Vaginal birth after cesarean delivery.

MANAGEMENT of labor after previous cesarean delivery continues to be a controversial area of obstetric practice. Neither repeat cesarean delivery nor a trial of labor are without risk. Currently, cesarean delivery is the most commonly performed operation, and repeat cesarean delivery is the most common indication. Although the prevalence of vaginal birth after cesarean delivery (VBAC) increased after publication of the National Institutes of Health Consensus Statement on cesarean childbirth in 1981, reports of maternal and fetal complications associated with VBAC have drawn attention to the problem of uterine rupture. In 1999, the American College of Obstetricians and Gynecologists (ACOG) changed its practice bulletin for VBAC to state that a physician who is capable of monitoring labor and performing an emergency cesarean delivery be “immediately” available as opposed to “readily” available when women attempt VBAC. This document also mandated the “immediate” availability of anesthesia and operative personnel for emergency cesarean delivery. Recently, ACOG issued the statement that “the college recognizes the implications such immediate availability has for smaller hospitals for the practice patterns of obstetricians and anesthesiologists, and for the incidence of VBAC in general. But while recognizing the possible difficulties this position may generate, this stand is taken in the interest of women’s health and patient safety.” Because VBAC continues to be controversial and affects anesthesia practice, this clinical commentary examines the epidemiologic data surrounding the VBAC controversy and discusses the obstetric risk, anesthetic implications, and management of VBAC.