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Rapid Responses: Rapid Responses published:
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Vaginal Birth after Caesarean: time for an International Forum and prospective multi-centre research
- Rajesh Varma, Janesh K. Gupta (4 July 2004)
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Think out side the box!
- Leeann M. Redman (10 July 2004)
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Query-maternal and fetal morbidity and mortality
- Michael Lockwood, DO (9 June 2005)
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Rajesh Varma, MRC Fellow in Obstetrics and Gynaecology Academic Department Obstetrics and Gynaecology, Birmingham Women's Hospital, Birmingham, UK, B15 2TG, Janesh K. Gupta
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This review 1follows others in showing trial of vaginal birth after caesarean (VBAC) is harmful for the fetus and mother, but less so than previously thought. Furthermore, the review further fuels the controversy of the precise causal relationship between uterine rupture and adverse maternal and fetal outcome, particularly as elective repeat caesarean is not completely protective. There has been a recent plethora of articles examining prognostic and predictive factors of VBAC success and adverse outcome, but virtually all are based on retrospective observational studies with obvious limitations. We feel we have probably exhausted this resource and urgently need a vehicle to generate high quality evidence- based guidelines on the selection and intrapartum management of women undergoing trial of VBAC. The obvious difficulty in this task is the need to obtain robust evidence, which is unlikely to be forthcoming, as prospective clinical trials relating to VBAC are deemed impractical and unethical. Improved data collection (prospective cohort, national registry) and standardised definitions, as stated by the authors1, are important preliminary steps. It was unfortunate the review did not systematically interrogate the 160 or so cases of uterine rupture reported. This process would have not only identified various prognostic and predictive factors, but also demonstrated the heterogeneity in practice that clearly exists. Such differences in case selection and trial abandonment between health care providers probably helps to explain the unexpected 10 times greater perinatal mortality found in Scotland2 but not in this mainly USA population based review1. Nevertheless, it could be argued that global evidence-based recommendations would be inappropriate because individual risk factors and women’s choice may not be fairly considered. However, the recommendations on VBAC produced by ACOG (1999) 3, NICE 4, and novel decision-analysis approach by Mankuta 20035, have not neglected these issues. These have centred on ensuring women are aware of the reasons for the trial of VBAC and consider this against the potential risks of accepting or declining the trial of VBAC. However, by being predominately based on heterogeneous observational studies, can their recommendations withstand quality guideline critical appraisal or even rigorous medico-legal challenge? An issue of this importance, with limited quality evidence, deserves an international strategy and consensus opinion. This body should also be actively pursuing research on preventative strategies that reduce adverse outcome, either through improved case selection, or specific intrapartum monitoring protocols. This requires international collaboration of observational data sets, standardising case ascertainment and terminology, and willingness to consider multicentre prospective research. Only then can accurate data be collected and used to establish recommendations and populate decision-analysis trees. 1. Guise JM, McDonagh MS, Osterweil P, Nygren P, Chan BK, Helfand M. Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section. BMJ 2004;329:19-25. 2. Smith GC, Pell JP, Cameron AD, Dobbie R. Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. JAMA. 2002;287:2684-90. 3. ACOG Committee on Obstetric Practice.. Vaginal birth after previous cesarean delivery. Clinical management guidelines for obstetrician-gynecologists.. International Journal of Gynaecology & Obstetrics. 1999;66:197-204. 4. NICE. Caesarean Section. 2004. National Institute of Clinical Excellence. 5. Mankuta DD, Leshno MM, Menasche MM, Brezis MM. Vaginal birth after cesarean section: Trial of labor or repeat cesarean section? A decision analysis. American Journal of Obstetrics and Gynecology 2003;189:714-9. Competing interests: None declared |
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Leeann M. Redman, Medical Lab Technologist T0A3A1
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""...vaginal birth after caesarean (VBAC) is harmful for the fetus and mother, but less so.." or more so. The debate goes on... with the goal of reducing pateint harm...right? Step back from the situation and look at the bigger picture. What was truely harm full to the patent?...the original C- section...resulting in damage...and the healing. It is actualy the damage and the healing that are both still at work in this situation....a natural process." We are only looking at one choise... cut or don't cut. Make more damage or not? I think it is sad that we have forgotten the true potential for the body to heal...and we are missing a golden oppertunity. How about build stronger muscles vs make more damage? Think out side the box for a moment: "Hospital do not heal anyone... the body heal it self (we might help of course)" Isn't it worth exploring building stronger mucles in the patients after C-section? Pregnancy takes a lot out of the body. "If the cutting... is causing the problem then why look at that as your only sol'n?" Chinese proverb" If you keep doing the exact same thing and expect to get a different out come...it's the definition of insanity. Do the patents that have uterine rupture have indicators showing they are more nutritionaly and physicaly weakened? ------------------------------------------------------------ Leeann Redman MLT lredman@myprivacy.com www.shareusana.com Competing interests: None declared |
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Michael Lockwood, DO, Physician/Department Chair 700 W Jefferson, Kirksville, MO 63501 USA
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After reading your article, I would like to compare fetal and maternal risk of a vaginal delivery after a previous succesful vaginal delivery -- no prior C-section. A VBAVB if you will. What is the risk when compared to the VBAC and repeat elective C-section rates? Competing interests: None declared |
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