The greatest social changes usually begin at the grassroots and works its way up. Based on growing dissent regarding limited options for VBACS, a panel of the National Institute of Child Health Development (NICHD) met in March of this year to determine why VBACs were declining. Between 2006 and 2008, 20% of obstetricians stopped offering VBAC as an option. In 2006, the numbers were even higher at a rate of 26%. The NICHD panel concluded that a trial of labor is a reasonable option for many women with a prior cesarean delivery (see “Vaginal Birth After Cesarean: New Insights”). So, why all the fuss and resistance? Because there is a small risk of uterine rupture (less than 1%) and most hospitals require a physician to be in the hospital to manage a laboring VBAC patient. Dr. George Macones was interviewed in a recent ob-gyn newspaper and I’d like to share some of his observations and comments. Macones is a maternal fetal medicine specialist and the ob-gyn chair at Washington University in St. Louis.
According to Macones, there are no scientific models that can predict who will succeed and who will fail a trial of labor after cesarean section but he did offer these helpful insights:
- A VBAC candidate who has had a previous vaginal delivery has an 89% success rate for a VBAC and fewer complications as opposed to a woman who has never had a vaginal delivery. It is therefore not appropriate to ask women who’ve had successful vaginal deliveries to have repeat c. sections based on “hospital policy.”
- Women who have spontaneous labors have more successful VBACs than women who are induced in labor.
- Doses of oxytocin or Pitocin greater than 20 mu/min increase the risk of uterine rupture
- Intrauterine pressure catheters do NOT accurately predict uterine rupture and should not be used for that purpose.
- VBAC candidates who need more than one medication to induce labor are at an increased risk of uterine rupture
- If a VBAC candidate has an epidural and still feels significant pain or needs frequent doses of the epidural anesthetic, there is a significant risk that there might be a uterine rupture.
Performing repeat c. sections in women who have had previous vaginal deliveries is morally wrong. Patient safety should always take precedence over physician convenience.