard the term TOLAC, the actual risks of uterine rupture, whether induced with Pitocon versus a prostaglandin or having spontaneous labor versus expectant management. We present the few cases in which a woman should not choose to VBAC and help mothers understand their decisions should not be driven by statistics alone. If you are considering a VBAC, get a pen and paper and arm yourself with all the stats from this data-rich dialogue. 

Also: Let's get HavBAC to take! (Inside Joke -- you'll get it when you listen!)

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Transcript

Not enough women are having V backs, and the evidence is so in favor of having a VBAC. That's a very dramatic life experience to plan your first pregnancy and end up in a C section. That's a real blow to a lot of women, and a lot of them, despite themselves, do walk off with a deep feeling of wondering, What if I really just can't do this? That's a lot to overcome. So what is the risk of uterine rupture? Let's talk about the statistics.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Alrighty. So this is not necessarily new news, but it's very important news the American College of Obstetrics and Gynecologists, also known as a cog, updated their practice bulletin on V back not too long ago. A few years ago, I recently just came across it. So it's it's new to me, new to us, and I think a really important topic that we have to continue to discuss. We've talked about V back on Patreon, we have a great episode on preparing for your successful VBAC. You know, our personal take on how to get yourself the most successful VBAC opportunity. And we have a great episode on V back on the podcast as well. You're gonna have to tell me the episode number, because I do not know it. I think, I think it went, remember, of 2020, and I'm thinking it feels like 63 or something like that. Whoa, that long ago. I think it was, well, because the number is making me remember the November that it was. Let's see if I'm right. Look it up. Let's find out. And while I'm looking at you're good, let's if I'm right about this. I'm really going to flip though, because I haven't thought about that episode in years. But let's see. It is such a weird it's just funny how I tend to remember numbers. Let's just see if I'm even close. Hang on. I'm scrolling, scrolling.

I just Google it down to birth VBAC episode usually pops right up, not right. Hang on. Oh, wait, I might be.

I was right. Seriously, that's bad. November of 2020, number 63 I was right. Planning, oh my gosh, that's amazing. We have to, we really need to find a way to, can we go gambling? We need to find a way to monetize my superpower. Should we go the casino this weekend? The slow way to do it, it's not why? Okay, Oh, seriously, I'm not kidding. Listen, I You didn't answer my question. You didn't hear it. No. It was like, Can we go to the casino this weekend? But it's not about
gambling. I didn't just just throw a dart. I I drew deep, unimportant knowledge from the depths of my mind to the surface. I want to comment on the fact that you just told everyone, because we don't talk about this enough of all the resources. We have over 50 hours of workshops with us, and counting and growing all the time. If you want to get that hour long video seminar we did on Planning Your Successful VBAC, there are two ways to do it. One, become a tier three Patreon member, and then you get every single thing we've ever produced at the click of a button. And if you're not joining Patreon, and for some reason you're just holding out, go to patreon.com/down, to birth show slash shop, and then I think it's only $15 for most of our workshops in there. You just pay one price. You don't have to join Patreon. You download the whole thing. You're done. So there are a couple of ways to access that. Okay, you may proceed when you're ready. Great, whatever you learn. Okay, so I'm coming back around to VBAC again, because it's not enough. Women are having VBACs, and the evidence is so in favor of having a VBAC, but there are still hospitals that don't allow it. There are still providers who don't support it. There are still women who are told that they're not good candidates for it. So you know, doctors aren't following their own guidelines, as we have seen in the previous time that we did an ACOG bulletin, which was episode what 253, which one did? Episode 353, ACOG files?

Yeah, February of 2024, yeah, yes. So in that episode, we talked a lot about how what ACOG is actually saying, and how you know what ACOG says. In their guidelines, is not practiced in private practice. It's not practiced in the hospitals. It's it's out there, and people don't follow it. And the same thing is going on with VBAC, even more. So, yeah, and I'm just, I'm mentally scamming my mind as to the reasons why it isn't practiced. And I've come up with two, one because C sections were completely non commonplace until the late 70s, mid 80s, when they finally reached 10% of course, they've been growing. They grew and grew and grew to about one in three births now. But for that period of time, when from like 1970 to the mid 80s, they until Nancy Wehner, frankly, had her C section. And the first plan to be back in in the country, they were telling women, once a C section, always a C section. So part of the problem is that the original training around this was was just that it was wrong. And the reason it was wrong was they couldn't do much research on something that wasn't happening. And very few women were having C sections only between two and four and a half percent for the decades before the 70s. And then the second thing is, again, we just have to be honest with ourselves. American listeners here, this doesn't apply to anyone else in the world, but the hospitals are for profit entities, even though they're dot org and they don't pay federal income tax. That was just a loophole given to them in 1986 under Ronald Reagan's Congress. That has given us all the impression that they're nonprofits, but they are very much for profit. And now, if you're an obstetrician, even with the best intentions, there is very real pressure on you, as there is in any corporation, if you're any executive, to bring in revenue. And we have to mention, they have very demanding lives. They're double booking all the time, and they can be done with a woman's birth and bring in the maximum revenue, not only if they perform a C section, but if they schedule A C section. And if they don't do that, then we're then. That's why they're scheduling all these inductions. So I just wanted to say we can't be terribly shocked that they're not sitting around reading a cog bulletins like you are Trisha to see what the latest says. Well, this came out in 2019 and here we are in 2025 and we still have about 13% of women having AV back when we know how successful they are. And ACOG is saying right here, women should be given the option to have a VBAC outside of a few very small specific scenarios, which we'll address today, for women who are not good candidates for a VBAC. And not only that, but 60 to 80% of planned VBACs are successful. Yes, a majority.

Yes, which is why they're saying you should have one because it's, you know, reduced morbidity, reduced mortality, higher satisfaction, better long term outcomes, all the things that we're going to talk about. But let's just go through the VBAC history a little bit. In 1970 the Cesarean rate was 5% by 2016 it went up to 31.9% in 1985 the VBAC rate was slightly more than 5% in 1996 it went up to 28.3% by 2006 it went back down to 8.5% so in 1996 almost 30% of women were having feedbacks. Everybody was like, once the can of worms was opened that you could do this, everybody was like, hooray. This is wonderful. Let's do this. By 2006 it had fallen back down to 8.5% and the Cesarean rate hit 31%

in the US. What was that? 13% you mentioned earlier? I thought that was the feedback rate. Was that today? Today's VBAC rate is Yes, about 13% today, yes. So inching, inching back up, yeah. Okay. And so the reason for that, the proposed reason for that, was continuous electronic fetal monitoring and liability. So they started to see that, you know, rupture was a thing. Uterine rupture is obviously a risk, with feedback. And they started to jump on that. And everybody got scared. And with continuous electronic fetal monitoring, they were, you know, in panic about babies heart rates and over monitoring, as we know, the continuous electronic fetal monitor creates a lot of false positives and non reassuring fetal heart rates that are actually okay. There's a lot of mixed opinion on how to read these strips, and both of those two things together caused the VBAC rate to dramatically rewind, and here we are now still struggling to get moms to understand that a VBAC is a good, safe option for the vast majority of women. So the saying once a cesarean, always a cesarean should be forever buried and never one. Never heard again. If you hear that from your provider, that is a major, massive red flag. You better run for the hills. I don't think they say that anymore. Now they just say you're gonna have a uterine rupture. I bet there's still some OBS out there who say that. I'm just saying it's, it's, it's just as unethical, if not more unethical, to scare her when it comes to her life and her baby's life. I had a client who was shown a video. I can't even believe this, shown a video during an appointment of a scene where a woman had a uterine rupture, which confuses me. I have no idea what kind of footage that was, but she showed her a video like this. She was trying to basically hypnotize her into fear of life and death. So to me, that's, it's like a step worse than the ignorance of saying once a C section, always a C section. It's just, it's actually, it's manipulative, it's actually evil to mess with someone's emotions like that around the life of their baby or themselves. I can't believe how. I can't believe how common that has become in recent years. It I remember the first time a client told me maybe it was five years ago that the doctor said the word die. And I gasped. They said the word die. They said you or your baby could die. Now women say it left and right. It's not. So it's become acceptable to speak to women this way, which I find completely unacceptable.

Yes, to to coerce women with fear mongering. That's what is happening. Just kind of spiritual perspective. Don't put out there a woman's worst nightmare. Just that is, I think it's the worst thing you can do to a woman, psychologically and emotionally. Once you plant a seed like that, it that thought can never leave the woman's mind. And there's a lot of harm in that, and it's irresponsible, it's mean, it's unnecessary, and it's selfish to say that because you're just putting your fears. I'm speaking as you know, the doctor, they are putting their fears out there, casually, freely, whatever, with no there's no consequence to them in saying that, and they think nothing of the harm that it does to the person they're saying it upon.

It's one thing to say. I really, I for one, want to see a healthy outcome here, like that's, that's, that's manipulation and all that. But to say I don't you know you're I don't want your baby to die, is infuriating to me, that it's a whole different thing. When they say the word die. I think that's just completely unacceptable. I actually, I really do. I feel like doctors should be reported for language like that. That's how strongly I feel about that. It's malpractice and it's ignorance, because it's not true. Is it malpractice? Though not to it's not malpractice, just to say whatever the heck they want to say those in my opinion, it is mine. It is, I mean, it's my personal opinion. It's, I don't know I can go on, and it's not supported by the evidence either. So it's ignorant manipulation.

It's wrong. They say it about everything, though, if I don't, they say it to women during the births. They say it about induction, they say it about the interventions.

Well, how about we just present the data instead. Now, not all the data is good, either. So that's another factor in this. You know, we have some data, and we're going to talk about some data today, but it's not all good, and there's a lot of conflicting evidence. When we look at the data around VBAC feedback and induction, some say that, you know, the chances are greater that you'll have a successful VBA if you are induced. Well, two other studies say that the risk of induction increases, you know, complications of VBAC. So really like to see that study that says, well, it reminds me of the arrive trial.

Yes, it reminds me of the arrive trial too. Like, come on, let's, let's see what that really says we do, do you? Do you see the link to that? Say we have to read that? Yes, that is in our okay, we've got, it's here in this report.

We've got to read that study and find what really happened to that study. There's no, it's so inconceivable that induction can lower the risk of an adverse outcome for a VBAC woman. So it's very hard to believe. Yeah, I want, I really would like to. So the other studies you're saying showed the opposite. That's much more credible, but I do miss that one, just to pick it apart, so let's just get it out there. Right at the beginning of this, ACOG clearly states in this practice, bulletin number 205, if you want to look it up, the preponderance of evidence suggests that most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about an offered TOLAC. We don't like the phrase, like that term, but this is the term they use. We I okay they say to lack all throughout this thing, trial of labor, after cesarean, we take issue with that term. We always have. We've been vocal about that on Instagram and on our podcast,

because we don't like the implication, like you can try. We don't like that. And a lot of a lot of Pro V back populations are very anti the term to lack so I if Trisha, if you wouldn't mind, even when we're quoting the article, if we just replace it with VBAC, I'd feel better about that.

Yes, I tried to propose a new term, HBAC. That's what it was. That's right HBAC. I thought it was good. I love that. Not everybody liked it. Some people loved it. Some people are like, Nah, okay, fine. I did a poll on it. Just like, hold it. I'm having a have-BAC. A have-BAC makes perfect sense. I'm having have-BAC is redundant. So they should just make it a verb: I'm Have-BACking. If they have-BAC, they should know, they should say, I'm have-BACking.

es, I have a planned Have-BAC. 

Okay. But for this episode, we're replacing to lack with VBAC, just so we don't sound totally off the rails when you do when you change the world, crazy, ladies, you have to do it step by step.

By default. You're planting the seed. People, it's all about planting the seed. Okay,
so now I'm all off track. Where are we? Okay, what do we want to talk about? First? Should we address those very, very few women out there where a VBAC is just off the table? Yes, of course. Okay, let's just clear the clear the air. There very, very few women are not good candidates for a VBAC those at the highest risk of uterine rupture. And that would be the reason that you wouldn't be a great candidate for a VBAC is because of a dramatically increased risk of uterine rupture that would just make it unsafe. The benefits do not outweigh the risks. In these cases, a woman with a previous classical or T incision on the uterus, so the the way a cesarean is performed today is a low transverse cut low in the uterus, so it's the least contracting part of the uterus women with a T so there's a cut higher up in the uterus, or middle of the uterus, that that risk of rupture is too great.

So they've done C sections, and do they still do them where there's actually a T shaped scar, like they'll go it's transverse, but higher up in the uterus, in the biggest part of the belly, essentially, and then a vertical line going down from there. Exactly yes. Why did? Why it's like overkill, isn't it? Or is that just the only way they knew how to do them years ago? Exactly yes. And then there are still some very rare scenarios where it may be used today, based on a variety of things that I'm not as knowledgeable about. To say when that a T incision would be used versus not, but it is sometimes still used today. Okay, so women with a prior uterine rupture, if you have had a previous uterine rupture, you are not a good candidate to have a feedback. The risk of a repeat uterine rupture, the risk of a repeat uterine rupture is too great. And then a woman who has undergone extensive transfundal uterine surgery. So if you have had surgery for, say, a fib, right, and it was in the fundus the top of the uterus, you're going to have damage to that uterine wall at the top of the uterus, which is the strongest, most contracting part of the uterus. And also in those cases, the uterus is at a greater risk of rupture, not worth it. The only other scenario that's listed in this is a placenta previa. You can't have a vaginal birth with a placenta previa as a VBAC, or your first time having a spontaneous, normal vaginal delivery, just doesn't work. Now we're not talking about the placenta previas That move out of the way, because lots of women are diagnosed with low lung placentas and placenta previas That ultimately at the time of birth are not a previa All right? So you hear women being like, but wait, I had a vaginal birth. Yes, you didn't have a full previa. A full previa covering the cervix completely is pretty much impossible to have a vaginal birth, right? Exactly, because nobody should Okay, right?

So that's very few women, right? Everybody else basically is a very good candidate for a VBAC, and should be offered a VBAC even if you have had more than one cesarean. Now, there's really no data on women who have had more than two we do know women who have had vaginal births after more than 2c sections. Oh, yeah, definitely can be done. But this is not addressed in the ACOG bulletin, only women who have had two prior C sections, and the recommendation is. Still that it is reasonable to offer them a feedback. I mean, that's coming straight from ACOG. You go to 100 doctors in this area, and I bet you 95% of them say, No, oh, yeah. I don't know. I don't know, but it's common. I will add that even if a woman has had three or four, there's no at all. There's no theoretical reason she shouldn't have a vaginal birth. I've taught women who've had up to 4c sections, and then took my class and had a vaginal birth. So I've had, I think, two who had 4c sections, and Nancy Weiner has told me a few stories herself up to the number four. But I do want to make an important point that if there is any added risk to those women, the only thing I can come up with in my mind, if there is any added risk to those women, is a matter of scar tissue. And I just want to put out there as a little footnote, it will always make sense to work with a pelvic floor specialist on working up this, you know, working on any scar tissue that that's it. It's not the fact that you've ever had an incision there. It's just the scar tissue and the healing around it that could potentially, potentially be something that could get in the way. So just in the name of taking good care of yourself, if you are planning a VBAC, do incorporate that into the group of people who are supporting you. I mean, I would, I would certainly invest time and money into that myself. There is also concern with multiple C sections of weakening of the uterus. So thinning of the uterus, which then does increase the risk of rupture.

So the uterus itself, as an organ, can thin, like the wall, thin, yes, become thinner and weaker the potentially, the more you cut into it. But there's no data that. There's no data on this and there.

Why would it? I don't understand why cutting into it would make the entire uterus thin in diet, in like thickness. Does that make any sense to you?

I don't know the exact mechanism of how it happens, but the potential, like the stretching every time you're pregnant, and then the cutting, and then the healing, and maybe it doesn't heal come back together is strong. So, yes, over time, the more you stretch and then cut, you have more risk of, you know, they call it a uterine window, where it's a very thin area of the muscle in the uterus that is a little bit more prone to rupture. Okay, so the risk is higher. Probably, there's no data on it, but it would stand to reason for these it would stand to reason that the risk is higher, but that doesn't it's not a contraindication. So let's talk about why a woman wouldn't choose feedback. What I mean? What's a What's the fear around feedback? What's the thing that's holding everybody back? What's the provider fear? What's the woman's fear? Why isn't everybody just having a feedback?

Well, I don't know. I can't speak to the providers fears because I don't totally trust what they may say are their fears. Because if they were informed, they would know, as we're going to get into the stats here, they would know the risk is extremely low. In fact, they should be more concerned about the risk of a repeat or unnecessary C section, because there are very real, measurable risks there. But for a woman, it's I completely understand the fear. I mean, first of all, she's in a society that doesn't support VBAC. She has family members who are uninformed, and they're terrified for her life and the life of her baby, and they may have all been led to believe that the C section saved her life, or her baby's life and her previous birth, which it may have. But statistically even that is not very likely in the United States, because there's so many unnecessary C sections. But to believe your body can't do it, even when a woman logically knows her body can, there's it's a very dramatic life experience to plan your first pregnancy and end up in a C section. That's a real blow to a lot of women, and a lot of them, despite themselves, do walk off with a deep feeling of wondering, What if I really just can't do this, which we would never agree with in a million years. But I think that's a lot to overcome. I think women are scared enough of giving birth the first time around, imagine attempting it the second time around when it didn't go the way you thought it would the first time, that's a lot to overcome. And isn't it interesting, when a woman is speaking with her provider, they are generally not talking about any of that. They're never talking about the emotional aspects, the psychological aspects, they're literally only talking about one thing, your risk of uterine rupture, that's the fear. That's the danger. The fear is blown out of proportion to the reality of the statistics.

I would be a lot more comfortable with. A provider who had that conversation, but then who also said, now let's talk about the risks of a repeat C section when they don't have the other half of that conversation. That tells you a lot right there, if they have both sides and then ultimately tell you it's your decision. You might walk away with a heavy heart, but you've been respected, and you've been spoken to like an intelligent person who's responsible for your own health and for your baby, so that I would trust those providers a lot more.

So what is the risk of uterine rupture? Let's talk about the statistics. What is, what are the real chances that if you have had a prior C section and you choose to have a vaginal birth the next time, what are the real chances that you are going to have a uterine rupture, and what is even a uterine rupture? Yeah, a catastrophic uterine rupture is life threatening to the mother and the baby. That is when the uterus basically completely opens. The baby can actually exit the uterine cavity and both the mother and baby are at significant risk when that happens, and you do need to have emergency services available to save them both. In that case of the most extreme example where a woman's life is saved, would they not have to just remove her uterus entirely? Or do they sometimes repair it.

No they can sometimes repair it. I do believe they make every effort possible to save a woman's uterus, if they can.

What approximate percent of the time does someone actually die of all the women who do have uterine ruptures? How often do women actually die from it, as opposed to being saved?

That statistic is not addressed in this bulletin. I mean, I know. I know of personal stories where it's happened or the the baby has died, one or the other. Yes, I do know of personal stories. And we bought somewhere everyone survived, right? We know of a few. We've had lots, many. And the thing is that most of the time, a uterine rupture isn't catastrophic, as they call it. So most of the time, a uterine rupture is a small either, what's either like, not a complete separation, just a very, very thin opening of the uterus, but still actually an enclosed area, or it's just a very small opening where a part of the baby could potentially, you know, foot could pop out. I mean, there's still risk of bleeding. It's still complicated. There's still problems with that, but it's not the full blown danger of a full uterine rupture, okay? And last question I have before we get into the statistics is, Are there signs beforehand procedures uterine rupture, and what's normally the window. And what are the signs? Is it just bleeding? Is it pain?

It could be both of those things. The first and the most common sign is significant change in the fetal heart rate. That's the most common one. And the you know, if you are working with a mom who is having a V back, if you notice something like that, then rupture should be on your mind. It doesn't always mean that, but that is a common indicator. The other thing that is often overlooked and really should be paid very careful attention to, is the mother's sense of something being wrong. The mother saying something just doesn't feel right, something feels right. I have a pain that doesn't feel this feels like an abnormal sensation, or she just has an overwhelming sense of impending doom, or a subtle sense of it doesn't have to be overwhelming. We had a woman on the podcast named Megan, and she had a uterine rupture. Two beautiful first births, and woke up third pregnancy, uterine rupture. And it was interesting in her case, because her intuition told her everything is fine. And she was bleeding, and she was calmly telling her husband, everything's fine, we're going to be okay. She just knew everything would be okay, and she had a uterine rupture. It's really interesting when we hear about women who have a feeling about how their outcome is going. It's it's it's more than a coincidence about how often they're exactly right. When women have a sense of things. We also just had a woman who shared her story of a cord prolapse, and the same thing she she felt her baby move after the chord prolapse was discovered, and she said, I felt my baby move and I knew everything was okay. And, you know, the whole duration of time, from finding that out to the baby being born, she trusted and knew that everything was going to be okay. She just that was a private birth story processing session that you just referenced, not a podcast episode, yes, I say podcast. I don't know I used. I think you said we just had a woman. So I just want to make sure the listeners don't go looking it was a private session we had Friday with a woman. So yes, we won't hear that on the podcast. All right. So now, so now that we talked about that a little bit, why don't you get into some of the stats? Okay, so

the important thing about what I was a. Explaining about the the various types of uterine rupture is that these statistics are all mixed together. So we don't really have the statistics to say, this amount of time you have catastrophic uterine rupture. In this amount of time you have partial, non life threatening uterine rupture, it's blended. And it basically works out to be for a woman who has had one prior C section, her rate of uterine rupture is approximately 0.5% to 0.9% so that is one in every 200 births to as high as closer to like one in every 121 in 200 to about one on 10 or so. Okay, now if you have an induced labor, especially with prostaglandins, that would be like cytotec. Yep, any prostaglandin type of induction method when having a VBAC, raises your risk of uterine rupture to 2.24% so that is the risk for a woman who has had one prior C section, if a woman has had more than one prior cesarean this report cites a higher risk of uterine rupture ranging from point 9% which is the high end of the woman who's only had 1c section, to about 3.7% it's also very wide range if you induce a labor, particularly with prostaglandins. So prostaglandins would be like misoprostol, cervidil. This is not Pitocin. This is prostaglandin for cervical ripening that has the highest increase in risk, and increases the risk to about 2.24% overall. So if you're planning a VBAC and you are offered induction, especially with cervical ripening, it's this is an important statistic to know, that it significantly, almost three times, increases the risk of uterine rupture. Interestingly, with Pitocin alone, the risk is not increased as much. However, they do cite that the risk of uterine rupture with Pitocin is dose dependent.

So the takeaway is, VBAC women are best not being induced. But if they must be induced, and they still want to plan a VBAC, avoid the cervidil, the cytotech, especially, I believe, and go the route of straight to Pitocin, which is not ripening the cervix. So maybe, do that evening primrose oil have sex? Do your natural, safe means of getting prostaglandins at the cervix, but going straight to Pitocin? All right?

One mechanical, like a, like a fully balloon, yeah, which is so weird, but still, we're, I mean, it isn't, it isn't, it's actually a, it's actually, I think, so much better than a medical induction. Oh, I would definitely do it over anything chemical. But I always think of Nancy Weiner the first time I asked her, years ago about a Foley balloon, and I remember she said, It's barbaric. And of course, ignition is kind of barbaric. It is kind of barbaric. I mean, the whole, the whole concept, is ludicrous. Imagine doing it to an animal. It's just, it's like, I'm going to put a little thing in here and push open your cervix. But yes, almost anything is preferable to something chemical, which comes with such increased risk. So you said Pitocin is a lesser risk than a misoprostol, but I believe it's still an increased risk. As you said, most it is for our stats nerds here, I'm going to list out the the various statistics. Now, remember, there's a lot of different data in this report, some contradicting others. So that's always the case with this. Is always the case, but this, this is the summary of it. Uterine rupture rates, overall, spontaneous labor about point 5% we addressed that one in 200 labor induced without prostaglandins point seven, 7% so slightly higher prostaglandin induced labor 2.24% induction with prostaglandins, with or without oxytocin, that's Pitocin. No, no, yes, yes. AK, that they have such an they at least should say synthetic oxytocin. I agree. So dishonest. And it's, it's written as oxytocin all over this. Ah, so crazy and wrong. And I mean, this doesn't really make sense to me. This comes out at 1.4%

Oh, okay, wait a minute. Did you just say that when you add Pitocin to the misoprostol, it reduces. Yeah, it makes no sense. Well, that just means it's different, different it says with or without oxytocin, which is what I mean. There's a lot of contradiction. Ah, yeah, information in this? No, that's a different study. Anyway, it is a different study. Yes. That's our proof. Okay, oxytocin alone for induction 1.1% okay, so not tremendously higher. But if you go on the low end of it's on the low end of inductions, but it does double the risk of a uterine rupture for a VBAC planning Mom, if opposed to having a totally physiologic beginning to her labor, yeah, in an augmented labor, which means Pitocin after Labor has already begun, 0.9% that's the high end of again, hands off doing nothing, exactly. I'm a little surprised by that, and I would like to see that study. I'd like to dive into that one as well. I know in Codd pored over this and published this, but again, you know, however they do, you know, Trisha actually does make sense. It's all, wait a minute. It's all kind of clicking. Now, when they said earlier that the risk is between point five and point 9% maybe they were including all of this. It's possible, because it's possible, all right, there's a lot of overlap. There's a lot of contradictory information here, but they do still conclude that their risk of rupture is greater with induction. But doesn't spontaneous labor mean they were not induced? Yes, well, the last stat you gave of point 9% was augmentation, and that still could have been a woman who had spontaneous labor, and maybe that point 9% isn't a coincidence that I set the high end of those statistics very possible. Yeah. Okay, all right.

And they also do note that the oxytocin dose in the rupture risk is dose dependent, meaning the threshold for rupture is going to become lower and lower the higher you go on the oxytocin, which when you're sorry, I'm reading, Okay, you're Judas over here, praying all of us.

You're they started on the article, and it changes even your thinking after one read. Isn't that scary? How easy it is to get people to change room all the I know it's scary. That's how easily we can get manipulated. People put words in our brains, and we start speaking the words, all right, you're forgiven. Don't worry. Thank you. We just had to repeat, I'm repeating.

They do state that the risk of rupture is dose dependent on Pitocin. So the higher the Pitocin goes, the lower the threshold for uterine rupture. And of course, when you're getting induced or even augmented labor, they do continue to increase the Pitocin throughout so hard to measure, right? It's real hard to measure, yes, it's real hard to measure. Multiple studies suggest that induced labor is associated with a lower likelihood of achieving a feedback compared to spontaneous labor regardless of cervical favorability, which means how red binder cervix was, yes. And then another study says the rate of VBAC was higher among women undergoing induction of labor at 39 weeks compared with expectant management. Okay, this is where it gets complicated. You can't compare expectant management loose spontaneous labor. They're not the same thing.

And in the arrive trial, they sure as heck Weren't they. They conflated categories in the expectant management this is, this is, this is the only possible way that they're getting this outcome in this large cohort study, which they said is a number of 104 which maybe statistically that's considered a large cohort, seems pretty small to me. Okay, so I just, I just share that as an example of how conflicting this data is and what it says about the quality of research that is done. There are no randomized controlled trials. That is the gold standard. Of course, there are no randomized, controlled trials that randomly assign women to VBAC, spontaneous labor, VBAC versus repeat C sections or even expectant management. The reason this gets confusing, I think because expected management is not the same as spontaneous labor. Okay, so explain that, right? I this is, I'm trying to understand this myself. I spontaneous labor is labor that is a normal spontaneous vaginal delivery without intervention. Expectant management is labor that is watched and monitored and potentially intervened if something arises. This tone, totally separate categories. There are women in the expectant management group who don't experience spontaneous labor. They were monitored. They may say, Look, we need to induce you. We have to intervene here. Or they were, they were not induced. But ultimately, they had interventions like augmentation. Or something like that. So you can't consider that a spontaneous labor. So expectant management group doesn't just have to do with how a woman goes into labor, it also carries through the labor. So augmentation plays a role in that, I believe. So, yes, I never, I never thought. So that's interesting. If that's the case, it is a it is a very nebulous term. I mean, it is thrown around all the time, and you do wonder how it lands in everyone's on everyone's ears when we hear it. I always equated it with spontaneous labor, and I think that's part of the reason the arrive trial was so misleading. But we did a whole, right, but we did a whole fabulous, I will say, if I may say so myself, we did a fabulous event on Patreon, on the arrive trial that will make anyone an expert immune arrive trial. So if any doctor ever mentions arrive trial too, you can come back at them so quickly with the faults in that study and what it really showed again on Patreon. We've got so much stuff there that is so far beyond the podcast content. So it's a gold mine over there.

People just don't know it yet. Not everybody. Some people do. We got a lot of people in there now, yeah, we've got, we've got hundreds in there, but 1000s, that's true. I'm just thinking of two or three.

Yes. So the last thing I think we should address before we summarize this and wrap it is just the VBAC predictor.

Well, that I know I have a really important point to make. Oh, okay, well, let's just touch on that. So, you know, there's been all kinds of models created to try to predict who is this successful candidate for a VBAC. And I think at the beginning of this episode, we pretty much mapped out that every woman is a good candidate for a VBAC other than those very, very few, very rare scenarios that we discussed, but still, providers are using models to try to predict if a woman is actually going to fall into that 60 to 80% of successful feedback outcomes. ACOG specifically says that these models are not good predictors. They're so silly. They use them, but they're not good predictors. And they love to, you know, interpret all the data and say that if you're over 40, or if you're morbidly obese, or if you go past 40 weeks, that your risk goes from 60 to 80% to 56% or maybe 47% or maybe, you know, somewhere in there. I mean, come on, it means absolutely nothing. But women are suckers for this stuff. I'm for this stuff. Do you know how many women listening are like making mental notes of all the stats you just gave? Or they're writing it down. And I want to just say it's great. It's great to hear it. Listen to it. What's the difference? Forget the statistics. How does it feel? Is this the right decision for you or not? That's right. Only answer there is, is within your own unconscious or consciousness, like there's not. We can look at statistics all day. What's the difference? When you take one individual woman, we still have no idea where in those statistics she's going to lie. So don't ever let these override and that's why they get to these silly things like V back predictors. It's it. I bet they're not predictive at all, by the way, be now provider, there's, there's a predictor. Who's who you've hired. The more than half of my VBA, they don't look at that in this No, more and more than half of my VBAC clients, and there have been hundreds of them, more than half birthed at home, and virtually zero. I think one was a maybe two, but only one is coming to mind from my the very early years when it was transferred. So almost 100% of them had successful V backs. Tell me the home birth midwife, midwives didn't play a big role in that when it was about 100% of them, your providers belief about V back success is a tremendous player, and whether or not you have a successful VBAC or not, because if they don't trust it, they are going to hold a very low threshold for calling a C section that has to do with their fears, that has to do with the rhetoric that they have been conditioned to believe that once a cesarean, always a cesarean, is still, you know, playing in their head, that V back is dangerous. This is why I wanted to go through these statistics, so that if your provider presents you with that type of rhetoric and fear mongering, you can say, hey, you know, look at the stats. I mean, really it's, it just comes down to the uterine rupture stats like, that's, that's the main thing, um, and think about it, their skill, because home birth midwives are there. I'm not saying especially I'm saying especially skilled. They are trained in unusual birth outcomes. We had one of the first birth stories on the podcast. I think it was episode seven, Jessica, a client of mine, wasn't a VBAC, but a super cool birth. She went to Amish country. She was told to have a C section. She ended up having to birth her baby in a runner's lunch to get a breech baby out. That was something that would not have happened in almost any hospital. Even if they wanted to, they wouldn't have had the tricks up their sleeve. So it's it's not just the home birth midwives support of having a VBAC. It's their skill. They sometimes have to work hard and be creative at getting babies out.

Well, it's understanding the biomechanics of birth that that is not taught in obstetrics. They understand pelvic shape, but they don't understand how to move the body in a way to facilitate birth. And the safety that you feel in birth plays a huge role in this. So you have to feel confident, and your your provider has to feel confident. Just a couple other barriers that that women might run into a big one, two big ones that I want to make sure that women understand that a cog actually does not support suspected big baby. They say, right here in the guidelines, suspected macrosomia, our favorite term, suspected macrosomia alone should not preclude offering VBAC, meaning it should still be supported. It should still be supported. If your provider thinks you have a big baby, they should not tell you that you shouldn't have a VBAC.

I'm so glad whoever is on the board at ACOG has been listening to our podcast.

They're coming around. I'm just kidding, coming around. They haven't changed their terminology. 

So gestational age, also beyond 40 weeks, is not a contraindication to a VBAC. Of course, we know that twin gestation is not a contraindication. I was surprised by that.

No, it shouldn't. It shouldn't be. I'm surprised as well, that they agree that the that ACOG says this, they say it but, but it shouldn't be that is they're saying, they're saying the right thing. I mean, that's, that's correct, but it's surprising, and it's impressive, and it's, it's great to see, it's great to see you should have a VBAC if you're having twins. It is sometimes surprising how much you and I are in alignment with ACOG, but the doctors who are supposed to be adhering to ACOG guidelines are so out of alignment. I know that's the whole thing. It would have done alignment with them. You wouldn't think or that they're in alignment with us. Vice versa. You wouldn't think, right. Okay. Do you have anything else before I do my favorite part? No, I think we, I think we covered it. Oh, no. Almost. We almost go, yes, you I want to share what I think are the most important sentences in this entire bulletin. And I think there are six of them that I highlighted. Listen up. This is the best. Is the best stuff of all these are quotes. The interest in considering VBAC varies greatly among women, and this variation is at least partly related to differences in the way individuals weigh potential risks and benefits. That was the first point. So leave it to her to assess the risk herself. Period, that's what that's saying. Two, the decision to attempt VBAC is a preference sensitive decision, and eliciting patient values and preferences is a key element of counseling. So doctors are not supposed to be issuing doctors orders. They are supposed to be issuing counseling. And this is emphasizing that third one after counseling, the ultimate decision to undergo VBAC or repeat C section delivery should be made by the patient in consultation with her obstetrician or obstetric care provider. Four consistent with the principle of respect for patient autonomy, patients should be allowed to accept increased levels of risk. However, patients should be clearly informed of the potential increase in risk, in management alternatives. She should be allowed to take on increased levels of risk. It's her body. It's her choice. We had an interesting conversation in our little Monday night Patreon chat live the other night about that with free birthing we had when there was a point we were talking about number five, coercion is not acceptable. Nice, short, succinct. Gotta get at that. I have an entire statement on that. Gotta cause an entire statement on that? Yes, they do. They have a whole statement on coercion. Yep, I read it to my HypnoBirthing classes in the last class, always leave them with that six, even if a sender does not offer V back, such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery. Meaning, if she says, I don't want a cesarean I want to attempt a V back, they are not allowed to say it's against our policy. That's what a cog is saying. You may not use policy against her. It says that such, listen, such a policy cannot be used to force women into cesarean delivery or deny care to women in labor who deny a cesarean they're saying you're not allowed to say hospital policy. Can't do this. Okay? What? That's huge. Because how many women write to us and say that their VBAC, their hospital, will not support VBAC? I always against hospital policy. I in my first day of HypnoBirthing classes, I say that women hospital policy means nothing. In the court of law, it's nothing. It means nothing. It's zero. It's a policy. They can say, our policy is that you can't eat in labor, and you can sit there with this cheesecake on your lap, please don't, but a cheesecake on your lap and a fork and knife, and you can sit there eating it. It's only a policy. And this is saying to them, now, this is not about the law. This is a cog saying to hospitals, don't use that to coerce women, because what if you do end up in court. It's not going to stand at all. So don't try to play that game with women. Well, this is very important, because women need to take that statement, and they need to go to their OB who is telling them that they won't do a VBAC. And they need to go to the hospital director. They need to go to the hospital CEO, President, whoever it is, and say, right here people, because that women don't have 10 hospitals to choose from. Many women have one.

So in the most extreme example, the woman's there in her labor. They're saying, it has to be another C section. We don't support VBAC. And she says, I refuse another C section. And they say, Well, we're at a loss. She wins. You're not at a loss. They can't deny her care, and they can't do anything but support what she says.

So you just keep going right ahead with your labor, and you push that baby out right there, wherever you are, bathroom, bed, anywhere in the hospital room, you stay out of the or unless you choose to go and by law, they have to support you. They can't leave you alone in the room. They can't say you're on your own. These are the best parts of the United States in our medical care. So use the best parts. Damn I thought the statistics that we had in this presentation were good, but that is definitely the most important point of this entire conversation. Yeah.

Well, Mic dropped them. Leave it there. Yeah, nothing more to say. Oh, it's always fun getting together and talking about ACOG who's turning out to be our friends in this more than we ever expected, because you would never know it when you're seeing how the treatment women are getting out there from their providers. Half the time, more than half the time, they need to talk to their people, because their people aren't following their directives.

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