In “VBAC: Safer than you think” [August], Ellen Mozurkewich, MD, recommends carefully selecting patients for vaginal delivery after cesarean (VBAC). However, she does not offer clear guidelines for such a selection process. Here at Elmhurst Hospital Center-Mt. Sinai affiliation, we utilize a scoring system to identify candidates at low, medium, and high risk for VBAC (Table 1). While patients who score from 16 to 20 points are considered low-risk and, therefore, good candidates for VBAC, patients who score 0 to 5 points are considered high-risk and should never be offered a trial of labor. Medium-risk patients, scoring from 6 to 15 points, require individualized consideration with extensive counseling.
—E. HAKIM-ELAHI, MD
CHIEF OF WOMEN’S HEALTH SERVICES
ELMHURST HOSPITAL CENTER
ELMHURST, NY
TABLE 1
VBAC risk scoring system*,†
| SCORE 2 FOR EACH ITEM | SCORE 1 FOR EACH ITEM | SCORE 0 FOR EACH ITEM |
|---|---|---|
| Past: | ||
| 1 cesarean | 2 cesareans | More than 2 cesareans |
| 2-layer closure | 2-layer closure, with postoperative fever | 1-layer closure |
| Cesarean more than 2 years ago | Cesarean 1-2 years ago | Cesarean less than 1 year ago |
| Cesarean not due to CPD | Cesarean performed due to dystocia | Cesarean performed due to CPD |
| Term vaginal birth | Premature vaginal birth | No vaginal birth |
| Present: | ||
| Singleton | Twins (both cephalic) | Twins (only first cephalic) |
| Cephalic | Breech | Other presentations |
| Fetal weight less than 3,500 g | Fetal weight 3,500-4,500 g | Fetal weight above 4,500 g |
| Expect spontaneous labor | Expect labor will need augmentation | Expect labor will need to be induced |
| Maternal weight less than 170 lbs | Maternal weight 171-250 lbs | Maternal weight above 250 lbs |
| CPD = cephalopelvic disproportion; VBAC = vaginal birth after cesarean | ||
| *Low risk: 16-20 points; medium risk: 6-15 points; high risk: 0-5 points | ||
| †Score 0 for each item you cannot document from history. | ||