Choice in childbirth: VBAC

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Childbirth is a ubiquitous experience among mothers. Birth can occur in many ways, from medication-free natural labour, to cesarean section. Mothers in Canada can, for the most part, choose how they want to deliver. However, women with a prior cesarean section have a more difficult choice to make. They can choose to have a repeat cesarean section, or to attempt a vaginal birth after cesarean – a VBAC. How do women make this decision, and how can healthcare providers support them?

Approximately 80% of women with a prior cesarean are good candidates for VBAC. It is recommended that these women labour in a hospital with access to an operating room for a repeat cesarean if needed. Contraindications for VBAC include previous uterine rupture, fetal malpresentation (i.e. breech), certain types of uterine scars from the previous c-section, and problems with the placement/attachment of the placenta (i.e. placenta previa). In a carefully selected population, the rate of VBAC success can be as high as 85%. Success is influenced by many factors, including spontaneous labour versus induced, as well as the method of induction.

The tables below highlight the risks and benefits of both VBAC and repeat cesarean for mother and baby.

Benefits of successful VBAC Maternal risks of VBAC Fetal risks of VBAC
-shorter recovery time and quicker return to normal activity -increased risk of uterine rupture

 

-increased morbidity and mortality associated with uterine rupture

 

-decreased rates of hysterectomy and thromboembolic complications -failed VBAC requiring emergency c-section (longer recovery time, higher rate of hysterectomy, higher rates of operative injury) -increased rates of neonatal sepsis in those who fail VBAC and require a repeat c-section
-decreased rates of neonatal respiratory complications

 

-reduced rates of potential complications in future pregnancies (i.e. placenta previa)

 

Benefits of elective repeat cesarean section (ERCS) Maternal risks of ERCS Fetal risks of ERCS
-avoid the risks associated with labour and VBAC -surgery-related risks:

-infection

-excessive bleeding

-damage to other  organs

-increased rates of

thromboembolic

complications

 

-increased risk of short-term breathing problems
-avoid the risks of an unplanned or emergency c-section -increased risk of problems with the placenta in future pregnancies (i.e. placenta accreta)

 

-plan a birthdate in advance (39-41 weeks) -risks due to anesthesia

The risks associated with VBAC and repeated cesarean are not equal. Here is a comparison of the estimated risks to mother and baby arising from each delivery mode.

Maternal risk Planned VBAC Elective repeat cesarean section
Maternal death 4 in 100,000 (0.004%) 13 in 100,000 (0.013%)
Uterine rupture 5 in 1,000 (0.5%) 0.2 in 1,000 (0.02%)
Hysterectomy 2-3 in 1,000 2-3 in 1,000
Blood transfusion 1-2 in 1,000 1-2 in 1,000
Infection 4 in 100 4 in 100

 

Infant risk Planned VBAC Elective repeat cesarean section
Perinatal death 4 in 10,000 (0.04%) <1 in 10,000 (<0.01%)
Permanent neurological injury 8 in 10,000 (0.08%) < 1 in 10,000 (<0.01%)
Short term breathing problems 2-3 in 100 4-5 in 100

In our era of patient-centered, even patient-driven healthcare, informed consent must be the key to helping women decide their mode of delivery after a c-section. However, physicians’ personal experiences and preferences inform how they practice, and many physicians will attempt to steer their patients towards what they think is best. To provide truly patient-centered care, healthcare providers should explain to patients (in a way that is easy to understand) the risks and benefits of their options, and then let the patient decide what is best for her. This is a very personal decision, as we know that women will place different levels of importance on the different risks and benefits of VBAC versus cesarean.

There is a long way to go before this kind of care is routinely provided. A first step on the road would be to standardize the information physicians give their patients regarding VBAC. Decision aids could also be a helpful tool for mothers to work through their decision.

The decision to VBAC rather than have a repeat cesarean section highlights the importance of women’s choice, autonomy, and patient-centered care. The consensus seems to be that supporting women in the delivery method they choose is what best fits with Canadian values and laws. We have some work to do before this becomes the standard reality, where mothers do not face judgment for their birthing choice from the medical establishment or from society.

 

References

  1. Martel, M.J., & MacKinnon, C. (2005). Guidelines for vaginal birth after previous Caesarean birth. Journal of Obstetrics and Gynaecology Canada, 27(2): 164-174.
  1. Davies GA, Hahn PM, McGrath MM. (1996). Vaginal birth after Cesarean section: physicians’ perceptions and practice. Journal of Reproductive Medicine, 41:515–20.
  1. Mozurkewich, E.L., & Hutton, E.K. (2000). Elective repeat Cesarean delivery versus trial of labor: a meta-analysis of the literature from 1989 to 1999. American Journal of Obstetrics and Gynecology, 183:1187–97.
  1. Hook, B., Kiwi, R., Amini, S.B., Fanaroff, A., & Hack, M. (1997). Neonatal morbidity after elective repeat Cesarean section and trial of labor. Pediatrics, 100:348–53.
  1. Chauhan, S.P., Martin, J.N., Henrichs, C.E., Morrison, J.C., & Magann, E.F. (2003). Maternal and perinatal complications with uterine rupture in 142,075 patients who attempted vaginal birth after Cesarean delivery: a review of the literature. American Journal of Obstetrics and Gynecology, 189:408–17.
  1. McMahon, M.J. (1998). Vaginal birth after Cesarean. Clinical Obstetrics and Gynecology, 41:369–81.
  1. Hibbard, J.U., Ismail, M.A., Wang, Y., Te, C., & Karrison, T. (2001). Failed vaginal birth after Cesarean section: how risky is it? American Journal of Obstetrics and Gynecology, 184:1365–73.
  1. Martin, J.N., Perry, K.G., Roberts, W.E., & Meydrech, E.F. (1997). The case for trial of labor in the patient with a prior low-segment vertical Cesarean incision. American Journal of Obstetrics and Gynecology, 177:144–8.
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Nicole Haywood

Associate editor for the IJHS. Bachelor of Health Sciences, class of 2014, University of Ottawa.

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