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The American College of Obstetricians and Gynecologists (ACOG) recently issued clinical management guidelines for vaginal birth after cesarean delivery (VBAC) in various situations. The complete guideline, ACOG Practice Bulletin no. 54, appeared in the July 2004 issue of Obstetrics and Gynecology.
According to the report, the cesarean delivery rate in the United States increased from 5 percent to nearly 25 percent between 1970 and 1988. The authors attribute this increase to pressure on physicians to not perform vaginal breech deliveries and midpelvic forceps deliveries, and an increasing reliance on continuous electronic monitoring of fetal heart rate and uterine contraction patterns. Several large series found that a trial of labor after a previous cesarean delivery was relatively safe, prompting organizations such as the National Institutes of Health and the ACOG to endorse VBAC as a way to reduce the number of cesarean deliveries in the United States. Between 1989 and 1996, the cesarean delivery rate decreased as the VBAC rate increased. However, reports of uterine rupture and other complications during trials of labor after previous cesarean deliveries caused this trend to reverse.
No randomized trials have compared maternal or neonatal outcomes for repeat cesarean delivery and VBAC. Rather, VBAC recommendations have been based on data from large clinical studies suggesting that the benefits of VBAC outweigh the risks in most women with a previous low-transverse cesarean delivery. Most of these trials have been performed in university or tertiary-level centers with in-house obstetric and anesthesia coverage. ACOG notes that only a few studies have documented the relative safety of VBAC in smaller community hospitals or facilities where resources may be more limited. The report adds that women who fail a trial of labor are at risk for several maternal complications, including uterine rupture, the need for transfusion, hysterectomy, endometritis, and perinatal morbidity and mortality.
Clinical Considerations and Recommendations
According to the report, the evidence suggests that most patients who have had a low-transverse uterine incision from a previous cesarean delivery and who have no contraindications for...