Friday, 16 May 2014

Research Supports VBA2C

According to Trinity College School of Nursing and Midwifery in Dublin, Ireland, "As the number of caesarean sections (CSs) increase, the risks for women also increase.  A systematic review and meta-analysis of 21 studies (Marshall et al. 2011) showed that the rates of hysterectomy, blood transfusions, adhesions, and surgical injury all increased with an an increasing number of caesarean births.  Thus, a second/third caesarean birth should be avoided by women who have had one/two CSs, if feasible and safe to do so."

In the spirit of promoting safe and positive birth options for mothers who have had prior caesarean(s) and wish to have more children, please find below a preliminary list of links that demonstrate the overall safety and success rates of VBA2C.  I will continue to add to this list over time, so check back for updates.  In the meantime, I hope readers find this information useful and heartening. Bulletins/Committee on Practice Bulletins -- Obstetrics/pb115.pdf?dmc=1&ts=20130415T1216109630 
American College of Obstetricians and Gynecologists (United States of America) Guidelines on VBAC, revised in 2010:
"Given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC, and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC."
The clinical practice guidelines for birth after previous caesarean birth, published by the Royal College of Obstetricians and Gynaecologists in the United Kingdom.  It states, "Women with a prior history of two uncomplicated low transverse caesarean sections, in an otherwise uncomplicated pregnancy at term, with no contraindication for vaginal birth, who have been fully informed by a consultant obstetrician, may be considered suitable for planned VBAC."
A publication from The Royal College of Obstetricians and Gynaecologists in the United Kingdom entitled, "Birth After Previous Caesarean: Information for You."  They claim, "Overall, about three out of four women (75%) with a straightforward pregnancy who go into labour give birth vaginally following one caesarean delivery . . . Most women with two previous caesarean deliveries will have their next baby by caesarean delivery.  However, should you go into labour your chance of a successful vaginal birth is slightly less than this (between 70% and 75%)."
"Delivery After Previous Caesarean Section Clinical Practice Guideline" from the Health Service Executive in the Republic of Ireland.  This document states, "In individual circumstances where a woman strongly desires a trial of labour after two previous CS, it may be considered.  If the head is engaged, if the cervix is favourable, if there is a history of a prior vaginal delivery and if labour starts spontaneously the risk of a successful VBAC may be high and the risk of UR may be low. However, the risks and benefits of a TOLAC in such cases should be documented antenatally in the notes. There is also a case for not using oxytocic agents either to induce or augment labour in such circumstances (Turner, 2002)."
A blogger references scientific research studies related to VBAMC in light of ACOG's revised guidelines.  A frank assessment of the culture of fear surrounding birth in our society.
A small study that shows a 75% VBA2C rate.  This was the same success rate as VBA1C but with increased morbidity.
A small study that demonstrated a 65% VBA2C success rate.
A small study showing an 89% VBA2C success rate.
A small study which showed no difference between VBA1C and VBA2C success rates, although rates of morbidity were increased for the VBA2C group.
A small study showing a 32% success rate in VBAC after 2 caesarean sections;jsessionid=DFE2CED959EF1294D077BCA8AD045250.f01t04?v=1&t=hvbzdwyd&s=85e75e2ce0081634cdee7bd686c2ea6a3f96a44d
This is a meta-analysis of many different studies, comparing success rates and maternal morbidity rates among VBA1C, VBA2C and RCS.  It notes a VBA2C success rate of 71.1% and a UR rate for attempted VBA2C as 1.36%.  What the authors fail to highlight either in the abstract or in the recommendations is that in the majority of the studies used, induction and augmentation of labour (e.g. oxytocin, syntocinon, prostaglandin gel) were used liberally by obstetricians, and epidurals were also used on many of the mothers involved.  Induction and augmentation of labour are known to be associated with comparatively higher rates of uterine rupture, and the use of epidurals is associated with higher rates of caesarean section even in unscarred moms.  Therefore, it is distinctly possible that the success rate is lower and the UR rate higher than one would find in a population of spontaneously labouring women who had no augmentation or epidural.
A story about an inspirational obstetrician in Northern Ireland who actively supports a mother's right to choose vaginal birth when it is safe and reasonable to do so.  In the 2010 article, Dr. McCabe says that she has facilitated 32 women in achieving vaginal births after 2 surgical births.

In addition to the above mentioned studies and articles, I HIGHLY recommend Jennifer Kamel's website  The website includes an extensive bibliography, which is an invaluable and fascinating resource.  One can also purchase the VBAC Facts Webinar and attend a virtual online course that provides an overview of available research relevant to VBAC candidates and their families.  Well worth the cost to inform your decision to plan either a VBAC or a repeat CS, depending on your unique circumstances.

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