The Viable Option of VBAC

VBAC is a real and significant option for women who have had one or more CSs. Until recent years, repeat CS after CS had dominated in clinical care, with VBAC being

6_{Trial of labour after caesarean (TOLAC) is described as a “planned labour with a view to safe vaginal} birth in a woman who has had a prior Caesarean section delivery” (The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2010, p.3). A TOLAC is often alternatively referred to in the literature and in practice as simply a Trial of Labour (TOL) or as a Planned VBAC (PVBAC). The OptiBIRTH study team had a firm policy in place from the start of the study that this terminology, which appears to place the woman and her body “on trial” was not to be used. The preferred terminology was “planned VBAC.

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viewed in the medical sphere as dangerous. Kotaska (2012) found that, due to various prominent reports that were released on the dangers of uterine rupture (UR), especially with regards to induction of labour, the rate of VBAC in the US fell to an extreme low of 10.6% in 2003. Similarly, in the UK, Black et al (2005) estimated recent trends in birth by CS during the years 1990-1999 and the percentage of VBACs that have occurred in this timeframe. Using information that was longitudinally gathered on the UK General Practice Research Database, they found that CS rates were “increasing since 1990, reaching 18.3% in 1999. During this same time period VBAC fell from 45% in 1991 to approximately 37% in 1999” (Black et al, 2005, p.154).

There are a growing number of clinicians however (Feldman et al, 2010), whodisagree with the idea of repeat CS being the only option and view VBAC as safe and viable and are advocating this mode of birth to women. Landon et al (2005) investigated maternal outcomes for a VBAC and found that one of the main factors for the decline of VBAC is the notion of risk and suggested counselling for women who need to make a choice about mode of birth. This situation changed in 2004 with the publication of a systematic review by Guise et al(2004)of the benefits and harms of VBAC compared with repeat CS. The results of their review demonstrated that there was no significant difference between the two modes of birth with regards to maternal death or hysterectomy, and found that “more than 3 of 5 women who attempt trial of labour will have a vaginal delivery” (Guise et al, 2004, p.426). To add to this, recent literature further highlights that

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“CS is associated with a higher rate of surgical, infectious, and thromboembolic complications than vaginal birth, as well as subsequent perinatal complications such as placenta praevia and placenta accrete” (Rozen et al, 2011, p.4).

However, after an extensive review of the literature, Dodd et al (2004) suggested that, as there are no randomised controlled trials that compare the two methods of birth, information should be given with caution about VBAC and ERCS and that all studies on the topic should be treated and interpreted in the same way. This would mean that for both methods of birth (CS and VBAC), caution about the risks and benefits of each and women‟s feelings towards VBAC and ERCS should be taken into consideration for every individual woman.

To further the legitimisation of VBAC, the Agency of Healthcare Research and Quality (2010) in the US published an extensive literature review on the risks and benefits of VBAC and revealed that VBAC was a viable and, more importantly, a safe option for women with a prior CS. To add to this recommendation, they also warned of the dangers of repeat CS for mothers, for example, maternal haemorrhage which results in increased rates of blood transfusion, infection and fever, and hysterectomy. Further studies have documented the option of VBAC as safe. Macones et al (2005)

investigated the incidence of and risk factors associated with UR in women attempting VBAC in various hospital settings. Through their analysis of data from a multi-centre cohort study involving a review of records of 25,005 women with a previous CS, they found the incidence of UR in women with a previous CS who were attempting VBAC was less than 1%. They concluded from this that women with a previous CS should be offered VBAC (Macones et al, 2005). Durnwald & Mercer (2004) purported the

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viability of VBAC as safe for women when they investigated the predictors of

successful trial of labour (TOL) after a previous CS. Their findings demonstrated that the rate of UR for women undergoing VBAC was 0.8% and that “the overall risk of this potentially catastrophic event is still rare and should not be used as a deterrent for a VBAC attempt” (2004, p.392). Studsgaard et al (2013) investigated the outcome difference between a TOL versus having a repeat CS and indicated that a TOL was a reasonable consideration for women with a previous CS and that in their participant population of 1,783 women, 1,161 chose a TOL and 783 (67%) of these women had a successful vaginal birth.

For many of the countries and studies above, maternal request for a CS was at the centre of the study. Weaver et al (2007) explored both women‟s and obstetricians‟ perceptions of CS in the absence of clinical indicators. Their findings from women and obstetricians appear conflicted. Obstetricians on the one hand, stated that maternal request was rare, but fear of childbirth was driving the CS rate upwards. In contrast, none of the women reported requesting a CS, yet thought it was the safest option for themselves and their baby. They recommend that, although the information about maternal request for CS is weak, if there is a fear about impending childbirth this must be “acknowledged by both women and health care professionals and time and resources allocated to deal with it” (2007, p.40).

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