First the good news: based on the presenters, it looks like the NIH VBAC conference will be a great improvement over the elective cesarean surgery travesty of four years ago. The conference seems likely to provide solid, evidence-based information on for whom and under what circumstances VBAC is safest and most likely to end in vaginal birth. Objective, unbiased information on these points is sorely needed, as illustrated by this 2008 response by ACOG vice president Dr. Ralph Hale, who one would expect to know better, to a plea to make VBAC more available:

VBAC is potentially an extremely dangerous procedure for both mother and infant. Although 98% of women can potentially have a successful VBAC, in two percent of cases the result can be a rupture of the old scar. If this happens, then death of the baby is almost certain and death of the mother is probable. Even if the mother does not die, virtually 100% will lose their child bearing ability. To prevent these disasters, the ability to perform immediate surgery is critical.

In point of fact, with appropriate care the scar rupture rate can be 0.5% or less (6,13,15), not 2%, and the chance of the baby dying as a result of scar rupture is 5% (9), not 'almost certain.' As for the mother, women rarely die or have hysterectomies, but both are more common with elective repeat cesarean than planned VBAC (3,17,18,19).

Before we break out the champagne, though, consider this: nowhere in the program is any acknowledgement of a patient's fundamental right to refuse surgery. Quite the opposite. The background statement is rife with the language of doctors giving (or withholding) permission:

For most of the 20th century, once a woman had undergone a cesarean . . ., many clinicians believed that all of her future pregnancies required delivery by cesarean as well. However, in 1980 a National Institutes of Health Consensus Development Conference panel questioned the necessity of routine repeat cesarean deliveries and outlined situations in which VBAC could be considered.

Even more telling, VBAC is positioned as a patient and provider 'preference.' The background section uses this term as does the title of the session on obstetric decision making, and Anne Lyerly, the obstetrician speaker on VBAC ethics, is co-author of the commentary 'Mode of delivery: toward responsible inclusion of patient preferences.'

The problem with patient preference is that it is readily trumped by provider preference. If VBAC is no more than a menu option, the danger in determining who makes a good candidate and what constitutes optimal circumstances for VBAC is that it legitimizes its opposite: doctors and institutions denying VBAC to women they don't think make the cut or where they don't think safety for VBAC is adequate. (The latter, BTW, is spurious. Emergencies occur in non VBAC labors. If a hospital isn't safe for a VBAC labor, then it isn't safe for any woman to labor there. Not to mention that ACOG guidelines for labor induction and American Society of Anesthesiologist guidelines for epidurals require the ability to perform an urgent cesarean because of the potential for just such emergencies, but no one is setting strictures on these procedures [1,2].)

A secondary danger of the 'preference' perspective is that conference presenters may treat non-clinical factors such as 'medico-legal concerns' and 'economic considerations' as valid reasons for VBAC refusal instead of obstacles that must be overcome. This would leave us where we are now with obstetricians and hospitals free to do as they choose, and what they choose is no VBACs. A 2005 survey found that more than half the women wanting a VBAC were denied that option, a 2009 survey of 2850 hospitals revealed that half of them had a ban or de facto ban against VBAC, and Lord knows we do not need any more stories like Joy Szabo's.

To give the conference planners and presenters their due, normally, it makes perfect sense to limit procedures to those with the skill to perform them and require their performance in environments with adequate resources. It makes sense as well as to allow providers and institutions to decline performing them. But VBAC is the exception because it is not a procedure. Labor is what inevitably happens at the end of pregnancy. Refusing VBAC means forcing women to agree to major surgery they neither want nor need in order to obtain medical care.

Depriving a woman of choice on grounds of the baby's safety, the primary clinical rationale for VBAC denial, values the child over the mother. This is not hyperbole. According to studies of a large U.S. population, the maternal risk of death (3 per 10,000) with elective repeat cesarean is in the same ballpark with the risk of the baby dying subsequent to scar rupture during a VBAC labor (1 per 10,000) (13,19). Moreover, as the conference will discuss, a woman undergoing repeat cesarean not only runs the risks of that surgery, but an increasing risk of placental attachment abnormalities in any future pregnancies as she accumulates surgeries, abnormalities that threaten both her life and that of the fetus. By contrast, once a woman has a VBAC, she will almost always continue to have uneventful VBACs in future pregnancies. VBAC denial is the sole instance where doctors feel justified in compelling one person to undergo a medical procedure to benefit another party, but no ethical principle or law allows this, including when the beneficiary will otherwise surely die, which is far from the case with VBAC.

Failure to recognize that VBAC is a right has another consequence as well. If you start from this premise, it follows that a key question will be how best to promote safe vaginal birth in women desiring VBAC, but this is missing from the agenda. My researches for the VBAC chapter of the new edition of Obstetric Myths turned up much food for thought on this issue. For example, a study on the large U.S. population mentioned above reported scar rupture rates of 9 per 1000 with labor augmentation and 10 per 1000 with induction but only 4 per 1000 in women laboring spontaneously (13). If every woman had labored without stimulation, 63 women would have had scar ruptures instead of 124. On the other hand, a study reported equally low scar rupture rates in induced labors (3 per 1000) as in labors with spontaneous onset (16), which suggests that while spontaneous labor is optimal, women who truly require induction can be induced without excess risk provided clinicians pay proper attention to patient selection and induction protocol. Research also shows that physiologic care substantially increases VBAC rate and reduces scar rupture rate (15). The birth center VBAC study reported a VBAC rate of 81% in women with no prior vaginal birth, 9 to 20 more women per 100 than among similar women in nine studies (4,5,7,8,10-12,14,20) who had conventional obstetric management. The scar rupture rate overall was a mere 2 per 1000.

We rightly should applaud any effort that helps women and clinicians decide between planned VBAC or repeat cesarean but lament any attempt to curtail a woman's right to refuse surgery, be it on clinical or nonclinical grounds. VBAC is a right, not a preference, a right, let me add, not abrogated by the clinician's opinion of its wisdom. It does not matter if you, me, and everyone on the planet were to line up and say to a woman VBAC is a bad idea in your case, she still has the right to say 'no' to surgery. Clinicians and institutions must be brought to accept their ethical and professional obligation to provide best practice care to every woman wanting planned VBAC. If the conference fails in this task, then whatever it accomplishes, it will fall short of its duty to childbearing women with previous cesareans.

1. ACOG. Induction of labor. ACOG Practice Bulletin No 107 2009.

2. ASA. Guidelines for regional anesthesia in obstetrics. 2007. (Accessed 2/12/2010, at http://www.asahq.org/publicationsAndServices/standards/45.pdf.)

3. Blanchette H, Blanchette M, McCabe J, et al. Is vaginal birth after cesarean safe? Experience at a community hospital. Am J Obstet Gynecol 2001;184(7):1478-84; discussion 84-7.

4. Cahill AG, Stamilio DM, Odibo AO, et al. Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery? Am J Obstet Gynecol 2006;195(4):1143-7.

5. Caughey AB, Shipp TD, Repke JT, et al. Trial of labor after cesarean delivery: the effect of previous vaginal delivery. Am J Obstet Gynecol 1998;179(4):938-41.

6. Chauhan SP, Martin JN, Jr., Henrichs CE, et al. Maternal and perinatal complications with uterine rupture in 142,075 patients who attempted vaginal birth after cesarean delivery: A review of the literature. Am J Obstet Gynecol 2003;189(2):408-17.

7. Gonen R, Barak S, Nissenblat V, et al. The outcome and cumulative morbidity associated with the second and third postcesarean delivery. Am J Perinatol 2007;24(8):483-6.

8. Goodall PT, Ahn JT, Chapa JB, et al. Obesity as a risk factor for failed trial of labor in patients with previous cesarean delivery. Am J Obstet Gynecol 2005;192(5):1423-6.

9. Guise JM, McDonagh M, Hashima JN, et al. Vaginal birth after cesarean (VBAC) Report/Technology Assessment No. 71. Rockville, MD: Agency for Healthcare Research and Quality; 2003 March 2003. Report No.: AHRQ Publication No. 03-E018.

10. Gyamfi C, Juhasz G, Gyamfi P, et al. Increased success of trial of labor after previous vaginal birth after cesarean. Obstet Gynecol 2004;104(4):715-9.

11. Hendler I, Bujold E. Effect of prior vaginal delivery or prior vaginal birth after cesarean delivery on obstetric outcomes in women undergoing trial of labor. Obstet Gynecol 2004;104(2):273-7.

12. Kwee A, Bots ML, Visser GH, et al. Obstetric management and outcome of pregnancy in women with a history of caesarean section in the Netherlands. Eur J Obstet Gynecol Reprod Biol 2007;132(2):171-6.

13. Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004;351(25):2581-9.

14. Landon MB, Leindecker S, Spong CY, et al. The MFMU Cesarean Registry: factors affecting the success of trial of labor after previous cesarean delivery. Am J Obstet Gynecol 2005;193(3 Pt 2):1016-23.

15. Lieberman E, Ernst EK, Rooks JP, et al. Results of the national study of vaginal birth after cesarean in birth centers. Obstet Gynecol 2004;104(5 Pt 1):933-42.

16. Locatelli A, Regalia AL, Ghidini A, et al. Risks of induction of labour in women with a uterine scar from previous low transverse caesarean section. BJOG 2004;111(12):1394-9.

17. Loebel G, Zelop CM, Egan JF, et al. Maternal and neonatal morbidity after elective repeat Cesarean delivery versus a trial of labor after previous Cesarean delivery in a community teaching hospital. J Matern Fetal Neonatal Med 2004;15(4):243-6.

18. McMahon MJ, Luther ER, Bowes WA, Jr., et al. Comparison of a trial of labor with an elective second cesarean section. N Engl J Med 1996;335(10):689-95.

19. Spong CY, Landon MB, Gilbert S, et al. Risk of uterine rupture and adverse perinatal outcome at term after cesarean delivery. Obstet Gynecol 2007;110(4):801-7.

20. Turner MJ, Agnew G, Langan H. Uterine rupture and labour after a previous low transverse caesarean section. BJOG 2006;113(6):729-32.

Published: March 05, 2010

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