dreamstime_6430821 The greatest social changes usually begin at the grassroots and works its way up. Based on growing dissent regarding limited options for VBACS, a panel of the National Institute of Child Health Development (NICHD) met in March of this year to determine why VBACs were declining. Between 2006 and 2008, 20% of obstetricians stopped offering VBAC as an option. In 2006, the numbers were even higher at a rate of 26%. The NICHD panel concluded that a trial of labor is a reasonable option for many women with a prior cesarean delivery (see “Vaginal Birth After Cesarean: New Insights”). So, why all the fuss and resistance? Because there is a small risk of uterine rupture (less than 1%) and most hospitals mandate that a physician be in the hospital to manage a laboring VBAC patient. Dr. George Macones was interviewed in a recent ob-gyn newspaper and I’d like to share some of his observations and comments. Macones is a maternal fetal medicine specialist and the ob-gyn chair at Washington University in St. Louis.

According to Macones, there are no scientific models that can predict who will succeed and who will fail a trial of labor after cesarean section but he did offer these helpful insights:

  1. A VBAC candidate who has had a previous vaginal delivery has an 89% success rate for a VBAC and fewer complications as opposed to a woman who has never had a vaginal delivery.
  2. Women who have spontaneous labors have more successful VBACs than women who are induced in labor.
  3. Doses of oxytocin or Pitocin greater than 20 mu/min increase the risk of uterine rupture
  4. Intrauterine pressure catheters do NOT accurately predict uterine rupture and should not be used for that purpose.
  5. VBAC candidates who need more than one medication to induce labor are at an increased risk of uterine rupture
  6. If a VBAC candidate has an epidural and still feels significant pain or needs frequent doses of the epidural anesthetic, there is a high probably that there might be a uterine rupture.

Performing repeat c. sections in women who have had previous vaginal deliveries is morally wrong. Patient safety should always take precedence over physician convenience.