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MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Vaginal Birth After Cesarean
Sponsored by The Indian Health Service Clinical Support Center
2. Background
Where have we been and where are we going with V.B.A.C.?
In 1970 the cesarean birth rate in the United States was approximately 5%, and Dr. Craigin's 1916 dictum, "once a cesarean, always a cesarean," was widely adhered to. However, by the early 1980s, the cesarean birth rate had risen to over 27%. It's worth noting that the improvement in the perinatal mortality rate over this time period was preceded by, not a result of, the increase in the cesarean rate.
With one in every 5 babies being born by "the abdominal alternative," you are bound to see many patients with a prior cesarean if you manage obstetric patients. At the present time, elective repeat cesarean accounts for one-half to one-third of all cesareans, and a prior cesarean is now the leading indication for cesarean birth. In an effort to reverse this trend, both the N.I.H. and the A.C.O.G. have endorsed vaginal birth after cesarean (V.B.A.C.) as a desirable option. "Third-party payers" were quick to pick up on this recommendation as a cost-effective alternative. Physicians were said to be motivated by reimbursement issues, of practicing "defensive obstetrics," and "daylight obstetrics."
Currently, however, the pendulum seems to be temporarily swinging away from V.B.A.C., as there is evidence drawing attention to both the maternal and fetal risks of V.B.A.C.. In addition to the catastrophic risks associated with uterine rupture, the risk of perineal damage and subsequent incontinence after vaginal birth makes a woman's right to choose cesarean particularly relevant to our practice today.
Let's attempt to review the evidence and see if we can arrive at a strategy for each of the cases above on the basis of what this evidence reveals.
