VBACs only slightly less safe than repeat cesarean

Whenever news abour labor and birth hits the mainstream media, I sit up and take notice. The fold-out section on Women’s Health in this sunday’s New York Times certainly caught my attention, and while perusing it, I read the following tidbit in Eric Nagourney’s article about shifting health guidelines for women:

    Caesarean Birth

    There was a time when women who had already given birth by Caesarean section would never be allowed to have their next child naturally. Doctors considered the practice too dangerous.

    That thinking changed about two decades ago. Doctors are now taught that in most cases, vaginal birth after Caesarean – often referred to as VBAC (commonly pronounced VEE-back) – is only slightly less safe than having another Caesarean.

    But try getting a hospital to allow it. After years in which the number of VBAC’s went up, many hospitals, concerned about medical complications and legal liability, have begun forbidding the practice.

    Part of the concern is that the stresses of labor may put so much pressure on the old incision site that the uterus can rupture, putting baby and mother at serious risk. Even advocates of VBAC say that it should be done in hospitals that are equipped to deal with a problem.

    The American College of Obstetricians and Gynecologists counsels that most women who have had what is known as a low-transverse incision Caesarean should be offered a chance to give birth vaginally. (The group advises against it with women who have had a “classical” Caesarean incision.) Epidural anesthesia is fine, the group says, but inducing labor should be discouraged.

According to the preliminary birth data for 2003, the cearean section rate is at an all time high in this country, coming in at a whopping 27.6%. Meanwhile, the report issued by the CDC noted that the VBAC rate has fallen abysmally from it’s high of 31% in 1998, and is now down to 10.6%. What I want to know is: what’s happening here? Why is the VBAC rate falling so precipitously?

The overall risks of a VBAC are low, but there is always the possiblity of uterine rupture, which occurs in approximately 1 out of every 2,000 births, and is pretty serious, of course, since it puts both the mother and baby at risk, depending on the severity of the rupture. However, a repeat cesarean is hardly risk free: not only does it bring with it the usual risks associated with abdominal surgery (risk of infection, anesthesia complications etc.), but the risks of infection and surgical complication are higher with a repeat, and the chance of incorrect placental implantation or placental accreta with future pregnancies is much higher as well. If a woman has one repeat cesarean, she will almost unequivocably be having a cesarean with her third child and fourth child too, and the risks associated with those cesareans will just keep rising each time.

I do wonder how much fear of litigation is affecting this. When a cesarean is viewed as the “safer” option, the consevative approach, the correct course of action and the solid defense that will hold up in court, then of course a nice, clean, quick cesarean would seem much more preferable to a long, drawn out (i.e. normal vaginal birth) VBAC, with its inherent risk of uterine rupture and potential malpractice claim. Even though the chance of uterine rupture is very low, when the cost of defending a malpractice claim is so high, I wonder if a lot of doctors just don’t think it’s worth it anymore?

A very large and comprehensive study of the risks of VBAC versus elective repeat cesarean was published in December, 2004 in the New England Journal of Medicine. This study found that the overall risk in having a VBAC was low, but nevertheless, slightly higher than the risks involved in having an elective repeat cesarean. Hospitals have been limiting the number of VBACs for several years now, and there are several hospitals which flat-out refuse to do VBACs, even if their attending doctors (not to mention the women giving birth) are willing. If a hospital was on the brink, perhaps this study has just offered up the unequivocal proof they were looking for, and tipped them over the edge, into the No VBAC zone.

ACOG still recommends that women with low-transverse incisions and no other obvious risks attempt a VBAC before having a repeat cesarean. The Healthy People 2010 guideline is recommending a 37% percent VBAC rate by 2010, so we’ve got a long ways to go to reach that, in not a lot of time. However, as Eric Nagourney’s article in the New York Times pointed out, guidelines keep changing, and what was seen as sound, incontrovertible medical practice now is often found to be questionable 10 years down the road. VBACs changed the landscape, challenging the old medical idea of “once a cesarean, always a cesarean”, but now perhaps we’re in the middle of a cesarean backlash, as the VBAC rate keeps plummeting. We can only hope that 10 years down the road, VBACs will be on the rise again, and the notion of “once a cesarean, always a cesarean” will be something relegated to history books.

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