A new evidence-based clinical practice guideline from the AAFP recommends that certain women with a single previous cesarean delivery are candidates for and should be offered a trial of labor to deliver subsequent infants.
The guideline, "Trial of Labor After Cesarean (TOLAC), Formerly Trial of Labor Versus Elective Repeat Cesarean Section for the Woman With a Previous Cesarean Section," also comes down on the side of greater patient choice and access by stating that such women need not be limited to attempting a trial of labor only at facilities in which surgical teams are present throughout the labor process.
However, the guideline adds, it is appropriate that a management plan for uterine rupture and other possible emergencies -- including potential surgical intervention -- be documented for all women undergoing TOLAC.
“The AAFP’s TOLAC guideline reflects family medicine’s patient-centered approach to care, while continuing the AAFP’s dedication to promoting evidence-based medical practices,” AAFP President Mary Frank, M.D., of Mill Valley, Calif., said of the announcement. “This will better inform the discussion a pregnant woman has with her family physician.”
The guideline was published July 26 as a supplement to the online version of the July/August Annals of Family Medicine. An executive summary of the guideline, including the practice recommendations, appears in the table below.
Clinical Guideline Offers Maternity Care Guidance
By Cindy Borgmeyer
7/29/2005
Modified with permission from Borgmeyer CM. Guideline Showcases AAFP's Commitment to Evidence-Based, Patient-Centered Care. Ann Fam Med 2005;3:378-380. Copyright (c) 2005 Annals of Family Medicine Inc.
The Making of a Guideline
The process the Academy uses to develop its clinical practice guidelines centers on a rigorous, systematic review of the available scientific evidence. To this end, the AAFP successfully nominated the topic to the Agency for Healthcare Research and Quality for an evidence review by the agency's Evidence-based Practice Centers, in this case, by its Oregon EPC (Oregon Health & Science University in Portland). The American College of Obstetricians and Gynecologists had earlier independently nominated the same topic to AHRQ.
Specific questions addressed during the VBAC evidence synthesis covered such issues as the frequency of successful vaginal delivery in women who undergo a trial of labor after prior low transverse cesarean; accuracy of risk-assessment tools in identifying patients likely to have a successful vaginal delivery after a TOL; and relative harms associated with a TOL versus repeat cesarean, including the incidence of uterine rupture.
Specific questions addressed during the VBAC evidence synthesis covered such issues as the frequency of successful vaginal delivery in women who undergo a trial of labor after prior low transverse cesarean; accuracy of risk-assessment tools in identifying patients likely to have a successful vaginal delivery after a TOL; and relative harms associated with a TOL versus repeat cesarean, including the incidence of uterine rupture.
Different Organizational Perspectives
AHRQ released its evidence report, "Vaginal Birth After Cesarean (VBAC)," in March 2003. ACOG updated its previous VBAC guideline and published its new guidance as ACOG Practice Bulletin no. 54 in the July 2004 Obstetrics and Gynecology. An overview of that practice bulletin appeared in the Oct. 1, 2004, American Family Physician.
The AAFP TOLAC clinical guideline panel completed its work this past March, having taken the additional step of conducting a systematic review of studies published since completion of the AHRQ report.
One change from the Academy's earlier clinical guideline on vaginal birth after cesarean, or VBAC, is that the new TOLAC guideline discourages administration of prostaglandins for cervical ripening or labor induction, as use of these agents has been associated with increased rates of uterine rupture and lower rates of successful vaginal delivery.
In most instances, the Academy guideline aligns with that published by ACOG. In one key aspect, however. the two organizations' guidelines diverge. Whereas the AAFP guideline states that TOLAC should not be restricted only to facilities with available surgical teams present throughout labor, ACOG takes the stance that VBAC should only be attempted in institutions equipped to respond to emergencies and with physicians "immediately available throughout active labor" to provide emergency care.
For the Academy, it came down to patient choice and access to care, according to Richard Roberts, M.D., J.D., an AAFP past president and member of the TOLAC clinical guideline panel.
"When a change in practice is proposed for all communities, we believe that there should be evidence that the change is more likely to do good than harm," Roberts explained. "In the matter of TOLAC, there are no studies that show that requiring the immediate presence of a surgeon improves outcomes. There is indirect evidence that such a policy has decreased access to TOLAC."
All of the Academy's clinical policy statements and recommendations may be accessed online.
The AAFP TOLAC clinical guideline panel completed its work this past March, having taken the additional step of conducting a systematic review of studies published since completion of the AHRQ report.
One change from the Academy's earlier clinical guideline on vaginal birth after cesarean, or VBAC, is that the new TOLAC guideline discourages administration of prostaglandins for cervical ripening or labor induction, as use of these agents has been associated with increased rates of uterine rupture and lower rates of successful vaginal delivery.
In most instances, the Academy guideline aligns with that published by ACOG. In one key aspect, however. the two organizations' guidelines diverge. Whereas the AAFP guideline states that TOLAC should not be restricted only to facilities with available surgical teams present throughout labor, ACOG takes the stance that VBAC should only be attempted in institutions equipped to respond to emergencies and with physicians "immediately available throughout active labor" to provide emergency care.
For the Academy, it came down to patient choice and access to care, according to Richard Roberts, M.D., J.D., an AAFP past president and member of the TOLAC clinical guideline panel.
"When a change in practice is proposed for all communities, we believe that there should be evidence that the change is more likely to do good than harm," Roberts explained. "In the matter of TOLAC, there are no studies that show that requiring the immediate presence of a surgeon improves outcomes. There is indirect evidence that such a policy has decreased access to TOLAC."
All of the Academy's clinical policy statements and recommendations may be accessed online.
