Vaginal birth after caesarean section: Current status and where to from here?

Vaginal birth after caesarean (VBAC) delivery remains a controversial topic, and one for which there is a lack of robust data to guide clinicians and parturients regarding their best option for mode of delivery in a subsequent pregnancy. In many developed countries the trend observed in recent years is that of progressively reduced VBAC rates, and hence increased use of elective repeat caesarean section (ERCS). This factor has contributed, more than any other, to the disproportionately high caesarean section (CS) rates in many countries. With current CS rates varying between 30 and 50% in the developed world, a previous CS is the cited primary indication in approximately 30%. To compound matters, there are huge variations in the reported VBAC rates between different countries, regions and even institutions. This review has focused on the recent trends in VBAC attempt, success and overall rates internationally, with inclusion of figures for a period of 25 years from a single Irish institution. An analysis of the reported factors that influence VBAC success, or failure, is presented. The complex task of estimating risk, both perinatal and maternal, for women who pursue VBAC or ERCS, is included in this review. Finally, the current evidence base for clinical practice pertaining to VBAC is outlined, with inclusion of commentary regarding the future for this difficult area of obstetric practice.