Can You Induce VBAC? – The Wrong Question

Which risks do YOU prefer? Remember, there are no risk free options.

Can You Induce VBAC? – The Wrong Question

Can you induce VBAC? That might just be the million dollar question. Yes you can! But is it the best question? The better questions might be “What would I like to do if a medical need for induction arises?” and “Does my care provider provide the service I want under those conditions?”. 

Induction of labour or a repeat caesarean are the two options most commonly presented to women as they inch past forty or forty-one weeks. There are VBAC hopefuls on both sides of the fence. Some would rather be induced than go straight for a repeat caesarean, and others would prefer to avoid induction at all costs, opting for surgery. Both are valid, and both are very personal preferences. 

The presentation seems to revolve around risk reduction, but this is, in a sense, dishonest, because by the time a woman is heavily pregnant there are no risk free options. Different care providers prefer different sets of risk, which is fine. However their job is not to herd women into accepting their professionally preferred risks. Their job is to support the woman’s decisional capacity as she navigates her way through the risks, deciding whether to induce, opt for surgery, or to simply wait patiently.

”My doctor won’t let me go past 40 weeks, and he won’t induce me. How can I bring on labour?”

So many women ask this question. And it’s clear that obstetric surgeons are not providing all the available options to women, nor encouraging women to make decisions for themselves. Many women seem to be under the impression that they must do what their doctor or hospital tells them to do, but this is not the case.

”My doctor won’t let me go past 41 weeks so I have to be induced”

No, you do not HAVE to be induced! Induction is definitely one option, but it is not a legal requirement, and any doctor who insists on induction is not following their actual legal obligation to gain informed consent. A woman who does not know all the facts, risks, benefits, and alternatives is unable to give informed consent to anything. A woman who knows her options but has a care provider dictating her course of action to her, can not give informed consent either.

The variations between recommendations and protocols around the world, and even in neighbouring hospitals, highlight just how little evidence goes into them. If booked induction dates or caesareans for VBAC hopefuls were really proven to be safer at a particular date, then surely there would be a uniform approach to maternity recommendations after that date. The consensus would be mirrored in maternity institutions around the world.

Moreover, if obstetric practices were within the law, women would clearly understand that protocols are there to ensure that each woman is OFFERED THE SAME STANDARD OF CARE, but that women are not required to submit to recommendations. Hospital protocols are not like the road rules.

If evidence and legal requirements were followed, doctors would not say anything like what we saw above, they might say something more like:

”You are now past your estimated due date by {this many weeks / days}. You have several options at this point. They are firstly, to wait and see what happens. We will monitor your health closely if you choose this option. Remaining pregnant at this gestation comes with {discussion of risks / benefits}. The second option is that we can induce labour using one of several methods, or a combination. That carries risks, including {risks / benefits discussion}. The third option is an elective repeat caesarean, which carries the risks of {risks / benefits discussion}. At this stage, based on your health, and the available evidence, my recommendation would be {discussion of recommendations / woman’s preferences} however the decision is ultimately yours and I’m happy to support you in any way I can”

Inducing any pregnancy introduces risks, which is why induction should only be offered when the benefits of finalising the pregnancy outweigh the risks of waiting for labour. Some surgeons won’t induce VBAC because they believe it increases the risk of rupture, others induce VBAC routinely at a certain gestation because they believe the risk of rupture increases with gestation, as does the risk of stillbirth.

The problem here is not whether women are induced with VBAC births, or whether they go straight to repeat surgery, the problem is whether women are provided with both options and the frequently omitted option, TO JUST WAIT. This option almost never makes it to the table for discussion.

At the end of the day, no matter what a surgeon perceives as the greater risk, the decision belongs to the woman. They should not book a caesarean for a woman who would prefer induction, simply because it is their belief that induction is unsafe for VBAC, nor push induction on a woman who would prefer to wait or have a planned caesarean.

In his famous essay titled Fish Can’t See Water – The Need to Humanise Birth, Marsden Wagner asserts:

”Doctors are human; birthing women are human. To err is human. Women have the right to have any errors committed during their birthing be their own and not someone else’s.”

And this is true for doctors as well. Doctors have the right to know that they did their best, they provided the woman with all the information, and supported her decision, even if they didn’t agree with it. The choice to induce VBAC should not be up to doctors though, it should be a decision that women make for themselves.

The fact of the matter is that ALL women go into labour if we just wait. And the simple truth is that there is no risk free way out of pregnancy. Promoting induction or caesareans as risk reduction is unethical because only individual women can assess the risks they prefer to take. Caesareans and inductions do not remove risks, they simply alter them. If all the decisions presented to pregnant women were thoroughly presented in terms of risk and benefit, health and evidence, we would see far higher trust and satisfaction levels in the services provided by hospitals and obstetricians. Unfortunately far too many obstetricians seem to have forgotten fundamental rule number one: The customer is always right. Whether the customer wants to induce VBAC, whether she wants to wait for labour to begin, or whether she wants a repeat caesarean. The customer is right. 

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Ca you induce VBAC - woman in hospital bed being induced
Induction is not risk free
License: Creative Commons CC0.

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