Vaginal birth after caesarean section: Seeing the bigger picture. (cover story)

RESEARCH; VAGINAL birth after cesarean; BIRTHING centers; OBSTETRICS; DELIVERY (Obstetrics)

Recent research has recommended that vaginal births after caesarean section (VBAC) should not be carried out in birth centres. The authors of that study did not quantify the effects of their recommendations on maternal and fetal mortality in future pregnancies. The current US repeat caesarean section (CS) rate of 90% and the UK repeat CS rate of 67% present us with the fact that for women who will have more than two pregnancies, the increased mortality experienced in downstream pregnancies due to repeat CS negates the advantages of attempting the first VBAC in hospital rather than a birth centre. Of those women with two CS scars attempting VBAC in hospital, 3.7% experience uterine rupture, and 20% of these, hysterectomy. The risk of third trimester unexplained stillbirth is increased by 1 per 1000 after one CS birth. No one has yet researched the rate of increase in stillbirths after two or more caesarean sections. If no further pregnancies occur after the VBAC, hospital VBACs have an advantage over birth centre VBACs. However, when further pregnancies are considered, this 1/1000 advantage has to be set against the increase of 1/1000 unexplained stillbirths after CS, and increased maternal morbidity and mortality due to uterine rupture, hysterectomy and placental praevia and accretas. [ABSTRACT FROM AUTHOR]