Assuntos
Fertilização in vitro/psicologia , Consentimento Livre e Esclarecido , Responsabilidade Legal , Religião , Má Conduta Científica , Transferência Embrionária/psicologia , Feminino , Humanos , Gravidez , Taxa de Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Projetos de Pesquisa , Má Conduta Científica/legislação & jurisprudênciaRESUMO
OBJECTIVE: Some women wish to avoid a repeat cesarean delivery and believe that a midwife-supported vaginal birth after cesarean (VBAC) in a nonhospital setting represents their best chance to do so; there is a small, persistent demand for out-of-hospital VBACs. We conducted a study to obtain the data necessary to formulate an evidence-based policy on this practice. METHODS: We prospectively collected data on pregnancy outcomes of 1,913 women intending to attempt VBACs in 41 participating birth centers between 1990 and 2000. RESULTS: A total of 1,453 of the 1,913 women presented to the birth center in labor. Twenty-four percent of them were transferred to hospitals during labor; 87% of these had vaginal births. There were 6 uterine ruptures (0.4%), 1 hysterectomy (0.1%), 15 infants with 5-minute Apgar scores less than 7 (1.0%), and 7 fetal/neonatal deaths (0.5%). Most fetal deaths (5/7) occurred in women who did not have uterine ruptures. Half of uterine ruptures and 57% of perinatal deaths involved the 10% of women with more than 1 previous cesarean delivery or who had reached a gestational age of 42 weeks. Rates of uterine rupture and fetal/neonatal death were 0.2% each in women with neither of these risks. CONCLUSION: Despite a high rate of vaginal births and few uterine ruptures among women attempting VBACs in birth centers, a cesarean-scarred uterus was associated with increases in complications that require hospital management. Therefore, birth centers should refer women who have undergone previous cesarean deliveries to hospitals for delivery. Hospitals should increase access to in-hospital care provided by midwife/obstetrician teams during VBACs. LEVEL OF EVIDENCE: III.
Assuntos
Centros de Assistência à Gravidez e ao Parto , Nascimento Vaginal Após Cesárea/estatística & dados numéricos , Adulto , Índice de Apgar , Centros de Assistência à Gravidez e ao Parto/estatística & dados numéricos , Feminino , Morte Fetal/epidemiologia , Humanos , Pessoa de Meia-Idade , Transferência de Pacientes/estatística & dados numéricos , Gravidez , Resultado da Gravidez , Estados Unidos , Ruptura Uterina/etiologia , Nascimento Vaginal Após Cesárea/efeitos adversosRESUMO
PURPOSE OF REVIEW: This brief review will focus exclusively on very recent developments and controversial aspects of vaginal birth after cesarean. Only papers published in 2001 or 2002 are included. RECENT FINDINGS: Recent studies have addressed the intrapartum management of vaginal birth after cesarean patients and the safety of trial of labor compared with elective repeat cesarean. SUMMARY: The recent trend has been towards a more cautious approach to vaginal birth after cesarean. Some are concerned that this trend may limit childbirth options for those women who wish to avoid repeat cesarean operations.
