Keep Up With Shifting VBAC Standards of Care.

SAN JUAN, P. R. -- Duck! The pendulum is swinging back.

In fact; when it comes to vaginal deliveries after a prior cesarean section, there are several swinging pendulums that obstetricians must keep an eye on to avoid being hit, Dr. Steven L. Clark said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Medically, culturally, emotionally, and economically, the standards are changing, and it is important to keep up in order to avoid litigation, said Dr. Clark, professor of obstetrics and gynecology and director of the IHC Perinatal Centers at the University of Utah in Salt Lake City.

Less than 15 years ago, the standard was an automatic trial of labor for any woman with a prior C-section. The data showed a low incidence of uterine rupture, and vaginal birth after cesarean (VBAC) was deemed safe. By 1994, the American College of Obstetricians and Gynecologists watered down its strong language encouraging routine VBACs to say that women with one previous C-section should be encouraged to have a VBAC and those with more than two prior C-sections should not be discouraged from having a VBAC.

In 1999, more data revealed that the incidence of uterine rupture following VBAC is not as low as once thought, with some studies showing the incidence is 1 in 100 VBACs. ACOG now suggests that women with one prior C-section be counseled about the risks of VBAC. Those with more than one prior C-section should not be considered candidates for the procedure, especially if the scar type is unknown or the woman had a low vertical incision, the fetus is breech or macrosomic, or the woman has a twin pregnancy or is post term.

Further, ACOG recommends that a physician be "immediately available" whenever any woman with a prior C-section undergoes a trial of labor, ...