Lessons learned from the history of VBAC

In December 2014, The Wall Street Journal ran an article about a young mother who wanted a vaginal birth after C-section (VBAC) for her second child. After her hospital stopped offering VBACs, the woman had to find another place to deliver. She did have a successful VBAC, but her story is not unique – many women may not receive adequate consultations about or provider support for VBAC as a delivery option.

According to the article, a lack of clinical support was the reason the hospital discontinued VBACs. Although the hospital’s decision may have frustrated the mother, this ensured that she would not be promised a birthing option that the hospital could not deliver – in all senses of this word. Successful VBAC requires proper patient selection, appropriate consent and adequate provisions in case of emergencies.

Dr. E. Albert Reece

Not every hospital has made such a choice. Based on studies of a trial of labor after cesarean, conducted after the 1960s, the rate of VBACs increased. As VBACs became more common, the approach to the procedure became more relaxed. VBACs went from only being performed in tertiary care hospitals with appropriate support for emergencies, to community hospitals with no backup. Patient selection became less rigorous, and the rate of complications went up, which, in turn, caused the number of associated legal claims to rise. Hospitals started discouraging VBACs, and ob.gyns. no longer counseled their patients about this option. The VBAC rate decreased, and the C-section rate increased.

Today, many women want to pursue a trial of labor after cesarean. Data from large clinical studies have demonstrated the safety and success of VBAC with proper care. Because of the storied history and a revival of interest in VBACs, we have invited Dr. Mark Landon, the Richard L. Meiling Professor and chairman of the department of obstetrics and gynecology at the Ohio State University, and the lead on one of the recent seminal VBAC studies, to address this topic.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece reported having no relevant financial disclosures. He is the medical editor of this column. Contact him at obnews@frontlinemedcom.com.