One of my favorite new blogs, Academic OB/GYN, has an interesting post up called Ten Thoughts on VBAC. I encourage you to read the entire post and comment thread. I was especially interested in #7 and #10, which said:
The single most important thing we can do to deal with VBAC issues is to not have them at all, by avoiding the first cesarean section. Many cesareans are absolutely necessary, but when possible we should achieve vaginal deliveries. I’m willing to push some grey cases that others might deliver by cesarean. Sometimes that means being more patients with a slow labor. Sometimes that means operative vaginal delivery. Because of that, more of my patients will have easy multiparous second labors rather than having to worry about VBAC issues. There is a receiver operator curve for cesarean necessity. Most OBs should push their needle a little towards “specificity”.
Here is my reply:
Thanks for a thoughtful post on a controversial issue.
When I selected an article on VBAC for our medical school ob/gyn interest group journal club, our faculty sponsor said we shouldn’t even waste our time, since no one is doing them any more. That is certainly true for our area, where most practices and hospitals refuse to allow trial of labor attempts for VBACs. We are hardly rural. I know of an ophthalmologist who had to hire a concierge obstetrician and pay $10,000 up front to get any obsterician to attend her VBAC. She had one prior successful spontaneous vaginal delivery and a cesarean for twins. Practice patterns are obviously not the same everywhere, especially when it comes to obstetrics. She had her cesarean in another part of the country, and was assured by her obstetrician that she would be a fine candidate for a future VBAC attempt. If she hadn’t moved, it probably wouldn’t have been an issue.
I have another local friend whose physician refused to attend a VBAC attempt she requested (her prior pregnancy ended in preeclampsia, a failed induction and a cesarean at full term). When she showed up a few days before her scheduled cesarean in spontaneous labor, they sectioned her anyway, even though an article in that month’s Green Journal found that emergent cesarean after onset of labor to be the most expensive choice in their study of VBAC with the worst maternal and fetal morbidity. Why not let her attempt the trial of labor, especially since she expressly asked to be able to do so, and prominent medical opinion found it to be not only a reasonable choice, but an easily defensible one?
And, the area primary cesarean rate, which is above 45% in most hospitals, means that less of our primips are “successful” at an attempted vaginal delivery (I put “success” in quotes because I think a safe delivery, even if by cesarean section, is still “successful”) than even the conservative estimates you quote as “success” rates for VBAC attempts in the original post in point #7. (I have usually read of a “success” rate of about 75% in several articles, but outcomes vary.)
But, ACOG’s Practice Bulletin on VBAC says women who are good candidates should be offered a trial of labor. And, practice patterns vary in different parts of the country, and many physicians and hospitals still offer VBACs, and the current literature seems to consider it to be a reasonable option and continues to publish articles on VBAC. But, when I did a history on a woman switching care to a midwife in her third trimester, she said her doctor told her he’d refer her to a psychiatrist before he’d let her attempt a VBAC. So, there’s obviously a wide range in opinions on how to interpret the risks.
This article on explaining obstetrical risk by Lyerly et al is one of my favorite articles I have read on the topic. It states that “Although rates of delivery-related perinatal death are indistinguishable between VBAC and primary vaginal delivery, there is a genuine differential in the rate of uterine rupture–related hypoxicischemic encephalopathy. Such perinatal morbidity is indeed devastating. It is also extremely rare. In a recent large prospective study, the probability of this outcome was 0.00046 in infants whose mothers underwent a VBAC trial at term compared with no cases in infants whose mothers underwent repeat cesarean delivery.” (Emphasis mine)
I think that indicated that there is some validity to the argument that anywhere that it is safe to allow a premip to labor and deliver, it should be safe to allow a good candidate to attempt a VBAC. However, some may disagree about where it is safe to deliver at all. Some may find the risk of a home birth not only acceptable but preferable to a medicalized birth experience. Others may only be comfortable with a delivery at a facility with on site 24 hour anesthesia and obstetricians, and a Level IIIC NICU.
I don’t want to paint all obstetricians with one brush, but neither do I want to disregard the possibility that out of hospital births can be safe. Well managed out of hospital births may have risks similar to real obstetrical care in many hospitals, which unfortunately is not always evidence based care optimizing good outcomes. But, women are not always given an unbiased view of true risk, whether it be the risks of a HBAC or the risks of an induced, augmented VBAC attempt or the risks of repeat cesareans. The Lyerly article concludes that “[T]hese tendencies in the perception, communication, and management of risk can lead to care that is neither evidence-based nor patient-centered, often to the detriment of both women and infants” when discussing the way obstetricians present these risks. I think the natural birth community can probably be equally possible of have members on the fringes who would de-emphasize the risks of a home birth VBAC or an unassisted VBAC.