New VBAC Study

[CTRedSoxMom]

http://www.medscape.com/viewarticle/703773

Neonatal Outcomes May Be Better With Vaginal Birth After Cesarean Delivery

Laurie Barclay, MD

June 3, 2009 — Neonates born after elective subsequent cesarean delivery have significantly higher rates of respiratory morbidity and neonatal intensive care unit (NICU) admission and longer length of hospital stay vs those with vaginal birth after cesarean (VBAC), according to the results of a retrospective cohort study reported in the June issue of Obstetrics & Gynecology.

"Controversy remains on whether a trial of labor or an elective repeat cesarean delivery is preferable for a woman with a history of cesarean delivery," write Beena D. Kamath, MD, MPH, from the University of Colorado School of Medicine in Denver, and colleagues. "Historically, concerns regarding the increased risk of uterine rupture and perinatal asphyxia in trial of labor after cesarean compared with planned repeat cesarean have swayed obstetricians away from recommending a trial of labor after cesarean delivery; however, the absolute risk of perinatal asphyxia remains small."

The goals of this study were to compare the outcomes of neonates born by elective subsequent cesarean delivery vs VBAC in women with 1 previous cesarean delivery and to compare the cost differences between these procedures. The study cohort consisted of 672 women with 1 previous cesarean delivery and a singleton pregnancy at or after 37 weeks of gestation. Participants were categorized based on their intention to have an elective subsequent cesarean delivery or a VBAC, whether successful or failed. The main endpoints of the study were NICU admission and measures of respiratory morbidity.

Compared with the VBAC group, neonates born by cesarean delivery had higher NICU admission rates (9.3% vs 4.9%; P = .025). Rates of oxygen supplementation were also higher in the subsequent cesarean group for delivery room resuscitation (41.5% vs 23.2%; P < .01) and after NICU admission (5.8% vs 2.4%; P < .028). The rates of delivery room resuscitation with oxygen were lowest in neonates born by VBAC and highest in neonates delivered after failed VBAC.

Although the costs of elective subsequent cesarean delivery were significantly higher vs VBAC, the highest costs for the total birth experience were for failed VBAC, considering both delivery and NICU use.

"In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay," the study authors write.

Limitations of this study include relatively short postpartum follow-up of the mothers to determine the additional costs of postsurgical complications and insufficient data to allow estimation of costs other than those for hospital care.

"Given the increasing rates of primary cesarean delivery and the concomitant decrease in VBACs, once a woman has had a primary cesarean delivery, we must consider the risks that this places on her subsequent deliveries and subsequent neonates," the study authors conclude. "Indeed, this argues for greater selectivity in performing a cesarean delivery in the first place, and certainly a greater need for counseling before a primary elective cesarean delivery. As investigators continue to search for ways to make cesarean delivery safer, we may be better served by exploring other means for reducing overall cesarean delivery rates and recognizing our own preoccupation with the individual that will be our patient, whether it be mother or neonate."

The study authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2009;113:1231-1238.

[mmtosam06]

 great post

[sunilyn]

Great post! I had one c-section and two v-backs! I am so happy they are doing studies on this. 

[CTRedSoxMom]

Thanks! 
Congrats on your VBAC's it is always great to hear about more moms opting for VBAC's!

[ShadowLark]

Not surprising, though.  But do the risks of VBAC go up with more C Sections?  Like say a woman had 3 C Sections (she was REALLY unlucky - the first was placenta previa, the second baby had an emergency and baby number 3 was transverse and wouldn't move).  Fourth baby, mom wants a VBAC (baby is PERFECTLY positioned, mom is totally healthy, and labor starts on it's own and progresses smoothly).  Is it riskier?

Also, do the risks ever lessen (or grow, for that matter) if you had 1 C Section and then your next 4 babies are VBAC?

Just curious!

[ttparks]

YES!  I just VBAC-ed three weeks ago...10 lbs, 7 oz, 23.5 in baby boy!  I feel so wonderful and so glad I didn't have to go through another c-section (though there were those in the medical profession who recommended I did simply because they didn't want to have to stick around for the entire labor).  Anyway, thanks for sharing the info!

[adulation]

i totally agree with the quoted.  wow.   i wish more doctors would be more concerned with their patients' well being than the incovenience of missing a flight or a golf game. 

Quote:

"Indeed, this argues for greater selectivity in performing a cesarean delivery in the first place, and certainly a greater need for counseling before a primary elective cesarean delivery.

[CTRedSoxMom]

Those are all things that need to be discussed with her provider.
With each cesarean her risk for things like hysterectomy, bladder damage, and other complications go up, as well as the risk for uterine rupture.
Depending on the type of cesarean, scarred tissue she has, time between pregnancies, how she heals, and things like that will determine how safe a VBAC is after 3 or 4 cesareans.

I know women who have had safe VBAC's after 5 and 6 cesareans. Also look at Michelle Duggar, she has had 6 cesareans, and many VBAC's.

Every woman is different which is why she should discuss it with her provider.

Quoting ShadowLark:

Not surprising, though.  But do the risks of VBAC go up with more C Sections?  Like say a woman had 3 C Sections (she was REALLY unlucky - the first was placenta previa, the second baby had an emergency and baby number 3 was transverse and wouldn't move).  Fourth baby, mom wants a VBAC (baby is PERFECTLY positioned, mom is totally healthy, and labor starts on it's own and progresses smoothly).  Is it riskier?

Also, do the risks ever lessen (or grow, for that matter) if you had 1 C Section and then your next 4 babies are VBAC?

Just curious!

[StarsChildren]

Great post! Thanks for the information!

[carlye828]

Quoting ttparks:

YES!  I just VBAC-ed three weeks ago...10 lbs, 7 oz, 23.5 in baby boy!  I feel so wonderful and so glad I didn't have to go through another c-section (though there were those in the medical profession who recommended I did simply because they didn't want to have to stick around for the entire labor).  Anyway, thanks for sharing the info!

That is wonderful!  I'm so happy for you!  It's time that we took back our births & told drs where to stick it!  It really doesn't matter what is easier for them!  Congratulations on your beautiful big boy! 

[junebug624]

Very informative post... too bad I'm not a candidate for a vbac, so when the next one comes along I'll grit my teeth and deal, happy for those who can have a vbac though

~June