Vaginal Birth After Cesarean (VBAC)
If you want to attempt a VBAC, talk to your obstetrician or midwife early in your pregnancy and make sure he or she is willing to perform one. Some obstetricians and an increasing number of hospitals have stopped performing VBACs due to concerns over legal action if something goes wrong and mother or baby is harmed. In fact, despite new research indicating the safety of VBAC, the percentage of women who had one fell from 28 percent in 1996 to 12.7 percent in 2002.
In 1999, the American College of Obstetricians and Gynecologists issued guidelines for VBACs that called for “immediate” availability of operating room teams to support every VBAC in case it required an emergency c-section. Hospitals and birthing centers were reluctant to keep a full surgery team on-call during a potentially lengthy labor and delivery and many prohibited VBACs as a result. However, the American Academy of Family Physicians recently revised its guidelines on trial of labor after cesarean (TOLAC) to state that “women should not be restricted only to facilities with available surgical teams present throughout labor. However, a management plan should be in place for each woman undergoing TOLAC in case of uterine rupture or other potential emergencies requiring rapid cesarean section. TOLAC should not be restricted only to facilities with available surgical teams present throughout labor since there are no studies that show these additional resources result in improved outcomes.”
A study released in the New England Journal of Medicine in December, 2004 followed nearly 34,000 women who were giving birth to their second child at 19 academic hospitals between 2000 and 2003. Approximately 18,000 of those women chose a VBAC, while 16,000 elected to have a second c-section. Of the women who attempted a VBAC, 74 percent of them succeeded in a vaginal birth, and 16 percent ended up having c-sections. Uterine rupture occurred in 0.7 percent of the VBAC women, seven babies (0.04 percent of all the planned VBAC) suffered hypoxia-related brain damage that was most likely caused by the uterine rupture, and two of those babies died (0.01 percent). However, twice as many women died during their second c-section as those who had a VBAC (7 and 3, respectively). The study concluded that a woman who chooses a VBAC over a second c-section increases her overall risk of adverse outcome by just 0.046 percent.
New research reported in the May/June 2006 issue of Annals of Family Medicine found that the maternal mortality rate remains about the same with either VBAC or repeat cesarean delivery, as does the neonatal mortality rate for infants whose birth weight is at least 1,500 grams (3.3 pounds). Smaller babies, however, have higher neonatal mortality rates with VBAC.
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