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Vaginal Birth After Previous Cesarean Section
Vaginal birth after cesarean section (VBAC) is an option for women who have had one or two csections with low transverse incisions on the uterus. VBAC has come in and out of favor over the years. In the past, after having one csection, all future births were required to be by csection. In the 1960s, research indicated that this was not necessary, but it wasn’t until the 1980s that VBAC became more common place. In the late 1990s, the VBAC rate began to drop because of a multitude of factors including the worsening medical-legal climate (risk of doctor getting sued) and the recommendation for 24 hour in- hospital anesthesia and operating teams. More recently, maternal mortality rates have increased in correlation with rising csection rates. This has brought a resurgence in attention to VBAC, and to the decision-making process regarding when to perform a csection.
As all birth has risk, whether vaginal of cesarean, the National Institute of Health drafted a consensus statement on VBAC to collate the data on risks and benefits of VBAC versus repeat csection.
In one retrospective trial, the VBAC success rate was 63% for those with no prior vaginal births, 83% for those with a prior vaginal birth, and 94% for those with a prior successful VBAC. The risk to the infant with a successful VBAC is similar to that of a first-time mom delivering vaginally. In deciding between a Trial of Labor after Csection (TOLAC) or a repeat csection, it is important to consider the risks to mom and baby, as well as the potential success rate and intended number of children as surgical risks increase with higher numbers of csection. The table below shows the number of adverse events per 100,000 episodes of VBAC or repeat csection; only moderate to high quality data is included.
There are clear risks to both VBAC and repeat csection. The relative importance of each factor can only be determined by the individual woman. With both VBAC and repeat csection as safe choices, each woman must make a decision that is appropriate for her and her family.
VBAC is considered a women’s rights issue with the American College of Obstetrician Gynecologists. Doctors are advised to educate patients about all of their options – VBAC and repeat csection. If a doctor individually opts to not perform VBACs, (s)he is obligated to refer to other doctors who do. ACOG recommends that VBAC only be performed at hospitals that offer 24 hour in-hospital anesthesia coverage which limits the number of hospitals at which VBACs can be offered. Unfortunately, even in hospitals which provide 24 hour in-hospital anesthesia, many doctors refuse to allow their patients to VBAC. Frequently, fear tactics regarding permanent infant damage or death are used to discourage women from choosing to VBAC. These statements are not based on fact. The physician preference for repeat csection is often due to the ability to schedule and quickly complete a csection (40 minutes). VBAC usually involves spontaneously labor which can occur during the day, night or weekend, and might take 24 hours or more. The convenience, efficiency, and money earned per unit time are very influential, but should never supersede a women’s right to choose her method of delivery.
At ObGyn North, we strongly support VBAC as a safe option for women and as their right if they so choose. Our statistics are similar to those quoted above, with a VBAC success rate for all patients of 81%. We are very proud of our success rate which we attribute primarily to having patience, and following the evidence-based guidelines for when a labor has truly failed to progress. We continue to advocate for greater availability of VBAC and look forward to a time when VBAC is an option for all women in appropriate hospitals.