Last week, the American College of Obstetricians and Gynecologists (ACOG) issued new guidelines stating that attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, as well as for some women who have had two previous cesareans.
The cesarean delivery rate in the U.S. increased dramatically over the past four decades--from 5% in 1970 to over 30% in 2007. Before 1970, the standard practice was to perform a repeat cesarean after a prior cesarean birth. During the 1970's, as women had successful VBACs, it was considered a viable option. 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%, reflecting restrictions hospitals and insurers placed on the trial of labor after cesarean (TOLAC) as well as decisions by patients when presented with the risks and benefits.
In keeping with past recommendations, ACOG says 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. 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.
Both repeat cesarean and a TOLAC carry risks including maternal hemorrhage, infection, 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.
The risk of uterine rupture during a TOLAC is less than 1%, but if it occurs it is an emergency situation that can cause serious injury to a mother and baby. ACOG maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean.
Lastly, ACOG 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. 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.
The fact is that much can wrong during childbirth, and often it is the result of medical malpractice. When that is the case, you should seek the services of Dr. Bruce G. Fagel, one of the nation's preeminent birth injury plaintiff attorneys. Call him at 800/541-9376 or go to his website at www.birthinjurydoctorlawyer.com.
