Placental Complications Increase With Prior Cesarean

April was Cesarean Awareness Month.  It was sponsored by The International Cesarean Awareness Network (ICAN), which seeks to help support women after cesareans, to raise awareness of the implications of a high cesarean rate, and to keep Vaginal Birth After Cesarean (VBAC) an accessible choice for women.

As a follow-up to Cesarean Awareness Month, let's discuss some of the possible complications of too many cesareans.

The importance of this discussion is highlighted this week by the recent tragic story of a woman who died from complications of Placenta Accreta during her sixth cesarean.

The fact is that each successive cesarean increases the risk for abnormal implantation of the placenta in future pregnancies, and this can be life-threatening to both mother and baby.

This is not to imply that all cesareans are bad; many are truly life-saving and necessary, and many others are probably prudent.  However, many non-indicated cesareans are being done these days. Cesareans are not without risks and this mother's death shows why they should not be done without good reason, especially multiple repeat cesareans.

The extremely high cesarean rates and lack of VBAC access in certain areas of this country and around the world has very distinct public health implications that should not be ignored.

One of those public health implications is the rising incidence of placenta previa and placenta accreta.  As one study summarized:

Placenta accreta is recognized as a catastrophic disease in obstetrics. Diagnosed incidentally, it has been a rare disease in previous decades prior [to] indiscriminate use of cesarean delivery. The World Health Organization has recently highlighted this disease as a new pandemic, which is directly related to patients who have two or more caesarean sections.

Abnormal Placentation

One of the most significant risks after having had a cesarean section is abnormal placental implantation in a future pregnancy.  There are several different types of these, which include:

• Placenta Previa (the placenta implants too low, near or over the cervix)
• Placenta Accreta (the placenta attaches abnormally and has difficulty detaching later)
• Placenta Increta (the placenta grows into the uterine muscle and has difficulty detaching)
• Placenta Percreta (the placenta grows through the uterus and into surrounding organs)

In addition, there is an increased risk of the placenta pulling away from the uterine wall prematurely (called placental abruption).  This, too, can be a serious complication.

Today we'll discuss overall increases in placental complications after prior cesareans; in later posts, we'll discuss each placental complication in more detail.

The big question is why a subsequent pregnancy after cesarean is at risk for placental issues.  Although the exact mechanism is not clear, most authorities agree that the damage to the lining of the uterus from a cesarean may predispose to placental implantation and/or detachment issues, especially if the fertilized egg implants near the scarred area.

Of course, it's not just cesareans; any damage to the lining of the uterus can predispose to placental issues.  A D&C procedure, whether after a miscarriage or to terminate a pregnancy, can cause problems with the uterine lining.  On the other hand, research differs on whether myomectomy (fibroid removal) does or does not have an association with placental issues.

Even such minor factors as uterine infection, smoking, drug or alcohol use, older age, or many pregnancies can predispose to placental implantation issues.  The theory is that they also damage the uterine lining, causing problems when the next pregnancy implants.

However, it's clear from research that one of the most powerful risk factors for placental issues is a prior cesarean, and that the risk increases as the number of prior cesareans increases.  This means that this condition is often iatrogenic (caused by the physician) and is a preventable risk in many cases.

Increase in Placental Complications

Research shows that the incidence of placental complications has risen in parallel with the burgeoning cesarean rate.

For example, one recent study on placenta accreta shows that

The incidence of placenta accreta has increased 13-fold since the early 1900s and directly correlates with the increasing cesarean delivery rate.

Another study that did a meta-analysis of the impact of multiple repeat cesareans found:

The incidence of placenta previa increased from 10/1000 deliveries with 1 previous cesarean delivery to 28/1000 with ≥3 cesarean deliveries. 

Now, keep in mind that most women with three or more cesareans still don't experience a previa. However, to increase from an incidence of 1% to 2.8% is a serious increase, given the risks associated with previas.

The authors of that meta-analysis also pointed out that women with previa who have had prior cesareans are at far greater risk for the very serious condition of Placenta Accreta than women with previa who have not had prior cesareans.

Compared with women with previa and no previous cesarean delivery, women with previa and ≥3 cesarean deliveries had a statistically significant increased risk of accreta (3.3-4% vs 50-67%), hysterectomy (0.7-4% vs 50-67%), and composite maternal morbidity (15% vs 83%; odds ratio, 33.6; 95% confidence interval, 14.6-77.4). 

In other words, the risk for having both previa and accreta jumped from 3-4% to 50-70% if you had three or more prior cesareans.  Clearly, multiple cesareans strongly increase the risk for placental issues in future pregnancies.

Many of these studies use risk ratios to compare the risk. This is useful in some ways, but mothers deserve to know what the exact numerical risk is for these conditions.  A 2006 large study was able to quantify this for women. In their study, they found that accreta was present in:

• 0.24% of women undergoing their first cesarean
• 0.31% of women having their second cesarean
• 0.57% of women having their third cesarean
• 2.13% of women having their fourth cesarean
• 2.33% of women having their fifth cesarean
• 6.74% of women having their sixth or more cesarean

In addition, they found that a hysterectomy was required in:

• 0.65% of  women having their first cesarean 
• 0.42% of women having their second cesarean 
• 0.90% of women having their third cesarean
• 2.41% of women having their fourth cesarean 
• 3.49% of women having their fifth cesarean
• 8.99% of women having their sixth or more cesarean

Obviously, the more cesareans you have, the more at-risk you are for complications. Complications like previa and accreta really start to rise after 3-4 or more cesareans.

However, sometimes these complications happen when a woman has "only" had one or two prior cesareans.  One study found that having a cesarean for the first birth raised the risk for placental abruption in the second pregnancy by 40% and for placenta previa by 47%.  So although the risks are greatest with 3 or more cesareans, poor outcomes can happen even after only one or two cesareans.  That's why it's important to prevent every cesarean that is not truly medically-indicated.

Even more important is to prevent the automatic repeat cesarean that happens to most women in this country (and in many countries around the world).  In many areas now, once a woman has a cesarean, she is not "allowed" to choose (or is pressured out of) having a subsequent vaginal birth.  And this is what leads to many cases of placental complications.

Most women will not experience severe complications despite undergoing multiple cesareans, but some WILL ─ like the woman who died recently while having her sixth cesarean. Now her children have to grow up without their mother.

This is why it is so important to prevent that first cesarean whenever possible, and why it is absolutely critical for women to have access to VBAC instead of being forced into cesarean after cesarean.



References

Increase in Incidence of Abnormal Placentation

Obstet Gynecol Clin North Am. 2013 Mar;40(1):137-54. doi: 10.1016/j.ogc.2012.12.002. Placenta accreta, increta, and percreta. Wortman AC, Alexander JM.  PMID: 23466142

Placenta accreta is an abnormal adherence of the placenta to the uterine wall that can lead to significant maternal morbidity and mortality. The incidence of placenta accreta has increased 13-fold since the early 1900s and directly correlates with the increasing cesarean delivery rate. The prenatal diagnosis of placenta accreta by ultrasound along with risk factors including placenta previa and prior cesarean delivery can aid in delivery planning and improved outcomes. Referral to a tertiary care center and the use of a multidisciplinary care team is recommended.

Risk Factors for Abnormal Placentation

Am J Obstet Gynecol. 2005 May;192(5):1458-61. Abnormal placentation: twenty-year analysis. Wu S, Kocherginsky M, Hibbard JU.  PMID: 15902137

OBJECTIVE: This study was undertaken to determine whether the rate of abnormal placentation is increasing in conjunction with the cesarean rate and to evaluate incidence, risk factors, and outcomes...RESULTS: There were 64,359 deliveries, with cesarean rates increasing from 12.5% (1982) to 23.5% (2002). The overall incidence of placenta accreta was 1 in 533. Significant risk factors for placenta accreta in our final analysis included advancing maternal age (odds ratio [OR] 1.13, 95% CI 1.089-1.194, P < .0001), 2 or more cesarean deliveries (OR 8.6, 95% CI 3.536-21.078, P < .0001), and previa (OR 51.4, 95% CI: 10.646-248.390, P < .0001). CONCLUSION: The rate of placenta accreta increased in conjunction with cesarean deliveries; the most important risk factors were previous cesarean delivery, previa, and advanced maternal age.

PLoS One. 2012;7(12):e52893. doi: 10.1371/journal.pone.0052893. Epub 2012 Dec 27. Incidence and risk factors for placenta accreta/increta/percreta in the UK: a national case-control study. Fitzpatrick KE, Sellers S, Spark P, Kurinczuk JJ, Brocklehurst P, Knight M. PMID: 23300807

...METHODS: A national case-control study using the UK Obstetric Surveillance System was undertaken, including 134 women diagnosed with placenta accreta/increta/percreta between May 2010 and April 2011 and 256 control women. RESULTS: The estimated incidence of placenta accreta/increta/percreta was 1.7 per 10,000 maternities overall; 577 per 10,000 in women with both a previous caesarean delivery and placenta praevia. Women who had a previous caesarean delivery (adjusted odds ratio (aOR) 14.41, 95%CI 5.63-36.85), other previous uterine surgery (aOR 3.40, 95%CI 1.30-8.91), an IVF pregnancy (aOR 32.13, 95%CI 2.03-509.23) and placenta praevia diagnosed antepartum (aOR 65.02, 95%CI 16.58-254.96) had raised odds of having placenta accreta/increta/percreta. There was also a raised odds of placenta accreta/increta/percreta associated with older maternal age in women without a previous caesarean delivery (aOR 1.30, 95%CI 1.13-1.50 for every one year increase in age). CONCLUSIONS: Women with both a prior caesarean delivery and placenta praevia have a high incidence of placenta accreta/increta/percreta. There is a need to maintain a high index of suspicion of abnormal placental invasion in such women and preparations for delivery should be made accordingly.

Acta Obstet Gynecol Scand. 2013 Apr;92(4):457-60. doi: 10.1111/aogs.12080. Placenta accreta: incidence and risk factors in an area with a particularly high rate of cesarean section. Morlando M, Sarno L, Napolitano R, Capone A, Tessitore G, Maruotti GM, Martinelli P. PMID: 23347183

Placenta accreta is a rare and potentially life-threatening complication of pregnancy characterized by abnormal adherence of the placenta to the uterine wall. A previously scarred uterus or an abnormal site of placentation in the lower segment is a major risk factor. The aim of this study was to investigate the change in the incidence of placenta accreta and associated risk factors along four decades, from the 1970s to 2000s, in a tertiary south Italian center. We analyzed all cases of placenta accreta in a sample triennium for each decade. The incidence increased from 0.12% during the 1970s, to 0.31% during the 2000s. During the same period, cesarean section rates increased from 17 to 64%. Prior cesarean section was the only risk factor showing a significant concomitant rise. Our results reinforce cesarean section as the most significant predisposing condition for placenta accreta.

Placenta. 2012 Apr;33(4):244-51. doi: 10.1016/j.placenta.2011.11.010. Epub 2012 Jan 28. Placenta accreta: pathogenesis of a 20th century iatrogenic uterine disease. Jauniaux E, Jurkovic D. PMID: 22284667

Placenta accreta refers to different grades of abnormal placental attachment to the uterine wall, which are characterised by invasion of trophoblast into the myometrium. Placenta accreta has only been described and studied by pathologists for less than a century. The fact that the first detailed description of a placenta accreta happened within a couple of decades of major changes in the caesarean surgical techniques is highly suggestive of a direct relationship between prior uterine surgery and abnormal placenta adherence. Several concepts have been proposed to explain the abnormal placentation in placenta accreta including a primary defect of the trophoblast function, a secondary basalis defect due to a failure of normal decidualization and more recently an abnormal vascularisation and tissue oxygenation of the scar area. The vast majority of placenta accreta are found in women presenting with a previous history of caesarean section and a placenta praevia. Recent epidemiological studies have also found that the strongest risk factor for placenta praevia is a prior caesarean section suggesting that a failure of decidualization in the area of a previous uterine scar can have an impact on both implantation and placentation. Ultrasound studies of uterine caesarean section scar have shown that large and deep myometrial defects are often associated with absence of re-epithelialisation of the scar area. These findings support the concept of a primary deciduo-myometrium defect in placenta accreta, exposing the myometrium and its vasculature below the junctional zone to the migrating trophoblast. The loss of this normal plane of cleavage and the excessive vascular remodelling of the radial and arcuate arteries can explain the in-vivo findings and the clinical consequence of placenta accreta. Overall these data support the concept that abnormal decidualization and trophoblastic changes of the placental bed in placenta accreta are secondary to the uterine scar and thus entirely iatrogenic.

Placental Abruption and Prior Cesarean

Am J Perinatol. 2007 May;24(5):299-305. Epub 2007 May 18. Predicting placental abruption and previa in women with a previous cesarean delivery. Odibo AO, Cahill AG, Stamilio DM, Stevens EJ, Peipert JF, Macones GA. PMID: 17514600

The purpose of this study was to determine if placental abruption or previa in women with a history of a prior cesarean delivery (CD) can be predicted. A retrospective cohort study of pregnant women with previous CD was conducted in 17 centers between 1996 and 2000. Women developing placenta previa or abruption in the subsequent pregnancy were compared with those without these complications...Among 25,076 women with prior CD, there were 361 (15 per 1000 births) with placenta previa and 309 (13 per 1000 births) with abruption. The significant risk factors for these complications include advanced maternal age, Asian race, increased parity, illicit drug use, history of spontaneous abortion, and three or more prior cesarean deliveries. Prediction models for abruption and previa had poor sensitivity (12% and 13% for abruption and previa, respectively). In women with at least one prior cesarean delivery, the risk factors for placental previa and abruption can be identified. However, prediction models combining these risk factors were too inefficient to be useful.

Obstet Gynecol. 2006 Apr;107(4):771-8. Previous cesarean delivery and risks of placenta previa and placental abruption. Getahun D, Oyelese Y, Salihu HM, Ananth CV. PMID: 16582111

...METHODS: A retrospective cohort study of first 2 (n = 156,475) and first 3 (n = 31,102) consecutive singleton pregnancies using the 1989-1997 Missouri longitudinally linked data were performed. Relative risk (RR) was used to quantify the associations between cesarean delivery and risks of previa and abruption in subsequent pregnancies, after adjusting for several confounders. RESULTS: Rates of previa and abruption were 4.4 (n = 694) and 7.9 (n = 1,243) per 1,000 births, respectively. The pregnancy after a cesarean delivery was associated with increased risk of previa (0.63%) compared with a vaginal delivery (0.38%, RR 1.5, 95% confidence interval [CI] 1.3-1.8). Cesarean delivery in the first and second births conferred a two-fold increased risk of previa in the third pregnancy (RR 2.0, 95% CI 1.3-3.0) compared with first two vaginal deliveries. Women with a cesarean first birth were more likely to have an abruption in the second pregnancy (0.95%) compared with women who had a vaginal first birth (0.74%, RR 1.3, 95% CI 1.2-1.5). Two consecutive cesarean deliveries were associated with a 30% increased risk of abruption in the third pregnancy (RR 1.3, 95% CI 1.0-1.8). A second pregnancy within a year after a cesarean delivery was associated with increased risks of previa (RR 1.7, 95% CI 0.9-3.1) and abruption (RR 1.5, 95% CI 1.1-2.3). CONCLUSION: A cesarean first birth is associated with increased risks of previa and abruption in the second pregnancy. There is a dose-response pattern in the risk of previa, with increasing number of prior cesarean deliveries. A short interpregnancy interval is associated with increased risks of previa and abruption.

BJOG. 2007 May;114(5):609-13. Epub 2007 Mar 12. Association of caesarean delivery for first birth with placenta praevia and placental abruption in second pregnancy. Yang Q, Wen SW, Oppenheimer L, Chen XK, Black D, Gao J, Walker MC. PMID: 17355267

...SETTING: Linked birth and infant mortality database of the USA between 1995 and 2000. POPULATION: A total of 5,146,742 singleton second pregnancies were available for the final analysis after excluding missing information...RESULTS: Placenta praevia was recorded in 4.4 per 1000 second-birth singletons whose first births delivered by caesarean section and 2.7 per 1000 second-birth singletons whose first births delivered vaginally. About 6.8 per 1000 births were complicated with placental abruption in second-birth singletons whose first births delivered by caesarean section and 4.8 per 1000 birth in second-birth singletons whose first births delivered vaginally. The adjusted odds ratio (95% CIs) of previous caesarean section for placenta praevia in following second pregnancies was 1.47 (1.41, 1.52) after controlling for maternal age, race, education, marital status, maternal drinking and smoking during pregnancy, adequacy of prenatal care, and fetal gender. The corresponding figure for placental abruption was 1.40 (1.36, 1.45). CONCLUSION: Caesarean section for first live birth is associated with a 47% increased risk of placenta praevia and 40% increased risk of placental abruption in second pregnancy with a singleton.

Risks of Multiple Repeat Cesareans

Am J Obstet Gynecol. 2011 Dec;205(6 Suppl):S2-10. doi: 10.1016/j.ajog.2011.09.028. Epub 2011 Oct 6. Long-term maternal morbidity associated with repeat cesarean delivery. Clark EA, Silver RM. PMID: 22114995

Concern regarding the association between cesarean delivery and long-term maternal morbidity is growing as the rate of cesarean delivery continues to increase. Observational evidence suggests that the risk of morbidity increases with increasing number of cesarean deliveries. The dominant maternal risk in subsequent pregnancies is placenta accreta spectrum disorder and its associated complications. A history of multiple cesarean deliveries is the major risk factor for this condition. Pregnancies following cesarean delivery also have increased risk for other types of abnormal placentation, reduced fetal growth, preterm birth, and possibly stillbirth. Chronic maternal morbidities associated with cesarean delivery include pelvic pain and adhesions. Adverse reproductive effects may include decreased fertility and increased risk of spontaneous abortion and ectopic pregnancy. Clinicians and patients need to be aware of the long-term risks associated with cesarean delivery so that they can be considered when determining the method of delivery for first and subsequent births.

 BJOG. 2013 Jan;120(1):85-91. doi: 10.1111/1471-0528.12010. Epub 2012 Oct 24.
Multiple repeat caesarean section in the UK: incidence and consequences to mother and child. A national, prospective, cohort study. Cook JR, Jarvis S, Knight M, Dhanjal MK. PMID: 23095012

...SETTING: All UK hospitals with consultant-led maternity units. POPULATION: Ninety-four women having their fifth or greater MRCS between January 2009 and December 2009, and 175 comparison women having their second to fourth caesarean section...RESULTS:...Women with MRCS had significantly more major obstetric haemorrhages (>1500 ml) (aOR, 18.6; 95% CI, 3.89-88.8), visceral damage (aOR, 17.6; 95% CI, 1.85-167.1) and critical care admissions (aOR, 15.5; 95% CI, 3.16-76.0), than women with lower order repeat caesarean sections. These risks were greatest in the 18% of women with MRCS who also had placenta praevia or accreta. Neonates of mothers having MRCS were significantly more likely to be born prior to 37 weeks of gestation (OR, 6.15; 95% CI, 2.56-15.78) and therefore had higher rates of complications and admissions. CONCLUSIONS: MRCS is associated with greater maternal and neonatal morbidity than fewer caesarean sections. The associated maternal morbidity is largely secondary to placenta praevia and accreta, whereas higher rates of preterm delivery are most likely a response to antepartum haemorrhage.

Semin Perinatol. 2012 Oct;36(5):315-23. doi: 10.1053/j.semperi.2012.04.013. Implications of the first cesarean: perinatal and future reproductive health and subsequent cesareans, placentation issues, uterine rupture risk, morbidity, and mortality. Silver RM.  PMID: 23009962

Rates of cesarean delivery have substantially increased worldwide during the past 30 years. Indeed, almost one-third of deliveries in the United States are cesareans. Most cesareans are safe, and major complications are uncommon. However, there is a "concealed" downside to cesarean deliveries. There are rare but life-threatening morbidities that may occur, which are often overlooked because most cesareans go well. In addition, subsequent pregnancies are fraught with an increased risk of both maternal and fetal complications. The worst of these are associated with placental problems such as previa, abruption, and accreta. The risk dramatically worsens in patients with multiple repeat cesarean deliveries. This article will summarize and highlight the implications of the rising cesarean rate on maternal and fetal morbidity and mortality. 

Am J Obstet Gynecol. 2011 Sep;205(3):262.e1-8. doi: 10.1016/j.ajog.2011.06.035. Epub 2011 Jun 15. Impact of multiple cesarean deliveries on maternal morbidity: a systematic review. Marshall NE, Fu R, Guise JM. PMID: 22071057

...RESULTS: Twenty-one studies (2,282,922 deliveries) were included. The rate of hysterectomy, blood transfusions, adhesions, and surgical injury all increased with increasing number of cesarean deliveries. The incidence of placenta previa increased from 10/1000 deliveries with 1 previous cesarean delivery to 28/1000 with ≥3 cesarean deliveries. Compared with women with previa and no previous cesarean delivery, women with previa and ≥3 cesarean deliveries had a statistically significant increased risk of accreta (3.3-4% vs 50-67%), hysterectomy (0.7-4% vs 50-67%), and composite maternal morbidity (15% vs 83%; odds ratio, 33.6; 95% confidence interval, 14.6-77.4). CONCLUSION: Serious maternal morbidity progressively increased as the number of previous cesarean deliveries increased.

Obstet Gynecol. 2013 Apr;121(4):789-97. doi: 10.1097/AOG.0b013e3182878b43. Consequences of a primary elective cesarean delivery across the reproductive life. Miller ES, Hahn K, Grobman WA; Society for Maternal-Fetal Medicine Health Policy Committee. PMID: 23635679

OBJECTIVE: To estimate cumulative risks of morbidity associated with the choice of elective cesarean delivery for a first delivery. METHODS: A decision analytic model was designed to compare major adverse outcomes across a woman's reproductive life associated with the choice of elective cesarean delivery compared with a trial of labor at a first delivery. Maternal outcomes assessed included maternal transfusion, hysterectomy, thromboembolism, operative injury, and death. Neonatal outcomes assessed included cerebral palsy and permanent brachial plexus palsy in the offspring. RESULTS: Choosing an initial cesarean delivery resulted in a 0.3% increased risk of a major adverse maternal outcome in the first pregnancy. In each subsequent pregnancy, the difference in composite maternal morbidity increased such that by the fourth pregnancy, the cumulative risk of a major adverse maternal outcome was nearly 10% in the elective primary cesarean delivery group, three times higher than women who initially underwent a trial of labor. Although the choice of an initial cesarean delivery resulted in 2.4 and 0.41 fewer cases of cerebral palsy and brachial plexus palsy, respectively, per 10,000 women in the first pregnancy, by a fourth pregnancy, the risk of a adverse neonatal outcome was higher among offspring of women who had chosen the initial elective cesarean delivery (0.368% compared with 0.363%). CONCLUSION: Maternal morbidity associated with the choice of primary elective cesarean delivery increases in each subsequent pregnancy and is greater in magnitude than that associated with the choice of a trial of labor. These increased risks are not offset by a substantive reduction in the risk of neonatal morbidity.

Fight Back For VBAC: Protesting the Sorry State of VBACs Today

As we finish up Cesarean Awareness Month, let's not forget to also discuss the decline of VBACs (Vaginal Birth After Cesarean) in this country and around the world.  There is a new study out showing just how dismal the VBAC climate still is in many places.

The lack of access to VBACs is one significant reason that the cesarean rate is so high.  More than 90% of women who have a pregnancy after a cesarean will have more cesareans, even though most of these women could have a vaginal birth if they were allowed to try.

The problem is that they are rarely allowed to try anymore. Either there is an outright ban on VBACs at their hospitals, their care provider won't/can't attend VBACs, or their care provider subtly sabotages their care so they don't get a real trial of labor ("Sure, you can have a VBAC ─ but only if you go into labor by 40 weeks, the baby isn't too big," etc.).

So as we finish Cesarean Awareness Month, let's take a moment to examine the sorry state of VBACs today, how we got to where we are, and how we can Fight Back for VBAC.

A Brief History of VBACs in the U.S.

Many years ago, VBACs were practically unheard of in the United States. "Once a cesarean, always a cesarean" was the rule because most cesareans were done with an up-down classical incision that increased the chances of a uterine rupture during labor.

However, in time cesarean technique changed, and most OBs opted to use side-to-side, low transverse incisions instead.  This meant that the risk for uterine rupture, while not zero, was low.  Still, most U.S. care providers did not allow VBACs, even though VBACs were allowed in Europe.

Then in 1980, a conference was co-sponsored by the National Institute of Child Health and Human Development (NICHHD) and the National Center for Health Care Technology.  It concluded that VBAC was a reasonable option and could help decrease rising cesarean rates.

Slowly, research began to accumulate that VBACs were a reasonable choice.  Although some areas were slow to allow VBACs, the U.S. national VBAC rate began to rise significantly.  In 1980, the VBAC rate was 3.4%.  By 1996, the VBAC rate reached its peak at 28.3%.

As the 90s progressed, however, a highly-interventive obstetrics model that utilized a lot of induction and augmentation of labor was applied to VBACs too. These interventions increased the risk of uterine rupture and poor outcomes and made VBAC look more dangerous than previously thought. This was documented in McMahon 1996, which was criticized for its methodology but was unfortunately widely-publicized despite its flaws.

In addition, some insurance companies required a trial of labor, even when women didn't want one or were poor candidates for a VBAC.  Some labors were not adequately monitored, and dangerous drugs like misoprostol (Cytotec) were used to induce VBACs.  As a result, some highly publicized catastrophic outcomes and lawsuits began turning the tide of obstetric opinion against VBAC.

As you can see by the graph above, by the very end of the 90s there was a distinct downfall in the rate of VBACs, and after 2000 the rate really began dropping off.  It is less than 10% now. The graph stops in the mid-2000s; sadly, the rate is even more dismal now than the graph shows.  In some areas, the VBAC rate is absolutely awful; one study reported that Florida had a VBAC rate of only 1%.  

The reason for the steep drop-off in VBACs is that in 1999, the American Congress of Obstetricians and Gynecologists (ACOG, the trade union for OBs) issued new guidelines for attending VBACs, requiring doctors and anesthesiologists to be "immediately available" instead of "readily available" during a VBAC labor. 

This meant that OBs and anesthesiologists had to be IN the hospital the whole time a VBAC mother was in labor....."just in case." This meant OBs couldn't hold office hours to see other patients during this time, and hospitals had to pay anesthesiologists to be constantly on-site. "Immediately available" was financially and logistically impractical, so more doctors quit attending VBACs.

In particular, a lot of smaller hospitals instituted official VBAC bans because they could not meet the "immediately available" guidelines for 24/7 anesthesia and surgical coverage. This has had a particularly significant impact on states with lots of rural or small-city hospitals.

Other hospitals instituted "de facto" VBAC bans, where there were no official policies against VBAC but no doctors would attend one because of the requirement to be in hospital during a woman's whole labor.  In one study, 57% of women who were interested in VBAC reported that they had a repeat cesarean because their hospital or caregiver was unwilling to allow VBAC.

Furthermore, some insurance companies declined to insure doctors who attended VBACs, or made their malpractice insurance virtually unaffordable. As one report noted:

Insurers have also pressured hospitals and administrators to close VBAC services, and have been very effective. There are few other procedures in medicine whose availability is dictated by malpractice insurers, and none that are so widely needed.

The combination of all of these factors obliterated VBAC as a choice from basically half the hospitals in the country. 

The Change in Guidelines

Graphic from the 2010 NIH VBAC Consensus Conference 

The ONE-WORD change to "immediately" available in the ACOG guidelines was a virtual death knell for VBACs in the U.S.  Sadly, many other countries in the world followed the U.S. trend. It is quite difficult to get even a chance at a VBAC in many areas now.

Was this change in guideline based on good solid evidence? No. As ICAN's press release about VBAC bans notes:

The ACOG guidelines stipulate that a full surgical team be “immediately available” during a VBAC labor, though the stipulation is a “Level C” recommendation, which means it is based on the organization’s opinion rather than medical evidence.

Dr. Marsden Wagner, neonatologist and perinatal epidemiologist, criticized the change in guidelines in this way:

This recommendation, "VBAC should be in institutions equipped to respond to emergencies with physicians immediately available," has no data to support it--no studies showing improvements in maternal mortality or perinatal mortality related to the characteristics of institutions or availability of physicians.

In other words, the change in guideline wording that obliterated VBAC access for so many was based on NO REAL EVIDENCE.

This is not good science nor good public health policy.  It's birth politics, pure and simple, and at the price of women's reproductive autonomy.

A Different Standard for VBACs

"Immediately available" sounds good on paper ─ someone there at all times in case of the true emergency of uterine rupture ─ but it puts a level of demand on VBACs that no other birth has.

For every other birth, it's fine to have doctors on call nearby but not constantly on-site. Yet VBACs are treated differently.  It's this different standard that is the biggest barrier to VBAC availability.

Of course, it would be nice to have a surgical team standing by at all times in hospitals, ready to intervene in case of any emergency (not just obstetric; car accidents can happen at any time of the day or night) ─ but it's simply not practical or affordable to have 24/7 constant on-site coverage in most institutions. On-call nearby coverage is good enough for everything else. Why isn't it good enough for VBACs?

VBACs should not be held to a stricter standard just because they are VBACs. All births have potential risks. Yes, uterine rupture is an emergency and deserves to be taken very seriously.  However, emergencies can happen in ANY birth, including life-threatening emergencies like placental abruption, umbilical cord prolapse, and shoulder dystocia, which have about the same incidence as uterine rupture.

To say that it's not safe to do a VBAC without 24/7 coverage means that it's not safe to do ANY births at that hospital.

Nor is there proof that 24/7 coverage improves outcomes, as a number of sources have noted. And research shows that the decline in VBAC rates has not improved neonatal mortality or maternal mortality at all.

Before instituting such restrictive guidelines that potentially impacts the health of women so deeply, it is important to have research showing that 24/7 coverage makes a difference, that any improvements from such coverage would balance the women harmed from being forced into thousands of repeat surgeries in the smaller hospitals.  And that research is simply not there.

While it's ideal to have 24/7 coverage for all births because of the potential for emergencies, "readily available" is considered close enough coverage because 24/7 coverage on site is simply not practical or affordable for most hospitals.  

ACOG guidelines are only guidelines, not laws, but because they are considered "standard of care" in the community, few hospitals dare to defy them. If a hospital lets doctors be merely "on call" during a VBAC labor and something bad happens, they risk a huge malpractice award to the parents because they permitted the doctors to practice outside the standard of care from their parent organization.

Since only the very largest hospitals are able to do 24/7 coverage, VBAC was effectively wiped out in many places, all from the change of one little word.

Tweaking the Guidelines ─ Barely

ACOG's 2004 VBAC Guidelines continued to uphold this "immediately available" requirement, and VBAC access continued to drop drastically in the U.S.  Other countries followed suit, and soon a trial of labor was difficult to find in many parts of the world.

However, there were signs of push-back. The American Academy of Family Practice Physicians took on this "immediately available" requirement in their 2005 Trial of Labor After Cesarean (TOLAC) guidelines. It is uncommon for major medical organizations to come out and contradict each other like this, so the fact that the AAFP did so was a major reprimand to ACOG (emphasis mine):

TOLAC should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes.... 

Current risk management policies across the United States restricting a TOL after a previous cesarean section appear to be based on malpractice concerns rather than on available statistical and scientific evidence...We could find no evidence to support a different level of care for TOLAC patients.

Basically, the AAFP is saying that the "immediately available" guidelines is really about protecting ACOG members in lawsuits, not improving outcomes in VBACs, and there is no evidence to support such a restrictive guideline.

In 2010, the National Institute of Health (NIH) held a VBAC Consensus Development Conference, examining the current state of VBAC in the U.S. and issuing some recommendations, including this one:

We are concerned about the barriers that women face in gaining access to clinicians and facilities that are able and willing to offer trial of labor. Given the low 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 with specific reference to other obstetric complications of comparable risk, risk stratification, and in light of limited physician and nursing resources.

Many birth advocates hailed the results of this conference as the start of a pendulum swing back towards VBAC and thought that surely ACOG would change its guideline back to "readily available" soon afterwards. Sadly, this was not to be.

ACOG Changes Its Guidelines - A Little

As a result of publicity from this consensus conference and pressure from advocacy groups, ACOG did adjust its VBAC guidelines ─ but only a little bit.  It kept the recommendation for "immediately available" but created a little bit of flexibility by saying that while women should be counseled to go to a hospital with staff "immediately available" for emergency care, if they chose not to do so, they should be allowed to accept an increased risk of laboring elsewhere.

However, because most hospitals are still afraid of the liability of doing this when the guidelines still recommend "immediately available" surgical coverage, most hospitals have not changed their VBAC policies, despite the change in ACOG guidelines. 

As one commenter wrote:

By not making any changes in this recommendation, hospitals that cannot meet this requirement are not likely to begin offering medical care for VBAC. The NIH reported that the ACOG recommendation to have personnel “immediately available” as opposed to “readily available”, as recommended in all prior VBAC guidelines issued since the 1980s, has influenced about one-third of hospitals and one-half of physicians to no longer provide care for women who want a VBAC.

The difference between the 2004 guidelines and the 2010 guidelines is highlighted on the Birthing Beautiful Ideas blog (differences are highlighted in bold). The 2004 bulletin says:

Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.

The 2010 bulletin says:

A trial of labor after previous cesarean delivery should be undertaken at facilities capable of emergency deliveries. Because of the risks associated with TOLAC and that uterine rupture and other complications may be unpredictable, the College recommends that TOLAC be undertaken in facilities with staff immediately available to provide emergency care. When resources for immediate cesarean delivery are not available, the College recommends that health care providers and patients considering TOLAC discuss the hospital’s resources and availability of obstetric, pediatric, anesthetic, and operating room staffs. Respect for patient autonomy supports that patients should be allowed to accept increased levels of risk, however, patients should be clearly informed of such potential increase in risk and management alternatives.

The new ACOG guidelines do represent some progress. The organization acknowledged that its "immediately available" guideline had had a chilling effect on VBAC access, and it tried to add additional language to soften the impact of this recommendation. However, in the end, they elected not to change that key phrase, so their efforts are not likely to change the VBAC climate.  As Lamaze International noted:

Although a step in the right direction, troubling elements remain in the new guidelines for vaginal birth after cesarean delivery...

The revised guidelines acknowledge that requiring “immediately available” resources for an emergency cesarean have resulted in hospitals, insurers and the obstetric community issuing formal or informal bans of VBAC, effectively denying women access to care and choice in birth. While this was not the intention, the “immediately available” language remains in the new guidelines, which may continue to unfairly limit women’s access to VBAC.

The 2010 ACOG guidelines basically tell women to go to a large urban hospital with 24/7 coverage if they really want a VBAC, but this is simply not feasible for most families and won't change VBAC access.

Most people in rural areas or small cities simply can't afford to drop everything and move to The Big City for several weeks around a birth, and inducing VBAC labors for convenience introduces greater risk. Nor do most women want to drive several hours to The Big City while in spontaneous labor.....especially in uncertain weather seasons like wintertime.

Even women who live in big cities may not be able to choose hospitals with 24/7 coverage because of insurance issues, and not all large urban hospitals with 24/7 surgical coverage even allow VBAC. Furthermore, even in hospitals where 24/7 coverage is available and VBAC is allowed, providers vary widely in their support of a trial of labor.  So this ACOG recommendation to go to big hospitals does little to increase access to VBAC for most women.

Remember, more cesareans create more billable services, require less staffing (no hands-on labor support), make it easier to schedule personnel, and fills their hospital beds predictably. The sad truth is that hospitals make money from banning VBACs and increasing cesarean rates.

VBAC bans are not about what's best for moms and babies; it's about what's best for hospitals' bottom line, convenience, and liability concerns. And that's just wrong.

Guideline Changes Had Little Impact on VBAC Rates

The authors hoped that tweaking ACOG's guidelines would allow more flexibility and improve women's access to VBAC.  Certainly it was a step in the right direction, but one that many childbirth advocates felt didn't go far enough.  Maureen Corry of Childbirth Connection concluded:

Overall, it’s dubious that these guidelines will in fact open up access for women.

The American College of Nurse-Midwives (ACNM) agreed, stating:

ACOG's revised guidelines are unlikely to increase access to trial of labor and VBAC in the U.S

ICAN, the International Cesarean Awareness Network (and premiere VBAC advocate in the world)
stated:

More than a revision of the VBAC Practice Bulletin is required to reverse the over a decade long trend of increasing cesarean rates and decreasing VBAC rates.

Well, now we have data to show that the new guidelines have had little impact.  A new study, Barger 2013, shows that ACOG's tweak had almost no effect on improving VBAC access in California.  

The authors investigated whether TOLAC rates in California had increased after the 2010 VBAC Consensus Conference and the ACOG guideline change.  They found only minor effects at best.

Nearly half of California hospitals still do not allow a TOLAC, even with changed guidelines, and among many of those that do allow VBACs, the actual VBAC rate is still abysmally low. From the abstract:

Since 2010, five hospitals started and four stopped offering TOLAC, a net gain of one hospital offering TOLAC with three more considering it. Only two hospitals cited change in ACOG guidelines as a reason for the change. CONCLUSIONS: Despite the 2010 NIH and ACOG recommendations encouraging greater access to TOLAC, 44% of California hospitals do not allow TOLAC. Of the 56% allowing TOLAC, 10.8% report fewer than 3% VBAC births. Thus, national recommendations encouraging greater access to TOLAC had a minor effect in California.

Similarly, the Portland chapter of ICAN surveyed 52 hospitals in the state of Oregon in 2011 and found that a year after the guideline revision, VBAC bans had actually increased slightly.  In all, the incidence of VBAC in Oregon was less than 2%.

This is the sorry state of VBAC access today, and it is unlikely to improve anytime soon.

Restoring VBAC Access

So what is the solution?

Bottom line, ACOG needs to remove "immediately available" from their guidelines. A lack of 24/7 surgical and anesthesia staffing should not be a requirement to permit VBAC because VBAC should not be held to a different standard than all other births.

Thousands of women are, in essence, being forced into unnecessary surgery because of lack of access to VBAC.  Given the well-documented risks of multiple cesareans, this lack of access is harming women. This is unconscionable.

Doctors, hospitals and elected officials MUST start pressuring ACOG to revise their guidelines, and pressuring insurance companies to remove VBAC barriers in malpractice insurance. 

A professional trade union, hospital administrators, and insurance companies should not have the power to deny reproductive decision-making autonomy to women. This is a reproductive rights issue. As the editor of the journal Obstetrics & Gynecology stated:

Currently, hospitals, insurance companies, and plaintiff attorneys decide or strongly influence whether VBAC is an option. Instead, the patient should be allowed to make that choice after she has been informed of the facts and has been counseled by her physician thoroughly.

Experience shows that when care providers, administrators, and consumers work together, VBAC access can be improved, as some organizations have managed despite the medico-legal climate. This system is not perfect, but it's better than what exists in many areas.  And increasing access to VBAC can have significant effects in lowering the total cesarean rate.

We consumers have been pressuring ACOG for years to change the "immediately available" wording but have been only marginally successful. Too many ACOG members do not care about the chilling impact their guidelines have had on childbirth choices all over the country. However, if there is enough push-back from their own members and other professional colleagues, along with continued pressure from consumers, change can happen.

It's time for healthcare professionals to stop acquiescing with VBAC bans, to step up and make their voices heard.  They, too, must fight back for VBAC. 

The ACOG VBAC guideline wording will only change when the big guns in the medical and political community start pushing back and stop letting the insurance companies, paper-pushers, and lawyers dictate reproductive decision-making. Consumers must keep up the pressure and get more doctors, hospitals, and elected officials involved.


Finally, it's also important for consumers and healthcare professionals to continue to advocate for a lower primary cesarean rate.  As Dr. James R. Scott points out:

...attempts to increase the VBAC rate make little sense without addressing the reason for the problem in the first place. Reducing the number of primary cesareans deals with the problem where it originates. Unless measures are instituted to reverse the rapidly rising cesarean rate, catastrophic complications from placenta accreta and percreta associated with multiple repeat cesareans soon may be a greater problem than uterine rupture.

Want to take action? Link to this article on your blog or Facebook page. Find out if any of your local hospitals has a VBAC ban and if it does, push it to reverse its ban.  Pressure your doctor or midwife to speak up for VBAC and for lowering the primary cesarean rate. Click on this link for ways to start making your views known to your elected officials. Or get involved with your local ICAN chapter or other birth advocacy group.

Make some noise before cesareans are the norm and VBACs disappear altogether.


References

Discussions of the NIH conference, ACOG's VBAC guidelines, and VBAC rates

• http://givingbirthwithconfidence.org/2-2/a-womans-guide-to-vbac/
• http://www.childbirthconnection.org/pdfs/ACOG-VBAC-guideline-comparison.pdf
• http://birthingbeautifulideas.com/?p=2051
• http://givingbirthwithconfidence.org/2-2/a-womans-guide-to-vbac/the-%E2%80%9Cimmediately-available%E2%80%9D-standard-where-it-came-from-what-it-means-and-how-to-move-forward-with-new-evidence-and-guidelines/
• http://blog.ican-online.org/2010/07/21/ican-responds-to-new-acog-guidelines-on-vbac/
• http://www.midwife.org/documents/ACNMResponsetoVBACBulletin_082610_000.pdf
• http://www.prlog.org/10809463-lamazes-statement-on-acogs-new-clinical-management-guidelines-on-vaginal-birth-after-cesarean.html
• http://www.nationalpartnership.org/site/News2?abbr=daily2_&page=NewsArticle&id=25308&security=1201&news_iv_ctrl=-1
• http://www.kevinmd.com/blog/2010/03/vbac-rates-obstetricians-blame.html
• http://www.ahrq.gov/research/findings/evidence-based-reports/er191-abstract.html
• http://www.vbac.com/2011/11/u-s-cesarean-rate-dips-slightly-is-there-hope-for-more-vbacs/
• http://www.ncbi.nlm.nih.gov/pubmed/9241315
• http://www.ncbi.nlm.nih.gov/pubmed/21645790
• http://www.ncbi.nlm.nih.gov/pubmed/20869548
• http://uncobgyn.blogspot.com/2011/05/new-vbac-guidelines.html
• http://www.jfponline.com/pages.asp?aid=2962
• http://dspace.library.cornell.edu/bitstream/1813/15113/2/Simon%2009%20pub%2004.pdf
• http://www.ncbi.nlm.nih.gov/pubmed/21133967
• http://www.ncbi.nlm.nih.gov/pubmed/16389024
• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1479438/
• http://journals.lww.com/greenjournal/Fulltext/2010/06000/Solving_the_Vaginal_Birth_After_Cesarean_Dilemma.2.aspx
• http://rhrealitycheck.org/article/2010/10/28/birth-advocates-push-acog-remove-barriers-vaginal-birth-after-cesareans/

VBAC Access After Most Recent ACOG 2010 Policy Change

BMC Pregnancy Childbirth. 2013 Apr 3;13(1):83. [Epub ahead of print] A survey of access to trial of labor in California hospitals in 2012. Barger MK, Dunn JT, Bearman S, Delain M, Gates E. PMID: 23551909

...METHODS: Between November 2011 and June 2012, charge nurses at all civilian California birth hospitals were surveyed about hospitals' TOLAC availability and requirements for providers...RESULTS: All 243 birth hospitals that were contacted participated. In 2010, among the 56% TOLAC hospitals, the median VBAC rate among TOLAC hospitals was 10.8% (range 0-37.3%). The most cited reason for low VBAC rates was physician unwillingness to perform them, especially due to the requirement to be continually present during labor. TOLAC hospitals were more likely to be larger hospitals in urban communities with obstetrical residency training. However, there were six (11.3%) residency programs in non-TOLAC hospitals and 5 (13.5%) rural hospitals offering TOLAC. The majority of TOLAC hospitals had 24/7 anesthesia coverage and required the obstetrician to be continually present if a TOLAC patient was admitted; 17 (12.2%) allowed personnel to be 15-30 minutes away...In 2012, 139 hospitals (57.2%) offered TOLAC, 16.6% fewer than in 2007. Since 2010, five hospitals started and four stopped offering TOLAC, a net gain of one hospital offering TOLAC with three more considering it. Only two hospitals cited change in ACOG guidelines as a reason for the change. CONCLUSIONS: Despite the 2010 NIH and ACOG recommendations encouraging greater access to TOLAC, 44% of California hospitals do not allow TOLAC. Of the 56% allowing TOLAC, 10.8% report fewer than 3% VBAC births. Thus, national recommendations encouraging greater access to TOLAC had a minor effect in California.

BMC Pregnancy Childbirth. 2011 Oct 12;11:72. doi: 10.1186/1471-2393-11-72. Providers' perspectives on the vaginal birth after cesarean guidelines in Florida, United States: a qualitative study. Cox KJ. PMID: 21992871

BACKGROUND: Women's access to vaginal birth after cesarean (VBAC) in the United States has declined steadily since the mid-1990s, with a current rate of 8.2%. In the State of Florida, less than 1% of women with a previous cesarean deliver vaginally. This downturn is thought to be largely related to the American College of Obstetricians and Gynecologists (ACOG) VBAC guidelines, which mandate that a physician and anesthesiologist be "immediately available" during a trial of labor...Fear of liability was a central reason for obstetricians and midwives to avoid attending VBACs. Providers who continued to offer a trial of labor attempted to minimize their legal risks by being highly selective in choosing potential candidates. Definitions of "immediately available" varied widely among hospitals, and providers in solo or small practices often favored the convenience of a repeat cesarean delivery rather than having to remain in-house during a trial of labor. Midwives were often marginalized due to restrictive hospital policies and by their consulting physicians, even though women with previous cesareans were actively seeking their care. CONCLUSIONS: The current ACOG VBAC guidelines limit US obstetricians' and midwives' ability to provide care for women with a previous cesarean, particularly in community and rural hospitals. Although ACOG has proposed that women be allowed to accept "higher levels of risk" in order to be able to attempt a trial of labor in some settings, access to VBAC is unlikely to increase in Florida as long as systemic barriers and liability risks remain high. 

Decline in VBAC Access After 1999 ACOG Policy Change

Semin Perinatol. 2010 Aug;34(4):237-43. doi: 10.1053/j.semperi.2010.03.002. Trends and patterns of vaginal birth after cesarean availability in the United States. Gregory KD, Fridman M, Korst L. PMID: 20654773

A review of the literature and analysis of the National Inpatient Sample Database was performed to describe the trends in vaginal birth after cesarean availability in the United States and the factors associated with changing use. Vaginal birth after cesarean increased after the first National Institutes of Health Consensus Conference on Cesarean Childbirth in 1981. It increased from 3% to a maximum rate of 28.3% in 1996. Despite studies reporting stable success rates of approximately 70% and low complication rates (<1%), concerns about patient safety and physician liability have led to more restrictive policies and a decrease in vaginal birth after cesarean use. The current rate is approximately 8.5%, and decreased rates have been noted for all age and ethnic groups. There is decreased use of vaginal birth after cesarean as the result of concerns about patient safety and physician liability, which has resulted in decreased availability.

Clin Perinatol. 2011 Jun;38(2):179-92. doi: 10.1016/j.clp.2011.03.007. Recent trends and patterns in cesarean and vaginal birth after cesarean (VBAC) deliveries in the United States. MacDorman M, Declercq E, Menacker F. PMID: 21645788

Cesarean delivery is the most common major surgical procedure for women in the United States, with 1.4 million surgeries annually. In 2008, nearly one-third (32.3%) of US births were by cesarean delivery. Cesarean delivery rates have increased rapidly in the United States in recent years because of an increasing primary cesarean delivery rate and a declining vaginal birth after cesarean (VBAC) rate. In 2007, the VBAC rate was 8.3% in a 22-state reporting area. The US VBAC rate was lowest among 14 industrialized countries; 3 countries had VBAC rates greater than 50%.

Matern Child Health J. 2005 Jun;9(2):181-8. The UTAH VBAC Study. Gochnour G, Ratcliffe S, Stone MB. PMID: 15965624

BACKGROUND: ...We examined the effect this new guideline [kmom: 1999 "immediately available" wording] would have on physician's VBAC/TOL practices in Utah...METHODS: In spring 2001, we surveyed by mail all physicians practicing obstetrics in Utah... RESULTS:...Forty-five percent of all physicians reported a decline in VBAC practices in the preceding 12 months. Urban physicians' use of VBAC/TOL decreased the least, followed by rural and suburban. Eighty-seven percent of physicians had C/S "immediately" available during TOL: urban physicians 100%, suburban 88%, and rural physicians 76%...CONCLUSION: Physicians use of VBAC/TOL has changed. TOL is offered less by obstetrical providers in Utah and more repeat C/S are performed since 1999 when ACOG updated this policy guideline. This decline has been more noticeable in suburban and rural hospitals and is consistent with recent national trends. Many rural physicians are unable to comply with ACOG Practice Guideline number 5 recommendations.

J Matern Fetal Neonatal Med. 2004 Jul;16(1):37-43. Vaginal birth after Cesarean rates are declining rapidly in the rural state of Maine. Pinette MG, Kahn J, Gross KL, Wax JR, Blackstone J, Cartin A.  PMID:

...STUDY DESIGN: We examined birth certificate and hospital data in the State of Maine from 1998 to 2001...RESULTS: VBAC rates declined by over 50% from 30.1 to 13.1%. The total Cesarean rate climbed from 19.4 to 24.0%. The most commonly reported reason for decrease in VBAC varied depending on whether a practitioner's hospital met ACOG guidelines. CONCLUSION: A marked decline in VBAC occurred after the change in ACOG vaginal birth after Cesarean policy. Multiple factors have contributed to this decline, including patients refusing VBAC after counseling and inability of institutions to meet ACOG guidelines.

Birth. 2007 Dec;34(4):316-22. Changing policies on vaginal birth after cesarean: impact on access. Roberts RG, Deutchman M, King VJ, Fryer GE, Miyoshi TJ. PMID: 18021147

...METHODS: Every hospital in Colorado, Montana, Oregon, and Wisconsin was contacted by telephone at least once during the period 2003 to 2005... RESULTS:...Almost one-third, 68 of 222 (30.6%), of responding delivery hospitals that previously offered VBAC services had stopped doing so; seven hospitals had never allowed VBAC. Of the hospitals that still allowed VBAC, 68 percent had changed their VBAC policies since 1999, with the most frequent changes requiring the in-house presence of surgery (53%) and anesthesia (44%) personnel when women desiring VBAC presented in labor...CONCLUSIONS: In the years following advocacy of the 1999 policy, the availability of VBAC services significantly decreased, especially among smaller or more isolated hospitals.

Keeping VBAC Accessible

Clin Obstet Gynecol. 2012 Dec;55(4):1021-5. doi: 10.1097/GRF.0b013e3182618921. Why VBAC in Northern New England is still viable: the Northern New England perinatal quality improvement network. Lauria MR, Flanagan V, Capeless E. PMID: 23090472

Under the strong leadership of Maternal-Fetal Medicine specialists and the support of the tertiary care centers serving the region, Northern New England (NNE) initiated a collaborative project to improve the availability and safety of trial of labor aftercesarean delivery. The project involved over 250 individuals from over 30 organizations and resulted in a strong regional guideline that has been implemented by institutions across the nation. The availability of trial of labor after cesarean in NNE has increased. The work led to the creation of the NNE Perinatal Quality Improvement Network, whose work has improved regional outcomes.

VBAC Conferences and Documents

National Institutes of Health. Cesarean childbirth. NIH publication no. 82-2067. Washington (DC): Government Printing Office, 1981.

NIH Consens State Sci Statements. 2010 Mar 10;27(3):1-42. NIH Consensus Development Conference Draft Statement on Vaginal Birth After Cesarean: New Insights. Bangdiwala SI, Brown SS, Cunningham FG, Dean TM, Frederiksen M, Hogue CJ, King TL, Lukacz ES, McCullough LB, Nicholson W,Petit NF, Probstfield JL, Viguera AC, Wong CA, Zimmet SC. PMID: 20228855

...CONCLUSIONS: (1) Given the available evidence, TOL is a reasonable option for many pregnant women with a prior low transverse uterine incision...When both TOL and ERCD are medically equivalent options, a shared decision-making process should be adopted and, whenever possible, the woman's preference should be honored. (3) 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...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. (4) 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....

VBAC After Prior VBAC: Decreased Risks, Not Increased Risks

Just in time for Cesarean Awareness Month, another *headdesk* moment from My OB Said What?!?.

This one is about whether a woman who has already had VBACs should continue to have more VBACs or whether she needs to sign up for more cesareans because having too many VBACs becomes "too dangerous."

"I will not go over this with you and you are being argumentative! More than a few VBACs will be unsafe because the scar stretches and can become unstable. I don't care how many safe VBACs you've had and about any of the other testing you've had in the past, this is dangerous!" --OB to mother trying to VBAC again

Sometimes I can't believe the stupid things that come out of some providers' mouths. With all the research out there disproving the foolish myths that circulate, I can't believe that this is even a question, yet every once in a while we still hear this one in VBAC groups. Sigh.

So let's go over what the research actually says:

• Prior vaginal births actually decrease your risk for rupture (de Lau 2011, Zelop 2000)
• Prior VBACs particularly decrease your risk for uterine rupture (Mercer 2008, Shimonovitz 2000)
• Each successive VBAC does not get more risky  (Mercer 2008)
• Each successive cesarean does get more risky (Silver 2006)
• Grand multiparity (5 or more pregnancies) is not a contraindication to a trial of labor (Kugler 2008) 
• Women with a history of VBAC have a very high success rate in subsequent trials of labor (Mercer 2008, Gyamfi 2004)

Of course, in the interest of accuracy, I would point out that once you've had a cesarean, the risk of uterine rupture is never zero or negligible, even with multiple prior VBACs.  However, the risk is decreased compared to a woman who has never had a VBAC.  And the risk of multiple repeat cesareans is certainly significant.

Given that the risk for rupture goes down somewhat with successive VBACs, given that women with a prior VBAC have a very high success rate in subsequent VBAC attempts, given that grand multiparity is not a contraindication to VBACs, and given that there are strong risks with multiple repeat cesareans, why would doctors limit how many VBACs a woman is "allowed" to have?

Mercer and colleagues stated as much in the conclusion of their study, saying (emphasis mine):

Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy. There is no reason to place a limit on the number of VBACs a woman can have.

That research was published in 2008.  It's long past time for the entire obstetric community to get the memo on this.


References

Mercer BM, Gilbert S, Landon MB. et al. Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstet Gynecol. 2008 Feb;111(2):285-291.  PMID:  18238964   You can read the entire study here.

OBJECTIVE: To estimate the success rates and risks of an attempted vaginal birth after cesarean delivery (VBAC) according to the number of prior successful VBACs. METHODS: From a prospective multicenter registry collected at 19 clinical centers from 1999 to 2002, we selected women with one or more prior low transverse cesarean deliveries who attempted a VBAC in the current pregnancy. Outcomes were compared according to the number of prior VBAC attempts subsequent to the last cesarean delivery. RESULTS:  Among 13,532 women meeting eligibility criteria, VBAC success increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%, and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively (P<.001). The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52%(P=.03). The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter. CONCLUSION: Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy.

Arch Gynecol Obstet. 2011 Nov;284(5):1053-8. Epub 2011 Aug 31. Risk of uterine rupture in women undergoing trial of labour with a history of both a caesarean section and a vaginal delivery. de Lau H, Gremmels H, Schuitemaker NW, Kwee A. PMID: 21879334

PURPOSE: To determine the risk of uterine rupture for women undergoing trial of labour (TOL) with both a prior caesarean section (CS) and a vaginal delivery. METHODS: A systematic literature search was performed using keywords for CS and uterine rupture. The results were critically appraised and the data from relevant and valid articles were extracted. Odds ratios were calculated and a pooled estimate was determined using the Mantel-Haenszel method. RESULTS: Five studies were used for final analysis. Three studies showed a significant risk reduction for women with both a previous CS and a prior vaginal delivery (PVD) compared to women with a previous CS only, and two studies showed a trend towards risk reduction. The absolute risk of uterine rupture with a prior vaginal delivery varied from 0.17 to 0.46%. The overall odds ratio for PVD was 0.39 (95% CI 0.29-0.52, P < 0.00001). CONCLUSION: Women with a history of both a CS and vaginal delivery are at decreased risk of uterine rupture when undergoing TOL compared with women who have only had a CS.

Obstet Gynecol. 2004 Oct;104(4):715-9. Increased success of trial of labor after previous vaginal birth after cesarean. Gyamfi C, Juhasz G, Gyamfi P, Stone JL.  PMID: 15458891

OBJECTIVE: To estimate whether a history of a previous successful vaginal birth after cesarean delivery (VBAC) has an effect on a subsequent VBAC attempt...RESULTS: Of the 336 patients with a history of one or more previous successful VBAC attempts, 94.6% had a subsequent successful VBAC, whereas 70.5% of the remaining 880 patients were successful (P <.001). For those patients with one or more previous successful normal spontaneous vaginal deliveries, 87.8% had a successful VBAC, whereas 75.6% were successful without this history (P =.001)...Patients with a history of previous VBAC were 7 times more likely to have a subsequent VBAC success (odds ratio 7.40, 95% confidence interval 4.51-12.16; P <.001)...CONCLUSION: A history of a previous successful VBAC increases the likelihood for success with future attempts....

Isr Med Assoc J 2000 Jul;2(7):526-8. Successful first vaginal birth after cesarean section: a predictor of reduced risk for uterine rupture in subsequent deliveries. Shimonovitz S, Botosneano A, Hochner-Celnikier D.  PMID: 10979328

BACKGROUND: Uterine rupture is a catastrophic obstetric complication, most often associated with a preexisting cesarean section scar. Although a vaginal birth after a cesarean is considered safe in modern obstetrics, it is not known whether repeated VBACs increase the risk of rupture, or whether the first VBAC proves the strength and durability of the scar, predicting further successful and less risky vaginal deliveries. OBJECTIVES: To evaluate the effect of repeated vaginal deliveries on the risk of uterine rupture in women who have previously delivered by cesarean section. METHODS: In this retrospective study, 26 VBAC deliveries complicated by uterine rupture were matched for age, parity, and gravidity with 66 controls who achieved VBAC without rupture. The histories, demography, pregnancy, labor and delivery records, as well as neonatal outcome were compared. RESULTS: We found that the risk of rupture decreases dramatically in subsequent VBACs. Of the 40 cases of uterine rupture recorded during the 18 year study period, 26 occurred during VBAC deliveries. Of these, 21 were complicated first VBACs. We also found that the use of prostaglandin-estradiol, instrumental deliveries, and oxytocin had been used significantly more often during deliveries complicated with rupture than in VBAC controls. CONCLUSIONS: Once a woman has achieved VBAC the risk of rupture falls dramatically. The use of oxytocin, PGE2 and instrumental deliveries are additional risk factors for rupture, therefore caution should be exerted regarding their application in the presence of a uterine scar, particularly in the first vaginal birth after cesarean.

Am J Obstet Gynecol. 2000 Nov;183(5):1184-6. Effect of previous vaginal delivery on the risk of uterine rupture during a subsequent trial of labor. Zelop CM, Shipp TD, Repke JT, Cohen A, Lieberman E.  PMID: 11084564

OBJECTIVE: We examined the effect of prior vaginal delivery on the risk of uterine rupture in pregnant women undergoing a trial of labor after prior cesarean delivery. STUDY DESIGN: The medical records of all pregnant women with a history of cesarean delivery who attempted a trial of labor during a 12-year period at a single center were reviewed...RESULTS: Of 3783 women with 1 prior scar, 1021 (27.0%) also had > or =1 prior vaginal delivery. During a subsequent trial of labor, the rate of uterine rupture was 1.1% among pregnant women without prior vaginal delivery and 0.2% among pregnant women with prior vaginal delivery (P =.01). Logistic regression analysis controlling for duration of labor, induction, birth weight, maternal age, year of birth, epidural analgesia, and oxytocin augmentation indicated that, among women with a single scar, those with a prior vaginal delivery had a risk of uterine rupture that was one fifth that of women without a previous vaginal delivery (odds ratio, 0.2; 95% confidence interval, 0.04-0.8)...CONCLUSION: Among women with 1 prior cesarean delivery undergoing a subsequent trial of labor, those with a prior vaginal delivery were at substantially lower risk of uterine rupture than women without a previous vaginal delivery.

Archives of Gynecology and Obstetrics. 2008 Apr;277(4):339-44. The safety of a trial of labor after cesarean section in a grandmultiparous population. Kugler E, Shoham-Vardi I, Burstien E, Mazor M, Hershkovitz R.  PMID: 17957377 

BACKGROUND: The rate of vaginal birth after a cesarean (VBAC) delivery in the multiparous population has decreased largely in recent years because of maternal and neonatal complications. The clinical management of grand multiparous (GMP) women (>5 births) with a prior cesarean delivery is even less clear. The purpose of the present study was to assess the risks of maternal and neonatal complications associated with VBAC compared to that of repeated elective cesarean section (CS) in the GMP population. METHODS: A retrospective study of 1,102 GMP women with a singleton gestation and a prior single CS was conducted. Data were retrieved from the database of the Department of Obstetrics and Gynecology at the Soroka University Medical Center, Beer Sheva, Israel. Maternal and neonatal outcomes were compared between women who underwent a successful VBAC attempt, women who had failed in a trial of labor and women who had an elective repeated CS. RESULTS: Six hundred and nineteen women (56%) underwent a successful VBAC, 155 (14%) underwent a trail of labor and 328 (30%) had an elective repeated CS. Women who had a successful VBAC required less blood transfusion, and had less puerperal fever diseases (P < 0.001). Induction or augmentation of labor was associated with failure of VBAC (P < 0.001). No significant differences in neonatal complications were observed between the groups. No significant difference in uterine dehiscence, uterine rupture, amnionitis, postpartum hemorrhage, hysterectomy, puerperal fever and thromboembolic diseases was observed between the groups. CONCLUSIONS: A successful VBAC in the GMP population was not associated with a higher risk of maternal complications in comparison with a repeated elective CS.

Obstet Gynecol. 2006 Jun;107(6):1226-32. Maternal morbidity associated with multiple repeat cesarean deliveries. Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y,Miodovnik M, Carpenter M, Peaceman AM, O'Sullivan MJ, Sibai B, Langer O, Thorp JM, Ramin SM, Mercer BM; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. PMID: 16738145

...METHODS: Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999-2002). RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively. 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.