VBAC in the journals: the good, the bad and the ugly

Over the past couple of days, some interesting press has me thinking. For instance, the lastest Annals of Family Medicine includes a study showing Reducing post-cesarean vaginal births has no effect on mortality:

Although attempted VBAC deliveries fell significantly after the guideline revision, from 24.0 percent beforehand to just 13.5 percent afterwards, neonatal mortality rates per 1000 live births were no different for attempted VBAC deliveries from those for repeat cesarean among neonates weighing at least 1500 g during either of the two study periods.

Neonatal mortality rates for attempted VBAC among neonates weighing less than 1500 g were higher than those for repeat cesarean deliveries. Their conclusion, "We recommend that a balanced presentation of risks and the encouraging outcomes found in this analysis be included in discussions with pregnant patients who have had a previous cesarean section." Excellent advice. Too bad fear of malpractice in the face of ACOG's VBAC guidelines will skew any "discussion" physicians have with expectant mothers so badly that the truth will rarely be seen.

Meanwhile, over at Obstetrics & Gynecology, their latest journal includes Dr. James Scott editorial, Cesarean Delivery on Request: Where Do We Go From Here? in which he concludes with the advice, "Go slow on this for now, be cautious, don’t get caught up in the rhetoric, and individualize until better evidence is available and the ultimate consequences are well known. To do otherwise just might come back to haunt us." (Obstet Gynecol 2006;107:1222-3) To be honest, ACOG has made a lot of decisions that should be haunting them based solely on bettering their members malpractice insurance rates and wallets with complete disregard for maternal-child health or evidence-based practice. But I digress...

O&G also has a brand new study, Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries which is something anyone knows who works at all with caesarean/vbac mothers, I mean it's simple common sense. Their conclusion, "Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery." (Obstet Gynecol 2006;107:1226–32)

Last but not least, they have the National Institutes of Health State-of-the-Science Conference Statement: Cesarean Delivery on Maternal Request from March 27–29, 2006 outcomes. Their conclusion, "The magnitude of cesarean delivery on maternal request is difficult to quantify. There is insufficient evidence to evaluate fully the benefits and risks of cesarean delivery on maternal request compared with planned vaginal delivery. Any decision to perform a cesarean delivery on maternal request should be carefully individualized and consistent with ethical principles." (Obstet Gynecol 2006;107:1386–97)

Hmm. So ACOG's "decision" to essentially eliminate VBAC Trial of Labour as a viable choice for women in the US is coming back to haunt them. Despite the carefully worded conclusions above, it is becoming more and more obvious to even the ones who have turned a blind eye to the risks of major abdominal surgery for deliveries. The well-touted risk VBAC has of uterine rupture is pailing strongly in the blinding glare of surgical risks with many of them long-term risks in future pregnancies.