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Increasing Patient Access to VBAC: New NIH and ACOG Recommendations



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Am Fam Physician. 2011 Jan 15;83(2):121-127.

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In March 2010, the National Institutes of Health (NIH) convened a consensus conference on vaginal birth after previous cesarean delivery (VBAC),1 using a systematic review from the Agency for Healthcare Research and Quality as its primary source of evidence.2 The conference occurred in the setting of an increasing U.S. cesarean delivery rate, which reached an all-time high of 32.3 percent in 2008.3 This increase was driven in part by a sharp decrease in the VBAC rate, from 28.3 percent in 1996 to 8.5 percent in 2006.4 An important factor in the decreased rate of VBAC is the inability of maternity care units to meet recommendations from the American College of Obstetricians and Gynecologists (ACOG), which stipulate that a trial of labor after previous cesarean delivery (TOLAC) should occur only in facilities with “immediately available” surgeons and anesthesiologists.5,6

The increasing rate of cesarean deliveries and the lack of access to TOLAC have created a major public health concern. Maternal morbidity and mortality seem to be increasing in the United States, partly as a result of the increase in repeat cesarean deliveries. The 2006 maternal mortality rate (13.3 deaths per 100,000 births7) is well above the Healthy People 2010 target of 3.3 per 100,000 births.8,9 The maternal mortality rate associated with elective repeat cesarean delivery is 13.4 deaths per 100,000 births, compared with 3.8 per 100,000 births for TOLAC.1

The risk of bladder injury, hysterectomy, and blood transfusion increases with a woman's number of previous cesarean deliveries.2,10 Pregnant women with three prior cesarean deliveries have a 3 percent risk of placenta previa, compared with 0.95 percent in women with a single prior cesarean delivery.1 The potential for neonatal death and neurologic injury resulting from maternal uterine rupture prompted ACOG's “immediately available” requirement. TOLAC is associated with a perinatal mortality rate of 1.3 deaths per 1,000 births, compared with 0.5 per 1,000 births for elective repeat cesarean delivery.2 It is important for physicians and patients to appreciate that the perinatal mortality rate for infants born to women attempting TOLAC is similar to that for all infants born to laboring nulliparous women.

The NIH consensus statement expresses concern about barriers faced by women who desire TOLAC, and recommends that ACOG and the American Society of Anesthesiologists consider the risks of TOLAC in the context of other obstetric risks.1 The newly updated ACOG guideline (summarized in the Practice Guideline in this issue of American Family Physician11) continues to recommend that TOLAC occur only in facilities with personnel immediately available for emergency cesarean delivery.12 Recognizing that this may not be feasible in smaller and rural hospitals, ACOG states that “respect for patient autonomy supports the concept that patients should be allowed to accept increased levels of risk, however, patients should be clearly informed of such potential increase in risk and management alternatives.”12  The guideline also contains several other provisions that may help increase the accessibility of TOLAC, including removing or relaxing several contraindications from previous guidelines (Table 112,13). Additionally, it recommends that women be transferred, as early in pregnancy as possible, to facilities that can provide TOLAC. The guideline states that women should not be forced to have a repeat cesarean delivery or be denied care if they desire TOLAC. Unfortunately, many women still may not have a practical option for TOLAC because the ACOG guideline, despite NIH recommendations, did not remove the “immediately available” stipulation.

Table 1.

Vaginal Birth After Previous Cesarean Delivery: Comparison of Guidelines from the American College of Obstetricians and Gynecologists

Recommendation 2004 Guideline13 2010 Guideline12

External cephalic version in women with previous cesarean delivery

No specific recommendations

External cephalic version for breech presentation not contraindicated in women with a prior low transverse uterine incision who are at low risk of adverse maternal and neonatal outcomes

Immediate availability of surgeons and anesthesiologists for emergency cesarean delivery

Required

Immediate availability preferred, but rural hospitals may offer TOLAC without this capability; patients can accept increased levels of risk after being counseled about risks and management alternatives

Planned response to need for emergency delivery is required

Labor induction or augmentation in TOLAC

Oxytocin (Pitocin) acceptable; prostaglandins discouraged

Oxytocin acceptable; misoprostol (Cytotec) should not be used in the third trimester; no adequate data for prostaglandin E2 (Cervidil); avoid sequential prostaglandin and oxytocin use, if possible; mechanical ripening with transcervical catheter acceptable

TOLAC in women who have had two previous cesarean deliveries and no previous vaginal deliveries

Contraindicated

May be a TOLAC candidate, based on other factors affecting chances of successful vaginal delivery

TOLAC in women with an unknown type of incision

No specific recommendations

TOLAC not contraindicated in women with an unknown scar type unless there is high clinical suspicion of previous classical incision


TOLAC = trial of labor after previous cesarean delivery.

Information from references 12 and 13.

Table 1.   Vaginal Birth After Previous Cesarean Delivery: Comparison of Guidelines from the American College of Obstetricians and Gynecologists

View Table

Table 1.

Vaginal Birth After Previous Cesarean Delivery: Comparison of Guidelines from the American College of Obstetricians and Gynecologists

Recommendation 2004 Guideline13 2010 Guideline12

External cephalic version in women with previous cesarean delivery

No specific recommendations

External cephalic version for breech presentation not contraindicated in women with a prior low transverse uterine incision who are at low risk of adverse maternal and neonatal outcomes

Immediate availability of surgeons and anesthesiologists for emergency cesarean delivery

Required

Immediate availability preferred, but rural hospitals may offer TOLAC without this capability; patients can accept increased levels of risk after being counseled about risks and management alternatives

Planned response to need for emergency delivery is required

Labor induction or augmentation in TOLAC

Oxytocin (Pitocin) acceptable; prostaglandins discouraged

Oxytocin acceptable; misoprostol (Cytotec) should not be used in the third trimester; no adequate data for prostaglandin E2 (Cervidil); avoid sequential prostaglandin and oxytocin use, if possible; mechanical ripening with transcervical catheter acceptable

TOLAC in women who have had two previous cesarean deliveries and no previous vaginal deliveries

Contraindicated

May be a TOLAC candidate, based on other factors affecting chances of successful vaginal delivery

TOLAC in women with an unknown type of incision

No specific recommendations

TOLAC not contraindicated in women with an unknown scar type unless there is high clinical suspicion of previous classical incision


TOLAC = trial of labor after previous cesarean delivery.

Information from references 12 and 13.

We encourage maternity care providers and hospitals that do not currently offer TOLAC to use the NIH statement and revised ACOG guidelines as an opportunity to reevaluate their policies on TOLAC. The Northern New England Perinatal Quality Improvement Network's VBAC project is an example of a collaborative effort between community hospitals and maternity care providers to develop risk-stratification guidelines and to facilitate planning for emergent cesarean delivery.14  Counseling patients about delivery options involves consideration of maternal and perinatal risks and benefits (Table 2 15), future childbearing plans, and the likelihood of successful VBAC. Most women who have had a previous cesarean delivery are candidates for TOLAC and should be offered that option. Women who have also had a previous vaginal delivery are at lower risk of uterine rupture, have a high likelihood of successful VBAC, and should be actively encouraged to consider TOLAC.16,17 Physicians should counsel women who plan to have subsequent pregnancies about the increased incidence of abnormal placentation with additional cesarean deliveries, and encourage them to consider TOLAC.10,18

Table 2.

TOLAC vs. ERCD: Maternal and Perinatal Outcomes

Outcome Level of evidence Effect Percent absolute risk (95% confidence interval)

Hysterectomy

Moderate

No significant difference (P =.50)

TOLAC: 0.17 (0.12 to 0.26)

ERCD: 0.28 (0.12 to 0.67)

Maternal death

High

Significantly reduced by TOLAC (P =.027)

TOLAC: 0.004 (0.001 to 0.015)

ERCD: 0.013 (0.004 to 0.042)

Neonatal death

Moderate

Significantly increased by TOLAC (P =.001)

TOLAC: 0.11 (0.06 to 0.20)

ERCD: 0.06 (0.02 to 0.15)

Perinatal death

Moderate

Significantly increased by TOLAC (P =.002)

TOLAC: 0.13 (0.06 to 0.30)

ERCD: 0.05 (0.007 to 0.38)

Transfusion

Moderate

No significant difference (P =.25)

TOLAC: 0.9 (0.4 to 2.0)

ERCD: 1.2 (0.5 to 2.6)

Uterine rupture

Moderate

Significantly increased by TOLAC (P <.001)

TOLAC: 0.47 (0.28 to 0.77)

ERCD: 0.026 (0.009 to 0.082)


ERCD = elective repeat cesarean delivery; TOLAC = trial of labor after previous cesarean delivery.

Adapted with permission from Guise JM, Denman MA, Emeis C, et al. Vaginal birth after cesarean: new insights on maternal and neonatal outcomes. Obstet Gynecol . 2010;115(6):1272, 1274.

Table 2.   TOLAC vs. ERCD: Maternal and Perinatal Outcomes

View Table

Table 2.

TOLAC vs. ERCD: Maternal and Perinatal Outcomes

Outcome Level of evidence Effect Percent absolute risk (95% confidence interval)

Hysterectomy

Moderate

No significant difference (P =.50)

TOLAC: 0.17 (0.12 to 0.26)

ERCD: 0.28 (0.12 to 0.67)

Maternal death

High

Significantly reduced by TOLAC (P =.027)

TOLAC: 0.004 (0.001 to 0.015)

ERCD: 0.013 (0.004 to 0.042)

Neonatal death

Moderate

Significantly increased by TOLAC (P =.001)

TOLAC: 0.11 (0.06 to 0.20)

ERCD: 0.06 (0.02 to 0.15)

Perinatal death

Moderate

Significantly increased by TOLAC (P =.002)

TOLAC: 0.13 (0.06 to 0.30)

ERCD: 0.05 (0.007 to 0.38)

Transfusion

Moderate

No significant difference (P =.25)

TOLAC: 0.9 (0.4 to 2.0)

ERCD: 1.2 (0.5 to 2.6)

Uterine rupture

Moderate

Significantly increased by TOLAC (P <.001)

TOLAC: 0.47 (0.28 to 0.77)

ERCD: 0.026 (0.009 to 0.082)


ERCD = elective repeat cesarean delivery; TOLAC = trial of labor after previous cesarean delivery.

Adapted with permission from Guise JM, Denman MA, Emeis C, et al. Vaginal birth after cesarean: new insights on maternal and neonatal outcomes. Obstet Gynecol . 2010;115(6):1272, 1274.

Preventing sequelae from cesarean delivery includes efforts to prevent primary cesarean delivery with evidence-based maternity care practices, such as increased use of intermittent monitoring, avoidance of elective labor induction, and the use of doulas for labor support. The American Academy of Family Physicians Board of Directors recently approved plans to revise its VBAC guideline, incorporating the evidence report from the Agency for Healthcare Research and Quality 2 and the NIH consensus statement.1 We believe the new guideline will further assist rural hospitals and family physicians as they work toward decreasing the cesarean delivery rate in the United States.

Address correspondence to Lawrence M. Leeman, MD, MPH, at lleeman@salud.unm.edu. Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

REFERENCES

1. National Institutes of Health Consensus Development Conference statement: vaginal birth after cesarean: new insights. March 8–10, 2010. Obstet Gynecol. 2010;115(6):1279–1295.

2. Guise JM, Eden K, Emeis C, et al. Vaginal birth after cesarean: new insights. Evid Rep Technol Assess (Full Rep). 2010;(191):1–397.

3. Hamilton BE, Martin JA, Ventura SJ. Births: preliminary data for 2008. http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_16.pdf. Accessed December 8, 2010.

4. Martin JA, Hamilton BE, Sutton PD, et al. Births: final data for 2006. http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf. Accessed December 8, 2010.

5. American College of Obstetricians and Gynecologists. ACOG practice bulletin. Vaginal birth after previous cesarean delivery. Number 5, July 1999 (replaces practice bulletin number 2, October 1998). Clinical management guidelines for obstetrician-gynecologists. Int J Gynaecol Obstet. 1999;66(2):197–204.

6. Roberts RG, Deutchman M, King VJ, Fryer GE, Miyoshi TJ. Changing policies on vaginal birth after cesarean: impact on access. Birth. 2007;34(4):316–322.

7. Heron M, Hoyert DL, Murphy SL, Xu J, Kochanek KD, Tejada-Vera B. Deaths: final data for 2006. http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf. Accessed December 8, 2010.

8. Healthy People 2010. Maternal, Infant, and Child Health. http://www.healthypeople.gov/document/html/volume2/16mich.htm#_Toc494699662. Accessed August 9, 2010.

9. The Joint Commission. Sentinel event alert: preventing maternal death. http://www.jointcommission.org/sentinel_event_alert_issue_44_preventing_maternal_death. Accessed August 9, 2010.

10. Silver RM, Landon MB, Rouse DJ, et al.; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006;107(6):1226–1232.

11. Armstrong C. ACOG updates recommendations on vaginal birth after previous cesarean delivery. Am Fam Physician. 2011;83(2):214, 216–217.

12. American College of Obstetricians and Gynecologists. ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstet Gynecol. 2010;116(2 pt 1):450–463.

13. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin #54: vaginal birth after previous cesarean. Obstet Gynecol. 2004;104(1):203–212.

14. Northern New England Perinatal Quality Improvement Network. VBAC project. http://www.nnepqin.org/site/page/vbac. Accessed August 9, 2010.

15. Guise JM, Denman MA, Emeis C, et al. Vaginal birth after cesarean: new insights on maternal and neonatal outcomes. Obstet Gynecol. 2010;115(6):1267–1278.

16. Mercer BM, Gilbert S, Landon MB, et al.; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Labor outcomes with increasing number of prior vaginal births after cesarean delivery. Obstet Gynecol. 2008;111(2 pt 1):285–291.

17. Zelop CM, Shipp TD, Repke JT, Cohen A, Lieberman E. Effect of previous vaginal delivery on the risk of uterine rupture during a subsequent trial of labor. Am J Obstet Gynecol. 2000;183(5):1184–1186.

18. Paré E, Quiñones JN, Macones GA. Vaginal birth after caesarean section versus elective repeat caesarean section: assessment of maternal downstream health outcomes. BJOG. 2006;113(1):75–85.


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