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New Guidelines for Women With Prior Cesareans

Ob-Gyns Make Guidelines Less Restrictive for Vaginal Birth After Cesarean, or VBAC
WebMD Health News
Reviewed by Laura J. Martin, MD

July 21, 2010 -- Many women who have had a cesarean section delivery -- and some who have had two C-sections -- can safely attempt to deliver vaginally, according to updated guidelines on vaginal birth after cesarean, or VBAC, issued by the American College of Obstetricians and Gynecologists.

''What is new are a couple of key things," says William A. Grobman, MD, an associate professor of obstetrics and gynecology at Northwestern University Feinberg School of Medicine, Chicago, and a co-author of the updated guidelines.

Under the new guidelines, women with two previous cesareans and no previous vaginal delivery, women expecting twins, and women with an unknown type of scar from the previous C-sections are now considered reasonable candidates for vaginal delivery, updating guidelines on the topic issued in 2004 and 2006.

"In the times since those guidelines [were issued], new information was available," Grobman tells WebMD, including two large and scientifically sound studies about VBAC.

New VBAC Guidelines: The Back Story

Over the past 40 years, the C-section delivery rate in the U.S. has risen from 5% in 1970 to more than 31% in 2007, write the authors of the guidelines, published as a practice bulletin in the journal Obstetrics & Gynecology.

Behind the rise, according to the authors, are changes in obstetrics practice, such as the introduction of fetal monitoring and a decrease in forceps delivery.

The old saying of "Once a cesarean, always a cesarean" was also at play, the authors say.

But by the 1970s, data were accumulating to support a trial of labor after cesarean, or what doctors call TOLAC. As the number of women who tried to deliver vaginally after a previous C-section rose, so did complications such as uterine rupture.

That triggered a reversal of the trend, with some hospitals no longer offering women TOLAC.

Then, earlier this year, at a National Institutes of Health consensus conference, experts found TOLAC was reasonable for many women and asked professional organizations to help them help women access the option.

New VBAC Guidelines: A Closer Look

In the guidelines, Grobman and his colleagues note that neither an elective repeat C-section nor a trial of labor after C-section are without risk to mother and baby. Both are associated with risks of maternal hemorrhage, infection, operative injury, and other problems.

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