NIH Podcast Reports on a Consensus Conference on Vaginal Birth after Cesarean

Traditional Labor is an Option Following a Cesarean Delivery

Although as many as 60 percent of hospitals in some states routinely prohibit vaginal delivery by women who have had a cesarean section, that practice is out of step with current medical research. An independent panel of leading medical, policy, and academic authorities convened by the National Institutes of Health for a consensus conference March 8th through the 10th, 2010, agreed that access to vaginal birth after cesarean (VBAC) should be broadened. "Pinn Point on Women's Health," a series of podcasts produced by the NIH's Office of Research on Women's Health, explores these issues in depth and examines the systemic barriers that need to be overcome to make this delivery option available to more women. Pinn Point's host, Vivian W. Pinn, M.D., director of NIH's Office of Research on Women's Health, was joined by Caroline Signore, M.D., M.P.H., a board certified obstetrician/gynecologist at the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and co-chair of the conference's planning committee. "The panel came out with a bottom-line statement (http://consensus.nih.gov/2010/vbac.htm) saying that a trial of labor after a previous cesarean delivery is a reasonable birth option for many women," Signore said. And while recognizing the complex reasons more women don't get to choose VBAC, Signore said, "Having limitations in childbirth choices because of factors beyond a woman's control and being denied a childbirth option that is medically reasonable is a shame." The 15-member consensus panel deliberated on VBAC rates, factors that influence those rates, and the potential benefits and harms to mother and baby in attempting VBAC. In addition, the panel covered nonmedical issues that play a role in VBAC patterns and the medical decision-making process. The decision to perform a cesarean is balanced carefully between risks of complication to the mother and infant. VBAC can be a desirable option over a repeat cesarean because there is less blood loss, less infection, a much shorter recovery from childbirth, a shorter hospitalization as well as fewer respiratory complications for the baby after birth. Rare, but serious complications can result from attempting VBAC, especially in women whose VBAC attempts are not successful, requiring a repeat, emergency cesarean. Affected women could experience uterine rupture, hemorrhage, hysterectomy, fetal neurologic injury, and possibly the death of the baby. Dr. Signore said uterine rupture happens in less than 1 percent of cases. Hospitals may tend to schedule repeat cesareans because of concerns about liability and adherence to medical society guidelines. Dr. Signore said, "We know that fears of litigation permeate this issue." She reports that many hospitals may more strictly interpret guidelines that recommend they have on hand the resources to perform a cesarean in case something goes wrong. Smaller community hospitals with fewer resources may view this guideline as requiring a "dedicated operating room, a dedicated anesthesiologist, and a dedicated obstetric surgeon in the hospital at all times while a woman is undergoing a trial of labor," a perceived standard that is unattainable by many small hospitals. The panel suggested that the guidelines be revisited so that hospitals could find it easier to increase access to VBAC. In addition, the panel heard testimony on the ethical implications of denying a woman a medically reasonable childbirth option. Ultimately, the panel viewed a shared decision-making model between patients and providers as optimal. "Patients' values and preferences should be respected," said Signore. "What needs to take place is an objective, reasoned discussion of the risks and benefits of both options, taking into account what is most important to the mother and what she wants out of her birth." To hear more of the discussion, listen to the podcast online by visiting http://orwh.od.nih.gov and clicking on “Vaginal Birth after Cesarean” under the Podcast heading. Transcripts are also available. Read more about the consensus conference at http://consensus.nih.gov/2010/vbacstatement.htm#panel. ### The Office of Research on Women's Health (ORWH), Office of the Director, National Institutes of Health (NIH) serves as a focal point for women's health research at the NIH. For more information about NIH’s Office of Research on Women's Health, visit http://orwh.od.nih.gov/. The NICHD sponsors research on development, before and after birth; maternal, child, and family health; reproductive biology and population issues; and medical rehabilitation. For more information, visit the Institute's Web site at http://www.nichd.nih.gov/. The National Institutes of Health (NIH) — The Nation's Medical Research Agency — includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.