WUNRN
July 21, 2010 |
Ob-Gyns
Issue Less Restrictive Vaginal Birth
After
Cesarean Guidelines
Washington,
DC
-- Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate
choice for most women who have had a prior cesarean delivery, including for
some women who have had two previous cesareans, according to guidelines
released today by The American College of Obstetricians and Gynecologists.
The cesarean
delivery rate in the US increased dramatically over the past four decades, from
5% in 1970 to over 31% in 2007.
Before 1970,
the standard practice was to perform a repeat cesarean after a prior cesarean
birth. During the 1970s, as women achieved successful VBACs, it became viewed
as a reasonable option for some women. Over time, the VBAC rate increased from
just over 5% in 1985 to 28% by 1996, but then began a steady decline. By 2006,
the VBAC rate fell to 8.5%, a decrease that reflects the restrictions that some
hospitals and insurers placed on trial of labor after cesarean (TOLAC) as well
as decisions by patients when presented with the risks and benefits.
"The
current cesarean rate is undeniably high and absolutely concerns us as
ob-gyns," said Richard N. Waldman, MD, president of The College.
"These VBAC guidelines emphasize the need for thorough counseling of
benefits and risks, shared patient-doctor decision making, and the importance
of patient autonomy. 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."
In keeping
with past recommendations, most women with one previous cesarean delivery with
a low-transverse incision are candidates for and should be counseled about VBAC
and offered a TOLAC. In addition, "The College 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," said Jeffrey L. Ecker, MD, from
Massachusetts General Hospital in Boston and immediate past vice chair of the
Committee on Practice Bulletins-Obstetrics who co-wrote the document with
William A. Grobman, MD, from Northwestern University in Chicago.
VBAC
Counseling on Benefits and Risks
"In
making plans for delivery, physicians and patients should consider a woman's
chance of a successful VBAC as well as the risk of complications from a trial
of labor, all viewed in the context of her future reproductive plans,"
said Dr. Ecker. Approximately 60-80% of appropriate candidates who attempt VBAC
will be successful. A VBAC avoids major abdominal surgery, lowers a woman's
risk of hemorrhage and infection, and shortens postpartum recovery. It may also
help women avoid the possible future risks of having multiple cesareans such as
hysterectomy, bowel and bladder injury, transfusion, infection, and abnormal
placenta conditions (placenta previa and placenta accreta).
Both repeat
cesarean and a TOLAC carry risks including maternal hemorrhage, infection,
operative injury, blood clots, hysterectomy, and death. Most maternal injury
that occurs during a TOLAC happens when a repeat cesarean becomes necessary
after the TOLAC fails. A successful VBAC has fewer complications than an
elective repeat cesarean while a failed TOLAC has more complications than an
elective repeat cesarean.
Uterine
Rupture
The risk of
uterine rupture during a TOLAC is low—between 0.5% and 0.9%—but if it occurs,
it is an emergency situation. A uterine rupture can cause serious injury to a
mother and her baby. The College maintains that a TOLAC is most safely
undertaken where staff can immediately provide an emergency cesarean, but
recognizes that such resources may not be universally available.
"Given
the onerous medical liability climate for ob-gyns, interpretation of The
College's earlier guidelines led many hospitals to refuse allowing VBACs
altogether," said Dr. Waldman. "Our primary goal is to promote the
safest environment for labor and delivery, not to restrict women's access to
VBAC."
Women and
their physicians may still make a plan for a TOLAC in situations where there
may not be "immediately available" staff to handle emergencies, but
it requires a thorough discussion of the local health care system, the
available resources, and the potential for incremental risk. "It is
absolutely critical that a woman and her physician discuss VBAC early in the
prenatal care period so that logistical plans can be made well in
advance," said Dr. Grobman. And those hospitals that lack "immediately
available" staff should develop a clear process for gathering them quickly
and all hospitals should have a plan in place for managing emergency uterine
ruptures, however rarely they may occur, Dr. Grobman added.
The College
says that restrictive VBAC policies should not be used to force women to
undergo a repeat cesarean delivery against their will if, for example, a woman
in labor presents for care and declines a repeat cesarean delivery at a center
that does not support TOLAC. On the other hand, if, during prenatal care, a
physician is uncomfortable with a patient's desire to undergo VBAC, it is
appropriate to refer her to another physician or center.
Practice
Bulletin #115, "Vaginal Birth after Previous Cesarean Delivery," is
published in the August 2010 issue of Obstetrics & Gynecology.