Issn Print: 0029-7828

Publication Date: 1998/11/01


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Point/Counterpoint: II. The VBAC "Con" Game

Jeffrey P. Phelan

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As we enter the new millennium, vaginal birth after cesarean (VBAC) will continue to be an acceptable alternative to an elective repeat cesarean [1-5]. As an early VBAC advocate and researcher, I have recently questioned whether we should reconsider VBAC and return to a policy of "once a cesarean, always a cesarean." [5]. Dr. Flamm, however, contends we should not because neither VBAC nor its alternative are risk free and that the overall risk of VBAC is small. But, the main risk of VBAC is uterine rupture. This occurs in 1 percent of patients [6]. Moreover, the risk of uterine rupture is in addition to the usual risks associated with a trial of labor in patients without a uterine scar. Nevertheless, I do not advocate a policy of "once a cesarean, always a cesarean"; rather, if a VBAC is contemplated, I believe the patient should be better informed.
When we, obstetricians, provide informed consent, we must understand that fetal brain injury can occur fairly quickly in cases of uterine rupture. If it does occur, for example, emergency cesarean will need to be performed within 17 to 18 minutes [6] from the onset of a prolonged fetal heart rate (FHR) deceleration or bradycardia to preserve fetal central nervous system integrity. This type of "fetal distress" affords the obstetrician and hospital personnel limited time to institute intrauterine resuscitative measures [7], to begin a cesarean section, and to also deliver the fetus. In light of the rapidity of response that is required both Dr. Flamm and I have advocated crash cesarean drills for several years. An integral part of the rapid response drill is the availability of a limited cesarean pack to further expedite the delivery. With the implementation of these approaches, the risk of fetal brain injury will be reduced but not eliminated.
The second issue is not whether uterine rupture is a material risk that requires disclosure, but what to tell the VBAC candidate of the potential risk of fetal brain damage. Dr. Flamm argues that we should not use the phrase "brain damage." Rather, he would prefer to label it under the umbrella of "injury to the fetus." According to Dr. Flamm, using the phrase "brain damage" would have a chilling effect on the VBAC rate and thwart any efforts to reduce the overall cesarean delivery rate. I would ask Dr. Flamm, why, then, should we trouble ourselves with all those vaginal cultures and antibiotics for Group B Streptococcal (GBS) infection [8]? After all, the attack rate for GBS is 1 to 3 per 1000 births and is considerably less than risk of fetal brain damage from a uterine rupture. On the basis of those same assumptions, we should stop offering HIV screening to every pregnant woman because 99 percent will have a negative test? Dr. Flamm seems to have forgotten the reasons why we offer these tests or inform patients about the options of VBAC and an elective repeat cesarean. First and foremost, it is not our pregnancy. Simply put, it is this fetus, it is this pregnant woman, and it is this family that suffers the consequences of a uterine rupture. None of us who are physicians or nurses who watch our patients undertake a VBAC will suffer brain damage or a hysterectomy or any other consequence. It is the patient and her baby. Thus, the simple solution is to let the patient decide, and allow her, not you, to assume the risk of a uterine rupture.
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