Vaginal birth after a caesarean is not always beneficial

The study by Montgomery et al and the accompanying editorial are based on the premise that vaginal delivery after one caesarean section is necessarily a beneficial and desirable objective or outcome.^{1 2} However, the risks and benefits as published in the recent RCOG (Royal College of Obstetricians and Gynaecologists) guidelines³ can be summarised as follows:

Risks

• Uterine rupture 22–74/10 000.

• 1% increase in risk of endometritis (289/10 000 versus 180/10 000).

• 1% increase in need for blood transfusion (170/10 000 versus 100/10 000).

• 2–3/10000 additional risk of birth-related perinatal death compared with planned caesarean section.

• Increased risk of antepartum stillbirths after 39 weeks with an overall increase in perinatal mortality at term.

• 8/10 000 risk of hypoxic ischaemic encephalopathy, which may have long term developmental implications.

Benefits

• Probable reduction in risk of neonatal respiratory problems: 2-3% with planned vaginal delivery after one caesarean section and 3-4% with caesarean section

• Caesarean section may increase the risk of serious complications in future pregnancies.

Given that most women in developed countries are unlikely to have more than two to three babies, the value of promoting vaginal delivery after one caesarean section is highly questionable.

Women with a breech presentation are no longer offered a choice between vaginal delivery and caesarean section on the basis of the results of the term breech trial.⁴ Must we wait for such a trial to recognise that vaginal delivery after one caesarean section costs lives and caesarean section saves lives? Women should have a choice, but this should not come before safety. To promote a process that is known to be associated with greater mortality and morbidity, or consider such a process as beneficial or desirable seems inappropriate irrespective of the reduction in women's anxiety.