Annals Articles Weigh Childbirth Options

Vaginal birth after cesarean, or VBAC, has been found to have encouraging outcomes unless infants have very low birth weight, says a new research report in the May/June issue of Annals of Family Medicine; an essay in the same issue advocates the concept of patient choice of vaginal delivery.

VBAC Study

The maternal mortality rate remains about the same with either VBAC or repeat cesarean delivery, as does the neonatal mortality rate for infants whose birth weight is at least 1,500 grams (3.3 pounds), according to "Vaginal Birth After Cesarean in California: Before and After a Change in Guidelines." Smaller babies, however, have higher neonatal mortality rates with attempted VBAC.

John Zweifler, M.D., M.P.H., of the family and community medicine department at the University of California, San Francisco, Fresno, and his co-authors compared California birth statistics from 1996 to 1999 and from 2000 to 2002 to gauge the impact of the 1999 VBAC guideline revision by the American College of Obstetricians and Gynecologists. According to the article, the ACOG revision advises, "because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care." The AAFP 2005 policy Trial of Labor After Cesarean (TOLAC) challenges ACOG's 2004 reaffirmation of its 1999 guideline revision.

"Overall, the percentage of women (in California) who attempted VBAC deliveries decreased significantly from 24 percent before the revision to 13.5 percent after the revision," say Zweifler and his co-authors. However, they note, "Neonatal and maternal mortality rates did not improve despite increasing rates of repeat cesarean delivery" during the years after the revision.

"We recommend that a balanced presentation of risks and the encouraging outcomes found in this analysis be included in discussions with pregnant patients who have had a previous cesarean section," say the authors.

Patient-Choice Deliveries

Childbirth options also take center stage in the article "Patient-Choice Vaginal Delivery?" which appears in the same issue of Annals of Family Medicine.

Patient-choice cesarean delivery already occurs in more than 2 percent of all U.S. births, and the national cesarean section rate in 2004 was 29.1 percent, say authors Lawrence Leeman, M.D., M.P.H., of the departments of family and community medicine and obstetrics and gynecology at the University of New Mexico, Albuquerque, and Lauren Plante, M.D., of the obstetrics and gynecology department at Thomas Jefferson University, Philadelphia. "The question of patient-choice cesarean delivery asks only whether a woman should have the right to choose a cesarean delivery in the absence of a medical indication," say the authors. "A woman's right to choose a vaginal delivery is not addressed."

The authors argue for a patient's right to choose vaginal delivery, warning that cesarean delivery carries risks of its own, such as hemorrhage, infection and venous thromboembolism, and may place future pregnancies at increased risk for placenta previa, placenta accreta, uterine rupture and peripartum hysterectomy.

"Currently there is silence on the right of a well-informed patient to choose vaginal breech delivery or VBAC in a rural community hospital," say the authors. "If we cannot find her (the patient) a hospital or a physician for the type of birth she desires, she may be left with no choice but to consent to a cesarean delivery. … As we push VBAC and vaginal breech delivery out of our hospitals, we may actually make outcomes worse: Women who believe their choices will not be respected in such situations may prefer to stay home, and surely VBAC is less safe at home than in the hospital."

Other Articles

Other articles in the May/June issue of Annals of Family Medicine include