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| |  Panel Questions "VBAC Bans," Advocates Expanded Delivery Options for Women BETHESDA, Md -- March 10, 2010 -- An independent panel convened this week by the National Institutes of Health, Bethesda, Maryland, confronted a troubling fact that pregnant women currently have limited access to clinicians and facilities able and willing to offer a trial of labour after previous cesarean delivery because of so-called vaginal birth after cesarean section (VBAC) bans. Many, even those at low risk for complications in a trial of labour, are not offered this option. The panel affirmed that a trial of labour is a reasonable option for many women with a prior cesarean delivery. They also urged that current VBAC guidelines be revisited, malpractice concerns be addressed, and additional research undertaken to better understand the medical and non-medical factors that influence decision making for women with previous cesarean deliveries. “Declining VBAC rates and increasing cesarean delivery rates over the last 15 years would seem to indicate that planned repeat cesarean delivery is preferable to a trial of labour,” said panel chair F. Gary Cunningham, MD, University of Texas Southwestern Medical Center, Dallas, Texas. “But the currently available evidence suggests a very different picture: a trial of labour is worth considering and may be preferable for many women.” Rigorous research shows that a trial of labour is successful in nearly 75% of cases, and maternal mortality is actually lower for women who have a trial of labour, regardless of whether they end up delivering vaginally or by cesarean, though those women who have an unsuccessful trial of labour and undergo a repeat cesarean delivery experience higher morbidity than those who have a successful VBAC. In light of their assessment of VBAC’s relative safety, the panel urged professional societies to revisit existing VBAC guidelines, in particular, the recommendation for “immediate availability” of surgical and anaesthesia personnel as prerequisites for offering a trial of labour, as recent surveys of hospital administrators found that 30% of hospitals had stopped offering trial of labour or providing VBAC services because they could not meet this standard, creating a serious barrier to that option. The panel thus advocated for additional research to develop clear, evidence-based risk assessment tools to assist mothers and providers in the decision-making process from early pregnancy through delivery, accounting for individual risk factors, values, and preferences. The panel also expressed concern that medico-legal considerations exacerbate other barriers to trial of labour for women with a previous cesarean delivery. They strongly recommended that policymakers and providers collaborate in the development and implementation of appropriate strategies to address malpractice concerns and mitigate this problem. “There’s still a lot we don’t know about which women will be successful in having a VBAC, but we believe it’s essential that women’s desires and preferences be respected throughout the decision making process,” said Dr. Cunningham. Safety is the chief concern for women and their providers in deciding whether to attempt a trial of labour or plan a repeat cesarean delivery. Each option carries important benefits and risks for both mother and baby. This poses a profound dilemma because benefits for the woman may come at the price of increased risks for the baby, and vice versa. For example, hysterectomy rates were comparable across both modes of delivery, but uterine rupture was higher in women who have a trial of labour. Conversely, women who had a VBAC had reduced abnormalities of placental growth and position in subsequent pregnancies. Unfortunately, the lack of high-quality evidence about many medical and non-medical factors prevents precise risk calculations that could inform the decision-making process. Factors contributing to some women’s desire to attempt a trial of labour include desire for their partner’s involvement in the delivery, belief that labour and vaginal delivery can be deeply empowering, enhanced opportunity for maternal-infant bonding, greater ease in establishing breast feeding, and easier recovery. Conversely, scheduling convenience, the desire to avoid labour pain, fear of failed trial of labour, avoidance of possible emergency cesarean section, and desire for surgical sterilisation at the time of delivery may all contribute to a preference for planned cesarean delivery. SOURCE: National Institutes of Health
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