Informed birth decisions hindered by lack of information: Expert

Evelyn Lewin

1/10/2019 3:01:17 PM

A study found vaginal birth after caesarean is associated with increased risks, but women can often remain in the dark about their options.

Mother new baby
The new study addressed the lack of robust information on the outcomes of birth options after a previous caesarean.

Following a caesarean, many pregnant women wish to attempt a vaginal birth after caesarean (VBAC) for their next delivery.
Simultaneously, many women are advised by their healthcare providers that opting for a VBAC is not only feasible, but safe.
But new research is shining a light on the risks of VBACs.
While some of the risks of VBAC are well known, the new study addressed the lack of robust information on the outcomes of birth options after previous caesarean.
The study used data from 74,043 full-term births of single babies in Scotland, born between 2002 and 2015. Of those, 45,579 women had a planned caesarean, while 28,464 attempted vaginal birth. Of the women who attempted a VBAC, 28.4% went on to have an emergency caesarean.
The researchers found that attempting VBAC was more likely to result in maternal complications such as uterine rupture (69 women versus 17); a blood transfusion (324 versus 226); sepsis and surgical injury.
VBAC also resulted in more serious infant outcomes such as stillbirth, admission to a neonatal unit, resuscitation requiring drugs or intubation, and an Apgar score of fewer than seven at five minutes.
However, the researchers noted that absolute risk of complications were small for either type of delivery. Just 1.8% of those attempting a VBAC and 0.8% of those with a planned caesarean experienced serious maternal complications, and 8% of VBACs and 6.4% of planned caesareans had one or more adverse infant outcomes.
Obstetrician, gynaecologist and fertility expert Dr Alex Polyakov is not shocked by findings that indicate VBACs pose greater risks than planned caesareans.
‘Overall it’s not really surprising that VBAC on a population level will have higher risks than a repeat caesarean,’ he told newsGP.
Despite this, Dr Polyakov said there is an ongoing push from the public sector towards women attempting VBAC due to financial considerations.  
‘It’s not a safety issue for them,’ he said.
‘It’s a fact that caesarean cost more and in terms of resources; women after a caesarean stay longer in hospitals and the recovery is usually longer.
‘So in the public sector there is this push towards increasing the rates of VBAC.’
Dr Polyakov is concerned this may lead to a lack of transparency regarding birth options being shared with pregnant women.
‘If you tell women that the risks are higher, a lot of women would probably choose to have a repeat caesarean,’ he said.
Dr Polyakov believes this stands in the way of pregnant women being able to make true informed decision over their birthing options.
‘It’s a problem,’ he said.
Dr Polyakov said that problem extends to women who are giving birth for the first time. While the risks of caesareans are often explained to first-time mums-to-be, he believes women are not receiving enough information on the very real risks of normal vaginal delivery (NVD).
‘Women are not really given the choice of how they want to deliver, because there are of course risks of normal delivery which people don’t seem to talk about a lot,’ he said.
‘In actual fact, if you do an elective caesarean at 39 weeks the risks are probably very similar to a normal delivery, but they’re different in terms of what can happen.’
For example, the risk of pelvic floor damage in women who have a caesarean is ‘non-existent’, Dr Polyakov said, while some women who have normal deliveries end up with severe problems which they may experience long term.
Dr Polyakov believes GPs are ideally placed to share ‘accurate, unbiased’ information when counselling pregnant patients about birth options.
‘A lot of GPs do shared care, so they’re in the frontline of obstetric management,’ he said.
‘I think women need to be fully informed about the risks and the likely outcomes [for each mode of delivery].’
As part of such counselling, Dr Polyakov feels women need to know their actual chances of having a successful VBAC, as many assume that attempting one will lead to a vaginal delivery.  
‘Overall, the chance of actually having a VBAC – or an instrumental delivery – is probably somewhere around 50–60%,’ Dr Polyakov said.
‘A lot of women go into [a VBAC] thinking their chance is very good of having a normal delivery, whereas in fact they’re not that great.
‘And if women go into labour and then end up with a caesarean, the complication rate is higher and women need to be told that.
‘They need to be able to make informed decisions.’

birth caesarean obstetrics VBAC

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Dr Erik Karl Beltz   2/10/2019 10:51:54 AM

This article seems to push towards repeat caesarean section, which in itself comes with risks also. Balanced information is needed and lots of factors need to be considered, like reason for first c/s, size of baby, future pregnancy wishes etc. With good counselling and discussion of different risks, VBAC could be a good choice for women.

Dr Emma Kozianski   2/10/2019 11:36:56 AM

In this article, Dr Polyakov appears to underestimate the chances of a successful VBAC as “…probably somewhere around 50–60%” whereas the cohort study states that only 28.4% of VBACs will go on to have an emergency caesar.

Dr Polyakov also asserts that in primips, elective caesars at 39 weeks have risks that are “probably very similar” to a normal delivery. This evidence appears to be founded in expert opinion alone and won’t enter my clinical practice given the established higher risks of VBACs after caesarians.

This lack of clarity in Dr Polyakov’s advice brings into question the validity of his argument. He is advocating that we deliver accurate and unbiased information to women when counselling regarding birthing options, while espousing what seems to be a view loosely based in evidence and shaped by a practice that would be the beneficiary of seeing additional women for elective caesars.

Dr Anna Clare Carswell   6/10/2019 3:59:09 PM

I am glad this study has been brought to our attention - good counselling about options is required. The public sector in our region is not pushing VBACs. I also disagree with the statement that the pelvic floor risk for caesarean is "non-existent".