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The American Congress of Obstetricians and Gynecologists (ACOG) recently issued a new set of medical guidelines that should make it easier for women to find doctors and hospitals that will allow vaginal birth after a cesarean, or VBAC. The new guidelines are an effort to reduce the steadily increasing number of cesarean births.
Cesarean delivery has become the most common surgical procedure in the United States.
Cesarean delivery has become the most common surgical procedure in the United States.
Despite the goals of the national initiative Healthy People 2010 to reduce cesarean section delivery rates to 15 percent of births, the national rate of women delivering by cesarean was 32.3 percent in 2008. Furthermore, 90 percent of the women with previous cesarean sections deliver the same way in subsequent pregnancies. Today, cesarean delivery has become the most common surgical procedure in the United States.
The advantages of a VBAC are that it avoids major abdominal surgery, lowers a woman’s risk of hemorrhage and infection and shortens postpartum recovery. It may also help women avoid possible future risks such as hysterectomy, bowel and bladder injury, transfusion, infection and abnormality of placental attachments that increase with multiple cesarean sections.
ACOG began advocating VBAC in the early 1980s for carefully selected patients as a means of safely reducing the cesarean delivery rate. Over the next several years the number of women delivering vaginally after previous cesarean section began to grow; but case reports of uterine rupture appeared.
A uterine rupture, although very rare, can be a life-threatening emergency for both the mother and the infant. An immediate cesarean section is required in order to minimize the risks to mother and infant. Litigation was followed by large medical payouts. In response, doctors became more cautious about offering VBAC.
The new guidelines go beyond the earlier ones in stating that VBACs are a reasonable alternative for most women, including those carrying twins and those who have had two prior cesarean sections. However, VBAC should be offered only in facilities with staff members “immediately available” to provide emergency care.
In a report published in the June 2010 issue of Obstetrics & Gynecology, a panel of experts convened by the National Institutes of Health reviewed evidence about maternal and neonatal outcomes relating to VBAC. They investigated factors that could influence a VBAC, benefits and harms of a VBAC compared with an elective repeat cesarean section, and factors that could influence maternal and neonatal outcomes.
The researchers looked at studies evaluating birth after previous cesarean delivery in the United States and developing countries. The studies involved 402,883 women and focused on high-risk maternal or neonatal conditions, including breech vaginal delivery.
According to the data, delivery by a prior cesarean section was the most common reason for a woman to have subsequent cesarean sections, accounting for more than one third of cesarean deliveries per year, twice the rate of other indications. Yet, according to the evidence, researchers concluded that a VBAC is “a reasonable and safe choice for the majority of women with a prior cesarean.”
Although maternal deaths were rare, there was a significant improvement for women who went through labor and delivered vaginally. The mortality rate was 0.013 percent for those having repeat cesarean sections compared with only 0.004 percent in the VBAC group. However, there was a slight increase in uterine rupture in the latter group.
Since a uterine rupture can cause serious injury to a mother and her infant, ACOG maintains a trial of labor should be offered to women who’ve had previous cesarean deliveries only “where staff can immediately provide an emergency cesarean.”
In an editorial accompanying the NIH report, James R. Scott, MD, editor-in-chief of Obstetrics & Gynecology, says that “VBAC is essentially a uterine-rupture issue.”
“What level of risk is acceptable and who decides?” he writes. “Currently, hospitals, insurance companies, and plaintiff attorneys decide or strongly influence whether VBAC is an option. Instead, the patient should be allowed to make that choice after she has been informed of the facts and has been counseled by her physician thoroughly.”
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We have been doing vaginal births after cesarean for a long time at the University of Kentucky. We are able to offer them because of the resources we have. One of the guidelines requires that a team be available for immediate response in the case of emergency. We have a team of doctors onsite – residents and attending faculty members – in labor and delivery, 24 hours a day, every day of the year. There is never a time we do not have a dedicated attending physician, residents, fellows and anesthesiologist ready to respond very quickly should the need arise.
“We have a team of doctors onsite … in labor and delivery, 24 hours a day, everyday of the year.”
This is one of the many benefits of an academic medical center like UK. Smaller hospitals generally do not have in-house anesthesia or obstetric physicians, and they are unable to respond immediately to emergencies. Therefore, they are unable to provide women the choice of a trial of labor.
The different social pressures on physicians and women have also changed the face of VBAC. When I was a resident in the early 1990s, most women at the academic center were having VBACs. By 2000, very few were. In part, I think we were unknowingly too nonchalant and did not recognize the risk.
Today, we are smarter. Not everyone is a good candidate for VBAC. I think you have to look at the circumstances surrounding that initial cesarean versus the present birth. The best candidates for a VBAC are women who have had a nonrecurring condition like a breech baby. With the next pregnancy, if the baby is in the proper, head-down position, then that woman is a wonderful candidate for a VBAC. Another possible candidate would be a woman who did not, for some reason, undergo a good trial of labor with her first delivery and had to have a cesarean section. Lastly, a woman with a previous vaginal delivery and a cesarean is a good candidate.
“The best candidates for a VBAC are women who have had a nonrecurring condition like a breech baby.”
There are risks and benefits with a VBAC. For example, there’s a higher risk of neonatal death, although the risk remains far less than 1 percent. The risk for the mother’s death is even lower. There is no data in the current study to indicate whether the risk of infection or trauma to the baby is less or greater, either way. I believe the choice is open to discussion between the woman and her physician.
We know there is less risk of uterine rupture if a woman is allowed to go into spontaneous labor versus having labor induced. The condition and position of the uterine scar from previous births is a factor in deciding whether to induce a woman. For example, an infection could keep the incision from healing properly. Or some women have had a vertical incision. Labor is not an option in those circumstances.
Women have a lot of autonomy nowadays in deciding whether to have a VBAC. If someone has had two prior cesarean sections, the risk for uterine ruptures is slightly increased over a single cesarean. If the woman very much wants a vaginal birth, she is usually able to try it.
There are many pressures on women these days from work and family. Most women receive only six weeks maternity leave from work. If a woman is out of work for one week before her due date, she misses that week with the baby when she returns to work. Consequently, many women choose to have an induction.
There are also pressures on doctors and hospitals, both concerned with malpractice suits. If a woman chooses to have a VBAC and there is a poor outcome for her or the infant, litigation often follows. A single uterine rupture can result in a huge settlement from both the doctor and the hospital.
The new ACOG guidelines will not change practice at UK a great deal. Physicians still need to work within the boundaries of their resources. We have been very supportive of VBAC, in the right set of clinical circumstances, for a very long time, so the change in guidelines will have very little effect. Overall, I welcome the guidelines.
Dr. Hansen is director of maternal and fetal medicine at UK HealthCare and associate professor and chair of obstetrics and gynecology at the UK College of Medicine.
Each issue of Advances & Insights summarizes an important piece of medical news, accompanied by commentary from a UK expert.
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