The International Cesarean Awareness Network has tracked over 300 hospitals across the U.S. that have instituted policies seeking to ban vaginal birth after cesarean (VBAC), misleading women to believe they must undergo cesarean surgery whether there is a medical need for it or not. Clinical research shows the risks of VBAC are small and that repeat cesarean surgery carries its own risks. In spite of this, many hospitals have attempted to ban VBAC in order to limit their exposure to liability. As a result, many women around the U.S. have been told they must choose unnecessary surgery or forgo hospital care altogether. Below is a guide for women in this situation. Women who are seeking to avoid other medical interventions will also find this information useful.

Q: Does my doctor or hospital have the right to force me to undergo surgery?

A: No. You have the legal right to refuse any medical treatment, including cesarean surgery. VBAC “bans” exist only because they have not been challenged by patients. The doctrine of informed refusal is upheld by common law, case law, Constitutional law, federal law, state law, state mandated medical ethics and the ethical guidelines of the American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG). Any facility or care provider claiming that you must undergo a cesarean you wish to refuse is violating the governing principles of their respective institutions and professions, as well as the rule of law.

Q: What can I do to protect myself from being forced into surgery?

A: There are multiple steps you can take to protect yourself:

• Know your rights. Visit BirthPolicy.org to learn more about the illegal and unethical status VBAC “bans.”

• File a grievance with the Chief Compliance Officer at the hospital where you plan to give birth. Hospitals that attempt to ban VBAC are in violation of the Center for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP), which require all federally funded hospitals (approximately 80%) to honor the rights of patients to be informed of the risks, benefits, and alternatives of all procedures, to refuse any proposed treatment, including cesarean surgery, and to participate in all treatment decisions. To hold your hospital accountable under these regulations, you must first file a complaint with the hospital’s Chief Compliance Officer, who is required to issue a ruling within 60 days. If the CCO rules against you, then you have the right, first, to appeal to the your state CMS office and then to Office of the Inspector General’s Office at the Department of Health and Human Services. If HHS rules against you, then your appeal goes to the Department of Justice, which is authorized to bring litigation against the hospital on your behalf. You can read the CoP regulations by going to the Code of Federal Regulation’s main page. Enter “42CFR482.13″ into the search engine, which will bring up all of the CoP regulations on patient rights and filing grievances. To find contact information for your state CMS office, go to MedLaw.

• Replace your birth plan with a customized form documenting your refusal to consent. By law, you are not required to sign the hospital’s consent form. You can either customize the hospital’s form or write down your refusal to consent to treatment on any piece of paper and sign it. Put a line through any listed procedure you want to decline and then add the list of routine procedures, including cesarean surgery, you want to refuse, initial each change or addition and make sure you have all the required signatures. Doing so will legally document your refusal to consent and alert staff that you understand and are prepared to protect your rights. In addition, such a document will require staff to obtain direct, verbal consent from you each time they want to do a procedure you’ve already declined in writing. If possible, pre-register at the hospital no sooner than thirty days before your due date and take the forms home with you to review, add to, and sign. Be sure to keep personal copies of any forms you sign ansk your partner or doula to record any changes that were made during the course of your labor.

Q: What if the hospital refuses to admit me unless I consent to a cesarean?

A: The federal Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to admit women in active labor and to abide by their treatment decisions until after the baby and placenta are delivered. The act was originally designed to prevent hospitals from “dumping” patients who couldn’t pay but has since been widely used to hold hospitals accountable for violating other patient rights, including the right to refuse treatment. If your hospital threatens to perform a cesarean despite your refusal, notify them that they are in violation of your rights under EMTALA and that you plan to file a complaint. To find out where to report an EMTALA violation, go to MedLaw.

Q: What happens if my care provider ignores my refusal to consent and performs a cesarean anyway?

A: Many women have been threatened by their care providers that they would be put under general anesthesia and sectioned if they sought care in the hospital, even if they were close to delivering the baby naturally. While these threats are intimidating, they are not supported in either legal or ethical guidelines. If your care provider performs surgery in spite of your refusal, you are within your legal right to file criminal assault and battery charges and, if you or your baby suffer an injury, you may also sue for negligence.

Q: What if I challenge my care provider and he or she decides to drop me from care?

A: Professional ethical guidelines state that a physician may only drop you from his care after giving you 30 days notice. This means that if you are within 30 days of your likely delivery date, your care provider cannot terminate your care. In addition, if you are pregnant and are outside of that 30 day time frame, your provider must give you a referral and ensure you are transferred to a specific provider. Physicians who fail to meet these guidelines may be charged with patient abandonment, which is grounds for malpractice and constitutes a violation of ethical conduct that could result in loss of licensure.

Q: What if my care provider or hospital seeks a court order to perform a cesarean?

A: While there is always the possibility that the local court could grant an order forcing you to undergo a cesarean, these cases have become very rare in the aftermath of several court rulings declaring that such orders violate the rights of pregnant women. As a result of these rulsing, both the AMA and ACOG have revised their ethical guidelines to state that court-ordered cesareans are rarely, if ever, justified, and are most definitely not justified in instances where the proposed treatment poses any risks to the mother.

Q: I want to give birth in a hospital, but I am afraid that this is too much stress on my pregnancy and my family.

A: Unfortunately, the options for women whose hospitals have attempted to ban VBAC are limited. Your choices are to fight and assert your legal rights, submit to surgery, or opt for homebirth, either unassisted or attended by a midwife. Educate yourself about the benefits and risks of each option, and make the decision that is best for you and your baby. Call your local ICAN chapter for more information on your options and on the resources available to facilitate your decision.

International Cesarean Awareness Network

What is Breech Presentation?

• Breech presentation is the most common human malpresentation and occurs in 3-4% of all term pregnancies.¹
• Three types of breech presentation occur: Frank (baby’s hips are flexed and knees extended bilaterally) , Complete (baby’s hips and knees are flexed bilaterally), and Incomplete (baby may present with one or two feet – ‘footling’- or one knee extended and the other flexed with hips flexed).^2,3
• Early in pregnancy about half of all babies are breech presentation.⁴ Babies continue to turn to cephalic presentation throughout all weeks of pregnancy.¹

What Causes Breech Presentation?

• Only about 15% of breech presentations have an identifiable etiology.⁵
• Established risks for breech presentation are: Previous breech presentation pregnancy,^5,6,7,8 Late or lack of antenatal care,^8,9 Prematurity (<37 weeks gestation),^6,7,8 Comparatively lower birth weight,^8,9 and Congenital anomalies.^8,9,10

Recent Rates of Vaginal Delivery for Breech Presentation By Country

• Japan 56%.¹¹ Findings: Poor outcome 1.2% vaginal delivery : 0.0% cesarean
• Sweden 52%.¹² Findings: No statistically significant difference between vaginal birth and cesarean section babies for perinatal/neonatal outcomes.
• Norway 40%.¹³
• Finland 39%.¹⁴ Findings: Less birth trauma for vaginal breech deliveries than vaginal vertex deliveries. More trauma for breech vaginal delivery than breech CS, but lower long-term morbidity for breech vaginal than breech cesarean deliveries. Breech vaginal death 0.07%, vertex vaginal delivery death 0.02%.
• Sweden 37%.¹⁵ Findings: Infant mortality, birth injury and convulsions higher for breech vaginal birth than breech CS
• Ireland 23%.¹⁶ Findings: No nonanomalous perinatal deaths, significant trauma, or neurological dysfunctions for vaginally or CS delivered breech babies.
• Denmark 15.3%.¹⁷ Findings: Higher rates of puerperal fever and pelvic infections for CS breech delivery.
• California 4.9%.¹⁸ Findings: Neonatal mortality, asphyxia, brachial plexus injury, and birth trauma higher for vaginally delivered breech than CS. If woman had a previous vaginal delivery no difference in neonatal mortality by delivery mode.
• Canada <5%.¹⁹

Other Research on Breech Presentation Outcomes by Delivery Method

• Meta analysis 1: 24 studies published between 1966-1992²⁰
  Findings: Higher perinatal mortality, traumatic morbidity, short-term morbidity, and long-term morbidity in vaginal delivery than in CS for breech presentation. Lower maternal morbidity and mortality for vaginal delivery of breech.
• Meta analysis 2: nine randomized trials or cohort studies published between January 1981 to June 1993²¹
  Findings: No statistically significant difference between infant mortality and morbidity between vaginal and CS delivery of breech presentation.
• Term Breech Trial: randomized controlled clinical trial in 121 centers in 26 countries and included 2088 women with term singleton breech pregnancies who were randomly assigned to give birth vaginally or by cesarean section²²
  Findings: Perinatal mortality, neonatal mortality, and serious neonatal morbidity higher for vaginal breech delivery than for CS in countries with low levels of infant mortality. No difference in infant outcomes by delivery method in countries with high infant mortality. No difference in maternal morbidity and mortality by delivery mode.

Turning Options

• External Cephalic Version (ECV) after 37 weeks has a success rate of 35% – 86% while spontaneous version occurs in 22%.^23,24 Women who have successful ECV are at higher risk of having cesarean deliveries than are women with vertex presentation babies who did not have ECV.²⁵
• Moxibustion or ginger paste applied close to the acupuncture point Bl 67. Small studies show a success rate of 66.6%-92%.^26-32
• Other less studied options: Homeopathic formulas pulsatilla and natrum muriaticum,^33-36 Gentle chiropractic treatments: Webster’s technique or Bagnell system,^37,38 Hypnosis,³⁹ Playing music over the maternal abdomen.^40,41

Overview

• Morbidity and mortality for breech infants and mothers is most related to inclusion and exclusion criteria adhered to by the hospital for determining mode of delivery, the competence of the attending physician, and the expectation of the mother rather than the mode of delivery.
• In general countries that perform more vaginal breech births have birth outcomes that are as good as or better than cesarean section outcomes. Countries that perform few vaginal breech births have birth outcomes that are worse than those for cesarean section births.
• In many countries breech vaginal birth has higher morbidity and mortality risks for babies, but the risk is still relatively low.
• Some of what has been typed as risk (e.g. low Apgar scores) is clearly not a long-term risk.
• Much of what has been typed as risk can be ameliorated by proper screening for vaginal birth.
• If you want to have a successful vaginal birth look for an old-time doctor or someone with a lot of experience with breech presentation.
• If you have a macrosomic baby or a footling breech cesarean may be better for you.
• To have a successful vaginal birth avoid induced or augmented labor and epidurals.
• If you are going to have a cesarean, consider having a scheduled cesarean without trial of labor.

References Cited

1. Hickok, D. E., Gordon, D. C., Milber, J. A., Williams, M. A., & Daling, J. R. (1992). The Frequency of Breech Presentation by Gestational Age at Birth: A large Population-Based Study. American Journal of Obstetrics and Gynecology, 166, 851-852.
2. Bennett, V. R., & Brown, L. K. (1999). Myles Textbook for Midwives.
3. Cruikshank, D. P. (1999). Malpresentation and Umbilical Cord Complications. In J. R. Scott, P. J. Di Saia, C. B. Hammond & W. N. Spellacy (Eds.), Danforth’s Obstetrics and Gynecology. (8th ed., pp. 419-436). Philadelphia: Lippincott, Williams & Wilkins.
4. Zhang, J., Park, M., & Reddy, U. (2004). Natural history of Fetal Position During Pregnancy and Risk of Breech Delivery. American Journal of Obstetrics & Gynecology, 191(6, Supplement 1), S169.
5. Luterkort, M., Persson, P.-H., & Weldner, B.-M. (1984). Maternal and Fetal Factors in Breech Presentation. Obstetrics & Gynecology, 64(1), 55-59.
6. Albrechtsen, S., Rasmussen, S., Dalaker, K., & Irgens, L. M. (1998a). The Occurrence of Breech Presentation in Norway 1967-1994. Acta Obstetricia et Gynecologica Scandinavica, 77, 410-415.
7. Albrechtsen, S., Rasmussen, S., Dalaker, K., & Irgens, L. M. (1998b). Reproductive Career After Breech Presentation: Subsequent Pregnancy Rates, Interpregnancy Interval, and Recurrence. Obstet Gynecol, 92, 345-350.
8. Amoa, A. B., Sapuri, M., & Klufio, C. A. (2001). Perinatal Outcome and Asoociated Factors of Persistent Breech Presentation at the Port Moresby General Hospital, Papua New Guinea. Papua and New Guinea Medical Journal, 44(1-2), 48-56.
9. Roberts, C. L., Algert, C. S., Peat, B., & Henderson-Smart, D. (1999). Small Fetal Size: A Risk Factor for Breech Birth at Term. International Journal of Gynecology & Obstetrics, 67, 1-8.
10. Rayl, J., Gibson, J., & Kickok, D. E. (1996). A population-Based Case-Control Study of Risk Factors for Breech Presentation. American Journal of Obstetrics and Gynecology, 174, 28-32.
11. Koike, T., Minakami, H., Sasaki, M., Tamada, T., & Sato, I. (1995). The Problem of Relating Fetal Outcome with Breech Presentation to Mode of Delivery. Archives of Gynecology and Obstetrics, 258, 119-123.
12. Hellsten, C., Lindqvist, P. G., & Olofsson, P. (2003). Vaginal Breech Delivery: Is It Still and Option? Obstetrics and Gynecology, 111, 122-128.
13. Haheim, L. L., Albrechtsen, S., Berge, L. N., Bordahl, P. E., Egeland, T., Henriksen, T., et al. (2004). Breech Birth at Term: Vaginal Delivery or Elective Cesarean Section? A Systematic Review of the Literature by a Norwegian Review Team. Acta Obstetricia et Gynecologica Scandinavica, 83, 126-130.
14. Ulander, V.-M., Gissler, M., Nuutila, M., & Ylikorkala, O. (2004). Are Health Expectations of Term Breech Infants Unrealistically High? Acta Obstetricia et Gynecologica Scandinavica, 83, 180-186.
15. Roman, J., Bakos, O., & Cnattingius, S. (1998). Pregnancy Outcomes by Mode of Delivery Among Term Breech Births: Swedish Experience 1987-1993. Obstetrics and Gynecology, 92, 945-950.
16. Alarab, M., Regan, C., O’Connell, M. P., Keane, D. P., O’Herlihy, C., & Foley, M. E. (2004). Singleton Vaginal Breech Delivery at Term: Still a Safe Option. Obstetrics and Gynecology, 103(3), 407-412.
17. Krebs, L., & Langhoff-Roos, J. (2003). Elective Cesarean Delivery for Term Breech. Obstetrics and Gynecology, 101(4), 690-696.
18. Gilbert, W. M., Hicks, S. M., Boe, N. M., & Danielson, B. (2003). Vaginal Versus Cesarean Delivery for Breech Presentation in California: A Population-Based Study. Obstetrics and Gynecology, 102, 911-917.
19. Nevo, O., Berger, H., Walsh, S., & Farine, D. (2004). Effect of Large Trials on Clinical Practice – The Term Breech Trial. American Journal of Obstetrics and Gynecology, 191(6, Supplement 1), S80.
20. Cheng, M., & Hannah, M. E. (1993). Breech Delivery at Term: A Critical Review of the Literature. Obstetrics & Gynecology, 82, 605-618.
21. Gifford, D. S., Morton, S. C., & Kahn, K. L. (1995). A Meta-Analysis of Infant Outcomes After Breech Delivery. Obstetrics & Gynecology, 85, 1047-1054.
22. Hannah, M. E., Hannah, W. J., Hewson, S. A., Hodnett, E. D., Saigal, S., & Willan, A. R. (2000). Planned Caesarean Section Versus Planned Vaginal Birth for Breech Presentation at Term: A Randomised Multicentre Trial. The Lancet, 356, 1375-1383.
23. Hofmeyr, G. J., & Kulier, R. (2002). External Cephalic Version for Breech Presentation at Term (Cochran Review).Unpublished manuscript, Oxford.
24. Lau, T. K., Lo, K. W. K., Wan, D., & Rogers, M. S. (1997). Predictors of Successful External Cephalic Version at Term: A Prospective Study. British Journal of Obstetrics and Gynaecology, 104, 798-802.
25. Vezina, Y., Bujold, E., Varin, J., Marquette, G. P., & Boucher, M. (2004). Cesarean Delivery After Successful External Cephalic Version of Breech Presentation at Term: A Comparative Study. American Journal of Obstetrics and Gynecology, 190, 763-768.
26. Cardini, F., Basevi, V., Valentini, a., & Martellato, A. (1991). Moxibustion and Breech Presenation: Preliminary Results. American Journal of Chinese Medicine, XIX(2), 105.
27. Cardini, F., & Hauang, W. (1998). Moxibustion for Correction of Breech Presentation: A Randomised Controlled Trial. Journal of the American Medical Association, 280(18), 1580-1584.
28. Cardini, F., & Weixin, H. (1998). Moxibustion for Correction of Breech Presentation. Journal of the American Medical Association, 11, 1580-1584.
29. Cooperative Research Group of Moxibustion Version of Jangxi Province. (1980). Studies of Version by Moxibustion on Zhiyin Points. In Z. Xiangtong (Ed.), Research on Acupuncture, Moxibustion and Acupuncture Anesthesia (pp. 810-819). Beijing, China: Science Press.
30. Cooperative Research Group of Moxibustion Version of Jangxi Province. (1984). Further Studies on the Clinical Effect and the Mechanism of Version by Moxibustion.Unpublished manuscript, Beijing, China.
31. Cai, R., Zhou, A., & Gao, H. (1990). Study on Correction of Abnormal Fetal Position by Applying Ginger Paste at Zhihying Acupoint. A Report of 133 Cases. Zhen Ci Yan Jiu, 15(2), 89-91.
32. Qin, G. F., & Tang, H. J. (1989). 413 Cases of Abnormal Fetal Position Corrected by Auricular Plaster Therapy. Journal of Traditional Chinese Medicine, 9(4), 235-237.
33. Baylies, B. L. (1890). Pulsatilla in Malposition of the Fetus. In IHA Transactions (pp. 133-146).
34. Farrington, E. A. (1988). Clinical Materia Medica. New Delhi: B. Jain Publishers.
35. Simkin, P. (1983). Turning a Breech Baby to Vertex. Minneapolis (MN): ICEA/Pennypress Publications.
36. Weed, S. (1986). Wise Woman Herbal for the Childbearing Year. Woodstock, NY: Ash Tree Publishing.
37. Bagnell, K. (2004). The Bagnell System for Breech Presentation. Today’s Chiropractic, 36-44.
38. Pistolese, R. A. (2002). The Webster Technique: A Chiropractic Technique with Obstetric Implications. Journal of Manipulative and Physiological Therapeutics, 25(6), E1-9.
39. Mehl, L. E. (1994). Hypnosis and Conversion of the Breech to the Vertex Presentation. Archives of Family Medicine, 3(10), 881-887.
40. Johnson, R. L., & Elliott, J. P. (1995). Fetal Acoustic Stimulation, an Adjunct to External Cephalic Version: A Blinded Randomised, Cross-Over Trial. American Journal of Obstetrics and Gynecology, 173(50), 1369-1372.
41. Johnson, R. L., Strong, T. H. J., Radin, T. G., & Elliott, J. P. (1995). Fetal Acoustic Stimulation as an Adjunct to External Cephalic Version. Journal of Reproductive Medicine, 40(10), 696-698.

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© International Cesarean Awareness Network, Inc. All Rights Reserved.

Read good pregnancy and Vaginal Birth After Cesarean books. Two suggestions are: “The VBAC Companion” by Diana Korte and “Open Season” by Nancy Wainer Cohen.

Focus on good nutrition and exercise. Make a daily checklist to ensure you are getting essential nutrients. Engage in daily exercise such as swim, walk, yoga, prenatal fitness class- whatever feels good. For information on diet throughout pregnancy, we recommend reading, “What Every Pregnant Woman Should Know” by Dr. Tom Brewer and Gail Sforza Brewer or The Brewer Diet.

Register for VBAC, refresher or another quality, independent prenatal program. Even though you may have taken classes in a previous pregnancy, an evening out together with your partner will help to prepare you both, promoting discussion, giving you ideas on coping with labor and bringing a focus to this baby and its birth.

Enlist the encouragement of a supportive care provider. Find a caregiver/hospital who ALREADY provide the options you want. Find someone who believes in VBACs, has a VBAC success rate over 75% and a cesarean rate that is lower than the community average. Consider having a midwife as your primary caregiver. Midwives have a very low rate of cesarean birth. If you are unsure about anything, get a second opinion. Trust your inner strength and knowledge.

Hire a doula/labor assistant/support person. It is worth every penny to be reassured during labor by someone who believes birth is a natural function. This person will have supportive non-medical skills to help you through labor for the birth you want. This person will assist you from your first contractions at home right through postpartum. A labor assistant, or doula, takes the pressure off fathers and family members so that the whole family can be supported.

Throughout pregnancy practice relaxation and visualization with exercises, tapes, massage, affirmations and touch. Use affirmations such as “Each contraction strengthens my baby and me.” Or “I will birth my baby vaginally, naturally, and joyfully.”

Write a birth plan. Discuss everything that is important to you with your care provider, putting it all into your birth plan. Make extra copies to be put in your chart. Know your hospital’s VBAC policies and negotiate well before the birth for anything different. Things to consider when writing your birth plan are:

• Establish a safe, supportive birth environment to encourage labor.
• Try a variety of positions. Instead of lying down, try standing or walking. Squatting to push can be most effective. Try the birth ball. Try walking the halls. Try ‘dancing’ with your partner.
• Continue your calorie and fluid intake. Labor is work and takes energy. Far from eliminating the risk of aspiration with general anesthesia, total fasting (NPO) may increase the risk by raising the acidity of the stomach contents.
• Avoid medical intervention whenever possible. Continuous electronic fetal monitoring may restrict your movement. Ask for noninvasive options. Ask what will be done with the results.
• Artificial induction should be avoided, if possible. Medical induction is linked with high rupture rates and many interventions.
• Ask for time to try non-medical methods to stimulate labor if your labor is not progressing. These include change of position, walking, nipple stimulation, aromatherapy, acupressure. Every labor is different. Unless you dilated to five or six centimeters during a previous labor, consider this one your first labor.
• Avoiding an epidural may increase your chance for a vaginal birth. An epidural interferes with the baby being optimally lined up and will reduce your ability to push effectively. Try natural pain relief measures, such as: hot/cold compresses, bath/shower (once labor is established), tenns unit, massage, relaxation, guided imagery, birth ball. If you start to think you really need an epidural, give yourself a few more contractions, or request that you be checked one more time. You may be moving quickly into transition without realizing it.

Having a birth plan cannot guarantee that your wishes will be followed. Working with a careprovider who believes in birth is easier than fighting one who does not. No amount of demanding or asking nicely will get you the birth you want.

Many cesareans are done due to posterior or asynclitic presentation. Avoiding reclining positions prenatally. Read Val el Halta’s “Posterior Presentation – A Pain in the Back” article and “Understanding and Teaching Optimal Fetal Positioning” by Jean Sutton and Pauline Scott.

Believe in yourself and the process of birth. Repeat affirmations to yourself constantly. Encourage yourself to believe that you are capable of delivering your baby vaginally. Get in touch with your inner self; your resources and abilities. Forget about your scar and focus on the positive aspects of your pregnancy.

Work on leftover negative emotions (guilt, disappointment, anger) from previous cesarean birth(s). Two wonderful books for this are Lynn Madsen’s “Rebounding From Childbirth”, and “Ended Beginnings” by Claudia Panuthos.

Learn to trust, cooperate with and listen to your body and baby. Listen to your own unique labor pattern.

Feel good about yourself and your relationship as a couple and keep a positive outlook.

Enlist the support of family and friends. Remember that according to medical studies VBAC is usually safer for both you and your baby than a repeat cesarean. Don’t be afraid to let your family know how much you need their unconditional emotional support.

Attend VBAC support meetings and join national organizations. Through meetings and newsletters, you will hear from others who have been there, sharing their VBAC experiences. Read “The VBAC Experience” by Lynn Baptisti Richards, a collection of VBAC stories.

Having a VBAC is worth it! You can do it. Not everything is within our control — however, it is within all of us to prepare ourselves as best we can to maximize the chance of VBAC.

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© International Cesarean Awareness Network, Inc. All Rights Reserved.