Caesarian Sections & VBAC

The rate of Caesarian sections in the United States has risen to 25 percent, the major reasons being medico-legal and convenience considerations (VBAC, 2003, 84-85). However, there is a wealth of data to suggest that they are more costly, and certainly not innocuous. Vaginal Birth After Caesarean (VBAC) is becoming increasingly popular, and the medical profession has tried somewhat to discourage it because of the risk of uterine rupture. While postpartum fever seemed to correlate with uterine rupture at VBAC in a recent study, there was no relationship between single or double layer closure, the use of antibiotics, or white blood cell count. The most critical factor seems to be the strength of the surgical scar. Some studies have suggested that wall thickness is a good indicator of the potential for uterine rupture. A French study of 642 patients undergoing VBAC showed a rupture rate of 2.5 percent. If the wall thickness was greater than 4 mm, there were no uterine defects, and using a cutoff of 3.5 mm, the negative predictive value was 99.3 percent.

VBAC is not new: the earliest such case on record dates back to 1500 when a farmer performed a Caesarean on his wife, who went on to have several more children by vaginal birth (Rinehart, 2001, 16). In Europe, VBAC was the norm throughout the last century, but in the United States it was almost unheard of until the late 1950s. The rate increased slowly until the 1980s, when a number of large studies showed it to b

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opening; induction of labor; use of Pitocin; failure to progress; forceps/vacuum, and epidurals (Rinehart, 2001, 20). Rates are higher if the TOL is less than 18 months after the C-section. Home VBAC does not produce any iatrogenic risks. The American College of Obstetricians and Gynecologists (ACOG) Clinical Management Guidelines do not acknowledge most of the risks listed above, though several studies have shown them to be statistically significant. The routine use of Pitocin decreases the chances of success with both VBAC and VBA2+C (Kmom, 2001). Adding it after labor has already begun spontaneously tends to impact VBAC less than when Pitocin is used to induce labor. The possible advantages and disadvantages of Pitocin use should be considered with VBAC because there are instances in which its careful use can be beneficial, but it should not be used routinely or aggressively. A recent study showed that the rupture rate after one previous C-section was 0.4 percent in spontaneously laboring women, 1.0 percent in oxytocin-augmented labors, and 2.3 percent in induced labors (Rinehart, 2001, 20). The risk of uterine rupture after one previous C-section is somewhere between 0.2 percent and 1.5 percent, with the average

Category: Medical - C