VBAC - Vaginal Birth
After Cesarean
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Preliminary data for 2005 indicate that 30.2% of all live births
in the United States were cesarean deliveries,
marking the highest U.S. total cesarean rate ever reported.
Since 1996, the total cesarean rate has increased by 46%,
driven by both an increase in the percentage of all women having
a first cesarean and a decline in the percentage of women
delivering vaginally after a previous cesarean.
Cesarean rates vary considerably among states but tend to be lower
in the western mountain states and upper Midwest region
and higher in the Southeast and East regions.
SOURCE: National Vital Statistics System, unpublished data.
Additional information is available at http://www.cdc.gov/nchs/births.htm.
from QuickStats
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VBAC
Resources
International Cesarean Awareness Network
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Complete
report available online: See http://www.cdc.gov/nchs
The
CDC published new cesarean section and VBAC stats for 2003.
2003 primary cesarean
rate: 19.1 (6% increase from last year)
2003 VBAC rate: 10.6 (16% decrease)
Excerpts "...the rate of cesarean delivery increased 5 percent to
27.5 percent of all births, the highest rate ever recorded
in the United
States. After falling between 1989 and 1996,
the cesarean rate has risen by
one- third.
The primary rate increased by 6 percent, and the rate of vaginal
birth
after cesarean delivery (VBAC) fell by 16 percent for 2002-03."
FACTS:
The
World Health Organization states that no country in the world is justified in
having a cesarean rate greater than 15%. (WHO 1995) According
to the Texas Department of Health In 1999:
Cesarean
Births 24.1%
VBAC Rate 1.8% Up
to 70% of women for whom the indication for cesarean delivery was a
non-progressive
labor and who labored again had a VBAC for a subsequent birth.
ACOG Committee
Opinion #143 |
What Does Evidence-based Research Say About the Safety of Labor Following a Previous
Cesarean birth? |
Cesarean
delivery rates can safely be reduced. Certain individual obstetrician characteristics
influence cesarean delivery rates. Obstetricians' commitment facilitates lowering
of cesarean delivery rates.
(Am J Obstet Gynecol 1999;180:1364-72.)
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A
trial of labor in women with previous low vertical cesarean sections results in
an acceptable rate of vaginal delivery and appears safe for both mother and fetus.
(AM J OBSTET GYNECOL 1996;174:966-70.)
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Our experience
indicates that a mother with a prior low-segment vertical cesarean delivery can
undertake a trial of labor with relative maternal-perinatal safety. The likelihood
of successful outcome and the incidence of complications are comparable to those
of published experience with a trial of labor after a previous low-segment transverse
incision. (AM J OBSTET GYNECOL 1995;172:1666-74.)
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Elective
repeat cesarean delivery versus trial of labor: A meta-analysis of the literature
from 1989 to 1999
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| Objective:
The aim of this study was to compare a trial of labor with elective repeat cesarean
delivery among women with previous cesarean delivery. Mothers undergoing a trial
of labor were less likely to have febrile morbidity or to require transfusion
or hysterectomy. |
Conclusion:
A trial of labor may result in small increases in the uterine rupture rate and
in fetal and neonatal mortality rates with respect to elective repeat cesarean
delivery. Maternal morbidity, including febrile morbidity, and the need for transfusion
or hysterectomy may be reduced with a trial of labor.
(Am J Obstet Gynecol
2000;183:1187-97.)
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Individual
physician's lower cesarean sections are primarily obtained by labor management
and attempting vaginal birth after cesarean delivery. These practice patterns
did not appear to lead to any increase in perinatal morbidity or mortality. Efforts
to lower cesarean section rates of individual practitioners should focus on the
areas of fetal distress, cephalopelvic disproportion, and repeat cesarean section.
(Am J Obstet Gynecol 1998;178:1207-14.)
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(1) Low-income,
uninsured, and underinsured women who have access to excellent prenatal care with
supervised certified nurse-midwives can have obstetric outcomes similar to women
having prenatal care with private obstetricians. (2) Prenatal care with supervised
certified nurse-midwives can reduce the cesarean section rate without compromising
infant outcome. (3) Utilization of certified nurse-midwives supervised by obstetricians
may provide the optimum model for perinatal care, particularly for those women
who are at high risk because of social and economic factors and who are currently
underserved.
(AM J OBSTETGYNECOL 1995;172:1864-71.)
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| OBJECTIVE:
We compared trends and current levels of cesarean section delivery by indication
in four countries to help us understand factors underlying national differences
in obstetric delivery practice and identify pathways to lower cesarean rates. |
| STUDY
DESIGN: We carried out a measurement of change in the use of cesarean delivery
by indication in Norway, Scotland, Sweden, and the United States during intervals
centered on 1980, 1985, and 1990. Indication for cesarean delivery was determined
by a standard set of selection rules. |
| RESULTS:
The rate of growth of national cesarean section rates dropped significantly between
the time periods 1980 to 1985 and 1985 to 1990 in all four countries; in Sweden
this led to an actual decline in the cesarean section rate. Fetal distress and
previous cesarean section were important contributors to cesarean section growth
in three of the countries in 1980 to 1985, but their contribution to growth dropped
off sharply in 1985 to 1990. By the 1990 interval, the overall rate ranged from
24% (United States) to 11% (Sweden), and all four countries had similar cesarean
section rates for breech presentation, fetal distress, and "other" indications.
Cesarean section deliveries for previous cesarean section and dystocia accounted
for the substantially higher U.S. cesarean section rate. |
CONCLUSIONS:
Cesarean section rates are approaching stability in the four countries and have
declined in Sweden. Previous cesarean delivery and dystocia may be the major sources
of future reductions in the U.S. cesarean rate. The Swedish example shows that
it is possible to reduce a relatively low national cesarean section rate. (AM
J OBSTET GYNECOL 1994;170:495-504.)
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Among women with
1 prior cesarean delivery undergoing a subsequent trial of labor, those with a
prior vaginal delivery were at substantially lower risk of uterine rupture than
women without a previous vaginal delivery.
(Am J Obstet Gynecol 2000;183:1184-6.)
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CONCLUSIONS:
We have demonstrated that the cesarean delivery rate can be safely lowered in
a private hospital without mandated clinical changes. Our data suggest that careful
and detailed feedback can lead to improved clinical practice.
(AM J OBSTET
GYNECOL 1996;174:184-91.)
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What Does
Evidence-based Research Say About Induction of Labor Following a Previous Cesarean
birth?
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Large
variations in labor induction were noted across maternal ethnicity and hospital
type categories. Labor induction increased cesarean delivery rates among nulliparous
women, whereas no increase was seen among parous women with no previous cesarean
delivery. Labor induction was used less often among those with previous cesarean
delivery; when it was used in this group, however, it was associated with a lower
cesarean delivery rate. (Am J Obstet Gynecol 2000;182:1355-62.)
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Misoprostol
(cytotec) may increase the risk of uterine rupture in the patient with a scarred
uterus. Carefully controlled studies of the risks and benefits of misoprostol
are necessary before its widespread use in this setting.
(Am J Obstet Gynecol
1999;180:1535-42.)
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Induction
of labor with oxytocin is associated with an increased rate of uterine rupture
in gravid women with 1 prior uterine scar in comparison with the rate in spontaneously
laboring women. Although the rate of uterine rupture was not statistically increased
during oxytocin augmentation, use of oxytocin in such cases should proceed with
caution. (Am J Obstet Gynecol 1999;181:882-6.)
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Compared with
prostaglandin E2, misoprostol is more effective in cervical ripening and induction
of labor, is as safe for patients who do not have a history of cesarean birth,
may carry a higher incidence of uterine rupture, and should not be used for patients
attempting vaginal birth after previous cesarean delivery.
(Am J Obstet Gynecol
1999;180:1551-9.)
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