| New VBAC Guidelines | | Print | |
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The cesarean delivery rate in the United States has increased from 4.5% in 1965 to 32.3% in 2008 (Guise JM, 2010). Meanwhile, the rate of Vaginal Birth after Cesarean (VBAC) has decreased from its peak of 28.3% of all women with a prior cesarean delivery in 1996 to the most recent rate of just 8% in 2006 (National Institutes of Health, 2010). The reasons for this decrease are numerous and complex involving fear of potential dangers of VBAC, lack of access to facilities that offer VBAC and fear of litigation among providers. In March 2010 the National Institutes of Health (NIH) held a consensus conference to examine the safety of VBAC and repeat cesarean for women with prior cesarean deliveries. Following the NIH consensus statement, the American College of Obstetricians and Gynecologists (ACOG) released a new practice bulletin outlining their guidelines regarding the mode of delivery for women with a prior cesarean delivery (American College of Obstetricians and Gynecologists, 2010). New Recommendations regarding VBAC The best current evidence available supports that women with one prior cesarean delivery with a low-transverse uterine incision (the most common kind performed) are candidates for VBAC and should be counseled about VBAC and offered a trial of labor. In addition, there is good evidence to support that epidural anesthesia is a safe option for women attempting a VBAC (American College of Obstetricians and Gynecologists, 2010). Based on limited or inconsistent evidence, ACOG supports offering the following women a VBAC: those with two prior low transverse uterine incisions, those with a current twin pregnancy who are otherwise good candidates for vaginal delivery, and those requiring an induction of labor for maternal or fetal indications (as long as prostaglandin preparations are not utilized). ACOG supports offering VBAC to women with an unknown uterine scar unless there is a high suspicion of previous classical (up and down) incision on the uterus. Women with a prior cesarean delivery and a current pregnancy complicated by a breech presentation can be offered external cephalic versions (a procedure of trying to turn a breech baby). Who should offer VBACs ACOG also outlines that VBACs should be attempted only in facilities capable of emergency deliveries. Surveys of hospital administrators found that 30% of hospitals do not offer VBACs due to the lack of emergency delivery services (National Institutes of Health, 2010). Providing care for women who desire a VBAC is within the scope of care for Certified Nurse Midwives who practice in facilities that have the ability to perform an emergency delivery (American College of Nurse-Midwives, 2000). The Certified Nurse Midwives at UNC work closely with our obstetricians and anesthesiologists and have a VBAC success great of greater than 80%. Based on the best available data, the newest guidelines from ACOG increase the number of women that should be offered a VBAC. The benefits and risks of VBAC should be discussed with each woman based on her individual history and desires. Because the greatest risks of VBAC occur when they are not successful and a repeat cesarean delivery is required following labor, attempts have been made to predict a woman’s likelihood of success at VBAC. Caution should be used when trying to predict the likelihood of individual success at VBAC based on programs that calculate likelihood of success: “VBAC calculators” have only been studied at the population, not the individual, level (National Institutes of Health, 2010). The decision about whether to attempt a VBAC or schedule a repeat cesarean is complex and multi-faceted. It can only be made by the woman and her family with appropriate, thorough counseling by her health care provider. More research is needed into the risks and benefits of VBAC and repeat cesarean and what factors influence these harms and benefits. |