Intended for healthcare professionals


Urge more women who have previously had a caesarean section to have vaginal delivery, experts say

BMJ 2010; 341 doi: (Published 03 August 2010) Cite this as: BMJ 2010;341:c4167
  1. Bob Roehr
  1. 1Washington, DC

    Doctors in the United States have emphasised the safety of vaginal delivery for women who have had one or two previous caesarean sections in an attempt to “swing the pendulum back to fewer caesareans and a more reasonable VBAC [vaginal birth after caesarean] rate.”

    In new guidelines the American College of Obstetricians and Gynecologists says that no woman who wishes to have a vaginal delivery should be forced to undergo a repeat caesarean section (Obstetrics & Gynecology 2010;116:450-63, doi:10.1097/AOG.0b013e3181eeb251). If a doctor is uncomfortable with a woman’s request during her prenatal care to have a vaginal delivery she should be referred to another doctor or centre, they say.

    Richard Waldman, president of the college, said that the current rate of caesarean sections was unacceptably high and that doctors needed “to work collaboratively with patients and colleagues, hospitals, and insurers” to bring down the rate of second caesareans.

    He said the new guidelines “emphasise the need for thorough counselling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy.”

    The college says that, in line with past recommendations, most women with one previous caesarean delivery with a low-transverse incision are candidates for vaginal delivery and should be counselled and offered a trial of labour.

    Jeffrey Ecker, from Massachusetts General Hospital in Boston and immediate past vice chairman of the college’s committee on obstetrics practice bulletins, who co-wrote the guidelines, said, “The college guidelines now clearly say that women with two previous low-transverse caesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a TOLAC [trial of labour after caesarean].”

    Between 60% and 80% of women who have previously had a caesarean section will have a successful vaginal delivery, says the college.

    The guidelines say that doctors should discuss vaginal delivery early in a second pregnancy so that plans can be made well in advance to accommodate a woman’s wishes. While it is safest to have a trial of vaginal delivery in hospitals where staff can provide emergency caesarean sections, hospitals that do not have the right personnel on site can still offer vaginal delivery by having processes in place to get staff in place quickly.

    In 2007, the last year for which complete statistics were available, nearly a third (31%) of all births in the United States were a result of caesarean section. In 1970 the proportion was 5%.

    The rise has been driven by a combination of factors, including women’s desire to plan their delivery better, higher revenues for hospitals, as revenue from a caesarean section is nearly double that from a natural birth, more efficient scheduled use of hospital resources, and, most importantly, fears of malpractice lawsuits.

    It has become common practice in the US for women who have had one caesarean section to have another. The rate of subsequent vaginal delivery among women who have had a first delivery by caesarean section has fluctuated from about 5% in 1985 to 28% in 1996 and 8.5% in 2006.

    A woman who has had a caesarean section faces a 0.4% to 0.5% risk of uterine rupture during a subsequent caesarean delivery; with natural delivery that rises to 0.7% to 0.9%. The risk averse practice of medicine in the litigious US has led many hospitals to establish policies that preclude the option of natural delivery for this group of women.

    The natural childbirth group Lamaze International said that the new guidelines were a step in the right direction in honouring women’s choices. However, it said that requiring a surgeon to be “immediately available” should an unplanned caesarean section be needed at birth reinforces current hospital policies “effectively denying women access to care and choice in birth.”


    Cite this as: BMJ 2010;341:c4167

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