Intended for healthcare professionals

Rapid response to:

Research

Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39405.539282.BE (Published 10 January 2008) Cite this as: BMJ 2008;336:85

Rapid Response:

Vaginal birth after caesarean section (VBAC): Lay guidelines must put risks into perspective

Offering vaginal birth after caesarean section (VBAC) is an
established recommendation to prevent further escalation in caesarean
sections (CS) rates worldwide and to combat the fivefold increased risk of
serious respiratory morbidity associated with early elective caesarean
sections. (1) Success rates of VBAC are extremely variable ranging from
10% with an unengaged head at term to 74% for low-risk women without co-
morbidities. (2) A planned VBAC carries a risk of uterine rupture of 22-
74/10,000 and a 2-3/10,000 additional risk of birth-related perinatal
death when compared with an elective repeat CS; the latter is comparable
to the absolute risk for nulliparous women.(3) In the UK, the overall
vaginal delivery rate is only 33% following a previous CS suggesting poor
uptake and supported by the fact that up to 60% women having a repeat CS
may be unaware of other delivery options.(4)

The National Institute for Health and Clinical Excellence (NICE)
developed a clinical guideline entitled ‘Caesarean Section’, published in
April 2004, to provide information on risks for women contemplating birth
after a previous CS.(5) The information for the public advises that
“[women] be aware that some rare but serious complications are increased
with vaginal birth after a caesarean section. These possible
complications include your scar tearing apart or the baby dying”.(6) This
statement is unqualified and clearly frightening. It is our experience
that women are unable to make a balanced judgement once they have read the
guideline. The actual risk of a perinatal loss following a VBAC is small
– 1 in 2500 in units with appropriate facilities including obstetrician
availability.(7) This equates to a comparable risk of perinatal death in a
nulliparous woman. There is no mention of the benefits of a successful
planned VBAC (7), or the serious morbidity that may be associated with
elective surgery(1) or multiple repeat caesareans. These issues are
equally emotive and it is inappropriate that they are not mentioned or
quantified for the lay person.

In an audit of 70 women referred to a VBAC clinic over a 3-month
period, conducted at two time points in 2006 and 2007, the proportion of
women receiving the leaflets increased from 41% to 71% with a concomitant
rise in the number of elective repeat CS performed from 19% to 27%. A
majority of women requesting elective CS directly cited the NICE
guidelines as providing the basis for this decision.

Guidelines should not only be accurate but balanced and either
quantify risks or put them in perspective for lay people. We believe the
current guideline is resulting in perverse and inappropriate practice.

References

1. Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB. Risk of
respiratory morbidity in term infants delivered by elective caesarean
section: cohort study. BMJ 2008; 336: 85-87.

2. Gregory KD, Korst LM, Fridman M, Shihady I, Broussard P, Fink A,
et al. Vaginal birth after caesarean: clinical risk factors
associated with adverse outcome. Am J Obstet Gynecol 2008; 198: 452.e1-
10.

3. Varma R, Gupta JK, Smith GCS. Birth after previous caesarean
birth. Green-top Guideline No. 45. London: RCOG Press, 2007.

4. Moffat MA, Bell JS, Porter MA, Lawton S, Hundley V, Danielian P,
et al. Decision making about mode of delivery among pregnant women who
have previously had a caesarean section: a qualitative study. BJOG 2007;
114: 86-93.

5. National Collaborating Centre for Women’s and Children’s Health.
Caesarean Section. London: RCOG Press, 2004.

6. National Collaborating Centre for Women’s and Children’s Health.
Caesarean Section – Understanding NICE guidance – information for pregnant
women, their partners and the public. London: RCOG Press, 2004.

7. Landon MB, Hauth JC, Leveno KJ, Spong CY, Leindecker S, Varner MW,
et al. Maternal and perinatal outcomes associated with a trial of labor
after prior caesarean delivery. N Engl J Med 2004; 351: 2581-2589.

Competing interests:
None declared

Competing interests: No competing interests

06 July 2008
Manju Chandiramani
Clinical research fellow in Obstetrics & Gynaecology
Nina Khazaezadeh, Anna Kenyon, Lucy Chappell, Andrew H. Shennan
St Thomas' Hospital, London