Tuesday, July 28, 2009

Neonatal Outcomes Better With VBAC

This is from the June issue of *Obstetrics and Gynecology*!! All of the things WE'VE KNOWN, yet they have been against admitting. Maybe the evidence of harm in ERCS is increasing?

Women need to be educated. That's the first step. They need to stop being so darn scared of the pain of labor, and educate themselves of the dangers of things like inductions, augmentation, epidurals, labor narcotics, artificial rupture of membranes, and delivering in the hospital period.


Neonatal Outcomes May Be Better With Vaginal Birth After Cesarean Delivery

Laurie Barclay, MD

June 3, 2009 — Neonates born after elective subsequent cesarean delivery have significantly higher rates of respiratory morbidity and neonatal intensive care unit (NICU) admission and longer length of hospital stay vs those with vaginal birth after cesarean (VBAC), according to the results of a retrospective cohort study reported in the June issue of *Obstetrics & Gynecology*.

"Controversy remains on whether a trial of labor or an elective repeat cesarean delivery is preferable for a woman with a history of cesarean delivery," write Beena D. Kamath, MD, MPH, from the University of Colorado
School of Medicine in Denver, and colleagues.

Wait? What?!?!?! Didn't the study prove that outcomes were better with VBAC?

"Historically, concerns regarding the increased risk of uterine rupture and perinatal asphyxia in trial of labor after cesarean compared with planned repeat cesarean have swayed obstetricians away from recommending a trial of labor after cesarean delivery; however, the absolute risk of perinatal asphyxia remains small."

Um - the risk of Uterine Rupture is approximately 0.3-0.7%. And that's not the risk of death with UR. The actual risk of death of baby after a Uterine Rupture is a FRACTION of this less than 1% risk. And the OBs are swayed against recommending it - why?? And historically? Really? Is that why the VBAC rates were HIGHER 10 years ago, and the cesarean rate lower?

The goals of this study were to compare the outcomes of neonates born by elective subsequent cesarean delivery vs VBAC in women with 1 previous cesarean delivery and to compare the cost differences between these
procedures. The study cohort consisted of 672 women with 1 previous cesarean
delivery and a singleton pregnancy at or after 37 weeks of gestation. Participants were categorized based on their intention to have an elective subsequent cesarean delivery or a VBAC, whether successful or failed. The main endpoints of the study were NICU admission and measures of respiratory morbidity.

Compared with the VBAC group, neonates born by cesarean delivery had higher
NICU admission rates (9.3% vs 4.9%; *P* = .025).

:Nods: I lived through the absolute HELL of this.

Rates of oxygen supplementation were also higher in the subsequent cesarean group for delivery room resuscitation (41.5% vs 23.2%; *P *< .01)

:Nods Again: Noah was on CPAP the first 2 days, intubated the following 2 days, and then on a nasal cannula for the remainder of his 9 day stay.

and after NICU admission (5.8% vs 2.4%; *P* < .028).

DOUBLE the risk of NICU stay - did you catch that?!?!

The rates of delivery room resuscitation with oxygen were lowest in neonates born by VBAC and highest in neonates delivered after failed VBAC.

Yep. I can see that. "Failed" VBAC = Another Cesarean Section. Cesareans are harmful for baby. Got it.

Although the costs of elective subsequent cesarean delivery were significantly higher vs VBAC,

And women really believe that their surgeon - Ooops! I mean OB - don't get paid more for elective surgeries? They can schedule it around their personal schedule, and they're in and out in about a total of 2 hours. Hmmmm ...

the highest costs for the total birth experience were for failed VBAC, considering both delivery and NICU use.

I would LOVE to see hospital VBAC success % vs Home VBAC success %. Those of us who know, know that VBACs are more likely to be successful at home, due to a NUMBER of different factors.

"In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay," the study authors write.

And yet, women are still told that VBAC is too dangerous. Really?!

Limitations of this study include relatively short postpartum follow-up of the mothers to determine the additional costs of postsurgical complications and insufficient data to allow estimation of costs other than those for hospital care.

Even if you don't know a whole lot about Cesareans vs. Vaginal Birth, it is a pretty logical conclusion to believe that complications are higher after surgery, correct? This study didn't account for those women who had to go back into surgery because of an infected uterus or incision. It didn't account for those who were sent home with Home Health Care Nurses, because they had to pack their incision for several weeks.

"Given the increasing rates of primary cesarean delivery and the concomitant decrease in VBACs, once a woman has had a primary cesarean delivery, we must consider the risks that this places on her subsequent deliveries and subsequent neonates," the study authors conclude.

Hmm. Okay study authors, are you suggesting that cesarean sections not be recommended for the slightest thing, as they are now? That would require OBs not intervening in normal labor as much as they do. That would mean not breaking a woman's water, not restricting women to the bed, and not recommending inductions or augmentation. Start THERE!

"Indeed, this argues for greater selectivity in performing a cesarean delivery in the first place, and certainly a greater need for counseling before a primary elective cesarean delivery.

The ways that "elective cesarean delivery" are used though, is what needs to be examined as well. My cesarean was labeled "elective" in my surgical notes. Did I ultimately consent? Sure, after having the crap scared out of me by my OB. Do they account for coercion? Abuse of perceived authority?

As investigators continue to search for ways to make cesarean delivery safer,

Wait - WHAT?!?! There *AREN'T* any ways to make cesareans safer. It's MAJOR ABDOMINAL SURGERY! You are literally removing a baby from a woman's body - most of the time before the baby is ready to be born. And has anyone missed how rough a cesarean can be for a baby?

we may be better served by exploring other means for reducing overall cesarean delivery rates and recognizing our own preoccupation with the individual that will be our patient, whether it be mother or neonate."

Not very intelligent or witty, I know - but my only response to this is DUH!

*The study authors have disclosed no relevant financial relationships.*

*Obstet Gynecol*. 2009;113:1231-1238.


Kayce Pearson said...

The commentary you had on this is perfect.

I get so tired of people downplaying the risks of a cesarean while only describing the risks of a VBAC.

The consent forms here are entitled "The benefits and risks of a cesarean" and "The risks of a VBAC". It is so one sided, and for every reason you said.

It is major surgery, and surgery has become so standard in our country that people don't even bat an eye, and that used to be me (sad to say).

I still say that if I can't have an elective appendectomy, they can't have an elective cesarean...

Rebekah Costello said...

So well said, I've got nothing to add!

It's truly mind-boggling they are still treating this like it's some mystery they can't solve! Sometimes, yes, the simplest, CHEAPEST solutions ARE the best.