Discussing delivery after a cesarean

Talks about trial of labor, vaginal birth, or elective repeat after cesarean should begin at a patient's first visit and continue throughout the course of the pregnancy.

Discussing VBAC deliveries
Discussing VBAC deliveries

In 2010, The American College of Obstetricians and Gynecologists (ACOG) issued a Practice Bulletin on vaginal birth after cesarean section (VBAC).

Its recommendation was that most females with a history of a prior cesarean were candidates for a trial of labor after cesarean (TOLAC) and should be counseled on the risks and benefits both VBAC as well as elective repeat cesarean delivery (ERCD).

Many patients come to us for obstetric care because our practice has long been one of the few in our area to offer VBAC deliveries. Based on the recommendations of the 2010 ACOG Practice Bulletin, our group also considers allowing a TOLAC after two cesarean deliveries.

I have attended many successful VBACs, but I truly believe that pregnant women should be counseled realistically regarding their options. I have seen many patients who had decided that they wanted a VBAC and refused to consider the indications for their prior cesarean section.

Female patients who have had at least one vaginal birth, either before or after a cesarean section, are the best candidates for TOLAC. If a woman had a cesarean section due to breech presentation or a non-reassuring fetal status, they essentially have the same chance of delivering vaginally as a first-time mom.

But women who have had a cesarean for circumstances such as arrest of descent or labor dystocia have a decreased chance of a successful VBAC. Maternal disease such diabetes and hypertension, as well as obesity also portend less of a chance for a VBAC.

Patients should be counseled that women who go into spontaneous labor have a better chance of having a VBAC than those who are induced. Though ACOG guidelines do state that induction of labor is an option for women with a history of cesarean delivery, many physicians and midwives will not induce or even augment labor for these patients.

I am a strong supporter of VBACs and feel that if more providers followed ACOG guidelines, the cesarean rate in this country would decrease. Discussion of options for TOLAC, VBAC, or ERCD should begin at a patient's first prenatal visit and continue throughout the course of the pregnancy.

Ultimately, the safety of both mom and baby are the first priority. The patient's desire should also be weighed. Counseling between midwife and patient should be ongoing and realistic in order to give the patient and her family a comprehensive idea of the true risks and benefits of every option.

Robyn Carlisle, MSN, CNM, WHNP, works as a full-scope midwife at University Doctors and Kennedy University Hospital in Sewell, N.J.

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