New Updated Guidelines on Vaginal Birth After Cesarean

by Dr. Michele Brown OB/GYN

Cesarean Section Delivery

The American College of Obstetrics and Gynecology in August 2010 has just issued brand new guidelines for allowing women with previous cesarean sections to undergo a trial of labor for a vaginal delivery. These "hot off the press" new recommendations were created in an effort to reduce the escalating cesarean section rate that has been plaguing American hospitals recently. Rates have spiraled from 5% in 1970 to 31% in 2007. Along with this statistic, it was found that VBAC rates have plummeted from 28.3% in 1996 to 8.5% in in 2006.

Of particular interest is the finding that although cesareans have increased in all states, there are large differences between the states. The lowest rates were found in Alaska, Idaho, New Mexico, and Utah. The highest rates were noted in Florida, Louisiana, Mississippi, New Jersey, and West Virginia.

What are some of the reasons behind this trend?

• Fear of liability on the part of the physician
• Electronic fetal monitoring with recording of minute to minute fetal heart activity
• Decreased training and use of forceps on the part of physicians
• Refusal to do vaginal breech deliveries
• Refusal of obstetricians to attempt turning babies to head down positions from other non deliverable positions (called external cephalic version)
• Hospitals refusing to allow doctors to allow a vaginal birth after cesarean section

Risks of Attempting a VBAC

The biggest reported risk of vaginal birth after a cesarean is separation of the previous scar on the uterus (dehiscence) or complete rupture of the uterus which causes significant risk to both mother and fetus. The incidence of this is between .5 to .9%. Risks with rupture include maternal hemorrhage, need for transfusion, potential hysterectomy, and severe consequences for the newborn including possible death.

Risks of a Repeat Cesarean Section

The risks of a cesarean are similar to the risks of any abdominal surgery. This includes:

• Hemorrhage
• Infection
• Operative injury to other organs (bowel or bladder).
• Blood clots
• Transfusion
• Hysterectomy
• Multiple incisions in the uterus can result in a placental problem in future pregnancies if the placenta attaches to the previous scar.
• How does one choose which women are more likely to be successful candidates for a vaginal birth after a cesarean?

Considering a VBAC

The chance of success for a vaginal birth after a cesarean in a well chosen patient can be as high as 60%–80%. Patient and physicians should consider the following important questions when making a decision.