Friday, January 21, 2011

Will vaginal birth after Cesarean section (VBAC) make a comeback?

My daughter, who turns three years old in June, is becoming something of a medical rarity. This isn't because she has a congenital disorder or extraordinary ability for her age; it's because she came into the world as a vaginal birth after Cesarean section (VBAC). Although 75 percent of women who choose a trial of labor over a repeat Cesarean section successfully deliver vaginally, studies showing slightly higher risks of uterine rupture with VBAC, concerns about lawsuits, and restrictive guidelines discourage most women from trying. After reaching a high in 1996 of 28.3 percent of U.S. women who previously delivered by Cesarean, the VBAC rate today is considerably less than 1 in 10.

The AAFP's 2005 guideline on trial of labor after Cesarean (TOLAC) noted that there was no good evidence that having surgical and anesthesia personnel "immediately available" (i.e., on site) during a trial of labor, as required in a 1999 ACOG guideline, improves maternal or infant outcomes. At an NIH conference last year, an expert panel also concluded that the scientific evidence did not support ACOG's position. However, the panel found that this restrictive requirement had led many hospitals without 24-hour availability of these services to discontinue VBAC entirely.

The January 15th issue of AFP summarizes the updated ACOG recommendations on VBAC, which state that a trial of labor is a reasonable option for the vast majority of women who desire a vaginal delivery after a previous Cesarean, including those who have had more than one prior Cesarean and those carrying twins. While continuing to assert that mothers and babies are best served by immediate access to emergency resources, the guideline adds: "Respect for patient autonomy also argues that ... [an institutional no-VBAC policy] cannot be used to force women to have Cesarean delivery or to deny care to women in labor who decline to have a repeat Cesarean delivery."

In a thoughtful and informative editorial in the January 15th issue, "Increasing Patient Access to VBAC: New NIH and ACOG Recommendations," Lawrence Leeman, MD, MPH and Valerie King, MD, MPH write:

We encourage maternity care providers and hospitals that do not currently offer TOLAC to use the NIH statement and revised ACOG guidelines as an opportunity to reevaluate their policies on TOLAC. The Northern New England Perinatal Quality Improvement Network's VBAC project is an example of a collaborative effort between community hospitals and maternity care providers to develop risk-stratification guidelines and to facilitate planning for emergent cesarean delivery. Counseling patients about delivery options involves consideration of maternal and perinatal risks and benefits, future childbearing plans, and the likelihood of successful VBAC. Most women who have had a previous cesarean delivery are candidates for TOLAC and should be offered that option.