NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights
March 8–10, 2010
The National Institutes of Health Panel Statement concludes that
‘TOL (trial of labour) is a reasonable option for many pregnant women with a prior low transverse uterine incision’ and that current barriers to informed choice and VBAC need lifting.”
Read the full statement here.
Vaginal Birth After Cesarean (VBAC) is becoming more and more common. The once true adage of ‘Once a Caesarean, always a Caesarean’ has been discarded. Topics included in this article:
Read full article here.
In 1995 the American College of Obstetricians and Gynecologists (ACOG) published updated guidelines for a vaginal birth after a cesarean. In the guides physicians are strongly encouraged to counsel and encourage women to plan labor rather than schedule a repeat surgery. Based on current evidence almost all women with prior cesareans can plan a VBAC.
Read full article here.
Please cite this paper as: Cahill A, Tuuli M, Odibo A, Stamilio D, Macones G. Vaginal birth after caesarean for women with three or more prior caesareans: assessing safety and success. BJOG 2010;117:422–427.
Objective To estimate the rate of success and risk of maternal morbidities in women with three or more prior caesareans who attempt vaginal birth after caesarean (VBAC).
Design Retrospective cohort design.
Setting Multicentre, from 1996 to 2000, including 17 tertiary and community delivery centres in north-eastern USA.
Population A total of 25 005 women who had had at least one prior caesarean delivery.
Methods Women who attempted VBAC with three or more prior caesareans were compared with those who attempted after one and two prior caesareans. Univariable and stratified analyses were used to select factors for multivariable analyses for maternal morbidity. Maternal characteristics were compared using a Student’s t test, Mann–Whitney U test, chi-square test or Fisher’s exact test, as appropriate.
Main outcome measures The primary outcome was composite maternal morbidity, defined as at least one of the following: uterine rupture, bladder or bowel injury, or uterine artery laceration. Secondary outcomes were VBAC success, blood transfusion and fever.
Results Of 25 005 women, 860 had three or more prior caesarean deliveries: 89 attempted VBAC and 771 elected for repeat caesarean. Of the 89 who attempted VBAC, there were no cases of composite maternal morbidity. They were also as likely to have a successful VBAC as women with one prior caesarean (79.8% versus 75.5%, adjusted OR 1.4, 95% CI 0.81–2.41, P = 0.22).
Conclusion Women with three or more prior caesareans who attempt VBAC have similar rates of success and risk for maternal morbidity as those with one prior caesarean, and as those delivered by elective repeat caesarean.
Obstetric outcomes in women with two prior cesarean deliveries: Is vaginal birth after cesarean delivery a viable option?
American Journal of Obstetrics and Gynecology
Volume 192, Issue 4,
April 2005, Pages 1223-1228
This study was undertaken to compare clinical outcomes in women with 1 versus 2 prior cesarean deliveries who attempt vaginal birth after cesarean delivery (VBAC) and also to compare clinical outcomes of women with 2 prior cesarean deliveries who attempt VBAC or opt for a repeat cesarean delivery.
We performed a secondary analysis of a retrospective cohort study, in which the medical records of more than 25,000 women with a prior cesarean delivery from 16 community and tertiary care hospitals were reviewed by trained nurse abstractors. Information on demographics, obstetric history, medical and social history, and the outcomes of the index pregnancy was obtained. Comparisons of obstetric outcomes were made between women with 1 versus 2 prior cesarean deliveries, and also between women with 2 prior cesarean deliveries who opt for VBAC attempt versus elective repeat cesarean delivery.
Both bivariate and multivariate techniques were used for these comparisons.
The records of 20,175 women with one previous cesarean section and 3,970 with 2 prior cesarean sections were reviewed. The rate of VBAC success was similar in women with a single prior cesarean delivery (75.5%) compared with those with 2 prior cesarean deliveries (74.6%), though the odds of major morbidity were higher in those with 2 prior cesarean deliveries (adjusted odd ratio[OR]=1.61 95% CI 1.11-2.33). Among women with 2 prior cesarean deliveries, those who opt for a VBAC attempt had higher odds of major complications compared with those who opt for elective repeat cesarean delivery (adjusted OR=2.26, 95% CI 1.17-4.37).
The likelihood of major complications is higher with a VBAC attempt in women with 2 prior cesarean deliveries compared with those with a single prior cesarean delivery. In women with 2 prior cesarean deliveries, while major complications are increased in those who attempt VBAC relative to elective repeat cesarean delivery, the absolute risk of major complications remains low.
It’s reasonable to assume variation between hospital VBAC rates and between individual consultants VBAC rates.