I know this will not be a popular article with most Obs in the US.



http://www.rcog.org.uk/news/bjog-release-do-we-need-revisit-vbac-gu...

New research to be published in BJOG: An International Journal of
Obstetrics and Gynaecology has found that women with three or more prior
caesareans who attempt vaginal birth have similar rates of success and
risk for maternal morbidity as those with one prior caesarean, and
similar overall morbidity (adding vaginal births and emergency
caesareans together) as those delivered by elective repeat caesarean.

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 authors suggest that, given the findings, precluding VBAC for all women with three or more prior
caesareans may not be evidence based. Although there is a measurable
maternal morbidity associated with delivery for a woman with a history
of three or more prior caesareans, it does not differ significantly by
mode of delivery. Risks associated with multiple caesareans are several,
including surgical morbidity and abnormal placentation in future
pregnancies.

Lead author, Dr. Alison Cahill, from the Department of Obstetrics and Gynaecology at Washington University in St. Louis
School of Medicine, said “These data suggest that women with three or
more prior caesareans who attempt VBAC have similar rates of success and
risk for maternal morbidity as those with one or two prior caesareans,
and along with other publications, suggest that perhaps it is time to
revisit the current recommendations for VBAC attempts for women with
more than one prior caesarean”.

“Many have proposed a ‘conservative’ approach to VBAC attempts, which we agree is prudent. But
our evidence does not suggest that a conservative approach, which we
interpret as one that aims to reduce morbidity - and specifically the
risk of uterine rupture - is necessarily achieved by allowing VBAC
attempts only in women with one prior caesarean. Given appropriate
patient selection, VBAC following two or even three previous caesareans
in certain cases may be reasonably safe.”

Prof. Philip Steer, BJOG editor-in-chief, said “Although confidence in the findings of the
study is limited by the relatively small sample size of women who have
had three previous caesareans, these findings provide additional
information for women, and contribute to the available evidence on VBAC
success and safety in women with more than one prior caesarean.

“As childbirth does not always ‘follow the plan’, the results may also
serve as a useful reference for clinicians when a women with three or
more prior caesareans presents in spontaneous labour.”

Tracy

http://www.GentleBirthUSA.com

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