This was successfully posted to your pofile.
This box will close automatically in a few seconds. Close this window
We don't have an e-mail address on file for you. To use AAFP Connection, you must have an e-mail address in our records. Click Here
NIH Panel Calls for Broader Access to TOL, VBAC
Recommendations Mirror Existing AAFP Policy
The NIH panel's recommendations were based, in part, on a new evidence report from the Agency for Healthcare Research and Quality, or AHRQ. The evidence report is an update to a 2003 evidence report that was originally requested by the AAFP and the American College of Obstetricians and Gynecologists, or ACOG.
The AAFP used the 2003 report, as well as additional literature review and analysis, to develop its current recommendations on TOL after cesarean section. Those recommendations say that "women with one previous cesarean delivery with a low transverse incision are candidates for, and should be offered, a trial of labor." In addition, women desiring a TOL after previous cesarean delivery should be counseled about the positive and negative factors influencing their chances for a successful VBAC.
The Academy plans to review its current policy and its shared decision-making tool in light of the new evidence report, said Bellinda Schoof, M.H.A, the AAFP's scientific affairs manager.
Barriers to Access
Liability fears and recommendations from professional medical associations -- particularly ACOG -- have proven to be barriers to access for women interested in TOL, according to the NIH panel.
In 1999, ACOG changed an earlier recommendation of "encouraging" VBAC to a recommendation that women should be "offered" TOL if there are no contraindications. The guideline also said that TOL should be performed only in facilities equipped to respond to emergencies and in settings where physicians capable of performing a cesarean are "immediately available."
According to FP Thomas Dean, M.D., a member of the NIH consensus panel, chief of staff at Avera Weskota Memorial Medical Center, and staff physician at Horizon Health Care Inc., Wessington Springs, S.D., the issue of immediacy has made TOL an unavailable service for a significant portion of the country, especially rural areas. "There are a lot of women who are being forced into unwanted repeat cesareans because VBAC is not available," said Dean, who is president-elect of the South Dakota AFP. "We need to figure out ways to improve communication between patients and physicians."
According to the panel's report, one-third of hospitals and half of physicians who offer obstetric care no longer provide TOL services.
"The data indicate that hospitals are not willing or able to provide (TOL)," said Cunningham, chair and professor in the department of obstetrics and gynecology at the University of Texas Southwestern Medical Center, Dallas. "That's closed the door to a lot of women having a choice between the two."
The panel recommended that ACOG and the American Society of Anesthesiologists reassess their guidelines. It also urged health care organizations and physicians to make public their TOL policy, VBAC rates and plans for responding to obstetric emergencies.
Dean said more reasonable standards would give maternity care providers some "backup, justification and defense."
"Now everyone is afraid of trial of labor unless they can meet the standard ACOG put out about 10 years ago," he said. "If anything goes wrong, it's hard to defend if they're not practicing the standard of care."
Although the rate of uterine rupture is significantly increased with TOL (325 per 100,000) compared to ERCD (26 per 100,000), the rate of maternal mortality is significantly higher in ERCD (13 per 100,000) than in TOL (4 per 100,000), according to the AHRQ evidence report.
"It’s surprising and very upsetting," Dean said of the findings related to mortality.
He noted that standards put in place by ACOG were intended to improve outcomes, "but it's gone in the other direction." Although cesarean section is slightly safer for the baby, it's significantly more dangerous for the mother, said Dean. And repeated cesarean deliveries increase maternal risks.
Emily Spencer Lukacz, M.D., M.A.S., associate professor of clinical reproductive medicine at the University of California, San Diego, said during the panel's media briefing that 30 percent of American women have three or more children. She said the risk related to repeat cesarean sections is a critical aspect of counseling a patient regarding her choice of delivery mode.
The rates of maternal hysterectomy, hemorrhage and transfusion were not significantly different between the two methods, according to the AHRQ report.
The panel called for policymakers, health care providers and other stakeholders to work together to increase access to TOL and VBAC. The panel also called for research to understand better the short- and long-term maternal, fetal and neonatal outcomes of TOL and ERCD.
Dean said more study is needed to better understand which women can safely labor in community hospitals and which need the extra services available in tertiary centers.