New Guidelines for Women With Prior Cesareans
Ob-Gyns Make Guidelines Less Restrictive for Vaginal Birth After Cesarean, or VBAC
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.
After evaluation of the evidence, the ACOG experts made updated recommendations, including:
- Women with more than one previous C-section may be candidates for a trial of labor. The experts reviewed two large studies that looked at the risk for women with two previous C-sections who attempted labor. One found no increased risk of uterine rupture in women with one vs. multiple previous C-sections, while the other study found the risk increased from 0.9% to 1.8% in women with one vs. two previous C-sections. The experts conclude that the chance of achieving a vaginal birth after C-section seems similar for women with one or more than one C-sections.
- Women who have an unknown type of scar from a previous C-section can also be considered for a trial of labor.
- Women expecting twins can be offered the trial of labor.
- A trial of labor is not recommended in others, including women who are at high risk for complications, such as women with a previous uterine rupture or extensive uterine surgery.
- Previous guidelines recommended that resources for emergency C-sections be ''immediately available." "That was interpreted to mean all staff, literally immediately available," Grobman says. In the new guidelines, the ACOG recommends that a trial of labor after C-section ideally be done in facilities well staffed to provide immediate emergency care, but that in a facility without immediate staff available, those doctors and patients discuss the resources and staff availability and carefully consider the decision to try labor.
Overall, about 60% to 80% of women who attempt labor after a previous C-section will deliver vaginally, the authors note.
The guidelines should be interpreted correctly, Grobman says. "This is never about saying that these women should have a trial of labor or shouldn't. It is about the offer and having a plan for a trial of labor and the concept of shared decision making and autonomy, and avoidance of coercion, in either direction."
New VBAC Guidelines: Other Opinions
''This is a fresh look at the evidence again," says Salih Yasin, MD, vice chair of the department of obstetrics and gynecology and director of obstetrics and patient safety at the University of Miami Miller School of Medicine, who reviewed the new guidelines for WebMD.
"Based on this extensive evidence, a trial of labor is a reasonably safe procedure [after C-section] as long as safety guidelines are followed," he says. That means choosing the right patient, he says, as well as the right baby and having the optimal setting in terms of staff and support.