Vaginal birth after Cesarean versus elective repeat Cesarean section: a discussion of risk, risk factors, and decision-making
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A major factor in the rising rate of cesarean deliveries in the United States is the large number of elective repeat cesareans performed on women with a history of cesarean sections. Until the 1980's, physicians were instructed that women with a history of cesarean section should only deliver by cesarean in any future pregnancies because the uterine scar was at risk of opening, leading to a dangerous uterine rupture that could result in severe consequences for the mother and infant. In the 1980's data became available that vaginal birth after cesarean (VBAC) was not as dangerous as previously believed. Subsequently, the VBAC rate rose to a high of almost 30% of all births in the 1990's with a concomitant drop in the total cesarean section rate to 20%. In 1996, a high profile paper reported the serious consequences that could accompany uterine rupture. The VBAC rate dropped precipitously and remains at a mere 9.2% today. Because of physician fear of uterine rupture, many women with prior cesareans are unaware of or denied a trial of labor after cesarean (TOLAC) in an effort to achieve vaginal birth. There appears to be poor understanding of the risks associated with elective repeat cesarean delivery (ERCD), the risks associated with VBAC, and no simple method to compare them. Based on many studies analyzing maternal and fetal outcomes of ERCD and TOLAC, it has been consistently shown that actual risk or frequency of uterine rupture for TOLAC is low, less than 1.2%. But when compared to an ERCD, the risk of uterine rupture during TOLAC becomes two to twenty times more likely than during an ERCD. Studies have uncovered numerous determinants that can either prevent or promote the risk of complications. Having had a prior successful vaginal delivery is most protective against uterine rupture, and an increasing number of prior cesareans leaves a woman more likely to fail TOLAC. Induction or augmentation of labor by using oxytocin, prostaglandins, or both may also increase risks of uterine rupture during TOLAC. With better knowledge of risk factors associated with uterine rupture and failed TOLACs, current guidelines suggest physicians consider a woman's choice and her desired child-bearing experience. Women prefer to be actively involved in their healthcare provision, and counseling of women with prior cesareans would ideally incorporate personal choice. While maternal and child health will always be the first priority in decision-making, if a woman is at low risk of TOLAC failure, modern medical practices and literature suggest granting her the option of attempting a VBAC rather than be subjected to another cesarean. [TRUNCATED]
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