Vaginal Birth After Cesarean
For three decades respected medical organizations have stated their support for vaginal birth after cesarean (VBAC), but beginning in 2000, challenges to this practice began and the high rate of women having repeat cesareans reflected this. Recent evidence has grown that most women should have the choice to have a trial of labor after previous cesarean delivery (TOLAC), yet the rate for vaginal birth after cesarean (VBAC) continues to be low, only 8.5% in 2006 according to the American College of Obstetricians and Gynecologists(ACOG). The American College of Nurse-Midwives (ACNM) has also stated their support for VBAC, and the National Institutes of Health has studied and issued statements in support of VBAC for women with one and even two prior cesarean births, most recently at a March, 2010 conference, when the NIH stated that "VBAC is a reasonable choice for the majority of women, and that adverse outcomes are rare for both elective repeat cesarean and trial of labor." [read the NIH statement]
In July, 2010 ACOG released a statement regarding the high rate of cesareans (31% in 2007) stating that, "A VBAC avoids major abdominal surgery, lowers a woman's risk of hemorrhage and infection, and shortens postpartum recovery." The statement also says that the risk of uterine rupture during a trial of labor after a cesarean (TOLAC) is low (.5-.9%), but that, "TOLAC is most safely undertaken where staff can provide an emergency cesarean."Who is a candidate for a trial of labor after cesarean (TOLAC)?
NIH's 2010 statement says, "Given the available evidence, trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision." A low-transverse incision is a side-to-side cut made across the lower, thinner part of the uterus. ACOG says, "Women with two previous cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are also considered appropriate candidates for TOLAC."
VBAC after successful TOLAC may have the following benefits over a repeat cesarean: no abdominal surgery, a shorter recovery period, a lower risk of infection, and less blood loss.
Women may also want to consider TOLAC if they plan to have a large family. By a woman's third c-section, the increased risk for mother and baby increases exponentially. Issues resulting from multiple cesarean deliveries may include increased risk of needing a hysterectomy, bowel or bladder injury, and certain problems with the placenta.
Calculated Risk
So what are the risks for a woman desiring a VBAC? Lisa Kane Low, Ph.D., C.N.M., F.A.C.N.M., assistant professor, school of nursing and women's studies and certified nurse midwife, University of Michigan Health System gave a presentation at the 2010 Terri Murtland Educational Series about VBACs and promoting choices in childbirth. Part of her presentation showed a slide of a skydiver, a skateboarder, and a pregnant woman with the title, "Contextualizing Risk...it is all in the presentation."
Low says that often women are told about increased risks without the specific statistics. Increase for uterine rupture is greater with a VBAC than a repeat cesarean, but that still only equates to less than 1%.
Which Hospitals Support Trial of Labor After Cesarean?
Low says, "The University of Michigan has always been a place where we look at what research evidence tells us." She says information from a 1980 NIH Conference showed repeat cesareans are not consistent with the best medical practice.
In addition, Low says, "U-M has a goal of individualizing care for women. We make sure we meet the needs of each woman as safely as possible."
The University of Michigan Health System has the resources to handle emergency situations, but too often, smaller hospitals don't give women the choice to try TOLAC out of concern for not having staff or facilities easily available to handle any unexpected emergencies.
July's statement from the American College of Obstetricians and Gynecologists expanded the recommendations regarding women safely selecting the option of having a VBAC. The American College of Nurse Midwives' (ACNM) response to ACOG's July statement agrees with increasing access to VBACs by saying that "Unfortunately, women with previous cesarean deliveries are often forced to choose between accepting the risks of unnecessary surgery, traveling great distances for trial of labor, or remaining in their communities even when skilled clinicians and integrated health systems are not available." [View this statement (PDF)] Additionally, the NIH VBAC consensus statement "recommends that hospitals, maternity care providers, and other stakeholders work together to eliminate current barriers to trial of labor."
Low says, "Not having options is forcing a choice." She adds, "Women need to be listened to and have options and choices." She encourages women to seek a place for medical care where "they can get all of their needs met."
VBAC vs. repeat cesarean is a multi-faceted choice that women should explore with their health care providers if they have had a cesarean and are expecting again.
More Information About Choosing Between VBAC and a Repeat Cesarean
Cesarean Section informational web pages part of the U-M Health System's Healthwise Knowledgebase.
VBAC or Repeat C-Section information web page, part of the Childbirth Connection website.
