Vaginal Birth After Cesarean

 

A woman who has had a cesarean delivery with a previous birth has a choice to make for subsequent deliveries: she might choose a repeat cesarean, or she might choose to plan for a VBAC, vaginal birth after cesarean.

For many years, the American College of Obstetricians and Gynecologists (ACOG) actively supported VBAC, and physicans were strongly encouraged to counsel and encourage women to plan a trial of labor, rather than schedule a surgery. See ACOG’s 1995 guidelines.

In 1999, the guidelines changed. (For a criticism of ACOG’s stance, see Marsden Wagner’s article). They recommended that for VBAC births, a physician must be “immediately available throughout active labor capable of monitoring labor and performing an emergency cesarean delivery,” and there must be “Availability of anesthesia and personnel for emergency cesarean delivery.” The cost and inconvenience of these recommendations led some hospital caregivers to begin re-examining their VBAC protocols. (It is likely that practice recommendations are also influenced by lawsuits and by pressure from insurance companies to minimize potential lawsuits. Here is a comment on VBAC’s from one insurance company.)

Then, in July of 2001, the New England Journal of Medicine published a study (Lydon-Rochelle et al) and an accompanying editorial by Michael Greene focused on the potential risk of uterine rupture with VBAC, or especially with an induced VBAC labor. (For criticism of these articles, and of the media coverage of them, see “Is Vaginal Birth After Cesarean Risky”)

With all of these influences, some hospitals and some caregivers are changing their care recommendations for women with prior cesarean. Some are choosing to no longer offer the option of VBAC to their patients.  (To learn whether your local hospital has banned VBAC, check this list: www.ican-online.org/vbac-ban-info)

Many birth professionals have questioned the ACOG guidelines, questioned the study, and questioned care providers who withhold the option of vaginal birth for women after cesarean. They argue that VBAC is still the safest option for women with a prior cesarean. There are also several excellent articles about VBAC on Mothering magazine’s website, and on www.ican-online.org

In 2005, the American Academy of Family Physicians revised its VBAC guidelines. They now encourage women to consider labor after a prior cesarean and encourage maternity care providers to support this option. The AAFP found no surgical evidence that having a surgical team and anesthesia “immediately available” significantly improved outcomes. The complete guidelines are here. They also have a worksheet you can take to your care provider to help determine if VBAC is a good option for you.

There are several other great resources about VBAC on the ICAN website.

Lots more about VBAC here: http://vbacfacts.com/vbac/

 

Support for VBAC by Seattle area providers

Data from the 2007 survey of local birthplaces and maternity services conducted by Great Starts / Parent Trust for Washington Children

 

The numbers here tell you

1. What percentage of moms with a prior cesarean attempt VBAC (generally a high number here may indicate that the service actively encourages VBAC rather than merely allowing it if the mom asks)

2. What percentage of moms attempting VBAC have a vaginal birth (again, a higher number may indicate that this service has a high degree of success in supporting moms with VBAC goal)

If the number has a ~ in front of it, it is an approximate number, if it doesn't, then it's based on records. (If they keep records on VBAC, they may be more committed to VBAC success)

Beyond asking whether hospitals allow VBAC, we also asked if they “actively encourage or promote VBAC for appropriate candidates”. We have starred the services that said yes to this.

 

Auburn ~6% / ~95%

Enumclaw 55% / 68%  *

Evergreen Hospital: ~5%/~50%

Group Health 44% / 76%  *

Highline ~10% / 70%

Northwest did not complete our survey

Overlake says "few doctors allow it"

St. Francis - not allowed

Stevens 1% / 1%

Swedish Ballard - not allowed

Swedish First Hill say ~5% attempt

UWMC ~50% / 50%  *

Valley Medical did not answer the question

 

Research has indicated that the highest rate of VBAC success is typically higher with a nurse-midwife as a primary care provider. So, here are the statistics on nurse-midwife practices:

 

Cynthia Brown (delivers at Group Health Central) ~90% / ~50%  *

Center for Women's Health (deliver at Evergreen) ~90% / ~90%  *

Group Health Central midwives ~70% / 90%  *

Group Health Eastside midwives (deliver at Overlake) ~33% / ~33%  *

Midwives at Valley 0%

Nadeshiko Clinic (Japanese speaking - deliver at Evergreen) ~50% / ~80%  *

PSNHC (Puget Sound Neighborhood Health - deliver at Group Health Central) 84% / 70% **

Swedish Midwives at Ballard - 0%

University Midwives (UWMC) - 95% / 78%  *

Sally Avenson also accepts VBAC clients for deliveries at Group Health, but we don’t have her stats

 

Home birth midwives who say that they accept VBAC clients:

Exodus Midwifery, Moonrise Health & Birth, Rainy City Midwifery, Seattle Home Maternity

 

Here are doctors that are rumored to be supportive of VBAC. I have not verified this with any of them. You should check with them directly to find out more about their stance.

 Beth Skrypzak, MD. Evergreen. Center for Women's Health at Evergreen  www.womenshealthcare.org 425-899-4455 Kirkland

Cynthia White, MD Swedish Ballard. North Seattle Women's Specialist 206-782-9335 Seattle

Debra Stemmerman, MD Evergreen Hospital. Evergreen Women's Care 425-899-6400 Kirkland

Elizabeth Sanford, MD St. Joes, Tacoma General. Pearl Place Women's Care www.obgyntacoma.com/ 253-761-2244 Tacoma

Gary Rogers, MD; Steven Woods, MD; Richard Graham, MD OverlakeGraham, Rodgers, Woods OBGYN 425-454-5758 Bellevue

James Haines, MD Overlake. Overlake OBGYN 425-454-3366 Bellevue

Maura Cardwell, MD Evergreen. Evergreen Women's Health Center 425-285-0060 Kirkland

Patricia Schuster, MD. Highline Medical Center Tukwila Women's Center 206-242-0680 Tukwila

Peter Brandon MD Swedish Ballard North Seattle Women's Specialists(206) 782-9335  Seattle

Peter Wall MD Evergreen & Overlake. Eastside Maternal Fetal Medicine www.eastsidemfm.com 425-899-2200  Kirkland & Bellevue

Richard Agress, MD Swedish First Hill The Polyclinic 206-860-4541 Seattle

Robin H. De Regt, MD Evergreen Maternal-Fetal Med. Program 425-899- 2200 Kirkland

Roque Lanza, MD Auburn Multicare Valley Women's Health Care  (253) 939-9654  Auburn

Stephen Hyde, MD Evergreen. Evergreen OB/GYN 425-899-4000 Kirkland

Tamara Sleeter, MD OBGYN Valley Medical Center. Valley Women's Health, 425-228-0722 Renton

 

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