There have been a number of media reports following the latest statement on cesarean delivery from the National Institutes of Health, and I have been concerned by the number of headlines that imply that the NIH has said "VBAC is safe". Now, while I am completely in support of low risk women making an informed decision to have a VBAC birth, and sympathize with those who have been refused their birth choice in some hospitals, it is dangerous to start describing a VBAC as 'safe'. There are indisputable risks involved, as there are with a repeat cesarean, and it's a case of choosing which set of risks and benefits (as they apply to your particular medical history) you are most comfortable with.
Therefore, I think it's useful to present the NIH's actual summary here (known as an 'Abstract') for women to read for themselves, and if you are considering a VBAC, I would suggest you read the whole statement in full as part of your birth research. Through my work, I am rarely contacted by women who are trying to plan a VBAC; on the contrary, I hear mainly from women who are trying to plan a cesarean for their first birth. And of course personally, I didn't choose a vaginal birth first time round, much less consider having one after a cesarean. But that was my personal decision, and I think it's important that every woman's personal decision is respected. Respected and informed.
Vaginal Birth After Cesarean: New Insights
Objective: To provide health care providers, patients, and the general public with a responsible assessment of currently available data on vaginal birth after cesarean (VBAC).
Participants: A non-DHHS, nonadvocate 15-member panel representing the fields of TEXT, and a public representative. In addition, 21 experts from pertinent fields presented data to the panel and conference audience.
Evidence: Presentations by experts and a systematic review of the literature prepared by the Oregon Evidence-based Practice Center, through the Agency for Healthcare Research and Quality. Scientific evidence was given precedence over anecdotal experience.
Conference Process: The panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at http://consensus.nih.gov. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.
Conclusions: Given the available evidence, TOL is a reasonable option for many pregnant women with a prior low transverse uterine incision. The data reviewed in this report show that both TOL and ERCD for a pregnant woman with a prior transverse uterine incision have important risks and benefits and that these risks and benefits differ for the woman and her fetus. This poses a profound ethical dilemma for the woman as well as her caregivers, because benefit for the woman may come at the price of increased risk for the fetus and vice versa. This conundrum is worsened by the general paucity of high-level evidence about both medical and nonmedical factors, which prevents the precise quantification of risks and benefits that might help to make an informed decision about TOL versus ERCD. We are mindful of these clinical and ethical uncertainties in making the following conclusions and recommendations.
One of our major goals is to support pregnant women with a prior transverse uterine incision to make informed decisions about TOL versus ERCD. We urge clinicians and other maternity care providers to use the responses to the six questions, especially questions 3 and 4, to incorporate an evidence-based approach into the decisionmaking process. Information, including risk assessment, should be shared with the woman at a level and pace that she can understand. When both TOL and ERCD are medically equivalent options, a shared decisionmaking process should be adopted and, whenever possible, the woman’s preference should be honored.
We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL. Given the level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement relative to other obstetrical complications of comparable risk, risk stratification, and in light of limited physician and nursing resources. Healthcare organizations, physicians, and other clinicians should consider making public their TOL policy and VBAC rates, as well as their plans for responding to obstetric emergencies. We recommend that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to TOL.
We are concerned that medico-legal considerations add to, as well as exacerbate, these barriers. Policymakers, providers, and other stakeholders must collaborate in the development and implementation of appropriate strategies to mitigate the chilling effect of the medico-legal environment on access to care.
High-quality research is needed in many areas. We have identified areas that need attention in response to question 6. Research in these areas should be prioritized and appropriately funded, especially to characterize more precisely the short-term and long-term maternal, fetal, and neonatal outcomes of TOL and ERCD.