Vaginal Birth After Cesarean: New Insights
Vaginal birth after cesarean (VBAC) describes vaginal delivery by a woman who has had a previous cesarean delivery. For most of the 20th century, once a woman had undergone a cesarean delivery, clinicians believed that her future pregnancies required cesarean delivery. The option for a woman with a previous cesarean delivery to attempt a trial of labor (TOL) was offered and exercised more often in the 1980s through 1996. Beginning in 1996, however, the number of VBACs has declined, contributing to the overall increase in cesarean delivery. An independent panel was convened by the National Institutes of Health recently to review and assess currently available data regarding VBACs.
Hamidi: Most women who deliver their first child by cesarean will opt to do the same for subsequent pregnancies. A panel of scientific experts convened by the National Institutes of Health, met recently to assess currently available data on vaginal birth after cesarean in a State-of-the-Science conference entitled: Vaginal Birth After Cesarean (VBAC) — New Insights.
Dr. Cunningham: This was stimulated by the obviously well-known rising cesarean section overall in this country, as well as the world, and we know that a primary cesarean (or one for the first time) will begat other cesareans and this has created some problems.
Hamidi: Dr. Gary Cunnningham is Chair in Obstetrics and Gynecology at the University of Texas Southwestern Medical Center at Dallas and served as the Panel Chair for the conference. He points out that, in some cases, women who have previously delivered via cesarean are not even given the option to attempt a vaginal birth — commonly referred to as trial of labor.
Dr. Cunningham: Another problem has been the voice of many women who have bemoaned the fact that they have not had access to care where a trial of labor can be offered as an alternative to an operative delivery and this, of course, is mirrored by the fact that the VBAC rate in the United States is diminished in the last almost fifteen years to 30 percent from about 10 percent — which is a marked change.
Hamidi: While the panel was clear in stating that their report should not be referenced as a set of guidelines, but rather as a consensus report, they did acknowledge that previous data indicates VBACs should be considered a safe alternative. The panel also pointed out that while VBACs are generally safe, the risks for pregnant woman must be weighed in combination with their individual health status. In particular, women who have had a low-transverse uterine incision — as opposed to the older and less popular vertical incision method — are considered to be a lower-risk group for a VBAC.
Dr. Cunningham: What we found was that the use or the employment of a vaginal delivery after caesarean with a trial of labor is certainly a safe alternative for the majority of women who have had one prior cesarean section, assuming that it’s of so-called low-transverse variety.
Hamidi: The panel also identified a variety of obstacles that may, in part, explain the significant decline of VBAC deliveries that ranged from fear of worst-case scenario complications to physician fears of medical malpractice lawsuits.
Dr. Cunningham: For example, we found that there is a medical/legal consideration that puts up some of these barriers. This is generated by the rather large awards that occur only rarely with bad outcomes to babies. And the fear of this has driven a lot of providers out of the business or the practice of offering VBAC because of those rare, but catastrophic, complications.
Hamidi: The panel concluded that given the available evidence, trial of labor is a reasonable option for many pregnant women with a prior low transverse uterine incision. The panel's complete and updated draft state-of-the-science statement is available at consensus.nih.gov. This is Anahita Hamidi, National Institutes of Health, Bethesda, Maryland.
About This Audio Report
Reporter: Anahita Hamidi
Sound Bite: Dr. Gary Cunnningham
Topic: birth, vaginal birth, cesarean, c-section, delivery, pregnancy, VBAC