1. OptiBIRTH VBAC-Data from Germany
PD Dr. Mechthild M. Gross, Andrea Matterne
Midwife, Head of Midwifery Research and Education Unit
Department of Obstetrics, Gynaecology and Reproductive Medicine 1

2. How „old“ are current numbers?
USA
England
Germany
Lower Saxony
Caesarean-Section Rate
2007
31.8%1
24.6%4
2008
31.6%5
30.9%7
Status Post Caesarean
11.6%6
2008 
12.6%7 
VBAC – rates =TOL
2006
~ 8.00%2
47.1%7
Successful – VBAC %3
67.2%7 
Failed - VBAC
32.8%7 
Going through the statistics it is rather challenging to find recent data from national records. The overall section rate does not differ much between the US and Germany but is higher compared to the c-section rate in the UK. Around 12% of women had a previous caesarean in their history in We found some US-data published in 2009 which reported a trial of labor of around 8% in Trial of labor of those who were VBAC-candidates in L.S. from 2008 appears to be around 47%. Taken these numbers as a reference for all VBAC-candidates, we found a S-VBAC rate of 67% in Lower Saxony in 2008.
1 U.S. Department of Health and Human Services. Centers for Disease Control and Prevention National Center for Health Statistics National Vital Statistics System. National Vital Statistics
Report. Births: Preliminary Data for Vol 57. Nr
2 U.S. Department of Health and Human Services. Centers for Disease Control and Prevention National Center for Health Statistics National Vital Statistics System. National Vital Statistics
Report. Births: Final Data for Vol 57. Nr
3 Rossi AC, D’Addario V. Maternal morbidity following a trial of labor after cesarean section vs elective repeat cesarean delivery: a systematic review with metaanalysis. AJOG 2008; 199:
4The Information Centre for health and social care. Maternity Statistics, England:
nhs-maternity-statistics-england:
5 BQS. Basisauswertung Geburtshilfe.
6 BQS. Basisauswertung Geburtshilfe.
7 Zentrum für Qualitätsmanagement. Auswertung Niedersächsische Perinatalstatistik.2008 2

3. The TOP 10 historical factors in pregnancy, Lower Saxony 2008
Parae %
Allergy
23,1
Hereditary predispositions
17,5
Maternal age > 35 years
14,8
Status post cesarean
12,6
Previous serious illness
10,1
Obesity
8,2
>= 2 previous (spontaneous) abortions
5,3
Other pregnancy related risk factors (anamnestic findings)
5,2
Addiction
4,2
Complications during previous deliveries
5,53
Multiparae %
Status post cesarean
23,9
Allergy
21,5
Maternal age > 35 years
19,7
Hereditary predispositions
16,2
Previous serious illness
9,2
Obesity
9,0
Complications during previous deliveries
8,7
>= 2 previous (spontaneous) abortions
7,6
Addiction
4,8
Other pregnancy related risk factors (anamnestic findings)
5,53
Status post caesarean section is part of a list of 52 historical factors which might be associated with a less favorable outcome of birth. If you summarize the incidence of these factors in Lower Saxony in status post caesarean is no. 4 of the most common risk factors for all pregnancies and no. 1 in the history of multiparae.
Centre for Quality and Management in Health Care at the Medical Chamber of Lower Saxony. Perinatal Statistics, 2008 3

4. Sucessful VBAC-Rate: 73%
NIH Consensus Development Conference Statement. Vaginal Birth After Cesarean. Draft Statement, March 26, 2010
“Although TOL rate has declined dramatically over the past several decades, the vaginal delivery rate after TOL has remained constant at approximately 74 percent.”
4-year-prospective study , TOL=14,529, S-VBAC=73.6%, Predictors for S-VBAC were previous vaginal delivery, previous indication not being dystocia, spontaneous labour, birth weight <4000g, Caucasian race (Landon 2005)
Population based cohort study from 2002, TOL=41,450, S-low-risk-VBAC= 73.76%, S-high-risk-VBAC=50.31% with at least one maternal, fetal, or placental condition (Gregory 2008)
Metaanalysis, 7 studies, , TOL=24,349, S-VBAC=73%, a higher risk of uterine rupture in women planning VBAC than ERCS is counterbalanced by a reduction of maternal morbidity and hysterectomy when VBAC is successful Rossi (2008)
Comparison of 364 VBAC with one previous caesarean and 6,448 women with their second labour in birth centres, S-VBAC=73.5% (David 2009)
1. The term S-VBAC rates deserves a closer look. Looking up some of the most significant papers we are able to learn that the rate of S-VBACs is easy to remember: Several papers mention the same number 73%. The Maternal Fetal Medicine Networks published a study in 2005 which referred to a multicenter 4-year-prospective study between 1999 and ,529 women underwent TOL and 73.6% achieved successful VBAC.
2. In a Californian population-based cohort study 41,450 women underwent a TOL and the VBAC-success-rate for low risk women was 73.76% vs % for high-risk women. High-risk women were defined as those with at least one maternal, fetal or placental condition complicating pregnancies (Gregory 2008).
3. The already mentioned Italian metaanalysis (Rossi 2008) reported also a S-VBAC rate of 73%.
4. David compared VBAC births with one previous caesarean with over 6000 women with their second labour and also found a S-VBAC rate of 73%
David M Gross MM Wiemer A. Pachaly J Vetter K. Prior cesarean section – an acceptable risk for vaginal delivery at free-standing midwife-led birth centers? Results of the analysis of vaginal birth after cesarean section (VBAC) in German birth centers. EJOGRB 2009;142:
Gregory KD, Korst LM, Fridman M, et al. Vaginal birth after cesarean: clinical risk factors associated with adverse outcome. Am J Obstet Gynecol 2008; 198: 452.e1-452-e12.
Landon MB et al. The MFMU Cesarean Registry: Factors affecting the success of trial of labor after previous cesarean delivery. Am J Obstet Gynecol. 2005; 193: 1016–234
Rossi AC, D’Addario V. Maternal morbidity following a trial of labor after cesarean section vs elective repeat cesarean delivery: a systematic review with metaanalysis. AJOG 2008; 199: 4

5. Collective Data of Lower Saxony and Hessen
                                                                                                                                                                                                        
Collective Data of Lower Saxony and Hessen
Land
Annual birth rate (2010)
C-section rate
Women with c-section in history
TOL with c-section in history
ERCS
f-VBAC
Overall Re-c-section rate
s-VBAC/ all TOL´s
S-VBAC/ women with c-section in history
Lower Saxony
2011
2010
56,532
58.492
33.4%
32,4%
13.8%
25,1% ?
51.3%
49.9%
21.4%
11.5% (unclear)
12.1%
73.6%
27.7%
26,2%
Hessen
48,544
16,488
34%
6,409
13.2%
2,864
44.7%
3545
55.3%
1,094
17.1%
4,639
72.4%
1770
61.8%
1,770
27.6%

6. Legend of the Table Federal state Annual birth rate C-section rate
                                                                                                                                                                                                        
Legend of the Table
Federal state
Annual birth rate
C-section rate
Women with c-section in history
SS-Risiko ist Z.n. Sectio as documented in the maternal record
TOL with c-section in history
Die Absicht einer vaginalen Entbindung wird nicht dokumentiert
Some of those may have documented a duration of labour
ERCS
SS-Risiko ist Z.n. Sectio und jetziger Geburtsmodus ist primäre Sectio, Resectio und primäre Sectio nach Misgav-Ladach
f-VBAC
SS-Risiko ist Z.n. Sectio und Sectio mit Geburtsdauer >0 (s. auch Anmerkung TOL)
Overall Re-c-section rate
Als Geburts-modus „Resectio“ ausgewiesene Geburten, denkbar wäre jedoch hier alle Sectiones bei SS-Risiko Z.n. Sectio zu zählen. Aus vielen Kliniken wissen wir, dass der OPS „Resectio“ gar nicht verwendet wird sondern prim. oder sek. Sectio ausgewählt wird. In den meisten Fällen wird die Resectio eine geplante also prim. Sectio sein.
s-VBAC/ all TOL´s
Mehrgebärende mit SS-Risiko ist Z.n. Sectio und Geburtsdauer > 0 (s. auch Anmerkung TOL)
S-VBAC/ women with c-section in history

7. Overview of Data Centre Annual birth rate (2010) C-section rate
Women with c-section in history
TOL with c-section in history
ERCS
f-VBAC
Overall Re-c-section rate
s-VBAC/ all TOL´s
S-VBAC/ women with c-section in history 1
2,012
28.3%
10.7%
55.4%
40.9%
35.8% 2
1,670
628
37.6%
181/1670
10.8%
69/181
38.1%
112/181
61.9%
24/69
34.8%
136/181
75.1%
45/69
65.2%
45/181
24.9% 3
2,596
824
31.7%
286/2596
11%
140/286
49%
146/286
51%
55/149
39.3%
201/286
70.3%
85/140
60.7%
85/286
29.7% 4
2,286
625
28.6%
242/2286
10.6%
107/242
44.2%
135/242
55.8%
40/107
37.4%
175/242
72.3%
67/107
62.6%
67/242
27.7% 5
1,995
30.2%
251 (in previous birth)
113/251
45%
80/
80/251
31.9%
1: Hannover Henriettenstiftung
2: MHH
3: Frankfurt Bürgerhospital
4: Leipzig Universitätsfrauenklinik
5: Wuppertal St. Anna Klinik

8. Guidelines 1 - USA 3 - Canada 4 - UK 5 - Germany RCOG NICE
SOGC clinical practice guidelines for vaginal birth after previous caesarean birth. 2005
NICE Clinical Practice Algorithm. RCOG Press. 2004
1 - USA
3 - Canada
4 - UK
RCOG
NICE
5 - Germany
German Society of Obstetrics and Gynecology (DGGG)
ACOG Practice Bulletin Nr.54 Vaginal Birth After Previous Cesarean Delivery. 2004
The American Academy of Family Physicians. Trial of Labor After Cesarean (TOLAC)
Daily Practice is led by guidelines and recommendations. Current guidelines in four selected countries published between 2004 and 2008 come to differing conclusions about the evidence. 8