Success of vaginal birth after cesarean delivery depends on multiple variables

A variety of clinical and nonclinical variables-including induction of labor, use of cervical ripening agents, private health insurance, and local practice guidelines-influence whether women who have had a cesarean delivery go on to deliver vaginally in subsequent pregnancies, according to 2 large reviews published in the August issue of the Journal of Advanced Nursing (2011;67[8]:1646-1661 and 1662-1675).

To explore clinical and nonclinical interventions that increase uptake and success of vaginal birth after cesarean delivery (VBAC), Australian researchers reviewed 27 studies of clinical factors, published between 1989 and 2008, that included more than 50,000 women and 34 studies of nonclinical factors, published between 1984 and 2007, that included more than 650,000 women. 

Researchers found lower VBAC rates and less success with VBAC when labor is induced by artificial rupture of membranes or when prostaglandins, oxytocin infusion, or cervical ripening agents are used. They recommend caution when using these methods in women with a prior cesarean delivery. VBAC rates also were lower among women who underwent radiographic pelvimetry, and using scoring systems to predict the success of VBAC generally weren’t effective. The researchers recommend against using these modalities exclusively to direct clinical practice.

Nonclinical variables also can significantly influence VBAC, including guidelines, audit, and feedback; attitudes and characteristics of individual clinicians; evidence-based information about cesarean delivery and VBAC, which can facilitate decision making by women; and private health insurance, which inconsistent evidence suggests may be a barrier to successful VBAC.

The researchers recommend that hospitals implement evidence-based local guidelines (which are often more effective than large-scale guidelines) and VBAC decision aids. They also advocate establishing clinics within existing antenatal facilities to provide women with clear, consistent, evidence-based information about their delivery choices.

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