The "Truth" about Pelvic Organ Prolapse

I'm not a Dr. Oz fan, but couldn't help noticing that he was talking about something not many women like to discuss: pelvic organ prolapse. I also was intrigued not only because of my birth nerdiness, but because I share some of these complaints and wondered: does anybody else?

Supposedly the "last taboo topic" in gynecology (nah, I think that'd be having a homebirth) I was curious, because I too was hesitant to talk about it. With strangers, sure; but friends - I wasn't really anxious to share that info with people I went to high school with (which is why I don't advertise my blog around casual acquaintances - I really don't want them knowing the intimate state of my vagina.)

Anyway, Dr. Oz revealed just how common pelvic prolapse - when your reproductive organs come out through the vagina - really is. The crowd was hushed as women in many age groups looked like they were hanging on to the edge of their seats. We all cruise through the female incontinence aisles at the grocery store (on our way to somewhere else, right?) and know those problems exist, and that they're actually pretty common. (There's even an entire company devoted to sending you your incontinence products, in discreet packaging directly to your house, so as to avoid being spotted at the grocery store.)

The primary risk factors are childbirth (especially after having several children), weight, and age. The problem is, Dr. Oz - and pretty much everyone else outside the birth advocacy circle - don't tell you that how you give birth can impact your risk factors.

If there's one thing I'd like to change about my vaginal birth, it's directed pushing. As one article on Dr. Oz's website said, "You take a genetic predisposition, a 9 pound baby, and three hours of pushing" and it's not a wonder we have these problems.

Back up a minute.

Three hours of pushing - even the one hour and ten minutes I pushed - is probably more common than it should be in hospitals. From my experience, I know I had absolutely no desire to push. Laboring down was not an option, and I wish I knew better to just wait for my body to do it on its own. Even if you were knocked unconscious, your body would still involuntarily contract and push that baby out on its own, but who has time for that anymore? It's rush rush rush to get the baby out (even in the absence of problems) and move on to someone else.

Consider what happens when you're constipated and trying to have a bowel movement. Pushing and straining - much like during childbirth - are probably going to do little more than produce a wicked case of hemmorhoids and even rectal bleeding. But if you wait until you have the urge (which is involuntary, much like pushing out a baby) it's a lot easier with a lot less work. So even though I personally detest the phrase 'it's like taking the biggest crap of your life' to describe childbirth, in some ways it can be compared, yes.

In the process of laboring down, the body can actually stop the labor process altogether, sort of as a last-ditch effort to conserve energy for the big event. And like a bowel movement, most women describe the urge to push as uncontrollable and something they just had to do. Unfortunately, I have never experienced that feeling, the feeling of knowing my body is doing something on its own volition because that's what it's supposed to do - not push a baby out at lightning speed just because somebody told me to.

In reading about the subject, some physicians simply blame childbirth in and of itself for prolapse, while others say traumatic childbirth is a cause. I'm not sure women realize there is any other kind, which is sad. Things like cord traction - literally pulling on the cord to get the placenta to detach from the uterine wall - is another risk factor. Forceps deliveries, episiotomies (again, largely unnecessary but done anyway) and prolonged, directed pushing are other causes, and yet all are considered standard procedure in many labor and delivery wards. In other words, we've experienced this crap for so long that we don't even know it's the cause - and that it's not really as normal as we think it is. We're normalizing the abnormal.

Many times, in an effort to avoid postpartum hemmorhaging after birth, they use cord traction to avoid a "retained placenta" - and cause even more bleeding as a result.

"Retained placenta" is another term I have a problem with. While the standard seems to be around 30 minutes after birth, it seems that, like everything else, it's different for everyone. While I'm obviously not an expert, I'd guess that in the absence of bleeding - and with the presence of breastfeeding right away - leaving it more than half an hour is probably okay. When I did some quick searching on it, I found several who said an hour, two hours - even 30 hours - and she lived to tell the tale. *gasp!*

More often than not it seems doctors are too quick to expect the placenta to come out and rush it with cord traction, which is often quite painful and dangerous if too much force is applied. I've also talked with people who agree their doctor was way too eager to detach the placenta and literally yanked on it - which can cause the very complications you're supposed to be preventing.

One study has shown that injections of oxytocin into the umbilical cord vein does not decrease the need for manual placenta removal; however, you're back to that murky definition of 'retained placenta' again. According to the article, retained placenta is more likely to happen to women in "wealthier nations." Not surprisingly, the study found that among women in the UK, Uganda and Pakistan, the women in the UK were more likely to have a retained placenta:

The researchers also found that the need for manual removal was higher in the United Kingdom (69 percent) than in Pakistan (62 percent) or Uganda (47 percent).

Many are quick to point out how dangerous it is to give birth in third-world nations like Pakistan and Uganda. While there is no doubt some truth to that, giving birth with overloads of obstetrical interventions - like in the UK - is probably just as bad. (Side note: not surprisingly, Uganda is the only nation of the three that doesn't have a relatively low rate of breastfeeding, which is often a good way to encourage the placenta to detach by itself. Incidentally, the CDC has determined that most US hospitals are severely lacking in their breastfeeding support, which could be further contributing to this problem. Add to that the frequent, often prolonged separation of mother and baby immediately following birth and it could add to further reliance on active management of the third stage of labor.)

Ironically, many in the UK scratch their hands and wonder why women in the UK are experiencing this problem, despite having access to all the best care and resources. Dr. Andrew D. Weeks of the University of Liverpool thinks prolonged cord traction might be an issue. Ya think?

Some sites list things like "unusually large babies" as a cause - perhaps it's more the interventions perceived as necessary in delivering that "large" child (and the idea that everyone has a different definition of what a large baby really is) that are key here. It's not uncommon for someone to have a very actively managed labor with a larger baby that results in significant trauma to the pelvic floor. Conversely, we hear of many women successfully delivering bigger babies with little if any tearing - which can depend on the birth setting. (Home birth? Natural hospital birth?) and the attendant (midwife vs. doctor? Someone who is more pro-natural birth?)

Sadly, doctors like Dr. Oz and urologist Jennifer Berman might hand out less-than-helpful advice because they've never actually seen a normal birth in progress. They often see the end result of years worth of obstetrical manipulation and intervention and chalk it up to just plain old childbirth itself, perhaps recommending an elective cesarean to avoid all that damage (even though studies have shown it doesn't). Yes, some women will be prone to this - for a number of factors besides childbearing - despite having an intervention-free birth. Some women get it and they've never even given birth. But until you can compare what often is and what could be, you have no real idea that the process is totally tampered with.

In doing some reading, I came across a very sad post by a nurse who experienced a pretty difficult birth, no doubt precipitated by the fact that she was induced at 37 weeks. The baby sounds like it just wasn't ready, but doctors attempted every means possible to get that child to come out, resulting in some nasty-sounding results. She wondered if she had a case against them because of everything she went through.

Some of the answers she got were quite shocking. Daring to call the normal 'abnormal,' she got berated, told she was a liar, and that what she went through didn't happen as she said it did. She was told that "controlled cord traction" was basically no big deal and an "acceptable practice." Maybe so, but it shouldn't be, especially in the absence of other complications. In the end, another forum user piped up and said "You think you had it bad??" as it to get into a virtual pissing contest about who could tell the most Horrible Birth Story Ever. I felt sad for the woman, not only because these women attacked her for questioning the status quo, but because they echoed what our legal system tells us: that unless you have something permanently wrong with either you or the baby, that you should just shut up and get over it.

After seeing some of the audience members on Dr. Oz's show, you realize that women have basically been giving birth violently for decades, perhaps even more than a century. I didn't see any hippie mamas standing up in the audience saying, "Well, I had a natural home birth and mother-led pushing in any position I wanted to, so I don't have that problem." She'd probably be stoned to death if she did. That, and the number of what we could call near-failed inductions - those where a vaginal birth happens but I'm not sure I'd call it successful, exactly - probably means more women are continuing to suffer.

While Dr. Oz's segment was titled "Suffering in Silence: The Shame of Pelvic Prolapse," I really think the people who should be feeling shame are those who insist on continuing these practices even though it's not in the best interests of their patients.

More reading:
Diagnosis and management of retained placenta after vaginal birth - Dr. Andrew Weeks talks about the risks and complications of retained placenta, but admits:

There is no consensus worldwide as to the length of the third stage after which a placenta should be termed "retained" and intervention initiated.

Controlled cord traction versus minimal intervention techniques in delivery of the placenta: a randomized controlled trial - This study suggests the use of CCT is beneficial and says that a continuous infusion of oxytocin were given to each patient after delivery of the placenta. I'm curious, though, what percentage of mothers breastfed immediately after birth, and how long were their placentas retained before someone decided to manually remove it?

Controlled Cord Traction During Third Stage of Labor - This study seems to contradict what the previous one said, in that

"Controlled cord traction (CCT) is actively promoted in combination with prophylactic uterotonics for the prevention of PPH. While the administration of uterotonics has been proven effective, there is no evidence of CCT being beneficial or safe. 

The purpose of the study was to determine: 

1. In women having term, single vaginal deliveries in hospital settings, in whom the third stage is managed with prophylactic oxytocin, does CCT produce a clinically significant reduction in the incidence of postpartum blood lose? (sic)
2. In these women, does CCT produce a clinically significant increase in the incidence of severe complications, including uterine inversion or the need for subsequent surgical evacuation of retained placental tissues and membranes (curettage or manual removal)?

Injections Aren't Solution for Retained Placenta: Study - ABC News
Management of the Third Stage of Labor - Medscape

The third stage of labor refers to the period following the completed delivery of the newborn until the completed delivery of the placenta. Relatively little thought or teaching seems to be devoted to the third stage of labor compared with that given to the first and second stages. A leading North American obstetrics text devotes only 4 of more than 1500 pages to the third stage of labor but significantly more to the complications that may arise immediately following delivery.^[1] One respected author states: "This indeed is the unforgiving stage of labor, and in it there lurks more unheralded treachery than in both the other stages combined. The normal case can, within a minute, become abnormal and successful delivery can turn swiftly to disaster."

While that may be true to some extent, why do our bodies have these built-in mechanisms to aid this natural, physiologic process?
Postpartum Hemorrhage - Wikipedia 

A Cochrane database study^[5] suggests that active management (use of uterotonic drugs, cord clamping and controlled cord traction) of the third stage of labour reduces severe maternal bleeding and anemia compared to expectant management. However, the review also found that active management reduced the baby’s birthweight and increased the mother's blood pressure, afterpains, nausea, vomiting, and use of drugs for pain relief. The number of women returning to hospital with bleeding also increased. Another Cochrane database study^[6], focusing specifically on the timing of the administration of the uterotonic drug oxytocin as part of the active management of the third stage of labour, suggested that administering the drug before the expulsion of the placenta did not have any significant influence on the incidence of postpartum hemorrhage when compared to administering the drug after the expulsion of the placenta.

 Eight Ways to Avoid Pitocin in Labor and Why You Should - Birth Sense blog 

The psychology of vaginal exams

Most women would never consider the state of their cervixes as having anything whatsoever to do with their brain. However, for many, this isn't entirely untrue.

Many people think that a vaginal exam in late pregnancy is just part of the old routine when it comes to maternity care. For probably a large portion of them, it is - but it doesn't mean it tells you (or the doctor) anything at all.

I've heard so many people ask "Will I go into labor soon?" after a 37-week cervix check. Or they're losing bits of mucus plug after an exam and think it's because they're dilating (which they might be), likely because the doctor's poking and prodding dislodged something. Many are downright depressed to hear that nothing's going on at all and some are elated to be dilated to 3 at 36 weeks because they think labor is coming soon - and maybe because their doctor said, "Oh, you'll go early." Wishful thinking, at best.

I ran across a very informative article by Robin Elise Weiss that outlines the "myth" of the vaginal exam and what it can (and can't) be good for. I've also survived three pregnancies and different stages of dilation in late pregnancy that tell me one thing: being dilated (or not) towards 40 weeks doesn't mean squat.

Many of us, including myself during all my pregnancies, are curious to find out if there is something going on in that department. Even during my third pregnancy, when I knew dilation and effacement meant little at that point, I was anxious to see if anything was happening - because, after all, this was my third pregnancy. Things are supposed to move faster at that point, right? Wrong. I was actually more dilated before labor (at probably 36 weeks) with my very first baby. I was so excited to learn that even as a first-timer, I could still dilate early and wondered if it meant I would deliver early (after all, both my mother and I had been born before our due dates). The doctor was skeptical. (It turns out I did deliver my baby five days before his due date, thank you very much. But I doubt that had anything to do with my cervical progress when he checked me.)

If you're simply curious (and who isn't?), I doubt having one in late pregnancy is going to necessarily be a bad idea. But neither does it mean you need to be checked at every visit (barring any conditions like preterm labor, etc.). I often tell women if you are dilated, it doesn't mean you'll go into labor anytime soon, and you can be dilated for weeks and still be overdue. Nor does not being dilated mean anything - you can deliver your baby in a matter of hours or days from a depressing cervical check that convinced you labor would never happen. This has happened to me as well: at my last prenatal appointment with my second baby, I was disappointed to learn that I was neither dilated nor effaced. And yet, a week later, I was holding my daughter. So you never know.

Some women refuse them completely in both pregnancy and labor because they know the results are not always that important. I will say this: from my experience I was thankful to have them in one sense - that it could verify my baby's position. With my first, we didn't find out he was breech until probably about ten days before he was born. That uncomfortable, crappy vaginal exam ended up helping me prepare for the very real surgical birth I was about to experience and helped me process it on an emotional level. My friend, however, who also has a history of breech babies, had no idea her baby was breech while she was laboring at the hospital. "Did you have an exam?" I asked her. She said her doctor never did a cervix check on her prior to labor, which can be considered good and bad, depending on your point of view.

The state of your cervix can also play tricks on your mind while in labor, too. Dilating fast? Great! Not so fast? Guess what, you'll be submitted to probably hourly dilation checks to make sure you're moving at one centimeter per hour, that Golden Rule of Obstetrics that means "you'd better make progress, lady!" If not, then some doctors will be patient and wait for you to progress. Others will label you "failure to progress" and you might be threatened with a c-section, or they'll ramp up the Pitocin to force things along. While I've never personally had this happen, I'd think that exploring your options might be a good idea: are baby and mom tolerating labor well? Can you please please please walk around/sit on the birthing ball/change positions/do something else in order to encourage dilation? I can't say for sure whether it worked or not, but I carried a coffee can lid around in my purse for weeks before my birth because it was the approximate size of a fully-dilated cervix - and I visualized my cervix opening up, just as many birth instructors have suggested. Mind over matter! If you can go to that special place inside yourself and focus on progressing, who knows - it just might work.

That famous rule - The Friedman Curve - is a huge pet peeve of mine. We're constantly told during our pregnancies that "every woman, every labor is different!" and yet when it comes right down to it, we're not treated as if we're different. We're forced into a nice, tidy box that says that "even though everyone is different, we're going to require you to perform in labor like everyone else." A brief search on The Friedman Curve draws some scrutiny: one article states that the half-century old rule is "the ideal, rather than the average" curve, calling it an "obsolete approach to labor assessment." If that's the case, and we're living in such a technologically-advanced medical community these days, then why is everyone and their surgeon still using it?

The body is an amazing machine, and if you listen to it, it'll tell you something. Just like the urge to push, when you're going through transition, you may feel a wide range of symptoms: nausea, irritability, vomiting (also affectionately called by some, "The Seven Centimeter Pukes,") feeling emotional and crying for no reason, or shaking. With all those obvious signals, who needs a cervix check?!

For some laboring women, repeated cervical checks can actually cause dilation to slow or stop altogether, what Ina May Gaskin calls the "Sphincter Law " in her book Ina May's Guide to Childbirth. A particularly harsh or brusque doctor with the bedside manner of a goat might create an atmosphere of hostility in the room that discourages the woman from opening up and dilating further. She compares this with trying to go to the bathroom while people are watching - not very easy, and a terrific analogy of how our minds can often control even the most involuntary of our body's actions.

Not only that, but the physical ramifications of constant vaginal exams while in labor can be great as well. Repeated exams can introduce infection, and often times women are led in 'directed pushing' when they reach completion simply because they're 10 cm and "it's time." Well, not if you have no desire to push. Directed, or coached, pushing simply based on your cervical status is probably a leading cause of tearing and trauma to the vaginal area. Again, throughout labor, your body will tell you when it's time to push, and it's not necessarily the exact minute you become fully dilated. If there's one thing I could do over in my vaginal birth it would be to push when I was ready to, not just because I was complete.

It's important for women to remember that the results of a cervical check should not be something to get upset over: if you're dilated, that's great. If not, it doesn't necessarily mean you will have to be induced, sectioned, any of that. All too often women place so much emphasis on those results that they become desperate to induce their labors and get things moving, but for what?

As someone said, checking women while in labor or late pregnancy often 'makes doctors feel like they're doing something useful.'

I couldn't agree more.

Additional links:

More on Pushing
Mother-Directed Pushing: Six Reasons to Listen to Your Body During Labor

Low Expectations: Labor Pain Management

I often visit a ton of forums that deal with pregnancy and childbirth, and am saddened, shocked and amused at what I read. The perceptions that women have - and pass on to each other - often frustrate the crap out of me, and I wish we could somehow erase all those myths, misperceptions and unfounded fears that often swirl around being pregnant and giving birth. 

Pain management is one of them. One forum that I used to frequent often had first-time soon-to-be-moms asking questions like "How will I know I'm in labor?" or "How badly does childbirth hurt?" All perfectly good questions, that are usually met with total crap answers. Of course, the minute the semi-crunchy granola mom like myself answers those questions you're usually scoffed at or blasted for your opinion that pain is different for each woman. "Trust me, honey," one woman says, "you'll want that epidural!"

Well, not necessarily. I am totally not trying to sound like SuperMom in need of a "vag badge" (good Lord, I hate that expression!), but geez, pain management is different for everyone! I usually tell people, when they ask, that you should take it as it comes - not insist for an epi the minute you step off the elevator - but wait and see what happens. You might get through it and say, "That wasn't too bad," or maybe need something like Nubain instead. There are alternatives to an epi that can bring some relief, or at least relax you so you can focus on the business at hand. 

I had Nubain with my vaginal birth and while it didn't do squat for the pain, it at least made me not care about it. LOL I remember getting half way through my delivery thinking, "Maybe I should get an epidural." Then I thought, "Nope, too late for that." (Maybe it was the Nubain talking? Who knows. LOL) 

With my third child, I essentially went through the entire labor, minus the pushing stage, and didn't have anything. It wasn't anything terribly unmanageable until my water broke, and even then, changing positions totally helped. That's the thing - pain is different for everyone, and can be totally dependent on a number of things: your positioning, the baby's positioning (back labor stinks!), and especially your state of mind. If you go into it with another woman's idea of what pain is, simply because they told you "you'll want that epi!," then you're bound to be scared to death and clenched up tighter than a clamshell about to relinquish its prized pearl. 

Midwife Ina May Gaskin has a terrific analogy for this, which she calls "Sphincter Law," as far as relaxation and dilatation during labor. Picture a man who's been offered a $100 bill, if only he can pee in front of 50 people. There's no way that's happening, right? Just like some people can't go to the bathroom in strange places, giving birth can kind of be the same way for some people. If you're more focused on the pain, or especially the idea that strange people are in the room looking at your female parts, then you cannot relax and neither can you effectively dilate. Some women no doubt become exhausted at this point and stall, causing the cervix to stop opening. 

One thing I did to encourage dilatation was to meditate and picture in my mind the cervix opening up, almost like a flower. I pictured the chart in my doctor's office that shows the different stages of dilatation, and made a circular shape with my hands to further illustrate that point to myself. For my third baby, I actually carried the lid of a coffee can (which is roughly the same size as a fully dilated cervix - can you believe it?)  around in my purse LOL and looked at it whenever I thought about it. (Perhaps it worked a little too well, then, when I showed up at the hospital and my water broke as I was signing myself in!)

Other ways to manage pain in labor can include massage, walking and changing positions. With my second baby, she was nearly posterior, which meant painful back labor. Lying on my left side encouraged her to turn, which made the pain much more manageable. Having a doula present can also help by keeping you focused on something other than the pain, and has been shown to decrease the rate of epidural use. Either way, if you decide to have one, then that's perfectly okay - some women have other issues going on that might necessitate having one, and there's nothing wrong with that. 

Whatever happens, I encourage women to take it on a "let's wait and see" basis, because you just never know how things will turn out. If you go into it having low expectations, then they will almost always be met. But if you think positively and say to yourself, "I think I can do this!," you might be pleasantly surprised. 

The Fight To Give Birth in the Age of Fear-Based Obstetrics

As I quickly approach the 40-week mark in my pregnancy, I am thankful for many things: namely the fact that my body has essentially "proven" itself to not only me but to my OB's. I am preparing for my second VBAC (Vaginal Birth after Cesarean) and while my journey has been fairly uneventful thus far (I won't say totally uneventful, because that's not the truth), it is nothing less than a tooth-and-nail fight for thousands of women to do the same all over the US. 

I am also thankful that my only reason for having a c-section was breech presentation of my first child - not failure to progress, a "small pelvis," or failed induction of labor. I went into labor on my own even then, and had already progressed well despite the fact that we knew the baby had to be delivered via cesarean. With my second pregnancy, to my OB's credit he did offer me the choice to do a VBAC initially (which I declined, knowing nothing about it) and I think he was secretly relieved when I said no. But as I approached 37 weeks, my baby was heads down - something I wasn't even sure my children could do because of a physical defect of my uterus - and realized quickly that I really didn't want to go through the painful recovery of another c-section. 

I consulted with my OB, whom I thought was going to stutter himself into oblivion at my choice. I had since done lots of research, lots of praying, and lots of reading of very positive birth outcomes that I felt was essential to the preparation process. I couldn't believe what I was about to embark on, but with God's help and my husband's support, I could get through this. And I did. Beautifully!

I'm not totally against c-sections: of course I think there are instances where they are totally necessary. Breech presentations, multiple births (although not necessarily with twins alone, as long as they present correctly), severe prematurity, dangerous pre-eclampsia, and fetal distress are all obvious red flags, at least to me. But with a c-section rate of roughly 30 percent in this country, you have to wonder if those reasons are really why women are having c-sections?

More common reasons that the c-section rate is so high is because OB's want to practice "daylight obstetrics" - they want the baby out in time for dinner, essentially. With the ability to control so many facets of our lives, why not birth? Anymore if you go one day past your due date, you seem to be a candidate for induction. Pitocin-happy doctors willingly try and induce (more like coerce) a baby out even if it's not ready. Unfortunately it seems that fewer and fewer women are sent home as a result and are almost definitely candidates for c-section. Pitocin can bring with it a cascade of interventions that can sometimes alter or stop labor completely - increased use of epidurals because of harder, stronger contractions is not uncommon, which can, in turn, stall labor - leading to an increased number of c-sections. 

Insufficient pelvis size is another common reason many women are encouraged to have a c-section. Scores of women are even told their babies are too big to deliver vaginally just by an estimate on ultrasound, which further scares them away from attempting a vaginal delivery. Sadly, there is no definite way to know how big a baby will be until they're born and put on the scales - and ultrasound measurements can be off by as much as a pound either way. Many, many petite women give birth vaginally to "large" babies (according to the March of Dimes, anything between six and nine pounds is considered average) and do just fine. Even many babies deemed to be "stuck" can be birthed vaginally provided the medical practitioner knows to instruct the woman to change positions to facilitate further widening of the pelvis (known as the "Gaskin Maneuver," named for renowned midwife Ina May Gaskin). 

Because of the high rate of c-sections in the US, many women are faced with a two-fold problem: if they want more children, do they deliver them via cesarean too? 

Not necessarily. The mantra "once a c-section, always a c-section" is thankfully being disproved by women everyday in this country, although we still have to fight for the right to do so. But unfortunately few women choose this option - whether because they're uneducated about the risks, their doctors scare them out of it, or they have no interest - which is their right. I would never advocate a woman do a VBAC if she really doesn't want to, but neither should I think women should be scared into repeat c-sections for no reason, either. 

One reason many women are scared away from VBACs is the phrase "uterine rupture." It is possible, but is rare, provided you have a low, transverse incision (bikini incision). Also, your chances of receiving Pitocin to induce labor are less - because it can increase your risk of rupture. To many women, the risks of a c-section, if they even know what they are, are somehow more acceptable than the risks of a VBAC, even though the percentage of complications is about the same. 

Risk of VBAC, with non-induced labor, include:

• uterine rupture - this is rare, and the rate is around 1 percent, depending on which source you site

• risk of needing emergency c-section, should the same complications arise as in the first birth

• if you can't go into labor on your own, induction is not recommended 

Risks of cesarean section include:

• increased blood loss and chance of infection

• respiratory complications in the infant because of spinal anesthesia

• increased risk of scar tissue adhesion, especially after several c-sections (which can cause pain and sometimes infertility)

• premature birth because due dates are off 

• risk of uterine rupture (without even going into labor) (although small, still a risk)

It all boils down to which risks you are more comfortable in taking - because don't kid yourself that a repeat c-section isn't without significant risks, too. Neither of them are decisions that should be taken lightly, but unfortunately many women shrug it off as though it's nothing. This unwittingly affects birth outcomes and choices for thousands of women they don't even know, because they either don't care or aren't willing to fight their doctor for the right to give birth. And if you don't fight it, nothing will change. 

http://www.ynhh.org/healthlink/womens/womens_11_01.html

http://www.vbac.com

http://www.vbacfacts.com

http://www.mothering.com/articles/pregnancy_birth/birth_preparation/inducing.html

http://www.buffalonews.com/248/story/573154.html

http://www.msnbc.msn.com/id/17796664/