The first woman in recorded history to survive a cesarean section, performed by her farmer husband in 1500, went on to have several more vaginal births. Even in the early 1900s a cesarean section was a radical surgery reserved for extreme obstetrical circumstances. The risks for women in terms of morbidity and mortality were substantial in that era. Though Dr. Cragin attended VBACs himself, he coined the famous saying, "once a cesarean, always a cesarean," to emphasize that the first operation often led to subsequent dangerous surgeries. In Europe VBAC was the norm throughout the last century, while in the United States VBAC was almost unheard of until the 1950s. The trickle of VBACs increased until the early 1980s when several large studies confirmed the relative safety of VBAC. About the same time, Nancy Wainer Cohen and Lynn Baptisti Richards published their influential books (see references at the end of this article) about the ill effects that cesareans can have on women's psyches and the joyful triumph that accompanies VBACs. The trickle of VBACs became a steady stream, to the point that obstetricians began attending meaningful numbers of VBACs in the late 1980s and 1990s.

The early 1990s saw VBACs being recommended to more and more women, managed care organizations encouraging doctors to do VBACs, the contraindications for VBAC shrinking, the uterine closure technique changing from a double-layer to a single-layer closure, and obstetricians managing VBACs like any other birth (induction, aggressive use of Pitocin, epidurals, etc.). Meanwhile, doctors and hospitals began seeing some catastrophic complications of previous cesareans, the most frequent being uterine rupture in labor and the most dramatic being placenta percreta. As a result, obstetricians lost some of their enthusiasm for VBACs when serious complications left vivid and terrifying memories. The American College of Obstetricians and Gynecologists (ACOG) retreated on some of its earlier endorsement of VBACs by changing the Clinical Management Guidelines for Obstetrician-Gynecologists in July 1999. These guidelines reflect a more cautious approach to VBAC and a less enthusiastic endorsement than previously. Some midwives have been attending VBACs for years, many with excellent outcomes. But there have been a few tragedies in the homebirth community that, together with the changing mood among obstetricians, have many midwives taking a second look at VBAC.

The likelihood that a woman will have a successful VBAC depends to some extent on her obstetrical history and the reason for her previous c-section. The published success rates for hospital VBACs generally range from 60-80 percent. A woman who had a vaginal birth followed by a c-section is much more likely to have a VBAC than a woman who has never had a vaginal birth. Women having a VBAV (a non-standard term that we use in our practice for a woman having a "vaginal birth after a VBAC") are also very likely, but not guaranteed, to have another successful VBAC. Women with non-recurring reasons for the first c-section, such as fetal distress or breech, have higher VBAC success rates than women given a diagnosis of cephalopelvic disproportion (CPD) or failure to progress (FTP). The initial CPD diagnosis is fraught with difficulty, since successful VBAC babies are sometimes 1 to 1.5 pounds bigger than the "CPD" older sibling.

From A VBAC Primer: Technical Issues for Midwives - by Heidi Rinehart, MD. This article first appeared in Midwifery Today Issue 57, Spring 2001.

I had the opportunity to work three years (1997-2000) in the department of Apurimac, Peru as director of a Child Survival Project. It was an incredible public health experience that deepened my nascent interest in midwifery.

A Child Survival Project works on public health interventions that have been proven to reduce infant mortality. These typically include vaccinations, access to care in cases of diarrhea and pneumonia, and may include growth monitoring, nutrition and other topics. Our project included diarrhea, pneumonia and growth monitoring/nutrition interventions, and we also worked on maternal health issues. The project was based in the approximately 140 communities in the province of Cotabambas, Apurimac, and focused on training community health workers (promotores), traditional birth attendants (parteras) and some traditional healers (hampiq runas in Quechua.) The project staff trained the promotores and hampiq runas in effective ways to treat diarrhea with and without signs of dehydration, and pneumonia, as these two diseases were the two primary killers of children under 5 in the zone and in most parts of the developing world. Project staff also trained promotores to refer mothers to the health posts for vaccines, growth monitoring checkups and enrollment in nutrition programs sponsored by the Fujimori government.

Our maternal health component included work with parteras, and was centered on teaching them the signos de alarma (danger signs) during pregnancy and how to refer those moms to the local health center for follow-up with the professional midwife on staff. The danger signs included swelling of hands and/or face, loss of blood, no movement of the fetus, headaches and attacks (signs of preeclampsia). Later on, the project was also able to give most parteras a kit de parto limpio (clean birth kit), which included soap, string to tie the umbilical cord, plastic for the delivery area and a razor. All health education was presented in Quechua, the language of the population.

From Peru: Midwifery on High - by Ruth Madison. This article first appeared in Midwifery Today Issue 61, Spring 2002