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Wednesday Jan 28, 2015

New AAFP Guideline Adds to Evidence Supporting VBAC

It has been more than four years since the American College of Obstetricians and Gynecologists updated its recommendations(www.acog.org) for vaginal birth after cesarean (VBAC), stating that VBAC is "a safe and appropriate choice" for most women who have had a cesarean delivery. Still, women are frequently denied labor after cesarean(www.nytimes.com) (LAC) because of hospital or practice policies that conflict with evidence-based guidelines.

Fortunately, this hasn't been an issue for me or my patients at either of the hospitals where I provide maternity care. My practice encourages VBAC whenever possible because the overall risks associated with a vaginal delivery are actually lower than the risks associated with a C-section, and certainly with subsequent C-sections. The recovery time is much faster with VBAC, and that shorter recovery contributes to a more positive experience for moms and also makes it easier for them to do other things, such as breastfeeding their babies.

LAC, of course, doesn't always lead to a vaginal delivery. In fact, less than a third of my patients who attempt it are actually successful. The two main challenges have been maternal exhaustion and the inability to help labor along with certain medications.

That second challenge, however, is changing. Although ACOG's recommendation statement offered limited and somewhat conflicting information about the use of oxytocin to induce labor, the majority of research in this area pointed to an increased risk of uterine rupture. Regarding the use of oxytocin to augment contractions, however, "The varying outcomes of available studies and small absolute magnitude of the risk reported in those studies support that oxytocin augmentation may be used in patients undergoing (trial of labor after cesarean)."

For me, that wasn't a strong enough endorsement at the time. But now, the AAFP has published a new VBAC guideline that also supports the use of oxytocin for induction and augmentation of labor.

In fact, the guideline states that "there does not appear to be an increased risk of uterine rupture associated with oxytocin augmentation of labor."  It also says that "augmentation of labor with oxytocin is associated with a 68 percent rate of VBAC."

For my practice, this changes everything and provides a new pathway to help my patients who want to try LAC. Having that chance is so important because some moms who want a vaginal delivery feel bad and blame themselves when they have to have a C-section. Having an attempt at vaginal delivery -- even if unsuccessful -- takes away some of that guilt because they know they did everything they could. This aspect shouldn't be overlooked given the importance of mental well-being during the postpartum period.

And when these moms succeed, the joy is immeasurable. They not only have the pride and happiness that is typical of a new mother, but they have accomplished something they previously were told they could not do and achieved the kind of delivery they wanted the first time.

Emily Briggs, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.

Posted at 04:26PM Jan 28, 2015 by Emily Briggs, M.D., M.P.H.

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