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Check it out: the latest research on “Neonatal outcomes after elective cesarean delivery” (and VBAC)

August 25, 2009

The June 2009 issue of Obstetrics and Gynecology featured an article on “Neonatal outcomes after elective cesarean delivery” (Beena Kamath, et al).  For those interested in the latest studies and research on VBAC and repeat cesarean, this is an article worth checking out!

Here is a summary of the study’s findings:

OBJECTIVE: To examine the outcomes of neonates born by elective repeat cesarean delivery compared with vaginal birth after cesarean (VBAC) in women with one prior cesarean delivery and to evaluate the cost differences between elective repeat cesarean and VBAC.

METHODS: We conducted a retrospective cohort study of 672 women with one prior cesarean delivery and a singleton pregnancy at or after 37 weeks of gestation. Women were grouped according to their intention to have an elective repeat cesarean or a VBAC (successful or failed). The primary outcome was neonatal intensive care unit (NICU) admission and measures of respiratory morbidity.

RESULTS: Neonates born by cesarean delivery had higher NICU admission rates compared with the VBAC group (9.3% compared with 4.9%, P=.025) and higher rates of oxygen supplementation for delivery room resuscitation (41.5% compared with 23.2%, P<.01) and after NICU admission (5.8% compared with 2.4%, P<.028). Neonates born by VBAC required the least delivery room resuscitation with oxygen, whereas neonates delivered after failed VBAC required the greatest degree of delivery room resuscitation. The costs of elective repeat cesarean were significantly greater than VBAC. However, failed VBAC accounted for the most expensive total birth experience (delivery and NICU use).

CONCLUSION: 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.

LEVEL OF EVIDENCE: II*

The study does report that the group of unsucessful VBAC attempts (or those that ended in cesarean delivery) experienced the highest rates of chorioamnionitis (or inflammation of the amniotic membranes) and non-reassuring fetal heart tones as compared to the other groups in the study (i.e. those whose VBACs were successful and those who had elective repeat cesareans).  This does not seem entirely surprising, however, since both problems are more likely to occur during labor rather than before labor.  It’s also not surprising that these problems occurred more frequently in the group of unsucessful VBACs since non-reassuring fetal heart tones can often lead a care provider to call for a cesarean, especially with a mom attempting VBAC.

Also noteworthy is that the study reports that “neonates born by failed VBAC required the most significant measures of delivery room resuscitation, including bag or mask ventilation and endotracheal intubation, than did the other three groups.”  Thankfully, these infants took up the smallest percentage of the study’s population, especially considering that the VBAC group experienced a 74% success rate.

Howeverit is especially noteworthy that when the authors reported that the elective cesarean group had nearly double the rate of NICU admission and oxygen supplementation as compared to the VBAC group, they were including failed VBACs in the “VBAC group” population.  In other words, these rates were nearly doubled even though the “VBAC group” included those infants who “required the most significant measures of delivery room resucitation.”

And this is why the authors go on to note that

The differences seen between the intended elective repeat cesarean delivery and VBAC groups take on greater significance when one notes that the intended VBAC group includes neonates born after failed VBAC delivery, who required the greatest measures of resuscitation due to fetal distress, characterized by nonreassuring fetal heart tones and meconium-stained amniotic fluid. At the other extreme, neonates born after successful VBAC had the lowest rates of admission to the NICU, shortest hospital stay, and the lowest incidence of ongoing respiratory support.

For those interested in examining this study in more detail, check it out here.  In my humble, VBAC-supporter’s opinion, it’s an interesting and informative read!

*Worth noting is that the evidence in this study was reported as “Level II evidence,” which means that it came from a well-designed and controlled trial without randomization.  (Randomization would have qualified it as a “Level I” study, but this would have also meant that the researchers would have had to have randomly assigned women either to elective repeat cesarean or to VBAC.  And at least to my layperson’s mind, this seems like it could lead to all sorts of ethical quandaries.)

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2 Comments leave one →
  1. August 27, 2009 3:24 pm

    That is awesome amazing news. I wish more people were willing to consider VBACs. I also hope that realizing that until changes are made VBACs are really difficult to obtain and taking all measures to prevent c-sections is the best plan. Are there initial vaginal birth vs. first c-section stats like this study provide?

  2. BirthingBeautifulIdeas permalink*
    August 27, 2009 5:13 pm

    “I also hope that realizing that until changes are made VBACs are really difficult to obtain and taking all measures to prevent c-sections is the best plan.”

    A resounding AMEN to that! That’s why I love that ICAN’s mission is not only to promote VBAC but also to reduce the number of unnecessary cesareans. It’s that “first cut” that can set up a mom for lots of struggles (with VBAC, fertility, placenta issues, etc.) in the future.

    I’ll have to look up more info on the comparisons between first-born infants (whether born vaginally or by cesarean)!

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