VBAC: Trends and Continued Debate
Vaginal birth after previous Cesarean delivery, known as VBAC, has been the subject of great debate among health care professionals for many years. According to The American College of Obstetricians and Gynecologists (ACOG), the Cesarean delivery rate in the United States increased dramatically, from 5 to nearly 25 percent, between 1970 and 1988, attributable in part to physicians’ reluctance to perform certain complicated vaginal deliveries as well as increasing reliance on continuous electronic monitoring of fetal heart and uterine contraction patterns.
In an apparent effort to curtail the number of Cesarean deliveries, organizations such as the National Institutes of Health and ACOG endorsed VBAC when clinical data suggested that a trial of labor after a previous Cesarean delivery was relatively safe. As a result, between 1989 and 1996, the rate of VBAC increased while the rate of Cesarean delivery decreased. This trend soon reversed, however, amid reports of uterine rupture and other complications during trials of labor after previous Cesarean deliveries, and VBAC became a less viable option for many women.
The concerns for the safety of VBAC have narrowed the circumstances under which it is currently recommended or permitted. In July 2004, ACOG released an updated version of its guidelines for VBAC that modifies previously published guidelines from July 1999. While some of the more significant recommendations did not change (such as the ability to promptly perform an emergency Cesarean delivery if necessary), many did change and in effect imposed added restrictions. For instance, the 2004 guidelines refer to the immediate availability of a physician throughout active labor as well as the availability of anesthesia and surgical staff. In addition, the 2004 guidelines further limit who may be regarded as an appropriate VBAC candidate.
While both VBAC and repeat Cesarean delivery have associated risks and benefits, some authorities have noted that complications stemming from a failed VBAC attempt can be catastrophic. These include, in addition to uterine rupture, hysterectomy, operative injury, increased maternal infection, the need for transfusion and neonatal morbidity. As a result, many conservative physicians may even preclude a woman from electing to VBAC despite circumstances that many would view as entirely favorable. Regardless of the current trends and debate, it seems clear that there remains much that is unknown about VBAC and that further research is necessary, as suggested by The American Academy of Family Physicians.
As with all medical decision making, the decision of a women to pursue VBAC is one that must be made with her physician after full disclosure and consideration of all risks and benefits evaluated together with her obstetrical history and overall state of general health.
For more information on the issue of VBAC, see the complete article in "American Family Practice" and other commentary regarding the above ACOG updates.