The Article in Brief

Vaginal Birth After Cesarean in California: Before and After a Change in Guideline

John Zweifler, MD, MPH, and colleagues

Background In 1999, the American College of Obstetricians and Gynecologists adopted more-restrictive guidelines for vaginal birth after cesarean delivery (VBAC), requiring a physician to be immediately available to perform emergency care, if needed. This study looks at trends in VBAC in California before and after the 1999 guideline revision.

What This Study Found The percentage of women attempting vaginal birth after cesarean delivery fell significantly, from 24 percent before the guideline revision to 13.5 percent after guideline revision. This decline, however, seems to continue a national trend that began in 1997. Although rates of repeat delivery by cesarean section increased during the years following the guideline revision, death rates among infants and mothers did not improve.

Implications

• The 1999 guideline revision reflects concern for the safety of VBAC deliveries and may have accelerated the trend away from VBAC and toward repeat cesarean deliveries, particularly at rural hospitals.
• This study found that, in delivery of normal or large birth weight infants, the infant death rate for VBAC was similar to the death rate for repeat cesarean delivery.
• The authors recommend that, when counseling pregnant patients who have had a previous cesarean delivery, physicians offer a balanced presentation of risk and inform them of the encouraging outcomes found in this study.