VBAC--is it worth the risk?

Vaginal birth after cesarean in California: before and after a change in guidelines

PURPOSE

In 1999 the American College of Obstetricians and Gynecologists (ACOG) adopted more-restrictive guidelines for vaginal birth after cesarean delivery (VBAC). This study assesses trends in VBAC in California and compares neonatal and maternal mortality rates among women attempting VBAC delivery or undergoing repeat cesarean delivery before and after this guideline revision.

METHODS

The 1996 through 2002 California Birth Statistical Master Files were used to identify 386,232 California residents who previously gave birth by cesarean delivery and had a singleton birth planned in a California hospital.

RESULTS

Attempted VBAC deliveries decreased significantly from 24% before to 13.5% after guideline revision (P <.001). Neonatal mortality rates per 1,000 live births for attempted VBAC deliveries were not different from repeat cesarean delivery rates among neonates weighing > or =1,500 g in either the study periods 1996 to 1999 or 2000 to 2002. Neonatal mortality rates for attempted VBAC deliveries were higher for repeat cesarean deliveries among neonates weighing <1,500 g in the same periods (attempted VBAC: 1996-1999, 253.2; 95% Poisson confidence interval [CI], 197.7-308.6; 2000-2002, 336.8; CI, 254.3-419.4; repeat cesarean delivery: 1996-1999, 59.1; CI, 48.3-69.9; 2000-2002, 60.5, CI, 48.4-72.5). Maternal death rates per 100,000 live births for attempted VBAC deliveries were similar for both periods (1996-1999, 2.0; CI, 0.1-11.0; 2000-2002, 8.5; CI, 1.0-30.6).

CONCLUSIONS

Neonatal and maternal mortality rates did not improve despite increasing rates of repeat cesarean delivery during the years after the ACOG 1999 VBAC guideline revision. Women with infants weighing > or =1,500 g encountered similar neonatal and maternal mortality rates with VBAC or repeat cesarean delivery.

Primary nonmedically indicated cesarean section ("section on request"): evidence based or modern vogue?

Cesarean section, initially described as an emergency operative procedure for delivering moribund parturients, is now advocated by many as a routine technique with major advantages over vagi-nal delivery. In fact, it has been suggested that labor and vaginal delivery are no longer the desired consequence of pregnancy, a conclusion that reflects perceived medical advantages and patient and physician convenience. This article systematically reviews the various medical implications to the mother and infant of this procedure in the hope of facilitating a more rational approach to this spreading and controversial phenomenon.