The early 1990s saw VBACs being recommended to more and more women, managed care organizations encouraging doctors to do VBACs, the contraindications for VBAC shrinking, the uterine closure technique changing from a double-layer to a single-layer closure, and obstetricians managing VBACs like any other birth (induction, aggressive use of Pitocin, epidurals, etc.). Meanwhile, doctors and hospitals began seeing some catastrophic complications of previous cesareans, the most frequent being uterine rupture in labor and the most dramatic being placenta percreta. As a result, obstetricians lost some of their enthusiasm for VBACs when serious complications left vivid and terrifying memories. The American College of Obstetricians and Gynecologists (ACOG) retreated on some of its earlier endorsement of VBACs by changing the Clinical Management Guidelines for Obstetrician-Gynecologists in July 1999. These guidelines reflect a more cautious approach to VBAC and a less enthusiastic endorsement than previously. Some midwives have been attending VBACs for years, many with excellent outcomes. But there have been a few tragedies in the homebirth community that, together with the changing mood among obstetricians, have many midwives taking a second look at VBAC. The likelihood that a woman will have a successful VBAC depends to some extent on her obstetrical history and the reason for her previous c-section. The published success rates for hospital VBACs generally range from 60-80 percent. A woman who had a vaginal birth followed by a c-section is much more likely to have a VBAC than a woman who has never had a vaginal birth. Women having a VBAV (a non-standard term that we use in our practice for a woman having a vaginal birth after a VBAC) are also very likely, but not guaranteed, to have another successful VBAC. Women with non-recurring reasons for the first c-section, such as fetal distress or breech, have higher VBAC success rates than women given a diagnosis of cephalopelvic disproportion (CPD) or failure to progress (FTP). The initial CPD diagnosis is fraught with difficulty, since successful VBAC babies are sometimes 1 to 1.5 pounds bigger than the CPD older sibling. In several large studies of VBACs, the following factors were seen more frequently with uterine rupture: prostaglandin cervical ripening, Cytotec/misoprostol ripening, induction of labor, use of Pitocin, failure to progress, forceps/vacuum, and epidurals. A recent study showed that rates of uterine rupture are 3.0 times higher when the trial of labor is less than 18 months after the cesarcan, suggesting that good scar integrity requires adequate time for healing before the next pregnancy ([Shipp T.D.] et al. 2001). While home VBAC does create time and distance barriers to responding to a crisis, home VBAC does not introduce iatrogenic risk. Home VBAC with rapid access to surgical intervention may be safer than interventionist hospital obstetrics with VBAC, but there are no data that midwives may cite to support that assertion. The ACOG Clinical Management Guidelines and most obstetricians do not acknowledge most of the iatrogenic risks listed above, even though several retrospective studies have shown statistical significance. A recently published study actually looked at rupture rates in VBACs after one previous c-section. They found that the rupture rate was 0.4 percent in spontaneously laboring women, while the rate was 1.0 percent in oxytocin-augmented labors and 2.3 percent in induced labors. There is a growing body of retrospective studies that suggest that meddlesome obstetrics increases the risk for VBACs, which suggests that the midwifery model of care is safer for women seeking VBAC. However, there may not be many medical professionals or public health officials who would agree that an out-of-hospital, mid-wife-attended VBAC could be safer than obstetrician-attended hospital VBACs.
Full text not available yet. Check back later