Precluding VBAC for all women with three or more prior caesareans may not be evidence based

 AT LAST!!! More research to add to that of Dr Mark Landon.

http://www.rcog.org.uk/news/bjog-release-do-we-need-revisit-vbac-guidelines-women-three-or-more-prior-caesareans:

Planned vaginal birth after caesarean (VBAC) refers to any woman who has experienced a prior caesarean birth who intends to try for a vaginal birth rather than to deliver by elective repeat caesarean. Although relatively low complication rates, including uterine rupture, have been demonstrated among women with two prior low-transverse caesareans who attempt vaginal birth, there are very limited data available on outcomes among women with more than two prior caesareans. Neither the American College of Obstetricians and Gynaecologists (ACOG) nor the Royal College of Obstetricians and Gynaecologists (RCOG) currently recommend planned VBAC attempt in women with three or more prior caesarean deliveries¹.

In this study, the researchers sought to estimate the rate of success and risk of maternal morbidity in women with three or more prior caesareans who attempt VBAC. The study reviewed multi-centre data from 17 tertiary and community delivery centres in the Northeastern United States from 1996 to 2000. A total of 25,005 women who had a least one prior caesarean delivery were included.

The findings indicate that women with three or more prior caesarean deliveries did not experience a difference in morbidity based on whether they attempted VBAC or elected for a repeat caesarean. The 89 women with three or more prior caesareans who attempted VBAC were as likely to be successful as women with one or two prior caesareans, 79.8% compared to 75.5% and 74.6% respectively. In addition, none of them experienced significant maternal morbidity such as uterine rupture, uterine artery laceration, and bladder or bowel injury.

The older findings of Dr Mark Landon back in 2006: 

The 19-academic center study was led by Landon and conducted through the National Institutes of Health, Maternal Fetal Medicine Units Network. Its data included more than 45,000 patients with previous cesarean section, which included almost 18,000 women undergoing a trial of labor or an attempt at VBAC.

 “This was the first large study of VBAC in which certain outcomes, such as uterine rupture, were studied prospectively,” notes Landon, who serves as vice chairman of obstetrics and gynecology at the Ohio State University Medical Center.

Landon found that the risk of uterine rupture was 0.9 percent in cases of women with a history of multiple prior cesarean deliveries undergoing a trial of labor, compared with 0.7 percent in the cases of patients who had experienced only one previous cesarean delivery. These data challenge the notion that women with more than one prior cesarean are at dramatically increased risk for uterine rupture with a VBAC attempt.

“We looked at the outcomes associated with uterine rupture, including catastrophic outcomes such as stillbirth, or hypoxic brain injury to the baby,” says Landon. “And the good news is that the vast majority of uterine ruptures fortunately are associated with healthy infants. The absolute risk of catastrophic rupture with poor outcome is, in fact, quite small.”

Landon’s study confirms that uterine rupture is the complication with the greatest risk attributable to trial of labor; however, it also shows the risk for uterine rupture is not significantly increased in women with multiple prior cesarean deliveries compared to a single prior operation.

“The study has confirmed that the majority of women with multiple prior cesarean deliveries undergoing trial of labor can expect to achieve a successful vaginal birth,” says Landon, whose findings were published recently in the journal Obstetrics and Gynecology.

The benefits of VBAC include a faster recovery time and avoidance of the operative risks of cesarean section, which is a major operation.

“Beyond these obvious benefits, there seems to be a component that is not completely tangible,” notes Landon. “It goes along with the experience of vaginal childbirth, which certain women value, and there is probably not a price that you could put on that for a certain subgroup of women.”

Each case should be individualized, says Landon, in terms of the risks involved, the likelihood of success of VBAC, and the individual woman’s desire to proceed with attempted vaginal delivery vs. cesarean section. “Future childbearing plans are important, since the risk of cesarean complications rises dramatically after three operations,” according to Landon.

Landon advises that women should carefully research the topic of VBAC, looking for a physician who is willing to share data in an unbiased manner, who supports the concept of VBAC provided that a woman is an appropriate candidate, and who is willing to evaluate each case individually.

“About two-thirds of women who have had a previous cesarean delivery are actually candidates for VBAC,” says Landon. “VBAC after multiple cesarean sections should remain an option for eligible women.”

Sadly, childbirth can be risky, so can crossing the road. We don't ban someone from crossing the road just because they happened to have an accident once, or twice.  Sorry to be flippant! I appreciate that things can go wrong during any birth. They happen to go wrong a bit more often in birth which has interference. I recall hearing from two women within a week or two who had suffered uterine ruptures. Both had been induced, but only one had a previous scar on her uterus!

So, when women want to plan a VBAC, of any kind, it is important to support them fully. They are not selfish, wanting something for themselves, at any cost..... They are human beings who want the best birth possible for themselves and their baby. If they are fully supported during their antenatal and intrapartum periods they have the highest chance of success. If they feel listened to and respected they will then trust their caregivers, will believe that the caregivers will provide quality care with honesty and, if the birth deviates from normal, will be able to listen and make informed decisions quickly during labour. If a repeat section or assisted delivery is required then the mother will not feel violated, let down, coerced, traumatised.... she may well feel disappointment at the outcome not being as she planned for, but she will be happy that she laboured, that she was treated like a normal human being, that the assisted birth or Caesarean was for sound medical reasons and that she gave it her best shot. I also believe that morbidity and mortality will be reduced significantly as a result.

She will probably still be angry about the first Caesarean if she felt violated, let down, coerced, traumatised during that birth. She needs to be listened to, and her feelings respected. Too many women get told "you should be grateful"  No, they shouldn't!!!! Their feelings are valid and how dare anyone think that a woman would put her baby second to herself! But a mother is not much use to her baby, or anyone, when she's suffering from Postnatal Depression or, more likely, Post Traumatic Stress Disorder. Childbirth is more than just a physical process, it is also hormonal and pyschological. 

If we support a woman to have the best birth for her then she can feel good about a necessary Caesarean, but if we do not provide care and respect then even a physiological birth which sounds great on paper could leave a woman feeling traumatised.

I believe childbirth is very much a mental health issue.