Both debaters for this year’s ABOG Educational Foundation Lectureship on Patient Safety and Quality Improvement agree that vaginal birth after cesarean delivery (VBAC) is not considered often enough. The question to be discussed during “Everyone Should VBAC! #NOTSOFAST” will be how much more common it should become. The session is from 10:25 to 11:15 am in Ballroom D.
James M. Palmer, MD, MS, residency program director, assistant professor, College of Medicine Obstetrics & Gynecology, University of South Florida Morsani College of Medicine, will say that physicians should support and encourage VBAC as the first option, changing to C-section after counseling and collaboration with the mother when contraindications are found.
Dr. Palmer will highlight the ACOG practice bulletin released late last year that said VBAC should be attempted at facilities that typically manage uncomplicated births if they are capable of performing emergency deliveries.
“That position has really changed,” he said. “They’ve really gone in and been very thoughtful about their wording about how providers should approach VBAC.”
Mark B. Landon, MD, FACOG, Richard L. Meiling chair of Obstetrics and Gynecology and professor of obstetrics and gynecology, The Ohio State University Wexner Medical Center, said that while he believes VBAC is clearly underutilized in the United States and that more women should undergo trial of labor after cesarean (TOLAC), a blanket policy promoting VBAC in all potential candidates requires scrutiny. The morbidity associated with failed TOLAC is significantly greater than for women successful at VBAC. Thus, being selective about recommending TOLAC is the preferred approach when discussing options for childbirth following previous cesarean delivery.
Dr. Landon emphasized the importance of counseling women so they understand their options and what their success rate would likely be if they attempt a trial labor. The VBAC calculator or some other more simplified approach should be employed to stratify women according to the likelihood of successful VBAC, he said.
The debate will also include a detailed review of induction in VABC and address concerns about whether induction increases the risk of uterine rupture, and the risks for women who have undergone multiple C-sections.
“Informed decision making is central, and the key component during counseling is the likelihood of success for a trial of labor and knowing the complications associated with a failed trial of labor, with the most feared complications being uterine rupture. Additionally, women must be aware of what the sequelae uterine rupture might be,” Dr. Landon said. “Physicians need to include some statistical estimate of such risks because if you don’t put some absolute numbers on these complications and only speak in terms of relative risk, it can be somewhat misleading.”
Dr. Palmer said that physicians still holding a neutral or negative stance on VBAC must not only consider uterine rupture; as the C-section rate has increased, so has incidences of life-threatening placenta accreta.
“What happens as the rate of accreta increases and it’s more common than uterine rupture, which is what everybody has been really worried about with VBAC?” he said. “Would that change their minds, and how close are we to that?”