1012 The dilemma of vaginal vs. elective caesarean delivery after previous caesarean section (c/s)

Whereas in 1996 the overall c/s rate in the USA was 21%, it has increased and in 2007 was 33%. While this is still approximately half the rate of South Africa’s privately-funded women undergoing delivery, the increase is of interest and concern to American health providers, policy-makers and other stakeholders. At a recent NIH conference entitled Vaginal Birth After Cesarean: New Insights, participants examined why the VBAC (vaginal birth after caesarean) rate had fallen and contributed to the striking increase in overall c/s rates. Participants discussed scientific evidence of varying grades and strength that included a trial of labour being safer for the mother than elective repeat c/s (4 deaths per 100 000 vs 13). However, this is contrasted with neonatal mortality of 50/100 000 for elective repeat c/s vs 130/100 000 for trial of labour. This presents mother and her caregiver with a significant dilemma: does she go the route that is encouraged by bodies such as the American College of Obstetricians and Gynecologists (ACOG) and opt for the lower risk of harm for herself and put the foetus at some risk, or does she choose to offer protection to her unborn child and expose herself to risk? Other important factors were highlighted, for example race and ethnicity are predictors of VBAC, with Hispanic and African American women having lower rates of vaginal delivery after a trial of labour than do ‘white’ women. Women who deliver at private hospitals have a lower rate of VBAC, as do those delivering at rural hospitals. Possibly related to the latter is the recommendation that trial of labour should not be offered unless there is guaranteed access to immediate emergency operative intervention in the event of a complication such as uterine rupture (which occurs in approximately 325 per 100 000 trials of labour overall, and 778 per 100 000 trials at term vs rates in the low to mid-20’s per 100 000 for elective repeat c/s). Statistics such as the above have no doubt played a role in the 26% reduction in the number of fellows of the ACOG offering trials of labour between 2003 and 2006.

Read more:
Lancet 2010; 375: 956
NIH Consensus Development Conference: http://consensus.nih.gov/2010/vbacstatement.htm