New Guidelines OK Vaginal Birth After Cesarean (VBAC)

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Main Category: Pregnancy / Obstetrics
Also Included In: Women's Health / Gynecology
Article Date: 23 Jul 2010 - 11:00 PDT


In a bid to bring down the high rate of cesarean delivery in the US, The American College of Obstetricians and Gynecologists (ACOG) has eased the guidelines on vaginal birth after cesarean (VBAC, pronounced "veebac") and declared it is a safe and appropriate choice for most women who have had a cesarean, and even for some who have had two.

In a press statement, ACOG said the rate of cesarean or C-section deliveries in the US over the last 40 years has risen dramatically from 5 per cent in 1970 to over 31 per cent in 2007, and the purpose of the new guidelines, published in the August issue of Obstetrics & Gynecology, was to help redress this trend.

Also, within the overall trend, there has been a rise, then fall, then rise again in the rate of repeat cesareans: before 1970 it was standard practice for women to have a repeat cesarean after a prior cesarean, then as evidence appeared to show VBACs were successful they went up from over 5 per cent in 1985 to 28 per cent in 1996, but after that they declined so that by 2006 they went down to 8.5 per cent.

ACOG said this decline in VBAC rates reflects two things: hospitals and health insurers placing restrictions on women having a normal labor after a cesarean (trial of labor after cesarean, TOLAC), and because the women themselves choose to have a repeat cesarean after reviewing the risks and benefits with their doctor.

Dr Richard N. Waldman, president of ACOG, said the College was very concerned about the high rate of cesarean births in the US.

The new guidelines stress the importance of patient autonomy in the context of thorough counseling regarding the benefits and risks, and shared decision-making between doctor and patient.

"Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate," he added.

According to ACOG, between 60 and 80 per cent of women who are suitable candidates for VBAC go through it successfully.

The advantage of VBAC is that it shortens recovery after birth, avoids major abdominal surgery and lowers the woman's risk of hemorrhage and infection. Also, by avoiding another cesarean, the woman lowers her risk of the complications that can occur from having multiple cesareans such as, injury to bowel and bladder, transfusion, infection, hysterectomy, and abnormal placenta conditions.

However, ACOG note that both repeat cesarean and a TOLAC have risks, including maternal hemorrhage, infection, blood clots, hysterectomy, operative injury, and death. Most of the injuries to the mother during a TOLAC occur when a repeat cesarean has to be done after a failed TOLAC.

The College pointed out that "successful VBAC has fewer complications than an elective repeat cesarean while a failed TOLAC has more complications than an elective repeat cesarean".

The main concern of something going wrong during a TOLAC is the risk of the uterus rupturing. And although this is low, between 0.5 and 0.9 per cent, says ACOG, it requires emergency attention because such a rupture can seriously injure the mother and her baby.

ACOG says the safest way to provide TOLAC is when emergency staff that can carry out a cesarean are at hand.

The new guideline keeps the previous recommendation that most women who have previously undergone a "low-transverse incision" cesarean should be counselled about the pros and cons of a VBAC and be offered a TOLAC.

However, the words are couched in more optimistic terms:

"Trial of labor after previous cesarean delivery (TOLAC) provides women who desire a vaginal delivery with the possibility of achieving that goal: a vaginal birth after cesarean delivery (VBAC)."

The previous (2004) version of the guidelines were phrased more alarmingly, saying for instance that although VBAC was appropriate for most women who have had a low-transverse cesarean, "several factors increase the likelihood of a failed trial of labor, which in turn leads to increased maternal and perinatal morbidity".

In addition, the new guidelines make a new point about women who have had more than one cesarean. Dr Jeffrey L. Ecker, from Boston's Massachusetts General Hospital, and who was vice chair of ACOG's Committee on Practice Bulletins-Obstetrics when they re-wrote the guidelines, explained that the new guidelines now clearly say that "women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a TOLAC".

Ecker said when a pregnant woman who has already had a cesarean before and her doctor make plans for delivery they should discuss and review her chance of a successful VBAC and the possible complications of a trial labor, in the context of whether she also plans to have more children.

ACOG said that women should not be forced to have repeat cesareans just because of restrictive VBAC policies, which can happen if a woman in labor who does not want a repeat cesarean goes to a hospital that does not support TOLAC.

However, on the other hand, the College said it would be appropriate for a doctor to refer a patient to another doctor or medical center, if after discussing options with the patient during pre-natal care, he or she was not happy with her wish to have VBAC.

Waldman said the "onerous medical liability climate" led many hospitals to interpret the College's earlier guidelines as grounds to refuse VBACs. Hopefully the new guidelines will start to redress this and help the pendulum swing back the other way:

"Our primary goal is to promote the safest environment for labor and delivery, not to restrict women's access to VBAC," said Waldman.

"Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery."
Obstetrics & Gynecology, 116(2, Part 1):450-463, August 2010.
DOI: 10.1097/AOG.0b013e3181eeb251

Source: ACOG.

Written by: Catharine Paddock, PhD
Copyright: Medical News Today
Not to be reproduced without permission of Medical News Today

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