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Ellen Mozurkewich, M.S., M.D.
Department of Obstetrics and Gynecology,
Division of Maternal-Fetal Medicine, University of Michigan
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YES
Nearly three-quarters of women who undergo a trial of labor after a c-section have a successful vaginal birth, according to our review of 15 studies, which included 28,813 women who tried a vaginal birth after cesarean delivery (VBAC).
Critics claim maternal morbidity is higher with a trial of labor than with elective repeat c-section. But, in fact, our review found that a trial of labor was safer for the mother. Women who planned to have vaginal birth had fewer hemorrhages, hysterectomies, and postpartum fevers (which often signify uterine infection) than those who had elective c-sections. Even after factoring in those women who try but don’t achieve vaginal birth, the overall risk to the mother is less from trial of labor than repeat c-section.
More women are choosing elective repeat c-sections because obstetricians fear litigation if uterine rupture kills or harms the baby. But in the 15 studies we looked at, the risk of rupture was only four in 1,000. We calculated that 374 to 809 women would need to have elective repeat c-sections to prevent one uterine rupture.
Looking at the risk of perinatal death, we could attribute two deaths per thousand to having a trial of labor, and one per thousand from elective repeat. The number of elective c-sections that would have to be performed to avoid the death of one baby is between 693 and 3,332 (95% CI).
A rare complication, placenta accreta, has become far more common because we’re doing so many c-sections.
Other advantages of vaginal delivery include a much shorter recovery period, typically one to two days in hospital, vs. two to four, resulting in lower hospital costs.
To be sure, c-sections are very safe. But so are VBACs.
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Jeff Phelan, M.D., J.D.
President and Director, Childbirth Injury Foundation,
Pasadena, Calif. |
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NO
VBACs carry a 1% risk of uterine rupture. In these cases hysterectomy may be necessary to save the mother’s life. This banishes fertility and can interfere with sexuality. In rare instances, the bladder may tear as well.
For the baby, sequelae can include brain damage and death. The risk rises dramatically when baby and/or placenta are expelled into the abdomen, a frequent occurrence. Half of all ruptures (one in 200 VBACs) occur without warning, and there is no way to predict which women are at risk.
For these reasons, some believe that a doctor must be present within a hospital when a mother undergoes VBAC. But maintaining readiness among OR personnel—who twiddle their thumbs while waiting for an uncommon emergency—may be too costly to justify continued use of VBAC in nontertiary-care hospitals.
The legal ramifications are also daunting. If a child is brain damaged, or dies, a lawsuit will follow. If you lose or settle, you will be reported to the National Practitioner Databank. With enough reports, you’ll be investigated for possible license revocation by the Board of Medicine.
You will also be reviewed independently by the managed-care entity to see if they want to continue to have you as a provider. If you are removed, you will be reported to the Databank and you must list the revocation on your site.
The safety net is written informed consent of the mother contemplating VBAC, during prenatal care, and again upon arrival in labor and delivery. With proper consent a woman ought to be able to undergo a VBAC. But with a big caveat emptor.
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