In every data set that I have reviewed, perinatal morbidity and mortality are clearly higher in the VBAC group than in the repeat cesarean group. In essence, the central issue with VBAC is uterine rupture and all the complications that can flow from that event.6
A problem for small hospitals. ACOG has already issued guidelines for what care should be “readily available” in a hospital that offers VBAC. For the College to retreat from these recommendations in an effort to increase acceptance of VBAC among smaller community hospitals—many of which are without students, residents, fellows, or myriad other support personnel—would, I think, be disingenuous and ill-advised. Add to this recent data suggesting that peripartum hysterectomy (for which VBAC patients are at increased risk) is best done in a high-volume hospital setting7 and you further reduce the likelihood that smaller community hospitals will ever embrace VBAC.
How well do patients accept VBAC?
It’s tough to sell a product that people don’t want. My anecdotal experience (meaning that my conclusions are unencumbered by data) is that informed health care personnel who themselves have had a cesarean delivery almost uniformly select cesarean delivery subsequently. They know the data and they’re aware of the risks. Often, they aren’t planning on having more than two children, so the problem of placenta accreta in the future doesn’t apply.
These observations suggest, to me, that maybe 1) we need to do a better job counseling patients or 2) our society’s value system overwhelmingly favors predictability of delivery and safety of the newborn at the expense of even a slight increase in risk to the mother.
Alas, common sense is the most difficult thing to legislate
VBAC was, and is, a good idea. It’s based on sound principles and good intentions.
Recall that, in 1970, our dictum was “once a section always a section.” The cesarean delivery rate in the United States was 5%, and we didn’t need to worry about VBAC.
VBAC became popular only as the primary cesarean rate began to rise above 15%; at that time, strict rules accompanied the procedure: no oxytocin or epidural anesthesia, and, in many institutions, x-ray pelvimetry was required to document “adequacy” of the pelvis.
Now, we’ve moved to the other end of the spectrum: It seems we offer VBAC to anyone who wants it, regardless of comorbidities.
Can we compromise?
I support a middle-of-the-road position that strongly encourages VBAC for women who:
- have no comorbidities
- have had a prior VBAC or previous vaginal delivery of a term baby and
- who have had no more than one prior cesarean delivery.
On the other hand, VBAC should be discouraged for women who:
- have a body mass index >40
- are post-term
- present at term with premature rupture of the membranes, an unengaged vertex, or an unfavorable cervix or
- have any other condition that might make emergency cesarean delivery more difficult and, therefore, best avoided.
Such risk assessment approaches have already been proposed.5
Applying common sense to the matter, we might be able to agree on a solution that makes VBAC attractive and, more important, safe for our patients and for us. Furthermore, we must diligently keep track of our own data on maternal and neonatal outcomes so that we can most appropriately counsel our patients.
It’s up to us to determine whether VBAC should stay or go
I estimate that we have a window of opportunity of 5 to 10 years to resolve whether VBAC remains part of practice. If we don’t take that opportunity, we’ll be left with a generation of physicians who have little or no experience performing the procedure. VBAC will disappear, in a self-fulfilling prophecy—which, when you think about what happened with vaginal breech delivery, may not be a bad thing.