A new evidence report, Vaginal Birth After Cesarean:New Insights, found that vaginal birth after cesarean delivery (VBAC) is a safe and reasonable choice for most women with a previous cesarean. The report was released by the Agency for Healthcare Research and Quality (AHRQ) in March 2010. Its purpose was to synthesize the published literature on VBAC, specifically, to review the trends and incidence of VBAC, maternal benefits and harms, infant benefits and harms, relevant factors influencing each, and the directions for future research. Led by researchers at the AHRQ research center in Oregon, the investigation found evidence that, although rare, the rate of maternal mortality was significantly higher for elective repeat cesarean delivery compared with vaginal delivery. Meanwhile, the risk of uterine rupture and perinatal death remains rare but higher for vaginal deliveries. Information about other important outcomes, such as hemorrhage/transfusion, adhesions, surgical injury, and wound complications, remains uncertain due to lack of consistent definition and reporting. Moreover, investigators also found increasing evidence that women who have had multiple cesarean deliveries are at significant risk of life-threatening conditions. The report is available fee of charge online at: http://www.ahrq.gov/clinic/tp/vbacuptp.htm.
New guidelines for VBAC have been published by the American College of Obstetricians and Gynecologists (ACOG) (Obstet Gynecol 2010;116:450–463), replacing the practice bulletin issued in July 2004. The guidelines supporting VBAC and trial of labor after previous cesarean (TOLAC) are divided into three levels, depending on the strength of the evidence. Level A recommendations, based on “good and consistent scientific evidence” are as follows:
- • Most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about VBAC and offered TOLAC.
- • Epidural analgesia for labor may be used as part of TOLAC.
- • Misoprostol should not be used for third trimester cervical ripening or labor induction in patients who have had a cesarean delivery or major uterine surgery.
Level B recommendations, based on “limited or inconsistent scientific evidence,” include:
- • Women with one previous cesarean delivery with a low transverse incision, who are otherwise appropriate candidates for twin vaginal delivery, may be considered candidates for TOLAC.
- • External cephalic version for breech presentation is not contraindicated in women with a prior low transverse uterine incision who are at low risk for adverse maternal or neonatal outcomes from external cephalic version and TOLAC.
- • Those at high risk for complications (e.g., those with previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise contraindicated (e.g., those with placenta previa) are not generally candidates for planned TOLAC.
- • Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC. TOLAC is not contraindicated for women with previous cesarean delivery with an unknown uterine scar type unless there is a high clinical suspicion of a previous classical uterine incision.
Level C recommendations, primarily based on “consensus and expert opinion,” are as follows:
- • A trial of labor after previous cesarean delivery should be undertaken at facilities capable of emergency deliveries.
- • After counseling, the ultimate decision to undergo TOLAC or a repeat cesarean delivery should be made by the patient in consultation with her health care provider. The potential risks and benefits of both TOLAC and elective repeat cesarean delivery should be discussed. Documentation of counseling and the management plan should be included in the medical record.
The current U.S. cesarean delivery rate of 32.3 percent in 2008 “is undeniably high and absolutely concerns us as ob.gyns,” said Dr. Richard Waldman, President of ACOG. “Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate” (ObGyn News 2010;45(8):1–2).
Many companies are reducing their maternity leave offers because of the struggle to balance profitability and employee benefits during the economic recession in the United States (M. Woolhouse, K. Johnston Chase, Boston Globe August 12, 2010). A 2010 survey by the Society for Human Resource Management found that 17 percent of employers offer paid maternity leave, but 7 percent plan to reduce or eliminate the benefit. The issue has come under renewed scrutiny after the Massachusetts Supreme Judicial Court ruled in August that the state’s Maternity Leave Act—which covers businesses with 50 or fewer employees—only allows job protection for up to 8 weeks after the birth of a child. The federal Family and Medical Leave Act requires companies with 50 employees or more to offer 12 weeks of unpaid leave for the birth of a child or other reasons, such as caring for a sick relative. According to the Center for Economic and Policy Research (CEPR), the federal law covers about 60 percent of the U.S. workforce, and about one-fifth of U.S. employers do not offer maternity-related leave of any kind.
The Globe reports that the U.S. has “one of the most stringent leave policies” in the developed world. The U.S. and Australia are the only countries out of 21 high-income nations that offer no paid parental leave, although Australia offers 1 year of unpaid leave, according to a 2008 study by CEPR. Canada offers women 1 year of maternity leave, including 29 weeks at full salary, whereas Sweden offers women 85 weeks of maternity leave—40 of which are paid—and up to 163 weeks off for both parents combined (Woolhouse/Johnston Chase, Boston Globe, Aug 12, 2010). Barry Zuckerman, chief of pediatrics at Boston Medical Center, said 8 weeks of maternity leave—the time frame used in state law—is not enough time for mothers to get to know their babies. Most mothers need 12 weeks to understand their newborn’s needs, as well as their own, he said. “I worry about the mothers who don’t have that sense of mastering that early period,” Zuckerman said.
Cesarean section rates have increased recently in Ireland, Scotland, and Wales, but the rate in England has remained the same at 24.6 percent in recent years from 2007–08 and 2008–09 (NHS Maternity Statistics, 2008–09, Dec 11, 2009). In Wales the rate of cesarean deliveries rose from 23 percent in 1999–00 to 27 percent in 2008–09 (Maternity Statistics Wales: Methods of Delivery, 1999–2009 February 10, 2010). In Scotland the cesarean delivery rate has increased from 8.6 percent in 1976 to 24.7 percent in 2008 (Statistical Publication Notice, Births in Scottish Hospitals, 2007/2008, September 29, 2009). In Ireland, the cesarean delivery rate increased from 20.5 percent in 1999 to 25.6 percent in 2006 (Recent Trends in the Caesarean Section Rate in Ireland 1999–2006, Working Paper No. 309, August, 2009).
Babies born by cesarean section had markedly different bacteria on their skin, noses, mouths, and rectums than babies born vaginally, according to a recent study (R. Ehrenberg, Science News June 21, 2010). The research added to evidence that babies born by means of cesarean section may miss out on beneficial bacteria passed on by their mothers. Previous research suggests that cesarean-born babies are more likely to develop allergies, asthma, and other immune system–related troubles than are babies born vaginally. The new study, published online June 22 in the Proceedings of the National Academy of Sciences, offers a detailed look at the early stages of the body’s colonization by microbes, which shape the developing immune system, help extract nutrients from food, and keep harmful microbes at bay. Babies born vaginally were colonized predominantly by Lactobacillus, microbes that aid in milk digestion, the research team from the University of Puerto Rico, the University of Colorado in Boulder, and two Venezuelan institutes reported. The cesarean-born babies were colonized by a mixture of potentially harmful bacteria typically found on the skin and in hospitals, such as Staphylococcus and Acinetobacter.
In Canada, rates of breastfeeding initiation have steadily increased in the last 5 years (Canadian Perinatal Health Report, 2008). In 2005, 87.0 percent of mothers who gave birth in the previous 5 years initiated breastfeeding compared with 81.6 percent in 2000–2001. (By comparison, in the United States the initiation rate for breastfeeding was 73.4% in 2004–2008.) Rates of exclusive breastfeeding for at least 6 months in Canada have similarly increased—in 2005, 16.4 percent of infants were breastfed exclusively for 6 months compared with 14.2 percent in 2003. Breastfeeding rates were higher among older mothers than those among younger mothers in both 2003 and 2005. Breastfeeding initiation rates varied by province, with an increasing trend from east to west, ranging from a low of 62.3 percent in Newfoundland and Labrador to 98.8 percent in the Yukon in 2005. The full report is available online at: http://www.publichealth.gc.ca/cphr/.
All women should be given an antibiotic 1 hour before a cesarean delivery to prevent infection, according to a new recommendation of the American College of Obstetricians and Gynecologists (ACOG Committee Opinion No. 465, September, 2010). Infection is the most common complication of cesarean delivery and can occur in 10 to 40 percent of women who have a cesarean compared with 1 to 3 percent of women who deliver vaginally. Although antibiotics have been given to women having cesareans to reduce their risk of postoperative infections, they have generally been given after the baby was born and the umbilical cord was clamped. The new procedure should help reduce the overall rate of cesarean-related infections.