Evaluating the Pros and Cons of VBACs


pregnant women these days. The problem is, some doc- tors aren’t giving patients the choice. Instead, many doctors


V


are not willing to work collab- oratively with patients or they’re reluctant to perform VBACs (vagi- nal birth after Cesarean-section) due to medical liability issues surrounding the procedure. Others subtly dissuade women from a trial of labor after Cesar- ean (TOLAC). These acronyms may be confusing


and this topic is complex. However, new ACOG (American College of Obstetri- cians and Gynecologists) guidelines is- sued in August of 2010 actually encour- age VBACs. In fact, it is estimated that 60 to 80 percent of appropriate candidates who attempt VBAC will be successful. Prior to the 1970s, conventional


wisdom held that once a woman had a C-section, she would continue to need repeat Cesarean-sections in subsequent pregnancies. In 1985, approximately five percent of all babies in this country were delivered via VBAC. This number climbed to 28 percent by 1996, as evidence mounted in favor of VBACs, but the VBAC rate dropped to 8.5 percent in 2006. Meanwhile, the C-section rate re-


cently hit an alarming all-time high: a government report issued last Spring found that C-sections have risen 50 per- cent in the past decade, and the surgery now accounts for almost one-third of all births.


Why did these trends occur? Accord-


ing to the 2010 National Institutes Health Consensus Development Conference, the lowered VBAC rate can be attributed to restrictions by hospitals and insurers as well as concerns by physicians regard- ing the risks and benefits. Some hospitals (typically those not equipped or staffed to perform VBACs) have actually banned doctors from performing the procedure, and other doctors don’t feel comfortable


30 January 2011


BAC or repeat C-sec- tion? That is the ques- tion facing many


nal surgery, lowering the risk of hemorrhage and infection, and shorten- ing your postpartum recovery time. A VBAC also may reduce the possibility of future Ce- sarean deliveries. In addition, a repeat


Cesarean carries multiple


risks, including maternal hemorrhage, infection, opera- tive injury, blood clots, hysterecto- my, and in rare cases, death. Multiple


performing VBACs, given the medical li- ability concerns. In a recent poll of 5,644 doctors conducted by ACOG, 29 percent of OB/GYNs said the fear of lawsuits has prompted them to perform more C-sec- tions.


So who is an appropriate candidate


for a VBAC? ACOG has concluded that a trial of labor is a reasonable option, primarily for pregnant women with one prior low transverse uterine incision (a horizontal incision in the lower part of the uterus). There are many complicat- ing factors reducing the success rate of a TOLAC, which is why physicians and pa- tients should discuss all of the pros and cons and come to a decision together. For example, a clear contraindication for a VBAC is if a woman has had a Cesarean- section requiring a classical or “T” inci- sion on the uterus. The following risk factors decrease a


woman’s chance of a successful TOLAC, although they do not necessarily preclude women from trying: Current macrosomia (a big baby), gestational age greater than 40 weeks, prior lower vertical incision, unknown scar type, no prior vaginal de- livery, maternal obesity, increasing ma- ternal age. If a patient wants to go this route, but her doctor dissuades her from attempting a VBAC, most insurance com- panies will pay for a second opinion. This is worth considering since there


are many benefits of a having a VBAC. Overall, you are avoiding major abdomi-


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Cesareans carry additional risks, includ- ing hysterectomy, bowel and bladder injury from extensive adhesions, blood transfusion, infection, abnormal placental pathology, and even injury to the baby. The main concern most physicians


have about allowing a VBAC is uterine rupture, which can cause injury to a mother or her baby. However, if patients are screened carefully, counseled, and closely monitored, the risk of uterine rupture during a TOLAC is less than one percent. Keep in mind that a TOLAC is most


safely undertaken if medical staff can im- mediately provide an emergency Cesar- ean-section, according to ACOG. Most OB/GYNs would agree. We have all witnessed patients who developed life- threatening complications in childbirth, which is why it is strongly discouraged to attempt a VBAC as a home delivery, or in a hospital or birthing center without ad- equate facilities. Remember, there are no guarantees,


and sometimes a C-section is neces- sary. But if a TOLAC is your desire, keep searching and you will find a doctor that will give you sound medical advice and may grant you your wish.


Karen Zino, M.D. is an OB/GYN physi- cian at Riverside Obstetrics and Gynecol- ogy in Greenwich, CT. www.riversideob- gyn.com.


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