VBAC Facts has an excellent post in which she looks at several small studies (if you know of any larger ones, let her know!) which looked at the risk of uterine rupture in VBACs based on the thickness of the uterus, as measured by sonograms.
Go over and read the whole thing; but one point that stuck out to me is the story with which she begins the post — that of a woman planning a VBAC in Switzerland, whose uterine thickness is not as good as they would like, so she’s at an increased risk of rupture — 3-4%, as opposed to 0.5%. Rather than just saying, “Oh, you’re at a 6-8 times higher risk of rupture, so you’ve got to have a C-section” (which is the knee-jerk reaction of so many American OBs… thanks at least in part to malpractice insurers), they said, “You’re at a higher risk of rupture, so we want to be extra-careful and monitor you more closely than usual, but you can still attempt a VBAC.”
Assuming this risk at these percentages to be correct, measuring uterine thickness and keeping a closer eye on those mothers and babies who are at risk, rather than just mandating C-sections for a half a percentage point risk of rupture (which does not necessarily translate into a negative outcome for the baby), it effectively reduces the rate of unnecessareans, while still keeping mothers and babies safe. Those women who need C-sections can still get them in a timely manner; and those women who don’t need them can avoid the cost and pain involved in such surgery.
It seems a much wiser course to take — to closely monitor only those women who need it — than the one we’ve currently got in much of the country. In many areas, a woman’s only options for VBAC are unassisted birth or illegal-midwife attended birth; her only other option is an “elective” C-section, which is not really of her choosing. Some women also have legal-midwife attended birth as an option, but in many cases, their only choice is an unwanted repeat C-section or an unassisted birth — neither of which she would freely choose.