More than 150 family physicians got the inside scoop on the process of developing an AAFP clinical guideline Oct. 1, when family physician Eric Wall, M.D., updated Assembly-goers on a maternity care guideline released in July.
The new guideline, "Trial of Labor After Cesarean (TOLAC), Formerly Trial of Labor Versus Elective Repeat Cesarean Section for the Woman With a Previous Cesarean Section," was developed by a panel of family physician experts using evidence from an Agency for Healthcare Research and Quality evidence report, Vaginal Birth After Cesarean. Wall led the guideline panel, which systematically reviewed the evidence provided in the AHRQ report, as well as subsequent relevant research reports, in formulating its recommendations.
At the beginning of the guideline development process, Wall noted, the Academy formally approached the American College of Obstetricians and Gynecologists about collaborating to produce a "jointly developed evidence-based guideline." Officials at ACOG declined the invitation, however, indicating "they really wished to stick with their own process of guideline development," Wall said.
With one exception, most of the recommendations included in the TOLAC guideline differ little from those in the Academy's 1995 guideline on elective repeat cesarean. The panel looked first at whether women who have had one previous cesarean delivery with a low transverse incision should be offered a trial of labor to deliver subsequent infants, Wall said. Panel members assessed such factors as the likelihood of vaginal delivery for these women, as well as rates of maternal and infant complications associated with trial of labor.
Overall, Wall said, the panel found fair to good evidence supporting the likelihood of successful vaginal delivery for these patients and recommended that a trial of labor be offered to those desiring that option. At the same time, he noted, the evidence highlighted factors that influence women's chances for a successful vaginal delivery, including maternal age and other factors. Patients desiring TOLAC should be counseled that their chance for a successful vaginal birth after cesarean is influenced by these factors, panel members recommended.
The panel also recommended against using prostaglandins for cervical ripening or induction because their use is associated with higher rates of uterine rupture and decreased rates of successful vaginal delivery, Wall said. Not surprisingly, the panel recommended that maternity care professionals explore with patients all the issues that may affect their decisions, including issues such as recovery time and safety, although no evidence-based recommendation could be made regarding the best way to present the risks and benefits of TOLAC to patients.
Where the new TOLAC guideline departed from the earlier AAFP clinical guidance, as well as from ACOG recommendations, was in a recommendation regarding appropriate surgical support. "This is the recommendation you're going to hear a lot about if you hear about this guideline," Wall said. "This is the most controversial of the recommendations."
The AAFP recommendation reads: "TOLAC should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes." That said, it is clinically appropriate to formulate and document a management plan for uterine rupture and other potential emergencies for any woman undergoing TOLAC, the panel further noted.
The AAFP recommendation flies in the face of the concept of "immediately available support" promulgated by ACOG in previous practice bulletins, Wall said. At many medical facilities, "This provision has been interpreted to mean the constant presence of surgical and support teams," he added. Even despite the fact that ACOG itself recently acknowledged a lack of clinical evidence showing that more rapid emergency response resulted in better outcomes, the college reiterated its restrictive recommendation in its 2004 recommendation on VBAC, said Wall.
The differences represent a clash of cultures, said Kent Lee, M.D., of Conroe, Texas. "I'm a little dismayed about the relationship between our two academies," Lee said. "It should be collaborative, not competitive. I think that happens far too often."
The situation also speaks to a need for advocacy by the Academy, said Sharon Mulvehill, M.D., of Billings, Mont. "AAFP needs to have a home for those of us who perform maternity care because we're becoming more and more marginalized," she said.
Others saw the guideline panel's work as a boon to patients wishing to have their family physicians attend their infants' births: "I really want to thank the Academy for this from those of us who practice in rural areas," said Katy Sheridan, M.D., of Soldotna, Ark. "This is about patients; this isn't about being able to do a few more deliveries."
